Every finding on record at Lafayette Center

Based on observation, interview, and record review, the facility failed to follow Centers for Disease Control and Prevention (CDC) guidelines for laundry services, failed to update their water management program to include information identified during a recent water infection control risk assessment, and failed to identify other potential risk areas in an effort to minimize the risk of Legionella that had the potential to effect the facility census of 58 residents.Findings include:Review on 6/24/26 of the CDC website titled Healthcare-Associated Infections (HAIs) Appendix D-Linen and Laundry management, retrieved from : https://www.cdc.gov/hai/prevent/resource-limited/laundry.html, revised on 3/27/20, revealed, .Best practice for linen (and Laundry) handling: .Always launder soiled linens from patient care areas in a designated area, which should: be a dedicated space for performing laundering of soiled linen .have a separation between the soiled linen and clean linen storage areas .Best practices for management for clean linen: Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items .Observation on 6/24/26 at approximately 11:30 a.m. on the dirty side of the facility laundry room with Staff H (Infection Preventionist) revealed 2 cardboard boxes of clean linen stored on the floor just inside the doorway, 2 cardboard boxes of clean linen stored on the floor behind the washing machine, and 3 cardboard boxes of clean linen to be stored on the floor next to the rinse sink.Interview on 6/24/26 at approximately 11:30 a.m. with Staff H confirmed clean linen was being stored in cardboard boxes on the dirty side of the laundry room. Review on 6/24/26 of the facility water management plan, revised 3/9/26, revealed that the plan identified one dead leg/capped pipe in the Director of Nursing's (DON) office, and the 2 ice machines would be cleaned on a bi-annual basis. The water management plan did not include the 2 water bubblers as a potential risk area with control measures, did not identify that the hot water boiler/heaters needed to be maintained at or above 140 degrees Fahrenheit, and failed to have monitoring and control measures in place in the event that the degrees fell below 140 degrees Fahrenheit.Review on 6/24/26 of the facility water Infection Control Risk Assessment, dated 6/4/26, accepted and reviewed by the Quality Assurance and Performance Improvement team on 6/16/26, revealed the assessment identified 2 water bubblers that are used within the facility, no dead legs in the facility, and stated that the facility's 2 ice machines would be cleaned by vender on a quarterly basis. Review on 6/24/26 of the facility policy titled Legionella Surveillance revised 6/2025, revealed, .d. Temperature controls:. ii. Hot water shall be stored above 140 [degrees] F [Fahrenheit] and circulated at a minimum return temperature of 124 [degrees] F [Fahrenheit].Interview on 6/25/26 at approximately 9:30 a.m. with Staff A (Administrator) confirmed that the 3/9/26 water management plan was not updated after the 6/4/26 Infection Control Risk Assessment. Staff A confirmed that water temperatures were not taken at the hot water boiler/heaters.

Based on interview and record review, the facility failed to implement their system for monitoring antibiotic use for 5 of 7 resident reviewed for antibiotic stewardship. (Resident identifiers are #6, #7, #35, #45 and #60.)Findings include:Review on 6/24/26 of the facility policy titled Antibiotic Stewardship Program, revised on 6/2025, revealed .iii. The facility uses .updated McGeer criteria.to define infections.Nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic time out within 48-72 [hours] of antibiotic therapy to monitor the response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings.Review on 6/24/26 of LOEB AND REVISED MCGEER CRITERIA, found at https://infectioncontrolma.org/docs/Loeb-and-Revised-McGeer-Criteria.pdf, updated September 2023, revealed .Revised McGeer criteria for urinary tract infection.UTI [Urinary Tract Infection] without indwelling catheter criteria.At least one of the following microbiologic criteria: 10,000 cfu [colony forming unit]/mL[milliliter] of no more than 2 species of organisms in a voided urine sample 1,000 cfu/mL of any organism(s) in a specimen collected by an in-and-out catheter.Review on 6/24/26 of the antibiotic use line listing for April 2026 through June 2026 revealed the following residents were prescribed an antibiotic for a diagnosis of Urinary Tract Infection (UTI) but did not have a Culture and Sensitivity to review during an antibiotic time out:Resident #7 was prescribed an antibiotic on 4/14/26; Resident #6 was prescribed an antibiotic on 5/10/26; Resident #35 was prescribed an antibiotic on 5/24/26; Resident #45 was prescribed an antibiotic on 6/2/26; and Resident #60 was prescribed an antibiotic on 6/5/26. Interview on 6/24/26 at approximately 10:00 a.m. with Staff H (Infection Preventionist) confirmed a culture and sensitivity was not available to review during the antibiotic time out for the above residents.

Based on interview, and record review, the facility failed to implement a care plan for Psychotropic Medications for 1 of 5 residents reviewed for unnecessary medications in a final sample of 17 residents. (Resident identifier is #3). Findings include: Review on 6/24/26 of Resident #3's care plan for risk for complications related to the use of psychotropic medications, dated 2/20/26, revealed an intervention, AIMS testing per protocol.Review on 6/24/26 of the facility's policy Use of Psychotropic Medication(s), dated 6/26, revealed, .13. Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, PRN, or as per facility policy .Review on 6/24/26 of Resident #3's medical record revealed a physician's order for Quetiapine Fumarate for Dementia with psychosis since admission.Review on 6/24/26 of Resident #3's medical record revealed an admission Screening Assessment, dated 2/20/26, under Section M. Antipsychotics/AIMS, 2. AIMS Assessment, it was documented that Resident #3 was not assessed due to impaired cognition. Section M. Antipsychotics/AIMS, 3. Facial and Oral Movements, 4. Extremity Movements, 5. Trunk Movements, 6. Global Judgements, 8. Movements in Sleep and 9. Scoring were not completed. Review on 6/24/26 of Resident #3's medical record revealed an admission Screening Assessment, dated 5/27/26, Section M. Antipsychotics/AIMS, 2. AIMS Assessment, 3. Facial and Oral Movements, 4. Extremity Movements, 5. Trunk Movements, 6. Global Judgements, 8. Movements in Sleep and 9. Scoring were not completed. Interview on 06/24/2026 at approximately 11:30 with Staff L (Unit Manager) confirmed that Resident #3 has been taking an antipsychotic medication since Resident #3 was admitted in February 2026 and that no AIMS testing was completed at admission or quarterly as per facility policy.

Based on observation, interview and record review, the facility failed to provide assistance with eating during meals for 1 of 2 residents reviewed for nutrition in a final sample of 17 residents. (Resident identifier is #47.)Findings include:Review on 6/22/26 of Resident #47's Activities of Daily Living (ADL) care plan, initiated on 5/1/26, revealed the following interventions:Provide setup to partial assistance for eating, dated 6/5/26; Monitor conditions that may contribute to ADL decline, including poor nutrition, dated 5/7/26; and Provide cuing for safety and sequencing to maximize current level of function, dated 5/7/26. Review on 6/22/26 of Resident #47's Nutrition care plan, initiated 5/4/26, revealed the following interventions:Resident does need assistance with eating at times. Assist as needed, dated 5/7/26; Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated, dated 5/4/26; and Monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake, dated 5/4/26. Observation on 6/22/26 at approximately 12:15 p.m. of Resident #47 while eating lunch revealed Resident #47 trying to pick up a piece of their hamburger for several minutes. All the ground meat fell out of the bun. Observation on 6/23/26 at approximately 8:15 a.m. of Resident #47 while eating breakfast revealed Resident #47 using their fingers to eat the scrambled egg that was on the plate. There was scrambled egg on their lap and on their tray as well.Observation on 6/23/26 at approximately 12:00 p.m. of Resident #47 while eating lunch revealed attempting to scoop up ground chicken with their spoon. Several empty spoonfuls were placed in their mouth. Approximately a quarter of the ground chicken was off the plate on the tray. Resident #47 attempted to scoop the broccoli with their spoon, but it fell off the plate on to the tray. Resident # 47 was able to eat approximately 25 % (percent) of the ground chicken that he/she was provided), half of a dinner roll that was cut in half, none of the broccoli, none of the macaroni, and all of the dessert.Interview on 6/23/26 at approximately 12:30 p.m. with Staff E (Licensed Practical Nurse) and Staff F (Licensed Nursing Assistant) revealed that the staff do not offer Resident #47 assistance at meals other than to set up the tray.Interview on 6/23/26 at approximately 12:30 p.m. with Staff G (Dietitian) confirmed that Resident #47 did require some assistance with meals.

Based on observation, interview and record review, the facility failed to implement interventions to reduce hazard(s) and risk(s) for 2 of 2 residents reviewed for elopement and for 1 of 1 resident reviewed for falls in a final sample of 17 residents. (Resident identifiers are #10, #49, and #56). Findings include: Resident #49 Interview on 6/22/26 at 11:27 a.m. with Resident #49 revealed that he/she fell in the bathroom shortly after she was admitted . There was one aide helping her in the bathroom when his/her knee gave out. Review on 6/23/26 of Resident #49's medical record revealed a care plan for assistance for ADL (Activities of Daily Living), with an intervention for two-person assist with a walker with a gait belt for all transfers, initiated on 6/1/26. Review on 6/23/26 of Resident #49's admission Minimum Data Set (MDS) with an assessment reference date of 6/1/26 revealed Resident #49 had a Basic Interview for Mental Status (BIMS) score of 15 out of 15, meaning cognitively intact. Further review revealed that under section GG – Functional Abilities, Resident #49 was coded as a substantia/maximal assistance for toilet transfer. Interview on 6/23/26 at approximately 11:00 a.m. with Staff M (Licensed Nursing Assistant (LNA)) revealed that he/she was assisting Resident #49 from the wheelchair to the toilet, Resident #49 slipped. Staff M stated that he/she was the only one assisting Resident #49 with the transfer to the toilet at the time of the fall. Interview on 6/23/26 at approximately 11:30 a.m. with Staff L (Unit Manager) confirmed that Resident #49 was a two-person assist with all transfers including transfers to the toilet. Interview on 6/23/26 at approximately 11:32 a.m. with Staff N (LNA) revealed that he/she was Resident #49's LNA on 6/23/26. Staff N stated they assisted Resident #49 to the bathroom and helped Resident #49 transfer to the toilet by themselves earlier today. Review on 6/23/26 of the facility's policy Fall Prevention Program, revised 6/26, revealed .8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. The plan of care will be revised as needed. 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. Resident #10 Review on 6/23/26 of Resident #10's medical record revealed a physician's order for a wander guard elopement device due to poor safety awareness written on 4/22/26. Review on 6/23/26 of Resident #10's Wandering Assessment (Elopement) dated 4/22/26 Section 5. History of Wandering: 5a. is marked as Resident #10 has a history of wandering and that this behavior occurred daily. Section 9. At Risk: 9a. is marked yes for Resident #10 is believed to be at risk for elopement. Review on 6/23/26 of Resident #10's Elopement Risk Identification Form revealed that the wander guard is on Resident #10's right wrist. Observation on 6/23/26 at approximately 9:18 a.m. of Resident #10 sitting up eating breakfast with no wander guard on right or left wrist. Observation on 6/24/26 at approximately 9:12 a.m. of Resident # 10 sitting up eating breakfast with no wander guard on right or left wrist. Interview on 6/24/26 with Staff K (Licensed Practical Nurse) who confirmed that Resident #10 has an active order for a wander guard to be placed on right wrist and Resident #10 did not have one. Resident #56 Interview on 6/22/26 at approximately 9:30 a.m. with Staff B (LNA) revealed that Resident #56 wears a wander guard device to their left ankle but they are known to remove it. Review on 6/23/26 of Resident #56's wandering assessment, dated 4/22/26, that indicated the resident has wandered aimlessly within the home or off the grounds, they were at risk for elopement and a wander guard device was placed on their left ankle. Review on 6/23/26 pf Resident #56's Care plan for elopement revealed an intervention, dated 4/8/26, wander guard to left ankle. Observation on 6/22/26 at approximately 9:00 a.m. ,12:00 p.m. and 2:15 p.m. of Resident #56 and their bed room revealed a wander guard device sitting on the top of their nightstand. Resident #56 was not wearing a wander guard. Review on 6/23/26 of the facility policy titled Elopement and Wandering Residents, revised 7/2025, revealed .4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement or unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. B. The interdisciplinary care team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan.e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly.

Based on interview and record review, the facility failed to provide the resident or the resident's representative with a bed hold notice that included the duration of the bed hold and reserve bed payment while hospitalized for 1 of 1 resident reviewed for hospitalizations in a final sample of 17 residents (Resident Identifier is #26). Findings include:Review on 6/24/26 of facility policy titled Bed Hold Notice, revised 6/2025, revealed .1. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility will provide the resident and/or resident representative written information that specifies a. The duration of the State bed-hold policy, if any, during which the resident is permitted to return and resume resident in the nursing facility b. The reserve bed payment policy in the state plan policy, if any.Review on 6/24/26 of Resident #26's medical record revealed that Resident #26 was transferred to the hospital on 2/10/26, 3/21/26, and 6/22/26. Further review revealed that Resident #26 received copies of the facility's policy titled Bed Hold Notice, dated June 2025 at the time of the hospital transfers. Interview on 06/24/26 at 9:22 a.m. with Staff A (Administrator) confirmed the Bed Hold Notice policy provided to Resident #26 did not include the duration of the bed hold and reserve bed payment for Resident #26's transfer to the hospital on 2/10/26, 3/21/26, and 6/22/26.

Based on observation, interview, and record review, it was determined that the facility failed to provide care consistent with professional standards of practice to promote healing for 1 of 3 residents reviewed for pressure ulcers in a final sample of 16 residents. The lack of treatment orders over a six day period resulted in a small open area that worsened into an Unstageable pressure area. (Resident identifiers is #158). Findings include: Review on 5/23/25 of Resident #158's admission Minimum Data Set with an Assessment Reference Date of 3/3/25 revealed that Resident #158 admitted to the facility on 2/2025 and under Section M - Skin Conditions was coded in item M0210 Unhealed Pressure Ulcers/Injuries as No (indicating that the Resident had no pressure ulcers during the 7 look-back period of 2/25/25 through 3/3/25). Right Buttock Review on 5/23/25 of Resident #158's Weekly Skin Review, dated 3/11/25, revealed that the Resident's skin was intact. This was completed by Staff H (Unit Manager). Review on 5/23/25 of Resident #158's Nursing Note, dated 3/18/25, revealed, Small open area noted in crease of right buttock area (appears [to be] from brief) . bordered [dressing] applied, [skilled nurse] to monitor. Review on 5/23/25 of Resident #158's Nursing Note dated 3/22/25 revealed, Peri wound is pink and warm . wound was cleansed with wound cleanser and dried. A small amount of barrier ointment was applied to the area and then covered with a pouffed silicon [sic] dressing . Review on 5/23/25 of Resident #158's medical record, including physician's orders and progress notes, revealed there was no documentation that the provider was notified of the above area or that a physician's order was obtained for the above treatment. Review on 5/23/25 of Resident #158's Provider Progress note, dated 3/24/25, (six days after open area to right buttocks was first identified) by Staff D (Advanced Practice Registered Nurse) revealed, . Patient has an Unstageable pressure ulcer on the right buttock wound bed 100% [percent] slough [a type of necrotic tissue], will order santyl gel to wound bed with silicone border cover [dressing] change [every] 3 days . Review on 5/23/25 of Resident #158's March 2025 Treatment Administration Record (TAR) revealed a physician's order, dated 3/26/25, for right buttock apply thin layer of santyl and cover with silicone border dressing every Monday, Wednesday and Friday for Unstageable pressure injury (ulcer). Further review revealed that the treatment was not signed on the TAR as being completed until 3/28/25. Review on 5/23/25 of Resident #158's medical record revealed there was no weekly documentation of the size and/or measurements of the above pressure ulcer between 3/18/25 through 4/18/25. Interview on 5/23/25 at 2:23 p.m. with Staff G (Wound Care Nurse/Infection Preventionist) confirmed there were no measurements for the right pressure area until 4/18/25. Review on 5/23/25 of Resident #158's April 2025 TAR revealed that there was no treatment ordered or documented as completed for the right buttock pressure ulcer between 4/9/25 through 4/23/25. Interview on 5/27/25 at 11:19 a.m. with Staff B (Director of Nursing), Staff D, Staff G and Staff H (Unit Manager) confirmed that the above pressure area to the right buttock was identified on 3/18/25 and that there was no physician's order for treatment until 3/26/25. Staff D confirmed that they were not aware of the open area to the right buttock until 3/24/25 when it was assessed as an Unstageable pressure ulcer. Left Buttock Review on 5/23/25 of Resident #158's medical record revealed the following progress notes: On 3/24/25 written by Staff D: . Left buttock with stage 2 pressure ulcer wound bed moist pink without [signs and symptoms] of infection triple [antibiotic] to wound ., On 3/26/25 by Staff D: . left buttock stage 2 pressure ulcer ., On 4/18/25 by Staff D: Resident has two pressure areas on bilateral gluteal folds, Left wound is improved with a 0.5 cm [centimeter] open area recommend protective silicone border dressing change 3 [times] weekly ., On 4/25/25 by Staff D: . Left wound is improved with a 0.25 cm open area recommend protective silicone dressing . Review on 5/23/25 of Resident #158's April 2025 TAR revealed there was no treatment ordered or documented as completed for the left buttock from 4/1/25 through 4/21/25. Review on 5/23/25 of Resident #158's medical record revealed there was no weekly documentation of the size and/or measurements of the above left buttock pressure area between 3/24/25 (when it was identified) and 4/18/25. Interview on 5/23/25 at 2:23 p.m. with Staff G confirmed there were no measurements for the left pressure ulcer until 4/18/25. Interview on 5/27/25 at 11:19 a.m. with Staff B, Staff D, Staff G and Staff H confirmed that the above pressure area to the left buttock was identified on 3/24/25. They confirmed that there was no treatment documented for the left buttock between 4/1/24 through 4/21/25. Dressing Change Observation Review on 5/23/25 of Resident #158's current treatment orders revealed the following: Cleanse site on interior heel (right) with normal saline, apply santyl cream to wound bed then cover with a silicone dressing change daily, with a start date of 5/22/25; Coccyx open site. Clean with normal saline, pat dry, then apply Santyl cream to site and cover with Silicone dressing every 3 days in the morning every Monday, Wednesday, Friday with a start date of 5/23/25; and Right lower buttocks reddened site, Clean with normal saline, pat dry, apply Medi honey and cover with silicone boarder dressing every 3 days in the morning every Monday, Wednesday, Friday, with a start date of 5/23/25. Observation on 5/23/25 at approximately 12:30 p.m. with Staff G and Staff D during Resident #158's wound care revealed the following: Right heel wound: Staff G applied skin prep to the wound bed and then covered the wound with a silicone dressing. Right Gluteal fold wound: Staff G applied skin prep to the wound bed, applied Medi honey, and covered the wound with a silicone dressing. No measurement was taken of this wound at the time of the dressing change. Staff D stated that it was probably 0.4 cm x 0.4 cm. Left Coccyx wound: Staff G applied skin prep to the wound bed and then applied Medi Honey. Staff D cleaned the wound to remove the treatment so they could visualize the area then reapplied Medi honey and covered with a silicone dressing. Interview on 5/23/25 at approximately 1:30 p.m. with Staff G confirmed they did not follow physician's orders for the above wound treatments and that no measurements were taken of the left gluteal fold wound.Review on 5/27/25 of the facility's policy titled Wound Treatment Management revised 9/2024 revealed, .1. Wound treatment will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders . 5. Treatment decisions will be based on . b. Characteristic of the wound . ii Size - including shape, depth, and presence of tunneling and/or undermining . 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. considerations for needed modifications include . b. Changes in the characteristics of the wound . Review on 5/27/25 of the facility's policy titled Skin Assessment revised 2/2025 revealed, . It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management . 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 2. Procedure . e. Begin head to toe, thoroughly examining the resident's skin for conditions. Pay close attention to pressure points, bony prominences, and underneath medical devices. f. Remove any special garments or devices, if not contraindicated or ordered to remain in place. g. Remove any dressings . and note findings. h. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions . 7 Documentation of skin assessment . b. Document observations . c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain) . Review on 5/27/25 of the facility's policy titled Maintenance and Thinning of Medical Records revised 9/2024 revealed, . 2. In accordance with accepted professional standards of practices, the facility must maintain medical records on each resident that are: a. Complete b. Accurately documented .

Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for 2 of 2 residents observed for wound care and failed to develop a water management program to minimize the risk of Legionella that had the potential to effect the facility census of 56 residents who resided at the facility. (Resident Identifiers are #32 and #158). Findings include: Resident #32 Observation on 5/23/25 at approximately 12:00 p.m. with Staff G (Infection Preventionist/ Wound Care Nurse) and Staff D (Advanced Practice Registered Nurse) performing wound care for Resident #32 revealed the following: Staff G gathered their supplies outside of the room and placed them on a clip board without cleaning the clipboard or placing a clean field barrier. There was a sign indicating the resident needed EBP (Enhanced Barrier Precautions) hanging on the outside of Resident #32's door. Staff G entered Resident #32's room. Staff G did not don an isolation gown. Staff G removed Resident #32's dirty coccyx wound dressing. Resident #158 Observation on 5/23/25 at approximately 12:30 p.m. with Staff G and Staff D performing wound care for Resident #158 revealed the following: Staff G gathered their supplies outside of the room and placed them on a clip board without cleaning the clipboard or placing a clean field barrier. Staff G removed a pair of scissors that were stored on the top of the treatment cart and placed them on the clipboard. There was a sign indicating EBP hanging on the outside of Resident #158's door. Staff G and Staff D entered the room without putting on an isolation gown. Staff G placed the clipboard with the dressing change supplies directly on Resident #158's bed. Staff G cut Resident #158's right heel wound dressing off with the scissors and placed them back on to the clipboard. Staff G removed the left gluteal fold wound dressing. Staff G removed right coccyx wound dressing. When treatments were completed, Staff G brought the clip board and placed it on top of the treatment cart Staff G placed the dirty scissors back into the holder on the top of the cart. Interview on 5/23/25 at approximately 1:00 p.m. with Staff G confirmed the above observations. Review on 5/23/25 of facility policy titled Enhanced Barrier Precautions, revised 1/2024, revealed .3. Implementation of Enhanced Barrier Precautions .a. Make gowns and gloves available immediately near or outside of the resident's room . b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .4. High-contact resident care activities include: .h. wound care: any skin opening requiring a dressing .10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk . Review on 5/23/25 of the facility policy titled Clean Dressing Change, revised 5/2024, revealed .5. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application .12. Cleanse the wound as ordered . Review on 5/22/25 of the water management plan provided by the facility revealed that it contained a water system for a 4 story building [The facility is only one story]. Interview on 5/22/25 at approximately 11:40 a.m. with Staff I (Administrator) revealed the facility did not have a water management plan that describes the flow of the water system at the facility. Review on 5/23/25 of the facility policy titled Infection Prevention and Control Program, revised 1/2024, revealed .16. Water Management: a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. c. The Maintenance Director serves as the leader of the water management program.

Based on interview and record review, it was determined that the facility failed to keep residents apprised of the progress towards resolution, and maintain evidence demonstrating the response and rationale of the resident group grievance for the attendees of the Resident Council Meeting for 3 of 3 months of meeting minutes reviewed. Findings include: Interview on 5/22/25 at approximately 10:00 a.m. during Resident Council Meeting revealed that the complaints about LNA's (Licensed Nursing Assistance) discussing other residents and being loud is an on going issue. All 9 residents at this meeting stated they do not feel this concern was addressed and that no one had followed up to inform them of what if any actions had been taken since the initiation of the concerns. Review on 5/22/25 of the facility's Resident Council Meeting minutes revealed the following documented concerns under Nursing: February 11, 2025 minutes: LNA's talking about residents in front of other residents; March 25, 2025 minutes: LNA's talking about residents in front of other residents. Has gotten better; April 15,2025 minutes: LNA's talking about residents in front of other residents or in the hallways near rooms. Still ongoing (Birch Wing). Hollering of staff in hallways and at nurse's stations (All wings). Interview on 5/22/25 at approximately 11:00 a.m. with Staff K (Activities Director) confirmed the above concerns regarding the LNA's had been an ongoing issue at the Resident Council Meeting. Staff K stated that Social Services is given the resident concerns after the meeting. Staff K confirmed that there was no written follow up of actions taken in the meeting minutes the months following the continued concerns. Interview on 5/22/25 at approximately 10:30 am with Staff E (Social Services coordinator) stated that they do not write the concerns from Resident Council as separate Grievances. Staff E stated that they verbalize the Resident Council concerns to the Department heads at the managers meeting the following day so all managers can be aware of what concerns are brought up and for them to address. Review on 5/22/25 of facility policy titled Resident Council Meetings, revised 10/2022, revealed .7. The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council .

Based on observation, interview and record review, it was determined that the facility failed to develop and update comprehensive care plans for 2 of 3 residents reviewed for pressure ulcers in a final sample of 16 residents. (Resident identifiers are #32 and #158). Findings include: Resident #32 Review on 5/22/25 of Resident #32's medical record revealed a provider note dated 5/19/25 written by Staff D (Advanced Practice Registered Nurse) that stated; Previously closed sacral ulcer now has one open area, mid-line, continue with medihoney and silicone border dressings to open area. Review on 5/22/25 of Resident #32's MAR (Medication Administration Record) revealed a physician's order with a start date of 4/21/25 to Cleanse sites on inner left and right buttock. Apply Medi honey and cover with silicone dressing. Change 3x [three times a] week in the morning every Mon, Wed, Fri [Monday, Wednesday, and Friday]. Interview on 5/23/25 at approximately 8:30 a.m. with Staff H (Unit Manager) confirmed that there were no new orders addressing the 5/19/25 wound note that identified the new area at mid-line. Interview on 5/23/25 at approximately 8:45 a.m. with Staff D confirmed that he/she saw Resident #32 on 5/19/25 and noted the new area at mid-line and did not write a new treatment order. Staff D further confirmed that the treatments had not been completed. Review on 5/23/25 of Resident #32's care plan for skin revealed that the last update to the care plan was on 3/27/25. Interview on 5/23/25 at approximately 9:00 a.m. with Staff H confirmed that Resident #32's care plan for skin had not been updated since 3/27/25.Resident #158 Review on 5/21/25 of Resident #158's progress notes revealed that on 3/27/25 there was an Unstageable pressure area to the right buttock and a stage 2 pressure ulcer to the left buttock. Further review revealed that on 4/12/25 there was a Deep Tissue Injury to the right heel. Observation on 5/23/25 at approximately 12:30 p.m. of Resident #158's wound care with Staff G (Infection Preventionist/Wound Care Nurse) and with Staff D revealed that Resident #158 has pressure areas to the right heel, left gluteal fold, and right coccyx area. Review on 5/23/25 of Resident #158's care plan initiated on 3/10/25 revealed, Resident at risk for skin breakdown related to impaired functional mobility and actual MASD [Moisture-associated skin damage]. Further review revealed that the care plan had not been updated to include interventions for the above pressure areas. Interview on 5/27/25 with Staff H confirmed that there was no care plan intervention for Resident #158's pressure ulcers that developed in March and April.

Based on observation, interview, and record review, it was determined that the facility failed to follow physician orders for 1 of 3 residents reviewed for choices in a final sample of 16 residents (Resident Identifier is #21). Findings include: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 2021. Chapter 31 Medication Administration Page 595, .Medications that are time critical most likely cause harm or have subtherapeutic effects if they are not administered in time (usually 30 minutes before and after the scheduled dose). Non-time-critical medications most likely do not cause harm if they are given within 1 hour to 2 hours before or after the schedule time. Thus, you need to administer time-critical medications at a precise time, within 30 minutes before and after a scheduled time. You administer non-time-critical medications within 1 to 2 hours of their scheduled times . Interview on 5/21/25 at 11:37 a.m. with Resident #21 revealed that his/her medications are often given late. He/she stated it has happened multiple times within the last month. Review on 5/22/25 of Resident #21's annual Minimum Data Set (MDS) with an assessment reference date of 3/18/25 revealed Resident #21 had a Basic Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review on 5/22/25 of Resident #21's Medication Administration Audit Report for the last 30 days revealed the following medications were given past the scheduled time: On 4/21/25 Methylphenidate (central nervous system stimulant) HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:13 a.m. On 4/22/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 7:05 a.m. On 4/28/25 Olanzapine (antipsychotic) Oral Tablet. Give 10 mg by mouth at bedtime for bipolar disorder, scheduled for 7:00 p.m., given at 8:52 p.m. On 4/29/25 Olanzapine Oral Tablet. Give 10 mg by mouth at bedtime for bipolar disorder, scheduled for 7:00 p.m., given at 8:52 p.m. On 5/3/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:17 a.m. On 5/4/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:14 a.m. On 5/5/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:35 a.m. Olanzapine Oral Tablet. Give 10 mg by mouth at bedtime for bipolar disorder, scheduled for 7:00 p.m., given at 8:53 p.m. On 5/7/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:07 a.m. Olanzapine Oral Tablet. Give 10 mg by mouth at bedtime for bipolar disorder, scheduled for 7:00 p.m., given at 8:57 p.m. On 5/8/25 Valbenazine Tosylate (treat various movement disorder) Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 7:00 a.m., given at 10:17 a.m. Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:51 p.m. On 5/9/25 Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:30 p.m. On 5/10/25 Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 2:25 a.m. Olanzapine Oral Tablet. Give 10 mg by mouth at bedtime for bipolar disorder, scheduled for 7:00 p.m., given at 2:25 a.m. Gabapentin (nerve pain medication) Oral Capsule 300 mg. Give 1 capsule by mouth three times a day for polyneuropathy, scheduled for 8:00 p.m., given at 2:24 a.m. Bupropion (antidepressant) HCI ER Oral Tablet Extended Release 12 Hour 150 mg. Give 1 tablet by mouth two times a day for depression and anxiety, scheduled for 8:00 p.m., given at 2:24 a.m. On 5/11/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:01 a.m. Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 7:35 p.m. 5/12/25 Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:15 p.m. On 5/13/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 7:21 a.m. Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:30 p.m. On 5/14/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 7:09 a.m. Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:05 p.m. On 5/15/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:06 a.m. Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:11 p.m. 5/16/25 Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:24 p.m. 5/17/25 Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:33 p.m. 5/18/25 Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:35 p.m. On 5/21/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:36 a.m. Interview on 5/23/25 at 8:51 a.m. with Staff D (Advanced Practice Registered Nurse) confirmed that the above medications were administered late. Review on 5/23/25 of the facility's policy titled Medication Administration revised on 3/25 revealed, .10. Ensure that the six rights of medication administration are followed: . e . right time .12b. Administer within 60 minutes prior to or after scheduled times unless otherwise ordered by physician .

Based on interview and record review, it was determined that the facility failed to assist a resident in gaining access to hearing services for 1 of 1 resident reviewed for communication in a final sample of 16 residents (Resident Identifier is #42). Findings include: Interview on 5/22/25 at 10:40 a.m. with Resident #42 revealed that he/she had requested to be seen by the audiologist. Resident #42 stated that he/she felt that his/her hearing was getting worse, and he/she was concerned. Review on 5/23/25 of Resident #42's medical record revealed that Resident #42 was admitted to the facility in 2023 and diagnosed with abnormal auditory perceptions in the left ear in 9/2024. Review on 5/23/25 of Resident #42's ambulatory clinic notes for a hearing evaluation dated 5/23/24 revealed that Resident #42 was a good candidate for bilateral hearing aides. Interview on 5/23/25 at approximately 1:00 p.m. with Resident #42's Durable Power of Attorney (DPOA) revealed that Resident #42 had difficulty communicating with family both in person and on the telephone. Interview on 5/23/25 at approximately 2:00 p.m. with Staff F (Medical Records/Central Supply coordinator) confirmed that Resident #42 had requested to be seen by the audiologist for a hearing consult and the facility did not make an appointment. Review on 5/23/25 of the facility's policy titled, Consultant Referrals dated 7/21 revealed, .1. Outside clinical services will be provided to the residents as ordered by the resident physician and as available by appointment from the outside provider .

Based on interview and record review, it was determined the facility failed to provide the necessary assistance in making transportation arrangements for a scheduled x-ray which resulted in a missed appointments for 1 of 1 resident reviewed for transportation assistance in a final sample of 16 residents. (Resident Identifier is #13.) Findings include: Review on 5/21/25 of Resident #13's medical record revealed that he/she was admitted to the facility on 12/2024. Interview on 5/21/25 at 10:42 a.m. with Resident #13 revealed that he/she was upset because they were supposed to have an x-ray of their knee at the orthopaedic clinic, but was told by Staff F (Medical Records/Central Supply coordinator), who sets up the transportation, that they did not know anything about an appointment and transportation had not been set up. Interview on 5/22/25 at 2:28 p.m. with Staff L (Certified Occupational Therapy Assistant) confirmed that they had seen paperwork at the nurses station for Resident #13 regarding an appointment for an x-ray of the knee on 5/21/25 and that they had reached out to Staff F to be sure they were aware of it. Interview on 5/22/25 at 2:35 p.m. with Staff F revealed that Staff L had told them that there had been paperwork at the nurses station regarding an appointment/x-ray for Resident #13. Interview on 5/23/25 at 9:55 a.m. with Staff F and with the orthopaedic clinic confirmed that Resident #13 had been seen at the clinic on 5/6/25 and given paperwork to Resident #13 that included an appointment for an x-ray and physician visit for 5/21/25 at 12:00 p.m. The clinic confirmed that Resident #13 did not go the appointment or have the x-ray.

Based on record review and interview it was determined that the facility failed to ensure that a resident was free from abuse for 1 of 3 residents reviewed for abuse (Resident Identifier #5). Findings include: Review on 8/7/24 of Resident #5's medical record revealed the following diagnosises: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Further review of the medical record that Resident #5 has a Brief Interview for Mental Status (BIMS) of 3. Review on 8/7/24 of a facility reported incident, dated 5/9/24, revealed that on 5/5/24, Resident #2 was observed by a staff member with his/her hand down the pants of Resident #5. Interview on 8/7/24 with Staff A (Activities Director) revealed on 5/5/24, Staff A observed Resident #2 with his/her hand down the pants of Resident #5. Further interview revealed that Staff A was aware of multiple incidents of Resident #2 being sexually inappropriate with residents who have cognitive issues. Interview on 8/7/24 at approximately 11:50 a.m. with Staff H (Licensed Nursing Assistant (LNA)) revealed that on 7/27/24, he/she observed Resident #5 lying in bed and Resident #2 was positioned with his/her right hand on Resident #5's left shoulder and Resident #2's other hand was rubbing back and forth on Resident #5's genital area. Interview on 8/16/24 at approximately 8:30 a.m. with Staff K (LNA) revealed that on 8/13/24 around dinner time, Staff K had witnessed Resident #1 touching Resident #5 at the top of their inner thigh near their genital area. Staff K stated that he/she immediately separated the residents and reported the incident to Staff M (Licensed Practical Nurse (LPN)) because it was inappropriate. Interview on 8/19/24 at approximately 1:20 p.m. with Staff L (LNA) revealed that Staff L witnessed Resident #1 run his/her hand up Resident #5's leg to where [pronoun omitted] leg meets [pronoun omitted] crotch. Staff L further revealed that he/she was not aware of any interventions in place for Resident #1 to prevent inappropriate behaviors. Review on 8/7/24 of Resident #2's medical record revealed that Resident #2 had a BIMS of 12 with no cognitive or mood related diagnosis. Review on 8/7/24 of Resident #2 care plan revealed a focus for potential to exhibit physical behaviors related to poor impulse control and adjustment disorder with depressed mood, created on 5/29/24, revealed the following interventions: Evaluate need for Psych/Behavioral Health consult, initiated on 5/29/24, Encourage resident/patient to seek staff support for distressed mood, initiated on 5/29/24, and Divert resident/patient by giving alternative objects or activities, created on 5/29/24. Further review Resident #2's care plan revealed a care plan for tendency to exhibit sexually inappropriate behavior related to: lack of disinhibition, created on 4/1/24 and revised on 5/6/24, with the following interventions: Evaluate need for Psych/Behavioral Health consult, initiated on 5/9/24, Provide psychosocial rehabilitation education regarding appropriate sexual behavior through use of Meditelecare, initiated on 5/9/24, When sexually inappropriate behaviors occur, approach [name omitted] in a calm, unhurried manner, reassure as necessary, initiated on 4/1/24 and revised on 5/9/24. Review on 8/7/24 of Resident #1's medical record revealed that Resident #2 had a BIMS of 3 and the following diagnsosises: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review on 8/7/24 of Resident #1's care plan revealed a focus for the potential to demonstrate verbal/physical behaviors toward others related to ineffective coping skills, with an intervention to provide 1:1 care when up in wheel chair, created on 8/7/24.

Based on interview and record review, it was determined that the facility failed to ensure that alleged violations of abuse were reported immediately to the State Survey Agency (SSA) for 3 of 4 allegations of abuse reviewed (Resident Identifiers are #1, #2 and #3). Findings include: Review on 8/7/24 of the facility policy titled, Abuse, Neglect and Exploitation, revised on 01/2024, revealed: .VII Reporting/Response .1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: a. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . Resident #2 Review on 8/7/24 of a facility reported incident, reported to the State Agency on 7/28/24 at 6:02 a.m., revealed that Resident #2 was observed by Staff H (Licensed Nursing Assistant (LNA)) with his/her right hand on Resident #5's left shoulder and his/her other hand placed on the genital area of Resident #5 on 7/27/24 at 8:30 a.m Interview on 8/7/24 at approximately 11:50 a.m. with Staff H (LNA) revealed that on 7/27/24, Staff H observed Resident #2 with his/her hands on the outside of Resident #5's clothing rubbing and squeezing his/her genital area. Staff H stated they immediately notified Staff I (Nurse). Interview on 8/7/24 at approximately 11:40 a.m. with Staff I revealed that on 7/27/24, Staff H reported to Staff I that Resident #2 was in Resident #5's room and was rubbing Resident #5's genital area. Staff I also revealed that he/she wrote a note for Staff J (Assistant Director of Nursing) about the incident and left it in their mailbox because Staff J was not in the facility. Interview on 8/7/24 at approximately 1:00 p.m. with Staff F (Director of Nursing) confirmed that the incident with Resident #2 and Resident #5 occurred on 7/27/24 and was reported to the SSA on 7/28/24, more than 2 hours after the incident. Resident #3 Review on 8/7/24 of a facility reported incident, reported to the State Agency on 8/6/24 at 1:38 p.m., revealed that Resident #4 had fallen, possibly due to an altercation with Resident #3. Interview on 8/7/24 at approximately 12:40 p.m. with Staff G (Social Services) revealed that on the morning of 8/1/24, Resident #4 had told Staff G that they were attacked by another resident the night before. Interview on 8/8/24 at approximately 7:25 a.m. with Staff C (Registered Nurse) revealed that on the evening of 7/31/24, Staff C had heard a commotion coming from Resident #4 room. Staff C had responded to the commotion and had seen Resident #3 exiting Resident #4's room. Resident #4 was on the floor inside the doorway when staff arrived. Resident #4 had stated that Resident #3 had hit them and caused them to fall. Interview on 8/7/24 at approximately 9:00 a.m. with Staff F confirmed that the incident with Resident #3 and Resident #4 had occurred on 7/31/24 was reported to the SSA on 8/6/24, more than 2 hours after the allegation was made. Resident #1 Interview on 8/16/24 at approximately 8:30 a.m. with Staff K (LNA) revealed that Staff K had witnessed an interaction between Resident #1 and Resident # 5 on 8/13/24 around dinner time. Interview further revealed that Resident #1 was seen touching Resident #5 on [pronoun omitted] inner thigh almost to [pronoun omitted [genital area]. Staff K stated that Resident #5 was visibly upset. Staff K stated that he/she immediately separated the residents and reported the incident to Staff M (Licensed Practical Nurse). Interview on 8/16/24 at approximately 10:00 a.m. with Staff E (Administrator) confirmed that the incident with Resident #1 and Resident #5 had occurred on 8/13/24 and had not been reported to the SSA.

Based on observation, interview, and record review, it was determined that the facility failed to revise care plans for 2 of 3 residents reviewed for abuse (Resident Identifiers are #1 and #3). Findings include: Resident #1 Review on 8/7/24 of a facility reported incident revealed that Resident #1 was observed by Staff B (Licensed Nursing Assistant) with his/her hand placed on the genital area of Resident #6 on 7/28/24 at 4:40 p.m. Review on 8/7/24 of Resident #1's medical record revealed a provider progress note, dated 7/30/24, that stated Resident #1 had been seen for increased sexual behaviors towards others and also indicated staff reported increased wandering behaviors with difficulty to redirect. Review on 8/7/24 of Resident #1's care plan revealed a care plan for the potential to demonstrate verbal/physical behaviors towards others related to ineffective coping skills, created on 7/1/24 and revised on 7/15/24. Resident #1's behavior care plan revealed the following interventions: Evaluate need/provide for Psych/Behavioral Health consultation, created on 7/15/24. Further review of Resident #1's care plan revealed no other interventions were added for behaviors. Resident #3 Interview on 8/7/24 at approximately 12:40 p.m. with Staff G (Social Services) revealed that on the morning of 8/1/24 that Resident #4 had informed Staff G that they were attacked by another resident the night before. Interview on 8/8/24 at approximately 7:25 a.m. with Staff C (Registered Nurse) revealed that on the evening of 7/31/24 Staff C had heard a commotion coming from Resident #4's room. Staff C had responded to the commotion and had seen Resident #3 exiting Resident #4's room. Resident #4 was on the floor inside the doorway of their room when staff arrived. Resident #4 had stated that Resident #3 had hit them and caused them to fall. Review on 8/7/24 of Resident #3's care plan revealed a care plan for potential to demonstrate verbal behaviors related to: Cognitive loss/ Dementia; and shaves head at times initiated on 8/23/23. Resident #3's behavior care plan identified the following interventions: If resident requests/attempts to shave head attempt to discourage from activity using calm, gentle approach and if unable to redirect, assure safety during activity, created on 8/23/23, Evaluate need/provide Psych/Behavioral Health consultation, created on 8/23/23, Explain all care, including procedures (one step at a time), and the reason for performing the care before initiating, created on 8/23/23, Provide consistent, trusted caregiver and structured daily routine, when possible, created 8/23/23, Remove resident/patient from environment, if needed. Gently guide the resident from the environment while speaking in a calm, reassuring voice, created on 8/23/23, Provide environment that is conducive to the patients ability to get adequate sleep and maintain preferred sleep/wake schedule, created 8/23/23, Allow time for expression of feelings, provide empathy, encourage, and reassurance, created 8/23/23. Further review of Resident #3's care plan revealed no other behavior care plans. Interview on 8/8/24 at approximately 1:10 p.m. with Staff F (Director of Nursing) revealed that Resident #1 and Resident #3 both had a room change in response to allegations and medication review requested in response to the above incidents.

Based on observation, interview and record review it was determined that the facility failed to ensure that residents who are trauma survivors were free from re-traumatization for 1 of 1 residents reviewed for trauma (Resident Identifier #4). Findings include: Review on 8/7/24 of a facility reported incident revealed Resident #4 yelled out for help. Staff observed Resident #3 exiting Resident #4's room. Resident #4 was found lying on the floor with a hematoma to the top right side of his/her head, a skin tear to the right elbow and complaints of rib pain. Interview on 8/7/24 at approximately 12:40 p.m. with Staff G (Social Services) revealed that Resident #4 had told Staff G that he/she had a past history of trauma. Staff G further revealed that Resident #4's daughter had revealed to Staff G that Resident #4 had a past history of trauma. Interview on 8/7/24 at approximately 1:15 p.m. with Resident #4 revealed that he/she remembered Resident #3 coming to his/her room and hitting him/her. Resident #4 stated that he/she had a traumatic past and was upset with Resident #3 trying to get into the room. Resident #4 further revealed that the lanyard that was worn around his/her neck with a whistle at the end is in case Resident #3 comes close to him/her. Review on 8/7/24 of Resident #4's medical record revealed a nurses note written by Staff C (Registered Nurse) that documented that Resident #3 entered Resident #4's room without consent and that Resident #4 told Resident #3 to get the hell out. Further review of the nurses note revealed that Resident #3 then hit Resident #4 and knocked him/her to the ground. Further review of Resident #4 medical record revealed no evidence of care plan interventions for history of trauma.

Based on interview and record review it was determined that the facility failed to ensure an accurately documented medical record for 1 of 4 allegations of abuse (Resident Identifier is #1). Interview on 8/16/24 at approximately 8:30 a.m. with Staff K (Licensed Nursing Assistant) revealed that Staff K had witnessed an interaction between Resident #1 and Resident # 5 on 8/13/24 around dinner time. Interview further revealed that Resident #1 was seen touching Resident #5 on [pronoun omitted] inner thigh almost to [pronoun omitted] [genital area]. Staff K stated that he/she immediately separated the residents and reported the incident to Staff M (Licensed Practical Nurse). Interview on 8/16/24 at approximately 9:00 a.m. with Staff M revealed that he/she was the nurse on duty when the above incident occurred. Staff M also revealed that he/she wrote a nurse's note, on 8/13/24, giving an accurate account of the above incident. Staff M further revealed that their nurse's note detailing the incident had been struck out, not by Staff M. Staff M was told by Staff F (Director of Nursing) that it was put in the wrong part of the medical record and it needed to be moved to another section. Review on 8/16/24 of Resident # 1's medical record confirmed that a nurse's note written by Staff M on 8/13/24 at 11:02 p.m. had been struck out. Further review of the medical recorded revealed no evidence of the incident that occurred on 8/13/24. Interview on 8/16/24 at approximately 10:20 a.m. with Staff F confirmed the above finding and revealed the incident had been struck out of the medical record and a note about the incident had been added to the Risk Management System, which is not part of the medical record.

Based on observation, record review, policy review, and interviews, it was determined that the facility failed to provide appropriate care and services to aide in the prevention of an avoidable pressure ulcer for 1 of 1 residents reviewed for pressure ulcers in a final survey sample of 19 residents (Resident Identifier is #48). Findings include: Review on 5/15/24 of the facility policy Pressure Injury Prevention and Management, dated 07/2021 and Reviewed and Revised 10/2022 and 10/2023 revealed: .4. Interventions for Prevention and to Promote Healing .a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries .c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present .i. Redistribute pressure (such as repositioning, protecting and/ or offloading heels, etc.) Review on 5/13/24 of the Nursing assessment dated [DATE] revealed: Section K. Skin Integrity: 4.) Skin observation a. skin intact. Further review of the Nursing Assessment revealed that in Section L. Braden Scale (For Predicting Pressure Sore Risk), the score was a 17, indicating that Resident #48 was considered at risk for developing a pressure ulcer. Review on 5/15/24 of Resident #48's care plan dated 5/5/24 revealed: care plan focus: Resident at risk for skin breakdown related to weakness with decline in functional mobility and bowel incontinence, and care plan goal: The resident will not show signs of skin breakdown by next review. Further review revealed interventions to observe skin for sign and symptoms of skin breakdown, weekly skin check, observe skin condition daily with Activities of Daily Living (ADL) care, and obtain a Physical Therapy and Occupational Therapy evaluation to improve functional mobility. Review also revealed no interventions for offloading and repositioning. Review on 5/15/24 of the Physician note dated 5/6/24 revealed: Skin: New left heel concern. Left heel DTI [Deep Tissue Injury] noted that is intact and non-tender Float heels. Further review of physician note dated 5/14/24 revealed: Acute concerns: Follow up left heel DTI, noted right heel DTI. Review on 5/15/44 of Resident #48's Point of Care Task Record revealed the task for offloading started on 5/6/24. Interview on 5/15/24 at approximatley 12:25 p.m. with Staff C (Licensed Nursing Assistant) revealed that he/she believed that Resident #48's heels had been floated for the last 5 days. Interview on 5/15/24 at approximately 12:20 p.m. with Staff B (Licensed Practical Nurse) assigned to care for Resident #48 confirmed that he/she did not know the date that Resident #48 was supposed to have heels floated. Staff B stated Maybe as of yesterday 5/14/24. Interview on 5/15/24 with Staff D (Director of Nursing) confirmed above findings. Staff D stated Resident #48's DTI on left and right heels were facility acquired.

Based on observation and interview, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards as is possible regarding storage of chemical cleaning solutions on 2 of 3 units observed (Birch Unit & Spruce Unit). Findings include: Observations on 5/13/24 at 1:15 p.m; 5/14/24 at 8:30 a.m and 9:30 a.m; and 5/15/24 at 7:40 a.m. of the Birch Unit Tub Room revealed that the door was open with a bottle of Rapid Multi Disinfectant Spray chemical cleaning solution hanging on the wall within reach of wandering residents. Interview on 5/15/24 at 7:40 a.m. with Staff F (Licensed Practical Nurse) confirmed the above finding. Observation on 5/15/24 at 7:30 a.m. of the Spruce Unit Tub Room revealed that the door was open with a container of Super Sani-Cloth Germicidal wipes on top of a portable cart within reach of wandering residents. Interview on 5/15/24 at 7:30 a.m. with Staff I (Licensed Nursing Assistant) confirmed the above finding. Interview on 5/15/24 with Staff D (Director of Nursing) further confirmed the findings and revealed there were 13 wandering residents in the facility. Review on 5/15/24 of the facility's policy titled, Hand Washing, Chemical Use, and PPE [Personal Protective Equipment], revealed: .Any area used for storing chemicals should be locked at all times, including carts and closets . Review on 5/15/24 of the facility's policy titled, Accidents and Supervision, last revised 10/2023, revealed: .The resident environment will remain free of accident hazards as is possible . Review on 5/15/24 of Rapid Multi Surface Disinfectant Cleaner Safety Data Sheet, revealed: .Section 11. Toxicological Information - Potential Health Effects: Eyes: Causes eye irritation .Eye Contact: Redness, Irritation. Review on 5/15/24 of Super Sani-Cloth Germicidal Wipes Data Sheet, last revised 2/18/2019, revealed: .11. Toxicological Information - Inhalation of high concentrations of vapors may cause upper respiratory tract irritation, headache and dizziness. May be harmful if inhaled .Eye Contact - This product is expected to cause moderate irritation to eyes based on test data .May cause redness, itching, and pain.

Based on record review and interview the facility failed to provide care and services to promote healing and prevent additional ulcers for 1 of 3 residents with pressure sores out of a standard survey sample of 15 residents. (Resident Identifiers are #1 and #14.) Findings include: Resident #1. During review of Resident #1's record on 4/24/12 and 4/25/12 it was found that on 6/15/11 Resident #1 sustained a fall and was transferred to the hospital. On review of the hospital Discharge Summary dated 6/18/12 record it was found that Resident #1 sustained a Left [MEDICAL CONDITION] for which he/she had surgery for [REDACTED]. On review of the Fall Risk Assessment titled, Admission Nursing Assessment-Expanded (MDS/Adm./Qtrly/Annual/Sig. Change) v1 with an effective date of 6/15/11, indicates that under Section 7 Integumentary d Skin impairment(s) including Foot Problems, Surgical Wounds [MEDICAL CONDITION] Not Applicable is checked. Review on 4/25/11 of Resident #1 nurse's note written by Staff G, (LPN) revealed that a nurse's note was written on 6/21/11 that Resident #1 is to be repositioned every 2 hours and has an abductor pillow in place. Monitor for pain. Review on 4/25/11 of Resident #1 nurse's note written by Staff H, (LPN) revealed that a nurse's note was written on 6/22/11 that Resident #1 "abductor wedge remains in place. No apparent irritation from device ... coccyx has some pink ares,.." Review of the Physician order [REDACTED]." Review of the Physician order [REDACTED]." On 6/27/11 a Resident/Patient Incident report was completed showing a DTI (Deep Tissue Injury) on Left heel. Description of injury is a "lite purple bruise like area- 4 cm (centimeters) x 3 cm." Under the section titled: Additional Contributing Factors: immobility secondary to fracture hip. Under the section Possible Causes for incident (consider all contributing factors carefully): pressure on mattress. On review of the significant change MDS coded 6/27/11 under Section G G0110 ADL Assistance under section A "Bed mobility- how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture" Resident #1 codes 3-3 Extensive assistance two persons physical assist. Review of the Physician order [REDACTED]." Resident #14. On 12/9/11 Resident #14 was admitted to the facility after receiving therapy at an outside facility for a fractured right hip. The "ADMISSION HISTORY & PHYSICAL EXAMINATION" under History of present illness states "Weakness (status [REDACTED]. Under Plan/Goals it states "PT/OT, plenty of encouragement or will remain bed bound...". Review of the CAA (Care Area Assessment ) dated 12/16/11 for Pressure Ulcer under nature of the problem/condition it states "(Resident #14) has no skin breakdown related to pressure at this time. (Resident #14) is incontinent of bowel and bladder. (Resident #14) requires extensive assist with bed mobility. (Resident #14) last Braden score on 12/15 was a 14 representing moderate risk. (Resident #14) has cognitive impairment related to a [DIAGNOSES REDACTED]. The care plan with a created on dated of 12/19/11 under Focus states "Resident requires extensive assistance for ADL care in bathing, grooming , dressing, bed mobility, transfer, locomotion, toileting due to L (left) hip Fx (fracture)" On further review of the record it states in the nurses notes dated 12/25/11 with a time of 11:50 a.m. "(Resident) has a new intact blister to (Resident #14) right heel, and (new order) apply sure prep to intact blister on right heel and cover with (non-adhesive) wrap with Kling and change BID, until healed". At 11:54 a.m. nurses notes dated 12/25/11 state "(Resident) has (new order) offload heels off bed on pillows @ all times while in bed". At 14:13 nurses notes dated 12/25/11 state "...(Resident was found to have a fluid filled blister on (Resident #14's right) heel Measures 4cm x 3.4 cm..." At 14:24 nurses notes dated 12/27/11 state "Area on (Right) heel is no longer clear and has deep purple color, is now classified as a DTI (Deep Tissue Injury). New order for (protective) boots at all times...". On 12/25/11 A new Care Plan was written with the Focus "Resident has actual skin breakdown related to shear/friction risks, limited mobility. Development of DTI to (Right) Heel". Under Interventions it states "Assist resident in turning and reposition every 2 hrs created : 12/25/11...Float heels while in bed created on 12/25/11...Protective boots to bilat (sic) feet @ all times may remove for bathing..." From the date of admission on 12/9/11 until 12/25/11 when Resident #14 developed a Stage II pressure sore on the right heel the facility failed to provide any offloading or repositioning of the heels for Resident #14 from review of the nurses notes LNA flow sheets and review of the TAR's who was admitted being extensive assistance for ADL care in bed mobility and transfer due to L (left) hip Fx (fracture).