Every finding on record at Matulaitis Rehabilitation & Skilled Care

Based on review of facility documentation, review of facility policy/procedure, and interviews, the facility failed ensure that documentation was available to indicate that when antibiotics were prescribed, an assessment was completed on a consistent basis to indicate whether or not an adjustment was necessary in the prescribed medication. The findings include. The findings include:Review of the antibiotic stewardship program for the period of December 2024 through June 2026 with the Infection Preventionist (IP) RN #1 on 7/1/26 at 12:35 PM failed to identify consistent and timely documentation of reviews completed when antibiotics were prescribed to determine whether the antibiotic is still indicated or if adjustment needed to be made. RN #1 identified when an antibiotic is prescribed the unit manager/supervisor should complete the antibiotic timeout document located in the observation section of the electronic medical record 3 to 4 days after the antibiotic had started. Review of the facility Antibiotic Use Tracking Sheet for the period of December 19, 2024, through May 3, 2026, identified a total of 288 antibiotics were prescribed to residents during the period of December 19, 2024, through May 31, 2026. The review further identified out of the 288 times when an antibiotic was prescribed to residents, only 98 of the 288 times an antibiotic timeout was completed or a review of the antibiotic prescribed completed by the APRN/MD. In addition, the review identified a total of 34 of the 288 times prescribed, antibiotic timeouts or MD/APRN review of the antibiotic prescribed was completed a day after the antibiotic was started and not 48 to 72 hours after starting empiric antibiotics. In addition, the review identified that 156 of the 288 times antibiotics was prescribed an antibiotic timeout or review by APRN/MD of the antibiotic was not completed as the column on the antibiotic use tracking sheet which indicates antibiotic timeout were blank. Interview with RN #1 on 7/1/26 at 2:26 PM identified an antibiotic timeout is completed 3 to 4 days after the antibiotic is started by the unit manager. RN #1 further identifies that the unit manager knows that they are to complete the antibiotic timeout document in the observation section once a resident is started on antibiotic therapy. She further identified that she was responsible for ensuring it was completed and would check at times when she had the time. Interview on 7/2/26 at 8:45 AM with RN #1 identified in-service was provided to the medical staff on July 8, 2025, about the antibiotic timeouts as a part of the annual antibiotic stewardship review. She further identified the antibiotic timeout should be completed as it reviews the resident's response to the antibiotic treatment and the appropriateness of the antibiotics prescribed. RN #1 identified it was a part of the facility procedure to complete an antibiotic timeout after a resident was started on an antibiotic. RN #1 identified the use of the antibiotic timeout was not new and the facility had been using it in 2024 based on her records Subsequent to surveyor's inquiry, RN #1 identified she will be providing in-service to nurses on antibiotic timeout. Interview with the Unit Manager (RN #5) on 7/2/26 at 11:55 AM identified she does not complete an antibiotic timeout when a resident is started on an antibiotic and the only thing she completes is the SBAR (situational background assessment and recommendation) form. RN #5 further identified the infection prevention nurse would know more information about the antibiotic time. When asked if she had received education regarding the antibiotic timeout when she responded that she could not recall off the top, but they have received several in-services, and the staff development nurse would be able to identify when she received the education. Interview on 7/2/26 at 2:00 PM with RN #1 identified she was unable to locate any in-services provided to nurse about the antibiotic timeout documentation. Review of the Antibiotic Stewardship: Review and Surveillance of Antibiotic Use and Outcomes policy and procedures identified the infection preventionist (IP) or designee will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. The policy and procedures identified therapy may require further review and possible changes if: the organism is not susceptible to antibiotic chosen, the organism is susceptible to narrower spectrum antibiotic, therapy was ordered for prolonged surgical prophylaxis and therapy was started awaiting culture, but culture residents and clinical findings do not indicate need for antibiotics. Also, the policy and procedures identified at the conclusion of the review, the provider will be notified of the review findings if needed. Review of the Antibiotic Stewardship Program policy identified the duration, or antibiotic therapy will be defined and/or regularly reviewed based on evidence-based guidelines and clinical improvement.

Based on observations, review of the clinical record, review of facility policy/procedures and interviews for 1 of 3 sampled residents (Resident #69) reviewed for medication self-administration, the facility failed to ensure Resident #69 was assessed and clinically appropriate for self-administration of medication after a significant change and failed to ensure self-administrated medications were stored properly. The findings include:Resident #69 was admitted to the facility with diagnoses that included Parkinson's disease, dementia with psychotic disturbances, recurrent major depressive disorder with psychotic symptoms and anxiety disorder. The self-administration of medication assessment dated [DATE] at 3:56 PM identified Resident #69 was able to self-administer some medications. The assessment identified that Resident #69 was able to read the prescription label and identify each medication, was not at risk and had no history of choking, aspiration or other swallowing difficulty. The assessment noted that Resident #69 could self-administer an inhaler, nasal spray and eye drops. It further noted the identified medications could be stored in the resident's room (this assessment was the most recent assessment completed). The physician's orders dated 6/3/26 directed administration of the following medications:Breo Ellipta with device 100-25 mcg/dose1 puff inhalation once a day with special instructions to rinse mouth with water after use and to not swallow.Flonase Allergy relief 50 mcg suspension spray with special instructions for 1 spray in each nostril daily at resident's request.Artificial tears 1.4% administer 1 drop to eyes twice a day as needed.Monitor for behaviors of paranoid delusions and anxiety/panic every shift.Administer whole medications in yogurtClonazepam 0.5mg tablet by mouth to be administered in the AM for anxiety (6am and 9:30am)Clonazepam 0.5 mg tablet 2 tabs (1mg) by mouth to be administered at bedtimeEliquis 2.5 mg tablet give 2.5mg by mouth twice a day (9:30am and 7pm)Loratadine 10 mg tablet give 1 tablet by mouth nightly for congestion.Quetiapine 200mg tablet give 200mg by mouth every evening for psychosisSenna plus 8.6-50 mg 2 tabs at bedtimeSinemet(carbidopa-levodopa) 25-100 mg tablet give 2 tabs twice a day (9:30am and 7pm)Trazodone 100mg tablet by mouth at bedtime for insomnia A review of the physician's orders failed to reflect an order for self-administration of medications. The Speech Therapy assessment dated [DATE] identified Resident #69 was assessed due to mild dysphasia (difficulty swallowing) and new dentures, it indicated Resident #69's diet was upgraded from puree to mechanical soft/chopped textures, soft, bite sized and thin liquids. The note indicated that the puree texture was Resident #69's preference when eating without teeth. The significant change MDS dated [DATE] identified Resident #69 had intact cognition, required setup or cleanup assistance with eating and substantial/maximal assistance with oral hygiene. It further noted the resident was edentulous and had a mechanically altered diet. Review of the care plan dated 6/17/26 identified Resident #69 had impaired communication related to dementia with decreased concentration and insight and was at risk for injury from tremors and/or involuntary muscle movements and impaired swallowing related to Parkinson's disease. The care plan did not address self-administration of medications. The psychiatric progress note dated 6/17/26 identified Resident #69 had recently returned to the facility after a month long stay at a psychiatric facility for suicidal ideation, psychosis and grief. The note indicated changes to psychiatric medications and noted the resident presented with a flat affect, musculoskeletal stiffness and generalized weakness. Observation on 6/29/26 at 10:53 AM identified that the overbed table in Resident #69's room contained a Trelegy Ellipta inhaler, fluticasone propionate nasal spray and artificial tears eye drops. Interview with Resident #69 identified that he/she keeps the medications in his/her room on the overbed table and self-administers the medications. Interview with RN #4 on 6/29/26 at 10:55 AM identified Resident #69 was allowed to keep the inhaler, nasal spray and eye drops on the overbed table so the medication could remain in Resident #69's line of sight due to the anxiety. RN#4 indicated that self-administration of medication was assessed and added to the care plan if appropriate. RN#4 was unable to locate the care plan that addressed self-administration. Subsequent to surveyor inquiry, a care plan entry dated 6/29/26 identified that Resident #69 expressed desire to self-administer artificial tears, the Breo Ellipta inhaler and fluticasone nasal spray. The care plan further identified that the interdisciplinary team would assess the resident's cognitive, physical and visual ability to self-administer the medications and noted that the self-administration assessment should be completed initially and then quarterly and as needed. The self-administration of medication assessment dated [DATE] at 4:15 PM identified Resident #69 was able to self-administer some medications (inhaler, nasal spray and eye drops) but was unable to open medication containers and pour pills out or punch pills out. The question asking if the resident can name the dosage, frequency and reason for use for each medication was marked not applicable. The assessment indicated Resident #69 could swallow medication without altering the dispensed form and was not at risk or had a history of choking, aspiration or other swallowing difficulties. Additionally, the assessment identified that the medications would be stored in the medication cart. A review of the self-administration assessment compared with the care plan documentation identified that they contained contradicting information because the care plan noted the resident had impaired swallowing related to Parkinson's disease, but the assessment identified the resident was not at risk for choking, aspiration or swallowing difficulties. Interview with the DNS and RN#1 (IP) on 6/30/26 at 12:47 PM identified that self-administration of medication is assessed to determine if the resident is physically able to take the medication. The DNS indicated that if a resident is able to self-administer medication there should be a physician's order and a care plan identifying which medications are applicable and can be kept at the bedside. RN#1 identified that Resident #69's last assessment for self-administration was prior to the resident's hospital admission and once the resident was readmitted from the hospital a new self-administration assessment should have been completed, as well physician's orders completed to reflect the medications that could be self-administered and the care plan should also reflect the resident's status. RN #1 further identified that storage of the medications should be addressed. Observation on 7/2/26 at 8:00 AM identified Resident #69 asleep in bed with nasal cannula (oxygen administration) in place, an eye mask over his/her eyes and a medication cup with residual pudding/yogurt like substance with an orange residual of a pill and a spoon in the medication cup. Resident #69 had several dried pill pieces on his/her t-shirt. There were three pieces of round light-yellow colored pills, one round dark yellow in color pill and 1 round white in color pill dried to the resident's t-shirt. Interview with Resident #69 on 7/2/26 at 8:05 AM identified that the nurses leave the medication on the table for him/her to self-administer and indicated that the cup left on the overbed table was self-administered. Resident #69 denied knowing that there were pill pieces on his/her t-shirt and could not identify how they would have gotten there. Interview with LPN#3 on 7/2/26 at 8:14 AM identified she had not administered medications to the resident that morning. LPN#3 removed the pills from Resident #69's chest/t-shirt and indicated that medication administration of the pills should be observed to make sure the medications are taken. LPN#3 identified that she mixes the medication into a small cup of yogurt and does not leave the room until Resident #69 consumes water after taking the pills, because one of the cups of water contains Miralax (laxative) and that should be observed as well. LPN#3 further indicated that although Resident #69 needs assistance at times, he/she is able to use the spoon to take the medications in the yogurt independently. LPN#3 identified that the only medications Resident #69 could take alone would be the inhaler, the nasal spray and the eye drops. Interview with RN#1 (IP) on 7/2/26 at 8:18 AM identified that the self-administration assessment should be completed on admission and quarterly. RN#1 indicated that Resident #69 returned from a long stay at the hospital for having bad thoughts and had medication changes. RN#1 identified that Resident #69 should have been reassessed for self-administration upon re-admission due to the changes and indicated that the pill administration was never identified as being able to self-administer. Interview with the DNS on 7/2/26 at 9:03 AM identified the expectation for medication administration is to observe until the resident completes the taking of the medications. The DNS indicated that Resident #69 was only approved to self-administer the inhaler, nasal spray and eye drops and should not be left with the pills. Review of the Medication Administration Record (MAR) dated 7/1/26 identified Resident #69 was administered the following medications at bedtime:Clonazepam (Klonopin) 0.5 mg tablet administered 1 mg at 7:04 PMEliquis 2.5 mg tablet administered at 7:04 PMLoratadine 10 mg tablet administered at 7:04 PMMelatonin 3 mg tablet administered at 7:04 PMQuetiapine (Seroquel) 200mg tablet administered at 7:04 PMSenna Plus 8.6-50 mg tablet administered at 7:04 PMSinemet (carbidopa-levodopa) 25-100 mg tablet administered 2 tablets at 7:04 PMTamsulosin 0.4 mg capsule administered at 7:04 PMTrazodone 100 mg tablet administered at 7:04 PM Interview with LPN#3 on 7/2/26 at 9:57 AM identified possibilities of medications not completely received, based on color and shape, and compared to what was contained in the bubble packs that were administered as the following medications that would have been administered at the bedtime administration on 7/1/26:Sinemet 25-200 mg are darker yellow in color round tabletTrazodone 100 mg was a round white tabletKlonopin (clonazepam) 0.5 mg were light yellow in color round tabletEliquis 2.5 mg were yellow in color round tabletSeroquel 200 mg was a white round tabletSenna plus was orange in color and round tablets LPN #3 indicated that the only medication administered on 7/2/26 at 6:00 AM was the Klonopin 0.5 mg which was a round tablet that was light yellow in color. The medication cup that was left contained an orange-colored pill residue. Interview with the Medical Director on 7/2/26 at 11:15 AM identified that residents should be assessed in order to self-administer medications. The Medical Director indicated that medications should be observed when they are administered so there is no diversion and to make sure the resident receives the prescribed dose. In review of Resident #69's medications, the Medical Director indicated that medication administration should be observed and not left at the bedside. The Medical Director additionally indicated that some residents could spit the medications back up after consumption and would be assessed for aspiration if indicated. Interview with the DNS on 7/2/26 at 2:12 PM identified that a medication self-administration assessment determines if a resident is physically able to take the medication and should be able to tell you what the medication is taken for and the need to be alert and oriented and demonstrate they are able to administer the medication properly. The DNS indicated residents should be re-assessed quarterly to make sure they remain appropriate for self-administration. The DNS additionally indicated that when a resident is readmitted to the facility or had a change in condition they would be reassessed and that Resident #69 should have been reassessed for the medication self-administration. Interview with RN#9 (who administered bedtime medication to Resident #69 on 7/1/26) on 7/2/26 at 3:10 PM identified that Resident #69 separates each pill individually and takes them one at a time and sometimes the administration can take over an hour. RN#9 indicated that she stayed at the bedside for the entire administration and identified that she visualized the entire administration and did not leave a medicine cup at the bedside. The facility policy for Administering Medication identified medication is administered in a safe and timely manner and as prescribed. The policy indicated that residents may self-administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. The facility policy for Medication Storage identified All drugs and biologicals will be stored in locked compartments under proper temperature controls. The policy indicated that during a medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart.

Based on clinical record review, facility documentation review, facility policy review and staff interviews for one sampled resident (Resident #86) reviewed for abuse, the facility failed to report an allegation of physical abuse between two residents to the state survey agency. The findings include:Resident #86 had diagnoses that included dementia with agitation, anxiety, and hydrocephalus.The quarterly MDS assessment dated on 4/8/26 identified Resident #86 had severe cognitive impairment, disorganized thinking, inattention, and wandering behaviors. The assessment further noted the resident was independent with transfers and ambulation and utilized a rolling walker for mobility. The Resident Care Plan (RCP) dated 4/22/26 identified Resident #86 had impaired communication related to dementia. The care plan interventions directed staff to approach the resident calmly and in a friendly manner, provide simple cues as needed, repeat information politely, and anticipate and provide for the resident's needs.The nurse's notes dated 6/9/26 at 8:22 PM identified Resident #86 reported that Resident #11 hit her/him. Staff ensured both residents were separated. A thorough investigation was conducted, including interviews with the resident and staff on all nursing units. Resident #86's responsible party was notified and stated that this had happened before and that it was possibly in the resident's head.The social worker progress note dated 6/10/26 at 8:45 AM identified the social worker met with Resident #86 who reported he/she had a great night, felt safe in the facility, and had no issues or concerns with peers. The resident's mood and behavior were noted to be stable.The psychiatrist progress note dated 6/10/26 identified Resident #86 was being followed regarding the alleged incident. The assessment noted Resident #86 claimed a friend had hit her/him, but the event was unwitnessed. Nursing staff assessed the resident for injury, and no injury was noted. Resident #86 had no recollection of the incident.The revised RCP dated 6/10/26 identified Resident #86 had accusatory behavior toward a peer related to cognitive impairment. The care plan interventions directed staff to encourage verbalization by allowing time for a response, involving behavioral health services as needed, providing consistent staff when possible, offering diversional activities, and encouraging participation in social and recreational activities.Resident #11 had diagnoses that included dementia, anxiety, and age-related cognitive decline.The quarterly MDS assessment dated [DATE] identified Resident #11 had severe cognitive impairment, had other behavior symptoms not directed toward others, and wandering behavior. The assessment documented that the resident was independent with transfers and ambulation using a rolling walker.The care plan dated 4/22/26 identified Resident #11 was at risk for adjustment difficulties related to having a new roommate. The care plan interventions directed staff to provide verbal reassurance during the transition, encourage the resident to express any concerns, offer emotional support as needed, and ensure the social worker was available as needed.The psychiatrist progress notes dated 6/10/26 identified Resident #11 was evaluated regarding the alleged altercation. Resident #11 and Resident #86 had been roommates at the time and were subsequently separated. The assessment noted Resident #11 could become agitated and frustrated with the roommate due to cognitive issues. Resident #11 was typically happy and pleasant and continued to wander throughout the facility looking for a friend. Resident #11 had no recollection of the incident.Review of the state survey agency's online reporting portal on 6/30/26 at 2:10 PM identified the facility had not submitted a reportable event involving the allegation of physical abuse between Resident #86 and Resident #11. The facility failed to report the incident within two hours of the allegation.Interview with the DNS on 7/1/26 at 10:40 AM identified Resident #86 reported that Resident #11 had hit him/her on 6/9/26. She identified that the two residents were roommates at the time. She reported the facility investigated the physical abuse allegation, but it was not substantiated. She identified that either she or the Administrator are responsible for reporting reportable events to the state agency. She further identified that she was unaware that an allegation of physical abuse must be reported even when unsubstantiated and believed reporting to the state agency was required only when an investigation was substantiated.After surveyor inquiry, the facility submitted a reportable event report regarding the allegation of physical abuse that occurred on 6/9/26 between Resident #86 and Resident #11 on 7/1/26 at 2:08 PM (21 days after the time it should have been submitted).The facility's policy on Reporting of Resident Abuse, Neglect, Mistreatment, Exploitation, Misappropriation of Property, Fear of Retaliation, and Serious Injury of Unknown Origin stated that all residents have the right to be free from abuse, neglect, misappropriation of property, exploitation, fear of retaliation, and serious injury of unknown origin. All employees, contractors, and volunteers are required to report any observed or suspected abuse.

Based on observation, review of the clinical record, review of facility policy/procedures and interviews for one of five sampled residents (Resident #69) observed during medication administration, the facility failed to ensure medications were administered according to professional standards. The findings include: Resident #69's diagnoses included dementia, major depressive disorder, and generalized anxiety disorder. The significant change MDS assessment dated [DATE] identified Resident #69 was cognitively intact and had no behaviors, required supervision or touching assistance with bed mobility, required partial to moderate assistance with ambulation and utilized a walker and wheelchair for mobility. The physician's orders in place for the month of June/2026 directed the following:allopurinol tablet 100mg, administer 1 tablet once a day at 9:30AMamlodipine tablet 5mg, administer 1 tablet once daily at 9:30AMEliquis tablet 2.5mg, administer 1 tablet twice daily at 9:30AM and 7:00PMfurosemide tablet 20mg, administer 1 tablet once daily at 9:30AMLexapro tablet 10mg, administer 1 tablet once daily at 9:30AM lisinopril tablet 10mg, administer 1 tablet once daily at 9:30AM Miralax powder 17grams/dose, administer 17grams once daily at 9:30AMquetiapine tablet 100mg, administer 1 tablet once daily at 9:30AMcarbidopa-levodopa 25-100mg tablet, administer 2 tablets twice daily at 9:30AM and 7:00PMclonazepam tablet 0.5mg, administer 1 tablet once in the AM at 9:30AMguaifenesin tablet 400mg, administer one table twice daily at 9:30AM and 7:00PM Observation of medication administration on 6/30/26 at 10:10AM identified LPN#1 preparing Resident #69's medication, the pills were placed in a plastic medication cup, the Miralax powder was placed in a plastic drinking cup, and one medication cup of pudding and entered Resident #69's room and asked the resident if he/she was ready to take his/her medication and Resident #69 replied no. LPN#1 placed the medication on the dresser which was within reach of the resident. LPN#1 walked out of the room at 10:13AM and stood at the medication cart outside of the door. LPN#1 glanced back at the resident while starting to prepare the next resident's medications. At 10:25AM LPN#1 moved the medication cart away from Resident #69's door and placed it in front of the next resident's room. Resident #69 was no longer within LPN#1's line of sight. At 10:31AM LPN#1 moved the cart back to Resident #69's room and reapproached the resident to take the medication. Resident #69 started to spoon the medication into the pudding and take the medication. LPN#1 moved back to the medication cart at the doorway, documented on the computer and glanced back to the resident on occasion. At 10:33AM Resident #69 dropped a pill in his/her lap and then scooped it back up with the spoon. LPN#1 turned around as the resident was scooping the pill and asked if they dropped something. Administration was completed at 10:35AM. Interview on 6/30/26 at 10:35AM with LPN#1 identified that Resident #69 only had a self-administration of medication order for nasal spray, inhaler, and eye drops. Resident #69 did not have a self-administration order for any other medications. LPN#1 identified that left the medications with the resident because she thought the resident would be more upset if she took them away once bringing them in. LPN#1 noted she did have concerns with leaving the medication in the resident's room and out of her line of sight and not fully observing the resident take the medications. Additionally, when asked about the standard or practice for medication administration, LPN #1 noted that she should not leave medication with the resident and she should witness the resident taking the medication. Interview on 6/30/26 at 10:40AM with the Nursing Supervisor (RN #4) identified that Resident #69 could not self-administer the medications outside of the nasal spray, inhaler and eye drops, however, was capable of taking the pills with the nurse watching. RN #4 identified that Resident #69 takes a lot of pills and the resident may drop one. Although RN #4 did not know the policy she would not recommend the nurse leave medication next to the resident and leave the room. Interview on 6/30/26 at 1:00PM with the DNS identified that medication should not be left at the bedside, the medication. Review of the administering medications policy directed medications are administered in a safe and timely manner and as prescribed. Residents may self-administer their own medications only if the attending physician in conjunction with the interdisciplinary care planning team has determined that they have the decision-making capacity to do so safely.

Based on review of clinical records, review of facility documentation, review of facility policy/procedures and interviews for two of seven sampled residents (Residents #6 and #88) reviewed for accidents, the facility failed to ensure a gait belt was utilized when assisting the resident to ambulate, resulting in a fall with injury and failed to provide adequate supervision in the bathroom resulting in a fall. The findings include: Resident #6's diagnoses included dementia without behavioral disturbance, mood disturbance, anxiety, and difficulty walking. The fall risk assessment tool dated 1/7/26 identified a score of 10 indicating Resident#6 was at moderate risk for falls. Review of the care plan dated 3/14/26 identified Resident #6 was at risk for decline in functional mobility, functional limitation in self-care and falls related to dementia with interventions that directed staff support provided for safety, assist of 1 for transfers and hand-held ambulation and substantial/maximal assistance with toileting hygiene, verbal cues and staff support provided for safety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident had severely impaired cognition (BIMS 5), required substantial/maximal assistance with toileting hygiene, lower body dressing, putting on and taking off footwear and personal hygiene, supervision or touching assistance to walk 10 feet, 50 feet or 150 feet. The physician's orders dated 6/9/26 directed Resident #6 receive an assist of 1 for transfers and hand-held assistance. The nursing note dated 6/16/26 at 6:46 AM identified Resident #6 had an unwitnessed fall in the bathroom; the bathroom call light was activated at 5:05 am. There was a question of head trauma, neurological assessment and fall prevention program was initiated. The Accident and Incident (A&I) report dated 6/16/26 identified NA #1 assisted Resident #6 to the bathroom, Resident #6 used the bathroom and then stood up from a seated position while NA #1 was getting clothes and fell. The A&I identified Resident #6 was an assist of 1 for transfers with hand-held ambulation and indicated the fall resulted in right wrist pain. Additionally, the report indicated that the likely cause of the fall was the height of the toilet. The toilet commode was high and could have been prevented by a lower commode chair and reminders to Resident #6 not to get up without assistance. The report further identified interventions added post fall included, obtain an appropriate commode chair in resident bathroom and staff to remain at resident's side until assisted to safe position with toileting and for NA to gather items for toileting prior to sitting resident on the toilet. Review of NA #1's written statement dated 6/16/26 identified she sat Resident #6 on the toilet and turned to grab items left on Resident #6's dresser in the resident's room that adjoined the bathroom and made it to the dresser when NA#1 heard resident say oh no, Oh no and then a bang and returning to the bathroom found Resident #6 on the floor of the shower area and alerted the nurse. The Physical Therapy progress note dated 6/16/26 identified a post fall assessment for Resident #6 indicated Resident #6 had a fall at 5:05 AM and noted the commode may be too high for the resident and identified the commode was removed and a request made to replace commode with a lower commode. The Occupational Therapy note dated 6/18/26 identified Resident #6 was started on service after a fall and to increase safety and ability with functional mobility and transfers, toileting, and to reduce wrist pain. Interview with NA #1 on 7/1/2026 at 1:04 PM identified she transferred Resident #6 to the toilet commode and left the resident to retrieve items from the resident room dresser. NA#1 indicated Resident #6 was left alone on the commode and that Resident #6's feet were not able to touch the floor when seated on the commode. NA#1 identified Resident #6 had recently been moved to the room and she did not know if the commode was left over from another resident. NA#1 identified Resident #6 required hand-held assistance for transfers and to walk but indicated that she has never had to help Resident #6 get on to the toilet and indicated Resident #6 was left alone in the bathroom most times. NA#1 identified she did not use the gait belt to transfer or ambulate Resident #6 and could not identify if she was supposed to use the gait belt. NA#1 could not identify if Resident #6's feet should be able to touch the floor. Interview with RN #2 on 7/1/2026 at 1:55 PM identified Resident #6 was an assist of 1 and indicated NA#1 should have stayed with Resident #6 at all times until the resident was in a safe position. RN#2 identified the commode was a little bit high and indicated therapy fits the height of the commode and could not identify if the commode moved to the new room when Resident #6 was moved or if the commode was old. Interview with the Director of Rehabilitation on 7/1/2026 at 2:10 PM identified that therapy usually recommends the use of the commode, but nursing staff may use the commode if it is already in place such as if the roommate uses one and there is a shared bathroom. The Director of Rehabilitation indicated that therapy usually provided education if they introduced the commode as part of the resident's care but identified education is not standard practice if therapy does not introduce the equipment. Additionally, the Director of Rehabilitation indicated it is not standard to do a commode assessment unless a resident is having difficulty and was referred to therapy and identified Resident #6 was not referred to therapy for a commode issue until after the fall. The Director of Rehabilitation indicated an assist of 1 for toileting would mean that the staff member has to stay in close vicinity to the resident. Review of the facility policy for Free of Accident Hazards/Supervision/Devices identified each resident receives adequate supervision and assistance devices to prevent accidents. Review of the facility policy for Fall Prevention identified all residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls and indicated each resident will be evaluated for safety risks. Review of the Certified Nurse Aide handbook (Titled Assisting in Long Term Care) pages 476 and 477, guideline for transfers, identified NA's should always use the correct transfer method as directed by the nurse of physical therapist and indicated that a transfer belt should be used for standing transfers unless contraindicated. Review of toileting procedure on Pg 344 identified the NA should assemble all supplies needed prior to assisting the resident with use of the bedside commode. And directed on page 345 that when assisting resident to use the bathroom, the resident should be assisted with sitting comfortably on the toilet with feet flat on the floor. Although requested, the facility failed to provide a policy for ADLs/toileting. Resident #88's diagnoses included vertigo, diabetes type II, and syncope. The quarterly MDS assessment dated [DATE] identified Resident #88 was cognitively intact, independent with bed mobility, transfers, dressing, personal hygiene and utilized a walker for ambulation. The care plan dated 12/22/25 identified Resident #88 was at risk for falls related to vertigo/syncopal episodes with interventions that included independent with ambulation using walker and sneakers during the day, assist of 1 at night, encourage fluids, assessment and treatment for postural/orthostatic hypotension. The APRN's progress note dated 3/25/26 at 3:10 AM identified Resident #88 had a witnessed fall with injury. The resident fell backwards and hit his/her head on the table in the room. RN#2 noted two small injuries to Resident #88's head that appeared to be scabs that were scraped off. Skin tears were also noted to the right upper extremity. Vital signs were noted to be stable with a reported blood pressure reading of 127/85 (normal BP parameters are less than 120mm Hg systolic (top number) and less than 80 mm Hg diastolic (bottom number)). Instructions were to complete neurological checks per protocol, assess for pain, fall precautions per facility protocol, and primary team to re-evaluate fall risk care plan, notify a clinician of any change in condition/neuro check. RN#2's nursing note dated 3/25/26 at 6:54AM identified the resident was observed sitting on the floor when RN#2 was called to the room. Resident #88 stated he/she felt dizzy and lost balance. There were no complaints of pain, hand grasp was strong, first aid was administered to the head x2 and right upper extremity (x3), skin wounds to right upper extremity measured 2x4cm, 2x4cm, and 2x2.5cm, head wounds cleansed with normal saline and left open to air, pupils were equal, round, reactive to light and accommodation. The APRN recommended to monitor for any signs and symptoms of infection, assess for pain per protocol, and to complete fall precautions per facility policy. Neuro-checks to be completed per protocol and to notify a physician with any changes in condition. RN #4's nursing note dated 3/25/26 at 9:06AM identified Resident #88 had a BP of 190/100, the resident reported increasing pressure in his head. Resident #88 was sent to the ER. RN #4's nursing note dated 3/25/26 at 2:00PM identified that the hospital reported Resident #88 was returning to the facility. CT Scan to head was negative. Two stiches were applied to the right forehead. Review of the facility Accident and Investigation report post fall huddle with the RN Supervisor#3, RN#2, and NA#2 identified the fall occurred due to dizziness. Summary of the investigation Staff re-education completed was on the use of gait belts with transfers. Interview with NA#2 on 7/1/26 at 9:19AM identified she was walking with the resident back from the bathroom when the resident saw a tissue on the floor. The resident reached down for the tissue after NA#2 told the resident she would get it for him. NA#2 said Resident #88 lost his/her balance and fell hitting his/her head on the bed rail. NA#2 said she was not utilizing a gait belt during the time of the fall because she had forgotten it at home, and when she went to the room they are sometimes on the back of the door but there was none. NA#2 stated it was the facility policy to utilize a gait belt, and Resident #88 was an assist of 1 during the night with the use of a gait belt. Resident #88 was standing and the bed alarm was going off at the time Resident #88 started to ambulate to the bathroom. On the return from the bathroom NA#2 was still not utilizing a gait belt and when the resident went to fall NA#2 hooked the resident's arm in her arm, however the resident still fell and hit their head and scraped their arm. NA#2 then yelled for help once Resident #88 fell. RN#2 was the nurse who responded to the room to complete the assessment, first aid, and notified the APRN. Interview with RN#2 on 7/1/26 at 1:54PM identified she was the RN to respond to Resident #88's room on 3/25/26. RN#2 completed her assessment, first aid, and then notification to the provider. RN#2 said that the APRN advised to not send out the resident and to monitor the resident in the facility due to the information provided. RN#2 identified the areas on the head did not look too deep and stopped bleeding after pressure, so she didn't have a concern with the resident needing stitches. RN#2 identified that she completed the vitals for Resident #88 and although the blood pressure was elevated BP and the resident was complaining of dizziness at the time of the fall, RN#2 administered the as needed hydralazine for the elevated blood pressure and meclizine for the dizziness. However, after administering the medication RN#2 did not notify any provider that the BP had remained elevated and passed the report along in the shift-to-shift report to the first shift nurse. RN#2 said the resident had no complaints therefore didn't have a concern. RN#2 further identified Resident #88 was a assist of 1 at nighttime, which meant a hands-on assist with a gait belt due to the fact he had diabetes, dizziness, and a history of falls, and blood pressure issues. Interview with the DNS on 7/1/26 at 10:10AM identified Resident #88 was an assist of 1 with a gait belt with ambulation at the time of the fall on 3/25/26. NA#2 was not utilizing a gait belt at the time of the fall and should have been. Re-education with staff was completed regarding gait belts. The DNS further identified if she was reviewing the blood pressures on the neuro checks as the nurse on at the time of the fall she would have been concerned about the elevated blood pressure and would have notified a provider. Review of the gait belt policy identified NA's are the utilize a gait belt according to the CNA book pages 476-477. Pages 476-477 directed to always use the correct transfer method as directed. Disregarding these instructions can result in injury to the resident or to you. If you have difficulty transferring with the resident by the indicated method consult the nurse. Review of the free of accident hazards/supervision/devices policy directed the facility must ensure that the resident environment is free of accident hazards as it is possible and each resident received adequate supervision and assistance devices to prevent accidents. Review of the fall prevention policy directed all residents received adequate supervision, assistance, and assistive devices to aid in the prevention of falls. Care plans will be created and implemented based on the individuals risk factors to aid in the prevention of falls.

Based on observation, clinical record review, review of facility policy, review of facility documentation, and interviews, for one sampled resident (Resident #116) who was on transmission-based precautions, the facility failed to utilize personal protective equipment (PPE) when entering a transmission-based precaution (TBP) resident's room. The findings include: Resident #116 diagnoses included extended spectrum beta lactamase (ESBL) resistance, urinary tract infection and hypertension. The admission MDS assessment dated [DATE] identified Resident #116 had intact cognition, required moderate assistance with dressing, toileting hygiene, transfers, and supervision or touching assistance with personal hygiene. The assessment further identified Resident #116 had an active diagnosis of a multidrug-resistant organism. The care plan dated 6/23/26 identified Resident #116 had contact precautions in use related to ESBL in the urine as evidence by the use of personal protective equipment (PPE) to prevent the spread of infection. The interventions directed providers and staff must put on gloves and gown before entering resident room, if there is a risk of exposure of infectious material to eyes, mouth, or nose, to apply goggles, mask, and/or face shield. The physician order dated 6/29/26 directed to maintain contact precautions every shift related to ESBL in urine. Observation on 6/29/26 at 11:21 AM identified posted signage on the wall outside of Resident #116's room which included instruction on how to don PPE and a contact precaution sign that identified everyone must clean their hands before entering and when leaving the room, and providers and staff must also put on gloves and gown before room entry and discard gloves and gown before room exit. The sign also indicates use of dedicated or disposable equipment, clean and disinfect reusable equipment before using it on another person. Also, outside of the room directly underneath the sign was a cart containing PPE supplies such as gowns and gloves. Further observation identified NA #3 was on the right side of Resident #116's leaning forward over the bed adjusting the linens on the resident's bed without the use of gloves and gown while Resident #116 was seated in his/her wheelchair located on the left side of the bed. After NA #3 completed the task, she discarded items in the receptacles in the room, performed hand hygiene and exited the room, then the surveyor intervened prior to her going to the next resident. Interview on 6/29/26 at 11:23 AM identified she was making the resident's bed and was not wearing a gown and gloves. She identified the resident was on precaution based on the sign posted on the outside of the resident's room. NA #3 then differed all other questions when asked to the nurse and to the supervisor. Interview on 6/29/26 at 11:28 AM with the nursing supervisor/unit manager (RN #5) in the presence of NA #3 identified when RN #5 indicated to NA #3 that she could answer the questions asked. RN #5 identified Resident #116 was on contact precautions for ESBL in the urine and a sign is posted outside of the resident's room to indicate the type of precaution the resident was placed on. She further indicated to NA #3 that she should wear gloves when changing or making the bed as the linens could be wet with urine. RN #5 and NA #3 reviewed the sign posted outside the room and identified NA #3 should have worn both gloves and gown when she had entered the room as directed by the sign. When NA #3 was asked why she had not done so, she responded that she would do better next time. Interview with the Infection Preventionist (IP) (RN #1) on 7/1/26 at 2:26 PM identified that staff should follow the sign posted on the outside of a resident's who is on transmission-based precautions (TBP) when entering the resident's room. She further identified staff knows when a resident is on TBP or other isolation precautions when they receive reports from the nurses on the shift, and a sign is posted outside of the resident's room along with a cart containing the PPE supplies. Review of the Transmission Based Precautions: Contact policy identified gloves should be worn when providing care that involves personal contact or contact with items that may be contaminated by the organism. The policy further identified to wear a clean non-sterile gown upon entering the resident's room if you anticipate substantial contact between your clothing and the resident, environment surfaces, or items in the room.

Based on review of facility documentation and staff interviews for one of three nurse aides (NA #1), the facility failed to complete an annual performance evaluation. The findings include:Record review of NA #1's personnel file showed a hire date of 9/15/23. The last documented performance evaluation was completed on 9/15/24. No annual performance evaluation had been completed for 2025.Interview with administrator on 7/1/26 PM at 10:30 AM identified that all employees were required to have a performance evaluation completed annually based on their hire date anniversary. He confirmed that the most recent evaluation for NA #1 was dated 9/15/24 and that no 2025 evaluation could be located. The administrator identified that the human resources had been responsible for tracking and ensuring completion of annual evaluations but noted there had been recent management changes across multiple departments, including the human resources.A performance evaluation policy was requested but was not provided. Facility leadership stated that performance evaluations were an established human resources practice and were completed as part of the personnel management process.

Based on observation, review of the clinical record, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for environmental conditions, the facility failed to maintain a safe environment by failing to ensure exterior fire doors in resident-accessible areas were functional and able to securely close. The findings include:Based on observation, review of the clinical record, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for environmental conditions, the facility failed to maintain a safe environment by failing to ensure exterior fire doors in resident-accessible areas were functional and able to securely close. The findings include:Resident #1 was admitted to the facility in August of 2025 with diagnoses that included repeated falls, insomnia and dementia. Resident #1 had a medical responsible party. The elopement evaluation dated 8/13/25 identified Resident #1 was at risk for elopement and an elopement care plan was initiated.The reportable event dated 12/16/25 at 6:45 AM identified the fan in a resident's bathroom on the A wing caught fire. A resident was evacuated from the room, the NA pulled the fire alarm pull station, retrieved a fire extinguisher and extinguished the fire. Facility Maintenance, the fire department, Fire Marshall and Life Safety from the Department of Public Health responded.The accident and incident (A&I) form dated 12/17/25 at 1:00 AM identified the exterior fire doors on D wing alarmed, a safety check was performed, and Resident #1 was located outside the exterior fire doors on his/her hands and knees with no identified injuries. The A&I identified a wander guard was placed to Resident #1's right wrist for elopement risk, maintenance checked the locking mechanism alarm on the exterior fire door at the end of D wing and maintenance adjusted the door alarm to sound unless the magnetic locks were engaged.Observation on 1/13/26 at 10:00 AM of the D wing exterior fire doors identified the exterior fire doors were locked, there was a pin pad observed to open the exterior fire doors and a magnetic lock on top of each exterior fire door. Upon opening the exterior fire doors after entering the code, the doors alarmed. The left exterior fire door closed but the right exterior fire door did not latch shut. The right exterior fire door needed to be pulled shut to securely close and there was a piece of weather strip on the bottom of the right exterior fire door.Interview with the Maintenance Director on 1/13/26 at 10:00 AM identified when there is a fire alarm, the alarms on the exterior fire doors are disabled and the doors open automatically. He identified the fire alarm that was triggered the day before (12/16/25) could have caused the exterior fire doors to open, and then not close and latch properly once the fire alarm was completed. He identified no one from maintenance checked the exterior fire doors after the fire alarm to ensure they were secured and latched. He identified the exterior doors are checked monthly and was aware the exterior fire doors at the end of D wing had to be pulled to close and secure because they are old doors. He identified the weather strip on the inside of the right exterior fire door may contribute to the exterior fire doors not securely closing and that he would fix it.Interview with the DNS on 1/13/26 at 2:45 PM identified after the fire event on 12/16/25, the exterior fire doors were not checked to ensure they were secured and latched.

Based on review of the clinical record, facility documentation, facility policy, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for elopement, the facility failed to develop a person-centered care plan with individualized interventions to address the resident's assessed risk for elopement. The findings include: Resident #1 was admitted to the facility in August of 2025 with diagnoses that included repeated falls, insomnia and dementia. Resident #1 had a medical responsible party. The elopement evaluation dated 8/13/25 identified Resident #1 was at risk for elopement and an elopement care plan was initiated.The Resident Care Plan (RCP) dated 8/13/25 identified Resident #1 was at risk for elopement related to dementia as evidenced by a history of wandering while in the community and at the facility. The RCP Identified Resident #1 was previously an elevator repair person and had a history of thinking he had a service call and wanting to leave at night per his daughter. Interventions included to introduce yourself in a calm, reassuring manner, explain routines and procedures, orient to room and environment, frequent checks as necessary, picture in business office and encourage family to bring in familiar objects.The physician's order dated 8/14/25 directed assist of one with no device in room and assist of one in hall with walker.The psychiatric note dated 9/16/25 identified Resident #1 had late evening and early morning wakefulness, agitation and walking around confused. She suggested Trazodone 25 mg every six (6) hours as needed for thirty (30) days for breakthrough agitation.The physician's order dated 9/16/25 - 10/16/25 directed Trazodone 25 mg every six (6) hours as needed for agitation/anxiety for thirty (30) days.The psychiatric note dated 10/22/25 identified Resident #1 was recently up during early morning hours wandering and looking for his/her family member. Resident #1 had a history of insomnia and sundowning. She suggested Trazodone 25 mg every six (6) hours as needed for thirty (30) days for breakthrough agitation.The physician's order dated 10/22/25- 11/19/25 directed Trazodone 25 mg every six (6) hours as needed for agitation/insomnia for thirty (30) days.The fall assessment tool dated 11/12/25 identified Resident #1 was at high risk for falling.The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), could walk at least 150 feet independently, and had wandering behaviors that occurred one (1) to three (3) days out of seven (7).The psychiatric note dated 11/12/25 identified Resident #1 had intermittent middle of the night confusion, insomnia, looking for his/her family member, was often re-directable, but if not re-directable had orders for Trazodone 25 mg as needed.The physician's order dated 11/20/25- 12/20/25 directed Trazodone 25 mg every twenty-four (24) hours as needed for agitation/insomnia for thirty (30) days.The accident and incident (A&I) form dated 12/17/25 at 1:00 AM identified the exterior fire doors on D wing alarmed, a safety check was performed, and Resident #1 was located outside the exterior fire doors on his/her hands and knees with no identified injuries. The A&I identified a wander guard was placed to Resident #1's right wrist for elopement risk, maintenance checked the locking mechanism alarm on the exterior fire door at the end of D wing and maintenance adjusted the door alarm to sound unless the magnetic locks were engaged.Interview with NA #1 on 1/13/26 at 3:02 PM identified Resident #1 had behaviors at night to include packing his/her belongings to go home.Interview with RN #1 on 1/13/26 at 3:11 PM identified Resident #1 had a history of staying up at night and would sometimes wander the hall.Interview with the DNS on 1/13/26 at 2:45 PM identified if a resident is exit seeking, ambulatory and/or making statements of wanting to leave, a wander guard should be placed on the resident. She identified there was no other room available for Resident #1 on admission (Resident #1's room was the furthest away from the nursing station and the closest room to the exterior fire doors). She further identified the facility had not done any elopement drills and had no documentation of drills.Review of the RCP failed to identify individualized interventions to address the resident's specific elopement risk behaviors such as: wandering at night, confusion and looking for family members at night, packing belongings at night to leave the facility and room location near exterior exits.Review of the Risk for Wandering/Elopement Resident policy and procedure identified that if a resident is identified as an elopement risk, the following measures will be implemented: a wander guard bracelet will be initiated to maintain the resident safety, the wander guard will be checked every shift and as needed for function, the resident's photo ID will be placed at the front desk and center court, and an elopement drill will be performed periodically and as needed.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for elopement, the facility failed to provide adequate supervision and prevent accidents by failing to ensure exterior fire doors in resident-accessible areas remained secured and failing to implement adequate interventions for an ambulatory resident assessed as being at risk for elopement, resulting in the resident exiting the facility unsupervised. The findings include: Resident #1 was admitted to the facility in August of 2025 with diagnoses that included repeated falls, insomnia and dementia. Resident #1 had a medical responsible party. The Elopement evaluation dated 8/13/25 identified Resident #1 was at risk for elopement and an elopement care plan was initiated.The Resident Care Plan (RCP) dated 8/13/25 identified Resident #1 was at risk for elopement related to dementia as evidenced by a history of wandering while in the community and at the facility. The RCP Identified Resident #1 was previously an elevator repair person and had a history of thinking he had a service call and wanting to leave at night per his daughter. Interventions included to introduce yourself in a calm, reassuring manner, explain routines and procedures, orient to room and environment, frequent checks as necessary, picture in business office and encourage family to bring in familiar objects.The physician's order dated 8/14/25 directed assist of one with no device in room and assist of one in hall with walker.The psychiatric note dated 9/16/25 identified Resident #1 had late evening and early morning wakefulness, agitation and walking around confused. She suggested Trazodone 25 mg every six (6) hours as needed for thirty (30) days for breakthrough agitation.The physician's order dated 9/16/25 - 10/16/25 directed Trazodone 25 mg every six (6) hours as needed for agitation/anxiety for thirty (30) days.The psychiatric note dated 10/22/25 identified Resident #1 was recently up during early morning hours wandering and looking for his/her family member. Resident #1 had a history of insomnia and sundowning. She suggested Trazodone 25 mg every six (6) hours as needed for thirty (30) days for breakthrough agitation.The physician's order dated 10/22/25- 11/19/25 directed Trazodone 25 mg every six (6) hours as needed for agitation/insomnia for thirty (30) days.The fall assessment tool dated 11/12/25 identified Resident #1 was at high risk for falling.The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), could walk at least 150 feet independently, and had wandering behaviors that occurred one (1) to three (3) days out of seven (7).The psychiatric note dated 11/12/25 identified Resident #1 had intermittent middle of the night confusion, insomnia, looking for his/her family member, was often re-directable, but if not re-directable had orders for Trazodone 25 mg as needed.The physician's order dated 11/20/25- 12/20/25 directed Trazodone 25 mg every twenty-four (24) hours as needed for agitation/insomnia for thirty (30) days.The reportable event dated 12/16/25 at 6:45 AM identified the fan in a resident's bathroom on the A wing caught fire. A resident was evacuated from the room, the NA pulled the fire alarm pull station, retrieved a fire extinguisher and extinguished the fire. Facility Maintenance, the fire department, Fire Marshall and Life Safety from the Department of Public Health responded.A Nursing note by RN #1 dated 12/17/25 at 6:45 AM identified at approximately 1:00 AM the exterior fire doors on D-Wing alarmed. She identified herself and NA #1 responded immediately. The supervisor (RN #2) was notified. NA #1 noted the exterior fire door to be slightly ajar and secured the door so it was fully closed. RN #1 directed NA #1 to perform a resident head count. Resident #1 was not in his/her room. Resident #1 was last observed at 12:00 AM resting in bed with no signs of distress. RN #1, RN #2 and NA #1 opened the exterior fire doors and observed Resident #1, who was wearing a jacket, pants and white sneakers, outside the facility door, kneeling on his/her hands and knees on the ground. RN #2 and NA #1 assisted Resident #1 to a standing position while RN #1 obtained a wheelchair and Resident #1 was safely wheeled into the facility.The accident and incident (A&I) form dated 12/17/25 at 1:00 AM identified the exterior fire doors on D wing alarmed, a safety check was performed, and Resident #1 was located outside the exterior fire doors on his/her hands and knees with no identified injuries. The A&I identified a wander guard was placed to Resident #1's right wrist for elopement risk, maintenance checked the locking mechanism alarm on the exterior fire door at the end of D wing and maintenance adjusted the door alarm to sound unless the magnetic locks were engaged.Observation on 1/13/26 at 10:00 AM of the D wing exterior fire doors identified the exterior fire doors were locked, there was a pin pad observed to open the exterior fire doors and a magnetic lock on top of each exterior fire door. Upon opening the exterior fire doors after entering the code, the doors alarmed. The left exterior fire door closed but the right exterior fire door did not latch shut. The right exterior fire door needed to be pulled shut to securely close and there was a piece of weather strip on the bottom of the right exterior fire door.Interview with the Maintenance Director on 1/13/26 at 10:00 AM identified when there is a fire alarm, the alarms on the exterior fire doors are disabled and the doors open automatically. He identified the fire alarm that was triggered the day before (12/16/25) could have caused the exterior fire doors to open, and then not close and latch properly once the fire alarm was completed. He identified no one from maintenance checked the exterior fire doors after the fire alarm to ensure they were secured and latched. He identified the exterior doors are checked monthly and was aware the exterior fire doors at the end of D wing had to be pulled to close and secure because they are old doors. He identified the weather strip on the inside of the right exterior fire door may contribute to the exterior fire doors not securely closing and that he would fix it.Interview with NA #1 on 1/13/26 at 3:02 PM identified Resident #1 had behaviors at night to include packing his/her belongings to go home. She identified on 12/17/25 she last saw Resident #1 at 12:00 AM asleep in bed wearing pajama pants, a white shirt, sweater and socks. She identified she was in the middle of the hall when she heard the alarm sound and did not know what it was. She identified she was directed to check the halls and identified the exterior fire door at the end of D wing was slightly open so she closed the door. She then began to check resident rooms beginning with Resident #1's room because his/her room was nearest to the exterior fire doors on the left. She identified Resident #1 was not in his/her room. She opened the exterior fire doors and found Resident #1 outside. She identified she had not done elopement drills since employed by the facility.Interview with RN #1 on 1/13/26 at 3:11 PM identified Resident #1 had a history of staying up at night and would sometimes wander the hall. She identified on 12/17/25 she last saw Resident #1 at 12:00 AM in bed. She identified she was at the nursing station when she heard an alarm sound. She identified herself and NA #1 were trying to figure out what alarm it was. She identified she called the nurse on the A wing to inquire, and that nurse also did not know. She then called the supervisor who notified her to start looking at the exterior fire doors. They started a resident head count when Resident #1 was identified outside of the D wing exterior fire doors. He/she was brought back inside and an assessment was completed with no injuries. She identified she had not done any elopement drills while being employed by the facility.Interview with the DNS on 1/13/26 at 2:45 PM identified if a resident is exit seeking, ambulatory and/or making statements of wanting to leave, a wander guard should be placed on the resident. She identified Resident #1 did not have a wander guard because he/she was not exit seeking or making statements of wanting to leave. She identified there was no other room available for Resident #1 on admission (Resident #1's room was the furthest away from the nursing station and the closest room to the exterior fire doors). She identified after the fire event on 12/16/25, the exterior fire doors were not checked to ensure they were secured and latched. She further identified the facility had not done any elopement drills and had no documentation of drills.Review of the Risk for Wandering/Elopement Resident policy and procedure identified that if a resident is identified as an elopement risk, the following measures will be implemented: a wander guard bracelet will be initiated to maintain the resident safety, the wander guard will be checked every shift and as needed for function, the resident's photo ID will be placed at the front desk and center court, and an elopement drill will be performed periodically and as needed.

Based on observation, staff interviews, and facility document review, the facility did not consistently complete sanitation logs for the sanitizing sink according to facility policy. The findings include: On 12/15/2024 at 10:15 AM a tour of the kitchen was completed with the facility dietary manager and assistant manager. A dietary aide was observed washing a pitcher in a 3-bay sink. There were two large gray baking pans soaking in the sanitizing sink (third bay from the left). The dietary aide indicated that she did not check the level of the sanitizer concentration because the cook checked it in the morning before the dishes were washed. A review of the facility documentation for pot sink and bucket sanitizer verification failed to identify that the sanitizer level was checked prior to the washing and sanitizing of the breakfast dishes. Further review of the pot sink and bucket sanitizer verification logs from 6/1/2024 to 12/15/2024 identified that for the months of June, October, and November 2024, there was no documentation of sanitizer verification for breakfast time. Additionally, for the months of July, August, September, and December, the sanitizer verification log was inconsistently completed, with several days missing for breakfast. For the months of June, July, October, November, and December, the sanitizer verification log was inconsistently completed, with several days missing for lunch. On 12/15/2024 at 10:30 AM an interview with [NAME] #1 indicated he filled the sanitizing sink with sanitizing solution in the morning when he came in to work and checked the concentration. [NAME] #1 indicated he does not always document the result of the sanitizer concentration test. Additionally, [NAME] #1 indicated that there are usually dishes for breakfast, lunch and dishes that are washed and sanitized in the 3-bay sanitizing sink daily. On 12/15/2024 at 10:45 AM an interview with the Dietary Manager indicated that it is the responsibility of the dietary staff to check the sanitizing solution before using it to sanitize dishes. The Dietary Manager further indicated that staff know how to check the sanitizer concentration but may forget to write it in the log. A review of the facility policy for Sanitizing Sink identified that testing of the sanitizing solution should be documented each time the sink is refilled and that each person filling the sink is responsible for documentation.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for skin alterations, the facility failed to review and revise the care plan timely to include surgical incisions present on admission and the identified risk for further skin impairment. The findings include: Resident #1's diagnoses included fusion of the spine, chronic congestive heart failure, history of Urinary Tract Infections (UTI's), functional urinary incontinence, muscle weakness and the need for assistance with personal care. The admission Observation dated 9/23/24 identified that Resident #1 was alert and oriented to person, place, time and situation, displayed weakness to both the right and left lower extremities and was observed with a mid-back surgical incision. A physician's order dated 9/23/24 directed to monitor the surgical incision to Resident #1's back for signs and symptoms of infection every shift. A nurse's note dated 9/23/24 at 7:02 PM identified that Resident #1 was admitted to the facility at 2:30 PM with a midline back incision with an intact dressing. The note reported that the resident's family member refused to allow staff to remove the dressing to assess the area. Review of the Resident Care Plans for Resident #1 failed to identify an actual skin impairment due to the surgical wound. Interview with the DNS on 12/09/24 at 11:51 AM identified that there should have been a care plan for surgical skin impairments for Resident #1. She reported that the admitting nurses should have initiated the care plans on admission. She identified that the care plans must have been missed and she was unsure why. Interview with RN #6 (MDS Coordinator) on 12/9/24 at 1:40 PM identified that the care plan for the surgical incision for should have been initiated on admission. Review of the Comprehensive Person-Centered Care Plans policy dated 04/2021 directed, in part that the comprehensive, person-centered care plan will include measurable objectives and time frames, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, incorporate identified problem areas, incorporate risk factors associated with identified problems, reflect treatment goals, timetables and objectives in measurable outcomes, identify the professional services that are responsible for each element of care and aid in preventing or reducing decline in the resident's functional status and/or functional levels.

Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of three (3) residents (Resident #1 and #2) reviewed for altered skin integrity, the facility failed to measure two (2) incisional wounds from admission through discharge , failed to ensure that an external catheter device had a physician's order, and failed to ensure that a pressure ulcer risk scale was completed in accordance with facility policy.The findings include: 1) Resident #1's diagnoses included fusion of the spine, chronic congestive heart failure, history of Urinary Tract Infections (UTI's), functional urinary incontinence, muscle weakness and the need for assistance with personal care. The admission Observation dated 9/23/24 identified that Resident #1 was alert and oriented to person, place, time and situation, displayed weakness to both the right and left lower extremities and was observed with a mid-back surgical incision. The Resident Care Plan (RCP) dated 9/23/24 identified that Resident #1 had a self-care deficit related to weakness and recent spinal surgery with interventions that included extensive staff assist of two (2) for bed mobility and performing weekly skin checks on bath day, documenting the findings in a progress note and updating the provider and family as needed. a) A nurse's note dated 9/23/24 at 7:02 PM identified that Resident #1 was admitted to the facility at 2:30 PM with a midline back incision with dressing intact. The note reported that the resident's family member refused to allow staff to remove the dressing to assess the area. Review of the clinical record from admission on 9/23 through discharge to the hospital on [DATE] failed to identify measurements of the two (2) surgical incisions to the back. Interview with APRN #1 on 12/06/24 at 2:26 PM identified that the facility should be following their wound protocol and measuring any skin irregularities, including surgical wounds on admission and weekly so that they can accurately monitor the improvement or decline of the area. Interview with the DNS on 12/09/24 at 11:51 AM identified that she expects all skin areas, including surgical incisions are measured on admission and weekly and signed off in the MAR. Additionally, she was unsure why no measurements were obtained of the surgical incisions. Review of the Wound Care Standard policy dated 08/2000 directed, in part, that a wound assessment will be done weekly by licensed nursing staff documenting the location, size and appearance of the wound, amount, color and odor of any drainage and any presence of redness, swelling, warmth and change in appearance should also be included in the documentation. b) Review of 09/2024 and 10/2024 nurse's notes identified that Resident #1 was utilizing an external catheter within the facility, which was first documented on 9/24/24 at 3:00 AM and last documented on 10/7/24 at 5:36 AM before his/her 10/08/24 discharge. Review of physician's orders dated 9/23/24 through 10/08/24 failed to identify an order for the external catheter. Interview with LPN #1 on 12/06/24 at 1:44 PM identified that Resident #1 did utilize the external catheter, and that the family member would apply it at night and would then pay a private aide to come into the facility in the morning and remove it. She identified that the aide would then take pictures of the canister and send them to the family everyday. She reported that staff did not apply or remove the catheter but that they would turn it on/off and empty it if needed. Interview with APRN #1 on 12/06/24 at 2:26 PM identified that the external catheter system should not have been utilized within the facility without a physician's order, as it is a medical device. Additionally, she reported that staff should be trained on the device, as it poses a risk for infections if not cleaned appropriately. Interview with RN #4 on 12/06/24 at 2:54 PM identified that staff did not take apart or manage the external catheter, reporting that they only turned it on/off as needed. He identified that there had been no staff training on the external catheter system. Interview with the DNS on 12/09/24 at 11:51 AM identified that although there was no policy or staff training, the facility allowed Resident #1 to utilize the external catheter device throughout his/her stay at the facility and also allowed the family and a private aide to manage the device. She reported that there should have been a physician's order for the external catheter system and they should not have allowed the family and private aide to manage it without oversight. She identified that she was unsure why staff may have turned on/off the device or emptied the device without proper training. Although requested, a policy on an external catheter system was not obtained. 2) Resident #2's diagnoses included fracture of the right femur, Parkinson's disease, dementia without behavioral disturbances, a stage 4 pressure ulcer of the sacral region (an ulcer at the base of the spine that is down to the bone), anemia and thrombocytopenia (low platelets in the blood that can cause a person to bleed or bruise easily). The admission Observation dated 8/9/21 identified Resident #2 was alert to person, place, time and situation, required assistance with Activities of Daily Living (ADLs) and was admitted to the facility with a pressure ulcer to the coccyx measuring 1.5 centimeters (cm) by 1 cm (not staged, please referemce F 686). A nurse's note dated 8/9/21 at 9:55 PM identified that Resident #2 arrived at the facility from the hospital at 3:30 PM and was noted with a pressure sore to the coccyx measuring 1.5 cm by 1 cm with a dry protective dressing in place and calmoseptine (barrier cream) applied as ordered. A physician's order dated 8/9/21 directed to apply calmoseptine to thearea and cleanse the coccyx with normal saline, pat dry and then apply protective dressing to the area daily and as needed. A care plan dated 8/10/21 identified that the resident was at risk for pressure ulcers due to decreased mobility, poor nutrition, and a pressure ulcer present on admisssion with interventions that directed to have a pressure relieving mattress and cushion for chair, and to encourage turning and repositioning. A focused observation dated 8/12/21 at 10:20 AM identified that the pressure ulcer to the coccyx measured 6 cm by 3.5 cm and the depth was unable to be determined due to a large, darkened area. It identified that an air mattress would be put in place (3-days after admission, the area was not staged). A physician's order dated 8/12/21 directed to reposition the resident every two (2) hours every shift. A nurse's note dated 8/23/21 at 10:27 AM identified that Resident #2 was increasingly confused and had refused breakfast. It reported that the pressure sore on his/her buttocks appeared to have gotten worse with a large, reddened area measuring 13 cm by 7 cm with a moderate amount of yellow/green drainage and small necrotic areas had been noted. The note reported that the physician was notified, and a new order had been obtained to send the resident to the Emergency Department (ED) for further evaluation, as there was question of sepsis. A Braden Scale for Predicting Pressure Sore Risk dated 9/1/21 (25 days after admission) identified that Resident #2 was at very high risk for pressure sores. Interview with the DNS and RN #3 on 12/09/24 at 1:01 PM identified that per policy, Braden Scale Assessments are to be done on all residents on admission, quarterly and with a change in condition. They reported that although Resident #2 should have had a Braden completed on 8/9/21 and 8/23/21, a Braden wasn't completed until 9/1/21 and they were unsure why. Interview with MD #2 (current wound doctor) on 12/09/24 at 12:36 PM identified that the facility should be following their Wound Protocol and Braden Risk policies at all times. Review of the Braden Scale Assessment policy dated 7/2020 directed, in part, that the Braden Scale Observation is used to assess a resident's risk of developing a pressure ulcer. All residents will be assessed upon admission, readmission, quarterly and at each change in condition to assess the potential for skin breakdown. A score of 18 or below will indicate the need for preventative intervention. All assessments and interventions will be documented in the Electronic Health Record.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for pressure ulcers, the facility failed failed to place additional interventions timely for a resident identified on admission to have a pressure ulcer, failed to ensure that the pressure ulcers were staged and assessed in accordance with facility policy. The findings include: Resident #2's diagnoses included fracture of the right femur, Parkinson's disease, dementia without behavioral disturbances, a stage 4 pressure ulcer of the sacral region (an ulcer at the base of the spine that is down to the bone), anemia and thrombocytopenia (low platelets in the blood that can cause a person to bleed or bruise easily). The admission Observation dated 8/9/21 identified Resident #2 was alert to person, place, time and situation, required assistance with Activities of Daily Living (ADLs) and was admitted to the facility with a pressure ulcer to the coccyx measuring 1.5 centimeters (cm) by 1 cm (not staged). The clinical record lacked a timely Braden Scale (identifies risk for pressures ulcers) identified upon admission (please cross reference F 684). A nurse's note dated 8/9/21 at 9:55 PM identified that Resident #2 arrived at the facility from the hospital at 3:30 PM and was noted with a pressure sore to the coccyx measuring 1.5 cm by 1 cm with a dry protective dressing in place and calmoseptine (barrier cream) applied as ordered (the clinical record failed to identify the pressure ulcer stage). A physician's order dated 8/9/21 directed to apply calmoseptine (a moisture barrier),cleanse the coccyx with normal saline, pat dry and then apply protective dressing to the area daily and as needed. A care plan dated 8/10/21 identified that the resident was at risk for pressure ulcers due to decreased mobility, poor nutrition, and a pressure ulcer present on admisssion with interventions that directed to have a pressure relieving mattress and cushion for chair, and to encourage turning and repositioning. A focused observation dated 8/12/21 at 10:20 AM identified that the pressure ulcer to the coccyx measured 6 cm by 3.5 cm (larger than on admission) and the depth was unable to be determined due to a large, darkened area (not staged). The observation identified that an air mattress would be put in place (3-days after being admitted with a pressure ulcer, and no staging of pressure ulcer was identified). A physician's order dated 8/12/21 directed to reposition the resident every two (2) hours every shift (3 days after being admitted with a pressure ulcer) There were no measurements identified in the clinical record from 8/12 through 8/22/24 (10 days). A nurse's note dated 8/23/21 at 10:27 AM identified that Resident #2 was increasingly confused and had refused breakfast. The pressure ulcer on his/her buttocks appeared to have gotten worse with a large, reddened area measuring 13 cm by 7 cm with a moderate amount of yellow/green drainage and small necrotic areas had been noted. The note reported that the physician was notified, and a new order had been obtained to send the resident to the Emergency Department (ED) for further evaluation, as there was question of sepsis. A nurse's note dated 8/23/21 identified that Resident #2 was transferred back to the facility at 4:45 PM and had been diagnosed with anemia and mental status change. Imaging to the head (CT scan) had been performed and was negative. No new orders were obtained. A physician's order dated 8/24/21 directed that Resident #2 may have a wound consult with the wound care group for pressure area on the buttocks until resolved. A wound physician's note dated 8/24/21 identified that the resident was seen for initial visit and was noted to have a sacral wound measuring 10 cm by 3.5 cm by 0.1 cm with noted slough and necrotic tissue. The note identified the area was debrided and Santyl (a wound product used to remove dead tissue from a wound) was applied to the wound bed followed by a dry protective dressing. The note reported that he wound follow-up with the resident weekly but that the prognosis was poor due to the resident's diagnoses and limited mobility. A nurse's note dated 8/24/21 at 1:13 PM identified that a new physician's order was obtained to apply Santyl to the wound bed, skin prep around the wound and then cover with a foam dressing daily and as needed. Interview with the DNS and RN #3 on 12/09/24 at 1:01 PM identified that for all residents that are admitted to the facility with a pressure ulcer, an air mattress is placed to their bed prior to their arrival. She statted that if a pressure ulcer is not communicated on report, they will place one on the bed after the resident's arrival and they were unsure why Resident #2 did not receive an air mattress until 8/12/21, after the pressure area had increased in size. The DNS identified that residents admitted to the facility with a pressure ulcer should be seen on the wound doctor's next visit to the facility but reported that the delay in the order and the initial visit was most likely due to COVID, reporting they didn't have a stable wound doctor during that time. The DNS identified that Resident #2 had treatment orders for the pressure ulcer, and the nurses were completing the treatment daily, however, the wounds should be staged and assessed per the facility policy (weekly). The DNS further identified that RN #3 identified that her documentation in the 8/12/21 focused assessment that referred to the area as 'darkened' meant it was red and not normal skin color, but not necrotic and that's why she obtained orders for the air mattress and turning and repositioning the resident every two (2) hours reporting that they should have been done on admission. Interview with MD #2 (current wound doctor) on 12/09/24 at 12:36 PM identified that with the resident's diagnoses and the fast decline of the wound, it was possible that the resident had developed Kennedy ulcers but reported that she would have expected that the resident received an air mattress and a turning schedule on admission. She identified that the facility should be following their Wound Protocol and Braden Risk policies at all times, but identified she was not working at the facility during Resident #2's admission in 2021 so she was unsure of all the specifics. Review of the Braden Scale Assessment policy dated 7/2020 directed, in part, that the Braden Scale Observation is used to assess a resident's risk of developing a pressure ulcer. All residents will be assessed upon admission, readmission, quarterly and at each change in condition to assess the potential for skin breakdown. A score of 18 or below will indicate the need for preventative intervention. All assessments and interventions will be documented in the Electronic Health Record. Review of the Pressure Ulcer policy dated 4/2023 directed, in part, that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Interventions will be implemented in the resident's plan of care to prevent deterioration and promote healing of the pressure sore. All residents will have a pressure redistribution mattress and position and reposition the resident with pillows and other supportive devices as needed. The nurse will notify the physician anytime the pressure sore is showing signs of non-healing or infection and request treatment order changes.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for incontinence, the facility failed to provide staff education to ensure competent nursing staffing related to an external catheter system. Resident #1's diagnoses included fusion of the spine, chronic congestive heart failure, history of Urinary Tract Infections (UTI's), functional urinary incontinence and the need for assistance with personal care. The admission Observation dated 9/23/24 identified that Resident #1 was alert and oriented to person, place, time and situation, displayed weakness to both the right and left lower extremities and had urinary incontinence with no catheters in place. The Resident Care Plan (RCP) dated 10/01/24 identified that Resident #1 was incontinent of urine with interventions that included approaching resident and providing incontinent care during rounds and as needed, assess if the resident is wet/soiled and assess for any redness or breakdown and notifying the nurse of any changes. Review of 09/2024 and 10/2024 nurse's notes identified that Resident #1 was utilizing an external catheter within the facility, which was first documented on 9/24/24 at 3:00 AM and last documented on 10/7/24 at 5:36 AM before his/her 10/08/24 discharge. Review of physician's orders dated 9/23/24 through 10/08/24 failed to identify an order for the external catheter. Interview with LPN #1 on 12/06/24 at 1:44 PM identified that Resident #1 did utilize the external catheter, and that the family member would apply it at night and would then pay a private aide to come into the facility in the morning and remove it. She identified that the aide would then take pictures of the canister and send them to the family everyday. She reported that staff did not apply or remove the catheter but that they would turn it on/off and empty it if needed. Interview with APRN #1 on 12/06/24 at 2:26 PM identified that the external catheter system should not have been utilized within the facility without a physician's order, as it is a medical device. Additionally, she reported that staff should be trained on the device, as it poses a risk for infections if not cleaned appropriately. Interview with RN #4 on 12/06/24 at 2:54 PM identified that staff did not take apart or manage the external catheter, reporting that they only turned it on/off as needed. He identified that there had been no staff training on the external catheter system. Interview with the DNS on 12/09/24 at 11:51 AM identified that although there was no policy or staff training, the facility allowed Resident #1 to utilize the external catheter device throughout his/her stay at the facility and also allowed the family and a private aide to manage the device. She identified that the facility should not have allowed the family and private aide to manage the external catheter without oversight. She identified that she was unsure why staff may have turned on/off the device or emptied the device without proper training. Although requested, a policy on an external catheter system was not obtained.

Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1), reviewed for abuse, the facility failed to ensure the resident with treated with dignity. The findings include: Resident #1's diagnoses included dementia with psychotic disturbances, infection to cystostomy catheter, heart failure, and depression. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severely impaired cognition, had no behaviors in the prior seven (7) days, and required extensive assistance with bed mobility and transfers. The Resident Care Plan (RCP) dated 10/22/23 identified Resident #1 has a history of exhibiting behavioral symptoms including rejection of care, cursing, spitting, and hitting. Interventions directed to provide diversional activities as needed, repeat yourself in a polite manner as needed and to provide simple cueing as needed. Always approach in a calm and friendly manner. Facility incident report and investigation dated 10/25/2023 at 1:00 AM identified NA #2 reported an allegation that NA #1 had slapped Resident #1. NA #1 was immediately removed from care and Resident #1 was assessed for injuries, and no injuries were identified. Interview with NA #2 on 11/15/23 at 10:00 AM identified on 10/25/2023 during the 11:00 PM to 7:00 AM shift, Resident #1 was restless and attempting to get out of bed throughout the night. NA #2 indicated RN #2 went to obtain a recliner chair for Resident #1, and NA #2 went to check on Resident #1. As NA #2 entered Resident #1's room, she observed NA #1 hunched over, and saw NA #1 raise her hand and slap Resident #1 in the face. Resident #1 then stated, get out, you hit me. NA #2 indicated he/she immediately confronted NA #1 and requested her to leave the room. NA #2 reported the allegation to RN #2 and LPN #1 and indicated the facility initiated an investigation. Interview with NA #1 on 11/15/23 at 11:20 AM identified on 10/25/2023 during the 11:00 PM to 7:00 AM shift, Resident #1 was attempting to get out of bed, yelling and shouting during the night. NA #1 indicated when RN #2 went to obtain a recliner chair Resident #1's roommate (Resident #2) began yelling at Resident #1 to shut him up. Both Resident #1 and Resident #2 were yelling at this point, and NA #1 identified she first placed her finger over Resident #1's mouth and indicated to shhh. When this didn't work, NA #1 identified she placed her hand over Resident #1's mouth and indicated to shhh. NA #1 identified she never slapped Resident #1 during this interaction, and NA #2 was not present during this interaction until possibly the ending. NA #1 identified she was removed from Resident #1's care and schedule pending an investigation and was subsequently terminated from her position after this event. Interview with DON on 11/15/2023 at 12:15 PM identified the facility was unable to substantiate that abuse occurred due to conflicting statements. Further, the DON indicated NA #1 should not have put her hand over the resident's mouth and should have waited for RN #2 to arrive with the recliner chair; further NA #1 could have attempted to de-escalate the situation with Resident #2 by providing reassurance. The DON identified the facility terminated NA #1's employment for not treating the resident with dignity. Review of the facility Quality of Life - Dignity Policy directed in part, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem, and residents are to be treated with dignity and respect at all times.

Based on review of the clinical record, facility documentation, facility policy and interview for 2 of 4 residents (Resident #181 and 4) reviewed for falls, the facility failed to ensure a pelvic positioning belt was applied according to the care plan, and failed to ensure 2 staff were present when the resident was positioned and fastened to the mechanical lift, which resulted in Resident #181 falling forward out of the wheelchair and onto the floor and sustaining a comminuted femoral fracture, and for Resident #4 who was at risk for falls, the facility failed to ensure a rehabilitation screen was completed upon admission. The findings include: 1. Resident #181 was admitted to the facility with diagnoses that included [CONDITION(S)] and dementia. The quarterly MDS dated [DATE] identified Resident #181 had severely impaired cognition and required extensive 2-person assistance for dressing and transfers. The care plan dated 6/5/20 identified Resident #181 required the assistance of 2 staff to get in and out of the tilt in space adaptive wheelchair via a sara (mechanical lift). Further, to position Resident #181 in the adaptive wheelchair with a cushion, head rest, lateral trunk supports, calf pads, leg rests, and pelvic positioning belt. A reportable event form dated 8/18/20 at 7:15 PM identified Resident #181 fell because the seat belt was not completely latched, and residents weight shifted forward. A nurse's note dated 8/18/20 at 11:10 PM, by RN #1, identified that she was called by the charge nurse, LPN #2, and observed Resident #181 on floor in front of the wheelchair on his/her side with a raised reddened area 2.0cm by 2.0cm by 1.0 cm area to forehead. Subsequent to physician notification, Resident #181 was sent to the emergency room for evaluation. Hospital emergency department notes dated 8/18/20 at identified Resident #181 was crying with pain to the left knee, 10 out of 10 by facial scale. The resident was medicated with [MEDICATION(S)] 15mg (nonsteroidal anti-[CONDITION(S)] drug used to treat pain) and [MEDICATION(S)] 2mg (narcotic pain medication) via IV and transported to radiology. The notes further identified that at 9:13 PM the resident was medicated with [MEDICATION(S)] 4mg (medication for nausea and vomiting) and [MEDICATION(S)] 4mg via IV and transferred to radiology and CT scan. The note identified on 8/18/20 at 9:26 PM the resident received [MEDICATION(S)] (analgesic for pain) via IV. A diagnostic report dated 8/18/20 identified a CT-Scan of the left leg identified severe osteopenia, and a comminuted (a bone that is broken in 2 or more pieces caused by severe trauma) femoral fracture with angulation and mild impaction. A nurse's note identified the resident returned from the hospital on 8/19/20 at 2:45 AM with a left lower leg immobilizer in place and a new order for [MEDICATION(S)] 10mg every 4 hours as needed for pain. A nurse's note dated 8/19/20 at 2:08 PM identified the resident had a follow up orthopedic appointment on Friday 8/25/20 and will go via ambulance. A nurse's note dated 8/19/20 at 11:27 AM identified the resident complained of increased pain to the knee. Tylenol and Motrin had no effect. The physician was made aware and ordered [MEDICATION(S)] 2mg until [MEDICATION(S)] received from pharmacy. Leg brace in place and the first dose of [MEDICATION(S)] was administered at 11:00 PM. A nurse's note dated 8/20/20 at 4:24 AM identified the resident complained of pain to the left leg, 5 out of 10, and Tylenol was given with good effect. A nurse's note dated 8/21/20 at 4:50 AM identified the resident complained of pain in the left leg 6 out of 10. [MEDICATION(S)] scheduled given this shift with good effect. Interview with NA #1 on 2/24/22 at 1:47 PM identified Resident #181 had a habit of unbuckling the seat belt while in the adaptive wheelchair prior to the 8/18/20 fall. NA #1 indicated Resident #181 was on her assignment that night and after supper she brought the resident into the room and started to give the resident a bed bath while the resident was in the adaptive wheelchair. NA #1 indicated she went and got the sara lift and placed the lift directly in front of Resident #181. NA #1 leaned Resident #181 forward to place the padded strap around the back of the resident and under his/her arms, and the resident fell forward out of the adaptive wheelchair onto the floor. NA #1 indicated at that time she realized Resident #181 may have unbuckled the seat belt so when she leaned Resident #181 forward to apply the lift strap, the resident fell out of the chair. NA #1 noted she was alone while attempting to hook Resident #181 up to the sara lift. NA #1 indicated she was going to hook Resident #181 up to the lift and then get a second person to assist with the transfer. NA #1 indicated there must be 2 people to use a mechanical lift. Interview with LPN #1 on 2/24/22 at 2:20 PM identified she was the staff development coordinator and did general orientation when NA #1 was hired in 2019. LPN #1 could not recall if she did competencies for mechanical lifts with NA #1 and was unable to find any documentation. Interview with NA #2 on 2/24/22 at 3:01 PM identified she was the regular aide on that unit and Resident #181 had a seat belt for at least a few months prior to the fall 8/18/20. NA #2 indicated there should always be 2 people to use the sara lift and nurse aides should get the second aide at the same time as they get the lift and do not set the resident up with the lift without another aide present in the room. Interview with the DNS on 2/24/22 at 3:00 PM identified the nurse aides must always have 2 people in the room with the sara lift, and that one staff member stands next to the resident to guide the resident while the other staff member uses and directs the lift. Interview with RN #1 on 2/24/22 at 4:00 PM indicated she recalls there was an issue with the seat belt not being latched correctly and the nurse aide went to get a mechanical lift and the Resident #181 fell out of the wheelchair forward without the seat belt on and was sent to the hospital. RN #1 indicated she did a corrective action form right away with NA #1 about the seat belt not being latched correctly. Although attempted multiple times, an interview with LPN #2 was not obtained. Review of the sara lift policy directed to use at least 2 nurse aides when transferring a resident using a mechanical device / sara lift. The procedure directs to bring sara lift carefully up to the resident placing the resident's feet on the footrest and continuing forward if possible until the kneepad is just in contact with the resident's knee, and or upper shin. Apply brakes. Help the resident's arms through the sling if they cannot manage to do this independently. Tighten the cords so they are taut, and the sling is firmly across the residents back. If possible, the resident should now hold onto the padded frame with one, or both hands. 2. Resident #4 was admitted to the facility on [DATE] with diagnosis that included dementia, hypertension, [CONDITION(S)] right eye and low vision left eye. A fall risk assessment tool dated 8/12/21 identified Resident #4 was at moderate risk to fall. The history and physical (H&P) dated 8/12/21 identified Resident #4 was in generally good health for his/her age, had been ambulating independently at home, but becoming more easily fatigued and napping more frequently. Resident #4 was being admitted as a long-term resident of the facility secondary to increased level of frailty. H&P identified Resident #4 had decreased vision, evidence of kyphosis and would be seen and evaluated by physical therapy. Review of the clinical record 8/12/21 through 10/18/21, over 2 months, failed to reflect physical therapy screening or evaluation had been done. Physician's orders dated 8/12/21 through 10/18/21 (date of fall) failed to reflect Resident #4's activity/mobility or ADL status. A nurse's note dated 8/12/21 identified Resident #4 was blind in the right eye and sees only shadows with the left eye due to [CONDITION(S)]. Additionally, Resident #4 had a 4 wheeled walker with seat that was rarely used. The resident representative indicated they would bring in a cane from home and otherwise the resident usually held someone's hand when walking longer distances. The admission MDS dated [DATE] identified Resident #4 had moderately impaired cognition, required supervision of 1 staff with transfers, ambulation in room and locomotion on and off unit. Balance during transitions and walking indicated resident was not steady, but able to stabilize without human assistance. Resident #4's vision was highly impaired, indicating object identification in question, but eyes appear to follow objects. The care plan dated 8/26/21 identified Resident #4 was at risk for falls due to [CONDITION(S)] and right eye [CONDITION(S)]. Interventions included to increased staff supervision with intensity based on resident need, provide individualized toileting interventions based on needs/patterns and bed alarm while in bed. Review of the nurse aide kardex prior to the fall, identified Resident #4 had a 4 wheeled walker and a cane and required continual supervision, cues (no hands-on assist) when walking. Physician's order dated 10/3/21 directed PT/OT/ST as needed due to change in condition. A reportable event form dated 10/18/21 identified at approximately 10:15 AM the housekeeping staff heard Resident #4 calling out for help and the resident was found by the housekeeper lying on the floor in a supine position. The Unit Manager was summoned, and the resident identified his/her legs just gave out. The resident denied feeling dizzy prior to falling and indicated he/she fell on to the right elbow. Resident #4 was able to actively move the right hand, however, could barely move the right arm without wincing in tremendous pain. Subsequent to physician notification, x-rays of right elbow and shoulder were obtained, and bloodwork was scheduled for the following day. X-ray report dated 10/18/21 identified an acute fracture involving right humeral neck with mild displacement. Subsequent to physician notification the following was ordered; PT evaluation and treatment, a sling to right upper extremity, schedule appointment with bone & joint for further evaluation and administer [MEDICATION(S)] 50mg every 4 hours as needed for severe pain. Corrective action plan to prevent reoccurrence identified ADL status changed to assist of one including transfers and bed mobility, use of wheelchair for mobility, adaptive equipment was added to continue independence with meals, resident was encouraged to call for help when needed and resident was currently receiving skilled OT and PT. Resident Activity Order form dated 10/20/21 identified Resident #4 now required assist of 1 with transfers out of bed to standard wheelchair using no assistive device. Interview with PT #3 and PT #2 (Directory of Rehabilitation) on 2/28/22 at 1:40 PM identified they could not find any documentation that a screen had been completed on Resident #4 when he/she was admitted to the facility on [DATE]. PT #2 indicated it was their policy to at least do a screen for all new long-term care residents and an evaluation for any short-term rehab residents. PT #3 identified she did not recall seeing the resident prior to the fall on 10/18/21 but was informed by nursing staff that resident had been using a 4 wheeled walker independently before the fall. Interview with the DNS on 2/28/22 at 2:30 PM identified that all new admissions should be screened on admission and should have an activity order. The DNS identified she did not know why there was no screen found and identified that although their facility policy did not indicate new admissions required a therapy screen, it was best practice to ensure screens were completed when new to the facility. Interview with PT #1 (Area Manager) on 3/1/22 at 10:00 AM identified that she was the Acting Director of Rehabilitation at the time of Resident #4's admission in August 2021. PT #1 identified not knowing why the resident was not screened upon admission but should have been especially because of his/her advanced age, being admitted for long term care, impaired vision and use of a 4 wheeled walker. PT #1 identified that someone could have screened the resident, took a quick look and felt resident was okay to ambulate with walker independently, however there was no documentation to support this. PT #1 identified that she might have been on vacation during that time but there was always someone else in charge who would have been responsible for screening the resident on admission. Review of Preferred Therapy Solutions Clinical Services Policies and Procedures identified the screening process is used to identify the need for rehabilitation evaluation and to determine the patient's ability to participate in either skilled rehabilitation or restorative nursing. It is also utilized to aid in the care plan process. The procedure directs to screen all newly admitted and readmitted patients within 48 hours of admission to the facility. Document the results of the screen using Preferred Therapy Solutions approved screen forms. The screen will be logged on the Screen Log which documents the date and type of the screen and whether an evaluation was recommended.

Based on observation, review of facility documentation, facility policies and interview, the facility failed to ensure food items were consistently labeled and stored to reflect its age or shelf-life or failed to ensure food items and utensils were distributed on the tray line under sanitary condition. The findings included. 1. Observation on 2/23/22 at 11:01 AM during the initial walk-through of the kitchen with the Dietary Supervisor identified the following food items lacked documentation or labeling of a date to reflect the age or shelf-life of a food item. a. Observation of the large walk-refrigerator identified beverages of water and juice were set up on two separate trays to be distributed for lunch. One tray contained 20 glasses of water and the 2nd tray contained 20 cups of juice. Although each beverage was covered with a lid, documentation was lacking to reflect the date the trays of beverages were prepared. It was further noted that a plastic bag containing a single bagel lacked a date. Although the DS indicated the beverage had been poured earlier in the morning on 2/23/22, the trays of beverages and the bagel should have been dated. b. Observation of an upright freezer was noted to have 3 packages of sliced Italian bread containing 4 slices each, 1 medium sized bag of frozen English muffins, 1 bag of 10 pieces of frozen fish portions (previously opened), 1-bag of 20 pieces of frozen fish cakes (previously opened) were not dated. Interview with the DS at the time indicated the food items should have been dated upon opening. c. Observation of the food storage room in the basement identified an additional freezer. Freezer #2 contained the following undated/labeled items; 4 boxes of froze apple pies, 1 large opened box of potatoes stuffed with cheese, 2 boxes of food items which were identified by the DS as pigs in the blanket appetizers left over from a sporting event. Interview with the DS identified that food items once opened or used should be labeled with a date to reflect the date the food item was opened or first used. 2. Observation on 2/24/22 at 11:27 AM during the tray line with the Dietary Supervisor (DS) a large air conditioner, suspended from the ceiling, had missing ceiling tiles surrounding the unit and the electrical cord from the air-conditioner was exposed as well as the internal structure of the ceiling. Two sections of the ceiling tiles that were present were noted to be cracked and stained with brown rust colored matter. At the start of the tray line, a compartmental storage bin for eating utensils, plate covers/lids and trays were positioned directly under the large air-conditioner and ceiling opening. Interview with the DS at the time of the observations indicated that she had previously brought the disrepair of the ceiling surrounding the air conditioner to the Building Supervisor (BS), but he has yet to follow up on the concern. Subsequent to surveyor inquiry, on 2/24/22 at 1:15 PM, the Building Supervisor completed repairs surrounding the large air conditioner with the installation of new ceiling tiles, closing up the opened areas above the tray line.

Based on review of records of staff testing for COVID-19, facility documentation, facility policies and staff interviews for two of twenty sampled staff who tested positive for COVID-19, the facility failed to take the necessary action to prevent the transmission of infection to the residents and staff. The findings include: Review of records of [MEDICATION NAME] testing dated 1/5/2021 and 1/6/2021 identified that Dietary Aide #1 had tested positive for COVID-19. Subsequent review of staff time cards for the week ending 1/9/2021 identified Dietary Aide #1 worked on 1/8/2021 from 12:00 Noon to 8:00 PM. Facility records of staff PCR testing dated 1/8/2021 further identified twenty staff members tested positive for COVID-19 including Nurse Aide (NA) #1 and Dietary Aide #1. Review of assignment schedules indicated that on 1/9/2021 and 1/10/2021 NA #1 was assigned to work on the C-wing which was designated as a unit for residents who had tested positive for COVID-19. NA #1's time cards identified that the nurse aide worked on 1/9/2021 from 7:04 AM to 3:15 PM and on 1/10/2021 from 7:00 AM to 3:15 PM. Interview with the Administrator on 1/14/21 at 9:30 AM indicated that all staff have been tested twice weekly, once with a PCR test and once with a rapid [MEDICATION NAME] test. The Administrator stated that staff who test positive for COVID-19 are to be sent home when the results are received, and staff are to be removed from the projected schedule after testing positive. The Administrator further indicated that prior to 1/7/2021 it was the facility's understanding that as long as staff who tested positive were not exhibiting symptoms, the staff could be assigned to work on the unit designated for residents who had tested positive for COVID-19 since the nursing home was experiencing staffing challenges. The Adminstrator stated that on 1/7/2021 the facility discontinued the practice of scheduling staff who had not completed the required isolation period after testing positive for COVID-19 Interview with Food Service Supervisor #1 on 1/14/2021 at 11:10 AM indicated s/he was unaware that staff who tested positive for COVID-19 without any symptoms were not permitted to work. The Food Service Supervisor stated that the dietary aide who was on duty on 1/8/2021 did not have any contact with the residents. Interview with the Director of Nursing on 1/14/2021 at 11:15 AM indicated that s/he had not checked whether NA #1 was on duty or on the schedule when the Administrator reported the names of the staff with positive COVID-19 test results on 1/8/2021. The Director of Nursing stated that s/he should have reviewed the schedule at the time and removed any staff on duty who had tested positive for COVID-19 as well as staff with positive results who were scheduled to work. Interview with the Infection Preventionist on 1/14/2021 at 11:30 AM identified that although s/he had been notified of the staff with positive test results, s/he had not looked at the schedule to ensure that staff who tested positive for COVID-19 were not on duty or scheduled to work. Further interview with the Administrator on 1/15/2021 at 11:00 AM indicated the laboratory had called on 1/8/21 at 9:30 AM to report that twenty staff had tested positive for COVID-19. The Administrator noted that the laboratory also sent an email message with the names of the staff, and the Director of Nursing and the Infection Control Nurse were informed, The Administrator further stated that although s/he did not look at the schedule to see who was working, the Director of Nursing and s/he had gone to the facility on Sunday, January 10, 2021 to review the schedules to ensure staffing levels were met. The Administrator noted the laboratory called again on 1/10/21 and indicated that atttempts to reach Nurse Aide #1 to report the positive results of the COVID test had been unsuccessful. The Administrator stated that although the laboratory was informed the facility would contact the employee, s/he did not look at the schedule to see if NA #1 was on duty. The Administrator identified that she contacted Nurse Aide #1 on Monday, January 11, 2021 to report the positive COVID-19 test results, and the nurse aide was removed from the schedule at that time. d

Based on observations, review of facility policies and staff interviews, the facility failed to ensure the necessary measures were implemented to prevent the transmission of infection during environmental cleaning of rooms and the processing of soiled linen. The findings include: 1. Observation and interview with Housekeeper #1 on 5/31/20 at 10:25 AM identified that routine cleaning of four of the facility's eight rooms designated for residents who required transmission-based precautions had been performed prior to the cleaning of rooms that were designated for residents who did not require these precautions. Interview and review of the facility policy Cleaning Isolation Room coronavirus disease 2019 (COVID-19) with the infection prevention and infection control nurse (Registered Nurse #1) identified that rooms designated for residents who required transmission-based precautions were to be cleaned at the end of the daily schedule. Subsequent interview with Housekeeper #1 on 5/31/20 at 11:15 AM in the presence of Registered Nurse #1 indicated that on 5/31/20 during the morning she had left her assigned unit where the isolation rooms were located to assist a co-worker who was assigned to other units because she was ahead of schedule and wanted to help the co-worker keep on schedule. Housekeeper #1 stated she had received recent in-service training on infection prevention cleaning strategies and was familiar with the protocols that were to be followed including the personal protective equipment (PPE) that was to be worn while cleaning an isolation room. 2. On 5/31/20 at 10:55 AM observation and interview with Laundry Staff #2 identified soiled linens were processed without the benefit of the necessary clothing protection. Laundry Staff #2 stated she routinely wore a long sleeved button up collared shirt and gloves when taking soiled linens from a laundry shoot to the facility's soiled linen room where the items were sorted. She was observed obtaining the shirt from the handle of a mop that was stored in a bucket in a corner of the soiled laundry room. After the shirt was donned and the collar was adjusted, one button secured the shirt over the staff person's uniform although the front center sections of the uniform were visible and unprotected. When Laundry Staff #2 sorted soiled laundry, a hand, arms and various surfaces of the clothing protector were in direct contact with moist body substances on the soiled linens. Laundry Staff #2 indicated the shirt used for clothing protection was reused about four times during a shift and was washed daily for reuse. Subsequent interview with Laundry Staff #3 on 5/31/2020 at 10:57 AM identified she wore a lab coat with snaps to close the front when sorting soiled laundry. Laundry Staff #3 stated that the lab coat was reused throughout the shift and laundered daily for reuse. Further observation failed to identify that the shirt and lab coat which were worn by the laundry staff were constructed of a fluid impervious material. Interview and review of the Linen and Laundry policy with Registered Nurse #1 on 5/31/20 at 11:00 AM identified laundry staff would follow the necessary precautions including the use of gloves and clothing protection that was fluid impervious when there was the potential for direct contact with moist body substances in order to prevent the transmission of infection during the laundry process.

Based on clinical record reviews, review of facility documentation and interviews for 2 of 3 sampled residents reviewed for accidents (R#100, 141), the facility failed to ensure that the residents had adequate supervision to prevent an accident/maintain safety and/or the facility failed to refill portable oxygen tanks in a safe and hazard free manner. The findings include: 1. Resident #//141's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented that the resident was moderately impaired cognitively, and required supervision with all activities of daily living. The care plan dated [DATE] identified that the resident was at risk for injury. Interventions included keeping the call bell with in reach and remind the resident to use the call bell as needed. A review of the nursing notes dated [DATE] - [DATE] indicated that the resident complained of light headedness almost daily. Further review of the nursing notes indicated that the resident had episodes of passing out and that he/she was found on the floor in his/her bedroom on [DATE] and then again on [DATE]. A review of the resident's medication administration record (MAR) from [DATE]-[DATE] indicated that the resident requested Meclizine for dizziness daily. An EKG completed [DATE] indicated that the resident was in normal sinus rhythm while an EKG dated [DATE] indicated that the resident was in heart block with a pulse rate in the 40's. On [DATE] the resident was found on the floor of his/her bedroom and was admitted to an acute care facility with a left hip fracture and heart block requiring a pace maker. A review of the social service note dated [DATE] indicated that the resident died while in the acute care facility. Interview with LPN #6 on [DATE] at 1 PM indicated the resident was up ad lib because the resident was able to communicate his/her needs. LPN #6 could not recall if any safety interventions were implemented due to the resident's symptomatic bradycardia and daily dizzy episodes. A review of the resident's clinical record with LPN#6 failed to provide documentation that additional interventions were initiated in the resident's plan of care and/or that the resident was non compliant with any attempted safety measures. Interview with LPN #6 indicated that additional interventions could have been implemented to prevent the fall and or alert the staff that the resident was moving without supervision. 2. Resident #100's [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that the resident scored a 3 on the brief interview for mental status indicating that the resident was severely impaired cognitively. The MDS indicated that the resident required extensive assistance from staff with walking in the room and in the corridor. The care plan (RCP) for ,[DATE] was not available upon request. Nursing notes dated [DATE] indicated that the resident was alert, oriented to self only, confused and forgetful. The resident required frequent cues from the nursing staff to use the walker. Nursing notes dated [DATE] indicated that Resident #100 went out to a physician appointment at 9:10 AM and was dropped off at a gas station with out the benefit of any supervision. Interview with LPN#5 on [DATE] at 1 PM indicated that she made the appointment for the resident but could not recall if she indicated to the facility scheduler that an escort would be needed for the appointment. A review of a police report indicated that the resident was dropped off at the gas station at an unknown time and was observed by the gas station attendant who alerted the facility that the resident was at the gas station without supervision. An interview with the Director of Nurses on [DATE] at 12:30 PM indicated that the nursing home should have ensured that the resident had supervision when he/she went to his/her dental appointment. 3. During tour of the facility on [DATE] at 8:44 AM, LPN#2 was observed transfilling portable oxygen (O2) tank from a large oxygen tank in the O2 room on the B-wing unit. The door of the O2 room remained open during the filling of the portable O2 tank. The unit manager (RN#3 ) was present during the observation and directed LPN# 2 to close the door while filling the tank. Interview with RN#3 at that time indicated that the door must be kept closed during transfilling of portable O2 tanks because of potential fire hazard.