Every finding on record at Mercy Circle

Based on observation, interviews and record review, facility failed to follow their policy and federal regulation and failed to ensure that the Daily Nursing Staffing Posting was completed appropriately. These failures have the potential to affect all 23 residents residing at the facility.Findings include:On 4/27/2026 at 9:45 AM, facility presented a census of 23 residents living at the 3rd floor unit.On 4/28/2026 at 12:12 PM, on the 3rd floor unit, observed Daily Nursing Staffing Posting displayed in the hallway by the first nursing station in the glass covered posting cabinet. Observed the Daily Nursing Staffing Posting sheet prefilled with dates from 4/26/2026-5/2/2026, with Facility's name, Nurses and Certified Nursing Assistants (CNA's) total hours per shift, and observed slots for the facility's Census empty, not filled out with the Census information for all the dates on the sheet.On 4/28/2026 at 12:53 PM, V8 (Clinical Services Manager/Assistant of Director of Nursing/ADON) stated that V8 performs scheduling for nursing staff and gives Daily Nurse Staffing Posting information to V9 (Administrator Services Manager) and V9 updates the postings daily. V8 stated that the Daily Nurse Staffing Posting Information should be posted in a visible area of the unit, and the sheets should include information on the total hours worked per shift for nurses and nursing assistants, the date, the facility's name and the current census. V8, looking at the displayed Daily Nurse Staffing Posting, affirmed that all the required information is not filled out and affirmed that the facility's census information is missing.On 4/28/2026 at 1:16PM, V9 (Administrative Services Manager) stated that V9 is responsible for filling out the Daily Nurse Staffing Posting forms and that V9 updates the postings daily if any changes are made. V9 stated that the Daily Nurse Staffing Posting information should be displayed prominently for all residents and visitors to see easily. V9 also said that the facility's posting should be located on the 3rd floor unit in the hallway by the first nurse's station, in the glass display cabinet. V9 stated that V9 is not familiar with the facility's Daily Nurse Staffing Posting policy and stated that the form should include the total number of hours worked per shift for nurses and nursing assistants, and the posting should include the date and the name of the facility. V9 stated, while looking at the copy of the facility's Daily Nurse Staffing Posting sheet, that there is a place on the form for facility's census information and that V9 thinks that the daily census information should be filled out, but V9 was not positive that it was one of the requirements. V9 affirmed that the facility's Daily Nurse Staffing Posting Form for the week of 4/26/2026 does not have facility's census information filled in. V9 presented Daily Nurse Staffing Posting Sheets for last 6 weeks, and while reviewing the sheets, V9 said that V9 has not been filling out the census information on the Daily Nurse Staffing Posting sheets. Observed Daily Nurse Staffing Posting sheets from 3/15/2026 to 4/28/2026 and was found that all of the sheets were missing facility's census information filled out for every day. V9 said that V9 was not familiar with the regulation requirements regarding the Daily Nurse Staffing Posting and that V9 should learn the required information that must be filled out on the Daily Nurse Staffing Posting Sheets. On 4/28/2026 at 1:23 PM, V1 (Administrator) stated that the Daily Nurse Staffing Posting Sheets should include the Date, Facility's name, Total number of hours per shift for nurses and nursing assistants and the facility's Census number. V1 affirmed, while looking at the copy of the facility's Daily Nurse Staffing Posting Form, that V1 does not see the facility's Census information filled in for any of the days on the sheet or the earlier Daily Nurse Staffing Posting sheets from 3/15/2026 to 4/28/2026. V1 stated that V1 is not sure if the facility has a policy for Daily Nurse Staffing policy but will check with corporate offices and provide when available. V1 also said that V1 should be familiar with the regulation and requirements for the Daily Nurse Staffing Posting Information.On 4/29/2026 at 12:52 PM, V2 (Director of Nursing/DON/Infection Preventionist/IP) stated that the Daily Nurse Staffing Postings should be visible at the 3rd floor unit and should have all necessary components filled out, but V2 is not very familiar with the requirements and stated that filling out the Daily Nurse Staffing Postings was not V2's responsibility.Facility's Documents titled Daily Staff Nursing 2026 (4/26/2026 to 5/2/2026) showed in part that facility's Census information for 4/26/2026 and 4/27/2026 are missing and are not filled out. Additional Facility's Daily Staffing Nursing sheets for the weeks of 4/19/2026 - 4/25/2026; 4/12/2026 - 4/18/2026; 4/5/2026 - 4/11/2026; 3/29/2026-4/4/2026; 3/22/2026-3/28/2026 and 3/15/2026-3/21/2026 showed that all facility's Daily Nurse Staffing Posting sheets were missing documentation of the facility's Census numbers for each day of the week from 3/15/2026 to 4/28/2026.Facility's Document titled Posting of Direct Care Daily Staffing Numbers (11/1/2019) showed in part that the facility should post at the beginning of each shift, in the prominent location that is accessible to residents and visitors the following information including but not limited to Facility name, Date, Total number and actual hours worked of licensed and unlicensed nursing staff and Resident Census.Facility's Document titled Position Description Administrative Services Manager (Undated) showed in part that some duties include but are not limited to preparing agendas, schedules, distribution of documents, anticipating changes and adjusting accordingly, preparing reports and non-routine information and performing of data entry and proofreading of internal and external documents.Facility's Document titled Role Profile Director of Nursing (Undated), showed in part that the Director of Nursing (DON) should provide management and supervision of the nursing care provided to the residents of the facility and the DON manages the day to day operations of the facility, ensures that the facility is operating within the state and federal regulations and is responsible for nursing outcomes, reviews and adjusts daily nursing hours in accordance to census and reviews and implements staffing plan for the facility's Nursing staff.Facility's Document titled Position: Executive Director (Undated), showed in part that some of the essential functions of the Executive Director (Administrator) include but are not limited to maintaining working knowledge of applicable federal and state laws and regulations and other policies and procedures to ensure adherence and insuring compliance with regulatory agencies.The (Rev. 229; Issued: 04-25-25; Effective: 04-25-25; Implementation: 04-28-25) State Operations Manual documents, in part,S483.35(i) Nurse Staffing Information.S483.35(i)(1) Data requirements. The facility must post the following information on a daily basis:(i) Facility name.(ii) The current date.(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides.(iv) Resident census.

Based on observation, interview and record review, the facility failed to ensure that the medication carts were kept clean and free of loose pills, failed to ensure multi-use medications were labeled with an open date, failed to discard expired medications and failed to discard expired medication supplies. These failures have the potential to affect all 23 residents assigned to the medication cart.Findings include:On 04/28/26 at 12:38pm during medication storage and labeling task with V4 (Registered Nurse/RN) of 3rd floor medication cart, there were 12 loose unidentified pills observed in the medication drawers, an opened tube of Diclofenac sodium topical gel 1% with no open date, an open tube if bacitracin zinc antibiotic ointment with no open date, Vitamin B1 100mg (milligram) with expiration date of 02/2026, Omeprazole 20mg with expiration date that was unable to be read, tuberculosis needle with expiration date of 01/31/25.On 04/28/26 at 12:38pm V4 (RN) stated that the loose pills on the medication cart should be discarded. V4 stated that the loose pills are trash because they are not labeled and are unsanitary. V4 stated that expired medications should not be given to residents because the expired medications lose their efficacy. V4 stated that supplies are not appropriate for use if they are expired. On 04/28/26 at 12:44pm observed medication storage room with V4 (RN). Observed medication Aspercreme with expiration date of 03/2026.On 04/29/26 at 3:25pm V2 (Director of Nursing/DON) stated that her expectation is that there's no expired medications or supplies in the medication cart. V2 stated that expired medications are detrimental to residents and should not be on the medication cart. V2 stated that expired medications and supplies should be discarded and replaced with non-expired supplies. V2 stated that loose pills are unacceptable and unsanitary. V2 stated that loose pills cannot be properly identified if they are not in their original package.Facility's policy titled Storage and Expiration Dating of Medications and Biologicals revised date 06/30/25 documents in part, Procedure: 10. Facility should ensure medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 11. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container when the medication has a shortened expiration dated once opened. 12. Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels or cautionary instructions.

Based on observations, interviews and record review, facility failed to follow their policy and federal regulation; failed to ensure that food safety is maintained during lunch serving from a steam table by staff touching ready to eat food with bare hands, wearing only one glove and not washing hands before glove applying or after glove removal; failed to follow proper sanitation practices to ensure that the dishwasher machine sanitized dishes at the proper temperature; and failed to properly contain and label open food in the freezer. These failures affected one resident (R22) and have the potential to cause foodborne illnesses for all 23 residents receiving oral nourishment in the facility.Findings include: On 4/27/26 at 9:15 am, kitchen tour was conducted with V7 Director of Dining Services, and the following findings were observed. At 9:25 am, Walk in freezer observed crab cakes in a silver tray with saranwrap not fully covering the crab cakes and the crab cakes were not dated. V7 Director of Dining Services stated, The crab cakes have been in the freezer since Friday, and they should have been dated. I will remove them. At 9:30 am, V7 ran a test strip to test the dish machine sanitation level. The dishwasher machine was observed, with two gauges in front of the machine. V7 stated that one gauge was for the wash cycle, and the other gauge was for the final rinse cycle. The first gauge during the wash cycle had a reading of 155 degrees Fahrenheit (F), and the second gauge was the final rinse cycle that had a reading of 150 degrees F. V7 stated that the final rinse should reach 160 degrees F. A second test was run with the same results. On 4/27/26, V7 Director of Dining Services presented a list of 23 residents who were receiving an oral diet in the facility. On 4/28/26, V7 presented a document titled, Education in-service training record, with content of ensuring all dishwashing equipment is operated at required sanitizing temperatures to reduce the risk of foodborne illness and maintain compliance with public health regulations. On 4/29/26 at 10:00 am, V7 stated that the dishwasher machine was not working and was serviced yesterday (4/28/26); we are rewashing all the dishes. The company had to change the heat booster element. It was not getting to the proper temperature to sanitize the dishes. On 4/29/26 at 11:00 am, V15 Director of Plant Operation stated that there was a work order placed on Monday, 4/28/26. It is a high temperature machine. The sanitation temp should be 160 degrees. We called out for the machine to be serviced. I saw the strip yesterday; the way I read the strip was not turning completely black. It should turn completely black. If it is not black, then it is not reaching the right temperature of 160 degrees. There were days on this month's log sheet that did not appear to have reached the right temperature. They should have rearranged it to make sure it was ok. If we failed again, we should have placed a work order in. If the machine does not reach the proper temperature, then it could still be dirty, and dirt carries bacteria. Facilities Dishwasher Test Strips Results sheet documents, in part, Corrective Actions: If the test strip result doesn't match the color for 160 degrees Fahrenheit, stop using the machine and notify your supervisor. For the month of April 2026, the dates that the strips were gray and not black were on April 11, 12, 21, 22, 23, 24, 25, and 26. Facility's dishwasher temperature sensitive tape label documents, in part, 4. The gray/white temperature sensitive element will turn black if the dish has reached the rated temperature. Facility document titled The Worx Hub dated 4/28/26, documents, in part, Main kitchen: Details: Dish machine's final rinse is not rising to 180 degrees. Dishwasher machine service ticket dated 4/28/26, documents in part, Description of work performed: Arrived at location and found final rinse was at 150 degrees. One contactor was burnt up and not pulling in. So, contactor removed and installed contactor in its place and then ran unit final rinse temperature now at 195 degrees. Ran temperature strips and they turned black. Facility's Policy titled, Sanitation an Infection Prevention/Control dated 1/26 documents, in part, Dish Machine Temperatures: Single tank conveyor dual temperature machine: wash temperature 160 degrees Fahrenheit. Final rinse temperature 180 degrees Fahrenheit - 194 degrees Fahrenheit. Facility's Policy titled, Food and Supply Storage dated 1/26 documents, in part, Policies: All food, nonfood items, and supplies used in food preparations shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures: Cover, label, and date, unused portions and open packages. Facility's Job description titled Director of Dining Services undated, documents in part, Leading Food and Beverage Operations: Perform daily walk-through to ensure full compliance with Département of Health regulations and Compass Group standards. Direct and conducts safety, sanitation, and maintenance programs. Findings include: On 4/27/2026 at 9:45 AM, the census presented is 23 residents in the facility. On 4/27/2026 at 12:01 PM, during lunch observation of the third floor unit, observed V3 (Server) behind the hot steam bar serving lunch for residents without gloves on. Observed V3 assembling garden salad for R22 with bare unwashed hands without using serving utensils or gloves. V3 was observed to touch and remove sliced cucumber from a container of precut cucumbers with bare hands and placed the cucumber on top of the lettuce along with the tomato that V3 also placed on R22's plate with bare hands. On 4/27/2026 at 12:03 PM, observed R22 receiving the salad plate and observed R22 eating salad including the cucumber that was placed by V3's bare hands on R22's plate. Observed V3 to continue to assemble salad for other residents in the dining room during lunch serve in the same manner, where V3 was touching vegetables with bare hands and placing on resident's plates without using serving utensils or gloves. On 4/27/2026 at 12:55 PM, V3 (Server) stated that V3 is allowed to touch and serve food with bare hands without using gloves as long as V3 washed hands. V3 also said that V3 can touch raw vegetables with bare hands when V3 is placing vegetables on resident's plate. On 4/28/2026 at 12:07 PM, observed V5 (Server) serving lunch for the residents on the 3rd floor unit behind the hot steam bar. Observed V5 to place one glove on the left hand and not on the right hand and removed a slice of toast from a toaster, placed on the table and cut toast in half. V5 was observed cutting the toast holding the sandwich in left hand and knife in the right hand that had no glove on. V5 placed the cut sandwich on the plate, then removed glove from the left hand, did not wash hands after glove removal. V5 with unwashed bare hands removed items from fridge, and ice cream from freezer, touching the ice cream bin, served ice cream into resident's bowl and placed ice cream bin back in the freezer. V5 immediately put one glove only on the left hand and touched and cut another toasted sandwich in the same matter, holding bread in left hand with glove on and holding knife in the right hand with no glove and with no hand washing observed. V5 removed the glove and immediately touched other resident's plates to serve food without washing hands between or prior to applying or after removing gloves. On 4/28/2026 at 12:23 PM, V5 (Server) stated that ready-to eat food should never be touched and served with bare hands and if no serving utensils are available, then gloves should be used for touching the food. V5 said that touching food with bare hands could cause infection and spread diseases and that food should be served in a sanitary matter. V5 stated that gloves should be worn on both hands and hands should be washed before applying gloves and after glove removal. On 4/28/2026 at 12:39 PM, V6 (Assistant Director of Dining Services) stated that the dietary staff serving food should be always wearing gloves when preparing and assembling salad and when they need to touch ready-to eat food. V6 stated that the staff should not be touching ready to eat food or vegetables with bare hands and placing on residents plates. V6 also said that staff should be washing hands before applying gloves and immediately after removing gloves. On 4/28/2026 at 12:40 PM, V7 (Dining Services Director) stated that the food servers and dietary staff should not use bare hands and touch resident's food to prepare salad for residents. V7 stated that the staff should always wear gloves on both hands when touching food and placing on plates and should wash hands prior applying and after removing of gloves. V7 stated that it is important to wash hands and not touching food with bare hands to prevent bacteria spreading. V7 stated that there are no residents on the unit with Nothing by mouth (NPO) precautions and that all 23 residents were being served lunch from the same hot steam table. V7 affirmed that if food server touches vegetables in the already prepared containers with bare hands, there is a risk of contamination and spreading of bacteria or infection that could potentially affect all 23 residents receiving lunch plates from the same vegetable containers. On 4/29/2026 at 12:40 PM, V1 (Administrator) stated that employees should not use bare hands to touch food when serving plates. V1 stated that is important because of infection control and spreading of germs and that employee touching food from main bowl and placing it on the plate would affect every resident eating at the facility. V1 also stated that hand hygiene is very important to prevent infection spreading and everyone should wash hands after removing gloves. On 4/29/2026 at 12:52 PM, V2 (Director of Nursing/DON/ Infection Preventionist/IP) stated that bare hands should not touch food, because it can cause contamination and infection spreading and that staff should always use gloves when touching food and placing on residents plates. V2 also said that hands should be washed before applying gloves and immediately after glove removal. R22's Diagnosis include but is not limited to Other secondary Parkinsonism; Meniere's Disease bilateral; Low Back Pain, Unspecified Sensorineural Hearing Loss; Obstructive Sleep Apnea; Lack of Coordination; Unsteadiness on feet; Vitamin D deficiency; History of Falling; Essential Hypertension; Muscle Weakness; Primary open-angle Glaucoma bilateral; Kyphosis of thoracic region and basal cell carcinoma of skin of scalp and neck. R22's Minimal Data Sheets (MDS) (4/13/2026), in section C for Cognitive Patterns showed in part the Brief Interview for Mental Status (BIMS) score of 15 which indicates intact cognition. R22's Active Diet order (1/6/2026) showed in part Regular diet, regular texture and regular consistency and Active order (1/12/2026) for Nutritional supplement once a day. R22's Care Plan (1/11/2026) showed in part that R22 has a potential nutritional and skin integrity problem and to provide and serve supplements and diet as ordered. Facility's Menu (Monday 4/27/2026) showed in part that Garden salad was on the menu for lunch starters for all residents with Regular diet and regular texture. Facility's Document titled Diet Type Report (4/29/2026) showed in part that 16 residents in the facility have a regular diet, 6 residents have No Added Salt (NAS) diet, and one resident has No concentrated Sweets Diet ordered. Document showed in part that all 23 residents have regular texture diet ordered. Facility's Document titled Education/In-Service Training Record (Undated), showed in part that objective is for dining services staff should demonstrate proper food safety and sanitation practices by preventing bare-hand contact with ready-to-eat foods to reduce the risk of foodborne illness. Document also showed in part that to prevent cross-contamination and foodborne illness bare-hands contact with foods including but not limited to cucumbers, vegetables, cut fruit, and breads is not allowed and if any employee touches food with bare hands the food should be discarded. Document also showed in part that approved barriers must be used at all times including but not limited to disposable gloves and that hands should be washed before putting on new gloves. Document showed in part that if the bare hands touch any food, the staff responsibility is to discard contaminated food immediately and that failure to follow procedures could result in foodborne illness. Facility's Document titled Resident Food Services Policy (1/2026) showed in part that Meal service should be provided in a safe, clean and home like environment and that gloves or barrier utensils should be utilized when staff handles ready to eat food. Document show in part that staff should wash hands or use alcohol sanitizer after touching resident or serving next course. Facility's Document titled Recommendations for Standard and Transmission-Based Precautions in Healthcare Settings (Undated), showed in part that standard precautions is infection control method that should help reduce transmission of disease and applies to all residents that are receiving care. Document also showed in part that hand hygiene used frequently is the most important measure to reduce the risks of transmitting organisms and in the dining services department, soap and water is the only approved method for decontaminating hands during food preparation and food service. Document showed in part that microorganisms that are present on staff's hands, would transfer to residents and that wearing gloves does not replace the need for hand hygiene, and hands should be decontaminated after gloves removal and between resident contact and the failure could cause infection control hazard. Facility's Document titled Chapter 1 Infection Control Guidelines (Undated), showed in part that compliance with specific requirements for infection control include but are not limited to provide a safe and sanitary environment and help prevent development and transmission of disease and infection. Facility's Document titled Chapter 2 Practice Guidelines (Undated) showed in part clean technique refers to reduction of numbers of microorganisms or reduction of the risk of transmission from one person or place to another person and that hand hygiene to reduce skin microorganisms include use of soap or hand sanitizer. Document also showed in part that wearing gloves reduces the risk of transmitting organisms on hands contaminated with microorganisms from one staff to resident and vice versa and to wash hands or use hand sanitizer after removal of gloves. Facility's Document titled Position: Server/Dietary Aide, (6/25/2025), showed in part that Server should ensure that all dietary procedures are followed according to the established policies and that the food should be prepared in accordance with sanitary regulations and facility's established policies and procedures and that safety regulations and precautions should be followed at all times. Facility's Document titled Assistant Director of Dining Services Job Description, (Undated),showed in part that the Assistant Director of Dining Services is responsible for assistance with all aspects of dining service , supervision of daily operations and maintaining the highest standards of food quality and ensures compliance with federal and state regulations and with facility's protocols regarding food service operations, safety and security and should follow facility's and department's Infection Control policies and procedures. Facility's Document titled Director of Dining Services Job Summary, (Undated), showed in part that the director should oversee the development and implementation of departmental strategies and should perform daily walk-through to ensure compliance with health regulations and standards and should direct and conduct safety, sanitation and maintenance program and ensures ongoing communication in all areas of food and beverage by conducting staff meetings to update staff members on relevant information. Facility's Document titled Infection Preventionist Responsibilities (Undated), showed in part that the Infection Preventionist's (IP) responsibility include but are not limited to prevention and control strategies, providing education and training, implementing evidence based infection control practices and recommend education for colleagues to minimize, prevent and control infections. Facility's Document titled Role Profile Director of Nursing (Undated), showed in part that the Director of Nursing (DON) should provide management and supervision of the nursing care provided to the residents of the facility and the DON manages the day to day operations of the facility, ensures that the facility is operating within the state and federal regulations and is responsible for nursing outcomes, reviews and adjusts daily nursing hours in accordance to census and reviews and implements staffing plan for the facility's Nursing staff. DON also develops and implements an Infection Control Program and selects and evaluates staff for departmental leadership and management. Facility's Document titled Position: Executive Director (Undated), showed in part that some of the essential functions of the Executive Director (Administrator) include but are not limited to maintaining working knowledge of applicable federal and state laws and regulations and other policies and procedures to ensure adherence and insuring compliance with regulatory agencies. The (Rev. 229; Issued: 04-25-25; Effective: 04-25-25; Implementation: 04-28-25) State Operations Manual Documents, in part, 483.60(i) Food safety requirements. The facility must – 483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Based on observation, interview and record review, the facility failed to label and date nebulizer mask for one resident (R34). These failures affected one resident (R34) reviewed for respiratory equipment in total sample of 21 residents.Findings include:On 4/27/26 at 11:00 am, R34 was observed in bed with a nebulizer mask not dated lying inside R34's nightstand. R34 stated that he gets nebulizer treatments every day and as needed.On 4/28/2026 at 12:10 PM V2 (Director of Nursing) stated that nebulizer mask should be dated when it is changed or when therapy is initiated. It should be changed weekly or as needed (e.g. (for example), if visibly dirty). The reason is for infection control regarding the nebulizer mask getting dirty and contaminated. On 4/29/2026 at 11:12 AM V11 (Registered Nurse) stated that nebulizer masks are usually changed and dated by Sunday night shift nurses. V11 also stated that if she sees any mask that is visibly dirty or not dated, she will change and date it. The purpose of this is infection control practice.R34's admission Record documents diagnoses which include but are not limited to pulmonary fibrosis, muscle weakness, obstructive sleep apnea, pulmonary embolism, difficulty in walking and presence of automatic cardiac defibrillator.R34's Brief Interview of Mental Status (BIMS) score is 15. R34 is cognitively intact.R34's Physician Order Sheet (POS) shows active order dated 4/19/26 documents, in part: Albuterol solution 2.5mg(milligram)/3ml(milliliter). 3 milliliter inhale orally via nebulizer one time a day related to pulmonary fibrosis.R34's Physician Order Sheet (POS) shows active order dated 4/19/26 documents, in part: Ipratropium-Albuterol inhalation Solution 0.5-2.5 (3) MG (Milligram)/3ML (Milliliter) 3 ml orally every 6 hours as needed for Shortness of Breath/Wheezing via nebulizer.The facility's job description titled Role Profile for Registered Nurse (undated) documents, in part: Position responsibilities: Adhere to state and federal rules and regulations concerning delivery of care and assure that effective quality nursing care is delivered. Assume responsibility of care interventions consistent with professional standards of care. Demonstrates working knowledge of infection control practices.The facility's policy titled Infection Control Guidelines (undated) documents, in part: CMS (Centers for Medicaid and Medicare Services) mandates compliance with specific requirements for infection control. Define policies, procedures and practices consistent with evidence based infection control practices. Provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection.

Based on observation, interview and record review the facility failed to reconcile control substance form and maintain an accurate account of the controlled substance record for one resident (R38) reviewed for controlled substance in a sample of 21 residents.Findings include:On 04/28/26 at 12:35pm reviewed 3rd floor medication cart with V4 (Registered Nurse/RN). R38's controlled substance form for phenobarbital 64.8mg (milligrams) showed quantity remaining as 28. 27 tablets observed.R38's physician's order dated 04/21/26 documents in part, Phenobarbital oral tablet 64.8mg. Give 1 tablet by mouth one time a day for seizures.On 04/28/26 at 12:35pm V4 (RN) stated that she forgot to sign the narcotic sheet when she removed R38's medication. V4 stated that not signing out narcotics when removing them could create a count discrepancy and/or diversion. On 04/29/26 at 3:25pm V2 (Director of Nursing/DON) stated that the purpose of signing the controlled substance form is to make sure that all narcotics are accounted for. V2 stated that If the nurse doesn't sign out narcotics at the time of removal, the nurse could forget to sign it later and create a discrepancy. Facility's policy titled Inventory Control of Controlled Substances revised 08/01/24 documents in part, Procedure: 1.1 Facility should maintain separate individual controlled substance records on all Schedule II medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the Controlled Substances Declining Inventory Record. These records should include:. 1.1.6 Quantity remaining.Facility's undated job description titled Registered Nurse documents in part, Position Responsibilities: Maintains an updated knowledge base in pharmacology. Demonstrates knowledge of policies governing medication administration and documentation. Assures that narcotics are accounted for properly.

Based on observations, interviews, and record reviews, the facility failed to properly store respiratory equipment in a sanitary manner to help prevent transmission of disease and infection. This failure could potentially affect 1 (R18) resident reviewed for infection prevention and control in a sample of 21.On 04/27/2026 at 12:27PM surveyor and V2 (Director of Nursing/Infection Preventionist, DON/IP) entered R18's room and observed R18 awake in bed. A suction machine inside a plastic bag was observed laying on the floor next to a chair. An oxygen mask with oxygen tubing inside a plastic bag was observed laying on the floor next to the suction machine. Surveyor asked V2 if suction machine and oxygen mask with tubing should be on the floor and V2 said, No. V2 took suction machine and oxygen mask with tubing out of R18's room.R18's Brief Interview for Mental Status (BIMS) dated 04/10/2026 documents R18 with a score of 00 which indicates that R18's cognition is severely impaired.R18's face sheet shows that R18 was admitted to the facility on [DATE] with diagnoses which include but are not limited to: Vascular dementia, Dysphagia, Oropharyngeal phase. R18's orders show that R18 was admitted to [NAME] Hospice on 05/11/2024.On 04/29/2026 at 1:46PM, V2 was interviewed and stated, suction machines and oxygen masks with their tubing should be laid on a bedside table or dresser. When asked why suction machines and oxygen masks with their tubing should not be on the floor, V2 stated It should not be on the floor because that's an infection control issue, it can get contaminated and transfer an infection to the resident. It's also hazardous because anyone can trip over it.Facilities Infection Control document (undated) Chapter 1 states in part, Provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection. Provide measures to prevent and control outbreaks and cross-contamination. Infection Preventionist responsibilities include in part, Monitor appropriateness of precautionary procedures for individual residents.

Based on interviews and record review, the facility failed to ensure that one resident (R1) had an informed signed consent prior to administering a psychotropic medication. Findings include:R1 is an [AGE] year old with diagnosis including but not limited to: Alzheimer's disease, Delirium due to known physical condition, unspecified lack of coordination, difficulty in walking and essential hypertension. R1 has a BIMS (Brief Interview of Mental Status) score of 7, which indicates severe cognitive impairment. On 9/17/25 at 12:57 pm, R1 was observed sitting in his room with his daughter. At that time, V9 (R1's Family) said the following, They (facility) were giving my father Trazadone and I asked that they discontinue the Trazadone because once, I came here and he (R1) was very lethargic and looked like a zombie. When I asked what he had, I was told that he had Melatonin and Trazadone for sleep the previous night. Melatonin alone is just fine for my father to sleep. He is [AGE] years old. Why would they give my father both medications to sleep? I never consented for Trazadone and I am his POA (Power of Attorney).On 9/17/25 at 4:15 pm, V6 (Nurse Manager) stated the following, We do not have any psychotropic consents for R1.The purpose of doing the informed consent is to let them know if there are any adverse effects to the medication and to get signed consent to give the medication.On 9/18/25 at 12:40 pm, V7 (Registered Nurse) stated the following, R1 has dementia and is here for rehabilitation. His daughter (V9) is here almost daily and oversees his care. She had concerns about his sleeping medication (Melatonin) and stated that she did not want it scheduled. She (V9) also wanted the Trazodone discontinued and complained that she didn't like the way that her father looked when she visited. I don't give any psychotropic medication without consent from either the patient or the family.R1's MAR (Medication Administration Record) for the period of 8/1/25- 8/31/25 documents both Melatonin 3 mg (milligrams) and Trazadone 50 mg administered to R1 on 8/6/25. R1's Order Report documents the following orders that started on 8/6/24 and ended on 8/9/25: Melatonin 3 mg and Trazadone 50 mg.Facility policy titled Psychotropic medication use documents the following: Facility should comply with the Centers for Medicare and Medicaid Services (CMS) State Operations Manual Appendix PP, and all other Applicable Laws relating to the use of psychopharmacologic medications including gradual dose reductions; Facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulations.

Based on interview and record review, the facility failed to implement and revise the resident-centered care plan for a resident with a diagnosis of urinary tract infection and hernia which affected one resident (R1) in the sample of 20 residents reviewed for care plan revision. Findings include:R1's admission Record documents, in part, diagnoses of urinary tract infection (UTI), Delirium, Benign Prostatic Hyperplasia with lower urinary tract symptoms Muscle weakness, difficulty in walking, chronic kidney disease stage 3, Essential hypertension, Unspecified Glaucoma, Alzheimer's, Anxiety, Malignant neoplasm of splenic.R1's Minimum Data Set (MDS), dated [DATE], documents, in part, a Staff Assessment for Cognitive Skills for Daily Decision Making is coded at 7 which is severe cognitive impairment. R1's Care Plan Report dated 8/5/2025 has no documentation stating care of UTI or hernia was observed in chart. On 9/18/25 at 10:56am, V6 ( MDS coordinator/Nurse) stated all diagnosis are care planned to ensure that staff is aware of plan of care for each resident, and if a resident is admitted with a diagnosis of infection such as urinary tract infection this diagnosis should be care planned to ensure staff will be able to plan the care of the resident and monitor sign and symptoms and monitor for adverse reactions and be able to perform appropriate assessments. I reviewed R1's admission paperwork, med list and diagnosis, but I do not read the information under the main diagnosis sheet, and if a resident was still being treated for UTI it is the nurse's responsibility to clarify that in nurse-to-nurse report prior to the resident transferring over to the facility. It is part of my responsibility to have care planned the diagnosis of UTI and Hernia. Hernia should be a focus on a care plan because the nurses can assess for size and monitor for pain and be able to report off to the physician for any changes to site.Facility job description undated and titled (Registered Nurse) documents, in part, . Position Summary: Responsible for the independent supervision of the delivery of care to a group of residents on a nursing unit. Assesses residents' needs, develops care plans, administers nursing care, evaluates nursing care, and supervises CNA and other personnel in the delivery of nursing care; Develops and implements Plan of Care for each resident.Facility policy titled Baseline Care Plan dated November 1, 2019, documents, in part, Purpose Statement: The community must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident. The community must provide the resident and representative a summary of the baseline care plan in a language and conveyed in a manner the resident and or representative can understand.2). The baseline /admission care plan will include information for the provision of effective person- centered care and will include the minimum healthcare information necessary to properly care for each resident immediately upon admission.

Based on observation, interview and record review, the facility failed to provide showers to a resident. This failure affected one resident (R1) reviewed for ADLs (activities of daily living) in a sample size of 20 residents. The findings include:On 9/17/25 at 12:52 PM, R1's white board in room displayed the dates that he was assigned to receive showers from facility staff, the dates listed were every Sunday and every Wednesday. R1 was eating his lunch at time of observation, his hair presented as oily and food debris were observed on his clothing.On 9/17/2025 at 12:57 PM, V9 (family member of R1) was in the room with R1 and stated that the facility has only provided R1 a shower once since admission and she knows this because she is always at the facility or has a caregiver present as a companion for R1 when she is not available.On 9/17/2025 at 1:24 PM, V8 (Certified Nursing assistant, CNA) entered the room of R1 to collect the food tray of R1, V8 stated he did not give R1 a shower. V8 stated I gave R1 a bed bath because I did not have any assistance from team members and the last time I gave R1 a shower was about two weeks ago. V8 stated he could not remember which team members he asked for assistance from, but V8 stated I was too busy to provide R1 a shower because I was assigned to provide a shower to another resident. V8 stated he informed his nurse that a bed bath was given.On 9/17/2025 at 1:27pm, V7 ( Registered nurse) stated she was the nurse assigned to R1 and that V8 informed her that R1 refused his shower, I did not get a chance to go and speak to R1 because V8 had informed me after he provided R1 with the bedbath.V7 stated the staff is aware to come and get the nurse when a resident refuses care so the nurse has the opportunity to speak with the resident to assess the reason for refusal of care and try and encourage the resident to receive treatment. If the resident continues to refuse showers the responsible power of authority (POA) is notified, and documentation is placed in the chart regarding the refusal. V7 provided copies of R1's shower review sheets and stated that the 7 sheets provided were the only shower review sheets available for R1.On 9/17/25 at 1:50 pm, V6 (MDS Nurse) stated the following, Our showers are documented via shower sheet at the nurse's station. We have demented residents who will refuse showers at times. We will attempt to shower the resident and it is documented on the shower sheet. The nurse and the CNA will document on the shower sheet. On 9/18/2025 at 2:45 PM, V2 (Director of Nursing) stated the following the nurse is responsible to ensure that residents showers are completed. The nurse is the direct supervisor of the certified nursing assistants and supervises the day-to-day care provided to the residents on the units each shift and if a resident refuses a shower a call should be placed to the POA because the POA must be made aware that the resident is declining showers to give the POA an opportunity to try and encourage the resident to shower, the refusal behavior should also be care planned in chart, so all staff are aware. I was made aware that R1 refuses showers by one of the staff members and I have never spoke with V9 to inform her that R1 has been refusing staff assistance to have showers taken, I signed R1's bed bath sheet one day but I cannot remember the day.R1's face sheet dated September 17,2025 states that R1 admitted to facility on 8/5/2025 with diagnosis of Urinary tract infection, Delirium, Benign Prostatic Hyperplasia with lower urinary tract symptoms, muscle weakness, difficulty in walking, chronic kidney disease #3, essential hypertension, unspecified glaucoma, Alzheimer's, anxiety, malignant neoplasm of splenic. R1's MDS (Minimum Data Set) dated August 12, 2025, shows R1 has a score of 7 which means R1 has severe cognitive impairment; Functional abilities score is 1 which means R1 is dependent on staff to provide all care for shower/bath; Transfer to tub/shower staff provides more than half of the effort for task to be completed.R1's care plan dated and revised on August 13,2024 shows R1 has a self-care performance deficit requires assistance with personal hygiene and ADLs including brushing teeth, washing/drying face, and hands, combing hair, cutting nails, shaving etc. due to Dementia, Impaired balance, and Fatigue. Intervention/Task: staff will provide [R1] with sponge bath when a full bath or shower cannot be tolerated.On 9/17/2025 reviewed R1's Shower/laundry/AD cleaning schedule, documents that R1 is scheduled to have showers on Sundays and Wednesdays.Skin monitoring: Comprehensive CNA shower review, there were seven sheets to review with listed dates:8/6/25 bed bath completed, 8/31/25 shower completed, 9/3/25 bed bath completed, 9/12/25 refused, asked three times in front of daughter too, refused nurse too, 9/14/25 bed bath, decline shower offered bed bath,9/15/25 bed bath, given bed bath, refused shower,9/17/25 Declined shower, no new skin areas observed, bed bath offered this was signed by V8 and V7.Since admission on [DATE] R1 was scheduled to receive 13 showers and only received one shower per document. Dates of scheduled showers that were to be given are listed below:8/10/25: No document provided,8/13/25: No document provided,8/17/25: No document provided,8/20/25: No document provided,8/24/25: No documents provided,8/27/25: No documents provided,9/7/25: No document provided,9/10/25: No document provided. V7 stated that there were no documented showers for dates listed.On 9/18/2025 at 2:30 PM, V1 stated the facility does not have a specific policy for Activity of daily living or showers.Job description titled Certified Nursing Assistant, documents in part; Essential Functions: (c) Attends to the individual needs of residents, which may include assistance with grooming, bathing, oral hygiene, feeding, incontinent care, toileting, transferring, communicating or other needs in keeping with the individuals care requirements.Job description titled Registered Nurse, documents in part; Position Responsibilities: Supervise CNA.Job description titled Licensed Practical Nurse, documents in part; Position Responsibilities: Supervise CNA.

Based on observation and interview, the facility failed to have signage posted identifying a resident who has oxygen in use in the resident's room to prevent a possible hazard. This affected one resident (R12) in a total sample of 21 residents. Findings include: On 02/03/2025 at 10:45am surveyor observed an oxygen tank, contained in a stand, sitting on the floor in R12's room. No Oxygen in Use sign posted on the outside of R12's door indicating that oxygen was in use in R12's room. On 02/03/2025 at 11:45am V1(Director of Nursing) stated, yes, there should be a sign on the door indicating that oxygen is in use in R12's room. On 02/05/2025 at 10:30am V1(Director of Nursing) stated the nursing staff are responsible for placing the Oxygen in Use sign on the resident's room door if the resident requires and receives an order for oxygen. V1 stated the sign is to be placed on front of the resident's door or there is a magnetic sign the staff can place on the door frame. V1 stated if the resident or family smokes in a room with oxygen; this can be a fire hazard. R12's diagnosis includes, but are not limited to, chronic obstructive pulmonary disease, unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris, acute combined systolic (congestive) and diastolic (congestive) heart failure, and type 2 diabetes mellitus without complications. R12 has a Brief Interview for Mental Status (BIMS) dated 12/04/2024 which documents R12 has a BIMS score of 15, indicating R12's cognition is intact. R12's most current Order Summary Report documents in part, O2(oxygen) 2L(liters) via nasal cannula prn (as needed). R12's care plan documents in part, Focus: R12 has COPD (Chronic Obstructive Pulmonary Disease). Goal: R12 will display optimal breathing patterns daily through review date. Intervention: Oxygen Settings: O2(oxygen) via NC9nasal cannula) @(at) 2L(liters). On 02/05/2025 reviewed the facility's policy dated May 2008 and titled Oxygen Administration, which documents in part, Underneath Supplies that may be required for this procedure: l) Oxygen in use, no smoking sign as required.

Based on observations, interviews, and record reviews the facility failed to ensure kitchen staff wearing hair restraint while in the kitchen and failed to ensure frozen meats were stored six inches above the floor in the freezer. These failures have the potential to affect 22 residents in the facility who are receiving oral diet. Findings Include: On 1/23/24 at around 9:36 AM, during the initial tour in the kitchen, V15 (Utility Worker) was observed handling the dishes in the dishwashing machine area. V15 had short length hair on V15's head and was not wearing any hair restraint. At 9:49 AM, the main freezer was inspected with V14 (Director of Dining) and observed a frozen packed beef brisket and a frozen packed beef eye round on the floor under the shelving unit. V14 stated that foods should not be stored on the floor. V14 placed both packages of meat back at the bottom of the shelf in the freezer. At 9:56 AM, V14 stated that anyone who enters the kitchen especially kitchen staff should wear hair net or hair restraint to keep any loose hair falling off on to the food. On 1/24/24 at 10:11 AM, V13 (Chef Manager) stated that foods in the dry storage, in the cooler, and in the freezer should be stored six inches off the ground. V13 stated that if the food is left on the floor, it needs to be thrown out. V13 stated that there are no residents in the facility that are NPO (Nothing by Mouth). The facility's roster documents 22 residents in the facility. The facility's policy titled; UNIFORM DRESS CODE dated 1/17 reads in part: PROCEDURES: Wear the approved hair restraints when on duty. The facility's policy titled; FOOD AND SUPPLY STORAGE dated 1/18 reads in part: FROZEN STORAGE Store food items _ above the floor, consistent with local food protection codes* *6 above floor is the federal guideline.

Based on observation, interview and record review, the facility failed to follow their policies and procedures to ensure proper infection control guideline practices are followed related to Personal Protective Equipment (PPE) was not worn prior to entering a contact/droplet isolation room for 1 (R20) out 4 residents reviewed for transmission-based precautions in sample of 12. This failure has the potential to affect all 22 residents residing in the facility. Findings Include: On 01/23/24 at 10:42 AM, surveyor noticed R20's door was closed with droplet/contact isolation sign for staff and visitor was posted on the front of R20's door. Surveyor observed V9 R20's son entered R20's droplet/contact isolation (Covid-19) room with surgical mask but without the proper Personal Protective Equipment (PPE) gown, gloves, N95 mask, and face shield. Surveyor called V8 (Certified Nursing Assistant) and asked V8 if it is proper for V9 to enter R20's room without PPE. V8 stated it is not proper for V9 to enter R20's room (Covid-19) without the PPE, V9 can be infected and pass it to others. V8 then told V9 to come out of R20's room for V9 to wear the PPE. V9 came out of R20's room to put on the gown, gloves, N95 mask, and a face shield by the door of R20's room. V9 stated I know it is wrong not to wear the PPE, but I come here to visit R20 every day, and I don't put on the stuff (PPE) by the door. I know I should have put on the PPE. On 01/24/24 at 9:40 AM, V2 (Director of Nursing/Infection Preventionist) stated that staff and visitors should not enter isolation room without donning the appropriate PPE (gown, gloves, N95 mask and a face shield). Because V9 entered R20's room without donning the proper PPE, V9 is vulnerable to infecting others. V2 did Covid-19 test for the residents on 1/23/24, surveyor noticed additional 3 residents positive for Covid-19. Surveyor also noticed no staff redirected V9 from entering R20's room until the surveyor called V8. V2 stated V1 and V2 have written a letter to be sent to family members on the importance of adhering to infection prevention control policy. V2 has stopped the communal dining and other communal activities. The facility policy on Infection and Control Manual Coronavirus (COVID-19) Transmission Based Precaution (TBP) and Visitation dated 5/15/23 reads in part: Before visiting residents, who are on TBP, visitors should be made aware of the potential risk of visiting and precautions necessary to visit the resident. Resident should adhere to the core principles of infection prevention. Recommended PPE: N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face. The facility Daily Census dated 1/23/24 has active 22 residents of which 7 are positive for Covid-19 and additional 3 residents at the end of 1/23/24.

Based on observation, interview and record review, the facility failed to follow their policies and procedures to ensure a resident received their medications according to the physician's order for 1 (R20) out of 3 residents reviewed for pharmaceutical services in a sample of 12. Findings Include: On 1/23/24 at 11:30 AM, during record review surveyor observed V20 has order for antibiotic starting from 1/18/24 to 1/22/24 for Zithromax 250 MG tablet, to give 2 tablets on the first day, then 1 tablet daily for 4 days was administered until 1/23/24. On 1/23/24 at 11:50 AM, R20 stated, R20 has received medications this morning. On 1/24/24 at 9:50 AM, V12 (Registered Nurse) stated V12 discontinued the medication (Zithromax 250mg tablet) this morning (1/24/24). V12 stated the medication was signed off in the medication administration record yesterday (1/23/24). On 01/24/24 at 10:50 AM, V2 (Director of Nursing) stated that the medication (Zithromax 250 MG Tablet) was administered on 1/23/24, V2 agreed the medication should have been discontinued after the dose of 1/22/24. Nursing note dated 1/23/24 written by V19, reads in part: R20 is on Z-PAK (Zithromax) for infiltrates. R20 Physician Order Sheet (POS) with active orders as of 1/23/24 shows an order for Zithromax Z-Pak Oral Tablet (Azithromycin) Give 1 tablet by mouth one time a day for infiltrates Z-PAK as directed. Medication Administration Record (MAR) shows Zithromax tablet was administered on 1/23/24. Pharmacy prescription shows give Z-PAK as directed (take 2 tablets first day, then 1 tab daily for 4 days, start date 1/18/24. Administrative Orders sheet shows Zithromax 250 MG tablet was discontinued on 1/24/24 instead of 1/22/24. The facility policy for Medication Administration dated 5/2008 reads in part: Medications must be administered in a timely manner and in accordance with the attending physicians written/verbal orders.

Based on observation, interview and record review, the facility failed to (a) properly date opened multi-dose eyedrops for 1 (R9) resident and (b) ensure that medication was stored properly in the correct medication packaging and for the right resident for 2 (R2 and R9) residents. These failures could potentially affect 2 (R2 and R9) residents from one of one medication carts inspected for medication storage and labeling. The findings include: R2's health record documented admitted [DATE] with diagnoses not limited to Acute and chronic respiratory failure with hypoxia, Chronic right heart failure, Chronic lymphocytic leukemia of b-cell type not having achieved remission, Unspecified atrial fibrillation, Essential (primary) hypertension, Malignant neoplasm of unspecified kidney, Chronic kidney disease, Other pulmonary embolism with acute cor pulmonale, Dyspnea, Other allergic rhinitis. R9's health record documented admitted [DATE] with diagnoses not limited to Periprosthetic fracture around internal prosthetic right hip joint, Mild persistent asthma, Dementia in other diseases classified elsewhere, Shortness of breath, Cardiac murmur, Gastro-esophageal reflux disease without esophagitis, Dry eye syndrome of bilateral lacrimal glands, Other seasonal allergic rhinitis, Cough, Hypothyroidism. On 01/23/24 at 10:38 am, Medication cart inspected with V10 (Licensed Practical Nurse) and found the following: - R9's Olopatadine HCl Ophthalmic Solution 0.2 % multi-dose eye drops without the date opened written. - R2's clear plastic bag with pharmacy labeled Fluticasone nasal spray and inside the clear plastic bag was R9's Olopatidine multi-dose eye drops. V10 confirmed that R9's Olopatadine HCl Ophthalmic Solution 0.2 % multi-dose eye drops with no open date written and was kept in R2's plastic bag with pharmacy labelled Fluticasone spray. V10 stated that R9's eye drops should not be in R2's plastic bag because it is a different medication and different resident. V10 stated that eyedrops should have a date written when it was opened. On 1/24/24 at 10:54 am, V4 (RN/Registered Nurse manager) stated that all medications should have an open date written once opened to know when it was opened and when it is supposed to be discarded or disposed. V4 stated that medication should be kept in proper pharmacy packaging with correct medication and right resident to avoid confusion and potential medication error. At 11:14 am, V2 (DON/Director of Nursing) stated that all medications should have an open date written after opening to know the date when it was opened to guide when to dispose the medication. Stated that medication should be kept in proper packaging with correct resident and medication to avoid confusion and potential administering medication to wrong resident. R2 order summary report dated 1/23/24 with active order not limited to: - Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) 2 sprays in both nostrils every 24 hours as needed for nasal. R9 order summary report dated 1/23/24 with active order not limited to: - Olopatadine HCL ophthalmic solution 0.2% Instill 1 drop in both eyes in the morning related to Other Seasonal Allergic Rhinits. Facility's medication storage policy dated 8/2022 documented in part: - Proper med storage is a standard of practice. The pharmacy fills medications using specially packaged administration systems designed to assist facilities in reducing medication error. - Medication dating: Eye Drops - eye medication bottles / tubes with accelerated expiration dates must be dated / initialed upon opening. - Medications should be stored separately according to route of administration. Further separate routes in medication carts (e.g. oral, injectables, liquids, eyes, ears, nose, inhalers).

Based on interview and record review, facility staff failed to immediately report an allegation of abuse and failed to protect one of two residents, (R1) reviewed for abuse. Findings include: Review of facility's abuse investigation (Investigation summary and conclusion) dated 6.16.2023 documents in part: On June 15. 2023, Dining Staff Member (V4-Server) made allegation that she saw CNA (V3-Certified Nursing Assistant) pinch the arm of resident (R1) in dining room last Saturday (6.10.2023). V4 who made the allegation did not report anything on day of the alleged incident but rather waited 5/several days, only expressing her concern, and reporting it when she saw resident rubbing his right arm. Employee believed that the alleged harm may still be happening given resident was rubbing his arm. At the time of interview, employee could not give details of her observation of the pinching except that it occurred after the resident slid off his chair and the pinching was done to his right arm. V3 (CNA) denied allegation and could not account for what could have been interpreted as pinching. On 8.5.2023 at 10:50 AM, V2 (DON-Director of Nursing) said, V4 (Server) did not report alleged incident until 7 days after alleged when she (V4) saw resident rubbing his upper arm. On 8.5.2023 at 1:18 PM, V1 (Executive Director) said V5 (Director of Pastoral Care and Mission Integration) texted her around 8:00 AM on 6.15.2023; I called him, got the basics. He said V4 (Server) reported that she observed V3 (CNA) pinch R1. V4 said it happened on Saturday. V4 (Server) reported it on 6.15.2023 because she saw R1 rubbing his arm and thought it was still happening (V3 still pinching R1). V4 (Server) told me that V3 (CNA) may have been punishing R1 because he kept sliding from his wheelchair. V4 (Server) stated she saw V4 (CNA) pinch him (R1). V1 (Executive Director) said any allegation or incident of abuse should be reported immediately to your supervisor. We interviewed V3 (CNA) in my office. V3 explained that it was Friday, not Saturday, that R1 was sliding on floor. She said she would never hurt a resident. I asked her if there was anything that could have been misconstrued as abuse, she said no. On 8.5.2023 at 1:56 PM, V5 (Director of Pastoral Care and Mission Integration) said, the server (V4) called me over and said, I know why he's (R1) rubbing his arm like that, the nurse (V3 CNA) from the overnight shift is pinching him. V4 (Server) reported to me on 6.15.2023 that incident had happened; she wasn't exactly clear when it did happen that day but probably within the last couple of days, I immediately reported to V1 (Executive Director), who asked me to ask a few more questions. V5 said, if you see something say something; everyone is responsible to report immediately upon forming a suspicion (of abuse). On 8.5.2023 at 1:38 PM, V4 (Server) said, I was serving upstairs on the skilled unit. I was serving from behind the steam table. He (R1) was at the first table by the steam table, sitting in a wheelchair at the table. He repeatedly tried to get up then actually fell on floor on his butt. I called (V3) to come to the dining room to help him. She took him back to the table, she yelled at him not get up out of the chair, she pinched him (demonstrated twisting motion using her thumb and index fingers). I told (V5-Director of Pastoral Care and Mission Integration) the next day, he told me to tell (V1-Executive Director), so I came to talk to her. I should have reported (the incident) to a supervisor or V1 that day. On 18.5.2023 at 12:41 PM, V3 (CNA-Certified Nursing Assistant) said, Wow, it happened about two months ago. Somebody told them that I was abusing R1. They alleged it happened on Saturday in the dining room but did not report until Thursday. They allowed me to work Saturday, Sunday, Monday, and Tuesday. I was off on Wednesday. (V1-Executive Director) called me on Thursday and told me to come to her office on when I came to work. Why would I abuse a resident in the dining room where everyone could see me? I did not abuse the resident. Facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition ([NAME] Health Senior Communities, revised December 2019) documents in part, Adherence to the organization's Code of Conduct, is an expectation of all staff. The staff shall report any incident or allegation/suspicion of abuse, neglect, misappropriation of resident funds/property, and/or exploitations to the Administrator immediately. Definitions A. Abuse willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. E. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Procedure D. Protection Staff should immediately report all incidents and/or allegations to the Administrator. The Administrator or his/her designee shall be notified immediately if an incident involving resident abuse, neglect, misappropriation of resident funds/property, or injury of unknown source is discovered to have occurred or is suspected. The community will take all action necessary to prevent abuse, neglect, or misappropriation of the resident's funds/property from occurring while it is conducting its investigation of the incident. 1.Protect the Resident Staff should report all incidents and allegations immediately to their direct supervisor/Administrator without the fear of retaliation and regardless of whether they feel the allegation is credible. Remove alleged perpetrator immediately, if known. If staff is accused or suspected: immediately remove from the Community and the work schedule pending the outcome of the investigation.

Based on observation, interview and record review the facility: 1. failed to properly store and label open items; 2. failed to discard open items by labeled use by dates; and 3. failed to ensure food is prepared and served [NAME] sanitary manner by failing to don personal protective equipment (PPE) properly; These failures have the potential to affect 23 residents who receive meals from the facility kitchen. 1. On [DATE] at 11:13 am, during the initial tour of the kitchen, inside the ICE CREAM FREEZER, there were 5 tubs of opened ice cream with different flavors that are not labelled with date it was opened and use by date. V3, Kitchen Manager, stated, This kitchen serves the Assisted Living, Supportive Living and Skilled Unit of the facility. The icer cream buckets are not dated, I will throw them all away. Facility provided a document titled Mercy Circle Always Available Menu which affirms that Assorted Ice Creams are being offered and served to residents in the skilled unit. 2. Inside the UNDER COUNTER REFRIGERATOR, there were 2 cartons of liquid eggs with USE BY DATE of [DATE]. V3 stated that it is the cooks who check the refrigerators for expired foods. V3 then took the expired cartons of liquid eggs and threw them in the garbage container. 3. On [DATE] at 11:14 AM V7, Cook, while preparing Monte [NAME], was wearing surgical mask but not covering the nose. On [DATE] at 11:21 AM, during the 3rd floor dining room observation, V5, Server, while preparing the food on the steam table, was wearing her surgical mask under her chin, not covering the mouth and nose. V4, Director of Dining Services, motioned for V5 to place her (V5) surgical mask properly. V5 then proceeded to put her mask on properly with the nose and mouth covered. [DATE] 11:16 AM, V4, Director of Dining Services stated, Any opened food should have an open date and use by date. Both myself, V4 and V3, Kitchen Manager, check for expired foods in the storage freezers and refrigerators. Facility presented policy with subject Food and Supply Storage under Procedures document in part: Cover, label and date unused portions and open packages. Use the [NAME] orange label, Medvantage label or Ecolab Prep N Print label; complete all sections on the label. Products are good through the close of business on the date noted on the label Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date.

Based on interview and record review the facility failed to follow Water Safety Plan to send water sample annually to rule out Legionella (a bacteria that can cause a serious type of pneumonia (lung infection) called Legionnaires' disease) and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter) could grow and spread. These deficient practices has the potential to affect all 23 residents in the facility. Findings include: On 03/29/2023 at 10:12 AM. V2 (Director of Nursing / Infection Preventionist) stated that facility is aware that water should be monitored to prevent Legionella infection or Legionnaires' disease. And the staff that is assigned to monitor water being used by residents is V17 (Director of Plant Operations). On 03/29/2023 at 10:20 AM. V17 (Director of Plant Operation) said, Yes, facility submits water sample to an outside vendor lab yearly. But I am new to this position, I started 15 months ago, and I think the last time facility submitted water sample to test for Legionella was 2019. I know it is important to make sure that water is free from Legionella. V17 submitted water report dated 03/08/2019. Per Water Safety Plan dated 2019 water sampling for Legionella frequency should be done annually with a minimum of ten (10) samples. On 03/30/2023 at 11:11 AM. V17 stated, I will check on the lab that handle checking water sample for legionnaire because I think there are specific days that they accept samples. I will also work on the details like checking water temperature. I know this is a concern, and it is important to check that water being used by residents. To reduce cases of Legionnaires' disease in health care facilities, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare certified healthcare facilities must develop and maintain water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. The directive has an immediate effective date. (https://www.ashrae.org/about/news/2017/cms-issues-directive-requiring-medicare-certified-healthcare-facilities-to-implement-and-maintain-legionella-prevention-policies) Legionella, the bacterium that causes Legionnaires' disease, .Legionella can pose a health risk when it gets into building water systems. Legionella first must grow (increase in numbers). Then it has to spread through small water droplets (aerosolization) that people can breathe in. (https://www.cdc.gov/legionella/wmp/overview/growth-and-spread.html) Seven key elements of a Legionella water management program are to: Establish a water management program team, describe the building water systems using text and flow diagrams; identify areas where Legionella could grow and spread; decide where control measures should be applied and how to monitor them; establish ways to intervene when control limits are not met; make sure the program is running as designed (verification) and is effective (validation) and document and communicate all the activities. (https://www.cdc.gov/legionella/wmp/overview.html)

Based on observation, interviews, and review of records, the failed to follow policy on testing residents immediately after a single new case (V11) of COVID-19. These failure has the potential to affect all 23 residents in preventing the risk of Covid-19 infection Findings include: On 03/28/2023 at 09:37 AM. During entrance conference, V2 (Director of Nursing (DON) / Infection Control Preventionist) stated that facility does not have resident positive of Covid-19. At 11:15 AM, at the floor V2 approached writer and said, I know I said in the conference room that we (facility) do not have Covid-19 positive resident. But today after testing 1 resident was positive (R1). One of the staff who worked 2 weeks ago tested positive. Then we decided to test the whole floor because we only have small number of residents. R1 was seen with V18 (R1's Power Of Attorney/POA) at the bedside. V18 said, I am here every day and takes care of R1. I am R1's power of attorney. Few days ago, R1 had a cold-like symptoms and a mild sore throat. V18 was seen with face shield, gown, and mask but her gloves was on the floor. V18 was asked if she was informed to wear gloves since she is performing direct care to R1. V18 took the gloves on the floor and wear the same gloves on both of her hands. At 02:44 PM, V2, DON, identified V11 (Licensed Practical Nurse) as the staff that tested positive for Covid-19. V2 said, Last time V11 worked on the floor was Wednesday (03/22/2023). And yes, V11 did have direct care with all residents every time she (V11) worked on the floor being a nurse. V2 came back and presented facility nursing staff schedule that reads, V11 worked on 03/18/2023 (Saturday), 03/19/2023 (Sunday), 03/20/2023 (Monday) and 03/21/2023 (Tuesday) evening shift between 2:00 PM to 10:00 PM. V2 said, I was mistaken, V11 last worked in the facility on Tuesday, March 21, 2023. V11 notified us that she (V11) was positive with Covid-19 infection on Friday (03/24/2023). We tested staff during weekend, Saturday and Sunday and residents were tested today (03/28/2023), which is 4 days after learning that V11 tested positive. V2 was asked why residents were tested 4 days after and not sooner because R1 turned out positive and may have exposed other persons on the floor. V2 kept silent for few minutes, and when asked again. V2 said, I am thinking. And did not answer the question. When asked why since V18 (R1's POA) who comes in the facility every day has seen R1 with cold-like symptoms, why was there no testing done with R1 until today (03/28/2023)? V2 said, Nursing staff on the floor did not observe R1 with cold-like symptoms. V2 confirmed that when facility tested all residents after 4 days of knowing that V11 had COVID-19 infection, R1 tested positive for COVID-19. V2 said, Yes R1 was positive, and it is considered an outbreak if a single staff is positive of Covid-19. V2 submitted list of staff positive of Covid-19 that includes 6 staff including V11: V20 (Therapist/Agency) on 02/26/2023 V21 (Reception Staff) on 03/01/2023 V22 (Nurse) on 03/06/2023 V23 (Human Resource Staff) on 03/13/2023 V15 (Reception Staff) 03/14/2023. V11 (Licensed Practical Nurse) 3/24/2023 V2 also submitted list of 6 residents including R1 that are Covid-19 positive date range from 01/03/2023 to 03/28/2023. Per facility policy for Infection Prevention and Control Coronavirus (Covid-19) provided by V2 dated as reviewed on 03/08/2023, in part reads: Under Outbreak Management, a single case of SARS-CoV-2 infection in any HCP (Healthcare Personnel) or resident should be treated as potential outbreak. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could be exposed. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier that 24-hours after exposure, and if negative, again after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3 and day 5.

Based on observations, interviews, and review of records, the facility failed to track and secure documentation of vaccination status of a contracted direct care staff (V17) who has been granted exemption from the COVID-19 vaccination (V17). This failure has the potential to affect all 23 residents residing in the facility in preventing the spread of COVID-19 infections. Findings include: On 03/28/2023 at 09:37 AM. During entrance conference, V2 (Director of Nursing / Infection Control Preventionist) stated that facility does not have resident positive of Covid-19. At 11:15 AM, at the floor V2 approached writer and said, I know I said in the conference room that we (facility) does not have Covid-19 positive resident. But today after testing 1 resident was positive (R1). One of the staff who worked 2 weeks ago tested positive. Then we decided to test the whole floor because we only have small number of residents. On 03/28/2023 at 09:355 AM. V17 (Hospice Nurse / Agency) was seen with R1. V2 later confirmed V17 was providing direct care with R1 since R1 was admitted to hospice. R1's order for hospice was dated 12/12/2022. At 02:44 PM, V2 submitted facility staff matrix or log that documents vaccination status of all staff including contracted or agency staff working in the facility. V2 also submitted names of contractual companies that includes, companies providing services for rehab/therapy and dining. Hospice company and staff performing direct care was not included. And upon review of facility matrix or log hospice staff was also not include. On 03/29/2023 at 10:01 AM. V2 presented hospice company and staff that the facility utilizes to perform direct care to residents. Under the document ,V17 (Hospice Nurse), who performed direct care to R1 was exempted and did not receive vaccination for Covid-19. On 03/30/2023 at 02:00 PM. After request for testing of exempted employees including contractual staff or agency, V2 with V12 (Human Resource Director) said, Yes, V17 is included on agency staff that is not vaccinated due to exemption. V17 performs direct care and was not tested for Covid-19. V2 submitted list of staff positive of Covid-19 that includes 6 staff including V11: V20 (Therapist/Agency) on 02/26/2023 V21 (Reception Staff) on 03/01/2023 V22 (Nurse) on 03/06/2023 V23 (Human Resource Staff) on 03/13/2023 V15 (Reception Staff) 03/14/2023 V11 (Licensed Practical Nurse) 3/24/2023 V2 also submitted list of 6 residents including R1 that are Covid-19 positive, date range from 01/03/2023 to 03/28/2023. Covid-19 Staff Vaccination Matrix Instructions for Providers as provided by V2 does not contain information regarding vaccinationn status of V17. Instructions under Section 1 reads: Total number of staff: All staff that work in the facility. Staff includes facility employees (regardless of clinical responsibilities or resident contact), licensed practitioners, adult students, trainees, and care, treatment, or other services for the facility and/or its residents, under contract or arrangement. Covid-19 Prevention Policy dated 7/8/2021, in part reads: Non-employees include but are not limited to non-employed clinical staff, contractors, consultants, temporary staff, students, volunteers, and service partners. Each Health Ministry will identify a member of the leadership team for each non-employee group who will be accountable to ensuring that non-employees who are conducting business in the facility are fully vaccinated.

Based on record reviews and interviews, the facility failed to follow their policy and procedure to develop a baseline care plan that included individualized information to provide effective, person-centered care for 3 (R2, R15, R18) of 12 residents in a sample of 12 reviewed for baseline care plans. The Findings Include: R2's clinical records show an admitted [DATE] with listed diagnoses not limited to fracture of lower end of left femur, hypoxemia, hypertension, and major depressive disorder. R2's physician order sheet (POS) shows R2 is receiving psychotropic medications, oxygen therapy, skin treatment, and on mechanically altered diet. R2's baseline care plan was not completed. R15's clinical records show an admitted [DATE] with listed diagnoses not limited to acute respiratory failure with hypoxia, dependence on renal dialysis, heart failure, and diabetes mellitus type 2, and end-staged renal disease. R15's POS shows R18 is receiving outpatient dialysis, on diuretic, and on therapeutic diet. R15's baseline care plan was not completed. R18's clinical records show an admitted [DATE] with listed diagnoses not limited to left humerus displaced fracture, left shoulder girdle fracture, chronic obstructive pulmonary disease, history falling, and major depressive disorder. R18's POS shows R18 is receiving as needed psychotropic and narcotic medications, and on skilled therapy services. R18's baseline care plan was completed and signed on 3/29/23. On 3/30/23 at 9:15 AM, V16 (MDS/Care Plan Coordinator) stated that baseline care plan should be completed and signed within 48 hours of the resident's admission. V16 stated that each area in the baseline care plan template is completed and signed by V16. At 11:59 AM, V2 (Director of Nursing) provided paper copies of R2, R15, and R18's Baseline Care Plan MC showing the timed stamps when they were signed as completed. V2 stated R2 and R15's baseline care plans were not completed and still in progress. V2 stated that R18 baseline care plan was completed and signed late on 3/29/23. The facility's policy titled; Baseline Care Plan dated 11/1/19 reads in part: 1. A baseline/admission care plan will be developed within 48 hours of the resident's admission. 2. The baseline/admission care plan will include information for the provision of effective person-centered care and will include the minimum healthcare information necessary to properly care for each resident immediately upon admission. 3. The baseline/admission care plan will address the initial goals of the resident based on admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, if applicable.

Based on interview and record review, the facility failed to ensure that staff were aware of and implemented interventions from the resident's plan of care for resident (R17) assessed as high risk for falls. This failure resulted in R17 having a fall and being hospitalized for [REDACTED]. The facility also failed to follow their policy by not having resident specific interventions for resident (R12) who was not responding to fall interventions due to cognitive status of being forgetful and noncompliant, which resulted in R12 having multiple falls. Findings include: 1.) R17 is an [AGE] year-old female admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. R17's fall assessment dated [DATE] documents R17 as a high risk for falls with a score of 80. R17's Kardex (communication sheet used by nursing to document information related to resident care needs) dated 11-5-19 documents: L[NAME]OMOTION: The resident requires (Stand by assistance) by (1) staff for locomotion using (walker); TRANSFER: The resident requires extensive assist of 1; Toileting: TOILET USE: The resident requires (extensive assistance) by (1) staff for toileting; NURSING REHAB/RESTORATIVE: ACTIVE ROM (range of motion) Program #1 AROM (active range of motion) to BUE (bilateral upper extremities) and BLE (bilateral lower extremities) 15 reps x's 2 6-7 days/week. MDS (Minimum Data Set) assessment dated [DATE] documents that R17 requires limited assistance of 1 staff when transferring to or from bed, chair, wheelchair, standing position and requires limited assistance of 1 staff with toilet use. MDS also documents that R17 is not steady, only able to stabilize with staff assistance while moving on and off toilet and with surface to surface transfers (transfer between bed and chair or wheelchair). R17's care plan initiated on 11-18-2019 with a revision date of 11-25-2019 includes goal of improving current level of function in (ADLs) through review date. Currently requires extensive assist with ADL's. Interventions include: TOILET USE: the resident requires extensive assistance by (1) staff for toileting; TRANSFER: the resident requires extensive assistance of 1 1-14-2020 at 10:30 [NAME]M. R17 observed in R17's room alert and oriented said, 'I like to walk but I am not steady (walking) and I need to get stronger to go back to my apartment. The white board in R17's room lists (R17's) shower days, as well as the names of the nurse and certified nursing assistant; no care plan interventions noted on the white board. 1-14-2020 at 14:48, after lunch R17 was observed in the television room sitting on a chair. R17 stated she had just fallen while trying to transfer from walker into wheelchair and she fell in between chairs, she states no one saw her fall and she got up. Facility X-ray of the left hip shows that R17 had a left [MEDICAL CONDITION] and was transferred to a local hospital for evaluation and treatment. R17 was subsequently admitted to local hospital with chief complaints of pain, injury, and swelling and a [DIAGNOSES REDACTED]. R17 had a previous fall on 11-6-2019 at 14:34; R17 was observed on R17's bathroom floor. 1-15-2020 at 12:15P.M. V3 (Licensed Practical Nurse) said, R17 called my attention and asked me if I could help her get the walker. The walker was next to R17's chair, when R17 stood up, she immediately complained of pain to left hip area. I called the medical doctor, ordered an emergent x-ray of the left hip, called the responsible party and the Director of Nursing. R17 is continent of bowel and bladder and goes to the bathroom independently. Frequently R17 does not use the call light and R17 assumes she is independent to do all the walking. The care plan is updated as needed and the interventions are documented on the white board by R17's bed side. 1-15-20 at 12:30P.M. V4 (Certified Nursing Assistant) said, on 1-14-2020 I had R17, I do not do much for R17. R17 is very independent on all ADL's and is continent of bowel and bladder I just come to the room, set up the linen and R17's daily cloths. R17 has a walker that R17 uses occasionally; I did not see when R17 was having a fall. 1-15-20 at 1:05P.M. V5 (Registered Nurse - MDS/Restorative) said, R17 ambulates with the rolling walker with stand by assistance. On multiple occasions R17 needs to be reminded to use the walker. I am responsible for updating the care plans for nursing. For falls we have an interdisciplinary meeting and the team will determine which intervention will be put in place next, the interventions need to be patient specific; once the care plan is in place we will update the white board in the residents' room for everyone to know the new interventions. R17 is currently in the restorative program and won't be able to be considered independent because she requires staff supervision. 01/15/20 at 02:00 PM V2 (Director of Nursing) said R17 ambulates independently with the rolling walker with supervision or assistance as needed. R17 can stand independently, able to dress independently, and is continent of bowel and bladder. The care plan is updated by the MDs coordinator after the interdisciplinary team meets and discuss the new patient specific interventions, the new interventions will be put in the Kardex (communication sheet used by nursing to document information related to resident care needs) for the staff to see and on the white board in resident' room. 2). R12 is an [AGE] year-old female admitted on [DATE] with medical [DIAGNOSES REDACTED]. R12 is alert and oriented but forgetful. MDS (Minimum Data Set) dated 8-23-2019 documents that R12 requires one-person physical assist with toileting and dressing. MDS dated [DATE] documents that R12 needs limited assistance of 1 person for bed mobility, transfers, walking in room and corridor, locomotion in unit, toileting and personal hygiene. Needs extensive assistance of one person for locomotion off unit and dressing. Fall evaluation dated 10-8-2018 (R12) scores 50, high risk for falls. R12's care plan initiated on 10-11-2018 with focus of high risk for falls related to confusion and unaware of safety needs/[MEDICAL CONDITION] disorder includes intervention: be sure call light is within reach and encourage resident to use it for assistance as needed. Resident needs prompt response to all requests for assistance. Interventions added include: 1-21-2019 educate R12 to use the walker when ambulating; 2-11-2019 remind R12 that R12's balance requires R12 to use the walker while in room when ambulating; 3-4-2019 anticipate R12's needs; 9-14-2019 educate R12 to use the call light and ask for assistance especially at night time; 10-18-2019 educate R12 to use the call light and walker when R12 needs assistance to use the bathroom for safety, requires assistance; 11-17-2019 educate R12 to use call light when toileting as R12 needs the assistance as R12 balance is unsteady. Per fall reports, R12 had falls as follows: 1-21-2019 at 15:57 unwitnessed fall in R12's room kneeling, R12 stated, I was trying to use my walker and I stumbled. 2-10-2019 at 10:24 am unwitnessed fall in R12's room, R12 was observed sitting on the floor in the bathroom. 3-4-2019 at 7:30 am unwitnessed fall in R12's room, R12 stated while in bed I reached out for my walker and fell out of the bed. Per nurses notes, R12 had bruising and hematoma to the forehead. V3 (Licensed Practical Nurse) asked R12 what had happened and she reported that 2 days ago she fell from bed. 9-14-2019 at 22:09 unwitnessed fall in R12's room, R12 stated, I fell last night when I was changing my shirt, I did not report it to the nurse, R12 complained of pain to the back and flank area, X-ray done, negative for fracture. 11-17-2019 at 6:28 am unwitnessed fall in R12's bathroom, staff assisted R12 to the bathroom, 5 minutes later staff went to check on R12, was observed sitting on the floor by her bed and stated, I tried to get back in bed by myself and I had a fall. On 1-14-2020 around 10:30 [NAME]M. R12 was observed in bed, alert and oriented to self, place and date. [NAME] board in R12's room lists the name of the nurse and certified nursing assistant the date and shower days; no mention of any fall interventions observed. 01/17/2020 at 11:20 AM V3(Licensed Practical Nurse) said, R12 needs assistance of one person for ambulation, transfers and toileting. R12 uses the call light occasionally but R12 is alert and forgetful. R12 had a few falls that R12 reported after they happened, not when the actual fall happens. 01/17/2020 11:30 AM V4 (Certified Nursing Assistant) said, R12 uses the rolling walker or the wheelchair but staff needs to make sure R12 is monitored when walking with the rolling walker or the wheelchair. R12 is continent of bowel and bladder. R12 needs to be taken to the toilet and wait until finished because R12 is forgetful to use the call light and has unsteady gait. R12 does not follow the instructions of calling for help when getting out of the bed. 01/17/2020 12:04 PM V2 (Director of Nursing) said, R12 is alert and forgetful; the staff needs to be with R12 when she is in the bathroom. R12 is not compliant with the use of the call light. When asked if interventions have been updated or revised because resident is not responding to education or to meet resident needs (since resident is known to be forgetful and does not usually use call light or ask for help), V2 stated that R12's care plan interventions need to be patient specific and evaluated for effectiveness. The interdisciplinary team needs to meet and update the interventions as per MDS schedule or as needed. Fall Prevention and Fall Occurrence Policy dated (MONTH) 2008 includes: All Elder/residents identified, as a high risk by the Fall Risk Assessment and/or clinical assessment will have an individualized care plan developed. The Kardex will reflect these interventions .Nursing has the overall responsibility to assure that care is coordinated among all disciplines and to achieve established goals .At the care conferences the care plans will be reviewed with the team and the resident/responsible party .Each care plan will be revised and updated with appropriate revisions and dates as applicable.

Based on interview and record review the facility failed to use appropriate transfer techniques and develop effective interventions for two residents (R15 and R17) reviewed for falls in the sample of twelve. These failures resulted in R15 falling and sustaining a torn quadriceps tendon and fractured toe; and R17 falling and sustaining an arm laceration. Findings include: 3/13/18 1:58 PM R15 stated that I had a fall because a gait belt was not used. I had a split tendon and a broken toe. 3/15/18 10:30 AM V1 (DON-Director of Nursing) stated that there was no gait belt used to transfer R15 (on 2/14/18). V1 stated that a gait belt should be used for all transfers, and there should have been two staff assisting in the transfer. There was only (V5). 3/15/18 11:10 AM V5 (CNA-Certified Nursing Assistant) stated that (R15) was going from the bed to the chair. (R15) was an inch from the chair and said my knees are buckling. (R15) went down on (R15's) knees. There was no gait belt used. The gait belt was not in the room. I had totally forgotten. I knew her to be one assist. The MDS (Minimum Data Sheet) dated 2/8/18 is coded for extensive assistance for transfers with two plus person physical assist. An untitled document reads: Problem/Violation: On 2/14/18 Resident 1 was being assisted out of bed into a chair to have her linen changed. Staff 1 failed to use a gait belt during the transfer which resulted in Resident 1 falling to her knees after (Resident 1's) right knee gave out. A progress note dated 2/14/18 9:17 AM by V12 (Physician) reads; (R15) had a fall morning of 2/14 at SNF (Skilled Nursing Facility) while care partner was attempting to help (R15) transition from bed to a chair, complained of severe mostly right-sided pain especially in (R15's) foot. A progress note dated 2/14/18 9:36 AM by V13 (Registered Nurse) reads; during ambulation, resident stated that (R15's) knees buckled and (R15) fell backward. A progress note from the hospital dated 2/16/18 reads; Right Quadriceps tendon rupture and fracture right great toe. 3/14/18 1:15pm R17 stated sometimes his bed is lowered to the lowest position when he is in it, at other times it is not. V10 (family member) is unaware of bed being used in a low position and has never seen R17 in bed in a low position. 3/14/18 2:25pm V7 (CNA-Certified Nursing Assistant) stated that R17 is monitored every 15-20 minutes when he is in his room. 3/14/18 2:25pm V8 (CNA) stated R17 slides in the wheelchair a lot. The star on the door shows he is at risk for falls and the picture shows it. 3/14/18 3:09 V8 was observed to be pushing R17 in his wheel chair in the hall and R17 was leaning to his right side. The back of the wheelchair was reclined back and the wheelchair foot pedals were in place. 3/15/18 11:07am V11 (CNA) reports she regularly cares for R17. V11 showed surveyor the computer system used for charting. On review the computer system did not list any care needs related to using a dycem, lowering R17s bed to the floor or the need for a star on the door to indicate a fall risk. V11 states I don't see any specific care needs updated for R17 in computer system. V11 stated I have never attended a care plan meeting, they are not for us. 3/15/18 12:25pm Interview with V9 (RN and MDS Coordinator) at nurses' station. V9 stated when a fall occurs she is notified and she completes a full investigation and an intervention will be done immediately. V9 stated if she is not in the facility The review waits until I'm here. V9 (RN) stated the Interdisciplinary Team (IDT) reviews falls and discusses the interventions the next morning in morning meeting. The interventions are communicated to staff verbally by 24 hour reports and stand up meetings. According to V9 she is responsible to add the new interventions to the care plan and CNA computer program. In discussing the fall of R17 on 12/29/17 V9 stated must have been a weekend. Definitely, no intervention in place. V9 stated she adds fall interventions to the care plan immediately, when I'm on. Record review shows R17 fell on [DATE], 12/31/17, and 1/6/18. V9 stated she was not sure what else to do in adding interventions to prevent falls. V9 stated there is no documentation to show that staff checked R17 every 15-20 minutes as stated by V7 or at increased times as indicated in the care plan. Per record review: 10/17/17 R17 had a fall with no injury. Intervention: do not leave walker in reach when unsupervised, increase rounds, remind to ask for assistance, and increase rounds when in bed. 11/12/17 R17 had a Fall with no injury. Intervention: encouraged to call for assist, pink reminder signs in room ask for assistance, sticky on recliner chair, and restorative programs. 12/29/17 R17 slid out of wheelchair no injury. Intervention: leg rests and position properly with butt back in wheelchair. 12/31/17 R17 on floor in bathroom. R17 sent to hospital for evaluation. Record review notes the facility received a call stating resident loss consciousness during hospital transfer. R17 was hospitalized from [DATE] until 1/5/18 until he returned to facility. [DIAGNOSES REDACTED]. 1/6/18 R17 slipped out of wheelchair no injury. Intervention: educate to call for assistance, sticky to wheelchair. 2/23/18 R17 had fall in bathroom and obtained laceration to right arm. Intervention: brightly colored signs placed in key areas in R17's room to remind him to ask for assistance. Re-educate R17 to call for assistance.