Every finding on record at Saint Mary Home

Based on staff interview, observations, review of the facility medication storage, review of facility documentation and facility policy/procedures, the facility failed to ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to ensure accurate reconciliation and the facility failed to ensure that an account of all controlled drugs is maintained and periodically reconciled. The findings include: Interview with the ADNS on 8/10/26 at 11:05 AM identified when the controlled substances are received into the facility, they are counted and signed by two nurses and placed on the appropriate medication cart. The ADNS indicated a duplicate copy of the Controlled Substance Disposition Record (CSDR) is placed in a binder in the nursing supervisor's office which is also the 1st floor medication room so that when the controlled substances come into the facility, the supervisors can put the duplicate CSDRs into the binder. The ADNS identified weekly, she takes a delivery slip, receives from the pharmacy, and matches this list of controlled substances to the CSDRs in the supervisor's binder to make sure the controlled substances received into the facility that week was accounted for. The ADNS identified her bi-weekly reconciliations were usually done at shift change when the nurses were doing the controlled substance shift counts and included checking the signatures for the shift counts and ensuring the counts in the medication cart was accurate. The ADNS indicated that she did not utilize the CSDR binder to complete the reconciliations.Observation of the CSDR duplicate binder on 8/10/26 at 11:45 AM identified the binder was kept in the nursing supervisor's office accessible to any staff member with access to the room which was also the 1st floor medication room and contained duplicate CSDRs dating back to 2024. Additionally, 25 of the CSDRs were flagged for the ADNS to copy for this surveyor. Interview with the ADNS on 8/10/26 at 12:00 PM identified she reconciles the duplicate CSDRs when the original CSDRs are returned to her when they are completed, destroyed or the resident has left the facility. The ADNS indicated the DNS trained her on the reconciliation process and could not identify the status of some of the controlled substances with older dates on them but indicated they must be used.Observation of the ADNS on 8/10/26 at 12:30 PM identified she had dismantled the duplicate CSDR binder and lost track of which pages had been flagged for copying. The ADNS indicated she was trying to find the original sheets to match them up. The following duplicate CSDRs were noted to not be accounted for: Hydromorphone ( Pain Management ) HCL 2 mg tablet (30 tablets) received into the facility 6/11/25Tramadol (Pain Management )HCL 50 mg tablet (60 tablets) received into the facility 3/14/26Oxycontin (Pain Management) ER 10 mg tablet (60 tablets) received into the facility 3/3/26Morphine Sulfate ( Pain Management) 100mg/5ml (30 mls) received into the facility 3/24/26Hydromorphone HCL 2mg (Pain Management) tablet (30 tablets) received into the facility 6/11/25Diazepam (Anti-anxiety) 2 mg tablets (30 tablets) received into the facility 5/27/26Zolpidem Tartrate ( Treatment for Insomnia) 10 mg tablet (30 tablets) received into the facility 5/29/26Zolpidem Tartrate 10 mg tablet (30 tablets) received into the facility 10/7/24Diazepam 2mg tablet (30 tablets) received into the facility 5/12/26Lacosamide (Anti-convulsant) 10 mg/ml solution (90 mls) received into the facility 3/5/26Clonazepam 0.5 (Treatment Panic Disorder) mg tablet (45 tablets) received into the facility 3/6/26Lacosamide 10 mg/ml solution (300 mls) received into the facility 5/18/26 with no signatures on the nurse's signature line.Lorazepam 0.5 mg tablet (#90 1/2 tablets) received into the facility 12/11/24Lorazepam 2mg/ml oral concentrate (30 mls) received into the facility 4/2/25Lorazepam 0.5 mg tablet (30 tablets) received into the facility 12/20/25Interview with the DNS and RN#6 on 8/10/26 at 1:15 PM identified the process for controlled substance reconciliation was to take the duplicate CSDR binder around the facility during the bi-weekly audits and ensure that all controlled substances received into the facility were accounted for and removed from the binder when completed, destroyed, discontinued or the resident left the facility. The DNS identified the ADNS was her designee to complete the reconciliations and was not aware that the reconciliations were not being completed adequately.Review of the facility policy for medication storage identified controlled medications must be counted with another qualified staff member when there's an exchange of key but did not indicate anything else regarding controlled substances. Although requested, the facility did not provide a policy identifying storage, handling or reconciliation of controlled substances.

Based on observations, review of facility documentation and staff interviews, the facility failed to ensure kitchen staff wore beard guards and appropriately placed hair restraints during the handling of food and beverage items. The findings include: a. On 8/5/2026 at 12:24 PM, an observation of the tray line was made with the Assistant Director of Dietary. Dietary Aide #1 was observed filling coffee cups. Dietary Aide #1 had a beard and mustache without a beard guard.b. Dietary Aide #2 was observed working on the tray line in the facility's kitchen. Dietary Aide #2 was plating food from the steam table onto plates and then passing the completed plates to other staff. Dietary Aide # 2 had short hair and was wearing a tan-colored hairnet; however, the hairnet covered only the sides of the head from the area above the left ear to the area above the right ear without the benefit of extending forward enough to cover the front hairline. The hairnet ended midway between the top of the scalp and the front hairline, resulting in several inches of hair at the front not being restrained.Dietary Aide #3 was observed working on the tray line, checking tickets against the plated food. Dietary Aide #3 had long hair styled towards the back and had a black-colored hairnet; however, the hairnet covered only the sides of the head from the area above the left ear to the area above the right ear without the benefit of extending forward enough to cover the front hairline. The hairnet ended midway between the top of the scalp and the front hairline, resulting in several inches of hair at the front not being restrained.On 8/5/2026 at 12:35 PM, an interview with the Assistant Director of Dietary indicated dietary aides' whole head should be covered. Additionally, the Director of Dietary indicated Dietary Aide #1 did not need beard restraint because his beard and mustache were short and further indicated that leadership had determined only large beards required a beard guard. The Assistant Director of Dietary was unable to indicate when the determination regarding beard restraints had been made.A continued constant observation of the tray line on 8/5/2026 at 12:55 PM identified Dietary Aides #2 and #3's hair net continued to leave the front portion of the hair uncovered. The administrator was observed to come into the kitchen and was notified of the observation of Dietary Aides #2 and #3.On 8/6/2026 at 12:28 PM, an interview with the Administrator in the facility conference room indicated the facility did not have a policy regarding hair restraints or beard guards. When questioned about the facility's expectation for staff on when to wear a beard guard, the administrator indicated there was no specific regulation on beard length, and so it was a judgment call.A review with the administrator of the untitled facility education and participant log dated July-August 2026 identified hair nets are required anytime staff are working in food preparation or serving areas and the hair nets must cover all the employee's hair. The education further identified that if an employee had a beard, goatee, mustache, or noticeable stubble, a beard net must also be worn.

Based on observation of the dumpster area and staff interviews, the facility failed to ensure appropriate disposal of garbage and refuse. The findings include: On 8/3/2026 at 10: 46 AM, an observation of the dumpster and dumpster area with the Director of Dietary identified that waste materials were not confined to the dumpster and were present on the ground, concrete, and surrounding wall.The concrete slab and ground surrounding the dumpster had scattered food-related debris, including disposable food packaging such as single-serve milk, pudding, butter, and creamer containers. There was also some visible food waste, such as a leftover carrot and a full mustard packet. There were many single use cups, lids, plastic utensils, and flattened cardboard boxes scattered throughout the area around the dumpster.Additionally, there were several purple-colored disposable gloves on the ground, the concrete slab, and a recessed area on a wall adjacent to the dumpster. An empty medication blister packet was also observed on the concrete, along with several empty cigarette boxes.An interview with the Director of Dietary indicated he or housekeeping cleaned the area regularly. The Director of Dietary indicated the area had been recently cleaned but could not recall the date. He also indicated he did not keep documentation on the cleaning of the dumpster area.On 8/3/2026 at 10:53 AM, an interview with the Trash and Linen [NAME] indicated trash overflows from the dumpster due to the positioning of the dumpster, the gap between the dumpster and the chute. The Trash and [NAME] further indicated between him and the Director of Dietary, they attempt to clean the area regularly. However, the Trash and Linen [NAME] could not recall the last time the area was cleaned.An interview with the Administrator on 8/6/2026 at 11:10 AM indicated the facility did not have a policy for maintaining the dumpster

Number of residents sampled: see list of residentsNumber of residents cited: see list of residentsObserved poor practice on 6 of 7 units Based on review of the facility infection control program, observations, review of the clinical records, review of facility documentation, facility policy/procedures and interviews, the facility failed to ensure gloves were used appropriately and hand hygiene was performed to prevent the spread of infection and failed to ensure collected specimens were not stored together and placed on top a cart containing clean supplies. Additionally, for 5 out of 9 sampled residents (Resident #11, Resident #50, Resident #177, Resident #198 and Resident #199) reviewed for Enhanced Barrier Precautions (EBP), the facility failed to utilize Personal Protective Equipment (PPE) appropriately according to Centers for Disease Control and Prevention (CDC) guidelines for residents on EBP and for 2 out of 2 sampled residents (Resident #85 and Resident #197) reviewed for Contact Precautions, the facility failed to utilize appropriate PPE when entering a transmission based precautions (TBP) resident's room. The facility also failed to ensure that trash cans for residents on transmission based and enhanced barrier precautions were placed inside the resident room near the exit per CDC guidance and the facility failed to ensure appropriate use of PPE for residents on precautions to prevent the spread of infection. The findings included: Tour of the facility and observation on [NAME] unit 8/5/26 at 5:42 AM identified there were specimen collection tubes containing blood specimens still attached to the hub with the straight bore needle still attached with the safety cover in place over the needle. The vials of blood were labeled with resident information and contained red substance in each of the vials and were left unattended on top of a clean precaution PPE cart. The Phlebotomist gathered blood vials and needles into her hands. When questioned about why the blood vials were left on top of the clean precaution PPE cart, she indicated she was unable to bring the items into an EBP designated room. The Phlebotomist also indicated the blood samples should have not be out of possession. She further indicated the needles were still present because there were no sharps containers in the resident 's rooms and she didn't have one on her person. Review of the Laboratory Record Sheet for 8/5/26 identified blood draws were completed for five residents on [NAME] unit including Resident #50, Resident #177, Resident #198, Resident #200.Interview with the Administrator on 8/5/26 at 8:15 AM identified that phlebotomy staff in the building are hired by the parent company of the facility. She further indicated she did have a contract agreement with the laboratory services. The Administration indicated laboratory staff would be expected to know and follow the PPE requirement for the precaution signage. She was unable to identify whether the external employees were facility oriented.Interview with the Laboratory Supervisor, Person #2 on 8/10/26 at 10:19 AM identified phlebotomy staff receive training in universal precautions and do not receive training regarding enhanced barrier precautions. Person # 2 indicated staff should not be reusing PPE from one resident to another. Person#2 indicated that all phlebotomy care should be provided at the bedside including labeling specimen tubes, removing and discarding sharps into a sharp container carried by the phlebotomist. Person #2 identified that the phlebotomist has all items needed to conduct their jobs and specimens and sharps should not be left unattended.Interview with the Medical Director on 8/11/26 at 1:34 PM identified that facility contract staff employed by the same umbrella company as the facility would receive the same training and education on infection control as the staff at the facility. He further indicated he was not aware that everyone coming into the facility required facility specific orientation or education.Review of the contract agreement between the facility and laboratory services dated 2/16/20 identified the laboratory would provide a member to the customer's infection prevention and anti-microbial stewardship committee as requested to serve in a consultative role.2.Observation on East 2 unit 8/5/26 at 5:30 AM identified a sign posted outside Resident #11's room identifying the need for Enhanced Barrier Precautions (EBP). The signage directed everyone to clean their hands before entering and when leaving the room, providers and staff to wear gloves and a gown for high-contact resident care activities such as dressing, bathing/showering, changing linens, changing briefs or assisting with toileting, device care or use of a central line, urinary catheter, feeding tube, tracheostomy and wound care for any skin opening requiring a dressing. The signage further indicates to not wear the same gown and gloves for the care of more than one person. Continued observation identified Nurse Aide (NA #1) placed an incontinent brief on a cart parked outside of the resident's room and entered the room with donned gloves, NA #1 then took up a gray basin and went to the next room to filled with water and then returned to Resident #11's room to provide care to the resident. NA #1 then entered the room with a syringe, and she was asked which resident was on EBP precautions when she identified Resident #11 was on precautions as the resident had a gastrostomy tube (g-tube). The nurse aide then came at the doorway of the room with gloved hands holding a bag containing soiled items which she placed into the cart that was immediately outside of the room. NA #1 then returned into the room and returned to the doorway with gloved hand holding soiled linen which she placed into a bag attached to the cart. She then removed her gloves and placed the gloves in the cart outside the room and then proceeded to the linen cart located in the hallway at which time she removed the clean gloves. NA #1 then pushed the cart to the next room which was Resident #43's room, who was not on any type of precautions. She then applied the gloves, placed the incontinent brief she retrieved from the top of the cart on the overbed table, then obtained a gray basin which she filled in the bathroom with water and placed it on the overbed table. Surveyor intervened at the time of the observation because NA #1 did not perform hygiene when gloves were removed nor did she perform hand hygiene prior to applying the new gloves.Interview with NA #1 at 5:35 AM identified she had just taken care of Resident #11. She identified she did not wear PPE as the resident at the door was on EBP and she took care of the resident by the window which was Resident #11. She observed the EBP sign posted outside of the room but thought it was for the resident that was by the door. She further identified she was new to the unit but should have read the sign posted outside. NA #1 further identified she was about to start providing care to Resident #43 and should have performed hand hygiene when she had removed her gloves and prior to applying gloves. Interview with Infection Preventionist (RN#1) on 8/5/26 at 10:58 AM identified staff are aware of residents placed on precautions by the signage outside of the resident room, the presence of a PPE cart outside of the room, and the information on the resident summary. RN#1 identified if there are 2 residents in the room, the sign will not state which resident is on precautions and indicated the Nurse Aide (NA) should check the resident summary and the physician's order. Furthermore, RN#1 identified staff should follow direction on the signage for use of PPE when providing care activities to residents. RN#1 further identified PPE should be used for one resident and not be reused on another resident and indicated there was not a shortage of PPE in the facility.Interview with RN#6, prior DNS for the facility, on 8/6/26 at 10:51 AM identified education is provided to all facility staff on contact precautions and enhanced barrier precautions on hire and annually at the skills fair where competencies are done.The review of Chapter 7 of the [NAME] Health Senior Community Guidelines on page 9 dated 11/12/24 identified that the facility uses CDC guidelines on information on CDC targeted Multi drug Resistant Organisms (MDROs) and current regulations on EBPs.3a.Resident #11's diagnoses included mechanical complication of gastrointestinal prosthetic device, type 2 diabetes mellitus, and chronic respiratory failure with hypoxia.The physician's order dated 5/21/26 directed Enhanced Barrier Precautions g tube status (gastrostomy).A review of the Nurse Aide care summaries identified Resident #11 had infection control concerns and is on EBP due to having a gastrostomy tube and PPE to be used as applicable.b. Resident #50's diagnoses included malignant neoplasm of overlapping sites of right female breast, and open wound of right breast.The physician's order dated 7/9/26 directed Enhanced Barrier Precautions during resident care wound care to the right breast.A review of the Nurse Aide care resident summary dated 7/9/26 identified Resident #50 is on Enhanced Barrier Precautions.The care plan dated 7/10/26 identified Resident #50 is on Enhanced Barrier Precautions due to wound. Interventions directed: to maintain Enhanced Barrier Precautions per facility policy and current CDC guidelines and to post appropriate EBP signage at the resident's entrance as indicated.c. Resident #177 was admitted to the facility with diagnoses including infection following procedure, deep incisional surgical site and infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts.The care plan dated 6/24/26 identified Resident #177 had a Hickman catheter to right upper chest for antibiotic therapy, an open wound/impaired skin integrity to the right groin related to infection and dehiscence of surgical sit and required enhanced barrier precautions due to wound. Interventions included: providing treatments as ordered and maintaining enhanced barrier precautions per facility policy and current CDC guidelines and posting appropriate EBP signage at the resident's entrance as indicated.A review of the Nurse Aide care resident summary dated 7/21/26 identified Resident #177 was on Enhanced Barrier PrecautionsThe physician's orders dated 7/21/26 directed enhanced barrier precautions with directions to maintain enhanced barrier precautions during high-contact resident care.d.Resident #198 was admitted to the facility with diagnoses including infection and inflammatory reaction due to other internal joint prosthesis and long-term use of A review of the Nurse Aide care resident summary dated 7/26/26 identified Resident #198 is on Enhanced Barrier Precautions and directed to refer to signage on the resident door secondary to peripherally inserted central catheter (PICC) line.The care plan dated 7/27/26 identified Resident #198 required Enhanced Barrier Precautions due to Intravenous (IV) therapy with directions to maintain enhanced barrier precautions per facility policy and current CDC guidelines and to post appropriate EBP signage at the resident's entrance as indicated for all staff.The physician's orders dated 7/29/26 directed Resident #198 to be on Enhanced Barrier Precaution and to maintain enhanced barrier precautions during high-contact resident care related to infection and inflammatory reaction due to other internal joint prosthesis.Observation on [NAME] unit 8/5/26 at 5:48 AM identified Person #3 (The Phlebotomist) exiting Resident #198's room wearing a full-face respirator mask with a yellow gown balled up in one gloved hand, and in the other gloved hand had at least one vial of blood still attached to the hub with the straight bore needle with the safety in place over the tip. When asked if she was aware of the signage and what it meant, she indicated that she did know that gown and gloves should be worn in the room. Person #3 identified she had the gown in her hand because there was not a garbage in the room to discard the gown. When asked why there were blood specimens left unattended in the hallway Person #3 indicated that she had drawn Resident #177, another EBP room, prior to collecting a blood specimen from Resident #198 and took off the gown in Resident #177's room but there was no garbage bin so she went into Resident #200's room (not a precaution room) to discard the gown. Observation of Resident #200's garbage bin identified no gown noted. Person #3 then identified she had worn the same gown used in Resident #177 and Resident #198's care. Further observation of the hallway identified one red garbage can approximately 50 feet from Resident #198's room.Observation on [NAME] unit on 8/5/26 at 6:00 AM identified a sign posted outside of Resident #50's room identifying the need for Enhanced Barrier Precautions (EBP) which noted the need for everyone to clean their hands before entering and when leaving the room, providers and staff to wear gloves and a gown for high-contact resident care activities such as dressing, bathing/showering, changing linens, changing briefs or assisting with toileting, device care or use of a central line, urinary catheter, feeding tube, tracheostomy and wound care for any skin opening requiring a dressing. The signage further indicates to not wear the same gown and gloves for the care of more than one person. Continued observation identified LPN#7 came out of Resident #50's room who was on EBP with gloves on her hands and walk down the hall and then entered Resident #198's room still wearing the same pair of gloves. As LPN#7 was entering Resident #198's room she removed what appeared to be a plastic item containing a syringe shaped item out of her pocket.Continued observation on 8/5/26 at 6:06 AM identified LPN#7 coming out of Resident #198's room with a used normal saline IV flush in her still gloved hand.Interview with LPN#7 on 8/5/26 at 6:08 AM identified LPN#7 had been in Resident #50's room setting up supplies for wound care and came to Resident #198's room to provide Intravenous (IV) care as Resident #198's IV pump was alarming. LPN#7 indicated she was aware that both Resident #50 and Resident #198 were on EBP but identified that although she was in Resident #50's room she was not providing care to the resident but setting up supplies for care. LPN#7 indicated she should have changed gloves and performed hand hygiene. LPN#7 identified she should have put on new gloves and worn a gown before managing an IV line. LPN # 7 indicated Resident #198 had pushed the call button and LPN#7 wanted to be prompt with responding to the call bell. LPN#7 further identified there was no garbage inside of the Resident #198's room to discard used items and continued to wear gloves and hold the normal saline flush until she was able to dispose of them.Interview with the Administrator on 8/5/26 at 8:15 AM identified that phlebotomy staff in the building are hired by the parent company of the facility. She further indicated she did have a contract agreement with the laboratory services and indicated that laboratory staff would be expected to know and follow the PPE requirement for the precaution signage. However, she was unable to identify whether the external employees were facility oriented.Interview with the Laboratory Supervisor, Person #2 on 8/10/26 at 10:19 AM identified phlebotomy staff receive training in universal precautions and do not receive training regarding enhanced barrier precautions Person#2 further indicated staff should not be reusing PPE from one resident to another. Person#2 indicated that all phlebotomy care should be provided at the bedside including labeling specimen tubes, removing and discarding sharps into a sharp container carried by the phlebotomist. Person #2 identified the phlebotomist has all items needed to conduct their jobs and specimens and sharps should not be left unattended.Review of the required education provided by the facility to contract staff identified Infection Control Education including hand hygiene, standard precautions and transmission-based precautions including contact, droplet and airborne precautions. However, education failed to identify Enhanced Barrier Precautions training as part of the required education. The education includes guidance that PPE is one use unless it can be cleaned between users.e.Resident #199 was admitted to the facility with diagnoses including diverticulitis of intestine with perforation and abscess without bleeding and Pneumonia with unspecified organism and catheter.The care plan dated 7/23/26 identified Resident #199 is at risk for infection related to infection or colonization with Multidrug-Resistant Organisms (MDRO), indwelling urinary catheter. Interventions directed to follow enhanced barrier precautions when performing high-contact resident care activities and educate resident/family on need for enhanced barrier precautions to reduce the spread of multidrug-resistant organisms.A review of the Nurse Aide care summaries dated 7/23/26 identified Resident #199 had infection concerns and was on Enhanced Barrier Precautions.The physician's orders dated 7/24/26 directed Enhanced Barrier Precautions with direction to maintain enhanced barrier precautions during high-contact resident care.Observation and tour with RN#6 on 8/6/26 at 11:16 AM identified EBP sign outside door of Resident #199 and noted NA #4 was changing bed sheets in Resident #199's room without benefit of PPE. Interview with NA#4 on 8/6/26 at 11:18 AM identified that she did not need PPE to change linens or do care on Resident #199.Interview with RN#6 on 8/6/26 at 11:22 AM identified NA#4 should be wearing appropriate PPE per EBP signage when caring for Resident #199.4. a.Resident #85's diagnoses included urinary tract infection (UTI), extended spectrum beta Lactamase (ESBL), and type 2 diabetes mellitus.The care plan dated 7/21/26 identified Resident #85 had ESBL in the urine and was on contact precautions related to a possible infection. Interventions directed anyone who entered the resident room to maintain contact precautions per facility policy and current CDC guidelines and post appropriate contact precaution signage at the resident's entrance as indicated.A review of the Nurse Aide care summaries identified Resident #85 had infection concerns and was on Contact Precautions due to having a UTI/ESBL on antibiotics with an active infection.The physician's order directed 7/21/26 for contact precautions.Observation on 8/3/2 at 10:06 AM identified posted signage outside of Resident #85's room a black and white copied contact precaution signage that identified stop in bold letters, everyone must clean their hands before entering and when leaving the room, and providers and staff must also put on gloves and gowns before room entry. The signage directs to discard gloves and gown before room exit. The signage also indicates use of dedicated or disposable individual equipment that must be cleaned and disinfected before use on another person. Visible outside of the resident room was a cart containing PPE supplies such as gowns and gloves. Further observation identified NA #2 was in Resident #85's room removing items and food tray off the resident's overbed table and then brought the food tray on the food cart outside of the room, without the use of PPE. NA #2 then entered the room after performing hand hygiene and donning PPE and went back into the room to the next resident (Resident #178) to remove his/her tray. NA#2 then placed the tray into the food cart and walked away while still wearing the PPE gown without performing hand hygiene.Interview with NA #2 on 8/3/26 at 10:10 AM identified Resident #85 was on contact precautions and after she read the sign posted outside of the resident's room, she indicated she should have worn PPE. NA #2 identified she was feeding the resident and not providing care, hence why she did not wear PPE. She later approached the surveyor to indicate that the resident had an infection in the urine, and she was told she only needed to wear PPE when providing care.Observation on 8/3/26 at 10:15 AM identified Social Worker (SW) 2 performed hand hygiene then entered Resident #85's room and spoke with the resident without applying PPE, then went and spoke with Resident #178 (Resident #85's roommate). Interview with SW #2 on 8/3/26 at 10:25 AM identified she was aware Resident #85 was on contact precaution and after reading the contact precaution sign, she should have worn PPE prior to entering the resident's room.Interview with nurse charge (LPN #6) on 8/3/26 at 11:30 AM identified Resident #85 is on contact precaution, and his/her last dose of antibiotic was administered this morning on the 11:00 PM to 7:00 AM shift. She further identified staff should wear PPE prior to entering the room and providing care as well as when feeding the resident.Interview with Infection Preventionist (RN#1) on 8/5/26 at 10:58 AM identified staff are aware of residents placed on precautions by the signage outside of the resident room, the presence of a PPE cart outside of the room, and the information on the resident summary. RN#1 identified if there are 2 residents in the room, the sign will not state which resident is on precautions and indicated the Nurse Aide (NA) should check the resident summary or care card and the physician's order. RN#1 identified if staff were going into a contact precaution room, they would not need to wear full PPE for just putting a tray down. After RN#1 read the Contact Precaution sign used by the facility she indicated that staff should be wearing full PPE when entering a Contact Precaution room. RN#1 indicated all staff should follow the signage outside of the resident's room.Interview with RN#6, prior DNS for the facility, on 8/6/26 at 10:51 AM identified education is provided to all facility staff on contact precautions and enhanced barrier precautions on hire and annually at the skills fair where competencies are done.b. Resident #197's was admitted to the facility on [DATE]. The residents' diagnosis includes diabetes mellitus. Observation on 8/5/26 at 12:35 PM when touring facility with RN#1, Licensed Practical Nurse (LPN#1) identified LPN #1 leaving a resident room on Contact Precautions with no gown and 2 gloves in the hallway after performing a fingerstick for a blood sugar check on Resident #197.Interview with LPN #1 identified that she should have been wearing a gown and gloves and donning and doffing appropriately in the room. She also indicated that two gloves should not be worn in the hallway.Review of the Center for Disease Control (CDC) guidance on how to safely remove and dispose of PPE used should be discarded in a trash can inside the patient room before leaving the patient room.The facility education provided to staff identified on the power point that staff should don or put on PPE prior to entering the resident room and doff or discard PPE before leaving the resident room. This information was also posted on each resident unit visible to staff.The review of the [NAME] Health Senior Community Guidelines, provided by the facility, on page 9 dated 11/12/24 identified the facility uses CDC guidelines on information on CDC targeted Multi drug Resistant Organisms (MDROs) and current regulations on EBPs.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #178) reviewed for advanced directives, the facility failed to ensure there was a physician's order in place for the resident wishes related to Cardiopulmonary Resuscitation ( CPR) code status.The findings include: Resident #178 was admitted to the facility in June of 2026 . The resident's diagnoses included dementia, depression, and sepsis.The admission Minimum Data Set ( MDS) assessment dated [DATE] identified Resident #178 had moderately impaired cognition.The Current Consent for Life Sustaining Procedure form dated [DATE] was signed by the Resident #178 representative and a witness on [DATE] which was signed by the physician on [DATE]. The form identified in section II for choices regarding the administration of life sustaining procedures notes the following : the resident does not want cardiopulmonary resuscitation (CPR), artificial respiration (a machine to aid breathing) and artificial nutrition. The form also identified the resident wants intravenous therapy and antibiotics.The Current Consent for Life Sustaining Procedure form dated [DATE] was signed by the Resident #178 representative on [DATE] and was not signed by the physician. The form identified in section II for choices regarding the administration of life sustaining procedures notes the following : the resident does not want cardiopulmonary resuscitation (CPR), artificial respiration (a machine to aid breathing) and artificial nutrition. The form also identified the resident wants intravenous therapy and antibiotics. A review of the physician's orders for the period of [DATE], through [DATE], failed to reflect a physician's order for no CPR, no artificial respiration, and no artificial nutrition according to the resident's wishes.Interview with the Charge Nurse Licensed Practical Nurse (LPN#6) on [DATE] at 12:54PM identified if a resident had a life-threatening emergency, she would grab the resident's physical chart and someone else would look in the computer. She identified the code status form is in front area of the physical chart and in the computer in the order section under advance directives. LPN #6 identified code status consent is obtained on admission from the resident's responsible party, and after it is signed by the physician/ Advanced Practice Registered Nurse (APRN), the form is then placed in the chart, and the physician's order is then put into the computer. She further identified this is done by the charge nurse or the nursing supervisor. After reviewing the Current Consent for Life Sustaining Procedure form in the physical chart and the computer for Resident #178 with LPN #6, she noted there was no physician's order in the computer that matches the Current Consent for Life Sustaining Procedure form completed on [DATE] and [DATE], as they should match. LPN #6 further identified Resident #178 was sent to the hospital recently and was readmitted , hence why another form was completed on [DATE] and the nursing manager Registered Nurse (RN #7) would know more as they usually follow up.Interview with Unit Manager (RN#7) on [DATE] at 1:16 PM identified he was with Resident #178 representative on Friday ([DATE]) and the code status form was then signed as the resident was readmitted to the facility recently. He identified the code status consent form is completed on admission and readmission so residents can change their minds. RN #7 identified Medical Doctor (MD#1) came in yesterday ([DATE]) and he may have not come to this side. MD#1 identified he did not put in a physician's order for the code status, but the resident would have had a previous order from his/her prior admission. He reviewed the resident's physician's order history and identified the resident did not have an order for both times ([DATE] and [DATE]) and this was an oversight. RN #7 returned to the surveyor at 2:58 PM and identified it is the facility's protocol the physician has to sign the form prior to the order be place in the computer and that he did not need to complete a new code status form if the code status is the same, unless the resident's code status changed. RN #7 was asked when he was made aware that he did not need to complete a new code status at which time he responded today ([DATE]). RN # 7 reviewed the clinical record and was unable to locate a physician's order for when the physician had signed the form on [DATE].Interview with the Director of Nursing Services (DNS) on [DATE] at 3:48 PM identified once the advance directive is signed by the physician/APRN, the order should be placed into the electronic medical records (EMR). She further identified the nurses are responsible for placing the physician's order into the electronic medical record to reflect the resident's elected code status wishes. The DNS then identified on [DATE] that an audit was completed last week (the week of [DATE]) which identified Resident #178 code status as not correctly documented in the electronic medical records system. However, the supervisor had an emergency and was unable to address the code status. She further identified staff was educated in April of 2026 regarding code status and to check both the physical chart and the EMR.After surveyor's inquiry, a physician order dated [DATE] directing a Do Not Resuscitate (DNR) (do not resuscitate, which means in the event the resident's heart stops, he/she does not want cardiopulmonary resuscitation administered) and DNI (Do Not Intubate).Interview with MD #1 on [DATE] at 12:10 PM identified when the provider signs the code status consent form it indicates they acknowledge the resident's wishes and the nurse is responsible for inputting the information in the computer as a physician's order. MD #1 further identified resident's code status should be in the EMR as a physician's order.Review of the nurse management monthly meeting education documentation dated [DATE] identified all residents must have their code status addressed at the time of admission. If a resident is unable to sign their code status documentation, two licensed staff members may contact the Power of Attorney (POA) and obtain consent over the phone. If the POA cannot be reached, the licensed staff must document all attempts made to contact the POA in the medical record. The next step in the process is for the physician to complete and sign their portion of the code status documentation. Once this is completed, the charge nurse is responsible for documenting the code status in the facility software for (electronic medical record system). Completion of these steps ensures the code status process is finalized and accurately documented. The document further identified when a resident is found unresponsive, first step is to verify the resident's code status by checking both the paper chart and the electronic medical record (EMR). This information will accurately guide on the appropriate next actions and not to call a code until the code status has been confirmed in both locations. Review of the DNR (DO-Not-Resuscitate Order policy identified do-not-resuscitate orders must be signed by the resident's attending physicians.

Based on clinical record reviews, observation, review of facility policy/procedures and interviews for 1 of 2 sampled residents (Resident #14) reviewed for pressure ulcers, the facility failed to ensure the skin checks were completed appropriately on a resident that developed a pressure ulcer and for o1 of 2 residents (Resident #4) reviewed for skin condition, the facility failed to ensure there was an active physician's order for the resident's left lower leg open wound. The findings included: 1.Resident #4 's with diagnoses included dementia, anxiety, cerebral infarction, and hypertension. A physician's order dated 7/1/26 directed staff to cleanse the resident's left lower shin with normal saline, pat dry, apply Xeroform to the wound, and cover with foam dressing daily and as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 with severe cognitive impairment and required extensive assistance with toileting, personal hygiene, bed mobility, transfer. Further review of the assessment indicated the resident was receiving an application of a non surgical dressing to an area other than the feet. A physician's order dated 7/6/26 directed staff to cleanse the resident's left lower shin with normal saline, pat dry, apply silver alginate to the wound base, and cover with a foam dressing daily and as needed. The Resident Care Plan (RCP) dated 7/17/26 identified Resident #4 at risk for skin breakdown related to decreased mobility, incontinence, and a history of a healing skin tear. Interventions directed staff to complete bi weekly head to toe skin assessments, complete the Braden assessment on admission and quarterly and update the care plan as needed, provide incontinent care and assess for skin breakdown, and notify the physician of any impaired skin integrity and to obtain treatment as ordered. A physician's order dated 7/20/26 directed staff to cleanse the resident's left lower shin with normal saline, pat dry, apply skin prep to the wound edges, then apply a nickel thick amount of Santyl (debridement ointment) to the wound bed, followed by regular alginate, and cover with a foam dressing daily. The nurse's notes dated 7/27/26 at 3:10 PM documented an assessment of Resident #4's left lateral lower extremity laceration. The wound measured 3.7 cm in length, 4 cm in width, and 0.3 cm in depth. The wound base was described as 25 percent non granulation tissue, 50 percent granulation tissue, and 25 percent yellow slough, with a moderate amount of serosanguineous drainage and no odor. The resident exhibited no complaints of pain, and no signs or symptoms of infection were noted. The late entry nurse's notes for dated 8/3/26 at 2:02 PM (documented on 8/5/26 at 2:05 PM) indicated an assessment of Resident #4's left lower leg laceration. The wound measured 2.3 cm in length, 3.0 cm in width, and 0.3 cm in depth. The wound base was described as 50 percent granulation tissue, 25 percent slough, and 25 percent non granulation tissue, with a moderate amount of serosanguineous drainage. The note indicated the wound physician changed the treatment as recommended, and the charge nurse was updated. Review of the physician's orders from 8/1/26 through 8/5/26 failed to identify any active treatment order for Resident #4's left lower leg wound. Review of the Treatment Administration Record (TAR) from 8/1/26 through 8/5/26 failed to show that nursing staff acknowledged or signed off that treatment to Resident #4's left lower leg wound was being administered. Interview and observation with RN #5 (charge nurse) on 8/5/26 at 1:40 PM identified a physician's order was required for any treatment to an open wound. RN #5 stated that treatments were transcribed into the electronic medical record for nursing staff to acknowledge once administered. She indicated the nursing supervisor and/or wound nurse was responsible for ensuring that active treatment orders were in place for all wounds. Review of Resident #4's active physician orders with RN #5 identified no current treatment order for the left lower leg wound, and RN #5 stated she was unaware Resident #4 had an open wound on the left lower leg. During observation in the dining room, RN #5 lifted Resident #4's left leg pants and noted a dry, clean foam dressing dated 8/4/26 on the left lower leg. She further identified she had not been a regular nurse on the unit and would not have known about the wound without an active physician order. Interview with RN #1 (wound nurse) on 8/5/26 at 2:00 PM identified she was responsible for weekly wound monitoring and ensuring physician orders were in place for all treatments. She stated that treatment orders were initiated immediately once a wound was identified. She reported that RN #5 informed her, after the surveyor inquiry, that there was no active treatment order for Resident #4. RN #1 stated that she completed wound rounds with the wound specialist on 8/3/26, during which the specialist changed the treatment for Resident #4's left lower leg wound to calcium alginate due to excess moisture in the wound bed. She could not explain why there was no active physician order for this treatment. After surveyor inquiry, a physician's order dated 8/5/26 was entered directing staff to cleanse the resident's left lower shin with normal saline, pat dry, apply silver alginate to the wound base, and cover with foam dressing daily. Wound treatment observation with RN #5 on 8/5/26 at 2:30 PM identified Resident #4 had an intact foam dressing on the left lower leg with slight edema present. RN #5 removed the dressing and noted calcium alginate with a small amount of serosanguineous drainage. Resident #4 was observed with an open wound on the left lower leg. The Wound Prevention and Management Guidebook identified that nursing staff are required to verify and obtain a physician's order prior to initiating any wound treatment. 2.Resident #14's diagnoses included difficulty in walking, diabetes mellitus without complications, adult failure to thrive, and moderate intellectual disabilities. The quarterly MDS assessment dated [DATE] identified Resident #14 was severely cognitively impaired, had no behaviors, required supervision or touching assistance with bed mobility, partial to moderate assistance with transfers, dependent with dressing and personal hygiene. The assessment further identified the resident did ambulate and utilized a walker and wheelchair for mobility. The care plan dated 7/15/26 identified Resident #14 was at risk for skin breakdown related to Braden score of 18, weakness, and disease process. Interventions included : complete weekly head to toe skin assessment, assist with turning and repositioning as directed on resident summary, assist and educate resident as needed per Activities of Daily Living (ADL) care plan and directed need to keep skin clean and dry. The physician's orders dated 6/9/26 directed skin checks twice a week The facility skin check monitoring symbol listed below noted the following: initial: 1= (I)No new Skin Problem 2= (N)New non ulcer identified (bruises, skin tears, etc.) 3= (P)Pressure or Non -Pressure Ulcer identified (diabetic, vascular, etc.) Must document any N or P findings in nursing notes and initiate the appropriate healing record. The skin check dated 6/28/26 on the 3:00PM-11:00 PM shift identified a code of 0 for the skin check completed. The skin check dated 7/2/26 identified a code of 0 for the skin check completed. The skin check completed on 7/16/26 identified a code of 0 for the skin check completed. The Braden Scale completed on 7/15/26 identified a total of 19 = no risk. The nurses note dated 7/15/26 identified Resident #14 had an open area to the coccyx region. An assessment was completed and the area measured 1.3 Centimeter (CM) long x 4 :00 CM wide. The APRN was updated and the Infection Control Nurse ( ICN) will follow up with Resident # 14 when in the building. Treatment was started on the area. The nurses note from ICN dated 7/16/26 identified Resident #14 was assessed for the coccyx open area. The site was currently unstageable and measured 1.5 cmx4.0 cm x 0.1cm. The base was 75% slough and 25% granulation tissue. Moderate serosanguinous drainage, with no odor. The wound edges were feathered and intact. No induration and the surrounding skin is baseline color, and the site is tender to the touch. An air mattress was in place with so signs of local infection. The Wound Physicians progress note dated 7/20/26 identified the resident was seen for first evaluation and management of a current wound located on the coccyx for identified pressure. The assessment completed identified the wound was staged as an unstageable wound measuring 1.5cm x3.0 cm x0.1cm. The wound base was 1-24% epithelial and 75-99% slough with a moderate amount of serosanguinous fluid. Treatment recommendation directed to cleanse the wound and apply calcium alginate to the wound bed and secure it with a dry clean dressing. Interview on 8/6/26 at 11:45AM with RN#1 Infection Preventionist identified the area on the coccyx was first assessed by her on 7/16/26 after it was identified on 7/15/26. RN#1 identified the area may have been missed on a skin assessment secondary to the fact that by the time she saw the wound it was already containing slough and indicated that it may have been missed due to the size of the area or due to the resident's skin tone. RN#1 could not identify what the 0 meant in the treatment record for the skin assessments coding. RN#1 identified she had heard Resident #14 can sleep for several hours and then arise towards the evening. She was unsure related to sundowning and the resident becoming very active. Interview on 8/6/26 at 1:45PM with LPN#7 identified the 0 on the skin check was an error and she thought that it should have been a 1 secondary to no new issue was present. LPN # 7 thinks that the wrong button may have been pressed as the 0 did not equal any of the items in the key. Interview on 8/10/26 at 9:25AM with MD#3 identified due to the small size of the area on the coccyx could be the reason why the area was missed during care or on a skin check. MD # 3 further indicated she would expect the facility policy for skin checks to be followed. MD#3 also identified that she was surprised Resident #14 developed a pressure area due to the fact during the time she saw Resident #14 he was moving. Interview on 8/10/26 at 10:20AM with the DNS identified, she would expect the facility nursing staff to be accurately documenting skin checks and following the protocol for coding on the bi-weekly skin checks on residents. Review of the Pressure Injury Management Long Term Care revised April 2026 directed specific interventions to manage pressure injuries include continuous skin assessment, consistent monitoring, and interventions to prevent the formation of pressure injuries.

Based on observation, facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure blood specimens were appropriately stored and monitored and failed to ensure sharps were disposed of appropriately and not left unattended in a common area accessible to other residents and staff to prevent potential accident hazards. The findings included: A tour of the facility and observation on [NAME] unit 8/5/26 at 5:42 AM identified a resident unit made up of two hallways in the shape of a T with 24 resident beds. There were no residents or visitors present in the unit hallways at the time of the observation. Observation of the area outside of room [ROOM NUMBER] identified a precautions cart with 4 specimen collection tubes containing blood specimens on top of the cart. The specimen tubes were still attached to the hub with the straight bore needle still attached. The safety covers were in place over the needles. The vials of blood were labeled with resident information and contained red substance in each of the vials were left unattended. Upon exiting a resident room, the Phlebotomist had gathered her blood vials and needles into her hands.Interview with the Phlebotomist on 8/5/26 at 5:48 AM indicated she could not bring the items into an Enhanced Barrier Precautious( EBP) designated room but acknowledge the items should not be out of her possession. The phlebotomist indicated the needles were still present because there were not sharps containers in the resident rooms and she didn't have a sharps container on her person. The Phlebotomist refused to answer any additional questions regarding practice regarding sharps and blood specimens while in the facility. Interview with the Administrator on 8/5/26 at 8:15 AM identified the phlebotomy staff are employed by the facility's parent company and all parent company employees receive the same training regarding securing specimens and sharp items . The Administrator identified that the phlebotomist would also have had training that was specific to her job and the expectation would be not to leave blood specimens or sharps unattended.Interview with the Infection Preventionist (IP) RN on 8/5/26 at 10:58 AM identified she was not sure if the facility did not provide education to outside contract staff in the facility and she had not provided any education. However, she would expect blood specimens not to be left unattended or on facility surfaces because of blood exposure or contamination. She further indicated needles, especially used needles should not be left where residents might access them or others could get stuck and potentially be infected with something.Interview with RN#6 (Intermittent staff educator) on 8/6/26 at 10:51 AM identified the facility follows [NAME] Chapter 2 guidelines for infection prevention for staff. She further indicated she would expect blood specimens or sharp not to be left in the hallway unattended. Sharps can be disposed of in the medication rooms on each unit and on the medication carts. RN#6 indicated that phlebotomists usually have their own sharps containers and other supplies to complete the blood draws.Interview with Person #2, Laboratory Supervisor ( Person # 2), on 8/10/26 at 10:19 AM identified all care should be completed at the resident's bedside. Once the blood specimen is obtained, the tube should be labeled and placed in the biohazard laboratory bag. Person #2 indicated that the phlebotomists carry sharps containers and should dispose of the sharps after the drawing, prior to leaving the resident room. Person #2 identified the phlebotomist received training/education/competencies on appropriate procedure for providing laboratory services and should follow that guidance.Review of the Phlebotomists completed education and competencies dated 5/5/26, received from Person#2 on 8/10/26 at 2:12 PM identified the procedure post obtaining blood specimen is to withdraw the needle and apply pressure to the site. After the drawing label the specimen tubes according to procedure with the resident information and the date, time, and initials of collector. The procedure then directs to discard phlebotomy consumables in the appropriate waste stream with no biohazard bags or needles in regular trash and inspection of the patient drawing area to ensure removal of all phlebotomy supplies. Education records identified the Phlebotomist received sharps safety training and standard precautions training on 9/17/25.Interview with the Medical Director on 8/11/26 at 1:34 PM identified he would expect blood products or sharps to be not left unattended in the hallway or anywhere that residents could have access or where patient information could be seen. The Medical Director indicated he would expect contract employees to have the same facility education as facility staff members in order to complete their jobs efficiently.Review of [NAME] Chapter 2 guidelines given and used by the facility identified sharps should be placed in an approved puncture resistant container as close as feasible to the site of use.Review of guidelines for standard precautions followed by the facility ([NAME] and OSHA) identified all human blood should be treated as infectious (standard precautions) and indicated blood specimens must be contained in sealed, leak-resistance biohazard bags.Although requested, policies and procedures for phlebotomists from the laboratory providing services in the facility were not received by the surveyor from the facility or the contracted laboratory.

Based on a review of the facility Infection Control program, review of facility documentation , policy review and staff interviews, the facility failed to ensure an up-to-date, effective training program was implemented and maintained for all individuals providing services under a contractual arrangement that met the infection control program training requirements, including Enhanced Barrier Precautions(EBP) was developed, implemented and maintained for all individuals providing services under contractual arrangements met the training requirements prior to and while providing ongoing services in the facility according to the facility assessment. The findings include: Review of the Facility Assessment identified the facility's resources included all personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care. The facility assessment indicated the administrator was designated as the leader for the facility assessment process and was responsible for ensuring the completion and maintaining all documents that pertain to the assessment.On 8/5/26 at 8:15 AM a request for contract staff facility specific education on Enhanced barrier precautions for individuals providing direct and indirect services under contractual arrangements to facility residents. The facility was only able to provide an education and training packet that is provided to the contracted agencies and a list of education completed by the phlebotomist through the parent company. Interview with the Administrator at this time of the review identified because the phlebotomist is employed by the same parent company and she would receive the same education as other facility staff under the parent company. The Administrator indicated the facility did provide education material for contract staff but left the completion up to the contracted agency. The Administrator further identified that although EBP education was not provided by the facility, she was sure the Phlebotomist had received this education and was aware of PPE use and EBP requirements.Review of the Service Partner education Packet (contract staff) updated August 2024 identified education including safety, emergency preparedness, red binder, resident rights, abuse and neglect, Health Insurance Portability and Accountability ( HIPAA), code of conduct, integrity and compliance and infection prevention. The education includes a power point presentation and indicates infection control included bloodborne pathogens and identified potentially infectious materials including any human body fluids and anything contaminated with blood. Additionally, the infection control includes standard precautions, hand hygiene and transmission-based precautions including contact, droplet and airborne precautions. The education further identified staff should use needle and sharp safety standards and use personal protective equipment. The education did not include guidance or expectations for enhanced barrier precautions in the long-term care facility.Review of the Education Record for Phlebotomist dated 5/16/24 through 3/4/26 (provided by the parent company human resources) identified infection: hand hygiene education completed 5/16/24, hand hygiene: preventing the spread of germs annual training completed 2/13/25, cleaning patient equipment and environment completed 2/13/25, sharp attack training completed 9/17/25 and education on hand hygiene preventing the spread of germs annual training completed 3/4/26, but failed to include precautions training for infection control or EBP training that would be long term care facility specific.Interview with the Infection Preventionist, RN #1 on 8/5/26 at 10:58 AM identified she does not provide any education or facility specific orientation to contract providers that provide services to the facility. RN#1 indicated that if there are questions on precaution signage, the contracted staff should ask the nurse for direction on Personal Protective Equipment ( PPE) use.Interview with RN#6, the prior DNS who provides staff education at the facility, on 8/6/26 at 10:51 AM identified the facility provides education to all facility staff annually and if concerns arise. RN #6 identified she was not aware of education or competencies provided to the contract staff but indicated EBP training was included in the facility staff education.Interview with the contracted Laboratory Supervisor, Person #2, on 8/10/26 at 10:19 AM identified that laboratory staff are educated on universal precautions, sharps and bloodborne pathogens through the laboratory. Person #2 was not sure if there was a contract between the laboratory and the facility. Person # 2 also indicated he was not aware of what enhanced barrier precautions were or what the requirements were but indicated he would expect phlebotomy staff to follow the universal precautions and sharps management requirements.Interview with the Medical Director on 8/11/26 at 1:34 PM identified Enhanced Barrier Precautions are used in the facility and although he was not aware of the training requirements for contract staff, he would expect they receive the same education as facility staff. The Medical Director indicated that because phlebotomy services were employed by the same parent company, he would expect they received the same education as the facility staff.The Facility Assessment completed while onsite identified under the staff competency section that mandatory education for staff included Respiratory Protection program, Emerging infection, Infection transmission -based precautions, Bloodborne Pathogens and standard precautions. Although these mandatory areas listed outlined frequency and training mechanism for facility employees, the Facility Assessment failed to outline the same parameters for contracted individuals.An interview with the Administrator on 8/10/26 at 10:41 AM identified that although the facility did provide some training for contracted staff, the facility assessment did not address the length, frequency or mechanism of training for the contracted individuals providing direct and indirect services to facility residents . She further indicated it was a facility practice to provide contracted agencies with some education but did not include contracted staff in annual education or competencies and did not keep track of the completed required education but expected the contracted agencies to maintain records. The Administrator indicated that because phlebotomy was under the same parent company as the facility, additional education was not necessary that was facility specific and the precautions and facility specific emergency procedures should be common sense. Additionally, the Administrator indicated the contract education was updated August 2024 but did not include the EBP which was implemented 4/1/24.Review of facility policies/guidelines identified infection prevention education included in Chapter 2 practice guidelines for facility staff identified guidance for infectious process, precaution systems, standard precautions, enhanced barrier precautions, transmission-based precautions, signage and notice, other transmission-based categories, handwashing with soap and water, waterless hand sanitizers, and PPE (storage, donning and doffing). This information is provided to facility staff and not to contract staff.

Based on clinical record review, interviews, and facility documentation/policies for one (1) of three (3) residents (Resident #5) reviewed for Advanced Directives, the facility failed to honor a resident's Advanced Directive which specified Do Not Resuscitate and Do Not Intubate (DNR/DNI) when the resident was found unresponsive and without a pulse. The findings included:Resident #5 was admitted to the facility in November of 2025 with diagnoses that included peripheral vascular disease, cellulitis of left lower limb, and unspecified open wound of left lower limb.The Nursing admission assessment by RN #6 dated [DATE] at 4:51 PM identified Resident #5 arrived to the facility by stretcher, had reduced strength of the lower extremities, could ambulate with assistance, and utilized a four (4) wheel walker.The Current Consent for Life Sustaining Procedure dated [DATE] (located in the resident's paper chart and signed by both the resident and Medical Director) identified Resident #5 refused cardiopulmonary resuscitation (CPR), artificial respiration, and artificial nutrition.The Electronic Medical Record failed to identify Resident #5's Advanced Directive to not resuscitate or intubate (DNR/DNI).A Nurse's note by LPN #5 dated [DATE] at 4:17 PM identified at about 8:00 AM, NA #1 (assigned to Resident #5) went to his/her room to obtain vital signs, noticed blood on the carpet in front of the bathroom door, and found Resident #5 seated on the toilet, unresponsive. Resident #5 was unresponsive and pulseless on the toilet. CPR was initiated, the nursing supervisor was paged STAT (immediately) to the unit, which was followed by a code blue page and the resident was pronounced deceased by the nursing supervisor.Interview with LPN #5 on [DATE] at 11:53 AM identified that upon being informed Resident #5 was unresponsive, he/she found Resident #5 pulseless, called the code, and initiated CPR. LPN #5 identified that upon arrival to the unit, LPN # 7 took over and continued to provide CPR to Resident #5. Interview with LPN #7 on [DATE] at 2:31 PM identified he/she was assigned to another unit on [DATE], responded to the code, and administered compressions after being informed Resident #5 was a Full Code. LPN #7 further indicated LPN #5 relieved him and continued CPR when Emergency Medical Services (EMS) arrived. However, after review of Resident #5's medical records, EMS informed staff Resident #5 had a Do Not Resuscitate/Do Not Intubate (DNR/DNI) order in his/her paper chart. Staff stopped performing CPR, and the resident was pronounced deceased .Interview with the Director of Nursing Services (DNS) on [DATE] at 2:09 PM identified Resident #5's Advanced Directives were not followed as LPN #5 failed to check Resident #5's paper chart (which contained the signed Current Consent for Life Sustaining Procedure) prior to assuming the resident was a Full Code and administering CPR. The DNS indicated that if the paper chart been checked, Resident #5's Advanced Directives would have been identified, and CPR would not have been administered. Although requested, the facility was unable to provide an Advanced Directive policy.The Heartsaver Cardiopulmonary Resuscitation (CPR) and Automatic External Defibrillator (AED) policy directed the American Heart Association had established evidenced-based decision-making guidelines for initiation CPR when cardiac arrest occurs. CPR was initiated unless one (1) of the three (3) conditions was present: a valid DNR order was in place, initiating CPR could cause injury or peril to the rescuer, and in the presence of obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition). In all other instances, CPR is to be administered.

Based on review of the clinical record, facility documentation, and staff interviews, for one (1) of two (2) residents (Resident #1) reviewed for an injury of known origin, the facility failed to ensure the resident received necessary care and services when a physician-ordered x-ray was not obtained following complaints of left lower extremity pain, resulting in an eight (8) day delay in diagnosis of acute displaced fractures of the distal tibia and fibula. The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included childhood polio, osteoporosis and Alzheimer's dementia.The Nursing admission assessment dated [DATE] identified Resident #1 was oriented to person, place, time and event.The Resident Care Plan dated 10/9/25 identified Resident #1 was at risk for bilateral leg pain with interventions that included pain medications as ordered, complete pain assessment/evaluations, and observe for non-verbal indicators of pain (facial grimacing, guarding, furrowed brow, increased fatigue).A Rehabilitation Screening dated 12/18/25 identified Resident #1 presented with decreased motorized wheelchair driving ability. Resident #1 was to be out of bed to the customized wheelchair with a 24-hour positioning plan.A Nursing note by LPN #1 dated 12/22/25 at 6:41 PM identified Resident #1 was in pain when he/she moved his/her left foot and would grimace when his/her left foot was moved. LPN #1 administered Tylenol (acetaminophen) 325 mg at 5:00 PM. MD #1 was on site, assessed Resident #1 and ordered an x-ray for suspicions of arthritis.A note by MD #1 dated 12/29/25 identified Resident #1 had a cognitive and functional decline along with weight loss and a sacral deep tissue injury (an area of damaged tissue under the skin that may appear dark purple or maroon and can develop into an open wound). Resident #1's representative agreed with a hospice consult due to a poor prognosis and ongoing decline.A Nursing note dated 12/30/25 at 10:14 PM identified Resident #1 was seen by hospice. Hospice reported that during repositioning of Resident #1's left lower extremity (LLE), Resident #1 complained of severe pain, deformity was noted and LLE swelling was identified below the knee. Per the MD an x-ray was ordered STAT (immediately). Subsequently, Resident #1 was not admitted to hospice.Review of the clinical record identified the physician ordered an x-ray on 12/22/25; however, the order was not entered into the medical record and the x-ray was not obtained until 12/30/25.X-ray reports dated 12/31/25 identified there were acute mildly displaced spiral fractures of the distal tibia and fibula and diffuse osseous demineralization was noted. A Nursing note dated 12/31/25 at 8:55 AM identified the physician was notified of the x-ray results and ordered Resident #1 be transferred to the Emergency Department (ED).An ED note dated 12/31/25 identified x-rays obtained confirmed a closed left distal tibia and fibula facture. Given Resident #1 was non-ambulatory, non-operative management would be trialed. Resident #1 was administered one (1) tablet of Oxycodone/Acetaminophen and 50 mcg of Fentanyl for pain.Although attempted, an interview with LPN #1 was not obtained.Interview with the DNS on 2/4/25 at 3:00 PM identified there was no order entered for an x-ray on 12/22/25, the x-ray order was missed. She further identified the facility did not have a policy for physician's orders but the facility practice was for the provider to enter the orders into the Electronic Medical Record (EMR) under drafts and a nurse would then finalize the order. She identified that a nurse would only enter orders into the EMR for a covering provider who was unfamiliar with the EMR. Interview with MD #1 on 2/5/25 at 10:40 AM identified on 12/22/25, he assessed Resident #1'S left foot for reports of pain and there was no swelling, deformity or bruising. He identified he thought the pain was arthritic. He identified that he ordered x-rays and did not know why the x-rays were not conducted until 12/30/25. He further identified nursing staff and the APRN's enter orders into the EMR and then the MD signs the orders.Although requested, the facility did not have a physician's orders policy or protocol.

Based on review of clinical records, facility documentation and policy, interviews for one (1) of three (3) residents (Resident #1) reviewed for wounds, the facility failed to ensure the clinical record was complete and accurate to include documentation of a physician order for wound care. The findings included:Resident #1 had diagnoses which included an unspecified wound, and local infection of the skin, subcutaneous tissue. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition. Review of the RCP dated 8/20/2025 identified Resident #1 had an open wound/impaired skin integrity to the left lower extremity. Interventions directed to apply treatment: wound vac on Mondays/Wednesdays/Fridays. A physician's order dated 8/31/2025 directed to apply a wound vac at a low, continuous suction of 125 millimeters. Review of a nurse's note dated 9/1/2025 at 12:34 AM identified Resident #1's wound vac was malfunctioning. The Infectious Disease Nurse and Med Essentials Representative (provider for the wound vac) were notified, and that staff were advised to apply a wet to dry dressing until the morning when a new wound vac would be delivered. Record review failed to identify a physician's order dated 8/31/2025 that directed a wet to dry dressing until the morning when a new wound vac would be delivered. Interview with APRN #1 on 10/6/2025 at 1:08 PM identified that he/she was aware the wound vac had malfunctioned. APRN #1 further identified that an order for wet to dry dressing changes was not provided as it was the facility protocol to perform a wet to dry dressing changes until a new wound vac was received and that he/she agreed with the protocol. Interview with the Director of Nurses (DON #2) on 10/6/2025 at 2:25 PM identified the facility did not have a facility policy/protocol that directed staff what to do when a wound vac malfunctioned. DON #2 stated staff was trained to follow the [NAME] Nursing Procedure and Skills Guidelines, which directed wet to dry dressing changes when a wound vac malfunctioned. Although APRN #1 was notified of the malfunctioning wound vac on 8/31/2025, and per the nursing note the APRN directed use of a wet to dry dressing, DON #2 was unable to provide documentation that a physician order was entered into the medical record. DON #2 stated she thought referring to [NAME] Guidelines was sufficient. Review of the Physician Services policy dated 11/1/2019 directed each resident must remain under the care of a physician and that a physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.

Based on review of the clinical records, review of facility documentation, facility policy/procedures, and interviews for 5 of 5 residents (Resident #83, Resident #97, Resident #120, Resident #160 and Resident #187), reviewed for immunizations, the facility failed to ensure that the COVID-19 vaccination were offered and/or assessed to residents. The findings include: 1. Resident #83 was admitted to the facility in the month of June 2024 with diagnoses that included pneumonia, multiple rib fracture, and Alzheimer's disease. The quarterly MDS assessment dated [DATE] identified Resident #83 had severely impaired cognition. The assessment further identified that Resident #83 COVID-19 vaccination was not up to date. Review of Resident #83's immunization consents and/records, along with the new admission vaccine audit documentation for June 2024 with the Infection Preventionist (RN #2) on 11/7/24 at 9:45 AM failed to identify that the COVID-19 booster vaccine was offered to the resident. 2. Resident #97 was admitted to the facility in the month of November 2023 with diagnoses that included type 2 diabetes mellitus, spinal stenosis and chronic obstructive pulmonary disease (COPD). The quarterly MDS assessment dated [DATE] identified Resident #97 was cognitively intact. Review of Resident #97's immunization consents and/records, along with the new admission vaccine audit documentation for November 2023 with the Infection Preventionist (RN #2) on 11/7/24 at 9:45 AM failed to identify that the COVID-19 vaccine was offered and/or assessed for past immunization. 3. Resident #120 was admitted to the facility in the month of October 2022 with diagnoses that included end stage renal disease, anemia and dementia. The annual MDS assessment dated [DATE] identified Resident #120 had severely impaired cognition. Review of Resident #120's immunization consent and/records with the Infection Preventionist (RN #2) on 11/7/24 at 9:45 AM failed to identify that the COVID-19 booster vaccine was offered to the resident. 4. Resident #160 was admitted to the facility in the month of June 2024 with diagnoses that included schizoaffective disorder, fracture of the right femur and heart failure. The quarterly MDS assessment dated [DATE] identified Resident #160 was cognitively intact. The assessment further identified that Resident #160 COVID-19 vaccination was not up to date. Review of Resident #160 immunization consents and/records, along with the new admission vaccine audit documentation for June 2024 with the Infection Preventionist (RN #2) on 11/7/24 at 9:45 AM failed to identify that the COVID-19 booster vaccine was offered to the resident. 5. Resident #187 was admitted to the facility in the month of August 2024 with diagnoses that included dislocation of internal right hip prosthesis, right artificial hip joint and dementia. The annual MDS assessment dated [DATE] identified Resident #187 had severely impaired cognition. Review of Resident #97's immunization consents and/records, along with the new admission vaccine audit documentation for August 2024 with the Infection Preventionist (RN #2) on 11/7/24 at 9:45 AM failed to identify that the COVID-19 vaccine was offered and/or assessed for past immunization. Interview with RN #2 on 11/6/24 at 11:33 AM identified that the COVID-19 vaccine was not offered to the residents as the facility was not offering the vaccine at the time. RN #2 identified that she would review the resident's COVID-19 vaccine status vaccination history, as when the vaccine became available, she would know what vaccine was needed. Interview with the Administrator and RN #2 on 11/6/24 at 2:30 PM identified that the COVID-19 immunization facility's policy in 2023 and 2024 did in fact indicated that the residents would receive the vaccine and the booster vaccine. The Administrator identified for some reason the vaccine was not offered and prior to this inquiry the COVID-19 vaccine consent was not apart of the admission packet. RN #2 identified that on admission the admitting nurse would obtain vaccine consents for all required vaccine, then obtain a physician's order for the requested vaccine for the vaccine to given by the nurse. The Administrator identified that the COVID-19 vaccine was schedule for November 2024, however, failed to identify that consents were provided to residents. Interview with the DNS on 11/7/24 at 10:55 AM identified that she thought that the COVID-19 vaccine was being offered to the residents as it was the infection preventionist responsibility to assess the resident's COVID-19 vaccination information on admission. Interview with the Nursing Supervisor/Unit Manager (RN #3) on 11/7/24 at 10:11 AM identified that vaccine consents were obtained by the charge nurse and the nursing supervisor for resident who were responsible for themselves and cognitively intact, but it was primarily the responsibility of the charge nurse. RN #3 identified that tetanus, pneumococcal and influenza vaccine consents were discussed and reviewed on admission, while for the COVID-19 vaccine, the nurses would inquire about the resident COVID-19 vaccine status but would let the resident know that the vaccine was not available currently and when it became available it would be administered. RN #3 identified that she could only recall the primary series (1st dose and 2nd dose) and one booster vaccine being offered and administered to the residents. RN #3 was asked if she recalled the COVID-19 vaccine being offered in 2023 and 2024 like the influenza vaccine in which she responded that it was not offered on an annual basis like the influenza vaccine. Interview with RN #2 on 11/8/24 at 10:00 AM identified that the COVID-19 vaccine was last offered for administration to the residents in January of 2023. RN #2 was asked if she was aware of the newsletter mailing with COVID-19 consents that was mailed to resident in October of 2023, which she responded that she was informed of the mailing that was going to be sent out, however did not received a consent form from the resident. RN #2 identified that she was and would be responsible for any COVID-19 vaccine administration as she would be the individual who orders the vaccine, ensured the consents were obtained and the vaccine was schedule to be administered. After surveyor's inquiry facility stating that the vaccine would be offered in November 2024, however consents are mailing yet to be obtained or initiated. Interview with the Pharmacy Technician #1 (the pharmacy provider of the facility) on 11/8/24 at 11:20 AM identified that the last ordering and delivered COVID-19 vaccine from the facility was on January 11, 2023, and failed to identify any order for the COVID-19 vaccine that was schedule for this year yet. The Pharmacy Technician #1 identified that she could not recall the pharmacy not having the COVID-19 vaccine available for homes and that there might had been a delay of a day or two but there was nothing major. In addition, the Pharmacy Technician #1 identified that homes (nursing homes) would schedule a clinic for the vaccine administration and notify the pharmacy of the schedule date so that the vaccines could be delivered timely. Interview with the DNS on 11/8/24 at 11:29 AM identified when asked where the facility obtained and/order vaccines in which the DNS identified that all vaccines are obtained and/order from the same pharmacy who provides the facility with all medications. Interview with Unit Manager (RN #5) on 11/8/24 at 12:00 PM identified that the COVID-19 vaccine consents were not completed in the resident's chart. RN #5 was asked since she was the unit manager of a long-term care unit if any resident had inquired about the COVID-19 vaccine, which she responded that the residents were asking especially with the influenza vaccine being offered and administered. RN #5 further identified that the COVID-19 vaccine was not offered as it was not available and was told recently after she had inquired about the COVID-19 vaccine that the vaccine would be offered to the residents soon. Review of the Infection Prevention and Control Manual Coronavirus (COVID-19) section of COVID-19 immunization dated 5/15/2023 and 10/3/24 identified in both that residents or resident representatives and staff at the facility will be provided education regarding the benefits and potential side effects associated with the Covid-19 vaccine and any boosters recommended and offered the vaccine when it is available to the facility, unless it is medically contraindicated, or resident or staff has already been immunized.

Based on review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure that resident rights were reviewed on an ongoing basis. The findings include: A review of the resident council's monthly meeting minutes for the period of May 2024 through October 2024 failed to identify that resident rights were reviewed at the resident council meetings and/or that resident rights information was disseminated to the resident council as a group or to the residents in general. Interview on 11/04/24 at 2:07 PM with the resident council identified that the facility did not review resident rights during the resident council meetings and did not disseminate resident rights information to the residents on a routine basis. Interview on 11/7/24 at 9:29 AM with the Therapeutic Recreation Director identified the residents received a Resident's [NAME] of Rights when admitted to the facility. She further noted that she is the designated person that assists the residents with the resident council meetings and noted that the meetings did not have a designated time to review resident rights. In addition, the facility did not have policies in place that addressed resident council. Interview on 11/7/24 at 10:27 with the Administrator identified the recreation department is responsible for conducting the resident council meetings and that the expectation is that the recreation staff will review resident rights with the residents during the meetings.

Based on observations, review of clinical records, review of the facility assessment and interviews for six sampled residents (Residents #29, #55, #60, #142, #167, and #184) residing on the secured unit (West 1), the facility failed to assess, care plan, demonstrate the secured unit was the least restrictive setting, and obtain consents for residents who were selected to reside on the secured unit. The findings included: Observations during all days of the survey October 31st, November 4, 5, 6, 7, and 8, 2024 identified the [NAME] 1 unit located on the first floor had entrance doors that were closed and secured. There was a key code pad adjacent to the doors that required a number code to be entered in order to gain access to the unit. All exterior doors and stairwell doors on the unit also required a key code to access the door. The staff was noted to input the code for visitors to exit the unit or enter the unit. Review of the Facility Assessment on 11/4/24 identified the facility's capability of managing residents with dementia and/or behaviors and indicated that residents with wandering behaviors would be considered for placement on the secured unit. The facility assessment did not include the criteria or specific function for placement on the unit. Interview on 11/4/24 at 12:47 PM with the Administrator identified the facility did not have a policy for the dementia unit (secured unit). She identified the unit was specifically a dementia unit and required a diagnosis of dementia for placement. She indicated she was unaware of other criteria for placement on the unit and that it would be an interdisciplinary decision for placement. Interview on 11/5/24 at 11:19 AM with SW #2 identified that placement on the secured unit involved the whole team and indicated the MDS, RN, SW, rehabilitation staff and Administrator were part of the team. She further identified that the doctor was not included at morning report when placement is discussed, and that nursing is responsible for completing the wandering assessments. She further identified that placement on the unit is talked about sporadically, but SW#2 was unsure what is documented in the clinical chart for residents residing on the secured dementia unit. Additionally, SW #2 indicated that some families request placement on the unit, but that most placements would be for safety reasons. Interview on 11/5/24 at 11:52 AM with the DNS identified placement on the secured unit depended on resident history. The DNS indicated the resident had to have a diagnosis of dementia, and if a resident was found wandering, they would be placed on the secured unit. If there was a placement on the unit, there were not consents, and the families, or conservators would be notified of the placement. The DNS identified the placements on the secured unit are discussed at the risk meetings which are run by the doctor. She indicated there are not re-assessments and the facility does not indicate whether the placement was the least restrictive. She indicated there was not an order placed for placement, nor a note regarding placement. Interview on 11/5/24 at 2:59 PM with the Administrator confirmed the facility did not have criteria outlined for placement on the secured unit. She identified the placements were discussed at the morning meetings daily and the risk meetings, weekly. She indicated that residents who exhibited behaviors in other areas of the facility would be placed on the secured unit. Additionally, she indicated that the secured unit was usually full because of requests for the residents to stay there, and there were rarely placements made. Interview on 11/6/24 at 2:13 PM with RN#1(unit supervisor) identified that placement on the secured unit or transfer onto the unit involved a discussion with the doctor and the family. RN #1 indicated the resident would have a diagnosis of dementia and would have to have wandering behaviors or safety concerns. Interview on 11/6/24 at 3:34 PM with the Medical Director identified there was a long process for placement on the secured unit, but if a resident was wandering or had a pattern of unsafe behaviors they would be placed on the secured unit. The Medical Director identified there were no guidelines for placement and that it was a medical assessment or a psychological assessment. He indicated that medical reasons for placement were ruled out and that he would expect a provider note indicating the resident resided on a secured unit but that the note might vary among different providers. Resident #29's diagnoses included unspecified dementia severe with other behavioral disturbance, Dysthymic disorder, and dysphagia oral stage. The wander/elopement risk assessments dated 4/15/24 and 7/23/24 identified the resident did not exhibit wandering behavior. The care plan dated 8/13/24 identified the resident had self-care deficits, falls, and confusion related to dementia but failed to identify the resident was placed on the secured unit and failed to identify behaviors of wandering. The quarterly MDS assessment dated [DATE] identified Resident #29 had severely impaired cognition, required substantial/maximal assistance for all transfers, and used a manual wheelchair for mobility, did not use physical restraints or alarms, and did not exhibit hallucinations, delusions, rejection of care or wandering behaviors. Resident #55's diagnoses included senile degeneration of brain, spinal stenosis, and dementia. The quarterly MDS assessment dated [DATE] identified the resident did not refuse care, did not exhibit wandering behavior, was dependent with toileting, shower/bathing, lower dressing, and required substantial/maximum assistance with upper body dressing and personal hygiene, sit to lying, lying to sitting on side of bed and all transfers. The assessment further noted the resident required a wheelchair and could not self-propel, thus was dependent on staff for movement around the unit. The care plan dated 9/16/24 identified Resident #55 was an elopement risk with an intervention to remains on secured locked unit. Additionally, the resident was identified as receiving Hospice care with interventions that included collaborate with hospice when changes to plan of care are made, Hospice SW and nurse to visit as needed to provide support, maintain an environment that promotes comfort, modify environment based on wants/needs and monitor for signs of restlessness or agitation. The wandering/elopement risk assessment dated [DATE] identified that wandering behavior was not exhibited. This was the only wandering/elopement risk assessment provided for this resident. Resident #60 was admitted to the facility in October of 2023 and had diagnoses that included dementia, psychotic disorder, anxiety, and repeated falls. The Wandering/Elopement Risk assessment dated [DATE] identified Resident #60 had not exhibited any wandering behavior and had no history of wandering behavior. The Wandering/Elopement Risk assessment dated [DATE] identified Resident #60 had exhibited wandering behavior 1 to 3 days, was wandering to find family or pet, wandering aimlessly, and exhibiting exit-seeking behavior. The assessment indicated that an elopement prevention care plan was initiated or updated. The Wandering/Elopement Risk assessment dated [DATE] identified wandering behavior had occurred 1 to 3 days since the last assessment. Additionally, this assessment indicated the resident was wandering to find family or pet, wandering aimlessly, and was actively exhibiting exit-seeking behavior and that an elopement prevention care plan had been initiated or updated. The Wandering/Elopement Risk assessment dated [DATE] identified wandering behavior was not exhibited and the resident had previously attempted to leave a residence or other place unescorted and that the resident was cognitively impaired and independently ambulatory and had two previous wandering events. The assessment form indicated that an elopement prevention care plan was initiated or updated. The Wandering/Elopement Risk assessment dated [DATE] identified wandering behavior was not exhibited and that the resident had not had a history of elopement but did indicate the resident was cognitively impaired and independently ambulatory. Directions on the assessment form identified initiating/updating a care plan or service plan for elopement risk. The annual MDS assessment dated [DATE] identified Resident #60 had severely impaired cognition, required partial/moderate assistance with chair to bed, toilet, and tub transfers, required supervision or touching assistance with walking 10 feet and wheeling 150 feet in the wheelchair. Additionally, the MDS indicated the resident did not exhibit wandering, rejection of care, or physical or verbal behaviors. The care plan reviewed for dates 10/17/2023 through 11/7/2024 identified Resident #60 had a chronic cognitive deficit and required ADL assistance related to dementia with interventions to provide cues/reminders during tasks, encourage involvement in activities and monitor baseline cognitive functions and monitor/record for changes. However, the care plan failed to identify any mention of wandering/elopement/or placement on the facility's secured unit. Review of Physician's orders, including discontinued orders from 10/17/2023 through 11/7/2024 identified the resident continued to require a skilled level of care based on evaluation of the resident' medical status, the orders failed to direct placement on a secured unit and failed to direct monitoring for wandering/elopement. Interview on 11/06/24 at 11:54 AM with resident's responsible party identified he/she was notified that the resident had a room change but was unaware that the resident was moved the secured unit. Resident #142's diagnoses included dementia, cerebral infarction unspecified, and peripheral vascular disease. The wandering/elopement risk assessment dated [DATE] identified wandering behavior was not exhibited. This was the only wandering assessment provided from the facility. The significant change MDS assessment dated [DATE] identified Resident #142 had severely impaired cognition, was dependent with toileting, showering, and personal hygiene, did not exhibit hallucinations, delusions, physical or behavioral symptoms, rejection of care, or wandering. The care plan dated 7/15/24 identified the resident was admitted for short term rehabilitation post hospitalization for stercoral colitis and lived on memory care unit with a goal to return to assisted living facility and interventions to include social work to work collaboratively with patient, family, IDT, and assisted living community to determine post discharge needs. Resident #167's diagnoses included Wernicke's encephalopathy, dementia, and difficulty in walking. Physician's progress notes dated 9/29/23, 1/24/24, 5/22/24, 7/25/24, and 9/18/24 identified the resident was transferred to memory unit because of agitation, risk of flight and indicated an attempted elopement in June 2023 but failed to identify re-assessment of placement on the secured unit and failed to identify that this was the least restrictive placement for the resident. The quarterly MDS assessment dated [DATE] identified Resident #167 had severely impaired cognition, did not exhibit hallucinations, delusions, physical or verbal behavioral symptoms, rejection of care or wandering behaviors, and required supervision or touching assistance with walking 10 and 50 feet with use of a walker. The care plan dated 10/7/24 identified resident #167 was at risk for wandering due to dementia and impaired safety awareness with a goal to not wander unsafely on or off memory lane through the next review with intervention to assess elopement risk upon admission, quarterly, or with significant change of condition and update care plan accordingly. Resident #184 was admitted to the facility in July of 2024 with diagnoses that included Alzheimer's disease, end stage renal disease, and diabetes mellitus without complications. The Wandering/Elopement Risk assessment dated [DATE] identified wandering behavior was not exhibited. Additionally, the assessment indicated the resident had not previously attempted to leave a residence or other place unescorted, was not cognitively impaired and independently ambulatory, did not have a history of elopement, was not on medication to manage elopement behaviors, had not verbalized intent to leave the facility, was not wandering to find family or a pet, was not wandering aimlessly and was not actively exit-seeking. Review of Nursing progress note from 7/22/24 through 11/6/24 identified the resident was placed on [NAME] 1 unit but failed to identify this was a secured unit, failed to identify consent for placement, assessment or reason for placement, or identification that this was the least restrictive placement for the resident. Additionally, nursing progress notes identified the resident was alert and oriented to self, was pleasant and cooperative with care, and did not have behavioral issues. Review of provider progress notes dated from 7/24/24 through 9/23/24 failed to identify assessment or reason for placement on a secured unit and failed to identify the placement on the secured unit as the least restrictive placement for the resident. The admission MDS dated [DATE] identified Resident #184 had severely impaired cognition, was always incontinent of bowel and bladder, utilized a walker and a wheelchair, required substantial/maximal assistance with toileting hygiene, shower/bathing, and partial/moderate assistance with all transfers and position changes. Psychiatric Evaluation and Consultation notes reviewed from 7/24/24 through 10/7/24 identified Resident #184 did not exhibit any behavioral or mood concerns and failed to identify resident was housed on a secured unit. The care plan dated 11/6/24 failed to identify the resident resided on a secured unit. Interview on 11/8/24 at 12:02 PM with the DNS and the Administrator identified placement on the unit would be for safety reasons, including wandering/elopement. Additionally, the Administrator indicated the residents were not re-evaluated for placement and that most placements remained in place based on requests from family members. Further, the Administrator could not identify whether or not consents for placement on the unit were obtained.

Based on observation, interviews and review of facility policy for 3 of 4 medication rooms, the facility failed to ensure medication rooms had sanitary refrigerators, maintained at appropriate temperatures and expired medications were removed from the cabinets. Additionally, for 3 of 5 medication carts, the facility failed to ensure the carts were clean. The findings include: Observation of the [NAME] Crossing medication storage room with LPN #4 on 10/31/24 at 10:30 AM noted expired medication contained in the overstock cabinet consisting of 1 full bottle of 325 milligrams(mg) of Aspirin (100 tablets) with an expiration date of 9/24, and the freezer had a heavy accumulation of frost/ice. Interview with LPN #4 on 10/31/24 at 10:35 AM identified that she was unsure of who was responsible for cleaning out and restocking medication in the medication storage room. LPN #4 identified that the freezer needed to be defrosted and that the 11:00 PM to 7:00 AM shift was responsible for picking up discontinued medications. Interview with RN #1 at 11:15 AM on 10/31/24 identified that everyone should be monitoring the refrigerators temperatures but usually it is 3PM-11PM and it should be done daily. Also, RN#1 identified that 11PM-7AM was responsible for cleaning out expired medications from the storage rooms, that the freezer needed to be defrosted, and the refrigerator was soiled. Observation of the [NAME] medication storage room with LPN #5 on 10/31/24 at 11:00 AM on identified that the freezer had a heavy accumulation of frost/ice and needed to be defrosted, temperature logs were missing from 9/2/24, 9/3/24, 9/6/24, 9/7/24, 9/11/24, 9/12/24, 9/16,24, 9/17/24, 9/21/24, 9/22/24, 9/25/24, 9/26/24, 10/24/24, and 10/31/24. The refrigerator was found to be soiled with a tan, dried liquid type substance. The refrigerator contained 650 milligram Tylenol suppository (5 suppositories) with an expiration date of 4/24 (7 months past the expiration date). Also in the refrigerator was Bisacodyl suppository 10mg house stock 10 in a box, 12 boxes of Influenza vaccine, Ziopetan 0.0015% eye vials (3 boxes), Trulicity 1.5mg/0.5ml-0.5ml, Formoterol Fumarate 40ml one unit dose, a bottle of Rocklaton 0.02-0.005% eye drops, a bottle of Dorzolamide HCL 2% eye drops, a bottle of Rhopressa 0.02%, a bottle of Brimonidine Tartrate , a bottle of Latanoprost 0.005%, 2 pens of Trulicity 0.75mg/0.5ml, 1 Insulin Glargine pen, and 2 vials of Lispro 100units/ml. Also, observed in the over stock cabinet in the [NAME] medication room, a full bottle of Aspirin 325 milligrams(ml) (100 tablet) with an expiration date of 9/24 (2 months past the expiration date). Interview on 10/31/24 at 11:00 AM with LPN #5 identified that the refrigerator was soiled, needed to be cleaned, and the freezer need to be defrosted. The temperature logs were missing numerous dates and that 11:00 PM-7:00 AM and 3:00 PM-11:00 PM nursing staff were responsible for tracking the temperatures. Observation of the East 2 medication cart on 10/31/24 at 12:00 PM with LPN #1 noted loose medication pills in the second drawer from the bottom along with loose pieces of paper. Interview with LPN #1 on 10/31/24 at 12:05 PM identified that that everyone was responsible for cleaning the medication cart and that she felt it was not clean. Observation of the [NAME] 1 medication cart along with the [NAME] 1 medication storage room on 10/31/24 at 12:15 PM with LPN #2 identified that there were dropped pills inside of the medication cart on the bottom along with a brown liquid substance. The refrigerator temperature logs were missing dates from 10/22/24, 10/23/24, 10/24/24, 10/29/24, 10/30/24, and 10/31/24. Contents of the refrigerator included: 2 bottles of Lorazepam 2mg/ml, 4 Lantus pens of 100units/ml, 3 vials of Lispro 100units/ml, and 1 pen of Trulicity 0.75mg/0.5ml-0.5ml. Interview with LPN #2 on 10/31/24 at 12:20 PM identified that the medication cart was not clean and that the brown substance was sticky. LPN #2 identified that 11:00 PM -7:00 AM nursing staff oversaw cleaning the medication cart, and she was unsure of the policy. Observation of the EAST 1 med cart on 10/31/24 at 12:30 PM with LPN #3 identified that the medication cart contained a Geria Lanta 325 Milliliter(ml)Full bottle with an expiration date of 9/24 (2 months past the expiration date). Inside the cart it was noted to have brown, substance with a bubble pack containing medication laying in the bottom of the med cart. Interview with LPN #3 on 10/31/24 at 12:35 PM identified that everyone was responsible for going through the cart, but 11:00 PM-7:00 AM nursing staff were responsible. LPN #3 stated that the staff could do better at cleaning the cart and identified that the bubble packed medication belonged to a current resident. LPN #3 identified that she would contact maintenance to clean the cart. An interview with the Infection Preventionist (RN #2) on 10/31/24 at 2:20 PM identified that she doesn't always have access to the medication storage rooms because the unit nurse has the keys. RN #2 also identified that she checks the refrigerators on her rounds but not the freezers. Both the Director of Housekeeping and RN #2 identified that the freezers on [NAME] and Fitsgerald both needed to be defrosted and that the refrigerator on [NAME] was soiled. Also, the Director of Housekeeping and RN #2 identified that [NAME] 1 and East 1 medication carts were soiled and needed to be cleaned stating that nursing staff was to communicate to housekeeping when the medication carts needed to be cleaned including the refrigerators/freezers. Review of the facility policy for Cleaning of Refrigerators identified that all refrigerators and freezers should be cleaned by housekeeping on a regular basis and as necessary by nursing departments for spills. Also, identified the temperatures of any refrigerator or freezer that contains drugs, should be checked daily per the night shift and logged to ensure proper temperature control. Review of the facility policy for Storage and Expiration of Medications identified that the facility should ensure that medications and biologicals that have an expired date on the label, have been retained longer than recommended by manufacturer or supplier guidelines or contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. Also, identified the facility should ensure that medication and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Facility staff should monitor the temperatures of vaccines twice a day. Refrigerators temperatures should be from 36 degree-46 degrees.

Based on review of clinical records, review of facility documentation, review of facility policy/procedures, and interviews for two of five sampled residents (Resident #83 and Resident #160), reviewed for immunizations, the facility failed to administer the pneumococcal vaccine as requested by the resident upon admission. The findings include: 1. Resident #83 was admitted to the facility in the month of June 2024 with diagnoses that included pneumonia, multiple rib fracture, and Alzheimer's disease. The quarterly MDS assessment dated [DATE] identified Resident #83 had severely impaired cognition. Review of the Vaccination Consent form for pneumovax identified Resident #83 gave the facility permission to administer the pneumovax vaccine on 6/26/2024. Review of Resident #83 clinical records failed to identify that he/she had received the vaccination at the facility or had change his/her decision. 2. Resident #160 was admitted to the facility in the month of June 2024 with diagnoses that included schizoaffective disorder, fracture of the right femur and heart failure. The quarterly MDS assessment dated [DATE] identified Resident #160 was cognitively intact. Review of the Vaccination Consent form for pneumovax identified Resident #160 gave the facility permission to administer the pneumovax vaccine on 6/26/2024. Review of Resident #160 clinical records failed to identify that he/she had received the vaccination at the facility or had change his/her decision. Interview with the Infection Preventionist nurse (RN #2) on 11/7/24 at 9:45 AM identified the charge nurses and/or supervisors are responsible to obtain the consent, obtain a physician's order, order the vaccine, administer the vaccine and document in the resident's immunization records. RN #2 further identified that she was not informed that the vaccine was not administer nor the charge nurse or supervisor notified her of any issues as to why the resident did not receive the vaccine as if the consent was signed the expectation was that it would be administered. Interview with the Nursing Supervisor/Unit Manager (RN #3) on 11/7/24 at 10:11 AM identified that the vaccine consents were obtained by the charge nurse and the nursing supervisor for resident who were responsible for themselves and cognitively intact, but it was primarily the responsibility of the charge nurse. RN #3 further identified the procedure after a vaccine consent was obtained from the resident or resident representative, that a physician's order would be obtained, the vaccine would be ordered from pharmacy then administered to the resident followed by updating the resident's immunization records. Review of the Immunization of Patients/Residents policy in effect up until of September 2024 identified all new patients/residents will be assessed for pneumococcal and Prevnar 13 vaccine status upon admission and permission obtained from the patient/resident (or representative) to administer the pneumococcal vaccine. The policy further identified that the pneumococcal vaccine should be administered one time only per physician's order.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one of six sampled residents (Resident #60) residing on the secured unit, the facility failed to ensure the resident's care plan was comprehensive in regards to behaviors of wandering, elopement risk and placement on a secured unit. The findings included: Resident #60 was admitted to the facility in October of 2023 with diagnoses that included dementia, personal history of disease of the nervous system and sensory organs, and unsteadiness on feet and repeated falls. The annual MDS assessment dated [DATE] identified Resident #60 had severely impaired cognition, required partial/moderate assistance with chair to bed, toilet, and tub transfers, required supervision or touching assistance with walking 10 feet and wheeling 150 feet in the wheelchair. Additionally, the MDS indicated the resident did not exhibit wandering, rejection of care, or physical or verbal behaviors. The care plan reviewed for dates 10/17/2023 through 11/7/2024 identified Resident #60 had a chronic cognitive deficit and required ADL assistance related to dementia with interventions to provide cues/reminders during tasks, encourage involvement in activities and monitor baseline cognitive functions and monitor/record for changes. However, the care plan failed to identify any mention of wandering/elopement/or placement on the facility's secured unit. Review of Physician's orders, including discontinued orders from 10/17/2023 through 11/7/2024 identified the resident continued to require a skilled level of care based on evaluation of the resident' medical status, failed to direct placement on a secured unit and failed to direct monitoring for wandering/elopement. The Wandering/Elopement Risk assessment dated [DATE] identified Resident #60 had not exhibited any wandering behavior and had no history of wandering behavior. A Social Services note dated 11/3/2023 at 6:29 PM identified Resident #60's Brother was notified the resident was moved to the secured unit for wandering off of the current unit. The Wandering/Elopement Risk assessment dated [DATE] identified the resident had exhibited wandering behavior 1 to 3 days, wandering aimlessly, and exhibiting exit-seeking behavior. The assessment indicated that elopement prevention care plan was initiated or updated. Review of Nursing Progress notes from 11/4/24 through 11/7/24 identified the resident was adjusting well to the secured unit without elopement behavior noted. The nursing progress note dated 11/8/24 at 12:28 PM identified the resident self-propelled in the wheelchair and was noted to be wandering on the East 1 unit and when interviewed Resident #60 indicated he/she was looking his/her daughter. Additionally, the note identified the resident was within staff site until able to move to [NAME] 1, the secured unit. Physician's note dated 11/29/24 identified the resident required long term care and had had multiple falls. The note did not indicate the resident resided on a secured unit or had a problem with wandering/elopement. The Wandering/Elopement Risk assessment dated [DATE] identified wandering behavior had occurred 1 to 3 days since the last assessment. Additionally, this assessment indicated the resident was wandering to find family or pet, wandering aimlessly, and was actively exhibiting exit-seeking behavior and that an elopement prevention care plan had been initiated or updated. The Wandering/Elopement Risk assessment dated [DATE] identified wandering behavior was not exhibited and the resident had preciously attempted to leave a residence or other place unescorted and that the resident was cognitively impaired and independently ambulatory and had two previous wandering events while looking for his/her daughter. The assessment form indicated that an elopement prevention care plan was initiated or updated. The Wandering/Elopement Risk assessment dated [DATE] identified wandering behavior was not exhibited and that the resident had not had a history of elopement but did indicate the resident was cognitively impaired and independently ambulatory. Directions on the assessment form identified initiating/updating a care plan or service plan for elopement risk. Interview on 11/5/24 at 11:18 AM with SW #2 identified that care plans were completed by all disciplines, but the baseline care plan would be completed by nursing and whomever needed to add to the comprehensive could add to it. SW#2 indicated the nursing staff does the wandering/elopement assessment immediately if there was a concern and then quarterly. Interview on 11/5/24 at 2:59 PM with the DNS identified behaviors such as wandering or elopement should be reflected in the care plan. Interview on 11/5/24 at 3:30 PM with the Medical Director identified placement on the secured unit was a collaborative effort and discussed at risk meetings. The medical director indicated that wandering/elopement or transfer to the secured unit would be reflected in the resident's care plan. The facility policy for comprehensive care planning identified residents would have a patient specific plan of care identifying services that would be in place to maintain the resident's well-being. The wandering/elopement policy identified monitoring for wander guards, however, the facility did not utilize wander guards.

Based on observation, review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #58) reviewed for Activities of Daily Living (ADL's), the facility failed to ensure the resident was provided nail care. The findings include: Resident #58's diagnoses include dementia, disorientation and difficulty swallowing. The quarterly MDS assessment dated [DATE] identified Resident #58 was severely cognitively impaired, was moderately visually impaired, required moderate assistance for personal hygiene and was dependent for toileting, showering, and transfers. The Social Worker note dated 9/5/24 at 12:55 PM identified Resident #58 was very hard of hearing and had poor eyesight. The care plan dated 9/24/24 identified Resident #58 was at risk for a self-care deficit, required assistance with activities of daily living related to a visual impairment with interventions that included providing assistance in completing ADL tasks, and assistance with meals. Observation on 10/31/24 at 11:30 AM identified a brown like substance under the fingernails on Resident #58's left hand, the nails affected included the pointer, middle and ring finger nails. Observation on 11/5/24 at 12:15 PM identified a brown/black colored substance under Resident #58's fingernails on both the left- and right-hand. Observation on 11/7/24 at 10:40 AM with RN#3 (unit manager on East 2) and NA #1 identified Resident #58's nails on both hands had a brown, black colored substance underneath the nails, and a couple of the nails on the right hand, had jagged edges. Interview on 11/7/24 at 10:45 AM with NA #1 indicated the resident does not always allow care to be provided. The resident yells and calls out at times during care. If the resident pulls away or says no to care, care including nail care, would not be provided. NA #1 noted the resident's nails should be cleaned. Interview on 11/7/24 at 10:46 AM with RN #3 indicated the resident's nails should be cleaned and gently filed, and the substance under the resident's nails, appeared to be something other than feces. If NA#1 needed assistance to provide nail care for Resident #58, RN#3 identified she would provide support. On 11/7/24 at 10:50 AM subsequent to surveyor inquiry, Resident #58's nails were cleaned by NA#1. Although requested, the NA ADL flow sheets for the last 2 months were not provided. Review of the Activities of Daily Living (ADL) policy directed to document and provide individualized ADL care to each resident. Individualized care needs will be documented as appropriate.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for accidents, the facility failed to ensure care was provided in accordance with the plan of care. The findings include: Resident #2's diagnoses included cerebral infarction, and hemiplegia (weakness) of left nondominant side. The admission MDS assessment dated [DATE] identified Resident #2 required extensive two (2) persons physical assist for bed mobility/support. Review of Physical Therapy evaluation note dated 5/4/2024 indicated that Resident #2 was instructed on rolling side to side with max assist of two (2), noted Resident #2 listed towards the right side with noted left hemiplegia neglect, attempted to sit at edge of bed with assist of two (2), and unable to sit fully upright at edge of bed. The Resident Care Plan (RCP) dated 5/6/2024 identified Resident #2 required assistance with ADLS. Interventions directed assist of two (2) with ADLs as needed. Physician's note dated 5/6/2024 indicated Resident #2 was oriented to person, place and time, had dense left hemiplegia and could not feel his/her left side, weakness. The nurse aide care card (Resident Summary) directed Resident #2 required the assist of two (2) at all times. Facility accident/incident report dated 5/8/2024 at 5:40 AM identified Resident #2 rolled out of bed onto floor during AM care. The facility investigation identified Resident #2 required total assistance with care, and Resident #2 stated he/she lost his/her grip on the bedrail during incontinent care. No injuries were identified. Review of NA #1's written signed statement after the fall identified Resident #2 was holding onto the railing when she provided care and Resident #2 let go of the bedrail and slipped onto the floor. Review of nursing note dated 5/8/2024 (written by LPN #1) identified that while Resident #2 was provided care, staff rolled Resident #2 onto his/her left side and Resident #2 tried to hold onto the bedrail. Resident #2 was too weak to hold onto the rail, let go of the rail and rolled out of bed onto the floor. The supervisor was notified at 5:40 AM, resident was assessed by supervisor, assisted back off floor with Hoyer lift, the family and APRN were notified. Interview, clinical record and facility documentation review with LPN #1 on 9/5/2024 at 12:31 PM identified NA #1 was a float staff and had provided care to Resident #2 by herself prior to the fall out of bed on 5/8/2024 at 5:40 AM. LPN #1 further indicated that a resident with a stroke should have a two person assist for care if the resident's care plan indicated two (2) person assist. On 9/5/2024 at 1:59 PM interview, clinical record review and facility documentation review with the DNS identified that Resident #2 could not use his/her left side, and that NA #1 should have had another staff member with her to provide care, as the Resident Care Plan directed assist of two (2) staff. The DNS was unable to explain why NA #1 did not have a second staff, and indicated that NA #1 was given a written warning regarding not having a second person to assist when providing ADL care to the resident. Interview, clinical record and facility documentation review with RN #2 on 9/9/2024 at 7:58 AM indicated that on 5/8/2024 when Resident #2 fell /slipped out of bed. RN #2 stated she provided education to NA #1 that a second NA was required for Resident #2's care and NA #1 needed to read the facility Resident Summary (NA care card). On 9/10/2024 at 12:51 PM interview, review of facility documentation with NA #1 identified she was aware Resident #2 required two (2) staff for care, but she provided the care alone because the other NA working was busy assisting another resident. NA #1 stated she was changing Resident #2 while Resident #2 was holding onto the railing, and then let go. Resident #2 slipped to the floor, and stated she could not hold Resident #2 to prevent the fall. NA #2 stated she had read the resident's care card and she should have had another staff with her to provide the care.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for accidents, the facility failed to ensure resident care was provided in accordance with the plan of care to prevent a fall. The findings include: Resident #2's diagnoses included cerebral infarction, and hemiplegia (weakness) of left nondominant side. The admission MDS assessment dated [DATE] identified Resident #2 required extensive two (2) persons physical assist for bed mobility/support. Review of Physical Therapy evaluation note dated 5/4/2024 indicated that Resident #2 was instructed on rolling side to side with max assist of two (2), noted Resident #2 listed towards the right side with noted left hemiplegia neglect, attempted to sit at edge of bed with assist of two (2), and unable to sit fully upright at edge of bed. The Resident Care Plan (RCP) dated 5/6/2024 identified Resident #2 required assistance with ADLS. Interventions directed assist of two (2) with ADLs as needed. Physician's note dated 5/6/2024 indicated Resident #2 was oriented to person, place and time, had dense left hemiplegia and could not feel his/her left side, weakness. The nurse aide care card (Resident Summary) directed Resident #2 required the assist of two (2) at all times. Facility accident/incident report dated 5/8/2024 at 5:40 AM identified Resident #2 rolled out of bed onto floor during AM care. The facility investigation identified Resident #2 required total assistance with care, and Resident #2 stated he/she lost his/her grip on the bedrail during incontinent care. No injuries were identified. Review of NA #1's written signed statement after the fall identified Resident #2 was holding onto the railing when she provided care and Resident #2 let go of the bedrail and slipped onto the floor. Review of nursing note dated 5/8/2024 (written by LPN #1) identified that while Resident #2 was provided care, staff rolled Resident #2 onto his/her left side and Resident #2 tried to hold onto the bedrail. Resident #2 was too weak to hold onto the rail, let go of the rail and rolled out of bed onto the floor. The supervisor was notified at 5:40 AM, resident was assessed by supervisor, assisted back off floor with Hoyer lift, the family and APRN were notified. Interview, clinical record and facility documentation review with LPN #1 on 9/5/2024 at 12:31 PM identified NA #1 was a float staff and had provided care to Resident #2 by herself prior to the fall out of bed on 5/8/2024 at 5:40 AM. LPN #1 further indicated that a resident with a stroke should have a two person assist for care if the resident's care plan indicated two (2) person assist. On 9/5/2024 at 1:59 PM interview, clinical record review and facility documentation review with the DNS identified that Resident #2 could not use his/her left side, and that NA #1 should have had another staff member with her to provide care to prevent the fall. The DNS was unable to explain why NA #1 did not have a second staff, and indicated that NA #1 was given a written warning regarding not having a second person to assist when providing ADL care to the resident. Interview, clinical record and facility documentation review with RN #2 on 9/9/2024 at 7:58 AM indicated that on 5/8/2024 when Resident #2 fell /slipped out of bed. RN #2 stated she provided education to NA #1 that a second NA was required for Resident #2's care and NA #1 needed to read the facility Resident Summary (NA care card). On 9/10/2024 at 12:51 PM interview, review of facility documentation with NA #1 identified she was aware Resident #2 required two (2) staff for care, but she provided the care alone because the other NA working was busy assisting another resident. NA #1 stated she was changing Resident #2 while Resident #2 was holding onto the railing, and then let go. Resident #2 slipped to the floor, and stated she could not hold Resident #2 to prevent the fall. NA #2 stated she had read the resident's care card and she should have had another staff with her to provide the care to prevent the fall.

Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #60) reviewed for hospitalization , the facility failed to ensure medications were accurately reconciled after the resident returned from the hospital resulting in the omission of a medication for 9 days which resulted in a significant change in the residents mental status and a subsequent 12 day hospitalization . The findings include: Resident #60's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, written by MD #3 (resident's primary care physician) dated 10/13/20 identified Resident #60 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] identified Resident #60 had moderately impaired cognition, required total 1-person assistance with bathing, extensive 2-person assistance with bed mobility, transfers, toilet use and locomotion on unit, extensive 1 person assistance with dressing, grooming and locomotion off unit and supervision with eating. Resident did not ambulate. The corresponding care plan identified the resident was taking medication to manage mood and depression related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to provide psychiatric services, observe for behaviors and support resident when exhibiting those behaviors. Physician's November 2020 orders (with original date of 10/26/18) directed to administer [MEDICATION(S)] 400mg once daily at 9:00 PM. A Nurse's Note dated 11/12/20 identified the resident was transferred to the hospital admitting at 12:25 PM for a planned overnight admission for bowel preparation for scheduled colonoscopy on 11/13/20. A Nurse's Note dated 11/14/20 identified the resident returned to the facility via stretcher from the hospital at 6:00 PM, was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders were verified with MD #2 by charge nurse. Review of the Hospital Medicine Inpatient Discharge Summary identified discharge date of [DATE] indicating there were no active hospital problems. Review of the discharge medication list did not include [MEDICATION(S)], which resident had been taking daily. Further review of the discharge instructions directed to resume all previous medications and the only new medication was [MEDICATION(S)]. Review of the November 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review indicated that subsequent to Resident #60 ' s return from the hospital on 11/14/21, the [MEDICATION(S)] 400mg was not administered between 11/14/20 through 11/20/20, 7 days. Review of a progress note, written by MD #3, dated 11/16/20 (2 days after readmission from scheduled inpatient colonoscopy) identified Resident #60 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MD #2's progress note dated 11/20/20 identified Resident #60 was seen and upon examination Resident #60 was not responding to painful stimuli, was not following any commands and was not seen spontaneously moving extremities. MD #2 identified resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . MD #2 ' s note indicated because of the altered mental status and unresponsiveness, will send to the ER as concerned about nonconvulsive [CONDITION(S)]. Resident #60 was maintaining airway and not in any acute respiratory distress. The hospital discharge summary dated 12/2/20 identified Resident #60 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #60 does not appear to be on the [MEDICATION(S)] which he/she had been taking in the past. It ' s unclear currently if this was a medication reconciliation error. The resident was admitted to the floor for further management of the altered mental status. Psychiatry was consulted and upon their assessment there was likely a component of catatonia. [MEDICATION(S)] was restarted at a small dose and increased every day by 25mg until reaching a dose of 200mg twice daily. Given the catatonia, the resident was started on an [MEDICATION(S)] taper with improvement in the mental status. Upon discharge the resident is back to baseline mental status but in terms of mobility, physical therapy was recommended. Interview with RN #5 on 2/2/22 at 11:50 AM identified that she no longer works at the facility and did not recall Resident #60's readmission to her unit on 11/14/20. RN #5 identified during this time, COVID-19 protocols were in place and admissions and readmissions were arriving on her unit constantly, because it was the unit where residents would quarantine after hospital stays or appointments. RN #5 indicated there was a lot of movement on that unit during this time because after quarantining, the resident would then be transferred back to their original unit. RN #5 identified although she did not recall this particular readmission, her usual practice was to contact resident's physician or APRN, if unavailable, or their covering provider to verify orders. RN #5 identified she typically compared resident's previous orders with those documented on the hospital discharge instructions and reviewed with physician. If any discrepancies were identified, RN #5 indicated she would bring the concern to the physician's attention to receive further instruction or clarification. Interview with MD #2 on 2/3/22 at 9:15AM identified he was the medical director for the facility and was not Resident #60's primary care physician, however after reviewing the clinical record, identified that he was the physician who verified orders upon resident's return to facility after the scheduled inpatient colonoscopy on 11/12/20 - 11/14/20. MD#2 identified he does rely on the nurse who is reviewing discharge orders with him to bring any discrepancies needing to be clarified or addressed, to his attention. MD #2 identified at that time, COVID protocols were in place requiring residents returning after appointments and hospitalization s to be quarantined on a designated unit. Resident #60, who resided on another unit prior to the scheduled 11/12/20 - 11/14/21 procedure, was readmitted on to the designated quarantining unit. MD #2 identified when nurses who are unfamiliar with a resident's medications are reviewing and verifying with physician, discrepancies can be missed. MD #2 identified because the discharge documentation did not list [MEDICATION(S)] on the medication list, it had been missed, and if not brought to his attention, he would not have known it needed to be addressed. MD #2 identified that it was his usual practice to write a note if there are any concerns or changes that he makes or addresses and in reviewing his notes, he did not see anything pertaining to the [MEDICATION(S)]. MD #2 identified when he was asked to see Resident #60 on 11/20/20, and found the resident to be unresponsive, and he was concerned about seizures. MD #2 identified that there were many holes, like swiss cheese, contributing to this missed medication and subsequent hospitalization . MD #2 identified he was working with the DNS and nursing to prevent and identify discrepancies in the future. Interview with Pharmacist #1 on 2/4/22 at 11:35 AM identified that abrupt cessation of [MEDICATION(S)] was not recommended due to the potential for cholinergic rebound (headache, nausea, vomiting, diarrhea), agitation, confusion, [CONDITION(S)] and extrapyramidal symptoms (EPS). Pharmacist #1 identified if [MEDICATION(S)] was to be discontinued, the recommendation was for a gradual dose reduction over 1 - 2 weeks. Interview with APRN #1 on 2/7/22 at 10:10 AM identified that she has known Resident #60 since 2015 and that the resident had been receiving [MEDICATION(S)] for as long as she's known the resident. APRN #1 identified she was aware resident had been scheduled for the inpatient prep and colonoscopy (11/12/20) because the resident was unable to tolerate the prep in the facility. APRN #1 identified that she had been off when resident returned to facility on 11/14/20 and for the next 2-3 days and was not the provider who reviewed the orders upon resident's reentry. APRN #1 identified when she saw the resident midweek, she noted resident to be alert but was not his/her usual self and ordered lab work, chest x-ray, KUB and ultrasound. APRN #1 identified that intravenous fluid were started however due to the resident' further decline after assessment by MD #2 on 11/20/20, the resident was sent to the ER for further evaluation. APRN #1 identified upon review of resident's clinical record on the day of hospital transfer (11/20/20), she noted that the [MEDICATION(S)] had been discontinued on 11/14/20 (upon return from colonoscopy procedure) but had not been resumed, indicating resident had not received the medication since 11/11/20, a total of 9 days. APRN #1 identified when she identified this 9-day lapse of the resident not receiving [MEDICATION(S)], she notified the hospital ER staff. APRN #1 indicated that although her usual practice was to inform the RN supervisor at the facility about any concerns needing to be addressed, she did not recall who she had informed about the discontinued [MEDICATION(S)] at the time. APRN #1 identified Resident #60's hospital admission was largely due to the abrupt discontinuation of [MEDICATION(S)], resulting in altered mentation, which could have been prevented had there not been so many missteps from the time of resident's return to facility, status post [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the DNS on 2/8/22 at 3:00PM identified that at the time of this incident, there was a different process in place for reconciliation of medications. The DNS indicated they implemented a more formalized procedure and educated licensed staff on verification of orders and their new process. Although requested, no documentation of education was provided. Although requested, a policy was not provided related to reconciliation of medications.

Based on clinical record review, facility documentation, interviews, and observations for one of three resident's reviewed for refusals of care, the facility failed to care for the resident without the use of physical restraints. The findings include: Resident #1 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] identified that the resident had severe cognitive impairment, exhibited physical behavioral symptoms which was directed towards others one to three days a week, was always incontinent of bowel and bladder, and required extensive assistance of 2 people with bed mobility, dressing, personal hygiene, and total dependence of 2 people with toileting and bathing, and requires a feeding tube for nutrition. A Resident Care Plan (RCP) dated 6/16/17 identified that the resident needs assistance with Activities of Daily Living (ADL's) with interventions that included to provide incontinent care every two to three hours, talk to the resident during care, provide assist of two with all care, and if resistive to care, re-approach later. A RCP dated 6/16/17 identified that the resident has agitation, strikes out at staff and will refuse care with interventions that included, explain all tasks, re-direct if resident's mood seems agitated, and re-approach. Review of segments of video footage regarding care and services provided to Resident #1 on 7/28/17 at 12:15 PM with the facility Administrator, Director of Nurses (DON), the Assistant Director of Nurses (ADNS) and the staff development coordinator identified the following: a. On 7/1/17 at 10:14 AM (time stamped), Registered Nurse (RN) #1, Nurse Aide (NA) #6 and, NA #7, were providing incontinent care to Resident #1. RN #1 pulled the resident towards her with the turning pad and appears to lean over the side-rail and lean into the resident to hold the resident towards the side-rail. At 10:15 AM, RN#1 leans in further holding down Resident#1 with her right arm. Interview and review of the video footage with RN#1 on 8/1/17 at 9:10 AM identified that she had her arm on the resident's back in order to hold the resident over for care, she was not holding her down, or leaning into her but she was holding her over so the care could be completed. RN#1 identified that if the resident is resistive to care she should leave the resident and re-approach at a later time, but identified that the resident can be resistive at times and she does not do any care without asking the resident's permission. Interview with the DON on 8/1/17 at 9:15 AM identified that it did not look like LPN#1 was restraining the resident, it appeared that she was leaning over the bed holding the resident over so the other NA's could complete perineal care. b. On 7/21/17 at 8:15 PM (time stamped), NA#1 and NA#8 entered the resident's room and the resident is lying in bed. NA#1 lifted up the resident's gown and removed the incontinent brief. At this time, the resident reaches for NA#1's hands and NA#8 takes the resident's right and left hands with her hands and holds them, meanwhile the resident's hands are in constant motion trying to break free from NA#8, and the resident appears to be calling out. NA #1 and NA #8 continued with care. NA#8 was unavailable for an interview. Interview and review of the video footage with NA#1 on 7/31/17 at 3:15 PM identified that she had completed the incontinent care on Resident #1 while NA#8 held the resident's hands because the resident may have been incontinent of feces and needed to be changed. NA#1 further identified that when the resident resists care, he/she should be left and re-approached later, but sometimes his/her hands are gently guided down to prevent her from putting her hands in feces. Interview with the DON on 7/31/17 at 3:20 PM identified that it appeared that NA#8 was holding the resident's arm gently so NA#1 could complete incontinent care. c. On 7/22/17 at 10:34 AM (time stamped), NA#4 gave RN#1 a washcloth from a basin. As RN#1 started to wash the resident's face, the resident reached to remove the washcloth from his/her face. NA#2 then takes the resident's left hand into hers, at this time the resident's right hand is underneath the gown in constant motion in an attempt to remove the facecloth, when the right arm comes out of the gown, NA #2 grabs the right hand as well and holds the resident's right and left hands down while RN#1 finishes washing his/her face. Interview and review of the video footage with RN#1 on 7/28/17 at 4:00 PM identified that she had asked the resident's permission to wash his/her face and although the resident was resistive to the care, she continued because the resident had given her permission. RN#1 further identified that she is aware when a resident is resistive to care he/she should be left and re-approached and although the resident was resisting care, she continue to provide care. Interview with and review of the video footage with NA#2 on 8/1/17 at 10:30 AM identified that the resident was kicking and cursing during care on that day and she had taken the resident's hands and held them down in an attempt to keep his/her hands away from the jejunostomy feeding tube (J-tube) and out of his/her perineal area. NA#2 further identified that she will only hold the resident's hands down when he/she is kicking and screaming and although his/her plan of care identifies that care should be stopped if the resident is resistive, sometimes care is continued because she needs the care. Interview and review of the video footage with the DON on 7/28/17 at 4:00 PM identified that it appeared that the NA's were not restraining the resident during care, but attempting to provide perineal care to the resident. d. On 7/24/17 at 6:30 AM (time stamped), NA#3 and LPN#1 were performing incontinent care on Resident#1. As NA#3 washed the resident, the resident started to resist the care. Observation identified LPN#1 took both of the resident's hands while the resident is noted to be attempting to break his/her hands free from NA#3. The residents arms are continually in motion and kicking at NA#2 while she was providing care. As the resident was turned, his/her right hand is holding onto the side rail, while his/her left hand was held in place by LPN#1, and the resident attempted to hit LPN#1 with his/her free right hand. As care continued, LPN#1 held the residents hands down while the resident appeared to be calling out and kicking at NA#3. At 6:36 AM (time stamped), LPN#1 approached the resident to apply the J-tube dressing and the resident appears to be calling out. NA#3 took both of the resident's hands into hers with the resident attempting to break free, and then the resident strikes out at LPN#1 while LPN #1 continues the dressing change. Interview and review of the video footage with the Administrator on 7/28/17 at 2:00 PM identified that the NA was not holding on tightly to Resident #1, as the resident was able to get his/her hands free, they are speaking to the resident the whole time they are providing care. Interview and review of the video footage with NA#3 on 8/1/17 at 11:40 AM identified that when she was providing perineal care, the resident had his/her legs squeezed together and she had to separate his/her legs to give proper perineal care. NA#3 further identified that she did not stop care even when the resident was noted to attempt to kick her several times. NA #3 continued to provide care because the resident had a bowel movement and the care needed to be provided. NA #3 identified she did not use force. NA#3 identified that she had grabbed Resident #1's hands while LPN#1 was doing the dressing change to the jejunostomy tube because the resident was trying to reach for the J-tube. NA#3 further identified that she is aware if a resident refuses care, they should be left, and re-approached later. Interview and review of the video footage with LPN#1 on 8/1/17 at 11:56 AM identified that while NA#3 was providing incontinent care, she had taken both of the resident's hands and held them because the resident was trying to reach for his/her perineal area and although she was holding the resident's hands as the resident was trying to break free, the grip was loose. LPN#1 further identified that she is aware that when a resident is refusing care, they should leave and re-approach later, but the resident need to have the incontinent care and the [DEVICE] dressing completed. Review of the resident bill of rights identified that all residents have the right to be free from physical restraints.

Based on clinical record review, facility documentation, interviews, and observations for one of three resident's reviewed for mistreatment (Resident #1), the facility failed to ensure the resident was free from mistreatment. The findings include: Resident #1 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] identified that the resident had severe cognitive impairment, exhibited physical behavioral symptoms including directed towards others one to three days a week, was always incontinent of bowel and bladder, and required extensive assistance of 2 people with bed mobility, dressing, personal hygiene, and total dependence of 2 people with toileting and bathing, and required a feeding tube for nutrition. A Resident Care Plan (RCP) dated 6/16/17 identified that the resident needs assistance with Activities of Daily Living (ADL's) with interventions that included to provide incontinent care every two to three hours, talk to the resident during care, provide assist of two with all care, and if resistive to care, re-approach later. A RCP dated 6/16/17 identified that the resident has agitation, strikes out at staff and will refuse care with interventions that included to explain all tasks, and to re-direct if resident's mood seems agitated, re-approach. Review of segments of video footage regarding care and services provided to Resident #1 on 7/28/17 at 12:15 PM with the facility Administrator, Director of Nurse (DON), the Assistant Director of Nurses (ADNS) and the staff development coordinator identified the following: a. On 7/1/17 at 10:14 AM (time stamped), Registered Nurse (RN) #1, Nurse Aide (NA) #6 and, NA #7, were providing incontinent care to Resident #1. RN #1 pulled the resident towards her with the turning pad and appears to lean over the side-rail and lean into the resident to hold the resident towards the side-rail. At 10:15 AM, RN#1 leans in further holding down Resident#1 with her right arm. Interview and review of the video footage with RN#1 on 8/1/17 at 9:10 AM identified that she had her arm on the resident's back in order to hold the resident over for care, she was not holding her down, or leaning into her but she was holding her over so the care could be completed. RN#1 identified that if the resident is resistive to care she should leave the resident and re-approach at a later time, but identified that the resident can be resistive at times and she does not do any care without asking the resident's permission. Interview with the DON on 8/1/17 at 9:15 AM identified that it did not look like LPN#1 was restraining the resident, it appeared that she was leaning over the bed holding the resident over so the other NA's could complete perineal care. b. On 7/21/17 at 8:15 PM (time stamped), NA#1 and NA#8 entered the resident's room and the resident is lying in bed. NA#1 lifted up the resident's gown and removed the incontinent brief. At this time, the resident reaches for NA#1's hands and NA#8 takes the resident's right and left hands with her hands and holds them, meanwhile the resident's hands are in constant motion trying to break free from NA#8, and the resident appears to be calling out. NA #1 and NA #8 continued with care. NA#8 was unavailable for an interview. Interview and review of the video footage with NA#1 on 7/31/17 at 3:15 PM identified that she had completed the incontinent care on Resident #1 while NA#8 held the resident's hands because the resident may have been incontinent of feces and needed to be changed. NA#1 further identified that when the resident resists care, he/she should be left and re-approached later, but sometimes his/her hands are gently guided down to prevent her from putting her hands in feces. Interview with the DON on 7/31/17 at 3:20 PM identified that it appeared that NA#8 was holding the resident's arm gently so NA#1 could complete incontinent care. c. On 7/22/17 at 10:34 AM (time stamped), NA#4 gave RN#1 a washcloth from a basin. As RN#1 started to wash the resident's face, the resident reached to remove the washcloth from his/her face. NA#2 then takes the resident's left hand into hers, at this time the resident's right hand is underneath the gown in constant motion in an attempt to remove the facecloth, when the right arm comes out of the gown, NA #2 grabs the right hand as well and holds the resident's right and left hands down while RN#1 finishes washing his/her face. Interview and review of the video footage with RN#1 on 7/28/17 at 4:00 PM identified that she had asked the resident's permission to wash his/her face and although the resident was resistive to the care, she continued because the resident had given her permission. RN#1 further identified that she is aware when a resident is resistive to care he/she should be left and re-approached and although the resident was resisting care, she continue to provide care. Interview with and review of the video footage with NA#2 on 8/1/17 at 10:30 AM identified that the resident was kicking and cursing during care on that day and she had taken the resident's hands and held them down in an attempt to keep his/her hands away from the jejunostomy feeding tube (J-tube) and out of his/her perineal area. NA#2 further identified that she will only hold the resident's hands down when he/she is kicking and screaming and although his/her plan of care identifies that care should be stopped if the resident is resistive, sometimes care is continued because she needs the care. Interview and review of the video footage with the DON on 7/28/17 at 4:00 PM identified that it appeared that the NA's were not restraining the resident during care, but attempting to provide perineal care to the resident. d. On 7/24/17 at 6:30 AM (time stamped), NA#3 and LPN#1 were performing incontinent care on Resident#1. As NA#3 washed the resident, the resident started to resist the care. Observation identified LPN#1 took both of the resident's hands while the resident is noted to be attempting to break his/her hands free from NA#3. The residents arms are continually in motion and kicking at NA#2 while she was providing care. As the resident was turned, his/her right hand is holding onto the side rail, while his/her left hand was held in place by LPN#1, and the resident attempted to hit LPN#1 with his/her free right hand. As care continued, LPN#1 held the residents hands down while the resident appeared to be calling out and kicking at NA#3. At 6:36 AM (time stamped), LPN#1 approached the resident to apply the J-tube dressing and the resident appears to be calling out. NA#3 took both of the resident's hands into hers with the resident attempting to break free, and then the resident strikes out at LPN#1 while LPN #1 continues the dressing change. Interview and review of the video footage with the Administrator on 8/1/17 at 12:00 PM identified that the NA was not holding on tightly to Resident #1, as the resident was able to get his/her hands free, they are speaking to the resident the whole time they are providing care. Interview and review of the video footage with NA#3 on 8/1/17 at 11:40 AM identified that when she was providing perineal care the resident had his/her legs were squeezed together, and she had to separate his/her legs to give proper perineal care, but she was not using force. NA#3 further identified that she did not stop care even when the resident was noted to attempt to kick her several times, because she had a bowel movement and the care needed to be provided. NA#3 identified that she had grabbed Resident #1's hands while LPN#1 was doing the dressing change to the [DEVICE] because the resident was trying to reach for the J-tube. NA#3 further identified that she is aware if a resident refuses care, they should leave and re-approach the resident later. Interview and review of the video footage with LPN#1 on 8/1/17 at 11:56 AM identified that while NA#3 was providing incontinent care she had taken both of the resident's hands and held them because the resident was trying to reach for his/her perineal area. Although she was holding the resident's hands, as the resident was trying to break free, the grip was loose. LPN#1 further identified that she is aware that when a resident is refusing care, they should leave and re-approach later, but the resident needed to have the incontinent care and the J-tube dressing completed. Interview with the Director of Nurses on 7/28/17 identified that RN#1, LPN#1, NA#1, NA#2, NA#3, and NA#8 were suspended pending further investigation for allegations of mistreatment. Review of the abuse policy identified that all residents have the right to be free from mistreatment.

Based on clinical record review and staff interview for one of four residents reviewed for falls (R# 135) the facility failed to ensure that the resident was cared for in a safe manner. The findings include: Resident #135's [DIAGNOSES REDACTED]. A significant change assessment dated [DATE] identified the resident with intact long and short-term memory, had some difficulty in new situations only, was totally dependent for all activities of daily living (ADL) , was incontinent of bowel and bladder, and had no falls since admission. A resident care plan (RCP) dated 6/7/11 identified a risk for falls related to severe rheumatoid arthritis with an approach to transfer with a mechanical lift and assist of two. A nurse's note dated 7/18/11, 10:45 AM identified that the resident fell from the shower chair backwards after transferred with assist of two via hoyer lift. The resident was observed lying on the floor backwards while still sitting on the shower chair. The resident complained of severe back pain and headache. An order was obtained to transfer the resident to the hospital. A CAT Scan identified a subdural hematoma. Interview with Nurse Aide (NA) # 1 on 3/9/12 at 12:45 P.M. identified that the resident was transferred from the bed to the shower chair via mechanical lift and two assist. NA#1 further stated that after transferring the resident to the shower chair the resident was strapped into the chair, began urinating, tremoring and fell backward. Interview with the nursing director identified that the resident should not have fallen. A written statement dated 7/18/11 identified that NA#1 transferred the resident from the bed to the chair and while he/she was disconnecting the mechanical lift from the resident and NA# 2 was standing at the resident's back the resident tilted backward forcefully and fell . A written statement dated 7/18/11 identified that NA#2 was standing behind the resident's chair, however he/she moved from behind the resident's chair and the resident went backwards. The facility failed to ensure assistance was provided to ensure the resident's safety.