Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose comprehensive plan of care indicated the call bell was to be within his/her reach when he/she was in his/her room, the Facility failed to ensure staff consistently implemented and followed this intervention, when on 10/15/24, Certified Nurse Aide (CNA) #1 left Resident #1 alone in his/her room without a call bell within reach, Resident #1 fell, later complained of pain, and was diagnosed several days later with a fractured finger. Findings include: Review of the Facility's policy, titled Care Planning-Interdisciplinary Team, dated 09/2013, indicated that an individualized, comprehensive care plan would be developed for each resident. Review of the Facility's policy, titled Fall Prevention and Management Plan, dated 11/02/18, indicated the Facility assesses each resident for his/her risk of falls, designs a plan for care, and implements procedures to minimize falls and/or injury. Resident #1 was admitted to the Facility in November 2023, diagnoses included history of falls, and abnormalities of gait and mobility. Review of Resident #1's Fall Risk Assessment, dated 08/01/24, indicated he/she was assessed by nursing as being at high risk for falls. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 08/01/24, indicated he/she required supervision/touching assistance for transfers and was moderately cognitively impaired with a score of 12 on the Brief Interview for Mental Status (BIMS- score of 13-15 suggests cognitively intact, 08-12 suggests moderately cognitively impaired, 00-07 suggests severe cognitive impairment). Review of Resident #1's Falls Care Plan, reviewed and renewed with his/her August 2024 Minimum Data Set (MDS) assessment, indicated he/she had an intervention, dated as initiated 12/21/23, for the call bell to be within his/her reach when he/she was in his/her room. Review of Resident #1's Certified Nurse Aide (CNA) Care Plan, undated, indicated to provide him/her with the call bell when in his/her room. Review of Resident #1's Post Fall Evaluation Form, dated 10/15/24 and completed by Nurse #2, indicated Resident #1 sustained an unwitnessed fall at 4:30 P.M., when he/she was found by nursing to be seated on the floor in his/her room. The Form indicated Resident #1's call bell was not within reach at the time of the fall and Resident #1 told nursing staff that he/she was trying to get into bed. The Form also indicated that Resident #1 had weakness/fatigue with recent fever/cold/cough due to recent Covid-19 illness. During a telephone interview on 11/14/24 at 3:42 P.M., Nurse #2 said she was the charge nurse on duty during the evening shift (3:00 P.M. through 11:00 P.M.) on 10/15/24 when she was told by another staff member that Resident #1 sustained a fall in his/her room. Nurse #2 said when she entered Resident #1's room, she observed the positions of the wheelchair, bed and bed side table, and she also observed that Resident #1's call bell was on the bed (toward the right side, opposite of where Resident #1 was seated). Nurse #2 said Resident #1 could not have reached his/her call bell from his/her wheelchair. Nurse #2 said Resident #1 used his/her call bell to request staff assistance. Review of the Post Fall Witness Statement, dated 10/15/24 and signed by Certified Nurse Aide (CNA) #1, indicated she had assisted Resident #1 to the bathroom at 4:10 P.M., then left Resident #1 in his/her room, per Resident #1's request. During a telephone interview on 11/14/24 at 2:14 P.M., Certified Nurse Aide (CNA) #1 said she worked at the Facility through a staffing agency and was assigned to care for Resident #1 on the evening shift of 10/15/24. CNA #1 said Resident #1 had used his/her call bell at 4:10 P.M. to request to go to the bathroom. CNA #1 said she assisted Resident #1 in the bathroom and following that, Resident #1 requested to stay in his/her room. CNA #1 said she left Resident #1 seated in his/her wheelchair in his/her room on the left side of his/her bed. CNA #1 said she did not know if Resident #1's call bell was left within his/her reach. CNA #1 said she was alerted by nursing a few minutes later that Resident #1 had sustained a fall in his/her room. Review of Resident #1's Nurse Practitioner (NP) note, dated 10/16/24, indicated Resident #1 reported discomfort to his/her left wrist which appeared to be bruised and discolored. During an interview on 11/14/24 at 11:30 A.M., Resident #1 said he/she used the call bell to request assistance from staff to go to the bathroom or to get in and out of bed. Review of Resident #1's x-ray report, dated 10/16/24, indicated there was no fracture of the left wrist, and no acute fractures throughout the left fingers. Review of Resident #1's Nursing Progress Note, dated 10/18/24, indicated Resident #1 continued to complain of left wrist and left finger pain. The Nurse Practitioner was notified and gave an order for another x-ray of Resident #1's left wrist and fingers to be done at the hospital. Review of Resident #1's hospital radiology report, dated 10/19/24, indicated an intra-articular fracture of the base of the proximal phalanx of the third digit (break in the bone between the second and third knuckle of the third finger). Review of Resident #1's Orthopedic Consult, dated 10/28/24, indicated to use a splint for comfort and weight bear as tolerated. During an interview on 11/14/24 at 1:55 P.M., Certified Nurse Aide (CNA) #3 said Resident #1 does use his/her call bell to alert staff of his/her needs. CNA #3 said staff were responsible to ensure Resident #1 had his/her call bell within reach when he/she was in his/her room. During a telephone interview on 11/15/24 at 2:37 P.M., the Director of Nurses (DON) said that Resident #1's call bell was not within his/her reach at the time of his/her fall on 10/15/24. The DON said it was her expectation that staff always follow each resident's plan of care.

Based on interview and record review the facility failed to ensure fall interventions were implemented for one Resident (#20) out of a total sample of 12 residents. Specifically, for Resident #20 the facility failed to ensure he/she was wearing non-skid socks and had a bed alarm in place, as indicated in the falls plan of care. Findings include: The facility policy titled Fall Prevention and Management, dated 11/2/18, indicated the following: -The Center assesses each resident for his or her risk for falls, designs a plan of care, and implements procedures to minimize falls and/or injury. B. Prevention. 1. General safety precautions and interventions may include: e. Promoting resident use of non-slip footwear/proper shoes when ambulating. 3. Prevention strategies to be implemented are listed on the plan of care. Resident #20 was admitted to the facility in November 2023 and had diagnoses that included a fall resulting in an L2 compression fracture and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/1/24, indicated that on the Brief Interview for Mental Status exam Resident #20 scored a 12 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #20 had no behaviors and for putting on/taking off footwear requires substantial/maximal assistance. Review of the record indicates that since admission Resident #20 has sustained 8 falls, including two that required hospitalization and one that resulted in a sternal fracture. Review of the current Falls care plan for Resident #20 indicated the following interventions: -Call light within reach when in room, start 12/21/23. -Offer/assist resident to BR (bathroom) upon rising after meals and before bed, start 12/21/23. -Keep room free of clutter, start 12/21/23. -Resident will have non-skid socks on at all times, start 1/21/24. -Non-skid markings to floor on each side of the bed, start 2/5/24. -Call, don't fall signs posted in room as a reminder to call for assistance, start 2/5/24. -Alarm mat to bed to remind resident to not rise unassisted, start 2/9/24. -Obtain urine to r/o (rule out) infection, start 3/18/24. -Consult Psych regarding aggressive behavior resulting in a fall, 3/18/24. -Alarm mat to w/c (wheelchair) as a reminder to not rise unassisted, start 6/3/24. -Staff reminders if a resident moves rooms, all equipment should go with them including alarms, start 6/27/24. Further review of the record failed to indicate Resident #20 refused to wear non-skid socks at all times. Review of the Falls report, dated 6/22/24, indicated the following: -Resident #20 sustained a fall in his/her bedroom on 6/22/24 at 7:15 P.M. A nurse was going to assist a resident in another room when she observed Resident #20 walking in his/her room from the bed to the wheelchair. According to the report Resident #20 was barefoot at the time of the fall and the bed alarm was not sounding because the Resident had had a recent room change and the alarm was not moved with the Resident. During an interview on 9/5/24 at 12:27 P.M., with Resident #20's Certified Nursing Assistant (CNA) #2, he said that Resident #20 is unsteady on his/her feet, requires staff assistance to put on socks and shoes and has no behavior of refusing assistance with dressing. CNA #2 said he was not working at the time of Resident #20's fall in June and was not sure what had occurred. During an interview 9/5/24 at 12:53 P.M., with the Nurse Unit Manager (#1) she said that when a resident has a room change, all their items and specialized interventions such as a bed alarm should be moved with them. She said that this had accidentally not happened when Resident #20 changed rooms in June, because the move was temporary. Nurse Unit Manager #1 said that if a resident is care planned to wear non-skid socks at all times, they should be wearing them and if not, the reason should be documented. During an interview on 9/5/24 at 1:14 P.M., with the Director of Nursing (DON) she said that she expects all care plan intervention to be followed and that Resident #20's bed alarm should have been moved with him/her when he/she changed rooms in June.

Based on observation, record review and interview the facility failed to ensure medications were properly labeled, topical medications were stored separately from oral medications in one of one medication carts and eye drops were properly labeled in one out of one medication rooms observed. Findings include: Review of the facility policy titled Medication Administration General Guidelines, not dated, indicated the following: *Do not store treatment preparations in the medication cart. *Do not pre-pour medications. Once medications are poured for administration, they are not to be stored in the medication cart. 1. On 9/26/23, at 2:00 P.M., the surveyor observed a medication cup in the top drawer of a medication cart containing 6 pills. The pills were not labeled. The surveyor also observed the following in the medication cart: 2 tubes of Diclofenac Sodium topical cream (used to treat pain). 1 bottle of wound cleanser. 4 tubes of Triamcinolone cream (used to treat eczema). 1 bottle of antifungal powder. 4 tubes Phytoplex cream. 1 tube Clobetasol Propionate shampoo (used to treat psoriasis and dermatitis). 1 bottle Ketoconazole shampoo (used to treat fungal conditions of the scalp) 1 tube Aquaphor cream 1 tube Lidocaine ointment 5% (used to relieve pain) 2 bottle of body lotion. 2 tubes of body cream. During an interview on 9/26/23, at 2:02 P.M., Nurse #1 said she was not aware that treatments were to be stored separately from oral medications. Nurse #1 said the medication cup containing 6 unlabeled pills were for a resident who was at a doctor's appointment. Nurse #1 then said that she should not have pre-poured the medication.

Based on observation and interview, the facility failed to perform hand hygiene to prevent cross contamination during observations of the breakfast meal. Findings include: During observations of breakfast service on 9/27/23 at 8:08 A.M. the cook was wearing gloves which he contaminated by touching a thermometer while taking the temperatures of the food items, and by touching the tops of food covers. With the same contaminated gloved hands the cook opened a package of bread and placed four slices of bread in the toaster. The cook then began plating foods with the same contaminated gloved hands touching utensils for items such as hot cereal or eggs, and with the same contaminated gloved hands, picked up ready to eat pieces of toast and scones to be served to the residents. At that time, the surveyor approached Team Leader #1 and inquired about the use of using gloved hands to touch the handles of utensils, the toaster and food items like toast and scones. Team Leader #1 said that the utensils are clean for the individual food items but that he/she should use tongs for the toast and scones. The cook then continued to plate two more plates using the same contaminated gloved hands picking up scones and toast.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to accurately transcribe a physician's order related to the treatment of a pressure ulcer for one Resident (#7) out of a total of 12 sampled Residents. Findings include: Resident #7 was admitted to the facility in August 2021 with diagnoses including peripheral venous insufficiency and glaucoma. Review of his/her Minimum Data Set assessment dated [DATE] indicated Resident #7 scored 15 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is cognitively intact and requires assistance with ambulation, transfers and personal hygiene. Review of the clinical record indicated Resident #7 had developed a pressure ulcer on his/her sacrum on 8/13/23 measuring 1 centimeter (CM) X .3 CM X .4 CM. Review of the Nurse Practitioner note dated 8/16/23 indicated: Complaint/Nature of presenting problem: Pressure ulcer to buttock. Patient is being seen for red sacrum .instructed to use Calazyme cream and use Calcium [Alginate] 3x a week. Review of Resident #7's Physician's orders for August 2023 indicated the Nurse Practitioner's instructions to use Calcium Alginate were never brought forward. During an interview on 9/26/23 at 12:59 P.M., Nurse #2 said that when a resident develops a pressure ulcer staff notify the physician who would then assess and prescribes treatment orders. Nurse #2 then reviewed the clinical record with the surveyor and said that she could not see that the Nurse Practitioner's instructions to use Calcium Alginate were added to Resident #7's physician's orders.