Based on observation, interview and record review, the facility failed to revise a care plan for 1 of 21 sampled residents (Resident #20) related to past trauma. Findings include: During an interview, on 2/24/25 at 12:55 PM, Resident #20 and his/her roommate stated that more than one wandering resident had entered their room in the middle of the night via a shared bathroom several times over the course of a few months. Resident #20 and his/her roommate requested that a lock be put on the bathroom door to prevent anyone from accessing their room via the shared bathroom, which was done. Resident #20 became visibly upset, with noticeable anxiety and agitation. His/her voice became louder and s/he was clutching the arms of his/her wheel chair during the interview, stating The staff always forget to lock it! Resident #20 is hearing impaired, and said I wouldn't hear someone come in if my back was to the bathroom door. During this interview, this surveyor observed Resident #20 check the bathroom door, which was unlocked at the time. Per record review, Resident #20 has a Care Plan for Actual Psychosocial Well-being problem related to sexual abuse at a young age dated 10/19/2023. There are no updates in the Care Plan regarding wandering residents entering his/her room, or regarding the need for the bathroom door to always locked from inside the resident's room. During an interview, on 2/26/25 at 1:20 PM, the Director of Nursing and the Clinical Lead both confirmed that Resident #20 should have interventions in his/her Care Plan relating to wandering residents and the need for the bathroom door to be locked at all times, and both confirmed that s/he does not have these interventions in place.

Based on interview and record review, the facility failed to ensure residents remained free of accident hazards related to falls and care plan interventions for 2 residents [Residents #55 & #3] of 25 sampled residents. Findings include: 1.) Per record review Resident #55 was admitted to the facility with diagnoses that include a history of falls, alcohol-induced dementia, lack of coordination, and muscle wasting. The resident's Care Plan identified the resident at risk for falls due to a primary medical history of falls, alcohol abuse, and increased weakness. Review of progress notes for the resident dated 2/1/25 reveal At 2:10 PM: Nurse was summoned to resident's room after [s/he] was found on the floor beside [h/her] bathroom door . Root cause of fall: Alone and unassisted- resident lacks safety awareness. Further review of progress notes reveal the next day, 2/2/25 at 04:45 AM: Resident was found on the floor, beside [h/her] bed in a sitting position. Resident was awake and alert. The following day, 2/3/25, Progress notes record at 12:00 AM Resident was found on the floor, in a sitting position beside [h/her] bed while this nurse was making rounds. When resident was asked what had happened, resident was speaking in word salad [unintelligible, extremely disorganized speech]. Resident is confused at baseline. Review of the facility's 'Resident Centered Approaches to Managing Falls and Falls Risk' policy [revised March 2018] records the staff will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. The policy continues If falling occurs despite initial interventions, staff will implement additional or different interventions .if underlying causes cannot be readily identified or corrected, staff will try various interventions .until falling is reduced or stopped. Review of Resident #55's Care Plan reveals no new interventions added to prevent further falls after falls on consecutive days 2/1/25 and 2/2/25. A third fall in 3 days [2/3/24] then resulted in interventions being added. 2.) Per record review Resident #3 was admitted to the facility with diagnoses that included paranoid schizophrenia, bipolar disorder, and borderline personality disorder. The resident's Care Plan identified the resident at risk for falls due to a history of falls and muscle weakness. Review of progress notes for the resident dated 12/7/24 reveal At 3:10 this morning this nurse was called into room by this resident's roommate via call light. On arrival [Resident #3] is seen laying on floor on the side of [h/her] bed. [Resident #3] stated had pain in chest area when asked why stated 'I fell on my chest facing down' . Resident skin assessment completed and noted redness on mid chest area,. During the end of skin assessment noted tenderness tor right side of chest wall under axillary area. Area is tender to touch and has a slight skin color change. Resident states this area hurts. MD suggested resident to go to Hospital. When asked resident if [s/he] would like to go to hospital to get x-ray and seen by MD there [s/he] declined. Review of Resident #3's Care Plan reveals no new interventions added to prevent further falls after the fall on 12/7/24. An interview was conducted with the Director of Nursing [DON] on 2/26/25 at 10:33 AM. The DON stated the expectation is that after a fall interventions are added to a resident's the care plan immediately to prevent any additional falls. The DON confirmed Resident #55 fell on 2/1, 2/2, & 2/3/25 before new interventions were added into the care plan on 2/4, after resident had fallen twice with no new actions taken. The DON also confirmed no new interventions were added to Resident #3's care plan interventions to prevent future falls after a fall on 12/7/24.

Based on observation, record review, and interview, the facility failed to ensure that dinnerware was sanitized and failed to maintain a clean kitchen environment, which has the potential to impact all residents in the facility. Findings include: On 02/24/25, at 10:41 AM, it was observed that the shelf under steam table was covered in a greasy residue with crumbs and dust adhering to it. This shelf contained the clean steam table trays, which were stacked, opening side down, on the soiled shelf. Crumbs were observed on the counter near and under the toaster, and there were brown stains on the counter at the window used to pass food and beverages to the dining room. The facility uses a high temperature dishwasher (which uses heat for sanitization rather than chemicals). Per regulatory requirements, the dishwasher must have a wash cycle temperature of 150 to 165 degrees Fahrenheit. A record review of the 12/2024 Dishwasher Temperature Log showed the following insufficient temperatures were recorded on the log by staff: 12/4/2024 148 degrees Fahrenheit (F), 12/5/2024 120 degrees F, 12/7/2024 140 degrees F, 12/8/2024 110 degrees F, 12/15/2024 125 degrees F, 12/16/2024 140 degrees F, 12/17/2024, 140 degrees F, and 12/21/2024 130 degrees F. During an interview, on 2/24/25 at 10:50 AM, the Certified Dietary Manager confirmed that the shelf under the steam table was not clean and that the counters were not clean. During an interview, on 2/26/25 at 10:16 AM, the Certified Dietary Manager confirmed wash cycle temperatures for the dishwasher were insufficient for sanitization on 12/4/2024, 12/5/2024, 12/7/2024, 12/8/2024, 12/15/2024, 12/16/2024, 12/17/2024, and 12/21/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections related to Legionella prevention. Findings include: Per record review of the facility's water management program, there was no risk assessment to identify areas in the building that could grow and spread Legionella in the facility water system. Per the facility's Water Management for Legionella policy [effective date: 1/1/23] states, [NAME] kare locations will utilize water management practices to reduce the risk of growth of Legionella and other opportunities pathogens in building water systems .Core elements of the water management plan are: .describe the facilities water system using text and flow diagram, risk assessment with control methods and corrective actions, monitoring control measures . The facility's water management system policy did not include any testing protocols. An interview was conducted with the Infection Preventionist and Director of Maintenance on 2/26/25 at 10:50 AM. The Director of Maintenance and Infection Preventionist confirmed that the facility did not complete a risk assessment, including identifying areas in the building where Legionella could grow or reside.