Congregational Home, Inc.

Inspectors wroteNumber of residents sampled: 61Number of residents cited:Based on observation, interview and record review, the facility did not ensure food was prepared, and served, in a sanitary manner. This was observed with the dish machine and the facility's 3 compartment sink which has the potential to affect all 61 Residents that reside at the facility.* The facility did not ensure the facility kitchen dish machine was functioning to sanitize dishware.*The facility did not ensure proper procedure for sanitization of dishes involving the 3-compartment sink.

Inspectors wroteNumber of residents sampled:8 of 12Number of residents cited:Based on interview and record review, the facility did not ensure admission and annual comprehensive Minimum Data Set (MDS) assessments were completed in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 8 (R38, R47, R48, R49, R53, R66, R79, and R91) of 12 residents reviewed for late MDS assessments.*R38's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R47's Annual MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R48's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R49's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, [...]

Inspectors wroteNumber of residents sampled:6 of 12Number of residents cited:Based on interview and record review, the facility did not ensure admission, quarterly, and discharge Minimum Data Set (MDS) assessments were completed and transmitted in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 6 (R24, R47, R61, R79, R81, and R88) of 12 residents reviewed for late MDS assessments.*R24's Discharge Return Not Anticipated MDS assessment dated [DATE] was not completed or transmitted by the specified timeframe.*R47's Annual MDS assessment dated [DATE] was not transmitted by the specified timeframe.*R61's Quarterly MDS assessment dated [DATE] was not transmitted by the specified timeframe.*R79's admission MDS assessment dated [DATE] was not transmitted by the specified timeframe.*R81's Discharge Return Anticipated MDS assessment dated [DATE] [...]

Inspectors wroteNumber of residents sampled:2 of 12Number of residents cited:Based on interview and record review, the facility did not ensure quarterly Minimum Data Set (MDS) assessments were completed in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 2 (R61 and R88) of 12 residents reviewed for late MDS assessments.*R61's Quarterly MDS assessment dated [DATE] was completed after the specified timeframe.*R88's Quarterly MDS assessment dated [DATE] was in progress and not completed by 7/4/2025 as specified in the RAI 3.0 User's Manual.

Inspectors wroteNumber of residents sampled:4Number of residents cited:1Based on interview and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R35) of 4 Residents reviewed for falls.*On 5/28/25, Certified Nursing Assistant (CNA)-N rolled R35 away from CNA-N during incontinence cares and R35 rolled off the bed and onto the floor. Findings Include:The facility's Safe Resident Handling, policy and procedure modified 8/21/19 documents: .F. If only one person assisting Resident should be rolled towards caregiver vs away from them. Call for extra assist as needed. [...]

Inspectors wroteBased on interviews and record review, the facility did not ensure that 1 (R1) of 1 allegations of neglect were reported to the State Survey Agency within the required reporting timeframe. On 11/25/24, R1 and R1's spouse (Spouse-N) filed a grievance with Social Worker (SW)-D regarding a care concern that occurred on 11/22/25. The grievance was investigated, and the written results and plan were given to R1, and Spouse-N. On 11/28/24, Spouse-N sent an email to SW-D, during the Thanksgiving holiday weekend, stating that R1 and Spouse-N believes that the incident that occurred on 11/22/24 was neglectful and abusive. Facility staff did not report the allegation of neglect to the State Agency until 12/2/24, when SW-D returned from the holiday weekend.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 (R1) of 1 residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. R1 informed surveyor that R1 does not always receive help from facility staff to complete stretches/range of motion (ROM) exercises 2 times a day as indicated in R1's Certified Nursing Assistant (CNA) [NAME]. Facility staff do not document when stretches/ROM exercises are completed. R1 has a diagnosis of Multiple sclerosis with spasticity. R1 does not have a care plan with measurable goals and interventions related to spasticity and ROM.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure that 1 (R2) of 2 residents reviewed received adequate supervision and asssitive devices to prevent accidents. * R2 suffered falls that were not thoroughly investigated, with fall interventions and revisions to the fall care plan post fall review & IDT (interdisciplinary team) not implemented.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries, and with pressure injuries, were comprehensively assessed for the development of an individualized plan of care with interventions to promote healing, prevent infection and prevent new pressure injuries from forming. This was observed with 1 (R34) of 3 residents reviewed with pressure injuries and at risk for the development of pressure injuries. *R34 was assessed at high risk for the development of pressure injuries. Despite this, the facility did not initiate a turning or repositioning schedule for R34. On 11/7/23, R34 was noted to have developed a suspected deep tissue injury to the right heel. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 serving kitchens. *Cook-J was observed preparing food for residents while not wearing a beard hair restraint. *Server- L was observed walking around the kitchen in areas where food is prepared for residents while not wearing a beard hair restraint. *Server-K was observed grabbing ready to eat food with gloved hands, after touching non-sanitized food surfaces, and placing the ready to eat food on plates for residents to eat. This deficient practice has the potential to affect 61 of 61 residents who eat and receive their meals from the main serving kitchen.

Inspectors wroteBased on observations, record review and interviews, the facility did not ensure that 1 (R59) of 15 residents reviewed had an individualized comprehensive plan of care. *R59 has bed canes on his bed and has a foley catheter. R59 did not have a comprehensive plan of care with individualized interventions to address the use of bed canes or a foley catheter. Findings Include: Surveyor reviewed the facility's Comprehensive Care Plan policy and procedure dated effective 3/15/18 and noted the following applicable documentation to R59 not having care plans in place for R59's foley catheter and the use of bed canes: .Policy: [...]

Inspectors wroteBased on observations, staff interview and record review, the facility did not ensure the environment remained as free of accident hazards as possible for 1(R 36) of 1 residents reviewed for falls. R36 fell in the facility on 3/29/24 and 4/22/24 from R36's recliner. R36's falls were not thoroughly investigated and R36's plan of care was not updated to prevent future falls with person-centered interventions. Findings Include: Surveyor reviewed the facility's Falls policy and procedure dated as modified 4/3/23 regarding R36's two falls and noted the following: Procedure: 1. Upon admission licensed nursing staff will complete the NSG Admit/Readmit Screener 2. Upon admission, quarterly, with a significant COC, licensed nursing staff will complete the 'Morse Fall Scale' form 3. Staff will review: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not have evidence that it attempted appropriate alternatives prior to installation of bed rails, did not have evidence it assessed residents at risk of entrapment from bed rails prior to installation, did not have evidence the risks and benefits of bed rails were discussed with the Resident and/or resident representatives and that informed consent was obtained prior to installation for 2 (R59 and R1) of 4 residents reviewed for repositioning bars. *R59 did not have a physician's order for the use of bed canes or a care plan in place for the use of bed assist bars. There is no documentation that the facility attempted to use appropriate alternatives prior to installing or using bed assist bars for R59. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure hospice services providing end of life were coordinated for 1 (R59) of 1 sampled residents receiving hospice services. *R59 was admitted on hospice to the facility on 3/13/24. R59 did not have a physician certification of terminal illness and the facility did not designate a specific individual of the facility's interdisciplinary team to act as a liaison between the facility and the hospice provider. Findings Include: Surveyor reviewed the facility's hospice services policy and procedure dated effective 3/2/18 documents: PURPOSE/POLICY STATEMENT: It is the policy of the facility to have a coordinated plan of care for any Resident electing to utilize the Medicare hospice benefit. The plan of care will reflect the hospice philosophy as well as the individual's needs and living situation in the facility. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility did not ensure infection control prevention was implemented with hand hygiene. This was based on 1 (R17) of 1 handwashing observations. The facility did not establish an infection control water plan to prevent Legionella in the facility. This has the potential to effect all 53 residents in the facility. * The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Include water management team members who were knowledgeable about Legionella and the facility's water system. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility did not develop and implement a comprehensive person-centered care plan for 3 (R24, R31, and R47) of 14 residents reviewed. -R24, R48 did not have a comprehensive plan of care related to the use of motion sensing alarms. -R31 did not have a comprehensive plan of care addressing the use of anticoagulant medication. -R47 did not have a comprehensive plan of care addressing the use of psychotropic medications.

Inspectors wrote7) R46 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Vascular Dementia without behavioral disturbance and Anxiety. R46's admission MDS (Minimum Data Set) assessment dated [DATE] indicates R46 receives antipsychotic, antidepressant and antianxiety medications on a daily basis. Surveyor reviewed R46's medical record. R46 was seen by psychiatric nurse practitioner on 1/19/23. Psychiatric nurse practitioner note dated 1/19/23 reads Seroquel 50 mg qd (every day). Surveyor notes an order implementation date of 1/10/23. Psychiatric nurse practitioner treatment recommendations dated 1/19/23 reads increase Seroquel (augement related to depression). Surveyor reviewed R46's January 2023 MAR (Medication Administration Record). R46's MAR reads Seroquel 75 mg qd for depression. Surveyor noted behavior monitoring on R46's January 2023 MAR for agitation. [...]

Inspectors wrote4) R24's medical record was reviewed by Surveyor. A Fall Risk Assessment was conducted on 11/9/22, and 2/25/23, and indicates R24 is a high-risk for falls. R24 has a high risk for falls plan of care initiated 12/10/2022 with a Goal date of 6/13/2023 and revised on 3/21/2022. The interventions include: -5/18/2022 anticipate and meet R24's needs; call light in reach; educate about safety reminders and review post falls to determine root causes; follow facility fall protocol. -11/15/2022 transfer with a full body lift and 2 staff. -11/23/2022 encourage activity that promotes exercise; ensure appropriate footwear; goals can only be accomplished through directions of a skilled therapist in order to provide a safe environment to appropriately challenge resident without injury while providing significant resistance to create physiologic change; manual therapy; mobility per therapy direction; [...]

Inspectors wroteBased on record review, and interview, the facility did not ensure residents received treatment and care in accordance with facility policy and procedure after unwitnessed falls for 2 (R50 and R19) of 6 residents reviewed for falls. R50 and R19 had multiple unwitnessed falls and were not neurologically assessed after the falls.

Inspectors wroteBased on observation, interview, record review the facility did not ensure that residents received care consistent with professional standards of practice to prevent pressure injuries from developing for 1 (R2) of 2 residents reviewed for pressure injuries. * R2 did not have interventions in place to keep R2's heels offloaded while lying in R2's bed and sitting in R2's recliner chair. Surveyor had observations of R2's heels not being offloaded while lying in bed and sitting in recliner chair on several occasions during the survey.

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 (R46, R47) of 5 residents reviewed for unnecessary medications were free from unnecessary drugs. *R46 had orders for antipsychotic medication and did not have documented targeted behaviors or specific indication for use of the antipsychotic medication in their medical record. R46 had an inappropriate diagnosis for usage of antipsychotic medication. *R47 had orders for a psychotropic medication and did not have specific documented targeted behavior monitoring and/or specific reasons for use of the medication in their medical records.