Every finding on record at Regalcare at Holyoke

Based on interview and record review, the facility failed to ensure that one Resident (#34), out of a total sample of 19 residents, was free from significant medication errors. Specifically, for Resident #34, the facility failed to ensure that the medication Ingrezza (Valbenazine Tosylate- a medication to treat Tardive Dyskinesia (TD) used to help reduce uncontrolled body movements) was transcribed accurately as prescribed by the Provider, resulting in missed medication administration for a total of ten occasions out of 47 opportunities, for May 2025 and June 2025, putting the Resident at risk for involuntary movements not being managed appropriately. Findings include: Resident #34 was admitted to the facility in June 2024 with diagnoses including malignant neoplasm of the brain (brain tumor), adult failure to thrive, Parkinson's Disease, Epilepsy, drug induced subacute dyskinesia, and a history of falling. Review of Resident #34's June 2025 Physician orders on 6/17/25 at 5:22 P.M., indicated no current order for Valbenazine Tosylate/Ingrezza medication. Review of Resident #34's Provider's Progress Note, dated 6/4/25, indicated the following: -Resident had been off the Ingrezza per nursing for several days, now receiving 80 mg and movements improving. He/she remains with notable involuntary movements but able to stay in bed. It seems he/she is getting his/her Ingrezza per Medication Administration Record (MAR) but missed a dose the other day. -Assessment and Plan: >Tardive Dyskinesia- continue Ingrezza 80 mg via G-tube (gastrostomy tube - a feeding tube inserted into the stomach through the abdomen) qhs (every night at bedtime) for significant TD. Involuntary movements likely contributing to falls. Review of Resident #34's Provider's Progress Note, dated 6/12/25, indicated the following: -Resident remains with notable involuntary[sic], but able to stay in bed -Assessment and Plan: >Tardive Dyskinesia, continue Ingrezza 80 mg via G-tube qhs for significant TD. Involuntary movements likely contribute to falls, Ingrezza seems to be helping. Review of Resident #34's Provider's Progress Note, dated 6/16/25, indicated the following: -Resident had a notable increase in movements so significant he/she had fallen out of the bed and the chair. -Per nursing today Ingrezza is in stock in the nursing cart but unclear if the Resident received the medication over the weekend as it was not indicated on the MAR and it was not charted as given consistently. Ingrezza has helped with TD symptoms and involuntary movements are likely contributing to falls. -Assessment and Plan: >Tardive Dyskinesia, continue Ingrezza 80 mg via G-tube qhs for significant TD. Involuntary movements likely contribute to falls, Ingrezza seems to be helping. Review of Resident #34's Provider's Progress Note, dated 6/17/25, indicated the following: -Assessment and Plan: >Tardive Dyskinesia, continue Ingrezza 80 mg via G-tube qhs for significant TD. Involuntary movements likely contribute to falls, Ingrezza seems to be helping. Review of Resident #34's May 2025 MAR indicated the following: -Valbenazine Tosylate Oral Capsule 40 milligrams (mg). Give one capsule via G-tube in the morning for TD -start date 5/9/25, discontinue date 5/15/25. >5/9/25 -initialed by the nurse as a 9 (other/see progress notes) indicating the medication was not administered. -Valbenazine Tosylate Oral Capsule 40 mg. Give two capsules (total dose of 80 mg) via G-tube at bedtime for TD -start date 5/15/25, discontinue date 6/13/25. >5/21/25, 5/22/25 and 5/30/25 were left blank and not initialed by the nurse as being administered. >5/25/25-initialed by the nurse as a 9. Review of Resident #34's June 2025 MAR indicated the following: -Valbenazine Tosylate Oral Capsule 40 mg. Give two capsules (total dose 80 mg) via G-tube at bedtime for TD -start date 5/15/25, discontinue date 6/13/25. >6/2/25 -initialed by the nurse as a 9. -Valbenazine Tosylate was discontinued on 6/13/25 and not administered on 6/13/25 6/14/25, 6/15/25 or 6/17/25. -A one-time order for Ingrezza 80 mg capsule to be given on 6/16/25 was administered and initialed by the Nurse. Further review of the medical record indicated no documented evidence, or correlating progress notes relative to why the Valbenazine Tosylate was not administered or that the provider had been notified that the medication had not been administered on 5/9/25, 5/21/25, 5/22/25, 5/25/25, 5/30/25, 6/2/25, 6/13/15, 6/14/25, 6/15/25 and 6/17/25 (10 occasions). During an interview on 6/18/25 at 5:22 P.M. Nurse #2 said Resident #34 was prescribed Ingrezza and currently received it in the evening. The surveyor and Nurse #2 reviewed the current order Physician orders and Nurse #2 said there was no current order for the Valbenazine Tosylate/Ingrezza. Nurse #2 said it appeared the medication was discontinued and was not sure why. Nurse #2 said there had been adjustments made to the medication to be administered in the evening at bedtime instead of in the morning, but the medication had not been discontinued to the best of her knowledge. During an interview on 6/23/25 at 11:06 A.M., the Nurse Practitioner (NP) said Resident #34 was prescribed Ingrezza because the NP felt the Resident was benefiting from it and had noted less (involuntary) movement. The NP further said she had not discontinued the Ingrezza medication since re-starting it in May 2025. During an interview on 6/23/25 at 12:01 P.M., with the Regional Nurse Consultant and the Director of Nursing (DON), the DON said there were dates that the medication was not available but would have to go back and research that information. The DON and Regional Nurse Consultant reviewed the May 2025 and June 2025 MARs and said it appeared the Resident did not receive the medication five times in May and once in June. The DON was unsure why the medication had been discontinued on 6/13/25, administered once on 6/16/25 and not administered again on 6/17/25. The DON said that the Resident missed an additional four doses of Ingrezza due to the medication being accidentally discontinued.

4. Resident #44 was admitted to the facility in August 2023 with diagnoses including Peripheral Vascular Disease, Type 2 Diabetes, and Chronic Kidney Disease. Review of the MDS Assessment, dated 3/19/25, indicated Resident #44 utilized an anticoagulant (blood thinner) medication within the seven day look back period (3/13/25 through 3/19/25). Review of Resident #44's March 2025 Physician's orders failed to indicate any orders for an anticoagulant medication. Review of Resident #44's March 2025 Medication Administration Record (MAR) failed to indicate any documentation that Resident #44 was administered an anticoagulant medication during the month of March 2025. During an interview on 6/20/25 at 10:05 A.M., the MDS Nurse said Resident #44 was not on an anticoagulant medication during the look back period for the MDS assessment dated [DATE], and the use of anticoagulant medication was coded incorrectly. 5. Resident #65 was admitted to the facility in March 2025 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, and Asthma. On 6/17/25 at 9:18 A.M., and 6/20/25 at 8:04 A.M., the surveyor observed Resident #65 with a nasal cannula in place and a portable oxygen tank delivering Oxygen via the nasal cannula at 2 liters per minute (LPM). Review of Resident #65's June 2025 Physician's orders indicated the following orders: -Oxygen at 0-4 LPM continuous to keep oxygen saturations above 90%, start date 3/28/25. Review of Resident #65's care plan titled Resident #65 had altered respiratory status/difficulty breathing .initiated 3/6/25, indicated the following interventions: -Oxygen Settings: Oxygen 1-4 via nasal cannula .initiated 4/17/25 Review of the MDS Assessment, dated 6/3/25, indicated Resident #65 had not utilized oxygen while a Resident at the facility. During an interview on 6/20/25 at 2:50 P.M., the MDS Nurse said Resident #65 had been utilizing Oxygen since his/her admission to the facility and the MDS Assessment, dated 6/3/25, was coded inaccurately and should have indicated Resident #65 had utilized Oxygen while a Resident at the facility. Based on observation, interview, and record review, the facility failed to accurately code Minimum Data Set (MDS) Assessments for six Residents (#83, #55, #91, #44, #65, and #93), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #83, to accurately code medications administered when the Resident received Insulin daily. 2. For Resident #55, to accurately code a pressure injury that was present upon admission to the facility. 3. For Resident #91, to accurately code a pressure injury that was present during the MDS observation look back time period. 4. For Resident #44, to accurately code medications administered while in the facility when the Resident was coded as utilized an anticoagulant (blood thinner) medication but was not ordered for an anticoagulant. 5. For Resident #65, to accurately code the use of oxygen therapy while in the facility when the Resident was coded as had not utilized oxygen, and was ordered for continuous oxygen and using oxygen. 6. For Resident #93, to accurately complete a Discharge MDS Assessment, when the Resident was coded as discharged to an acute hospital and the Resident was discharged to home. Findings include: 1. Resident #83 was admitted to the facility in October 2024 with diagnoses including Type 2 Diabetes Mellitus (DM) without complications. Review of the Resident's MDS Assessment, dated 5/28/25, indicated that the Resident had not been administered any Insulin or had any injections during the MDS observation period. Review of Resident #83's June 2025 Physician's orders included: -Insulin Glargine Subcutaneous Solution 100 UNIT/ML (milliliter), Inject 18 units subcutaneously (under the skin) at bedtime for diabetes. (Start date 12/18/24) Review of the Resident's May 2025 Medication Administration Record (MAR) indicated that the Insulin Glargine injection was administered to the Resident each evening as ordered by the Physician. During an interview on 6/24/25 at 11:20 A.M., the MDS Nurse said that the Resident did receive Insulin injections each evening during the MDS lookback observation period and the correct response on the MDS dated [DATE] should have been 7 days of injections and 7 days of Insulin administration. The MDS Nurse said the MDS dated [DATE] was coded inaccurately for injections and Insulin. 2. Resident #55 was admitted to the facility in September 2024 with diagnoses including corns and callosities, muscle weakness, and Dementia. Review of the Physician's Progress Note, dated 10/21/24, included . left foot has a large callous to the base of foot which has been there for years per pt (patient). He/she has a new open area towards the base of the mid foot/ankle that is open and bleeding. Pt states his/her callous was taken off and it is attached to his/her sock. Foot was placed in a soapy bath of warm water and will have a dressing placed daily. Wound Consult to see in the near future. Review of the Initial Progress Note by the Wound Care Physician, dated 10/23/24, indicated that the pressure ulcer to the left plantar heel began as a callous which was present when the Resident was admitted to the facility and was considered community acquired. The Wound Care Physician continued to evaluate and treat the Resident's left plantar heel. The follow-up progress note, dated 4/22/25, noted that the open area on the left plantar heel was the result of a callous falling off that was present upon admission to the facility. Review of the facility Weekly Wound Rounds Report, dated 4/22/25, indicated that the Left heel plantar Stage 3 pressure ulcer was present upon admission to the facility. Review of the MDS Assessment, dated 4/23/25, indicated that the Stage 3 pressure area was not present upon admission to the facility. During an interview on 6/25/25 at 12:22 P.M., the Assistant Director of Nursing (ADON) said the open area on the Resident's left plantar heel was a result of a callous falling off. The ADON said that the callous was present upon the Resident's admission to the facility. During an interview on 6/25/25 at 2:20 P.M., the MDS Regional Nurse said that the MDS Assessment, dated 4/23/25, was coded incorrectly and the Stage 3 pressure area noted in Section M of the MDS Assessment should have also indicated that the pressure area was present upon admission to the facility. 3. Resident #91 was admitted to the facility in May 2025 with diagnoses of Type 2 Diabetes, Essential Hypertension, and Unspecified Fall. Review of the Resident's clinical record included a Nursing Progress Note, dated 5/22/25, which noted .one cm (centimeter) open area observed on coccyx, uneven borders, red, 0 (no) s/sx (signs and symptoms) infection, triad (a cream that creates a moist wound healing environment) applied, nsg (nursing) and cna (Certified Nursing Assistant) to inform colleagues to monitor. Note left in dr (Doctor) book for evaluation and tx (treatment) . Review of Resident #91's May 2025 Physician's orders and Treatment Administration Record (TAR) included: -apply zinc paste to coccyx 2x day, two times a day for skin integrity, Start Date 5/23/25, D/C (discontinue) 5/27/25. The zinc paste treatment was noted as done daily 5/23/25 through 5/27/25. -coccyx, cleanse with N/S (normal saline) pat dry gently, apply Silver Alginate (a dressing that is absorbent with antimicrobial silver) to wound bed f/b (followed by) dcd (dry clean dressing) daily and prn (as needed). Start Date 5/28/25. The treatment was noted on the TAR as done daily 5/28/25 through 5/31/25. Review of the Resident's June 2025 TAR indicated that the treatment to the coccyx started on 5/28/25 was still in place and noted as done daily on the TAR from 6/1/25 through 6/23/25, except for four days when the Resident was in the hospital (from 6/5/25 through 6/8/25). Review of the MDS Assessment, dated 6/5/25, failed to indicate the Resident had any pressure areas present. During an interview on 6/23/25 at 9:34 A.M., the MDS Nurse said that the MDS Assessment, dated 6/5/25, was coded inaccurately. The MDS Nurse said that the Resident had a Stage 3 pressure area present during the MDS observation period and it should have been coded on the MDS Assessment but it had not been. 6. Review of the RAI (Resident Assessment Instrument) Manual, dated October 2024, indicated the following for MDS item A2105: -This item documents the location to which the resident is being discharged at the time of discharge. -Knowing the setting to which the individual was discharged helps to inform discharge planning. -Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. Resident #93 was admitted to the facility in May 2025. Review of Resident #93's MDS Assessment, dated 5/23/25, indicated the following: -the Resident was discharged to a Short-term General Hospital (acute hospital .) Review of Resident #93's Clinical Nurse Progress Note, dated 5/23/25, indicated the Resident was discharged home. During an interview on 6/20/25 at 1:02 P.M., the MDS Nurse said she had incorrectly coded the Resident's Discharge MDS Assessment regarding the Resident's discharge location. The MDS Nurse said that she refers to the RAI Manual for accuracy of Assessments completed.

Based on record reviews, and interviews, the facility failed to ensure the environment remained free of accidental hazards and was safe for one Resident (#27), out of a total sample of 19 residents. Specifically, for Resident #27, the facility failed to ensure that the call bell was placed within reach for the Resident's use and that fall mats were appropriately implemented after the Resident sustained an unwitnessed fall. Findings include: Review of the facility's policy titled Fall and Fall Risk Managing, revised on 3/2022, indicated the following: -Based on previous evaluations and current data, the staff will identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. -The staff, with the input of the attending physician, will implement a resident centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Resident #27 was admitted to the facility in March 2025 with diagnoses including paraplegia, spinal stenosis, contracture of muscles, blindness in the left eye, and indwelling urinary catheter. On 6/18/25 at 5:06 P.M., the surveyor heard a muffled, groaning sound from Resident #27's room. The surveyor did not observe a Resident from the room doorway but heard a muffled, groaning sound and observed a urinary catheter attached to the right side of the bed which stretched across the bed. The surveyor further observed Resident #27 lying on the floor on the left side of his/her bed. The surveyor immediately notified staff that Resident #27 was heard by the surveyor from the hallway groaning and making muffled sounds and was found lying on the floor, on the left side of his/her bed. The surveyor observed that Resident #27's call bell had not been activated as it was not lit up in the hallway. During an interview on 6/18/25 at 5:11 P.M., the Unit Manager (UM) said the Resident had experienced an unwitnessed fall out of bed but was thankfully okay. During an interview on 6/18/25 at 5:14 P.M., Certified Nurses Aide (CNA) #1 said Resident #27 was alert and orientated to him/herself and able to use a call bell. CNA #1 said he was not sure why the Resident did not use his/her call bell to ask for help as he/she usually does. CNA #1 said sometimes Resident #27 will roll side-to-side putting him/her at risk of rolling out of the bed. During an interview on 6/18/25 at 5:34 P.M., Nurse #6 said she and two CNAs had assessed Resident #27 after his/her fall and then placed him/her back into the bed using a Hoyer Lift (a mechanical lift used to move residents who are dependent on staff to be transferred from one space to another). Nurse #6 further said the Resident was able to use the call bell to ask for help. The surveyor and Nurse #6 entered the room and observed Resident #27 lying in bed. The surveyor observed the Resident's call bell was located on the floor on the left side of the Resident's bed, partially under the bed, and out of reach for the Resident. Nurse #6 said the call bell should be within reach and was not. The surveyor observed that three staff members (Nurse #6 and 2 - CNA's) had exited the Resident's room after assisting with getting him/her into bed after the unwitnessed fall, and failed to place the call bell within reach to ensure the Resident could call for assistance as needed before exiting the room. Review of the At Risk for Falls Care Plan, initiated on 6/3/25 and updated on 6/19/25, indicated the following: -Place mats on both sides of the bed, initiated on 6/19/25. On 6/23/25 at 4:27 P.M., the surveyor and Nurse #2 observed the following: -Resident #27 was lying in bed with the bed in the low position. -the Resident was alert and leaning slightly to the left. -the call bell was within reach. -there were no bilateral mats on the floor next to the Resident's bed. During an interview immediately following the observation, Nurse #2 looked throughout the Resident's room and said she did not see any fall mats available in the room that could be placed on the floor. The surveyor and Nurse #2 reviewed Resident #27's Care Plan and observed the following intervention was updated on 6/19/25: -place mats on both sides of the bed. Nurse #2 said the intervention had not been implemented and should have been. During an interview on 6/23/25 at 4:46 P.M., the Assistant Director of Nursing (ADON) said Resident #27 had been provided the fall mats as a new intervention for safety relative to falls, however the housekeeping staff removed the mats to clean the floors and had placed them in the shower room while the Resident was out at an appointment. The ADON said the housekeeping staff had not replaced the fall mats on each side of the Resident's bed prior to the Resident returning to the facility.

Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR - preadmission screening to identify residents with mental health disorders or intellectual disabilities) was accurately completed prior to admission for one Resident (#46), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled admission Criteria, revised 4/22, indicated the following: -All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. [sic] Resident #46 was admitted to the facility in March 2025 with a diagnoses including Schizoaffective Disorder and a history of alcohol use. Review of the Hospital Discharge/Transfer Note, dated 3/13/25, indicated Resident #46 had a diagnosis of Schizoaffective Disorder and had medication changes in the hospital relative to his/her antipsychotic medication. Review of the Medical Doctor's (MD) History and Physical, completed on 3/18/25, indicated Resident #46 had a diagnosis of Schizoaffective Disorder. Review of Resident #46's PASRR, dated 3/19/25 (completed post admission to the facility), indicated the following: -Resident #46 had no diagnosis of serious mental illness (SMI). During an interview on 6/17/25 at 2:45 P.M., the Social Worker (SW) said prior to being admitted to the facility all residents needed to have a PASRR completed. The SW said for Resident #46, his/her PASRR was not completed until after he/she had been admitted to the facility. The SW said Resident #46's PASRR was also completed inaccurately and did not indicate he/she had a diagnosis of Schizoaffective Disorder and a new PASRR needed to be submitted with the accurate diagnosis. The SW further said she was aware there were issues with PASRR completion and PASRR accuracy, but no audit had been completed to see which residents in the facility did not have PASRRs completed at admission and/or if their PASRRs had been completed accurately. During an interview on 6/18/25 at 7:33 A.M., the Ombudsman said the facility was not ensuring PASRRs were being completed accurately and when the Nurses from the local Elder Services Agency were reviewing resident PASRRs during Medicaid Screenings, the PASRRs were often missing mental health diagnoses and other information.

Based on record reviews, and interview, the facility failed to provide services that meet professional standards of quality for one Resident (#34), out of a total sample of 19 residents. Specifically, for Resident #34, the facility failed to administer the medication Ingrezza (Valbenazine Tosylate - medication used to treat tardive dyskinesia (TD) and help reduce uncontrolled body movements) as prescribed: -for increased involuntary movement symptoms when the medication was ordered to be administered daily. -when the medication was discontinued by facility staff, and was being administered without current Physician orders. Findings include: Review of [NAME], Manual of Nursing Practice 11th ed, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of the facility's policy titled Change of Condition in a Resident Status, dated 3/17, indicated the following: -the facility shall notify the resident, his or her attending physician, and representative (sponsor of changes in the resident's medical mental condition). -The nurse will notify the resident's Attending Physician or On-call Physician when there has been a need to alter the resident's medical treatment significantly. Resident #34 was admitted to the facility in June 2024 with diagnoses including malignant neoplasm of the brain (brain tumor), adult failure to thrive, Parkinson's Disease, epilepsy, drug induced subacute dyskinesia, and a history of falling. Review of Resident #34's May 2025 Medication Administration Record (MAR) indicated the following: -Valbenazine Tosylate Oral Capsule 40 milligrams (mg). Give one capsule via G-tube (gastrostomy tube - a feeding tube inserted into the stomach through the abdomen) in the morning for TD (tardive dyskinesia) - start date 5/9/25, discontinue date 5/15/25. >5/9/25 - initialed by the Nurse as a 9 (other/see progress notes) indicating the medication was not administered. -Valbenazine Tosylate Oral Capsule 40 mg. Give two capsules via G-tube at bedtime for TD - start date 5/15/25, discontinue date 6/13/25. >5/21/25, 5/22/25 and 5/30/25 were left blank and not initialed by the Nurse as being administered. >5/25/25-initialed by the Nurse as a 9. >Valbenazine Tosylate Oral Capsule was not administered on 5/9/25, 5/21/25, 5/22/25, 5/25/25, and 5/30/25. Review of Resident #34's June 2025 MAR indicated the following: -Valbenazine Tosylate Oral Capsule 40 mg. Give two capsules via G-tube at bedtime for TD -start date 5/15/25, discontinue date 6/13/25. >6/2/25 - initialed by the Nurse as a 9. Review of Resident #34's Provider's Progress Note, dated 6/4/25, indicated the following: -Resident had been off the Ingrezza per nursing for several days, now receiving 80 mg and movements improving. He/she remains with notable involuntary movements but able to stay in bed. It seems he/she is getting his/her Ingrezza per Medication Administration Record (MAR) but missed a dose the other day. -Tardive Dyskinesia - continue Ingrezza 80 mg via G-tube (gastrostomy tube - a feeding tube inserted into the stomach through the abdomen) qhs (every night at bedtime) for significant TD. Involuntary movements likely contributing to falls. Review of Resident #34's Provider's Progress Note, dated 6/12/25, indicated the following: -Resident remains with notable involuntary [sic], but able to stay in bed -Tardive Dyskinesia, continue Ingrezza 80 mg via G-tube qhs for significant TD. Involuntary movements likely contribute to falls, Ingrezza seems to be helping. Review of Resident #34's Provider's Progress Note, dated 6/16/25, indicated the following: -Resident had a notable increase in movements so significant he/she had fallen out of the bed and the chair. -Tardive Dyskinesia, continue Ingrezza 80 mg via G-tube qhs for significant TD. Involuntary movements likely contribute to falls, Ingrezza seems to be helping. Review of Resident #34's June 2025 MAR indicated the following: -Valbenazine Tosylate Oral Capsule 40 mg. Give two capsules via G-tube at bedtime for TD - start date 5/15/25, discontinue date 6/13/25. >6/2/25 - initialed by the Nurse as a 9. -Valbenazine Tosylate was discontinued on 6/13/25 and not administered on 6/13/25, 6/14/25, 6/15/25 or 6/17/25. -A one-time order for Ingrezza 80 mg capsule to be given on 6/16/25 was administered and initialed by the nurse. Further review of Resident #34's medical record failed to indicate any evidence or correlating progress notes relative to why the Valbenazine Tosylate medication was not administered or Provider communication that the medication had not been administered on 5/9/25, 5/21/25, 5/22/25, 5/25/25, 5/30/25, 6/2/25, 6/13/15, 6/14/25, 6/15/25 or 6/17/25 (10 occasions). During an interview on 6/18/25 at 5:22 P.M., Nurse #2 said Resident #34 was prescribed Ingrezza and currently received it in the evening. The surveyor and Nurse #2 reviewed the current Physician's orders and Nurse #2 said there was no current order for the Valbenazine Tosylate/Ingrezza. Nurse #2 said it appeared the medication was discontinued and she was not sure why. Nurse #2 said there had been adjustments made to the medication to be administered in the evening at bedtime instead of in the morning, but the medication had not been discontinued to the best of her knowledge. On 6/18/25 at 5:25 P.M., the surveyor and Nurse #2 observed multiple blister packs that held the Valbenazine Tosylate/Ingrezza, located in the nurses' medication cart. Nurse #2 was unable to determine the last time Resident #34 received the Ingrezza medication based on what medication was left in the blister packs. During an interview on 6/23/25 at 11:06 A.M., the Nurse Practitioner (NP) said Resident # 34 was prescribed Ingrezza because the NP felt he/she was benefiting from it and had noted less (involuntary) movement. The NP said she had not discontinued the Ingrezza medication since re-starting it in May 2025. The surveyor and the NP reviewed the dates that indicated the Resident did not receive the Ingrezza. The NP said she was not made aware Resident #34 had not received the medication that many times. The NP said that the staff had notified her about some missed doses, but not that many. The NP further said that she would not expect the staff to call her for one missed dose but to notify her when she came in the following morning. The NP said she did not recall the facility staff notifying her that the Resident had not received the Ingrezza medication on the ten missed occasions noted and should have. Please Refer to F760

Based on record review and interview, the facility failed to ensure that a quarterly review assessment was completed as required to ensure critical indicators of gradual status change were monitored for one Resident (#58) out of a total sample of 19 residents. Specifically, for Resident #58, the facility failed to ensure that the Resident was reviewed between comprehensive assessments with respect to the Minimum Data Set (MDS) items specified in the quarterly assessment. Findings include: Review of the RAI (Resident Assessment Instrument) Version 1.19.1 dated October 2024, indicated the following: -The Quarterly assessment is an OBRA (Federal law, known as the Omnibus Budget Reconciliation Act of 1987) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. -It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. -The ARD (Assessment Reference Date) must not be more than 92 days after the ARD of the most recent OBRA assessment of any type. Resident #58 was admitted to the facility in February 2023. Review of the clinical record indicated an MDS assessment was submitted for the Resident on 2/5/25. Further review of the clinical record failed to indicate that any other subsequent quarterly assessment was completed. During an interview on 6/20/25 at 12:20 P.M., the MDS Nurse said a quarterly MDS assessment should have been completed in May 2025 for Resident #58, but one was not completed. The MDS Nurse said she refers to the RAI Manual for timeliness of MDS assessments.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#22), of one applicable resident receiving dialysis (process that filters wastes, salts and fluid from your blood when the kidneys are unable to work adequately) services, out of a total sample of 19 residents. Specifically, for Resident #22, the facility failed to ensure: -timely medication administration on the Resident's dialysis scheduled days, when scheduled morning medications were delayed in being administered until after the Resident's return to the facility in the early afternoon on Mondays, Wednesdays, and Fridays. -that Sevelamer (medication to lower phosphorus levels in the blood) medication was administered as ordered by the Physician with meals, when the Resident's blood phosphorus level was elevated, and the Resident was missing the breakfast Sevelamer medication dosage on Mondays, Wednesdays, and Fridays. Findings include: Review of the facility's policy titled Care of a Resident with End-Stage Renal Disease, revised 4/2022, indicated the following: -Residents with End-Stage Renal Disease (ESRD) will be cared for according to currently recognized standards of care -staff caring for residents with ESRD, including residents receiving dialysis care outside of the facility, shall be trained in the care and special needs of these residents -education and training of staff include, specifically: >timing and administration of medications, particularly those before and after dialysis . Review of the facility's policy titled Administering Medications, revised 1/2025, indicated: -medications are administered in a safe and timely manner, and as prescribed. -medications are administered in accordance with prescriber orders, including any required time frame -medication administration times are determined by resident need and benefit, not staff convenience. Factors that are covered include: >enhancing optimal therapeutic effect of the medication >preventing potential medication or food interactions; and >honoring resident choices and preferences, consistent with his or her care plan -medications are administered within one (1) hour of their prescribed time, . Resident #22 was admitted to the facility in April 2025 with diagnoses including Chronic Kidney Disease. Review of the Minimum Data Set (MDS) Assessment, dated 5/17/25, indicated Resident #22 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and received dialysis while in the facility. Review of the Renal/Dialysis Care Plan, initiated 5/21/25, indicated Resident #22 had a potential for complications related to hemodialysis (use of a machine to conduct dialysis) and included the following interventions also initiated 5/21/25: -administer and monitor effectiveness of medications as ordered (see Physician's orders/Medication Administration Record [MAR]) -communicate with dialysis center regarding medication, diet, and lab results -dialysis days: Mondays, Wednesdays, Fridays Review of Resident #22's lab work, dated 4/21/25, indicated a Phosphorus level of 5.4 mg/dL (High) (hyperphosphatemia = level greater than 4.5 milligrams (mg) per deciliter (dL); Normal phosphorus level = 2.5 to 4.5 mg/dL). Review of Resident #22's Nutrition Evaluation, dated 5/14/25, indicated: -phosphorus level obtained on 4/21/25 was 5.4 mg/dL . communicated to Nurse Practitioner (NP) Review of the Resident #22's lab work, dated 6/4/25, indicated the Phosphorus level remained at 5.4 mg/dL (High). During an interview on 6/17/25 at 9:01 A.M., Resident #22 said he/she received dialysis on Mondays, Wednesdays, and Fridays at an outside clinic. Resident #22 said he/she was picked up by transportation services at 6:15 A.M. and returned around 1:30 P.M. Resident #22 said he/she received a bagged breakfast prior to leaving the facility and did not have medications from the facility sent with him/her. Resident #22 further said a dialysis communication book was sent with him/her from the facility to dialysis. Review of Resident #22's June 2025 Physician's orders indicated the following: -Folic Acid 1 milligram (mg) daily, initiated 4/9/25 -Oxybutynin Chloride ER 24 hour (medication for overactive bladder), 10 mg daily, initiated 4/9/25 -Pantoprazole Sodium Delayed Release (medication to reduce stomach acid), 40 mg daily initiated 4/10/25 -Fluticasone Propionate Nasal Spray (allergy medication), 50 micrograms (mcg) per actuation (ACT), 2 spray in each nostril daily, initiated 4/10/25 -Potassium 20 milliequivalents (mEq) daily, initiated 4/10/25 -Cholecalciferol (Vitamin D supplement) 50000 international units (IU) every Monday, initiated 4/14/25 -Dialysis on Mondays, Wednesdays, and Fridays initiated 4/18/25 -Torsemide (diuretic medication), 20 mg twice daily, initiated 4/20/25 -Selevamer HCL (phosphate binder) 800 mg, one tablet with meals (TID: three times daily), initiated 5/14/25 -Apixaban (anticoagulant) 5 mg every 12 hours (twice daily), initiated 5/15/25 -Carvedilol (blood pressure medication) 25 mg twice daily, initiated 5/15/25 -Losartan Potassium (blood pressure medication), 25 mg daily, may hold on dialysis days, initiated 5/22/25 -Fluticasone Furoate-Vilanterol 50-25 mcg/ACT, 1 puff inhale orally in the morning . initiated 6/6/25 Review of Resident #22's June 2025 Medication Administration Record (MAR), indicated the following medications were documented as administered at the prescribed morning times from 6/1/25 through 6/19/25 (exception of Wednesday 6/4/25 when the Resident was documented to be out of the facility): -Folic Acid 1 mg, scheduled to be administered daily at 8:00 A.M., -Oxybutynin Chloride ER 10 mg, scheduled to be administered daily at 8:00 A.M., -Pantoprazole 40 mg, scheduled to be administered daily at 9:00 A.M., -Fluticasone Propionate 50 mcg/ACT, scheduled to be administered daily at 9:00 A.M., -Potassium 20 mEq, scheduled to be administered daily at 9:00 A.M., -Cholecalciferol 50000 IU, scheduled to be administered on Mondays at 9:00 A.M., was documented as administered on 6/2/25, 6/9/25 and 6/16/25 -Torsemide 20 mg, scheduled to be administered at 8:00 A.M., -Sevelamer HCL 800 mg, scheduled to be administered at 8:30 A.M., -Apixaban 5 mg, scheduled to be administered at 8:00 A.M., -Carvedilol 25 mg, scheduled to be administered at 8:00 A.M., -Losartan Potassium 25 mg, scheduled to be administered daily at 8:00 A.M., -Fluticasone Furoate-Vilanterol 50-25 mcg/ACT, scheduled to be administered daily at 8:00 A.M., During an interview on 6/18/25 at 2:13 P.M., Nurse #2 said Resident #22 left the facility for dialysis on Mondays, Wednesdays and Fridays around 6:00 A.M. and returned to the facility around 1:00 - 1:30 P.M. Nurse #2 said no medications from the facility were sent to dialysis with Resident #22, and the medications scheduled to be administered in the morning (8:00 A.M., 8:30 A.M., and 9:00 A.M.) when the Resident was out at dialysis, would be administered when he/she returned from dialysis treatment at 1:00 P.M. - 1:30 P.M. Nurse #2 further said the Resident's MAR should reflect the times that the Resident's medications were administered and currently the MAR was not accurate relative to the medication administration times. During an interview on 6/18/25 at 2:30 P.M., Unit Manager (UM) #2 said no medications were sent from the facility with Resident #22 to dialysis, and that he/she received a bagged breakfast prior to leaving the facility and that he/she would receive the lunch meal when he/she returned from dialysis. The surveyor and UM #2 reviewed Resident #22's June 2025 MAR which indicated the Resident was receiving morning medications (scheduled for 8:00, 8:30 and 9:00 A.M.) on Mondays, Wednesdays and Fridays,when he/she was not in the facility and UM #2 said she would have to look into this. UM #2 further said she would also look into the Sevelamer medication which was scheduled to be given with the Resident's meals. Review of the Nutritional Evaluation Note, dated 6/18/25, indicated: -Resident was evaluated for monthly high nutrition risk related to hemodialysis and ESRD. -Phosphorus level obtained on 6/4/25 was 5.4 mg/dL . -Phosphorus binder initiated on 5/14/25 . During an interview on 6/18/25 at 4:45 P.M., the Director of Nursing (DON) said Resident #22 started dialysis treatments after admission to the facility, and that his/her medication administration times should have been adjusted based on his/her dialysis schedule. The DON further said she would have to look into the Sevelamer medication administration. During a follow-up interview on 6/25/25 at 8:23 A.M., the DON said Resident #22's orders were adjusted after the surveyor brought the concerns about the medication administration times. The DON further said she was unsure if the Provider was made aware that morning medications scheduled for 8:00 A.M. and 9:00 A.M. on dialysis days were given after the Resident's return from dialysis prior to this adjustment or that the Sevelamer medication (scheduled for 8:30 A.M. with breakfast) was not being administered as ordered for the breakfast meal on the days (Mondays, Wednesdays, and Fridays) Resident #22 was at dialysis. During an interview on 6/25/25 at 9:37 A.M., the Registered Dietitian (RD) said Resident #22 was considered high nutritional risk due to hemodialysis treatments and was followed monthly and as needed (PRN). The RD said when he completed his assessments, he contacted the Resident's dialysis clinic to coordinate the Resident's plan of care, which included a review of the Resident's weights, intake and lab work. The RD said he noted the Resident's elevated phosphorus level on 5/14/25 and relayed this information to the NP, who added a phosphorus binder medication (Sevelamer). The RD said the Sevelamer medication would need to be administered with the Resident's meals so that it could bind to the phosphorus in the food, and that the medication would not be effective if administered after the meal as the medication would not serve its purpose. The RD further said he was unaware that the Sevelemar was not being administered with the Resident's breakfast meal on dialysis days. During an interview on 6/25/25 at 10:41 A.M., the NP said she was made aware of the issue with Resident #22's medications administration times the previous week (week of 6/17/25) by UM #2, and the medication times have been adjusted based on his/her dialysis schedule. The NP said prior to last week, she was unaware that the Resident's morning medications were administered after (he/she returned from) dialysis, and she was not made aware that the Sevelemar medication was not being administered on dialysis days for the breakfast meal. The NP said she would have expected the facility staff to review the Resident's medication times and coordinate theses times based on his/her dialysis schedule to ensure the medications were administered as ordered. The NP said Resident #22's medications would have needed to be adjusted once the dialysis schedule was determined since dialysis treatments started after his/her admission. The NP said relative to the Sevelamer medication, some dialysis clinics administer this medication to the resident while at dialysis. The NP further said she was made aware by UM #2 that the Sevelemar medication was not administered to Resident #22 at dialysis and that it would now be sent with him/her on dialysis days from the facility. During an interview on 6/25/25 at 11:49 A.M., the Regional Nurse said the facility policy should have been followed relative to dialysis and medication timing for Resident #22. The Regional Nurse said the facility should have coordinated with the Resident's dialysis clinic relative to his/her medications and should have made adjustments to the medication administration times on dialysis days. Please refer to F842

Based on observation, interview and record reviews, the facility failed to ensure complete and accurate medical records were maintained for two Residents (#22, and #91), out of a total sample of 19 residents. Specifically, 1. For Resident #22, the facility failed to ensure accurate documentation of medications scheduled at 8:00 A.M., 8:30 A.M. and 9:00 A.M., were administered, when the Resident was out of the facility receiving dialysis services on Mondays, Wednesdays, and Fridays, and the medications were documented as being administered during the time the Resident was away at dialysis. 2. For Resident #91, the facility failed to ensure accurate documentation on the Skin Observation/ Assessment Tools and Nursing Evaluations when the Resident had a Stage 3 pressure area present on his/her coccyx. Findings include: 1. Resident #22 was admitted to the facility in April 2025 with diagnoses including Chronic Kidney Disease. Review of the facility policy titled Administering Medications, revised 1/2025, indicated: -medications are administered in a safe and timely manner, and as prescribed. -medications are administered in accordance with prescriber orders, including any required time frame -medication administration times are determined by resident need and benefit, not staff convenience. Factors that are covered include: >honoring resident choices and preferences, consistent with his or her care plan -medications are administered within one (1) hour of their prescribed time, Review of the Minimum Data Set (MDS) Assessment, dated 5/17/25, indicated Resident #22: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 possible points -received dialysis while in the facility. Review of the Renal/Dialysis Care Plan, initiated 5/21/25, indicated Resident #22 had a potential for complications related to hemodialysis (use of a machine to conduct dialysis) and included the following interventions: -administer and monitor effectiveness of medications as ordered (see Physician's orders/Medication Administration Record [MAR]) -communicate with dialysis center regarding medication, diet, and lab results -dialysis days: Mondays, Wednesday, Fridays During an interview on 6/17/25 at 9:01 A.M., Resident #22 said he/she received dialysis on Mondays, Wednesdays, and Fridays at an outside clinic. Resident #22 said he/she was picked up by transportation services at 6:15 A.M. and returned to the facility around 1:30 P.M. Resident #22 said he/she received a bagged breakfast prior to leaving the facility and did not have medications from the facility sent with him/her to dialysis. Review of the June 2025 Physician's orders indicated the following: -Folic Acid 1 milligram (mg) daily, initiated 4/9/25 -Oxybutynin Chloride ER 24 hour (medication for overactive bladder), 10 mg daily, initiated 4/9/25 -Pantoprazole Sodium Delayed Release (medication to reduce stomach acid), 40 mg daily initiated 4/10/25 -Fluticasone Propionate Nasal Spray (medication for allergies), 50 micrograms (mcg) per actuation (ACT), 2 spray in each nostril daily, initiated 4/10/25 -Potassium 20 milliequivalents (mEq) daily, initiated 4/10/25 -Cholecalciferol (Vitamin D supplement) 50000 international units (IU) every Monday, initiated 4/14/25 -Dialysis on Mondays, Wednesdays, and Fridays initiated 4/18/25 -Resident may receive, as per Medical Doctor (MD) order, while at dialysis, initiated 4/18/25 -Torsemide (diuretic medication), 20 mg twice daily, intimated 4/20/25 -Selevamer HCL (phosphate binder), 800 mg, one tablet with meals, initiated 5/14/25 -Apixaban (anticoagulant) 5 mg every 12 hours (twice daily), initiated 5/15/25 -Carvedilol (blood pressure medication) 25 mg twice daily, initiated 5/15/25 -Losartan Potassium (blood pressure medication), 25 mg daily, may hold on dialysis days, initiated 5/22/25 -Fluticasone Furoate-Vilanterol 50-25 mcg/ACT, 1 puff inhale orally in the morning . initiated 6/6/25 Review of Resident #22's June 2025 Medication Administration Record (MAR), indicated the following medications were documented as administered at the prescribed morning times from 6/1/25 through 6/19/25 (except Wednesday 6/4/25 when the Resident was documented to be out of the facility): -Folic Acid 1 mg, scheduled to be administered daily at 8:00 A.M., -Oxybutynin Chloride ER 10 mg, scheduled to be administered daily at 8:00 A.M., -Pantoprazole 40 mg, scheduled to be administered daily at 9:00 A.M., -Fluticasone Propionate 50 mcg/ACT, scheduled to be administered daily at 9:00 A.M., -Potassium 20 mEq, scheduled to be administered daily at 9:00 A.M., -Cholecalciferol 50000 IU, scheduled to be administered on Mondays at 9:00 A.M., was documented as administered on 6/2/25, 6/9/25 and 6/16/25 -Torsemide 20 mg, scheduled to be administered at 8:00 A.M., -Sevelamer HCL 800 mg, scheduled to be administered at 8:30 A.M., -Apixaban 5 mg, scheduled to be administered at 8:00 A.M., -Carvedilol 25 mg, scheduled to be administered at 8:00 A.M., -Losartan Potassium 25 mg, scheduled to be administered daily at 8:00 A.M., -Fluticasone Furoate-Vilanterol 50-25 mcg/ACT, scheduled to be administered daily at 8:00 A.M., During an interview on 6/18/25 at 2:13 P.M., Nurse #2 said Resident #22 left the facility for dialysis on Mondays, Wednesdays and Fridays around 6:00 A.M. and returned to the facility around 1:00 -1:30 P.M. Nurse #2 said no medications from the facility were sent with Resident #22, and that the medications scheduled to be administered in the morning (8:00 A.M., 8:30 A.M., and 9:00 A.M.), when the Resident was out at dialysis, would be administered when he/she returned from dialysis treatment at 1:00 P.M.-1:30 P.M. Nurse #2 further said the Resident's MAR should reflect the times that the Resident's medications were administered and currently the MAR was not accurate relative to the time the medications were administered. During an interview on 6/18/25 at 2:30 P.M., Unit Manager (UM) #2 said no medications were sent from the facility with Resident #22 to dialysis. The surveyor and UM #2 reviewed Resident #22's June 2025 MAR which indicated the Resident was being administered morning medications at scheduled times (scheduled for 8:00, 8:30 and 9:00 A.M.), when he/she was not in the facility and UM #2 said she would have to look into this. During an interview on 6/25/25 at 11:49 A.M., the Regional Nurse said the facility policy should have been followed relative to dialysis and medication timing for Resident #22. The Regional Nurse said the facility should have coordinated with the Resident's dialysis clinic relative to his/her medications and should have made adjustments to the medication administration times on dialysis days. 2. Resident #91 was admitted to the facility in May 2025 with diagnoses of Type 2 Diabetes, Essential Hypertension, and Unspecified Fall. Review of the facility policy titled Comprehensive Assessments and the Care Delivery System, effective 4/17 revised 2/2025, included but was not limited to: -Assessment and information collection includes (what, where, and when). The objective of the information collection (assessment) phase is to obtain, organize, and subsequently analyze information about a patient. -Assess the individual: observation; physical assessment; consultant reports. Review of Resident 91's Nursing Evaluation, dated 5/12/25, indicated that the Resident had no pressure injury and the goal would be for the Resident's skin to remain intact. Review of the Resident's MDS Assessment, dated 5/18/25, indicated that the Resident was severely impaired cognitively as evidenced by a BIMS score of two out 15 possible points and that the Resident did not have any pressure injuries noted on his/her skin. Review of the Resident's clinical record included a Nursing Progress Note, dated 5/22/25, which noted .one cm (centimeter) open area observed on coccyx, uneven borders, red, 0 (no) s/sx (signs and symptoms) infection, triad (a cream that creates a moist wound healing environment) applied, nsg (nursing) and cna (Certified Nursing Assistant) to inform colleagues to monitor. Note left in dr (Doctor) book for evaluation and tx (treatment) . Review of Resident #91's May 2025 Physician's orders and Treatment Administration Record (TAR) included: -apply zinc paste to coccyx 2x day, two times a day for skin integrity, Start Date 5/23/25, D/C (discontinue) 5/27/25. The treatment was noted as done daily 5/23/25 through 5/27/25. -coccyx, cleanse with N/S (normal saline) pat dry gently, apply silver alginate (a dressing that is absorbent with antimicrobial silver) to wound bed f/b (followed by) dcd (dry clean dressing) daily and prn (as needed). Start Date 5/28/25. The treatment was noted as done daily 5/28/25 through 5/31/25. Review of the Resident's June 2025 TAR indicated that the treatment to the coccyx started on 5/28/25 was still in place and noted as done daily on the TAR through 6/23/25. Review of the Resident's Care Plan included: -Alteration in skin integrity on the coccyx, Stage 3, initiated 5/27/25 revised 6/9/25, Review of the Wound Consultant Initial Progress Note, dated 5/27/25, indicated the Resident was seen for a Stage 3 pressure ulcer to the coccyx. Review of the clinical record included Skin Observation Tools, skin assessments completed by nursing, which indicated the following: -5/28/25 skin intact -5/30/25 skin intact -6/3/25 noted skin tear on right elbow, no other open areas Review of the Nursing Evaluation Skin Assessment, dated 6/9/25, indicated the Resident had no pressure injuries present. During an interview on 6/23/25 at 9:16 A.M., the Assistant Director of Nursing (ADON) said the Skin Observation Tools, dated 5/28/25, 5/30/25, and 6/3/25, and the Nursing Evaluation Skin assessment dated [DATE], which were completed by the Nurses, were inaccurate. The ADON said that the Resident continued to have an open pressure area on his/her coccyx, which was first identified on 5/23/25. The ADON said that the Resident was still evaluated weekly by the Wound Consultant, and was receiving a daily treatment for the ongoing open area on his/her coccyx. The ADON said that the pressure area on the Resident's coccyx should have been noted on the Skin Assessments dated 5/28/25, 5/30/25, and 6/3/25, as well as the Nursing Evaluation completed on 6/9/25, but they had not been.

Based on observations, record reviews, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one unit (Unit Four), out of three units and for two Residents (#37 and #70) residing on Unit Four. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP) when providing care on Unit Four: 1. For Resident #37, when the facility staff failed to wear the appropriate Personal Protective Equipment (PPE) when providing direct care for the Resident on EBP due to foot wound and a recent amputation. 2. For Resident #70, when the facility staff failed to don the appropriate PPE while providing high contact care for the Resident on EBP related to an indwelling urinary catheter. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions (EBP), revised 9/2022, indicated the following: -Enhanced Barrier Precautions are an infection prevention intervention designed to reduce the transmission of multi-drug-resistant organisms (MDROs) in the facility. The precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with MDROs as well as those with an increased risk of contracting MDROs. -Use of EBP includes but was not limited to residents with indwelling medical devices or wounds (regardless of MDRO colonization or infection status in addition) . 1. Resident #37 was admitted to the facility in January 2025 with diagnoses including chronic ulcer of the right heel and mid foot, Type 2 Diabetes with diabetic peripheral angiopathy, infection following a procedure deep incisional surgical site, Type 2 Diabetes with foot ulcers, osteomyelitis of the right ankle and foot. Review of Resident #37's June 2025 Physician orders indicated the following in part: -4th and 5th toe amputation and surgical site to the left foot . -Right foot distal plantar surgical wound . On 6/17/25 at 9:46 A.M., the surveyor observed the following from the doorway of Resident #37's room, located on Unit Four: -An EBP sign posted at the entrance of the Resident's doorway to the room. -A three drawer PPE bin with the necessary PPE required located in the hallway directly outside of the Resident's room. -Resident #37 had bilateral bandages on his/her feet. -A Certified Nurses Aide (CNA), wearing a surgical mask and gloves was bent down assisting Resident #37 with putting on his/her shoes. -The CNA was observed assisting the Resident from the bed into the wheelchair and then from the wheelchair into the bathroom. -The CNA exited the bathroom with an empty wheelchair and doffed (took off the gloves, exited the room, and performed hand hygiene). -The CNA was not observed to don (put on) a gown while putting on the Resident's shoes and while assisting with the Resident transfers. During an interview on 6/18/25 at 3:51 P.M., the Assistant Director of Nursing (ADON) said Resident #37 was on EBP due to his/her foot wound and recent amputation. The ADON said a gown and gloves should be worn when providing care for Resident #37. 2. Resident #70 was admitted to the facility in February 2025 with diagnoses including BPH with lower urinary tract symptoms and obstructive and reflux uropathy requiring the use of an indwelling catheter. Review of Resident #70's June 2025 Physician's orders indicated the following in part: -Foley catheter (a medical device that helps drain urine from your bladder) care, initiated 5/7/25 -Change Foley catheter as needed, initiated 5/7/25 On 6/17/25 from 10:08 A.M. until 10:19 A.M., the surveyor observed the following from the doorway of Resident #70's room, located on Unit Four: -An EBP sign posted at the entrance of the Resident's doorway to the room -A three drawer PPE bin with the necessary PPE required located in the hallway directly outside of the Resident's room. -A CNA provided care to Resident #70 behind the closed curtain. -The CNA came out from behind the curtain to gather supplies and was observed donning a surgical mask and gloves. The CNA did not don a gown. During an interview on 6/17/25 at 10:19 A.M., while standing outside of Resident #70's room, the ADON said the Resident was on EBP due to his/her urinary catheter and that staff were required to don full PPE when providing high contact care such as toileting and changing a resident. The surveyor discussed the CNA observation with the ADON, who entered the room to observe the CNA providing care. When the ADON exited the room, she said the CNA providing care worked with Hospice Services and was providing patient care. The ADON further said the CNA donned gloves and a surgical mask but did not don a gown as required, when providing high contact care.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed and transmitted within 14 days of completion for two Residents (#26, #45) reviewed, out of a total of three residents reviewed for MDS records over 120 days, and for one Resident (#25) reviewed, out of a total of three resident reviewed for closed records. Specifically, the facility failed: 1. For Resident #26, to complete a Discharge MDS Assessment. 2. For Residents #45 and #25, to complete Death in the Facility Tracking Records resulting in inaccurate resident tracking. Findings include: Review of the Resident Assessment Instrument (RAI) Version 1.19.1 dated [DATE] indicated the following: -Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. -Must be completed .within 14 days after the discharge date . -Must be submitted within 14 days after the MDS completion date . Review of the RAI Manual Version 1.19.1 dated [DATE] indicated the following: -A Death in Facility Tracking Record must be completed when the resident dies in the facility. -Must be completed within 7 days after the resident's death -Must be submitted within 14 days after the resident's death. 1. Resident #26 was admitted to the facility in February 2024 with a diagnosis of Sepsis. Review of the Nursing Progress Note, dated [DATE], indicated Resident #26 was discharged from the facility back to his/her home in the community. Review of Resident #26's MDS Assessments failed to indicate that a Discharge MDS Assessment had been completed at the time of Resident #26's discharge. During an interview on [DATE] at 8:43 A.M., the MDS Nurse said a Discharge MDS Assessment for Resident #26 should have been completed but was not. 2A. Resident #45 was admitted to the facility in [DATE] with a diagnosis of Malignant Neoplasm of the skin (skin cancer). Review of Resident #45's Registered Nurse (RN)/Physician Assistant (PA)/Nurse Practitioner (NP) Pronouncement of Death, dated [DATE], indicated he/she expired in the facility on [DATE]. Review of Resident #45's MDS Assessments failed to indicate a Death in the Facility Tracking Record had been completed when Resident #45 expired on [DATE]. During an interview on [DATE] at 8:43 A.M., the MDS Nurse said a Death in the Facility Tracking Record for Resident #45 should have been completed but was not. B. Resident #25 was admitted to the facility in [DATE]. Review of Resident #25's nursing progress notes indicated the following: -the Resident expired in the facility on [DATE]. Review of the MDS Assessments failed to indicate a Death in the Facility Tracking Record had been completed when the Resident expired on [DATE]. During an interview on [DATE] at 1:03 P.M., the MDS Nurse said that a Death in the Facility Tracking Record should have been completed for Resident #25, but one was not. The MDS Nurse said that she refers to the RAI Manual for accuracy and timeliness of MDS Assessment completion.

Based on interviews and records reviewed for one of three sampled residents (Resident #1), who back in June 2024, alleged that during care by a staff member, he/she was physically abused, the Facility failed to ensure they reported the final results of their abuse investigation to the Department of Public Health (DPH) within five working days, when although an allegation of abuse, involving Resident #1 and Certified Nurse Aide (CNA) #1, was reported on 06/06/24, the final results of the investigation however, were not reported to the DPH until 10/01/24, almost four months later. Findings include: Review of the Agency Policy titled Abuse: Identification and Reporting, dated as revised March 2022, indicated the results of all investigations must be reported to the administrator and to other officials in accordance with state law within five working days of the incident and if the alleged violation is verified, appropriate corrective action must be taken. Review of Reports submitted to the DPH by the facility via the Health Care Facility Reporting System (HCFRS) indicated that on 06/06/24, the Facility submitted an initial report that indicated Resident #1 alleged that on 06/05/24, CNA #1 dropped his/her legs during care, resulting in severe pain. Further review of the Report from the Facility in HCFRS indicated, after submission of the initial report, the Facility was repeatedly contacted by the DPH Intake Department (on 06/11/24, 07/17/24, 08/29/24, 09/04/24, 09/17/24, and 09/20/24) requesting a final summary of the outcome of the Facility's Internal Investigation, and the summary was not received by DPH until 10/01/24. During an interview on 10/23/24 at 8:00 A.M., the Director of Nurses (DON) said that she was not working at the Facility at the time of the investigation, and that she was not sure why the final report was not submitted within the required time frame.

Based on observation, interview, and record review, the facility failed to establish and implement policies, in accordance with applicable Federal, State and local laws and regulations regarding smoking for two Residents (#82 and #244) out of four applicable residents out of a total sample of 21 residents. Specifically, the facility failed to: 1. Ensure their smoking policy addressed what preventative measures were in place in the event of a fire emergency. 2. The facility failed to ensure they implemented their smoking policy relative to two Residents (#82 and #244) relative to possession of smoking materials. Finding include: Review of the Department of Health and Human Services Centers for Medicare and Medicaid Services Memorandum titled, Smoking Safety in Long Term Care Facilities, dated 11/10/11 included but was not limited to: - Facilities must include assessment of smoking areas and provision of emergency equipment in the designated smoking areas. - The facility is obligated to ensure the safety of designated smoking areas .the facility is also required to provide portable fire extinguishers in all facilities 1. The facility failed to ensure their smoking policy addressed what preventative measures were in place in the event of a fire emergency. Review of the facility policy titled Smoking, revised 3/2022, indicated the following: -Smoking is only permitted in designated resident smoking areas, which are located outside of the building. -Metal containers, with self-closing cover devices, are available in smoking areas - Residents who have independent smoking privileges are not permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. - Residents without independent smoking privileges may not have or keep any smoking articles including cigarettes, tobacco, etc., except when they are under direct supervision. Further review of the facility smoking policy did not indicate what fire prevention equipment should be available in the smoking areas or what preventative measures were to be implemented in the event of a fire emergency related to smoking. 2. The facility failed to ensure they implemented their smoking policy relative to two Residents (#82 and #244) relative to possession of smoking materials. During an observation of resident smoking and a concurrent interview on 5/21/24 from 9:27 A.M. until 9:35 A.M., the surveyor observed three Residents (#82, #244, and #245) outside smoking accompanied by Certified Nursing Assistant (CNA) #5. The surveyor asked CNA #5 if the residents were allowed to keep their cigarettes on their person or if they were required to have their smoking paraphernalia locked up on the unit. CNA #5 said Resident #82 and Resident #245 had permission to keep cigarettes in their possession, but Resident #244 was not allowed to keep cigarettes in his/her possession. At that time, Resident #244 spoke up and said he/she kept his/her cigarettes in his/her possession because, they trust me with them. 2a. Resident #82 was admitted to the facility in October 2023 with a diagnosis of Dementia. Review of the Resident's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15. Further review of the MDS assessment indicated the Resident was able to make him/herself understood and understood others. Review of the Resident's Smoking Safety Screen dated 10/13/23 indicated the Resident was a smoker, required supervision, and that the Resident required the facility to store lighter and cigarettes. Review of the Resident's Smoking Care Plan dated 10/24/23 and revised on 5/6/24 indicated the Resident required supervised smoking, smoking materials were to be stored in a secured area and the smoking policy was to be reviewed with the Resident and/or his/her health care representative. During an observation and interview on 5/21/24 at 9:11 A.M., the surveyor observed Resident #82 seated in his/her wheelchair on the nursing unit waiting for a staff member to take him/her outside to smoke. Resident #82 said he/she goes outside approximately three times per day, depending on when staff were available to take him/her outside. Resident #82 then said that he/she keeps his/her cigarettes with him/her pointing to a small, zippered bag next to him/her on the wheelchair, and that staff trust him/her to keep the cigarettes with him/her. During an observation and interview on 5/23/24 at 9:05 A.M., Resident #82 said he/she was waiting to go outside to smoke and opened his/her zippered bag next to him/her on his/her wheelchair and showed the surveyor a pack of cigarettes in his/her bag. During an observation of resident smoking on 5/23/24 from 10:05 A.M. until 10:35 A.M., the surveyor observed Resident #82, with the assistance of the Activity Director, remove a cigarette from a pack of cigarettes Resident #82 removed from his/her zippered bag, and the Activity Director assisted the Resident in lighting his/her cigarette. 2b. Resident #244 was admitted to the facility in May 2024 with diagnoses including: Fractured Femur, Chronic Obstructive Pulmonary Disease (COPD, a group of diseases that block airflow and make it difficult to breathe), and Dementia. Review of the Nursing Admission assessment dated [DATE] indicated the Resident was oriented to person, place, and time. Review of the Resident's Smoking Evaluation dated 5/13/24 indicated the Resident was a smoker, required supervision and smoking materials were to be stored by the facility. Review of the Resident's Smoking Care Plan dated 5/10/24 and revised on 5/17/24 indicated the Resident required supervised smoking and was to wear a smoking apron while smoking. During an observation of resident smoking on 5/21/24 from 9:27 A.M. until 9:35 A.M., the surveyor observed the Resident smoking without a smoking apron. During an observation on 5/23/24 at 9:50 A.M., the Resident showed surveyor a pack of cigarettes he/she keeps in his/her nightstand and said he/she was allowed to keep them because they trusted him/her. During an interview on 5/22/24 at 4:00 P.M., CNA #6 said he often brings residents outside to smoke and residents were not allowed to keep smoking materials in their possession due to safety concerns. During an interview concurrent with resident smoking observation on 5/23/24 from 10:05 A.M. until 10:35 A.M., CNA #4 said there have not been many residents who were smokers in the building until very recently. CNA #4 said there was no system in place to ensure the residents' smoking materials were secured and up until now there were no smoking aprons, no fire blankets, and no fire extinguisher available to staff who take the residents out to smoke. CNA #4 further said there should be a process in place to ensure resident safety and there was none. CNA #4 said that no resident was allowed to keep smoking materials on their person or in their rooms, and they were supposed to be secured by the nursing staff.

Based observations, interviews, policy and record review the facility failed to ensure that there was sufficient nursing staff to assist residents in attaining and maintaining the highest practicable physical, mental, and psycho-social well-being on three (Unit Two, Unit Three and Unit Four) out of three observed units. Specifically, the facility failed to: 1)Ensure sufficient staff as determined by the Facility Assessment 2)Ensure call bells were responded to timely for Residents #83 & Resident #22 Findings include: Review of the facility policy titled Emergency Staffing Strategies, dated September 2020, indicated but was no limited to the following: -In the event that sufficient staff is not available from the individual SNF's (Skilled Nursing Facility) workforce, the facilities incident commander shall coordinate other available corporate resources to obtain additional employees from other facilities to staff the stricken facilities during emergencies and disasters. -Assign ancillary staff who possess Registered Nurse (RN)/Licensed Practical Nurse (LPN)/Certified Nurse Aide (CNA) license to work on units for direct care 1) Review of the Facility Assessment (an assessment completed by the facility to identify what resources are necessary for competent care of residents on a day-to-day or emergency basis), dated 4/17/24, indicated but was not limited to: -Direct care staff CNA or Licensed Nurse providing Activity of Daily Living (ADL- self-care activities like bathing, dressing, eating) care to residents for the day ratio should be the following to meet the resident needs: > 1:10 (number of direct care staff to number of residents) on the Day shift (7:00 A.M.- 3:00 P.M.), >1:11 on the Evening shift (3:00 P.M.-11:00 P.M.), and >1:17 on the Night shift (11:00 P.M.- 7:00 A.M) Review of actual worked nursing schedules with daily unit census data (number or residents residing on a given unit on a given day) from 4/19/24 through 5/19/24 indicated the following: -Unit Two: > Day Shift Staffing Ratios had one day greater than the ratio per the Facility Assessment of 1:10 on 5/3/24 (1:16). >Evening Shift Staffing Ratios were greater than the 1:11 ratio on six days; 4/19/24, 4/20/24, 4/22/24, 5/2/24, 5/13/24, 5/14/24, and 5/18/24 (ratios ranged from 1:11.5 to 1:14.7). -Unit Three: >Day Shift Staffing Ratios were greater than the 1:10 ratio on 18 days; 4/19/24 through 4/25/24, 4/27/24 through 5/3/24, 5/11/24, 5/13/24, 5/18/24 and 5/19/24(ratios ranged from: 1:10.7 to 1:17) > Evening Shift Staffing Ratios were greater than the 1:11 ratio on 2 days; 5/1/24 and 5/14/24 (ratios ranged from 1:13.6 to 1:33) -Unit Four: > Day Shift Staffing Ratios were greater than the 1:10 ratio on 6 days; 4/20/24, 4/21/24, 4/23/24, 4/28/24, 5/18/24 and 5/19/24 (ratios ranged from 1:10.7 to 1:15) > Evening Shift Staffing Ratios were greater than the 1:11 ratio on 2 days; on 4/20/24 and 4/24/24 (ratio of 1:12.8) 2) On 5/21/24 from 9:46 A.M. until 9:51 A.M., the surveyor observed the following on Unit Four: -Resident #83's call bell light to be on -Call bell system located at the nurses indicated Resident #83's call bell light had been on for 13 minutes -Surveyor went to the Resident's room to inquire about the call bell wait time. Upon arriving to Resident #83's room, the surveyor found the Resident to be at the doorway, holding a soiled hospital gown, wearing a brief with feces coming out of the brief, onto his/her leg and on the wheelchair. -Resident said that he/she had trouble controlling his/her bowels and needed help getting cleaned up. The Resident thought his/her call bell light was not working because no one had come to see what he/she needed. Resident #83 said that because he/she thought the light was not working, he/she would go to the bathroom to pull the bathroom cord, hoping that would work. -9:47 A.M. bathroom light on and flashing red -9:48 A.M. Resident calling out hello from the bathroom. -9:51 A.M. CNA entered the bathroom to assisted Resident #83 -In total, the Resident waited 18 minutes for facility staff to provide assistance 3) On 5/22/24, the surveyor conducted a Resident Council Meeting with 11 residents. Of the 11 residents who were present, 10 actively participated in the meeting and resided Units 3 and 4. The following concerns were identified by the participating residents: -four residents said that there were long wait times for call bells due to low levels of staffing. -One resident specified at times the wait had been over a hour for the call bell to be answered. -One resident said that there was only two CNAs sometimes for 18 rooms that mostly house 2 residents per room, and it is not enough staff. -One resident said there are frequent call outs that leave them with 2 CNAs on a unit. 4) During an interview on 5/21/24 at 4:24 P.M., Nurse #3 said that today, on the 4th floor the staff worked the entire shift down two (CNA's). She said it was difficult, but the team worked together to get through the day to provide care for the residents. She said that she spent much of her day near the nurse's station and the dining room because they have multiple residents who are fall risks. During an interview on 5/22/24 at 7:30 A.M., Nurse #3 said that there were currently two Nurses and two CNA's. She said that there were four CNAs scheduled, one called out, one would be coming in at 7:30 A.M., and that two CNAs came in at 7:00 A.M. She said there were call outs on all three units today. During an interview on 5/22/24 at 3:13 P.M., CNA #13 said she worked at the facility 40 hours a week for several years on Unit Four. CNA #13 said it is hard to complete the assignments if the unit was short (2 CNAs for the unit) and residents sometimes have had to stay in bed because they don't have enough time to care for them. CNA #13 said that the facility considers Unit 4 fully staffed at 3 CNAs, but 4 CNAs are needed to properly care for the residents, many of whom were dependent on staff and use mechanical lifts (a machine that requires two qualified staff members to operate to lift a resident to transfer them to and from the bed and chair) to get them out of bed. During an interview on 5/22/24 at 4:04 P.M., CNA # 14 said that there were times the unit has been left with one CNA for the evening shift which can leave one staff member responsible for all the care of 29 residents or more. CNA #14 said it was extremely hard to provide the care the residents need with one CNA on the unit. During an interview on 5/22/24 at 4:20 P.M. CNA # 11 said she was a regular staff member for evening shift and work mostly on Unit Three and Unit Four. CNA #11 said they have typically worked with two CNAs on a unit once or twice a week. CNA #11 further said that call outs often left them short staffed and there was no plan or replacements for staff who called out. CNA #11 said when there was only two CNAs on a unit, nurses did not help, and the two CNAs were responsible for all the resident care, meal passes, assistance with eating and answering call bells for the residents. During an interview on 5/23/24 at 6:45 A.M. CNA #10 said she had worked at the facility for many years on Unit Four. CNA #10 said that night shift was usually staffed with two CNAs but that on occasions they have worked with only one CNA for the unit but that was not typical. During an interview on 5/23/24 at 6:59 A.M. CNA #9 said she was a regular staff member that had worked several years at the facility on Unit Three. CNA #9 said sometimes they work alone on night shift (as the only CNA for the unit) but that staffing on day shift was always bad causing night shift staff to have to unexpectedly stay late when relief didn't arrive or came in late. CNA #9 further said that Unit Three often had two CNAs on day and evening shift. CNA #9 said that short staffing caused her to not be able to take care of residents the way she wanted or should and it was frustrating. During an interview on 5/23/24 at 7:09 A.M. CNA #8 said she typically worked on Unit Two but sometimes worked Unit Three. CNA #8 said they typically have two to three CNAs for Unit Three but when they have two it is hard to provide care to the residents due to the workload. During an interview on 5/23/24 at 8:27 A.M., the Administrator said they currently did not have a staffing coordinator for the last week or two but had hired someone who had not started yet, and the Assistant Director of Nursing (ADON) was currently overseeing staffing for nursing staff on the units. The Administrator said that they had agency contracts in place, but they did not use agency staff at all since she had been there (started in the beginning of May). When asked for contingency staffing plan, the Administrator indicated the Emergency Staffing Strategies policy would be utilized. 5) During an observation and interview on Unit Three on 5/23/24 at 10:22 A.M., the surveyor heard the call bell system ringing at the nurse's station for Resident #22. The surveyor went to the Resident's room, observed the call bell light to be on at the Resident's door, and the Resident (who was in the room) said he/she had been waiting a long time and just wanted to have his/her radio plugged in and turned on. During an interview and observation on 5/23/24 at 10:28 A.M., directly following the surveyor's interaction with the Resident #22, the surveyor and Nurse #2 observed the call bell system at the nurse's station indicated the call bell in Resident #22's room had been on for 82 minutes. Nurse #2 said the call bell system at the nurse's station starts when the call bell system is activated in a resident's room and tracks how long the call light is on for. He said currently on Unit Three there was only two CNAs, and this was not enough CNAs on the Unit to meet the needs of the residents and to answer call bell lights timely. He further said the Unit needed three CNAs for the resident's needs to be met and that initially at the beginning of the day the Unit only had one CNA until a CNA from another unit came to assist. 6) During an interview on 5/23/24 at 10:52 A.M. the ADON said she did not know when she took over staffing the facility but believed it was in the beginning of April. The ADON said prior to taking over she had not been involved with staffing. The ADON said that on day shift Units Two and Three should have three CNAs and Unit Four should have four, on evening shift Unit Two should have two CNAS, Unit Three should have three CNAs and Unit Four should have four CNAs, and on night shift all three units should have 2 CNAs. The ADON said this staffing pattern was based off of census and the acuity (need level) of the residents on each unit. The ADON sad that she had heard from staff almost weekly that they were frustrated when they had to work short due to call outs. The ADON said that the Director of Nursing, Unit Manager and Infection Control Nurse were all hands on with the schedule but that there were still issues with staffing and that staffing issues would cause problems with everything including meals and call bell response times. Relative to call bell wait times the ADON said that her expectation would be no more than 15 minutes at the longest to wait but would more likely be five to ten minutes for someone to respond. During an interview on 5/23/24 at 2:13 P.M., Nurse Practitioner (NP) #1 said that it had been frustrating to ensure follow up appointments and referrals were completed. She said that there seemed to be a communication breakdown maybe due to lack of consistent staff, staff being per diem and not having enough staff. She said that the NP's try to follow up on referrals and recommendations that have made but do not always have time to do so and that the NP's relied on the staff to ensure the orders and referrals are being carried out.

Based on observations, interviews, and test tray results, the facility failed to serve palatable food at an appetizing temperature, to all residents, on three Units (Unit Two, Unit Three, and Unit Four) of three units observed as well as in the Main Dining Room. Findings include: On 5/22/24, the surveyor conducted a Resident Council Meeting with 11 residents. Of the 11 residents who were present, 10 actively participated in the meeting and resided Units Three and Four. The following concerns were identified by the participating residents: -Two residents said the food was always cold -One resident said the food was bland but otherwise is good -One resident said the food was either too bland or had too much salt -One resident agreed the food was salty, specifically that the gravy was salty During the initial walkthrough on 5/21/24 at 10:15 A.M., the surveyor received the following comments from two residents on Unit Two: -The food is cold and is never hot enough. -The food is always cold. I don't think they cook it right or they need heat boxes. 1. On 5/23/24 from 11:43 A.M. to 12:06 P.M., the surveyor observed meal tray pass on Unit Three. -At 11:43 A.M. the first meal cart was delivered to the unit. -At 11:45 A.M. Nurse #2 and an activities assistant began passing trays from the first meal cart. -At 11:49 A.M. the second meal cart was delivered to the unit. A second nurse joined Nurse #2 and the activities assistant in passing trays. -At 11:51 A.M. Regional Consultant Nurse #1 and a second Regional Consultant Nurse arrived to the unit and began to assist the two nurses and activities assistant with passing trays. -At 11:54 A.M. staff began passing trays from the second meal cart. -At 12:06 P.M. the last tray was passed from the second meal cart and tray pass was complete. On 5/23/24 at 12:06 P.M. Regional Consultant Nurse #1 took temperatures of the food on the Unit Three test tray and beverages with the surveyor as follows: -Hamburger macaroni: 108 degrees Fahrenheit (F) -Cooked carrots: 90 degrees F -Banana cream pie: 70 degrees F -Milk: 52 degrees F At 12:10 P.M. the surveyor tasted the test tray: -Hamburger macaroni: mixed temperature throughout, some areas warm, others cold to taste -Cooked carrots: lukewarm to taste -Banana cream pie: lukewarm to taste -Milk: cool to taste 44129 2. On 5/23/24 at 11:55 A.M. on Unit Two, the surveyor along with Unit Manager #1 obtained temperatures from the lunch test tray. The temperatures were as follows: - Sliced carrots, 90 degrees F - cool to taste - Cheesburger macaroni, 119 degrees F in the center, however there were areas of warm mixed with very cool temperatures. 42690 3. On 5/23/24 from 11:31 A.M. to 11:56 A.M., the surveyor observed the lunch service in the main dining room. At 11:56 A.M., the Food Service Director (FSD) and the surveyor obtained the temperature and tasted each item, and observed the following: -Cheeseburger macaroni- 155 degrees F -Steamed carrots- 128.4 degrees F -Roll - 76 degrees F The FSD and surveyor each tasted the cheeseburger macaroni and steamed carrots. The FSD said that both were lukewarm to taste. He said that it was hard maintain the temperature with the Styrofoam trays that the food was being served on today. He said they were serving the food on Styrofoam take out containers today due to the boiler that the kitchen runs off being down. 42741 4. On 5/23/24 from 11:55 A.M. to 12:10 P.M., the surveyor observed the following on Unit Four: -11:55 A.M., the 2nd meal cart arrived on Unit Four, the 1st meal cart was already on the unit, but no trays had been passed from the 1st meal cart. -From 11:55 A.M. to 12:01 P.M., trays were passed from the 2nd meal cart -From 12:01 P.M. to 12:10 P.M., trays were passed from the 1st meal cart -12:10 P.M., the surveyor received the test tray which came up on the 2nd meal cart At 12:10 P.M., Nurse #5 and the Regional Consultant Nurse obtained temperature of the food on the test tray, the surveyor tasted each item, and the following was observed: -Pureed Pork with gravy- 82 degrees F, cool to taste and was very salty -Mashed Potatoes with gravy- 78 degrees F cool to taste -Pureed Carrots- 72 degrees F cold to taste and liquid in consistency -Chocolate pudding- 64 degrees F cool to taste but not cold -Carton of milk- 60 degrees F cool to taste but not cold During an interview following the test tray observation Nurse #5 said he was unsure what the temperature of the food should be when it was served to the residents. During an interview on 5/23/24 at 2:00 P.M., the FSD said hot food should arrive hot and cold foods should arrive cold to the units. When discussing the temperatures taken during the test trays on the units the FSD said food coming up from the kitchen to the units should change no more than 5-6 degrees F by the time it is served to the residents and should be a palatable temperature.

Based on observations, interviews, and record review, the facility failed to ensure precautions are taken for the resident's individual safety relative to smoking. Specifically, the facility failed to: 1. Ensure fire prevention equipment was readily available in the smoking area to ensure a safe smoking environment. 2. Ensure the smoking plan of care was implemented for two Residents (#82 and #244) out of four applicable residents out of a total of 21 sampled residents relative to resident possession of smoking materials (Resident #82 and #244) and providing a safety intervention (smoking apron) (Resident #244 and #245) assessed to require one. 3. Ensure staff, who accompanied residents outside to smoke, were educated as to what safety interventions to implement in the event of an emergency relative to resident smoking. Findings include: Review of the Department of Health and Human Services Centers for Medicare and Medicaid Services Memorandum titled, Smoking Safety in Long Term Care Facilities, dated 11/10/11 included but was not limited to: - Facilities must include assessment of smoking areas and provision of emergency equipment in the designated smoking areas. - The facility is obligated to ensure the safety of designated smoking areas .the facility is also required to provide portable fire extinguishers in all facilities Review of the facility policy titled Smoking, revised 3/2022, indicated the following: -Smoking is only permitted in designated resident smoking areas, which are located outside of the building. -Metal containers, with self-closing cover devices, are available in smoking areas. - Residents who have independent smoking privileges are not permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. - Residents without independent smoking privileges may not have or keep any smoking articles including cigarettes, tobacco, etc., except when they are under direct supervision. 1. The facility failed to ensure fire prevention equipment such as a fire extinguisher and a fire blanket were readily available to ensure a safe smoking environment. During an observation and subsequent interview following a resident smoking break on 5/21/24 between 9:27 A.M. until 9:35 A.M., the surveyor observed Certified Nursing Assistant (CNA) #5 escort three residents (Residents #82, #244, and #245) outside to smoke. The surveyor did not observe any fire prevention equipment in the smoking area such as a fire blanket or fire extinguisher. The surveyor asked CNA #5 what she would do if there was a fire emergency. CNA #5 looked around the area and said, good question. The surveyor asked CNA #5 if there was a fire blanket or fire extinguisher nearby and CNA #5 said there was not. CNA #5 then said she did not know what to do if there were to be a fire that involved one of the residents other than attempt to pat the fire out and yell for help. During an observation and interview on 5/21/24 at 9:40 A.M., the surveyor observed the front entrance to the building, both inside and outside, as well as the main lobby and did not observe fire prevention equipment. The surveyor asked the receptionist if there were any fire extinguishing materials behind her desk or anywhere in the lobby and she said there were not. During an interview on 5/22/24 at 3:35 P.M., the Regional Director of Operations said there was not a fire extinguisher located in the vicinity of the designated smoking area. 2. The facility failed to implement the smoking plan of care for two Residents related to possession of smoking materials (Resident #82 and #244) and applying a protective smoking apron to two Residents assessed to need one (Resident #244 and #245) During an observation of resident smoking and a concurrent interview on 5/21/24 from 9:27 A.M. until 9:35 A.M., the surveyor observed three Residents (#82, #244, and #245) outside smoking accompanied by CNA #5. The surveyor asked CNA #5 if the residents were allowed to keep their cigarettes on their person or if they were required to have their smoking paraphernalia locked up on the unit. CNA #5 said Resident #82 and Resident #245 had permission to keep cigarettes in their possession, but Resident #244 was not allowed to keep cigarettes in his/her possession. At that time, Resident #244 spoke up and said he/she kept his/her cigarettes in his/her possession because, they trust me with them. 2a. Resident #82 was admitted to the facility in October 2023 with a diagnosis of Dementia. Review of the Resident's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15. Further review of the MDS assessment indicated the Resident was able to make him/herself understood and understood others. Review of the Resident's Smoking Safety Screen dated 10/13/23 indicated the Resident was a smoker, required supervision, and that the Resident required the facility to store lighter and cigarettes. Review of the Resident's Smoking Care Plan dated 10/24/23 and revised on 5/6/24 indicated the Resident required supervised smoking, smoking materials were to be stored in a secured area and the smoking policy was to be reviewed with the Resident and/or his/her health care representative. During an observation and interview on 5/21/24 at 9:11 A.M., the surveyor observed Resident #82 seated in his/her wheelchair on the nursing unit waiting for a staff member to take him/her outside to smoke. Resident #82 said he/she goes outside approximately three times per day, depending on when staff were available to take him/her outside. Resident #82 then said that he/she keeps his/her cigarettes with him/her pointing to a small, zippered bag next to him/her on the wheelchair, and that staff trust him/her to keep the cigarettes with him/her. During an observation and interview on 5/23/24 at 9:05 A.M., Resident #82 said he/she was waiting to go outside to smoke and opened his/her zippered bag next to him/her on his/her wheelchair and showed the surveyor a pack of cigarettes in his/her bag. During an observation of resident smoking on 5/23/24 from 10:05 A.M. until 10:35 A.M., the surveyor observed Resident #82, with the assistance of the Activity Director, remove a cigarette from a pack of cigarettes Resident #82 removed from his/her zippered bag, and the Activity Director assisted the Resident in lighting his/her cigarette. 2b. Resident #244 was admitted to the facility in May 2024 with diagnoses including: Fractured Femur, Chronic Obstructive Pulmonary Disease (COPD, a group of diseases that block airflow and make it difficult to breathe), and Dementia. Review of the Nursing Admission assessment dated [DATE] indicated the Resident was oriented to person, place, and time. Review of the Resident's Smoking Evaluation dated 5/13/24 indicated the Resident was a smoker, required supervision and smoking materials were to be stored by the facility. Review of the Resident's Smoking Care Plan dated 5/10/24 and revised on 5/17/24 indicated the Resident required supervised smoking and was to wear a smoking apron while smoking. During an observation of resident smoking on 5/21/24 from 9:27 A.M. until 9:35 A.M., the surveyor observed the Resident smoking without a smoking apron. During an observation on 5/23/24 at 9:50 A.M., the Resident showed surveyor a pack of cigarettes he/she keeps in his/her nightstand and said he/she was allowed to keep them because they trusted him/her. During an observation of resident smoking on 5/23/24 from 10:05 A.M. until 10:35 A.M., the surveyor observed the Resident to be smoking without a smoking apron. 2c. Resident #245 was admitted to the facility in May 2024 with a diagnosis of Acute Respiratory Failure. Review of the Resident's Nursing Admission Evaluation dated 5/14/24 indicated Resident was alert, followed commands, and had both short- and long-term memory loss. Further review of the Nursing Admission Evaluation dated 5/14/24 indicated the Resident was a smoker, required supervision, required the use of a smoking apron and smoking materials were to be stored by the facility. Review of the Resident's Smoking Care Plan dated 5/15/24 and revised on 5/16/24 indicated the Resident required supervised smoking and was to wear a smoking apron while smoking. During an observation of resident smoking on 5/21/24 from 9:27 A.M. until 9:35 A.M., the surveyor observed the Resident smoking without a smoking apron. During an interview on 5/22/24 at 2:55 P.M., CNA #5 said that smoking aprons were a new thing at the facility, they have not used them in the past and that they were on order for the residents who need them. During an interview on 5/22/24 at 4:00 P.M., CNA #6 said he often brings residents outside to smoke, smoking aprons were not available until yesterday and residents were not allowed to keep smoking materials in their possession due to safety concerns. During an interview on 5/23/24 at 8:00 A.M., the Director of Nursing (DON) said for the longest time the facility did not really have many smokers, however there are now several residents who smoke. The DON said there were currently residents whose care plans indicated a need for smoking aprons for safety, however the facility did not have any smoking aprons on hand. During an observation of resident smoking on 5/23/24 from 10:05 A.M. until 10:35 A.M., the surveyor observed the Activity Director place a smoking apron on Resident #245. Directly after the Activity Director placed the smoking apron on Resident #245, the Resident told the surveyor this was the first time he/she ever wore a smoking apron. During an interview concurrent with resident smoking on 5/23/24 from 10:05 A.M. until 10:35 A.M., CNA #4 said there have not been many residents who were smokers in the building until very recently. CNA #4 said there was no system in place to ensure the residents' smoking materials were secured as well as ensuring smoking aprons were provided as needed, and up until now, there were no smoking aprons, no fire blankets, and no fire extinguisher available to staff who take the residents out to smoke. CNA #4 further said there should be a process in place to ensure resident safety and there was none. CNA #4 also said if a resident required a smoking apron, that information should be available to CNAs in the resident's care plan, so the CNAs know which residents required them, and the reason he placed a smoking apron on Resident #245 was because he knew the Resident once burned a hole in his/her pants while smoking at the facility. CNA #4 said that no resident was allowed to keep smoking materials on their person or in their rooms, and they were supposed to be secured by the nursing staff. 3. During an interview on 5/23/24 at 1:40 P.M. Unit Manager (UM) #1 said education provided to facility staff regarding the resident smoking process and safety was ongoing, however no formal education was provided by the Staff Development Coordinator. During an interview on 5/23/24 at 1:55 P.M., CNA #7 said she takes residents outside to smoke occasionally and has not received any education related to the resident smoking process and smoking safety. During an interview on 05/23/24 at 2:25 P.M., CNA #4 said he takes residents outside to smoke regularly and has not received any education related to the resident smoking process and smoking safety. During an interview on 5/24/24 at 8:47 A.M., CNA #5 said she takes residents out to smoke regularly and has not received any education related to the resident smoking process and smoking safety. CNA #5 said she had never given it any thought until the surveyor asked her what she would do if a resident ignited him/herself. See F926

Based on observation and interview the facility failed to ensure two Unit (Unit #3 and Unit #4) kitchenettes were maintained in a clean and sanitary manner out of three Unit kitchenettes observed. Findings include: Review of the facility policy titled Food Brought Into Facility, revised 5/22, indicated the following: -Perishable foods must be stored and identified with the resident ' s name, food item, and use by date. These can be stored in the nursing unit kitchen nourishment refrigerator. Review of the Daily Checklist for Dietary Cleanliness, undated, provided by the Food Service Director (FSD), indicated the following: -Make sure Unit Kitchens are stocked, cleaned, and rotated all shifts. This includes Microwave, Refrigerators, Toaster, etc. Unit Three During an observation on 5/21/24 at 8:47 A.M., in the Unit Three Kitchenette the following was observed: -Toaster crumb drawer laden with crumbs and toaster had burnt on material inside. -Frozen item in kitchenette freezer dated 6/1/24 with no name. During an observation on 5/22/24 at 12:38 P.M., in the Unit Three kitchenette the following was observed: -Toaster crumb drawer laden with crumbs and toaster had burnt on material inside. -Frozen item in kitchenette freezer dated 6/1/24 with no name. During an observation and interview on 5/22/24 at 12:53 P.M., Nurse #1 and the surveyor observed the Unit Three Kitchenette. Nurse #1 said it did not appear the toaster was cleaned regularly and having excess crumbs in the toaster was a fire risk. Additionally, Nurse #1 said all food items placed in the freezer should be labeled with the date the item was brought in and a resident ' s name and she was unsure who the item in the freezer belonged to or when it was placed in the freezer. Nurse #1 also said she was unsure whose responsibility it was to clean the kitchenette or how often it was cleaned. Unit Four During an observation and interview on 5/22/24 at 2:50 P.M., Nurse #3 and the surveyor observed the Unit Four kitchenette and the following was observed: -Toaster crumb drawer was laden with crumbs and large chunks of toasted were in the bottom of the toaster. Nurse #3 said the kitchenettes should be cleaned daily by the kitchen staff in the morning. She further said that amount of dried bread in the toaster was a fire risk. During an interview on 5/23/24 at 10:48 A.M., the surveyor showed the FSD the photos of the toasters on Unit Three and Unit Four and of the freezer item that was dated 6/1/24. The FSD said the kitchenettes should be cleaned daily and daily cleaning included the toasters. He said the toasters did not appear that they had been cleaned recently. The FSD further said items in the freezer should be dated with the date the food was brought in so it could be discarded after three days, and he was unsure why an item was dated 6/1/24. He said with out a proper date and name he could not be sure who the item belonged to and how long it had been in the freezer.

Based on observations and interviews, the facility failed to ensure Administration and/or the Governing Body provided residents in the facility with appropriate care and services in order to maintain their highest practicable physical, mental, and psychosocial well-being. The facility failed to identify and implement plans to address numerous facility wide concerns, failed to fully assess the facility staffing needs in order to meet resident needs, and failed to ensure supplies for resident care were available and accessible. Findings include: During the re-certification survey conducted by the survey team from 5/21/24 through 5/24/24, the following concerns were identified by residents/resident representatives and staff: -resident supplies including incontinence briefs, washcloths or towels, and clothes were not always available 1. Review of the Facility Assessment, dated 4/17/24, indicated the facility accepts residents with a broad range of diseases and disabilities primarily including common diseases of the elderly for its long-term care unit. These conditions, physical and cognitive disabilities, or combinations of conditions require complex medical care and management and included: -urinary incontinence 2. On 5/22/24 at 10:32 A.M., the surveyor conducted a resident council meeting and 11 residents were present. One resident who was present did not participate. The following concerns were discussed: -One resident said they don't have enough incontinence briefs sized extra large -Two other residents said the facility does not have medium size incontinence briefs and that they had to purchase their own. -One resident said that facility staff recommended that he/she drink less so he/she does not need so many incontinence briefs -Four residents said they do not have enough soup, one of the resident said he/she has family bring in soap and has loaned it to facility staff to use on other residents because there is none. -One resident said that CNAs have purchased soap to use on the residents due to not having any. -One resident reported that he/she took a shower and the towel he/she used was thread bare and had holes in it. -One resident said the CNAs have cut up old towels to use as face clothes. During an interview on 5/22/24 at 3:13 P.M., CNA #13, who has worked on Unit Four, said they are short on incontinence briefs for residents and are currently using small incontinent briefs for residents who need large incontinence briefs. CNA #13 said this has been going occurring on/off for a long time. She said there is never have enough linen-specifically towels, wash cloths and the amount available varies. Sometimes when the CNAs ask for supplies and don't get it, they have to go downstairs (where the laundry room is located) to get linens, towels and face clothes and there isn't enough to take. CNA #13 said there isn't always soap available to use for the residents and sometimes she and other CNAs have had to bring their own soap to provide care. She said sometimes they have had to borrow from other residents family supplied soap because it was the only option to get residents washed. During an interview on 5/22/24 at 3:29 P.M., CNA #12 said sometimes they run out of incontinence briefs for residents. On 5/22/24 at 3:56 P.M., the surveyors observed the Unit Three clean utility room. There were minimal towels and washcloths available and one sized brief observed. A supply cart was observed outside of the clean utility room had a minimal supply of one size incontinence briefs and minimal linen available. During an interview on 5/22/24 at 4:04 P.M., CNA #14 said they do not always have incontinence briefs, soap, gloves and laundry items to care for the residents on the unit and at times there don't have the supplies in the building because they are waiting for a shipment. She said that many of the CNAs bring in their own supplies to use for resident care because they want to make sure they are clean and cared for. CNA #14 said that they currently only have large incontinence briefs for residents and there are residents who need the extra large size but they have to use what they have. During an interview on 5/22/24 at 4:20 P.M., CNA #3 said the CNAs are struggling to have the needed supplies like soap and incontinence briefs. She said they currently only have one size incontinence briefs on the unit she works. She further said there are times when they have to purchase soap to use for the residents because they don't have soap. CNA #3 said at times, there is not enough wash clothes/towels. She said they used to have disposable wipes but they don't have those anymore. During an interview on 5/23/24 at 6:45 A.M., CNA #10 said that they don't always have supplies like towels, washcloths, soap, tissues, incontinence briefs. She said currently they only have small incontinence briefs which they are using on residents who need larger sizes and this has been a struggle for awhile. CNA #10 said that administration has been told and tell them that they are working on it and that supplies are coming. She said that some of the CNAs have to hide supplies so they have a stash to use for their residents and that she has had to purchase tissues, soap, and incontinence briefs for residents. During an interview on 5/23/24 at 6:54 A.M., CNA #15 said there are not enough incontinence briefs for the larger residents. She said that have regular and medium sized incontinence briefs but don't have the larger ones. She said when this occurs, the CNAs will double up and use two smaller incontinence briefs to make a larger one. During an interview on 5/23/24 at 6:59 A.M., CNA#9 said they recently went a long time without soap and incontinence briefs. She said if they don't have to needed size for incontinence briefs, they put a small size on and don't tape it closed. When administration is told, they respond and say the supplies are coming and then it doesn't come. During an interview on 5/23/24 at 7:09 A.M., CNA #16 said sometimes there is no soap or incontinence briefs available. She said that she purchases soap to use for residents care. During an interview on 5/23/24 at 9:52 A.M., the Director of Laundry/Maintenance said supplies are delivered to the units at 6:00 A.M., 2:00 P.M. and 9:00 P.M. He said he orders supplies monthly and if supplies are needed like linen, washcloths and towels, he can order them or can get them from sister facilities if needed immediately. During an interview on 5/23/24 at 12:49 P.M., a family member of a resident who resided at the facility said there were no towels in the facility on 5/22/24 because staff told her. She said she previously had to buy toilet paper for her family member and roommate because the facility ran out and they have had to purchase incontinence briefs and hide them because they run out. During an interview on 5/23/24 at 8:26 A.M., the Administrator said the central supply position has been vacant for about a week and currently the Assistant Director of Nurses (ADON) and the Unit Manager (UM) on Unit Two have been ordering the facility supplies. She said she was not aware of any issues with lack of supplies, that two large orders with supplies recently came in, but has only worked in the facility for 16 days. She further said the ADON, the UM and the Infection Preventionist (IP) check in with the staff about supplies and what is needed. During an interview on 5/23/24 at 10:52 A.M., the ADON said she took over ordering facility supplies since the beginning of April. She said that there is an order that is completed weekly for facility supplies and she speaks with staff about what items are needed and what is out so that it can be added to the list to order. The ADON said there was a recent delay in an delivery, she had to contact the person who handles their account in order to get the order delivered. She said that if supplies are low or unavailable, they could contact their sister facility to get those supplies or they could purchase items from the store. The ADON said she was made aware of the shortage of incontinence briefs on Tuesday (5/21/24) evening and an order was placed on Wednesday. She said she was not made aware that there were continued to be a shortage of incontinence briefs on Wednesday and did not check in with staff about the supplies. The surveyor relayed concerns expressed by residents present in resident council as well as facility staff on the units about supplies and the ADON said she was not aware of any other resident supplies that were lacking. She said that if the incorrect incontinence briefs have been used for residents there could be a concern of skin breakdown. She further said that the facility is currently working on levels of what to order for supplies and that it felt like structure was needed.

Based on interviews, records review and policy review, the facility failed to implement their abuse policies and procedures. Specifically; 1) The facility failed to investigate an allegation of abuse according to policy and procedure for one Resident (#30), out of a total of 21 sampled residents resulting in potential for psychological harm. 2) The facility failed to implement their employee screening procedures to ensure new employees have no previous abuse, neglect or mistreatment findings for one staff member (CNA #4) out of 5 staff members reviewed. Findings include: Review of facility policy titled Abuse: Investigation, dated March 2022, indicated but was not limited to the following: -The nursing supervisor will coordinate the interview process during the shift in which the event was reported. Any individual who may have knowledge of the event should be interviewed. This includes the alleged victim, employees working during the shift when the event was discovered/reported, as well as visitors and other residents who may have witnessed something. -Documentation of the incident/alleged incident will be entered into the resident's medical record Review of the facility policy titled Abuse Screening, dated March 2022, indicated but was not limited to the following: -The Nurse Aide Registry is checked prior to employment for all facility employees. If applicant indicates employment in another state, that Nurse Aide Registry is checked. -The person responsible for hiring will ensure that the request for the required criminal background check (CORI) has been submitted no later than the date of initial orientation. -Documentation on all of the above information will be maintained as part of the employment record. 1) Resident # 30 was admitted to the facility in June 2023 with diagnoses of Anxiety Disorder (feelings of fear, dread, uneasiness) and Depression (a recurring feeling of sadness/hopelessness, loss of interest in activities). Review of Resident #30's Minimum Data Set (MDS) Assessment, dated 4/3/24, indicated a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact) out of 15. During an interview on 5/22/24 at 1:00 P.M., Resident #30 made an allegation of verbal abuse by staff to the surveyor. The Resident alleged the following: -Approximately 4 months ago the Resident asked a Certified Nurse Aide (CNA)for a ginger ale, and she told him/her no, she didn't feel like it. -The Resident reported the interaction relative to ginger ale to the Man Director. -The CNA returned the next day and made comments to the Resident that he/she likes to report people. The Resident felt afraid the CNA would hit her. -The Resident observed the CNA to eat off residents' tray and then pass the tray to those residents 4 separate times during a meal. -The Resident reported the tray incident to a staff member. -The CNA came into the Resident's room and said to the Resident if he/she kept reporting people he/she'd find him/herself on the floor with his/her head split open. -The Resident reported the CNA's threatening comments to the head nurse. -The CNA was moved to a different unit (fourth floor). The Resident still saw her when he/she would go upstairs to play bingo and the CNA would give him/her the middle finger. -The Resident reported the CNA's gestures to an activities assistant. -At the conclusion of the interview, the Resident said that he/she did not feel safe. Immediately after the Resident interview, the surveyor informed the Director of Nursing (DON) and Administrator of the allegation. The DON said an investigation of the allegation and a report to Department of Public Health (DPH) would be initiated immediately. A review of Resident #30's May 2024 interdisciplinary progress notes on 5/24/24 at 8:30 A.M. indicated no documentation of interview or follow-up on reported allegations. During an interview on 5/24/24 at 8:38 A.M., Social Worker (SW) #2 said that she had not been working on this investigation, but that SW #1 had been unable to interview the Resident because he/she had attended activities during the day on 5/22/24 and 5/23/24. SW #2 said the expectation for an allegation of abuse would be that the resident would be interviewed the same day as the allegation was received, and that the interview or attempted interview(s), (if unable to obtain the interview), would be documented in a social work progress note within the resident's clinical record. SW #2 further said that there would be an expectation of psychosocial follow-up for this type of allegation with a minimum of three visits over about a 3-week period with the first visit typically occurring the day after the allegation was made. Review of a typed, unsigned addendum to SW #2's summary of interview with Resident #30 dated 5/24/24 at 10:25 A.M. indicated the surveyor's reported allegation to SW #1 and that the Resident was unable to meet with the Social Worker when three attempts were made on 5/22/24 and three attempts were made on 5/23/24 due to his/her attendance in activities. During a review of Resident #30's Interdisciplinary Progress Notes on 5/24/24 at 11:00 A.M., a late entry Nursing Progress Note written by the DON for 5/22/24 at 1:30 P.M. was entered into the medical record on 5/24/24 at 10:30 A.M. that indicated the Resident was provided support by social services. During an interview on 5/24/24 at 11:00 A.M., Resident #30 said the first-time staff met with him/her to discuss the allegations reported to surveyor on 5/22/24, was that morning (two days later). When asked, Resident #30 said that no one had attempted to meet with him/her when he/she was at an activity. During an interview on 5/24/24 at 11:48 A.M., Activity Assistant (AA) #1 said she has worked at the facility for many years as an activities assistant and is familiar with Resident #30. AA #1 said that a couple months ago when the Resident resided on the second floor, he/she brought a concern about CNA #5 to her. AA #1 said the Resident would not specify the concern and only reported to her that he/she did not like CNA #5 at that time. AA #1 said she brought the Resident down to speak with the former administrator and former director of nursing who worked at the facility at the time the concern was brought to her, and CNA #5 was moved to the fourth floor. During an interview on 5/24/24 at 1:46 P.M., the Administrator said that the involved resident should be interviewed right away when allegations of abuse are made. The Administrator said any staff member can complete the interview and that evidence that the interview occurred or had been attempted should be documented in the resident's interdisciplinary progress notes. During an interview on 5/24/24 at 4:03 P.M. the DON said the expectation for investigating abuse means the involved resident would immediately be interviewed about the allegation. The DON said this process did not occur for Resident #30's allegation of abuse. Relative to the late entry Nursing Progress Note dated 5/22/24 at 1:30 P.M., the DON said she entered this progress note because she thought that someone would interview the Resident about the allegation of abuse but said that she did not verify the interview occurred before documenting the nursing progress note. 2) CNA #4 was hired to the facility in March 2023. Review of CNA #4's Human Resources (HR) file indicated no evidence of a CORI check or Nurse Aide Registry check being completed. During an interview on 5/24/24 at 3:20 P.M., Regional Consultant Nurse #1 said that the facility was unable to provide documentation of a CORI check or Nurse Aide Registry check for CNA #4.

Based on observation, interviews, records review and policy review, the facility failed to prevent the potential for further abuse for one Resident (#30) out of a total of 21 sampled residents. Specifically, the facility failed to follow their policy and take steps to protect the Resident and prevent him/her from the potential of further abuse during an investigation of an allegation of abuse. Findings include: Review of the facility policy titled Abuse: Identification & Reporting dated March 2022 indicated but was not limited to the following: -All alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process Review of the facility policy titled Abuse: Investigation dated March 2022 indicated but was not limited to the following: -The nursing supervisor will take appropriate steps to protect the resident, if applicable, from further mistreatment and to ensure appropriate care is provided. Separate accused/suspected employee or resident from alleged victim and other residents. Suspension of employee pending investigation as indicated. -Interviews of appropriate individuals. The nursing supervisor will coordinate the interview process during the shift in which the event was reported. Any individuals who may have knowledge of the event should be interviewed. This includes the alleged victim, employees working during the shift when the event was discovered/reported, as well as visitors and other residents who may have witnessed something. Resident # 30 was admitted to the facility in June 2023 with diagnoses of Anxiety Disorder (feelings of fear, dread, uneasiness) and Depression (a recurring feeling of sadness/hopelessness, loss of interest in activities). Review of Resident #30's Minimum Data Set (MDS) Assessment, dated 4/3/24, indicated a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact) out of 15. During an interview on 5/22/24 at 1:00 P.M., Resident #30 made an allegation of verbal abuse by staff to the surveyor. The Resident alleged the following: -Approximately 4 months ago the Resident asked a Certified Nurse Aide (CNA)for a ginger ale, and she told him/her no, she didn't feel like it. -The Resident reported the interaction relative to ginger ale to the Man Director. -The CNA returned the next day and made comments to the Resident that he/she likes to report people. The Resident felt afraid the CNA would hit her. -The Resident observed the CNA to eat off residents' tray and then pass the tray to those residents 4 separate times during a meal. -The Resident reported the tray incident to a staff member. -The CNA came into the Resident's room and said to the Resident if he/she kept reporting people he/she'd find him/herself on the floor with his/her head split open. -The Resident reported the CNA's threatening comments to the head nurse. -The CNA was moved to a different unit (fourth floor). The Resident still saw her when he/she would go upstairs to play bingo and the CNA would give him/her the middle finger. -The Resident reported the CNA's gestures to an activities assistant. -At the conclusion of the interview, the Resident said that he/she did not feel safe. Immediately after the Resident interview, the surveyor informed the Director of Nursing (DON) and Administrator of the allegation. The DON said an investigation of the allegation and a report to Department of Public Health (DPH) would be initiated immediately. During an interview on 5/24/24 at 8:38 A.M., Social Worker (SW) #2 said that she had not been working on this investigation, but that SW #1 had been unable to interview the Resident because he/she had attended activities during the day on 5/22/24 and 5/23/24. SW #2 said the expectation for an allegation of abuse would be that the resident would be interviewed the same day as the allegation was received, and that the interview or attempted interview(s), (if unable to obtain the interview), would be documented in a social work progress note within the resident's clinical record. On 5/24/24 at 10:50 A.M., Resident #30 was observed exiting the elevator onto the third floor. The Resident said he/she had returned from an activity on the second floor where the accused CNA was currently working. The Resident said he/she left the activity because the CNA was giving him/her the finger while he/she was there. The Resident said that until that morning (5/24/24), no staff member had approached him/her to discuss the allegations made to the surveyor on 5/22/24. When asked, the Resident said specifically that no one had approached him/her to speak about his/her concerns with the CNA while at an activity. On 5/24/24 at 11:15 A.M. the surveyor observed an activity occurring in the dining room of the second floor. Review of the investigation data provided by the DON on 5/24/24 at 11:15 A.M. indicated one completed interview with Resident #30. There was no documented evidence of interviews with other residents, staff or visitors provided. During an interview on 5/24/24 at 11:48 A.M., Activity Assistant (AA) #1 said she has worked at the facility for many years as an activities assistant and was familiar with Resident #30. AA #1 said that a couple months ago, when the Resident resided on the second floor, he/she brought a concern about CNA #5 to her. AA #1 said the Resident would not specify the concern and only reported to her that he/she did not like CNA #5 at that time. AA #1 said she brought the Resident down to speak with the former Administrator and former DON and CNA #5 was moved to the fourth floor to work. During an interview on 5/24/24 at 1:46 P.M., the Administrator said that the involved resident should be interviewed right away when allegations of abuse are made. The Administrator further said that the expectation would be that social services would interview all alert and oriented residents on the same assignment about their care relative to the allegation. During an interview on 5/24/24 at 1:57 P.M., SW #2 said that she was given a name for the staff member today (5/24/24) during her interview with the Resident at 9:30 A.M. SW #2 further said the Resident also gave information about the CNA's car to assist in identifying the staff member. During an interview on 5/24/24 at 4:03 P.M., the DON said the Resident should have been interviewed immediately upon identification of the allegation. When asked, the DON said that interviews were being completed now, but that she could not provide any additional evidence of other interviews that had been completed. The DON said that efforts to identify the accused CNA should have been made so the facility could implement measures, such as removing the accused CNA from the schedule, to protect the Resident from the potential for further abuse while the investigation was ongoing.

Based on record review and interviews the facility failed to implement their grievance policy and assist one Resident (#56) to file a grievance out of a total sample of 21 residents. Specifically, the facility staff failed to follow up and investigate a report of a missing electric razor. Findings include: Review of the facility policy titled Grievances, dated 8/2019 indicated the following: -Staff members are encouraged to assist residents in filing a grievance and/or complaint when the resident believes that his/her rights have been violated. -Upon receipt of a grievance, complaint report or the missing items form, the Director of Social services will begin an investigation into the allegation. Resident #56 was admitted to the facility in August 2023 with diagnoses that include Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Review of the Minimum Date Set (MDS) Assessment, dated 3/29/24, indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 10 out of a possible 15 and, and was dependent on staff for personal hygiene. Review of the Nurses Notes dated 12/10/23, indicated the Resident's family reported a missing electric razor. The charger was plugged into the wall in his room, but the razor could not be found. During an interview on 5/23/24 at 5:08 P.M., Social Worker (SW) #1 said she had not been aware of the missing razor until the surveyor had informed her of the Nurses Note dated 12/10/23. SW #1 said that since that time, she had talked with staff on the unit, and they remembered the razor going missing. SW #1 said she had reviewed the grievance log and said there was no evidence that a grievance form had been filled out or that an investigation into the missing razor had been initiated. SW #1 said the process for missing items is that facility staff should assist the resident or family to fill out a grievance form and the staff should give the form to a Unit Manager or anyone in management. She said an investigation should have been initiated and if the missing razor was not found the Resident should have been reimbursed.

Based on observation, records reviewed and interviews, for one of three sampled residents (Resident #3), who was readmitted to the Facility with a reddened area to the coccyx (lower back), and was assessed by nursing as being at high risk for skin breakdown, the Facility failed to ensure that a comprehensive person-centered care plan based on his/her individual wound care needs for the promotion of healing or the prevention of worsening of wounds, which included and identified interventions, measurable objectives and desired outcomes was developed, and that interventions that were in place were consistently implemented by nursing, as a result Resident #3's wound deteriorated to an unstageable pressure injury (full-thickness skin and tissue loss that is obscured by eschar and slough- dead tissue). Findings Include: Review of the Facility's Policy, Pressure Ulcers/Injuries Overview, dated as revised March 2022, indicated the following: -Pressure injuries are defined as localized damage to the skin and/or underlying soft tissue usually over a bony prominence, and occur as a result of intense and/or prolonged pressure or pressure and combination of shear. Review of the Facility's Policy, Pressure Ulcer/Injury Risk Assessment, dated as revised March 2022 indicated the following: -Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure ulcers/injuries. -Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. -The interventions must be based on current, recognized standards of care. -The effects of the interventions must be evaluated -The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Resident #3 was admitted to the Facility in December 2022, diagnoses included partial symptomatic epilepsy, Hypertension and a history of falls. Review of Resident #3's Nurse Progress Note, dated 09/25/23, indicated Resident #3 was readmitted to the Facility following a brief hospitalization , wished to be Comfort Measures Only (CMO) and to transition to Hospice services. Review of Resident #3's Skin Condition Evaluation Form, dated 09/25/23, indicated that Resident #3 had a pressure injury to the coccyx that measured 3 centimeters (cm) x 3 cm. Further review of the Skin Condition Evaluation Form indicated the stage of the pressure injury was listed as Not Available. Review of Resident #3's Norton Plus Pressure Scale Assessment, dated 09/26/23, indicated that Resident #3 was assessed by nursing to be at high risk for skin breakdown as evidenced by a score of 7 (a score of less than 10 indicates very high risk for skin breakdown). Review of Resident #3's medical record indicated he/she had a quarterly Minimum Data Set (MDS) Assessment completed on 9/21/23, and his/her care plans were reviewed and renewed at that time. Review of Resident #3's Care Plan related to Potential Alteration in Skin Integrity, indicated Resident #3 had the potential for an alteration in skin integrity and the goal was to keep Resident #3's skin intact. Further review of Resident #3's Care Plan related to Potential Alteration in Skin Integrity, indicated that only the following interventions were in place: -Follow Physician's orders for skin care and treatments -Dietary intervention/evaluation -Protect skin with incontinent care -Toileting assistance on toileting schedule or routine However, further review of Resident #3's care plan indicated that although he/she was assessed upon readmission to have actual skin breakdown on 09/26/23, with a pressure injury to his/her coccyx, the care plan was not updated, and there were no additional interventions identified related to wound healing or for prevention of deterioration. Review of Resident #3's Physician's Orders for October 2023, indicated he/she had an order for Barrier Cream to the coccyx twice a day and as needed. The Order also included that nursing was to the cover the coccyx wound with Optifoam (foam adhesive) dressing every day and evening shift for wound care. Review of Resident #3's TAR, dated October 2023, indicated he/she had an order to apply Barrier Cream to the coccyx twice a day and as needed, and for nursing to cover with Optifoam dressing every day and evening shift for wound care. Further review of the TAR indicated that the treatment was signed off by nursing as having been completed twice a day, as ordered, from 10/01/23 through 10/11/23. Review of Resident #3's Skin Observation Tool, dated 10/03/23 and signed by Nurse #2, indicated Resident #3 had pressure wounds on his/her coccyx area and Barrier Cream had been applied. However, there were no measurements of the pressure wounds documented on the Tool. During an interview on 10/12/23 at 2:30 P.M., Nurse #2 said that she did the skin evaluation for Resident #3 on 10/03/23. Nurse #2 said Resident #3 had reddened pressure areas to his/her coccyx but she did not think it required a dressing. Nurse #2 said Resident #3 was getting Barrier Cream to the area and she thought that was all Resident #3 needed. Nurse #2 said that the CNAs apply the Barrier Cream and the nurses sign it off on the TAR. Nurse #2 said the CNAs were not supposed to apply dressings. Nurse #2 said that she had worked the evening shift on 10/10/23 and a CNA told her that Resident #3's dressing needed to be changed. Nurse #2 said she removed the dressing from Resident #3's coccyx and it was rolled up and had a mix of drainage on it. Nurse #2 could not identify what type of drainage was on the old dressing. Nurse #2 said the dressing she removed was dated as either 10/03/23 or 10/04/24, but said she could not remember exactly which date was on the dressing. Nurse #2 said when she removed the dressing she saw a red, open wound that had areas of white tissue in the wound bed. Nurse #2 said she went to the supply room to get an Optifoam dressing, because that's what the physician ordered. Nurse #2 said she could not find the foam dressing so she used a tan square dressing but she did not know the name of the dressing. Nurse #2 said when she signed off on Resident #3's treatment for application of Barrier Cream on the TAR on 10/02/23, 10/03/23, 10/05/23, 10/06/23, and 10/08/23, but said she had not realized that the order for Barrier Cream to the coccyx also included applying an Optifoam dressing, so on those days she had not applied a dressing Nurse #2 said the last time she had seen Resident #3's coccyx prior to 10/10/23, was on 10/03/23, when she did the weekly skin assessment. Nurse #2 said the first time she applied a dressing to Resident #3's coccyx was on 10/10/23. Nurse #2 said she had not reported anything about the status of the wound to either the Wound Nurse of the Nursing Supervisor. On 10/11/23 at 1:40 P.M., the surveyor observed the Wound Nurse complete Resident #3's dressing change. The Wound Nurse removed a tan colored dressing, dated 10/10/23, from Resident #3's coccyx, there was no drainage on the dressing. The Wound Nurse said the dressing she removed was a DuoDerm (waterproof dressing used to treat mildly draining wounds) and not an Optifoam as was ordered. The Wound Nurse cleansed Resident #3's coccyx with Wound Cleanser. The surveyor observed an area on Resident #3's coccyx that had eschar and an area of slough along the bottom edge of the wound, there was also an intact reddened area above the eschar. The Wound Nurse said there was necrotic tissue and slough in the wound bed. The Wound Nurse said she did not have anything to measure Resident #3's wound with her, but said it looked to be approximately 5 cm x 5 cm and that she could not determine the depth of the wound because of the slough. The Wound Nurse applied Barrier Cream to the surrounding skin of the wound and covered the wound with a foam dressing. The Wound Nurse said she did not want to apply Barrier Cream to the eschar area. The Wound Nurse said that today (10/11/23) was the first day she observed Resident #3's wound. The Wound Nurse said no one (nurses caring for and treating Resident #3) had given her any updates of the status of the wound and she would have expected the nurses to have notified her of the wound's deterioration. The Wound Nurse said Resident #3's physician order was for Optifoam dressing, not a DuoDerm dressing. The Wound Nurse said that Resident #3's wound should have been measured weekly. The Wound Nurse said that once a pressure injury was identified on Resident #3, a care plan with specific interventions, and goals related to the pressure injury should have been put in place. The Wound Nurse said she was the one responsible for creating care plans when a pressure injury was newly identified. During an interview on 10/12/23 at 11:37 A.M., the Director of Nurses (DON) said that Resident #3's Care Plan had not been updated until 10/11/23, after the Wound Nurse changed Resident #3's dressing.

Based on observation, records reviewed and interviews, for one of three sampled residents (Resident #3), who was readmitted to the Facility with a reddened area to the coccyx (lower back), and was assessed by nursing as being at high risk for skin breakdown, the Facility failed to ensure Resident #3 received care and services consistent with professional standards of practice related to the promotion of healing or the prevention of worsening of his/her wound, when treatment orders were not implemented as ordered by the physician, the wound was not adequately assessed by nursing, and the wound deteriorated to an unstageable pressure injury (full-thickness skin and tissue loss that is obscured by eschar and slough- dead tissue). Findings Include: Review of the Facility's Policy, Pressure Ulcers/Injuries Overview, dated 03/2022, indicated the following: -Pressure injuries are defined as localized damage to the skin and/or underlying soft tissue usually over a bony prominence, and occur as a result of intense and/or prolonged pressure or pressure and combination of shear. -Avoidable means the resident developed a pressure ulcer/injury and that one or more of the following was not completed: -Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice. -Monitoring or evaluation of the impact of the interventions; or revision of the interventions as appropriate. Review of the Facility's Policy, Pressure Ulcer/Injury Risk Assessment, dated 03/22, indicated the following: -Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure ulcers/injuries. -Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. -The interventions must be based on current, recognized standards of care. -The effects of the interventions must be evaluated. -The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Resident #3 was admitted to the Facility in December 2022, diagnoses included: partial symptomatic epilepsy, Hypertension and history of falls. Review of Resident #3's Nurse Progress Note, dated 09/21/23, indicated Resident #3 was lethargic and pocketing food in his/her mouth. Resident #3's blood pressure was 62/44, pulse was 132, and respirations were 40. The on-call Physician/Nurse Practitioner was notified and Resident #3 was sent to the Hospital Emergency Department (ED)for an evaluation. Review of Resident #3's Nurse Progress Note, dated 09/23/23, indicated the Facility was notified that Resident #3 was admitted to the Hospital with a diagnosis of a bacterial infection. Review of Resident #3's Nurse Progress Note, dated 09/25/23, indicated Resident #3 was readmitted to the Facility following the hospitalization , wished to be Comfort Measures Only (CMO) and to transition to Hospice services. The Progress Note indicated Resident #3 had redness to his/her coccyx area. Review of Resident #3's Nursing Evaluation, dated 09/25/23, indicated the following: -Upon assessment no observable pressure injuries were present however the Resident does have some redness to his/her bottom and barrier cream has been applied. -Resident requires extensive assistance for bed mobility. -Resident is always incontinent of urine, requires assistance for incontinence care. -Resident is always incontinent of bowels, requires assistance for incontinence care. Review of Resident #3's Skin Condition Evaluation Form, dated 09/25/23, indicated that Resident #3 had a pressure injury to the coccyx that measured 3 centimeters (cm) x 3 cm. However, further review of the Skin Condition Evaluation Form indicated the stage of the pressure injury was listed as Not Available. Review of Resident #3's Norton Plus Pressure Scale Assessment, dated 09/26/23, indicated that Resident #3 was assessed by nursing to be at high risk for skin breakdown as evidenced by a score of 7 (a score of less than 10 indicates very high risk of skin breakdown). Review of Resident #3's Physician's Orders, dated October 2023, indicated he/she had an order to apply Barrier Cream to the coccyx twice a day and as needed. The Order also indicated nursing to cover with Optifoam (foam adhesive used to provide thermal insulation and maintain moisture to the wound and prevent damage to the wound at the time of it's removal) dressing every day and evening shift for wound care. Review of Resident #3's Treatment Administration Record (TAR), dated September 2023, indicated he/she had an order to apply Barrier Cream to the coccyx twice a day and as needed, and to cover with Optifoam dressing every day and evening shift for wound care. Further review of the TAR indicated that nurses signed off on the treatment as completed twice a day, as ordered. Review of Resident #3's TAR, dated October 2023, indicated he/she had an order to apply Barrier Cream to the coccyx twice a day and as needed. The Order also indicated to cover with Optifoam dressing every day and evening shift for wound care. Further review of the TAR indicated that nurses signed off on the treatment as having been completed twice a day, as ordered, from 10/01/23 through 10/11/23. Review of Resident #3's Skin Observation Tool, dated 10/03/23 and signed by Nurse #2, indicated Resident #3 had pressure wounds on his/her coccyx area and Barrier Cream had been applied. However, the further review of the Tool indicated it was incomplete, because there were no measurements of the pressure wounds documented in the required section of the Tool. During an interview on 10/11/23 at 12:56 P.M., the Wound Nurse said the nurses were responsible to notify her when a resident had a change in their skin condition. The Wound Nurse said she was notified somewhere between 09/25/23 and 09/28/23 that Resident #3 had an area on his/her coccyx when he/she returned from the hospital, but said she could not recall the exact date she was notified. The Wound Nurse said once she was notified that a resident had a skin condition or pressure ulcer, she entered their name on her tracking log and that she usually sees the wound herself within a day or two. The Wound Nurse said she did not know the current status of Resident #3's wound. On 10/11/23 at 1:40 P.M., the surveyor observed the Wound Nurse complete Resident #3's dressing change. The Wound Nurse removed a tan colored dressing, dated 10/10/23, from Resident #3's coccyx, and there was no drainage on the dressing. The Wound Nurse said the dressing she removed was a DuoDerm (waterproof dressing used to treat mildly draining wounds) and not an Optifoam as was ordered. The Wound Nurse cleansed Resident #3's coccyx with Wound Cleanser. The surveyor observed an area on Resident #3's coccyx that had eschar and an area of slough along the bottom edge of the wound, there was also an intact reddened area above the eschar. The Wound Nurse said there was necrotic tissue and slough in the wound bed. The Wound Nurse said she did not have anything to measure Resident #3's wound with her, but said it looked to be approximately 5 cm x 5 cm and that she could not determine the depth of the wound because of the slough. The Wound Nurse applied Barrier Cream to the surrounding skin of the wound and covered the wound with an Optifoam dressing. The Wound Nurse said that today (10/11/23) was the first day she had observed Resident #3's wound. The Wound Nurse said no one (nurses caring for and treating Resident #3) had given her any updates of the status of the wound and she would have expected the nurses to have notified her of the wound's deterioration. The Wound Nurse said that Resident #3's wound should have been measured weekly. The Wound Nurse said Resident #3 was never put on the list to be seen by the Wound Physician who visits the facility weekly because she thought the area was originally reported to her as being excoriated and not as a pressure injury. During an interview on 10/12/23 at 1:54 P.M., Certified Nurse Aide (CNA) #1 said when Resident #3 returned from the hospital he/she had a small reddened area on his/her bottom. CNA #1 said she showed one of the nurses (exact name unknown), and was told to put Barrier Cream on it. CNA #1 said she had not taken care of Resident #3 in a couple of weeks. During an interview on 10/12/23 at 2:30 P.M., Nurse #2 said that she did the skin evaluation for Resident #3 on 10/03/23. Nurse #2 said Resident #3 had reddened pressure areas to his/her coccyx but she did not think it required a dressing. Nurse #2 said Resident #3 was getting Barrier Cream to the area and she thought that was all Resident #3 needed. Nurse #2 said that the CNAs apply the Barrier Cream and the nurses sign it off on the TAR. Nurse #2 said the CNAs were not supposed to apply dressings. Nurse #2 said that she had worked the evening shift on 10/10/23 and a CNA told her that Resident #3's dressing needed to be changed. Nurse #2 said she removed the dressing from Resident #3's coccyx that was rolled up and said it had a mix of drainage on it. Nurse #2 said the dressing she removed was dated as either 10/03/23 or 10/04/24, but said she could not remember exactly which date was on the dressing. Nurse #2 said when she removed the dressing she saw a red, open wound that had areas of white tissue in the wound bed. Nurse #2 said she went to the supply room to get an Optifoam dressing, because that's what was ordered, but could not find that dressing so she used a tan square dressing, but did not know the name of the dressing. Nurse #2 said when she signed off on Resident #3's TAR on 10/02/23, 10/03/23, 10/05/23, 10/06/23, and 10/08/23, that the treatment for the Barrier Cream had been completed, said she had not realized that the treatment order to the coccyx also included that nursing was to apply an Optifoam dressing. Nurse #2 said the last time she had seen Resident #3's coccyx prior to 10/10/23, was on 10/03/23, when she did the weekly skin assessment. Nurse #2 said the first time she applied a dressing to Resident #3's coccyx was on 10/10/23. Nurse #2 said she had not reported anything about the status of the wound to either the Wound Nurse of the Nursing Supervisor. During an interview on 10/12/23 at 4:21 P.M., Nurse #4 said he had done Resident #3's skin assessment on 10/10/23. Nurse #4 said he had a hard time getting help to reposition Resident #3 so he completed the skin assessment to the best of his ability. Nurse #4 said he could not turn Resident #3 on his own, so he had not assessed his/her coccyx area. Nurse #4 said he was not told that Resident #3 had a wound. During an interview on 10/12/23 at 4:33 P.M., Nurse #1 said she was unaware of Resident #3 having any wounds. Nurse #1 said Resident #3 had an order for Barrier Cream to his/her coccyx, but did not have an order for a dressing. Nurse #1 said she could not recall the last time she saw Resident #3's coccyx. Nurse #1 said she had never applied a dressing to Resident #3's coccyx. Nurse #1 said when she signed off on the TAR on 10/05/23 and 10/07/23 (day and evening shift), that his/her treatment for Barrier Cream had been completed, said she did not realize that the treatment to the coccyx also included for nursing to apply an Optifoam dressing. Nurse #1 said that although she signed off on the order, said the CNAs applied the Barrier Cream , and she did not know a dressing was included in the order, so she did not apply one. During an interview on 10/11/23 at 2:57 P.M., the Director of Nurses (DON) said that the nursing staff should be reporting any new skin conditions or changes in skin conditions to the Wound Nurse. The DON said she expected the nursing staff to follow the physician's orders and that the nursing staff should call the physician for new orders when there has been a change in a wound condition.

Based on records reviewed, interviews, and observations, for one of three sampled residents (Resident #1), the facility failed to ensure that staff implemented interventions to prevent a fall. Findings include: Resident #1 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse Progress Note, dated 07/09/19 (the day prior to Resident #1's fall), indicated that an X-ray of his/her left hip was negative for any fracture, which indicated that his/her prior left [MEDICAL CONDITION] had healed. Review of Resident #1's CNA (Certified Nurse Aide) Care Card, revised 06/11/19, indicated that he/she had a bed sensor, and that other considerations included not to leave him/her in the bathroom unattended. The Surveyor interviewed CNA #1 at 1:07 P.M. on 07/25/19 and CNA #2 at 1:36 P.M. on 07/25/19. CNA #1 and CNA #2 said Resident #1's CNA Care Card was posted inside his/her bathroom, was accessible at the time of his/her fall on 07/10/19, and included an intervention to not leave him/her unattended in the bathroom. CNA #1 said that on 07/10/19, she left Resident #1 unattended in the bathroom to go empty a dirty commode bucket in a room across the hallway from Resident #1's room. CNA #1 said that when she re-entered Resident #1's room, she observed Resident #1 sitting on the floor next to his/her roommate's bed, just outside of the bathroom door. CNA #1 said she knew there was an intervention on Resident #1's CNA Care Card to not leave him/her unattended in the bathroom. Review of Resident #1's Nurse Progress Note, dated 07/10/19, indicated that Resident #1 was found on the floor in his/her room. The Note indicated that Resident #1 was in the bathroom for care, and a CNA had to clean a commode that was left soiled. The Note indicated that Resident #1 was yelling for help, staff entered the room and found Resident #1 on the floor in distress. The Note indicated that Resident #1 was unable to say what had happened, but complained of left leg pain. The Note indicted that Resident #1 was sent to the hospital for evaluation. Review of Resident #1's Nurse Progress Note, dated 07/15/19, indicated that he/she was readmitted to the Facility following surgical repair of a left [MEDICAL CONDITION]. On 07/25/19, the facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A.) CNA #1 was re-educated on 07/12/19 regarding the use of resident CNA Care Cards. B.) Staff was interviewed between 07/10/19 and 07/24/19 to ensure staff was aware that residents with alarms, whether the alarm was on the bed, chair, or both, could not be left unattended in the bathroom. C.) CNA Care Card was renamed the Resident Safety and Care Card, and the format was revised to ensure Fall Prevention interventions were at the top of the Card to make the information more visually apparent. D.) To indicate residents at a high risk for falls, the Resident Safety and Care Card was covered with a red sheet of paper. E.) A Facility-wide audit was completed by 07/24/19 to ensure Resident Safety and Care Cards indicated that those residents at high risk for falls and/or who had alarms had documentation to indicate not to leave the resident unattended in the bathroom. F.) Nurse to CNA Shift Huddle was instituted to ensure all staff were aware of residents who were not to be left unattended in the bathroom. G.) Residents at high risk for falls and any resident falls are reviewed daily in morning clinical meeting to review and revise the plan of care as needed. H.) The Director of Nurses or designee is responsible for ongoing compliance. I.) The Quality Assurance Performance Improvement Committee will continue to review findings with additional measures to be implemented as needed.

Based on records reviewed, interviews, and observations, for one of three sampled residents (Resident #1), the facility failed to ensure that staff provided adequate supervision in accordance with the plan of care to prevent a fall. On 07/10/19, Resident #1 was left unattended in the bathroom, fell , and sustained a left [MEDICAL CONDITION]. Findings include: Resident #1 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse Progress Note, dated 07/09/19 (the day prior to Resident #1's fall), indicated that an X-ray of his/her left hip was negative for any fracture, which indicated that his/her prior left [MEDICAL CONDITION] had healed. Review of Resident #1's CNA (Certified Nurse Aide) Care Card, revised 06/11/19, indicated that he/she had a bed sensor, and that other considerations included not to leave him/her in the bathroom unattended. The Surveyor interviewed CNA #1 at 1:07 P.M. on 07/25/19 and CNA #2 at 1:36 P.M. on 07/25/19. CNA #1 and CNA #2 said Resident #1's CNA Care Card was posted inside his/her bathroom, was accessible at the time of his/her fall on 07/10/19, and included an intervention to not leave him/her unattended in the bathroom. CNA #1 said she knew there was an intervention on Resident #1's CNA Care Card to not leave him/her unattended in the bathroom. CNA #1 said she knew that residents who had chair alarms could not be left unattended, but did not know that residents with bed alarms (sensors) could not be left unattended also. CNA #1 said that on 07/10/19, she left Resident #1 unattended in the bathroom to go empty a dirty commode bucket in a room across the hallway from Resident #1's room. CNA #1 said she was only a few feet outside of Resident #1's room when she heard Resident #1 yell for help. CNA #1 said that when she re-entered Resident #1's room, she observed Resident #1 sitting on the floor next to his/her roommate's bed, just outside of the bathroom door. Review of Resident #1's Nurse Progress Note, dated 07/10/19, indicated that Resident #1 was found on the floor in his/her room. The Note indicated that Resident #1 was in the bathroom for care, and a CNA had to clean a commode that was left soiled. The Note indicated that Resident #1 was yelling for help, staff entered the room and found Resident #1 on the floor in distress. The Note indicated that Resident #1 was unable to say what had happened, but complained of left leg pain. The Note indicted that Resident #1 was sent to the hospital for evaluation. Review of Resident #1's Nurse Progress Note, dated 07/15/19, indicated that he/she was readmitted to the Facility following surgical repair of a left [MEDICAL CONDITION]. On 07/25/19, the facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A.) CNA #1 was re-educated on 07/12/19 regarding the use of resident CNA Care Cards. B.) Staff was interviewed between 07/10/19 and 07/24/19 to ensure staff was aware that residents with alarms, whether the alarm was on the bed, chair, or both, could not be left unattended in the bathroom. C.) CNA Care Card was renamed the Resident Safety and Care Card, and the format was revised to ensure Fall Prevention interventions were at the top of the Card to make the information more visually apparent. D.) To indicate residents at a high risk for falls, the Resident Safety and Care Card was covered with a red sheet of paper. E.) A Facility-wide audit was completed by 07/24/19 to ensure Resident Safety and Care Cards indicated that those residents at high risk for falls and/or who had alarms had documentation to indicate not to leave the resident unattended in the bathroom. F.) Nurse to CNA Shift Huddle was instituted to ensure all staff were aware of residents who were not to be left unattended in the bathroom. G.) Residents at high risk for falls and any resident falls are reviewed daily in morning clinical meeting to review and revise the plan of care as needed. H.) The Director of Nurses or designee is responsible for ongoing compliance. I.) The Quality Assurance Performance Improvement Committee will continue to review findings with additional measures to be implemented as needed.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure staff implemented and followed interventions in Resident #1's plan of care requiring close supervision and assistance with transfers and toileting. On 4/13/19, Certified Nurse Aide (CNA) #1 transferred Resident #1 to the bathroom, assisted him/her to the toilet and then left Resident #1 unattended and unsupervised in the bathroom, Resident #1 attempted to transfer him/herself off the toilet, fell and sustained a laceration to the right side of his/her face and was diagnosed with [REDACTED]. Findings include: The Facility Policy titled, Managing Falls and Fall Risk, dated 12/2007, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes, to try to prevent the resident from falling and to try to minimize complications from falling. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required extensive assistance of one staff person with transfers and toileting. Review of Resident #1's Plan of Care, dated 03/18/19, indicated Resident #1 was at risk for falling due to impaired balance, unsteady gait and poor safety awareness related to [DIAGNOSES REDACTED]. Review of Resident #1's physician's orders [REDACTED].#1 required the use of bed alarm and self-releasing seatbelt due to poor safety awareness, impaired cognition, right sided weakness, decreased balance and impulsivity related to his/her stroke. Review of Resident #1's clinical record indicated that on 11/08/18, 12/19/18 and 4/9/19, the Occupational Therapist (OT) recommended that Resident #1 have close supervision at all times with toileting and to continue the use of wheelchair seat belt to maximize safety due to confusion. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:40 A.M. on 05/06/19. CNA #1 said she assisted Resident #1 to the bathroom, transferred him/her onto the toilet and said she left Resident #1 in the bathroom alone for approximately 10 minutes to help another resident. CNA #1 said when she (CNA #1) returned to Resident #1's room, CNA #2 and CNA #3 were in Resident #1's bathroom and Resident #1 was on the floor. CNA #1 said she was aware that Resident # 1 needed assistance and close supervision in the bathroom. CNA #1 said she knew she was not supposed to leave Resident #1 alone in the bathroom. CNA #1 said she had not followed Resident #1's care plan. The Surveyor interviewed the Director of Nurses (DON) at 2:15 P.M. on 05/06/19. DON said she would have expected CNA #1 to remain with Resident #1 and provide supervision while he/she was in the bathroom. The DON said CNA #1 had not followed Resident #1's plan of care, when she left him/her alone in the bathroom. The Hospital Discharge Summary, dated 04/13/19, indicated Resident #1 was treated for [REDACTED].

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required supervision and assistance with transfers and with toileting care needs, the Facility failed to ensure Resident #1 received adequate staff assistance and supervision to prevent an accident with injury, when Certified Nurse Aide (CNA) #1 left him/her unattended and unsupervised in the bathroom, Resident #1 attempted to transfer him/herself, fell and sustained a laceration to the right side of his/her face and a fractured cheekbone. Findings include: The Facility Policy titled, Managing Falls and Fall Risk, dated 12/2007, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes, to try to prevent the resident from falling and to try to minimize complication complications from falling. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required extensive assistance of one staff person with transfers and toileting. Review of Resident #1's Care Plan, dated 03/18/19, indicated Resident #1 was at risk for falling due to impaired balance, unsteady gait and poor safety awareness related to [DIAGNOSES REDACTED]. Review of Resident #1's physician's orders [REDACTED].#1 required the use of a bed alarm and self-releasing seatbelt due to poor safety awareness, impaired cognition, right sided weakness, decreased balance and impulsivity related to stroke. The Facility's Incident Report dated 04/08/19, indicated that Resident #1 transferred him/herself from the bathroom, unassisted and unsupervised with his/her walker, lost his/her balance and fell backward. A Nurse Progress Note, dated 04/08/19, indicated CNA #4 left Resident #1 unattended in the bathroom; he/she attempted to transfer transfer him/herself and fell backward. The note indicated Resident #1 had a small abrasion to his/her right elbow. Review of Resident #1's clinical record indicated that on 4/9/19, Resident #1 was evaluated by occupational Therapy after his/her fall on 4/08/19. The Occupational Therapist (OT) evaluation recommended that Resident #1 have close supervision at all times when on toilet and to continue the use of wheelchair seat belt to maximize safety due to confusion. The Surveyor interviewed the Occupational Therapist (OT) at 12:20 P.M. on 05/06/19. The OT said she evaluated Resident #1 on 04/09/19 after the fall incident of 04/08/19 and recommended that Resident #1 be closely supervised and to continue the use of wheelchair alarm seat belt to maximize safety due to confusion. A Nurse Progress Note, dated 04/13/19, indicated Resident #1 was found on the floor, against his/her walker and that Resident #1 had an open area to the left eye (it was actually right eye) and that Resident #1 said he/she fell while transferring him/herself off the toilet. The Facility's Incident Report dated 04/13/19, indicated Resident #1 fell during an attempt to self-transfer off the toilet and that Resident #1 fell against his/her walker, injured his/her face and was transferred to the Hospital Emergency Department. The Hospital Discharge Summary, dated 04/13/19, indicated Resident #1 was treated for [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:40 A.M. on 05/06/19. CNA #1 said she assisted Resident #1 to the bathroom, transferred him/her on to the toilet and left Resident #1 in the bathroom alone for approximately 10 minutes to help another resident. CNA #1 said when she (CNA) #1 returned to Resident #1's room, CNA #2 and CNA #3 were in Resident #1's bathroom and Resident #1 was on the floor. CNA #1 said she was aware that Resident # 1 needed assistance and close supervision in the bathroom. CNA #1 said she knew she was not supposed to leave Resident #1 alone in the bathroom. CNA #1 said she failed to follow Resident #1's care plan. The Surveyor interviewed CNA #2 at 12: 50 P.M. on 05/06/19 and CNA # 3 at 10:50 A.M. on 05/07/19. CNA #2 and CNA #3 said they were in the common area completing documentation when they heard a cry for help from Resident #2 (Resident #1's roommate). CNA #3 said when they arrived in the bedroom, Resident #1 was on the floor by the bathroom door, was lying on top of his/her walker, had blood oozing from his/her right side of face and said that Resident #2 was attempting to help Resident #1 up from the floor. CNA #2 said she called for Nurse #2, who assessed Resident #1. The Surveyor interviewed the Director of Nurses (DON) at 2:15 P.M. on 05/06/19. DON said she would have expected CNA #1 to remain with Resident #1 and provide supervision while he/she was in the bathroom. The DON said CNA #1 had not followed Resident #1's plan of care, when she left him/her alone in the bathroom. The DON said for both fall incidents, the one of 4/8/19 and again on 4/13/19, Resident #1 should not have been left unsupervised.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 was free from abuse, when he/she was physically restrained by two staff members with a bath blanket for approximately 10 to 15 minutes, so they could perform incontinence care. Resident #1 continued to be combative and upset while he/she was restrained with the bath blanket. - On 5/13/18, Resident #1 became confused, combative during care, was striking out at and hitting staff. Nurse #1 and Certified Nurse Aide (CNA) #2 restrained Resident #1's hands and arms with a bath blanket, enabling CNA #3 to complete Resident #1's incontinence care without getting hit. Findings include: The Facility's Policy, titled Patient Protection and Response for Allegations of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 12/11/17, indicated that: - The Resident has the right to be free from abuse, neglect, misappropriation of patient property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and physical and chemical restraint not required to treat the resident's medical symptoms. - Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. - Physical Abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. The Facility's Policy, titled Use of Restraints, dated 9/4/17, indicated that: - Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. -Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. - Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. - The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered a restraint. - Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted which include, tucking sheets so tightly that a bed bound resident cannot move. The Health Care Proxy Activation Form, signed and dated, 4/20/17, by the Physician, indicated Resident #1's Health Care Proxy was invoked due to advanced dementia, progressive confusion and an inability to make appropriate decisions regarding health. Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 4/8/18, indicated Resident #1 was severely cognitively impaired, had hallucinations, exhibited physical and verbal behaviors directed at others, was a two-person physical assist with bed mobility, and he/she was non-ambulatory. Resident #1's [DIAGNOSES REDACTED]. Resident #1's Behavioral care plan regarding decreasing symptoms, revised (MONTH) (YEAR), indicated interventions included; when Resident #1 is agitated or aggressive, staff may need to give him/her space and stand aside to give him/her time to calm down. The behavioral care plan indicated, if appropriate stop giving care when he/she is hostile or having behaviors and try again later. The Health Care Facility Reporting System (HCFRS) Report, dated 5/14/18, indicated that an allegation of physical abuse occurred on 5/13/18 at 6:00 P.M. The Report indicated, two Certified Nurse Aides (CNA)'s reported that, after CNA #1 was punched by Resident #1 during direct care, CNA #3 then witnessed Nurse #1 wrap a blanket around Resident #1's arms to prevent further incidences of harm to the staff and to calm the resident. The Facility's Internal Investigation, dated 5/15/18, indicated on 5/13/18 at approximately 6:00 P.M., Resident #1 was agitated and combative during direct care, and punched CNA #1 in the jaw. The Investigation indicated that, CNA #1 left Resident #1's room and reported the incident to Nurse #1. The Investigation indicated, Nurse #1 enlisted the help of CNA #2 and entered Resident #1's room to help CNA #3 with incontinent care. The Investigation indicated, Nurse #1 took a bath blanket, folded it in half, put Resident #1's folded arms into the blanket, and, then she instructed CNA #2 to wrap the other side of the blanket. Certified Nurse Aide (CNA) #3's Witness Statement, undated, indicated that on 5/13/18, at approximately 6:00 P.M, Resident #1's mood changed, he/she struck CNA #1, and CNA #1 left the room to get more help. Nurse #1 entered the room, and brought in a bath blanket to wrap Resident #1's arms in so he/she could not hit me (CNA #3). Nurse #1 put the bath blanket on Resident #1's arms, and had CNA #2 help her hold it down. The Statement indicated that CNA #3 said she told Nurse #1 that it was wrong and that they should not do that (restrain Resident #1) but that Nurse #1 said it was Ok and to just wash Resident #1, while she (Nurse #1) and CNA #2 held the bath blanket over Resident #1's hands and arms. CNA #2's Witness Statement, dated 5/14/18, indicated that on 5/13/18, at approximately 6:00 P.M., while sitting at the Nurses Station, CNA #1 walked out of Resident #1's room and stated, He/she just punched me in the jaw, I can't do this anymore. Nurse #1 then went into Resident #1's room to assist CNA #3, who was already in the room. Approximately two minutes later Nurse #1 called me (CNA #2) into the room. Nurse #1 had a bath blanket on Resident #1's hands and told me (CNA #2) to hold the corner of the blanket, without thinking I (CNA #2) then grabbed the blanket and held it while Nurse #1 also continued to hold the blanket, and CNA #3 changed Resident #1's soiled brief. Nurse #1's Witness Statement, undated, indicated that on 5/13/18, at approximately 6:00 P.M., after CNA #1 said that Resident #1 punched her and she was not going back into his/her Room, she went into Resident #1's room to see if CNA #3 needed assistance and then called CNA #2 to come to the room and help also. The Statement indicated Nurse #1 said she was concerned for Resident #1's and staff's safety, so she used a bath blanket to swaddle (to wrap a blanket to restrict movement of the limbs) him/her for approximately 30 seconds to one minute, while CNA #3 provided care. The Facility's Investigative findings, indicated that Resident #1 was swaddled in a bath blanket which lasted for 30 seconds to one minute, but this did not constitute (physical) abuse. Nurse #1 did not have any intention of restraining or harming Resident #1, but it was an emergency response to a dangerous situation. Resident #1 had delusional thoughts and he/she had punched CNA #1. This was not consistent with CNA #3's witness statement and interview that indicated that Nurse #1 and CNA #2 held Resident #1's hands and arms in place with a bath blanket while she provided incontinent care, which took approximately 10 to 15 minutes to complete. The Surveyor interviewed the Director of Nurses (DON) at 9:19 A.M. on 10/23/18. The DON said that CNA #1 and CNA #2 met with her on 5/14/18 to report their concerns that Nurse #1 restrained Resident #1 on 5/13/18. The DON said that Resident #1 was not intentional restrained by Nurse #1, that Nurse #1 had attempted to sooth him/her while incontinent care was provided. The Surveyor interviewed CNA #2 a 10:05 A.M. on 10/23/18. CNA #2 said when she entered Resident #1's room on 5/13/18 at approximately 6:00 P.M., Resident #1 was so upset and was cursing, saying the F word to Nurse #1 and CNA #3, and that he/she was threatening to punch them in the head and then shoot them. CNA #2 said Resident #1 was not approachable and said we couldn't communicate with him/her. CNA #2 said Resident #1 was hostile from the time she walked into his/her room until she left after his/her direct care was performed. CNA #2 said, although she did not walk away, she said next time she would walk away when he/she is combative, as care planned. The Surveyor interviewed CNA #3 at 1:20 P.M. on 10/23/18. CNA #3 said that on 5/13/18, for approximately 10 to 15 minutes while she performed direct care for Resident #1, his/her hands were restrained in a bath blanket. CNA #3 said Resident #1's hands were crossed over his/her chest. Nurse #1 took a bath blanket and folded it in half, put the blanket over his/her chest and under the his/her arm pits, and Nurse #1 held one end of the blanket while CNA #2 held the other end of the blanket, to restrain his/her hands. CNA #3 also said that Resident #1's mood changed from happy and smiling to angry and combative. CNA #3 said when Resident #1 becomes hostile, the staff are supposed to leave him, walk away and re-approach later when he/she is calmer, but we did not do this. We performed direct care, his/her behavioral plan of care was not followed. The Surveyor interviewed Nurse #1 at 11:13 A.M. on 10/24/18. Nurse #1 said that during direct care on 5/13/18, she applied a bath blanket to Resident #1's upper body, but said she could have temporarily restricted Resident #1's upper arms with the blanket for approximately 30 seconds to one minute, but said she used it to swaddle and calm him/her. Nurse #1 said that she did not know the plan of care was to walk away and leave Resident #1 when he/she was agitated.