**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #17 was admitted to the facility in November 2010 with diagnoses including Cerebral Palsy, contractures of unspecified wrist and hand, contractures of the right and left knee, Torticollis (condition in which the neck muscles contract causing the head to twist to one side), and muscle weakness. Review of the Activity of Daily Living (ADL) Care Plan, initiated 10/12/24, indicated Resident #17 required the following: -extensive assistance of one staff for dressing. Allow sufficient time for dressing and undressing ., revised 10/12/24 -extensive assistance of one staff for personal hygiene/oral care . revised 10/16/24 -encourage Resident to participate to the fullest extent possible with each interaction, revised 10/12/24 Review of the MDS assessment dated [DATE], indicated Resident #17: -was understood and understands -was cognitively intact as evidenced by a BIMS score of 14 out of a possible 15 points. -had no behaviors. -had range of motion (ROM) impairments on both upper and lower extremities. -was dependent on staff for bathing, dressing, toileting and personal hygiene/grooming needs. Review of the Certified Nurses Aide (CNA) Care Card, indicated for Resident #17: -requires extensive assist of one for personal hygiene. -please have Resident toileted, washed and dressed daily around 6:00 A.M. -respect Resident preferences at all times. -requires extensive assist of one staff to dress. -allow sufficient time for dressing and undressing. On 4/6/25 at 11:17 A.M., the surveyor observed Resident #17 lying in bed dressed in a shirt. A blanket was observed covering the Resident's lower body. During an interview at the time, Resident #17 said one of the CNAs on the 11:00 P.M. to 7:00 A.M.(night) shift would wash and only dress his/her upper body and would usually leave the bottom half for the next shift (7:00 A.M. to 3:00 P.M.- day shift). Resident #17 said this had been occurring with one specific CNA for one to two months, that he/she had reported this concern to multiple staff, and it continued to occur where the CNA refused to wash/dress his/her lower half. Resident #17 said he/she preferred to be fully washed and dressed and could not understand why this continued to occur with the specific CNA and he/she had filed a grievance relative to this. After the observation and interview, the surveyor reported Resident #17's concerns to the Director of Nursing (DON) and Assistant Director of Nurses (ADON). On 4/6/25 at 11:34 A.M., the surveyor observed the DON knock and enter Resident #17's room. Shortly after, the DON exited the Resident's room and told the surveyor that he spoke with Resident #17 about his/her concern. On 4/9/25 at 8:43 A.M., the surveyor observed Resident #17 lying in bed with a regular shirt on and a blanket covering his/her lower half. During an interview at the time, Resident #17 said he/she was washed on the 11:00 P.M. to 7:00 A.M. shift by the CNA and the CNA put a shirt on him/her but did not dress his/her lower half even when he/she requested to be fully dressed. Resident #17 proceeded to show the surveyor that he/she had on underwear and no pants at the time and said he/she liked to be fully dressed because he/she got cold. Resident #17 said it was the same CNA as previously reported on 4/6/25 and he/she could not understand why this continued to occur. Resident #17 said CNA #3, who worked 7:00 A.M. to 3:00 P.M. shift was aware of his/her concerns about getting dressed. During an interview on 4/9/25 at 8:46 A.M., CNA #3 said she regularly worked the 7:00 A.M. to 3:00 P.M. shift, and Resident #17 required total assistance from staff with bathing, dressing, and personal hygiene needs. CNA #3 said Resident #17 was supposed to get washed and dressed for 6:00 A.M., and that the Resident had a routine in the morning and would ring for staff assistance with bathroom needs. CNA #3 said certain CNAs would not fully wash and dress Resident #17, and when this occurred, she encouraged Resident #17 to tell administration. CNA #3 said Resident #17 wanted to be fully washed and dressed including having his/her shoes on in the morning because he/she gets cold. CNA #3 said she had been aware of Resident #17's concern for about a year and that it has been a specific CNA on the 11:00 P.M. to 7:00 A.M. shift that did not fully wash and dress the Resident as preferred. CNA #3 further said Resident #17 deserved to have the care he/she requests and could not understand why this continued. CNA #3 said she has provided Resident #17 with the morning care routine which included toileting, washing and dressing and it took a total of 15 to 20 minutes to provide the care the Resident wanted which was not a long time, so staff should be able to do as he/she requests/prefers. Please refer to F677 Based on observations, interviews and records reviewed, the facility failed to provide a dignified existence for two Resident's (#9 and #17), out of a total sample of 23 residents. Specifically, the facility failed to: 1. ensure that Resident #9 had appropriate clothing to wear while out of his/her room. 2. For Resident #17, ensure dressing assistance was provided in accordance with the Resident's preference to be washed and fully dressed by 6:00 A.M., when the Resident required assistance from staff with dressing needs. Findings include: Review of the facility policy titled Resident Rights, revised 11/5/24, indicated it was the policy of the facility to respect the rights of the residents by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents . The policy also included the following: -the facility supports the resident's right to knowledgeably participate in decisions concerning their healthcare and medical treatment . Review of the facility policy titled Your Rights and Protections As a Nursing Home Resident, undated, indicated the following: -You have the right to be treated with dignity . 1. Resident #9 was admitted to the facility in December 2024, with diagnoses including Cerebral Palsy, suicidal ideation, and Depression. Review of the Minimum Data Set (MDS) Assessment, dated 12/23/24, indicated Resident #9 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Personal Effects Inventory, undated, labeled with Resident #9's name, indicated the following: -List how many items in each box with a small descriptor . -Make sure the resident's name is on all belongings. -When a new item is received list it on the inventory sheet and if something is discarded from the inventory, list it also. -How many shirts -1x -Visual Appliances -1x -Cell Phone -1x Further review of the Residnt's Personal Effects Inventory indicated all other areas/items, including clothing with a zero next to them, indicating no items in that category. On 4/6/25 at 10:05 A.M., Resident #9 was observed seated in his/her room, in his/her wheelchair, wearing a hospital gown. During an interview at the time, Resident #9 said that he/she has had no clothes since his/her admission to the facility. Resident #9 said the facility donated a couple of items of clothing, however those items were never returned to him/her after being brought to the laundry. Resident #9 said he/she was not sure if the facility staff labeled the donated items or not. Resident #9 said that when he/she goes to the rehabilitation gym for physical and occupational therapy, he/she does not have many clothing options and would often wear a hospital gown. On 4/7/25 at 8:15 A.M., the surveyor observed the following: -Resident #9's was lying on his/her bed, wearing a hospital gown. -The Resident's dresser and closet was empty of clothing. During an interview at the time, Resident #9 said that his/her dresser and closet has looked that way for a long time. During an interview on 4/7/25 at 8:21 A.M., Nurse #3 said Resident #9 often did not have any clothing. Nurse #3 said the staff had brought the Resident clothing from lost and found or clothes that had been donated in the past but Nurse #3 could not speak to where those items had gone to. During an interview on 4/7/25 at 3:17 P.M., the Administrator said the facility typically gave donations to a Resident when they were admitted to the facility with minimal or no clothing. The Administrator said the facility staff label the donated clothing with the receiving Resident's name to ensure that the items would be returned to the Resident which the clothing items had been donated to. On 4/8/25 at 7:57 A.M., the surveyor observed the following: -A T-shirt and sweatpants draped over the foot of Resident #9's bed. -Multiple items of clothing hanging in the Resident's closet. -Resident #9 was lying in bed wearing a hospital gown. During an interview at the time, when the surveyor asked how Resident #9 felt about having clothes to put on today, the Resident said, I am looking forward to getting up and dressed after I have breakfast. I feel good about having something to wear other than a hospital gown. On 4/8/25 at 11:26 A.M., Resident #9 was observed in the second-floor center day room, talking with another resident. Resident #9's was observed to be relaxed and smiling while talking to other residents. During an interview at the time, Resident #9 said he/she was happy to have clothes on and to not be wearing a hospital gown. On 4/9/25 at 10:28 A.M., Resident #9 was observed in the second-floor center day room, dressed, smiling and talking with other residents.

Based on interview, and record review, the facility failed to uphold resident rights for one Resident (#13), out of a total sample of 23 residents, relative to rights exercised by the Resident's Representative (RR #1). Specifically, the facility failed to provide Resident #13's Representative with a copy of the Resident's medical record when RR #1 was exercising the Resident's right to review a copy of the medical records, and the medical records were requested through the appropriate process from the facility by RR #1. Findings include: Review of the facility's HIPPA Notice of Privacy Practices, undated, from the Office of Civil Rights, indicated the following: -Rights that you have regarding your protected health information: >Access to your protected health information- you have the right to copy and/or inspect much of the protected health information that we retain on your behalf. >For protected health information that we maintain in any electronic designated record set, you may request a copy of such health information in a reasonable electronic format, if readily producible. >Requests for access must be made in writing and signed by you or your legal representative. Resident #13 was admitted to the facility in November 2023 with diagnoses including Unspecified Dementia. Review of Resident #13's clinical record indicated a Health Care Proxy (HCP) Invocation form, dated 6/12/24, to have the Resident Representative make decisions due to the Resident's cognitive impairment. Review of the facility's Authorization for Release of Information, dated and signed by the Resident's Representative on 5/24/24, indicated that a copy of all Resident #13's medical records for personal reasons was requested. Review of the Comprehensive Minimum Data Set (MDS) Assessment, dated 12/7/24 indicated Resident #13 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of a total of 15 possible points. During an interview on 4/8/25 at 1:08 P.M., with Resident #13 and his/her Resident Representative (RR) #1, RR #1 said he/she had requested a copy of the Resident's medical record on 5/24/24, after the Resident developed a wound in the facility. Resident #13 said he/she knew RR #1 requested the medical records at that time and was not surprised they were not received. RR #1 said a form was completed and submitted to the facility Administrator who told him/her that it could take three to six months to obtain the records from facility headquarters. RR #1 said he/she followed-up with the facility Administrator a few times since the request on 5/24/24, and was told the facility was still working on obtaining the medical records. RR #1 said when he/she visited Resident #13 on 4/6/25, he/she told the Administrator that he/she was still waiting for the requested medical records. RR #1 said he/she was told that the Medical Records staff would get them for him/her. RR #1 said the next day (4/7/24), the Medical Records Staff told RR #1 that she was told by the Administrator to obtain Resident #13's medical record and the Medical Records Staff was working on it. RR#1 said he/she had not yet received the requested medical records as requested. During an interview on 4/8/25 at 1:14 P.M., Medical Record Staff said she was told on 4/7/25 by the Administrator that RR#1 had requested Resident #13's medical record. Medical Records Staff said she was unsure of the original date the medical records was requested because the Administrator had that information. On 4/8/25 at 2:03 P.M., Medical Records Staff provided the surveyor a copy of the Authorization for Release of Information Medical Request Form for all Medical Records, completed by RR #1, and dated 5/24/24. The Medical Records Staff said she was unaware of the 5/24/24 request. During an interview on 4/8/25 at 2:37 P.M., with the Administrator and Medical Records Staff, the Administrator said he received the request for Resident #13's medical records on 5/24/24 and thought he had told Medical Records to mail the records because the Resident was in the hospital. The Medical Records Staff said that she had not received a request from the Administrator to gather Resident #13's medical records prior to 4/7/25 and had not mailed any medical records to RR#1. The Administrator said that the facility policy was to provide medical records upon written request within 48 hours, but this did not happen. The Administrator said that the facility had a miscommunication and did not provide the medical records documents that were requested when they should have. The Medical Records Staff said that she would not mail a medical record unless she was instructed to do so by the Administrator and if she did mail anything, it would be sent by certified mail. The Medical Records Staff was unable to show evidence that the medical records certified mail had been sent to RR #1.

Based on interview, and record review, the facility failed to act upon, provide timely responses, and document written responses and rationale to grievances of resident care and services brought to facility administration by the Resident Council. Specifically, the facility failed to promptly respond to resident grievances relative to laundry delays, loss and errors. Findings include: Review of the facility policy titled Resident and Family Concerns and Grievances, revised on 10/5/24, indicated the following in part: -Residents or their family members, guardian, or representative may voice a grievance to the facility staff in person, by telephone or via written communication. -The facility shall provide a grievance report form to facilitate the voicing of a grievance if requested by a resident or family member the facility compliance and ethics officer or a designated staff will document and keep a log of all grievances expressed either orally and or in writing on the day that it is received or as soon as possible after the event or events that precipitated the grievance. -The facility will follow up with the resident, or their family members, guardian or representative within 72 hours of filing the grievance. -The facility will make a reasonable effort to ensure that all grievances are adequately resolved within 30 calendar days from the day the grievance was received -The facility will advise the resident of the outcome of the grievance investigation and shall make reasonable efforts to contact the resident's family members to advise them of the outcome of the grievance investigation. -The facility will provide the residents with a written grievance decision which shall include the date the grievance was received, a summary statement of the residents grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents' concerns, a statement as to whether the grievance was confirmed or not confirmed, any action taken or to be taken by the facility as a result of the grievance and the date the written decision was issued. -In the event the facility cannot resolve the grievance within 30 calendar days, the facility will notify the resident, their family members, guardian or representative of the status and estimated completion date with the grievance resolution. -The facility will document all steps of the grievance resolution and the facility's records including whether or not the resident/family was satisfied with the grievance. -The documentation will be kept for a minimum of three years. Review of the Grievance Log provided by the facility indicated: -a grievance was filed by three residents on 9/16/24, and 9/18/24 relative to laundry concerns. -these laundry concerns had not been resolved. -no grievance forms corresponding to the 9/16/24 and 9/18/24 dates were available to review. Review of the Resident Council Meeting Minutes, dated 12/18/24, indicated the following: -Laundry/Housekeeping concern: --Reports of residents' clothing missing and not returned from the laundry department. Review of the Resident Council Meeting Minutes, dated 1/15/25, indicated the following: -Laundry/Housekeeping concern: --Laundry delays/loss/errors. Review of the Resident Council Meeting Minutes, dated 2/19/25, indicated the following: -Laundry/Housekeeping concern: --Laundry delays/loss/errors. Review of the Resident Council Meeting Minutes, dated 3/26/25, indicated the following: - Laundry/Housekeeping/Maintenance concern: --Laundry delays/loss/errors. -- Action - Improve laundry process. During a Resident Council Meeting held on 4/7/25 from 10:00 until 10:50 A.M., the following was discussed: -Resident #5 said that he/she was missing five pairs of pants that were labeled with his/her name. -Resident #14 said when he/she received his/her clothing after a long wait, the clothes were so wrinkled that he/she did not want to wear them. -Resident #6 said that he/she waited nearly four weeks to get clothes back from the laundry. -Resident #11 said that he/she sometimes never received his/her items back from the laundry. With a show of hands, eight out of 22 Residents indicated they had experienced waiting long periods of time to have their clothing returned to them, and said this concern has been going on for a long time. During an interview on 4/7/25 at 3:17 P.M., the Administrator said the facility had been experiencing laundry challenges due to a high turnover in laundry managers, a total of four managers in the last six months. The Administrator said that the facility now has a new laundry manager, but he had been at the facility for less than 30 days. During a follow-up interview on 4/9/25 at 10:20 A.M., the Administrator said he was unable to locate at this time the three missing grievances that had been filed on 9/16/24 and 9/18/24. The Administrator further said they have been aware of the ongoing laundry concerns but due to the turnover in that department, the laundry concerns continued to be an issue.

Based on interview and record review, the facility failed to ensure that advanced directives were honored for one Resident (#2), out of a total sample of 23 residents. Specifically, for Resident #2, the facility failed to ensure that the Medical Orders for Life-Sustaining Treatment (MOLST: legal document that allows individuals to communicate their preferences for life-sustaining treatment to healthcare providers) form and Physician's orders accurately reflected the Resident/Resident Representative's wishes putting the Resident at risk for being resuscitated (perform full measures including cardiopulmonary resuscitation and intubation) when the advanced directive wishes were for no resuscitation (do not resuscitate [DNR] and intubate [DNI]). Findings include: Review of the facility policy titled Advanced Directives, dated 10/16/23, indicated it was the policy for the facility to ensure the residents' right to request, refuse, and/or discontinue treatment, to participate or refuse in experimental research and to formulate an advance directive. The policy also included the following: -the MOLST form is designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. -upon admission, the facility should determine whether the resident has an advance directive, and, if not, determine whether the resident wishes to formulate an advance directive. -the Advanced Directive shall be reviewed and updated upon resident request, with the comprehensive care plan, and with significant changes in resident condition. -if the resident or the resident's representative has executed an advance directive, or executes one upon admission, copies of these documents must be obtained and maintained in the same section of the resident's medical record readily retrievable by facility staff. Facility staff must document in a prominent part of the resident's current medical record whether or not the resident has executed an advance directive and what those wishes are. -The facility shall: >not be required to provide care that conflicts with an advance directive. >not be required to implement an advance directive if, as a matter of conscience, the facility cannot implement an advance directive and state law allows any health care provider or any agent of such provider to conscientiously object. -the facility will implement the instructions outlined in the Advanced Directive. To ensure appropriate implementation, the facility will: >periodically assess the resident for decision-making capacity and invoke health care agent or representative if the resident is determined not to have decision-making capacity. >identify the primary decision-maker (assessing the resident's decision-making capacity and identifying or arranging for an appropriate representative for the resident assessed as unable to make relevant health care decisions). >define and clarify medical issues and present the information regarding relevant health care issues to the resident or his or her representative, as appropriate. >identify situations where health care decision-making is needed, such as a significant decline or improvement in the resident's condition. -to be legally binding, the advanced directive must be signed by the resident or legal guardian as recognized by the state. If utilizing a MOLST form, the order will take effect after signatures of the resident/resident representative AND order is signed by the Provider (Physician or designee), or two Nurses receive the order and place the order on the form. Resident #2 was admitted to the facility in October 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF), Dementia and Adult Failure to Thrive. Review of Resident #2's clinical record indicated a MOLST form which included: -full code status (attempt resuscitation, intubate and ventilate, transfer to the hospital and provide all other life saving measures). -the form was signed and dated by Resident #2 on 10/26/22. -the form was signed and dated by the Provider on 10/28/22. Review of the Advanced Directive Care Plan, initiated 10/26/22, indicated Resident #2 had an established advanced directive and included the following: -Health Care Proxy (HCP: representative designated to make medical decisions when a person was no longer able) was invoked. -MOLST- see document for details. -Activate Resident's advanced directive as indicated. Review of the HCP Invocation Form, signed and dated by the Provider on 5/29/24, indicated the Resident's designated HCP was invoked indefinitely. Review of the Minimum Data Set (MDS) Assessment, dated 1/14/25, indicated the following for Resident #2: -he/she had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15 points. -HCP was invoked. -do not resuscitate (DNR), do not hospitalize (DNH), do not intubate (DNI) and feeding and other treatment restrictions were in place. Review of the April 2025 Physician's orders included the following relative to advanced directives for Resident #2: -DNR, DNI, DNH, no dialysis, no artificial nutrition, use artificial hydration but short term only, invoked (HCP), dated 3/27/25. On 4/8/25 at 3:27 P.M., the surveyor and Unit Manager (UM) #1 reviewed Resident #2's clinical record. UM #1 said the Resident's wishes for advanced directives were located in the electronic medical record (EMR) under the Physician's orders and a copy of the MOLST form should also be scanned into the system. UM #1 reviewed Resident #2 current advanced directives orders and said Resident #2 was a DNR, DNI, DNH, no dialysis, no artificial nutrition and artificial hydration for short term only. The surveyor and UM #1 reviewed the MOLST form located in Resident #2's clinical record which indicated he/she was a full code status. UM #1 said the Resident's HCP had updated the Resident's advanced directives recently, but the HCP updates did not appear to be in the Resident's record. During an interview on 4/8/25 at 3:29 P.M., Nurse #2 said if Resident #2 was found unresponsive and not breathing, she would refer to the Resident's MOLST Form to determine what measures the Resident wanted for advanced directives. Nurse #2 said the current MOLST Form for Resident #2 indicated he/she was a full code status so she would attempt to resuscitate Resident #2. Nurse #2 said regardless of what the electronic health record indicated under the April 2025 Physician's orders, she would refer to the MOLST form for advanced directives. During a follow-up interview on 4/8/25 at 3:30 P.M., UM #1 said she would have to clarify Resident #2's advanced directives. UM #1 said she could recall a new MOLST Form being completed by the HCP but was not sure where the updated MOLST Form was. UM #1 said at this time, Resident #2 was considered a full code status.

Based on record review, and interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing, of a transfer or discharge for three Residents (#58, #13 and #47), out of a total sample of 23 residents. Specifically, the facility failed to provide written notification to the Office of the State Long-Term Care Ombudsman: 1. For Resident #58, when the Resident was transferred out of the facility to the hospital on 3/11/25. 2. For Resident #13, when the Resident was transferred out of the facility to the hospital on 3/27/25. 3. For Resident #47, when the Resident was transferred out of the facility to the hospital on 3/8/25. Findings include: During an interview on 4/3/25 at 2:35 P.M. (prior to the start of survey), the Ombudsman said that she did not receive Discharge/Transfer notices from the facility. 1. Resident #58 was admitted to the facility in December 2024 with diagnoses including Alzheimer's Disease, Congestive Heart Failure and Cerebrovascular Accident (CVA -Stroke). Review of Resident #58's medical record indicated the Resident was sent to the hospital on 3/11/25. Review of Resident #58's clinical record failed to indicate documented evidence that the Ombudsman was notified of the Resident's transfer to the hospital on 3/11/25. 2. Resident #13 was admitted to the facility in November 2023 with diagnoses including Dementia. Review of Resident #13's medical record indicated the Resident was sent to the hospital on 3/27/25. Review of Resident #13's clinical record failed to indicate documented evidence that the Ombudsman was notified of Resident #13's transfer to the hospital on 3/27/25. 3. Resident #47 was admitted to the facility in February 2025 with diagnoses including Respiratory Failure and Pneumonia. Review of Resident #47's medical record indicated the Resident was sent to the hospital on 3/11/25. During an interview on 4/7/25 at 3:38 P.M., the Social Worker Assistant said the facility had been setting aside the required resident transfer documentation that was needed to be provided to the Ombudsman and when the Ombudsman comes into the facility, they would stop at the office and pick up the documentation. The Social Worker Assistant said to the best of her knowledge this was the previous process as well. During a follow-up interview on 4/8/25 at 3:33 P.M., the Ombudsman said that prior to the change in the Social Service Department, the facility would send the required transfer documents via fax, but she had not received any notifications from the facility since 2/3/25. The Ombudsman said that the fax she received on 2/3/25 was for the residents' that had transferred or discharged for the month of January 2025. The Ombudsman said it was her expectation and agreement with the facility that the resident transfer notices were to be sent to her monthly. The Ombudsman said anything a resident could appeal or had the right to appeal, she expected to be notified of. The Ombudsman further said she had not received any notifications of transfers or discharges for the months of February 2025 and March 2025, including Resident's #58, #13, and #47.

Based on record reviews, and interviews, the facility failed to ensure a comprehensive care plan was initiated for the care and services of one Resident (#9), out of a total sample of 23 residents. Specifically, the facility failed to develop a comprehensive care plan for Resident #9 relative to Suicidal Ideations (SI) that the Resident experienced in the hospital, prior to his/her admission to the facility, which continued after his/her admission to the facility. Findings include: Resident #9 was admitted to the facility in December 2024 with diagnoses including Cerebral Palsy, Type II Diabetes and Depression. Review of a Hospital Consultation Note, dated 12/8/24, indicated the following for Resident #9: -was seen for a safety consult as he/she alluded to passive SI, expressed frustration with being in the hospital and his/her overall health. -was withdrawn, reporting he/she did not want to continue medication or procedures. -said he/she wished he/she would go to sleep and not wake up. -had a history of Depression with outpatient psychiatry and psychotherapy support. -reported feeling depressed at the time of the assessment. Review of the Provider Encounter Note, dated 3/3/25, indicated Resident #9: -endorsed passive SI with plans to stop taking his/her insulin and medication. -was visibly distressed and appeared depressed. Review of Resident #9's Alteration in Mood Care Plan, initiated on 2/27/25 (greater than two months after the Resident's admission to the facility) failed to indicate any documented evidence relative to the Resident's history of SI. During an interview on 4/8/25 at 10:54 A.M., with Minimum Data Set (MDS) Nurse #1 and MDS Nurse #2, the following was discussed relative to Resident #9: -MDS Nurse #1 said she added the SI diagnosis on 4/7/25, when she learned about the diagnosis while completing the Resident's quarterly review, which was in progress now. -MDS Nurse #2 said this was new information to them and did not know that Resident #9 had been seen by Psychiatry while at the hospital for SI. -MDS Nurse #1 said an Alteration in Mood Care Plan had been developed for Resident #9, however she would have expected a care plan to have been developed upon admission for a Resident with history of SI, but one had not been developed. -MDS Nurse #1 and MDS Nurse #2 said based on the Resident's history, comprehensive care plans for both mood and SI should have been developed upon admission and sooner than the 2/27/25 care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that three Residents (#2, #17, and #88), were provided activity of daily living (ADL) care in accordance with their needs/preferences, out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #2, ensure grooming assistance relative to facial hair removal was provided when the Resident was dependent on staff for personal hygiene needs. 2. For Resident #17, ensure dressing assistance was provided in accordance with his/her preferences when the Resident required assistance from staff with dressing needs. 3. For Resident #88, provide grooming assistance when the Resident required extensive physical assistance with grooming and had a preference for facial hair removal daily. Findings include: Review of the facility policy titled Resident Rights, revised 11/5/24, indicated it was the policy of the facility to respect the rights of the residents by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents . The policy also included the following: -the facility supports the resident's right to knowledgeably participate in decisions concerning their healthcare and medical treatment . 1. Resident #2 was admitted to the facility in November 2022 with diagnoses including Dementia, Adult Failure to Thrive and need for assistance with personal care. Review of the ADL Care Plan, initiated 10/25/22, indicated Resident #2 required assistance with ADL care and included the following interventions: -provide two staff with all care, initiated 9/23/23 -provide extensive assistance for personal hygiene (grooming). Resident was dependent on staff when fatigued, revised 10/16/23 Review of the Minimum Data Set (MDS) Assessment, dated 1/14/25, indicated the following relative to Resident #2: -he/she was understood and understands. -has moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15 points. -was dependent on staff for personal hygiene (including grooming/hair removal). Review of Resident #2's April 2025 Physician's orders included the following: -monitor for rejection of care every shift, dated 10/8/24 -weekly shower on evenings (3:00 P.M. to 11:00 P.M. shift) on Fridays, dated 2/28/25 Review of Resident #2's April 2025 Medication and Treatment Administration Record (MAR and TAR) indicated no refusals of care. Review of the Certified Nurses Aide (CNA) Care Card (resident specific information to assist with care) included the following relative to Resident #2: -two staff for all care -extensive assistance with personal care for grooming -dependent for care when the Resident was fatigued Review of the CNA documentation for March 2025 and April 2025 indicated Resident #2 required assistance from staff with grooming needs, accepted care and had no refusals of care. Further review of the CNA documentation failed to indicate documented evidence that shaving (facial hair removal) assistance was provided to Resident #2. The surveyor observed Resident #2 dressed and lying in bed with numerous long facial hairs measuring approximately 1/2 inch to one inch in length on the Resident's upper lip and chin on the following occasions: -4/6/25 at 10:42 A.M. -4/7/25 at 11:39 A.M. and 2:04 P.M. On 4/8/25 at 10:37 A.M., the surveyor observed Resident #2 lying in bed and dressed in a hospital gown. The surveyor observed numerous long facial hairs remained on the Resident's upper lip and chin. During an interview at the time, Resident #2 said he/she had not been washed/dressed yet and that he/she waited for staff to come in to assist him/her when staff were able. Resident #2 said he/she did not like to have facial hair and would like to have staff remove it but no one had offered to remove the facial hair for him/her. During an interview on 4/8/25 at 11:45 A.M., CNA # 4 and #5 were observed entering Resident #2's room to provide morning care. During an interview at the time, CNA #5 said Resident #2 required assistance from staff with all personal care including grooming and hygiene. During an interview on 4/8/25 at 12:18 P.M., CNA #4 said Resident #2 required assistance from staff with ADL care. On 4/8/25 at 12:22 P.M., the surveyor and Nurse #3 observed that Resident #2 was dressed and lying in bed. During an interview at the time, Resident #2 said he/she would like to have his/her facial hair removed and did not like having hair on his/her face. During an interview on 4/8/25 at 12:25 P.M., Nurse #3 said he observed the facial hair on the Resident's upper lip and chin and would alert the CNA's to assist in removing the facial hair for him/her. 2. Resident #17 was admitted to the facility in November 2010 with diagnoses including Cerebral Palsy, contractures of unspecified wrist and hand, contractures of the right and left knee, Torticollis (condition in which the neck muscles contract causing the head to twist to one side), and muscle weakness. Review of the ADL Care Plan, initiated 10/12/24, indicated Resident #17 required the following: -extensive assistance of one staff for dressing. Allow sufficient time for dressing and undressing ., revised 10/12/24 -extensive assistance of one staff for personal hygiene/oral care . revised 10/16/24 -encourage Resident to participate to the fullest extent possible with each interaction, revised 10/12/24 Review of the MDS assessment dated [DATE], indicated the following relative to Resident #17: -was understood and understands -was cognitively intact as evidenced by a BIMS score of 14 out of a possible 15 points. -had no behaviors -had range of motion (ROM) impairments on both upper and lower extremities -was dependent on staff for bathing, dressing, toileting and personal hygiene/grooming needs Review of the CNA Care Card, indicated the following for Resident #17: -required extensive assist of one for personal hygiene -please have Resident toileted, washed and dressed daily around 6:00 A.M. -respect Resident preferences at all times -required extensive assist of one staff to dress. Allow sufficient time for dressing and undressing. On 4/6/25 at 11:17 A.M., the surveyor observed Resident #17 lying in bed dressed in a shirt. A blanket was observed covering the Resident's lower half. During an interview at the time, Resident #17 said one of the CNAs on the 11:00 P.M. to 7:00 A.M. (night) shift would wash and dress only his/her upper half and leave the lower body for the next shift (7:00 A.M. to 3:00 P.M. [day]). Resident #17 said this had been occurring with this specific CNA for one to two months, that he/she had reported the concern to multiple staff, and the CNA refusing to wash/dress his/her lower half continued. Resident #17 said he/she preferred to be fully washed and dressed and could not understand why this continued to occur with this CNA. Resident #17 said he/she had filed a grievance relative to this concern. After the observation and interview, the surveyor notified Resident #17's concerns to the Director of Nursing (DON) and Assistant Director of Nurses (ADON). On 4/6/25 at 11:34 A.M., the surveyor observed the DON knock and enter Resident #17's room. Shortly after, the DON was observed exiting the Resident's room and told the surveyor he spoke to the Resident about the concerns he/she had relative to the 11:00 P.M. to 7:00 A.M. CNA who provided personal care. On 4/9/25 at 8:43 A.M., the surveyor observed Resident #17 lying in bed with shirt on and a blanket covering his/her lower body. During an interview at the time, Resident #17 said he/she was washed on the 11:00 P.M. to 7:00 A.M. shift by the CNA and the CNA put a shirt on him/her but did not dress his/her lower half even when the Resident requested to be fully dressed. Resident #17 showed the surveyor that he/she had on underwear and no pants at the time. Resident #17 said that he/she liked to be fully dressed because he/she got cold. Resident #17 said it was the same CNA who was previously reported on 4/6/25, and he/she could not understand why this continued to occur. Resident #17 said CNA #3, who worked on the 7:00 A.M. to 3:00 P.M. shift was aware of his/her concerns. During an interview on 4/9/25 at 8:46 A.M., CNA #3 said she regularly worked the 7:00 A.M. to 3:00 P.M. shift, and that Resident #17 required total assist of staff with bathing, dressing, and personal hygiene. CNA #3 said because there were more residents on the unit and they were short staffed, there were times when residents had to wait. CNA #3 said Resident #17 was supposed to get washed and dressed for 6:00 A.M., that the Resident had a routine in the morning, and would ring for staff assistance with bathroom needs. CNA #3 said certain CNAs would not fully wash/dress Resident #17, and when this occurred, she encouraged Resident #17 to tell administration. CNA #3 said Resident #17 wanted to be fully washed and dressed including having his/her shoes on in the morning because he/she would get cold. CNA #3 said she was aware of Resident #17's concern for about a year and that it was a particular CNA on the 11:00 P.M. to 7:00 A.M. shift who did not fully wash/dress the Resident on that shift. CNA #3 further said Resident #17 deserved to have the care he/she requested and could not understand why this continued. CNA #3 said she had provided Resident #17 with the morning routine which included toileting, washing and dressing and it took a total of 15 to 20 minutes to provide the care the Resident wanted which was not a long time, so staff should be able to do as he/she requests/prefers. 2. Resident #88 was admitted to the facility in September 2023 with diagnoses including Parkinson's Disease, muscle weakness and Adult Failure to Thrive. Review of the MDS assessment dated [DATE], indicated Resident #88: -was cognitively intact, as evidenced by a BIMS score of 14 out of 15. -required maximum assistance from staff for personal hygiene, including facial hair removal. -exhibited no behaviors or refusals of care. During an interview on 4/6/25 at 4:30 P.M., Resident #88 said that he/she has not had his/her facial hair removed in over a week. The surveyor observed facial hair about ¼ inch in length on the Resident's neck, cheeks and chin. Resident #88 said he/she had always preferred to have no facial hair and prior to admission at the facility he/she used to remove his/her facial hair daily. Resident #88 said he/she had asked to have his/her facial hair removed that morning and was told it could happen after suppertime. On 4/7/25 at 8:22 A.M., the surveyor observed that facial hair about ¼ inch in length remained on the Resident's neck, cheeks, and chin. During an interview at the time, Resident #88 said staff did not offer to remove his/her facial hair last night after suppertime and when he/she asked again this morning, he/she was told the staff would do it that night. During an interview on 4/7/25 at 2:25 P.M., CNA #6 said residents should have their facial hair removed every week on their shower day unless they requested or wanted their facial hair removed in between the shower days. CNA #6 said residents should not have unwanted facial hair. During an interview on 4/8/25 at 7:36 A.M., Resident #88 said his/her facial hair was not removed when care was provided the previous night. Resident #88 said the CNA was going to come back to provide assistance with removing his/her facial hair if they had time but the CNA never came back. Resident #88 said the staff helped him/her get washed and out of bed this morning, but facial hair removal was not offered. The surveyor observed that the Resident remained with hair about ¼ inch in length on the cheeks, upper lip, neck and chin. Resident #88 said he/she has always preferred to have no facial hair. During an interview on 4/8/25 at 8:43 A.M., CNA #8 said Resident #88 was assigned to her, but she did not offer facial hair removal because the Resident was provided morning care on the 11:00 P.M. to 7:00 A.M. shift. CNA #8 said that a few weeks prior, Resident #88 told her that he/she preferred to not have facial hair and had removed his/her facial hair every day prior to coming to the facility. CNA #8 said she provided facial grooming to the Resident on the assigned shower day on 3/27/25 and was unsure if he/she has had his/her facial hair removed since. CNA #8 said that CNAs were expected to remove residents' facial hair weekly on their shower day but that CNAs' should also ask residents if they wanted to have their facial hair removed daily. CNA #8 said sometimes when staffing was lower (two CNAs versus three or three and half CNA's) the facial hair removal did not always happen. During an interview on 4/8/25 at 11:45 A.M., Unit Manager (UM) #4 said CNAs should be offering residents facial hair removal daily. UM #4 said facial hair removal for residents has been an ongoing issue in the building and that staff have been educated on this concern but it continued to be a problem.

Based on observation, interview and record review, the facility failed to ensure treatment and care in accordance with professional standards of practice relative to monitoring and assessing skin conditions for two Residents (#30 and #45), out of a total of 23 sampled residents. Specifically, the facility failed to: 1. For Resident #30, identify, assess and implement interventions timely when skin areas developed on his/her inner and outer left lower leg. 2. For Resident #45, perform weekly skin assessments as per the comprehensive plan of care. Findings include: Review of the facility policy titled Skin Prevention, Assessment and Treatment, revised October 2024, indicated the following: - purpose of the policy was to identify factors that place the residents at risk for the development of pressure ulcers - implement appropriate interventions to prevent the development of clinically avoidable wounds - all residents should have their skin integrity examined thoroughly at least weekly by the licensed nurse . - findings from the weekly skin assessment should be documented by the licensed nurse - Certified Nurse Aides (CNAs) should observe skin integrity during the daily provision of routine cares and report any impairments to the Charge Nurse for appropriate follow-up. - any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee, in the medical record. - documentation should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues, and a description of any drainage, eschar, necrosis, odor, tunneling, or undermining. - upon identification of the development of a wound, the wound assessments/treatments will be documented in the medical record and start the weekly Wound Log. - Nursing staff should keep the attending physician aware of the progress of all ulcers 1. Resident #30 was admitted to the facility in September 2023 with diagnoses including Type 2 Diabetes Mellitus with neuropathy and Hemiplegia and Hemipararesis following a Cerebral Infarction affecting the Left Non-Dominant side. Review of the Minimum Data Set (MDS) Assessment, dated 2/8/25, indicated the following for Resident #30: - he/she understood and understands - was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15 points - had no behaviors or rejections of care - had bilateral lower extremity range of motion (ROM) impairments - utilized a wheelchair - required substantial/maximum assistance from staff with bathing and upper and lower body dressing - was dependent on staff for personal hygiene and putting on shoes - was at risk for pressure ulcers, had no pressure ulcers and had no arterial and venous ulcers - had application of medications/ointments other than to feet Review of the Weekly Wound Log, dated 3/7/25, indicated Resident #30 had a left lower leg blister that was resolved (healed) at that time. Review of the April 2025 Physician's orders included the following: - Diabetic foot care/check daily, observation of feet, toes, ankles, soles noting any alteration in skin integrity, color, temperature, and cleanliness. Inspect shoes for proper fit and excessive wear, check pedal pulses every evening shift, initiated on 9/4/23 - Follow initial wound care dressing guidelines if provider was not in office. May utilize until the provider examines or other orders are obtained. Place order individually for documentation of the wound as needed ., initiated 12/28/23 - May be followed by the in-house wound provider for wound evaluation and treatment, initiated 12/28/24 - Weekly skin check on Tuesdays, 7:00 A.M. to 3:00 P.M. shift. Please complete weekly skin assessments in charting under assessments, initiated 2/27/25 - Weekly shower on Tuesdays, 7:00 A.M. to 3:00 P.M. shift, initiated on 2/27/25 Review of the March 2025 through April 6th 2025 Treatment Administration Records indicated: - Diabetic foot care was performed daily with the exception of on 3/27/25 and on 3/28/25 where if was marked NA - received weekly showers and skin checks as ordered - the Resident had no documented refusals of care - there was no documented evidence of treatments for the Resident's left lower extremity areas Review of the Weekly Skin Check form, completed on 4/1/25, indicated Resident #30's skin had redness present on his/her left and right front lower legs and the skin was intact. On 4/6/25 at 9:59 A.M., the surveyor observed Resident #30 dressed in shorts and seated in a wheelchair in his/her room. The Resident was wearing a sock and shoe on his/her right foot and had on a non-skid sock on his/her left foot. The Resident's left lower extremity was observed to be swollen and the left calf was pink and had peeling skin. Two round quarter-sized areas with yellow centers were observed on the outer and inner middle left calf. During an interview, Resident #30 said the open areas on the outer and inner left calf were caused from his/her brace and pointed to a leg brace which was near his/her dresser. Resident #30 said he/she had a dermatology appointment on 4/1/25 for removal of skin tags and the skin doctor also looked at his/her left lower leg. On 4/06/25 at 3:32 P.M., the surveyor observed Resident #30 dressed in shorts and seated in a wheelchair in his/her room. The areas remained on his/her left lower extremity. Shortly after the observation, the Resident was observed to self propel out of the room, down the hallway and off the unit passing several staff. Review of Resident #30's clinical record included the following: - Provider Visit Note, dated 3/19/25, that indicated Resident #30 had a dermatology appointment on 4/1/25 at 2:00 P.M. for skin tags - Provider Visit Note, dated 4/4/25, that indicated the Resident had a follow-up appointment with dermatology on 8/5/25 at 2:15 P.M. - there was no documented evidence of identification, assessment or that interventions were in place for the Resident's areas located on his/her inner and outer middle lower left leg. - no documented evidence of the Resident's results from the dermatology consult that occurred on 4/1/25. On 4/7/25 at 11:27 A.M., the surveyor observed Resident #30 dressed in shorts and seated in a wheelchair in his/her room. The Resident's left lower leg remained swollen, was pink in color and had peeling skin. The two round quarter-sized areas on the Resident's middle left outer and inner calf were visible and remained with a yellow center. During an interview, Resident #30 said he/she was going out of the facility for a bit with a friend in the afternoon. Review of a Nurse's Note, dated 4/7/25, indicated the dermatology office contacted the facility at 3:50 P.M. to report results from a culture that was obtained from Resident #30 at his/her appointment last week (on 4/1/25). The Resident was positive for Methicillin Resistant Staphylococcus Aureus (MRSA: type of bacteria that can cause a serious infection and was difficult to treat with antibiotics) in his/her left lower extremity. The facility requested a copy of the laboratory results and the on-call provider was contacted regarding the results and requested the dermatology provider write the order for antibiotics and the dermatology office was closed at that time. The on-call provider gave an order for one time dose of antibiotic and requested the facility staff contact the dermatology office on 4/8/25 to obtain additional orders for antibiotics and wound care treatment orders. Review of the April 2025 Physician's orders indicated the following: - Infection Precautions- Contact Isolation: Resident is isolated in room, without a roommate or cohort with like pathogen, due to active infection with transmissible significant pathogens. Above standard transmission precautions maintained, with activities and all services brought to the resident, every shift, initiated 4/7/25 - Bactrim DS (antibiotic) 800-160 milligrams (mg), twice daily for one day pending dermatology recommendations on 4/8/25, initiated 4/7/25 - Doxycycline Monohydrate (antibiotic), 100 mg twice daily for ten days for MRSA infection in left lower leg, initiated 4/8/25 - Wound- left lower leg: cleanse with wound cleanser, xeroform/ABD/rolled gauze daily. Elevate legs as tolerated every day shift, initiated 4/8/25 Review of the Wound Logs, dated 4/7/25 indicated the following: - left shin lateral aspect (outer), acquired on 4/7/25, quarter-sized blister caused by leg brace and was 50% yellow slough and 50% epithelial tissue which measured 2.5 centimeters (cm) length by 2.5 cm width by 0.1 cm depth. The peri-wound was red, inflammation was present and infection was suspected, positive MRSA. - left shin medial aspect (inner), acquired on 4/7/25, quarter-sized blister caused by leg brace and was 50% yellow slough and 50% epithelial tissue which measured 2.5 centimeters (cm) length by 2.5 cm width by 0.1 cm depth. The peri-wound was red, inflammation was present and infection was suspected, positive MRSA During an interview, on 4/8/25 at 10:55 A.M., Medical Records Staff said she was responsible for coordinating resident medical appointments. She said resident information including the medication list, physician notes, most recent laboratory work and a blank consult sheet would be sent with the resident for the appointment. Medical Records Staff said when the resident returned to the facility, the completed consult sheet would be given to the nursing staff and they would review it for orders/recommendations and ensure the provider was aware. Medical Records Staff said if a resident returned from a medical appointment without a completed consult sheet, the nurses would notify her and she would contact the outside provider for information regarding the appointment. Medical Records Staff said she was not notified that consult information was not obtained when Resident #30 returned from the dermatology appointment on 4/1/25. During an interview, on 4/8/25 at 10:58 A.M., Nurse #3 said when Resident #30 returned from the dermatology appointment on 4/1/25 without consult information, the nurse should have contacted the dermatology office to obtain information about the appointment and receive any orders if any. During an interview, on 4/8/25 at 11:10 A.M., Unit Manager (UM) #1 said when a resident returns from an outside medical appointment, the nurse would receive the information from the resident regarding the visit and any instructions that would need to be relayed to the provider. UM #1 said if a resident returns without information from an appointment, the facility would contact the outside provider for information regarding the visit, and she was not sure this was done for Resident #30. UM #1 said she was unaware Resident #30 had left leg wounds or that a culture was obtained until the dermatology office contacted the facility on 4/7/25 (six days after the appointment). UM #1 said the Resident had skin checks that were performed weekly, but said there were times when he/she refused them. UM #1 said the Resident required assistance from staff with ADL care and that the Certified Nurse Aides (CNAs) also would report skin changes. The surveyor relayed observations of the Resident's left lower extremity from 4/6/25 which was swollen, pink with peeling skin and the presence of two round quarter-sized areas with yellow centers located on the outer and inner middle left calf. UM #1 said she was unaware of these areas and said the Resident did wear a brace on his/her left leg when he/she was out of the facility and that she observed him/her wearing the brace on 4/7/25. Review of the Weekly Skin Check, dated 4/8/25, indicated the Resident's skin was warm and dry, had no skin or foot problems and also indicated the Resident refused to be assessed. During an interview, on 4/8/25 at 11:54 A.M. and at 1:51 P.M., the Director of Nurses (DON) said the Resident's left lower leg areas were obviously missed by facility staff and should have been identified prior to 4/7/25. The DON said Resident #30 had an appointment on 4/1/25 to remove skin tags, but the facility was not aware that a lower extremity skin culture was obtained on that day. The DON said when a resident had a medical appointment outside of the facility and returns with no information, the facility should contact the outside provider to obtain information on what transpired at the appointment and this did not occur for Resident #30. The DON said had the facility known a culture of the Resident's left lower extremity was pending, contact precautions would have been initiated (on 4/1/25) pending the result of the culture. During a follow-up interview on 4/08/25 at 3:17 P.M., with the DON, UM #1 and the Director of Rehabilitation (DOR), the DOR said the therapy department was not made aware that Resident #30 was wearing a left leg brace, that there was no Physician's order for the Resident to use the brace and that it had been discontinued for quite some time. UM #1 said she was aware the Resident wore the brace at times when he/she was going out of the facility but was not aware Resident #30 had two areas on his/her left lower legs that he/she said were caused by the brace. On 4/09/25 at 4:03 P.M., the surveyor observed Resident #30's wound with UM #1. Resident #30 was observed dressed in shorts and seated in a wheelchair in his/her room. The Resident's left foot remained swollen and the Resident had a non-skid sock in place. A gauze wrap was observed dated 4/9/25 around the Resident's middle left lower leg. UM #1 removed the dressing and two quarter-sized circular areas were observed on the Resident's inner and outer left middle calf. The open area on the left inner leg was clean and no yellow discoloration was observed. The open area on the outer left calf had a yellow center. The Resident's left lower leg remained pink and had some flaking skin. During an interview following the observation, UM #1 said the Resident's left lower extremity wounds were not identified by the facility until the surveyor brought it to their attention on 4/7/25. UM #1 said Resident #30 had a history of lower extremity wounds, but the current wounds were not previously identified. Please refer to F880. 2. Resident #45 was admitted to the facility in April 2024 with diagnoses including Chronic Kidney Disease (CKD), Dementia and heart failure. Review of the Resident's At Risk for Skin Alteration Care Plan, initiated 4/4/24 indicated Resident #45 was at risk for skin concerns related to possible shearing due to sliding down in bed, impaired mobility and incontinence, and included the following interventions initiated 4/4/25: - weekly nurse skin review, - lotion to dry skin, and - skin checks weekly Review of the MDS Assessment, dated 3/25/25 indicated the following for Resident #45: - he/she understands and was understood - was cognitively intact as evidenced by a BIMS score of 14 out of a possible 15 points. - required assistance of staff with dressing, toileting and personal hygiene - was at risk for pressure ulcers and had none at the time of the assessment. Review of the clinical record indicated no documented evidence that weekly skin checks were performed on after 1/14/25 until 3/4/25. On 4/6/25 at 10:16 A.M., the surveyor observed Resident #45 dressed and seated in a wheelchair. A bruise was observed on the top of the Resident's left hand and the Resident's bilateral lower extremities were observed to be swollen and had very dry, flaky skin. During an interview at this time, Resident #45 said the bruise on his/her left top hand was from an intravenous (IV) line from a recent hospitalization. Resident #45 said the edema in his/her lower legs had improved and that staff were supposed to apply lotion to his/her lower extremities daily but this rarely happened because the staff are too busy and running around. During an interview, on 4/9/25 at 10:34 A.M., the Assistant Director of Nurses (ADON) said skin checks for all residents were to be performed weekly and the nurses would be completing a head to toe entire body assessment weekly to identify any new skin areas or changes. The ADON said this information would be documented in the resident's electronic medical record. At this time, the surveyor reviewed Resident #45's clinical record with the ADON and she said weekly skin checks should have been completed between 1/14/25 through 3/4/25. The ADON further said Resident #45 was not a person who would refuse care or a skin assessment. On 4/9/25 at 2:40 P.M., the DON said he was unable to provide documented evidence that weekly skin checks had been performed during the week of 1/21/25, 1/28/25, 2/11/25 and 2/18/25. The DON said monthly skin assessments were completed on 2/2/25 and on 3/2/25 by the nurses and the CNAs observe the Resident's skin during care but the CNA's were not able to assess the Resident's skin.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#45) out of a total sample of 23 residents, was provided assistance as required to prevent falls. Specifically, for Resident #45, the facility failed to provide assistance of two staff with transferring resulting in the Resident sustaining a fall with assistance of one staff for a transfer from wheelchair to bed. Findings include: Review of the facility policy titled Accidents and Incident Investigation, dated 11/15/15, indicated the purpose was to ensure all accidents, incidents and allegations of abuse involving residents, visitors, or employees are investigated and reported to the facility administration. The policy also included the following: -an employee witnessing an accident, incident or abuse involving a resident, visitor,or employee shall report such occurrence as soon as practical. The victim of an accident or incident should not be left unattended to summons help unless absolutely necessary. -the assigned nurse or nursing supervisor shall complete an assessment and provide medical interventions as warranted. -the assigned nurse or nursing supervisor shall: >examine all accident, incident or abused victims >notify the attending physician or medical director of the occurrence >follow the physician orders and instructions for rendering care >designate an employee to accompany the victim if necessary >minor injuries shall be treated per facility protocol >investigative action shall be initiated by the attending nurse and/or nursing supervisor . and forwarded to the Director of Nurses (DON), or designee >the administrative staff shall complete the investigation . >complete the Incident/Event Investigation form or the Investigation Follow-up form including specifics as indicated, such as: a. date, time and location of the accident/event . b. nature of the injury . c. circumstances surrounding the occurrence d. name(s) of witness(s) and their account of the occurrence- account should be conducted by an in-person or phone interview e. the injured person's account of the occurrence, if they are able to convey the information f. date and time the physician/responsible party notification g. condition of the resident- including vital signs h. disposition of the resident . i. corrective action taken j. documentation in medical record completed, recorded on the 24 hour report k. care plan updated if indicated l. follow up information-such as 72 hour assessment and charting . m. other pertinent data n. signature and title of the person completing the form. Resident #45 was admitted to the facility in April 2024 with diagnoses including Osteoporosis, Parkinson's Disease, dizziness and giddiness, difficulty walking and unsteadiness on feet and Hypotension. Review of the Activities of Daily Living (ADL) Care Plan initiated 4/4/24, indicated Resident #45 had an alteration in ability to care for him/herself and required assistance. The ADL Care Plan included the following interventions: -wheelchair with supervision, initiated 4/7/25. -required mechanical lift with assistance of two staff with transfers, initiated 4/4/24. Review of the Falls Care Plan initiated 5/7/24, indicated the Resident was at risk for falls and included the following interventions: -follow facility fall protocol initiated 5/7/24. Review of the Nursing Progress Note dated 4/5/25, indicated the following relative to Resident #45: -was lowered to the floor during a transfer from the wheelchair to the bed. -said his/her legs gave out and was lowered to the floor by the CNA who was assisting him/her. -was in stable condition and vital signs were stable. -reported no pain to the Nurse and no injuries were sustained. Review of the Certified Nurses Aide (CNA) Care Card on 4/7/25 at 12:03 P.M., indicated the following: -Resident #45 transfers with assistance of two staff with mechanical lift. On 4/6/25 at 10:16 A.M., the surveyor observed Resident #45 dressed and seated in a wheelchair in the common room located on the unit. During an interview at the time, Resident #45 said he/she had a fall last night (4/5/25) because there were not enough staff to assist in transferring him/her from the wheelchair to the bed. Resident #45 said one CNA assisted him/her and two staff were supposed to assist with transfers. Resident #45 said four to five staff had to assist him/her off the floor and to the bed. Resident #45 said his/her elbow hurt from the fall. Review of the facility schedule on 4/5/25 for the 3:00 P.M. to 11:00 P.M. shift on Resident #45's unit indicated two CNAs were scheduled. On 4/7/25 at 1:55 P.M., the surveyor requested the fall investigation for Resident #45 on 4/5/25, from Unit Manager (UM) #1. On 4/7/25 at 2:18 P.M., the Director of Nursing (DON) said they were unable to locate a completed fall investigation on 4/5/25 for Resident #45. The DON said the facility had a fall protocol and risk assessment that should be completed when a Resident falls. The DON further said that staff statements would be obtained at the time of the fall and that Resident falls were reviewed in the morning meeting. During an interview on 4/7/25 at 2:46 P.M., CNA #1 and CNA #2 said Resident #45 was one assist of staff with transfers from the wheelchair to the bed, but sometimes he/she needed assistance of two staff because of fatigue. When the surveyor asked how the CNA's would know how much assistance the Resident would need at any given time, CNA #1 and CNA #2 said they were regular staff, knew the residents and knew what they needed. CNA #1 and CNA #2 said the specific resident care information was available in the computer. CNA #1 said Resident #45 had a recent fall on the 3:00 P.M. to 11: 00 P.M. shift during a transfer and the Resident was lowered to the floor. Both CNA #1 and CNA #2 said they were unaware of any changes to the Resident's plan of care after his/her recent fall. During an interview on 4/7/25 at 2:57 P.M., Nurse #1 said she worked on the 3:00 P.M. to 11:00 P.M. shift on 4/5/25 when Resident #45 fell. Nurse #1 said the Resident was lowered to the floor by the CNA. Nurse #1 said that she had not completed a fall investigation for this incident and should have. During an interview on 4/7/25 at 3:29 P.M., UM #1 said a fall investigation for Resident #45 was not completed on 4/5/25 and they were currently completing one. During an interview on 4/7/25 at 3:44 P.M., the DON and Assistant Director of Nurses (ADON) said there was no fall investigation completed for Resident #45 on 4/5/25. The DON said at a minimum, the Resident's care plan should have been adjusted but it was not adjusted until today (4/7/25). The DON said the Resident's care plan indicated he/she required assistance of two staff with transfers and the Resident had assistance of one staff when the fall occurred on 4/5/25. During an interview on 4/7/25 at 3:55 P.M., CNA #5 said she worked on the 3:00 P.M. to 11:00 P.M. shift on 4/5/25, and was present when Resident #45 fell. CNA #5 said she had worked with Resident #45 previously on the 7:00 A.M. to 3:00 P.M. shift and that the Resident usually required assistance from one staff for transfers during that shift. CNA #5 said she received a verbal report from the CNAs on the care needs of residents when she worked and said that it could be difficult to get information that was needed for resident care because when staff were asked, sometimes they did not know. CNA #5 said after Resident #45 fell, she was told by the 3:00 P.M. to 11:00 P.M. staff that the Resident required assistance of two staff with transfers on that shift. CNA #5 said that prior to the Resident's fall, she was unaware of this information. During an interview on 4/7/25 at 4:00 P.M., the Director of Rehabilitation (DOR) said staff should have provided assistance of two staff for all transfers for Resident #45. Please refer to F725

Based on interview, and record review, the facility failed to ensure that competency in skills and techniques necessary to provide resident care were demonstrated for four staff members (#7, #8, #9 and #10) out of a total of five staff reviewed. Specifically, for Staff Member's #7, #8, #9, and #10, the facility failed to ensure that the staff members completed the necessary competencies as indicated in the Facility Assessment. Findings include: Review of the Facility Assessment (self-completed assessment that indicated what types of care a facility provided as well as what their staffing and educational plans to meet the Resident's needs), dated 1/28/25, indicated the following competencies would be completed during new employee orientation, annually, and as needed: -For all staff: person-centered care, infection control-hand hygiene, infection control-universal precautions, infection control-protective equipment, disaster planning. -For clinical staff: activities of daily living, caring for people with Dementia, Alzheimer's and cognitive impairments, caring for residents with mental and psychosocial disorders. -For Nurses: medication administration, resident assessment. -For Nurses aide and Nurses: measurements - vital signs and intake and output. -For social services, clinical staff, activities, and therapy: non - pharmacological management of responsive behaviors, caring for residents with trauma/Post Traumatic Stress Disorder (PTSD). Review of Staff Member #7's education records failed to indicate evidence that any competencies had been completed. Review of Staff Member #8's education records failed to indicate evidence that any competencies had been completed. Review of Staff Member #9's education records failed to indicate evidence that any competencies had been completed. Review of Staff Member #10's education records failed to indicate evidence that any competencies had been completed. During an interview on 4/9/25 at 2:32 P.M., the Administrator said the facility was unable to provide any evidence that the competencies indicated by the Facility Assessment had been completed for Staff Members #7, #8, #9 and #10.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #30 was admitted to the facility in September 2023 with diagnoses including Type 2 Diabetes Mellitus with neuropathy and Hemiplegia and Hemipararesis following a Cerebral Infarction affecting the Left Non-Dominant side and Methicillin Resistant Staphylococcus Aureus (MRSA: type of bacteria that could cause a serious infection and was difficult to treat with antibiotics). Review of the facility policy titled Contact Precautions, revised 10/29/24, indicated Contact Precautions are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or the patient's environment. The policy also included the following: -Contact Precautions include: >handwashing . >glove use . >gowns . Review of the Minimum Data Set (MDS) Assessment, dated 2/8/25, indicated the following for Resident #30: -he/she understood and understands -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15 points On 4/6/25 at 9:59 A.M., the surveyor observed Resident #30 dressed in shorts and seated in wheelchair in his/her room. The Resident's left lower extremity was observed to be swollen and the calf was pink with peeling skin. Two round quarter-sized areas with yellow centers were observed on the outer and inner middle left calf. During an interview at the time, Resident #30 said the open areas on the outer and inner calf were caused from his/her brace and pointed to a leg brace which was near his/her dresser. Resident #30 said he/she had a dermatology appointment on 4/1/25 for removal of skin tags and the skin doctor also looked at his/her left lower leg. Review of Resident #30's clinical record included the following: -Provider Visit Note, dated 3/19/25, indicated Resident #30 had a dermatology appointment on 4/1/25 at 2:00 P.M. for skin tags -no documented evidence of the Resident's results from the Dermatology Consult on 4/1/25 Review of a Nurse's Note, dated 4/7/25, indicated the dermatology office contacted the facility at 3:50 P.M. to report results from a culture that was obtained from Resident #30 at his/her appointment last week (on 4/1/25) which indicated the Resident was positive for MRSA infection in his/her left lower extremity. The facility requested a copy of the lab results and the on-call Provider was contacted regarding the results and requested the Dermatology Provider write the order for antibiotics and the dermatology office was closed at that time. The on-call Provider gave an order for one time dose of antibiotic and requested the facility staff contact the dermatology office on 4/8/25 to obtain additional orders for antibiotics and wound care treatment orders. Review of the April 2025 Physician's orders indicated the following: -Infection Precautions- Contact Isolation: Resident is isolated in room, without a roommate or cohort with like pathogen, due to active infection with transmissible significant pathogens. Above standard transmission precautions maintained, with activities and all services brought to the resident, every shift, initiated 4/7/25 -Bactrim DS (antibiotic) 800-160 milligrams (mg), twice daily for one day pending dermatology recommendations on 4/8/25, initiated 4/7/25 -Doxycycline Monohydrate (antibiotic), 100 mg twice daily for ten days for MRSA infection in left lower leg, initiated 4/8/25 -Wound- left lower leg: cleanse with wound cleanser, xeroform/ABD/rolled gauze daily. Elevate legs as tolerated every day shift, initiated 4/8/25 On 4/8/25 at 10:48 A.M., the surveyor observed the following: -Contact Precaution signage posted outside of Resident #30's room which indicated to conduct hand hygiene prior to and upon exiting the room and to put on a gown and gloves prior to room entry. -a bin was outside of the Resident's room and did not contain gowns. During an interview at the time, UM #1 said Contact Precautions were put into place for Resident #30 because he/she had an MRSA infection. UM #1 said she had contacted laundry approximately 20 minutes prior to request more gowns and they have not been provided yet. When the surveyor asked if there were gowns available elsewhere on the unit, UM #1 said she checked the clean utility room and there were none available. On 4/8/25 at 10:54 A.M. through 11:00 P.M., the surveyor observed the following: -Housekeeping Staff #1 entered Resident #30's room without a gown. Several minutes later, UM #1 approached the surveyor, who was outside of the Resident's room. UM #1 said Housekeeping Staff #1 should have a gown on when in the Resident's room. -Rehabilitation Staff entered Resident #30's room with no gown or gloves worn and was observed to exit the room several minutes after, perform hand hygiene and walk down the hallway. During an interview on 4/8/25 at 11:10 A.M., UM #1 said when a Resident returns from an outside medical appointment, the Nurse would receive the information from the Resident regarding the visit and any instructions that would need to be relayed to the Provider. UM #1 said if a Resident returns without information from an appointment, the facility would contact the outside Provider for information regarding the visit, and she was not sure this was done for Resident #30. UM #1 said she was unaware Resident #30 had a culture obtained until the dermatology office contacted the facility on 4/7/25. During an interview on 4/8/25 at 11:54 A.M., and at 1:51 P.M., the DON said Resident #30 had an appointment on 4/1/25 to remove skin tags, but the facility was not aware that a lower extremity skin culture was obtained. The DON said when a Resident had a medical appointment outside of the facility and returns with no information, the facility should contact the outside Provider to obtain information on what transpired at the appointment and this did not occur for Resident #30. The DON said had the facility known a culture of the Resident's left lower extremity was pending, contact precautions would have been initiated (on 4/1/25) pending the result of the culture. The DON further said he was made aware of the infection control concerns relative to facility staff not donning the appropriate PPE for Resident #30. Based on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the transmission of communicable diseases and infections for two Residents (#272 and #30), out of a total sample of 23 residents. Specifically, 1. For Resident #272, the facility failed to ensure infection control practices were maintained in donning (putting on)Personal Protective Equipment (PPE: items worn to protect from the spread of infection such as a gown or gloves) before administering medication through a [NAME] Catheter (a type of central intravenous line that is inserted through the chest into a larger vein near the heart) placing the Resident at risk for contamination and infection of the [NAME] Catheter. 2. For Resident #30, the facility failed to ensure Contact Precautions were implemented when the Resident was pending labwork for potential transmissible organisms and that facility staff adhered to infection control practices by donning PPE as required, to decrease the risk of potential transmission and exposure of infection. Findings include: 1. Review of the facility policy titled Hand Washing, revised 10/28/24, indicated the following: -Handwashing is an integral part of an effective infection control program. Its purpose is to reduce the risk of blood borne illness and prevent cross contamination. -Hands should be washed before resident care . Review of the facility policy Enhanced Barrier Precautions, revised 10/28/24, indicated the following: -Enhanced Barrier Precautions (EBP) is used during high-contact care activities for residents with chronic wounds or indwelling medical device . -Indwelling medical device: examples include but are not limited to central lines . Resident #272 was admitted to the facility in April 2025 with diagnoses including acute and subacute infective Endocarditis and Bacteremia. Review of the Enhanced Barrier Precautions sign posted outside of Resident #272's room indicated: -Everyone Must: clean their hands, including before entering and when leaving the room. -Providers and staff must also wear gloves and gown for the following high contact Resident care activities: >Device care use: central line . On 4/8/25 at 10:30 A.M., during an intravenous (IV) medication administration observation by Nurse #4, the surveyor observed the following: -Nurse #4 obtained medications from the medication storage room -Nurse #4 obtained an alcohol preparation pad from inside her medication cart -Nurse #4 proceeded to Resident #272's room where she donned a gown and gloves without performing hand hygiene and entered the room to complete the medication administration process -Nurse #4 administered the medication, doffed (removed) her PPE, and performed hand hygiene before exiting the room. During an interview on 4/8/25 at 10:46 A.M., Nurse #4 said she should have performed hand hygiene before donning her PPE due to the risk of contamination of the [NAME] catheter, but she did not. During an interview on 4/9/25 at 9:52 A.M., the surveyor reviewed Nurse #4's intravenous medication observation with the Director of Nursing (DON) and Assistant Director of Nursing/Infection Preventionist (ADON/IP). The ADON/IP said that Nurse #4 should have performed hand hygiene between touching her medication cart and donning PPE. The DON said not performing hand hygiene posed a risk for potential contamination of a central line.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to ensure that six Residents (#2, #45, #48, #108, #3 and #9) and/or their Resident Representatives were afforded the right to participate in the scheduled interdisciplinary (IDT) care plan meetings, out of a total sample of 23 residents. Specifically, the facility failed to: -For Resident #2, Resident #45, and Resident #108, ensure quarterly IDT care plan meetings occurred and that the Resident was invited to participate in the meetings. -For Resident #48, ensure quarterly IDT care plan meetings occurred and the Resident and/or Resident Representative were invited to participate in the meetings. -For Resident #3, and Resident #9, ensure IDT care plan meetings occurred and the Resident and/or Resident Representative were invited to participate in the meetings. Findings include: Review of the facility policy titled Care Plans, revised 11/20/24, indicated the following: -The resident, the resident's family and/or the legal representative/guardian or surrogate are encouraged to participate in the development of any revisions to the resident's care plan. -Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. -The mechanics of how the IDT meets its responsibilities in the development of the interdisciplinary care plan (face-to-face, teleconference, written communication .) is at the discretion of the care planning committee. 1. Resident #2 was admitted to the facility in October 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF), Dementia and Adult Failure to Thrive. Review of the Minimum Data Set (MDS) Assessment, dated 1/14/25, indicated for Resident #2: -he/she was understood and understands -had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of nine out of 15 possible points -Health Care Proxy (HCP: designated person who makes medical decisions if the resident was no longer able) was invoked. Review of the IDT Care Plan Meeting schedule indicated meetings were scheduled for the following dates/times: -9/19/24 at 1:00 P.M. -12/19/24 at 1:30 P.M. -4/16/25 at 1:30 P.M. Review of the Resident's clinical record failed to indicate documented evidence that IDT care plan meetings on 9/19/24 and 12/19/24 occurred as scheduled for Resident #2. During an interview on 4/9/25 at 2:56 P.M., Unit Manager (UM) #1 said she was unable to find evidence that an IDT care plan meeting occurred on 12/19/24 as scheduled. UM #1 further said that even though the Resident's HCP was invoked, the Resident should be invited to attend the meeting and there should be documentation that the Resident was invited and declined to attend the 9/19/24 IDT care plan meeting. 2. Resident #45 was admitted to the facility in April 2024 with diagnoses including Osteoporosis, Parkinson's Disease, dizziness and giddiness, difficulty walking and unsteadiness on feet, and Hypotension. Review of the MDS Assessment, dated 3/25/25, indicated the following relative to Resident #45: -he/she understands and was understood -was cognitively intact as evidenced by a BIMS score of 14 out of a possible 15 points. Review of the Resident's clinical record failed to indicate documented evidence of the required quarterly IDT care plan meetings for Resident #45. On 4/8/25 at 3:33 P.M., the surveyor requested evidence of the IDT care plan meetings since admission for Resident #45 from UM #1. During an interview on 4/8/25 at 3:35 P.M., Resident #45 said he/she was not aware of any IDT care plan meetings about his/her care. Resident #45 said if there were meetings to discuss his/her care, he/she would like to be included in them. During an interview on 4/8/25 at 4:30 P.M., UM #1 said the Resident's IDT care plan meeting was not held on 10/10/24 because the Resident was out of the facility on a medical leave of absence. UM #1 said there was no evidence that the IDT care plan meeting was held when the Resident returned to the facility and UM #1 was only able to find evidence that a meeting occurred with the Social Worker and the Resident Representative via telephone on 1/9/25. UM #1 said there was no indication of any other IDT members that participated in the meeting on 1/9/25 or that Resident #45 was invited to attend. UM #1 further said she was unable to find evidence of other scheduled IDT care plan meetings for Resident #45. 3. Resident #48 was admitted to the facility in November 2024 with diagnoses including Parkinson's Disease, Depression and Dementia. Review of the MDS Assessment, dated 1/6/25, included the following relative to Resident #48: -he/she understands and was understood -was moderately cognitively impaired as evidenced by a BIMS score of 11 out of a possible 15 points. Review of the Social Service Note, dated 1/31/25, indicated an IDT care plan meeting was scheduled for 2/6/25 at 10:30 A.M. Review of the April 2025 Physician's orders indicated Resident 48's HCP was invoked on 1/18/25. Review of the Resident's clinical record failed to indicate documented evidence that IDT care plan meetings were held and that the Resident and/or HCP were invited to attend. During an interview on 4/9/25 at 11:06 A.M., Resident #48's HCP said he/she has not been invited to participate in any IDT care plan meetings scheduled for Resident #48 since his/her admission. Resident #48's HCP said he/she would like to be included in any IDT care plan meetings as the Resident was requesting a plan to be discharged from the facility. During an interview on 4/9/25 at 2:23 P.M., UM #1 said the facility was unable to find evidence that an IDT care plan meeting occurred on 2/6/25. 6. Resident #9 was admitted to the facility in December 2024 with diagnoses including Cerebral Palsy, suicidal ideation (SI), and Depression. Review of Resident #9's medical record failed to indicate documented evidence that an IDT care plan meeting took place at the facility since his/her admission in December 2024. Review of the MDS assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a BIMS score of 15 out of 15. During an interview on 4/8/25 at 11:26 A.M., Resident #9 said he/she did not recall participating in any type of team meeting at the facility that included different departments from the facility. During an interview on 4/8/25 at 11:20 A.M., the Social Worker Assistant said that she could not find evidence that any care plan meetings took place for Resident #9. During an interview on 4/8/25 at 11:53 A.M., MDS Nurse #1 said that a 48-hour or 72-hour meeting occurs when a Resident was admitted to the facility. MDS Nurse #1 said that a care plan meeting was scheduled within two weeks after a Resident's quarterly assessment had been completed. MDS Nurse #1 said to the best of her knowledge, no care plan meetings were scheduled in between the date of admission and that first quarterly assessment. 4. Resident #108 was admitted to the facility in February 2025 with diagnoses including Traumatic Subdural Hemorrhage and Anxiety Disorder. Review of Resident #108's MDS Assessment, dated 3/1/25, indicated the Resident was cognitively intact as evidenced by a BIMS score of 15 out of a total possible score of 15. Review of Resident #108's medical record failed to indicate documented evidence that an IDT care plan meeting took place at the facility since his/her admission in February 2025. During an interview on 4/8/25 at 2:35 P.M., UM #2 said that there was no evidence that Resident #108 had an IDT care plan meeting that involved the Resident. UM #2 further said Resident #108 was not involved in the care plan process for the comprehensive care plan that was developed based off the MDS assessment completed on 3/1/25. 5. Resident #3 was admitted to the facility in March 2025 with diagnoses including Schizophrenia. Review of Resident #3's MDS assessment dated [DATE], indicated the Resident had severe cognitive impairment as evidenced by a BIMS score of six out of a total possible score of 15. Review of Resident #3's medical record indicated the following: -the Resident had a court appointed Guardian -no evidence that the Resident's Representative had been included in the care planning process after completion of the MDS Assessment. During a telephone interview on 4/8/25 at 2:31 P.M., Resident Representative #3 said he/she had not been invited to a care plan meeting for Resident #3. During an interview on 4/8/25 at 2:35 P.M., UM #2 said that there was no evidence that Resident #3 had an IDT care plan meeting that involved the Resident Representative. UM #2 further said that the Resident and Resident Representative were not involved in the care plan process for the comprehensive care plan that was developed based off the MDS assessment completed on 3/11/25.

Based on interviews, and record review, the facility failed to ensure that four Resident's (#12, #6, #45 and #84), out of a total sample of 23 residents, had the right to privacy when receiving letters, packages and other materials delivered to the facility via postal services. Specifically, for Resident's #12, #6, #45 and #84, the facility failed to ensure that mail addressed to the Residents' was delivered unopened. Findings include: Review of the facility policy titled Communication Rights, revised on 11/5/24, indicated the following in part: -The resident has the right to send and receive mail and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a Postal Service including the right to privacy . During a Resident Council Meeting held on 4/7/25 from 10:00 until 10:50 A.M., the following was discussed: -Resident #12 said he/she had received his/her mail opened about two weeks ago. Resident #12 said the opened mail was a letter from his/her doctor's office and that the facility did not have the right to open the mail. Resident #12 said he/she spoke to the person who opened the mail and declined to provide additional information to the surveyor. -Resident #6 said he/she received his/her mail opened about one month ago. Resident #6 said while it was only junk mail, it had his/her name, and that the facility should not be opening his/her mail. -Resident #45 said he/she received his/her mail opened about one month ago. Resident #45 said it was a letter from his/her brother, and the facility should not have opened his/her mail because it was a federal offense. During an interview on 4/7/25 at 3:05 P.M., the Director of Activities and the Activity Assistant (AA) said the mailman brings the mail to the facility, separated by department and then the mail goes into the Activities mailbox. The Director of Activities said she and her staff distribute the resident mail every day except Sundays. The Director of Activities said that she recently encountered an opened box that belonged to Resident #84. The Director of Activities said she was not aware of who opened the box belonging to Resident #84 and said residents' mail should never be opened prior to giving it to them, as it was a privacy concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #51 was admitted to the facility in February 2019 and resided on the F-Wing Unit. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the following for Resident #51: -he/she understands and was understood. -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of a possible 15 points. -had bilateral range of motion (ROM) impairments of his/her lower extremities. -was dependent on staff for toileting needs. During an interview on 4/7/25 at 8:07 A.M., Resident #51 said he/she had a horrible night last night (4/6/25). Resident #51 said he/she rang his/her call light on the Evening shift for assistance with toileting and a staff person came in and turned off the light, left the room and did not provide toileting assistance until two hours later. Resident #51 said he/she was so upset that he/she could not go to sleep until 4:00 A.M. the next morning. After the interview, the surveyor immediately notified the DON of the Resident's concern. On 4/7/25 from 10:40 A.M. through 11:01 A.M., the surveyor observed the following: -10:40 A.M.: a red blinking light was lit outside of Resident #51's room. Two CNAs were previously observed in other residents' room and there was no staff visible in the hallway. A light was observed blinking near the nurses station and there was an audible beeping coming from the nurses station. -10:58 A.M.: Resident #51's call light remained on and no staff were observed to enter the Resident's room. -11:00 A.M.: Resident #51's call light remained lit. The surveyor knocked and entered the Resident's room and observed the bathroom door to the room was open and Resident #51 was seated on the toilet. During an interview at the time, Resident #51 said he/she had been on the toilet and utilized the call light for assistance in the bathroom but no one had come to see him/her yet. -11:01 A.M.: CNA #2 entered the Resident's room at the time to provide assistance (21 minutes after the call light was initiated). During an inteview on 4/7/25 at 11:04 A.M., CNA #1 said Resident #51 required assistance of two staff with transfers and the Unit was scheduled with two and a half (2.5) CNAs today. CNA #1 said two CNAs on the hallway where Resident #51 resides was not enough. CNA #1 said she and CNA #2 were running around to get residents washed and dressed and up for the day, and they did not have time to take their scheduled breaks. CNA #1 said there are 11 residents on the F-Wing that required assistance of two staff. During an interview on 4/7/25 at 1:29 P.M., the DON said when a resident call light was initiated, it should be answered within five minutes. The DON said the staffing at the facility was a challenge, the facility was currently working on this concern, had hired nursing and understood the concern relative to CNAs. The DON said that the facility needed to work on the staffing. 3. Resident #45 was admitted to the facility in April 2024 and resided on the F-Wing Unit. Review of the Activities of Daily Living (ADL) Care Plan, initiated 4/4/24, indicated Resident #45 had an alteration in ability to care for him/herself and required assistance. The ADL Care Plan included the following interventions: -requires mechanical lift with two staff assistance with transfers, initiated 4/4/24. Review of the Nursing Progress Note dated 4/5/25, indicated Resident #45: -was lowered to the floor during a transfer from the wheelchair to the bed. -said his/her legs gave out and he/she was lowered to the floor by the CNA who was assisting him/her. -was in stable condition and vital signs were stable. -reported no pain to the Nurse and no injuries were sustained. Review of the CNA Care Card on 4/7/25 at 12:03 P.M., indicated the following: -Resident transfers with assistance of two staff with mechanical lift. On 4/6/25 at 10:16 A.M., the surveyor observed Resident #45 dressed and seated in a wheelchair in the common room located on the unit. During an interview at the time, Resident #45 said he/she had a fall last night (4/5/25) because there were not enough staff to assist in transferring him/her from the wheelchair to the bed. Resident #45 said one CNA assisted him/her and two staff were supposed to assist with transfers. Resident #45 said four to five staff had to assist him/her off the floor and to the bed, and his/her elbow hurt from the fall. Review of the facility schedule on 4/5/25 for the 3:00 P.M. to 11:00 P.M. shift on Resident #45's unit (F-Wing) indicated that two CNAs were scheduled. During an interview on 4/7/25 at 4:00 P.M., the Director of Rehabilitation (DOR) said staff should provide assistance of two staff for all transfers for Resident #45. 4. Resident #13 was admitted to the facility in November 2023 and resided on the C-Wing. Review of the person-centered Integumentary (skin) Care Plan, initiated 5/15/24, indicated Resident #13: -had an alteration in the integumentary system due to cerebrovascular accident (CVA: stroke), Left hemiparesis, Dementia, use of anticoagulation, neuropathy, wound on left ischium, right 1st metatarsal head, and right heel. The Integumentary Care Plan included the following intervention: >will be monitored for a change in condition and the Physician will be notified, initiated 5/15/24. Review of the MDS Assessment, dated 3/7/25, indicated Resident #13: -had severe cognitive impairment as evidenced by a BIMS score of four out of a total of 15 points. -was at risk for developing Pressure injuries. -had no unhealed Pressure Injuries. During an interview on 4/9/25 at 10:18 A.M., CNA #8 said Resident #13 had a right heel wound that had a black area in the center for a long time. CNA #8 said that while working on 3/23/25, she and CNA #7 identified that the Resident had right foot swelling and redness, and that the Resident's right heel wound looked different. CNA #8 said she had also noticed the Resident was acting differently and was quiet, which was not the Resident's usual behavior. CNA #8 said both she and CNA #7 were concerned, and that CNA #7 reported the concern about the Resident's change in condition to Nurse #5 and the Assistant Director of Nurses (ADON). During an interview on 4/9/25 at 10:50 A.M., the ADON said she had worked on 3/23/25 from 7:00 A.M. to 7:00 P.M. but did not recall hearing anything about Resident #13's change in condition relative to his/her right heel. The ADON said she may have been unable to recall hearing anything because she had worked 27 hours that weekend, after working her regular 40-hour schedule, due to a staffing shortage. During an interview on 4/9/25 at 2:52 P.M., the DON said that weekend (3/22/25 and 3/23/25) was hell weekend due to staffing. The DON said he also had to work on the Units during that time. Based on observations, interviews, 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 four units (A-Wing, C-Wing, D-Wing, and F-Wing), out of a total of four units, and for three Residents (#51, #45, and #13), out of a total sample of 23 residents. Specifically, 1. The facility failed to ensure that staffing levels on the A-Wing, C-Wing, D-Wing and F-Wing were provided to meet the residents needs of each unit safely. 2. For Resident #51, the facility failed to ensure toileting assistance was provided promptly when the Resident was indisposed and had the call light on for over 20 minutes. 3. For Resident #45, the facility failed to provide assistance of two staff with transfers as required resulting in a fall when the Resident was transferred with one staff memebr. 4. For Resident #13, the facility failed to provide timely notification to the Physician when the Resident experienced a change in condition and the Nurse responsible for providing care had worked 27 hours that weekend in addition to her regularly worked 40-hour schedule. Findings include: 1. Review of the Facility Assessment (self-completed assessment that indicate what types of care the facility provided as well as what their staffing and educational plans are to meet the residents residing in the facility's needs), dated 1/28/25, failed to indicate evidence that the facility had assessed for how many Certified Nurses Aides (CNAs) were required per resident, unit or shift to ensure appropriate care was provided to the residents residing in the facility. During an interview on 4/8/25 at 11:37 A.M., the Director of Nursing (DON) said the facility staffing plan was to have: -three CNAs on each unit for the Day (7:00 A.M. to 3:00 P.M.) shift -three CNAs on each unit for the Evening (3:00 P.M. to 11:00 P.M.) shift -two CNAs on each unit for the Night (11:00 P.M. to 7:00 A.M.) shift. The DON said in an ideal world they would additionally have one CNA split between the A-Wing and C-Wing, and one split CNA between the D-Wing and F-Wing during day and evening shifts, but that the facility could run adequately with three CNAs on each unit. During a follow-up interview on 4/8/25 at 1:58 P.M., the DON said he knew there were staffing shortages, and it was visible on the schedule. Review of the CNA schedule from 3/2/25 through 4/5/25 indicated the following: -On 3/2/25: F-Wing was staffed with two CNAs working on the Day shift and was staffed with two CNAs for the Evening shift -On 3/4/25: A-Wing was staffed with one CNA working on the Evening shift -On 3/5/25: C-Wing was staffed with two CNAs working on the Day shift -On 3/7/25: A-Wing was staffed with two CNAs working on the Day shift and C-Wing was staffed with two CNAs working on the Evening shift -On 3/10/25: C-Wing was staffed with two CNAs working on the Day shift -On 3/15/25: C-Wing was staffed with two CNAs working on the Evening shift -On 3/16/25: A-Wing was staffed with two CNAs working on the Evening shift -On 3/18/25: C-Wing was staffed with two CNAs working on the Day shift -On 3/24/25: C-Wing was staffed with two CNAs working on the Day shift and D-Wing was staffed with one CNA working on the Day shift -On 3/25/25: F-Wing was staffed with two CNAs working on the Day shift -On 4/2/25: A-Wing was staffed with two CNAs working on the Evening shift Review of the Resident Council Meeting Minutes, dated 2/19/25, indicated the following: -Residents shared concerns about staffing levels affecting timely care. Review of the Resident Council Meeting Minutes, dated 3/26/25, indicated the following: -Concerns relative to slow response times -Delay in help -Staff not listening During the initial pool process on 4/5/25 and 4/6/25, the following included information shared with the survey team: -Resident #41 said the facility was short-staffed and the 11:00 P.M. to 7:00 A.M. (Night) shift was the worst. Resident #41 said there are usually two CNAs at night but sometimes there is one CNA. Resident #41 said he/she would have to wait 35-40 minutes several times a week for staff assistance. Resident #41 said the DON was aware of these concerns. -Resident #94 said it could take up to one to two hours for staff to answer his/her call light and provide assistance. Resident #94 said that he/she needed assistance from staff to use the bathroom and facility staff have told him/her to hold it until they are able to assist him/her. Resident #94 said this occurred on all shifts at least weekly, and that he/she had not been incontinent but had to try hard to not have incontinence happen. -Resident #18 said it took sometimes an hour for facility staff to assist him/her with toileting assistance and has had episodes of incontinence due to having to wait for staff assistance. -Resident #108 said he/she sometimes had to wait up to a half hour for the call light to be answered and that this occurred typically on the Day shift. During a Resident Council Meeting held on 4/7/25 from 10:00 until 10:50 A.M., the following was discussed: -Resident #6 said that the call bell wait times can range anywhere from five minutes to one hour. Resident #6 further said that his/her experience with long call bell wait times had primarily been with the Evening shift. -Resident #11 said that his/her experience with long waiting times had been mainly on the Day shift. Resident #11 said about a week ago, he/she called for help, but no one came for quite some time. Resident #11 said that he/she could not wait any longer, so he/she walked to the nurses station alone, even though there is a sign in his/her room on the mirror, that says to call before you fall. Resident #11 said he/she went to the nurses station, there was no one around, he/she was afraid that he/she might fall but needed help and could not wait any longer for someone to answer the call bell. Resident #11 said that he/she could not recall how long he/she waited but it was well over five minutes. During an interview on 4/7/25 at 2:30 P.M., two CNAs, who requested to remain anonymous said the following: -one CNA felt it could be neglectful to not have at least three CNAs on the unit for care because the CNAs are rushing and unable to provide the time and care to the residents. -the second CNA said he/she had told administration about the need for three CNAs on the shift, that they were exhausted, burnt out and unable to provide the care that they deserve to the residents. The second CNA said they did not feel appreciated and administration staff did not usually assist on the units with resident meals or check in with the staff to see how they were managing their residents. During an interview on 4/8/25 at 9:05 A.M., a Nurse, who requested to remain anonymous, said there were currently four CNAs on the unit today which was not typical. The Nurse said they usually have three CNAs and often have two CNAs for 30 to 31 residents which was not enough. The Nurse said when there was a call-out of staff on one of the other floors, administration will pull a CNA from his/her unit, even if there were three CNAs, leaving them with two CNAs. The Nurse said when the main dining room was open, it was difficult to manage the unit because a Nurse had to be in the main dining room from 11:30 A.M. until 1:00/1:30 P.M. or until the last resident in the main dining room had completed eating and that left the unit with less staff. The Nurse said it had been very difficult to work and felt it was not safe for the residents who live on the unit. The Nurse said these concerns have been relayed by staff to administration and nothing changes. During an interview on 4/8/25 at 10:32 A.M., a CNA, who requested to remain anonymous, said when there are two and a half CNAs on each of the second floor units (F-Wing and D-Wing), it was not manageable. The CNA said the main resident dining room was not typically open on the weekends and there were staff call-outs on the weekend and there were not enough staff to have the main dining room open. The CNA said the resident's really enjoy the main dining room and were excited to have their meals there because the atmosphere was nice and the residents enjoy the socialization. During an interview on 4/9/25 at 4:40 P.M., the Administrator said the main dining room was not open during the weekends due to staffing shortages because a Nurse and a CNA need to observe the residents during that time.

2. Resident #23 was admitted to the facility in October 2023 with diagnoses including Dementia and Type 2 Diabetes. Review of the Resident's clinical record indicated the Consultant Pharmacist had recommendations for the following dates and noted to refer to the report for details on: -9/19/24 -11/20/24 -12/18/24 -1/23/25 Further review of the Resident's clinical record failed to indicate documented evidence on what the Consultant Pharmacist recommendations were or that the recommendations were addressed by the facility and/or the Physician. On 4/9/25 at 2:21 P.M., the surveyor requested the Consultant Pharmacy Recommendations for Resident #23 from the DON. During an interview on 4/9/25 at 5:20 P.M., the Administrator said he was unable to find evidence of the Consultant Pharmacist's Recommendations made on 9/19/24, 11/20/24, 12/18/24 and on 1/23/25 and whether the recommendations were addressed by the facility and/or the Physician. 3. Resident #48 was admitted to the facility in November 2024 with diagnoses including Parkinson's Disease, Depression and Dementia. Review of the Resident's clinical record indicated the Consultant Pharmacist made recommendations for the following dates and noted to refer to the report for details on: -12/13/24 -1/21/25 -2/24/25 Further review of the Resident's clinical record failed to indicate documented evidence on what the Consultant Pharmacist Recommendations were or indication that the recommendations were addressed by the facility and/or the Physician. During an interview on 4/9/25 at 11:33 A.M., the DON said he receives the recommendations from the Consultant Pharmacist and they are given to the Unit Managers (UM) to address with the Physician. The DON said when the Consultant Pharmacist Recommendations are responded to by the facility and/or the Physician, the DON would keep the original recommendation in his/office. The surveyor requested the Consultant Pharmacist Recommendations from the DON for Resident #48. On 4/9/25 at 12:35 P.M., the DON provided Resident #48's Consultant Pharmacy Recommendations as requested. The DON said the recommendation from 12/13/24 was not addressed until 2/28/25, after the Consultant Pharmacist made the recommendation again on 2/24/25. The DON said he was unable to see that the recommendation from 1/21/25 was addressed by the Physician. Based on record review, and interview, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were reviewed by the Physician as required for five Residents (#29, #23, #48, #84 and #32), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #29, ensure that a MRR was reviewed by the Physician for the month of December 2024 when recommendations had been made by the Consultant Pharmacist. 2. For Resident #23, ensure MRRs were reviewed and responded to by the Physician when recommendations were made by the Consultant Pharmacist on 9/19/24, 11/20/24, 12/18/24, and 1/23/25. 3. For Resident #48, ensure MRRs were reviewed and responded to timely by the Physician when recommendations were made by the Consultant Pharmacist on 12/13/24, 1/21/25, and 2/24/25. 4. For Resident #84, ensure MRRs were reviewed and responded to by the Physician when recommendations were made by the Consultant Pharmacist on 4/17/24, 7/24/24, and 9/19/24. 5. For Resident #32, ensure the Physician reviewed and responded to the MRR completed by the Consultant Pharmacist. Findings include: Review of the facility policy Medication Regimen Review, revised on 11/5/24, indicated the following: -Any irregularities will be communicated to the physician utilizing a written recommendation and report for consideration -Copies of the medication regimen review and written recommendations will be maintained as a part of the permanent medical record -Information on the medical regimen reviews and written recommendations will be reviewed by the Director of Nursing (DON). 1. Resident #29 was admitted to the facility in October 2023 with diagnoses including Cerebral Infarction (stroke), Type II Diabetes Mellitus, Depression, Mood Disorder, and Orthostatic Hypotension. Review of Resident #29's medical record indicated a MRR had been conducted on 12/17/24 and indicated to see the report for details. Further review of the medical record failed to indicate any documented evidence of the MRR report for 12/17/24. During an interview on 4/7/25 at 1:59 P.M., the DON said that at this time he was unable to locate the report for the December 2024 MRR. 4. Resident #84 was admitted to the facility in October 2023 with diagnoses including Hemiplegia and Dementia. Review of Resident #84's Consultant Pharmacist Progress Notes indicated the following: -4/17/24: MRR completed Medications reviewed. Please see the Consultant Pharmacist Report for the Recommendations. -7/24/24: MRR completed Medications reviewed. Please see the Consultant Pharmacist Report for the Recommendations. -9/19/24: MRR completed Medications reviewed. Please see the Consultant Pharmacist Report for the Recommendations. Review of Resident #84's medical record failed to provide any evidence of the Pharmacy Recommendations and Clinical Pharmacy Reports indicated in the Pharmacist Progress Notes on 4/17/24, 7/24/24, and 9/19/24. Further review of Resident #84's medical record failed to indicate that the Physician had reviewed the 4/17/24, 7/24/24, and 4/17/24, Pharmacy Recommendations. During an interview on 4/9/25 at 2:30 P.M., the DON said that he was unable to locate the Pharmacy Recommendations for the requested dates and was also unable to provide evidence that the Clinical Pharmacy Reports had been reviewed by the Physician as required. The facility was unable to provide any additional information pertaining to the Clinical Pharmacy Reports and Physician Review of the Pharmacy Recommendations to the survey team at the time of survey exit. 5. Resident #32 was admitted to the facility in October 2024 with diagnoses including Cerebral Infarction. Review of Resident #32's medical record indicated a Consultant Pharmacist MRR Recommendation, undated, printed on 1/29/25, that had not been reviewed by the Physician as evidenced by an incomplete/blank Physician/Prescriber response section. During an interview on 4/9/25 at 2:34 P.M., the surveyor and the DON reviewed the undated Pharmacy Recommendation printed on 1/29/25. The DON said that there was no evidence that the Physician had reviewed and addressed the MRR printed on 1/29/25.

Based on observations, interviews and record review, the facility failed to maintain a clean and sanitary facility kitchen and on two units (A-Wing and F-Wing) out of four units observed. Specifically, the facility failed to: -ensure Dietary Staff adhered to the hair restraint policy to minimize the potential for physical contamination during food preparation and meal service in the main facility kitchen. -label, date and store foods in the facility kitchen to decrease potential for food contamination and food-borne illnesses. -ensure that outside windows to the facility kitchen had screens to prevent pests/rodents from entering. -maintain and store food service equipment in a clean and sanitary manner in the main facility kitchen and on A-Wing and F-Wing units. Findings include: Review of the facility policy titled Staff Attire, revised 10/2023, indicated all employees wear approved attire for the performance of their duties. The Staff Attire policy also included the following: -All staff members will have their hair off their shoulders, confined in a hair net or cap, and facial hair properly restrained. Review of the facility policy titled Environment, revised 9/2017, indicated all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The Environment policy also included the following: -The Food Service Director (FSD) will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. -The FSD will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment after each use. -All food contact services will be cleaned and sanitized after each use, including tables, chairs, and floors. Review of the Labeling and Dating Inservice, undated, indicated the following: -Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and ensure that items that are past their due date are discarded. -All foods should be dated upon receipt before being stored. -Food labels must include: >the food item name >the date of preparation/receipt/removal from freezer >the use by date as outlined in the attached guidelines -Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate use by date as outlined in the Retention Guide . -Leftovers should be labeled and dated with the date they were prepared and the use by date. On 4/6/25 from 7:15 A.M. through 7:38 A.M., the surveyor conducted an initial tour of the kitchen and observed the following: -two Dietary Aides preparing the breakfast meal with no facial hair restraints being worn. -ice machine external filter had evidence of dust. The ice scoop was observed hanging on the outside of the ice machine exposing it to dust and potential contamination. -reach-in refrigerator had two bagels that were not labeled and dated, and an unlabeled energy drink. -walk-in refrigerator: >contained a rack that had uncovered raw hamburger patties on a tray with a use by date 3/26/25. >Below the raw hamburger tray was a tray of individual covered cups of cranberry sauce that were unlabeled and undated. >The bottom of the rack had a tray containing a closed package of raw white meat that was unlabeled and undated. >Another rack had multiple trays with styrofoam cups which were uncovered (open to air) and had applesauce and canned fruit that were unlabeled and undated. -shelving near the walk-in refrigerator was observed to be dirty, with debris and had clean pans stored. -closed container of a sugar-like substance that was unlabeled and undated. A container of thickener was undated, loosely covered and left open to air. -the ovens had dark dried cooked on debris on the bottom and internal doors. During an interview at the time, the [NAME] said he thought the ovens were cleaned monthly. -shelving over the three compartment sink was dirty with multiple different colored substances, and was tacky and greasy to the touch. -A window sill located next to the shelf and over the three compartment sink had multiple plates, a knife and cleaning pads. -a window located next to a pot/pan storage rack was open and did not have a screen. -a vent above the clean pot/pan storage rack had a thick gray coating of dust. -an open plastic bag with stained rags was on the floor next to the pot/pan storage rack and had fallen over and stained rags were observed spilling onto the floor. The surveyor observed an ice machine on the A-Wing unit, an ice scoop that was stored uncovered on a hook hanging on the outside of the ice machine with the ice scoop open to air on the following days: -4/6/25 at 9:45 A.M. -4/7/25 at 12:45 P.M. On 4/8/25 at 7:21 A.M., the surveyor conducted another walk through of the facility kitchen with the FSD and observed the following: -the [NAME] serving the breakfast line did not have a facial hair restraint on. -the ice machine external filter had evidence of dust. The ice scoop was observed hanging on the outside of the ice machine exposing it to dust and contamination. During an interview with the [NAME] at 8:42 A.M., he said he thought the ice scoop should be in a closed container to protect it from dust, debris and potential contamination. -visible dust was observed on the ceiling and lighting over the food preparation and service areas, in the vents near shelving above the food preparation sink and the dust was visibly blowing outward into the kitchen, and the vent above the clean pot/pan storage rack had a thick gray coating of dust. During an interview at the time, the surveyor relayed previous observations from 4/6/25 with the FSD and she said she heard the kitchen was a mess when the initial tour was conducted. The FSD said the maintenance department takes care of the dust on the vents, ceiling and lighting, but she was not sure how often this was done. The FSD said the kitchen windows should not be open unless there was a screen because it could allow pests/rodents to enter into the kitchen. The FSD said she saw the open window on 4/6/25 when she came into work that day. The FSD said that the ice scoop was supposed to be in a housing station, she had asked for one and was awaiting approval. The FSD said the way the ice scoop was stored currently was a potential infection control issue because it was exposed and could be contaminated and then used to get ice. During an interview on 4/8/25 at 1:14 P.M., the Director of Maintenance (DOM) said the vents in the facility kitchen were cleaned about two months ago and probably needed to be cleaned more frequently. The DOM said the dust on the walls, ceiling and lights in the facility kitchen were the responsibility of the kitchen staff. On 4/8/25 at 1:30 P.M. on the F-Wing unit, the surveyor observed an ice machine with an ice scoop stored uncovered on a hook hanging on the outside of the ice machine. On 4/9/25 at 3:40 P.M., the surveyor conducted another observation of the facility kitchen with the Regional FSD, and observed the following: -two Dietary Staff in the kitchen with no facial hair restraints on. During an interview at the time, the Regional FSD said hair restraints including facial hair restraints, should be worn to cover head and facial hair, if present. The surveyor relayed previous observations from 4/6/25 and 4/8/25 to the Regional FSD who said he understood the concerns relative to kitchen sanitation. During an interview on 4/9/25 at 3:52 P.M., the [NAME] said hair restraints should be worn to prevent hair from contaminating the food, that the hair restraint should cover all hair and included facial hair. The [NAME] said when items were pulled from the freezer, they should be dated when the item was pulled, covered and have a use by date. The [NAME] said all food items should be labeled and dated. The [NAME] further said the cranberry sauce observed on 4/6/25 should not have been stored under the tray of raw meat and that the hamburger patties should have been covered and discarded if the use by date was 3/26/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of four sampled residents (Resident #1), who required post-surgical care, including antibiotic therapy, wound monitoring and dressing changes, the facility failed to ensure Resident #1 was provided with nursing care and treatment that met professional standards for quality when 1) antibiotic therapy was not started upon admission despite the medication being available within the facility emergency supply, and 2) wound assessments upon admission, daily monitoring, and documentation related to treatment orders were not completed by Nursing, Findings include: Review of the Facility Policy titled, Nursing admission to the Facility, revised October 2023 indicated the following: -Observe the general condition of the resident (i.e., obvious skin issues, bruises, lacerations, bandages, any acute distress noted, general mood, etc.,) as well as his or her reaction to the admission. - All findings are to be documented in skilled charting admission note within residents' electronic medical record. - LPN/RN (must complete a full initial skin check within eight hours of admission and document in progress note. - LPN/RN must complete full skin check within 24 hours of admission and document in progress note/admission record. - LPN/RN: Completion of skilled charting admission note to be completed within 24 hours of admission by resident's primary nurse. - LPN/RN: Completion of nursing admission assessment to be completed within 24 hours of admission. Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulations (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and function of a Registered Nurse and Practical Nurse, respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define the Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. 1) Resident #1 was admitted to the Facility in April 2024, diagnoses included right below knee amputation, fracture of ribs right side, fracture of left tibia (the larger of two bones in the lower leg), and fracture of T11-T12 vertebra (bones that make up the spinal column). During a telephone interview on 10/17/24 at 11:30 A.M., Witness #1 said Resident #1 was admitted to the Facility after having his/her right leg amputated, that he/she required antibiotic therapy, surgical wound treatment and monitoring to both his/her right leg amputation site as well as to his/her lower left leg surgical site. Witness #1 said the Facility did not provide Resident #1 with timely antibiotic treatment, dressing changes or wound monitoring and that caused a worsening of his/her wound infection which then required him/her to be hospitalized again. Witness #1 said on 04/16/24 when Resident #1 went to a scheduled follow-up appointment with the Surgeon, the Surgeon immediately sent Resident #1 to the Hospital for evaluation of his/her infection and that Resident #1 was re-admitted to the Hospital for treatment. Review of Resident #1's Hospital Discharge/Transfer Note, dated 04/10/24 indicated that Resident #1 was to receive Cephalexin (an antibiotic medication) 500 milligrams (mg) by mouth every six hours and received his/her last dose on 04/10/24 at 2:00 P.M. Review of Resident #1's Hospital Inpatient Adult Discharge Instructions, Discharge Medications, dated 04/10/24, indicated Resident #1 should receive the next dose of Cephalexin on 04/10/24 at 8:00 P.M. Review of Resident #1's April 2024 Medication Administration Record (MAR) indicated he/she had a Physician's order for: - 04/11/24, Cephalexin Oral Tablet 500 mg by mouth four times a day for infection for ten days, discontinued 04/21/24. Review of Resident #1's April 2024 Physician's Orders and MAR indicated his/her Cephalexin was not started at the Facility until 04/11/24 at 5:00 P.M., resulting in three missed doses of the antibiotic (he/she therefore missed a total of 1500 mg of an antibiotic, that was ordered to treat his/her active infection). Review of the Cubex/MedBank (electronic medication dispensing system at the facility) inventory provided to the surveyors by the Director of Nursing, indicated that there were three Cephalexin 250 mg tablets, which was regularly stocked in the Cubex. However, further review of Resident #1's MAR, dated 04/10/24, indicated that even though the Cephalexin was available in the Cubex, it was not dispensed or administered to him/her. Resident #1's April 2024 MAR indicated Cephalexin was not administered on 04/10/24 at 8:00 P.M., or on 04/11/24 at 9:00 A.M. and 12:00 P.M. During a telephone interview on 10/22/24 at 1:40 P.M., the Facility's Pharmacy Customer Service Representative said Cephalexin was delivered to the facility on [DATE] at 2:33 P.M. During an interview on 10/22/24 at 1:50 P.M., Nurse #1 said when a Resident was admitted to the facility, the Nurse reviews the Hospital Discharge Summary to determine what was required to care for the new Resident. Nurse #1 said if Physician's orders were required, the Nurse would review the Discharge Summary with the Facility's Provider (Physician/Nurse Practitioner/Physician's Assistant), obtain the necessary orders and then enter the orders into the computer. Nurse #1 said the medication orders are entered, the Facility's computer system automatically communicates with the Pharmacy computer system and medications are usually delivered twice per day from the Pharmacy. Nurse #1 said if a Resident arrives after the last Pharmacy delivery of the day, Nursing will refer to the Discharge Summary to determine which medications were due next and check the Cubex system to see if any of those medications were available to dispense. During the interview, Nurse #1 and the surveyor reviewed Resident #1's Hospital Discharge Summary and noted that the Resident was to receive Cephalexin on 04/10/24 at 8:00 P.M. Nurse #1 said based on that information, the Nurse who completed Resident #1's admission should have ensured, when obtaining admission orders with the on-call Provider, that the Cephalexin had a start date of 04/10/24, not 04/11/24, and then obtained the medication from the Cubex, and administered the medication to Resident #1. Nurse #1 reviewed Resident #1's MAR with the surveyor, confirmed that Cephalexin was not scheduled to start until 04/11/24, and that the dosages due on 04/11/24 for 9:00 A.M. and 12:00 P.M. were left blank. Nurse #1 said she would have to assume Resident #1 did not receive the Cephalexin at that time. During an interview on 10/22/24 at 2:20 P.M., Nurse #2 said when a Resident was admitted to the Facility, she reviews the Hospital Discharge Summary and/or the Hospital Discharge/Transfer Note, which was more detailed than the Discharge Summary. Nurse #2 said if it was during regular hours, she would bring the Discharge Summary or Discharge/Transfer Note directly to the Facility Provider to determine what the admission orders would be and enter them into the computer accordingly. Nurse #2 said if the admission occurred after the Facility Provider left for the day, the Nurse is supposed to call the on-call Provider to review the Hospital Discharge Summary and/or the Hospital Transfer/Discharge Note over the phone with the Provider to obtain admission orders and then enter the orders into the computer. During the interview, Nurse #2 reviewed Resident #1's Hospital Discharge Summary and said based on the information provided, Cephalexin should have been ordered, removed from the Cubex, and administered to Resident #1 during the evening on 04/10/24. Nurse #2 said if there were blank spaces on the MAR, it was assumed the medication was not administered. Review of Resident #1's Medical Record which included a Physician's Assistant Progress Note, dated 04/15/24, that indicated the following: Resident #1 was evaluated sitting up in bed. Below Knee Amputation (BKA) incision appears to have purulent (thick, milky or pus-like fluid that oozes from a wound and is a sign of infection) drainage with possible dehiscence (partial or total separation of previously approximated wound edges, due to a failure of proper wound healing). He/She (Resident #1) notes the Surgeon called the Facility to change antibiotics on Friday afternoon, however, has not received them. Spoke to Unit Manager who reached out to his office and noted they sent in a prescription for Augmentin (Amoxicillin-Potassium Clavulanate) x 14 days. This writer suggested Resident #1 should go to the Emergency Department for further management and concern for dehiscence however he/she declined and will wait for his/her appointment with the Surgeon tomorrow. Review of Resident #1's Outpatient Surgical Visit Note, dated 04/16/24, indicated the following: Right below knee wound infection. The wound is poorly healing, and I suspect it will require surgical excisional debridement (a procedure where devitalized/dead tissue in the presence of underlying infection is removed using a sharp instrument, such as a scalpel). It would be best treated with intravenous antibiotics (injected directly into the vein to treat bacterial infections) and hospitalization. During an interview on 10/22/24 at 12:45 P.M., The Director of Nursing (DON) and surveyor reviewed Resident #1's Medication Administration Record (MAR) and Treatment Administration Record (TAR). The DON said it was her expectation that if a Nurse administered a medication or performed a treatment, the Nurse was to sign it off as completed on the MAR or TAR. The DON also said it was her expectation that if a medication was not given or a wound treatment was not provided, the Nurse was to document the reason on either the MAR, TAR or in a Nursing Progress Note. The DON said where there were blank spaces on the MAR and TAR, she would have to assume medications were not given and/or the treatments were not completed, as ordered. 2. Review of the Facility Policy titled, Skin Prevention, Assessment, and Treatment, revised October 2023 indicated the following: - Purpose: To provide a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. - Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse or designee, in the Medical Record. Review of Resident #1's Hospital Discharge/Transfer Note dated 04/10/24 indicated the following: - Left foot in CAM boot (a boot used to stabilize the foot and ankle after an injury or surgery). - The skin edges of the Below the Knee (BKA) amputation site are beginning to separate with some signs of white ischemic (tissue death) changes, re-evaluated by the surgeon today, ready for discharge to Rehab on Cephalexin (an antibiotic medication) for ten days. - Right BKA incision line management: Betadine (an antiseptic) paint to incision line, cover with dry dressing and secure. Change twice daily and as needed. Apply ACE wrap and stump sock (sock used to protect the amputation site). Patient is to wear right BKA Ampushield (a removable, adjustable, rigid plastic limb protector that helps patients heal after an amputation) as much as possible. - Left lower extremity management: Staples/sutures have been removed from left lower extremity, steri-strips (provides wound support and increases tensile strength of the wound) applied and will fall off on their own, continue to wrap ACE bandage around lower left leg until incisions fully heal to prevent friction against boot. Resident #1's April 2024 Treatment Administration Record (TAR) indicated he/she had Physician's orders for the following treatments: - 04/11/24, Manage incision of right BKA, apply Betadine paint to incision line, cover with dry dressing and secure, apply ACE wrap and stump sock, twice per day, discontinued 04/15/24. - 04/15/24, Manage incision of right BKA, apply Betadine paint to incision line, cover with dry dressing and secure, apply ACE wrap and stump sock, three times per day. Review of Resident #1's Medical Record, which included Nursing Progress Notes and his/her Treatment Administration Record (TAR), indicated there was no documentation to support that Nursing staff performed a full skin assessment upon admission, regularly monitored and assessed his/her left leg surgical incision, or infected right leg amputation site until 04/15/24, the day before Resident #1 was re-hospitalized . Further review of Resident #1's Medical Record indicated there was no documentation to support that Nursing was applying the CAM boot to his/her left leg and the Ampushield to his/her right leg as indicated in the Hospital Discharge/Transfer Note. Review of Resident #1's April 2024 Treatment Administration Record indicated the wound treatment was not documented as being completed on the following dates and times: - 04/11/24 9:00 A.M. - 04/12/24 9:00 P.M. - 04/14/24 9:00 A.M. - 04/16/24 8:00 A.M. During an interview on 10/22/24 at 1:50 P.M., Nurse #1 and the surveyor reviewed Resident #1's April 2024 TAR. Nurse #1 confirmed Resident #1's wound treatment orders were not signed off as being completed by Nursing on 04/11/24, 04/12/24, 04/14/24 and 04/16/24. Nurse #1 said she would have to assume that Resident #1 did not receive any wound care treatment on those dates and times, because they were left blank. During an interview on 10/22/24 at 2:20 P.M., Nurse #2 and the surveyor reviewed Resident #1's April 2024 TAR. Nurse #2 confirmed Resident #1's wound treatment orders were not signed off as being completed by Nursing on 04/11/24, 04/12/24, 04/14/24, and 04/16/24 and said if there were blank spaces on the TAR it was assumed the wound treatments were not completed. During an interview on 10/22/24 at 11:45 A.M., the Assistant Director of Nursing (ADON) said Assessments were documented and filed under the Assessment tab in the Electronic Health Record (EHR), when a resident was admitted , the Nurse was required to complete a Nursing admission Assessment. The ADON reviewed Resident #1's EHR and said a Nursing admission Assessment, which contained a comprehensive skin assessment, was never completed for him/her. The ADON said during the time Resident #1 was admitted , there was an issue with the Unit Manager on the Resident's unit ensuring necessary paperwork was completed. During an in-person interview on 10/22/24 at 12:45 P.M., the Director of Nurses (DON) said Skin Assessments should be completed upon admission and weekly. The DON said the Assessments should be located under the Assessment tab in the Electronic Health Record (EHR). The DON reviewed Resident #1's EHR and said since Resident #1 had not been in the facility for a full seven days, she did not expect to see a weekly Skin Assessment, however she would expect a Nursing admission Assessment, which included a Skin Assessment to have been completed. Upon reviewing Resident #1's EHR, the DON said the Nursing admission Assessment was never completed, there was no documentation to support Resident #1's wounds were assessed by Nursing, and said she had no explanation other than there had been a series of Unit Managers on A-Wing (where Resident #1 resided) that did not work out. During a follow-up telephone interview on 10/25/24 at 1:25 P.M., the Director of Nurses (DON) and the surveyor reviewed Resident #1's Hospital Discharge/Transfer Note. The DON said the Nurse that admitted Resident #1 should have ensured there were orders in place for Nursing to monitor Resident #1's left lower leg surgical incision, when to apply the CAM boot to his/her left leg (a boot used to stabilize the foot and ankle after an injury or surgery), and when to apply the Ampushield to Resident #1's right leg. The DON said those orders were not in place and there was no documentation in Resident #1's Medical Record to support that Nursing staff were monitoring his/her left leg, applying the CAM boot appropriately and applying the Ampushield to his/her right leg.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review, the facility failed to implement a care plan intervention for one Resident (#20) out of a total sample of 18 Residents. Specifically, the facility failed to implement an intervention for servings of double protein for Resident #20 who had experienced severe weight loss. Findings include: Review of the facility policy for Weight Assessment and Interventions last revised 1/19/22, indicated: -it is the policy of the facility to prevent significant unplanned or unavoidable weight loss for our residents. -interventions for undesirable weight loss should focus first on food (extra food, snacks, calorie dense food). -recommendations from the provider and/or dietitian will be followed. -the threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. Resident #20 was admitted to the facility in October 2023, with diagnoses including recent stroke (when blood supply to the brain is blocked or a blood vessel in the brain bursts, which may result in temporary or permanent disabilities) and Diabetes Mellitus (DM - metabolic disorder where the body has high blood sugar levels for prolonged periods of time). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident #20 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) Score of 15 out of 15. Review of Resident #20's Dietary assessment dated [DATE], indicated the following: -the Resident was not receiving dietary supplements. -the Resident was eating mostly 100% of all meals. -The Resident was continuing to lose weight. -Recommended a trial of double protein serving for added nutrition. Review of the weight record for Resident #20 indicated the following: -10/25/23: 201.8 lbs (pounds) -11/22/23: 202.0 lbs -12/3/23: 175.8 lbs -12/8/23: 181.2 lbs -1/18/24: 174.6 lbs Further review of the weight record indicated that Resident #20 lost 27.4 pounds (13.56% - severe weight loss) from 11/22/23 to 1/18/24. Review of Resident #20's Care Plan for Nutrition last revised 12/8/23, indicated an intervention for double protein servings. During an interview on 1/17/24 at 10:47 A.M., Resident #20 said that he/she had lost weight and would like some help gaining weight. On 1/18/24 at 12:16 P.M., the surveyor observed Resident #20's lunch tray with a dietary slip documenting to provide double protein servings. The surveyor further observed that the lunch meal that the Resident was served did not include double protein servings. During an interview on 1/18/24 at 12:53 P.M., the Dietitian said that Resident #20 appeared thin. When the surveyor discussed with the Dietitian that an observation of Resident #20's lunch tray did not include a double serving of protein, the Dietitian said that she would follow-up with the kitchen staff. During an interview on 1/18/24 at 1:39 P.M., the Dietitian said that Resident #20 had been experiencing weight loss and the facility was attempting to maximize his/her meal intake. The Dietitian thanked the surveyor for observing and relaying the error (lack of double protein servings) and said that she had notified the kitchen staff. On 1/22/24 at 8:11 A.M., the surveyor observed Resident #20's breakfast tray along with Nurse #3, and the Activities Director who were assisting with meal pass. The surveyor observed that Resident #20's tray did not have double servings of protein. During an interview at the time, Nurse #3 and the Activities Director both said that the Resident was not provided double protein servings and should have been, as the double protein servings had been documented on the dietary slip.

Based on interview, record and policy review, the facility failed to provide appropriate indwelling urinary catheter (also referred to as Foley catheter- a flexible tube inserted through the urethra to the bladder allowing urine to flow from the bladder to a drainage bag outside the body) care and services for one Resident (#29) out of a total sample of 18 residents. Specifically, the facility staff failed to obtain Physician orders relative to the size and care of the indwelling urinary catheter utilized for Resident #29. Findings include: Review of the facility clinical competency for Indwelling Urinary Catheter, last revised February 2023, indicated that the first critical element of the urinary catheter care education is to verify the order. Review of the facility policy for an Indwelling Catheter initiated 12/29/23, indicated that for the purpose of insertion, verify the Physician's order for the procedure noting the catheter size (Fr - French scale) and bulb/balloon (retention balloon - tiny balloon at the end of the catheter that is inflated with water to prevent the tube from sliding out of the body) inflation (milliliters). Resident #29 was admitted to the facility in July 2023 with diagnoses including urinary incontinence (the involuntary loss or leakage of urine) and neurogenic bladder (bladder dysfunction caused by brain, spinal cord, or nerve problems). Review of Resident #29's care plan for the indwelling urinary catheter last revised 9/21/23, did not indicate the Resident's catheter tubing size and the amount of balloon inflation required to stabilize the urinary catheter and prevent it from dislodging. Review of Resident #29's Nursing progress notes dated 11/23/23, indicated that the Resident's Foley catheter had been dislodged and was re-inserted by Nurse #7. Further review of the Nursing progress notes did not indicate the replacement urinary catheter size and the amount of balloon inflation needed to prevent the urinary catheter that had been re-inserted from dislodging. Review of the January 2024 Physician's orders indicated to change the indwelling urinary catheter as needed per protocol. Further review of the January 2024 Physician's orders did not indicate the ordered urinary catheter size and how much balloon inflation was needed to prevent the Resident's catheter from dislodging. During an interview on 1/22/24 at 10:48 A.M., the Director of Nurses (DON) said that there should have been an order for the Foley catheter and that the Nurse should have contacted the Physician prior to re-inserting the catheter to determine the catheter size.

Based on observations, interviews, record and policy review, the facility failed to ensure that medication for one Resident (#137) was appropriately managed by staff prior to administration. Specifically, for Resident #137, the facility staff left antibiotic medication that was not stored or secured in the Resident's room prior to the medication being administered for wound treatment. Findings include: Review of the facility policy titled Storage, Labeling of OTC (Over the Counter) Medication, Destruction and Disposal of Medication, revised 11/9/21, indicated the purpose of the policy was to ensure medications and biologicals were stored in safe, secure storage and safe handling. The policy also included the following: -medications will be stored in an orderly manner in cabinets, drawers, or carts . Resident #137 was admitted to the facility in December 2023 with diagnoses including Multiple Sclerosis (MS: disease in which the immune systems destroys the protective covering of the nerves). Review of the Resident's medical record indicated that no Minimum Data Set (MDS) Assessment had been completed by the survey exit. Review of the January 2024 Physician's orders initiated 1/11/24, included the following: -Left buttocks wound: cleanse with normal saline (mixture of sodium chloride and water). -sprinkle crushed Metronidazole tablet (antibiotic) and apply calcium AD (type of dressing) to the wound base. -cover with a foam dressing daily every day shift. On 1/17/24 at 10:03 A.M., the surveyor observed Resident #137 seated in a wheelchair positioned next to the bed in his/her room. A medication cup containing a crushed white substance was observed on the bedside table next to the Resident's bed. The surveyor did not observe any staff members in the Resident's room or outside of the room. During an interview at the time, the Resident said he/she acquired a wound prior to admission which was being treated at the facility and that the medication cup containing the white crushed substance was for his/her wound. Resident #137 further said that the Nurses crush the medication and place it on the bedside table, where it was left until the wound treatment was completed. On 1/18/24 at 9:27 A.M., the surveyor observed Resident #137 lying upright in bed eating breakfast. A medication cup containing a crushed white substance was observed on the bedside table next to the Resident's bed. The surveyor did not observe any staff present in the room or vicinity of the room. Review of Resident #137's clinical record did not indicate that he/she requested or had Physician's orders to self-administer medications. During an interview on 1/23/24 at 12:01 P.M., the surveyor and UM #1 discussed the surveyor's observations of the medication cup containing the crushed white substance at the Resident's bedside. UM #1 said the crushed medication observed at the bedside should not have been left unattended by the Nurse. UM #1 said that she would look into the matter.

1b. For Resident #59, the facility failed to ensure the staff wore the required PPE when providing care when the Resident was positive for Influenza infection. Resident #59 was admitted to the facility in June 2022 with a diagnosis of Dementia and resided on the D-Wing. Review of a laboratory report dated 1/11/24 indicated the Resident was positive for Influenza A. Review of the January 2024 Medication Administration Record (MAR) indicated the following: -Resident is currently on Contact Droplet CDC isolation precautions due to Influenza. All services are provided in room, initiated 1/12/24. On 1/17/24 at 10:54 A.M., the surveyor observed both a Droplet Precaution and a Contact Precaution sign on the closed door of Resident #59's room. On 1/18/24 at 7:39 A.M., the surveyor observed CNA #4 open the door from inside Resident #59's room, and the surveyor observed CNA #4 was not wearing any PPE. During an interview on 1/18/24 at 7:39 A.M., CNA #4 said that she had been providing care for Resident #59. She said that she had worn gloves but had forgotten to wear a mask, gown, and eye protection. On 1/18/24 at 8:34 A.M., the surveyor observed CNA #5 enter Resident #59's room without wearing eye protection. During an interview on 1/18/24 at 8:34 A.M., CNA #5 said that she should have worn eye protection, but she did not think there was any. When CNA #5 checked the PPE storage bin at the entrance to the Resident's room, she found a face shield available in the bin. During an interview on 1/19/24 at 1:48 P.M., the Director of Nurses (DON) said the facility was having an outbreak of Influenza. The DON said Resident #59 was on Contact and Droplet Precautions for Influenza through 1/18/24 and would be out of isolation on 1/19/24. She said CNA's #4 and #5 should have followed the signs and should have worn mask, gown, gloves, and eye protection when entering the Resident's room. 2a. For Resident #56, the facility failed to ensure the staff wore the required PPE when providing care when the Resident tested positive for COVID-19 infection. Review of the facility policy titled Coronavirus Disease (COVID-19), dated 10/16/23, indicated the following: -If a resident is suspected/symptomatic or confirmed to have COVID-19, Health Care Provider (HCP) must wear an N-95 or other respirator, eye protection, gown, and gloves for that resident. Resident #56 was admitted to the facility in November 2021 with the diagnosis of mild cognitive impairment and resided on the D-Wing. Review of the Physician's Order Summary, dated 1/18/24, indicated: -Resident #56 was COVID-19 positive -isolate Resident -implement Standard, Droplet and Contact Precautions. On 1/18/24 at 9:16 A.M., the surveyor observed Nurse #6 enter Resident #56's room without donning (put on) eye protection. The surveyor observed that both Contact Precautions and Droplet Precautions signage were posted on the door to the Resident's room. During an interview on 1/18/24 at 9:26 A.M., Nurse #6 said that she should have worn eye protection, but she did not. Nurse #6 said there was no eye protection available in the PPE storage cart outside of the Resident's room and she did not go and get one from another location. On 1/18/24 at 11:55 A.M., the surveyor observed CNA #4 enter Resident #56 without an N-95 mask. During an interview on 1/18/24 at 11:57 A.M., CNA #4 said she did not wear an N-95 mask because she thought if there were N-95 masks and surgical masks available in the PPE storage bin she could choose which type of mask she wanted to wear. During an interview on 1/19/24 at 1:48 P.M., the DON said Resident #56 was placed on isolation for COVID-19 on 1/18/24. She said Nurse #6 and CNA #4 should have worn N-95 masks, gown, eye protection and gloves when they entered the Resident's room. 2b. For Resident #187, the facility failed to ensure the staff wore the required PPE when providing care when the Resident was positive for COVID-19 infection. Resident #187 was admitted to the facility in December 2023 with a diagnosis of unspecified Congestive Heart Failure (inability of the heart to pump blood effectively resulting in fluid retention and causing shortness of breath) and resided on the A-Wing. Review of the Lab (laboratory) Results Report, dated 1/15/2024, indicated that Resident #187 tested positive for COVID-19 on 1/15/2024. Review of the Resident's Physician's orders included: -Resident is currently on Contact Droplet CDC Isolation Precautions due to COVID 19. -All services provided in room. Every shift for preventative for 10 days (initiated 1/15/2024, end date 1/25/2024). Review of the Resident's Care Plan, updated 1/15/2024, indicated that the Resident was on Isolation precautions per CDC guidelines. On 1/17/24 at 11:28 A.M., the surveyor observed CNA #6 preparing to enter the Resident's room. The surveyor observed signage on the outside of the door which indicated Contact Precautions and Droplet Precautions. CNA #6 donned (put on) a gown and gloves, was already wearing a surgical mask which was not changed, and no eye protection was donned. CNA #6 then entered Resident #187's room. When CNA #6 exited the room, she doffed (removed) her gown and gloves. She did not remove her surgical mask. During an interview at the time, CNA #6 said that one of the residents in the room had COVID. She also said that anyone entering the room should wear an N-95 mask and goggles. When the surveyor asked why she did not don an N-95 mask and eye protection, CNA #6 said that she was in a hurry. CNA #6 said that she knew that she should have put on an N-95 mask and goggles but had not done so. CNA #6 showed the surveyor that there were N-95 masks available in the PPE bin located outside the door to Resident #187's room. During an interview on 1/18/24 at 7:55 A.M., the Infection Control Preventionist (ICP) said that the staff have been educated and the supplies have been made available for the care of residents on Precautions. The ICP said that all staff entering a room with Droplet and Contact Precautions due to a resident testing positive for COVID-19 must don an N-95 mask, eye protection, gown, and gloves. She said that when exiting the room the staff must doff all PPE and perform hand hygiene, with reusable eye protection being sanitized. The ICP said that CNA #6 should have worn an N95 mask and eye protection before entering Resident's #187's room. Based on observations, interviews, records and policies reviewed, the facility failed to ensure the staff adhered to infection control standards for transmission based precautions for four Residents (#144, #59, #56 and # 187), out of a total sample of 18 residents, on three out of four units observed. Specifically, the facility failed to ensure: 1. For Resident #144 and #59, that staff wore the required personal protective equipment (PPE) when caring for an Influenza positive resident, to mitigate the spread of infection during an Influenza outbreak in the facility. 2. For Residents #56 and #187, that staff wore the required PPE when caring for COVID-19 positive residents, to mitigate the spread of infection during a COVID-19 outbreak in the facility. Findings include: Review of the facility policy titled Infection Prevention and Control dated 10/16/23, indicated the following: -Important facets of infection prevention include following established general and disease-specific guidelines such as those of the Center for Disease Control (CDC). Review of the facility policy titled Isolation Precautions, dated 10/16/23 indicated the following: *Droplet Precautions: -Implement droplet precautions for residents suspected or confirmed to be infected with a communicable disease/infection transmitted via droplets generated by sneezing, talking, or during procedure such as suctioning. -Prior to entering the isolation room perform hand hygiene and apply gloves and mask. *Contact Precautions: - Implement for residents suspected or confirmed with a communicable disease/infection that can be transmitted by direct contact with the resident or indirect contact with the environmental surface/equipment in the resident's environment. -Prior to entering the room perform hand hygiene and apply gloves and gown. Review of the Droplet Precautions sign, utilized by the facility, indicated the following: -Everyone Must: clean their hands, including before entering and when leaving the room. -Make sure their eyes, nose and mouth are fully covered before room entry, remove face protection before room exit. Review of the Contact Precautions sign, utilized by the facility, indicated the following: -Everyone must clean their hands, including before entering and when leaving the room. -Providers and staff must also put on gloves before room entry. Discard gloves before room exit. -Put on gown before room entry. Discard gown before room exit. 1a. For Resident #144, the facility failed to ensure the staff wore the required PPE when providing care when he/she was positive for Influenza infection. Review of the CDC Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities, updated February 2017, indicated to implement Standard and Droplet Precautions for all residents with suspected or confirmed influenza . Resident #144 was admitted to the facility in December 2023 with a diagnoses including weakness and difficulty walking, and resided on the C-Wing. Review of the Resident's January 2024 Physician's orders initiated on 1/14/24, included the following: -Resident is currently on Contact/Droplet CDC Isolation Precautions due to Influenza A, all services to be provided in the room for ten (10) days . On 1/18/24 at 7:48 A.M., the surveyor observed the following signage on Resident #144's bedroom door: -STOP CHECK WITH NURSE BEFORE ENTERING -Droplet Precautions . -Contact Precautions . The surveyor observed a bin containing PPE outside of the Resident's room, which contained masks, eye protection, gowns and gloves. Resident #144 was observed lying in bed and was not wearing a mask. Certified Nurses Aide (CNA) #3 was observed at the Resident's bedside obtaining vitals signs (measurement of temperature, blood pressure, pulse using a machine). CNA #3 was observed to be wearing a surgical mask, a gown and gloves but did not have eye protection on. At 7:50 A.M., the surveyor observed CNA #3 remove her gown and gloves and dispose in the trash bin and perform hand hygiene, within the Resident's room. CNA #3 did not remove her surgical mask and was observed to exit the room and walk down the hallway wearing the same mask. During an interview immediately following the observation, CNA #3 said that she should have also put on eye protection prior to entering Resident #144's room but she did not.

Based on observation and interview, the facility failed to ensure that its staff followed infection control standards during a medication pass on one unit out of four units observed. Findings include: Review of the facility policy titled Medication Administration: General, last revised 6/1/21, indicated a Licensed Nurse will administer medications to patients, accepted standards of practice will be followed, and standard precautions will be maintained. During a medication pass observation on 7/26/22 at 9:00 A.M., the surveyor observed Nurse #1 don (put on) gloves, bring eye drops in the labeled pharmacy box into the resident's room, place the eye drops box onto the resident's overbed table, administer, and return the eye drops in the box to the medication cart drawer. Nurse #1, with her still-gloved hands, touched the computer keypad to document, before removing her gloves and performing hand hygiene. In an interview during the observation with Nurse #1, she said that she should not have brought the eye drops box into the room, should have wiped the box down upon return to the cart, removed her gloves, performed hand hygiene and then returned the eye drops box back into the medication cart drawer. She said she should have prevented potential transmission of germs from the Resident's room to the medication cart and computer keypad and she did not. During an interview on 7/26/22 at 12:40 P.M., with the Director of Nurses (DON) and the Regional Nurse Consultant (RNC), the RNC said Nurse #1 should have put a barrier down on the overbed table to prevent direct contact with the Resident's environment. The DON said Nurse #1 should not have brought the box into the Resident's room and should have cleaned the box prior to returning it to the medication cart. The DON also said Nurse #1 should have performed hand hygiene after she removed her gloves and before touching the computer keyboard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that its staff documented in the medical record that the recommendations from the Pharmacist medication regimen review had been reviewed by the Physician and what, if any, action had been taken to address them for five Residents (#35, #51, #6, #14, #18) out of a total of 18 sampled residents. Findings include: Review of the facility policy titled Medication Regimen Review (MRR), revised 3/3/20, indicated the following: -The facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. -For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendation contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. -The attending Physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. -If the attending Physician has decided to make no change in the medication, the attending Physician should document the rationale in the residents' health record. -The attending Physician should address the consultant Pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident . -Facility should maintain readily available copies of MRRs on file in Facility as part of the resident's permanent health record. 1. Resident #35 was admitted to the facility in May 2022. Review of the record indicated the following Physician's orders: Quetiapine, give 50 mg (milligram) by mouth one time a day for mood disorder, order start date 5/25/22. Lorazepam 0.5 mg by mouth two times a day for anxiety, order start date 5/26/22. Citalopram 40 mg by mouth one time a day for depression, order start date 5/25/22. Review of the Pharmacy Consultation Report dated 5/27/22, indicated the following: -Review Quetiapine for GDR (gradual dose reduction). -Plan for GDR Lorazepam. -Current Citalopram dose of 40 mg/day exceeds the recommended maximum dose of 20 mg/day for individuals over [AGE] years of age due to the increased risk of QT prolongation (heartbeat abnormality). Consider reducing the dose to 20 mg daily or consider alternative therapy. Review of the medical record did not indicate the Physician had reviewed the Pharmacist's recommendations. During an interview on 7/22/22 at 1:02 P.M., Physician Assistant (PA) #1 said he could not recall seeing the recommendations dated 5/27/22, prior to today. 3. For Resident #6 the facility failed to provide evidence that a consultant Pharmacist recommendation, following a MRR was reviewed by the Physician, responded to, and/or acted upon, on four separate occasions. Facility staff also failed to ensure on one occasion, that a recommendation was reviewed and acted on in a timely manner by the Physician. Resident #6 was admitted to the facility in May 2018. A record review indicated that MRRs had been conducted on 2/3/22, 3/11/22, 4/27/22, 5/6/22, and 6/14/22. Review of the Pharmacy Consultation Reports from the MRRs indicated recommendations had been made by the Pharmacist on 2/3/22, 3/11/22, 4/27/22, 5/6/22, and 6/14/22. Review of the Consultation Reports from the MRR on 2/3/22, 3/11/22, 5/6//22, and 6/14/22 indicated no documentation the Physician had reviewed, responded to, and/or acted on the recommendations from the Pharmacist. Review of the Consultation Report from the MRR on 4/27/22 indicated the Physician did not review, respond to, and/or act on the recommendation until 6/24/22. During an interview on 7/25/22 at 10:21 A.M., UM #1 said the MRR recommendation from 4/27/22 had not been reviewed, responded to, or acted on by the Physician in a timely manner, and it should have been addressed sooner. During an interview on 7/25/22 at 11:07 A.M., the Director of Nursing (DON) said there was a facility issue with the process of assuring MRR recommendations were reviewed, responded to, and acted upon by the Physician. She said for Resident #6 she was unable to tell if the MRR recommendations from 2/3/22, 3/11/22, 5/6/22, and 6/14/22 were reviewed, responded to, or acted on by the Physician as they were not completed as required. 4. For Resident #14 the facility failed to provide evidence that a consultant Pharmacist recommendation, following a MRR was reviewed by the Physician, responded to, and/or acted on, on one occasion. Resident #14 was admitted to the facility in April 2021. A record review indicated that an MRR had been conducted on 6/14/22. Review of the Consultation Report from the MRR indicated a recommendation had been made by the Pharmacist on 6/14/22. Review of the Consultation Report from the MRR on 6/14/22 indicated no documentation the Physician had reviewed, responded to, and/or acted on the recommendation from the Pharmacist. During an interview on 7/26/22 at 8:55 A.M., the DON said the recommendations from the MRR on 6/14/22 were not completed until 7/25/22, and should have been completed sooner as required. 5. For Resident #18 the facility failed to provide evidence that a consultant Pharmacist recommendation, following a MRR was reviewed by the Physician, responded to, and/or acted on, on two occasions. Resident #18 was admitted to the facility in August 2021. A record review indicated that MRRs had been conducted on 1/18/22 and 3/11/22. Review of the Consultation Report from the MRR indicated the following recommendation had been made by the Pharmacist on 1/18/22 and 3/11/22: Resident #18 is a moderate or high risk for falls due to continued orthostatic hypotension .Identifying the following medications which may contribute to falls: Seroquel 25 mg at bedtime .Please consider reducing Seroquel dose to 12.5 mg at bedtime Review of the 1/18/22 Consultation Report from the MRR indicated the Physician signed the Report but the signature was undated, and checked off the following information: I have re-evaluated this therapy and wish to implement the following changes: Further review of the Report indicated no further documentation from the Physician regarding what changes he/she wanted implemented for the Resident. Review of the Resident's current Physicians orders indicated an order for Seroquel 25 mg with a start date of 9/22/21. Further review of the medical record indicated no additional Physician's orders were in place to indicate the Pharmacist's recommended reduction of the Seroquel occurred. During an interview on 7/26/22 at 8:47 A.M., the DON said it appeared that the Physician signed the 1/18/22 recommendation but did not date when it was signed, provide further direction on reducing the Seroquel, and the dose reduction was not done. 2. For Resident #51 the facility failed to provide evidence that a consultant Pharmacist recommendation, following a MRR was reviewed by the Physician, responded to, and/or acted upon, on two separate occasions. Resident #51 was admitted to the facility in September 2017. A record review indicated that MRRs had been conducted on 1/25/22 and 2/21/22, and indicated the facility staff see the report for any noted irregularities and/or recommendations. Review of the Consultation Report dated 1/25/22, indicated the following recommendations made: -Please update the person-centered care plan and medical record to include: - .Documentation of the impact of the target behaviors including distress or potential harms to the resident or others. -Potential adverse events and associated monitoring . Further review of the Consultation Report indicted it was reviewed by the Physician on 3/18/22. Further review of the medical record did not indicate evidence of a Consultation Report for the 2/21/22 MRR. During an interview on 7/25/22 at 12:55 P.M., Unit Manager (UM) #1 said the recommendation that was made on 2/21/22 was not in the medical record. She obtained a copy of the recommendation from the Pharmacist and stated that the recommendation had not been addressed by the provider as required. During an interview on 7/25/22 at 1:38 P.M., UM #1 said that the recommendation dated 1/25/22, was not addressed in a timely manner, nor is there evidence that the recommendation had been completely acted upon as required.

2. For Resident #6 the facility failed to ensure its staff monitored for potential adverse consequences, related to use of Mirtazapine (generic name for Remeron-an antidepressant) and Sertraline (generic name for Zoloft-a Selective Serotonin Reuptake Inhibitor-SSRI used to treat depression). Resident #6 was admitted to the facility in May 2018 with a diagnosis of Major Depression. Review of the July 2022 Physician orders indicated the following orders: -Mirtazapine Tablet 7.5 milligrams (mg) one tablet by mouth at bedtime with a start date of 3/16/21 -Sertraline HCI Tablet 50 mg give one tablet by mouth one time a day with a start date of 6/7/22. -Is resident free from side effects of psychotherapeutic medications .Remeron .every shift with a start date of 7/5/22. -Is resident free from side effects of psychotherapeutic medications .Zoloft .every shift with a start date of 7/5/22. Review of the July 2022 Medication Administration Record (MAR) indicated for 29 of 59 shifts the Resident did not have documentation showing he/she was being monitored for potential adverse consequences from his/her Mirtazapine (Remeron) and Sertraline (Zoloft) use. 3. For Resident #18 the facility failed to ensure staff monitored for potential adverse consequences, related to the use of Seroquel (an antipsychotic). Resident #18 was admitted to the facility in August 2021 with diagnoses including Dementia with Behavioral Disturbance, Delusional Disorder, and a history of Psychosis. Review of the July 2022 Physician's orders indicated the following orders: -Seroquel Tablet 25 mg give 25 mg tablet by mouth at bedtime with a start date of 9/22/21 -Is resident free from side effects of psychotherapeutic medications .Seroquel .every shift with a start date of 7/5/22. Review of the July 2022 MAR indicated for 28 of 59 shifts the Resident did not have documentation showing he/she was being monitored for potential adverse consequences from his/her Seroquel use. During an interview on 7/26/22 at 8:03 A.M., UM #1 said for Resident #6 and Resident #18 there was no documentation to indicate the Residents were being monitored for adverse consequences related to the psychoactive medications used during the shifts in question. Based on record review and interview the facility failed to ensure its staff appropriately monitor the potential adverse effects due to psychotropic medication use for three Residents (#51, #6, and #18) out of a total of 18 sampled residents. Findings include: Review of the facility policy titled Psychotropic Medication Use, revised on 1/1/22, indicated the following: - .All medications used to treat behaviors should be monitored for: efficacy, risks, benefits and harm or adverse consequences. 1. For Resident #51 the facility staff failed to monitor for potential adverse consequences, while using Haloperidol (an antipsychotic medication). Resident #51 was admitted to the facility in September 2017. Review of the July 2022 Physician orders indicated the following orders: -Haloperidol tablet 0.5 milligrams (mg) four times a day, with a start date of 6/23/22. -Is resident free from side effects of psychotherapeutic medications .with a start date of 7/4/22. Further review of the medical record indicated no evidence that Resident #51 was being monitored for adverse side effects while being medicated with Haloperidol until 7/4/22. During an interview on 7/25/22 at 1:38 P.M., Unit Manager (UM) #1 said that Resident #51 had been on Haloperidol since October 2021. She further said that she did not recall any monitoring being done prior to the July 2022 new order to monitor. During an interview on 7/25/22 at 1:56 PM., the Director of Nursing (DON) said that there was no documentation as far as she could tell that Resident #51 was being monitored prior to 7/4/22 and should have been as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure its staff maintained complete and accurately documented medical records for: 1) Medication administration documentation for Resident (#6), and 2) Advanced directive documentation and documentation related to the use of an assistive hearing device for Resident (#21) out of a total of 18 sampled residents. Findings Include: 1. For Resident #6 the facility failed to document that medication had been administered as ordered. Resident #6 was admitted to the facility in May 2018 with diagnoses including Atrial Fibrillation (AFib) and Parkinson's Disease. Review of the facility policy titled Medication: Administration: General, revised 6/1/21 indicated the following: Documentation -Administration of medication on the Medication Administration Record (MAR) Review of the Resident's current Physicians Orders indicated the following orders: -Digoxin (an antiarrhythmic and blood pressure support medication) Tablet 125 mcg (micrograms), give 125 mcg by mouth one time a day every 2 days(s) related to AFib -Eliquis (an anticoagulant) Tablet 2.5 mg (milligrams) give 2.5 mg by mouth two times a day for AFib -Sinemet (a dopamine promoter used to treat Parkinson's Disease) tablet 10-100 mg give one tablet by mouth four times a day related to Parkinson's Disease Review of the July 2022 MAR indicated the following: -On 7/15/22 and 7/19/22: no documentation that the Resident had been administered his/her Digoxin as ordered. -On 7/20/22: no documentation that the Resident had been administered his/her Eliquis as ordered. -On 7/15/22 for the 4 P.M. dose and 7/19/22 for the 4 P.M. dose: no documentation that the Resident had been administered his/her Sinemet as ordered. During an interview on 7/25/22 at 3:35 P.M., the Director of Nurses (DON) said she was unable to tell if the medications were given as the dates in question had not been signed off on the MAR. She further said the Nurses should have documented at the time the medications were given, and this had not been done as required. 2. For Resident #21, the facility failed to ensure that the documentation in the medical record was complete and accurately documented on: a) The Medication Administration Record (MAR) pertaining to the use of an assistive hearing device, and b) on the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST). Resident #21 was admitted to the facility in February 2020. a) Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident used a hearing device and had no difficulty understanding others and being understood. Review of Resident #21's medical record indicated that the Resident was hard of hearing and used a pocket talker device (a device to improve hearing) to facilitate hearing. During observations on 7/21/22 at 2:42 P.M., and on 7/25/22 at 10:20 A.M., the surveyor observed Resident #21 without a pocket talker device in use. Review of the July 2022 MAR indicated the Resident had a pocket talker to be worn on the day and evening shift and returned to the medication cart at bedtime daily on the evening shift. All MAR entries were signed off as being completed as ordered. Review of the July progress notes indicated no documented evidence that the pocket talker was refused by the resident. During an interview on 7/25/22 at 2:20 P.M., Nurse #2 showed the pocket talker device, stored in the medication cart, to the surveyor. She said Resident #21's hearing was better some days than others and if he/she was having trouble hearing, he/she would use the pocket talker, but other times he/she had thrown it on the floor. She said the Resident did not like to use the device and could hear without it so he/she would not use it. She also said the staff will offer the pocket talker to the Resident but usually it's refused. During an interview on 7/25/22 at 2:42 P.M., Unit Manager (UM) #1 said the Resident was supposed to wear the pocket talker and, if offered and refused, the refusal code should be used on the MAR and it was not. b) Review of Resident #21's MOLST, signed by the Resident on 2/16/2020, indicated that the Resident wanted to be transferred to the hospital. This was crossed out and the Do Not Transfer field was checked, and a handwritten note indicated that the Health Care Proxy was invoked on 9/13/2021, and the MOLST form was updated on that date. During an interview on 7/21/22 at 11:05 A.M., with UM #1, after reviewing the changes made to the Resident's MOLST, UM #1 said that when a Health Care Proxy is invoked the whole MOLST form should be redone. The MOLST form was not redone as required.