**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/11/2024, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain grooming, personal, and oral hygiene. This was identified for one (Resident #146) of two residents reviewed for Activities of Daily Living. Specifically, Resident #146 was observed with long and yellow fingernails on their contracted right hand on multiple occasions. The finding is: The facility's policy and procedure titled Activities of Daily Livings (ADLs) last reviewed 1/2024 documented that residents who are unable to carry out Activities of Daily Living independently will receive the necessary services including but not limited to hygiene such as bathing, dressing, grooming and oral care. Resident #146 was admitted with diagnoses including Hemiplegia and Hemiparesis on the Right Dominant Side, Cerebral Infarction, and Type 2 Diabetes Mellitus. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 10, indicating the resident had moderately impaired cognition. The Minimum Data Set assessment documented functional limitations in the range of motion on one side of the upper and lower extremity. The resident required moderate assistance for personal hygiene tasks. A Comprehensive Care Plan titled Activity of Daily Living (ADL) dated 9/18/2024 documented Resident #146 had a self-care deficit and potential decline in Activity of Daily Living function due to muscle weakness and/or muscle wasting and atrophy (muscle weakness). Resident #146 required moderate assistance for general hygiene. The Nursing Instructions for Certified Nursing Assistants, as of 12/9/2024, documented that Resident #146 had Hemiplegia (paralysis) on the right side and required moderate assistance for general hygiene. The instructions included skin checks and care every day at all shifts. A review of nursing progress notes from 11/1/2024 to 12/3/2024 revealed no documentation that Resident #146 refused to have their fingernails trimmed. During an initial tour conducted on 12/3/2024 at 10:51 AM, Resident #146 was observed in their room lying in bed. Resident #146 was alert and able to provide appropriate answers when asked. Resident #146 stated that they suffered right-side paralysis from a Stroke for a long time and had made limited progress in regaining function. Resident #146 stated they required assistance from staff for most of their daily needs. Resident #146 was observed reaching under their blanket with their left hand to lift their right hand. Resident #146's right hand was contracted into a fist and the fingernails on the right hand (all) digits were long and yellow. Resident #146's left-hand fingernails were trimmed. Resident #146 stated they would like their nails trimmed but could not do so on their own. During a follow-up observation on 12/3/2024 at 2:46 PM, Resident #146's right-hand fingernails remained long, yellow, and untrimmed. Resident #146 stated they received their morning care and ate lunch. Resident #146 stated staff has not offered to trim their nails and that they (Resident #146) would not refuse to have their nails trimmed. During an observation and interview on 12/3/2024 at 2:50 PM, Certified Nursing Assistant #3 stated they were the assigned aide to the resident this shift; however, they were not regularly assigned to Resident #146. Certified Nursing Assistant #3 stated they did not notice the resident's long nails until after the lunch meal. Certified Nursing Assistant #3 stated they left Resident #146's room about 10 minutes ago and were on their way to get a nail clipper. Certified Nursing Assistant #3 stated they should ask a nurse to see if it was appropriate for them (Certified Nursing Assistant #3) to cut the resident's nails. During an observation and interview on 12/3/2024 at 2:59 PM, Licensed Practical Nurse #6 (unit nurse) Resident #146's right-hand fingernails were observed to be long and yellow. Licensed Practical Nurse #6 stated Certified Nursing Assistant should check the resident's hands and report to the nurse if the nails were long and required trimming. Licensed Practical Nurse #6 stated if the resident has a diagnosis of Diabetes, then a nurse must trim the nails but the Certified Nursing Assistant could file the nails to prevent any skin breakdown. Resident #146's nails should have been cut as overgrown nails on the resident's contracted right hand could cut into their skin causing skin tears. During an interview on 12/4/2024 at 3:41 PM, Certified Nursing Assistant #7, who was the resident's regularly assigned Certified Nursing Assistant, stated they noticed Resident #146's nails getting long about a week ago. Certified Nursing Assistant #7 stated they encouraged Resident #146 to cut their nails but Resident #146 was nervous about getting their nails trimmed. Certified Nursing Assistant #7 stated they reported the refusal to a nurse; however, they could not recall the name of the nurse. Certified Nursing Assistant #7 stated they did not follow up and did not cut the resident's fingernails. During an interview on 12/10/2024 at 9:38 AM, the Director of Nursing Services stated Certified Nursing Assistant who provided care to the resident should look at the resident's skin and check their fingernails. The Director of Nursing Services stated Certified Nursing Assistants should report to the nurse if the resident's nails are long. The Director of Nursing Services stated that Certified Nursing Assistant could trim nails for non-diabetic residents but a nurse must trim the nails for residents with Diabetes diagnosis. The Director of Nursing Services stated overgrown nails with contracted hands could lead to possible skin breakdown. 10 NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/11/2024, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #120) of two residents reviewed for Skin Conditions and for one (Resident #93) of one resident reviewed for Communication-Sensory. Specifically, 1) Resident #120 was observed with a dressing on the left side of the forehead on 12/3/2024 and 12/5/2024; however, there was no physician's order for any assessment treatment for the left side of the forehead lesion. Additionally, the facility did not initiate a care plan for the left side of the forehead lesion. 2) Resident #93 had Physician's Orders to receive an antibiotic eye drop indefinitely until seen again by their Retinal Surgeon and the resident did not receive dosages of their eye drops from 11/19/2024 through 11/25/2024. The finding is: 1) The facility's undated policy and procedure titled Skin Care Protocol documented that the Nurse will initiate an analysis, to identify risk factors, contributing factors, and source of the impaired skin. It may include but is not limited to a review of the medical record, medications, nutritional status, functional and self-care status, present plan of care for prevention of skin impairment, and staff statements. Notify the attending Physician upon identification or change in skin condition. Orders will be obtained for treatment specific to the wound for cleaning, treatment, dressing, and frequency. The Certified Nursing Assistant is responsible for monitoring the resident's skin during care and reporting any changes in skin integrity immediately to the Nurse in charge. Resident # 120 was admitted with diagnoses including Pulmonary Embolism, Atrial Fibrillation, and Disorder of the Skin and Subcutaneous Tissue. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #120 had intact cognition. The Minimum Data Set (MDS) assessment documented Resident # 120 had a skin condition that included open lesions other than ulcers, rashes, and cuts. A Progress Note dated 10/18/2024 documented the Nurse Practitioner had seen Resident #120 to evaluate the left-side forehead lesion that had gotten bigger and changed color. The nurses reported Resident #120 scratched the area (left-sided forehead lesion) with their nails at times. A Dermatology consult for biopsy was recommended but Resident #120's family member refused and requested that Resident #120 be treated by the facility as best as possible. Bacitracin (topical antibiotic) ointment was ordered twice a day for one week for the left side forehead lesion. A Physician order dated 10/18/2024 documented Bacitracin (topical antibiotic) ointment to the left side forehead lesion, twice a day for one week. The order was completed on 10/25/2024 and was not revised. Resident #120's medical record review revealed no care plan for Resident #120's lesion on the left forehead. Resident #120 was observed lying in bed on 12/3/2024 at 10:25 AM with a small band-aid on the left side of the forehead. An irregular, red-scabbed area was sticking out of the band-aid. During a second observation on 12/5/2024 at 9:04 AM, Resident #120 was lying in bed. A small band-aid was observed on Resident #120's left side of the forehead. The band-aid appeared loose and soiled. A scabbed area was sticking out of the band-aid. During an interview on 12/5/2024 at 10:42 AM, Certified Nursing Assistant #2 stated at times Resident #120 scratched the lesion on the left forehead, which made the area bleed. Certified Nursing Assistant #2 stated they reported the bleeding skin lesion to the nurses numerous times and the nurses applied dressing to cover the area. During an interview on 12/5/2024 at 10:54 AM, Licensed Practical Nurse #4 (Charge Nurse) stated when Certified Nursing Assistants reported that Resident #120's left forehead lesion was bleeding, a dressing was applied to the area. Licensed Practical Nurse #4 stated there are times when Bacitracin ointment was applied. Licensed Practical Nurse #4 stated the Nurse Practitioners were aware of the treatment. Licensed Practical Nurse #4 stated because the lesion was chronic, they used their Nursing judgment and applied treatment to the left forehead when the lesion was open and bleeding. During an interview on 12/5/2024 at 11:02 AM, Nurse Practitioner #2 stated the growth on Resident #120's forehead was chronic. Nurse Practitioner #2 stated the nurses updated them (Nurse Practitioner #2) about the lesion, but they (Nurse Practitioner #2) did not order a treatment because the lesion was chronic. During an interview on 12/9/2024 at 3:00 PM, Physician #3 stated Resident #120's forehead was chronic and the resident's family did not want further workup or consultations. Physician #3 stated they did not know Resident #120 had a behavior of scratching the lesion. During an interview on 12/10/2024 at 9:00 AM, the Director of Nursing Services stated a physician order is needed for all treatments. The Director of Nursing Services stated that Nurses cannot just use their judgment to apply treatments. The Director of Nursing Services stated a care plan for the chronic left-sided forehead lesion should have been in place with goals and interventions. 2) The Consultation Policy and Procedure last reviewed in January 2024 documented residents will be evaluated by a Consultant as ordered by the Primary Medical Doctor (PMD). The Primary Medical Doctor will review the Consultant's recommendations and follow up accordingly. Resident #93 had diagnoses that included Status Post Corneal Repair and Hypertension. The admission 5 Day Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognitive skills for daily decision-making. The Minimum Data Set documented the resident wore corrective lenses and the resident was able to see under adequate light. The Physician's Order dated 10/25/2024 documented for the resident to have an Optometry Consult. The Physician's Order dated 10/25/2024 documented for the resident to receive Polytrim eye drops (a prescription antibiotic for certain eye infections caused by bacteria) by ophthalmic (eye) route - place 1 drop to left eye 4 times daily for Unspecified Infectious Disease. This order was discontinued on 11/4/2024. The Physician's Order dated 10/26/2024 documented for the resident to wear a patch to their left eye for status post corneal repair. The Physician's Order dated 10/31/2024 documented the resident to go to an Eye Institute for a follow-up appointment on 11/4/2024. The Nursing Progress Note dated 11/4/2024 documented the resident returned from their eye appointment and recommendations included continuing the Polytrim eye drops 4 times per day and following up with the Eye Institute in one month. The Ophthalmology Report of Consultation 11/4/2024 documented as one of the recommendations for the resident to continue Polytrim eye drops four times daily. The Physician's Order dated 11/4/2024 for the resident to receive Polytrim eye drops by ophthalmic route for 7 days, place one drop to the left eye 4 times daily for Unspecified Infectious Disease. This order was discontinued on 11/11/2024. The Nursing Progress Note dated 11/12/2024 written by Registered Nurse #1 documented that Registered Nurse #1 spoke with the resident's (eye) Surgeon and the resident was to continue the Polytrim eye drops by ophthalmic route for 7 days. Place 1 drop to the left eye 4 times daily as per the Ophthalmology Medical Doctor (MD) with no stop date. The resident was to continue to receive the medication until further notice. The Physician's Order dated 11/12/2024 entered into the resident's Electronic Medical Record by Registered Nurse #1 documented Polytrim eye drops by ophthalmic (eye) route for 7 days place 1 drop to left eye 4 X [times] daily As per Ophth. M.D No stop date. Pt. [resident] to continue to receive medication until further Notice. This order was discontinued on 11/19/2024. A review of the resident's November 2024 Medication Administration Record revealed that the resident did not receive the Polytrim eye drops from the 11/19/2024 4:00 PM dose to the 11/25/2024 1:00 PM dose. The Physician's Order dated 11/25/2024 (last renewed on 12/4/2024), entered into the Electronic Medical Record by Licensed Practical Nurse #1, documented for the resident to receive Polytrim eye drops by ophthalmic (eye) route - place 1 drop to left eye 4 times daily for prophylactic measures. During an interview on 12/6/2024 at 9:40 AM, Registered Nurse #1 stated they should not have put a stop date for the Polytrim eye drop order when they entered the order into the Electronic Medical Record on 11/12/2024. Registered Nurse #1 stated that was an error because they knew the resident's eye drops needed to continue until they saw their eye doctor again. During an interview on 12/6/2024 at 10:00 AM, Licensed Practical Nurse #1 stated they realized the resident's Polytrim eye drops had stopped when the resident told them (Licensed Practical Nurse #1) on 11/25/2024 that they (Resident #93) had not received their eye drops on 11/24/2024. Licensed Practical Nurse #1 stated that they called the resident's representative, who had taken the resident to her Ophthalmology appointment on 11/4/2024, and the representative told them that the Ophthalmologist did not want to stop the Polytrim eye drops. Licensed Practical Nurse #1 stated that Registered Nurse #1 had called the resident's Ophthalmologist on 11/12/2024 to clarify the order and was told that the resident's Polytrim eye drops should continue until they were seen by the eye doctor again. Licensed Practical Nurse #1 stated that was why they got a new Physician's Order for the resident's eye drops to start again on 11/25/2024. During an interview on 12/6/2024 at 11:15 AM, the Optometrist who works with the resident's Corneal Specialist stated that the resident was being seen at the Eye Institute for a perforated ulcer of their left eye. The Optometrist stated that the resident's visit on 11/4/2024 was a follow-up to examine the bandage contact lens placed in the resident's left eye to seal the perforation in the resident's cornea. The Optometrist stated that it was important for the resident to receive the Polytrim eye drops until their next visit to the Eye Institute because the drops were an antibiotic given to avoid infection with the bandage contact lens on the resident's left eye. The Optometrist stated that the resident had a very severe infection, possibly herpetic, and could have lost their eye. During an interview on 12/10/2024 at 9:50 AM, the Director of Nursing Services stated Registered Nurse #1 accidentally put the Physician's Order for the Polytrim eye drops into the resident's Electronic Medical Record on 11/12/2024 with a stop date. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/11/2024, the facility did not ensure that drugs and biologicals were stored in a locked compartment. This was identified for one (Resident #46) of one resident reviewed for Accident Hazards. Specifically, Resident #46 was observed with a Calcitonin (Salmon) spray bottle on their overbed table and there was no staff in the vicinity. Additionally, Resident #46 was not assessed to self-administer their medication. The finding is: The facility's policy and procedure titled, Medication Storage, last revised on 1/2024, documented that medications must be stored in accordance with the manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. Storage areas may include, but are not limited to, drawers, cabinets, medication rooms, refrigerators, and carts. Resident #46 was admitted with Diagnoses including Legal Blindness, Osteoporosis, and Myelodysplastic Syndrome (a group of disorders caused by blood cells that are poorly formed or do not work properly). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #46 had intact cognition. The Minimum Data Set (MDS) assessment documented Resident #46 had an active diagnosis of Osteoporosis and severely impaired vision. The physician's order dated 10/3/2024 and last renewed on 11/18/2024 documented to administer Calcitonin (Salmon) Spray 200 units per actuation (mouthpiece). One spray by nasal route daily in one nostril, rotating nostrils every day for age-related Osteoporosis. The medical record review revealed no care plan for the use of Calcitonin spray for age-related osteoporosis. During an observation on 12/3/2024 at 10:28 AM, a Calcitonin spray bottle was lying flat on Resident #46's overbed table. Resident #46 was in bed and there was no staff in the vicinity. During an interview on 12/3/2024 at 11:00 AM, Licensed Practical Nurse #3 (Medication Nurse) stated they administered the Calcitonin nasal spray to Resident #46 at 9:00 AM today. Licensed Practical Nurse #3 stated they must have forgotten to take and place the nasal spray in the medication cart. Licensed Practical Nurse #3 stated that Resident #46 cannot self-administer any medications. Licensed Practical Nurse # 3 stated they should not have left the nasal spray unattended in the resident's room. During an interview on 12/3/2024 at 11:15 AM, Licensed Practical Nurse #4 (Charge Nurse) stated Licensed Practical Nurse #3 should have taken the Calcitonin spray after administering the medication to Resident #46. Licensed Practical Nurse #4 stated that Resident #46 cannot self-administer any medications and all the nurses in the unit were aware that there should not be any medications left with Resident #46. During an interview on 12/9/2024 at 10:39 AM, Pharmacist #1 stated due to sedimentation, it is recommended the Calcitonin spray bottle should be kept in an upright position during storage and shaken before use. During an interview on 12/10/2024 at 8:58 AM, the Director of Nursing Services stated that the medication nurse should not have left the medication with the resident. The Director of Nursing Services stated that all medications should be kept in the medication carts unless the resident had an order for self-administration. The Director of Nursing Services stated that their expectation is for the Nurses to ensure that all medications are given and stored according to the facility's policy and procedure. 10NYCRR 415.18(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/11/2024, the facility did not implement an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infection to the extent possible. This was identified for one (Resident #14) of two residents reviewed for Skin Conditions. Specifically, there was no documented evidence that Resident #14, with a diagnosis of a chronic infected wound on the right hip, was placed on Enhance Barrier Precautions as per the facility's policy. The finding is: The facility's policy and procedure titled Enhanced Barrier Precaution, dated 4/1/2024 documented the facility will implement Enhanced Barrier Precaution to include any resident with chronic wounds (e.g. pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers) regardless of Multidrug Resistant Organisms colonization or infection status. Resident #46 was admitted with diagnoses of an Open Wound of the Right Hip, Infection due to Internal Right Hip Prosthesis, and Cellulitis. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated Resident #14 had intact cognition. The assessment documented that Resident #14 had a Multidrug-Resistant Organism, Wound Infection, and Infection due to an Internal Right Hip Prosthetic. The resident had a surgical wound that required wound care and received antibiotics on admission. The Comprehensive Care Plan titled Skin Integrity - Surgical Right Hip, dated 9/6/2024 documented the resident had chronic infected prosthetic hardware with an open area along the scar line. Resident #14 was hospitalized from [DATE] to 10/8/2024 for a non-healing wound to the right hip. Interventions included but were not limited to the surgical incision site treatment per the Physician's order. Maintain precautions as per the physician's order; maintain single room isolation; wear Personal Protective Equipment (PPE); and monitor for signs and symptoms of infection. A physician's order dated 10/8/2024 documented Contact Precautions. The order was discontinued on 11/15/2024 due to the Contact Precautions no longer being necessary. The Comprehensive Care Plan titled Infection - Chronic Cellulitis of Right Hip, dated 10/8/2024 documented interventions that included but were not limited to administering medications and changing the dressing to [the surgical site] per physician orders. During an observation on 12/3/2024 at 10:13 AM, there was no signage observed indicating Resident #14 was placed on Enhanced Barrier Precautions. During an interview on 12/3/2024, immediately after the observation, Licensed Practical Nurse #5 stated residents on Enhanced Barrier Precautions should have an orange dot sticker placed next to their name by the door. Resident #14's name by the door did not have an orange dot sticker. During an observation on 12/4/2024 at 11:28 AM, Resident #14's name by the door did not have an orange dot, no Enhance Barrier Precaution sign was posted, and no Personal Protective Equipment cart was observed in front of Resident #14's room. During an interview on 12/6/2024 at 1:32 PM, the Wound Care Nurse stated Resident #14 has a chronic open surgical wound on their right hip. The Wound Care Nurse stated that Resident #14 received daily wound treatments. During an interview on 12/6/2024 at 1:57 PM, the Infection Preventionist stated residents with chronic wounds should be placed on Enhanced Barrier Precautions. The Infection Preventionist stated Resident #14 had a chronic wound and they did not know why the resident was not placed on Enhanced Barrier Precaution. A review of the physician's orders on 12/6/2024 from 11/15/2024 to 12/5/2024 revealed no orders for Enhanced Barrier Precautions for Resident #14. A physician's order dated 12/6/2024 documented Enhanced Barrier Precautions due to a chronic wound. A review of the Comprehensive Care Plan on 12/6/2024 from 11/15/2024 to 12/5/2024 revealed no care plan for Enhanced Barrier Precautions for Resident #14. The Comprehensive Care Plan titled Enhanced Barrier Precaution dated 12/6/2024 documented the resident was placed on Enhance Barrier Precaution due to a chronic wound. Interventions included but were not limited to maintaining Enhanced Barrier Precautions during high-contact resident care activities. During an additional interview on 12/6/2024 at 3:17 PM, the Infection Preventionist stated they were responsible for tracking residents requiring Enhanced Barrier Precaution and other levels of isolation/precaution. The Infection Preventionist stated Resident #14 should have been placed on Enhanced Barrier Precautions because of an existing chronic wound, and it was an oversight. During an interview on 12/10/2024 at 9:38 AM, the Director of Nursing Services stated residents who had chronic wounds should be placed on Enhanced Barrier Precautions following Center for Disease Control and Prevention guidelines. The Director of Nursing Services stated that the Infection Preventionist is responsible for monitoring and ensuring residents are placed on appropriate precautions to prevent transmission of infections. 10 NYCRR 415.19(a) (1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review during the Recertification Survey completed on 05/04/2021, the facility did not ensure that each resident has the right to make choices about aspects of life that are significant to the resident. Specifically, one (Resident #548) of three sampled pooled residents, requested to take a nutritional supplement purchased by the resident. Resident #548 was not assessed by the facility staff to determine if the resident was a candidate to self-medicate. The findings are: The facility's Self Administration of Medication policy dated 11/01/2020 documented a resident may be allowed to self-administer medications if the team and the Primary Care Physician concurs the resident is capable of safe and effective self-administration. The policy documented to provide the opportunity to qualified residents that request to self-administer medications. Resident #548 was admitted on [DATE] with diagnoses including Left Femur Fracture, Status Post (S/P) Repair on 04/01/2021 with an Intramedullary Rod Placement. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental status (BIMS) score of 15 indicating the resident's cognitive status was intact. The resident required supervision with set-up help for eating. The resident had no behaviors. The resident had functional Limitation in Range of Motion to one side of the lower extremities. Resident #548 was observed on 4/27/2021 at 11:58 AM in the resident's room sitting on the side of the bed. The resident stated that a choice was not given to the resident to self administer a nutritional supplement that the resident had ordered online. The Physician orders dated 4/23/2021 documented Magnesium Plus Protein 133 Milligrams (mg) tablet as a supplement. The order documented the resident has provided their own medication and the medication will be kept in the medication cart. The Registered Nurse Supervisor (RNS) #4 was interviewed on 4/29/2021 at 2:00 PM and stated the facility does not allow residents to take their own nutritional supplements. RNS #4 further stated the resident had communicated this concern to the Assistant Director of Nursing Services (ADNS). The ADNS, RNS #2, was interviewed on 5/3/2021 at 2:15 PM and stated residents cannot just order their own medications and take the medications or nutritional supplements without the physician's approval. When Resident #548 ordered the nutritional supplement, the staff took the nutritional supplement from the resident and explained that it would be kept on the medication cart until the Physician's approval. The resident was upset because of the facility policy. The Physician ordered the supplement to be kept on the cart. The ADNS stated that Resident #548 was not assessed to deternine if the resident could self administer the nutritional supplement. The Director of Nursing Services (DNS) was interviewed on 5/3/2021 at 11:45 AM and stated that residents are not allowed to self-medicate. The physician would not allow this resident to self-administer the nutritional supplement. The facility does not have a self-medication screening assessment to evaluate residents who want to self-medicate. 415.5 (b)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey completed on 5/4/2021, the facility did not ensure that all alleged violations of abuse were thoroughly investigated for 1 of 1 resident reviewed for Dignity. Specifically, the facility did not investigate an allegation of a Certified Nursing Assistant (CNA) attempting to photograph Resident #174 while disrobed. The finding is: The facility's Abuse, Neglect, and Mistreatment policy dated 1/5/2018 (revised on 1/2021) documented that the policy ensures that all patients will be treated with dignity, consideration, and respect at all times by employees. Any patient that reports fear or signs of abuse shall be evaluated by provider team as appropriate when a Patient verbalizes abuse, neglect or mistreatment. A full investigation of the incident will be done by the facility, immediately. When staff suspects that a patient is a possible victim of abuse, neglect, or mistreatment, the attending physician along with other relevant healthcare providers should be notified. Allegations against employees or other Healthcare Providers regarding patient abuse must be immediately escalated to the employee's supervisor. The supervisor must immediately informing the Administrator on Duty who must then immediately inform quality and nursing who will determine others who must be notified. The administrator on duty or a supervisor must immediately relieve the accused employee of responsibilities and either suspend pending investigation or place the employee on administrative leave pending the outcome of the investigation. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #174 had diagnoses including Depressive Disorder, Rheumatoid Arthritis, and Hereditary Neuropathy. The MDS documented that Resident #174 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Behavior Care Plan (CCP) dated 4/26/2017 documented that Resident #174 exhibits confabulation and is easily agitated related to functional loss. Resident #174 gets easily aggravated with staff and confabulates stories. Resident #174 will [NAME] and puff and stare at aides in anger. Resident #174 accuses staff and saying things that staff has not said. Resident #174 gets angry very quickly. The care plan notes dated 2/5/2020 documented Resident #174 had accusatory behavior and alleged staff did not want to care for the resident. The Psychotropic Medication CCP dated 3/17/2017 documented that Resident #174 had Depression. The care plan note dated 11/26/20 documented Resident #174 was calm and cooperative with the plan of care. The nursing progress note dated 12/5/2020 at 11:10 AM, Licensed Practical Nurse (LPN) #5 documented that Resident #174 had a right groin open area and was seen by the Nurse Practitioner who ordered Silvadene (topical medication) twice a day. During the resident council meeting held on 4/27/2021 at 11:42 AM, Resident #174 stated that some CNAs would take their cell phones into the bathroom and bedroom area while providing resident care. Resident #174 expressed worry that there may be a person on the other end of the phone who will hear or see the resident they are providing care for. Resident #174 reported the concerns to the Registered Nurse (RN) Supervisor and the LPN. LPN #5 was interviewed on 5/4/2021 at 11:37 AM and stated that a few months ago CNA #9 attempted to use the cell phone to take a photo of Resident #174's groin area to show the LPN an abrasion in the skin folds. LPN #5 stated that CNA #9 was later fired but not for that reason. LPN #5 stated CNA #9 was given a verbal education on not using the phone in the care areas. LPN #5 stated that the RN Supervisor was made aware of the attempt to take a photo by CNA #9 but there was no investigation completed. LPN # 5 did not document the incident and thought the RN Supervisor would. Resident #174 was re-interviewed on 5/4/2021 at 12:55 PM and stated that on December 5th, 2020, a CNA (#9) was assisting the resident with cleaning the groin area while Resident #174 was seated on the toilet in the bathroom. While wiping the stomach folds over the groin, there was blood on the towel. The CNA (#9) then took out a cell phone and offered to take a photograph to show Resident #174 the wound. Resident #174 repeatedly told the CNA (#9) no and was shocked at the suggestion. Resident #174 stated that the CNA insisted and then offered to take a video. The CNA (#9) stated that it would be deleted afterwards. Resident #174 again said no and did not want any video or photo taken. Resident #174 stated that Resident #174 was not sure if any videos or photos were taken. Resident #174 felt horrible, nervous, and vulnerable. Resident #174 stated that immediately after the photo incident, Resident #174 informed LPN # 5. Resident #174 stated that the next day, the same CNA (#9) was assigned to Resident #174 again with an additional CNA. Resident #174 stated it did not make a difference in the experience because the original CNA (#9) insisted on handling Resident #174 without assistance and the other CNA was just standing there. Resident #174 stated that after that experience, Resident #174 requested that CNA (#9) not be assigned to the resident. Resident #174 thought the CNA (#9) was removed from the unit but on a 3pm-11 pm shift, the CNA once stood at the doorway and was glaring at Resident #174. Resident #174 felt fearful of the CNA (#9). The RN Supervisor was interviewed on 5/4/2021 at 2:02 PM and stated that the RN Supervisor works per diem for the unit. The RN Supervisor stated LPN #5 reported that Resident #174 did not like the way the assigned CNA #9 provided care. The RN Supervisor stated that LPN #5 did not inform the RN Supervisor of any attempt of CNA #9 taking a photograph of the resident while disrobed. The RN Supervisor reassigned CNA #9 for the rest of the shift. The incident was not documented . The RN Supervisor reported Resident #174's discomfort to the Assistant Director of Nursing Services (ADNS). The RN supervisor did not inform the next shift RN Supervisor. The RN Supervisor stated that they assumed that Resident #174 would inform the other staff members so that CNA #9 would not be assigned to Resident #174 again. The ADNS was interviewed on 5/4/2021 at 2:31 PM and stated that the ADNS did not investigate the allegation reported by the RN Supervisor and assumed that the RN Supervisor took care of it. The ADNS did not think a follow up investigation was necessary. The ADNS stated that if it was a bigger deal, Resident #174 would have reported it directly to the ADNS and Resident #174 did not make a formal grievance. The ADNS stated that Resident #174 is vocal about experiences and expected Resident #174 to directly report to the ADNS. The Director of Nursing Services (DNS) and the Administrator was interviewed concurrently on 5/4/2021 at 3:32 PM. The DNS stated that the RN Supervisor and the ADNS did not know about Resident #174's complaint regarding CNA #9 attempting to take photos and a video while disrobed in the bathroom. The DNS stated that Resident #174 is care planned for confabulation and generally reports that Resident #174 does not like the CNAs in general. Resident #174 has never made a complaint like this before and the DNS was not aware that Resident #174 had this specific concern about CNA #9. The Administrator stated that CNAs are not allowed to use the cell phone in resident rooms and it is not appropriate to take photos or videos of residents while providing care. The Administrator stated that LPN #5 should have documented the allegation made by Resident #174 and there should have been an investigation initiated. 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey completed on 05/04/2021, the facility did not provide the necessary care and services to attain and maintain the resident's highest practicable well-being for one (Resident #550) of three residents reviewed for Quality of Care. Specifically, Resident #550 had a Pulmonary Consult dated 4/23/2021 that was not addressed by the attending physician in a timely manner. The findings is: Resident #550 has diagnoses that include Hypertension (HTN) and Coronary Artery Disease (CAD). The Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) Score of 15 indicating the resident's cognitive status was intact. Review of nursing progress notes documented Resident #550 was seen by the Pulmonary Consultant on 4/23/2021 and documented the resident was noted with Shortness of Breath (SOB), Orthopnea (SOB while laying flat) and crackles likely due to Congestive Heart Failure (CHF). The resident will need to be aggressively treated with Diuretics (medication to help the body get rid of extra fluid). The recommendation was to start Lasix (Diuretic) 40 Milligrams (mg) by mouth (po) daily (QD) and start Albuterol 2 puffs every 6 hours. The Physician orders dated 4/27/2021, three days after the Pulmonary consult, documented to administer Albuterol sulfate aerosol 2 puffs by inhalation route every 6 hours as needed (prn) and Lasix 40 mg daily. The Medication Administration Record (MAR) for April 2021 revealed Albuterol was never provided (because it was ordered as needed) and Lasix was first administered on 4/28/2021 at 10 AM. The attending Physician Note dated 4/25/2021 did not address the Pulmonologist recommendations made on 4/23/2021. The attending Physician was interviewed on 5/4/2021 at 12:23 PM and stated that the attending Physician was not aware of the Pulmonologist's recommendation until 4/27/2021. The attending Physician stated that the resident was seen by the attending Physician on 4/25/2021. The attending Physician was not aware that there was a Pulmonologist consult for review on 4/25/2021. On 4/27/2021 when the attending Physician became aware of the Pulmonologist's recommendation, albuterol and Lasix were then ordered. The attending Physician stated that the expectation was that the the attending Physician should have been notified of the Pulmonologist's recommendation after the resident was seen. The Pulmonologist was interviewed on 5/4/2021 at 11:30 AM and stated that the Pulmonologist examined Resident #550 and the resident required the recommended medications (Albuterol and Lasix). The Pulmonologist further stated that the consult should have been addressed by the attending Physician within 1 to 2 days and that the 4 days wait was excessive. The Registered Nurse (RN) Supervisor #4 was interviewed on 5/4/2021 at 3:07 PM and stated that on 4/27/2021, the RN Supervisor noticed there was a Pulmonology consult completed for Resident #550 on 4/23/2021. The Pulmonologist normally provides a list of residents that are seen for consultation; however, the list was not provided to the Nursing supervisors or the Director of Nursing Services on 4/23/2021. When a consult list is provided, the RN Supervisor would review the consult and if there were any recommendations in the consult, the Physician would be notified for directions and orders. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey completed on 05/04/2021, the facility did not ensure that the attending Physician must document in the resident's medical record that an irregularity identified by the Pharmacy consultant was reviewed and a rationale was documented for disagreement with the pharmacy consultant. This was identified for 1 (Resident #222) of 6 residents reviewed for unnecessary medications. Specifically, the Pharmacy Medication Regimen Review (MRR) documented a recommendation to stop the use of Diphenhydramine (Benadryl) for Resident #222. The medical record lacked documented evidence of a Physician's rationale to address continued use of Benadryl for Resident #222. The finding is: Resident #222 was admitted with diagnoses that included Generalized Anxiety Disorder, Depression, and Agoraphobia (fear of open spaces) with panic disorder The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident's cognitive status was intact. The resident was taking antianxiety and antidepressant medications 7 of 7 days during the assessment look back period. The Physician orders dated 3/13/2021 documented Fluoxetine (Prozac) 40 Milligrams (mg) capsule- give 1 capsule (40 mg) by oral route once daily in the morning for Depression; Alprazolam (Xanax) give 1 tablet (1 mg) by oral route every 8 hours; and Diphenhydramine (Benadryl) 25 mg at bedtime. The Pharmacy MRR dated 4/14/2021 documented, Currently receiving Diphenhydramine without a stop date. Long-term use is not recommended due to the high incidence of anticholinergic side effects. Please evaluate the continued need and add stop date x 1 week. The physician disagreed, did not sign the MRR, and did not document a rationale why the Physician disagreed with the Pharmacist's recommendation in the resident's medical record. The Physician was interviewed on 5/3/2021 at 12:53 PM and stated the Physician disagreed with the pharmacy consult to discontinue Benadryl because the resident has severe pruritus (itchiness). The Physician further stated he should have documented a rationale in the medical record to continue the use of Benadryl for Resident #222. 415.18(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey completed on 05/04/2021, the facility did not ensure that each resident remains free of psychotropic drugs unless the medication is necessary. This was identified for 1 (Resident #498) of 6 residents reviewed for unnecessary medications. Specifically, Resident #498 with a diagnosis of Dementia was prescribed Seroquel (an antipsychotic medication) XR (extended release) for Agitation for behavior management. The finding is: The facility's policy, dated 9/4/2018 and revised on 10/2020, documented that residents displaying symptoms of a psychiatric disorder and/or behavioral symptoms shall have non-pharmacological interventions planned and carried out prior to psychiatric intervention. The manufacturer's safety information for Seroquel XR documented that elderly patients with dementia-related psychosis (having lost touch with reality due to confusion and memory loss) treated with this type of medicine are at an increased risk of death, compared to placebo (sugar pill). Seroquel XR is not approved for treating these patients. Resident #498 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Malnutrition. The admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #498 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS documented that Resident #498 did not have indications of psychosis including hallucinations and delusions. The MDS also documented that Resident #498 did not have any behavioral symptoms, rejection of care, and wandering. Additionally, the MDS documented that Resident #498 received antianxiety medication for 6 of 7 days and antipsychotic medication 0 of the 7 days in the look back period. The physician's orders dated 4/6/2021 documented a request for a Psychiatrist Consultation. The Physician's orders dated 4/7/2021 documented Aricept 5 Milligram (mg) give 1 tablet once daily in the evening for Unspecified Dementia with Behavioral Disturbance. Additionally, the physician's orders documented Xanax 0.25 mg at 9:00 AM and 9:00 PM for Anxiety Disorder unspecified. The Physician's orders dated 4/15/2021 documented for the Registered Nurse (RN) Supervisor to check the wander guard every week on Sunday for placement and functionality. The Physician's orders dated 4/23/2021 documented Psychiatric consult to address Resident #498 being verbally aggressive toward staff, up all night accusing family member/staff of stealing from her, attempting to leave, and packing a suitcase multiple times. The Physician's order also documented Seroquel 25 mg give 1 tablet oral route 2 times per day without a diagnosis or indication for use. The Physician's orders dated 4/30/2021 documented Psychological Evaluation: reason: Emotional. The Physician's order also documented Seroquel 25 mg, give 1 tablet by oral route 2 times per day for agitation for behavior management. The Wandering/Elopement Risk Comprehensive Care Plan (CCP) dated 4/15/2021 documented Resident #498 had wandering, pacing and elopement behavior due to Dementia, Depression, Anxiety, and increased confusion. Interventions included placement of a roam alert bracelet and wander guard on the right ankle. The Psychotropic Medication CCP dated 4/16/2021 documented that Resident #498 takes antianxiety medication related to Dementia with behavior for the psychiatric disorder of Anxiety. Interventions included to administer medication per Physician's order, monitor for changes in behavior, functional status, side effects of medications, and the resident's response to medication. The Behavior CCP dated 4/23/2021 documented Resident #498 had verbal behavior symptoms, screaming at others, behaviors not directed towards others, verbal disruption, excessive agitation, and resistance to care. The resident had poor safety awareness, sundowning, motor restlessness, easily agitated and poor impulse control. The behaviors had mild-moderate intensity and the duration of behaviors varied. The behaviors were related to the medical condition of Dementia. Interventions included to assess behavior patterns for causative factors, develop/implement a behavior management plan created with the resident's input when able to participate, and provide psychiatric evaluation and treatment. The Care Plan Monitoring notes documented Resident #498 had behaviors of wandering on the unit, roaming in and out of resident's rooms, easily agitated, and resistant to care. Resident #498 was noted to be by the elevator doors stating that Resident #498 wanted to go home. Roam alert was in place to monitor safety, 1:1 provided, support and reassurance provided. The Certified Nursing Assistant Accountability Record (CNAAR) from 4/5/2021 to 4/30/2021 documented Resident #498 resisted care 16 of 25 days, displayed frequent crying/tearfulness 11 of 25 days, Yelling/Screaming 3 of 25 days, and Wandering 11 of 25 days. The progress note dated 4/23/2021 documented that Resident #498 was having behaviors, required 1:1 attention, did not sleep all night and was trying to get on the elevator repeatedly. Resident #498 was on Xanax 0.25 mg twice a day and Remeron 7.5 mg. A new order for Seroquel 25 mg twice a day was received, the Remeron was discontinued, and a Psychiatric evaluation was pending. The Medical Progress Note dated 4/23/2021 documented that Resident #498 was awake, alert, very confused, responsive, and pleasant. The physician documented that Resident #498 had unstable behavior including anxiousness and was trying to leave as per the nurse. The physician documented that the treatment plan included to continue Aricept 5 mg for Dementia with Behavior, to discontinue Remeron and to start Seroquel 25 mg twice a day for unstable depression, and to continue using Xanax 0.25 mg twice a day. The Psychiatric evaluation was pending. The Medication Administration Record for April 2021 documented that Resident #498 received Seroquel 25 mg two times per day from 4/23/2021 to 4/30/2021. The Psychological evaluation dated 4/30/2021 documented that Resident #498 had a primary psychological diagnosis of Adjustment Disorder with mixed disturbance of emotions and conduct. The current/past psychiatric diagnoses section of the evaluation documented that there was no known significant mental health or substance abuse history and the records indicated diagnoses of Dementia, altered mental status and anxiety. The mental status section of the evaluation indicated that Resident #498 had no psychotic symptoms. The psychologist documented that Resident #498 was able to converse fairly well, however the Resident's memory was poor and appeared to confabulate in an effort to conceal limitations. Resident #498 did not recall having been upset during a night last week which included yelling, packing personal items and attempting to elope from the facility. The 7:00 AM-3:00 PM Licensed Practical Nurse (LPN #4) on the Cedar Unit was interviewed on 4/30/2021 at 12:29 PM. LPN #4 stated that Resident #498 used to reside on the Cedar Unit. Resident #498 was pleasant but was very anxious about being in the facility due to unfamiliarity with the staff. LPN #4 stated at one point, Resident #498 would just pack the suitcase and roll down the hallway. LPN #4 stated that Resident #498 was never combative or challenging during care. The 3:00 PM- 11:00 PM LPN (#3) on the Dogwood Unit was interviewed on 4/30/21 at 3:58 PM. LPN #3 stated that Resident #498 is new to the Dogwood Unit and has lived there for about a week. Resident #498 is often sad and tearful. LPN #3 stated that the resident is always asking for family, can be confused about where she is and why she is here. Resident #498 has been responsive to the approach in care and is not combative or behaviorally challenging. The 11:00 PM-7:00 AM Certified Nursing Assistant (CNA #3) on the Cedar Unit was interviewed on 5/3/2021 at 2:29 PM. CNA #3 stated that Resident #498 used to live on the Cedar Unit and CNA #3 was assigned to provide care for the resident. Resident #498 cried a lot and wanted attention. If medication would not come to Resident #498 fast enough, Resident #498 would get angry and scream. Resident #498 did not have these behaviors every day. CNA #3 would talk to Resident #498 and offer tea when Resident #498 was upset. Resident #498 usually would calm down with the CNA #3's interventions. The 3:00 PM-11:00 PM CNA (#2) on the Cedar Unit was interviewed on 5/3/2021 at 2:49 PM. CNA #2 was assigned to provide care to the resident. Resident #498 was very depressed, always calling for a family member. Resident #498 liked to be talked to and was responsive to CNA #2's approach in care. Resident #498's behavior never escalated while CNA #2 provided care. The 3:00 PM-11:00 PM LPN (#2) on the Cedar Unit was interviewed on 5/3/21 at 3:34 PM. LPN #2 stated that she was the regular LPN on the Cedar Unit when Resident #498 resided there. LPN #2 stated that Resident #498 was constantly wandering and did not know what was going on. Resident #498 was often crying. Resident #498 liked to talk and would calm down when LPN #2 took the time to talk. The Physician was interviewed on 5/4/2021 at 10:07 AM. The Physician stated that Resident #498 did not receive a Psychiatric consultation to determine the appropriateness of the psychotropic medications. The Physician stated that another order for a psychiatric consultation will be placed. The Physician stated that he knows of the manufacturer's warning against using Seroquel for Dementia. The Physician stated that Resident #498 was treated with Seroquel to address Depression and Agitation associated with Dementia despite the warning. The Physician stated that Resident #498 was noted to attempt to elope the facility and the Physician was concerned for Resident #498's safety. The Physician further stated that there were no other interventions available to prevent elopement and the medication would help restrict Resident #498's ability to elope from the facility. The Director of Nursing Services (DNS) was interviewed on 5/4/2021 at 5:09 PM. The DNS stated the facility's policy is to assess the resident and ensure that non-pharmacological interventions are attempted prior to introducing psychotropic medications. The nursing staff should inform the attending physician that a referral for a Psychological or psychiatric consultation should be made in order to further assess the resident's clinical presentation. The DNS stated that the facility has been having a hard time getting Psychiatrists to visit the facility due to COVID-19. The DNS stated that professionally, she knows that the antipsychotic medication is not indicated for Dementia, but the physician makes the final determination of the medication regimen. 415.12(l)(2)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey completed on 5/04/2021, the facility did not ensure that outside professional services were furnished in a timely manner for one (Resident #222) of 6 residents reviewed for unnecessary medications. Specifically, Resident #222 had a Physician's order for a Psychiatry consult dated 3/13/2021 and the Psychiatry consult was not completed until 4/29/2021, more than six weeks after the consult was ordered. The finding is: Resident # 222 was admitted with diagnoses that include Generalized Anxiety Disorder, Depression and Agoraphobia (fear of open spaces) with panic disorder. The Minimum Data Set Assessment (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 that indicated the resident's cognitive status was intact. The Physician orders dated 3/13/2021 documented a psychiatry consult and to administer Fluoxetine (Prozac) 40 mg capsule 1 capsule (40 mg) by oral route once daily in the morning for Depression and Alprazolam (Xanax) 1 tablet (1 mg) by oral route every 8 hours. The medical record lacked documented evidence that a Psychiatry consult was completed as of 4/29/2021. The Comprehensive Care Plan (CCP) dated 3/13/2021 for Psychotropic Drug Use documented the resident was on Antidepressants related to Depression. Interventions included to provide Psychiatric evaluation and treatment. The Physician was interviewed on 5/3/2021 at 12:53 PM , an order was placed for a Psychiatry consult on 3/13/2021. The Physician did not know why the Psychiatrist consult was not done until 4/29/2021. The Physician stated that the Psychiatrist consult should have been done sooner due to use of the psychotropic medications and the resident's diagnoses. The Registered Nurse (RN) Supervisor #5 was interviewed on 5/4/2021 at 3:32 PM and stated RN #5 admitted Resident #222 and the Psychiatrist and other consults that were ordered by the Physician were were entered into the Electronic Medical Record system. It has been difficult getting consultants to come into facility. Resident #222 does have anxiety issues and the resident should have been seen sooner then 4/29/2021 by the Psychiatrist . The Director Nursing Services (DNS) was interviewed on 5/4/2021 at 5:45 PM and stated there was a problem scheduling Psychiatrists to come to the facility. The the resident should have been seen sooner once a consult was ordered. 415.26(e)(i-iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey completed on 05/04/2021, the facility did not maintain accurate Electronic Medical Records (EMR) for one (Resident # 550) of 70 sampled resident records. Specifically, EMR system used by the facility erroneously deleted a consultation note that was written by the Pulmonologist consultant on 4/23/2021 when a correction update to the consult was made by the Pulmonologist on 4/28/2021. The finding is: Resident #550 has diagnoses that include Hypertension (HTN) and Coronary Artery Disease (CAD). The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident's cognitive status was intact. Review of Nursing progress notes documented Resident #550 was seen by the Pulmonologist on 4/23/2021 with recommendations. The Pulmonologist note dated 04/28/2021 documented a correction to the 4/23/2021 note indicating that the medications recommended on 4/23/2021 by the Pulmonologist were non-urgent. The 04/28/2021entry by the Pulmonologist to update the 04/23/2021 note erroneously deleted the 4/23/2021 note from the EMR. The Director of Nursing Services (DNS) was interviewed on 05/14/2021 at 2:37 PM and stated that the 4/23/2021 note should not have been deleted and the EMR vendor will be contacted to correct the issue. The Administrator was interviewed on 5/4/2021 at 5:45 PM and stated that when a clinician is correcting the notes in the EMR it should not delete the previous entries and the EMR vendor will be made aware. 415.22(a)(1-4)