Based on observation and interview during the recertification survey conducted 02/5/24-02/9/2024, the facility did not ensure the results of the most recent Federal/State survey were posted in a place readily accessible to residents, family members, and legal representatives of residents. Specifically, the results of the most recent Federal health recertification survey conducted 11/4/2021 were located within a chest of drawers that was not accessible to all residents without asking for assistance. Findings include: The facility policy Resident Rights, reviewed by the facility 10/2023, documented all residents of the facility would have their rights protected and promoted. Every resident would be encouraged and assisted to exercise their rights. The facility policy did not include documentation residents' rights to review the results of the most recent Federal/State survey or that they were posted in an accessible location. During the resident council meeting on 02/05/2024 at 2:18 PM, there were 9 residents present. An anonymous resident stated they knew where the previous survey results were located. However, due to the location they needed to ask for staff assistance to view them. The remaining 8 anonymous residents agreed that staff assistance was required to review the survey results. During an observation and interview on 02/06/2024 at 10:07 AM, a small sign was located at the bottom of the hanging locked glass case that stated, The New York State Department of Health survey results can be found in the chest in the front lobby. Administrative Assistant #7 stated the chest was the drawer set underneath the glass case. The survey results were in a bent folded over plastic dust cover in the top drawer, underneath a cane and two gavels. It was not accessible to residents without requesting assistance. During a follow up interview on 02/8/2024 on 11:18 AM, Administrative Assistant #7 stated the survey book was kept in the chest of drawers and there was a sign in the hanging glass case that indicated to look in the chest for the survey results. They were not aware of any issues of residents not being able to access the drawers, but they would assist residents if needed. They stated they were previously asked for assistance to locate the survey book and were not able to recall if they were asked by residents or visitors. During an interview on 02/08/2024 at 11:33 AM, the Social Services Director stated they reviewed where the survey results book was located during every Resident Council meeting. They stated they were not aware of residents having stated they had trouble accessing the survey book. They stated it was understandable that a resident may have difficulty to access to the survey book without assistance because it was in a drawer which could be difficult for some residents to pull open. During an interview on 02/09/2024 10:55 AM, the Administrator stated the summaries of the previous survey results were in the glass case above the chest. The chest contained the actual results of the survey. They believed the results were easily accessible but stated it was subjective. They were not aware residents stated they had to ask for assistance with the drawer to access the survey results. 10NYCRR 415.3(c)(v)

Based on observation, record review, and interview during the recertification survey conducted 2/5/2024- 2/9/2024, the facility did not develop and implement a comprehensive person-centered care plan to meet a resident's medical and nursing needs for 1 of 3 residents (Residentv#66) reviewed. Specifically, Resident #66 did not have a comprehensive person-centered care plan that included a safety gate at the doorway to their room. Findings include: The 9/2023 facility policy Comprehensive Care Plan documented a comprehensive, person-centered care plan would be developed and implemented for each resident consistent with resident rights and include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. The comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Resident #66 was admitted to the facility with diagnoses including stroke with hemiplegia (one sided weakness) on the non-dominant side, aphasia (difficulty speaking), and dysphagia (difficulty swallowing). The 9/12/2023 Minimum Data Set assessment documented the resident was cognitively intact, required extensive of assistance of two for most activities of daily livings, was non-ambulatory, and did not use restraints. During observations on 2/5/2024 at 11:24 AM and 11:55 AM; 2/6/2024 at 9:59 AM; and 2/7/2024 at 12:47 PM, there was a wooden safety gate across the doorway, latched into the door frame of Resident #66's room. During observations on 2/6/2024 at 8:42 AM and 12:18 PM, there was a wooden baby gate at the doorway of the resident's room that was not pulled across the opening to the room. The 12/5/2023 comprehensive care plan did not document any safety care plans, or use of locking door or baby gate at the resident's room entrance. The psychosocial well-being care plan initiated on 12/19/23 documented the resident was alert, oriented, and able to make their needs known. The 2/5/2024 at 4:44 PM and 2/6/2024 at 5:23 PM, pocket care plan (care instructions) did not document use of a locking door or safety gate at the resident's room entrance. Nursing progress notes dated 10/5/2023 to 2/6/2024, did not document a reason for the use of a safety gate at the entrance of the resident's room. During an interview and observation on 2/5/2024 at 11:55 AM, Resident #66 and the resident's family stated the safety gate at the entrance of the room was used to discourage wandering residents on the unit from entering. The family stated that the resident could not open the gate at the doorway, but the resident was also non-ambulatory, and they could not propel their wheelchair to the door on their own. During an interview on 2/6/2024 at 12:11 PM, certified nurse aide #2 stated the safety gate had been used for approximately 2 to 3 months. It was used to keep other residents out of the room. The gate was opened by a lift bar in the front, the mechanism pulled upward to unlatch. Resident #66 did not have the strength to open the gate, or ability to reach over the gate to pull up on the bar. During an interview on 2/6/2024 at 12:28 PM, licensed practical nurse #3 stated the pocket care plan was the resident's care plan and was used it to determine the care needs for the residents. They stated the pocket care plan was generated from the computer, but they were not sure how to get to the electronic medical record care plan. They stated it had been a while since they used the electronic medical record care plan. At 12:31 PM, licensed practical nurse #3 stated the safety gate was used keep other residents from going into the room and was provided by the facility. The resident's roommate had an electronic care plan and a paper pocket care plan for the safety gate but Resident #66 did not. During an interview on 2/6/2024 at 1:00 PM, registered nurse #4 stated that other residents wandered into the resident's room, and it upset the resident and their roommate. The resident could not get to the door on their own accord due to their physical limitations. The facility tried to use a stop sign and locking door, without success. The family was very particular about what they wanted for the resident. The safety gate had a bar that lifted on the front and could be pushed in if needed. The unit staff had been trained on using it. Registered nurse #4 stated they were responsible for the nursing portions of the care plans for the residents, but the facility had 2 types of care plans. The main care plan was documented in the electronic medical record, and the pocket care plan was on paper and included basic care required for the resident. The paper care plan could be updated by any licensed staff. Resident #66 did not have a care plan for the safety gate at the door. The roommate did have a care plan for the safety gate, and the 2 residents shared the same doorway. Registered nurse #4 stated Resident #66 should have an electronic care plan and a paper pocket care plan for the safety gate. During an interview on 2/8/2024 at 8:54 AM, social worker #5 stated the Unit Manager and the social worker were responsible for the resident's care plan. The social worker was responsible for the sections in the care plan that included psychosocial needs, mood, and behaviors. There was no care plan area for safety related to the residents. They could include a care plan for safety within any area of the care plan. The safety gate was kept in the common doorway for the resident and their roommate. Resident #66 did not have a care plan for the safety gate and should have. They stated the electronic care plan could not be viewed by certified nurse aides, and frequently froze which made it no longer viewable by anyone. The facility created the paper pocket care plan for ease of access to information that was reviewed daily by nursing. During an interview on 2/8/2024 at 11:43 AM, the Director of Nursing stated they expected a resident's care to have all required components and be updated by the interdisciplinary team. The registered Nurse Manager was responsible for the main care plan. The Director of Nursing stated both residents should have been care planned for the safety gate. The lack of a care plan for Resident #66 was an oversight. The safety gate should have been electronically care planned and added to the paper pocket care plan. The electronic care plan and paper pocket care plan did not interface with each other and needed to be updated separately. The current electronic care plan system used was very difficult to navigate and utilize, so the facility developed its own paper pocket care plan. There was a possibility that information went into the electronic care plan but not the paper pocket care plan, and vice versa. The paper pocket care plan was a shortened version of the electronic care plan. The resident's information should be on the electronic care plan first and then moved to the paper pocket care plan. 10NYCRR 415.11(c)(1)

Based on observation, interview, and record review during the recertification survey conducted 2/05/2024-2/09/2024, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 of 1 resident (Resident #33) reviewed. Specifically, Resident #33 did not have their resting hand splint applied appropriately as ordered. Findings include: The facility policy Orthopedic Devices, Care of the Resident With reviewed by the facility 10/2023, documented the nursing staff would apply splints and braces according to the physician's order and under the direction of physical or occupational therapy. The application and removal of the orthopedic device would be monitored by the licensed nurse. Resident #33 had diagnoses including unspecified severe dementia with mood disturbances, personal history of traumatic brain injury, and muscle weakness. The 6/14/2023 Minimum Data Set assessment dated documented the resident had severely impaired cognition, was totally dependent for activities of daily living, and had functional limitation in range of motion in both arms. A 9/22/2023 occupational therapist #16 Therapy Communication Form documented resting hand splint to be donned (applied) after AM self-care and doffed (removed) and doffed at HS (bedtime) and replaced with a palmar pose (hand splint) as tolerated for bedtime. There was a photo that included instructions of how to apply the splint. A physician #15 order dated 11/9/2022 and renewed 12/18/2023 documented left-hand splint on during daytime every day 7:00 AM-3:00 PM. The 12/18/2023 comprehensive care plan documented the resident was at risk for impaired skin integrity and had a left hand contracture. Interventions included a left hand blue palmar posy (hand-splint) on at all times and remove for care. The 2/5/2024 to 2/07/2024 pocket care plans (care instructions) documented a left hand splint was to be applied in the morning. The February 2024 treatment administration record documented the left-hand splint was in place every day. The February 2024 certified nurse aide treatment sheet documented the resident had a left-hand splint applied every day shift from 2/01/2024 to 2/8/2024 except for 2/04/2024 where there was nothing documented. The resident was observed without a left-hand resting hand splint applied or applied inappropriately: - On 2/05/2024 at 10:46 AM, sitting in their room in a wheelchair with their left arm curled over their chest and their fingers curled into the palm. The resting hand splint was on the resident's bed, away from the resident. - On 2/07/2024 at 9:14 AM, sitting in their room in their wheelchair with the resting hand splint on their left arm with the straps very loose. Their thumb was off the bracing and curled under. - On 2/08/2024 at 8:53 AM, the resting hand splint was on the resident's lap without the straps on tightly. The resident's forearm and hand were curled into the resident's lap, not on the resting hand splint. During an interview on 2/08/2024 at 9:14 AM, certified nurse aide #12 stated if a resident was gotten up by the night shift, they applied the resident's splint. The day shift certified nurse aide verified it was applied correctly. Therapy educated the certified nurse aides on the splints and there were pictures of how the splint was applied in the certified nurse aide documentation book. They also signed a treatment sheet indicating the splint was applied. Certified nurse aide #12 stated Resident #33's splint was applied by the night shift regularly. They stated the straps on the splint were labeled to ensure correct position and the goal was to keep the left hand open. They stated the resident was unable to remove the resting hand splint themselves. The resident was able to move the splint around slightly by moving around their arm, but the splint should not be completely off the resident. Staff should check the splint periodically to ensure correct positioning. During an interview on 2/08/2024 at 10:24 AM, registered nurse Unit Manager #13 stated splints and contracture management braces were placed on the resident per the physician order. They stated some braces were more complicated than others so therapy would provide education to the staff on how to don and doff the braces. There was a picture of the splint applied to the resident in the certified nurse aide documentation book. The licensed nurses also had a treatment order to check the splints as part of a double check system. Resident #33 could shift their splint with arm movement and the staff should fix it. The straps of the splint should not have been loose enough for their arm or hand to come completely out of the splint when applied appropriately. During an interview on 2/08/2024 at 10:57 AM, licensed practical nurse #14 stated the splints were applied as ordered and licensed nurses documented the splint was applied on the resident in the treatment administration record. They stated Resident #33 could shift the splint. If a certified nurse aide or other staff saw the splint was not on correctly and did not know how to reapply the splint, they should come to them or contact therapy. Therapy would come down and look at the splint. If a resident did not have their splint on, they could become more contracted. During an interview on 2/08/2024 at 11:10 AM, occupational therapist #16 stated if a resident had a specialized splint or if there were questions from the nursing staff, they would provide education. They provided nursing staff a picture of the splint on the resident for reference. They stated Resident #33 had a resting hand splint which should be applied during the day. The resident sometimes maneuvered the brace out of the correct position. The splint would not have been applied appropriately if the straps of the splint were loose enough to still be connected and the resident's hand/arm was not in the splint. If the splint was not applied correctly, the resident could have an increase in tone (increased tension in the muscles which makes it difficult for them to relax). If the splint was being dislodged or taken off a lot, they should be notified so an assessment could be conducted on the continued use of the splint or re-education could be provided to the nursing staff. During an interview on 2/08/2024 11:43, the Director of Nursing stated the splint devices should be care planned and include directions on how to apply the splint was applied. They stated there was a picture available to the certified nursing aides. The staff should keep track of the splints and have them replaced when dirty. They expected the splints to be applied as care planned per the occupational or physical therapy determination and orders. The nursing staff should notify therapy if the resident was slipping out of their splint so a reassessment could be conducted. Improper placement or application of a splint could cause skin breakdown. 10NYCRR 415.12(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey conducted 2/5/2024 to 2/9/2024, the facility did not complete or electronically submit encoded, accurate and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services System for 65 of 69 residents (Resident #1, 6, 7, 9-11, 13-18, 20-24, 27, 28, 30-39, 41, 43-45, 50-53, 55-59, 61, 62, 64, 66, 67, 70, 176, 182, 183, 186-188, and 373-383) reviewed. Specifically: - Residents #1, 6, 7, 9-11, 13-18, 20-24, 27, 28, 30-39, 41, 43-45, 50-53, 55-59, 62, 64, 66, 67, 70, 176, 182, 183, 186, 373-375, and 377-383 had Minimum Data Set assessments that were electronically submitted greater than 14 days following the completion of the assessment, or not submitted at all. - Residents #23 and #61 had Minimum Data Set (MDS) assessments that were completed later than 14 days following the Assessment Reference Date (ARD). - Residents #187, #188, and #376 had Minimum Data Set (MDS) assessments that were completed later than 14 days following their admission date. Findings include: The 10/2020 facility policy Documentation 9.3 documented that the resident assessment instrument would be completed according to the regulation of Centers for Medicare/Medicaid Services as outlined in [Centers for Medicare/Medicaid Services' Resident Assessment Instrument] Version 3.0 Manual. The most current Minimum Data Set Assessment 3.0 and active Medicare Minimum Data Set Assessment 3.0 for each resident would be filed in the resident record. A written assessment via progress notes by all disciplines (nursing, dietary, activities, resident services, and physical therapy) would be completed on admission, quarterly, annually after three quarterly assessments, and when a significant change was identified. The assessment progress notes should have included information necessary for the completion of the Minimum Data Set 3.0 assessment questions. All assessment progress notes were to be completed by or on the assessment reference date for each Minimum Data Set 3.0 assessment. The schedule for all assessments was created by the Minimum Data Set assessment coordinator. Section Z (Z0500) was signed by the Minimum Data Set assessment coordinator or nurse manager. The completed and locked Minimum Data Set assessment was then submitted to the state by the nursing administrative assistant or Minimum Data Set assessment coordinator. The facility did not have a policy that outlined the minimum data set submission requirements. The Centers for Medicare/Medicaid Services Minimum Data Set Resident Assessment Instrument Version 3.0 Manual documented that comprehensive assessments must be transmitted electronically to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system using the Centers for Medicare/Medicaid Services wide area network within 14 days of the care plan completion date and all other Minimum Data Set assessments must be submitted within 14 days of the Minimum Data Set completion date. For the admission assessment, the Minimum Data Set assessment completion date must be not later than 13 days after the Entry Date. An Omnibus Budget Reconciliation Act assessment (comprehensive or quarterly) was due every quarter unless the resident was no longer in the facility. There must be no more than 92 days between Omnibus Budget Reconciliation Act assessments. During the entrance conference on 2/5/2024 at 9:23 AM, the Administrator stated the facility had a census of 94 with 24 new admissions in the last 60 days. During an interview on 2/6/2024 at 1:29 PM, registered nurse Unit Manager #11, stated if a resident was missing a Minimum Data Set assessment in the electronic record it was because they were on paper in registered nurse/Minimum Data Set Assessment Coordinator #6's office. COMPREHENSIVE ASSESSMENTS: 1) Resident #187 was admitted to the facility on [DATE]. The undated Minimum Data Set assessment, section Z documented verified completion by registered nurse/Minimum Data Set Assessment Coordinator #6 on 2/9/2024 (32 days after admission). 2) Resident #376 was admitted to the facility on [DATE]. The 1/20/2024 Minimum Data Set assessment, section Z documented verified completion by registered nurse/ Minimum Data Set Assessment Coordinator #6 on 2/9/2024 (20 days after admission). 3) Resident #188 was admitted to the facility on [DATE]. The 1/21/2024 Minimum Data Set assessment, section Z documented verified completion by registered nurse/ Minimum Data Set Assessment Coordinator #6 on 2/1/2024 (16 days after admission). QUARTERLY ASSESSMENTS: 1) Resident #23's 1/24/2024 Minimum Data Set assessment, Section Z documented registered nurse Minimum Data Set Assessment Coordinator #6 completed all sections of the assessment and signed the document on 2/9/2024. 2) Resident #61's Minimum Data Set assessment, Section Z was not provided by the facility. MINIMUM DATA SET ELECTRONIC SUBMISSION: During an interview on 2/8/2024 at 3:44 PM, registered nurse/Minimum Data Set Assessment Coordinator #6 stated there had been problems with the computer system, and the Infection Control nurse had been assisting them with Minimum Data Set Assessments since November 2023. The facility software had been problematic since the Centers for Medicare/Medicaid Services update in October 2023. The facility software was not able to comply with the new assessment requirements. Due to the errors in the facility software, they started completing the Minimum Data Set assessments on paper. There was a specific timeline and due dates for new admissions. The admission assessment would open for entries on day one, they would review clinical data from the hospital, and the Minimum Data Set assessment would open on days 4 through 8, the Care Area Assessments were due by day 14, and the care plan was due by day 21. Quarterly assessments were due minimally every 92 days. The purpose of the Minimum Data Set assessment was to develop the care plan, monitor progress, and meet the needs of the resident. The assessment must be completed within 2 weeks of the Assessment Reference Date or the open date of the assessment. They could not submit any assessments since 10/1/2023. The first batch of assessments for October 2023, were sent electronically on 1/30/2024. They were trying to submit all assessments for 2023 by next week. The expectation was that assessments be submitted within two weeks of completion. The assessments were submitted in batches. They were responsible for batching and submitting Minimum Data Set assessments. The Centers for Medicare/Medicaid Services would become aware of the facilities census; however, they had not been able to submit assessments. Resident #23 had a quarterly Assessment Reference Date of 1/24/2024, and the assessment was not completed as of 2/8/2024, it should have been completed by 2/7/2024. Resident #61 had a quarterly Minimum Data Set Assessment Reference Date of 12/27/2023, it was completed on paper, but they could not locate the document in their office. During a follow-up interview on 2/9/2024 at 9:20 AM, registered nurse/Minimum Data Set Assessment Coordinator #6 stated they did not have documentation of Resident #61's assessment and had to check with another nurse. Resident #187's admission assessment was partially completed in the computer, was completed on paper, but they could not find the paper copy. Resident #376's admission assessment was completed on paper but was not completed timely. Resident #188's admission assessment was completed on paper but was not completed timely. Residents #1, 6, 7, 9-11, 13-18, 20-24, 27, 28, 30-39, 41, 43-45, 50-53, 55-59, 62, 64, 66, 67, 70, 176, 182, 183, 186, 373-375, and 377-383 all had assessments completed on paper, but they were not submitted timely as required. Residents #9, 11, 20, 23, 27, 34, 36, 70, 176, 373, 375, and 378-382 had assessments completed on paper, and the assessments were submitted electronically greater than 14 days after completion. Residents #1, 6, 7, 10, 13-18, 21, 22, 24, 28, 30-33, 35, 37-39, 41, 43, 44, 45, 50-53, 55-59, 62, 64, 66, 67, 182, 183, 186, 374, 377, and 383 had assessments completed on paper, but the assessments were not submitted electronically. During a follow-up interview on 2/9/2024 at 10:30 AM, registered nurse/Minimum Data Set Assessment Coordinator #6 stated the facility had to train the interdisciplinary teams on the new electronic Minimum Data Set assessment before they could use it completely. The new electronic system was set to start in March 2024. Until then, when a new resident was admitted to the facility, the resident's admission assessment was completed in the old electronic medical record and on paper, the nursing notes were completed in the old electronic medical record, and medical orders were reviewed in the new electronic medical record system. The whole process was very fragmented, but it was what they had to do until the new electronic medical record system was fully operational and everyone was trained. During an interview on 2/9/2024 at 10:55 AM, the Administrator stated the vendor they used for Minimum Data Set assessments was not able to comply with the new Centers for Medicare and Medicaid Services updates. They were in contact with the vendor several times between 10/1/2023 and 11/7/2023 and the vendor could not make the system work. The facility received proposal for a new system that went through the quality assessment team. They signed with the new system on 12/26/2023, with the holidays they were able to train the staff and get the old minimum data sets put into the new system on 1/17/2024. They completed 158 submissions in the last week, and stated they had to have all assessments submitted by 2/14/2024. The Administrator stated to their knowledge all the assessments were on time as scheduled. They were unaware that assessment must be submitted within 14 days of completion. During a follow up interview on 2/9/2024 at 1:18 PM, the Administrator stated they did not have a Minimum Data Set assessment policy, the facility used the Centers for Medicare/Medicaid Services manual for guidance. During an interview on 2/9/2024 at 1:47 PM, registered nurse/Minimum Data Set Assessment Coordinator #6 stated Resident #187's admission assessment and Resident #61's quarterly assessment were completed on paper on 2/9/2024, and they were not completed timely. 640 - 10 NYCRR 415.11(a)(5) 636 - 10 NYCRR 415.11(a)(3)(i) 638 - 10 NYCRR 415.11(a)(4)

Based on observation, record review and interview during the recertification survey conducted from 11/2/21-11/4/21 the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #67) reviewed. Specifically, Resident #67 had an order to receive oxygen therapy at all times and was observed with an empty oxygen tank. Findings include: The facility policy Oxygen Therapy updated 6/2019, documented oxygen must be administered safely and properly in an effort to help the resident with a respiratory impairment breathe easier. It is administered and monitored by licensed nursing staff. All residents using oxygen must have a physician order for oxygen (O2) saturations to be maintained greater than 90%, staff were to check O2 saturations as needed for shortness of breath and change the nasal cannula tubing and oxygen canister once a week. Resident #67 had diagnoses including chronic obstructive pulmonary disease (COPD, blockage of air flow) and pneumonia. The 9/29/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance with most activity of daily living (ADLs) and required oxygen. The 10/10/21 physician orders documented the resident was to receive oxygen at 2-3 liters (L) via nasal cannula at all times (AAT). The comprehensive care plan (CCP), updated 10/13/21, documented the resident was at risk for respiratory distress related to diagnosis of COPD. Staff were to apply oxygen as ordered daily and monitor oxygen saturation (amount of oxygen in the blood stream) as needed for shortness of breath. The 11/2021 treatment administration record (TAR) documented oxygen at 2-3 liters AAT to keep oxygen saturations equal to or greater than 90%. Nursing staff signed the oxygen was administered as ordered on 11/2/21 and 11/3/21. There was no documentation if the resident was on 2 or 3 liters or what their oxygen saturations were. The resident was observed on 11/2/21 at 12:42 PM, seated in the dining room eating lunch. The resident's portable oxygen tank was hanging on the back of their wheelchair and was observed to be empty. The resident did not exhibit signs or symptoms of respiratory distress. The resident remained seated in the dining room with an empty portable oxygen tank at 1:24 PM. At 3:12 PM, the resident was seated in the activity room with an empty portable oxygen tank with no visible signs of respiratory distress. During an interview on 11/2/21 at 3:20 PM, licensed practical nurse (LPN) #10 stated it was the responsibility of the nurses and the certified nurse aides (CNA) to check that portable liquid oxygen tanks were full or empty. The LPN stated residents that had oxygen tanks should be checked every shift especially before the resident went to meals. The LPN stated they had not yet checked the resident's oxygen tank that shift. During the interview at 3:24 PM, the LPN walked over to the resident to check the oxygen tank. They lifted the tank by the handle, and it was light-weight and the LPN stated the tank was empty. An 11/3/21 registered nurse (RN) #6 progress note documented a late entry for 11/2/21 at 3:30 PM, the resident was seated in the lounge with an empty portable oxygen tank. The resident's oxygen tank was replaced by the nurse. On 11/3/21 at 9:04 AM, the resident was observed in the TV room with an empty oxygen tank. The resident had no visible signs and symptoms of respiratory distress. During an interview on 11/3/21 at 9:13 AM, CNA #9 stated they would check the resident's oxygen tank after meals and on rounds. The CNA stated that they did not check the tank that morning because the LPN student was assigned to the resident. The CNA stated the student should have checked to make sure that the oxygen tank was full. The CNA stated they did check the tank at some point between 1:00 PM-1:30 PM on 11/2/21, and there was oxygen in the tank at that time. During an observation on 11/3/21 at 9:17 AM CNA #9 checked the resident's portable oxygen tank by pulling the strap by the dial and CNA #9 stated the tank was empty. During an interview on 11/3/21 at 9:20 AM, LPN student #13 stated when they got a resident up, they were to make sure the oxygen was on and working properly. The LPN student stated to make sure the tank was full they held the tank by the handle and read the gauge. The LPN student stated they got the resident out of bed about 2-2.5 hours before and the tank was half empty at that time and the tank was now empty. During an interview on 11/3/21 at 9:22 AM, LPN #11 stated resident's that were on oxygen therapy usually had their oxygen saturation checked once a day. They stated the resident usually ran a lower oxygen saturation level, and their saturation level was 91% yesterday. They stated that the goal was to have a resident's oxygen saturation level be greater than 90 %. The LPN stated that since the resident had an oxygen saturation level above 90% the resident was doing good. They stated that a nursing student was assigned to the resident on 11/2/21 and as far as they knew the resident had oxygen in their tank and they were not aware the resident had an empty tank. The LPN recalled that the resident was brought to the dining room in the morning and the tank was not empty. They stated that it was the responsibility of the nurses and CNAs to make sure that the resident's oxygen tank was checked and was not empty. During an interview on 11/4/21 at 10:19 AM, RN Unit Manager #12 stated that it was the responsibility of the nurse to fill the oxygen tank, set the flow, and make sure there was oxygen in the tank. They stated the CNA was only responsible to assist in getting a new tank. The RN stated the only time the resident was using the portable oxygen tank was when they were attending activities outside of their room. When in their room they would use wall unit oxygen. The resident required oxygen therapy due to a diagnosis of COPD, a history of pneumonia and shortness of breath. A resident could last through a meal with a partial oxygen tank, but ideally the resident should have been provided a full tank before the meal. The resident should have been brought back to their room to use their wall unit oxygen at some point. The RN stated the resident had a routine that they liked to go back to their room and sit in the recliner. They believed on 11/2 a newer CNA cared for the resident and was not used to the resident's routine. On 11/3/21, the assigned staff and the LPN instructor should have checked the resident's oxygen and not relied on the student. 10NYCRR 415.12(k)(6)

Based on observation, record review, and interview during the recertification survey conducted 11/2/21-11/4/21, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 kitchenettes (main dining room). Specifically, a food service worker (dietary aide #7) did not change gloves after handling raw eggs and before serving residents breakfast, and unlabeled and undated soups were observed in a hot box (insulated food storage system) after a breakfast meal. Findings include: The undated facility policy General Food Preparation and Handling documented food is covered for storage. Leftovers were to be dated, labeled, covered, cooled, and stored in a refrigerator. Bare hands should never touch raw food directly. During an observation on 11/3/21 at 8:31 AM, dietary aide #7 was at the stove in the main kitchenette area in the main dining room. The dietary aide was making a fried egg for a resident. At 8:33 AM, the dietary aide cracked a raw egg while wearing gloves. The dietary aide did not change their gloves, touched the clean plate being used for the resident, and touched the spatula to flip the egg. At 8:35 AM, the dietary aide plated 2 resident meals wearing the same gloves they had worn to crack the raw egg. The dietary aide then touched French toast and a ham steak with the same hand. The plate was then removed from the serving table and served to a resident. During an interview with dietary aide #7 on 11/3/21 at 8:43 AM, they stated they should wash their hands between glove changes. The gloves should be changed between cooking items and touching raw meats. They stated they should have changed their gloves after cracking the egg(s). During an observation on 11/3/21 at 8:48 AM, there were 6 trays at the bottom of the hot box located in the main dining room kitchenette. One of them was labeled chicken noodle and one of them was rice. The remaining trays were marked in illegible black marker. The lids were bent in/warped allowing air flow and food to be visible. There were no dates on the trays. During an interview with the Director of Food Service on 11/4/21 at 9:56 AM, they stated staff should wash their hands before moving to a different task, when changing gloves, or anytime they were going from raw to ready to serve food. The Food Service Director stated this was important to prevent cross contamination and foodborne illness. They stated the staff should not have touched the raw egg then utensils, plates, and food items. The staff should have changed their gloves after cracking the egg. They stated staff did not usually put any foods into the hot box. The hot box was used to keep plates hot. Anything not being used for that meal service should have been labeled and should not have been stored in the hot box overnight. Soup was not served for breakfast and should have not been in the kitchenette. The hot box should have been cleaned before the end of the shift the night before. If the hot box had been turned off and back on, the food left inside could cause foodborne illness. That food would not be able to be reused and would have to be discarded. 10NYCRR 415.14(h)

Based on observation and interview during the recertification survey conducted 11/2/21-11/4/21, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 3 nursing units (Units 1, 2 and 3) reviewed. Specifically, the facility did not dispose of expired medications and biologicals in the medication storage area on Units 1, 2 and 3. Findings Include: The facility policy General Medication Administration updated 3/2015 documented before administering the medication, check for irregularities such as expiration date. During a Unit 2 cart A medication storage observation on 11/2/21 at 1:42 PM with licensed practical nurse (LPN) #3, there was a tube of Ben Gay (pain relief rub) with a manufacturer expiration date of 9/2021 and a handwritten opened expiration date of 7/2020. The LPN stated it was expired as it was opened over a year ago. The LPN stated the resident was to use the medication as needed but was unaware if it was recently used. During a Unit 2 medication storage room and refrigerator observation on 11/2/21 at 1:49 PM with LPN #3, the following was observed: - 3 unopened single use vials of Fluad quadrivalent (flu vaccine) 0.5 milliliters (ml) syringes with a manufacturer expiration date of 6/15/21; - 1 opened stock vial of fluzone (flu vaccines) 5 ml that was half filled and had no opened date; - 2 unopened stock bottles of atropine sulfate (eye drops) solution with a manufacturer expiration date of 10/2021; and - an opened bottle of Scalpicin (scalp anti itch medicine) solution with a manufacturer expiration date of 10/20 and opened date of 9/12/19 handwritten on the tube. When interviewed on 11/2/21 at 2:00 PM, LPN #3 stated all of the Unit 2 medications observed were expired. The 5 ml flu vial had no handwritten date on it to determine when it had been opened and was considered expired as it was only good for 30 days once opened. The LPN stated the nurse opening a vial was supposed to write the open date on the vial. The LPN stated there was no specific shift assigned to check medication storage areas for expired medications, but all nurses were to check each medication prior to administration. The LPN stated they were unaware of any resident receiving any of the expired medications. During a Unit 1 cart B medication storage observation on 11/2/21 at 2:22 PM with licensed practical nurse (LPN) #4, the following was observed: - an opened bottle of colbetasol shampoo 0.05% with a manufacturer expiration date of 9/21; - an opened bottle of fluticasone (nasal) spray 50 micrograms (mcg) with a manufacturer expiration date of 8/2021; - an opened container of ammonium lactate 12% (facial cream) with a manufacturer expiration date of 10/4/05; and - 2 tubes of stock miconazole nitrate 2% (antifungal) with a manufacturer expiration date of 8/2021. During a Unit 1 medication room storage observation on 11/2/21 at 2:24 PM with LPN #4, the following were observed: - an unopened stock bottle of aspirin 81 milligrams (mg) with a manufacturer expiration date of 4/21; and - an unopened stock bottle of guaifenesin (cough syrup) 100 mg/5 milliliters (ml) 16 ounce (oz) with a manufacturer expiration date of 10/21. During a Unit 1 medication room refrigerator observation on 11/2/21 at 2:24 PM with LPN #4, the following were observed: - an opened stock vial of Levemir (insulin) 100 units/ml with no written date of when it had been opened; and - an opened vial of tubersol (tuberculin test) 1 ml vial with a manufacturer with no written date of when it had been opened. During a Unit 3 short hall' cart medication storage observation on 11/2/21 at 2:02 PM with LPN #5, there was a resident specific ear drop container that had a manufacturer expiration of 2021 and the month was faded so that it was unreadable. The LPN stated they were unable to read the expiration month, the bottle was received at 8:30 PM on an evening shift and the resident still had an active order for the medication. The LPN was unaware if the resident received the drops recently. When interviewed on 11/2/21 at 2:26 PM, LPN #4 stated the observed medications on Unit 1 were past the manufacturer expiration date and the vials with no written opened date were considered expired. Vials were good for 28 days once opened and since there was no open date, there was no way to know how long they were there. LPN #4 stated all nurses should check expiration dates prior to administering medications. The LPN stated there was no specific shift assigned to check the medication storage areas for expired medications and treatment supplies. The LPN was unaware of any resident receiving any of the expired medications. When interviewed on 11/2/21 at 2:38 PM, registered nurse (RN) Unit Manager #6 stated all nurses were to check for expiration dates of medications or treatments prior to administering them. The pharmacy consultant came in occasionally to check for expired medications. The Unit Manager did not know if those checks were random regarding treatments or medications. The Unit Manager stated the expiration checks were not assigned to a specific shift and were not documented. The Unit Manager stated medications were to be discarded once expired and the nurse opening a vial should date the vial with the open date. If the vial was not dated with an open date, it was considered expired. When interviewed on 11/3/21 at 3:52 PM, the Director of Nursing (DON) stated expired medications should be checked every so often and the consulting pharmacist checked for them quarterly. There was no specific shift assigned to check for expired medications, but it was usually the midnight shift nurse who was asked to check. Those checks were not documented. The person checking for expired medications should check the medication room, medication refrigerator and medication carts. The nurse should also check the expiration dates of any treatments and creams. When a nurse opened a vial, they should date the vial or the box with the open date. Any opened vial was good for 28 days. 10NYCRR 415.18(d)(e)(2-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey the facility did not ensure residents who enter the facility with an indwelling catheter (a tube which drains urine from the bladder) or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for 1 of 2 residents (Resident #59) reviewed for urinary catheters. Specifically, Resident #59 had a urinary catheter placed without valid medical justification. The facility's Use of Urinary Catheterization policy reviewed 5/2012 documented: - A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization is necessary. - The facility will assess all resident's at risk for urinary catheterization and assess any resident currently with a catheter on an ongoing basis. - The comprehensive assessment will include underlying factors supporting the medical justification for the initiation and continuing need for catheter use and development of a plan for removal. - If the physician/NP decides to use an indwelling catheter, it must be based on valid clinical indicators. Resident #59 was admitted to the facility on [DATE] and had diagnoses including urinary tract infection (UTI) and muscle weakness. The 3/14/19 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance of two persons for toileting and hygiene, did not have a catheter, was frequently incontinent, and had a toileting program or trial. The resident had no pressure ulcers/injuries, and no other wounds or skin problems. The physician's progress note dated 12/18/18, documented the resident was admitted to the facility from the hospital following a UTI. She had acute urinary retention, a urinary catheter was placed, and arrangements were made for urology follow-up. The Medical Referral for Consultation form dated 1/7/19, documented the resident was referred to a urologist for trial of voiding due to urinary retention. Treatment recommendations completed by the urologist included: - The resident passed the voiding trial; - Keep the catheter out and monitor for retention; - If 350 milliliters (ml) of post void residual (PVR, amount of urine remaining in bladder after voiding), replace indwelling catheter, and complete bladder scans as necessary; - Continue weekly oral antibiotics; and - Follow up appointment in three months with a bladder scan. A nursing progress note dated 1/8/19 at 2:41 PM documented the resident was voiding well. The comprehensive care plan (CCP) dated 1/8/19, documented the resident's catheter was removed and she was voiding well. Orders were in place to bladder scan as needed and reinsert the catheter if PVR was greater than 350 ml. The resident required staff support for all aspects of toileting, was taking diuretic and blood pressure medication that effected urine output, and the resident was at risk for recurrent UTIs. Approaches included a bladder scan as needed and assess for signs of UTI and urinary retention. A bladder scan dated 1/26/19, documented the PVR was 217 ml. A nursing progress note dated 2/24/19 at 2:56 PM, documented a family member stated she wanted the resident's catheter back in and the family had spoken with the urologist. A nursing progress note dated 3/10/19 at 2:45 PM, documented the resident had no complaints of urinary symptoms. The urologist visit summary dated 3/18/19, documented the resident was seen for follow-up for urinary retention and was accompanied by her family member. The resident had a history of retention but had not required a catheter. The resident had persistent incontinence. A bladder scan showed the PVR was 122 ml. Persistent incontinence and skin breakdown had been affecting the resident's quality of life and a catheter was placed during the visit. A nursing progress note dated 3/18/19 at 10:29 PM, documented the resident returned to the facility from her urology appointment with a urinary catheter. Consultation paperwork was left in the NP communication book. The CCP updated 3/28/19, documented the resident had a catheter in place due to urinary retention, had a history of frequent of UTIs and was on Monurol (antibiotic) and cranberry extract routinely. The goal was the resident would be free from UTIs and did not include a plan to remove the catheter. Approaches included to monitor for signs of UTI, urology consult as needed, and catheter care. The NP progress note dated 4/1/19, documented the resident had a history of recurrent UTIs, followed with urology, history of urinary retention, and now had an indwelling urinary catheter per urology's recommendation. During an interview on 5/8/19 at 2:30 PM, Resident #59 stated she had a catheter and she was not sure why she had a catheter, she was able to use the bathroom, she had a history of UTIs, and was unaware of any plans to remove the catheter. She stated the catheter had at one point been out for a while and she was able to go to the bathroom without difficulty. The physician was interviewed on 5/10/19 at 3:40 PM and stated indications for an indwelling catheter included urinary retention, skin issues, wound healing, and comfort care. He stated there had to be a medical indication for use of an indwelling catheter. He stated urinary incontinence and/or family request was not a valid reason for reinsertion of the resident's catheter. The resident had a history of UTIs, catheter use increased the risk of UTIs, and the goal was to remove catheters when in use. He was unaware of any recent concerns with urinary retention or skin breakdown which would justify catheter use for the resident. A PVR of 122 ml would not indicate urinary retention, and he would look for a PVR of 350 ml or greater to indicate the need for the catheter. The physician stated he was unaware of the urologist's documentation regarding the reasons for the replacement of the catheter and if he had seen it, he would have had a conversation with the urologist and the family. The physician stated based on the low PVR, lack of ongoing urinary issues, and no skin issues, there was not a valid medical justification for the resident to have the catheter. Registered nurse (RN) Unit Manger #2 was interviewed on 5/10/19 at 4:35 PM and stated she recalled the family member asking about having the catheter replaced. The RN stated an appointment was set for the resident to see the urologist and she deferred to the urologist to help the family member understand there was no medical need for the catheter to be replaced. The resident was voiding well since the catheter was removed in early 1/2019, had no signs of retention, and no complaints of urinary difficulties. She stated the resident returned from the urology appointment with the catheter already in place, which was unusual, as typically residents returned with orders and the catheter insertion would be completed at the facility. If the resident returned with an order for the catheter, she would not have placed the catheter, as incontinence was not a valid indication, and she would have discussed it with the physician. 10 NYCRR 415.12 (d)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification survey, the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (Resident #101) reviewed for respiratory care. Specifically, Resident #101 was receiving supplemental oxygen without a physician's order and indications for use. Findings include: The 4/2019 Oxygen Therapy policy documented a resident would be administered oxygen in accordance with the physician's order and monitored by the licensed practical nurse (LPN). Resident #101 was admitted to the facility on [DATE] with diagnoses including community acquired pneumonia. The 4/29/19 Minimum Data Set (MDS) assessment documented the resident's cognition was intact, she required extensive assistance of one staff for transfers and dressing, and she received oxygen therapy. The 4/15/19 hospital discharge instructions did not include oxygen use. The 4/15/19 Nursing admission Data Collection form documented the resident used oxygen, was not having respiratory difficulties and her lung sounds were clear. The 4/2019 and 5/2019 physician's orders did not document an order for oxygen. Physician and nurse practitioner (NP) progress notes from 4/15 - 5/10/19, documented the resident experienced shortness of breath relieved with rest. The progress notes did not document the resident required the use of oxygen. The 4/2019 and 5/2019 medication and treatment administration records (MAR and TAR), did not document the resident used oxygen. The 5/2/19 comprehensive care plan (CCP) did not document the resident used oxygen. The 5/9/19 Pocket Care Plan (direct care instructions) did not document the resident used oxygen. The resident was observed: - On 5/8/19 at 10:22 AM, in her room wearing oxygen via nasal cannula at 2 liters (L) per minute. - On 5/8/19 at 3:23 PM, 5/9/19 at 12:11 PM, 5/10/19 at 11:54 AM and 5/14/19 at 9:49 AM, in her room without the nasal cannula in her nose. The piped wall oxygen regulator above the resident's arm chair was set to 2 L and the humidifier bottle was visibly bubbling. During an interview on 5/10/19 at 1:09 PM, the resident stated that she had not used supplemental oxygen before being admitted to the hospital, used it intermittently when hospitalized , and had used supplemental oxygen intermittently since she was admitted to the facility. During an interview on 5/14/19 at 10:09 AM, LPN #1 stated if she knew a resident was using oxygen and did not see an order for it, she would go to her nurse manager to clarify the orders. During a telephone interview on 5/14/19 at 11:03 AM, physician #6 stated each resident was reviewed on an individual basis, and if a resident was receiving oxygen, nursing staff would contact a provider to get an order. He could not recall if he had been contacted about Resident #101 using oxygen. During an interview on 5/14/19 at 11:15 AM, registered nurse (RN) #2 Unit Manager stated if there was an episode where a resident required oxygen who previously was not ordered oxygen, the physician should have been contacted for an order. It was an oversight that Resident #101 did not have an order. 10NYCRR #415.12 (k)(6)