**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Complaint investigation (#NY00355148) during a Standard survey completed on 4/11/25, the facility did not ensure the residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for three (3) (Residents #38, #121 and #355) of four (4) residents reviewed. Specifically, a resident's foley catheter was not changed monthly as per the physician order (#355) and infection control practices were not maintained (#38 and #121). The findings are: The policy and procedure titled Catheter Foley dated 4/25/22 documented a procedure to ensure the safe, sterile placement and removal of the foley catheter and provided guidelines for catheter care. When a catheterization is determined to be clinically indicated, verify physician order for catheter placement or catheter change, and gather the equipment. Additionally, infection control considerations included, do not allow catheter bag or tugging to lay on floor. If resident in low bed place catheter bag and tubing in dignity bag and or wash basin to avoid laying on floor. 1. Resident #355 had diagnoses including neurogenic bladder (a chronic condition that occurs when the nervous system's connection to the bladder is disrupted), benign prostatic hyperplasia (enlarged prostate), and cerebral infarction (a condition where a part of the brain is damaged or dies due to a lack of blood supply). The Minimum Data Set (a resident assessment tool) dated 6/27/24 documented Resident #355 was cognitively intact and had a urinary catheter. The comprehensive care plan dated 8/24/24 documented Resident #355 had an alteration in their elimination and utilized an indwelling foley catheter (22 French, 30 cc (cubic centimeter) balloon). Review of the Physician Orders dated 6/20/24 through 8/24/24 revealed an order dated 6/20/24 to change Resident #355's foley catheter monthly using a 22 French (refers to specific type), 30 (cc) cubic centimeter balloon. Review of Resident #355's Progress Notes dated 6/20/24 through 8/24/24 revealed the following: -6/20/24 2:30 PM admission Note: Resident was treated for a urinary tract infection during hospitalization, failed multiple voiding trails, and had #22 French with 30 (cc) cubic centimeter balloon indwelling foley catheter intact. -8/9/24 at 6:57 AM, Licensed Practical Nurse #6 documented on 8/8/24 during the 7:00 PM - 7:00 AM the residents foley catheter port was leaking. Writer replaced the foley catheter using a 20 French 5 cc (cubic centimeter) balloon as the 22 French was not available. -8/11/24 at 6:41 PM Nurse Practitioner #1 documented an Acute Visit assessment. There was no evidence they were notified the 22 French, 30 cc (cubic centimeter) balloon foley catheter was not available, and that a 20 French 5 cc (cubic centimeter) was inserted. Review of the Treatment Administration Records (TAR) dated 6/20/24 through 8/24/24 revealed an order to change Resident #355's foley catheter monthly utilizing a 22 French 30 cc (cubic centimeter) balloon and had a start date of 6/20/24. Treatment Administration Records documented the following: - 7/7/24 Licensed Practical Nurse #7 documented - Not Administered - reason 22 French unavailable. Review dates 7/1/24 through 7/31/24 revealed there was no documented evidence the foley catheter was changed. -8/1/24 through 8/24/24 revealed there was no documented evidence a Foley catheter 22 French 30 cc (cubic centimeter) balloon was inserted as ordered. -8/7/24 was blank and there was no rational as to why the Foley catheter 22 French 30 cc (cubic centimeter) balloon was not changed as ordered. During an interview on 4/11/25 at 1:00 PM, Registered Nurse Unit Manager #1 stated Resident #355 had an order for the 22 French 30 cc (cubic centimeter) balloon foley catheter to be changed monthly. They stated they were not aware a 22 French 30 cc catheter was not available or that the foley had not been changed as ordered. Licensed Practical Nurse #6 and #7 should have informed them a 22 French 30 cc (cubic centimeter) was not available and would have expected them to also call a provider to obtain further orders. During an interview on 4/11/25 at 1:17 PM, Central Service stated the facility did not have a 22 French 30 cc (cubic centimeter) foley catheter in stock because it was a specialty item and they had not been asked to order any. Registered Nurse Unit Manager #1 should have notified them to place an order for the specialized item. During an interview on 4/11/25 at 1:20 PM, Registered Nurse Unit Manager #1 stated they were not aware a Foley catheter 22 French 30 cc (cubic centimeter) balloon was a specialized item that they needed to order from Central Service. During an interview on 4/11/25 at 1:27 PM, Nurse Practitioner #1 stated they would have expected Licensed Practical Nurse #6 and #7 to have changed Resident #355's foley catheter using a 22 French 30 cc (cubic centimeter) balloon as ordered monthly and to notify a provider if the foley size ordered wasn't available. They stated Licensed Practical Nurse #6 should not have inserted a 20 French 5 cc (cubic centimeter) without an order. During an interview on 4/11/25 at 1:36 PM, the Director of Nursing stated Resident #355 foley wasn't changed as ordered and Licensed Practical Nurse #6 replaced the foley catheter on 8/8/24 using an incorrect size catheter and balloon. They stated they were not aware Central Service did not stock a 22 French 30 cc (cubic centimeter) balloon foley catheter and would have expected Registered Nurse Unit Manger #1 to have ensured they had appropriate supplies to follow the orders. Licensed Practical Nurse #6 and #7 should have informed a provider when they were unable to follow the physician's orders. 2. Resident #38 had diagnoses including neurogenic bladder, cerebral infarction, chronic kidney disease. The Minimum Data Set, dated [DATE] documented Resident #38 was moderately cognitively impairment and had an indwelling foley catheter. The comprehensive care plan dated 8/26/24 documented Resident #38 had an alteration in their elimination and had foley catheter (16 French, 30 cubic centimeter balloon). Interventions included to change catheter as ordered, empty bag every shift and monitor for signs and symptoms of urinary tract infection. Review of Physician Orders dated 4/11/25 documented Resident #38 had an order to change their foley catheter with a 16 French 30 cc (cubic centimeter) balloon every month and had a start date of 8/26/24. During a continuous observation on 4/9/25 at 9:09 AM until 11:05 AM, Resident #38 was sitting in their wheelchair at the nursing station dozing on an off. Their foley bag (urine collection/drainage bag) was hanging on their wheelchair in a blue privacy bag and about 18 inches of the foley tubing was directly on the floor. The urine in the tubing was noted to be red tinged with mucous shreds. Numerous staff members walked past and at times interacted with the resident. At 11:05 AM Certified Nurse Aide #4 woke Resident #38, placed their foley tubing into the blue privacy bag and transported the resident away from the nursing station into the dining room. During a foley catheter care observation at 4/9/25 at 4:12 PM, Resident #38 was in bed, the bed was in the low position and there were floor mats to both sides of the bed. The residents foley catheter bag was touching the floor and there was no barrier in place. After Certified Nurse Aide #3 emptied the urine from the collection/drainage bag, they hung the bag from the bed frame. The bottom of the bag was directly on the floor. During an interview at this time Certified Nurse #3 stated that care was complete and the bag should never touch the floor. They stated the foley catheter/drainage bag should have been placed in privacy bag for dignity and to keep it off the floor for infection control purposes. During an interview on 4/10/25 at 2:47 PM, Certified Nurse Aide #4 stated on 4/9/25 Resident #38's foley tubing was directly on the floor while the resident was at the nursing station, and they had placed it into the privacy bag prior to transporting the resident into the dining room. Certified Nurse Aide #4 stated they did not want to run the tubing over and the tubing should not have been on the floor because of infection control reasons. During an interview on 4/9/25 at 4:16 PM, Licensed Practical Nurse #5 stated that Resident #38 had some hematuria (presence blood in urine) in their catheter tubing and bag for the past couple days. They stated the foley catheter bag and tubing should never directly touch the floor because of dignity, infection control and accident reasons. During a telephone interview on 4/10/25 at 11:45 AM, Nurse Practitioner #1 stated Resident #38 had a foley catheter. and stated Resident #38 did have a history of e-coli (Escherichia coli, which is a type of bacteria) in per a urine culture and sensitivity report. Nurse Practitioner #1 stated a foley bag should always be covered, with the tubing placed into the privacy bag and should never touching the floor for infection control purposes. During an interview on 4/11/25 at 9:53 AM, the Director of Nursing stated at no time should the foley catheter bag and tubing be touching the floor because of infection control concerns. During an interview on 4/11/25 at 10:35 AM, the Infection Preventionist stated that foley catheter tubing and collection bag should never be laying directly onto the floor because that could lead to infection. 3. Resident #121 had diagnoses including spastic diplegic cerebral palsy (cerebral palsy characterized by muscle stiffness and spasms primarily in the legs), neurogenic bladder, and epilepsy (seizure disorder). The Minimum Data Set, dated [DATE] documented Resident #121 had severe cognitive impairment and had an indwelling catheter. The comprehensive care plan documented Resident #121 had an alteration in elimination as evidenced by a suprapubic catheter (tube inserted into the bladder, through the abdomen, to drain urine. Interventions included change catheter monthly and monitor for signs and symptoms of urinary tract infection. During an observation on 4/9/25 at 2:22 PM, Resident #121 was lying in bed with approximately twelve (12) inches of the catheter tubing lying directly on the floor. During an observation on 4/11/25 at 7:39 AM Resident #121 was lying in bed with approximately ten (10) inches of catheter tubing and fifty (50) percent of the drainage bag lying directly on the floor. During an interview on 4/11/25 at 7:43 AM, Certified Nurse Aide #5 stated the catheter drainage bag was not attached to the bedframe correctly and the catheter drainage bag and tubing should not be directly on the floor for infection control purposes. During an interview on 4/11/25 at 7:52 AM, Licensed Practical Nurse #8 stated the catheter drainage bag and tubing should not be directly on the floor secondary to contamination. During an interview on 4/11/25 at 10:43 AM, Nurse Practitioner #1 stated anyone with an indwelling catheter was at risk for urinary tract infections. The catheter drainage bag should be hung from bedframe by something that keeps the drainage bag and tubing off the floor as there was an increased risk of infection when lying directly on floor. 10NYCRR 415.12(d)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint (#NY00369028) investigation completed on 2/3/25, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choice for one (Resident #1) of three residents reviewed. Specifically, Resident #1 was permitted by staff to leave the facility at 5:30 AM and independently walk to a nearby hospital. Upon their return the facility initiated an electronic monitoring device without adequate indications for its use. The findings are: Resident #1 had diagnoses which included intellectual disabilities, anxiety, and chronic obstructive pulmonary disease (airflow obstruction and breathing problems). The Minimum Data Set (a resident assessment tool) dated 1/8/25 documented the resident was cognitively intact and did not have wandering or exit seeking behaviors. a. The Physician Order Activity Report as of 1/12/25 revealed the resident did not have an order for ALOA (approved leave of absence). The Health Care Decision-Making Capacity Determination signed and dated 4/28/23 by the Medical Director documented Resident #1 lacked complete, lifelong, personal medical decision-making capacity secondary to intellectual disability. The Progress Noted dated 1/12/2025 at 11:58 AM, authored by Registered Nurse Assistant Director of Nursing, documented the resident requested to go to local hospital for evaluation of anxiety and insomnia. The resident was educated on staying in the facility and a call can be placed to on-call provider. Resident preferred to sign out on pass instead of being transferred by emergency medical services. Resident #1 signed out and left the facility around 5:30 AM. Documentation request was e-mailed on 1/31/25 at 9:10 AM to the Administrator for the facility to provide a Release of Responsibility form signed by the resident at their time of departure from the facility and they were unable to provide one. During a telephone interview on 1/31/25 at 10:30 AM, Licensed Practical Nurse #2 (11:00 PM -7:00 AM nursing supervisor on 1/12/25) stated on 1/12/25 Licensed Practical Nurse #3 reported Resident #1 couldn't sleep and was hearing voices. Licensed Practical Nurse #2 stated they responded to the unit and Resident #1 was very aggressive, adamant about seeing a doctor immediately. Licensed Practical Nurse #2 stated they had Resident #1 sign a Release of Responsibility form and the resident left the facility at 5:30 AM. During a telephone interview on 1/31/25 at 10:23 AM, Licensed Practical Nurse #3 stated they were assigned to Resident #1's unit on the 11:00 PM -7:00 AM shift on 1/12/25. Licensed Practical Nurse #3 stated at 5:00 AM Resident #1 was walking about the unit stating they were hearing voices, and they administered 5:00 AM medications to the resident. The nurse stated they were unaware Resident #1 had left the unit. During an interview on 1/31/25 at 11:45 AM, the Director of Nursing stated Licensed Practical Nurse #2 should have contacted them or the Assistant Director of Nursing to get direction on how to proceed with the resident. The medical provider should have been contacted if the resident required medical assistance and the resident should have been transported by emergency medical services to the emergency department. Additionally, the nursing supervisor should not have allowed the resident to leave the facility at 5:30 AM to walk through the parking lot to the hospital. During an interview on 1/31/25 at 1:42 PM, the Director of Social Work stated it was unsafe to allow a resident that complained of auditory hallucinations to leave the facility at 5:30 AM, when it was cold and dark outside. Additionally, the Director of Social Work stated Resident #1 lacked the capacity to make health care decisions. During a telephone interview on 1/31/25 at 1:53 PM, the Nurse Practitioner stated Resident #1 had cognitive impairments secondary to intellectual disabilities and serious mental health issues. Additionally, the resident lacked capacity to make complex decisions, the supervisor did the wrong thing. The facility policy Leave of Absence (LOA) last date revised 3/14/23, documented it is the policy of the facility to encourage outside socialization for the resident when appropriate. A cognitively intact resident can leave the facility independently with the appropriate physician order. The facility will track the departure and return of a resident on the Release of Responsibility for leave of absence form. When a leave of absence is to occur evaluate resident for a change in condition, notify physician of any concerns/changes. b. The Elopement Risk assessment dated [DATE] documented the resident was not an elopement risk. The Physician Order Activity Detail Report dated 1/12/2025 - 2/3/2025 revealed a physician's order dated the 1/14/25 that documented to check placement of wander guard (electronic monitoring device) to the LLE (left lower extremity) Q (every) shift and check functioning of wander guard to LLE (left lower extremity) Q (every) shift. The undated Certified Nurse Aide Care Guide included Safety: Wander Guard (electronic monitoring device). The Progress Note dated 1/12/2025 at 11:54 AM, authored by Licensed Practical Nurse #1, documented wander guard (electronic monitoring device) placed to left lower extremity, resident educated on needing to have a staff member take them off the unit. The Progress Noted dated 1/12/2025 at 11:58 AM, authored by Registered Nurse Assistant Director of Nursing, documented Resident #1 signed out on pass at 5:30 AM and left the facility to go to a local hospital. During an observation on 1/31/25 at 10:05 AM Resident #1 was observed with an electronic monitoring device on their left lower extremity. Resident #1 stated the facility placed the device on their ankle a few weeks ago, and the resident felt they were being punished. Resident #1 stated they enjoyed leaving the unit to go on the first floor to the vending machines, the facility store, and interacting with residents from other units. Additionally, the resident stated, I can't move around and go where I want to with this wander guard (electronic monitoring device) on. During a telephone interview on 1/31/25 at 11:28 AM, Licensed Practical Nurse #4 stated they placed a wander guard on the residents left lower extremity because it was reported the resident left the unit and didn't notify the nurse. During an interview on 2/3/25 at 10:58 AM, the Director of Nursing stated they removed the wander guard from Resident #1 on 1/31/25 secondary to the resident was not at risk for wandering, there was no reason for them to have a wander guard. Additionally, Resident #1 was educated to sign out at the nurses' station when they leave the unit. The facility policy Abuse Policy Prevention and Management dated 9/2023, documented the facility must provide a safe resident environment and protect residents from abuse including involuntary seclusion. Involuntary seclusion was defined as separation of resident from other residents against their will, that may take many forms including but not limited to confinement, restriction, or isolation of a resident. The facility policy Elopement Prevention and Management review dated 8/2023, documented the facility recognizes mobility as strength to be supported and promoted. The facility will strive to identify residents at risk for unsafe wandering and exit seeking behavior and to develop individualized prevention and management interventions based on Exit Seeking/Elopement Evaluation. 10 NYCRR 415.12(h)(2)

Based on interview and record review conducted during a Standard survey completed on 5/24/23, it was determined that the facility did not ensure that a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #84) of four residents reviewed for dignity. Specifically, a resident, who was continent of bowel, was told to have their bowel movement in their brief instead of being toileted. The finding is: A policy and procedure (P&P) titled, Dignity and Respect dated 9/8/22 documented that residents shall be treated with dignity and respect. Further review of the P&P documented that staff shall promote dignity and assist residents by promptly assisting a resident with their toileting needs. 1. Resident #84 was admitted to the facility with diagnoses of fractured right leg and arthritis. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 3/17/23 documented that the resident was cognitively intact, understood by others, understands others, and is a limited assist (guiding limbs or other non-weight bearing assistance) of two staff members for toileting. Resident #84's Care Plan Activity Report initiated on 3/10/23 documented the resident had impaired balance issues related to their broken right leg, required assistance from staff, and the resident may have episodes of bowel incontinence. Review of the resident's Occupational Therapy (OT) Evaluation & Plan of Treatment dated 4/28/23 documented that the resident is totally dependent on others for transfers from bed to chair. Review of the resident's Physical Therapy (PT) Evaluation & Treatment Plan dated 3/10/23 documented that the resident was dependent for chair to chair and toilet transfers. Review of the resident's Resident CNA (Certified Nurse Aide) Documentation Record for May 2023 did not have documented toileting activities on the 11:00 PM to 7:00 AM shift from 5/19/23 to 5/22/23. During an interview on 5/22/23 at 11:01 AM, Resident #84 stated that they were incontinent of bowel on a 11:00 PM to 7:00 AM shift. They stated that they rang their call light because they had to go to the commode at 4:30 AM on 5/20/23. After they rang their call light, a CNA (unidentified) came into their room, turned off their call light, and would not put them on the commode. They stated that they still needed to use the commode and rang their call light again. Another CNA, CNA #9, came in their room, turned off their call light, and told the resident to go in their brief. They stated that they couldn't hold it anymore and had a bowel movement in their brief. The resident stated they were embarrassed and they were an assist of two staff members to use the commode with a sit to stand lift (mechanical lift used for someone is unable to perform positional transitions on their own). Resident #84 stated that they stayed in the soiled brief until breakfast time. During an interview on 5/22/23 at 11:29 AM with CNA #10, they stated they took care of Resident #84 that morning (5/20). CNA #10 stated that they changed the resident and the resident had dried feces on their skin and in their brief. CNA #10 stated Resident #84 kept apologizing about the mess in their brief. CNA #10 stated, it is a dignity thing to make a resident go in their brief when they can use a commode. During an interview on 5/22/23 at 11:40 AM, Licensed Practical Nurse (LPN) #6, stated they expect CNAs to put a resident on a commode if the resident requested it. LPN #6 stated that it was unacceptable for the CNA to tell a resident to go in their brief and that it was undignified for a resident to go in their brief. During an interview on 5/23/23 at 1:00 PM, the Director of Nursing (DON), they stated they expected CNAs to answer the call light and take care of the resident's needs. The DON stated that they have no words to say about this incident. During an interview on 5/24/23 at 8:32 AM, CNA #9 stated that they were busy during their shift (5/20) and could not toilet Resident #84. CNA #9 stated that it was undignified to tell a resident to go in their brief and not to toilet the resident. 10NYCRR 415.3(c)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Standard survey completed on 5/24/23, it was determined that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin are reported immediately, but not later than 2 hours after the allegation is made to the Administrator and State Survey Agency for two (Resident #93 and #109) of four residents reviewed for abuse. Specifically, Resident #93 was involved in an alleged staff-to-resident verbal abuse, involving Certified Nurse Aide (CNA) # 7 which was not reported to the Administrator and to the State Agency. In addition, Resident #109 was found to have a bruise of unknown origin and it was not reported to the State Agency within the required timeframe of two hours. The findings are: A policy and procedure (P&P) titled, Abuse Prevention and Management revised on 9/8/22 documented that the facility will report allegations of abuse, neglect, misappropriation, or injury of unknown source. The responsible manager will report any abuse allegation or injury of unknown source to the Administrator or the Director of Nursing (DON) immediately and that the State agency will be notified within two hours after the identification of the allegations. 1. Resident #93 had diagnoses of Parkinson's (tremors and rigidity of movement) disease, heart failure, and diabetes mellitus. The Minimum Data Set (MDS - a resident assessment tool) dated 2/22/23 documented the resident was cognitively intact, understands others, and is understood by others. Further review of the MDS revealed the resident was a supervision of one staff member with set up help. Review of the resident's Care Plan Activity Report initiated on 4/12/22 revealed staff assist with toileting as necessary to promote continence, the resident has an activity of daily living (ADL) self-care, and mobility deficit. Anticipate resident needs as it relates to present ADL status. Review of a facility generated Accident/Incident Report dated 5/22/23 revealed that there were no accidents or incidents reported for Resident #93 between 11/22/22 to 5/22/23. Review of the Nurse Supervisor Log Sheet dated 5/12/23 for Unit 4 revealed the unit nurse called the Supervisor's phone regarding CNA #7 and Resident #93's transfer status and to see note. Review of a nursing progress note dated 5/12/23 at 6:54 PM revealed there was an altercation between CNA #7 and Resident #93. CNA #7 stated that the resident would not help toilet themselves. The resident stated that CNA #7 was nasty and mean and reported to Licensed Practical Nurse (LPN) #8 that CNA #7 stated to them to pull their own pants down and would leave them on the toilet for hours. The nursing progress note documented that CNA #8 went to toilet the resident and had no issues assisting the resident. LPN #8 document in the progress note that the resident was visibly upset, and they would call the police if CNA #7 came back into their room. LPN #8 further documented they removed CNA #7 from the resident's assignment and LPN #9 Nursing Supervisor was notified. During an interview on 5/19/23 at 10:23 AM, Resident #93 stated CNA #7 swore at them during toileting care. The resident stated they asked CNA #7 to assist them with their pants and CNA #7 told them to do it themselves. They stated CNA #7 swore at them saying (explicit word) you and left them in the bathroom. During an additional interview on 5/23/23 at 10:20 AM Resident #93 stated they almost fell trying to get on the toilet without assistance and were very upset about the incident. During an interview on 5/23/23 at 10:28 AM, LPN #11 Unit Nurse Manager stated they saw a note from LPN #8 concerning Resident #93 on 5/15/23. LPN #11 stated the resident informed them that CNA #7 had an attitude with them and was very rude and nasty and told Resident # 93 they would leave them on the toilet for hours. LPN #11 stated that the resident can direct care and let staff know their needs. LPN #11 stated that on 5/15/23 during morning report they let the Director of Nursing (DON) know about the verbal abuse. During an interview on 5/23/23 at 12:23PM, LPN #9 Nursing Supervisor, stated LPN #8 may have sent a text to the Nursing Supervisor's phone, but they didn't notice it. An additional interview on 5/24/23 at 12:48 PM, LPN #9 Nursing Supervisor stated they should have gone to the floor and initiated an investigation, if it involved an altercation between a resident and a staff member, especially if there was verbal abuse. LPN #9 also stated that they should have reported the incident to the DON. During an interview on 5/23/23 at 12:31 PM, the DON stated what CNA #7 did was verbal abuse. The DON stated they didn't have notes from morning report on 5/15/23 concerning any altercation between Resident #93 and CNA #7. They stated they don't recall LPN #11 telling them about any verbal abuse between Resident #93 and CNA #7. The DON stated that they expect nursing supervising staff to report any type of altercation to themselves or the Administrator as soon as possible in case it may be a reportable incident to the State Agency. During an interview on 5/23/23 at 1:07 PM, the Administrator stated the Nursing Supervisor should call the DON or themselves for any allegation of abuse so it can be reported timely. 2. Resident # 109 had diagnoses including dementia, diabetes mellitus, and depression. The MDS dated [DATE] documented moderately impaired cognition, usually understands and was understood. The MDS further documented no falls. The Care Plan Activity Report with a revised date 12/27/22 documented Resident #109 was a fall risk and maintain a safe environment. The undated CNA Assignments Summary (a guided tool) documented limited assist for bed mobility, nonskid footwear, and left side bed assist with padding. Review of the Accident report dated 12/1/22 revealed at 8:00 PM Resident #109 was noted with a bruise on the lumbar part of their back, discovered during their shower. The bruise measured 15 1/2cm (centimeters) x (by) 7 cm. Resident #109 was unaware of when and how the bruise occurred. The Accident report was signed by the DON on 12/2/22 as reviewed. Review of the NYS(New York State) DOH(Department of Health) Automated Complaint Tracking System (ACTS) revealed no complaint/investigation report was submitted by the facility for Resident #109 on 12/1/22. During an interview on 5/24/23 at 12:45 PM, the DON stated the bruise was an injury of unknown origin therefore should have been reported to the NYS DOH within 2-hours and was missed. During an interview on 5/24/23 at 1:04 PM, the Administrator stated the 12/1/22 incident should have been investigated thoroughly and immediately. Injuries without a known cause were reported to the NYS DOH within a 2-hour window. This bruise was not reported and should have been. 10 NYCRR 415.4(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Standard survey, completed on 5/24/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary assistance to maintain grooming and personal hygiene for two (Resident #11 and #70) of five residents reviewed. Specifically, Resident #11 was not provided incontinence care as planned. In addition, Resident #70 had multiple long whiskers on their chin and upper lip, and long jagged fingernails beyond their fingertips on their right contracted hand. The findings are: The policy and procedure (P&P) titled ADL Care; Toileting-Bowel and Bladder Incontinence Care dated 4/25/22 documented the facility will ensure a resident who is incontinent of bladder, receives appropriate treatment and services to prevent urinary tract infections, and to keep the perineal (area between the anus and genitalia) area clean, dry and odor free. The P&P titled ADL Care/Personal Care/Grooming-Nail Care dated 4/20/22 documented nail care would be provided on shower days and as necessary to provide cleanliness, prevent the spread of infection, provide comfort, and prevent skin injuries. The P&P titled Dignity and Respect dated 5/2023, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her Self-esteem and self-worth. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). 1. Resident #11 had diagnoses including dementia, peripheral vascular disease, and depression. The Minimum Data Set (MDS-a resident assessment tool) dated 5/3/23, documented Resident #11 had severely impaired cognition, was totally dependent on staff for toileting, and was always incontinent of bowel and bladder. The Care Plan Activity Report dated 4/14/20 documented Resident #11 had urinary incontinence and interventions included to check and change upon waking, before or after meals, at bedtime and prn (as needed). During a continuous observation on 5/22/23 from 8:18 AM to 1:49 PM, Resident #11 sat in their Broda (wheelchair that provides supportive positioning) chair with a mechanical lift sling underneath them. The resident was not toileted by staff during this timeframe. During an observation on 5/22/23 at 1:49 PM, Certified Nurse Aide (CNA) #1 stated to CNA #2 that they had to lay Resident #11 down and transported the resident to their room. At 1:55 PM, the mechanical lift was brought into the resident's room. At 1:58 PM, the resident was in their bed and CNA #1 left the room to get more linens. At 2:03 PM, CNA #1 and #2 turned the resident and removed their pants, mechanical lift sling and brief. The resident's brief was soiled with urine. The resident's skin on their posterior thighs had indentation marks from wrinkles in their brief and clothing, and their skin was red in these areas. The resident also had an outline of the edge of the mechanical lift sling in their skin along their medial posterior (middle back) thighs to the lateral (outer) thighs. CNA #1 stated the indentations were from the resident's clothing and mechanical lift sling. During an interview on 5/2/23 at 2:12 PM, CNA #2 stated Resident #11 was in their chair since they arrived at work that morning at 7:00 AM and that's why they put the resident back to bed after lunch. During an interview on 5/2/23 at 2:13 PM, CNA #1 stated they tried to change residents every two hours and Resident #11 was not toileted before lunch. The CNA #1 reviewed Resident #11's care plan in the electronic medical record (EMR) and stated the resident was supposed to be changed before/after meals. CNA #1 stated they got to work late that day and had to catch up when they got there. During an interview on 5/23/23 at 1:42 PM, the Licensed Practical Nurse (LPN) #2 Unit Manager (UM) stated if a resident wasn't changed frequently enough, they worried about skin breakdown. The LPN #2 UM stated if Resident #11 was up in the morning, they should have been changed before lunch. The LPN #2 UM stated it was their responsibility to make sure the CNAs were following care plans, and that CNA #1 never told them they were running behind on their assignment. During an interview on 5/24/23 at 1:32 PM, the Director of Nursing (DON) stated the staff (CNAs) should check the residents every two to three hours to make sure they don't need to be changed. If an incontinent resident wasn't changed for an extended period, there was risk for infection and skin breakdown. The UM should make sure the CNAs followed the care plans. 2. Resident #70 had diagnoses which included hemiplegia (paralysis on one side of body) and hemiparesis (weakness of one side of body) following cerebral infarction (CVA-stroke) and diabetes. Review of the MDS dated [DATE], documented Resident #70 was sometimes understood/understands and required limited to extensive assistance for ADLs. Resident #70's Care Plan Activity Report comprehensive care plan (CCP) with active effective date of 10/24/2018 documented the resident had an ADL self-care and mobility deficit related to weakness secondary to CVA. Interventions included limited assistance of one-person physical assist for personal hygiene. During intermittent observations on 5/19/23 at 8:40 AM, 5/22/23 at 11:56 AM, 3:56 PM, and 5/23/23 at 8:30 AM, 9:31 AM Resident #70 had multiple dark facial hairs, half inch long, on their chin and left upper lip. Additionally, on 5/23/23 at 9:31 AM the resident's right hand index finger and thumb nail were observed long beyond the pad of fingers. The resident's right hand was contracted and fingers curled into the palm of their hand. Resident #70's Treatment Administration Record (TAR) dated May 2023, documented an order the nurse was to check skin, and trim nails on shower/bath days as needed on the 11:00 PM-7:00 AM shift. There was no documented evidence this was completed on Monday, 5/22/23 as ordered. Review of Resident #70's Progress Notes dated 3/2/23 - 5/22/23 revealed there was no evidence the resident refused to have their facial hair shaved from their chin and upper lip or their nails trimmed. During an interview on 5/23/23 at 11:44 AM, LPN #7 stated resident's nail care and shaving was to be completed on their shower day or when noticed to be needed. During an interview on 5/23/23 at 12:05 PM, CNA #5 stated the CNAs were responsible for trimming nails and shaving residents usually on their shower day or as soon they could. During an observation and interview on 5/23/23 at 12:15 PM, Registered Nurse Unit Manager (RNUM) #2 stated that full grooming was to be completed on the resident's shower day. Resident #70's shower day was scheduled on Wednesday evening shift. RNUM #2 extended Resident #70's fingers from the right palm of their hand, exposing all fingernails of right hand and stated they were long and should be trimmed. All nails of the resident's right hand were long, over pads of fingers, and jagged in appearance. RNUM #2 stated Resident #70 had facial hair present on their chin and upper lip and should be shaved. RNUM #2 stated nails need to be trimmed to prevent skin injuries, infection and facial hair present was a dignity issue. During a follow up interview on 5/24/23 at 11:25 AM, RNUM #2 stated Resident #70s shower day was recently changed from Monday 11-7 shift to Wednesday 3-11 shift. RNUM #2 reviewed the EMR for Resident #70 and stated the last documented weekly skin check was on Monday, 5/15/23 on the 11-7 shift. During an interview on 5/24/23 at 12:55 PM, the DON stated they would expect the nursing staff to trim residents' nails anytime they were noticed long. Shaving was to be done on shower days and as needed. Additionally, the DON stated the nursing were fully responsible for the care of dependent residents. 10 NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 5/24/23, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident encouraging both independence and interaction in the community for one (Resident #70) of two resident reviewed for activities. Specifically, Resident #70 was not asked to participate in activities on a daily basis and was not provided with one-on-one visits/activities. The finding is: The policy and procedure (P&P) titled Activity Department Practice dated 4/2023, documented the facility will provide an ongoing program to support residents in their choice of activities, both facility sponsored groups and individual activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encourage both independence and interaction in the community. 1. Resident #70 had diagnoses which included hemiplegia (paralysis on one side of body), hemiparesis (weakness of one side of body) following cerebral infarction (CVA-stroke), aphasia (absence or difficulty with speech) and depression. Review of the MDS dated [DATE], documented Resident #70 sometimes understands, sometimes understood and was unable to complete a cognitive interview. The MDS dated [DATE] documented the Activity Preferences were somewhat important to do things with groups of people, to do favorite activities, go outside to get fresh air and participate in religious services or practices. The document titled Activities-Quarterly assessment completed on 4/17/23 documented Resident #70 prefers to go outside to get fresh air when the weather is good and to participate in religious services. The assessment documented activity participation will be monitored and encouraged. The Care Plan Activity Report for Resident #70 entered on 5/26/2021 documented the resident had limited ability to participate was a passive observer in relation to participation in activities secondary to cognition. Goals included the resident would participate in 1:1 visits to maintain socialization to see that leisure needs are being met; maintain present level of socialization and leisure interests through participation in various programs; Resident will participate in person centered life enrichment and engagement activities, such as room visits or one to one programming, a minimum of 1x daily to prevent loneliness, helplessness and boredom. Interventions included the resident would receive 1:1 visit with the Activity Aides, provide monthly calendars, remind, invite and escort to recreational programs, provide stimulation using radio or television and maintain preferred independent leisure activity. The activity report documented Resident #70 was at risk for social isolation and depression since being encouraged to practice social distancing to minimize exposure to COVID-19. Interventions included: involve resident in activities of interest during room visits and 1:1 programming, offer 1:1 out of room to prevent feeling of isolation, provide 1:1 activity outdoors if weather permits, and offer exercise, stretching, movement activities during 1:1 programming. Review of the Record of One-on-One Activities for Resident #70 from December 2022 through April 23, 2023, documented two visits on 3/3 and 3/5. Review of Resident #70's activity list and attendance for May 2023 identified by AD, indicated S for resident sleeping. Review of April 1st though the 30th attendance, revealed Resident #70 attended 4 activities. During intermittent observations on 5/19/23 at 8:40 AM and 12:21 PM Resident #70 was sitting at a table in the lounge by them self in a Geri-chair not facing the television (TV was on). There were no other activities in session in lounge during the observations. The attendance log for May 19th documented an S - sleeping. During an interview on 5/19/23 at 10:04 AM, Resident #70's responsible party stated they have requested the resident to be taken to activities, they want them to have stimulus. Resident #70's responsible party also stated the facility chronically does not get Resident #70 out of bed and when they ask questions, they get the run around. During an observation on 5/22/23 at 8:59 AM, Resident #70 was in bed awake, there was no activity calendar available in the resident's room (radio, music), there were no in room activities available, and the TV was not on. During an observation on 5/23/23 at 9:31 AM, Resident #70 was sitting in Geri-chair awake in room by them self with the door closed. There were no activities available in the room, and the TV off. Review of the May 2023 activity calendar revealed: May 22nd: 10:00 AM Coffee/Chat, 2:00 PM Cooking Club, 6:00 PM Helping Hands 5th Floor May 23rd: 10:00 AM Coffee/Chat in mall walk (MW), 11:00 AM Catholic Bible Study (MW), 2:00 PM Karaoke (MW) and 6:00 PM Helping Hands 5th floor. During an interview on 5/24/23 at 8:26 AM, the Activities Director (AD) stated they were short staffed and just hired a bunch of activity staff. Depending on the day of week there were 2 to 4 activity staff in the facility. Attendance logs were completed daily for resident attendance in activities. AD stated Activity Aides were responsible to encourage and get residents to attend activities. The Activity Aides should be to going floor to floor, asking residents if they want to attend the activity, and bring some of the residents down. The AD stated there were not always enough nursing aides to get Resident #70 out of bed, so they were unable to attend activities off the unit. The AD stated they have never seen Resident #70 off their floor for an activity and upon reviewing Resident #70's Record of One-on-One Activities noted they haven't had any 1:1 activity documented for April. The AD stated it was important for residents to have activities to make them happy, provide stimulation and interaction. Additionally, the AD stated it was especially sad that Resident #70 hadn't received any 1:1 visits from the Activity Aides. During an interview on 5/24/23 at 11:25 AM, RN #2 stated they have not seen activity staff offer or take Resident #70 to activities. RN #2 stated it wasn't just important for Resident #70, but all residents should be offered activities to keep their functionality and quality of life. RN #2 stated Resident #70 should be receiving some activities, likes to be outside, look out window, 1:1, and offered other sensory activities. Additionally, RN #2 stated if the activities staff communicated with nursing, they could help with designating staff to assist with getting residents to activities. During an interview on 5/24/23 at 11:43 AM, Activities Aide #1 stated they were familiar with Resident #70 and they usually were not awake for activities. Activity Aide #1 did not recall Resident #70 recently attending any activities. Activity Aide #1 stated they don't usually try and wake the residents up. Additionally, Activity Aide #1 stated they do not document activity refusals, but it would be an idea so staff know if it had been offered and refused. During an interview on 5/24/23 at 12:55 PM, Director of Nursing (DON) stated their expectation was that activities would make rounds several times a day and offer activities. The DON stated it was important to keep residents as active as possible, keep them engaged, occupied, and happy. 10 NYCRR 415.5(f)(1)(i)

Based on interview and record review during the Standard survey completed 5/24/23, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs, when used without adequate monitoring for one (Resident #83) of five residents reviewed for unnecessary medications. Specifically, the resident received metoprolol (medication used to treat high blood pressure) twice daily without their heart rate being monitored per the physician's order. The finding is: The policy titled Medication Management-Utilizing and Prescribing dated 2/2023 documented medications shall be administered in a safe manner as prescribed by the physician. 1. Resident #83 had diagnoses including dementia, supraventricular tachycardia (heart condition with abnormally fast heart rate), and epilepsy (neurological disorder). The Minimum Data Set (MDS - a resident assessment tool) dated 4/26/23 documented Resident #83 had moderate cognitive impairment, sometimes understands, and was sometimes understood. Review of an untitled document identified by the Administrator as the metoprolol order history, revealed Resident #83 had an order dated 4/14/21 at 3:46 PM for metoprolol 25 milligrams (mg), with instructions to give 0.5 tablet (12.5mg) twice daily, and to hold for heart rate under 60. The monitor section was blank. This order was discontinued for an order change on 5/24/23 at 9:21 AM by the Licensed Practical Nurse (LPN) #2 Unit Manager (UM). The updated order dated 5/24/23 at 9:21 AM monitor section documented pulse. Review of Medication Administration Records (MARs) dated 5/1/2022 to 5/24/23 revealed there was no documented evidence that Resident #83's heart rate was monitored twice daily when the metoprolol 12.5 mg was administered. Review of an untitled document, identified by the Administrator as the EMR (electronic medical record) vital sign monitoring documentation, dated 5/1/22 to 5/24/23 revealed the resident's pulse was obtained on 20 occasions. During an interview on 5/24/23 at 9:04 AM, LPN #1 stated they were the regular, full-time nurse for Resident #83. LPN #1 stated if a resident had parameters ordered for a medication, the blood pressure or pulse would be under the administration time in the MAR. The LPN #1 stated they didn't check the residents blood pressure or pulse that morning before administering their medications because nothing popped up. LPN #1 checked Resident #83's MAR and stated they never noticed the part of the order to hold the medication for a pulse below 60. LPN #1 reviewed the metoprolol blister pack, and the blister pack was labeled with the parameter to hold the medication for a heart rate under 60. LPN #1 checked the physician orders in the electronic medical record (EMR) and stated whoever put the order in, should have put in to monitor the pulse, and it looked like the former Assistant Director of Nursing put the original order in. LPN #1 stated the resident's vital signs were ordered monthly and last had them completed on 5/10/23. During an interview on 5/24/23 at 9:10 AM, the LPN #2 UM stated the order for the metoprolol has been in place since 4/14/21 and nothing had been changed with the order since then. The LPN #2 UM stated nobody had pointed out the lack of pulse monitoring for this medication. The LPN #2 UM stated who ever put the order in needed to complete a separate part in the protocol section for the pulse monitoring to show up for the nurses. During an interview on 5/24/23 at 9:23 AM, Physician Assistant (PA) #1 stated they expected the nurses to check the resident's pulse if it was part of the order. The PA stated this medication had the potential to lower the heart rate and in the EMR if certain boxes weren't checked, it wouldn't trigger for the nurses (to complete a pulse). During an interview on 5/24/23 at 10:37 AM, the Pharmacy Consultant stated Resident #83 was on metoprolol for supraventricular tachycardia, which means the heart rate can go very high, but doesn't mean their heart rate can't go low at times, so that's the reason for the hold parameter. The Consultant Pharmacist stated the resident's recent pulses were documented on 4/12/23 and 5/10/23. During an interview on 5/24/23 at 10:49 AM, the Director of Nursing (DON) stated the nurses should be verifying and checking that they are doing what coincides with each medication. They should be reading the MAR and the blister pack label to double check they are following the order. 10 NYCRR 415.12(l)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 5/24/23, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for one (Resident #70) of two residents reviewed for infection control practices during incontinence care. Specifically, staff did not perform adequate hand hygiene while providing fecal incontinence care and staff emptied the dirty washbasin water directly into the sink of a shared bathroom. The findings are: The policy and procedure (P&P) titled Hand Hygiene revised 10/27/22, documented all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Alcohol-based hand rub (ABHR) is the preferred method for routine hand hygiene. Use an ABHR; or, alternatively, soap and water for the following situations: before and after direct contact with residents; before moving from working on a soiled body site to a clean body site on the same resident; after contact with a resident's intact skin; after contact with objects in the immediate vicinity of the resident; and immediately after removing gloves. Wash hands with soap and water for the following situations: when hands are visibly soiled. 1. Resident #70 had diagnoses which included hemiplegia (paralysis on one side of body) and hemiparesis (weakness of one side of body) following cerebral infarction (CVA-stroke), aphasia (absence or difficulty with speech) and type 2 diabetes mellitus. The Minimum Data Set (MDS - a resident assessment tool) dated 4/13/23 documented Resident #70 was sometimes understood and sometimes understands and was unable to complete the cognitive interview. The MDS documented the resident required total assist of two persons for toileting and was always incontinent of urine and bowel. The Care Plan Activity Report, comprehensive care plan (CCP) dated 5/26/2021 documented Resident #70 had an alteration in elimination related to CVA. Interventions included to provide peri care with each episode of incontinence. Ensure skin, linens and clothing are clean and dry. Total dependence of 2-person physical assist for bladder and bowel incontinence. During a continual observation on 5/23/23 at 9:38 AM to 10:37 AM, certified nurse aide (CNA) #5 and #6 applied gloves. CNA #6 provided fecal incontinent care to Resident #70 and removed a large amount of feces (stool) with a washcloth. CNA #6 did not remove their visibly soiled (with feces) gloves and wash their hands prior to continuing incontinent care. CNA #6 placed their hands into the wash basin containing clean water, touched clean linen (towel), adjusted the clean bed linen, and moved the location of the garbage can. CNA #6 dried the resident's buttocks and rectal area with the contaminated towel. CNA #6 did not remove their soiled gloves prior to opening room door to exit room to obtain additional linens. CNA #6 was observed to remove their soiled gloves after exiting the room in hallway prior to entering soiled work room. Upon returning to the resident's room with additional linen, CNA #6 applied clean gloves obtained from front the pocket of their scrub top, then applied a clean brief to the resident, picked an item up off floor, and placed it in the garbage can. While wearing the same gloves CNA #6 then placed their hands, on Resident #70's exposed skin during positioning, reapplied the resident's pants and then transferred Resident #70 via mechanical lift into their Geri-chair. CNA #6 then removed the wash basin from tray table and dumped contaminated water into bathroom sink. While wearing the same gloves repositioned bed, touched the bed remote, call bell and repositioned the tray table in room. CNA #6 then proceeded to remove garbage/linen and mechanical lift from room without removing both gloves and washing hands. CNA #6 entered the soiled work room with same gloved hands, sorted the soiled disposable items from the soiled linen items, then removed their gloves from both hands and washed hands with soap and water. During an interview on 5/23/23 at 10:38 AM, CNA #6 stated they should have changed their gloves if they were soiled, and Wouldn't want feces to get all over them. CNA #6 stated they should have noticed their gloves were soiled prior to touching anything clean and changed their gloves so they didn't contaminate anything. CNA #6 stated they should wash their hands before and after incontinent care. CNA #6 stated they should have removed both their gloves, washed hands prior to leaving the resident's room to obtain additional linens, and should have only had one gloved hand upon transferring soiled linen/garbage to soiled work room. Additionally, CNA #6 stated the dirty water from the basin should have gone into the bathroom toilet because it was contaminated. During an interview with CNA #5 that was present during incontinent care on 5/23/23 at 10:50 AM, CNA #5 stated anytime gloves were soiled they should be changed due to contamination. CNA #5 stated, CNA #6 should have changed their gloves when they got poop on them and before they touched clean things. CNA #5 stated wash basins were to be emptied in the toilet because residents use the sink to brush their teeth and wash their faces. During an interview on 5/23/23 at 11:44 AM, Licensed Practical Nurse (LPN) #7 stated they would expect CNAs to remove their gloves and wash their hands anytime they are soiled, prior to touching anything clean, prior to entering the hallway, and after/between resident care to prevent cross contamination. LPN #7 stated only one gloved hand was to be used to carry soiled linen to utility room. Additionally, LPN #7 stated wash basin water should be dumped into the toilet. During an interview on 5/23/23 at 12:15 PM, the Registered Nurse Unit Manager (RNUM) #2 stated they expected the CNA to absolutely change their gloves after cleaning feces during incontinent care and prior to touching any clean linen for infection control purposes. Additionally, RNUM #2 stated for sanitary and infection control purposes the water should be disposed of in the toilet. During an interview on 5/23/23 at 12:15 PM, the Director of Nursing (DON) stated it was an inappropriate practice to pour wash basin water into the bathroom sink. During a follow up interview on 5/24/23 at 12:55 PM, DON stated gloves need to be removed and changed if soiled due to risk of infection, contamination, and infection control practice; and hands should be washed prior to care then when care is finished on a resident. 10 NYCRR 415.19 (a)(1)(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (Complaint #NY00308552) completed during a Standard survey completed on 5/25/23, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for three (Resident #s 93, 109, and 212) of four residents reviewed for abuse. Specifically, there was a lack of an investigation for Resident #93's allegation of verbal abuse by Certified Nurse Aide (CNA #7) that was reported to Licensed Practical Nurse (LPN #9) Nursing Supervisor. Resident #109 had a bruise of unknown origin which lacked staff statements, root cause and analysis. Resident #212 had a description of bilateral chest bruising with lack of staff statements. The findings are: The policy titled Incident Reporting and Investigation of Accident Hazards, Supervision, Assistive Devices dated 1/17/23, documented the facility will thoroughly investigate any adverse occurrence that is not consistent with the routine operation of the facility or the care of a resident. All accidents/incidents where there is mistreatment, neglect, abuse, or injury of unknown origin will be reported to the Director of Nursing (DON) and Administrator immediately for further review. An incident report is to be completed for any happening which is not consistent with everyday operation of the facility or care of residents including but not limited to: resident injury related to falls, skin alteration. The unit manager/supervisor/charge nurse were to conclude investigations as needed, obtain staffing from the past 24 hours and obtain employee statements as appropriate (i.e., bruise/skin tear of unknown origin). The policy titled Abuse Policy-Prevention and Management dated 2/2022 documented the facility must provide a safe environment to protect residents from abuse. Verbal abuse includes oral language that willfully includes disparaging and derogatory words to the resident or within their hearing distance. Injuries of unknown source include the source of the injury was not observed by any person, the source of the injury cannot be explained by the resident, the injury is suspicious because of the extent and the location (in an area not generally vulnerable to trauma). 1. Resident #93 had diagnoses of Parkinson's disease (tremors and rigidity of movement), heart failure, and diabetes mellitus. A review of the Minimum Data Set (MDS-a resident assessment tool) dated 2/22/23 documented that the resident was cognitively intact, understands others, and is understood by others. Further review of the MDS documented that the resident was a supervision of one staff member with set up help. Resident #93's Care Plan Activity Report initiated on 4/12/22 documented that staff assist with toileting as necessary to promote continence, the resident has an activity of daily living self-care, and mobility deficit. Anticipate resident needs as it relates to present ADL (activities of daily living) status. Review of the Nurse Supervisor Log Sheet dated 5/12/23 for Unit 4 revealed the unit nurse called the Supervisor's phone regarding CNA #7 and Resident #93's transfer status and to see note. Review of a nursing progress note dated 5/12/23 at 6:54 PM revealed there was an altercation between CNA #7 and Resident #93. CNA #7 stated that the resident would not help toilet themselves. The resident stated that CNA #7 was nasty and mean and reported to LPN #8 that CNA #7 stated to them to pull their own pants down and would leave them on the toilet for hours. The nursing progress note documented that CNA #8 went to toilet the resident and had no issues assisting the resident. LPN #8 document in the progress note that the resident was visibly upset and that they would call the police if CNA #7 came back into their room. LPN #8 further documented they removed CNA #7 from the resident's assignment and LPN #9 Nursing Supervisor was notified. During an interview on 5/19/23 at 10:23 AM, Resident #93 stated CNA #7 swore at them during toileting care. The resident stated they asked CNA #7 to assist them with their pants and CNA #7 told them to do it themselves. They stated CNA #7 swore at them saying (explicit word) you and left them in the bathroom. During an additional interview on 5/23/23 at 10:20 AM Resident #93 stated they almost fell trying to get on the toilet without assistance and were very upset about the incident. During an interview on 5/23/23 at 10:28 AM, LPN #11 Unit Nurse Manager stated they saw a note from LPN #8 concerning Resident #93 on 5/15/23. LPN #11 stated the resident informed them that CNA #7 had an attitude with them and was very rude and nasty and told Resident # 93 they would leave them on the toilet for hours. LPN #11 stated that the resident can direct care and let staff know their needs. LPN #11 stated that on 5/15/23 during morning report they let the Director of Nursing (DON) know about the verbal abuse. During an interview on 5/23/23 at 10:59 AM, LPN #8 stated Resident #93 was very upset about the altercation with CNA #7. They stated that Resident #93 was a very nice person who would not make up an altercation about anyone. LPN #8 stated that they left a note with LPN #9 Nursing Supervisor concerning the altercation. A further interview at 3:15PM LPN #8 stated that they texted to the Nursing Supervisor's phone about the altercation and called the Nursing Supervisor's phone three times, and each call went straight to voicemail. LPN #8 stated they went and found LPN #9 Nursing Supervisor to tell them about the altercation between CNA #7 and Resident #93. They stated LPN #9 Nursing Supervisor wrote something on a piece of paper and that was the end of it. LPN #8 stated LPN #9 Nursing Supervisor did not come up to the floor and they were not asked to provide a witness statement. During an interview on 5/23/23 at 12:23 PM, LPN #9 Nursing Supervisor, stated LPN #8 may have sent a text to the Nursing Supervisor's phone, but they didn't notice it. On 5/24/23 at 12:48 PM, LPN #9 Nursing Supervisor stated they should have gone to the floor and initiated an investigation, if it involved an altercation between a resident and a staff member, especially if there was verbal abuse. LPN #9 also stated that they should have reported the incident to the DON. During an interview on 5/23/23 at 12:31 PM, the DON stated what CNA #7 did was verbal abuse. The DON stated they didn't have notes from morning report on 5/15/23 concerning any altercation between Resident #93 and CNA #7. The DON stated they did not recall LPN #11 telling them about any verbal abuse between Resident #93 and CNA #7. On 5/24/23 at 1:00 PM, the DON stated they expected their Nursing Supervisors to investigate any incident between staff and residents and expected them to initiate an investigation. During the interview, the DON verified that a text about the altercation between Resident #93 and CNA #7 was sent from LPN #8 to LPN #9 Nursing Supervisor's phone on 5/12/23. The DON also verified that there was no reply text from LPN #9 to LPN #8. During an interview on 5/23/23 at 1:07 PM, the Administrator stated they expect the Nursing Supervisors to investigate any altercation or incident between staff and residents and should initiate an investigation. 2. Resident #212 had diagnoses which included dementia, anxiety disorder, and adult failure to thrive (a state of decline that may be caused by chronic disease and functional impairments). The MDS dated [DATE] documented the resident had severely impaired cognition, wandered daily, ambulated independently, and had no falls since the prior assessment. Care Plan Activity Report effective 2/25/21 for Resident #212 documented the resident was at risk for being harmed by other residents due to verbal outbursts and socially inappropriate behavior, exhibited wandering behavior, and had poor safety awareness. The document titled Accident dated 3/14/22 at 7:30 AM, documented Resident #212 was reported to have two large areas of discoloration to their upper chest. Contributing factors included dementia and the resident may have fallen and gotten themselves back up. There were no staff statements included or description of the bruising to include color, shape, or measurements. The facility document titled Accident dated 3/14/22 at 12:20 PM, documented Resident #212 had a fall onto their back near the nurse's station, the nursing supervisor assessed the resident, no injury was noted. There were no other Accident reports related to falls from 3/1/22 to 3/14/22. Review of the Progress Notes dated 3/15/22 at 10:01 AM, written by current DON, revealed on 3/14/22 at 9:00 AM, they were Resident #212's room to help assist the provider. Two large bruises were noted to upper chest, one on the right and one on the left side. The resident complained of pain to the left hip and lower leg. The resident did not know what happened to cause the injury. During a telephone interview on 5/23/23 at 1:31 PM, the Registered Nurse (RN) Supervisor #1 stated they could not specifically remember this incident or incident report. The RN Supervisor #1 stated that if bruising was found on a resident, they would normally get statements from staff working and the staff that worked the prior 24 hours. During an interview on 5/24/23 at 8:33 AM, the DON stated they were the wound nurse in March of 2022. The DON stated they must have been doing wound rounds with a provider when the bruises were found. The DON stated they let the unit manager (UM) know about the bruises and the UMs were responsible to do an investigation and get staff statements. The DON stated they didn't remember the size or color of the bruising and they could have documented that information. During an interview on 5/24/23 at 8:35 AM, the Administrator stated they could not find any further documentation pertaining to the incident reports dated 3/14/22. During an interview on 5/24/23 at 8:42 AM, the Assistant Administrator stated they would expect documentation of a description of the bruise size and color to determine if it was old or new. During an interview on 5/24/23 at 8:50 AM, the LPN #3 MDS assistant (former 5th floor unit manager (UM)) stated they did not remember Resident #212's bruising from March 2022. The LPN #3 stated when a bruise was found, they do an accident report and investigation that included asking staff from all shifts if anyone knew anything or saw anything to explain the bruising. The LPN #3 stated whoever completed the accident report was responsible for obtaining the statements, and the UM was responsible to get statements from the staff who worked the prior 24-36 hours. During further interview on 5/24/23 at 10:54 AM, the DON stated they didn't specifically remember the color or size of the bruising and they documented the bruises were large in size, on the resident's upper chest which meant the clavicle area. The DON looked in the electronic medical record (EMR) and stated there were no skin assessments regarding the bruising. The DON stated that as the current DON, they would have expected staff statements. During an interview on 5/24/23 at 12:34 PM, the Assistant Administrator stated they were the DON in March of 2022. The Assistant Administrator stated they did not think the chest bruises were injuries of unknown origin because Resident #212 had falls and was able to get themselves up independently, so they contributed that ability to the chest bruising. The Assistant Administrator stated the chest area being a common area of trauma depended on the resident and that this resident was a wanderer and was hard to keep close watch of. The Assistant Administrator stated the bilateral nature of the bruising was not suspicious but would expect statements from the staff who worked on that unit when it was found, and the prior 24-48 hours. During an interview on 5/24/23 at 1:40 PM, the Administrator stated they expected an investigation of bruise of unknown origin to include staff statements to rule out abuse or neglect. They are supposed to do their best to get to the root cause. 3. Resident #109 had diagnoses including dementia, diabetes mellitus, and depression. The MDS dated [DATE], documented moderately impaired cognition, usually understands and was understood. The MDS further documented no falls. The Care Plan Activity Report revised on12/27/22 documented Resident #109 was a fall risk and maintain a safe environment. The undated CNA Assignments Summary (a guided tool used by staff to provide care) for REsident #109 documented the resident required limited assist for bed mobility, nonskid footwear, and left side bed assist with padding. Review of the Accident report dated 12/1/22 documented that at 8:00 PM Resident #109 had a bruise on the lumbar part of their back. Resident #109 was unaware of how the bruise occurred. There was no investigation into how the bruise occurred. The Investigation Statement dated 12/1/22, CNA #3 documented they did not witness a fall. Resident #109 refused help. There were no employee statements documented from additional staff members on how the bruise occurred. During an interview on 5/24/23 at 11:30 AM, CNA #3 stated they didn't recall the bruise to Resident #109's back and wasn't aware of any falls. During a telephone interview on 5/24/23 at 12:25 PM, LPN #4 stated the bruise was noted during Resident #109's shower. LPN #4 reported the bruise to LPN #5, Nursing Supervisor. Skin abnormalities were reported when there was an unknown cause. Resident #109 bruised easily. LPN #4 told Resident #109 to be more careful. LPN #4 stated Resident #109 would tell us if someone abused them. LPN #4 stated Nursing Supervisors were responsible for starting investigations, gathered employee statements and notified the DON. LPN #4 couldn't recall filling out a statement about Resident #109's bruise. During a telephone interview on 5/24/23 at 12:37 PM, LPN #5 could not recall the 12/1/22 incident. An investigation included the completed accident report, employee statements from CNAs who had contact with Resident #109 when the bruise was found, and the previous shift CNAs. A cause should have been determined to make sure abuse didn't occur. LPN #5 checked the medical record and ensured the bruise was new and notified the DON. The DON finished the investigation. During an interview on 5/24/23 at 12:45 PM, the DON stated there was one employee statement available. The investigation should have included additional employee statements, progress notes, medications and contributing factors which could lead to bruising. The DON stated the investigation for the bruise on 12/1/23 was incomplete. There was no reasonable cause determined for the bruise. During an interview on 5/24/23 at 1:04 PM, the Administrator stated the DON should have investigated further into the bruise on Resident #109's back and gathered more statements from staff and determined if the bruise was medically related. A completed investigation required looking at the big picture. This was not the big picture. 10 NYCRR 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (Complaint #NY00280885) during the Standard survey completed on 11/3/21, the facility did not ensure that a resident has a right to choose health care and providers of health care services consistent with his or her assessments and plan of care, including arranging transportation to outside medical appointments for one (Resident #131) of two residents reviewed for choices. Specifically, the resident missed two neurological appointments on 7/2/21 including an imaging scan and provider follow up. The finding is: The facility policy and procedure titled Consultations dated 7/2017 documented the facility would obtain additional assessment from an outside source for a resident to assist in care and treatment. Prior to consult they would secure an order with consultant's name, specialty, and reason for consult and make transportation arrangements. On the day of the appointment, they would document the resident's departure to see consultant, mode of transportation, with whom, etc. in nurse's notes. 1. Resident #131 had diagnoses including malignant neoplasm (tumor) of brain, epilepsy (seizure disorder), and hydrocephalus (build-up of fluid in the brain). The Minimum Data Set (MDS-a resident assessment tool) dated 9/30/21 documented Resident #131 was cognitively impaired and required total assist for locomotion (how resident moved between locations in their room and corridor). Review of the Care Plan Activity Report effective 4/15/21 revealed Resident #131 had neurological diseases: seizure disorder and was at risk for falls due to a malignant brain tumor. Review of the Appointment Note (from the neurologist's office) dated 5/21/21 documented Resident #131's next appointment was on 7/2/21 at 11:30 AM. Review of the Appointment Request Form dated 5/21 revealed Resident #131 had a follow up appointment scheduled on 7/2/21 at 11:30 AM for a CT (computed tomography) scan, then an MD appointment after the scan. The form did not document which transportation company was to be used or a pick-up time. Review of the Physician Order Activity Detail Report dated 8/1/21-11/3/21 revealed an order dated 5/25/21 for a neurology appointment on 7/2/21 at 11:30 AM for follow up subdural hematoma (SDH-buildup of blood on surface of the brain)/hygroma (collection of fluid under the [NAME] membrane of brain). Review of the nursing Progress Notes dated 7/2/21 revealed there was no documentation Resident #131 was transported to a neurology appointment on that date or that the appointment was rescheduled. During an interview on 11/1/21 at 12:36 PM, Licensed Practical Nurse (LPN) Unit Manager (UM) #1 stated when a resident had an appointment, they would fill out a form and send it to the scheduler, who then would set up transportation. The LPN UM #1 stated when Resident #131 came back from an appointment, it would say on their paperwork if there was a follow up appointment, and the LPN UM #1 wasn't aware of any missed appointments. LPN UM #1 stated Resident #131 was transported to appointments via non-emergency ambulance because their chair didn't fit in a wheelchair van. During an interview on 11/2/21 at 8:30 AM, the LPN UM #1 reviewed the nurse progress notes and stated they didn't know if Resident #131 made it to any appointments on 7/2/21, the consultation order said the resident had an appointment on that date but that didn't mean they actually went to the appointment. The LPN UM #1 stated there might have been a transportation issue and didn't know if the transportation was scheduled or not. During a telephone interview on 11/2/21 at 9:11 AM, the Neurooncology Nurse Care Coordinator (from the neurologist's office) stated the resident had two no shows on 7/2/21, which meant no imaging (CT/MRI) was done and the follow up with the provider was also not done that day. During a telephone interview on 11/2/21 at 12:04 PM, the per diem Resident Scheduler stated they remembered the resident's transportation needed to be changed at some point over the summer and they required a stretcher for appointments. They didn't know for certain if the resident's July 2nd transportation was set up as they did not have documentation to review during this interview. The Resident Scheduler stated if the resident didn't make it to the appointment on 7/2, there was probably a miscommunication and that the Unit Managers should have filled out the appointment request form. During an interview on 11/3/21 at 9:17 AM, the current Resident Scheduler reviewed the Appointment Request Forms for Resident #131 and stated they couldn't tell from the forms if transport was set up for the appointments on 7/2/21 as they didn't see a pick-up time or transport company listed. The Patient Scheduler stated there might have been a change in the type of transport the resident needed, but it should have been worked out in time for the appointment. The Patient Scheduler stated they did not have the appointment list for July. During an interview on 11/3/21 at 11:07 AM, the Physician's Assistant (PA) stated the resident went to a lot of specialists' appointments due to their history of brain cancer, traumatic brain injury (TBI) and had frequent MRIs (magnetic resonance imaging) and CT scans to monitor a subdural hematoma. The PA stated it was important that the resident attended these specialists appointments because they were the ones that primarily managed those conditions and would make changes if needed. The PA stated the facility needed to make sure the resident made it to their appointments. During an interview on 11/3/21 at 11:59 AM, the Director of Nursing (DON) stated if they knew about the 7/2/21 appointments then the DON would have expected the Scheduler to set it up for the resident. The DON stated if there was no nurse's note about the appointment, it was possible it was an error, and the Scheduler didn't make the transportation appointment at all. During an interview on 11/3/21 at 12:47 PM, the Administrator stated they don't know why the resident's July appointment was missed, and it was the Scheduler's responsibility to arrange transportation. The Administrator stated there was nobody that oversaw that the Scheduler made the transportation arrangements and that process needed to be tightened up. The Administrator also stated there may have been lack of communication as to the type of transportation the resident needed for their appointments. 415.5(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a Complaint investigation (Complaint #NY00281939) during the Standard survey completed on 11/3/21, the facility did not ensure that all alleged violations involving abuse are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, to appropriate officials (including the State Survey Agency) for two (Resident #36, 62) of four residents reviewed for alleged abuse. Specifically, an alleged incident of sexual abuse was not reported timely to the New York State Department of Health (NYS DOH) within the two-hour timeframe as required. The findings are: Review of facility policy and procedure (P&P) titled Abuse Policy revised 3/2021 documented the facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing (DON) immediately and initiate gathering requested information. An investigation must be directed by the Administrator or designee immediately. The Administrator, DON, or designee shall notify the DOH, via the Event Reporting System electronically, or by phone in the event of the electronic system being unavailable within two hours of knowledge of the alleged incident. 1. Resident #62 was admitted to the facility with diagnoses including dementia, anxiety, and delusional disorder. The Minimum Data Set (MDS- a resident assessment tool) dated 10/27/21 documented the resident had severe cognitive impairment. The resident had a history of being hypersexual in the past with inappropriate behaviors. 2. Resident #36 was admitted to the facility with diagnoses including diabetes, depression, and seizure disorder. The MDS dated [DATE] documented the resident was cognitively intact. The resident had a history of socially inappropriate behavior and false accusations. Review of a facility investigation dated 8/23/21 at 5:00 PM documented that on 8/23/21, at approximately 5:00 PM, Resident #36 was witnessed by Certified Nursing Aide (CNA) touching Resident #62 breast/chest area in the hallway. Both residents were fully clothed. Resident #36 stated Resident #62 told me to do it. Resident #62 could not answer questions, appropriately, when questioned. The residents were immediately separated, assessed by a Registered Nurse (RN) and placed on 15- minute safety checks. Resident #36 was provided with health teaching/education. A police report was filed for inappropriate touching. Review of the NYS DOH Automated Complaint Tracking System Complaint/Incident Investigation Report revealed; Date/Time of occurrence: 8/23/21 at 5:00 PM. Submitted by facility: 8/24/21 at 1:41 PM. During an interview on 11/3/21 at 12:26 PM, the DON stated that they (the DON) were immediately informed, the evening of the incident, by the Registered Nurse (RN) Supervisor on duty. The DON stated they were aware of regulatory reporting requirements. Additionally, the DON stated that is my fault. I guess I wasn't looking at it as abuse because it was inappropriate touching, in a common place, and the residents were fully clothed. I could not rule out that Resident #62 did not take Resident #36 hand and place it on their shirt when it was witnessed by the CNA. During an interview on 11/3/21 at 1:41 PM, the Administrator stated they were aware of the incident and depending on the time we find out about an allegation it should be reported within two hours, as required. 415.4(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 11/3/21, the facility did not ensure that each resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain personal hygiene for two (Residents #76 and 135) of five residents reviewed for ADLs. Specifically, the lack of timely toileting/changing of an incontinent resident (Resident #76) and lack of proper hand hygiene and glove changes during incontinence care (Residents #76 and 135). The findings are: The facility policy and procedure (P&P) titled Hand Hygiene dated 12/2020 documented single use disposable gloves should be used when anticipating contact with blood or body fluids and staff were to perform hand hygiene for the following situations: before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's skin, after contact with bodily fluids, and after removing gloves. The facility P&P titled Bladder and Bowel Incontinence Care dated 2/2020 documented the policy was to prevent breakdown due to incontinence and keep perineal area clean, dry and odor free. The staff were to wash hands, don gloves, clean perineal area with washcloth, wash front to back, dry thoroughly, apply moisture barrier cream and a new incontinence brief. Reposition resident to ensure safety, place call bell in reach, then remove gloves, dispose of soiled items then wash hands. The policy did not include changing gloves and washing hands after providing the incontinence care before touching clean items in the resident's environment. 1. Resident #76 had diagnoses including hypothyroidism (thyroid disease), macular degeneration (eye disease that causes vision loss), and anxiety disorder. The Minimum Data Set (MDS-a resident assessment tool) dated 9/8/21 documented Resident #76 was cognitively impaired, was totally dependent on staff for toileting, was occasionally incontinent of bladder, always incontinent of bowel, and was at risk for developing pressure ulcers. Review of the Care Plan Activity Report effective 6/3/21 revealed Resident #76 had urinary incontinence. Interventions included bedpan upon waking, after meals, at bedtime and as needed (PRN). The resident also had impaired skin integrity moisture associated skin damage (MASD-redness/excoriation to abdominal folds and buttocks). Review of the Certified Nurse Aide (CNA) Assignments Summary dated 11/2/21 revealed Resident #76 was totally dependent on staff for toilet use and was incontinent, bedpan upon waking, after meals, at bedtime and PRN. During continuous observation on 11/2/21 from 9:06 AM to 10:45 AM and 10:55 AM to11:53 AM Resident #76 self-propelled in their wheelchair around the unit or sat in their wheelchair near the nurse's station, wearing a maroon shirt and light gray pants. The resident was not toileted or changed during this timeframe. At 11:53 AM the resident self-propelled back to nurse's station and was noted to be visibly soiled in their groin region, their light gray pants were dark gray, and the resident had a urine odor. The resident continued to sit in their wheelchair near the nurse's station. At 12:26 PM Licensed Practical Nurse (LPN) #3 told CNA #2 that Resident #76 needed to be changed. During an interview on 11/2/21 at 12:27 PM, CNA #2 stated they got Resident #76 out of bed around 8:00 AM and hadn't toileted or changed them since that time. The CNA #2 stated Resident #76 was always incontinent and CNA #2 hadn't had time to toilet the resident because there were 14 residents on their assignment that were mostly mechanical lifts and two assist transfers. During an observation of incontinence care on 11/2/21 at 12:34 PM, CNA #2 and CNA #9 donned (put on) gloves and transferred Resident #76 into bed with a mechanical lift. The CNAs then turned the resident onto their right side and CNA #2 removed the pants and brief which was saturated with urine and a moderate amount of stool. The resident's skin on buttocks and upper thighs was moist, red, with excoriated areas and indented lines where the brief had been wrinkled underneath the resident. Resident #76's pants were soaked through and the mechanical lift sling that was under the resident while in the wheelchair was also wet. CNA #2 provided urinary and bowel incontinence care using a wet washcloth. CNA #2 did not remove their gloves and wash their hands after incontinence care was completed. CNA #2 wore the same gloves and proceeded to apply a clean brief and pants to Resident #76. LPN #3 was in the room and stated the resident had an excoriated area on their buttocks that they had been putting cream on. CNA #2 wore the same gloves and put a clean sling under the resident, hooked it to the mechanical lift, used the bed remote to put the head of bed up, and touched the wheelchair handles to position it for the transfer. Once Resident #76 was back in their wheelchair, the CNA #2 applied the nasal cannula tubing to the resident's nose. The CNA #2 then removed their gloves and washed their hands. During an interview on 11/2/21 at 1:05 PM, CNA #2 stated they didn't change their gloves and wash their hands, but they should have because they touched dirty stuff and then touched clean stuff. The CNA #2 stated they should have used clean hands to apply the resident's oxygen tubing. During an interview on 11/2/21 at 1:10 PM, LPN #3 stated the resident was up before breakfast, should have been changed sooner and should not have been soaked through. LPN #3 stated they only had three aides on the unit today, it was difficult to get everything done, and that they really needed at least four aides on the unit because they had many mechanical lifts and incontinent residents and not a lot of independent residents. During an interview on 11/2/21 at 1:21 PM, LPN Unit Manager (UM) #2 stated Resident #76 was care planned for toileting upon waking, after meals, at bedtime and as needed. The LPN UM #2 stated they expected staff to change the resident prior to being visibly soiled and that the nurses on the unit should make sure CNAs were toileting the residents as care planned, but a lot of times those nurses were helping with hands on care because they didn't have enough CNAs. During an interview on 11/3/21 at 9:36 AM, the Registered Nurse (RN) Infection Preventionist (IP) stated the CNA should have removed the gloves, washed their hands and put on a new pair of gloves prior to touching clean items in the resident's room, including the clean brief, clothing, wheelchair handles and oxygen tubing in order to prevent transmission of germs. During an interview on 11/3/21 at 11:51 AM, the Director of Nursing (DON) stated Resident #76 should have been changed before they were visibly soiled and sitting in urine for too long could cause skin breakdown. The DON stated the resident should have been changed after breakfast and usually incontinent residents are changed every 2-3 hours. 2. Resident #135 had diagnoses including dementia, urinary tract infection, and anxiety. The MDS dated [DATE] documented Resident #135 was cognitively impaired, was totally dependent on staff for toileting, and was always incontinent of bowel and bladder. Review of the Care Plan Activity Report effective 7/24/18 (identified as current) revealed Resident #135 had urinary incontinence. Interventions included to check and change the resident every 2-3 hours and prn when out of bed and to provide peri care with each episode of incontinence to ensure skin, linens, and clothing are clean and dry. During observation of incontinence care on 10/29/21 at 11:28 AM, CNA #1 donned gloves and turned Resident #135 onto their left side while CNA #9 assisted to keep the resident on their side. The resident's brief was soiled with stool. CNA #1 provided bowel incontinence care using a washcloth. The CNA #1 rinsed and dried the resident's skin then applied a zinc-based barrier cream using their left hand. CNA #1 removed their left glove and kept the right hand glove on (the hand used to wipe/clean the resident's buttocks) and did not wash their hands. CNA #1 applied a new brief and the resident's pants, then removed their right glove. CNA #1 did not wash their hands and opened the closet doors, touched the bed control to put the bed in low position, placed a fleece blanket on the resident, put the call light within the resident's reach, and touched the handles of the mechanical lift to move it out of the way. CNA #1 then washed their hands. During an interview on 10/29/21 at 11:52 AM, CNA #1 stated they weren't taught when to change their gloves, they took the left glove off because it had barrier cream on it. CNA #1 stated the other glove wasn't visibly soiled, so they got confused about when to remove their gloves and wash their hands. During an interview on 11/1/21 at 12:30 PM, the LPN UM #2 stated they expected CNAs to change their gloves and wash hands after they change a resident's soiled brief, and the CNA should not have touched the clean items without washing their hands first. During an interview on 11/3/21 at 9:32 AM, the RN IP stated they expected staff to change gloves and wash their hands after providing fecal incontinence care, prior to touching clean items to prevent transmission of germs. During an interview on 11/3/21 at 11:49 AM, the DON stated they expected the staff to take their gloves off and wash their hands after incontinence care for infection control purposes because they don't know what germs they are leaving behind on those clean surfaces. 415.12 (a)(3)

Based on observation, interview, and record review conducted during the Standard survey on 11/3/21, the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for one (Resident #76) of two residents reviewed for nutrition. Specifically, the resident's significant weight loss was not identified by a Registered Dietician (RD) and there were no nutritional interventions initiated to address the significant weight loss. The finding is: The facility policy titled Weight Assessment and Interventions dated 8/2019 documented any weight change of greater than or less than 5 pounds within 30 days will be retaken the next day for confirmation with a licensed nurse confirming the weight. The dietician will review the unit weight record by the 15th of the month to follow individual weight trends over time. Negative trends will be assessed and addressed by the Dietician whether or not the definition of significant weight change is met. 1. Resident #76 had diagnoses including hypothyroidism, macular degeneration (eye disease that causes vision loss), and anxiety disorder. The Minimum Data Set (MDS-a resident assessment tool) dated 9/8/21 documented Resident #76 was cognitively impaired, was independent for eating, and had a weight of 179 pounds (lbs) that indicated a weight loss of 5% or more in the last month or loss of 10% or more in the last six months, and was not on a physician prescribed weight loss program. Review of the Care Plan Activity Report effective 6/3/21(identified as current) revealed Resident #76 was at risk for weight loss related to edentulism (lack of teeth), gastric bypass surgery, and a swallow disorder. Goals included to maintain a weight range between 185-195 lbs. Interventions included to provide mechanical soft consistency diet, ensure plus (supplement) everyday with breakfast, large portion breakfast, monitor intakes and weights, and planned HS (bedtime) snack. The care plan did not address the resident's significant weight loss on 8/5/21. Review of the Initial Nutrition Risk Assessment Short-Term Stay completed by the RD on 6/25/21 documented Resident #76 was 68 inches tall and had an admission weight of 190 lbs. The resident had missing/broken teeth, had a pressure ulcer and was at risk for unintended weight loss. The resident had complete edentulism related to full upper and lower dentures not in the facility and had no edema (swelling caused by excess fluid) The plan included to provide a large portion of breakfast, ensure plus every day with breakfast, and 30 milliliters (mL) of liquid protein twice daily with medication pass to help meet increased needs for wound healing. Review of the Clinical Monitoring Detail Report dated 5/12/21-11/2/21 revealed the following weights: 5/21/21: 190 lbs 6/12/21: 191.8 lbs 7/13/21: 189.3 lbs 8/5/21: 179 lbs 10/14/21: 169.2 lbs There was no documented weight for September 2021 Review of dietary Progress Notes from 5/25/21-11/2/21 revealed there were no nutritional notes that addressed the resident's weight loss. Review of the Dietary-Quarterly Nutrition Review completed on 9/28/21 documented Resident #76's weight in 8/21 of 179 lbs was possibly inaccurate and they would monitor weights as available. They would continue the current nutritional interventions and monitor for need to adjust the meal plan. The resident's estimated nutrient needs were based on 7/21 weight of 189.3 pounds. There was no documentation that the resident had edema or that a re-weight was requested. Review of medical Progress Notes dated 10/11/21 at 9:58 AM revealed the resident appeared well nourished with a weight of 179 lbs. During an observation on 10/29/21 at 8:35 AM, Resident #76 was sitting near the nurse's station eating breakfast. Resident #76 did not have any edema. During a telephone interview on 11/2/21 at 2:42 PM, the RD stated they just reviewed the resident's weights in the electronic medical record (EMR) and it looked like the resident may have lost some weight. The RD stated they thought the August and October weights were inaccurate as the weights were documented by other staff members and not the RD. The RD also stated that they didn't see a September weight documented in the EMR. The CNAs would usually write weights on paper, then when the RD reviewed them, they would document them in the EMR. If a weight looked far off, they requested a re-weight to confirm if there was actual weight loss. The RD stated a re-weight was requested in August for this resident, but they did not follow up to make sure it was done. A weight should have been obtained to confirm if the resident was meeting their weight goal of 185-195 lbs or if they had an actual weight loss. The RD stated residents should be weighed every month. The RD also stated they didn't know about the resident's October weight until the surveyor brought it to their attention. During further telephone interview on 11/2/21 at 3:36 PM, the RD stated they knew they didn't follow up on this resident as fast as they should have in order to put new nutritional interventions in place. During a telephone interview on 11/3/21 at 10:30 AM, the RD stated the resident did have a significant weight loss in three months and that they found a weight on September 15th that was 170.2 lbs for this resident. The resident showed a 10.6% (20.1 lb) weight loss in three months and using the 169.2 lb October weight, that showed a 10.9% (20.8 lb) weight loss in five months. The RD stated they talked to the Unit Manager today and they obtained a weight of 168 lbs today. During an interview on 11/3/21 at 11:56 AM, the Director of Nursing (DON) stated they would expect the RD to follow up on a re-weight especially if they thought it was inaccurate. If the RD was having trouble getting the weights, the RD could have brought it up in morning report, when the entire team was present, including Unit Managers. The DON stated they would expect the RD to confirm weights they thought were inaccurate within the month of when the weight was obtained, so they could put recommendations in place to address the weight loss and then update the provider. 415.12 (i)(1)

Based on interview and record review conducted during the Standard survey completed on 11/3/21, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified four (Employees A, B, C, D) of nine employees reviewed who were hired in the last four months and were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their employment. The findings are: The facility's policy and procedure titled, Abuse Prevention, revised 3/12/21, documented that all potential employees are screened for a history of abuse, neglect, or mistreating residents/patients during the hiring process. Screening will consist of, but not be limited to, inquiries into the state nurse aide registry. 1a. Review of the personnel file for Employee A (Temporary Nurse Aide) on 10/29/21 revealed Employee A was hired (start date) on 10/5/21 and the New York State Nurse Aide Registry Verification Report was dated 10/29/21. During an interview on 11/1/21 at 3:25 PM, the Senior Executive Assistant stated Employee A worked as a full-time Temporary Nurse Aide on Unit 1 on the 7:00 AM to 3:00 PM shift. 1b. Review of the personnel file for Employee B (Activities Aide) on 11/1/21 revealed Employee B was hired (start date) on 10/5/21 and the New York State Nurse Aide Registry Verification Report was dated 11/1/21. During an interview on 11/1/21 at 3:25 PM, the Senior Executive Assistant stated Employee B worked as a full-time Activities Aide throughout all four resident units on the 9:00 AM to 5:00 PM shift. 1c. Review of the personnel file for Employee C (Social Work Assistant) on 11/1/21 revealed Employee C was hired (start date) on 10/12/21 and the New York State Nurse Aide Registry Verification Report was dated 11/1/21. During an interview on 11/1/21 at 3:25 PM, the Senior Executive Assistant stated Employee C worked as a part-time Social Work Assistant on the 9:00 AM to 2:00 PM shift and has the potential to work with all skilled nursing residents. 1d. Review of the personnel file for Employee D (Country Store Attendant) on 11/1/21 revealed Employee D was hired (start date) on 10/12/21 and the New York State Nurse Aide Registry Verification Report was dated 11/1/21. During an interview on 11/1/21 at 3:25 PM, the Senior Executive Assistant stated Employee D worked as a part-time Country Store Attendant in various four-hour shifts during daytime hours, and the Country Store was open to skilled nursing residents. During an interview on 11/1/21 at 2:25 PM, the Senior Executive Assistant stated it was the responsibility of the Human Resources (HR) staff to check the New York State Nurse Aide Registry for all new hires, but HR staff left employment at this facility in September 2021. The Senior Executive Assistant stated it was not clear who took over the responsibility of Nurse Aide Registry checks in the absence of HR staff. During an interview on 11/3/21 at 12:00 PM, the Administrator stated the purpose of checking all new hires on the New York State Nurse Aide Registry was to see if that person ever worked as a Certified Nurse Aide and if that person had any abuse findings in their past. Additionally, the Administrator stated the facility missed the nurse aide registry checks on new hires because HR unexpectedly left their position at the end of September or early October 2021. 415.4(b)(1)(ii)(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed 11/3/21, the facility did not ensure that the residents' environment remains as free from accident hazards as is possible and that each resident received adequate supervision and assistance devices to prevent accidents. Four (Units 1,3,4,5) of four resident care units had issues with water temperatures exceeding 120 degrees Fahrenheit (°F) in resident rooms and care areas. In addition, one (Resident #117) of two residents reviewed for accidents had an issue involving a resident smoking without supervision and lacked completion of timely smoking assessment. The findings are: 1) The facility's undated policy and procedure called, Hot Water Temperatures and Testing, documented that the facility will provide a consistently controlled domestic hot water temperature throughout the facility that prevents residents, visitors, and staff from injury due to scalding. Also, water temperatures will be maintained between 100 and 120 degrees and temperatures that exceed 120 degrees will require an investigation and resolution by Maintenance personnel. Additionally, any area(s) affected with high readings will be closed for use until the problem is resolved. Review of the facility's Water Management Plan, dated 7/2/21, revealed it contained a description of the facility's hot water heating and distribution system. It stated cold water enters two 800-gallon heat exchangers and is heated to a temperature of 145 degrees, one loop goes directly to dietary and housekeeping, the second loop goes through a mixing valve and is reduced down to 115 degrees and sent to domestic hot water, and both loops are on a constant recirculating system. Observations on 10/28/21 between 9:15 AM and 10:11 AM revealed the following hot water temperatures were obtained in resident rooms and care areas using digital stem-type thermometers: Resident room [ROOM NUMBER] - 128.4 °F Resident room [ROOM NUMBER] - 130.0 °F Resident room [ROOM NUMBER] - 128.4 °F Resident room [ROOM NUMBER] - 127.0 °F Resident Room #R-3 - 128.4 °F Shower head Unit 1 Shower Room - 124.0 °F Resident room [ROOM NUMBER] - 128.4 °F Resident room [ROOM NUMBER] - 127.9 °F Resident room [ROOM NUMBER] - 128.3 °F Resident room [ROOM NUMBER] - 129.1 °F Resident room [ROOM NUMBER] - 127.3 °F Shower head Unit 3 Shower Room - 126.8 °F Resident room [ROOM NUMBER] - 128.3 °F Resident room [ROOM NUMBER] - 125.0 °F Resident room [ROOM NUMBER] - 125.1 °F Resident room [ROOM NUMBER] - 130.1 °F Resident room [ROOM NUMBER] - 130.6 °F Resident room [ROOM NUMBER] - 129.6 °F Resident room [ROOM NUMBER] - 126.3 °F Resident room [ROOM NUMBER] - 121.5 °F Resident room [ROOM NUMBER] - 126.7 °F Shower head in Unit 5 Shower Room - 123.6 °F During an interview on 10/28/21 at 9:50 AM, the Maintenance Director stated the ideal hot water temperature at resident sinks was 112 to 114 °F and if temperatures went over 120 °F, they would adjust the mixing valve. The Maintenance Director added that hot water temperatures should not got over 120 °F because the residents have sensitive skin. Observations in the Boiler Room, at this time and in the presence of the Maintenance Director, revealed the gauge located on the hot water pipe, after passing through the mixing valve, read 125 °F. Immediately, the Surveyor and the Maintenance Director walked to Resident room [ROOM NUMBER] and took a hot water temperature from the sink inside Resident room [ROOM NUMBER] (126.3 °F) using the Surveyor's digital thermometer. The Maintenance Director stated that temperature was too high. The Maintenance Director added that the mixing valve was installed about one and a half to two years ago and there had been no recent work on it. They added that the mixing valve was a mechanical device, not electrical, and the temperature was set by turning a nut and was not equipped with electrical controls such as temperature limits or alarms. At this time, the Maintenance Director stated hot water temperatures were taken daily by staff on weekdays on each resident unit and recorded in their automated maintenance record-keeping system. Review of the facility's hot water temperature records taken between 10/11/21 through 10/27/21 revealed the hot water temperatures on the resident units ranged from 111 °F to 116 °F during that time period. During an interview on 10/28/21 at 9:58 AM, the Maintenance Director stated they would manually adjust the mixing valve immediately. At this time, the facility increased their hot water monitoring from once daily on weekdays only to three times daily, including weekends. During an interview on 10/28/21 at 10:55 AM, Certified Nurse Aide (CNA) #3 stated sometimes the water does get hot and they have to turn the cold water on. CNA #3 further stated some days the water was hotter than others, and when they washed their hands in the staff bathroom, the water was too hot, but they had not told anyone that the water was hot, they adjusted the water. Observation of hot water temperatures on 11/1/21 between 8:20 AM and 9:30 AM revealed the following hot water temperatures were obtained in resident rooms using digital stem-type thermometers: Resident room [ROOM NUMBER] - 122.0 °F Resident room [ROOM NUMBER] - 121.1 °F Resident room [ROOM NUMBER] - 129.9 °F Resident room [ROOM NUMBER] - 122.4 °F Resident room [ROOM NUMBER] - 121.6 °F During an interview on 11/1/21 at 8:25 AM, the Maintenance Director stated since 10/28/21, the mixing valve had been adjusted as low as it would go, but there were still some hot water temperatures above 120 °F over the weekend on 10/30/21 and 10/31/21. Observation in the Boiler Room, in the presence of the Maintenance Director, on 11/1/21 at 8:30 AM revealed the digital thermometers on the hot water boilers read 145 °F and 146 °F and the gauge located on the hot water pipe after passing through the mixing valve read 120 °F. At the time of the observation, the Maintenance Director stated the mixing valve had been adjusted to its lowest setting, but some water temperatures were still rising to above 120 °F. The facility planned to lower the set point of the two hot water holding tanks to 130 °F. On 11/1/21 at 9:25 AM, the Maintenance Director stated after reviewing the weekend water temperature logs on Monday morning, there water temperatures that were above 120 °F over the weekend. The Maintenance Director stated they were not of water temperatures above 120 °F over the weekend by the staff members who took the temps, a Maintenance Assistant and two Custodians. The Maintenance Director added that direction was not provided to the Maintenance Assistant or the Custodians as to what to do or who to call if temperatures exceeded 120 °F over the weekend, but the Maintenance Director should have done so. During an interview on 11/1/21 at 9:30 AM, Maintenance Assistant #1 stated they did monitor hot water temperatures over the weekend and the highest temperature reached was 123.4 °F. Additionally, at 11:30 AM, Maintenance Assistant #1 stated they did not call the Maintenance Director, when some water temperatures above 120 °F were identified. Maintenance Assistant #1 added that the Maintenance Director had advised that 120 °F was the upper limit for water temperatures on 10/28/21, when the facility began monitoring water temperatures on each shift, but the Maintenance Director did not provide further instruction. During an interview on 11/3/21 at 11:25 AM, Custodian #1 stated they did monitor hot water temperatures over the weekend. Custodian #1 further stated they did not know what water temperature was too hot and they were given no instruction to call anyone if a certain temperature was reached. During an interview on 11/1/21 at 10:45 AM, the Administrator stated hot water temperatures should not exceed 120 °F. The Administrator stated they were made aware that water temperatures exceeded 120 °F on 10/28/21 and knew that the mixing valve was adjusted at that time. The Administrator also stated water temperatures were stable when they left the faciity on Friday afternoon, they were not aware that water temperatures above 120 °F were identified during the weekend until this morning, and they probably should have been notified at the time the elevated water temperatures were identified over the weekend. During an additional interview on 11/1/21 at 12:15 PM, the Administrator stated they did not communicate any instruction to the staff members who were taking water temperatures and they should have done so. During an interview on 11/01/21 at 11:15 AM, Resident #91 stated the water in the bathroom gets really hot, you can make oatmeal and tea with it. Resident #91 further stated they couldn't recall telling any staff member about it and they knew where to put the dial so the water was right for them. 2) Resident #117 had diagnoses including Hemiplegia (loss of strength or paralysis on one side of the body)- affecting left nondominant side, Chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing related problems), Nicotine dependence-cigarettes. The Brief Interview for Mental Status (BIMS) dated 4/28/21 revealed Resident #117 scored a 12 indicating moderately impaired cognition. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 9/29/21 for significant change revealed that the resident required extensive assist for locomotion on and off unit and required limited assist for personal hygiene. The facility policy titled Smoking dated 1/21/21 documented that the facility did not permit smoking inside the facility, unless inside the designated smoking room. Smoking was permitted at outside designated area. Residents would be supervised by a staff member. Smoking materials must be retained by facility staff at the area the facility keeps cigarettes/lighters. Residents may not keep smoking materials with them or in their rooms. Smoking materials must be retained by staff, in the designated area. Patient's safety awareness status would be evaluated quarterly or as determined by the interdisciplinary team. Review of Nursing-Smoking evaluation revealed last smoking assessment completed on Resident #117 was on 11/10/17. During an observation on 10/29/21 at 9:34 AM, Resident #117 was outside of the facility exit door, near room [ROOM NUMBER] on rehab unit, sitting with the back of wheelchair positioned against the brick wall of building, smoking a cigarette. Resident #117 was smoking unsupervised. No facility staff was observed with the resident. During an interview on 10/27/21 at 12:05 PM, Resident #117 stated they go outside every morning to smoke. They keep their cigarette's and lighter in their room. During an interview on 11/2/21 at 2:07 PM, Director of Activities stated no one is to be left unsupervised while smoking. Everyone is observed in the smoking room or outside of the facility, for safety. Smoking used to be allowed outside, off the rehab unit, but was stopped during March or April. The Director of Activities stated Resident #117 doesn't smoke anymore, to my knowledge, and Activities has not had any smoking material for Resident #117 since early summer. During an interview on 11/3/21 at 11:54 AM, Licensed Practical Nurse (LPN) #7 stated smoking materials are kept with activities or locked in the medication room. The smoking area is designated to the smoke room at the front of the building. Resident's do smoke where they aren't supposed to smoke. Residents smoke outside of the rehab unit. During an interview on 11/3/21 at 12:12 PM, LPN #4 stated that resident #117 smoked and occasionally the LPN will hold onto their smoking materials. Smoking outside of the rehab unit, in the courtyard, was allowed prior to COVID and during the summer. During an interview on 11/3/21 at 12:42 PM, LPN #6 stated Resident #117 gave them their cigarettes and lighter that were in their room without a problem on 11/2/21. Resident #117 can leave unit independently and wheel self to and from the smoke room. Resident #117 smoking material was placed inside the locked nursing cart. LPN #6 did not know why or how resident #117 even had smoking stuff in their room. LPN #6 further stated that if a resident left the facility due to being sent to hospital, had a change in level of consciousness or a change in physical ability to manage smoking on their own, a smoking assessment should be done. Resident smoking is to take place in the smoking room in the front of the building past the lobby. During an interview on 11/3/21 at 1:53 PM, Director of Nursing (DON) stated that if a resident smokes, a smoking assessment is completed upon admission and then quarterly. Residents can smoke on the first floor in the smoking room near the staff entrance at the end of the hall. Smoking is also allowed outside in the courtyard, at least 30 feet away from the building, off the rehab unit and outside near smoke room. Residents who smoke are supervised and should not be maintaining their own smoking materials, for safety purposes. The DON stated they do not want other residents to have the ability to access smoking material. During an interview on 11/3/21 at 2:07 PM, the Administrator stated the expectation is that a smoking assessment be done quarterly by nursing staff because resident status can change. Residents are not supposed to have any smoking materials on them. Smoking materials are maintained by the activity department and nursing. 415.12 (h)(2)

Based on observation, interview and record review conducted during the Standard Survey and Complaint (NY00284800) completed on 11/3/2021, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, four (Unit 3, 4, 5, and Rehabilitation) of four resident care units did not have adequate staff based on the facility's established minimum number of staff for each unit and each shift. In addition, the Facility Assessment did not address Certified Nursing Assistants (CNAs). The finding is: Review of the Facility Assessment Tool 2021 dated 6/22/21 documented the average daily census 150 - 155 and the facility resources needed to provide competent support and care for the resident population every day and during emergencies include a staffing plan of: Days Shift - 1 Licensed Practical Nurse (LPN) per long term care (LTC) unit and 2 LPN's for rehab unit; Evening shift - 1 Registered Nurse (RN) or LPN Supervisor and 4 LPN's, Night Shift - 1 Registered Nurse (RN) or LPN Supervisor and 4 LPN's. There was no documented evidence of a Certified Nursing Assistant (CNA) Plan in the Facility Assessment Tool. Review of a facility policy titled On Call Procedure for Nurse Coverage and Supervision dated 8/22/2020 documented, to implement an on-call system with nurse managers and the upper nursing management team (Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Nurse) to ensure adequate nurse and aide staffing coverage of nursing units and supervision for all shifts. Additionally, identified by the DON, they (facility) hand wrote the Bare Minimum Staffing requirements for each shift on the policy: 7 AM - 3 PM shift - 4 Nurses and 8 CNAs 3 PM - 11 PM shift - 4 Nurses and 8 CNAs 11 PM - 7 AM shift - 4 Nurses and 4 CNAs. a.) Review of an undated, untitled documented identified by the DON as the current number of residents requiring total assistance with meals was 14 residents; and the total number of residents requiring 2 staff to assist with transferring was 59 residents in the facility. Review of the Daily Nursing Schedule from 9/27/21 through 10/26/21 revealed the facility did not meet their minimum staffing requirements as documented by the DON with a census from 153 to 158 residents per day on the following dates and shifts: -9/27/21 evening shift -9/28/21 night shift -10/1/21 evening shift -10/3/21 day shift -10/4/21 evening shift -10/5/21 day shift and evening shift -10/10/21 evening shift -10/23/21 evening shift During an interview on 11/3/21 at 10:43 AM the Scheduling Coordinator stated the staffing plan for each unit was as follows: Day Shift - 2 nurses and 4 CNA on each unit to equal 8 nurses and 16 CNAs, plus a nursing supervisor. Evening Shift - 2 nurses and 4 CNAs on each unit to equal 8 nurses and 16 CNAs, plus a nursing supervisor. Nights 2 nurses on the rehabilitation unit and 1 nurse on the skilled units and 2 CNAs on each unit to equal 5 nurses and 8 CNAs, plus a nursing supervisor. The Scheduling Coordinator stated for the past year the facility has been having difficulty getting enough staff to meet the Bare Minimum requirements the facility had determined. The Scheduling Coordinator stated, they are aware some shifts are below the facility's minimum number and the DON is aware. The Scheduling Coordinator reviewed the following dates and verified the facility did not meet their minimum staffing requirements for the following dates and times: -On 9/27/21 9:00 PM - 11:00 PM Unit 5 documented 1 CNA below the minimum number - the facility did not provide 2 CNAs to each unit as planned. -On 9/28/21 11:00 PM - 3:00 AM Unit 3 documented 1 CNA below the minimum number - the facility did not provide 1 CNA to each unit as planned. -On 10/1/21 7:00 PM - 11:00 PM Unit 5 documented 1 CNA below the minimum number - the facility did not provide 2 CNAs to each unit as planned. -On 10/3/21 7:00 AM - 11:00 AM Rehabilitation Unit documented 1 CNA below the minimum number - the facility did not provide 2 CNAs to each unit as planned. -On 10/4/21 3:00 PM - 7:00 PM Rehabilitation Unit documented 1 CNA below the minimum number, 7:00 PM - 11:00 PM Unit 3 documented 1 CNA below the minimum number and 9:00 PM - 11:00 PM Unit 5 documented 1 CNA below the minimum number - the facility did not provide 2 CNAs to each unit as planned. -On 10/5/21 7:00 AM - 3 PM Rehabilitation Unit 1 CNA below the minimum number and 3:00 PM - 7:00 PM Rehabilitation Unit and Unit 4 documented 1 CNAs below the minimum number - the facility did not provide 2 CNAs to each unit as planned. -On 10/10/21 3:00 PM - 4:00 PM Rehabilitation Unit documented 1 CNA below the minimum number and 3:00 PM - 7:00 PM Unit 3 documented 1 CNA below the minimum number - the facility did not provide 2 CNAs to each unit as planned. -On 10/23/21 3:00 PM - 5:00 PM Unit 5 documented 1 CNA below the minimum number - the facility did not provide 2 CNAs to each unit as planned. During an interview on 11/3/21 at 11:17 AM, the DON stated they were not aware the facility was below the minimum staffing numbers on all the identified dates (dates listed above). At 11:33 AM the DON stated they were aware the residents have voiced complaints there was not enough staff to provide care (what kind of care). During interview on 11/3/21 at 12:03 PM, the Scheduling Coordinator stated the facility's minimum staffing numbers for the resident care units was approximately a ratio of 1 CNA to 20 residents and believes it was not feasible for day and evening shift staff to provide all the care required by the plan of care for all residents. During an interview on 11/3/21 at 12:19 PM, the Administrator verified the facility's minimum staffing numbers to be correct as written by the DON. The Administrator stated they were not aware the facility was not meeting their minimum staffing numbers and should have been notified to prevent being below the facility's minimum staffing requirements. The Administrator stated they do not believe all aspects of resident care such as showers can be accomplished with a staffing ratio of approximately 1 CNA to 20 residents on the day and evening shifts. b.) During continuous observations on 11/2/21 from 9:06 AM to 10:45 AM and 10:55 AM to11:53 AM Resident #76 self-propelled in their wheelchair around the unit or sat in their wheelchair near the nurse's station, wearing a maroon shirt and light gray pants. The resident was not toileted or changed during this timeframe. At 11:53 AM the resident self-propelled back to nurse's station and was noted to be visibly soiled in their groin region, their light gray pants were dark gray, and the resident had a urine odor. The resident continued to sit in their wheelchair near the nurse's station. At 12:26 PM LPN #3 told CNA #2 that Resident #76 needed to be changed. During an interview on 11/2/21 at 12:27 PM, CNA #2 stated they got Resident #76 out of bed around 8:00 AM and hadn't toileted or changed them since that time. The CNA #2 stated Resident #76 was always incontinent, and CNA #2 hadn't had time to toilet the resident because there were 14 residents on their assignment that were mostly mechanical lifts and two assist transfers. c.) Review of Resident Council Minutes dated 9/28/21 documented, residents voiced concerns call lights were not being answered, long wait times for call lights to be answered and waiting over 30 min to have incontinent care provided. During the Resident Council Meeting on 10/27/21 at 2:15 PM, revealed residents stated there was not enough staff; they were waiting too long for call lights to be answered; and when only 2 CNAs are assigned on a unit, showers were not able to be provided. In addition, residents voiced concerns there was only 1 CNA scheduled on Unit 3 for the entire floor at times. d.) Additional interviews: During an interview on 10/27/21 at 12:26 PM, Resident #92 stated the facility was short staff and sometimes they wait 1 - 2 hours for staff to provide assistance for toileting. During a confidential interview on 10/29/21 at 12:50 PM, a family member of a resident stated the facility does not have enough staff and recalled their loved one was still in bed 20 minutes before supper during a visit because there was only one CNA working on the unit. During an interview on 11/2/21 at 8:23 AM, CNA #8 stated they only have 2 CNAs right now. CNA #8 stated the facility was very short staffed and frequently we are unable to get all the residents out of bed. During an interview on 11/2/21 at 8:30 AM, CNA #5 stated the staffing was terrible and they frequently work short staffed. Usually working with two CNAs on the evening shift and one CNA on the night shift. CNA #5 stated sometimes showers were not provided because there was not enough time, and some residents don't get turned and positioned timely. During an interview on 11/2/21 at 1:10 PM, LPN #3 stated they've had several communications with the DON and ADON about staffing issues and they were told Administration was working on it. Some days they work with two CNAs and two nurses on the floor, and they can't get all the meal trays passed and residents fed. LPN #3 stated staffing has been an issue for a long time and residents aren't getting the care they need. During an interview on 11/2/21 at 1:18 PM, LPN Unit Manager (UM) #2 stated sometimes there are only 2 CNAs on the unit, the expected care was impossible to provide, and the facility was still taking new admissions. During an interview on 11/3/21 at 8:41 AM, CNA #2 stated they have worked alone as the only aide on day shift on the rehab unit a few times. The nurses help when they can, but showers don't get done, oral care does not get completed, and the incontinent residents only got checked once per shift. During a confidential interview on 11/3/21 at 9:01 AM, a family member of a resident stated the facility does not have enough CNAs and Nurses to provide care; causing the call lights not being answered timely and insulin administered late. During an interview on 11/3/21 at 9:11 AM, CNA # 3 stated they worked alone on the rehabilitation unit on 10/3/21 until approximately 11:00 AM and was not able to provide oral care and get all the residents out of bed that should have been. CNA #3 stated they frequently were unable to provide showers to residents because of being short staffed. During an interview on 11/3/21 at 9:30 AM, RN # 3 stated the facility was frequently short staffed. RN #3 stated there were some days the residents were unable to get up at 6:00 AM per their request and some residents were not gotten out of bed at all. During an interview on 11/3/21 at 9:56 AM, CNA # 6 stated the facility was frequently short staffed. Working with 2 CNAs on the evening shift and 1 CNA on the night shift does not allow all residents to receive oral care and ROM (range of motion) to those who require it and timely incontinent care. 415.13(a)(1)(i-iii)

Based on interview and record review during the Standard survey completed on 3/20/19, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified two (Employee #1 and Employee #2) of five employees who were hired in the last four months and were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their employment. The findings are: 1. Record review of the personnel file for Employee #1 (Housekeeper) revealed Employee #1 was hired on 2/18/19 and the New York State Nurse Aide Registry Verification Report was dated 2/28/19. Further review revealed Employee #1 worked in the facility on 2/20/19, 2/21/19, 2/22/19, 2/26/19, and 2/27/19 before the New York State Nurse Aide Registry was checked on 2/28/19. 2. Record review of the personnel file for Employee #2 (Custodian) revealed Employee #2 was hired on 1/7/19 and the New York State Nurse Aide Registry Verification Report was dated 1/10/19. Further review revealed Employee #2 worked in the facility on 1/7/19, 1/8/19, and 1/9/19 before the New York State Nurse Aide Registry was checked on 1/10/19. During an interview on 3/14/19 at 2:15 PM, the Human Resources Coordinator stated she usually checks the New York State Nurse Aide Registry for new employees when they hand in their new hire paperwork, prior to the start of employment. Additionally, on 3/15/19 at 10:30 AM, the Human Resources Coordinator stated new Housekeepers and Custodians work on all resident units in the Skilled Nursing Facility. 415.4(b)(1)(ii)(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 3/20/19, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain grooming, personal and oral hygiene for one (Resident #33) of six residents reviewed for ADL's. Specifically, the lack of proper fecal incontinence care, oral care was not provided and a palm guard (assistive device that positions the fingers away from the palm) was not removed to provide care to the resident's left hand. The findings are: The policy and procedure (P&P) entitled Incontinence Care, With or Without Catheter dated 8/18 documented it was the facilities policy to provide adequate cleanliness for residents to prevent urinary tract infection and to provide personal hygiene. Wash perineal area (area between the anus and genitalia) with soap and water, rinse and dry well from front to back. Turn resident on side and wash the back of buttocks (right and left sides), then wash from the anal area to the back (front to back). The P&P entitled AM Care dated 7/18 documented personal hygiene is provided and maintained by CNA's (certified nurse aides). Wash hands and face first. Then underarms, breasts, and perineal area. Brush teeth, do oral care and denture care. 1. Resident #33 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (DM), dementia, and urinary tract infection (UTI). The Minimum Data Set (MDS, a resident assessment tool) dated 12/24/18 documented the resident had severe cognitive impairments, sometimes understood and sometimes understands. The MDS also documented the resident required total assist of two people for personal hygiene and was always incontinent of bowel and bladder. The Care Plan Activity Report identified as current with a print date of 3/18/19 documented the resident was incontinent of bowel and bladder and interventions included to monitor for signs and symptoms of UTI and to provide peri care with each incontinent episode. The Care Plan Activity Report further documented the resident required staff assistance with oral care and to provide oral hygiene daily to prevent infection and cavities. The CNA Assignment Summary (guide used by staff to provide care) identified as current with a print date of 3/18/19 documented the resident was always incontinent and required total assist for oral care twice daily. In addition, the summary included the use of a left palm guard at all times, which included instructions the palm guard may be removed for AM care and prior to PM care. During an observation of morning care on 3/18/19 at 9:35 AM the resident had a left-hand palm guard in place. Certified Nurse Aide (CNA#3) washed the resident's face, arms and torso. Licensed Practical Nurse (LPN #3) requested CNA #3 to wash the resident's right hand. CNA #3 proceeded to wash the right hand, both legs, and feet. CNA #3 did not remove the palm guard to wash the resident's left hand. During the observation, the resident was incontinent of large amount of loose stool. CNA #3 rolled the resident towards herself and with a wash cloth cleansed the resident from the sacrum (area above the tail bone on right and left buttocks) toward the perineal area (back to front). The wash cloth was visibly soiled with a large amount of loose stool. CNA #3 folded the soiled wash cloth and cleansed the resident again from the sacrum to the perineal area. The washcloth was visibly soiled with stool. Then with a clean washcloth, CNA #3 again washed the resident from the sacrum to the perineal area; this time there was no visible stool. At 10:15 AM CNA #3 and LPN #3 transferred the resident into a wheel chair. CNA #3 brushed the resident's hair and applied her glasses. At 10:20 AM, LPN #3 transported the resident to the dining lounge. There was no oral care provided as planned. During interview on 3/18/19 at 10:27 AM, CNA #3 stated the palm guard should have been removed, and both hands should have been washed during morning care. CNA #3 stated she was nervous, in a hurry, and did not think to remove the palm guard. CNA#3 stated she should have washed the resident's peri area and buttocks from the front to the back. I was really off, stating oral care was not done because the resident can be combative when you try to clean her mouth. During interview on 3/18/19 at 10:30 AM LPN #3 stated splints (palm guards) should be removed during hygiene and the left hand should have been washed. The CNA should have cleansed the residents peri area from front to back, She did the opposite, I think she was nervous. LPN #3 also stated she did not pay attention to oral care not being done prior to transporting the resident out of the room. During interview on 3/18/19 at 10:55 AM, Registered Nurse (RN) Unit Manager #2 stated the splint (palm guard) was to be on at all times except for hygiene, oral care was expected to be done with morning care or after breakfast. RN #2 further stated when providing incontinent care, it's always front to back, clean to dirty. During interview on 3/18/19 at 11:38 AM, the Director of Nursing (DON) stated the expectation was for the care plan to be reviewed prior to care. The staff are always in serviced on washing from clean to dirty, It's common sense. Typically, oral care is done first thing in the morning when care is given. 415.12 (a)(3)

Based on observation, record review, and interview completed during the Standard survey completed 3/20/19, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, one (Resident # 33) of one resident observed for position/ mobility did not receive range of motion - (ROM, normal range of motion of a joint) as planned. The findings are: The policy & procedure entitled Clinical Management dated 1/2017 documented the resident's activity level or joint function is at risk or decreases, range of motion should be started as soon as possible. Joints begin to stiffen within 24 hours of disuse. Keep extremity in proper alignment and repeat exercises at least three times, but more if tolerated. Encourage the resident to participate in the exercise. 1. Resident #33 was admitted into the facility on 2/24/12 and had diagnoses which included diabetes mellitus (DM), dementia, and CVA (cerebral vascular accident, stroke). The Minimum Data Set (MDS, a resident assessment tool) dated 12/24/18 revealed the resident had severe cognitive impairment, sometimes understood/sometimes understands. The Care Plan Activity Report dated 3/28/18 documented activity of daily living (ADL) and mobility deficits related to a CVA and dementia with a plan to provide restorative PT/OT (Physical Therapy/Occupational Therapy) program prn (as needed). The undated CNA (certified nurse aide) Assignments Summary (guide used by staff to provide care) documented PROM (Passive Range of Motion, exercises preformed on the resident by nursing staff) to bilateral upper extremities and bilateral lower extremities two times (2 x) per day. Review of an Interdisciplinary Therapy Screen dated 6/4/18 revealed the resident had a change in strength and contractures. The screen documented the resident required skilled PT and OT for wheel chair positioning, ankle contractures and LUE (left upper extremity) ROM and strengthening. The Physical Therapy Functional Status Update dated 6/28/18 documented the resident was non-ambulatory and a mechanical lift. Comments documented included the patient would benefit from PROM to bilateral lower extremities 2 x per day. The Physical Therapy Discharge Summary dated 6/6/18 - 7/12/18 and signed by the PT (Physical Therapist) 7/18/18 documented recommendations for RNP/ FMP (Rehab Nursing Program/ Facility Maintenance Program) to facilitate patient maintaining current level of performance in order to prevent decline, instruction has been completed with the IDT: ROM (Passive). The Occupational Therapy Discharge Summary dated 1/23/19 - 2/21/19 and signed by the Occupational Therapist on 2/28/19 documented recommendations for RNP/ FMP to facilitate patient maintaining current level to prevent decline, instruction has been completed with the IDT (interdisciplinary team): ROM (active, ROM without assistance from staff) ROM (Passive). During an observation of morning care on at 3/18/19 at 10:27 AM, CNA #3 completed the resident's morning care including incontinent care, bathing, dressing, and grooming. The CNA did not complete range of motion exercises as planned. During an interview on 3/18/19 at 10:50 AM, CNA #3 stated typically ROM exercises are done during morning care when dressing. CNA #3 stated she was in a hurry and did not do ROM exercises. Review of the Resident CNA Documentation Record dated 3/18/19 revealed ROM was not documented as being completed. During an interview on 3/18/19 at 10:55 AM, Registered Nurse (RN) Unit Manager #2 stated ROM exercises are listed on the CNA assignment summary and was expected to be reviewed and completed during morning care. If ROM was not documented on the Resident CNA Documentation Record, then it was not done. During an interview on 3/18/19 at 11:38 AM, the Director of Nursing (DON) stated ROM exercises were expected to be completed with morning care and the completion of ROM was to be recorded on the Resident CNA Documentation Record. During an interview on 3/19/19 at 8:28 AM, the Director of Rehab Services stated CNA's were responsible to ensure ROM exercises are completed and the Unit Managers are responsible to make sure the CNA's are completing ROM daily. 415.12(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 3/20/19, the facility did not ensure provision of a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for three (Unit 1, 3 and 5) of four resident care units. Specifically, the facility did not implement control measures and place a resident with a diagnosis of Shingles (a viral disease characterized by a painful skin rash with blisters in a localized area) on contact precautions, the lack of maintaining proper use of gloves and hand hygiene procedures, and the lack of maintaining infection control practices for the storage of urinary catheter drainage and collection systems. In addition, the lack of maintaining appropriate measures for the handling and transport of soiled linens. Resident's #85 and 50 were involved. The findings are: 1. Resident #50 was admitted into the facility on [DATE] with diagnoses of zoster (a viral disease characterized by a painful skin rash with blisters in a localized area) without complications, type II diabetes (DM), and hyperlipidemia (elevated fat levels in the blood). The Minimum Data Set (MDS, a resident assessment tool) dated 1/6/19 documented the resident was cognitively intact and was understood and usually understands. Review of the policy entitled Infection Control- Transmission Based Precautions dated 5/2017 revealed all known or suspected infections are reported to the Infection Prevention Coordinator. If a resident is identified as being infected with an infectious organism that requires transmission-based precautions, the nurse implements the precautions as soon as possible. The infected resident will be placed in a single room whenever possible. Herpes Zoster (Shingles): if a resident is suspected of having shingles, the nurse will notify the physician for a diagnosis and orders for treatment or consultation; notify the Infection Prevention Coordinator; inform the resident and/or family; inform staff; initiate contact precautions, including notice on the door. During intermittent observation from 3/13/19 through 3/18/19 revealed the following: - On 3/13/19 at 1:29 PM there was no sign or PPE (personal protection equipment) outside the door or inside of the resident's room. At this time the resident stated they have shingles again and sometimes staff wear gowns and gloves. Resident #50 stated, They told me I was in quarantine. - 3/14/18 at 9:30 AM, there was no sign or PPE outside of the resident's room. - 3/15/18 at 10:45 AM, there was no sign or PPE outside of resident's room. - 3/17/19 at 12:12 PM, the resident was in her room. There was no PPE available and there was no precautionary sign. - 3/18/19 at 8:18 AM, the resident was in the room eating breakfast. There were no precaution signs up or PPE supplies available. The roommate was also observed in the room. - 3/18/19 at 10:29 AM, the board in nurse's office had nothing regarding Resident #50 having shingles and that no pregnant woman was to go into the room. Date on board had Monday 3/18/19 written on it. Review of the Mc Geer-Infection assessment dated [DATE] revealed infection type: shingles with onset dated of symptoms 2/26/19. Signs and symptoms include purulent drainage, pustules or vesicles at wound, skin or soft tissue site, redness and pain or tenderness. Antibiotic therapy: Valtrex (antiviral medication) 2/26/19- 3/3/19. Isolation needed: yes, contact. Review of Nursing Progress Note dated 2/26/19 revealed Nurse Practitioner (NP) ordered Valtrex 1000 mg (milligrams) every eight hours for seven days related to shingles, rash under breast. Precautions initiated. Review of an Acute Visit Progress Note completed by the NP dated 3/12/19 revealed the resident was found to have blistering under her left breast and she was placed on valacyclovir (Valtrex, an antiviral medication) for seven days. Staff has noted small blisters under the left breast and groin. Lengthy discussion with her, staff and physician regarding the same. We have discussed continued precautions and valacyclovir prophylactically for now. She will be on suppression and we will follow her closely. No recent change or problem. Assessment #1: Hx (history) Zoster without complications- continue precautions, give valacyclovir and monitor closely. She has had recurring shingles. Follow-up at a later date. Review of the CNA (certified nurse aide) Assignment Summary (guide used by staff to provide care) dated 3/15/19 and the Care Plan Activity Report dated 3/18/19 revealed under skin integrity there was no documentation regarding shingles and precautions. During an interview on 3/18/19 at 10:22 AM, the resident stated, the staff are to be using precautions on me because of my shingles, but they don't. Some may wear gloves, but not everyone does. There is only one staff member who uses a gown. During an interview on 3/18/19 at 10:25 AM, Licensed Practical Nurse (LPN) #2 stated, Resident #50 just has to stay in her room. We are to be using standard precautions where everyone has to wear gloves. We let staff know in the morning if they are pregnant that should not be taking care of Resident #50. There is a board in the back that everyone looks at and it would be written on that if a resident has shingles and is on precautions. During an interview on 3/18/19 at 10:33 AM LPN #1, Unit Manager stated, The NP looked at her and stated it almost looks like shingles, but it is not and that it doesn't present like shingles. He placed her on a suppressive dose of valacyclovir prophylactically. At that time, I took the resident off contact precautions because of what the NP told me. I did not read his notes, but if I did the contact precautions would have remained. If a resident has a diagnosis of shingles, they should be placed on contact precautions. Staff should be wearing gowns and gloves, there should be cart outside the room with supplies, and a note should be outside the room near the door. Anyone who is pregnant, or nursing would not be taking care of that resident and they would be re assigned. Right now, we have Resident #50 only on standard precautions, not contact precautions. During a telephone interview on 3/18/19 at 10:46 AM, the NP stated, Resident #50 has had a history of recurrent shingles and when I looked at her she had some areas under her breast and groin area, a couple of blisters. I didn't think they were shingles but because of her history, I continued her on the valacyclovir prophylactically. I believe that the area was an irritation from poor hygiene but was not completely sure and I wanted her to remain on contact precautions until those area scabbed over and then they could go to standard precautions. She should have been remained on contact precautions until then. During an interview on 3/18/19 at 12:21 PM, the Quality Assurance/ Infection Control Registered Nurse (RN) #1 stated, If a resident is on contact precautions staff should be wearing gloves and gowns, there should be a sign on the door and a cart outside the room with PPE in it. If a resident is diagnosed with shingles, they should absolutely be placed on contact precautions. If resident who has shingles has a roommate, as long as there is a curtain in between them it should be alright that they are in the same room. We were doing contact precaution with Resident #50. I was not aware that it was discontinued. If it was, I should have been notified that the resident was being taken off of contact precautions as I would have gone to look at the areas to see if they were scabbed over and it was alright to take them off. 2. Resident #85 was admitted into the facility on 1/3/19 with diagnoses including dementia, hypertension (HTN, high blood pressure), and diabetes (DM). The MDS dated [DATE] documented the resident had severely impaired cognition, required total assistance for toileting, and was always incontinent. Review of the policy entitled Standard Precautions dated 11/18 documented it is the policy of the facility to prevent the spread of infectious disease. It is the responsibility of individual health care workers to ensure they follow the Infection Control guidelines to minimize the spread of infection. Standard precautions are to be utilized in every resident care situation and are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. Gloves should be worn when touching blood, body fluids, secretions, excretions, and contaminated items. Change gloves between tasks and procedures on the same resident after contact with material that may contain microorganisms. Gloves should be removed before touching non-contaminated items and surfaces and should not be worn away from the bedside. During an observation of morning care, on 3/15/19 at 11:02 AM, the resident was incontinent of a small amount of soft stool. CNA #1 used a basin of water and a soapy washcloth to clean the resident's buttocks and rectal area. Without changing the soiled gloves and washing her hands, CNA #1 applied a new, clean incontinent pad and clean brief under the resident and fastened it closed. While wearing the same gloves CNA #1 then placed the transfer sling under the resident. While wearing the soiled gloves, CNA #1 wrapped the dirty linens in a bundle with her left hand and adjusted the bed controls to place the bed in low position and elevate the head of the bed with her right hand. At 11:23 AM, still wearing the same soiled gloves, CNA #1 opened the resident's door with her right hand then removed the glove from her right hand to close the door behind her and transport the soiled linens to the soiled utility room. The CNA did not wash her hands before exiting the resident's room. During an interview on 3/15/19 at 11:36 AM, CNA #1 stated she should have washed her hands. She stated I was really nervous, I should have taken my gloves off and washed my hands after I did her incontinent care, after a bowel movement, but I didn't. I know better, I was nervous. During an interview on 3/19/19 at 10:01 AM, the LPN #1 Unit Manager stated she would expect the CNA to have changed her gloves at minimum, but she should have washed her hands especially after any incontinent care. During an interview on 3/19/19 at 11:13 AM, RN #1 stated she would have expected the CNA to take off the dirty gloves and wash her hands before touching clean items in the room. During an interview on 3/19/19 at 1:59 PM, the Director of Nursing (DON) stated she would expect the CNA to change her gloves and wash her hands after providing incontinent care prior to dressing the resident or continuing on with care. We have reeducating to do. 3. During an observation of a shared bathroom on the Rehab Unit (Unit 1) on 3/13/19 at 9:51 AM, two urine graduates (device used to measure urine) were located on the back of the toilet tank upside down on a brown paper towel. In addition, a urinary leg drainage bag was located directly on the back of the toilet. During an observation of a shared bathroom on the Rehab Unit on 3/15/19 at 2:59 PM, one graduate and one urinary leg drainage bag were located on the back of the toilet. During an observation of a shared bathroom on the rehab unit on 3/18/19 at 8:26 AM, one graduate was located on a wet paper towel on the back of the toilet. In addition, one urinary leg drainage bag was located directly on the back of the toilet. During an interview on 3/18/19 at 12:11 PM, RN #1 Quality Assurance/ Infection Control Registered Nurse stated, the over the bed table has bottom storage where the bedpan, graduate, or leg bag should be stored. They (graduate, leg bag) shouldn't even be stored in the bathroom because of infection control. Pathogens (bacteria) can get into the drainage bag. Also, it's a shared bathroom. During an interview on 3/18/19 at 1:19 PM, the Director of Nursing (DON) stated the graduate and urinary leg drainage bag should be stored in a basin, in the night stand. It's an infection control issue if they (graduate and drainage bag) are stored in a shared bathroom. 4. During an observation on Unit 3 on 3/18/19 at 10:25 AM, CNA #3 gathered soiled a fitted and flat sheet with soiled incontinent pads that were visibly soiled with yellow urine and loose stool from the bed. With a gloved hand transported the soiled linens out of the room [ROOM NUMBER] ft to the soiled utility room. The soiled linens were touching her clothing. During interview on 3/18/19 at 10:27 AM, CNA #3 stated normally there was a soiled bin outside the room, I must have left the bin on the other side of the hallway. CNA #3 stated she was unaware she had touched the soiled linens to her clothing. During interview on 3/19/19 at 9:21 AM, Infection Control Nurse Assistant LPN #4 stated it was not acceptable to hold soiled linens against clothing, transferring germs and contaminating the next resident. During interview on 3/19/19 at 9:30 AM, the DON stated she would expect soiled bins to be kept outside of the resident room and not to transport soiled linens down the hall to reduce the risk of contaminating other residents. 415.19(a)(1) 415.19(b)(1)(4) 415.19(c)