Based on observation, interviews, and record review conducted during an Abbreviated Survey (2582483), the facility did not ensure a resident received adequate supervision and assistance consistent with the resident's needs to prevent accidents. This was evident for one (1), (Resident #2) out of five (5) residents reviewed and sampled. Specifically, during a review of the facility's surveillance video footage dated from 07/10/2025 at 07:58 PM to 07/12/2025 at 03:29 PM, showed on 07/10/2025 from 08:36 PM to 08:42 PM for six minutes, Resident #2 entered and exited Resident #1's room unsupervised. Three other residents reside in the room with Resident #2 (Resident #3, Resident #4, and Resident #5). No staff were seen on the surveillance redirecting Resident #2 from going into other Residents' rooms.The findings are: The facility's Policy and Procedure entitled Behavior Management Strategies, dated 08/05/2020, documented that it is the policy of the facility to provide the best quality of life and quality of care to residents with behavioral health needs. The purpose of the policy is to manage residents' behavior, direct and motivate residents to change their actions or interactions in certain settings, and guide staff on effective interventions to de-escalate behaviors. Behavioral symptoms which residents may exhibit include but are not limited to wandering into others' rooms/spaces.Resident #2 was admitted to the facility with diagnoses including vascular dementia (decline in mental abilities, such as memory and thinking), alcohol dependence, and adult failure to thrive (a syndrome characterized by weight loss, decreased appetite, reduced physical activity, and decline in overall health in older adults). The Minimum Data Set (a resident assessment tool) dated 07/10/2025, documented that Resident #2 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information), documenting that Resident #2's cognition was severely impaired.A Care Plan for Resident #2 titled elopement risk /wanderer was initiated on 11/4/2021, with a target date 10/14/2025, documented interventions that included hourly check and wander alert. A Behavior Care Plan initiated on 08/04/2022, documented Resident #2 exhibited physical and verbal aggression with interventions to provide a calm structural environment, and to offer diversional activities. A review of the Documentation Survey Report (Certified Nursing Assistant Accountability) dated 07/01/2025 to 07/31/2025 documented Resident #2 was monitored hourly every shift for unsafe wandering/elopement. A review of video footage recorded on 07/10/2025 at 7:58 PM showed that Resident #1(female) was brought from the hospital via stretcher by two attendants. Resident #2 (male) wandered into Resident #1's room at 8:36 PM and exited at 8:42 PM. Resident #2 was in the room for six minutes unsupervised. No staff member redirected Resident #2. Resident #1's three roommates (all cognitively impaired) were in the room at the time. Resident #2 was observed entering approximately one minute on multiple occasions Resident #1's room on 07/11/2025 at 10:45 AM, at 10:51 AM, at 11:07 AM, at 11:20 AM, at 02:11 PM, at 02:58 PM, at 03:09 PM, at 03:14 PM, at 03:39 PM, at 03:44 PM, at 03:50 PM, at 04:12 PM, at 04:39 PM, at 04:43 PM, at 04:50 PM, at 05:01 PM, at 05:06 PM, at 05:10 PM, at 05:15 PM, at 05:25 PM, at 05:29 PM, at 05:37 PM, at 05:43 PM, at 05:48 PM, at 07:48 PM, at 07:55 PM. On 07/12/2025: at 07:21 AM, at 11:51 AM, at 12:16 PM, 12:39 PM, and 12:45 PM. Resident #2 (male) was also observed going in and out of other residents' rooms. During an interview on 08/08/2025 at 2:45 PM, Certified Nursing Assistant #3, who was assigned to Resident #2 on 07/10/2025 and 07/11/2025, 3-11 shift, stated that Resident #2 has wandering behavior and enters other residents' rooms. Certified Nursing Assistant #3 stated that they know Resident #2 goes to their room to look in the window but does not bother anyone. Certified Nursing Assistant #3 stated that Resident #2 starts walking around as soon as they wake up, and they are monitoring them hourly. Certified Nursing Assistant #3 stated that they are responsible for monitoring Resident #2 and preventing them from entering other rooms. Certified Nursing Assistant #3 stated they redirected Resident #2 when they saw them entering another room. During an interview on 08/08/2025 at 04:45 PM, Resident #1's roommate (Resident #3), who had moderately impaired cognition, stated that a man was coming to their room, and looked out the window. Resident #3 stated that the man did not bother them and never touched them. Resident #3 stated that they shouted at the man, and they left the room. Resident #3 stated that the man is good, but they do not want the man to come into their room because they do not know what the man will do. During an interview on 08/08/2025 at 11:15 AM, Registered Nurse #2 stated Resident #2 has a Dementia diagnosis, ambulates independently, and likes to go to other residents' rooms to look in the window. Registered Nurse #2 stated that Resident #2 was on hourly monitoring, and if staff saw Resident #2 go to other rooms, they would redirect them. Registered Nurse #2 stated that all Certified Nursing Assistants on the unit are responsible for monitoring Resident #2's behavior and preventing them from entering other residents' rooms. During an interview on 08/11/2025 at 2:10 PM, Registered Nurse Supervisor #1 stated they are usually assigned Resident #2's unit. Registered Nurse Supervisor #1 stated Resident #2 does wander on the unit, but they have not been involved with any inappropriate behavior on the unit. Registered Nurse Supervisor #1 stated that Certified Nursing Assistants perform hourly rounding during awake hours and every two hours during sleeping hours. Registered Nurse Supervisor #1 stated that since Resident #2 is roaming on the unit, it's easy for the Certified Nursing Assistants to locate Resident #2. During an interview on 08/11/2025 at 12:27 PM, the current Director of Nursing stated that the Resident #2's care plan addressed the behavior of wandering. The Director of Nursing stated that staff were in-serviced on proper monitoring and rounding to ensure residents who wander are safe and redirected appropriately. During the subsequent interview on 08/21/2025 at 1:45 PM, the Director of Nursing stated that all staff on the unit, including Certified Nursing Assistants, recreation staff, and nurses responsible for monitoring residents who wander and preventing them from entering other residents' rooms. The Director of Nursing stated that nurses on the unit and supervisors are responsible for ensuring that staff properly monitor residents through rounding and spot checking. During an interview on 08/08/2025 at 12:30 PM, the Administrator stated that during camera review, they saw Resident #2 entering Resident #1's room, but the resident is harmless and only goes to the room and looks out the window. The Administrator stated that Resident #2, in the past, resided in other units and was not suitable there due to aggressive behavior. 10 NYCRR 415.12(h)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the Recertification and Abbreviated Survey (NY00354048) from 10/21/2024 to 10/28/2024, the facility did not ensure that it promoted and facilitated resident self-determination through the support of residents choice for 1 (Resident #190) of 2 residents reviewed for Choices out of 38 sampled residents. Specifically, the preferred number of showers per week were not obtained and not provided in accordance with Resident #190's wishes. The findings are: The facility's policy and procedure titled Showers and Bed Bath reviewed 08/2020 documented, It is the policy of the facility that each resident is to have a minimum of two baths/showers each week and all residents shall receive a bath between scheduled showers or tub/whirlpool bath unless otherwise requested by resident. Resident #190 was admitted with diagnoses of Hypertension, Depression and Cervical Disc Disorder with Myelopathy (is a serious condition that occurs when the spinal cord in the neck is compressed, often due to a herniated disc). The Minimum Data Set, dated [DATE] documented Resident #190 was cognitively intact. Resident #190 required dependent assistance with shower/bathing self. MDS documented that Resident #190 was interviewed for daily preferences and stated that it was very important for them to choose between a tub bath, shower, bed bath, or sponge bath. The New York State Department of Health Complaint Intake (NY00354048) received 09/11/2024 documented that Resident #190's shower was not given as scheduled. On 10/21/2024 at 10:27 AM, an interview conducted with Resident #190 who stated they get showers every couple of days, before, they gave them maybe 3 or 4 times and then no more. Resident #190 stated that staff only washed them in bed and does not remember their shower days. On 10/22/2024 at 10:50 AM, Complainant at Resident #1's bedside (complainant was a Spanish speaking, Resident #190 translated the concern) stated that Resident #190 was not given showers as scheduled. The Comprehensive Care Plan Titled Activities of Daily Living Self- Care Performance Deficit dated 02/10/2024 documented that Resident #190 was dependent with shower/bathing self. The Comprehensive Care Plan Title Resident Preferences dated 02/17/2024 did not document Resident #190's specific preferences for showers/bathing. The Certified Nursing Assistant Documentation Report dated 08/01/2024 to 08/30/2024 documented Resident #190 was showered 4 (08/07/2024, 08/14/2024, 08/21/2024 and 08/24/2024) out of 9 days in August 2024. There was 1 refusal documented and dated 08/03/24. There were 4 occasions that bed bath was provided. The Certified Nursing Assistant Documentation Report dated 09/01/2024 to 09/30/2024 documented Resident #190 was showered 1 (09/28/2024) out of 8 days in September 2024. There was 1 refusal documented dated 09/14/24. There were 6 occasions that a bed bath was provided. A review of behavior and nursing notes dated 08/03/2024 to 09/28/232024 revealed there was no evidence of documentation that Resident #190 refuses showers or prefers bed bath. Documented Resident #190 was calm and cooperative. On 10/23/2024 at 3:05 PM Certified Nursing Assistant #2 was interviewed and stated, they were the regular Certified Nursing Assistant assigned in the evening shift for Resident #190. Certified Nursing Assistant #2 stated that Resident #190 is scheduled 2 shower days in a week, every Wednesday and Saturday. Certified Nursing Assistant #2 stated that sometimes they give showers even if not scheduled because Resident #190 messed with stool and mostly gives bed bath because Resident #190 is stiff. Certified Nursing Assistant #2 stated that Resident #190 does not refuse showers but occasionally they (Resident #190) refused a showers then they give a bed bath. On 10/23/2024 at 3:40 PM Registered Nurse #4 was interviewed and stated, that with regards to showers, Resident #190 is okay and was showered every Wednesday and Saturday. Registered Nurse #4 stated that shower schedule is posted at the nursing station, and they inform the staff which residents are scheduled for showers. Registered Nurse #4 stated that they do not recall Resident #190 refusing a shower because staff did not report to them. Registered Nurse #4 stated they are responsible to monitor and to ensure that staff provided the care as instructed. On 10/25/2024 at 9:25 AM Registered Nurse Supervisor #6 was interviewed and stated, they checked the Certified Nursing Assistant documentation, and it showed that a shower was not given as scheduled to Resident #190. Registered Nurse Supervisor #6 stated that staff should notify the nurse when a resident refuses shower. Resident #190 has no behavior issues of refusing showers. Registered Nurse Supervisor #6 stated that they did not observe any documentation in the medical record that Resident #190 refused showers. Registered Nurse Supervisor #6 stated they plan to give an in-service to staff regarding providing showers, documentation and notifying the nurse regarding residents refusal of care. On 10/25/2024 at 2:16 PM, the Director of Nursing was interviewed and stated, they did not personally hear Resident #190 refuses showers and mostly Resident #190 was given a bed bath. Director of Nursing stated that staff provided bathing but not just in the shower room (while looking at the Certified Nursing Documentation Survey Report dated 9/2024). Director of Nursing stated they were not aware of this reason, normally if resident refused shower the staff informs the nurse. Director of Nursing stated that the nurse in the unit is responsible for monitoring staff to insure care is provided and documented. 10 NYCRR 415.5(b) (1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for 1 (Resident #209) out of 5 residents reviewed for Accidents out of 37 total sampled residents. Specifically, the facility did not report an incident when Resident #209 was found on the floor with laceration on the hand and a head contusion, to the New York State Department of Health. The findings are: The facility's policy and procedure titled, Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/Exploitation and Mistreatment reviewed 10/2022 documented the facility shall ensure that alleged violations involving mistreatment, neglect, or abuse including significant injuries of unknown source are reported immediately to the Administrator of the facility or designee. When required by regulation, the facility shall ensure timely notification to the Department of Health. Resident #209 admitted to the facility with diagnoses of Hypertension, Hyperlipidemia and Non-Alzheimer's Dementia. The Minimum Data Set, dated [DATE] documented cognition is severely impaired; had short-term memory problem. Resident #209 is dependent on staff assistance to roll left and right, sit to lying and lying to sitting on side of bed, and chair to bed transfer. The Comprehensive Care Plan for Actual Fall revised 9/18/2024 documented Resident #209 had an unwitnessed fall on 9/15/2024 with injuries. The Nursing Note dated 9/15/2024 documented, Resident #209 was found on side of bed on floor, unable to determine cause of fall due to language barrier. Resident was noted with contusion to right posterior head and skin tear to the right hand. Physician was notified and ordered the resident transfered to the hospital. The Physician Order dated 9/15/2024 documented Resident #209 to transfer to hospital for status post fall with injury. The Occurrence Investigation Form completed 9/15/2024 documented on 9/15/2024 at 10 AM, Resident #209 was found on floor by the bed; noted contusion to right posterior head and skin tear to the right hand. It documented that it was an unwitnessed occurrence. Resident #209 did not provide any explanation/statement about the occurrence. The review of Accident Report and Investigation Forms revealed there is no documented evidence that Resident #209 provided a statement about the incident that occurred on 9/15/2024. The Hospital Discharge summary dated [DATE] documented Resident #209 was admitted following a fall with head trauma at the nursing home. Resident noted with hematoma on right side of scalp and skin tear to right hand. Resident was treated with staples to the scalp and skin tear with Steris strips. The facility's Investigation Summary documented that on 9/15/2024 at 10 AM, Certified Nurse Aid responded to a noise and observed Resident #209 on the floor beside the bed. Resident #209 was unable to provide any information regarding the fall secondary to their cognition. Upon assessment, Resident #209 was noted with a contusion to their scalp and skin tear to the right hand. Resident was transferred to the hospital and was treated with staples applied to the scalp, adhesive strips to the hand. The investigation concluded that resident rolled out of bed sustaining injuries to head and hand due to poor awareness of the bed boundaries. There was no abuse, neglect or mistreatment that occurred to Resident #209. It further documented that as a result of this investigation, this incident will not be reported to Department of Health. The investigation summary with conclusion was signed by Director of Nursing Services and Administrator on 9/18/2024. There was no documented evidence the facility reported Resident #209's unwitnessed fall incident, resulted in injuries, to the New York State Department of Health. On 10/24/2024 at 2:56 PM, Director of Nursing Service stated they will report alleged violations involving mistreatment, neglect, or abuse to New York State Department of Health. Director of Nursing Services stated this incident was not reported to New York State Department of Health because staff responded to a loud noise and saw Resident #209 on the floor in the room. This was an unwitnessed fall resulting in injuries. Director of Nursing Service stated Resident #209 went to the hospital for evaluation and returned to the facility with staples on the head and skin tear treated from the hospital. The investigation concluded that Resident #209 rolled out of the bed resulting in those injuries and that there was no suspicion of resident-to-resident altercation, or staff abuse. On 10/24/2024 at 4:19 PM, Administrator could not recall if they were on duty but stated they were notified about this incident immediately after it occurred on 9/15/2024. Administrator stated the incident was not reported to the New York State Department of Health because resident had a fall incident and ruled out that abuse occurred. 10 NYCRR 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews conducted during the Recertification survey from 10/21/2024 through 10/28/2024, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status for 2 ( Resident #170 and #79) residents out of total 38 sampled residents. Specifically, (1) Resident #170 who was not receiving anticoagulant medication was coded as receiving anticoagulant medication. (2) Resident #79 was coded as receiving hospice services after hospice services were ordered disconinued . The findings include are: The facility policy titled MDS Assessment Version 3.0 effective 10/2023 documented the facility will conduct initially and periodically a comprehensive, accurate, standardize reproducible assessment of each resident's functional capacity. The assessment must reflect the status of the resident including resident strengths and needs that must be addressed in an individualized care plan. The Minimum Data Set Assessment Version 3.0 Correction / Modification Policy dated effective 10/2023 documented any errors discovered in a completed Minimum Data Set must be corrected through the appropriate modification process, ensuring the resident clinical status is accurately reflected in the record. Modification request is used to correct an IQIES record containing incorrect Minimum Data Set item values due to transcription errors, data entry errors, software problems errors , item coding errors and /o other error requiring modification. A Minimum Data Set assessment can be modified or corrected if there are errors in the date before submission After submission if an error is found after the assessment is accepted by the State Minimum Data Set data base the facility must complete a Correctio request form to modify the assessment. Complete a significant correctio of a prior full assessment if needed within 14 days of identifying the error. A major cl error occurs when the resident's clinical status is not accurately represented in the Minimum Data Set. The Significant Correction of a Prior Full Assessment is a comprehensive assessment that requires completing the Full Minimum Data Set, Comprehensive Annual Assessment and Comprehensive Annua Assessment Summary. 1) Resident #170 admitted with diagnoses of Hypertension, Peripheral Vascular Disease, Cerebrovascular Accident and Hemiplegia or Hemiparesis. The Order Summary Report as of 08/2024 documented Resident #170 was ordered Clopidogrel Bisulfate Tablet 75 milligram - 1 tablet by mouth one time a day for blood clot prevention. The Medication Review Report dated 08/01/2024 to 08/31/2024, documented that Resident #170 received Clopidogrel Bisulfate Tablet 75 milligram tablets. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented in Section N: Medications under section N0415: coded that Resident #170 was taking anticoagulant medication. The Modification of Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented in Section N: Medications under section N0415: modified that Resident #170 was taking antiplatelet medication. The Modification of Minimum Data Set 3.0 (MDS) assessment under Section X - Correction Request was modified dated 10/22/2024. On 10/24/2024 at 11:00 AM, an interview conducted with the Minimum Data Set Coordinator and stated that Resident #170 was on antiplatelet medication and not an anticoagulant medication. The Minimum Data Set Coordinator stated the Minimum Data Set Assessor is responsible for the accuracy of the assessment. The Minimum Data Set Coordinator stated they are responsible for signing the completeness of the assessment. The Minimum Data Set Coordinator stated that they review the Minimum Data Set, dated [DATE] on 10/22/2024 and noticed that the medication, Clopidogrel Bisulfate was incorrectly coded, and they modified the assessment on 10/22/2024. The Minimum Data Set Coordinator stated they counselled the Minimum Data Set Assessor and provided with the lists of medications that required to be coded in Minimum Data Set. [NAME], [NAME] 2) Resident #79 diagnoses which include Dementia, Major Depression Disorder Recurrent Unspecified and Insomnia Unspecified. The Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the Resident #79 had severely impaired cognition and documented in Section O: (Special Treatments and Programs) that Resident #79 was on hospice services. The Significant Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented Resident #79 had severely impaired cognition and documented in Section O:(Special Treatments and Programs) that Resident #79 was on hospice services. This was done by Minimum Data Set Assessor #2. The Physician Order's Summary for Resident #79 was reviewed and documented orders for Hospice were from 11/29/2023 -05/13/2024. The Dietary Progress note dated 12/29/2023 documented resident #79 remains in hospice care. The Social Work Progress note dated 11/29/2023 documented that they were informed by the Hospice care representative that Resident #79 was admitted into Hospice care with a primary diagnosis of Vascular Dementia secondary to multiple Cerebrovascular accident and the interdisciplinary team was informed and resident care plan updated. The Social Work Progress note dated 2/27/2024 documented the Quarterly Care Plan meeting documented the resident representative and the Hospice social work in attendance, all questions addressed, and no concerns noted. The Medical Progress notes dated 3/6/2024, 4/4/2024 documented that Resident #179 was on hospice services. The Comprehensive Care Plan for Hospice effective 11/29/2023 with interventions assess and monitor resident for signs and symptoms or discomfort, encourage expressions of feelings related to diagnosis and disease progression, engage resident/family in discussion related to goals of care. obtain MD order for Hospice services. On 10/23/2024 at 11:20AM the Minimum Data Set Coordinator was interviewed and stated that they modified the Minimum Data Set for 08/07/2024 and it was modified due to a coding error. They completed Section X (Correction Request) on 10/23/2024. On 10/24/2024 at 11:49 AM, the Minimum Data Set Coordinator was interviewed and stated the last Quarterly Minimum Data Set on 10/07/2024. Resident #79 was not on hospice care at the time of the Minimum Data Set review. While reviewing the chart, they noticed that hospice was checked, and they submitted a correction for the Minimum Data Set. They completed the original Minimum Data Set, and it was incorrectly coded. The assessment should reflect the resident status as of the reference date of the Minimum Data Set. On a regular basis they look at audits of the Minimum Data Sets and the last audit was done for dialysis. They try to take last Minimum Data Sets coded and it is used for internal learning and education and talk to staff to improve in relation to their accuracy. We do it once a quarter, do reviews and look at special triggers (hospice, dialysis and do look backs to make sure it matches. On 10/24/2024 at 04:58 PM, the Minimum Data Set Assessor #1 stated when they complete Section O: Special Treatments and Programs. They go thru progress notes from the previous day of the Assessment Reference Date, consults for the reference and any pertinent information or labs or orders for the residents. They look at the medical provider notes in relation to hospice and nurse's notes if a resident is still under hospice care. We always get in-services or counseling if there are any updates for the section. The Minimum Data Set should be accurately coded to reflect the resident's chart and assessment and it should be accurate. Minimum Data Set Assessments are done in person or offsite. The assessment needs to be accurate so the resident will get the proper care that they need. They stated that they saw a note from the doctor and that's why they may have gotten confused. On 10/24/2024 at 05:04 PM, the Minimum Data Set Assessor #2 stated that they do a 14 day look back period based on the resident's assessment and Section O: Special Treatments and Programs Section O0110: Hospice Care. If the resident is on Hospice, then you have to click hospice on the assessment. You have to capture 14 days from the Assessment Reference Date. They look at the Hospice notes, documents such as physician orders and if the resident is still on hospice the box is checked. They also look at the medical provider notes in the last 30 to 60 days and nurse's notes in the last 14 days. We have to make sure it is accurate, since we are sending it to the Centers for Medicaid and Medicare Services, so they know the residents are on special care. They are provided in-services if there are new updates to the Minimum Data Set and perform webinar trainings also. On 10/24/2024 at 12:21 PM, Registered Nurse # 8 was interviewed and stated Resident #79 was on Hospice when they started working there but they are no longer on Hospice services. On 10/24/2024 at 11:45 AM, the current Attending Provider #1 stated that resident #79 was not on Hospice Services and they took over the resident's care in June 2024 and they used to be assigned to Attending Physician # 2. On 10/25/2024 at 11:22 AM Attending Physician #2 was interviewed and stated, They recall Resident #79 who had Advanced Dementia, and they were also on hospice services. The resident was losing weight and they were admitted to hospice services after a discussion with their family. They stated they communicated with the Hospice nurse in relation to recommendations and plan of care updates for Resident #79. They further stated that the Social Worker will confirm the resident was on hospice and there was an order in the resident's chart and the resident may have a Hospice assistant assigned. If a resident is on hospice they document this diagnosis in the notes. They stated, the unit they worked on changed between January to June 2024. The electronic medical record documents if a resident is on Hospice along with orders for advance directives and Hospice care. On 10/25/2024 at 11:36 PM, The Social Worker #2 was interviewed ant stated that Resident #79 was on Hospice for a period of time. They were referred to hospice services on 11/2/2023 and accepted on 11/29/2023. The reason for the referral was Vascular Dementia due to multiple Cerebrovascular accidents and it was recommended by the interdisciplinary treatment team after discussion and the resident's representative who was in agreement. The attending physician sent the referral to Hospice provider on 11/27/2023 and the order was discontinued on 5/8/2024. They have communicated with the hospice social worker. 10 NYCRR 415.11 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not provide, based on the comprehensive assessment, interests, and the preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not appropriately assess interests and activity preferences for non-English speaking resident and provide an ongoing program of activities designed to meet their interests for Resident #209. This was evident for 1 (Resident #209) resident reviewed for Activities out of 37 total sampled residents. The findings are: The facility's policy and procedure entitled Activity Recreation Program and Assessment revised 11/2016 documented that facility shall provide for an ongoing program of activities designed to meet the interest and the physical, mental, psychosocial well-being of each resident. Recreation Therapist shall complete a comprehensive assessment and develop a plan of care that reflect the resident's level of leisure and lifestyle satisfaction, response to recreational activity goals which is reviewed on a regular basis. Resident #209 admitted to the facility on [DATE] with diagnoses of Hypertension, Hyperlipidemia and Non-Alzheimer's Dementia. The Minimum Data Set, dated [DATE] documented Resident #209's preferred language is Mandarin and Resident/Designated Representative were not interviewed for Daily and Activity Preferences because resident is rarely/never understood, and family/significant other was not available. The Minimum Data Set, dated [DATE] documented Resident #209 has severely impaired cognition and requires substantial/maximal assistance to sit to lying and lying to sitting on side of bed, and chair to bed transfer. On 10/22/2024 at 11:42 AM, Resident #209 was awake, lying in bed with television on, not in their preferred language. The remote control was on the windowsill and not easily accessible for the resident. On 10/23/2024 at 10:18 AM, Resident #209 was awake, lying in bed with television on the same channel, not in their preferred language. There was no list of a channel guide for the resident in the room. On 10/24/2024 at 12:54 PM, Resident #209's family was interviewed who stated they are the designated representative to discuss about Resident #209. Designated representative stated that they have been contacted related to resident's treatment/care needs but never been contacted about resident's daily and activity preferences. Designated representative further stated that they were not aware that there were activity programs for residents in the facility. The Comprehensive Care Plan for Therapeutic Recreation initiated/last revised 6/28/2024 documented to establish/record the resident's prior level of activity involvement and interests by talking with the resident caregivers, and family on admission and as necessary. Invite/encourage the resident's family members to attend activities with resident to support participation. The Therapeutic Recreation Initial assessment dated [DATE] documented Resident #209 is long term, speaks Mandarin. The daily and activity preferences for Resident #209 were checked as no response because resident not able to communicate and family interview could not be completed. It indicated that resident's past/current activities obtained from the chart were inside the home, watching TV/movies, family centered activities, and solitary activities. The Therapeutic Recreation Assessments dated 9/23/2024 documented Resident #209/family member were unable to complete the interview. The daily and activity preferences were checked as no response. It documented staff interview indicated keeping up with the news is important for Resident #209's activity preference. The Therapeutic Recreation Activity Log from 10/1/2024 to 10/23/2024 revealed Resident #209 participated total of 1 activity program: 1 to 1 visit on 10/8/2024. The review of Therapeutic Recreation Notes from 10/1/2024 to 10/23/2024 revealed there was no documented evidence Resident #209 was offered any activities or that they refused the activity program. There was no documented evidence that Resident #209 and/or family member participated in the initial/quarterly assessment process and that ongoing assessment/program of activities that meet the resident's interests and functional capacity were provided for the resident. On 10/24/2024 at 12:04 PM, Certified Nurse Aid #1 stated Resident #209 is dependent for all ADL care and will require Hoyer lift to get out of bed. They further stated Resident #209 is mostly sitting in the bed and watches television. On 10/24/2024 at 11:39 AM, Licensed Practice Nurse #1 stated Resident #209 is assisted out of bed with Hoyer lift and sits in the dining room at times. They further stated they have not seen Resident #209 participating in any activity program with activity staff. On 10/23/2024 at 10:47 AM, Activities Aid stated resident #209 was transferred to this unit about a month ago. Resident #209 can express yes/no or simple terms in English but needs to be prompted for response. Resident #209 was assessed for their activity preferences using hand gestures and resident responded yes if they liked the activity. Activities Aid stated they don't recall calling the family or utilizing the translation service for resident's information because resident understood the simple words/gestures. Activities Aid stated Resident #209 does not really engage in any social activity so Activities Aid will visit resident in the room for 1 to 1 visits. On 10/23/2024 at 9:48 AM, Recreation Director stated activity staff is responsible to introduce the activity programs and interview the resident/family member upon admission to gather information about resident's interests. Activity staff will also introduce different activity programs with the resident to assess their preferences and offer programs that resident can enjoy based on their participation and responses to the program. Recreation Director stated Resident #209's assessment was conducted with assistance of the interpreter hotline; however, the resident was unable to complete the interview due to confusion. Resident #209 did not answer questions as per interpreter, resident repeated the questions instead of answering. 10 NYCRR 415.5(f)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility failed to ensure that the physician reviewed the resident's total program of care at each visit. This was evident for 1 (Resident #74) of 1 resident reviewed for an Optometry consult. Specifically, there was no documented evidence that the recommendations by the Optometrist to see the Ophthalmologist was carried out. Additionally, the Optometry consult was dated 04/05/2024 and attending physician reviewed and signed the consult on 09/07/2024 which was 5 months later then the consult date. The findings are: The facility policy titled Medical and dental Consults dated 05/2024 documented it is the policy of the facility to arrange for services of qualified professional personnel to render specific medical services. An order for consultation shall be placed in the electronic medical record (EMR) with the reason for consultation. Consultations shall be completed within 30 days of the initial order. The Licensed Nurse or Registered Nurse Supervisor documents in progress notes that resident was seen by the consultant and any recommendations. The medical provider reviews the recommendations of the consultant and indicates agreement or non-agreement. Resident #74 admitted with diagnoses including Hypertension, Peripheral Vascular Disease (a disorder of the blood vessels outside the heart), Renal Insufficiency, and Age-Related Nuclear Cataract, Bilateral. The Minimum Data Set assessment dated [DATE] documented Resident #74 has intact cognition. The Optometry Consult dated 04/05/2024 documented the diagnosis of Cataract NS (Nuclear Sclerotic) OD (right eye), OS (left eye) Moderate OD OS first study refer for CE (Cataract Extraction) monitor for progression. Referred to Ophthalmologist Cataract Surgery OD. The Optometry Consult dated 04/05/2024 was reviewed and signed by the attending physician on 09/07/2024 which was 5 months later than the consult date. A review of the nursing and physician progress notes dated 03/20/2024 through 04/15/2024 did not reveal documented evidence that Resident #74 's referral to Ophthalmology was carried out and there was no evidence of documentation that Resident #74 refused the recommendation from the Optometrist to consult with the Ophthalmologist. On 10/21/2024 at 2:49 PM, an interview conducted with Resident #74 who stated, they knew they had cataracts prior to admission to the facility and was seen by an eye doctor in the facility but there was no follow up done. On 10/25/2024 at 9:59 AM, an interview conducted with Nurse Practitioner who stated that they were not the one who signed the Optometry consult dated 04/05/2024 but they were aware when the Optometry consultation was made with the recommendation of referral to the Ophthalmologist. Nurse Practitioner stated that they discussed the recommendation with Resident #74, and they (Resident #74) preferred to be followed up from their outside Ophthalmologist. Nurse Practitioner stated they do not have documentation about their discussion with Resident #74. Nurse Practitioner stated that they talked to Resident #74 about the consult now and Resident #74 got an appointment on 11/15/2024 with the Ophthalmologist. On 10/28/2024 at 4:13 PM, an interview conducted with the Attending Physician who stated, they read and reviewed the Optometry consult signed by them. They stated that the consult also usually is reviewed by the Nurse Practitioner in the unit and if there were questions or clarifications with the consult, the Nurse Practitioner would notify them. They further stated that Resident #74 had an Optometry consult made but was not sure if the Nurse Practitioner made a referral to Ophthalmology as what was recommended in the Optometry Consult. They stated they did not speak to Resident #74 regarding the recommendation to see the Ophthalmologist. They stated they do not recall if there is a documentation about the recommendation for the Ophthalmology consult. Consults are usually documented by the Nurse Practitioner. They stated the Optometry Consult was performed on 04/05/2024. They further stated they reviewed and signed this Optometry Consult on 09/07/2024 which was 5 months later. On 10/28/2024 at 4:27 PM, an interview was conducted with the Medical Director who stated, the recommendation by the Optometrist in the Optometry Consult to see the Ophthalmologist should have been carried out. 10 NYCRR 415.15(b)(2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in 1 of 1 resident observed for tube feeding. Specifically, Enhanced Barrier Precautions were not maintained during tube feeding administration for residents with gastrostomy tubes. (Residents #187) The findings are: The Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memorandum titled Enhanced Barrier Precautions in Nursing Homes, Ref: QSO-24-08-NH dated 03/20/2024 documented that effective 04/01/2024, Centers for Medicare and Medicaid Services is issuing a new guidance for long term care facilities on the use of enhanced barrier precautions to align with nationally accepted standards. Enhanced Barrier Precautions recommendations now include use of enhanced barrier precautions for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. The new guidance related to enhanced barrier precautions is being incorporated into F880 Infection prevention and Control. The facility policy and procedure titled Enhanced Barrier Precautions effective 07/26/2024 documented all personnel which have direct contact with a resident with indwelling medical devices even if the resident is know to be infected or colonized with a multi drug resistant organism will observe Enhanced Barrier Precautions (EBP). Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities which provide opportunities for transfer of MDRO to staff hands and clothing. 1.) Resident #187 was admitted to the facility with diagnoses that include Dysphagia following Cerebral Infarction. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #187 had moderately impaired cognitive skills for daily decision making and had a gastrostomy tube. A Physician's Order dated 07/10/2024, documented enhanced barrier precautions due to presence of feeding tube. 2.) Resident #60 was admitted to the facility with diagnoses that include Non-Alzheimer's Dementia and Dysphagia. The Minimum Data Set assessment dated [DATE] documented that Resident #60 had severely impaired cognitive skills for daily decision making and had a gastrostomy tube. A physician's order dated 04/15/2024 documented enhanced barrier precautions during high contact resident care activities indwelling medical device gastrostomy tube. Order as of 10/16/2024 documented Enteral Feed four times a day, feed flushed 120 cubic centimeters water before and after. Enteral feeding every shift total formula 24 hours (960 ml rate of flow) 240 cubic centimeters four-time day bolus. Enteral feed every shift feed by pump bolus. Order as of 10/18/2024 documented - Four times a day bolus feeding Glucerna 1.5 240 cubic centimeters four times a day at 10 AM, 2PM, 6PM and 10 PM, 120 cubic centimeters before and after. The Nutritional assessment dated [DATE] documented the following goals include the resident will accept and follow Therapeutic/mechanically altered diet through the review date. Resident will accept and follow Supplement/Nourishment plan to aid with intake/healing/abnormal labs through the review date. Resident will tolerate tube feedings with no nausea, vomiting, diarrhea, constipation, aspiration, abdominal distension. Remain free of side effects/complications, through review date. Resident will maintain adequate nutritional and hydration status and stable weight without significant gain/loss, no signs and symptoms of malnutrition or dehydration, through review date. Resident will be provided and consume adequate fluids to maintain hydration, skin turgor and promote bowel regularity through review date. During medication administration observation on 10/24/2024 at 09:59 AM to 10:14 AM, Licensed Practical Nurse #2 was observed performing the administration of enteral feeding to Resident #187 via gastrostomy tube without wearing a gown. At 9:20 AM, Licensed Practical Nurse # 2 was observed taking a gown into resident #187 room, washed their hands in the sink, put gloves on, placing sterile drape to bedside table, 120 ml cup placed on sterile drape field, the 8 ounce carton box of Glucerna 1.5 carton was opened, the cup was filled with water from the sink, resident bed adjusted up toward the Licensed Practical Nurse #2 between knee and hip height. Gloves were removed and Licensed Practical Nurse #2 washed their hands in the sink and new gloves placed on hands, syringe from piston set reassembled 20 cc air placed and abdomen was auscultated. Free water was placed to gravity feed. No gown was worn by the nurse only gloves were worn. Feeding placed to gravity feed, additional feeding from carton placed in syringe to gravity feed. Licensed Practical Nurse #2 asked resident if they are having any pain at this time. The last among of the tube feeding was administered followed by free water for the Resident #187. the resident stomach to assess their bowel sounds, removed gloves and washed hands placed another pair of gloves on, they administered free water via large syringe and tube feeding and then free water flush after. Licensed Practical Nurse #2 did not put on the isolation gown while administering the free water or tube feeding for Resident #187. At the end of the enteral feeding Licensed Practical Nurse # 2 stated that they forgot to put on the isolation gown when doing the free water and tube feeding for Resident #187. The gastrostomy tube cap was replaced, and Resident #187 bed was adjusted down lower. Licensed Practical Nurse # 2 took their gloves off and washed their hands in the resident sink and they took the unused isolation gown with them. On 10/24/2024 at 10:11 AM, Licensed Practical Nurse #2 was interviewed and stated that they brought the isolation gown in the room but they forgot to put it on. The stated the required personal protective equipment includes a gown, gloves and mask for enteral feeding. They should wear the personal protective equipment to protect the resident from anything that they can carry on their uniform since Resident #187 has an opening on their body. Licensed Practical Nurse # 2 stated that their nerves got the best of them. They stated they had training on personal protective equipment 2 months ago and we have personal protective equipment on the unit. The had enhanced barrier training last week. They stated that they wear gloves all the time and wearing the gown slipped their mind and they understand that it is important to wear the personal protective equipment. On 10/24/2024 at 11:30AM, Registered Nurse #8 was interviewed and stated, that they inform staff about hand washing, personal protective equipment before they start working their shift. They let staff know that they need to wear personal protective equipment for residents on enhanced barrier protections. Patients on enhanced barrier protections have their door labeled. Personal protective equipment is adequate on the cart. For enhanced barrier protection staff should be wearing gloves and mask. There are two residents on the unit on enhanced barrier protection. They stated that they make rounds every hour. For infection control don't want to spread bacteria from resident to resident, staff to resident and to protect staff also. Residents on enhanced barrier protection are more prone to infection or bacteria because of open entry ways. On 10/28/2024 at 12:58PM, the Infection Preventionist was interviewed and stated, they do rounds daily in the morning on all floors and also check the personal protective equipment supplies on the unit and do rounds before lunch and before they leave for the day. For enhanced barrier precautions the staff are required to wear the following personal protective equipment (gown, gloves and surgical mask). Personal protective equipment should be used for us not to give resident an infection since they have an open site and no bacterial infection from our scrubs, and we have to protect the residents. They do random checks when they do unit rounds, and they check that staff are wearing the correct personal protective equipment. On 10/03/2024 at 08:29 AM, the Director of Nursing, who was also the Infection Preventionist, was interviewed and stated that enhanced barrier precautions are required when administering medications to residents with gastrostomy tubes. 10 NYCRR 415.19 (a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure infection control practices were followed. This was evident during the Dining Task for 1 of 5 dining rooms. Specifically, 1. The kitchen did not ensure that food items were discarded by the use/expiration date. This was evident for the Kitchen Task. 2. Certified Nursing Assistant #8 did not perform hand hygiene in between residents while assisting multiple residents with hand hygiene prior to lunch being served this was evident for the 5th floor. The findings are: The facility policy titled Standard Precautions for Infection Control that was revised on 11/2017 and reviewed 07/23/2024 documented, It is the policy of the facility to follow and apply standard precautions as infection prevention measure during all resident care regardless of suspected or confirmed infection status of the resident. Standard precautions is based on the principle that all blood, body fluid, secretions, excretions except sweat, regardless of whether they contain visible blood, non-intact skin and mucous membranes may contain transmissible infections agents. Hand hygiene before and after contact with the resident. 1. During observation of the kitchen task on 10/21/2024 from 09:20 AM- 09:54 AM the following was observed: In the emergency food storage area they were 4 boxes of Chefler Foods mayonnaise containing 200 -7/16-ounce pouches of mayonnaise with a use by date of 12 July 2024 and 1 box of mayonnaise with expiration date of 5/2/2024. On 10/23/2024 at 12:20 PM, an interview was conducted with the storeroom person who stated they are in charge of the storeroom and the emergency food room. Last week or prior week they noticed a few expired items that included canned food and enteral feeding and the items were discarded. They saw the mayonnaise in the storage room [ROOM NUMBER]-3 weeks ago. It was an old delivery, and they are not sure when it was received. They rotated items this month for all food items. The mayonnaise in individual packets are only placed in the storeroom. There should not be any expired food items in the storeroom. They use first in first out and they are in-serviced on it daily. It was a mistake that the expired food item was still there. On 10/24/2024 at 09:18 AM, Food Service Supervisor # 1 was interviewed and stated; I look at items in the storeroom daily and I take expired items and throw them out. Last Friday was the last time I looked at the emergency food storage room and noticed expired items of mayonnaise and threw out on Monday. They stated that on Friday everything was good, and it was on Monday that they found the expired items. We cannot give expired food to the residents, and it will be bad if we give to the residents. They have to make sure food is in good condition. If it is one to two days before expiration date, we throw the food item out. The staff are in-serviced every time we receive items. We put the older items in the back and the dates to use up first. During an interview on 10/24/2024 at 11:21 AM, Food Service Supervisor # 2 was interviewed and stated that they look at the food items daily and at all items for meals. They look at the emergency food daily. No items were expired in the emergency food room that they noticed. They stated they were not informed of the expiration of the mayonnaise. They stated it was curious that they did not notice. The food items needed to be discarded so we won't get risk from expired items and so there is no cross contamination. They stated moving forward they are aware that they need to check more closely for dates of food products. On 10/24/2024 at 11:27 AM, the Dietary Director was interviewed and stated; they look at the storeroom every 6 months and do a thorough check. They stated 1 to 2 times a month they look at food items. They did not notice the items before. We don't want to get anyone sick, and it is something we overlooked and when items come in and when expired. This is something that rarely happens. On 10/28/2024 at 1:05 PM, the Infection Preventionist was interviewed and stated; they inspect the kitchen environment to include the storage room. They look at the expiration date of items in the kitchen storage room. They stated they have not looked at the emergency food. We cannot give expired food which can cause infections and diarrhea. The expiration date is very important. They stated they have not done an in-service on expired items for the kitchen. Mayonnaise if it is expired and not at the correct temperature can give bacteria and cause vomiting among residents. 2. During dining observation on 10/21/2024 between 12:25 PM and 12:31 PM, Certified Nursing Assistant # 5 was observed passing out hand wipes from the dining table on the left side of the room to the right side of the room and assisting residents with hand hygiene by passing out the hand sanitizing wipes in the dining room with bare hands and assisting residents who needed assistance to clean their hands. Certified Nursing Assistant #5 assisted Resident #134 in cleaning their hands with wipes, Certified Nursing Assistant #5 then took additional clean hand wipes from the container and passed the wipes to additional residents who did not require assistance with hand hygiene and then proceeded to assist the following residents to perform hand hygiene with their bare hands, Resident #114's, #176's, 130's and #56. Certified Nursing Assistant #5 did not perform hand hygiene in between residents. On 10/21/2024 at 12:54 PM, Certified Nursing Assistant #5 was interviewed and stated; they are aware that they did not do hand hygiene between residents and there was no reason why it was not done. They further stated that for infection control we don't want to cross germs from one resident to another. Certified Nursing Assistant #5 stated they were supposed to clean their hands in-between residents to prevent the spread of germs from one resident to another. They were supposed to clean their hands for infection control in between residents but they did not do so. On 10/22/2024 at 03:50 PM, Registered Nurse #7 was interviewed and stated; that staff will prepare residents for dining by doing hand hygiene. If staff pick up hand wipes, they are to clean their hands. Residents should be given separate hand wipes. For infection control there are germs, and they can pass from hand to hand, so staff wash their hands before they assist residents. We might get another bacteria or germs from resident to control infection. We make sure we wash hands before touching another resident. We remind staff and staff are re-inserviced. On 10/22/2024 at 03:55 PM, Registered Nurse #8 was interviewed and stated; they are in the dining room during lunch to make sure that the certified nursing assistants wash their hands and kitchen staff washes their hands as well. Certified Nursing Assistants offer hand wipes to each resident in the dining room as well as residents in their rooms before meals. For infection control don't want to spread bacteria from resident to resident and from staff to protect self as well. There has been recent inservice on hand hygiene. On 10/28/2024 at 12:58 PM, the Infection Preventionist was interviewed and stated; they do rounds in the mornings on all floors, they look at personal protective equipment supplies, before lunch and during dining. They observe cleaning of the dining room. They set up and randomly pick a floor for observing the cleaning of residents hands. They stated they have done in-services in relation to hand hygiene as needed. Hand hygiene is for us not to give residents an infection if they have an open site. They do random checks when they do rounds and knock on doors to observe staff are wearing the correct personal protective equipment. 10 NYCRR 415.19(b)(4)

Based on interviews and record review conducted during the Recertification and Complaint survey (NY00293567) from 9/7/22 to 9/14/22, the facility did not ensure that in accordance with accepted professional standards and practices, medical records were maintained that were complete and accurately documented for each resident. Specifically, medication administration was not documented for scheduled medication and there was no documented evidence that medication had been refused by the resident. This was evident for 1 of 3 resident reviewed for Pain Management out of 38 sampled residents. (Resident # 361) The finding is: The policy and procedure titled Medication Administration Guidelines effective 6/17 documented medication are given only with a physician's order. Medication are to be administered no more than one hour on either side of time. STAT and as needed (PRN) medications are to be entered on the EMAR/MAR along with the date, dose and time of administration and medication nurse's initials and the reason for the as needed medications. All medication administered are to be signed for in the EMAR. Medications note administered (refused, etc.,) are to be recorded using the code on the EMAR/MAR. And an appropriate explanatory statement is to be entered in the nurse's progress note. Resident # 361 had diagnoses which include Aftercare Following Joint Replacement Surgery, Unilateral Primary Osteoarthritis Left Knee, Presence of Left Artificial Knee Joint, Gastroesophageal Reflux Disease (GERD, Obstructive and Reflux Uropathy Unspecified. Physician order dated 3/5/2022 documented Acetaminophen tablet 325 mg -give 3 tablets every 8 hours for pain for 14 days, Finasteride tablet 5mg give 1 tablet by mouth in the evening for Benign Prostate Hyperplasia (BPH), Protonix tablet delayed release 40 mg daily, Aspirin Enteric Coated Tablet Delayed Release 81 mg give 1 tablet by mouth every 12 hours for Coronary Artery Disease (CAD) and vital signs (temperature, blood pressure, respiratory rate, pulse rate, pulse oximetry, pain level) every shift for first 7 days. Review of the Medication Administration Record for March 2022 documented Protonix tablet delayed release 40 MG at 06:00 AM was not documented on 3/11/2022-3/13/2022, 3/16/2022 -3/19/2022 and 3/252022. Aspirin Enteric coated delayed release 81 mg was not documented on 03/06/2022 at 21:00, 3/15/2022 at 09:00 and 3/17/2022 at 21:00. Acetaminophen 325 mg was not documented on 3/6/2022 at 22:00, 3/11/2022 at 06:00 and 22:00, 3/12/2022 at 06:00, 3/13/2022 at 06:00 and 3/15/2022 at 14:00, 3/16/2022 at 06:00, 3/17/2022 at 22:00 and 3/19/2022 at 06:00. Pain monitoring was not documented on 3/10/2022 and 3/11/2022 on the 11 PM-7 AM shift. Review of the Medication Administration Record for April 2022 documented that Finasteride tablet 5mg ordered at 19:00 was not documented on 4/5/2022-4/10/2022. Protonix tablet delayed release 40MG ordered at 06:00 was not documented on 4/6/2022-4/11/2022. Review of the Nurses Progress notes dated 3/5/2022 to 4/5/2022 contained no evidence that resident had refused medication or any documentation related to why ordered medication had not been administered. On 09/14/2022 at 11:28 AM, Registered Nurse (RN) # 3 was interviewed. RN #3 stated that the Medication Administration Record (MAR) for March 2022 was reviewed and they do not know why documentation was missing. On 09/14/2022 at 11:55 AM, the Registered Nurse Supervisor (RNS) #1 was interviewed and stated that they review medication administration in relation to new order, they observe medication pass and perform random checks. RN #1 also stated they audit the MAR every day and if have admission and they review the admission orders. On 09/14/2022 at 1:29 PM, the Director of Nursing (DON) was interviewed and stated the nurses should document medication administered. The DON stated that there was documentation missing for Tylenol for Resident #361 on 3/11/2022, 3/12/2022, 3/13/2022 and 3/19/2022 and documented Resident #361 was given Oxycodone on 3/11/2022, 3/16/2022 and 3/19/2022. The DON also stated there was no documentation of the resident refusing any medication including Tylenol and if it was not administered there should have been documentation in either progress notes or on the MAR as to why. 415.22(a)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, staff did not identify and address a resident's abrasions/injuries during skin assessments. This was evident for 1 of 2 residents reviewed for Skin Conditions. (Resident #22) The findings are: A facility policy and procedure related to Skin Inspection Treatment dated 4/16 documented that a thorough inspection of the resident's skin surface, particularly all areas over bony prominence, on each shift by the assigned Certified Nursing Assistant (CNA) and weekly by the licensed nurse. The CNA reports all changes to the licensed nurse. The licensed nurse documents weekly observation in the medical record. Resident #22 was admitted to the facility on [DATE] and had a diagnosis of viral hepatitis and depression. The most recent Minimum Data Set (MDS) dated [DATE] documented that the resident is severely cognitively impaired, did not have any skin conditions, and did not have any falls since the previous assessment was completed. On 12/08/19 at 09:28 AM Resident #22 was observed to be sitting up on his bed in his room. The resident had a short-sleeved shirt on, was alert, and displayed some confusion. The Surveyor observed a linear scab of about 4 inches in length on the bottom portion of the resident's right forearm. The scab was dry and a deep red color. There was no active bleeding observed from the site. The resident stated that he fell but was unable to provide any further information. Resident #22 then raised his left arm and showed the surveyor that he had round quarter-sized scab to the bottom of his left forearm, approximately 2 inches from his elbow. The scab was brown in color and dry with no oozing or active bleeding observed. The surrounding area of the scab appeared slightly inflamed and red. Physician Orders as of 12/09/19 did not document any treatment orders related to the resident's forearms. The Nursing Skin Inspection forms dated 12/10/19, 12/2/19, 11/20/19, and 11/12/19 documented that the resident did not have any rashes, excoriated areas, bruises, open lesions, cuts, laceration or skin tears. The Certified Nursing Assistant (CNA) [NAME] Task form dated 12/10/19 documented that the CNA should monitor the resident's skin condition each shift. Medical Doctor (MD) notes from 9/1/19 through 12/09/19 did not document that Resident #22 had any skin conditions to his bilateral forearms. Nursing Notes from 9/1/19 to 12/9/19 did not document that the resident had any skin conditions to his bilateral forearms. The Treatment Administration Record (TAR) for December 2019 did not document that that any treatment was provided to the resident's bilateral forearms prior to 12/11/19. A December 2019 Documentation Survey Report that is used to document the daily tasks and observations performed by the CNA documented that skin observations were made every shift (three times daily). The record documented that no skin conditions were observed on any of the three shifts from 12/1/19 through 12/9/19. A Comprehensive Care Plan (CCP) related to Falls was initiated on 6/26/17 and documented that the resident had stepped on his shoe string on 6/25/17 and had a bruise to the right knee on 1/1/18. There was no documented evidence that the resident sustained a fall between 1/1/8 and 12/09/19. A CCP related to Activity of Daily Living (ADL) self-care performance deficit initiated on 12/27/2016 documented that the resident the CNA and Nursing Staff are to inspect the resident's skin for redness, open areas, scratches, cuts, bruises and repot changes to the nurse. An interview was conducted with CNA #4 on 12/10/19 at 02:47 PM. CNA #4 has been working with Resident #22 intermittently since July 2019 and is currently assigned to care for him. She assists the resident with changing, choosing his clothes, showering, and observing his skin during care. CNA #4 makes her skin observations while assisting the resident in changing his clothes and/or when she provides him with a shower. She had observed the resident's skin today while changing his clothes in the morning and she did not observe any cuts, bruises rashes, or skin conditions of any sort. She did not observe any scabs to the resident's bilateral forearms. After SA brought the CNA to the resident's room, CNA #4 observed the resident's forearms and stated that she did not notice the scabs to his bilateral arms. If she did observe any skin conditions, she would have reported it to the nurse. The nurse did not report to the CNA that the nursing staff was aware that the resident had scabs on his bilateral arms during the morning meeting on the resident's unit. On 12/10/19 at 2:55 PM, an interview was conducted with the Registered Nurse (RN) #3, the RN assigned to the resident's unit. He has been working on this unit for approximately 8 months and is familiar with Resident #22. Skin assessments of residents are done by the CNAs during shower days. The CNA assesses the resident's skin and then reports any issues to the Licensed Practical Nurse (LPN) or RN. The RN or LPN then documents the CNA's findings on the skin assessment form. If there is any issue found with the resident's skin, the RN must assess the skin condition for particulars, complete a wound care referral form, and communicate it to the interdisciplinary team. The MD is also made aware of the resident's skin condition since the MD may want to give an order for treatment. RN #3 stated that none of the resident's CNA's reported any issue with the resident's bilateral forearms. The resident has not had any falls recently. He is not aware of any skin conditions for Resident #22. After going to the resident's room with the SA, RN #3 observed the resident's bilateral forearms. RN #3 stated that he has never observed these scabs or skin conditions on the resident's bilateral forearms before. This has not been reported to him and he was unaware of any prior injury. He will need to look into this. Each shift is responsible for verbally communicating any incidents that have occurred, writing a progress note, and documenting the incident on the 24-Hour Nurse Report. There are no nursing notes related to this skin condition and nothing was verbally communicated to him. Now that this has come to his attention, the RN stated that he will contact the MD. On 12/11/19 at 9:37 AM, an interview was conducted with the Director of Nursing (DON). The DNS stated that no incidents or skin conditions have been reported to nursing administrations in relation to Resident #22. The DON first became aware that the resident had scabs on his bilateral forearms on the evening of 12/10/19. As soon as the DON became aware, an investigation was initiated. The DON stated that the resident's roommate reported that he observed the resident sliding from his bed in the evening between 12/9 and 12/10. When she was made aware that the resident was observed with this skin condition on 12/8/19, the DON stated that she would need to expand her investigation. The DON stated that the injuries are consistent with the resident sliding from his bed and then using his elbows to lift himself back up and is likely the result of a fall. Although Resident #22 is confused, he did report that he fell. The question is the timeframe of when this occurred. The CNA is responsible for conducting a skin observation of the resident and then documenting accordingly. The CNA informs the nurse who then performs a skin assessment, writes a progress note, and then informs the resident's designated representative and the MD. A follow up interview was conducted with the DON on 12/12/19 at 12:55 PM. The DON stated that the resident is sometimes guarded about having staff complete a skin assessment and sometimes wears long-sleeved shirts. Skin monitoring should be done by CNAs daily to report any irritation or breakdown. CNAs should attempt to check the resident's entire body unless the resident refuses. If the resident refuses, the nurse should be made aware. If there is anything irregular on the skin, the CNA must let the nurse know. The nurse then assesses the resident's skin and lets the MD or wound care nurse know. If it is a skin tear, bruising, or an injury then an Accident/Incident investigation is initiated, and the DON is made aware. The nurse is required to assess the resident's skin independently and should not rely only upon the CNA's report. Licensed Practical Nurses (LPN) conduct a body check once weekly. Nursing notes are written, and the CNA accountability is updated. A Skin Assessment form is then filled out after the LPN visually observes the resident's skin. The DON stated that she does not believe that a skin assessment was done thoroughly for Resident #22. The DON believes that the staff may have done a cursory check of the resident's skin but not enough to see the injuries to his bilateral forearms. On 12/11/19 at 10:19 AM, an interview was conducted with CNA #3, the resident's regularly assigned CNA. CNA #3 stated that she has been assigned to the resident daily since 12/1/19. She assists him with taking showers, choosing his clothes, and getting him dressed. She also assists with applying A&D ointment to his skin to protect against dryness and observing the resident's skin for any conditions or injuries. The resident has never refused showers or having his skin checked by CNA #3. She has not noticed anything unusual with his skin and did not notice any scrapes that he has on his forearm. CNA #3 stated that if she observed that any resident had scrapes or bruises on him, then she would report it to the nurse. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that a resident received devices to prevent pressure ulcers. Specifically, a resident was observed on multiple occasions without heel booties or diabetic shoes as ordered by the Physician. This was evident for 1 of 2 residents reviewed for Pressure Ulcers. (Resident #37) The findings are: Resident #37 had a diagnosis of diabetes mellitus and dementia. On 12/08/19 at 10:34 AM and 12/10/19 at 10:33 AM, Resident #37 was observed to be laying in bed in her room. Two blue heel booties were observed to be on the resident's bedside table in the far-right corner of the room and no heel booties were observed on the resident's feet. On 12/10/19 at 11:00 AM and 12/11/19 at 11:35 AM, the resident was observed to be dressed, groomed, and out of bed to her wheelchair. The resident was observed to be wearing black regular sneakers. There were no diabetic shoes observed in the resident's room on 12/11/19 at 11:37 AM. The most recent quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident has severely impaired cognition and is at risk for pressure ulcers. A Comprehensive Care Plan (CCP) initiated on 4/8/19 and related to the resident's potential for skin breakdown due to diabetes documented that nursing staff are responsible for assessing and providing appropriate pressure relieving devices as per physical therapy occupational therapy recommendations. The CCP also documented that nursing staff are to offload pressure areas. The Physician's Orders also documented that as of 5/3/19, the resident has had an order for bilateral cushioned heel booties to be worn when in bed with regular skin checks every shift for discomfort and discoloration. The Physician's Order dated 11/8/19 documented that the resident is to receive bilateral diabetic shoes to be worn when out of bed with regular skin checks every shift for any discomfort and discoloration. The Certified Nursing Assistant (CNA) [NAME] tasks as of 12/11/19 documented that the resident is to have bilateral cushioned heel booties to be worn in bed with regular skin checks every shift for any discomfort and discoloration. A CCP initiated 4/8/19 and related to the resident's limited physical mobility documented that the CNA is responsible for ensuring that resident has bilateral cushioned heel booties to be worn when in bed with regular skin checks every shift and diabetic shoes to be worn when out of bed with regular skin checks. A CCP initiated 4/11/19 and related to the resident's risk for pressure ulcer development documented that the resident has a history of pressure ulcers. The licensed nurse is responsible for following the skin integrity protocol and offloading pressure areas. A Skin/Wound Note dated 5/7/19 documented that the resident was evaluated by the vascular doctor for friction blisters to bilateral lower extremities. The Medical Doctor (MD) recommended to offload resident's bilateral heels. The resident's CCP related to pressure ulcer development was updated on 4/11/19 to reflect this recommendation by the MD. The CNA Documentation Survey Report, the Treatment Administration Record, and the Medication Administration Record did not contain a section for nursing staff to document the usage of bilateral cushioned heel booties and or diabetic shoes. A MD Note dated 5/2/19 documented that the resident had a bilateral heel tissue injury and heel booties are to be applied to bilateral heels while in bed. The CCP related to the resident's limited physical mobility was updated on 5/3/19 to reflect the MD recommendation for resident to have heel booties applied while in bed. The CCP was updated on 11/8/19 to reflect the order of diabetic shoes. A Rehab Intervention Note dated 11/8/19 documented that the resident was evaluated by a certified Pedorthist on 11/7/19 and recommended to have diabetic shoes. Diabetic shoes are to be worn when the resident is out of bed and nursing was informed. The CCP related to limited physical mobility was updated to reflect that the resident is to wear diabetic shoes while out of bed. An interview was conducted with CNA #2, the CNA assigned to Resident #37, on 12/12/19 at 9:53 AM. CNA #2 stated that she has been working with the resident since 12/1/9. She believes the resident wears regular sneakers and crocs style shoes. CNA #2 is aware what a diabetic shoe looks like but Resident #37 has never had this type of shoe in her closet or her room since CNA #2 has started working with her. The only special type of shoes that are provided to the resident by the facility are the heel booties that the resident wears while she is in bed to protect her feet from getting pressure ulcers. The resident is not currently wearing the booties even though she is still in bed. CNA #2 does not believe that the booties are in the resident's room because the resident was not wearing the booties when the CNA came in this morning and the CNA did not observe the heel booties anywhere in the room. Usually, CNA #2 removes them when she comes in at 7 AM to start her shift. She then provides the resident with breakfast, washes her, and takes her out of bed by 11 AM. At 9:59 AM heel booties were observed in the resident's closet, the CNA was present during this observation. CNA #2 stated that it is not a regular occurrence for the resident to be without her heel booties and she has observed this approximately 2-3 times since she began working with the resident on 12/1/19. She is unsure whether the CNA [NAME] Tasks includes documentation of the order for the resident to wear heel booties while in bed and is only aware of this resident having heel booties because she physically saw them in the room. When the Physical Therapy Department recommends a device for a resident, they communicate it to the nurse and the nurse gives the CNAs instruction on how and when to use it by giving a verbal instruction. The Nurse did not communicate anything special to CNA #2 about how to use the heel booties for Resident #37. On 12/12/19 at 10:12 AM, an interview was conducted with the charge nurse, Registered Nurse (RN) #2. RN #2 stated that she is familiar with the resident and that Resident #37 has an MD order for heel booties to be worn while she is in bed. This is communicated to the assigned CNA via the CNA [NAME] Tasks. The CNA must sign off on the [NAME] Tasks each day indicating that they are providing the resident with the heel booties. RN #2 stated that the resident was not wearing them this morning because the aide is preparing the resident to come out of bed. She made rounds this morning between 7:30 AM and 8AM to visually check whether each resident is wearing their appropriate devices and is pretty certain that Resident #37 was wearing her heel booties while in bed. RN #2 is unaware of an order for diabetic shoes. If the resident had an order for special shoes, such as diabetic shoes, then the Physical Therapy Department would come to the unit and communicate this to the staff and ensure that they understand how to properly use the devices. The RN does recall being inserviced on using heel booties for the resident while in bed but does not recall an inservice being given in relation to the resident's use of diabetic shoes while out of bed. After RN #2 checked the resident's medical record, and acknowledge the Physician's Order for the resident to wear diabetic shoes while out of bed. She checked the At resident's room and was unable to find the diabetic shoes. She stated that a few weeks ago, there were several residents that received diabetic shoes, but the residents are usually in bed when she conducts her rounds. RN #2 stated that the shoes would be labeled with the resident's name and she is going to inform the Physical Therapy Department that they are missing. On 12/12/19 at 10:48 AM, an interview was conducted with the Physical Therapist (PT) that had worked with Resident #37. The PT stated that she recommended for the resident to have heel booties while in bed and that is highly recommended that the resident wear the heel booties the entire time that she is in bed. The PT Department comes to the unit and provides the device to the nursing staff. They inservice them on how to use the device. It is then expected that the nursing staff will ensure that the resident receives the device as ordered. The diabetic shoes were ordered for the resident after a specialist came into the facility in November of 2019. The PT Director would know more about that order. The PT stated that she is responsible for updating the resident's care plan with to include devices that have been ordered for her but does not know how the CNA [NAME] Tasks are updated to reflect this information. The CNA [NAME] had been updated to reflect that the resident was to have heel booties applied while in bed; however, the CNA [NAME] did not document that the resident is to wear diabetic shoes out of bed. The PT stated that the SA would need to speak with her Director regarding the documentation related to the diabetic shoes. An interview was conducted with the Director of the PT Department (DPT) on 12/12/19 at 11:03 AM. The DPT stated that there was a specialist that came in and evaluated Resident #37 in November of 2019 and ordered for her to have diabetic shoes. The nursing staff was provided with a list of those residents who received diabetic shoes and the resident's CCP was updated to reflect this information. The heel booties order is included on the CNA [NAME] Task but not the order for diabetic shoes. The DPT was unaware of how to include this on the [NAME] since this option is not available on pre-populated drop-down list available on the Electronic Medical Record (EMR). The DPT then began to look at the options available on the EMR and was able to find a way to manually input this information onto the [NAME] in order for the CNA to be aware that the resident has an order for diabetic shoes to be worn when out of bed. The PT Department is responsible for conducting rounds to check that residents are being provided with their ordered devices quarterly when the MDS is completed. 415.12(c)(1)

Based on observation, record review and staff interviews during the recertification survey the facility did not maintain infection control practices to help prevent the development and transmission of communicable diseases and infections. Specifically, one resident receiving oxygen by a nasal cannula with the oxygen tubing coming from the oxygen concentrator was resting on the floor in the residents room. This was evident for 1 of 1 resident reviewed for oxygen therapy. (Resident #81). The facility policy titled, Oxygen Therapy dated 6/17 documents: General Instructions- 2) The Nursing staff will set up, check and supervise all treatments. Procedure - 6) Oxygen tubing and masks will be changed weekly unless soiled by the 11PM - 7AM staff and as necessary if cleanliness is compromised. On 12/08/19 at 9:53 AM and 12:54 PM, Resident #81 was observed lying in bed. The resident was receiving oxygen via nasal cannula from an oxygen concentrator on the left side of the bed. The oxygen tubing coming from the oxygen concentrator was running along the floor and up the side of the bed to the resident's nasal cannula. Resident #81 had diagnoses that included chronic obstructive pulmonary disease. The Care Plan for Respiratory status dated 9/7/19 documents -Resident is at risk for altered respiratory status. related to a diagnosis of chronic obstructive pulmonary disease. The resident receives oxygen therapy. Goal- Resident will be free of signs and symptoms of respiratory distress. Physician's orders dated 12/19 document: Oxygen- clean filter every week. 11-7 shift on Sunday. Oxygen - change tubing every week 11-7 shift on Sunday. Oxygen 2 liters/minute via nasal cannula or mask as needed for shortness of breath, humidified. On 12/8 /19 at 9:55AM CNA #1 came into the room while the SA was present and did not observe the oxygen tubing resting on the floor. On 12/08/19 at 12:56 PM, the Registered Nurse (RN #1) was interviewed and acknowledged the tubing on the floor. The RN stated the oxygen tubing should not be lying on the floor. The staff should make sure the excess tubing is attached to the side of the bed and not touching the floor. This is an infection control issue, and she will tell the nurse to replace the tubing. On 12/08/19 at 1:01 PM, the Licensed Practical Nurse (LPN #1) was interviewed and acknowledged the oxygen tubing was on the floor running from the oxygen concentrator to the nasal cannula. LPN #1 stated the tubing should go from the machine to the bed to the resident. I came in the morning at 7AM and I make my rounds. We have to put the oxygen tubing into a plastic bag and the into the drawer so it does not touch the floor. On 12/09/19 10:36 AM, Resident #81 was interviewed and stated, Until yesterday they never educated me about not letting the oxygen tubing lay on the floor. Before yesterday, the staff never placed the oxygen tubing in a plastic bag so as to keep it off the floor. If they would have educated me about the tubing it would not be on the floor. Yesterday, after they attached the plastic bag to the side of my bed, they folded the tubing and put it in the bag so it would not touch the floor. Before yesterday it did not occur to me that the tubing on the floor is a problem. On 12/12/19 at 12:09 PM, the Director of Nursing was interviewed stated, Oxygen tubing should not be lying on the floor. I was not told that the oxygen tubing was coming out of the oxygen concentrator and was lying on the floor as the opposite end of the tubing was running up the side of the bed and into the nasal cannula the resident was wearing. The oxygen tubing should be rolled up in a plastic bag tied to the concentrator or tied to the side rail of the bed. The nursing staff did not follow the protocol to prevent the oxygen tubing from touching the floor. This is an infection control issue. I was told the tubing was immediately changed . As a result of this situation we reeducated the staff. We reeducated all the residents that are on oxygen about the importance of not letting the oxygen tubing touch or lay on the floor. 415.19(b)(1)