**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification/Complaint survey (NY00349608) from 12/02/2024 to 12/09/2024, the facility did not ensure all alleged violations involving resident to resident physical abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident for 2 (Resident # 193 and # 325) of 5 residents reviewed for Abuse out of sample size 38 residents. Specifically, the facility did not report Resident # 325 hit Resident # 193 on the right shoulder with a grabber to the New York State Department of Health within 2 hours after the allegation was made The findings are: The facility policy titled Abuse - Prohibition Protocol, Types of Abuse, Response/Reporting with effective date 10/97 and last revision date 5/23, documented in the section Response/Reporting under abuse that the persons observing an incident of resident abuse or suspecting resident abuse must attempt to stop the abuse and must immediately report such incident to their immediate supervisor or administrative staff. The policy also documented that long term care facilities must report abuse, neglect, and misappropriation within 24 hours after reasonable cause threshold in concluded. 1) Resident #193 was admitted to the facility with diagnoses which included End stage renal disease, Cerebral infarction, and Polyneuropathy. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #193 was cognitively impaired in cognition and had no behavioral symptoms towards others. 2) Resident #325was admitted to the facility with diagnoses which included Other Alzheimer's disease, Unspecified dementia without behavioral disturbance, and Major depressive disorder. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #325 was severely impaired in cognition and had no behavior symptoms towards others. The facility investigation report documented the occurrence happened at approximately 1:40 PM on 07/28/2024. It also documented Resident # 193 and Resident #325 shared a room. The report documented Certified Nursing Assistant # 7 heard loud noises from Resident #193 and Resident #325's room while they were walking in the hallway. It also documented Certified Nursing Assistant #7 went to the room, observed Resident #325 holding a cup and standing by the sink next to Resident #193's bed and Resident # 193 was trying to take the cup from Resident # 325. It further documented Certified Nursing Assistant # 7 called for help, took the cup away from Resident #325, and proceeded to escort Resident #325 out of the room. It documented Resident #325 got the grabber from Resident #193's bed, flailed it, and hit Resident #193's right shoulder. The New York State Department of Health Aspen Complaint Tracking System intake documented the incident happened on Sunday 07/28/2024 at 13:40. The intake also documented the Administrator was first made aware of the incident on Sunday 07/28/2024 at 13:55. The auto reply email from New York State Department of Health to Assistant Director of Nursing # 1 documented the facility submitted the report to Department of Health on 07/29/2024 at 12:31. On 12/02/2024 at 09:51 AM, Resident # 193 was interviewed and stated they recalled they were taped by something on the right shoulder by Resident #325 on the day the incident happened. Resident #193 also stated they were not injured. On 12/03/2024 at 12:23 PM, Certified Nursing Assistant # 7 was interviewed and stated they witnessed the incident that Resident #325 took the grabber from Resident #193's bed and hit Resident # 193's right shoulder when they tried to escort Resident #325 out of the room. Certified Nursing Assistant # 7 also stated they reported what they observed to Registered Nurse #4 upon their arrival to the unit. On 12/03/2024 at 12:08 PM, Registered Nurse # 4 was interviewed and stated they reported the incident that happened on the unit immediately to Assistant Director of Nursing and Director of Nursing. Registered Nurse # 4 also stated they had cell phone numbers of Assistant Director of Nursing and Director of Nursing and was able to call them at anytime to report. Registered Nurse # 4 further stated they called Assistant Director of Nursing # 1 immediately to report the resident-to-resident alteration between Resident # 193 and Resident # 325 after they knew what happened from Certified Nursing Assistant # 7. On 12/04/2024 at 11:24 AM, Assistant Director of Nursing #1 was interviewed and stated the Assistant Director of Nursing, Performance Improvement Director, Director of Nursing, and Administrator had access to Health Commerce System to report allegations to Department of Health. Assistant Director of Nursing #1 stated Registered Nurse # 4 reported the resident-to-resident alteration between Resident # 193 and Resident # 325 to them on the day the incident happened. Assistant Director of Nursing #1 also stated they had to report the allegation to Department of Health as it was considered as allegation of abuse. Assistant Director of Nursing #1 further stated they knew they had to report allegation of abuse to Department of Health within 2 hours after making aware of the allegation. Assistant Director of Nursing #1 stated they reported the allegation to Director of Nursing. Assistant Director of Nursing #1 also stated they did not obtain the instruction from Director of Nursing to report the incident to Department of Health until next day on 07/29/2024. On 12/04/2024 at 11:53 AM, the Director of Nursing was interviewed and stated Assistant Director of Nursing # 1 called them and reported the allegation on 7/28/2024. The Director of Nursing also stated the incident was considered as allegation of abuse and they had to report it to Department of Health within 2 hours after they were made aware of it. The Director of Nursing stated they discussed with the Administrator about the allegation and decided it was a reportable incident. The Director of Nursing also stated the staff who had access to Health Commerce System can submit the report to Department of Health at anytime and anywhere as long as they had access to a computer. The Director of Nursing stated they did not recall when they instructed Assistant Director of Nursing # 1 to submit the report to Department of Health. On 12/04/2024 at 12:09 PM, the Administrator was interviewed and stated the Director of Nursing called and discussed with them if the incident that happened on 07/28/2024 was reportable to Department of Health. The Administrator also stated the facility had to report all allegations of abuse to the Department of Health within 2 hours after they were making aware of it. The Administrator further stated they did not recall the details of the incident and why it was not reported to Department of Health until next day on 07//29/2024. 10 NYCRR 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Record reviews and interviews during the Recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure that all completed resident assessments were submitted and transmitted into the Quality Improvement Evaluation Assessment Submission and Processing in a timely manner. Specifically, 9 (Resident #10, Resident #76, Resident #83, Resident #326, Resident #345, Resident #355, Resident #420, Resident #493, and Resident #572) of 9 Minimum Data Set submissions reviewed for Resident Assessments were not submitted to Centers for Medicaid and Medicare Services system within 14 days of completion. The findings are: The facility's policy and procedure titled Minimum Data Set 3.0 Submission revised 1/2024 documented it is the policy of [NAME] Harbor Multicare Center to ensure timely submission of all Minimum Data Sets to Centers for Medicare and Medicaid Services via Internet Quality Improvement and Evaluation System. Resident #10's quarterly Minimum Data Set 3.0 with assessment reference date of 10/23/2024 and completion date of 10/29/2024. The assessment was not submitted as of 12/06/2024. Resident #76's quarterly Minimum Data Set 3.0 with assessment reference date of 10/24/2024 and completion date of 10/30/2024. The assessment was not submitted as of 12/06/2024. Resident #83's quarterly Minimum Data Set 3.0 with assessment reference date of 10/23/2024 and completion date of 10/29/2024. The assessment was not submitted as of 12/06/2024. Resident #326's quarterly Minimum Data Set 3.0 with assessment reference date of 10/24/2024 and completion date of 10/30/2024. The assessment was not submitted as of 12/06/2024. Resident #345's quarterly Minimum Data Set 3.0 with assessment reference date of 10/18/2024 and completion date of 11/1/2024. The assessment was not submitted as of 12/06/2024. Resident #355's quarterly Minimum Data Set 3.0 with assessment reference date of 10/19/2024 and completion date of 10/25/2024. The assessment was not submitted as of 12/06/2024. Resident #420's quarterly Minimum Data Set 3.0 with assessment reference date of 10/12/2024 and completion date of 10/25/2024. The assessment was not submitted as of 12/06/2024. Resident #493's quarterly Minimum Data Set 3.0 with assessment reference date of 10/11/2024 and completion date of 10/24/2024. The assessment was not submitted as of 12/06/2024. Resident #572's quarterly Minimum Data Set 3.0 with assessment reference date of 10/23/24 and completion date of 10/29/24. The assessment was not submitted as of 12/06/2024. On 12/09/2024 at 12:30 PM, the Assistant Director of Nursing #3 who is also responsible for Resident Assessments was interviewed and stated, the batch that was scheduled for a 11/06/2024 submission was accidentally missed. They were not aware that the assessments were not submitted until it was pointed out by the surveyor. The Assistant Director of Nursing #3 also stated they just checked the validation report which showed the batch was cued on 11/06/2024 and wasn't submitted. The Assistant Director of Nursing #3 stated Information Technology Support submits the batch once it is cued. The Assistant Director of Nursing #3 further stated the assessments were submitted today. On 12/09/24 at 12:44 PM, the Information Technology Support person was interviewed and stated, they had two files to submit and accidentally one single file was submitted twice. They received two reports and one report indicated duplicate submission and they did not spot the error at that time. The Information Technology Support person further stated they didn't realize this until today that the assessments weren't submitted. On 12/09/24 at 1:03 PM, the Administrator was interviewed and stated, this is the first time this has been an issue. The Information Technology Support person sent the same batch twice. The Administrator further stated it was an honest mistake that happened. 10 NYCRR 415.11

Based on observations, interviews, and record review during the Abbreviated Survey (NY 00351995), the facility failed to protect residents' rights to be free from physical abuse by nursing home staff. This was evident in one out of six residents (Resident #1) reviewed for abuse. Specifically, on 08/20/2024 at approximately 4:45 PM, Certified Nursing Assistant #2 reported to Registered Nurse Supervisor #1 that at 6:53 AM, Certified Nursing Assistant #2 assisted Certified Nursing Assistant #1, in the care of Resident #1. During care, Resident #1 held on tightly to Certified Nursing Assistant #1's hand, sinking their fingers into Certified Nursing Assistant #1's arm. Certified Nursing Assistant #1 raised their hand and with a deliberate, forceful slap to Resident #1's face between their forehead and eyes. The findings are: The Facility's Policy and Procedure titled Combative Resident with revision date 08/2023, documented it is the policy of the facility to maintain the safety of residents and staff during resident combative behavior/outburst. Any physical or verbal behavior/outburst from residents is to be reported to the Registered Nurse Manager or Nursing Supervisor immediately. The Facility's Policy and Procedure titled Abuse Reporting with revision date 12/2023, documented the residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. All personnel must promptly report any incident or suspected incident of resident abuse, including injury of unknown source. An Occurrence Note dated 08/20/2024 at 05:12 PM, written by the Assistant Director of Nursing, documented that Certified Nursing Assistant #2 reported on 08/20/2024 at approximately 4:45 PM, they witnessed during care, Resident #1 held on tightly to Certified Nursing Assistant #1's hand, sinking their fingers into Certified Nursing Assistant #1's arm. Certified Nursing Assistant #1 raised their hand and with a deliberate, forceful slap to Resident #1's face between their forehead and eyes. Resident #1 responded by letting go immediately of the Certified Nursing Assistant #1's hand. Resident #1 did not scream or try to fight back. Resident #1 was assessed with no apparent injury. Facility Summary of Investigation dated 08/20/2024, documented Law Enforcement was called, but no arrest was made. Certified Nurse Assistant #1 neither admitted nor denied slapping Resident #1. Certified Nursing Assistant #1 was suspended and terminated. The facility concluded that abuse may have occurred during the time Certified Nursing Assistant #1 cared for Resident #1. Resident #1 was admitted to the facility with diagnoses including Dementia, Alcohol Abuse, and Delirium. A Minimum Data Set (a resident assessment tool) dated 05/31/2024, identified that Resident #1 had a Brief Interview of Mental Status and scored 0/15 indicating Resident #1 was cognitively impaired. Resident #1 required supervision or touching assistance with bed mobility, transfer, and toileting. A Care Plan Titled Resident Abuser/Victim initiated on 02/22/2024, documented interventions to separate the victim from the abuser and affirm appropriate behavior. A Care Plan Titled Alteration in Behavior effective date 02/22/2024, documented interventions to maintain a calm environment, and use behavior modification techniques. The care plan notes from 05/09/2024 to 08/20/2024, documented Resident #1 was physically aggressive and resisted care at times. Nursing progress notes from 05/01/2024 to 08/20/2024, documented that Resident #1 was observed to be physically aggressive toward staff, resisting care, hitting staff, and yelling at staff at times. A New York Police Department Omni form System-Complaint dated 08/20/2024, documented the classification of the occurrence as Harassment and no arrest. During an interview on 08/27/2024 at 12:17 PM, Assigned Certified Nursing Assistant #1 stated that they provided care to Resident #1 on 08/20/2024 at around 6:30 AM. Certified Nursing Assistant #1 stated that they knew that Resident# 1 might be combative when trying to change them. Certified Nursing Assistant #1 stated that the nurse on the unit told them to get help when they were going to provide care to Resident #1. Certified Nursing Assistant #1 stated they asked Certified Nursing Assistant #2 to assist them. Certified Nursing Assistant #1 stated that when they attempted to change Resident #1, Resident#1 put their fingernails on Certified Nursing Assistant #1's arm in the wrist area. Certified Nursing Assistant #1 stated it was hurting, and Certified Nursing Assistant #1 released Resident #1's hand. Certified Nursing Assistant #1 stated they did not hurt Resident #1. Certified Nursing Assistant #1 also stated that they did not slap Resident #1 in the face. They moved Resident #1's hand and continued to provide care. Certified Nursing Assistant #1 stated that they should have notified the nurse that Resident #1 was combative. During an interview on 08/27/2024 at 12:53 PM, Certified Nursing Assistant #2 stated that on 08/20/2024 around 6:50 AM, Certified Nursing Assistant #1 asked them to assist with Resident #1 care. Certified Nursing Assistant #2 stated that when they went to the room, they observed Resident #1 hitting Certified Nursing Assistant #1 over the upper body with both hands while they were changing Resident #1. Certified Nursing Assistant #2 stated Certified Nursing Assistant #1 stopped providing care and asked them to help turn Resident #1. Certified Nursing Assistant #2 stated they helped to turn Resident #1, but the resident was still fighting and moving their hands toward Certified Nursing Assistant #1. Certified Nursing Assistant #2 stated that they should stop providing care and call the nurse if the resident resisted or was fighting, but in Resident #1's case, they did not want to leave them unchanged. Certified Nursing Assistant #2 stated that when Certified Nursing Assistant #1 was washing Resident #1's back, Resident #1 held Certified Nursing Assistant #1 's hand around the wrist area and sank their fingernails in their skin. Certified Nursing Assistant #2 stated that Certified Nursing Assistant #1 gave Resident #1 a forceful slap in the face between the eye and forehead. During an interview on 08/27/2024 at 11:44 PM, Licensed Practical Nurse #1 stated they worked on 08/20/2024 11 pm-7 am shift, and no staff reported any abuse. Licensed Practical Nurse #1 also stated that no staff had reported to them that Resident #1 was resistant to care and combative. During an interview on 08/27/2024 at 3:50 PM, Registered Nurse Manager #1 stated they were responsible for updating the care plan and Resident Nursing Instructions. Registered Nurse Manager #1 stated that Resident #1 was resistant and combative at times, when the resident moves/transfers. Registered Nurse Manager #1 stated that staff was instructed that when Resident #1 became resistant, they should stand back, report to the nurse or supervisor, and get help from another staff member. Registered Nurse Manager #1 stated that it should be documented in Resident Nursing Instructions to notify the nurse and get a second person if the resident became combative, and it was omitted. Registered Nurse Manager #1 also stated staff cannot retaliate if the resident hits or hurts the staff. During an interview on 08/28/24 at 2:56 PM, the Risk Manager #1 stated that Resident Nursing Instructions should include instructions to the Certified Nursing Assistants on what they should do if Resident #1 resists care or is combative/ aggressive. During an interview on 08/29/2024 at 12:25 PM, Assistant Director of Nursing #1 stated they were informed about the alleged abuse on 08/2024 at 4:45 PM and investigated the incident. Assistant Director of Nursing #1 stated Certified Nursing Assistant #2 reported witnessing Certified Nursing Assistant #1 slapped Resident #1 in the face at 6:53 AM. Assistant Director of Nursing #1 stated they interviewed Certified Nursing Assistant #1 over the phone, and they did not acknowledge or deny if they slapped Resident #1. Assistant Director of Nursing #1 stated according to Certified Nursing Assistant #1, Resident #1 was combative and hit them. Assistant Director of Nursing #1 stated Certified Nursing Assistant #1 was supposed to stop providing care and report to the nurse immediately. Assistant Director of Nursing #1 stated that calling the nurse or having a second person assist was not documented in Resident#1's instructions prior to the incident. Assistant Director of Nursing #1 stated that Certified Nursing Assistant #1 was terminated for abuse based on an incident witnessed by Certified Nursing Assistant #2. During an interview on 08/29/2024 at 2:29 PM, the Administrator stated that they were notified immediately and were physically present. The Administrator stated they met with the Director of Nursing and Risk Manager to discuss the incident and concluded that abuse may have occurred. The Administrator stated that law enforcement came to the facility, no arrest was made, and Certified Nursing Assistant #1 was terminated. 10 NYC RR 415.4(b)(1)(i)

Based on record review and interviews conducted during the abbreviated survey (NY00341680) on 08/27/2024-08/29/2024, the facility failed to ensure the resident was free of significant medication errors. This was evident for one out of five sampled residents (Resident #2). Specifically, on 05/08/2024 at approximately 10:50 PM, Registered Nurse # 1 administered 24 units of insulin Lantus (long-acting insulin) to Resident #2, who was not on insulin therapy. The Medical Doctor was made aware and immediately ordered dextrose 5 % and 0.45 % sodium chloride intravenous solution to be infused at 70 ml/hour for 24 hours. Fingerstick Blood Sugar and vital signs (blood pressure, pulse, and temperature), monitor every four hours for 24 hours. The findings are: The facility Policy and Procedure titled, Administration of Insulin Injection and Preparation with revision date 01/2018, documented it is the facility policy to administer insulin preparations safely and appropriately. The nurse responsibility included. Review medication order, identify resident, explain procedures, and follow the rights for medication administration. Resident #2 was admitted to the facility with a diagnosis of Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and chronic kidney disease. The Minimum Data Set (an assessment tool) dated 04/13/2024, documented that Resident #2 had intact cognition. A Physician Order Activity Detail Report dated 05/01/2024 to 05/08/2024, revealed there were no Physician Order for insulin Lantus. A Care Plan Alteration in Blood Glucose Level effective date 05/03/2023, documented interventions, including monitoring blood glucose levels as ordered and notifying the Medical Doctor of changes. The Facility's Fall/Occurrence Report dated 05/08/2024, documented at 10:50 PM, License Practical Nurse #1 reported to Registered Nurse Supervisor #1 that Resident #2 was given insulin in error. A complete assessment was done. Emotional support was provided. The Medical Doctor and family were notified. Intravenous fluid was administered as ordered by the Medical Doctor. A Medication Error Incident Report dated 05/08/2024, documented that Licensed Practical Nurse #1 asked Registered Nurse # 1 to administer Lantus to Resident #3. Registered Nurse #1 failed to identify the resident prior to administering the medication and inadvertently administered 24 units of Lantus to Resident #2, who has a diagnosis of Diabetes, but is not on insulin therapy. Resident #2 remained asymptomatic. Registered Nurse #1's employment was terminated. A Situation Background Assessment Recommendation Note dated 05/09/2024 at 02:55 AM, written by Registered Nurse #1 documented that on 05/08/2024 at approximately 10:50 PM, they incidentally administered Insulin to Resident #2. Registered Nurse #1 immediately told Licensed Practical Nurse #1, who called Registered Nurse Supervisor #1. Resident #2 was alert and responsive. Resident #2 was not in any acute distress with Blood Sugar 136 milligram/deciliter, Blood Pressure 165/81, Pulse 94, Respiration 19, Temperature 98.0, Oxygen saturation 95% Room Air. The Medical Doctor was made aware immediately and ordered dextrose 5 % and 0.45 % sodium chloride intravenous solution infuse by intravenous route 70 ml per hour for 24 hours. Monitor Fingerstick Blood Sugar and vital signs every 4 hours for 24 hours. The orders were implemented. The vital signs were re-checked at 11:25 PM and were within normal limits. The Blood Sugar was 136 milligram/deciliter. A Situation Background Assessment Recommendation Note dated 05/09/2024 at 01:49 AM, written by Registered Nurse Supervisor #1 documented that Registered Nurse #1 incidentally administered insulin Lantus 24 units to Resident #2 at 10:50 PM. Resident #2 stated in an interview that the nurse gave them insulin injection, and they know they don't get any insulin. A Physician Order Activity Detail Report dated 05/09/2024, documented the orders for dextrose 5 % and 0.45 % sodium chloride intravenous solution, infuse 70 milliliters by intravenous route immediately 70 ml/hour for 24 hours. Fingerstick Blood Sugar every 4 hours for 24 hours. Call the Medical Doctor for blood sugar below 75 mg/dl. A Medical Interim Progress Note dated 05/15/2024 at 12:05 AM, documented Resident #2 received a dose of long-acting insulin by error last week. Today, 05/15/2024, the resident states that they did not feel too well yesterday, which could have been secondary to the sustained effect of the long-acting insulin dose. During a telephone interview on 08/28/2024 at 1:49 PM, Resident #2 stated that the incident happened around 11:00 PM, and they were dosing off. Resident #2 stated that the room was dark, and they felt someone uncovering them and saying something, but they were wearing masks, and they did not hear what the staff said. Resident #2 stated that they thought it was a nurse administering cream for the rash on their tummy, and they allowed to uncover them. Resident #2 stated that they felt that the nurse injected something in their tummy, woke up fully, and asked what they were doing. Resident #2 stated the nurse said it was their insulin. Resident #2 stated that they told the nurse that they were not taking insulin, and the nurse said, yes. Resident #2 stated that after they convinced the nurse that they had the wrong resident, the nurse left. Resident #2 stated a Licensed Practical Nurse #1 came into the room and said everything would be all right and checked their blood pressure and glucose. Resident #2 stated that they texted their adult child and notified them of what happened. During an interview on 08/28/2024 at 2:05 PM, Licensed Practical Nurse #1 stated that the incident happened on 05/08/2024 during the 3-11 shift, they asked Registered Nurse #1 to give Resident #3 their insulin. Licensed Practical Nurse #1 stated they already prepared the insulin with a pen and told Registered Nurse #1 the name of the resident and showed them the Medication Administration Record for Resident #3. Licensed Practical Nurse #1 stated that later Registered Nurse #1 told them that they thought they made a mistake by giving insulin to the wrong resident. Licensed Practical Nurse #1 stated they notified the supervisor and Medical Doctor. During an interview on 08/28/2024 at 2:38 PM, Registered Nurse #1 stated on 05/08/2024, around 10:30 PM -10:45 PM, Licensed Practical Nurse #1 asked them to administer insulin to Resident #3 and said it had already been prefilled. Registered Nurse #1 stated that they were very busy and fixated on another resident under their care and had a lot of pressure in their head. Registered Nurse #1 stated that they did not check the Electronical Medical Administration Record as they were supposed to and went to the wrong room. Registered Nurse #1 stated that the room was dark and they did not open the light, and they did not check the resident's wristband as they were supposed to. Registered Nurse #1 stated that after the resident told them that they were not taking insulin, they realized that they had administered the insulin to the wrong resident. Registered Nurse #1 stated that they immediately told the Licensed Practical Nurse #1, Nursing Supervisor and called the Medical Doctor. During an interview on 08/29/2024 at 11:19 AM, Registered Nurse Supervisor #1 stated they were called to the unit by Registered Nurse #1, who notified them that they administered insulin to the wrong resident. Registered Nurse Supervisor #1 stated that they assessed and interviewed Resident #2. Registered Nurse Supervisor #1 stated Resident #2 told them that they got injections, and they were not receiving any insulin. Emotional support was provided. Registered Nurse Supervisor #1 stated they did not observe any adverse reaction, vital signs were normal, and the Medical Doctor was notified. Registered Nurse Supervisor #1 stated Registered Nurse #1 did not follow the five rights of medication administration and assumed that it was the right resident without checking the resident's wristband as a part of identification. During an interview on 08/28/2024 at 1:22 PM, the Medical Doctor stated Resident #2 had no order for insulin. The Medical Doctor stated they evaluated Resident #2 after the incident on 05/08/2024. The Medical Doctor stated that Resident #2 did not sustain any harm, emotional or physical, due to the one-dose injection of the insulin Lantus. Resident #2 was monitored and received dextrose 5% intravenously, and it was discontinued due to the increase in blood glucose level. During an interview on 08/29/2024 at 2:36 PM, the Administrator stated that they were informed about Registered Nurse #1 not following facility policy on medication administration, which resulted in administering insulin to the wrong resident. The Administrator stated Registered Nurse #1 and was terminated from employment. 10 NYCRR 415.12 (m)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification and Complaint (NY00311511) survey from 04/27/23 to 05/04/23, the facility did not ensure a resident was treated with respect and dignity. This was evident for 1 (Resident #402) of 6 residents reviewed for Activities of Daily Living (ADL) out of 41 total sampled residents. Specifically, Resident #402 was served and ate lunch while waiting for incontinence care after having a bowel movement. The findings are: The facility policy titled Toileting last revised 04/18 documented all residents are brought to the toilet regardless of continence status, unless physically or medically contraindicated. Resident #402 had diagnoses of diabetes mellitus and non-Alzheimer's dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #402 was cognitively intact, always incontinent of bowel, and required 1 person to assist with transfers and toilet use. On 05/01/23 at 12:02 PM, Resident #402 was observed sitting in their wheelchair in the hallway on their unit. Resident #402 stated they have been having diarrhea for a few days due to recent antibiotic use, bowel movement, and they are waiting to be put back to bed to have their incontinent brief changed. Resident #402 was in the dining room preparing to have lunch with other residents and left to sit in the hallway once they realized they had a bowel movement. At 12:10 PM, Licensed Practical Nurse (LPN) #1 was interviewed and stated they were aware Resident #402 needed to have their incontinence brief changed. Resident #402's room is being cleaned and the staff are serving lunch so Resident #402 will be changed when lunch service is done. Certified Nursing Assistant (CNA) #1 assigned to Resident #402 is on break. At 12:15 PM, CNA #1 was observed walking up and down the hallway on the unit. On 5/1/23 at 12:40 PM, Resident #402 was observed in their room in the wheelchair feeding themselves lunch from the tray in front of them. Resident #402 stated they still had a bowel movement in their incontinence brief that needed to be changed. Staff have not provided incontinence care yet. On 05/01/23 at 12:45PM, Registered Nurse (RN) #1 was observed entering Resident #402's room. On 05/01/23 at 3:00PM, Resident #402 was interviewed and stated the nursing staff eventually changed their incontinence brief earlier. Resident #402 stated they understand it always takes a while to get changed. The Comprehensive Care Plan (CCP) related to ADL - Toilet Use, initiated 05/06/20 and last reviewed 4/19/23, documented Resident #402 was unable to transfer to the toilet and required extensive assistance of 1 person to be toileted. Nursing Note dated 4/30/23 documented Resident #402 was receiving Sulfamethoxazole 400mg twice daily for 10 days for a urinary tract infection. Nursing Note dated 05/01/23 at 3:49 PM documented Resident #402 completed antibiotic therapy and was noted with loose bowel movements. Staff will continue to assist the resident as needed. On 05/01/23 at 02:39 PM, CNA #1 was interviewed and stated they were assigned to Resident #402 and CNA #1 cleaned the resident's bowel movement this morning before taking them out of bed at 11:20 AM. Resident #402 was taken out of the room so staff could clean the room. Resident #402 can wheel themselves and the resident chose where they went after leaving their room. CNA #1 stated they served lunch in the dining room earlier and were not aware Resident #402 needed their incontinence brief changed. CNA #1 then went to lunch from 12:30 PM to 1:00 PM. Another staff member placed Resident #402 back in bed and performed incontinence care while CNA #1 was on lunch. On 05/01/23 at 02:51 PM, a follow up interview was conducted with LPN#1 who stated if a resident needs assistance, any CNA can be assigned to assist the resident. The unit usually uses a buddy system to address the issue of residents who require ADL care while their CNA is on break. LPN#1 stated the Social Worker informed LPN #1 that Resident #402 had a bowel movement and required incontinence care. CNA #1 was on lunch when Resident #402 needed to be changed and then LPN #1 stated they went on lunch at 12:15 PM. On 05/03/23, at 11:08 AM, LPN#2 stated LPN #1 mentioned Resident #402 needed to be changed and LPN #1 looked for CNA #1 to change the resident. LPN #2 found that CNA #1 was on break. RN #1 was notified, and 2 other CNAs were tasked with changing the resident. If there is any issue where a resident needs assistance, LPN #2 would pull a CNA from another assignment to attend to the resident in need. On 05/01/23 02:58 PM, RN#1 was interviewed and stated the unit has a buddy system where a CNA covers the assignment of the CNA going on lunch. RN#1 stated the delay in ADL assistance for Resident #402 could have been avoided if RN #1 was made aware. The delay should not have occurred, and RN #1 had another CNA change Resident #402 right away once RN #1 was made aware. On 05/04/23, at 09:03 AM, the Program Director was interviewed and stated they are familiar with Resident #403 and knows that the resident requires assistance. Staff are responsible for finding someone available to address the resident's needs. The facility uses a buddy system to address concerns with ADL care like this. A resident may wait a few minutes to be toileted, but the resident should not be waiting for 45 minutes to get staff assistance. 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification and abbreviated survey (NY00307515) from 4/27/23 to 5/4/23, the facility did not ensure the resident's representative was notified of a significant change in the resident's condition and a need to alter treatment. This was evident in 1 (#936) out of 5 residents reviewed for Notification of Change of 41 total sampled residents. Specifically, Resident #936's representative was not notified after the resident sustained a rib fracture. The findings include: The facility policy titled Notification of Changes, revised 09/2022, documented the resident, physician, and legal representative or family member should be immediately notified when there is an accident or incident involving the resident, a significant change in status or condition, or changes in resident's rights. Resident #936 had diagnoses of chronic obstructive pulmonary disease (COPD) and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #936 was severely cognitively impaired. The Medical Doctor (MD) Note dated 11/17/2022 documented Resident #936 had volume depletion, was positive for cough, the MD ordered a chest x-ray, and the resident was started on Levaquin for pneumonia. The Radiology Report dated 11/19/2022 documented Resident #936's chest x-ray findings of visualized osseous structures that demonstrated degenerative changes and fracture deformities of multiple left ribs. The Nurse Practitioner (NP) Note dated 11/19/22 documented Resident #936's chest x-ray result showed degenerative changes and fracture deformities of multiple left ribs and left lower lobe consolidation. The plan documented to continue with Levaquin, encourage oral fluid intake, and continue monitoring for adverse reaction. There was no documented evidence that Resident #936's designated representative was notified when the resident's chest x-ray showed left rib fractures. During an interview on 05/04/2023 at 12:44 pm, LPN (Licensed Practical Nurse) #1 stated they informed the NP of Resident #936's left rib fracture when they received the chest x-ray report. During an interview on 05/01/2023 at 1:55 pm, the NP stated that Resident #936 was started on an antibiotic, and a chest x-ray was ordered because the resident had a cough that kept coming back and a chest x-ray result on 11/19/2022 showed rib fractures. The NP stated that they did not call the resident's family to notify them of the rib fractures, and that it is usually the nursing supervisor who notifies the family. During an interview on 05/01/2023 at 1:08 pm, the MD stated that they were the attending physician for Resident #936. The MD stated that they do not recall speaking with the family about the rib fractures, and if they did, they would have documented it in the progress notes. The MD states that the NP should have been the one that communicated the rib fractures to the family when they reviewed the x-ray report. During an interview on 05/04/2023 at 1:04 pm, the Director of Nursing (DON) stated that the MD and the nurse should have immediately notified Resident #936's family of the rib fractures upon identification. During an interview on 05/04/2023 at 1:21 pm, the Administrator stated that Resident #936's family should have been immediately notified by the NP or the MD as soon as they saw that the x-ray report suggested rib fracture. 415.3(f)(2)(ii)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during a Recertification and Abbreviated survey (NY00312479), the facility did not ensure a resident was free from abuse. This was evident for 1 (Resident #193) of 41 total sampled residents. Specifically, Resident #193 picked up the call bell remote after telling Certified Nurse Assistant (CNA) #1 to stop providing care without a 2nd staff member present to assist. CNA #1 grabbed the call bell remote from Resident #193's hand. Resident #193 sustained trauma and pain to the left-hand 4th finger (ring finger), and they continue to have pain and functional limitations in the left-hand ring finger. The findings are: The facility policy titled Abuse Prohibition Protocol dated 02/2023 documented every resident has the right to be free from abuse, mistreatment, neglect, misappropriation of property and to be free from abuse facilitated or caused by the facility's staff. Resident #193 had diagnoses of osteoarthritis and osteoporosis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #193 had mild cognitive impairment and was totally dependent on 2 people for toileting and bed mobility. On 05/02/2023 at 9:00 AM and 05/02/2023 at 3:09 PM, Resident #193 was observed with a swollen left-hand ring finger (RF) resting in a straight position. Resident #193 attempted to bend their left RF and was unable to do so without wincing and grimacing in pain. Resident #193 was not able to fully bend the finger. During the observation, Resident #193 was interviewed and stated on 3/10/23, Certified Nursing Assistant (CNA) #1 came into their room to provide care after Resident #193 had a bowel movement. CNA #1 did not have another staff member in the room to assist with care. Resident #193 asked CNA #1 to get the nurse, and CNA #1 told them they will get the nurse after they are finished providing care. Resident #193 told CNA #1 to stop providing care and not to touch them, but CNA #1 continued to give them care. Resident #193 stated they picked up the call bell/television remote in their hand to call the nurse. CNA #1 grabbed the remote out of Resident #193's hand, bending the resident's left RF back in the process. Resident #193 stated they sustained swelling, discoloration, limitation in mobility, and persistent pain that still has not resolved. Resident #193 noticed the discoloration on 3/11/23 and reported the incident to the nurse. The Employee File of CNA #1 documented mandatory in-service related to abuse was provided to CNA #1 on 07/27/2022. The CNA Documentation Record from 03/01/2023 to 03/31/2023 documented Resident #193 required 2 people to assist with bed mobility and toilet use. The Nursing Note dated 3/11/2023 documented Resident #193 was assessed for a complaint of left RF pain, swelling, and discoloration. Resident #193 stated they were unable to move the finger. The Investigation Report dated 03/11/2023 documented Licensed Practical Nurse (LPN) #1 responded to Resident #193's call light, and Resident #193 complained of pain to their left RF. Resident #193 was observed with left RF discoloration extending to the palm of their hand. Registered Nurse Supervisor (RNS) #1 was notified, assessed Resident #193, and determined the resident's left RF was swollen, discolored (purplish), and tender to touch. The Medical Doctor (MD) was notified, an x-ray ordered, and no fracture was noted. The facility investigated Resident #193's allegation that CNA #1 provided care without a 2nd staff member present and grabbed the remote from the resident's hand during care. The report documented the facility concluded the abuse allegation was substantiated. The MD Note 3/13/2023 documented Resident #193's left RF sustained trauma after being bent backwards with pain, swelling, ecchymosis extending to the palm of the hand, tenderness over the metacarpophalenageal joint, and motor restriction from edema. The X-ray result for Resident #193's left hand was negative for fracture. The MD documented a plan to ice Resident #193's finger as tolerated, repeat x-ray, and obtain an orthopedic consult. The MD documented Resident #193 had a questionable fracture versus ligament tear versus unreadable fracture due to degenerative joint disease and osteopenia. Radiology Reports dated 3/12/23 and 3/13/23 documented the x-rays determined there was no fracture to Resident #193's left RF. The Employee Disciplinary Action dated 03/13/2023 documented CNA #1 was terminated from the facility. The MD Note dated 3/15/23 documented Resident #193 continued to have pain in their left hand and was unable to flex their left RF. The pain was controlled with Tylenol, and the MD was awaiting the orthopedic consult. The MD Order dated 3/15/23 documented orders for an orthopedic consult following trauma to the left RF and repeat left hand x-ray. The MD Order dated 3/16/23 documented orders for ice to be applied to Resident #193's left RF for 10 minutes as tolerated for 3 days. The Medication Administration Record (MAR) for March 2023 documented Resident #193 received ice to their left RF for 10 minutes every shift from 3/13/23 to 3/15/23. Gabapentin 100mg was administered once daily to Resident #193 starting 3/30/23 for chronic pain. Tylenol extra strength 1000mg was administered to Resident #193 three times a day from 3/1/23 to 3/21/23 for unspecified pain. The Radiology Report dated 5/1/23 documented Resident #193 had an x-ray of the left hand due to swelling and no fracture was noted. During an interview on 05/02/2023 at 4:45 PM, CNA #1 stated on 3/10/23 they were assigned to Resident #193 on the 3 PM-11 PM shift. During their shift, Resident #193 was soiled and requested to be changed. CNA #1 stated they were providing care to Resident #193 when the resident requested to see the nurse. CNA #1 told Resident #193 they were in the middle of providing care and will notify the nurse once care is completed. CNA #1 left the room after they were finish providing Resident #193 with care and informed the nurse the resident wanted to see them. Resident #193 never expressed any pain or discomfort. CNA #1 did not observe any discoloration of swelling of Resident #193's left RF. CNA #1 never asked any staff members for help to change Resident #193. Resident #193 is alert and can turn themselves. CNA #1 stated they were aware that Resident #193 required two people to assist with toileting and bed mobility. CNA #1 denied the allegation of abuse involving Resident #193 and received in-services on abuse prevention. During an interview on 05/03/2023 at 12:44 PM, LPN #1 stated they worked on 3/11/23 and responded to Resident #193's call bell. Resident #193 reported the incident involving CNA #1 and left RF pain. LPN #1 reported the allegation to RNS #1. During an interview on 05/03/2023 at 1:00 PM, RNS #1 stated they assessed Resident #193's left RF swelling and pain on 3/11/23. Resident #193 reported on 03/10/2023, CNA #1 was attempting to take the call bell/TV remote from them and hurt the resident's finger. Resident #193 had discoloration, swelling, and pain, and they were unable to bend their finger. The MD was informed, and an x-ray was ordered. During an interview on 05/03/2023 at 1:30PM, the Director of Nursing (DON) stated they were informed of Resident #193's allegation involving CNA #1 on 03/11/2023. Resident #193 was interviewed and reported CNA #1 was rough with them and tried to grab the call bell away from them. Resident #193 was immediately assessed, the MD was made aware, and psychiatry and psychology consults were obtained. CNA #1 denied the allegation and was terminated. The DON stated that they were aware that the incident must be reported to the police, and they are not sure why it was not reported. An abuse prevention care plan is initiated upon admission, quarterly and annual assessment by nursing and social services. There was no abuse prevention care plan in place for Resident #193 because the resident is alert, oriented, and able to make their needs known. 415.4(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #193 had diagnoses of osteoarthritis and osteoporosis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #193 had mild cognitive impairment and was totally dependent on 2 people for toileting and bed mobility. The Investigation Report dated 03/11/2023 documented the nurse responded to Resident #193's call light and the resident complained of pain to their left RF and was observed with discoloration extending to the palm of their hand. The registered nurse supervisor (RNS) was notified and Resident #193's left RF was found swollen, discolored (purplish), and tender to touch. The Medical Doctor (MD) was notified, x-ray ordered, and no fracture was noted. The facility investigated Resident #193's allegation that CNA #1 provided care without a 2nd staff member present and grabbed the remote from the resident's hand during care. The report documented the facility concluded the abuse allegation was substantiated. The Employee Disciplinary Action dated 03/13/2023 documented CNA #1 was terminated from the facility. During an interview on 05/04/2023 at 12:14 PM, the Risk Manager (RM) stated Resident #193's allegation of abuse was investigated, and CNA #1 was interviewed. CNA #1 denied the allegation and the incident was not reported to the NYPD. During an interview on 05/03/2023 at 1:30PM, Director of Nursing (DON) stated they were informed Resident #193's allegation of abuse on 03/11/2023. CNA #1 was rough and was trying to grab the call bell and television remote away from the resident. The DON stated that they are aware the incident should have been reported to the NYPD, but they are not sure why it was not reported. 10 NYCRR 415.4(b) Based on observation, interview, and record review conducted during the recertification and complaint survey (NY00293108 and NY00312479) from 4/27/23 to 5/4/23, the facility did not ensure that all allegations of abuse, involving an injury of unknown source, were reported to the New York State Department of Health and suspicion of a crime was reported to the New York Police Department (NYPD. This was evident for 2 (Resident #937 and #193) of 41 sampled residents. Specifically, 1) Resident #937 sustained a left hip fracture of unknown origin that was not reported to the NYSDOH and 2) a substantiated allegation of abuse involving CNA #1 and Resident #193 was not reported to the NYPD. The findings are: The facility policy titled Abuse - Prohibition Protocol dated 2/2023 documented any alleged violations abuse, including injuries of an unknown source, must be reported to the Administrator, an investigation must be made, and the findings of such investigation must be reported within 24 hours of occurrence/discovery. 1) Resident #937 had diagnoses of dementia and benign prostatic hyperplasia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #937 was severely cognitively impaired. Nursing Note dated 03/19/2022 documented the Certified Nursing Assistant (CNA) reported Resident #937 had left hip pain and swelling when the CNA was providing activities of daily living (ADL) care to the resident. The Licensed Practical Nurse (LPN) and Registered Nurse Manager (RNM) were notified, Resident #937 left hip was assessed, and the resident left lower extremity (LLE) was observed pronated inward. Resident #937 grimaced in pain during range of motion (ROM) of the LLE. MD was notified, Tylenol 650 mg every 6 hours was ordered, and Stat x-ray of bilateral hips was ordered. Resident #937 was unable to state what occurred due to cognitive impairments. The Radiology Report dated 03/19/2022 documented the x-ray findings that Resident #937 had an acute moderately displaced left intertrochanteric fracture present with mild displacement resulting in varus angulation. The facility Summary of Investigation dated 03/24/2022 documented the CNA immediately notified the LPN on the unit when Resident #937 expressed pain on 3/19/22. X-ray findings were likely pathological in nature and there was no evidence to support abuse or neglect. The incident was not reported to the NYSDOH. During an interview on 05/04/2023 at 1:10 pm, the Director of Nursing (DON) stated there was no abuse and Resident #937's left hip fracture was probably pathological in nature secondary to osteoporosis. This was an injury of unknown origin and should have been reported to the NYSDOH. During an interview on 05/04/2023 at 1:16 pm, the Administrator stated a fracture of unknown origin must be investigated and reported to the NYSDOH.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey (NY00307515), the facility did not ensure that all alleged violation of abuse, including injuries of unknown source, were thoroughly investigated. This was evident in 1 (Resident #936) of 41 sampled residents. Specifically, Resident #936 was found to have multiple left rib fractures of unknown origin without evidence of an investigation to rule out abuse. The findings are: The facility policy titled Investigations dated 2/2022 documented all injuries of unknown origin will be investigated to determine abuse or mistreatment. Resident #936 had diagnoses of chronic obstructive pulmonary disease (COPD) and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #936 was severely cognitively impaired. The Medical Doctor (MD) Note dated 11/17/2022 documented Resident #936 had volume depletion, was positive for cough, the MD ordered a chest x-ray, and the resident was started on Levaquin for pneumonia. The Radiology Report dated 11/19/2022 documented Resident #936's chest x-ray findings of visualized osseous structures that demonstrated degenerative changes and fracture deformities of multiple left ribs. The Nurse Practitioner (NP) Note dated 11/19/22 documented Resident #936's chest x-ray result showed degenerative changes and fracture deformities of multiple left ribs and left lower lobe consolidation. The plan documented to continue with Levaquin, encourage oral fluid intake, and continue monitoring for adverse reaction. There was no documented evidence the facility investigated Resident #936's left rib fractures of unknown origin. During an interview on 05/04/2023 at 1:04 pm, the Director of Nursing (DON) stated that they briefly reviewed the case on Resident #936's left rib fractures and that an investigation should have been conducted. During an interview on 05/04/2023 at 1:21 pm, the Administrator stated that based on their policy, Resident #936's rib fractures should have been investigated to rule out abuse, neglect, or mistreatment. 10 NYCRR 415.4 (b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during a recertification and abbreviated survey (NY00307515) from 4/27/23 to 5/4/23, the facility did not ensure a resident's physician (MD) documented in the resident's medical record the basis for hospital transfer or discharge. This was evident in 1 (Resident #936) of 41 total sampled residents. Specifically, the MD did not document the reason Resident #936 was transferred to the hospital on [DATE]. The findings are: The facility policy titled Resident Transfer last revised 9/2021 documented that a medical order is required to initiate a transfer. Resident #936 had diagnoses of chronic obstructive pulmonary disease (COPD) and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #936 was severely cognitively impaired. Nurse Practitioner Note dated 11/19/22 documented Resident #936 had a chest x-ray. Nursing Note dated 11/25/2022 documented Resident #936 was less responsive, MD was notified, and a telephone order was given to transfer the Resident #936 to the emergency room for altered mental status. Resident #936 was transferred and left the unit at 12:15 PM. A Transfer to Acute Hospital Notice form dated 11/25/2022 documented Resident #936 required immediate transfer or discharge due to the resident's urgent medical need. There was no documented evidence the MD documented the reason for Resident #936's transfer to the hospital 11/25/22. During an interview on 05/01/2023 at 1:08 pm, the MD stated Resident #936 was transferred to the hospital on [DATE] due to altered mental status. The MD stated that that they do not have to document a resident's hospital transfer. The nurse manager is responsible for documenting who gave the MD order and the purpose for the hospital transfer. During an interview on 05/04/2023 at 1:04 pm, the Director of Nursing (DON) stated the MD does not need to document a resident's transfer to the hospital. Nursing should document a resident's hospital transfer. During an interview on 05/04/20223 at 1:33 pm, the Medical Director stated that for hospital transfers, the MD should write a note if they are available. If the MD gave the order for hospital transfer over the phone, the MD does not necessarily need to document in the resident's medical record. MDs usually document hospital transfers when the resident is discharged and does not come back to the facility. 415.3(i)(1)(ii)(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification and Complaint (NY00311511) survey from 04/27/23 to 05/04/23, the facility did not ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene. This was evident for 1 (Resident #402) of 6 residents reviewed for ADLs out of 41 total sampled residents. Specifically, Resident #402 was not provided with incontinent care after having a bowel movement. The findings are: The facility policy titled Toileting last revised 04/18 documented all residents are brought to the toilet regardless of continence status, unless physically or medically contraindicated. Resident #402 had diagnoses of diabetes mellitus and non-Alzheimer's dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #402 was cognitively intact, always incontinent of bowel, and required 1 person to assist with transfers and toilet use. On 05/01/23 at 12:02 PM, Resident #402 was observed sitting in their wheelchair in the hallway on their unit. Resident #402 stated they have been having diarrhea for a few days due to recent antibiotic use, bowel movement, and they are waiting to be put back to bed to have their incontinent brief changed. Resident #402 was in the dining room preparing to have lunch with other residents and left to sit in the hallway once they realized they had a bowel movement. At 12:10 PM, Licensed Practical Nurse (LPN) #1 was interviewed and stated they were aware Resident #402 needed to have their incontinence brief changed. Resident #402's room is being cleaned and the staff are serving lunch so Resident #402 will be changed when lunch service is done. Certified Nursing Assistant (CNA) #1 assigned to Resident #402 is on break. At 12:15 PM, CNA #1 was observed walking up and down the hallway on the unit. On 5/1/23 at 12:40 PM, Resident #402 was observed in their room in the wheelchair feeding themselves lunch from the tray in front of them. Resident #402 stated they still had a bowel movement in their incontinence brief that needed to be changed. Staff have not provided incontinence care yet. On 05/01/23 at 12:45PM, Registered Nurse (RN) #1 was observed entering Resident #402's room. On 05/01/23 at 3:00PM, Resident #402 was interviewed and stated the nursing staff eventually changed their incontinence brief earlier. Resident #402 stated they understand it always takes a while to get changed. The Comprehensive Care Plan (CCP) related to ADL - Toilet Use, initiated 05/06/20 and last reviewed 4/19/23, documented Resident #402 was unable to transfer to the toilet and required extensive assistance of 1 person to be toileted. Nursing Note dated 4/30/23 documented Resident #402 was receiving Sulfamethoxazole 400mg twice daily for 10 days for a urinary tract infection. Nursing Note dated 05/01/23 at 3:49 PM documented Resident #402 completed antibiotic therapy and was noted with loose bowel movements. Staff will continue to assist the resident as needed. On 05/01/23 at 02:39 PM, CNA #1 was interviewed and stated they were assigned to Resident #402 and CNA #1 cleaned the resident's bowel movement this morning before taking them out of bed at 11:20 AM. Resident #402 was taken out of the room so staff could clean the room. Resident #402 can wheel themselves and the resident chose where they went after leaving their room. CNA #1 stated they served lunch in the dining room earlier and were not aware Resident #402 needed their incontinence brief changed. CNA #1 then went to lunch from 12:30 PM to 1:00 PM. Another staff member placed Resident #402 back in bed and performed incontinence care while CNA #1 was on lunch. On 05/01/23 at 02:51 PM, a follow up interview was conducted with LPN#1 who stated if a resident needs assistance, any CNA can be assigned to assist the resident. The unit usually uses a buddy system to address the issue of residents who require ADL care while their CNA is on break. LPN#1 stated the Social Worker informed LPN #1 that Resident #402 had a bowel movement and required incontinence care. CNA #1 was on lunch when Resident #402 needed to be changed and then LPN #1 stated they went on lunch at 12:15 PM. On 05/03/23, at 11:08 AM, LPN#2 stated LPN #1 mentioned Resident #402 needed to be changed and LPN #1 looked for CNA #1 to change the resident. LPN #2 found that CNA #1 was on break. RN #1 was notified, and 2 other CNAs were tasked with changing the resident. If there is any issue where a resident needs assistance, LPN #2 would pull a CNA from another assignment to attend to the resident in need. On 05/01/23 02:58 PM, RN#1 was interviewed and stated the unit has a buddy system where a CNA covers the assignment of the CNA going on lunch. RN#1 stated the delay in ADL assistance for Resident #402 could have been avoided if RN #1 was made aware. The delay should not have occurred, and RN #1 had another CNA change Resident #402 right away once RN #1 was made aware. On 05/04/23, at 09:03 AM, the Program Director was interviewed and stated they are familiar with Resident #403 and knows that the resident requires assistance. Staff are responsible for finding someone available to address the resident's needs. The facility uses a buddy system to address concerns with ADL care like this. A resident may wait a few minutes to be toileted, but the resident should not be waiting for 45 minutes to get staff assistance. 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification and abbreviated survey (#NY00308148) from 4/27/23 to 5/4/23, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evidenced for 1 (Resident #475) of 41 total sampled residents. Specifically, Resident #475 was not assessed after a a family member reported swelling and discoloration to their right hand. The findings are: Resident # 475 had diagnoses of dementia and renal failure. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #475's cognition was severely impaired. On 04/28/23 at 10:52 AM, an interview was conducted with NOK #2. NOK #2 stated that they noticed Resident # 475's right hand and knuckles were swollen during visitation, but they were not notified about the swelling and what happened to the hand. The nurse told them that nothing happened to the resident's hand. The Aspen Complaint Tracking System (ACTS) intake dated 1/6/23 documented the complainant, Next of Kin (NOK) to Resident #475, visited the facility on 5/1/22 at 12:00 PM and saw Resident #475 in the dayroom complaining their hand was hurting and wincing when the complainant touched their hand. The complainant noticed swelling by the knuckles and some bruising and reported it to Licensed Practical Nurse (LPN) #6. The complainant was told by LPN #6 that nothing happened and their expressed concern was ignored. The complainant took pictures of the Resident #475's hand and returned the next day, 5/2/22, to visit. Resident #475's hand was still bruised and very painful and the complainant and went to report the concern again to nursing staff. Another nurse on the unit asked LPN #6 what occurred with Resident #475 and LPN #6 replied Resident #475 hit their hand on the table. Program Director (PD) #1 told the family the incident with Resident #475's hand happened right before they visited the facility on 5/1/22. A Nursing Behavior Note dated 5/1/22 at 2:25 PM documented that Resident #475 was observed slapping both hands on the table repeatedly and tossed over the bedside table. The resident was flailing their arms and coming into contact with staff. A Medical Doctor (MD) Note dated 5/1/22 at 9:49 PM documented Resident #475 had abnormal gait, used a wheelchair, had no falls, was not in distress, heart, lungs, abdomen, and calves were ok. There was no documented evidence Resident #475 was assessed on 5/1/22 after NOK #2 reported swelling in the hand. A Nurse's Progress Note dated 5/2/22 at 2:08 PM documented that the PD #2 was informed that Resident # 475's right hand was swollen. Upon assessment, the resident was observed with some swelling to the right-hand dorsum, right #1&2 knuckles. The NOK was on the unit at the time. The facility Fall/Occurrence Report dated 5/3/22 documented Resident #475 had a right hand x-ray that showed a fracture at the base of the 2nd and 3rd fingers. A complete body assessment was completed, the MD was notified, the family was notified, and an orthopedic evaluation was ordered. On 5/2/23 at 10:54 AM, an interview was conducted with Certified Nursing Assistant # 5 (CNA #5). CNA #5 stated that Resident #475 was agitated and was banging their hands on a table. The nurse was informed and went to see the Resident. On 5/2/23 at 03:54 PM, an interview was conducted with Licensed Practical Nurse #6. (LPN #6) LPN # 6 stated that Resident # 475 got agitated but was unsure about the time. LPN # 6 does not remember Resident #475's NOK #2 reporting the Resident's hand was swollen. On 05/03/23 at 11:12 AM, an interview was conducted with Registered Nurse Manager # 2(RNM #2). RNM #2 stated that on 5/1/22, around 2:00 PM, Resident # 475 was observed banging on the bedside table during rounds. The resident tossed the bedside table. Upon assessment, there was no swelling or bruises. The nurse knew that the resident was agitated and banging on the bedside table. RNM #2 stated that nurses must notify the supervisor of any changes in the resident's condition, bruises, or swelling. On 5/03/23 at 10:15 AM, an interview was conducted with Program Director #2 (PD #2). PD #2 stated that on 5/2/22, during rounds at 2:08 PM, they were informed that resident #475's right hand was swollen. Upon assessment, Resident # 475 was noted to have swelling of the right-hand dorsum and the 1st and 2nd knuckles. NOK #2 was on the unit at that time. PD #2 stated they must call the family if a resident has swelling or a bruise. They are supposed to inform the family, whether in person or by phone. Resident # 475's family should have been told when the incident happened. On 5/4/23 at 2:56 PM, an interview was conducted with the Assistant Director of Nursing (ADNS). The ADNS stated that once there is a change in behavior and condition, the nurse was supposed to inform the family of the resident status. Once there was swelling, the supervisor and the family should have been notified. They should have seen and documented that the resident's arm was swollen during the day shift. On 5/4/23 at 3:18 PM, an interview was conducted with the Director of Nursing (DNS). The DNS stated that changes in the resident's condition should be immediate. The doctor and the family are to be notified after the assessment. They should have gone and looked at the resident hand and addressed the family in person or over the phone 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #513 had diagnoses of end stage renal disease (ESRD) and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #513 was cognitively intact and received dialysis treatment. The Physician's Orders renewed 04/21/23 documented Resident #513 had dialysis treatment on Tuesday, Thursday, and Saturday. The resident's permacath site was ordered to be checked for signs and symptoms of infection and bleeding. A Nursing Note dated 4/27/23 documented pre- and post-dialysis assessments of Resident #513 permacath site dressing before and after dialysis treatment. There was no documented evidence a CCP related to ESRD and dialysis treatment was developed and implemented for Resident #513. On 05/03/23 at 12:02 PM, the Registered Nurse (RN) #2 was interviewed and stated Resident #513 did not have a CCP related to ESRD. The admitting RN was responsible for initiating the CCPs for residents and the RN should check to see if a new CCP should be done. On 05/03/23 at 04:36 PM and 05/04/23 at 09:54 AM, the Assistant Director of Nursing (ADNS) was interviewed, and stated the RNs are responsible for initiating the CCPs upon a resident's admission and readmission. Resident #513 was previously diagnosed with ESRD but only began receiving dialysis treatment upon readmission and the CCP should have been updated to reflect the resident's change in condition. The CCP related to ESRD was included in Resident #513's initial admission to the facility. The CCP was not initiated again upon Resident #513's readmission to the facility from the hospital. Based on observation, record review, and interview conducted during the Recertification and Complaint (NY00312479) survey from 04/27/23 to 05/04/23, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet resident needs. This was evident for 3 (Residents #193, #513, and #936) of 41 total sampled residents. Specifically, 1) a CCP related to abuse prevention was not developed for Resident #193 following a substantiated abuse allegation, 2) a CCP related to dialysis treatment was not developed for Resident #513 who receives dialysis, and 3) a CCP related to fractures was not developed for Resident #936 following a left rib fracture. The findings are: The facility policy titled CCP last revised 4/2022 documented the CCP should be kept current by all disciplines on an ongoing basis. Disciplines will be responsible for updating the plan of care when there is a new problem that requires that discipline to intervene. The care plan will be revised to reflect the resident's current status, need, and achievements. 1) Resident #193 had diagnoses of osteoarthritis and osteoporosis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #193 had mild cognitive impairment and was totally dependent on 2 people for toileting and bed mobility. On 05/02/2023 at 9:00 AM and 05/02/2023 at 3:09 PM, Resident #193 was observed with the ring finger (RF) on their left hand swollen and resting in a straight position. Resident #193 attempted to bend their left RF and was unable to complete the task without wincing and grimacing in pain. The Nursing Note dated 3/11/2023 documented Resident #193 was assessed for a complaint of left RF pain, swelling, and discoloration. Resident #193 stated they are unable to move the finger. The Investigation Report dated 03/11/2023 documented the nurse responded to Resident #193's call light and the resident complained of pain to their left RF and was observed with discoloration extending to the palm of their hand. The registered nurse supervisor (RNS) was notified, and Resident #193's left RF was found swollen, discolored (purplish), and tender to touch. The Medical Doctor (MD) was notified, x-ray ordered, and no fracture was noted. The facility investigated Resident #193's allegation that CNA #1 provided care without a 2nd staff member present and grabbed the remote from the resident's hand during care. The report documented the facility concluded the abuse allegation was substantiated. The MD Note 3/13/2023 documented Resident #193's left RF sustained trauma after being bent backwards and had pain, swelling, ecchymosis extending to the palm of the hand, tenderness over the metacarpophalangeal joint, and motor restriction from edema. X-ray of Resident #193's left hand was negative for fracture. The MD documented a plan to ice Resident #193's finger as tolerated, repeat x-ray, and obtain an orthopedic consult. The MD also documented Resident #193 had a questionable fracture versus ligament tear versus unreadable fracture due to degenerative joint disease and osteopenia. The MD Note dated 3/15/23 documented Resident #193 continued to have pain in their left hand and was unable to flex their left RF. Pain is controlled with Tylenol and the MD was awaiting the orthopedic consult. MD Order dated 3/15/23 documented Resident #193 was ordered to have an orthopedic consult following trauma to the left RF and repeat left hand x-ray. On 3/16/23, ice was ordered to be applied to Resident #193's left RF for 10 minutes as tolerated for 3 days. The Medication Administration Record (MAR) for March 2023 documented Resident #193 received ice to their left RF for 10 minutes every shift from 3/13/23 to 3/15/23. There was no documented evidence a CCP related to abuse treatment and prevention was developed and implemented following a Resident #193's substantiated allegation of abuse on 3/10/23. During an interview on 05/02/2023 at 12:47 PM, the Social Service Director (SSD) stated the social services and nursing department assess the residents and determine whether to initiate an abuse prevention CCP. Resident #193 did not have an abuse prevention CCP in place because the resident is alert and able to make their needs known. During an interview on 05/03/2023 at 1:30PM, the Director of Nursing (DON) stated the nursing and social services department initiate abuse prevention CCPs upon admission, quarterly, significant changes and during annual assessments. A CCP related to abuse prevention was not initiated for Resident #193 because the resident is alert, oriented, and able to make their needs known. Resident #936 had diagnoses of chronic obstructive pulmonary disease (COPD) and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #936 was severely cognitively impaired. The Medical Doctor (MD) Note dated 11/17/2022 documented Resident #936 had volume depletion, was positive for cough, the MD ordered a chest x-ray, and the resident was started on Levaquin for pneumonia. The Radiology Report dated 11/19/2022 documented Resident #936's chest x-ray findings of visualized osseous structures that demonstrated degenerative changes and fracture deformities of multiple left ribs. The Nurse Practitioner (NP) Note dated 11/19/22 documented Resident #936's chest x-ray result showed degenerative changes and fracture deformities of multiple left ribs and left lower lobe consolidation. The plan documented to continue with Levaquin, encourage oral fluid intake, and continue monitoring for adverse reaction. There was no documented evidence a CCP related to Resident #936's left rib fractures was developed and implemented. During an interview on 05/01/2023 at 2:24 pm, Registered Nurse (RN) #1 stated they did not initiate a care plan for rib fracture because they were not aware of the fracture prior to Resident #936's hospitalization on 11/25/2022 and was not the nurse manager on the resident's unit upon readmission from the hospital. During an interview on 05/01/2023 at 1:40 pm, the Program Director (PD) was interviewed and stated they were responsible for readmitting Resident #936 to the facility. The PD did not initiate a CCP related to left rib fractures because they did not know Resident #936 was diagnosed with rib fracture when they were readmitted . If they knew about the resident's rib fractures, the PD could have developed a CCP to address Resident #936's rib fractures. During an interview on 05/04/2023 at 1:04 pm, the Director of Nursing (DON) stated a care plan related to Resident #936's rib fractures should have been initiated by the RN. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews conducted during the recertification survey, the facility did not ensure that a resident's dignity was maintained. Specifically, a resident with a urinary catheter was observed on multiple occasions to have no dignity bag covering the attached urine bag. This was evident for 1 of 1 resident reviewed for Dignity out of a sample of 38 residents (Resident # 444). The findings are: The facility policy and procedure titled Catheter Care Protocol dated 6/2018 documented that when the resident is in bed, assure the Foley bag is hanging off the bed, not on the floor/not visible. If the bag is visible, use a privacy bag. Resident # 444 was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia, Malignant Neoplasm of unspecified Kidney and Gross Hematuria. The Quarterly Minimum Data Set (MDS) 3.0 dated 8/4/20 documented that the resident had intact cognition, needed extensive assistance of one person for bed mobility, toilet use, and personal hygiene and was using an indwelling catheter. The Comprehensive Care Plan (CCP) Alteration in Bowel and Bladder Elimination dated 5/6/20 documented that the resident uses an indwelling catheter due to urinary retention and is bowel incontinent. Interventions included providing dignity and privacy in managing incontinent episodes and during toileting, providing catheter care as per protocol, and assessing the continued need for an indwelling catheter. The physician order dated 7/2/20 documented Foley indwelling catheter sized 16 for urinary retention, Foley care daily or as needed, Foley catheter change every month or as per needed, and Foley/ catheter output monitoring every shift. During multiple observations on 9/24/20 at 11:57 AM, 9/25/20 at 10:45 AM, and 9/28/20 at 12:45 PM, the resident was observed lying in the bed closest to the door of the room. The resident's Foley catheter drainage bag and catheter tubing were observed hanging from the left side of the bed that was closest to the door. Yellow urine was observed draining into the uncovered catheter bag, and the catheter bag and tubing were visible from the hallway. On 09/30/20 at 11:00 AM, an interview was conducted with Resident # 444. The resident reported wanting to be in bed at all times. The resident stated that the bag has always been placed on the left side, so it is visible for the staff to know when to drain the bag. The resident stated education was received about the privacy bag when using the wheelchair but the resident was not informed that the catheter bag should be placed somewhere that is not visible from the hallway while the resident is in bed. The resident further stated that it is the nurses who place the catheter bag on the left side of the bed. On 09/28/20 at 12:47 PM, an interview was conducted with Certified Nursing Assistant (CNA) # 1. CNA #1 stated that anyone could see the catheter bag lying on the footbed area upon entrance or walking in the corridor. CNA #1 added that it has always been placed on the footbed area on the left side since it is easy to access and is near the resident's wheelchair. CNA #1 added that she always placed the bag on the same side at all times. On 09/28/20 at 12:49 PM, an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 stated that she saw the resident lying in bed, and the catheter was exposed and was visible when walking in the hallway or from the room entrance. The LPN stated that she does not know why it was placed on the left side where it is exposed and it should have been placed on the less visible side of the bed. On 09/28/20 at 12:51 PM, an interview was conducted with the Registered Nurse (RN) #1. RN#1 stated that the catheter bag was visible from the hallway and upon entering the room. The RN added that she did not notice the catheter bag while she was doing her morning rounds. RN#1 stated that it is her duty and the assigned staff to ensure that the resident is provided with privacy and dignity, but this time they may have overlooked the catheter bag. On 9/30/20 at 1:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she has not visited the unit recently and that the urinary drainage bag should be adequately placed on the bed's side, not visible from the hallway or from the entrance of the room. 415.5 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review conducted during the Recertification and Abbreviated Survey, the facility did not ensure that advanced directives were reviewed periodically with resident representative. Specifically, there was no documented evidence advance directives had been discussed with the resident's representative. This was evident for 1 of 4 residents reviewed for Advance Directives (Resident #237). The findings are: The facility policy and procedure tiled Advance Directives revised 4/2018 documented the facility shall discuss/review the Advance Directive with resident, designated representative and CCP Team upon admission, annually, quarterly and at a change in the resident's condition warranting a review. Resident #237 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Dementia with behavioral disturbance, Delusional Disorder and Adult Failure to Thrive. The MDS also documented the resident had severe cognitive impairment. Social Services MDS Progress Note dated 2/26/20 documented information had been mailed annually. The facility was unable to provide documentation that this was done or had confirmation that information had been received by the resident's representative. Social Service MDS Progress note dated 5/18/2020 and 7/27/20 documented in the section Advance Directives that there had been no changes to advanced directives. There was no evidence the document was reviewed/discussed with resident representative as the field was blank. On 09/30/20 at 10:46 AM, the Social Worker (SW) was interviewed. The SW stated Advanced Directives are discussed when there are significant changes and annually. If the resident has capacity they execute, if not it is done with the family. Annually advance directives are mailed out to families for review. The SW also stated there should be a follow-up telephone call and/or email to confirm the documents had been received and this should be documented in the EMR. The SW stated that she could not locate any documentation that this had not been done for this resident. On 09/30/20 11:03 AM, the Assistant Director of Social Services (ADSS) was interviewed. The ADS stated advance directives are reviewed on an annual basis with residents or family members. Advance Directives are reviewed to establish if one is in existence or need to be initiated and this is documented in the assessment. Advance Directives should be reviewed with the resident's representative and information entered in the field provided or documented in the progress notes. The ADSS was unable to locate documentation in the record that this had been done. The ADSS also stated audits are done on a quarterly basis but did not include checking to ensure follow-up had been done for mailed documents. 415.3(e)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the Re-certification survey, the facility did not maintain infection control practices to help prevent the development and transmission of communicable diseases and infections. Specifically, the Foley catheter drainage bag and tubing were observed touching the floor in a resident's room. This was observed on multiple occasions during the survey. This was evident for 1 of 4 residents reviewed for Urinary Catheter or UTI out of a sample of 38 residents. (Resident #444) The findings are: The facility policy and procedure titled Catheter Care Protocol dated 6/18 documented that when the resident is in bed, assure the Foley bag is hanging off the bed, not on the floor/not visible. Resident # 444 was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia, Malignant Neoplasm of unspecified Kidney and Gross Hematuria. The Quarterly Minimum Data Set (MDS) 3.0 dated 8/4/20 documented that the resident had intact cognition, needed extensive assistance of one person for bed mobility, toilet use, and personal hygiene and was using an indwelling catheter. The Comprehensive Care Plan (CCP) Alteration in Bowel and Bladder Elimination dated 5/6/20 documented that the resident uses an indwelling catheter due to urinary retention and is bowel incontinent. Interventions included providing dignity and privacy in managing incontinent episodes and during toileting, providing catheter care as per protocol, and assessing the continued need for an indwelling catheter. The physician order dated 7/2/20 documented Foley indwelling catheter sized 16 for urinary retention, Foley care daily or as needed, Foley catheter change every month or as per needed, and Foley/catheter output monitoring every shift. On 09/24/20 at 11:57 AM, during the initial pool process, Resident # 444 was observed lying in a lowered bed closest to the room's door. The resident's Foley catheter bag and tubing were observed resting on the floor. On 09/25/20 at 10:45 AM and 12:10 PM, Resident # 444 was observed asleep lying in a lowered bed. The resident's Foley catheter bag and tubing were observed resting on the floor. On 09/28/20 at 12:45 PM, Resident # 444 was observed lying asleep in a lowered bed. The Foley catheter bag was observed hanging on the left side rails near the foot area of the bed and was observed resting on the resident's overbed table wheels with the right side of the bag touching the resident's trash can. On 09/28/20 at 12:45 PM, an interview was conducted with Resident # 444. The resident stated the Certified Nursing Assistant (CNA)s are the persons who move and drain the catheter bags. The resident denied moving the catheter bag on this date. On 09/28/20 at 12:47 PM, an interview was conducted with CNA#1. CNA #1 stated that the overhead table was placed it near the resident for meals and she did not notice that the catheter bag was resting on top of the wheels. CNA #1 also stated she did not know why the trash can was under the tray table and the trash can is in contact with the catheter bag. CNA#1 further stated that she is in charge of draining the urinary catheter bag and that it should not be touching the overhead table wheels or the trash can. On 09/28/20 at 12:49 PM, an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN#1 stated that she noticed that the catheter bag was resting on the overbed table wheels, and the trash can was also observed under the overbed table. The LPN #1 stated that the catheter should be hanging and not in contact with the overbed table wheels and trash can. On 09/28/20 at 12:51 PM, an interview was conducted with Registered Nurse (RN) #1. RN #1 stated that she observed the urinary drainage bag was touching the overbed table wheels. RN#1 also stated the urinary drainage bag should be hanging at all times and not touching other items or the floor to prevent infection. The RN also stated that as the unit nurse manager she should ensure that the urinary catheter drainage bag is not be touching the floor or other items at all times and may have overlooked the issue during rounds earlier in the day. On 9/30/20, at 1:27 PM, an interview was conducted with the Director of Nursing. The DON stated that the urinary drainage bag and tubing should be adequately placed on the bed below the resident's bladder and not touching the floor or any items. The DON also stated that this year the facility had not provided catheter care education as most in-services for staff focused on COVID-19. 415.19(b)(1)