**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 01/13/2025 to 01/21/2025, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented to address each residents' medical, physical, mental, and psychosocial needs. This was evident in 1 (Resident #146) of 1 resident reviewed for Antibiotic Use, out of 37 total sampled residents. Specifically, a care plan was not developed for Resident #146's diagnosis of Sinusitis and antibiotic use. The findings are: The facility's policy titled Comprehensive Care Plan with a revised date of 12/27/2024 documented that the residents of the facility will have an individualized Comprehensive Care Plan completed in accordance with Federal and State requirements. The Comprehensive Care Plan will include measurable objectives and timetables in order to meet the resident's medical, nursing, mental, and psychosocial needs which are identified from the comprehensive assessment (MDS 3.0) and application of the Care Area Assessment. Additional problems, strengths, or needs identified by members of the Comprehensive Care Plan Team will be included in the Comprehensive Care Plan as appropriate. On 01/13/2025 at 11:44 AM, Resident #146 was observed in bed and was interviewed. Resident #146 stated they had Pneumonia for the past week and had been taking antibiotic. Resident stated they had been in bed because of the flu. Resident #146 was observed with occasional non-productive cough during the interview. Resident #146 had diagnoses that included Anemia, Hypertension, Asthma/Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set, dated [DATE] documented Resident #146 had intact cognitive status and required substantial/maximal assistance for bed mobility, and dependent on staff for most activities of daily living. A Nurse Practitioner progress note dated 01/07/2025 documented Resident #146 was seen for chief complaint of cough and chest congestion. Resident was previously seen on 01/03/2025 for complaints of chest congestion, cough, and tested positive for Influenza A. A previous chest x-ray indicated no active disease. No treatment at this time, symptoms are more than 48 hours, will monitor for elevated temperature and changes in respiratory status; will offer increased fluids if tolerated. The Primary Medical Doctor was made aware. A medical progress note dated 01/08/2025 documented Influenza A positive, symptoms were greater than 48 hours, observe off antiviral, agreed to antibiotics for yellowish phlegm and malodor phlegm. On contact/droplet isolation, antibiotics for Sinusitis. A physician's order dated 01/08/2025 documented Amoxicillin and Clavulanate Potassium 875 mg - 125 mg tablet, 1 tablet by oral route every 12 hours for 10 days for Acute Sinusitis. A review of the electronic Medication Administration Record showed that Amoxicillin and Clavulanate Potassium 875 mg - 125 mg tablet (brand name: Augmentin) was administered to Resident #146 from 01/08/2025 - 01/14/2025. An entry dated 01/14/2025 at 6:00 AM documented that Amoxicillin and Clavulanate Potassium was not administered due to hospitalization. A review of Resident #146's Comprehensive Care Plan showed no documented evidence that a care plan with interventions to address the Resident's diagnosis of Acute Sinusitis and use of antibiotic was developed. On 01/21/2025 at 11:03 AM, Registered Nurse #1, who was Unit Manager, was interviewed and stated that Resident #146 tested positive of Flu on 01/07/2025 was started on Augmentin for Acute Sinusitis. Registered Nurse #1 stated they do not know why a care plan for Sinusitis and antibiotic use was not initiated for Resident #146. On 01/21/2025 at 11:45 AM, the Infection Control Prevention Registered Nurse was interviewed and stated that the Unit Mangers, Supervisors, or the Infection Control Registered Nurse are responsible for initiating a care plan for resident's use of antibiotic. They stated that Resident #146 tested positive for influenza and was ordered Augmentin for Sinusitis. The Infection Control Prevention Registered Nurse stated they must have forgotten to put in the care plan for Resident #146. On 01/21/2025 at 12:16 PM, the Director of Nursing was interviewed and stated that the nursing supervisor on duty is primarily responsible for initiating the episodic care plan. If the nursing supervisor missed it, the Unit Manager and the Infection Control Registered Nurse are supposed to check and capture it. The Director of Nursing stated the care plan is the blueprint of how to care for the resident and should have been in place. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 1/13/2025 to 1/21/2025, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, and comprehensive person-centered care plan. This was evident for 1 of 1 resident reviewed for Insulin (Resident #149), out of a sample of 37 residents investigated. Specifically, Resident #149 had a physician's order to notify the physician when Resident's finger stick blood sugar (method of drawing drops of blood from the finger for testing the blood glucose level) result is less than 200 milligrams per deciliter or more than 350 milligrams per deciliter. The licensed nurse failed to notify the physician when Resident #149's finger stick blood sugar was lower than 200 milligrams per deciliter on 7 occasions from 1/02/2025 through 1/13/2025 and higher than 350 milligrams per deciliter on 3 occasions from 12/02/2024 through 12/31/2024. In addition, Resident #149 was administered 6 units of Novolog insulin (a short acting insulin that lowers blood sugar) on 12/02/2024 and 12/10/24, and 8 units on 12/31/2024, when Resident #149's finger stick blood sugar results were above 350 milligrams per deciliter, without a physician's order. The findings are: The facility's policy titled Diabetes Management with a revised date of 6/18/2024 documented blood sugar level and frequency measured, per physician orders and facility protocol in place for physician notification with specific parameters. Resident #149 had diagnoses of Diabetes Mellitus, Peripheral Vascular Disease, and Cancer. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #149 had intact cognition. A Comprehensive Care Plan for Diabetes was initiated on 7/20/2022. The facility interventions include to monitor blood glucose level and administer oral hypoglycemic/insulin injection as per physician's orders. A physician's order dated 9/26/2024 documented check finger stick at bedtime. Notify the physician if blood sugar results are below 200 milligrams per deciliter. A physician's order dated 11/29/2024 documented Novolog FlexPen 100 units per milliliter (3 milliliters) subcutaneous, inject subcutaneously two times per day when finger stick blood sugar readings are as follows: Between 120 and 200 give 2 units, between 200 and 279 give 4 units, between 271 and 350 give 6 units. Above 350, call the physician. A physician's order dated 12/21/2024 documented Novolog FlexPen 100 units per milliliter (3 milliliters) subcutaneous, inject subcutaneously two times per day when finger stick blood sugar readings are as follows: Between 120 and 200 give 2 units, between 200 and 279 give 4 units, between 271 and 350 give 8 units. Above 350, call the physician. The electronic Medication Administration Records for 12/2024 and 1/2025 documented the following finger stick blood sugar results: On 12/02/2024 at 4:30 PM, 530 milligrams per deciliter. On 12/10/2024 at 12:00 PM, 370 milligrams per deciliter. On 12/31/2024 at 4:30 PM, 355 milligrams per deciliter. On 1/02/2025 at 9:00 PM, 192 milligrams per deciliter. On 1/04/2025 at 9:00 PM, 179 milligrams per deciliter. On 1/06/2025 at 9:00 PM, 174 milligrams per deciliter. On 1/07/2025 at 9:00 PM, 116 milligrams per deciliter. On 1/09/2025 at 9:00 PM, 187 milligrams per deciliter. On 1/10/2025 at 9:00 PM, 153 milligrams per deciliter. On 1/13/2025 at 9:00 PM, 176 milligrams per deciliter. A further review of Resident #149's electronic Medication Administration Record showed that 6 units of Novolog insulin was administered at 4:30 PM on 12/02/2024 and 12:00 PM on 12/10/24, and 8 units were administered at 4:30 PM on 12/31/2024, when Resident #149's finger stick blood sugar results were above 350 milligrams per deciliter, without a physician's order. A review of the nurses' and medical progress notes from 12/02/2024 through 1/13/2025 showed no documentation that the physician was notified when Resident #149's finger stick blood sugar results were below 200 milligrams per deciliter and above 350 milligrams per deciliter. On 1/16/2025 at 3:20 PM, Licensed Practical Nurse #1 was interviewed and stated the range for Resident #149's high blood sugar is not specified on the physician orders. Licensed Practical Nurse #1 stated they call the doctor when the blood sugar is alarming and then document in the resident's medical record. Licensed Practical Nurse #1 further stated they should have called the physician when Resident #149's blood sugar was 530 milligrams per deciliter because it was out of range. On 1/16/2025 at 11:16 AM, the Medical Doctor was interviewed and stated the licensed nurse should have followed the physician's orders to notify them of finger stick blood sugar results below 200 and above 350 so further instructions can be given. The Medical Doctor further stated they would give orders for insulin for high blood sugar results and request nurse to check blood sugar again and call if blood sugar is still high. On 1/16/25 at 3:32 PM, the Director of Nursing was interviewed and stated Licensed Practical Nurse #1 should have followed the physician's orders to notify the physician when Resident #149's blood sugar was below 200 or above 350 milligrams per deciliter. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification Survey conducted from 1/13/2025 to 1/21/2025, the facility did not ensure that food served were at an appetizing temperature. This was evident in 1 (Resident #134) of 4 residents reviewed for Dining Observation out of 37 total sampled residents. Specifically, food served during lunch meal service was not maintained at palatable and appetizing temperatures. The findings are: The facility's policy titled Meal Service with a reviewed date of 10/2023 documented that the facility will assure adequate and appropriate meal service to all residents. The facility's policy titled Food Preparation and Appropriate Temperature with a revised date of 9/26/2024 documented that hot foods will be held at 135 degree Fahrenheit or higher. Resident #134 was admitted to the facility with diagnoses of Diabetes Mellitus, Hyperlipidemia and Hypertension. The Minimum Data Set assessment dated [DATE] documented that Resident #134 had intact cognition and required substantial assistance with eating. On 1/13/2025 at 12:25 PM, Resident #134 stated their food was cold by the time their tray reach their room. On 1/16/2025 at 12:40 PM, the food carts arrived in the dining room. From 12:45 PM to 1:11 PM, the nursing staff prepared and distributed the trays to residents in the dining room and delivered trays to residents in their room. On 1/16/2025 at 1:11 PM, test trays were conducted on Unit 5. The food temperatures were as follows: baked potato 138.2 degrees Fahrenheit, [NAME] chicken 106.6 degrees Fahrenheit, broccoli 105 degrees Fahrenheit, summer squash soup 134 degrees Fahrenheit, mashed potato 131 degrees Fahrenheit, pureed broccoli 133 degrees Fahrenheit, pureed chicken 132 degrees Fahrenheit, pureed soup 134 degrees Fahrenheit, and coffee 155 degrees Fahrenheit. On 1/21/2025 11:29 AM, Registered Nurse #1, who was the Unit Manager stated early trays are delivered to the unit around 12:30 PM and followed by rest of the trays in the food truck. The nursing staff will distribute trays to the residents in the dining room first and then to the rooms. Meal distribution is completed within 15 minutes after the truck arrives to the unit. On 1/17/2025 at 11:22 AM, the Food Service Director was interviewed and stated that hot foods are held above 140 degrees Fahrenheit or higher on the steam table and should be served above 135 degrees Fahrenheit for hot foods to be palatable. The Food Service Director stated food temperature issue had been brought up in the past and the team initiated a plan to change the meal service process. This change was only implemented in the Rehab Unit and is currently on pause due to some equipment/staffing issues. On 1/21/2025 at 11:50 AM, the Director of Nursing stated the food temperature issue was already identified some time last year and they initiated a plan to improve the dining experience including food temperature. They stated the plan was only implemented on Unit 6 because there were some challenges during implementation process. 10 NYCRR 415.14

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Abbreviated survey (NY00297954) the facility did not ensure an alleged violation involving abuse was reported to the New York State Department of Health (NYSDOH) within 2 hours of occurrence. This was evident for 1 (Resident #543) of 2 residents reviewed for Abuse out of 39 total sampled residents. Specifically, the facility did not report an allegation of resident-to-resident abuse between Resident #90 and Resident #543 within 2 hours of the occurrence. The findings are: The facility's policy titled Abuse Prohibition dated 10/24/2022 documented alleged or suspected incidents of Abuse will be immediately investigated, and findings of such investigation will be provided to the Administrator within three working days of the occurrence of such incident and to the department of health within five working days. Resident # 90 had diagnoses of epilepsy and cerebral infarction. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 90 was severely cognitively impaired. Resident # 543 had diagnoses of heart failure and seizure disorder. The MDS assessment dated [DATE] documented Resident # 543 was cognitively intact. The NYSDOH Aspen Complaint Tracking System (ACTS) facility-reported incident (NY00297954) dated 6/23/22 at 1:38 PM documented staff responded to Resident #543's call bell on 6/22/22 at 1:37 AM. Resident #543 reported Resident #90 turned on the light and swung an extension cord that hit Resident #543 on the arm. The facility Summary of Case #NY00297954 dated 06/24/2022 documented that on 06/21/2022 at 11:37 PM, staff responded to the call bell in the resident's room. Resident # 543 reported that their roommate, Resident #90, turned on the light while they were sleeping and begun to swing a cord from a personal device brought in by family and hit Resident # 543 on the right forearm. The Registered Nurse supervisor with immediate response to the room and assessed both residents. Resident # 543 sustained a bruise on the right forearm. No prior issues were noted between the parties and statements obtained by Resident # 543 and the unit staff. There was no documented evidence the facility reported the allegation of resident-to-resident abuse within 2 hours of occurrence. On 12/02/22 at 9:22 AM, an interview was conducted with Registered Nurse Supervisor # 1(RNS #1) who stated they initiated the investigation into the incident between Resident #543 and Resident #90. RNS #1 then informed the Director of Nursing (DNS). The DNS is informed immediately anytime something happens. On 12/02/2022 at 2:17 PM, the DNS was interviewed and stated the unit manager informed them of the incident on 06/22/2022 at approximately 11:00 AM. The RNS placed the incident investigation in the DNS' mailbox. The DNS completed the investigation and wrote the investigation summary. The incident was reported to NYSDOH within 24 hours. When abuse is suspected and there is injury, it is reported to NYSDOH within two hours of the occurrence. All other incidents are reported in 24 hours. Resident-to-resident abuse occurred, and the victim had a minor bruise on the arm. The Administrator, the DNS, and the Assistant DNS are required to report allegations of abuse to the NYSDOH. 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #544 had diagnoses of acute kidney disease and chronic obstructive pulmonary disease. The admission MDS dated [DATE] documented Resident #544 was cognitively intact and received oxygen therapy. On 11/30/22 at 9:39 AM, 12/01/22 at 10:13 AM, and 12/2/22 at 10:17 AM, Resident #544 was observed receiving oxygen therapy via nasal canula. The Physician's Order dated 11/15/22 documented orders for continuous oxygen via nasal canula at 2 liters per minute. A Nursing Note dated 12/1/22 documented Resident #544 was receiving oxygen according to the physician order. The Treatment Administration Record (TAR) dated 11/15/22 to 12/04/2022 documented Resident #544 received Oxygen at 2 liters per minute continuously. On 12/02/22 at 2:24 PM, the MDS Coordinator (MDSC) was interviewed and stated Resident #544 should have had a CCP related to Oxygen as it was identified on the MDS but not documented on the Cardiac Decompensation CCP. There should have been a CCP developed for oxygen use since Resident has an order for oxygen. The MDS assessor (MDSA) was responsible for initiating and updating the CCPs upon admission and readmission and did not capture oxygen for Resident #544. The nurses on the unit should also be checking the residents' CCPs to ensure accuracy. On 12/05/22 at 11:08 AM, the Registered Nurse Educator (RNE) was interviewed and stated the Registered Nurse Supervisor (RNS) should have developed a CCP related to oxygen use within 48 hours on Resident #544. 415.11(c)(1) Based on observations, record review and interviews conducted during the Recertification Survey from 11/28/22 to 12/05/22, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the residents' medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #73) of 1 resident(s) reviewed for Dialysis and 1 (Resident #544) of 1 resident(s) reviewed for Hospitalization out of 39 total sampled residents. Specifically, 1) a CCP was not developed to address Resident #73 hemodialysis (HD) and Diabetes Mellitus (DM) treatment and, 2) a CCP was not developed to address Resident #544's oxygen therapy. The findings are: The facility policy titled CCP last revised 11/01/2017 documented the CCP will include measurable objectives and timetables in order to meet the resident's Medical, Nursing, Mental, and Psychosocial needs which are identified from the comprehensive assessment Minimum Data Assessment 3.0 (MDS). Additional problems, strengths, or needs identified by members of the CCP Team will be included in the CCP as appropriate. 1) Resident #73 had diagnoses of end-stage renal disease (ESRD) and DM. On 11/29/22 at 10:50 AM, Resident #73 was interviewed and stated they receive HD treatment and had a serious bleeding incident where they were transferred to the hospital for evaluation. Resident #73 has fingerstick blood sugar (FSBS) testing and insulin administration daily to address their diagnosis of DM. The MDS dated [DATE] documented Resident #73 was moderately cognitively impaired, received HD treatment as a resident, and received insulin injections daily. Physician's Order initiated 9/23/2022 and renewed 11/16/22 documented Resident #73 received HD three times weekly, had FSBS testing three times daily, and received Admelog SoloStar U-100 insulin 5 units 3 times daily after FSBS testing for diagnosis of DM, and received Januvia 100 mg once daily for a diagnosis of DM. Nursing Note dated 9/23/2022 documented Resident #73 was readmitted to the facility from the hospital with diagnosis of ESRD on HD and DM. There was no documented evidence the facility developed a CCP related to Resident #74 HD treatment and DM diagnosis with insulin use. On 12/01/22 at 10:25 AM, an interview was conducted with Registered Nurse (RN) #1 who stated Resident #73 has been receiving HD and insulin injections for DM since admission. The nurse who completed the admission assessment for Resident #73 was responsible for developing CCPs to address the resident's diagnoses and treatments. RN #1 could not provide a reason Resident #73 did not have CCPs with interventions to address HD and DM. The unit RNs and the MDS Department are responsible for checking and updating a resident's CCP as needed. On 12/01/22 at 11:28 AM, an interview was conducted with MDS Coordinator (MDSC) who stated they are responsible for checking a resident's record and initiating and/or updating CCPs upon admission and readmission. The RN on the unit is responsible for initiating episodic CCPs and updating the CCPs in the resident's chart. The CCPs related to HD and DM were available in Resident #73's CCP library in their medical record but they were not activated upon the resident's readmission to the facility. The MDS assessors may not be able capture care plan updates. The nursing staff on the resident's unit should be checking to ensure the resident's plan of care is updated. On 12/02/22 at 11:55 AM, an interview was conducted with the Director of Nursing (DNS) who stated Resident #73 receives HD treatment and DM management. The CCP Library contained the CCPs related to HD and DM upon admission, but they were not activated when the resident was admitted by RN Supervisor. MDS staff failed to activate the care plans when they are doing the assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification survey from 11/28/2022 to 12/5/2022, the facility did not ensure residents were involved in developing the comprehensive care plan (CCP) and making decisions about their care. This was evident for 1 (Resident #81) of 3 residents reviewed for Participation in Care Planning out of 39 total sampled residents. Specifically, Resident #81 was not invited to participate in their quarterly CCP meeting with the interdisciplinary team (IDT). The findings are: The facility policy titled CCP dated 11/1/17 documented the IDT prepares the CCP which includes the resident and the resident's family or legal representatives. The resident and the resident's representative should be involved in the development of the CCP. Resident # 81 had diagnoses of vascular dementia without behavioral disturbance and schizophrenia. The Quarterly Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident # 81 had moderate cognitive impairment and no designated representative participated in the assessment. On 11/29/22 at 10:59 AM, Resident #81 was interviewed and stated they are responsible for making their own decisions. The resident stated they were not invited to every care plan meeting to discuss and develop their care plan. The MDS Monthly Schedule for January 2022 documented Resident # 81 had a quarterly CCP meeting 1/11/2022. The CCP Attendance Record dated 1/11/2022 did not document a signature from Resident #81 and/or their designated representative. There was no documented evidence Resident #81 and/or their designated representative was invited to attend the quarterly CCP meeting held 1/11/22. On 12/01/22 at 02:56 PM, Director of Social Worker (DSW) was interviewed and stated they invited residents and/or their designated representatives to all care plan meetings. They received monthly schedule of CCP from the MDS department and invited residents and/or their designated representatives to the CCP about 1 week in advance of the meeting. DSW stated they invited residents by invitation letters and the designated representatives by calls. DSW also stated all the CCP invitations were documented in the Social Services notes. DSW checked Resident # 81's medical record and was not able to find any documented evidence that Resident # 81 and/or their designated representative were invited to the care plan meeting on 1/11/2022. DSW stated they were not able to explain the reason Resident # 81 and/or their designated representative were not invited to the care plan meeting on 1/11/2022. 415.11(c)(2)(i-iii)

Based on observations, record review, and staff interviews conducted during the Recertification survey from 11/28/22 to 12/05/22, the facility did not ensure food was stored in accordance with professional standards for food service safety. This was evident during review of the Kitchen. Specifically, 2 cold sandwiches placed on resident meal trays during tray line service were not maintained at a safe temperature of 41 degrees Fahrenheit (F) or below. The findings are: The facility policy titled Food Temperatures Prior to Meal Service revised 7/22 documented cold food should be kept under 41 F. Cold food is placed on ice for proper temperature holding; all cold foods are to be prepared in advance to allow foods to be under 41 F. The Manger/Supervisor monitors compliance by signing off on sheets daily, conducting test tray audits, training staff on appropriate food temperatures, calibrating thermometers, and maintaining copies of temperatures on file for 3 months. Kitchen tray line service was observed on 11/29/22 at 12:01 PM. The Director of Buildings (DOB) conducted random temperature checks on two sandwiches (turkey and cheese) placed on individual resident trays for service. The turkey sandwich temperature was 67.5 F, and the cheese sandwich temperature was 67.5 F. The DOB directed staff to remove and replace the 2 sandwiches on the resident trays. On 12/01/22 at 11:28 AM, Dietary Aide (DA) #1 was interviewed and stated the sandwiches go from the freezer onto the resident trays about 10 minutes before service starts. When the sandwiches come out of the freezer, the DA keeps them on a pan filled with ice. No one checks the temperatures of the sandwiches. On 12/01/22 at 12:05 PM, DA #2 was interviewed and stated sandwiches go into the refrigerator once they are made and must be kept at 41 F prior to serving the residents. On 12/01/22 at 11:58 AM, the DOB was interviewed and stated the kitchen staff who prepared the sandwiches did not have time to cool the sandwiches down. The sandwiches were prepared and placed on ice instead of in the refrigerator because it was close to tray line service time. The person who prepares the sandwiches is responsible for checking sandwich temperatures. 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification Survey from 11/28/22 to 12/05/22, the facility did not ensure a resident with an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. This was evident for 3 of 4 residents reviewed for Urinary Catheter out of 39 total sampled residents (Residents #34, #62, #149). Specifically, 1) there were multiple observations of Resident #34's Foley Catheter (FC) drainage bag touching the floor and there was no physician order (PO) for FC, 2) there were multiple observations of Resident #62's FC drainage bag touching the floor, and 3) there were multiple observations of Resident #149's FC drainage bag touching the floor. The findings are: The facility's policy titled Urinary Catheter Care last revised 07/20/2021 documented goal with urinary catheter is to maintain patency and minimize the risk of urinary tract infection. 1) Resident # 34 had diagnoses of obstructive and reflux uropathy and urinary tract infection. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #34 was severely cognitively impaired, required total assistance from staff to perform activities of daily living, and had an indwelling catheter. On 11/28/22 at 12:17 PM, 11/29/22 at 12:58 PM, and 11/30/22 at 10:03 AM, Resident #34 was observed in bed. The FC drainage bag attached to the resident was touching the floor upon each observation. On 12/01/22 at 11:15 AM, Resident #34 was observed with their FC drainage bag touching the floor. Registered Nurse (RN) #2 was present in the room during the observation and stated the resident's drainage bag should not be touching the floor. The Comprehensive Care Plan related to Urinary Incontinence initiated 12/8/2021 and last revised 10/20/2022 documented check Resident #34 every 2-4 hours and assess FC. Physician Notes dated 10/1/2022 documented resident has cloudy urine, labs, antibiotics were ordered. Nursing notes dated 10/20/2022 documented Resident #34 had an indwelling catheter, and it was draining an adequate amount of yellow urine. FC as per protocol. There was no documented evidence of a PO for FC care upon Resident #34's readmission to the facility on [DATE]. On 12/02/22 at 10:12 AM, an interview was conducted with Certified Nursing Assistant (CNA) #6 who stated they were given in service that FC drainage bag should not touch the floor as part of proper infection prevention protocols. On 12/02/2022 at 10:59 AM, an interview was conducted with RN # 2 who stated the PO for Resident #34's FC was missed. A PO is important because it is part of the facility's protocol when a resident has an FC in place. RN #2 stated staff received an inservice to ensure they are aware that FC drainage bags should not touch the floor. On 12/02/2022 at 02:22 PM, the Director of Nursing was interviewed and stated the order for FC was missed and the RN obtained an order for FC from the physician today. Staff were in-serviced regarding facility policy to promptly and accurately obtain a FC order. 2) Resident #62 had diagnoses of diabetes mellitus and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #62 was severely cognitively impaired and had an indwelling catheter. On 11/28/22 at 12:03 PM, 11/29/22 at 1:03 PM, 11/30/22 at 10:45 AM, and 12/01/22 at 11:05 AM, Resident #62 was observed lying in bed. The FC drainage bag attached to the resident was observed touching the floor upon each observation. The Comprehensive Care Plan related to Urinary Incontinence initiated 5/6/2014 and last revised 6/28/2022 documented check Resident #62 every 2-4 hours and assess FC. Physician order dated 11/21/2022 documented FC due to stage 4 pressure ulcer. Care for FC daily with soap and water. On 12/02/22 at 10:12 AM, Certified Nursing Assistant (CNA) # 5 was interviewed stated they were not assigned to work with Resident #62 prior to today. CNA #5 noticed the FC drainage bag was touching the floor when they were assigned to Resident #62 today and repositioned the FC drainage bag, so it was no longer touching the floor. On 12/02/22 at 10:20 AM, Licensed Practical Nurse (LPN) # 1 was interviewed and stated FC drainage bags should not be touching the floor and the staff were inserviced regarding this. 3) Resident # 149 had diagnoses of chronic kidney disease and type 2 diabetes. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #149 was moderately cognitively impaired, was totally dependent on staff to perform activities of daily living and had an indwelling catheter. On 11/28/2022 at 10:52 AM, 11/29/22 at 1:04 PM, 11/30/22 at 11:05 AM, and 12/01/22 at 11:20 AM, Resident # 149 was observed lying in bed. The FC drainage bag attached to the resident was touching the floor. Physician order dated 11/13/2022 documented FC care daily with soap and water and record FC output every shift. On 12/02/22 at 10:30 AM, Certified Nursing Assistant (CNA) # 4 was interviewed and stated they are a floater, and this was the first day they were assigned to Resident #149. CNA #4 stated they observed Resident #149's FC drainage bag touching the floor this morning but received inservice that the FC drainage bag should not be touching the floor and attached the FC drainage bag to the bed frame to prevent it from touching the floor. On 12/05/22 at 12:30 PM, the Infection Control Preventionist (ICP) was interviewed and stated FC drainage bags must not touch the floor as part of infection control and facility protocol. On 12/02/22 at 02:25 PM, an interview was conducted with the Director of Nursing (DON) who stated observations of FC drainage bags touching the floor numerous times is a concern and staff will be inserviced regarding proper infection prevention and care of FC drainage bag. 415.12(d)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Recertification survey, the facility did not ensure that services provided, as outlined per the comprehensive care plan, met professional standards of quality. Specifically, residents prescribed oxygen as needed did not have oxygen saturation levels monitored as ordered to assess the need for oxygen. This was evident for 2 of 3 residents reviewed for Respiratory Care (Resident #141 and #220). The findings are: The policy and procedure for Care of Residents on Humidified Oxygen dated 5/15/12 documented: It is the responsibility of the Registered Nurse (RN) or Licensed Practical Nurse (LPN) to check and review the Physician's order, set up oxygen concentrator with humidifier, administer oxygen as ordered, assess resident's response to oxygen therapy, and report any changes in resident's condition to MD (Physician). The policy does not specify how the resident's response to oxygen therapy should be assessed. It does contain specifics regarding how oxygen saturation monitoring should be done. 1.) Resident #141 was admitted with diagnoses which include: Asthma, Chronic Obstructive Pulmonary Disease (COPD), B-Cell Lymphoma, and history of Pneumonia. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had moderately impaired cognition. The MDS further documented the resident was completely dependent on the assist of staff for bed mobility, transfer, dressing, toileting, personal hygiene, and locomotion. On 2/7/20 at 15:05 PM and 2/10/20 at 11:00 AM, the resident was observed with oxygen not in use. The Comprehensive Care Plan (CCP) for Respiratory Distress dated 11/5/19 documented the resident had the potential for respiratory distress as evidenced by history a history of aspiration pneumonia. The CCP further documented the resident was on Proventil HFA inhaler every 6 hours as needed. The CCP interventions included: monitor of signs and symptoms (s/s) and/or c/o (complaints of) of respiratory distress and notify MD of abnormal findings; and administer treatments per MD order. The CCP was updated 2/10/20, after surveyor intervention, with the interventions of administer 2 liters oxygen as needed and monitor oxygen saturation every shift. Nursing Notes dated 12/10/19 documented that the resident was transferred to the hospital with a temperature of 102.1 and oxygen saturation of 81% on room air. The resident was readmitted to the facility on [DATE]. The readmission physician's orders dated 12/18/19 documented orders for oxygen via nasal cannula @ 2 liters per minute (L/m) as needed (PRN) and oxygen saturation monitoring every shift. These orders were renewed on 01/15/2020. There was no documented evidence that oxygen saturation monitoring every shift was done from 01/15/2020 to 02/07/2020. The Nursing Notes documented oxygen saturation for one shift only on 5 days (1/21, 1/25, 1/29, 1/30, and 1/31). 2) Resident #220 was admitted with diagnoses which include Hypertension, Non- Alzheimer's Dementia, and Seizure Disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified the resident had severely impaired cognition and was completely dependent on staff for activities of daily living. The Comprehensive Care Plan (CCP) for Respiratory Distress dated 8/27/15 documented the resident had the potential for respiratory distress related to a history of Pneumonia. The interventions included: monitor for s/s of respiratory distress and notify MD of abnormal findings; monitor for effectiveness; and administer oxygen 2 L/min (Liters per minute) via N/C (nasal cannula) PRN (as needed). The CCP intervention of monitor oxygen saturation eery shift was added on 2/10/20 after surveyor intervention. The Physician's order dated 01/31/2020 documented renewal orders for oxygen saturation every shift and administer oxygen 2 L/min via N/C if less than (<) 94%. There was no documented evidence that oxygen saturation monitoring every shift was done from 01/01/2020 to 02/07/2020. The oxygen saturation monitoring record documented oxygen saturation taken daily on four days (1/7, 1/22, 1/31, and 2/7). On 02/07/2020 at 1:20 PM, the Licensed Practical Nurse (LPN #4) was interviewed. The LPN stated that she takes the resident's oxygen saturation but does not always record it. The nurse who picked up the order for oxygen saturation monitoring did not register it in the EMR in the pulse oximeter level section. She stated there is no place to document the oxygen saturation monitoring. On 02/07/2020 at 1:20 PM, the Unit Registered Nurse Manager (RN #3) was interviewed and stated the nurses pick up up and transcribe any new physician's orders. She acknowledged there was no documentation of oxygen saturation levels taken after 1/31/20. She stated she did not know what happened, but she will get back to the surveyor. On 02/07/2020 at 4:30 PM, the 3-11 shift LPN was interviewed and stated she spoke to her supervisor. She stated that she does not take the oxygen saturation level regularly, but she should have done so as ordered and documented it in the record. 483.21(b)(30(1)

Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, a resident's right hand splint was not applied as ordered and per the Comprehensive Care Plan (CCP). This was evident for 1 of 2 resident reviewed for limited range of motion (Resident #119). The findings are: The facility policy Contractures/Adaptive equipment dated 01/04/2019 documented: All residents with contractures will be identified upon admission and ongoing basis. Interventions will be provided as appropriate .Interventions will be provided. If needed, in-services will be provided to the caregivers with return demonstrations noted. Resident #119 was admitted to the facility with diagnoses that included Cerebrovascular Accident (CVA), Hemiplegia affecting unspecified side, and Respiratory Failure. The Annual Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 12/19/2019, documented that the resident had severe impairment in cognition with long and short-term memory problems. The MDS documented the resident required total dependence of 2 for bed mobility, transfer, toilet use, and total dependence of one person for Locomotion, dressing, eating, and personal hygiene. The resident had range of motion impairment on both sides of the upper and lower extremities. The CCP further documented the resident received no splint or brace assistance. On 02/04/20 at 11:24 AM, 02/05/20 at 11:05 AM, and 02/07/20 at 09:53 AM the resident was observed in bed with a right hand contracture and no splint device in place. On 02/05/20 at 10:04 AM and 02/06/20 at 10:48 AM and 12:31 PM, the resident was also observed in bed with no hand splint in place, and a hand splint was at the foot of the resident's bed. The Comprehensive Care Plan (CCP) for ADL (Activities of Daily Living): Rehabilitation, effective 8/10/13, documented that resident had a right hand contracture and foot drop. The CCP included the intervention of Right (Rt) grip orthosis to be worn in the morning and evening with removal during hours of sleep, hygiene care, and Passive Range of Motion (PROM). The intervention was added 4/9/15. The CCP was last reviewed on 12/27/19 at the quarterly care plan meeting. The Physician's Order dated 01/29/2020 documented renewal orders for Right grip orthosis to be worn in the am and pm. Remove during hours of sleep, hygiene care and PROM. The order was initiated 3/1/18. On 02/06/20 at 12:31 PM, and interview was conducted with the Certified Nursing Assistant (CNA#1). CNA #1 stated that she has been caring for the resident for about 5 years. CNA #1 stated that resident has a right-hand splint that is used when the resident is out of bed which is every other day or if the nurse instructs them to take the resident out of bed. The application of the splint is documented whenever the resident is taken out of bed. On 02/07/20 at 09:53 AM, an interview was conducted with the Certified Nursing Assistant (CNA#2). CNA #2 stated that she is assigned to the resident if the regular CNA is off. The resident has a device for the right hand that is only applied when the resident is out of bed. On 02/07/20 at 10:00 AM the Registered Nurse (RN#2) was interviewed. The RN stated that she has been on the unit since December 2019. Report is given to the CNAs by the nurses every shift regarding the care needs of the residents assigned to them. The CNA Accountability Record includes all care and interventions needed by the resident as per the plan of care. The RN stated that she believes the device is placed on the resident's hand after the CNA provides care. On 02/07/20 at 11:14 AM, an interview was conducted with the Occupational Therapist-OT, (Staff#3). The OT also stated that resident was recommended to have grip orthosis to be worn on right hand in the AM (Morning) and PM (Evening), to be removed during hours of sleep, hygiene care and passive range of motion. The OT stated that the nursing staff are educated on the placement of the device and they are expected to be placing the device every day except during care for hygiene/range of motion and during hours of sleep. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the recertification survey, the facility did not ensure that appropriate care and services to prevent complications of tube feeding were provided. Specifically, the medication nurse did not use the correct amount of water to flush the feeding tube prior to initiating tube feeding. This was evident for 1 of 3 residents reviewed for Tube Feeding (Resident #203). The findings are: A facility policy and procedure related to Enteral (Tube) Feeding revised as of 4/30/14 documented that the nurses should check the Physician Orders for formula, rate, and mode of delivery. The tube should be flushed with the amount of water prescribed by the Medical Doctor at the beginning and end of feeding. Resident #203 had a diagnoses of dysphagia and Parkinson's disease. The quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident was cognitively intact and had a peg tube. On 02/06/20 at 03:57 PM, the Licensed Practical Nurse (LPN #1) was observed starting the tube feeding for Resident #203. LPN #1 looked at the electronic medical record (EMR) then gathered a flush bottle, a bottle of Vital AF 1.2 formula, and a tray and entered the resident's room. She washed her hands and then brought the flush bottle into the resident's bathroom to fill it with water. After donning gloves, the LPN checked for placement of the peg tube by inserting a syringe into the tube and checking for residual. She then filled a flush bag and hung it along with the formula from the tube feeding pole. Once she started priming the pump, LPN #1 drew 30mls (milliliters) of water into a syringe to flush the peg tube prior to starting the feeding. The 30mls of water was observed being inserted into the peg tube. The LPN then connected the feeding tube to the pump and started the tube feeding. The Physician's Orders renewed 2/5/20 documented the following tube feeding orders: Vital AF 1.2 to be administered at 4 PM with 100mls of water to be delivered before and after each feeding. The orders documented that the resident should receive 30ml of water before and after med pass. The Medication Administration Record (MAR) for January and February 2020 documented that the resident had been receiving tube feeding and flushes according to the Physician's Orders. An interview was conducted with LPN #1 on 02/06/20 at 04:07 PM. The LPN stated that she provided the resident with a flush of 30mls of water prior to initiating the tube feeding. This is per the facility policy related to tube feeding, and this is the amount of water she has always given to the resident when starting the tube feeding. LPN #1 had initiated the resident's tube feeding on multiple occasions. After reviewing the Physician's Order, the LPN stated that she misread the order and that the resident should receive 100mls of water before tube feeding is started. She stated since the feeding has already been started, she would be unable to provide additional water at this time to account for the missing 70mls. LPN #1 stated that she will need to add water to the resident's flush during medication administration or at the end of the resident's tube feeding. An interview was conducted with the Registered Nurse (RN) Manager for the unit, RN #1, on 02/07/20 at 11:03 AM. RN #1 stated that the resident should receive 100mls of water flush prior to tube feeding administration. She performs competencies with the staff on the unit to ensure that they are able to understand the Physician's Orders and administer tube feeding appropriately. The medication nurse needs to check the Physician's Order prior to each tube feeding administration. 415.12(g)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Recertification survey, the facility did not ensure that a resident on oxygen therapy received respiratory care consistent with professional standards of practice and the comprehensive person-centered care plan. Specifically, residents prescribed oxygen as needed did not have oxygen saturation levels monitored as ordered to assess the need for oxygen. This was evident for 2 of 3 residents reviewed for Respiratory Care (Resident #141 and #220). The findings are: The policy and procedure for Care of Residents on Humidified Oxygen dated 5/15/12 documented: It is the responsibility of the Registered Nurse (RN) or Licensed Practical Nurse (LPN) to check and review the Physician's order, set up oxygen concentrator with humidifier, administer oxygen as ordered, assess resident's response to oxygen therapy, and report any changes in resident's condition to MD (Physician). The policy does not specify how the resident's response to oxygen therapy should be assessed. It does contain specifics regarding how oxygen saturation monitoring should be done. 1.) Resident #141 was admitted with diagnoses which include: Asthma, Chronic Obstructive Pulmonary Disease (COPD), B-Cell Lymphoma, and history of Pneumonia. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had moderately impaired cognition. The MDS further documented the resident was completely dependent on the assist of staff for bed mobility, transfer, dressing, toileting, personal hygiene, and locomotion. On 2/7/20 at 15:05 PM and 2/10/20 at 11:00 AM, the resident was observed with oxygen not in use. The Comprehensive Care Plan (CCP) for Respiratory Distress dated 11/5/19 documented the resident had the potential for respiratory distress as evidenced by history a history of aspiration pneumonia. The CCP further documented the resident was on Proventil HFA inhaler every 6 hours as needed. The CCP interventions included: monitor of signs and symptoms (s/s) and/or c/o (complaints of) of respiratory distress and notify MD of abnormal findings; and administer treatments per MD order. The CCP was updated 2/10/20, after surveyor intervention, with the interventions of administer 2 liters oxygen as needed and monitor oxygen saturation every shift. Nursing Notes dated 12/10/19 documented that the resident was transferred to the hospital with a temperature of 102.1 and oxygen saturation of 81% on room air. The resident was readmitted to the facility on [DATE]. The readmission physician's orders dated 12/18/19 documented orders for oxygen via nasal cannula @ 2 liters per minute (L/m) as needed (PRN) and oxygen saturation monitoring every shift. These orders were renewed on 01/15/2020. There was no documented evidence that oxygen saturation monitoring every shift was done from 01/15/2020 to 02/07/2020. The Nursing Notes documented oxygen saturation for one shift only on 5 days (1/21, 1/25, 1/29, 1/30, and 1/31). 2) Resident #220 was admitted with diagnoses which include Hypertension, Non- Alzheimer's Dementia, and Seizure Disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified the resident had severely impaired cognition and was completely dependent on staff for activities of daily living. The Comprehensive Care Plan (CCP) for Respiratory Distress dated 8/27/15 documented the resident had the potential for respiratory distress related to a history of Pneumonia. The interventions included: monitor for s/s of respiratory distress and notify MD of abnormal findings; monitor for effectiveness; and administer oxygen 2 L/min (Liters per minute) via N/C (nasal cannula) PRN (as needed). The CCP intervention of monitor oxygen saturation eery shift was added on 2/10/20 after surveyor intervention. The Physician's order dated 01/31/2020 documented renewal orders for oxygen saturation every shift and administer oxygen 2 L/min via N/C if less than (<) 94%. There was no documented evidence that oxygen saturation monitoring every shift was done from 01/01/2020 to 02/07/2020. The oxygen saturation monitoring record documented oxygen saturation taken daily on four days (1/7, 1/22, 1/31, and 2/7). On 02/07/2020 at 1:20 PM, the Licensed Practical Nurse (LPN #4) was interviewed. The LPN stated that she takes the resident's oxygen saturation but does not always record it. The nurse who picked up the order for oxygen saturation monitoring did not register it in the EMR in the pulse oximeter level section. She stated there is no place to document the oxygen saturation monitoring. On 02/07/2020 at 1:20 PM, the Unit Registered Nurse Manager (RN #3) was interviewed and stated the nurses pick up up and transcribe any new physician's orders. She acknowledged there was no documentation of oxygen saturation levels taken after 1/31/20. She stated she did not know what happened, but she will get back to the surveyor. On 02/07/2020 at 4:30 PM, the 3-11 shift LPN was interviewed and stated she spoke to her supervisor. She stated that she does not take the oxygen saturation level regularly, but she should have done so as ordered and documented it in the record. 483.25(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews during the re-certification survey, the facility did not ensure infection prevention and control practices were followed to help prevent the development and transmission of communicable diseases and infections. Specifically, (1) a resident's motorized scooter was observed parked inside the 6th floor clean linen room where clean linens were being stored; (2) during wound care treatment observation, the Licensed Practical Nurse (LPN) was observed closing and opening the treatment cart, then started pulling the irrigation syringe cap with her bare hands and placed the syringe back inside the irrigation bottle filled with Dakin's solution. The LPN also failed to performed hand hygiene before touching the irrigation syringe. (3) the resident was observed in her room in bed with oxygen by nasal cannula at 2 liters (l/m) connected to an oxygen concentrator on the right head part of the bed. Oxygen tubing was observed touching the floor from the concentrator to the side of the bed going to the resident. This was evident for 1 out of 1 resident for wound treatment (Resident # 203), one clean linen room observation (6th floor) and during the initial tour for the facility recertification survey. The findings are: 1.) The policy and procedure for storage of motorized scooter dated June 22, 2019, documented that the facility will store one motorized scooter in the waiting area on the 6th floor. The storage of the wheelchair will be checked weekly by the rehab department. On 02/07/2020 at 1:36 PM, the 6th floor clean linen room was observed with a red motorized scooter being stored inside with the clean linen. The maintenance supervisor was present during the observation. The red motorized scooter had dirt and debris on the handles, chair, footrest, and wheels. The Motorized Wheelchair Monthly Checklists dated August 2019 to February 2020 documented that the motorized wheelchair (w/c) is stored in the 6th floor TV Room and was checked every Monday. The last check was done on 2/3/2020. On 02/07/2020 at 01:36 PM, the maintenance supervisor was interviewed and stated that the electric scooter wheelchair should never be inside any clean linen room. The clean linen room should only have clean linens, towels and new resident briefs. The red electric scooter wheelchair has dirt and debris on the handle, seat, foot area and wheels. The scooter should not be inside this linen room. On 02/07/2020 at 01:51 PM, the laundry team leader was interviewed and stated that clean linen rooms should only have clean linens and a clean company blue linen cart inside. All materials for use should be covered. There should be nothing else inside the clean linen room. On 02/07/2020 at 03:15 PM, the Director of Nursing was interviewed and stated that nothing should be inside the clean linen room except clean linens that are covered with plastic. She did not know who placed the electric wheelchair inside the clean linen room. On 02/07/2020 at 03:35 PM, the rehabilitation supervisor was interviewed and stated that the scooter should be stored on the 6th floor unit behind the TV room. It should not be stored inside the clean linen room. Rehab checked the location of the scooter randomly. 2) The policy for Care and Treatment of Pressure Ulcer dated 09/28/2012 documented that Methods of Cleansing: 4-15 psi considered safe and effective pressure to use in cleaning and irrigating pressure ulcers. The use of irrigating piston syringe approximates this level of pressure for debridement and types of debridement. The Handwashing policy and procedure dated 01/16/07 documented that hand washing is done using proper infection control procedure, and hand washing is done for at least 30 seconds. Resident #203 had diagnosis which include pressure ulcer of the sacral region stage 4, pressure ulcer on the right buttock stage 4, pressure ulcer on the heels, and pressure-induced deep tissue damage. The Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had intact cognition. On 02/06/2020 at 10:37 AM, a wound care observation was done with the Licensed Practical Nurse (LPN #2). The LPN washed her hands and began setting up her supplies by removing items from the drawers of the treatment cart, placing them on top of the cart. The LPN then opened the irrigation kit and placed the plastic bottle on top of the treatment cart with the syringe inside. She took the syringe out of the plastic bottle and held it with her bare hands while she poured Dakin's solution into the irrigation bottle. The LPN attempted to remove the cap from the tip of the syringe with her bare hands, but was unable to do so. The LPN then placed the capped syringe inside the bottle with the Dakin's solution. The LPN then proceeded to take all the supplies into the room and completed the wound care using the Dakin's solution. The LPN did not wash her hands and don gloves after touching various areas of the treatment cart before handling the syringe and placing it into the Dakin's solution that would be used to irrigate the wound. The Treatment Administration Record (TAR) dated February 2020 documented treatment orders to irrigate sacral ulcer with Dakin's solution, pat dry, then pack with calcium alginate silver. Protect edges with Zinc Oxide and cover with a dry gauge. The ulcer is located in an area affected by incontinence, apply a transparent film cover and secure edge with thin hydrocolloid to change daily and as per needed. On 02/06/2020 at 11:00 AM, LPN #2 was interviewed and stated that when she realized that the irrigation syringe cap was on, she immediately tried to take it off with her hands but was unsuccessful. She then placed the syringe back into the irrigation bottle. LPN #2 stated she should have washed hands and donned gloves before removing the cap. She stated she forgot to do those steps. On 02/06/2020 at 12:10 AM, the RN Manager was interviewed and stated that when preparing for any treatment, the nurse should have everything prepared and placed on the tray using an aseptic technique. When preparing the solution, the nurse should tear the plastic covering the irrigation bottle, and drop it on the tray. After washing hands and putting gloves on, the nurse removes the syringe from the bottle and syringe cap, pours the solution into the container, and places the uncapped syringe back inside the bottle. On 02/07/2020 at 3:45 PM, the Director of Nursing was interviewed and stated that after all the treatment supplies is ready, the nurse should wash hands, don gloves and a face protector. The nurse should remove the syringe and the syringe cap out from the irrigation bottle then pour the solution inside the irrigation bottle. After all the treatments are ready, the nurse should bring it inside the room and do another set of handwashing and gloving. The face mask should remain in use when irrigating any wound to prevent the water from splashing into the nurse's face. 3.) Resident # 200 was admitted with diagnoses which include: Non- Alzheimer's Dementia, Asthma, and Respiratory Failure. The minimum data set (MDS) 3.0 assessment dated [DATE] identified the resident had severely impaired cognition and required assistance with activities of daily living. On 02/04/20120, during the initial tour for the facility, the resident was observed in bed with oxygen by nasal cannula at 2 liters per minute ( l/m ) connected to an oxygen concentrator located near the head of the bed on the right side. The oxygen tubing running from the concentrator to the side of the bed was on the floor. On 02/05/2020 at 11:30 AM, the resident was observed in the gerichair with oxygen via nasal cannula in use. The oxygen tubing running from the concentrator was on the floor. On 02/07/2020 at 4:25 PM, the resident was observed in bed with oxygen in use via nasal cannula. The tubing was touching the floor. The physician's order dated 02/02/2020 documented: oxygen by nasal cannual at 2 liters and monitor oxygen saturation every shift , The registered nurse unit supervisor # 3 was interviewed on 02/05/2020 at 12:00 PM and stated the licensed nurse and certified nursing assistant should be checking and ensure that the tubing is not touching the floor. She stated she would reinservice everyone. The Licensed practical nurse (LPN #4) working the 7-3 shift was interviewed and stated she checks that the tubing is not touching the floor when she administers medications. She also changes the oxygen tubing once per week. She stated maybe the CNAs forget to check the tubing when they do care. On 02/10/2020 at 12:00 PM, the certified nursing assistant (CNA #4) assigned to the resident stated when I care for her, I make sure the tubing is not touching the floor. 483.80(a)(1)(2)(4)(e)(f)

Based on interviews and record review conducted during the recertification survey, the facility did not ensure that residents were provided with information on how to file grievances. Specifically, all resident council members at the Resident Council Meeting were unaware that they had the right to file a grievance in writing and to obtain a decision regarding his or her grievance in writing. This was evident for 12 out of 12 residents who attended the Resident Council Meeting. The findings are: The policy and procedure related to Grievances, revised on 3/20/13, documented that if a complaint/grievance is expressed by a resident/family/legal representative, a Grievance/Misappropriation Reporting and resolution Form is filled out and given to the Director of Social Work (DSW). If a resident needs assistance with filling out the form, any staff member can assist. A copy of the form will be distributed by the social worker to all disciplines required to resolve the complaint/grievance and must be returned to the DSW within 7 days. The social worker (SW) and staff from any other discipline involved with the complaint will meet with the resident to chare the investigative findings. On 02/05/20 at 11:03 AM, a Resident Council Meeting was held with the President of the Resident Council, Resident #16, and 11 additional members of the resident council who regularly attend meetings. When the members were asked if they were aware of how to file a grievance, 12 out of 12 of the attendees stated that they did not know how to file a written grievance and were unaware that they had the right to do so in writing. The council members stated that when they voice a concern, the social worker or other facility staff member that they report it to, do not follow-up with them regarding an outcome. The staff do not provide any investigative findings in writing. The attendees stated that these concerns were related to nursing staffing concerns, care issues, and attitudes of some of the staff. The Grievance Misappropriation Log documented that there were missing clothing, dentures, earrings, makeup, phones, and other items from July of 2018 through January 2020. There was no Grievance Misappropriation Log for 2017. There were no documented grievances concerning issues with facility staff or care received. Documentation regarding the last Resident Council Meeting where resident's rights were reviewed was requested, but it was provided. An interview was conducted with the DSW on 02/10/20 at 11:59 AM. The DSW stated that he had been working for the facility for approximately 14 years, and he attends Resident Council Meetings approximately twice per year to review grievance reporting rights and other areas related to resident's rights. He does not put every concern that a resident has in writing for a grievance. The DSW writes a SW note in the resident's medical record. A meeting is held with resident's family if they have concerns. The meeting allows the family to report their concerns. The Director of Nursing (DNS) is then informed of concerns involving the nursing staff, which are most of the concerns. The DNS does her own investigation and informs the DSW of the outcome of the investigation. He stated he does not always follow-up with the resident regarding the outcome because there are times when personnel decisions have been made, and the resident should not be aware of this information. Personnel decisions were defined as instances when a nursing staff member may be reprimanded, suspended, or fired as a result of a resident's complaint. The DSW does not inform the resident or family member in writing of the outcome of any investigations. Sometimes, the residents have an issue with the Certified Nursing Assistant (CNA) assigned to them and just request for this CNA to stop taking care of them. The DSW was unable to recall all of the incidents or complaints that have been reported to him because he does not document them on any tracking/log or grievance form. He stated there have not been any care grievances recorded in the last 3 years. An interview was conducted with the DNS on 02/10/20 at 02:11 PM. The DNS stated that the residents, including those from Resident Council, began coming to her individually about issues with nursing care and nursing staff. This began approximately 4 months ago. Resident #16 meets with her about personal issues with the nursing staff or dietary issues such as food temperatures. He also makes the DNS aware of concerns from the Resident Council. Resident #16 will also inform the DNS if there are other residents that may want to speak with her about general concerns, but Resident #16 has not brought any specific care concerns to her attention in these meetings. Any specific care concerns are communicated to the DSW who then reports those concerns to the DNS so that she can investigate them. The DNS then informs the DSW what the outcome of those investigations are. The DNS does not update the residents about the outcome of the investigations. The DNS stated that she believes it is the DSW's responsibility to inform the residents of the outcome of the investigation and provide them with something in writing that they must sign to acknowledge receipt. 415.3(c)(1)(i)