**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the Recertification survey from 3/3/2024 to 3/8/2024, the facility did not provide an environment that is free from hazards. This was evident for 1 (Resident #274) of 6 residents reviewed for accidents out of 38 total sampled residents. Specifically, Resident #274 was provided with a disproportionately smaller mattress atop a wider bedframe, a hazard increasing the resident's risk for falling from bed. The findings are: Resident #274 had diagnoses of coronary artery disease and dementia. The facility policy titled Bed Inspection and Maintenance revised 2/2024 documented the safety and comfort of the residents will be ensured by regularly inspecting and maintaining bedframes and mattresses upon admission, readmission, and during a periodic comprehensive audit including bed area assessment. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #274 had severe cognitive impairment. On 3/05/2024 at 11:23 AM, Resident #274 was observed in their room lying on a mattress that was approximately 4 inches smaller in width than the bedframe [NAME] out beneath it. Resident #274 appeared confused, sat up in bed, and attempted to stand up by swinging their legs over to one side of the bed and placing their feet on the exposed edge of the bedframe that the mattress did not cover. Resident #274 appeared unsteady and at risk for sliding or falling from the bed. Unit Nursing staff were made aware and Certified Nursing Assistant #11 and Registered Nurse #5 were observed entering Resident #274's room and assisting the resident with repositioning. The Comprehensive Care Plan related to falls last revised 3/2/2024 documented Resident #274 had actual falls on 2/12/2023, 4/14/2023, 11/13/2023, 12/12/2023, and 1/5/2024 due to cognitive impairment, poor coordination, and poor balance. Documented interventions included providing a hazard-free environment to Resident #274. The Accident/Incident Investigation Report dated 12/1/2023 and 1/5/2024 documented Resident #274 was found lying on their bedroom floor next to their bed. Resident #274 was unable to state what occurred due to cognitive impairment. An Annual Bed/Side Rail Audit dated 2/27/2024 documented the mattress in Resident #274's room was appropriate for the bedframe. There was no documented evidence Resident #274's mattress size was appropriate for their bedframe on 3/5/2024 and the size discrepancy was a fall-risk hazard. On 03/07/2024 at 2:38 PM, Certified Nursing Assistant #11 was interviewed and stated they were assigned to Resident #274 every day for approximately one week prior to 3/5/2024 and did not realize Resident #274's mattress was smaller than the resident's bedframe until Resident #274 was observed attempting to get out of bed unassisted. Certified Nursing Assistant #11 stated they provided Resident #274 with activity of daily living assistance and change their sheets frequently due to the resident's incontinence and did not notice the resident's mismatched mattress and bedframe sizes. On 03/08/2024 at 11:11 AM, Registered Nurse #5 was interviewed and stated Resident #274 was confused, at risk for falls, and hospitalized for falls. Registered Nurse #5 was called to Resident #274's room on 3/5/2024 because Resident #274 appeared to be at risk for falling from their bed. Resident #274 was seated at the edge of their mattress on one side of their bed with their right leg hanging down off the bed and their right foot touching the floor mattress. The mattress on the opposite side of the bed was tilted up off the bedframe and Resident #274 leaned on their right elbow for support. Resident #274 was in a slanted position at the edge of the mattress placing them at risk for falling off the bed. Registered Nurse #5 and Certified Nursing Assistant #11 assisted Resident #274 with sitting up in bed and repositioned the mattress to the center of the bedframe. Registered Nurse #5 informed Assistant Director of Nursing #1 about the resident's smaller mattress versus bedframe and the entire bed was changed. Registered Manager #5 did not notice Resident #274's mismatched mattress and bedframe sizes until 3/5/2024 and stated Resident #274 was at risk of falling off the bed or getting entrapped between the mattress and bedframe because the mattress was too small. On 03/08/2024 at 11:52 AM, Maintenance Worker #1 was interviewed and stated they completed bed size and safety audits for the entire facility on 2/27/2024 and Resident #274's mattress and bedframe size matched. Maintenance Worker #1 observed that Resident #274's bedframe was the same on 3/5/2024 but the mattress was different and no longer fit the bedframe. Maintenance Worker #1 was unable to determine how or when Resident #274's mattress was switched after the audit completed on 2/27/2024. On 03/07/2024 at 3:01 PM, an interview was conducted with Assistant Director of Nursing #1 who stated they were responsible for coordinating bed requests from the Maintenance Department during a resident's admission to the facility and as needed based upon the bed safety audits. Resident #274 was readmitted from the hospital on 2/20/2024 and their bed safety audit was completed 2/27/2024. The bed in Resident #274's room on 3/5/2024 was not the same bedframe and mattress observed during the 2/27/2024 audit. Assistant Director of Nursing #1 stated they were unable to explain how Resident #147's bedframe and mattress were switched since the audit on 2/27/2024. On 03/07/2024 at 4:10 PM, the Director of Maintenance was interviewed and stated they observed Resident #274's mismatched mattress and bedframe on 3/5/2024. Resident #274 had a 38-inch-wide mattress on a 42-inch-wide bedframe. The mattress was the facility's standard size. Standard bedframes measured 38-inches wide to match the standard size mattress. The bedframe in Resident #274's room was wider than standard size and did not match the mattress on top of it. On 3/08/2024 at 12:14 PM, the Director of Nursing was interviewed and stated bed sizes were checked upon a resident's admission to the facility and the Certified Nursing Assistants were responsible for checking bed safety when they cleaned resident's rooms. On 3/8/2024 at 12:30 PM, the Administrator was interviewed and stated that there is no formal process for checking bed safety and that they are in the process of putting a process in place to check new admission and readmission beds. The Administrator stated they were made aware of issues identified during the bed safety audits. 10 NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #181 had diagnoses of non-Alzheimer's dementia and heart failure. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #181 had severe cognitive impairment and did not display behavioral symptoms. Resident #66 had diagnoses of Alzheimer's dementia and coronary artery disease. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #66 had severe cognitive impairment and displayed behavioral symptoms. An Accident/Incident Report dated 6/19/2023 documented staff responded to an altercation in the hallway between Resident #66 and Resident #181. Resident #66 alleged they were slapped in the face by Resident #181 and Resident #181 alleged Resident #66 threw coffee at them. The Facility Incident Report documented the facility reported the resident-to-resident altercation between Resident #66 and Resident #181 on 6/21/2023, more than 2 hours after the occurrence on 6/19/2023. On 3/8/2024 at 12:15 PM, the Director of Nursing was interviewed and stated they were aware they reported the resident-to-resident altercation between Resident #66 and Resident #181 to the New York State Department of Health more than 2 hours after the occurrence and this was not in compliance with the regulatory requirement to report abuse suspicion immediately, but not later than 2 hours of occurrence. 10 NYCRR 415.4(b)(2) Based on record review and interviews conducted during the recertification and complaint (NY00324696 and NY00318663) survey from 3/3/2024 to 3/8/2024, the facility did not ensure that all alleged violations involving abuse were immediately reported to the New York State Department of Health, but not later than 2 hours after the allegation was made. This was evident for 3 (Resident #265, #181, and #66) of 38 total sampled residents. Specifically, 1) Resident #265's abrasion and bruise to their face and head of unknown origin were not reported to the New York State Department of Health, and 2) a resident-to-resident altercation between Resident #181 and #66 was not reported to the New York State Department of Health within 2 hours of occurrence. The findings are: The facility policy titled Abuse Prevention Program dated 1/2024 documented all reports of resident abuse, neglect, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies as defined by current regulations. 1) Resident #265 had diagnoses of non-Alzheimer's dementia and aphasia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #265 was severely cognitively impaired. The Accident/Incident Report dated 9/18/2023 documented Resident #265 was observed with an abrasion and bruise on the left side of their face and back of their head. The Aspen Complaint Tracking System (ACTS) intake dated 9/22/2023 documented a complainant called to report Resident #265 was found with injuries of unknown origin to their face and head on 9/18/2023. There was no documented evidence Resident #265's injuries of unknown origin were reported to the New York State Department of health within 2 hours of discovery on 9/18/2023. During an interview on 3/8/2024 at 12:48 PM, the Director of Nursing stated they were informed of Resident #265's injuries on 9/19/2023, more than 2 hours after the injuries were discovered on 9/18/2023. The Director of Nursing was unable to explain the reason the facility did not report Resident #265's injuries of unknown origin to the New York State Department of Health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, a resident's wander guard was not captured on the Minimum Data Sets (MDS). This was evident for 1 of 13 residents reviewed for Accidents out of total sample of 35 residents (Resident # 184). The findings are: The facility policy and procedure titled Resident Assessment MDS 3.0 revised 11/2021, documented: All persons who have completed any portion of the MDS resident assessment forms must sign and document attesting to the accuracy of such information. and The results of the assessments are used to develop, review and revise the resident's comprehensive care plan. Resident #184 was admitted with diagnoses which included Alzheimer's disease, Restlessness and agitation, and Major depressive disorder. On 02/02/22 at 3:16 PM, Resident #184 was observed wandering in the hallway and then standing in another resident's doorway. MD orders dated 12/14/2021 and renewed 1/11/22 documented: Wanderguard to right ankle for elopement risk. The Comprehensive Care Plan (CCP) for Wandering/Elopement Risk, created on 12/14/21, documented: Wanderguard placed to right ankle and check on the beginning and at the end of each shift. The Certified Nurse Aide (CNA) documentation history dated 12/14/2021-12/31/2021, documented Wanderguard in place. The Resident Nursing Instructions dated 12/14/21 -12/31/21 documented: Wanderguard placed to right ankle and check on the beginning and at the end of each shift. The admission MDS dated [DATE] documented in Section P0200 Alarms that the resident did not use a Wander/elopement alarm. The MDS did not accurately capture that the resident used a Wanderguard daily. On 02/04/22 at 9:26 AM, MDS Coordinator (MDSC) was interviewed. MDSC stated that Section P of MDS which captures Restraints and Alarms is completed by the MDS Assessor (MDSA). MDSC also stated the MDSA did not capture Wander/elopement alarm during the 7 day look back period for the admission MDS dated [DATE]. MDSC further stated that the MDSA was instructed to review CNA Documentation, Physician orders, Care plans, and progress notes when completing the MDS. On 02/04/22 09:53 AM, (CNA) #2 Interviewed. CNA #2 stated resident has a Wanderguard and has had it for a couple of months. CNA #2 further stated the resident's Wanderguard is checked for placement at 7:00 AM and at 3:00 PM. The resident's Wanderguard is checked around the clock. This is documented in the computer. On 02/04/22 at 9:59 AM, MDSA was interviewed. Wanderguard is documented in the doctor's order dated 12/14/21. I missed coding Wanderguard in section P on admission MDS dated [DATE]. MDSA also stated we were instructed to check doctor's orders, assess resident, CNA documentation, and progress notes when completing MDS. MDSA further stated there is a physician's order for wanderguard and it should have been coded in section P of MDS. I am responsible for accuracy of this section since I signed for it. On 02/04/22 at 1:31 PM, Assistant Director of Nursing (ADNS) was interviewed. ADNS stated resident #184 is a wanderer with a wander guard in place. ADNS also stated the Assessors are responsible for coding the MDS Assessments. The Wanderguard should have been coded in the MDS. ADNS further stated there is documentation on resident's wander guard to check placement at beginning and end of every shift. The CNA documentation history dated 12/14/2021-12/31/2021, documented a G in Safety section for alarms which indicates Wanderguard is present. 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident #386 was admitted to the facility with diagnoses of Dementia, Hypothyroidism, Hyperlipidemia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #386 had severely impaired cognition with short-term memory problem. The MDS documented that resident required extensive assistance with one person assist for bed mobility, transfer, eating and toilet use. The resident required total dependence with one person assist for personal hygiene. The resident was frequently incontinent of urinary and always incontinent of bowel. On 1/31/22 at 11:13 AM, Complainant was interviewed via phone. Complainant stated that he/she was not notified of any accidents or incidents that led up to the event of hospitalization. Complainant stated he/she received a call on 4/2/20 when resident was being hospitalized for fractured hip. The Comprehensive Care Plan (CCP) titled Fall Actual related to use of BP medication, dx of syncope, wandering episode, impaired balance and mobility, incontinence, fall risk = 5 was created on 5/13/2019 and revised on 3/20/20 with goal of no incidence of falls or serious injuries in the next 90 days. The interventions include family notification, MD evaluation and medical work up prn, keep resident's items within easy reach and level of vision, keep call bell within reach and answer promptly. The Nursing Note dated 4/1/20 at 9:07 PM, documented that Resident #386 was observed with right thigh swelling and resident complained of pain. Attending Physician was notified, and STAT ordered right hip and right femur x-rays and Tylenol for pain. The Physician Note dated 4/2/20 at 9:44 AM, documented Resident #386 was seen and was noted with shortened and externally rotated right hip and tenderness to the right hip. Review of x-ray report dated 4/2/20 revealed the radiographs of the right hip demonstrate an acute comminuted fracture of the right femur. The Nursing Note dated 4/2/20 at 7:29 PM, documented Attending Physician was informed of positive x-ray result for fracture. Resident #386 to be transferred to hospital for further evaluation and treatment of right hip fracture. It further documented family representative was also notified of the x-ray results & hospital transfer. The Physician Note dated 4/2/20 at 7:39 PM, documented Resident #386 had a right hip fracture and was transferred to the hospital for evaluation. There was no documented evidence in the medical record that the resident had any accidents or falls from 3/30/20 to 4/1/20. This fracture of unknown origin was not reported to the NYSDOH or the administration. An Accident/Incident (A/I) Investigation written by the Assistant Director of Nursing (ADON #1) was initiated on 4/3/20 after a phone call was received from the designated representative. The A/I documented ADON #1 received a call from Resident #386's designated representative on 4/3/20. The representative was upset regarding Resident s#386's transfer to the hospital. ADON #1 informed the NOK that an investigation is on-going. The investigation documented RN #2 was interviewed, and the facility's surveillance camera was reviewed. The summary documented that RN #2 was interviewed and stated Resident #386 had a fall incident during RN #2's tour on 3/30/20. Resident #386 was assessed with no visible injuries. The investigation concluded there was no abuse, neglect, or mistreatment occurred. On 2/2/22 at 3:09 PM, Assistant Director of Nursing (ADON #1) was interviewed. ADON #1 stated when a resident was noted with a serious bodily injury of unknown origin, the resident's representatives were notified immediately and document in the nurse's note. It is the licensed unit nurse who will complete A/I Report and notify nursing supervisor on duty, attending physician, and resident's representative. Nursing A/I Investigation for all accidents are also completed by RN Supervisor. ADON #1 stated that ADON #1 received a call on 4/3/20 from Resident #386's designated representative who was very upset about Resident #386's hospitalization. ADON #1 stated that it was then the investigation was initiated. ADON #1 also stated after interview with the RN on duty and reviewing the camera footage, Resident #386 was observed getting up from the wheelchair and lost balance and fell to the floor. Therefore, it was ruled out that there was no alleged abuse, mistreatment, or neglect. ADON #1 stated that Resident #386's A/I Report was not found in the binder located in the Nursing Office. On 2/3/22 at 10:23 AM, Registered Nurse (RN #2) was interviewed via phone. RN #2 stated RN #2 was on duty during 7 AM to 3 PM on 3/30/20. RN #2 stated Resident #386 was trying to get up from the wheelchair and fell on the floor. RN #2 stated A/I Report was completed as per protocol but could not recall the names of CNAs assigned to the unit on the day of the incident. RN #2 stated the nursing supervisor was informed but does not recall the name of the nursing supervisor. On 2/04/22 at 9:28 AM, the Registered Nurse Supervisor (RN #1) who worked on 3/30/2020 was interviewed. RN #1 stated they could not recall any fall occurring for Resident #386, and no fall was reported to him/her on 3/30/2020. 415.4(b)(2) Based on record reviews and interviews conducted during the Recertification and Abbreviated survey (NY00259038 and NY00252716), the facility did not ensure that an alleged violations involving Abuse and serious bodily injury were reported to the New York State Department of Health (NYSDOH) within 2 hours. Specifically, (1) allegations of resident-to-resident abuse were not reported within 2 hours, and (2) incidents of resident-to-resident abuse and a fracture of unknown source were not reported. This was evident for 7 of 8 residents reviewed for Abuse (Resident #130, #131, # 191, #199, # 205, #536, and #386). The findings include but are not limited to: The facility policy titled Abuse Prevention Program with revised date 11/2017 documented that An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 1) Resident #191 was admitted to the facility on [DATE] with diagnoses that include Dementia, Diabetes Mellitus, Major Depressive Disorder. The MDS assessment dated [DATE] identified Resident # 191 had severely impaired cognition with a Brief Interview of Mental Status score of 3 out of 15. Resident #130, the was admitted to the facility on [DATE] with diagnoses including cerebral Ischemia, Major Depressive Disorder, and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #130 cognition as intact with a Brief Interview for Mental Status (BIMS) score of 13. The facility Summary of Investigation dated 05/05/2020 documented that at 4:30 PM, Resident #191 was lying on Resident #130's bed. Resident #130 asked Resident #191 to leave, but it resulted in a physical altercation, and both residents had an injury. Resident #130 sustained 7.5 centimeters cut on the head with mild bleeding. Resident # 191 sustained a superficial linear skin tear above the left eyebrow and bruised with mild bleeding. The facility Summary of Investigation dated 05/08/2020 documented that at 3:25 AM, Resident #130 was sitting in front of the nurse's station. Resident #130 came out of the elevator and assaulted Resident #191 with a belt. Resident #191 sustained a 1-centimeter cut to the right forehead at the hairline, two superficial scratches to the forehead, and one superficial scratch to the left forearm The NYSDOH Intake Information form dated 05/13/2020 documented the facility reported the incident between Resident #191 and Resident #130 had a resident -to-resident altercation on 5/5/2020. The facility made no reference to the second altercation that occurred on 5/8/2020. The incident on 5/5/2020 was not reported within 2 hours, and the incident on 5/8/2020 was never reported. 2) Resident #205 was admitted to the facility on [DATE] with the diagnoses, including Heart Failure, Diabetes Mellitus, and Major Depressive Disorders. The MDS assessment dated [DATE] identified Resident # 205 had severely impaired cognition. The facility summary of investigation dated 08/05/2020 at 2:47 PM documented that Resident #205's wheelchair hit Resident #191's foot. A verbal altercation started and escalated to a physical altercation. Both residents sustained injury from the incident. The NYSDOH Intake Information form documented that the alleged incident occurred on 08/05/2020. The incident was reported to NYSDOH on 08/12/2020. During an interview on 02/04/2022 at 11:08 AM, the Assistant Director of Nursing #2 (ADNS #2) stated that the incident with Resident #130 and Resident #191 on 05/08/2020 was not reported because it was a related to the previous incident on 5/5/2020 with the same residents. ADNS #2 stated he/she reported the incidents late because they had to complete the investigation and obtain statements prior to reporting. During an interview on 02/04/2022 at 11:40 AM, the Director of Nursing (DON) stated that resident to resident altercations, abuse, and mistreatment should be reported to the Department of Health (DOH). The Administrator, DON, and ADONs are responsible for reporting incidents to DOH. The DON stated cases of confirmed abuse are supposed to be reported within two hours, and suspected abuse is reported within 24 hours. The facility has five days to complete the investigation. The incident between Resident #130 and Resident 191 on 05/08/2020 should have been included in the report on 05/12/2020, but it was not mentioned. The DON said that they recognized that their submissions were late and will take the concern to the Quality Assurance committee. During an interview on 02/04/22 at 12:11 PM, the Administrator stated that the DON, ADONs, and the Administrator are responsible for reporting incidents to the DOH. Resident to resident altercation is a reportable incident to rule out abuse. The incidents were not reported in time because it was the height of COVID. The Administrator said that there was no reason why the 05/08/2020 incident between Resident #130 and Resident #191 was not reported, and it should have been reported. The Administrator acknowledged that the facility submissions were late.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility did not ensure that the Optometry provided the resident privacy during care. Specifically; the Optometry did not take the resident to her room and provide privacy prior to her examining the resident eye. This was evident for 1 of 40 sampled residents. The findings is: The facility policy and procedure titled Consults dated January 2011; rev 2018 rev8/27/19pc documented the following. All Consultants will ensure that resident's privacy and dignity during visits. All Consultants will utalize the 1 East Beauty Parlor room to ensure privacy during visit. In-house residents will be escorted to the 1 East Beauty Parlor room by facility staff. Resident # 121 was admitted [DATE] with diagnosis which includes hypertension, Coronary Artery Disease, Neurogenic Bladder and Depression. The Minimum Data Set 3.0[MDS] assessment dated [DATE] documented the resident is cognitively intact,requires limited assistance of one person with activities of daily living and impaired vision with no corrective lenses. On 08/26/19 at 11:07AM the SA (State Surveyor) observed the Optometrist performing an eye exmaination of Resident #121 in the 6th floor dining room. There were ten other resident and three staff members in the dining room at the time of the examination. The Optometrist used was a flash light and retinoscopy equipment during the examination. There was no screen or curtain to maintain privacy. On 08/26/19 11:17 AM the Registered Nurse Manager was interviewed. The RN stated the Optometrist should examine the resident in the day/dining room The resident should have been brought to the resident's room where privacy could be mainatained. On 8/26/2019 11:28 AM the Optometrist was interviewed. The Optometrist stated that she usually examines the resident[s] in the day room, or their room. She did not think this was an issue. She further stated that there the facility does not provide any designated areas for examinations. The resident was interviewed on 08/29/19 at 09:21AM. The resident stated the eye doctor usually examines her in the day/dining. She further stated that since she is not taking off her clothes it did not bother her. On 8/29/2019 at 10:30 AM the DNS (Director of Nursing) was interviewed. The DNS stated that all consultants were told during orientation not to examine residents in day/dining room and corridors. They were told that they must use the resident's room and provide privacy. 415.3(d)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not maintain infection control practices to help prevent the development and transmission of communicable diseases and infections. Specifically, a CNA was observed on multiple occasions holding resident bread with bare hands, buttering bread and giving bread to residents (resident # 266 and resident #230). 2. The LPN did not change gloves and perform hand hygiene during wound observation when she cleansed the dirty wound and moved on to apply the clean dressing to wound for one resident (#284). The findings are: The facility policy entitled Handwashing/Hand Hygiene under section Policy Interpretation and Implementation stated use alcohol-based hand rub containing at least 62% alcohol; or alternative, soap (antimicrobial or non-antimicrobial) and water for the following situations: before moving from a contaminated body site to a clean body site during resident care, after handling used dressings, contaminated equipment. 1) Resident # 230 is a [AGE] year-old admitted to the facility on [DATE], with diagnoses which included Anemia, Hypertension, Schizophrenia, and Asthma. The Annual Minimum Data Set (MDS), Assessment Reference Date (ARD) 7/4/2019 documented the resident has severe cognitive impairment, with short term and long-term memory problem. Resident # 266 is a [AGE] year-old admitted to facility on 8/8/2019, with diagnoses which included Hypertension, Hyperlipidemia, and Dementia. The 14-day Schedule Minimum Data Set (MDS), Assessment Reference Date (ARD) 7/22/2019 documented the resident has severe cognitive impairment, with short term and long-term memory problem. 1. On 08/26/19 at 12:06 PM, an observation was conducted in third floor dining room during lunch. Twenty-four residents were seated in the dining area with six (6) staff assisting as needed. CNA #1 was observed assisting a resident with the meal. CNA#1 took a slice of white bread from Resident #230 with her bare hands, applied butter on bread, and then returned the bread back to the resident and the resident ate the bread. After assisting the resident, the CNA went to the sink in the dining area, washed her hands and went on to assist another resident. On 8/26/19 at 12:10 PM, a second observation was conducted in the third-floor dining room at lunchtime. CNA #1 took white bread from a resident tray, open the plastic wrapping and proceeded to place the bread in the palm of her bare hand, and applied butter to the bread. When finished buttering the bread, CNA #1 gave the buttered bread to Resident #266. Resident ate the bread. No barrier observed between staff hands and resident bread. On 08/26/19 at 12:30 PM, an interview was conducted with CNA #1 working in facility for past month. CNA stated she is a new CNA and is still in the process of learning things. CNA stated she made an error in touching the resident bread, and she knows she supposed to keep the bread in plastic, butter it and give it to the resident without using her bare hands. CNA stated she was provided orientation on handling resident's room. On 08/29/19 at 03:18 PM, an interview was conducted with RN #1 who stated she is the Supervisor for the 3rd floor. RN stated all staff was in serviced on dining and the appropriate way to assist resident with their food. RN#1 stated all staff was trained in handling resident's food, and staff can use a napkin to hold the bread, butter the bread and give it back to the resident without using their bare hands. RN#1 also stated the CNA was in-serviced by the In-service Coordinator, immediately after incident, and she also reinforced the in-service by letting staff know they cannot use their bare hands when buttering the bread, but they can use a napkin as a barrier. 2. Resident #284 is a year old admitted to the facility on [DATE] with diagnoses includes Pressure Ulcer Stage 4, Anoxic Brain Damage, Essential Hypertension, and Cerebrovascular Disease. The Quarterly MDS dated [DATE] documented in resident with severe cognitive impairment, and documented resident had one Stage 4 pressure ulcer. Physician's orders dated 8/14/19 documented the following treatment: apply calcium Alginate post Normal Saline wash then cover with foam dressing twice daily and as needed to Sacrum Stage IV re-opened, Tylenol 325mg give two tablets by G-Tube route once 30 minutes to one hour prior to treatment. Wound Consult note dated 8/27/2019 documented Pressure Injury to Sacrum stage 4 measuring 0.3cm x 0.1 cm x 0.2 cm. An observation of wound care was conducted on 08/28/19 at 09:32 AM with LPN #1. LPN #1 and a CNA knocked on the resident's door, greeted the resident and explained to the resident they were here to change the dressing. LPN #1 and the CNA washed hands at sink, drew the curtain around resident and closed the door. LPN cleansed the overbed table and set-up supplies. A garbage bag was taped to the overbed table and drape placed on the resident. The LPN placed a sterile drape on the overbed table, then opened and dated the following as necessary-normal saline, tape, treatment of Calcium Alginate, foam barrier and border dressing. The LPN then washed her hands, donned gloves, wet gauze with saline, removed gloves, and washed hand. The LPN instructed the CNA to position the resident on the right side. The LPN removed the old dressing from wound to sacrum and discarded the dressing. LPN removed gloves, washed hands and donned new gloves. LPN proceeded to clean the sacrum wound counterclockwise, clockwise and down the middle x 3 using clean gauze each time. LPN then pat dry the sacral wound with clean gauze. LPN then proceeded to pick up the calcium alginate, applied it to sacrum wound, apply the foam covering on the calcium alginate, and then applied the border gauze dressing to cover wound. The LPN did not remove gloves and perform hand hygiene after cleaning the wound and before applying the treatment and dressing. The LPN then gathered all the used supplies discard same in the garbage, washed hands and exited the room. On 08/28/19 at 09:52 AM, an interview was conducted with LPN #1. LPN #1 stated she is responsible for wound treatment on the unit. LPN#1 also stated she did something wrong as she did not change her gloves after cleaning the wound and before applying the treatment and dressing. LPN #1 further stated she was so nervous being observed while performing dressing change. On 08/28/19 at 10:02 AM, an interview was conducted with RN#2, Infection Control and Wound Care Nurse. RN#2 stated changing of gloves and hand washing should be done a lot of times during care. When gloves are dirty, they should be removed, and hands washed. RN#2 also stated when going from dirty area to clean area, staff should wash hands and place new gloves on to continue care. RN#2 further stated that all staff receive in-service on hand hygiene and LPN#1 had been in-serviced the day prior. RN #2 stated she makes frequent rounds and observations to ensure staff is compliant with hand hygiene. 415.19(b)(4)