Based on observation, record review, and interviews conducted during the recertification survey from 11/27/2023 to 12/1/2023, the facility did not ensure infection control practices and procedures were maintained. This was evident for 1 (Unit 6) of 5 resident units. Specifically, blood pressure (BP) cuffs were not disinfected between resident use. The findings are: The facility's policy titled Infection Control: Point of Care Devices dated 06/12/2023 documented blood pressure machines should be cleaned between use to prevent spread of germs from one resident to the other. On 11/29/2023 at 08:29 AM, Unit 6 Licensed Practical Nurse (LPN) #1 was observed applying the BP cuff to Resident #64 arm and reading their BP. LPN #1 removed the BP cuff and returned it to the BP machine. LPN #1 moved on to Resident #122, applied the BP cuff to the resident's arm, and obtained their BP reading. LPN #1 did not sanitize the BP cuff in between use with Resident #64 and Resident #122. On 11/29/2023 at 08:49 AM, LPN #1 was interviewed and stated they just realized they did not sanitize the BP cuff in between resident use. BP cuffs should be sanitized before and after it is applied to residents. On 11/30/2023 at 12:45 PM, an interview was conducted with the Director of Nursing (DON) who stated staff were responsible for sanitizing vital sign equipment prior to obtaining a resident's vital sign reading. Sanitizer wipes were stocked on each unit cart for staff to frequently sanitize equipment used on residents. Staff were given inservice to ensure compliance with facility policy. The DON stated any staff observed not practicing infection prevention protocol will be reeducated. 10 NYCRR 415.19(b)(4)

Based on record review and staff interview conducted during the Recertification and Complaint Survey (NY00277748), the facility did not ensure that residents' representatives were immediately notified about residents' conditions. Specifically, (1) the facility did not notify the resident's representative prior scheduled and taken resident for consult surgical procedure, (Resident #172). This was evident for 1 of the 3-residents reviewed for Notification of Change (Resident #172). The findings are: According to the CMS Guidance §483.10(g)(14) Notification of Changes, the facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). 1) Resident #172 was admitted to the facility 11/12/2020, with diagnoses that included Coronary Artery Disease (CAD), Congestive heart failure (CHF), Diabetes Mellitus (DM), Cerebrovascular Accident (CVA). The Annual Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 08/12/2021 documented that resident had moderately impaired cognition (decisions poor, cues/supervision required). The MDS also documented that it is very important to the resident to have family or a close friend involved in discussions about care being provided. On 09/02/21 at 12:02 PM, a telephone interview was conducted with the resident's designated representative, the Complainant. The Complainant stated they were not notified before Resident #172 was scheduled for medical consultations and procedures. Resident #172 is confused and has been noted with increased periods of confusion. The Complainant stated they had to make several telephone calls to demand updates about the resident's condition before getting information. The Complainant further stated that Resident #172 was taken for a medical consult to remove a toenail in July without their knowledge. Resident was also scheduled for and taken to get a procedure done without their knowledge. The Consultant called the Complainant when Resident #172 was already at the appointment to obtain consent, but the Complainant declined consent because they did not know about the appointment. As a result, the appointment had to be canceled and re-scheduled. Resident #172 has no mental capability to understand. On 09/03/21 at 09:21 AM, Resident #172 was interviewed and stated, I don't really know much; it is my family that are in-charge of everything. They come regularly to take me out. They are also in care of my financial. Resident #172 appeared alert and oriented with confusion. Resident #172 was able to participate in Yes or No conversation. A Nursing Progress Note dated 07/21/2021 at 10:32 pm documented Resident #172 was observed with yellow drainage from the right big toe with smelly odor upon dressing change. Discoloration and slight detachment nail were observed. The supervisor was made aware, the toe was wrapped with a DPD (Dry Protective Dressing). Will continue follow up with MD. A Vascular Consult dated 07/22/2021 documented that resident was seen by Vascular. The Physician documented the resident was assessed and evaluated. The resident had a clinical history of chronic venous insufficiency of the Left lower extremity and was a candidate for sclerotherapy/ablative treatments. Venous insufficiency related symptoms may have improved with conservative management but have not resolved completely. The resident suffers with lower extremity edema, pain, and hyperpigmentation. The Physician completed the following Treatment/Procedure: the leg was elevated, manual compression was applied to the puncture site, immediate use of the calf muscle was encouraged and/or passively applied. Upon completion, the puncture site(s) were observed for bleeding. After no bleeding or hemorrhage was noted, a sterile dressing to the puncture site was applied tolerated the treatment well. The procedure was followed by the application of a compression wrap. There was no documented evidence that resident's representative was notified about the vascular consult before and/or after the above procedure was carried out. On 09/08/21 at 12:32 PM, the Nurse Practitioner, NP, was interviewed. The NP stated that the family is always made aware of any issue going on with the residents before they are sent to any consult appointment. The NP stated that Resident #172's representative was called on phone on 9/3/2021 when the nursing staff reported that the representative had requested to speak with the physician. NP stated that during the discussion the representative was concerned that the resident was getting more confused. The resident was assessed, lab work ordered, and reviewed with negative results. Charts was reviewed, and noticed the psych recommendation for Aricept, and was ordered for the resident's cognitive disorder. NP stated that they are not aware that the representative was not notified of the vascular consult appointment of 7/22/2021. On 09/08/21 at 02:28 PM, and interview was conducted with the Social Services Director (SSD). SSD stated that resident's family should be informed prior to a resident being sent to an outside consult appointment. The family should also be informed of consultant recommendations by the Nurse or Physician. On 09/09/21 at 09:57 AM, an interview was conducted with RN Supervisor (RNS #1). RNS #1 stated that outside consults are scheduled by the unit nurse. The consult schedule is sent down to the nursing office to schedule for the appointment and arrange for transportation. RNS stated that the nurse that enters order for the consult should notify the family prior to the consult appointment. RNS #1 did not know why Resident #172's representative was not informed about the consult. RNS #1 stated: I am a per-diem Supervisor, working only 2-3 days per week, but I know the family should be notified of any procedure to be done. The Licensed Practical Nurse (LPN) Supervisor that entered the vascular consult order for the resident, and the Nurse Practitioner, NP, that signed off on the order were unavailable for interview. Attempts made to speak with them on phone via the telephone numbers provided were not successful. On 09/09/21 at 10:16 AM, an interview was conducted with the Director of Nursing, (DON). The DON stated residents' representatives are informed of routine consults provided in-house, like dental, upon admission. And for outside consults, such as Vascular, the nurse will enter the order and bring the list down to schedule for the appointment and for transportation. DON stated that the nurse that enters the order is expected to notify the family about the appointment prior the consult date. The DON also stated that the NP or the Doctor always speak with the family members regarding the changes in any resident's condition. The DON was not aware that resident's #172's representative was not notified of the resident's Vascular appointment. On 09/09/21 at 10:35 AM, an interview was conducted with the Medical Director, (MD). The MD stated that the nurse and/or the Physician is expected to let the family member know if the resident is being sent to an outside Consultation appointment. The MD stated that not informing the family member of the resident's scheduled outside appointment is a concern that should be addressed. The MD stated that the timeframe for the Attending Physician to review the Consultant's recommendation should not be more than one week, and the family member should also be notified of any recommendation to be ordered. 415.3(e)(2)(ii)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure that a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet resident's goals, and address the resident's medical, physical, mental, and psychosocial needs. Specifically, there was no CCP developed for resident's use of Oxygen therapy. This was evident for 1 of 3 residents reviewed for Respiratory Care out of a sample of 38 residents. (Resident #167) The findings are: The facility Policy on Comprehensive Care Plan (CCP), last reviewed on 06/2021 documented the CCP is to include resident's problems, strengths and needs. An individual CCP will be developed for each problem, strength or need with intention of a culture of Person-Centered Care throughout the facility .Each CCP is to include measurable objectives and timetables in order to meet the resident's physical, mental, and psychosocial needs that are identified from the resident Comprehensive Assessments. Resident #167 was admitted to the facility with diagnoses that included Congestive Heart Failure (CHF), Pneumonia, Anxiety, and Asthma/COPD. The admission Minimum Data Set (MDS) dated [DATE] documented that the resident had intact cognitive status and was receiving Oxygen therapy. On 09/02/21 at 01:01 PM, Resident #167 was observed in their room with continuous Oxygen in place via nasal cannula. The Oxygen and nebulizer tubing were not dated. Resident stated that the tubing was being changed by the staff regularly but they cannot remember the date that it was last changed. The tubing and the mask appeared clean. On 09/07/2021 at 09:30 AM, Resident #167 was observed in room with oxygen in place via nasal cannula from concentrator, tubing dated 9/5/2021. The Comprehensive Care Plan (CCP) titled Respiratory dated 7/30/2021 documented that resident had active diagnosis of Emphysema; Chronic respiratory failure; Chronic Obstructive Pulmonary Disease (COPD); Shortness of breath (SOB) exacerbated by CHF. Goals included: Resident will maintain adequate respiratory functioning as demonstrated by stable vital signs including respiratory rate. Interventions included assess resident for signs and symptoms of respiratory distress, assess pulse oximeter as ordered and PRN if resident shows any s/s of respiratory, and assess vital signs as needed and before and after all treatments. The Comprehensive Care Plan (CCP) for Cardiac dated 7/30/2021 documented that resident is at risk for alterations in cardiac functioning, has Pulmonary Edema as evidenced by diagnosis of Pulmonary edema. Interventions included monitor for signs and symptoms of chest pain, assess and monitor for signs and symptoms of cardiac compromise/distress such as shortness of breath, pallor, chest pain, cyanosis, edema of the extremities, chest congestion, cold and clammy skin, alterations in BP or pulse, and observe for side effects of medications. The Physician's order dated: 7/29/2021 (1st became standing) documented: Supplementary oxygen via nasal cannula at 2/LPM continuously. Change Oxygen/Nebulizer Tubing weekly. There was no documented evidence of a care plan that contained interventions for oxygen use, and oxygen equipment maintenance. On 09/07/21 at 11:40 AM, an interview was conducted with the Licensed Practical Nurse (LPN) #5. LPN #5 stated that the resident's oxygen tubing is changed weekly by the night shift nurse. LPN #5 also stated that the Registered Nurse (RN) Supervisor or MDS Coordinator are responsible for the residents' care plan. On 09/09/21 at 03:21 PM, an interview was conducted with the RN-MDS Coordinator (MDSC). The MDSC stated that the care plan is initiated upon admission by an RN and updated by an RN as needed. The Episodic care plan is also initiated by an RN. The MDSC stated that the MDSC reviews the care plan and intiates any missing care plans at the Care Plan Meeting held with the Interdisciplinary Team 14 days after admission. The resident is physically assessed, Physicians orders, and progress notes are reviewed to check for the care plans needed by the resident. The MDSC further stated that the resident has an order for oxygen, and the oxyen should be included in the care plan, but it was omitted. On 09/09/21 at 03:31 PM, the Director of Nursing (DON) was interviewed. The DON stated that the electronic medical record system will populate most of the baseline care plans needed for the resident, and the admitting RN will check to initiate the other additional necessary care plans. The DON also stated that the MDS Coordinator is expected to review the CCP to ensure all necessary care plans are in place before the care plan meeting is completed. The DON further stated that they were not aware of Resident # 167's missing oxygen care plan, but the care plan will be reviewed to ensure everything necessary is in place. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , record review and staff interviews , the facility did not ensure that services provided or arranged by the facility as outlined by the Comprehensive Care Plan meet professional standards of quality including current evidence based practice. Specifically, Licensed Nurses did not inform the physician / Nurse practitioner when a resident with diagnosis of Diabetes Mellitus had elevated Blood glucose readings and refusing treatment as ordered by the Physician. This was evident for 1 of 38 residents reviewed for care. (Resident #9) The finding is: The Licensed Practical Nurse job description states on the purpose as The primary purpose of your position is to provide direct nursing care to the residents ,and to supervise the day to day nursing activities performed by CNAs and other nursing personnel. On duties and responsibilities on charting and documentation includes amongst other -- transcribe physician's orders to resident charts , cardex , medication cards , treatment or careplans,as required and chart nurses notes in an informative and descriptive manner that reflects the care provided to the resident as well as the resident's response to the care , prepare and administer medications as ordered by the Physician and notify the Nurse Supervisor or Unit Manager for any discrepancies noted on your shift. Resident # 9 was admitted to the facility with diagnoses of Diabetes Mellitus (DM), Cerebrovascular Accident (CVA), and Atrial Fibrillation. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #9 had moderately impaired cognition and was able to make their needs known. On 09/02/2021 at 10:30 AM, Resident #9 was observed asleep in bed. On 09/08/2021 at 11:00 AM, Resident #9 was observed in bed with Intravenous fluid of D5 (dextrose 5)0.9% Normal Saline Solution (NSS), 1 liter at 125 cubic centimeter(cc) per hour inserted to right antecubital area and regulated with the use of a diaflo.The resident appeared frail, weak, and cachectic. The Comprehensive Care Plan (CCP) for Diabetes Mellitus dated 12/14/2020 08/26/2021 and renewed on 09/02/2021 documented the resident had Insulin Dependent DM, Hyperglycemia, and Chronic Kidney Disease. The goal of the CCP was for the resident to take all prescribed medications. Interventions included administer insulin per MD order, administer medications as prescribed, monitor Hemoglobin A1c and laboratory results, and monitor for signs and symptoms of hypo and hyperglycemia. The CCP for Non-Compliance dated 12/14/2020 and renewed on 8/26/21 documented Resident #9 refuses to follow the plan of care, medications, and treatments. The CCP goal was for Resident #9 to allow and cooperate with the plan of care. Interventions included resident and family/next of kin education regarding the risk of non-compliance, encourage participation and increased involvement, provide explanation of procedures, give ample time to express feelings, and set a limit for Resident #9's behavior and referral to psychiatrist. The Physician's order dated 09/07/2021 documented Resident #9 was to receive Fingerstick (FS) three times a day before meals (TID/AC) with Humalog sliding scale coverage: 181-230 = 3 units; 231-280 = 5 units; 281-330 = 7 units; 331-380 = 9 units; 381-430=12 units; 431-500 = 16 units. Call Medical Doctor (MD) if lesser (<) 70 and greater (>) 500. Levemir 10 units subcutaneous every 12 hours was also ordered. The Fingerstick Monitoring Records (FMRs) from 07/01/2021 to 09/07/2021 documented sporadic and elevated FS blood sugar (FSBS) values for Resident #9. Most of the time, the FSBS were not done. From 07/01/2021 to 07/31/2021 there were 93 opportunities for FSBS, but only 18 FSBS values were documented. Of the 18 documented FSBS values, 13 were elevated above 181 mg/dl, requiring insulin administration. Eleven of FSBS were 400 mg/dl (milligrams per decilitre) and above, with 4 values of 500 mg/dl. The resident had one FSBS over 500. From 08/01/2021 to 08/31/2021 there were 93 opportunities to document the resident's FSBS; however, 16 FSBS values were documented. Of the 16 documented FSBS values, 6 of 16 were elevated above 181 mg/dl, requiring insulin administration. Four of 16 were in the 400s, and 2 of 16 were 500 mg/dl and above. From 09/01/2021 to 09/07/2021, there were 21 opportunities to document FSBS values; however, only 11 FSBS values were documented with all 11 above 181 mg/dl, requiring insulin administration. Six of 11 were above 400 mg/dl with one value of 500 mg/dl. The Nursing Notes reviewed from 07/01/21 through 09/02/21 documented Resident #9 refused medication and/or FSBS monitoring on multiple occasions. There was no documented evidence the MD or NP were informed of the refusals or the FS results over 500 mg/dl per MD orders. Further review of the record reveals no documented evidenced that staff attempted to revisit the resident or new interventions were in place. The Nurse Practitioner (NP) and MD notes from 07/01/2021 to 09/02/2021 contained no documented evidence that the MD or NP assessed or addressed Resident #9's elevated FSBS levels and/or resident's non-compliance with Diabetic management. On 09/09/2021 at 2:30 PM, LPN # 5 was interviewed and stated maybe they informed the NP on occasion but LPN #5 could not recall. LPN #5 could not find documentation confirming the NP or MD were informed of the elevated finger sticks and medication refusals in the records. Resident #9 takes the medications at times, depending on their mood. Resident #9 can be really aggressive. On 09/10/2021 at 2;41 PM LPN # 2 was interviewed and stated they are new at the facility and everybody says Resident #9 refuses medications and treatments. LPN #2 stated they did not notify the MD nor NP of the refusals because once a refusal is documented in the Medication Administrtaion Record (MAR), it automatically populates in the 24-hour report. This report is then read and reviewed by those who attend the morning rounds like the DNS, ADNS, Unit Managers, NP, Physicians and others. On 09/10/2021 at 11:13 AM The Assistant Director of Nursing /Educator (ADON) was interviewed and stated in service is done quarterly and mandatories are reviewed . If there is a need for the staff to reinforce learning then we do it . Mostly the emphasis is on infection control, hand washing. After reviewing the resident's medical record with FS results and Licensed Nurses documentation, the ADON akcknowledged the nurses documented elevated FS, and they did not document steps taken to address or notification of the MD or NP. On 09/10/2021 at 3:10 PM the Director of Nursing was interviewed and stated when a refusal is documented by the LPNs, it is normally populated in the 24-hour report, which is available for management during the morning meeting. The DON further stated they review the report. When asked if reporting concerns to the MD or NP should wait until morning, the DON had no response and stated I see what you mean. 415.11(c)(3)(i)

**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 an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident based on the comprehensive assessment and care plan. Specifically, a resident with severe cognitive impairment was observed for extended periods of time without meaningful activities. This was evident for 1 of 2 residents reviewed for Activities out of 38 sampled residents (Resident # 61). The finding is: The facility policy and procedure dated 2/21/2021 titled Activity Programs documented it is the policy of Throgs Neck Rehabilitation and Nursing Center to provide Activity programs which are meaningful, age appropriate, designed to promote self-esteem and allow residents to exercise their right to indulge in and to participate in activities of interest. Resident # 61 was admitted to the facility with diagnoses which included Peripheral Vascular Disease, Huntington Disease, Seizure Disorder, Anxiety Disorder and Depression. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident with severely impaired cognition and dependent on staff for all activities of daily living. The MDS also documented that listening to music was important to the resident. On 09/07/2021 at 11:20 am, Resident #61 was observed in bed in room. Resident was alert and did not respond to verbal commands. There was a television playing an English Language news program. On 09/08/2021 from 11:00 AM to 1:00 PM, and from 2:00 PM to 5:00 PM Resident #61 was observed in room in bed. There was no evidence that there were any activities occurring. On 09/09/2021 from 10:00 am to 2:00 PM, ADL care was rendered and observed. After the care the Certified Nursing Assistant (CNA) left the room and there was no observation that activities were provided for the resident. The Comprehensive Care Plan (CCP) titled Activities revised on 06/24/2021 documented the resident is unable to develop a meaningful routine daily and staff must anticipate all activity needs and interventions. Goal was the resident will continue 1:1 room visits daily and is unable to attend to any group activities on the unit. Resident will respond to 1:1 contact at least once a day. Interventions included coordinate resident's needs, interests, and activities with department, keep resident's attention by gently addressing them by saying name frequently and using touch and observing of non- verbal responses. The Activity Assessment dated 6/18/21 documented Resident #61's preference was Italian, listening to Italian music. Resident responds at times to Italian music by babbling and hand movements. The Activity Record for Resident #61 dated 08/01/2021 to current documented that resident was receiving 1:1 activities 5 days a week, but not on weekends. It also documented that the resident does not participate in group activities. On 09/08/2021 at 2:30 PM, Certified Nursing Assistant (CNA) # 2 was interviewed. immediately after dressing the resident. CNA # 2 stated Resident#61 is taken out of bed to the geri chair 2-3 times a week in their room.CNA #2 also stated that the resident stays mostly in their room with the television on, on an English language station. On 09/09/2021 at 11:27 AM, an interview was conducted with the Director of Activities (DOA). The DOA stated that 1:1 activities are done daily for the resident and includes putting in music and the Walking Minstrel. The DOA also stated that the resident is Italian, and the television is tuned to the Italian Channel. The Surveyor escorted the DOA to the resident's room and where the television was observed to be tuned to an English language station. The DOA attempted to change the channel to an Italian channel for several minutes but was unable to find a channel that played content in Italian. The DOA was asked about the availability of a radio to play Italian music and subsequently returned to the unit with a new compact disc player with 3 CDs of Italian songs. On 09/09/2021 at 2:30 PM, the Recreational Leader (RL) was interviewed. The RL stated they come to the unit daily and see the resident and spend time with the resident. The RL also stated they try to talk to the resident in Spanish since the resident speaks Italian and the language is similar, and the RL plays Italian music for at least 10-20 minutes. The RL further stated the resident has not been provided with a radio. 415.5(f)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan to address a resident's elevated glucose levels and non-compliance with diabetes management. Specifically, a resident's frequent refusals of medication, finger sticks, and elevated blood glucose levels were not addressed by the care team to prevent possible complications associated with Diabetes Mellitus. This was evident in 1 of 38 sampled residents. (Resident #9) The finding is: The facility Policy and Procedure titled Diabetic Management dated 06/2021 documented the attending Physician orders treatment modalities in conjunction with a resident's individual needs. Disease management may include insulin management, fingerstick checks for blood glucose monitoring, and labs as indicated. Resident # 9 was admitted to the facility with diagnoses of Diabetes Mellitus (DM), Cerebrovascular Accident (CVA), and Atrial Fibrillation. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #9 had moderately impaired cognition and was able to make their needs known. On 09/02/2021 at 10:30 AM, Resident #9 was observed asleep in bed. On 09/08/2021 at 11:00 AM, Resident #9 was observed in bed with Intravenous fluid of D5 (dextrose 5)0.9% Normal Saline Solution (NSS), 1 liter at 125 cubic centimeter(cc) per hour inserted to right antecubital area and regulated with the use of a diaflo.The resident appeared frail, weak, and cachectic. The Comprehensive Care Plan (CCP) for Diabetes Mellitus dated 12/14/2020 08/26/2021 and renewed on 09/02/2021 documented the resident had Insulin Dependent DM, Hyperglycemia, and Chronic Kidney Disease. The goal of the CCP was for the resident to take all prescribed medications. Interventions included administer insulin per MD order, administer medications as prescribed, monitor Hemoglobin A1c and laboratory results, and monitor for signs and symptoms of hypo and hyperglycemia. The CCP for Non-Compliance dated 12/14/2020 and renewed on 8/26/21 documented Resident #9 refuses to follow the plan of care, medications, and treatments. The CCP goal was for Resident #9 to allow and cooperate with the plan of care. Interventions included resident and family/next of kin education regarding the risk of non-compliance, encourage participation and increased involvement, provide explanation of procedures, give ample time to express feelings, and set a limit for Resident #9's behavior and referral to psychiatrist . The Physician's order as of 09/07/2021 documented Resident #9 was to receive Fingerstick (FS) three times a day before meals (TID/AC) with Humalog sliding scale coverage: 181-230 = 3 units; 231-280 = 5 units; 281-330 = 7 units; 331-380 = 9 units; 381-430=12 units; 431-500 = 16 units. Call Medical Doctor (MD) if lesser (<) 70 and greater (>) 500. Levemir 10 units subcutaneous every 12 hours was also ordered. A lab report dated 10/20/20 documented Resident #9's Hemoglobin A1c (reference range 4.8% - 5.6%) was elevated at 12.4%. The Fingerstick Monitoring Records (FMRs) from 07/01/2021 to 09/07/2021 documented sporadic and elevated FS blood sugar (FSBS) values for Resident #9. Most of the time, the FSBS were not done. From 07/01/2021 to 07/31/2021 there were 93 opportunities for FSBS, but only 18 FSBS values were documented. Of the 18 documented FSBS values, 13 were elevated above 181 mg/dl, requiring insulin administration. Eleven of FSBS were 400 mg/dl (milligrams per decilitre) and above, with 4 values of 500 mg/dl. The resident had one FSBS over 500. From 08/01/2021 to 08/31/2021 there were 93 opportunities to document the resident's FSBS; however, 16 FSBS values were documented. Of the 16 documented FSBS values, 6 of 16 were elevated above 181mg/dl, requiring insulin administration. Four of 16 were in the 400s, and 2 of 16 were 500 mg/dl and above. From 09/01/2021 to 09/07/2021, there were 21 opportunities to document FSBS values; however, only 11 FSBS values were documented with all 11 above 181 mg/dl, requiring insulin administration. Six of 11 were above 400 mg/dl with one value of 500 mg/dl. Review of the HemoglobinA1C from 10/20/202 to 07/31/2021 reveals no documented evidenced that the test was done quarterly . Record review reveals it was done on: 10/20/2020 --- 12.4 % (reference range 4.8%--5.6% ) 08/31/2021 ---13.4 % A complete metabolic profile was done on 08/31/2021 with glucose result of 446 mg/dl (reference range 65-99 mg/dl ) . This was repeated on 09/07/2021 with glucose result of 374 mg/dl The Nursing Notes reviewed from 07/01/21 through 09/02/21 documented Resident #9 refused medication and/or FSBS monitoring on multiple occasions. There was no documented evidence the MD or NP were informed of the refusals or the FS results over 500 mg/dl per MD orders. Further review of the record reveals no documented evidenced that staff attempted to revisit the resident or new interventions were in place. The Nurse Practitioner (NP) and MD notes from 07/01/2021 to 09/02/2021 contained no documented evidence that the MD or NP assessed or addressed Resident #9's elevated FSBS levels and/or resident's non-compliance with Diabetic management. On 09/09/2021 at 2:30 PM, LPN # 5 was interviewed and stated maybe they informed the NP on occasion but LPN #5 could not recall. LPN #5 could not find documentation confirming the NP or MD were informed of the elevated finger sticks and medication refusals in the records. Resident #9 takes the medications at times, depending on their mood. Resident #9 can be really aggressive. On 09/10/2021 at 2;41 PM LPN # 2 was interviewed and stated they are new at the facility and everybody says Resident #9 refuses medications and treatments. LPN #2 stated they did not notify the MD nor NP of the refusals because once a refusal is documented in the Medication Administrtaion Record (MAR), it automatically populates in the 24-hour report. This report is then read and reviewed by those who attend the morning rounds like the DNS, ADNS, Unit Managers, NP, Physicians and others. On 09/07/2021 at 2:30 PM, NP # 4 was interviewed and stated I am very new and started working her last month. Iam still getting to know and learning about the residents under my care which includes Resident #9. She stated she speaks with the nursing staff and reviews the medical record, including labs, of the resident for monthly evaluation and if there is any referral. NP #4 was aware the resident was Diabetic, but NP #4 was not aware Resident #9 refused medications and other diabetic treatments. After reviewing the FSBS monitoring and Labs of Resident #9, NP #4 stated the elevated results should have been addressed. On 09/07/2021 at 2:30 PM, Attending Physician # 10 was interviewed and stated they were a new employee of the facility. Resident #9 was seen and evaluated on 9/2/21 and a long narrative was written. During the interview, the MD was made aware that the resident has been refusing the medications, the fingerstick testing and if and when it was done, the result is elevated. There was no changes on the medication and they stated they had made changes now to the medication and that the FS has been reduced in order to make the resident amenable and then they may comply. On 09/10/2021 at 11:13 AM. the Assistant Director of Nursing /Educator (ADON) was interviewed and stated in service is done quarterly and mandatories are reviewed. If there is a need for the staff to reinforce learning then we do it. Mostly the emphasis is on infection control, hand washing. After reviewing the resident's medical record with FS results and Licensed Nurses documentation, the ADON akcknowledged the nurses documented elevated FS, and they did not document steps taken to address or notification of the MD or NP. On 09/10/2021 at 3:10 PM the Director of Nursing was interviewed and stated when a refusal is documented by the LPNs, it is normally populated in the 24-hour report, which is available for management during the morning meeting. The DON further stated they review the report. When asked if reporting concerns to the MD or NP should wait until morning, the DON had no response and stated I see what you mean. On 09/09/2021 at 11:20 AM, the Facility Medical Director was interviewed and stated the resident was originally under the service of MD #4. The Hemoglobin A1c should have been evaluated every 3 months as a standard of practice; however, the Medical Director did not oversee MD #4 to ensure this was done. The Medical Director stated the Physician and Nurse practitioner are new, but they were given information on the facility policy and they were working with a physician who has been here for sometimes. I guess, I have to reorient and make them understand that the facility has its own policies and is not the same always like in the hospital. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey, the facility did not ensure that a resident received necessary services to prevent new ulcers from developing. Specifically, a resident was not turned and positioned as indicated on the care plan This was evident for 1 of 2 residents reviewed for Position, Mobility and 1 of 1 residents reviewed for Physical Restraints out of total sample of 38 residents. (Resident # 105 and Resident #61) The findings are: Resident #105 was admitted to facility with diagnoses that included but Dementia, Contracture of right hand, Functional Quadriplegia, and skin changes. The Quarterly Minimum Data Set (MDS) dated [DATE] documented short and long term memory problem and severely impaired cognitive skills. Resident at risk of developing pressure ulcers. Documented no venous or arterial ulcers. Resident has pressure relieving device for chair and bed. Resident on nutrition or hydration intervention and turning and positioning program. The Annual MDS dated [DATE] documented short and long term memory problem. Resident at risk of developing pressure ulcers. The MDS also documented that resident has pressure relieving device for chair and bed and is on nutrition or hydration intervention and turning and positioning program. On 9/3/21 at 9:20 AM, 10:42 AM, 11:22 AM, 11:49 AM, and 12:52 PM, Resident #105 was observed lying on back in bed. On 9/7/21 at 10:12 AM, 11:28 AM, 12:30 PM, and 2:03 PM, Resident #105 was again observed in bed lying in a supine position. The Comprehensive Care Plan (CCP) titled Pressure Ulcers effective 4/13/16 and reviewed 5/24/21 documented a goal that the resident's skin will remain intact X 3 months. Interventions included turn and position every two hours and provide gel cushion on high back wheelchair The Comprehensive Care Plan titled Skin Prevention effective 5/11/21 and reviewed 8/30/21 documented a goal that resident will have no skin breakdown. Interventions included turn and position every two hours and will monitor skin surfaces for changes every shift. The Certified Nursing Assistant (CNA) Accountability Record documented turn and position task on 9/3/21, resident positioned on back from 9:30 am to 3:30 pm. On 9/7/21, CNA documented resident positioned on left side from 7:30 am to 1:30 pm. On 09/09/21 at 11:15 AM, CNA #1 was interviewed. CNA # 1 stated when resident is in bed, we turn resident every 2 hours and when resident is in geri-chair we reposition resident in it. CNA # 1 worked on 9/7/21 with resident and stated resident was turned and repositioned. CNA #1 stated turning and repositioning task documented in CNA documentation record. On 09/10/21 at 10:44 AM, Licensed Practical Nurse (LPN) # 1 was interviewed. LPN #1 stated aides reposition resident pretty frequently on average every 2 hours. LPN #1 also stated that CNAs are responsible for turning and positioning resident and documenting this task. LPN # 1 further stated that there are fewer regular aides now since pandemic. As a result, LPN # 1 stated aides require more supervision since they are not regulars on unit. LPN # 1 stated they walk around unit and reminds aides to do certain tasks for residents. Surveyor discussed observations that aides on 9/3/21 and 9/7/21 did not turn and postion resident as instructed on the CNA task. LPN # 1 stated that the aides documented that they did turning and positioning task in the documentation record. LPN #1 also stated that the resident can move self around in bed and that is probably why the aide did not turn resident. Surveyor did not observe resident reposition self in bed. On 09/10/21 at 11:37 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that the unit nurse is responsible for walking around the unit and making sure tasks are done for the residents. The ADON also stated that the aides have the CNAs accountability record which gives information on whatever care is needed to be given to the resident. #2. Resident # 61 was admitted to the facility with diagnoses that included Peripheral Vascular Disease, Huntington Disease, and Seizure Disorder. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident with severely impaired cognition and dependent on staff for all activities of daily living. The MDS also documented that the resident was at risk for pressure ulcers and was using pressure-relieving devices for bed and chair. The Physician order dated 08/20/2021 documented an order for bilateral booties while in bed. On 09/02/2021 at 10:00 AM, Resident #61 was observed in bed in their room with mitten on right hand. Heel booties were not observed in place as ordered. On 09/07/2021 at 11:20 AM, Resident #61 was observed in room in their bed. There were no heel booties to bilateral feet. On 09/08/2021 at 10:30 AM, Certified Nursing Assistant (CNA) #2 was observed providing ADL care. Mitten was removed however resident was not wearing booties and booties were not applied after care was provided. CNA#2 was interviewed immediately after care was provided. CNA #2 stated they had provided care for the resident on and off for the past two months. CNA also stated that the resident has no devices. After checking the computer, CNA#2 checked the resident's room and closet, and was unable to locate booties for the resident. 415.12 (c) (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that services and treatments were provided to prevent further decrease in range of motion (ROM) or mobility. Specifically, a hand roll and a hand splint were not provided to resident as per physician order. This was evident for 1 of 2 residents reviewed for Position, Mobility out of total sample of 38 residents. (Resident # 105) The findings are: The facility policy and procedure titled, Issue of AFO's and other uncovered hard plastic splints/orthoses/prosthesis reviewed on 11/17 documented that the nursing department will take responsibility for daily applications/removal of device and Nurse Manager will be responsible to ensure that the information is entered in the CNA Accountability record. 1. Resident #105 was admitted to facility with diagnoses that included Dementia, Contracture right hand, Functional quadriplegia, and skin changes. The Quarterly Minimum Data Set (MDS) dated [DATE] documented short and long term memory problem, severely impaired cognition, and no behaviors. The MDS also documented that the resident required dependent assistance of 2 persons for transfers and toilet use and dependent assistance of one person for bed mobility. The MDS also documented that the resident had impairment on both sides of upper extremity. Passive range of motion was performed for at least 15 minutes a day in the last 7 days. No splint or brace assistance was documented. The Annual MDS dated [DATE] documented the resident had short and long term memory problem and severely impaired cognition. The MDS also documented that the resident required total assist of 2 for bed mobility and transfers. The MDS also documented that the resident had impairment on both sides of upper extremity. In addition, the resident received Occupational Therapy (OT) and Passive range of motion (ROM) in last 7 days. No splint or brace assistance documented. The Occupational Therapist (OT) Discharge summary dated [DATE] documented discharge recommendations: resident discharged (d/c) from skilled OT services to the unit on 5/11/2021 and placed on nursing rehab program. Passive range of motion (PROM) to Bilateral upper extremities (BUE) 15 reps (2 times a day) BID. Hand roll to left hand, resting hand splint to right hand. The Physician Order dated 5/11/21 and renewed 8/25/21 documented SPLINTS AND BRACES: Hand roll to L hand, resting hand splint to right hand at all times except for during hand hygiene. During the following times, Resident #105 was observed in bed without left-hand roll and right resting hand splint on: On 9/2/21 at 1:20 PM, On 9/3/21 at 9:20 AM, 10:42 AM, 11:22 AM, 11:49 AM, and 12:52 PM, On 9/7/21 at 10:12 AM, 11:28 AM, 12:30 PM, and 2:03 PM, and on 9/9/21 at 10:28 AM. On 9/8/21 at 9:35 AM resident observed sitting up in Geri chair with hand roll in left hand and no resting hand splint to right hand. The CNA Accountability Record dated 08/01/21 to 9/8/21 documented nursing rehab splint/brace 7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00PM- 7:00 AM. The task was documented as completed for placement of the splint brace on 9/3, 9/7, and 9/8/21. The Comprehensive Care Plan (CCP) titled ADL Functional/Rehabilitation dated 7/1/18 documented interventions which included Splints/braces (hand roll splint) to be worn at all times except for skin check 2 hours, ROM, and hygiene. On 09/09/21 at 11:15 AM, Certified Nursing Assistant (CNA) CNA #1 was interviewed. CNA # 1 stated Resident has a brace and hand roll. Aides put devices on resident after resident is washed. CNA # 1 further stated the devices are not on when they start their shift in the morning. CNA #1 also stated that the Rehab department taught them how to apply the devices. On 09/10/21 at 10:44 AM, Licenced Practical Nurse (LPN) # 1 was interviewed. LPN #1 stated they walk around unit checking on residents to make sure everything was done. While walking around the unit, they remind aides to do certain tasks for the residents. LPN #1 also stated there is a general order for hand roll to left hand and splint to right and the CNAs are responsible for applying devices and documenting. LPN #1 further stated they are responsible for ensuring devices are in place and they are not sure why the resident did not have a hand roll or splint on. LPN #1 stated that there are fewer regular aides now since the pandemic so they (aides) need more supervision. On 09/10/21 at 11:37 AM, Assistant Director of Nursing (ADON) was interviewed. The ADON stated the unit nurse is responsible for walking around the unit and making sure tasks are done for the residents. The ADON also stated that the aides have the CNA accountability record which gives them information on the care that is to be given to the resident. 415.12(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the Recertification survey, the facility did not ensure that the Physician reviewed the resident's total program of care at each visit. Specifically, there was no documented evidence the Physician addressed a resident's consistently high blood sugars and non-compliance with diabetic management. This was evident for 1 of 38 sampled residents. (Resident #9) The finding is: The facility Policy and Procedure titled Diabetic Management dated 06/2021 documented the attending Physician orders treatment modalities in conjunction with a resident's individual needs. Disease management may include insulin management, fingerstick checks for blood glucose monitoring, and labs as indicated. Resident # 9 was admitted to the facility with diagnoses of Diabetes Mellitus, Cerebrovascular Accident (CVA), and Atrial Fibrillation. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #9 had moderately impaired cognition and was able to make their needs known. The Comprehensive Care Plan (CCP) for Diabetes Mellitus dated 12/14/2020 , 08/26/2021 and renewed on 09/02/2021 documented the resident had Insulin Dependent DM, Hyperglycemia, and Chronic Kidney Disease. The goal of the CCP was for the resident to take all prescribed medications. Interventions included administer insulin per MD order, administer medications as prescribed, monitor Hemoglobin A1c and laboratory results, and monitor for signs and symptoms of hypo and hyperglycemia. The CCP for Non-Compliance dated 12/14/2020 and renewed on 8/26/21 documented Resident #9 refuses to follow the plan of care, medications, and treatments. The CCP goal was for Resident #9 to allow and cooperate with the plan of care. Interventions included resident and family/next of kin education regarding the risk of non-compliance, encourage participation and increased involvement, provide explanation of procedures, give ample time to express feelings, and set a limit for Resident #9's behavior and referral to psychiatrist . The Physician's order dated 06/03/2021 and updated on 09/07/2021 documented Resident #9 was to receive Fingerstick (FS) three times a day before meals (TID/AC) with Humalog sliding scale coverage: 181-230 = 3 units; 231-280 = 5 units; 281-330 = 7 units; 331-380 = 9 units; 381-430=12 units; 431-500 = 16 units. Call Medical Doctor (MD) if lesser (<) 70 and greater (>) 500. Levemir 10 units subcutaneous every 12 hours was also ordered. A lab report dated 10/20/20 documented Resident #9's Hemoglobin A1c (reference range 4.8% - 5.6%) was elevated at 12.4%. The Fingerstick Monitoring Records (FMRs) from 07/01/2021 to 09/07/2021 documented sporadic and elevated FS blood sugar (FSBS) values for Resident #9. Most of the time, the FSBS were not done. From 07/01/2021 to 07/31/2021there were 93 opportunities for FSBS, but only 18 FSBS values were documented. Of the 18 documented FSBS values, 13 were elevated above 181 mg/dl, requiring insulin administration. Eleven of FSBS were 400 mg/dl (milligrams per decilitre) and above, with 4 values of 500mg/dl. The resident had one FSBS over 500. From 08/01/2021 to 08/31/2021 there were 93 opportunities to document the resident's FSBS; however, 16 FSBS values were documented. Of the 16 documented FSBS values, 6 of 16 were elevated above 181mg/dl, requiring insulin administration. Four of 16 were in the 400s, and 2 of 16 were 500mg/dl and above. From 09/01/2021 to 09/07/2021, there were 21 opportunities to document FSBS values; however, only 11 FSBS values were documented with all 11 above 181mg/dl, requiring insulin administration. Six of 11 were above 400 mg/dl with one value of 500 mg/dl. The Nursing Notes reviewed from 07/01/21 through 09/02/21 documented Resident #9 refused medication and/or FSBS monitoring on multiple occasions. There was no documented evidence the MD or NP were informed of the refusals or the FS results over 500 mg/dl per MD orders. Further review of the record reveals no documented evidenced that staff attempted to revisit the resident or new interventions were in place. The Nurse Practitioner (NP) and MD notes from 07/01/2021 to 09/02/2021 contained no documented evidence that the MD or NP assessed or addressed Resident #9's elevated FSBS levels and/or resident's non-compliance with Diabetic management. A lab report dated 8/31/21 documented Resident #9 had an elevated Hemoglobin A1c level of 13.4% (reference range 4.8% - 5.6%) and an elevated Glucose level of 446 mg/dl (reference range 65-99 mg/dl). The Nursing Notes reviewed from 07/01/21 through 09/02/21 documented Resident #9 refused medication and/or FSBS monitoring on multiple occasions. Further review reveals no documented evidenced that the MD/NP was informed of the elevated FS values. The Nurse Practitioner (NP) and MD notes from 07/01/2021 to 09/02/2021 contained no documented evidence that the MD or NP assessed or addressed Resident #9's elevated FSBS levels and/or resident's non-compliance with Diabetic management. A Complete Metabolic Profile (CMP) lab report dated 09/07/2021 documented the resident's continued elevated glucose result of 374 mg/dl. On 09/07/2021 at 2:30 PM, NP # 4 was interviewed and stated I am very new and started working her last month. Iam still getting to know and learning about the residents under my care which includes Resident #9. She stated they speak with the nursing staff and reviews the medical record, including labs, of the resident for monthly evaluation and if there is any referral . NP #4 was aware the resident was Diabetic, but NP #4 was not aware Resident #9 refused medications and other diabetic treatments. After reviewing the FSBS monitoring and Labs of Resident #9, NP #4 stated the elevated results should have been addressed. On 09/07/2021 at 2:30 PM, Attending Physician # 10 was interviewed and stated they were a new employee of the facility. Resident #9 was seen and evaluated on 9/2/21 and a long narrative was written. During the interview, the MD was made aware that the resident has been refusing the medications, the fingerstick testing and if and when it was done, the result is elevated. There was no changes on the medication to which the Attending Physician stated they have made changes now to the medication and that the FS has been reduced in order to make the resident amenable and may comply. On 09/09/2021 at 11:20 AM, the Facility Medical Director was interviewed and stated the resident was originally under the service of MD #4. The Hemoglobin A1c should have been evaluated every 3 months as a standard of practice; however, the Medical Director did not oversee MD #4 to ensure this was done. The Medical Director stated the Physician and Nurse practitioner are new , but they were given information on the facility policy and they were working with a physician who has been here for sometimes. I guess I have to reorient and make them understand that the facility has its own policies and is not the same always like in the hospital. 415.15 (b)(2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview conducted during the Recertification/Complaint survey, the facility did not ensure that the medication error rate was not less than 5%. Specifically, a resident was not administered with six (6) of the prescribed medications due during the Medication Administration Observations. This was evident for 6 of 29 opportunities observed, resulting in a medication error rate of 20.69%. (Resident #86). The findings are: The facility Policy on Unavailable Medications last revised 07/2021 documented that resident will receive necessary medications as ordered by the MD/NP. When the medication is not available, the MD/NP will be notified .Inform the resident of the medications that are unavailable and actions to be taken .Medication will be re-ordered via Sigma when resident has approximately one week supply remaining. Resident #86 was admitted on [DATE] with diagnoses that included Anemia, Folate deficiency, Congestive Heart Failure (CHF), Hypertension, Asthma, and Chronic Obstructive Pulmonary Disease (COPD). The Quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident has intact cognitive status and required extensive assistance of staff for most Activities of Daily Living. On 09/03/21 at 09:42 AM, Licensed Practical Nurse (LPN) #6 was observed administering medication to Resident #86. LPN #6 was observed pre-pouring and administered the following medications to the resident: - 1. Folic Acid 1mg PO daily 2. Furosemide 80mg PO 3. Isosorbide 20mg PO 4. Metoprolol 25 mg PO 5. Vitamin B complex tablet 1 tablet PO 6. Vitamin C tab PO 7. Tylenol 325mg 2 tabs (650 mg) PO 8. Albuterol inhale 2 puffs 9. Brimonidine 0.2 % eye drops instill 1 drop in each eye 10. Polycarb 625mg PO 11. Aspirin 81 mg tablet, delayed release 1 tablet PO Following the observation of medication administration, review of the Physician's Orders and the Medication Administration Record (MAR) was conducted for medication reconciliation. Review of the records revealed that the nurse failed to administer the following ordered medications to the resident during the medication administration observation: 1. Amlodipine 5 mg tablet 2. Vitamin B-12 500 mcg tablet 1 tablet ordered once daily 3. Calcitonin (salmon) 200 unit/actuation 1 spray by nasal route ordered once daily in alternating nostrils. 4. Calcium 500 + D 500 mg (1,250 mg)-400-unit 1 tablet ordered 2 times per day 5. Fluticasone 250 mcg-salmeterol 50 mcg/dose inhale 1 puff ordered 2 times per day approximately 12 hours apart at the same times each day. 6. Artificial Tears apply 1 drop by ophthalmic (eye) route in each eye ordered TID (three times daily) The MAR documented that the medications had been administered but surveyor observed that the medications were not given to the resident. LPN #6 did not inform the resident that some medications were not being administered at that time. On 9/03/21 at 11:44 AM, an interview was conducted with LPN #6. LPN #6 stated that the missed medications were not available in the medication cart and they should have informed the resident of the missing medications that were not available during the medication pass but did not. LPN #6 also stated that they were going to look for the medications or call the pharmacy to check when the medication was last ordered and re-order more medication. LPN #6 further stated that they are not regular on the unit and was not aware that the medications were not present in the cart before the medication pass. On 09/07/21 at 11:33 AM, an interview was conducted with Resident #86 who stated that the nurses do not explain the medications they are giving, and all the medications are not being given most of the time. Resident # 86 also stated they do not get the same medication each time medication is received. Resident #86 further stated that the spray for Asthma and the eye drops are not being given regularly. On 09/07/21 at 11:40 AM, an interview was conducted with the Charge Nurse (LPN #5). LPN #5 stated that there is one nurse using 2 carts to give medications to the residents on the unit. LPN #5 also stated that the nurses try to place the order before the medication is exhausted, and if any medication is not seen in the cart, pharmacy is called to send the needed medications. On the Calcitonin 200 unit/actuation nose spray and eye drops that were observed not administered to the resident, LPN #5 stated that the nose spray was just delivered over the weekend, and new artificial eyedrops are to be taken from the medication storage to administer them to the resident later in the day. LPN #5 further stated that there was delay in giving the eye drops and nose spray to the resident because the nurse was going to take the medication from the stock after finishing with the other residents on the other cart. On 09/08/21 at 12:13 PM, an interview was conducted with Director of Nursing (DON). The DON stated that once there is one week of medication remaining, the nurse needs to click re-order to get new medication for the residents. The DON also stated that the nurses are supposed to follow up and get medication before they are exhausted, and they did not know why the staff are not doing that. The DON further stated that they were not aware that there were medications not available to be administered for resident, and if there is an issue on getting any medication, the staff is supposed to notify the DON so that follow up can be done. 415.12 (m)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews conducted during the recertification survey, the facility did not ensure that proper infection control practices and procedures were maintained. Specifically, an oxygen tubing was observed with no label, and there was no documented evidence that the oxygen tubing was changed. This was evident for 1 of 3 residents reviewed for Respiratory Care out of a sample of 38 residents. (Resident #111) The finding is: The facility's policy and procedure titled Oxygen Therapy, last updated on 06/2021, documented that oxygen tubing should be dated and initialed when started each week. Resident #111 was admitted to the facility with diagnoses that included Chronic Obstructive Pulmonary Disease, Hypertension, and Heart Failure. The Minimum Data Set (MDS) dated [DATE] documented Resident # 111 with intact cognition. Section O of the MDS documented that Resident #111 was receiving Oxygen. On 09/02/2021 at 9:45 AM, Resident # 111 was observed using Oxygen, and the tubing was not labeled. On 09/03/2021 at 10:20 AM, Resident #111 was observed using Oxygen, and the tubing was not labeled. On 09/07/2021 at 11:06 AM, Resident #111 was observed using Oxygen, and the tubing was not labeled. The Physician's Orders dated 08/15/2021 included an order for supplemental Oxygen at 2 liters per minute as needed for oxygen saturation less than 95%. Physician Orders contained no documented evidence of an order for changing the oxygen tubing once every week. The Treatment Administration Record (TAR) dated 08/01/2021 to 08/31/2021 contained no documented evidence of when the oxygen tubing was changed. A TAR review dated 09/01/2021 to 09/07/2021 revealed no documented evidence of when the oxygen tubing was changed. On 09/07/2021 at 11:13 AM, Resident # 111 was interviewed and stated that the oxygen tubing had not been changed since last month. On 09/07/21 at 11:42 AM, Licensed Practical Nurse (LPN) # 8 was interviewed. LPN #8 stated that Resident # 111 is on Oxygen 2 liters via nasal cannula. LPN #8 also states that the night nurse is required to change the oxygen tubing once a week on Wednesday. LPN #8 further said that the tube is labeled with the date and time it was changed, and the morning staff checks the tubing to make sure it is dated. LPN #8 stated that the night nurse was reminded to change the tubing. LPN #8 did not check the tubing in the morning. On 09/08/2021 at 9:22 AM, LPN #7 was interviewed. LPN #7 stated that oxygen tubing is changed every Wednesday and is labeled with the date and initials. LPN #7 also said that Resident #111's tubing was soiled, and they decided to change it on Tuesday instead of Wednesday but forgot to label it. LPN #7 further stated that the oxygen tubing is changed once a week but not documented in the treatment administration record. On 09/08/2021 at 3:13 PM, the Registered Nurse Supervisor (RNS) #2 was interviewed. RNS #2 stated that the oxygen tubing is changed once a week. RNS #2 also noted that the night shift nurse changed the tubing but forgot to label it. RNS #2 also stated that the label was found in the resident's bed. On 09/08/2021 at 3:26 PM, the Director of Nursing (DON) was interviewed. The DON stated that the oxygen tubing is changed weekly, and the night supervisor is the one who ensures that the tubing is changed. The DON also said there is an order in the computer for the tubing to be changed weekly, and the nurse must sign the Treatment Administration Record (TAR) when the tubing is changed. The DON later stated that there is nowhere it is not in the TAR for the nurse to sign when it is done. 415.19(b)(1-3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure that individual financial records were available to individual residents through quaterly statements. Specifically, During interviews, two cognitively intact residents with personal funds held by the facility; stated that they did not receive quarterly statements of their account. This was evident for 2 out of 2 residents reviewed for Personal Funds out of 38 sampled residents. (Resident #45 and #142). The facility policy Resident Personal Funds Accounts revised 10/12 document Individual financial records will be available through quarterly statements and upon request to the resident or her legal or designated representative. The finding is: Resident #45 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented that the resident had intact cognition. On 02/13/19 at 10:21 AM, an interview was conducted with Resident #45 who stated she does not receive quarterly statements. Resident #142 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented that the resident had intact cognition. On 02/13/19 at 12:52 PM, an interview was conducted with Resident #142 who stated he did not know if he receives quarterly statements. On 02/22/19 at 01:06 PM, a followup interview was conducted with Resident #142 who stated he did not receive quarterly statements since entering the facility. On 02/22/19 at 11:40 AM, an interview was conducted with the Director of Admissions (Employee #1), who is in charge of the accounting and maintenance of resident's personal funds. Employee #1 stated that based on the facility's policy, alert and oriented residents must make a request to receive their quarterly statements. If the resident does not request their quarterly statement, the quarterly statement is automatically mailed out to their primary contact. Two copies are sent out to the primary contact, one is kept by the primary contact and the secondary copy is signed by the primary contact and sent back to the facility. Employee #1 stated moving forward she will have to interview each resident to determine if the resident wants to receive their quarterly statement (hand delivered) or have it mailed to their primary contact. Employee #1 also stated, residents who receive their quarterly statements will sign the statement keep the original and a copy will be kept by the department. 415.26(h)(5)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, Electronic health record review, and interviews the facility did not ensure that infection control practices were maintained. Specifically, a Resident (res) with use of a wound vac to the right foot was observed on two occasions with tubing and the wound vac machine on the floor. Res #237. This was evident for 1 of 38 res reviewed in the Investigation sample. Resident #237. The Finding is: Resident #237 admitted to the facility on [DATE] with diagnoses which include Osteomyelitis, Diabetes Mellitus and the presence of a Right Lateral Malleolus Vascular site and use of a wound vac. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident's cognition is intact. the MDS further documented that the res requires extensive assist of one with all activities of daily living. On 2/14/19 at 12:15PM during an interview with the resident, state agent (SA) observed the Licensed Practical Nurse (LPN) and the nurse practitioner entered the res room to do fingerstick and check the res for a concern of pain on his right side. The wound vac machine and tubing was on the bare floor and they didn't say anything. On 2/15/19 at 9:45AM res was being attended to by the RN supervisor and the SA observed the wound vac catether and the wound vac machine resting on the bare floor, and was shown to supervisor who stated he had not seen it until brought to his attention. The physician order dated 2/15/19 documented post cleansing to the right lateral malleolus, the wound vac is to be applied at 125 continuous every 72 hours and when necessary. The surgical consults dated 1/23/19 and 2/4/19 documented res with pressure ulceration and recommendations to continue vac to right ankle. CCP 1/22/19 documented problems of presence of skin breakdown a right lateral malleolus vascular wound and receiving treatment for infection-osteolyelitis thru a central line. On 02/15/19 at 09:53 AM the Supervisor was interviewed and stated the wound vac and tubing should not have been on the floor. On 02/15/19 at 10:02 AM the Nurse Practitioner was interviewed and stated the tubing and machine should not be on the floor at any time and should have seen it on the floor and removed it but became focused at the fact that res was complaining of chest pain. On 02/21/19 at 12:45 PM the LPN was interviewed and stated on the day the insulin was checked she saw the machine and tubing on the floor but did not remove it and should have. She further stated that the resident had placed the machine on the floor earlier and because she had removed it earlier in the morning, she did not do it again. She stated she has found him before putting the wound vac machine on the floor and did not educate the resident not to put machine on the floor. On 02/22/19 at 01:11 PM the Assistant Director of nursing/Infection Preventionist was interviewed and stated that she has been doing infection control inservice with staff and that the wound vac machine and tubing should not be placed on the floor. staff should be checking where the vac is and tubing not on floor and is intact. She further stated if the res has intact cognition he should be educated to not put the machine on the floor and call fo help when mobile with the vac. 415.19 (a) (1-3)