Based on observations, record review, and interview conducted during the Recertification Survey from 07/21/2024 to 07/26/2024, the facility did not ensure that residents remained free from physical restraint. This was evident in 1 (Resident #106) of 1 resident reviewed for Restraints out of 29 total sampled residents. Specifically, Resident #106 was observed with a mitten on the right hand. There was no documented evidence of appropriate assessment and care planning prior to the application of right hand mitten. Additionally, there was no documented monitoring provided while the right hand mitten was applied. The findings are: The facility's policy titled Restraint Use with a last revised date of 12/2023 documented that the facility will promote a restraint-free environment in accordance with State and Federal regulations. When the use of restraints is indicated, the least restrictive alternative for the least amount of time will be used and ongoing evaluation for the need of restraint will be documented. Resident #106 had diagnoses of Other Specified Disorders of Brain, Vascular Dementia, and Non-traumatic Intracerebral Hemorrhage. The admission Minimum Data Set 3.0 dated 05/12/2024 documented Resident #106 had severely impaired cognition and had no behavioral symptoms. The Minimum Data Set also documented Resident #106 had no restraint. During multiple observations between 07/21/2024 at 12:23 PM and 07/23/2024 at 9:27 AM, Resident #106 was observed lying in bed or in geriatric recliner chair with a mitten on their right hand. The Interdisciplinary Team Meetings and Evaluation form with an effective date of 05/08/2024 at 11:37 AM documented that an initial restraint review was conducted on 05/08/2024. The form documented in the summary that mittens to hands will be applied to prevent scratching and pulling at equipment. The type of equipment was not documented. The form documented that the device does prevent normal movement and is a restraint. Review of Resident #106's progress notes revealed no documentation regarding the use of right hand mitten and there was no documentation that Resident #106 had behaviors related to scratching or pulling equipment. Further review of Resident #106's medical record revealed no documented restraint assessment, there was no care plan related to the use of right hand mitten, there was no physician's order, and no documented monitoring while right hand mitten was in use. The Certified Nursing Assistant Accountability for July 2024 did not include instructions to apply mitten on Resident #106's right hand. On 07/23/2024 at 9:35 AM, Certified Nursing Assistant #6 was interviewed and stated they applied mitten to Resident #106's right hand to prevent Resident #106 from scratching their body. Certified Nursing Assistant #6 stated that Resident #106 had the mitten on their right hand since their admission to the facility in May 2024. They also stated they were instructed by the unit charge nurse to apply the mitten at the beginning of the shift. Certified Nursing Assistant #6 further stated they did not have instructions in the Certified Nursing Assistant task to apply mitten for Resident #1. On 07/23/2024 at 9:51 AM, Registered Nurse #3, who was the unit supervisor, was interviewed and stated they were aware that Resident #106 had mitten applied on their right hand to prevent the Resident from scratching their body. Registered Nurse #3 stated they thought Resident #106 had the restraint assessment and physician's order to apply the right hand mitten. On 07/23/2024 at 10:07 AM, the Director of Rehabilitation was interviewed and stated Resident #106 was unable to follow instruction and they did not recommend further rehabilitative service for Resident #106. They stated Resident #106 was not able to remove the mitten from the right hand by themselves. On 07/23/2024 at 10:13 AM, Nurse Practitioner #1 was interviewed and stated they observed Resident #106 with hand mitten being worn occasionally on the right hand. They stated they did not order to apply the right hand mitten. On 07/23/2024 at 10:24 AM, the Director of Nursing was interviewed and stated they were not aware that Resident #106 had mitten applied to their right hand. The Director of Nursing stated it is considered a physical restraint if Resident #106 was unable to remove the mitten and it limits Resident #106's right hand movement. 10 NYCRR 415.4(a)(2-7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey from 07/21/2024 to 07/26/2024, the facility did not ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. This was evident in 1 (4th floor) of 3 units. Specifically, on 07/24/2024 at 10:57 AM, Resident #14's medication were left unattended on top of the medication cart. The findings are: The facility's policy titled Medication Storage with a revised date of 09/2023 documented that the facility will store medications in a manner that maintains the integrity of the product, ensures the safety of the residents, and in accordance with Department of Health guidelines. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. Resident #14 had diagnoses of Essential Hypertension, Epilepsy, Gastroesophageal Reflux Disease and Cardiomyopathy. The Minimum Data Set assessment dated [DATE] documented that Resident #14 had severely impaired cognition. The July 2024 electronic Medication Administration Record and the physician's orders dated 07/24/2024 included the following medication orders for Resident #14: Spironolactone 25 milligram, 1 tablet once daily by mouth for diuretic; Levetiracetam 750 milligram tablet, 1 tablet twice daily by mouth for seizure disorder; Famotidine 20 milligram tablet,1 tablet once daily by mouth; and Losartan Potassium 100 milligram tablet, 1 tablet once daily by mouth for hypertension. On 07/24/2024 at 10:57 AM, medication blister packs labeled with Resident #14's name were observed on top of an unattended medication cart. The medications were as follows: 2 tablets of Losartan 100 milligram, 1 tablet of Spironolactone 25 milligram, 1 tablet of Famotidine 20 milligram, and 1 tablet of Levetiracetam 750 milligram. Licensed Practical Nurse #2 was observed entering Resident #76's room. These medications were left continually unsecured on top of the medication cart for more than 15 minutes. The medications were secured after the State Surveyor brought it to the Licensed Practical Nurse's attention. On 07/24/2024 at 11:17AM, Licensed Practical Nurse #2 was interviewed and stated that the medications on top of the medication cart were Resident #14's. These were older medication blister packs that were pulled from the drawer for return to the pharmacy. They stated that since they were near the medication cart, they can see if anyone tries to take the blister packs. Licensed Practical Nurse #2 stated that the medications should have been secured under lock and key inside the medication cart instead of being left on top of the cart. On 07/24/2024 at 3:08 PM, Registered Nurse Supervisor #1 was interviewed and stated that medications are supposed to be secured properly and must not be left unsecured on top of the cart. On 07/25/2024 at 10:43 AM, the Director of Nursing Services was interviewed and stated that medications should not be left on top of the cart and all medications should be locked. They stated it is not a safe practice to leave medications out in the open and unattended. 10 NYCRR 415.18(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) The facility policy titled Hand Hygiene with a revised date of 05/18/2023 documented that the facility adheres to recommendation by the Centers for Disease Control and Prevention for the practice of hand hygiene in accordance with standard and transmission- based precautions. Hand hygiene is performed as a minimum before performing an aseptic task and after removing personal protective equipment (e.g. gloves, gown, face mask, eye protection). The facility policy titled Enhanced Barrier Precautions with a revised date of 05/30/2024 documented that enhanced barrier precautions is applicable for residents with indwelling medical devices regardless of multidrug-resistant organism colonization status. Enhanced barrier precautions require wearing disposable gloves and an isolation gown prior to high contact activity. Hand hygiene should be performed before and after each resident contact and after removing personal protective equipment. Resident #80 had diagnoses of Gastrostomy, Multidrug Resistant Organism, Dependence on Respiratory (ventilator) Status, and Dysphagia. The Minimum Data Set assessment dated [DATE] documented Resident #80 was dependent for eating, enteral feeding provided 50% or more of calories. During an observation on 07/22/2024 from 5:03 PM to 5:25 PM, Registered Nurse #2 was observed performing enteral feeding for Resident #80. After assembling the enteral feed, Registered Nurse #2 performed dressing change on Resident #80's gastrostomy site. Registered Nurse #2 disposed the old dressing, removed the old gloves, and donned new gloves without performing hand hygiene. Registered Nurse #2 placed a new dressing on the gastrostomy site and continued to attach the tube feeding to Resident #80's gastrostomy tube. On 07/22/2024 at 5:27PM and on 07/23/2024 at 5:24 PM, Registered Nurse #2 was interviewed and stated they were supposed to wash their hands between glove changes. On 07/24/2024 at 3:55PM, the Infection Preventionist was interviewed and stated hand washing is the most important procedure to minimize cross infection. On 07/24/2024 at 2:39 PM, the Director of Nursing was interviewed and stated that hand hygiene must be performed when taking off gloves and before donning new gloves. They stated that the same principle of infection control must be applied during glove changes. The hands must be washed, and gloves changed as often. 3.) The facility's policy titled Legionella Water Management Program with a revised date of 07/31/2023 documented that the facility would maintain and monitor the water system for Legionella. The water management program was missing a component specifying the range of acceptable pathogen levels. During an interview on 07/23/2024 at 1:50 PM, the Administrator stated they would ensure that the water management plan includes all the required components. 415.19(a)(1-3) 415.19 (b)(4) Based on observation, record review, and interview conducted during the Recertification Survey from 07/21/2024 to 07/26/2024, the facility did not ensure infection prevention and control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1.) A resident's urinary drainage bag was observed on the floor on multiple occasions. This was evident for 1 (Resident #27) of 2 residents reviewed for Urinary Catheter out of 29 sampled residents. 2.) Registered Nurse #2 did not perform hand hygiene between glove changes during gastrostomy dressing change. This was evident for 1 (Resident #80) of 4 residents observed for the nutrition investigation. 3.) The facility did not have a facility-specific water management plan for Legionella with mandatory components including but not limited to identifying acceptable pathogen levels. This was evident during the Water Management Plan review for Legionella. The findings are: 1.) The facility's policy titled Catheter Care with a last revised date of 05/2023 documented that the purpose of the policy is to prevent catheter-associated urinary tract infections and provide required care of residents who have an indwelling catheter. Resident #27 had diagnoses that included Cancer, Atrial Fibrillation, and Benign Prostatic Hyperplasia. The Minimum Data Set assessment dated [DATE] documented that Resident #27 had intact cognition. A Comprehensive Care Plan for Catheter dated 06/18/2024 documented Resident #27 had an indwelling suprapubic catheter related to neurogenic bladder, urinary retention, and urinary stricture or blockage. The facility interventions include catheter / perineal care and to monitor for signs of urinary tract infection. A Comprehensive Care Plan for Urinary Tract Infection dated 07/17/2024 documented that Resident #27 had a suspected/actual infection related to urinary tract infection. The facility interventions include to monitor for increased symptoms and to administer antimicrobials as ordered. A physician's order dated 06/26/2024 documented indwelling catheter to down drain, French 18, 30 milliliter balloon, change as needed, suprapubic care every shift. During multiple observations from 07/21/2024 to 07/24/2024, Resident #27's urinary drainage bag had been observed on the floor. On 07/21/2024, Resident #27's urinary drainage bag was observed on the floor on the right side of their bed on 3 occasions. At 9:57 AM while Resident was in bed; at 12:26 PM, while Resident #27 was in bed having lunch; and at 1:02 PM, while in bed being rendered care by the Certified Nursing Assistant. On 07/23/2024 at 10:39 AM, Resident #27 was observed in bed with their urinary drainage bag placed on the right side of their bed touching the floor. On 7/24/2024 at 10:26 AM, during an observation conducted with Certified Nursing Assistant #2 and Registered Nurse Supervisor #1, Resident #27 was observed in bed with their urinary drainage bag hanging on the right side of the bed touching the floor. Certified Nursing Assistant #2 stated they had been in Resident #27's room earlier but did not check to see that the urinary drainage bag was on the floor. On 07/24/2024 at 10:17 AM, an interview was conducted with Certified Nursing Assistant #2. The Certified Nursing Assistant stated they had been educated on urinary catheter and that the urine bag should be placed without kink below the resident's bladder and above the floor. On 07/24/2024 at 2:31 PM, Registered Nurse Supervisor #1 was interviewed and stated that staff were educated not to place the urinary drainage bag on the floor. They stated they had an urgent situation this morning and was not able to make rounds and did not notice that Resident #27's urinary drainage bag was on the floor. On 07/25/2024 at 9:10 AM, Licensed Practical Nurse #2 was interviewed and stated they did not check if Resident #27's urinary drainage bag was on the floor. On 07/25/2024 at 10:18 AM, an interview was conducted with the Director of Nursing. The Director of Nursing stated that the staff were educated that urinary drainage bags should not be placed on the floor to prevent infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during an abbreviated survey (NY00347659), the facility did not ensure care plans were reviewed and revised by the interdisciplinary team. This was evident for 1 out of 4 residents (Resident #1) sampled. Specifically, Resident #1's toes, on their left lower extremity, was observed with discolorations on 06/21/2024. The Medical Doctor was notified and ordered an Arterial Doppler Study on 06/21/2024. Review of Resident #1's Comprehensive Care Plans, revealed that the risk for Impaired Skin Integrity care plan was not updated to reflect on the discolorations to Resident #1's left toes. The findings are: The facility Policy and Procedure titled, Care Plans- Comprehensive, revised on 10/2023 documented that a comprehensive person-centered care plan that includes measurable objectives, timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The policy also states that assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. Resident #1 has diagnosis including Dementia, Atherosclerotic Heart Disease, and Chronic Atrial Fibrillation. The Minimum Data Set assessment dated [DATE], documented that Resident #1 has a Brief Interview for Mental Status, used to determine attention, orientation, and ability to recall information score of 01 out of 15, associated with severely impaired cognition. A Care Plan dated 11/30/2022 titled Alteration in Comfort - Peripheral Vascular Disease, left foot, and toes. The interventions documented administer medications as ordered and evaluate the effectiveness of pain as needed. The care plan was last revised on 06/09/2024. The facility updated the Alteration in Comfort care plan, on 07/10/2024 while surveyor was onsite. A Care Plan - at risk for Impaired Skin Integrity related to fragile skin/blood thinner dated 08/10/2020 was last reviewed on 03/17/2024. The care plan was not updated with interventions to reflect that on the skim impairments to Resident #1's toes. A Physician's Order dated 06/21/2024 documented - Arterial Doppler to bilateral lower extremities to rule of peripheral artery disease. A Physician's Progress Note dated 06/22/2024 at 6:27 pm documented seen and examined for discoloration on the left toes. Arterial Doppler ordered. No palpable pulses to the left lower extremity with dark area on the toes. A Nursing progress note dated 06/24/2024 at 3:48 pm documented staff observed Resident #1 with discoloration on left foot and a closed blister. The physician assistant examined Resident #1 and an order was given to transfer Resident #1 to the hospital to rule out Arterial Ischemia. During a telephone interview on 07/12/2024 at 3:44 pm, the Regional Registered Nurse stated that they are responsible for updating the care plans. The Regional Registered Nurse went on to say that they were not aware of the discolorations on Resident #1's left toes, therefore, the care plan was not updated to reflect on the discolorations. The Regional Registered Nurse stated that while they were going through Resident #1's medical record on 07/10/2024, they came across a Physician's Order for a doppler study and they updated the care plan to reflect on the order. The Regional Registered Nurse stated that they were not aware of the surveyor's presence in the facility on 07/10/2024 when they were updating the care plan. 10 NYCRR 415.11(c)(2) (i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during an abbreviated survey (NY00347659), the facility did not ensure that a resident medical record accurately reflected on the resident current condition. This was evident in 1 out 4 residents (Resident #1) sampled. Specifically, Resident #1's representative reported on 06/22/2024 at 5:00 pm that Resident #1's toes on the left lower extremity had discolorations. According to an interview with Primary Medical Doctor #1 on 07/10/2024 at 12:10 pm, they were in the facility and was notified of the discolorations on 06/21/2024. Primary Medical Doctor #1 stated that they assessed Resident #1 but did not document their assessment in Resident #1's medical record on 06/21/2024. The findings are: A Policy and Procedure titled Charting and Documentation last reviewed on 06/2023 states that all services provided to the resident, or any changes in the resident's medical or mental condition, should be documented in the resident's medical record. Resident #1 has diagnosis including Dementia, Atherosclerotic Heart Disease, and Chronic Atrial Fibrillation. The Minimum Data Set assessment dated [DATE], documented that Resident #1 has a Brief Interview for Mental Status, used to determine attention, orientation, and ability to recall information score of 01 associated with severely impaired cognition. A Physician's Order dated 06/21/2024 documented - Arterial Doppler to bilateral lower extremities to rule of peripheral artery disease. There was no documentation of an assessment done on 06/21/2024 of Resident #1's lower extremities. During an interview on 07/10/2024 at 12:10 pm, Primary Medical Doctor #1 stated that Licensed Practical Nurse #1 informed them that Resident #1 has a very small discoloration on one of their toes (on the left foot) on 06/21/2024 (does not recall the time). Primary Medical Doctor #1 went on to say that they were in the facility on 06/21/2024 and assessed Resident #1's toes. Primary Medical Doctor #1 stated on assessment, Resident #1 had a very small area with discoloration on their toe (does not recall how many toes were affected). Primary Medical Doctor #1 stated that Resident #1 did not have a blister and the toe was not gangrene at the time of the assessment. Primary Medical Doctor #1 also stated that they instructed Licensed Practical Nurse #1 to monitor Resident #1's foot and to order an Arterial Doppler Study to rule out arterial issues and embolus. Primary Medical Doctor #1 stated that they did not document their assessment in Resident #1's medical record on 06/21/2024 and that they should have. Licensed Practical Nurse was not available for an interview. During an interview on 07/10/2024 at 12:25 pm, the Director of Nursing stated that the staff who informed Primary Medical Doctor #1 on 06/21/2024 and received the order for the Arterial Doppler Study, should have written a note in Resident #1's medical record. 10 NYCRR 415.22(a)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews conducted during the recertification survey from 6/1/2022 to 6/8/2022, the facility did not ensure a resident's Comprehensive Care Plan (CCP) was reviewed and revised after each assessment, including both the compehensive and quarterly reviewed assessments. This was evident for 1 (Resident #87) of 3 residents reviewed for pressure ulcers (PU). Specifically, the CCPs related to Resident #87's PUs were not reviewed and revised after each assessment to reflect changes in the condition of the wounds. The findings are: The facility policy titled, Care Plans-Comprehensive dated 10/2021 documented CCPs are revised when resident's condition changes or at least quarterly in accordance with the Minimum Data Set 3.0 (MDS) assessment. Resident #87 had diagnosis of chronic respiratory failure with hypoxia and ventilator dependence. The MDS dated [DATE] documented the Resident #87 was severely cognitively impaired, was at risk for PUs, had two stage 3 wounds, and had one stage 4 wound. The CCP related to alteration in skin integrity initiated 9/8/2020 and last revised 10/29/2021 documented Resident #87 had a stage 3 PU to the right ischium. The size was 2.5 x 2 x 0.2 CM, surface area was 5 CM 2, and wound bed was 5% necrosis, 60% muscle, and 35 % granulation. The CCP related to alteration in skin integrity initiated 9/8/2020 and last updated 10/29/2021 documented Resident #87 had a stage 4 PU to the sacrum with size of 3 x 2 x 0.3 CM, surface area of 6 CM, and wound bed of 100% granulation. The CCP related to alteration in skin integrity initiated 9/8/2020 and last updated 10/29/2021 documented Resident #87 stage 3 right planter PU with a size of 1 x 7 x 0.2 CM, surface area of 7 CM, serosanguinous exudate, and wound bed of 30% necrotic, and 70% granulated. Medical wound note dated 5/12/2022 documented Resident #87 had a stage 3 wound to right ischium with size of 3 x 2 x 0.2 CM, surface area of 6 CM, and wound bed of 10% slough, 50% Muscle, and 40% granulation. Medical wound notes dated 5/12/2022 documented Resident #87's stage 4 sacral ulcer had a size of 4 x 4 x 0.3 CM, surface area of 16 CM, and wound bed of 70% granulation, 20% muscle, and 10% slough. Medical wound note dated 5/12/2022 documented Resident #87 had a stage 3 PU to the right plantar with a size of 0.5 x 0.5 x 0.2 CM, surface area of 0.25 CM, serosanguinous exudate, and a wound bed of 30% necrotic and 70% granulation. Physician order dated 05/18/2022 documented the following wound orders for Resident #87: 1) Right Ischium Pressure Injury: Cleanse wound with soap and water and apply Medi-honey, cover with dry protective dressing one time a day for stage 3 pressure injury, skin prep to peri wound; 2) Sacrum Pressure Injury: Cleanse wound with Dakins' solution, apply Hydrogel wafer every two days, cover with dry protective dressing every 48 hours for stage 4 pressure injury; 3) Right Plantar Pressure Injury: Cleanse wound with Dakins' solution, apply Hydrogel wafer and silver nitrate sticks every two days, cover with dry protective dressing. On 06/07/22 at 09:45 AM, Registered Nurse (RN#2) was interviewed and stated all resident CCPs are initiated upon admission and evaluated and updated at least quarterly or as needed. The unit manager is responsible for updating and revising the CCPs. RN #2 can update CCPs but is not responsible for Resident #87's unit. On 06/07/22 at 10:19 AM, the Registered Nurse Manager (RNM) was interviewed and stated they were responsible for Resident #87's unit and updating all CCPs. The CCPs related to PUs and wounds are updated at least quarterly, annually, and when there are changes in the wound treatments and or measurements. RNM stated they thought Resident #87's CCPs were updated but were unable to fund documented evidence of updates to Resident #87's CCPs related to wounds/PUs after 10/29/2021. RNM was unable to explain the reason Resident #87's CCPs were not updated. On 06/07/22 at 11:21 AM, the Director of Nursing Services (DNS) was interviewed and stated the RN unit manager is responsible for updating the resident CCPs quarterly, annually, and if there is any change in the resident's condition. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review during the recertification survey from 6/1/22 to 6/8/22, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident #41) of 3 residents reviewed for limited range of motion. Specifically, Resident #41, a resident with bilateral hand contractures, was observed on multiple occasions without gauze rolls to bilateral hands as per Medical Doctor Order (MDO). The findings are: The facility policy titled Splints, Prosthetics and Orthotics dated 10/12/21 documented to promote quality care, the facility uses appropriate techniques and devices for splints, prosthetics and orthotics. Resident #41 had diagnoses of dementia, cerebral infarction, and quadriplegia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #41 had moderately impaired cognition. The resident was not provided with splinting devices. On 6/02/2022 at 09:31 AM, 6/06/22 at 09:16 AM, 6/06/22 at 10:34 AM, and 6/06/22 at 04:45 PM, Resident #41 was observed in bed with contractures to bilateral hands. Rolls of gauze were not observed in either hand. On 6/02/22 at 12:44 PM, Resident #41 was observed in the dining room and rolls of gauze were not observed in their bilateral hands. The MDO as of 6/4/2022, initiated 7/20/20, documented Resident #41 should have rolled sterile gauze to both hands every shift for protection. The Rehabilitation Audit for Splints and Braces dated 5/26/2022 documented Resident #41 was identified as having an MDO for rolled gauze to bilateral hands. The corrective action was to apply rolled gauze to bilateral hands. On 6/6/22 at 4:49 PM, Certified Nursing Assistant (CNA) #1 was interviewed and stated they were familiar with Resident #41 who has contractures of both hands. CNA #1 stated Resident #41 is supposed to have bilateral hand rolls. When CNA #1 observed Resident #41 with the surveyor, CNA #1 confirmed the hand rolls were not in place. CNA #1 stated he/she was distracted and did not place the hand rolls in place today, but they were in place yesterday. On 6/07/22 at 10:26 AM, the Director of Rehabilitation (DOR) was interviewed and stated occupational therapy recommended Resident #41 have hand rolls in place on 2/17/2022. The rehabilitation department audits residents with adaptive devices monthly, and if a device is not in place, nursing is made aware. On 6/08/22 at 1:24 PM, Licensed Practical Nurse (LPN) #3 was interviewed and stated the nurses are responsible for checking that adaptive devices are in place and sign for them in the resident's treatment record. The CNAs inform the nurses if the adaptive devices are soiled or need to be replaced. 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 from 6/1/22 to 6/8/22, the facility did not ensure a resident's medical records were complete. This was evidenced by 1 (Resident #72) of 5 residents reviewed for unnecessary medication. Specifically, there was no documented evidence in the Medication Administration Record (MAR) Resident #72 received their hypertensive medication as per Medical Doctor Order (MDO) on multiple occasions. The findings are: The facility policy titled Medication Administration dated 12/2021 documented medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. If a drug is withheld, refused or given at another time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. Resident #72 had diagnoses of end stage renal disease (ESRD) and essential primary hypertension. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #72 was severely cognitively impaired. The Comprehensive Care Plan (CCP) related to potential for fluid deficit or overload due to ESRD initiated 7/13/2020 and last revised 4/20/2022 documented Resident #72 will be administered medications as ordered and nursing staff would monitor for side effects and effectiveness. The MDO as of 6/2/2022 documented Resident #72 was ordered to receive Hydralazine Hydrochloride 25 mg every 8 hours for hypertension; hold medication if blood pressure (BP) is 100/60 or below and notify Medical Doctor (MD) or Nurse Practitioner (NP). There was no documented evidence Resident #72 was administered Hydralazine in accordance with the MDO: 5 times in January 2022, 4 times in February 2022, 9 times in March 2022, 8 times in April 2022, and 10 times in May 2022. On 6/06/22 at 9:55 AM, Licensed Practical Nurse (LPN) #2 was interviewed and stated the LPN checks a resident's BP according to MDO. If the BP is not within the acceptable parameters, the MD is contacted and the LPN documents in the resident's medical record. If the LPN does not document medication administration or medication hold, the electronic box on the MAR will remain red until it is completed. On 6/06/22 at 10:20 AM, Registered Nurse Manager (RNM) was interviewed and stated a resident's BP reading is documented on the MAR by the nurse. If a medication is held, the MD is contacted and the nurse documents accordingly on the MAR. If the MAR is blank, the nurse did not document the administration of medication not the resident. The RNM stated they should have checked the MAR at the end of each shift to ensure completion. The RNM is responsible for informing nursing staff of missing MAR documentation. On 6/06/22 at 10:36 AM, the Director of Nursing (DON) was interviewed and stated the electronic medical record allows the DON and/or RNM to pull a report of MARs with missing signatures or documentation. The DON tries to pull the report daily and inquire with the nurses if there are blanks where medication should have been administered. The DON was unaware Resident #72's MAR had missing signatures for Hydralazine. On 6/07/22 at 10:03 AM, LPN #1 was interviewed and stated Resident #72 does not refuse medication and it would be documented on the MAR if they did. 415.22(a)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and staff interviews during the recertification and abbreviated survey, the facility did not ensure that an incident was thoroughly investigated. Specifically, the facility did not obtain staff statements from all witnesses and the previous shift for an investigation conducted regarding a resident being found with their sheets tied around the neck, holding the resident to the mattress. This was evident of 1 out of 2 residents reviewed for Abuse out of 53 residents sampled (Resident #390)(#NY00233795). The finding is: The facility Policy entitled Abuse/Behavior Reporting Accident/Incident Reporting dated 7/2019 documented under the following headings Licensed Nurse : monitors and documents resident conditions and vital signs every shift for 72 hours, Director of Nursing or Quality Assurance Director Review form and data with Interdisciplinary Team for root cause and prevention and any additional care plan issue; Quality assurance Director/Designee Analyzes collected data for trends and need for corrective action, review and analysis with appropriate committee. Resident #390 was admitted to the facility on [DATE] with last admission date of 4/29/2019. Diagnoses included Dementia Without Behavioral Disturbance, Malignant Neoplasm of the Prostate, and Pressure Ulcer. The Quarterly Minimum Data Set (MDS), Assessment Reference date (ARD) 1/25/19 documented the resident was rarely/never understood with short and long-term memory problems. The resident had severely impaired cognition and rarely/never made decisions. The resident required the total assistance of two staff persons for bed mobility, transfer and toileting. The resident required the total assist of one person for personal hygiene and supervision with set-up assistance for eating. On 10/18/19 at 08:48 AM, a telephone interview was conducted with the resident's wife. She stated that on 1/9/2019, she came to the facility around 12 noon to visit the resident, and he was tied up in bed. The resident had a sheet tied around his neck. The wife stated she immediately left the room and went to the Nurses' station to let the staff know. The sheet was over the resident's neck and affixed to the mattress on both sides at the foot of the bed. She further stated the sheets were holding the resident down in the bed. The wife added the sheet had two knots at the bottom. All the staff came into the room and told her this was unacceptable. She stated they looked at the resident and cleaned him up. The resident was not hurt, but she did tell the staff this should not happen again. The facility did not tell her anything about the incident and what measures they took after the incident. On 10/21/at 12:04 PM, the state agent (SA) observed Rooms 311A and 309B with the Certified Nursing Assistant (CNA #5) to see how the sheets are attached to the air mattresses in the facility. The air mattress had a flat sheet affixed to the mattress using black ties that are on the four corners of the mattress. This flat sheet is used instead of a fitted sheet. The Grievance/Complaint Report dated 1/9/2019 documented, [Resident #390] was in bed with a sheet tied around his neck and the sheet tied on both side of the foot of the bed. The witnesses listed were the Director of Social Services (DSS) and the Registered Nurse Supervisor (RN #5). This report was completed and signed by the resident's wife. The facility document entitled Grievance Accident or Incident Report dated 1/9/2019, completed by RN #5, documented that staff was called to Resident #390's room by his wife. The resident was in bed with the top part of the bed sheet tied loosely around the right shoulder side. The resident was not in any respiratory distress. The corrective actions were to place the resident on visual checks every 15 minutes and take the resident Out Of Bed (OOB) daily for a maximum of two hours daily as per MD (Physician's) order. The facility document entitled Investigation Summary dated 2/7/2019 documented: On January 9th, at approximately 11:49 AM, the resident's wife visited and reported that his cover sheet was tied around his neck. The resident was immediately assessed by the Registered Nurse Supervisor (RN #5), and she observed the sheet was loosely tied around his neck and resting on his right shoulder. He had also removed his bed gown and same was lying on the cover. There were no visible marks on his skin, nor did he complain of pain. The physician was informed, and he was placed on visual checks every 15 minutes. Staff were interviewed and statements were obtained. The staff did not observe that behavior during rounds. The last rounds were done at 11:00am. Staff also stated that the resident removes his gowns at times while in bed. Due to his cognitive status, the resident was unable to give an account of what happened. Staff stated that the resident could pull the sheet up around him. Due to information obtained from staff interviews and the resident's observed capability of lifting his hands above his head, the investigation concluded the resident could have placed the sheet in that position to cover himself. Based on the investigation, the resident's capabilities and staff interviews, there was no reason to believe the resident was abused. The corrective actions were that the resident would continue to be monitored, and staff were reeducated on Abuse, mistreatment, and neglect. There was no documented evidence that statements were taken from all the staff that witnessed the incident. In addition, there were no statements taken from the staff that worked with the resident from the previous shift regarding how the resident's sheet was tied. There was no documentation in the medical record regarding the incident on 1/9/19 or any assessments completed in relation to the incident. There was no Comprehensive Care Plan for behavior in the medical record. Review of all progress notes with dated range from 3/15/2018 to 1/25/2109 show no documented evidence the resident displayed behaviors. The CNA Accountability Record (CNAAR) dated January 2019 documented no behaviors. The CNAAR contained instructions which included: bed in the lowest position, Alert and confuse, A and D ointment skin protectant, bilateral side rails, recliner for safety, resident can only come out of bed wheel chair (w/c) for two hours per day. On 10/22/2019 at 12:11PM, an interview was conducted with CNA #7, the assigned 7-3 shift CNA. The CNA stated she did not clearly remember the incident and was not there when it was reported. She was told by the other staff members that the resident's wife stated he had a sheet around his neck. The CNA also stated when she went into the room, another staff was already cleaning the resident so she did not see the sheet around the resident. The CNA stated she did monitor the resident several times throughout the shift. The resident usually comes out of bed later in the shift, so she started to take care of the other residents she was responsible for and saw no issue with resident when she made rounds. The CNA stated the resident would be able to pull the sheets up around his neck because he was able to feed himself with set-up assistance. In addition, the resident displayed behaviors of removing his gown and pulling the sheets off the bed, and the nurses were aware of this behavior. CNA stated the staff tie the bottom sheet to secure the sheet to the mattress because the material the air mattress is made of is very silky. When you do not have a fitted sheet, the bottom sheet can easily come off if it is not secured to the bed. The CNA stated when the incident occurred, staff was told not to tie the sheets. She stated she did not remember who told her this directive or signing any Inservice attendance sheets about the incident. The CNA stated she was told the facility will be getting fitted sheets soon. On 10/21/19 at 12:04 PM, an interview was conducted with CNA #5. CNA #5 stated she heard of the incident that happened in January with the resident, but she did not recall if she was working at the time the incident occurred. CNA #5 stated she took care of the resident in the past. The resident was strong and able to move his hands above his head. CNA #5 stated the air mattress has four strings attached and hanging from the mattress. CNA #5 stated the facility does not use fitted sheets, and they only have flat sheets to make the beds. As a result, staff use the strings on the mattress to affix the bottom flat sheet at all ends so that the sheet does not slide off the bed. The material the air mattress is made of is very smooth, and if you do not secure the sheet, the sheet could slide off with the resident when the resident moves in bed. CNA #5 stated once tied, the sheet cannot move if the resident moves in the bed. CNA #5 demonstrated what she was saying by showing the SA the air mattresses in rooms [ROOM NUMBERS]. The CNA attempted to pull the affixed flat bottom sheet with both hands, and the sheet did not move. The CNA was able to easily remove the tie when she tugged on it. CNA #5 stated because of the material the mattress is made, of it is easy for the resident to slip from the bed if the sheet is not secure. The CNA stated she remembered the resident had behaviors of pulling the top sheet over his head and staff would monitor him and remove the sheet. She stated she believed how the sheet was tied, it could not move from its position even if the resident was lying in bed and pulling at it. CNA added, the sheet cannot move unless she untied the sheet. If the resident happened to pull at the sheet, the tie might come off. CNA #5 added if the sheet is not secured, a resident could fall from bed during care or with movement. On 10/18/19 at 12:51 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she started two months ago and is aware of the incident. The DON stated if an incident occurs, the supervisor is informed and reports it to the DON. The DON should then report the incident to the Administrator. The supervisor is responsible for securing the resident and starting the investigation by collecting staff statements. The DON stated after the investigation is completed it is report to Department of Health if warranted. DON stated incident must be reported in a timely manner and it all depends on the severity of the incident. DON went on to state some incidents need to be reported right away, some two hours or forty-eight hours, it all depends on the incident. DON stated the investigation can focus on one shift or it can be done over multiple shifts. DON added timely reporting is very important and states the facility currently does not have the issue. On 10/18/19 at 11:35 AM, an interview was conducted with the License Practical Nurse (LPN #3). LPN #3 stated that resident had a habit of rolling up the sheets, holding onto the sheets like a baby, and disrobing while in bed. The LPN stated on the day of the incident, the wife came in to visit and she came to the nurse's station very upset. She stated herself and the Nursing Supervisor went to the room, and the resident had taken the cover sheet and put it around his neck. LPN stated the bottom sheets had been tied onto the bed because the resident pulls the sheets all the way up to his face. LPN stated the resident was on an an alternating air mattress, and the sheet was tied at foot of the bed. The LPN added the sheets were tied to prevent the resident form putting the sheets over his head. LPN #3 stated the wife stated the resident was being restraint and wrote a grievance about it. She stated somehow the wife did not feel it was possible for the resident to put the sheet around his neck. The LPN stated the supervisor removed the sheet, and the resident had on a shirt and diaper because he removed his clothing. LPN #3 stated the sheet was removed by just pulling it to the side, and the resident had no redness, bruising or injuries. LPN #3 stated the staff removed the sheet, straightened the bed, dressed the resident, and took him out of bed. The Director of Nursing(DON) came to the unit and stated the bottom sheet should not be tied to the bottom of the bed and instructed all staff to monitor the resident to ensure he does not remove the sheets. LPN #3 also stated she did not recall signing any in-service on the incident. Even though the sheet was around the resident's neck, she believes the resident did not have the strength to harm himself with the sheet. She stated she believes the resident was able to put the sheet around his neck by himself. On 10/18/19 at 10:55 AM, an interview was conducted with the Social Worker. The SW stated he recalled the resident's wife was upset about what happened and showed him a picture. The picture he saw showed the sheet was laying across the resident's upper torso from the right shoulder and around the body. The SW stated he could not recall seeing a knot in the picture, but the sheet appeared to be around the resident's body. The sheet was close to resident's shoulders, and the SW did not recall seeing the sheet around the resident's neck. SW stated the wife was visibly upset at the time and he communicated this to the Director of Nursing. He gave emotional support to resident's wife. The SW also stated he saw the resident after the fact, and there were no issues with resident. The SW added he does not believe there was a meeting regarding the incident because there was an ongoing investigation. On 10/18/19 at 10:16 AM, an interview was conducted with the Director of Social Services (DSS). The DSS stated she was on the unit and heard the wife of the resident saying, Look at my husband. Why did they do that to him? She went in to see the resident, as a result. The DSS stated she saw the sheet was not tucked under the mattress. The sheet was covering the resident and had a knot on the sheet end, and the sheet was around the resident's neck. DSS gestured the sheet was covering his neck and repeated she saw a tie in the sheet, and it was around his neck. The DSS added the sheet was not tight around the neck, and the nurse on the unit as well as the supervisor was also in the room. The DSS stated she saw the wife was very upset, so she asked the resident's Social Worker to go and speak to the wife because she realized the wife was very upset. The DSS stated the resident was not hurt. On 10/18/19 at 10:33 AM, an interview was conducted with the Registered Nursing Supervisor (RN #5) for the unit. RN #5 recalled being in the room, but she was not sure who informed her about the incident. RN #5 stated she vaguely remembered and was trying to think about what happened. After several minutes of silence, RN #5 stated she recalled the resident was in bed and it appeared he had a sheet draped around his neck. RN #5 took of her lab coat and demonstrated that the resident was lying with the sheet up to his neck. The RN then denied the sheet was around the resident's neck and stated she was unable to give any more information about the incident. The RN stated the resident was not hurt. 415.4(a)(2-7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the re-certification survey, the facility did not ensure Minimum Data Set 3.0 (MDS) non-comprehensive assessments were electronically submitted and transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System in a timely manner. Specifically, a discharge assessment was not completed and transmitted within fourteen (14) calendar days. This was evident for 1 of 1 resident reviewed for the Resident Assessment facility task (Resident #1). The finding is: The undated facility policy titled Minimum Data Set (MDS) Completion Policy documented the MDS Coordinator assigns the staff to complete the specified sections of the MDS. Federal regulations at 42 C.F.R.483.20(C)(2) requires each individual who completes a portion of the assessment to sign and certify its accuracy. The regulation requires the MDS Coordinator to certify that the assessment is complete (42 C.F.R.483.20(C)(2) (1) (ii)). The MDS assistant completes the entry tracking and schedules discharge tracking. CMS RAI Version 3.0 Manual (Dated October 2018)- Chapter 5 titled Submission and Correction of the MDS Assessments documented: The MDS completion date must be no later than 14 days after the assessment reference date (ARD) for all non-admission, OBRA, and PPS assessments. The MDS completion date must be no later than 13 days after the entry date for admission assessments. Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date. Resident #1 was admitted to the facility on [DATE]. The Discharge Assessment- return not anticipated had an Assessment Reference Date of 5/18/19. It was completed on 10/21/19 and submitted on 10/21/19. On 10/21/19 at 11:54 AM, the MDS Coordinator was interviewed. The MDS Coordinator stated she schedules, checks for the completion, and submits the MDS. The MDS coordinator stated there is an offsite employee who helps complete MDS assessments. The MDS coordinator stated for Medicare and Medicaid resident the assessment is due 7 days after completion and 14 days after completion for OBRA residents. The MDS coordinator stated she gets discharge information from the census and morning report. The MDS coordinator stated she must have missed the book for this resident and was not sure why it was over 120 days late. 415.11

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey, the facility did not develop and implement a baseline care plan for a newly admitted resident. This was evident for 1 of 3 residents reviewed for closed record, out of 53 sampled residents. (Resident #141) The finding is: The facility policy titled Goals and Objectives, Care Plans dated September 2018 documented care plans will incorporate goals and objectives that lead to the residents highest obtainable level of independence. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. Goals and objectives are entered on the resident's care plan so all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. The facility policy titled Comprehensive Person-Centered Care Planning dated August 2018 documented a Comprehensive Care Plan (CCP) will be developed and implemented to meet all the needs for the resident that includes measurable objectives and timetables to meet each residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Baseline care plans will be developed within 48 hours of all residents admissions. Baseline care plans will include the instructions needed to provide effective and person-centered care plan that meets professional standards of quality care. Resident #141 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus, Pulmonary Embolism, Chronic Pain, Heart Disease, and Sepsis. Physicians Orders dated 7/11/19 documented Advance Directives of Do Not Resuscitate (DNR), Do Not Intubate (DNI). On 7/19/19 the resident was placed on Hospice Care. Review of the record revealed Comprehensive Care Plans (CCP) were developed for Activities and Advance Directives. CCP titled Activities dated 7/12/19 documented resident will make a smooth adjustment/transition into the facility x 30 days. No goals exist for this focus, no interventions exist for this focus, no notes exist for this focus. CCP titled Advance Directives: MOLST/DNR/DNI/DNH dated 7/19/19 documented resident surrogate has most as follows: DNR/DNI/DNH. No goals exist for this focus, no interventions exist for this focus no notes exist for this focus. A review of the record provided no evidence a baseline care plan was developed for the resident. On 10/18/19 at 02:25 PM, the Director of Nursing (DON) stated there was no baseline care plan for the resident #141. On 10/21/19 at 10:10 AM, an interview was conducted with Registered Nurse #1 (RN #1). RN #1 stated care plans are created by unit managers on all shifts. RN #1 stated usually the evening and night shifts get new admissions and will create baseline care plans. RN #1 stated sometimes she will check the day after an admission to see if any care plans need to be added. RN #1 stated she has only been working at the facility for a few months and is not sure if she was here when the resident was admitted . 415.11 (c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification and abbreviated survey, the facility did not ensure that the environment remained free from accident hazards. Specifically, a flat sheet that required being tied to the four corners of the mattress was used for a resident with Dementia instead of a fitted sheet. The sheet became untied at the head of the mattress, and ended up around the resident's neck, at the food of the bed, holding the resident to the bed. This was evident for 1 of 1 resident reviewed for Restraints out of a sample of 53 sampled residents (#NY00233795) (Resident #390). The findings are: Resident #390 was admitted to the facility on [DATE] with last admission date of 4/29/2019. Diagnoses included Dementia Without Behavioral Disturbance, Malignant Neoplasm of the Prostate, and Pressure Ulcer. The Quarterly Minimum Data Set (MDS), Assessment Reference date (ARD) 1/25/19 documented the resident was rarely/never understood with short and long-term memory problems. The resident had severely impaired cognition and rarely/never made decisions. The resident required the total assistance of two staff persons for bed mobility, transfer and toileting. The resident required the total assist of one person for personal hygiene and supervision with set-up assistance for eating. On 10/18/19 at 08:48 AM, a telephone interview was conducted with the resident's wife. She stated that on 1/9/2019, she came to the facility around 12 noon to visit the resident, and he was tied up in bed. The resident had a sheet tied around his neck. The wife stated she immediately left the room and went to the Nurses' station to let the staff know. The sheet was over the resident's neck and affixed to the mattress on both sides at the foot of the bed. She further stated the sheets were holding the resident down in the bed. The wife added the sheet had two knots at the bottom. All the staff came into the room and told her this was unacceptable. She stated they looked at the resident and cleaned him up. The resident was not hurt, but she did tell the staff this should not happen again. The facility did not tell her anything about the incident and what measures they took after the incident. On 10/21/at 12:04 PM, the state agent (SA) observed Rooms 311A and 309B with the Certified Nursing Assistant (CNA #5) to see how the sheets are attached to the air mattresses in the facility. The air mattress had a flat sheet affixed to the mattress using black ties that are on the four corners of the mattress. This flat sheet is used instead of a fitted sheet. The Grievance/Complaint Report dated 1/9/2019 documented, [Resident #390] was in bed with a sheet tied around his neck and the sheet tied on both side of the foot of the bed. The witnesses listed were the Director of Social Services (DSS) and the Registered Nurse Supervisor (RN #5). This report was completed and signed by the resident's wife. The facility document entitled Grievance Accident or Incident Report dated 1/9/2019, completed by RN #5, documented that staff was called to Resident #390's room by his wife. The resident was in bed with the top part of the bed sheet tied loosely around the right shoulder side. The resident was not in any respiratory distress. The corrective actions were to place the resident on visual checks every 15 minutes and take the resident Out Of Bed (OOB) daily for a maximum of two hours daily as per MD (Physician's) order. The facility document entitled Investigation Summary dated 2/7/2019 documented: On January 9th, at approximately 11:49 AM, the resident's wife visited and reported that his cover sheet was tied around his neck. The resident was immediately assessed by the Registered Nurse Supervisor (RN #5), and she observed the sheet was loosely tied around his neck and resting on his right shoulder. He had also removed his bed gown and same was lying on the cover. There were no visible marks on his skin, nor did he complain of pain. The physician was informed, and he was placed on visual checks every 15 minutes. Staff were interviewed and statements were obtained. The staff did not observe that behavior during rounds. The last rounds were done at 11:00am. Staff also stated that the resident removes his gowns at times while in bed. Due to his cognitive status, the resident was unable to give an account of what happened. Staff stated that the resident could pull the sheet up around him. Due to information obtained from staff interviews and the resident's observed capability of lifting his hands above his head, the investigation concluded the resident could have placed the sheet in that position to cover himself. Based on the investigation, the resident's capabilities and staff interviews, there was no reason to believe the resident was abused. The corrective actions were that the resident would continue to be monitored, and staff were reeducated on Abuse, mistreatment, and neglect. There was no documentation in the medical record regarding the incident on 1/9/19 or any assessments completed in relation to the incident. There was no Comprehensive Care Plan for behavior in the medical record. Review of all progress notes with dated range from 3/15/2018 to 1/25/2109 show no documented evidence the resident displayed behaviors. The CNA Accountability Record (CNAAR) dated January 2019 documented no behaviors. The CNAAR contained instructions which included: bed in the lowest position, Alert and confuse, A and D ointment skin protectant, bilateral side rails, recliner for safety, resident can only come out of bed wheel chair (w/c) for two hours per day. On 10/22/2019 at 12:11PM, an interview was conducted with CNA #7, the assigned 7-3 shift CNA. The CNA stated she did not clearly remember the incident and was not there when it was reported. She was told by the other staff members that the resident's wife stated he had a sheet around his neck. The CNA also stated when she went into the room, another staff was already cleaning the resident so she did not see the sheet around the resident. The CNA stated she did monitor the resident several times throughout the shift. The resident usually comes out of bed later in the shift, so she started to take care of the other residents she was responsible for and saw no issue with resident when she made rounds. The CNA stated the resident would be able to pull the sheets up around his neck because he was able to feed himself with set-up assistance. In addition, the resident displayed behaviors of removing his gown and pulling the sheets off the bed, and the nurses were aware of this behavior. CNA stated the staff tie the bottom sheet to secure the sheet to the mattress because the material the air mattress is made of is very silky. When you do not have a fitted sheet, the bottom sheet can easily come off if it is not secured to the bed. The CNA stated when the incident occurred, staff was told not to tie the sheets. She stated she did not remember who told her this directive or signing any Inservice attendance sheets about the incident. The CNA stated she was told the facility will be getting fitted sheets soon. On 10/21/19 at 12:04 PM, an interview was conducted with CNA #5. CNA #5 stated she heard of the incident that happened in January with the resident, but she did not recall if she was working at the time the incident occurred. CNA #5 stated she took care of the resident in the past. The resident was strong and able to move his hands above his head. CNA #5 stated the air mattress has four strings attached and hanging from the mattress. CNA #5 stated the facility does not use fitted sheets, and they only have flat sheets to make the beds. As a result, staff use the strings on the mattress to affix the bottom flat sheet at all ends so that the sheet does not slide off the bed. The material the air mattress is made of is very smooth, and if you do not secure the sheet, the sheet could slide off with the resident when the resident moves in bed. CNA #5 stated once tied, the sheet cannot move if the resident moves in the bed. CNA #5 demonstrated what she was saying by showing the SA the air mattresses in rooms [ROOM NUMBERS]. The CNA attempted to pull the affixed flat bottom sheet with both hands, and the sheet did not move. The CNA was able to easily remove the tie when she tugged on it. CNA #5 stated because of the material the mattress is made, of it is easy for the resident to slip from the bed if the sheet is not secure. The CNA stated she remembered the resident had behaviors of pulling the top sheet over his head and staff would monitor him and remove the sheet. She stated she believed how the sheet was tied, it could not move from its position even if the resident was lying in bed and pulling at it. CNA added, the sheet cannot move unless she untied the sheet. If the resident happened to pull at the sheet, the tie might come off. CNA #5 added if the sheet is not secured, a resident could fall from bed during care or with movement. On 10/21/19 at 03:10 PM an interview was conducted with the Assistant Administrator (AA) during Quality Assurance and Assessment(QAA)/Quality Assurance and Performance Improvement(QAPI). The AA stated he was not aware of issues regarding staff tying sheets to the air mattresses because there were no fitted sheets, and he will follow up quickly. The AA also stated most of the staff are new, and the administration is trying to teach new behaviors and change the culture of the facility. The AA added the facility is working on a lot things, and things around the facility will change. On 10/18/19 at 12:51 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she started two months ago and is aware of the incident. The DON stated if an incident occurs, the supervisor is informed and reports it to the DON. The DON should then report the incident to the Administrator. The supervisor is responsible for securing the resident and starting the investigation by collecting staff statements. The DON stated after the investigation is completed it is report to Department of Health if warranted. DON stated incident must be reported in a timely manner and it all depends on the severity of the incident. DON went on to state some incidents need to be reported right away, some two hours or forty-eight hours, it all depends on the incident. DON stated the investigation can focus on one shift or it can be done over multiple shifts. DON added timely reporting is very important and states the facility currently does not have the issue. On 10/18/19 at 11:35 AM, an interview was conducted with the License Practical Nurse (LPN #3). LPN #3 stated that resident had a habit of rolling up the sheets, holding onto the sheets like a baby, and disrobing while in bed. The LPN stated on the day of the incident, the wife came in to visit and she came to the nurse's station very upset. She stated herself and the Nursing Supervisor went to the room, and the resident had taken the cover sheet and put it around his neck. LPN stated the bottom sheets had been tied onto the bed because the resident pulls the sheets all the way up to his face. LPN stated the resident was on an an alternating air mattress, and the sheet was tied at foot of the bed. The LPN added the sheets were tied to prevent the resident form putting the sheets over his head. LPN #3 stated the wife stated the resident was being restraint and wrote a grievance about it. She stated somehow the wife did not feel it was possible for the resident to put the sheet around his neck. The LPN stated the supervisor removed the sheet, and the resident had on a shirt and diaper because he removed his clothing. LPN #3 stated the sheet was removed by just pulling it to the side, and the resident had no redness, bruising or injuries. LPN #3 stated the staff removed the sheet, straightened the bed, dressed the resident, and took him out of bed. The Director of Nursing(DON) came to the unit and stated the bottom sheet should not be tied to the bottom of the bed and instructed all staff to monitor the resident to ensure he does not remove the sheets. LPN #3 also stated she did not recall signing any in-service on the incident. Even though the sheet was around the resident's neck, she believes the resident did not have the strength to harm himself with the sheet. She stated she believes the resident was able to put the sheet around his neck by himself. On 10/18/19 at 10:55 AM, an interview was conducted with the Social Worker. The SW stated he recalled the resident's wife was upset about what happened and showed him a picture. The picture he saw showed the sheet was laying across the resident's upper torso from the right shoulder and around the body. The SW stated he could not recall seeing a knot in the picture, but the sheet appeared to be around the resident's body. The sheet was close to resident's shoulders, and the SW did not recall seeing the sheet around the resident's neck. SW stated the wife was visibly upset at the time and he communicated this to the Director of Nursing. He gave emotional support to resident's wife. The SW also stated he saw the resident after the fact, and there were no issues with resident. The SW added he does not believe there was a meeting regarding the incident because there was an ongoing investigation. On 10/18/19 at 10:16 AM, an interview was conducted with the Director of Social Services (DSS). The DSS stated she was on the unit and heard the wife of the resident saying, Look at my husband. Why did they do that to him? She went in to see the resident, as a result. The DSS stated she saw the sheet was not tucked under the mattress. The sheet was covering the resident and had a knot on the sheet end, and the sheet was around the resident's neck. DSS gestured the sheet was covering his neck and repeated she saw a tie in the sheet, and it was around his neck. The DSS added the sheet was not tight around the neck, and the nurse on the unit as well as the supervisor was also in the room. The DSS stated she saw the wife was very upset, so she asked the resident's Social Worker to go and speak to the wife because she realized the wife was very upset. The DSS stated the resident was not hurt. On 10/18/19 at 10:33 AM, an interview was conducted with the Registered Nursing Supervisor (RN #5) for the unit. RN #5 recalled being in the room, but she was not sure who informed her about the incident. RN #5 stated she vaguely remembered and was trying to think about what happened. After several minutes of silence, RN #5 stated she recalled the resident was in bed and it appeared he had a sheet draped around his neck. RN #5 took of her lab coat and demonstrated that the resident was lying with the sheet up to his neck. The RN then denied the sheet was around the resident's neck and stated she was unable to give any more information about the incident. The RN stated the resident was not hurt. 415.12(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident #17 was admitted to the facility on [DATE] with diagnoses which included Non-Alzheimer's Dementia, Psychotic Disorder with delusions due to known physiological condition, Restless and Agitation, Cerebrovascular Accident, Hemiplegia or Hemiparesis, Seizure Disorder or Epilepsy. The Quarterly Minimum Data Set (MDS) 7/15/2019 documented resident with severe cognitive impairment. On 10/16/19 at 08:58 AM, resident was observed sitting in Geri chair in room. ADL care completed by CNA, resident in no distress. On 10/16/19 at 02:58 PM, resident was observed in the dining room where live Jazz music was playing. On 10/17/19 at 10:39 AM, resident observed participating in calming exercise with recreation staff. Nursing progress note dated 10/15/2019 documented resident has periods of confusion. Received in day room on Geri chair. Care given was taken to bed. Refuse to stay in bed. Redirected as needed. Resident was taken back to day room. safety maintained. Nurse Practitioner progress note dated 10/14/2019 documented resident has been refusing meds intermittently, including his seizure medications. Also refusing blood draws for routine or STAT labs. Plan redirect and re-offer medications or blood draw. Monitor carefully to avoid triggering seizure activity. Encourage resident to get blood draw. Nursing progress note dated 10/2/2019 at 7:29 am documented resident restless during tour talking loudly and using profanities in his room and disturbing his roommate. Taken to the day room to monitor closely. Remains combative. Nursing progress note dated 9/13/2019 documented resident transfer from 4th floor refuse Dilantin on this tour for seizures saying, I do not want it I take what I want. He adjusting to new environment. Nursing progress note dated 8/23/2019 documented resident continues to refuse all medications. Activities quarterly progress noted dated 7/31/2019 documented resident alert and oriented x 2 able to make needs known. Behavioral issues. He sometimes screams at staff and other residents. When he exhibits aberrant behavior, he refuses to eat, refuses medication, refuse to come to programs and he will refuse to calm down. Doing activities with him calm him down sometimes. He engages in some activities like exercise, bingo with encouragement, group discussions, nail care, birthday parties, special events, movie social, socializing with peers and staff coffee socials. Nursing progress notes dated 6/24/2019 documented the resident began to curse using profanities while in the day room. Resident spoken to regarding inappropriate behavior. Continue to curse very loud disturbing the other residents. Remove from day room to his room to calm down. Emotional support given. Nursing progress notes dated 6/27/2019 documented refuse all pm medications except for Levetiracetam 1000 mg. will continue to monitor Nursing progress note dated 7/8/2019 documented refused evening medications. Combative during care. Comprehensive Care Plan (CCP) entitled Psychotropic Drug Use: Behavioral Problem dated effective 11/14/2018 with last monitoring note dated 10/14/2019 documented the goal is Resident will not experience symptoms of anemia as evidence by edema, cold extremities, clotting, tissue necrosis, pallor/cyanosis, etc. Interventions include; Psych consult as needed, assess effectiveness of medication, and monitor for change in behavior with medication change. Comprehensive Care Plan (CCP) entitled Dementia - Impaired Decision dated effective 11/14/2018 with last monitoring note dated 10/4/2019 documented the following interventions: evaluate pain management, offer choices between two items, Use simple words or instructions. The facility did not ensure that a resident with verbal and combative behavior had person-centered appropriate goals and interventions in the Comprehensive Care Plan. There were no documented evidence that the care plan was revised to include person-centered interventions that were effective in managing the resident behavior. On 10/18/19 at 12:47 PM an interview was conducted with the Director of Nursing (DON) for the facility. DON stated care plans are supposed to have appropriate goals, interventions and be updated at least quarterly, annually, when there are significant changes and as needed. The DON also stated the care plan needs to be person centered and have interventions tailored to the individual resident's needs. DON further stated the current care plan for the resident does not have the appropriate goals and is not tailored for a resident on psychotropic medication, adding I believe this is an error. On 10/18/19 at 11:48 AM, an interview was conducted with staff # 3,LPN. LPN stated the resident is new to unit for past month and resident had behaviors of yelling, curses, preaches about black person condition, and what it means to be black. LPN stated resident stated he knew [NAME] X, and [NAME] King. LPN stated she has a good relationship with the resident and tried to build a good rapport with him. LPN stated when he starts yelling, she goes to him and rub his back, sit next to him and listen to what he is saying, and this helps calm him down. LPN stated although resident is confused, he wants someone to listen to him. LPN added she is not responsible for care plans on the unit. On 10/18/19 at 10:40 AM, an interview was conducted with Staff #5, Registered Nurse Supervisor (RNS). RNS stated she normally works 3-11 shift and all the RNS are responsible for creating and updating care plans. RNS stated the care plan is to document if the medication is effective and make a short-term goal to monitor side effects, new behaviors or decrease in behaviors. Care plans are updated as needed if there is change in the medication. RNS stated the person-centered care plan is a care plan that is specific to the resident. It is not a generic plan, and it is not one care plan fits all, it is customizing to the patient needs. RNS stated resident has certain stimuli, people, situations upset him, and if the behavior is directed to one person, she usually asks that person to leave. RNS was unable to explain the goal listed on the Psychotropic Care Plan and gave no reason why the interventions were not customized to fit the resident needs. On 10/18/ at 11:06 AM, an interview was conducted with Staff # 4, Social Worker (SW) for unit #3. The Social Worker stated the resident talks a lot very loudly , is very angry at times, and at times you can understand him and other times you cannot. SW stated resident is angry that his daughter placed him in a nursing home, and has behaviors that include being verbally abusive with profanity, as well as being combative at times. SW stated the resident is also prone to remember the past and how he was treated. SW stated the team meets about resident behaviors and discusses ways to redirect the behaviors. SW stated the team encourages staff to explore what the issue was with resident and a lot of times just listening and giving him the attention he needs redirects the behaviors. SW stated the resident verbalized he worked all his life and he was respected in the community and wants to be respected here. Social Worker went on to state in terms of the care plan, as a SW we are doing so much here, and I wish I have the time to write it all down. SW added the job requires so much, because the resident wants personal time and I must learn to balance that in terms of implementing all that we do in the care plan. On 10/17/19 at 02:31 PM, an interview was conducted with staff # 4,CNA. CNA stated she is the CNA assigned to the resident and has a special relationship with the resident. CNA stated the resident behavior comes and goes, and at times he yells, screams profanity at the top of his voice. CNA stated she approaches resident calmly and ask resident what the problem is, and at times she whispers, talking to resident in a calm manner and resident responds and stay calm. CNA stated one of the things available to staff is they can offer resident new clothing, new socks and new shoes and this makes him comfortable. CNA stated staff usually call her to talk with the resident when he has behaviors, and he usually calms down. CNA stated she was given in-service on dealing with resident with combative behaviors and how to deal with dementia residents. CNA added once you approach resident in a in a calm voice, and calm manner and ask the resident what the problem is he usually calms down. CNA stated any behavior with the resident if she can redirect the behaviors, she does and if there is some behavior she cannot re-direct she reports to the charge nurse. 415.11(c)(1) 2) Resident #54 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia with Behavioral Disturbances, Blindness, Benign Prostatic Hyperplasia (BPH) without Lower Urinary Tract Symptoms, and Urinary Tract Infection. The Comprehensive Annual assessment dated [DATE] documented the resident with moderate independence with some difficulty in new situations only, total dependence for Activities of Daily Living (ADLs), had an indwelling catheter, and was always incontinent of bowel. Physicians orders dated 10/16/19 documented the following: catheter care Q shift, PRN and Monitor Foley catheter in place Q shift, Finasteride 5 mg tablet for BPH, and Tamsulosin 0.4 mg capsule for BPH. A review of the records revealed there was no care plan developed for Resident #54 that addressed care and management for a resident with a Foley Catheter. On 10/21/19 at 10:10 AM an interview was held with RN #1. RN #1 stated care plans are completed by unit supervisors. RN #1 stated supervisors on all shifts can work on care plans. When asked if there was a Foley Catheter care plan for the resident RN #1 stated the resident should have a care plan because he goes out for monthly catheter replacements. RN #1 stated the resident is also followed by the urologist secondary to his urinary retention. RN#1 was unable to provide documented evidence of a care plan addressing the residents Foley Catheter. Based on record reviews and staff interviews conducted during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans for residents, consistent with the resident rights that includes measurable objectives and time frames to meet residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, (1) a comprehensive care plan was not developed for a resident with a left hand contracture who was receiving range of motion exercises, (2) a comprehensive care plan was not developed for a resident with a Foley catheter, (3) a person centered care plan was not developed for a resident receiving antipsychotic medications. This was evident for 1 of 1 resident reviewed for Urinary Catheter (Resident #54), 1 of 5 residents reviewed for Limited Range of Motion (Resident #77), and 1 of 5 residents reviewed for Unnecessary Medication (Resident #17) out of 53 sampled residents. The findings are: The facility policy titled Goals and Objectives, Care Plans dated September 2018 documented care plans will incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment. The facility policy titled Comprehensive Person-Centered Care Planning dated August 2018 documented a comprehensive care plan (CCP) will be developed and implemented to meet all the needs for the resident that includes measurable objectives and timetables to meet each residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plans must always reflect the current status of the resident and should be reviewed and revised on an ongoing basis. 1) Resident #77 was admitted on [DATE] with diagnoses which included Respiratory Failure, Hypoxia, Dysphagia, Dependence on Respiratory Status and Tracheostomy Status. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident cognition is severely impaired and required extensive assistance and two persons assist with all Activities of Daily Living (ADLs). The MDS also documented the resident has limitations in upper and lower extremities. On 10/15/19 at 11:07 AM, on 10/16/19 at 12:20 PM and on 10/17/19 03:17 PM, Resident # 77 was noted to have contracture of the left hand. The Physician's Orders dated 6/27/19 documented gentle Passive Range of Motion exercises on joints of bilateral upper and lower x 10 reps one to two sets daily as tolerated. The Certified Nursing Assistant Accountability Records documented that the resident is receiving passive range of motion exercises on upper and lower extremities. Review of the comprehensive care plan on 10/17/19 at 03:17 PM, documented the Comprehensive Care Plan (CCP) was last updated on 9/30/19 and did not identify that the resident had a contracture or limited range motion in upper and lower extremities. The CCP did not document the interventions that are being implemented to prevent further contractures. On 10/21/19 at 11:26 AM, CNA # 6 stated that range of motion exercises are done during care in the mornings and afternoons. The resident requires two persons assist for ADLs. The resident receives passive range of motion exercises in all the four extremities at least twice a day. When the exercises are provided, it is documented in the CNA accountability book. On 10/21/19 at 11:50 AM, RN # 1 stated that she supervises the unit, all of the nurses, and the CNAs for the 7 AM to 3 PM shift. RN # 1 stated that she develops and revises care plans. RN # 1 stated that care plans are reviewed daily. Any time there are changes in residents 'condition, the care plans are updated. RN # 1 also stated that the resident does not have a care plan for limited range of motion and to address contractures. RN # 1 further stated it is an oversight. The resident should have a care plan to address limited range of motion and contractures. RN # 1 also said that it will be corrected right away. Currently, there is no care plan with interventions to address limited range motion and contractures. On 10/21/19 at 02:11 PM, the Director of Nursing Services stated that she supervised all of the nursing staff and managers. The DNS also stated that the RN Manager is responsible for implementing and updating care plans. Care plans should be developed and revised as needed. The DNS stated that she started auditing care plans to ensure there are appropriate goals, appropriate interventions and timeliness. This will be an ongoing process. The goal is to have 95% compliance with all care plans. DNS also stated this is a work in progress and ongoing monitoring continues,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #130 was admitted to the facility on [DATE]. Resident diagnoses included Hypertension, Multi-Resistant Organism, Sepsis due to Pseudomonas, Diabetes Mellitus, Acute Respiratory Failure, Encounter for attention to tracheostomy. The MDS dated [DATE] documented the resident is cognitively intact, requires extensive assistance for bed mobility, requires total dependence for other ADLs. Physicians orders dated 10/13/19 documented contact precautions for CRE Pseudomonas Aeruginosa in trach secretion. Comprehensive Care Plan titled Isolation Precautions dated 9/14/19 documented resident has an active infection requiring isolation precautions. Interventions included maintain isolation cart outside of residents room, maintain contact precautions, and maintain infection control practices through proper handwashing. 2) Resident #130 was admitted to the facility on [DATE]. Resident diagnoses included Hypertension, Multi-Resistant Organism, Sepsis due to Pseudomonas, Diabetes Mellitus, Acute Respiratory Failure, Encounter for attention to tracheostomy. The MDS dated [DATE] documented the resident is cognitively intact, requires extensive assistance for bed mobility, requires total dependence for other ADLs. Physicians orders dated 10/13/19 documented contact precautions for CRE Pseudomonas Aeruginosa in trach secretion. Comprehensive Care Plan titled Isolation Precautions dated 9/14/19 documented resident has an active infection requiring isolation precautions. Interventions included maintain isolation cart outside of residents room, maintain contact precautions, and maintain infection control practices through proper handwashing. On 10/15/19 at 10:12 AM a Nun providing spiritual support was observed in residents room not wearing PPE speaking to the resident at bedside. Nun was further observed exiting the room and not using alcohol-based hand sanitizer or washing hands. Sign on door reads- STOP Report to nurse before entering the room. On 10/15/19 at 10:39 AM an interview was held with the Nun. The Nun stated she comes to talk to the residents once a week. The Nun stated the staff have not told her about not entering certain residents' rooms. The Nun stated she was unaware of any residents on the unit that she had to wear PPE in their room. When asked about the sign on the resident's door the Nun stated she did not see the sign or read it. The Nun further stated she did not touch the resident so it should be ok. On 10/21/19 at 11:16 AM an interview was held with LPN #1. LPN #1 stated there are two rooms on his side of the unit that have contact precautions. LPN #1 stated he wears gloves and a mask in these room. LPN #1 stated when visitors come they are supposed to go to the nursing station and speak to the nurse before entering a residents room who is on contact precautions. LPN #1 stated when the Nuns come each week they do not ask about contact precautions. LPN #1 stated the Nuns will just enter rooms and staff will have to tell them to put on PPE. LPN #1 stated the staff have to educate the Nuns on contact precautions continuously. On 10/21/19 at 02:11 PM an interview was held with the Director of Nursing (DON). The DON stated she had not observed any of the sisters visiting, but the staff on the unit should monitor, and if they observe anyone going in they should alert then the requirements. 3) The facility did not ensure the Infection Prevention and Control Policies (IPCP) were updated and reviewed annually. The facility policy titled Infection Prevention and Control: Cleaning Communal Equipment was last reviewed August 2015. The facility policy titled Infection Control: Standard Precautions was last revised December 2016. The facility policy titled Infection Control: Staff Guidelines was last revised December 2016. The facility policy titled Infection Control: Isolation General Principles was last revised August 2015. The facility policy titled Infection Control: Contact Precautions was last revised August 2015. The facility policy titled Infection Control for Candida Auris was last revised October 2017. The facility policy titled Infection Control for Transmission Based Precautions was last revised October 2017. On 10/21/19 at 10:50 AM an interview was held with the Assistant Director of Nursing (ADON). The ADON stated she started at the facility a few months ago and is aware the policies are not up to date. The ADON stated she is working on updating the policies with the Director of Nursing. 415.19 (b) (1) Based on observations, record reviews and staff interviews during the recertification survey, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) for two residents on contact precautions, one Licensed Practical Nurse (LPN#1) and one visitor (Nun giving pastoral care) were observed entering the residents rooms not wearing proper Personal Protective Equipment (PPE). 2) The infection control policies and procedures were not updated annually. This was observed for 1 LPN and 1 visitor who entered rooms of 2 residents on contact precautions. The findings are; The State Operations Manual for Long Term Care Facilities documents Contact Precautions are intended to prevent transmission of infections that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves upon entering (i.e., before making contact with the resident or resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed, and hand hygiene is performed. The facility policy titled Infection Control: Contact Precautions last revised August 2015 documented it is the intent of this facility to use contact precautions for residents known or suspect to have serious illness easily transmitted by direct resident contact or by contact with items in the resident's environments. Contact precautions will be used in addition to standard precautions for residents with infections that can easily be transmitted by direct or indirect contact. Visitors should be kept to a minimum since they may become infected. Signs must be posted on the door to the resident's room signaling to all visitors that they must see the charge nurse before entering the room. Gloves should be worn when entering the room and while providing care for the infected resident. After glove removal hands should be washed immediately. Gowns should be worn when entering the room if it is anticipated that clothing will have substantial contact with the resident or environment. 1.) Resident #119 was admitted on [DATE] with diagnoses which includes respiratory failure with hypoxia, heart failure, dysphagia and anemia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident cognition is severely impaired and required total assistance with all Activities of Daily Living (ADLs). On 10/21/19 at 10:12 AM and at 10:31 AM, LPN #1 was observed entering resident #113 room without wearing personal protective equipment which include gown, gloves and mask. On 10/21/19 at 10:12 AM, A sign on the door was noted and it reads report to nurse before entering the room. The Physician's (MD) Orders dated 10/13/19 documented an order for contact precautions for Klebsiela PNA in urine and sputum. On10/21/19 at 10:34 AM, LPN # 1 stated that he is aware that the resident on transmission-based precautions. LPN #1 said that personal protective equipment (PPE) are not required prior to entering the room. LPN # 1 further stated that he is not supposed to wear gown, mask and gloves if he is just going into the room. LPN # 1 also stated that the resident is on contact precautions for bacteria in trach and urine. LPN # 1 further stated that he is required to wear mask and gloves only when he is providing care for the resident. On 10/21/19 at 10:57 AM, the Director of Nursing stated that all staff are expected to put on gown, gloves and mask prior to entering the rooms of resident who are transmission-based precautions. The DNS further stated that as the DNS and Infection Control Nurse, she is supposed to ensure that all staff are following infection control protocols. The DNs also stated that two months ago, she did an audit and realized that the PPEs were being kept in a separate room on the unit. The DNS stated she was the one who implemented the protocol that all PPEs should be placed outside of the resident's rooms. The DNS also stated that all staff were in serviced a few months ago about infection control policies and procedures, put it on PPEs and hand hygine. It is unacceptable for staff to enter resident's rooms who are on contact precautions without wearing gown, mask and gloves.