**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #194 was had diagnosis that include Schizophrenia, Type 2 Diabetes Mellitus, and Unspecified Cataract. The admission Minimum Data Set (MDS) dated [DATE] documented the resident was cognitively intact, required extensive assistance of 2 persons for toileting and extensive assistance of one person for dressing. There was no behavior documented. During an observation on 10/02/2023 at 11:06 AM, CNA #8 was observed pushing Resident #194 from the shower room in their rolling walker and assisting the resident back to their room down the hallway. The back of the hospital gown that Resident #194 was wearing was opened exposing their lower back and buttock while they were ambulating in the hallway on the way back to their room. Resident #194 was noted holding their clothes in their hands while they were escorted back to their room. On 10/02/23 at 12:00 PM, Resident #194 stated that staff show them respect and dignity most of the time and some staff are hard to get along with. During an interview on 10/10/2023 at 1:48 PM, CNA #8 stated that they noticed that Resident #194 was exposed. CNA #8 also stated that the is alert, they were trying to get them back to their room and there was nothing else they could do. and they wanted to get the resident back to their room and there was nothing they can do. CNA #8 further stated that they usually take two gowns with them when they take residents into the bathroom for showers. During an interview on 10/10/2023 at 12:10 PM, Licensed Practical Nurse (LPN) #2 stated that CNAs are supposed to make sure residents are fully covered when returning to their rooms after a shower. During interviews on 10/10/2023 at 12:19 PM and 12:42 PM, Registered Nurse (RN) #10 states that all parts of body should be covered when residents are being moved on the unit. RN #10 also stated that if they observe a resident is not covered, they will help CNA get more gowns and cover resident. RN#10 further stated that they do rounds on the unit every 30 minutes when they are not on occupied. 415.5(a) Based on observations and interviews conducted during the Recertification survey from 10/2/23 to 10/10/23, the facility did not ensure that two residents were cared for in a manner that maintained or enhanced his or her dignity. Specifically, 1) a resident's Foley catheter bag and tubing were left uncovered and exposed to public view, and 2) another resident was observed being transported in hallway with their back and buttocks exposed. This was evident for 2 of 2 residents reviewed for Dignity out of 38 sampled residents. (Residents #47 & #94). The findings are: 1. The facility's policy titled Foley Cather, Insertion, Removal, and Maintenance effective 09/2021 did not document the application of privacy bag for indwelling catheters to promote privacy and dignity at all times. Resident #47 was admitted with diagnoses which included Renal Insufficiency, Neurogenic Bladder, and Alzheimer's Disease. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that Resident #47 had severely impaired cognition, required dependent two person assist for most Activities of Daily Living, and used an indwelling catheter. Physician orders active as of 10/05/2023 documented the use of indwelling catheter and urinary catheter care every shift. The Comprehensive Care Plan titled Alteration in Urinary Elimination related to Catheter usage, last reviewed on 09/11/23 documented the application of privacy bag/barrier cover for drainage bag to promote privacy and dignity. On 10/02/23 at 10:48 AM, 10/03/23 at 09:37 AM, 10/04/23 at 02:30 PM, 10/05/23 at 09:51 AM, and 10/05/23 at 02:25 PM, the resident was observed lying in bed with door wide open. The Resident's Foley catheter drainage bag and catheter tubing were on the side of the bed facing the door. There was yellow urine draining into the uncovered catheter bag, and the catheter bag and tubing were visible from the hallway. On 10/05/23 at 02:28 PM, Certified Nursing Assistant (CNA) #1 was interviewed and stated that they provide ADL care for, and turn and positioning the resident every two hours. CNA #1 also stated that they work with the resident during the day and they close the room door to ensure the resident's privacy. CAN #1 further stated that when they provide catheter care they empty the drainage bag and that they were told to apply the privacy bag to the catheter bag when resident is in the wheelchair. CNA #1 stated that no one told them that the catheter bag is supposed to be covered while the resident in bed. CNA #1 also stated that they were not sure if there are any privacy bags on the unit, will check the supply room to see if there any privacy bags in the supply room, and going forward will ensure that the resident's catheter bag is covered. On 10/05/23 at 02:39 PM, Registered Nurse (RN) #1 was interviewed and stated they were on the unit on most days doing MDS assessments and was aware that Resident #47 had a Foley catheter and required total assistance with ADL care. RN #1 also stated that the catheter bags must be covered at all times and residents who use wheelchairs need to use a privacy bag. RN #1 further stated that there are privacy bags in the supply room and all CNAs were trained on catheter care and how to provide privacy and maintain residents' dignity. During an interview on 10/06/23 at 10:29 AM, RN #2 stated that they are the charge nurse for the unit and does rounds frequently on the unit to ensure all residents are safe and to ensure that the CNAs are doing what they are supposed to do. RN #2 also stated that the residents' catheter bags are supposed to be covered with a privacy bag which are available in the supply room. RN #2 further stated that all CNAs were trained on catheter care and ensuring resident's privacy and dignity, and the CNAs most likely forgot that the privacy bag must be applied. During an interview on 10/06/23 at 03:06 PM, the Director of Nursing (DON) stated that it is the facility's policy that catheter bags are covered with privacy bags. The DON also stated that all CNAs were trained on maintaining resident's dignity and privacy, and were told to apply privacy bags on catheter bags The DON further stated that there are privacy bags on every unit, and catheter bags and the tubing are supposed to be covered and are not supposed to be exposed to the public.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification survey conducted from 10/2/23 to 10/10/23, the facility did not ensure that residents were free of physical restraints. Specifically, hand mittens were not released every two hours as ordered by the physician. This was evident for 1 of 1 resident reviewed for Physical Restraints out of total sample of 38 residents. (Resident #251). The findings are: The facility's policy & procedure titled Restraints Devices and Siderails dated 11/16, last revised on 11/17 documented: Physical or chemical restraints will only be utilized after less restrictive alternatives have been attempted and considered as a last resort to treat the resident's medical symptoms. Restraints will be utilized for the least amount of time and documentation of ongoing evaluation of the need for the restraints is required. The release schedule is a minimum of every two hours for 15 minutes and as necessary. The CNA will record the restraint release schedule in the Point of Care Module of the EMR. Patients should be checked at least every two (2)hours (at time of the release of the restraints) for any evidence of adverse effects. The Restraint/Device evaluation will be completed quarterly or more frequently at a frequency determined by the resident's condition and reviewed during the CCP meeting. The interdisciplinary will focus on restraint reduction and discontinuance. The interdisciplinary Team will develop a care plan using CAA-18 Restraints for Restraint use. This care plan will be evaluated quarterly and as needed. Resident #251 was admitted to the facility with diagnoses that included Unspecified Dementia, End Stage Renal Disease, and Generalized muscle weakness. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the cognitive skills of the resident as completely impaired for daily decision making. The MDS documented that the resident was dependent on staff for all Activities of Daily Living and had functional limitations in range of motion in upper and lower extremity. In addition, physical restraints were documented as other and used daily. On 10/04/23 at 09:45 AM, Resident #251 was observed out of bed in a reclining chair with mittens applied to both hands. On 10/05/23 09:25 AM, 10:51 AM, 11:42 AM, 12:02 PM, 12:20 PM, 12:38 PM, and 2:39 PM Resident #251 was observed lying in bed with bilateral hand mittens applied. On 10/06/23 at 09:00 AM and 10:11 AM, Resident # 251 was observed with bilateral hand mittens on awaiting transportation to dialysis. On 10/10/23 at 08:50 AM, 10:50 AM, and 10:58 AM, Resident # 251 was observed in bed supine, resting comfortably. Bilateral hand mittens observed on both hands. SBAR Progress note dated 6/3/23 at 20:12 documented: Situation: Pulled out right upper chest permacath (catheter inserted into a blood vessel which allows prolonged access into the bloodstream). Physician Orders for restraints: 6/9/23 19:00 documented: Device bilateral (B/L) hand mittens to be applied for protection against permacath self-removal to be released every 2 hours for 15 minutes. The Interdisciplinary Team Restraint/Device Evaluation (Non-Siderails) dated 06/09/2023: documented that Resident #251 was given Mittens as a restraint to prevent resident from injuring self, severe dementia, and history of removal of his tunneled dialysis catheter. The evaluation also documented that resident's mental status was confused, they were non-ambulatory, and totally dependent on staff. The reason for use was documented as danger to self on Hemodialysis and repeatedly removing tunneled dialysis catheter and plan was to continue device use. There was no documented evidence that the use of restraints had been re-evaluated quarterly. On 10/10/23 at 11:00 AM, an interview was conducted with the Certified Nursing Assistant (CNA) #11) assigned to the Resident #251 who stated that Mittens are taken off for 15 minutes to 20-25minutes with feeding. CNA #11 also stated they were not sure of when mittens are to be removed but they document every two hours. CNA #11 also stated that they report to the nurse if the resident removes the mittens. If dirty, clean mittens are obtained from downstairs. CNA #11 further stated that the resident has not been seen trying to remove the dialysis catheter by them, but had been observed trying to remove their brief and play with feces when the mittens were released. On 10/10/23 at 11:30 AM an interview was conducted with the Assistant Director of Nursing (ADNS) #1 who confirmed overseeing unit 5 [NAME] where the resident is housed. The ADNS #1 stated staff is observed/spot checked and assisted with providing care twice a shift, and that mittens are supposed to be released every two hours to check the resident's skin. The ADNS #1 further stated that a re-evaluation for continued use of the mittens is completed every quarter. The ADNS viewed the resident electronic record and stated that the initial evaluation was done on 6/14/23, and the re-evaluation should have been done already. The ADNS #1 further stated that the evaluation is usually done with quarterly MDS review, and the charge nurse would fill it out. MDS staff schedules it but they do not see where it was scheduled by MDS in the computer. On 10/10/23 at 11:50 AM, the Minimum Data System Assessor (MDSA) was interviewed and stated that when completing Section P of the MDS they check for the physician order and if a restraint is implemented. The MDSA also stated that they do not know how often the re-evaluation for use is completed because it is not the MDS staff that would re-evaluate. The MDS Assessor further stated that they do not open the evaluation in the computer. In an interview conducted on 10/10/23 at 12:03 PM, the MDS Coordinator (MDSC) was interviewed regarding MDS Assessors responsibility in the process of re-evaluating for restraints. The MDSC stated that assessors visit resident on units to see if the restraint is in place but have no additional responsibility. The MDSC further stated that that they were unsure of the frequency of the restraint use re-evaluation form and that MDS staff members do not open the evaluation form in the electronic medical record. On 10/10/23 at 01:34 PM, the Director of Nursing (DON) was interviewed and stated that the facility has one resident with treatment orders for mittens due to episodic behavior that removed an access and that the hospital sent a strong request to place mittens to prevent re-hospitalizing the resident. The DON also stated that the need for restraints is re-evaluated quarterly, and the MDS department is opening the evaluation form quarterly in the electronic medical record where it's scheduled as part of the MDS assessment. The DON further stated they were not aware that this was not being done by the MDS department. 415.4 (a)(2-7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during Recertification and Complaint investigations (NY00321292), the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported to the State Survey Agency. Specifically, the facility did not report an injury of unknown origin where there the resident sustained a hematoma to right side of their head. This was evident for 1 of 3 residents reviewed for Accidents out of a sample of 38 residents. (Resident #478). The findings are: The facility policy and procedure titled Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/Exploitation and Mistreatment effective 10/2022 documented all personnel have the responsibility to report any incident or suspected incident of resident abuse including injuries of an unknown source. The facility shall conduct a thorough investigation of all alleged violations involving exploitation, mistreatment, neglect or abuse, and misappropriation of resident property and comply with state reporting regulations. All alleged violations and results of investigations shall be reported shall be reported immediately to the Administrator/DNS. To ensure that all alleged violations involving abuse, neglect, exploitation of mistreatment, including injuries of unknown source and misappropriation of result property, are reported immediately, but not later than 2 hours after the allegation is made if it involves abuse or result in serious bodily injury or not later than 24 hours if the allegation does not involve abuse and do not result in serious bodily injury. Resident #478 was admitted with diagnoses which included Non-Alzheimer's Dementia, Radiculopathy of the Lumbar and Cervical region, and Unspecified Glaucoma. The admission Minimum Data Set (MDS) assessment dated [DATE] documented that resident had severely impaired cognition and had no behavioral symptoms exhibited. The MDS also documented that Resident #478 had not exhibited any wandering behavior, required extensive assistance of 2 persons for transfer and had no impairment of upper and lower extremity. An Accident Report dated 7/29/2023 at 4:35 PM documented resident was lying on floor on right side of wheelchair and had a bump on right forehead. Oriented to person and time and confused and required extensive x1 for ambulation. The summary also documented that resident left for hospital at 5:55 PM and returned on 7/30/23 at 3:47 AM. CT of head with contrast- findings: right frontotemporal scalp hematoma, moderate atrophy, no acute territorial infarction, intracranial hemorrhage, or mass. The summary also documented no abuse, neglect, mistreatment was identified. Ice pack applied; acetaminophen given documented. The RN Supervisor Occurrence Investigative Form dated 7/29/23 documented that there was an unwitnessed occurrence and Resident #478 was not able to recall what happened. There was no documented evidence that the incident had been reported to the Department of Health in the Health Electronic Response Data System (HERDS). On 10/05/23 at 03:59 PM, Certified Nursing Assistant (CNA #10) voice mail left and no return call was received by survey exit. On 10/06/23 at 12:24 PM, the Registered Nurse Supervisor (RN) #4 was interviewed and stated that on 7/29/23 they were asked to see the resident. Resident #478 was already placed back to bed. The Nurse Practitioner (NP) was contacted for a telemedicine consultation and sent pictures of the resident's injuries as resident had a bump on head. The resident was sent out since they are on Aspirin and Nurse Practitioner (NP) recommend resident sent to hospital since it was a head strike. The resident was sent out for CT of the head. The resident was alert and oriented to person and had pain at the site of impact. The resident returned at 3AM in the morning and CT scan was unremarkable and resident monitored. The Accident and Incident (A& I) packet is reviewed by the ADNS and since it was a weekend they would see it on Monday and check if it was complete and notes entered in the electronic medical record. RN #4 also stated that if it is a reportable incident, then they contact the Assistant Director of Nursing (ADNS) and Director of Nursing (DNS) and the DNS will report right away. RN #4 further stated that they contacted the ADNS and informed them that the resident had a fall. During an interview on 10/06/23 at 01:00 PM, the Assistant Director of Nursing (ADNS) stated that the supervisor contacted them, and supervisor completed the Accident and Incident (A&I) report which they are in responsible for reviewing. The ADNS also stated that incidents reportable to the State include burns, altercation with resident to resident, resident to staff, falls to result in death and injury of unknown origin, misappropriation of property, and they did not believe the incident was a reportable incident. Resident #478 was not able to explain what happened, received care prior to the fall and they reviewed exit camera and there was no one there at the time for the fall. The ADNS further stated that they no longer had the video footage as it had been overwritten. The ADNS stated they have been trained on reporting incidents. On 10/06/23 at 01:16 PM and 2:21 PM, the Director of Nursing (DNS) was interviewed and stated that the ADNS informed them the resident had a fall and they were sent out to the hospital for a computerized tomography (CT) scan. They had an unwitnessed fall and had a raised area to right side of forehead; they had an abrasion related to fall on right side of forehead. The DON also stated that an injury of unknown origin needs to be reported. If there is any abuse, crime, injury of unknown origin should be reported within 2 hours and other incidents report within 24 hours. The DON further stated that the incident was not reportable, as they ruled out abuse neglect and mistreatment and they will ask the ADNS if there is a video available related to the incident. On 10/10/23 at 01:55 PM and 2:53PM, the Administrator was interviewed and stated they were notified that the resident had a fall and it was discussed at the morning meeting. For reporting of incidents, the DNS is in charge and if anything needs to be reported in a specific time frame they also have access. If there is any incident with an injury, suspicion of crime and call police and report to the state. They have to report within 2 hours anything with injury causing death, resident to resident and death. The resident had a negative CT scan and no injury reported for resident. An injury of unknown origin is reportable. 415.4(b)(1)(2)

Based on observation, record reviews, and staff interviews conducted during the Recertification Survey from 10/2/23 to 10/10/23, the facility did not ensure that residents were free from unnecessary antipsychotic medications. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of 38 sample residents (Resident #206). Specifically, Resident #206 was given psychotropic medication (Celexa) for resistive and aggressive behavior which was increased without documented evidence of ongoing behaviors or of any nonpharmacological interventions applied to address behavior. The findings are: The facility Policy and Procedure for Psychotropic medications created 12/13 effective 11/16 documented it is the policy of the facility to utilize psychotropic drugs appropriately for the purpose of assisting the resident in attaining and maintaining optimum and emotional functioning. Procedure: Medical provider/Psychiatrist will only order psychotropics based on a comprehensive assessment of a resident to treat a specific documented condition except in emergencies, only as an integral part of resident comprehensive care plan. Only when alternative method has been tried and failed. Never for purposes of discipline or convenience. Resident #206 was admitted with diagnoses that included Non-Alzheimer's Dementia and Depression. The Quarterly Minimum Data Set (MDS) assessments dated 05/08/2023 and 08/04/2023 documented resident had short and long-term memory impairment and severely impaired cognitive skills for decision making, and was feeling down, had trouble sleeping, feeling tired, poor appetite, trouble concentrating and moving slowly on 7-11 days for a total mood score of 12. The care plan titled resident received antipsychotic medication R/T Citalopram Hydrobromide Tab 10mg for resistive behavior created 11/06/2022 and reviewed 08/12/2023 documented a goal of resident will participate in daily activities without interference of symptoms or side effects through review period. Interventions included administer medication as per order, monitor medication response, and observe and report side effects abnormal s/s or any adverse condition. On 10/03/2023 at 9:50 AM, Resident #206 was observed eating breakfast, pureed renal diet with good appetite. Resident was verbally responsive when greeted and was not displaying any signs of resistive or aggressive behaviors. On 10/06/23 at 10:50 AM, Resident #206 was observed in bed, finishing breakfast with 100% consumed. Resident's mood was pleasant and resident displayed no behaviors. On 10/06/23 at 4:50 PM, Resident #206 was observed completing dinner with the assistance of the Certified Nursing Assistant (CNA), with calm mood, and no behaviors displayed. Psychiatry notes dated 09/17/2023 documented possible intermittent delirium, restlessness, and agitation due to GMC (general medical condition). Recommendation increase Celexa to 15mg daily to address poor self-control and resistiveness behavior. Instead of clonazepam can give Ativan 1 mg 45 minutes prior to HD (hemodialysis). Patient lacks capacity for medical or discharge decisions. Follow up 4-6weeks. Nursing, MD, or NP progress notes dated 01/11/2023 to 10/05/2023 did not document an increase of resistive and aggressive or depressed behavior by Resident #206. There was no documented evidence of ongoing resistive, aggressive, or depressed behaviors and the use of any nonpharmacological interventions applied to address behavior when dosage of medication was increased in September 2023. Review of the Dialysis Interfacility Communication Forms dated 08/02/2023 to 09/27/2023 were blank in the section designated dialysis notes to floor and contained no documented evidence that resident was displaying resistive or aggressive behavior while receiving dialysis treatment. During an interview on 10/10/23 at 12:30 PM, Certified Nursing Assistant (CNA) #7 stated that sometimes when it is time to provide care to Resident #206, they may try to grab the CNA's hand tight and try to hold on. CNA #7 also stated that if they talk to resident slowly, the resident relaxes and lets the CNA do their work. CNA #7 further stated that the had not observed Resident #206 display any depressed, aggressive, or resistive behavior. During an interview on 10/10/2023 at 12:40 PM, Registered Nurse (RN) #5 stated that sometimes Resident #206 refuses medication, has a very good appetite and is always asking for food and drink which they give to the resident. RN #5 also stated that CNAs had reported in the past that the resident can be aggressive and refuse care but when you speak to the resident calmly they are no longer aggressive. RN #5 further stated that after dialysis Resident #206 is usually much calmer. RN #5 further stated that they had not received any report that the dialysis nurse reported to nurses on unit that resident was behaving aggressively in dialysis. RN #5 stated that they had not observed aggressive or depressed behavior, and they did not know why the dosage of medication was increased as no one had explained to them why the dosage of medication had been changed. On 10/10/23 at 10:59 AM, Nurse Practitioner (NP) #1 was interviewed and stated that they responds to interim calls regarding resident concerns but was not contacted to see Resident #206 in relation to behaviors. On 10/10/23 at 11:25 AM, NP #2 interviewed and stated that Resident #206 has a diagnosis of Depression and that is the reason that the Celexa was prescribed. NP #2 also stated that they did not know why the Celexa would be increased, and they did not have documentation of any behaviors in their notes. On 10/10/23 at 01:05 PM, the Registered Nurse Supervisor (RN #6) was interviewed and stated that they think a consult was put in for Resident #206 because dialysis was reporting that resident was aggressive. RN #6 also stated that they were not sure of the date that the consult was requested. On 10/10/23 at 01:16 PM, the Medical Director (MD) #1 who is also Resident #206's Attending Physician was interviewed. MD #1 stated they increase resident's medication based on the recommendation of the Psychiatrist and the psychiatrist must have based it on what they saw at the time of evaluation. MD#1 also stated that Psychiatrist is the expert and if they believe the increase is necessary, they follow what the psychiatrist says. MD#1 further stated that they could not tell why Celexa dose was increased from 10mg to 15mg, and they had not reviewed the nursing progress notes to determine whether an increase in dosage was necessary for this resident. During an interview conducted on 10/10/23 at 01:50 PM, the Psychiatrist, (MD #2) stated the reason for the consultation was written on by the staff and they believed believe it was restlessness and agitation. MD #2 also stated that by the time they see the resident all their interventions would be pharmacological in nature, and they would not be able to say whether non-pharmacological interventions were attempted by the staff. MD #2 further stated they were responding to the staff request and Celexa can be helpful with agitation so that would be an appropriate diagnosis. MD #2 stated that they did not have a photographic memory so would not be able to tell what was going on with the resident or why nothing was documented. 415.18 (c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews conducted during the Recertification survey from 10/2/23-10/10/23, the facility did not ensure that infection control practices and procedures were maintained to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, while performing wound care for Resident #251, Registered Nurse (RN) #13 was observed not performing hand hygiene directly after removing a soiled dressing and during the dressing change did not maintain aseptic technique while cleansing the wound according to professional standards. This was evident for 1 of 5 residents reviewed for Pressure Ulcer/Injury out of a sample of 38 residents. The findings are: The facility policy and procedure titled Clean Dressing Change effective 3/16 documented that it is the policy that wounds are cared for in a safe, sanitary manner to promote healing, to protect adjacent skin surfaces from irritation from drainage, and to prevent infection. The policy also documented procedural steps for performing a dressing change which included don clean gloves, remove old dressing, deposit dressing into disposable plastic bag, observe wound, remove gloves, deposit into plastic bag, perform hand hygiene, don new clean gloves, cleanse wound maintaining aseptic technique (i.e., cleaning from inner to outer aspect), and irrigate all deep and necrotic wounds with piston syringe as ordered by the physician. Resident #251 was admitted with diagnoses that include End Stage Renal Disease. The Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #251 was severely cognitively impaired, was dependent on staff for all Activities of Daily Living, was at risk for pressure ulcer development, and had an unhealed Stage 4 sacral pressure ulcer on admission. Physician Order dated 6/9/23 documented Calcium Alginate Silver. Apply to sacrum topically every day shift for PU (pressure ulcer). Clean with NS (normal saline), cover with dressing. Physician Order dated 6/13/23 documented Santyl Ointment 250Unit/GM (collagenase) Apply to sacrum topically every day shift for S4 Pressure Ulcer/Injury. Apply to sacrum topically for removal of devitalized tissue. Clean wound first using Normal Saline. Apply ointment to wound bed, Calcium alginate, then cover with comfort foam Border or Border Foam dressing. On 10/06/23 at 09:00 AM, a wound care observation was conducted for Resident #251. Registered Nurse (RN) #13 washed their hands, applied gloves, wiped the over bed table with disinfecting wipes and then waved their gloved hand over the table for several seconds to dry the disinfectant. A paper barrier was placed on the table followed by a cardboard tray on which foam dressing packets were opened and labeled (with a marker) with date and time, and calcium Alginate dressings and gauze dressings to which Santyl Ointment was applied. RN #13 then removed gloves, washed hands with soap water, and applied a new pair of clean gloves. RN #13 informed Resident #251 that the dressing change would be performed, and with the assistance of CNA #14 positioned resident on the right side of their body. RN #13 removed the soiled dressing which contained moderate bloody and serosanguinous drainage, discarded it in the garbage bag and opened the sealed normal saline bottle without removing gloves or performing hand hygiene. RN #13 then applied clean gloves and poured normal saline solution onto the open gauze dressings and placed a barrier between the wound and the soiled brief. RN #13 cleansed the wound with the normal saline-soaked gauze in a swiping motion from the outer edge of the wound to the inner area of the wound. Santyl Ointment was then applied to all areas of the wound bed which was then covered with Calcium Alginate dressings and secured with bordered foam gauze. Soiled dressings, barriers and gloves were disposed of in the garbage bag which was then taken to the soiled utility room. RN #13 then washed hands. On 10/6/23 at 10:11 AM, an interview was conducted with RN #13 and described steps in the dressing change procedure as follows: preparation of supplies, handwashing, application of gloves, removal of old dressings, handwashing, putting new gloves on, cleansing wound with one swipe across from the outer edge to the inner area of the wound, patting the wound dry, placing Santyl on the wound, applying calcium alginate and then a dry dressing. RN #13 also stated that they thought they had removed gloves and performed hand hygiene after removing the soiled dressing and before opening the normal saline bottle. RN #13 further stated that hand hygiene should be performed, and clean gloves donned after removal of a soiled dressing. The RN was unable to describe aseptic wound cleansing technique. On 10/10/23 at 11:43 AM, an interview was conducted with the Assistant Director of Nursing (ADNS) #1 who sometimes covers for the Wound Care Coordinator. ADNS #1 stated that they observe wounds and the nursing staff that performs the dressing changes when they are on the floor. ADNS #1 also stated that hands should be washed and new gloves donned after removing soiled dressings, and wound should be cleansed in a circular motion from the center of the wound outward to the edges of the wound. On 10/13/23 at 11:57 AM, an interview was conducted with the Wound Care Coordinator (WCC) who stated that their role primarily consisted of inspecting wounds at admission, skin inspections and ensuring orders are in place. The WCC stated that they perform a wound consultation if requested but that it is the responsibility of the charge nurse to assist the staff nurses with wound care treatments and the role of the ADNS (in-service education) to ensure that the treatments are performed appropriately. On 10/10/23 at 12:08 PM, ADNS #2, the Inservice Coordinator, was interviewed and stated that they observe wound care on the units once or twice a week, complete staff competencies, education, and re-education if they observe incorrect procedures. ADNS #2 also stated that hand washing should be done when the soiled dressing is removed, the wound observed, clean gloves donned, wound cleaned from inside out, gloves removed, hands washed, treatment applied and all soiled items discarded. The ADNS #2 further stated that a competency was completed with RN #13 on 9/29/23 and that they were nervous when observed by surveyors and so did not perform wound care correctly. On 10/10/23 at 12:20 PM, an interview was conducted with the Infection Preventionist (ICP) who stated that they make observations of wound care as needed to remind staff about what needs to be done. The ICP also stated that hands should be cleaned after the soiled dressing is removed, and the wound should be cleaned from inner to outer. The ICP further stated that they make observations of staff twice a week and as needed and offer more verbal cueing if needed. The ICP also stated that whenever gloves are removed hands should be washed if a sink is available. 415.19 (b)(4)

Based on observations, record review, and staff and resident interviews conducted during the Recertification survey from 10/2/23 to 10/10/23, the facility did not ensure that notice of the availability of the survey results in areas of the facility that are prominent and accessible to the public was posted. Specifically, the survey results were in a binder placed behind the security desk outside of the second-floor nursing office. The label of the binder faced away from the reception area. There was no notice posted about the availability of results in any facility location. This was observed on 6 of 6 resident units and in the facility lobby. The findings are: During multiple building observations conducted between 10/2/23 at 9:00 AM and 10/10/23 at 2:00 PM survey results were observed in a binder in the lobby area. There were no notices observed posted on any of the resident units about where the survey results could be located. On 10/4/23 at 11:00 AM, during the Resident Council meeting, residents were asked about the location and availability of survey results. 12 of the 12 residents in attendance stated they did not know where the results were located. On 10/10/23 at 1:45 PM, the Administrator was interviewed and stated that the binder with the survey results is located near the front of the building entrance or near security. The Administrator stated that they are responsible for survey results and the binder can be made available to residents, family members or visitors when requested. The Administrator further stated that the survey results could be visualized from the reception desk so could easily be located. On 10/10/23 at 2:00 PM, an observation of the lobby are from the the security desk was made with the Administrator. The Administrator confirmed that they could not see the label on the survey results binder while standing by the side of the security desk or when passing by from the lobby to the elevators. 415.3 (d)(1)(v)