**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey from 2/25/2025 to 3/3/2025, the facility did not ensure infection prevention was maintained. This was evident for 1 (1st Floor) of 3 resident units. Specifically, Housekeeper #3 was observed in a contact/droplet precaution room without the required personal protective equipment. The findings are: On 2/26/2025 at 12:12 PM, Resident #50 and #52 were observed out of bed and in room [ROOM NUMBER] on the 1st Floor. A Enhanced Barrier Precaution sign was posted on the wall in the hallway to the left of entryway to the room. A Contact/Droplet Precaution sign was posted on the door. Housekeeper #3 was observed wearing N95 mask and mopping the floor in room [ROOM NUMBER]. Housekeeper #3 was not wearing a gown, gloves, or protective eyewear. At the time of the observation, Housekeeper #3 was interviewed and stated they received inservice from the Infection Preventionist yesterday and was told they did not have to don full personal protective equipment in rooms with certain precaution signs. The Infection Preventionist showed Housekeeper #3 a sign that was posted on another room as an example. Housekeeper #3 stated they were confused about the precautions for room [ROOM NUMBER] because there were 2 signs placed outside the room and they were unsure what personal protective equipment they should wear when entering the room. On 3/03/2025 at 12:25 PM, the Infection Preventionist was interviewed and stated Housekeeper #3 was confused by the different precaution signs outside of room [ROOM NUMBER] and made a mistake by not wearing a gown, gloves, and protective eyewear to enter the room. Resident #50 and #52 were tested and negative for COVID-19 infection but were on contact/droplet precautions due to exposure to other residents who tested positive for COVID-19. 10 NYCRR 415.19(a)(1-3)

Based on record reviews and interviews conducted during an abbreviated survey (NY00351622), the facility did not ensure timely removal of discontinued medications from the narcotic cabinet. This was evident for 1 (Resident #1) out of 3 Residents reviewed for medications. Specifically, Resident #1's Oxycodone-Acetaminophen (Percocet) tablet 5-325 mg-controlled medication was discontinued as per prescriber's order on 07/11/2024. The controlled medication remained in the medication cabinet/room and narcotic records were still available from 7/11/2024 to 8/18/2024. On 8/18/2024 Licensed Practical Nurse #10 accessed and administered the discontinued controlled medication to Resident #1 without a prescriber's order. The findings are: The facility policy titled Controlled Substances dated 08/06/2024 documented that controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed. Resident #1 had diagnoses that included Malignant Neoplasm of the Colon, Emphysema (a lung condition that causes shortness of breath), and Cardiomegaly (enlarged heart). The Quarterly Minimum Data Set (resident assessment tool) dated 07/23/2024 documented resident had intact cognition and residents' pain should be assessed. Resident had no indicators of pain or possible pain in the last 5 days. The Physician Order dated 06/11/2024 documented Oxycodone - Acetaminophen tablet 5-325 mg give 1 tablet by mouth every 6 hours as needed for moderate to severe pain scale 6-10 for 30 days with start date on 06/11/2024 and end date 07/11/2024. There was no documented evidence that the order was renewed. The 30-tablet blister pack of Oxycodone-Acetaminophen (Percocet) tablet 5-325 mg-remained in the medication cabinet/room on the unit with the narcotic record from 07/11/2024 to 08/18/2024. Review of the incident report dated 08/18/2024 documented that a Narcotic Drug - Oxycodone -Acetaminophen tablet 5-325 mg 1 tablet was administered to Resident #1 on 08/18/2024 without an order. The Conclusion of the Investigation revealed that Licensed Practical Nurse #10 took the medication and administered to Resident #1 without following the policy of checking the order before getting and administering the medication. A drug diversion investigation was conducted and was unsubstantiated. Resident #1 was assessed and there was no harm to the resident. Licensed Practical Nurse #10 was suspended pending investigation. During an interview on 10/7/2024 at 1:30PM Licensed Practical Nurse #11 stated when a narcotic is discontinued it is removed from the narcotic cabinet and the sheet is removed and it is taken down to the director of nursing's office. During a follow up interview on 10/10/2024 at 9:24 AM, the Director of Nursing stated the medication should have not been in the medication room after it was stopped (discontinued). The Director of Nursing stated the procedure is that the medication nurse should have removed from the unit, the medication, and the narcotic sheet within 24 hours from discontinuation (07/11/2024). If the discontinuation occurs on a weekend the expectation is for the medication to be in their office by Monday. The Director of Nursing stated they don't know why the process was not followed and the medication was kept on the unit until 8/18/2024. 10 NYCRR 415.18(a)

Based on record reviews and interviews conducted during an abbreviated survey (NY00351622), it was determined that the facility did not ensure residents were free from medication errors. This was evident for 1 (Residents #1) out of 3 residents reviewed for medication administration. Specifically, Licensed Practical Nurse #10 administered a Narcotic Drug Oxycodone-Acetaminophen (Percocet) tablet 5-325 mg 1 tablet to Resident #1 without an order on 08/18/2024. The findings are: The facility policy titled Administering Medications dated 4/2019 documented the individual administering medications checks the physician order/label three times to verify the right resident right medications, right dosage, right time, and right method (route) of administration before giving medication. Resident #1 had diagnoses that included Malignant Neoplasm of the Colon, Emphysema (a lung condition that causes shortness of breath), and Cardiomegaly (enlarged heart). The Quarterly Minimum Data Set (resident assessment tool) dated 07/23/2024 documented resident had intact cognition and residents' pain should be assessed. Resident had no indicators of pain or possible pain in the last 5 days. The Comprehensive Care Plan for Pain dated 04/15/2024 documented administer medication as ordered by Physician and to monitor and document for probable cause of each pain episode. The Physician Order dated 06/11/2024 documented Oxycodone - Acetaminophen tablet 5-325 mg give 1 tablet by mouth every 6 hours as needed for moderate to severe pain scale 6-10 for 30 days with start date on 06/11/2024 and end date 07/11/2024. There was no documented evidence that the order was renewed. Review of the incident report dated 08/18/2024 documented that a Narcotic Drug - Oxycodone -Acetaminophen tablet 5-325 mg 1 tablet was administered to Resident #1 on 08/18/2024 without an order. The Conclusion of Investigation revealed that Licensed Practical Nurse #10 took the medicine to Resident #1 and administered it but didn't follow the policy of checking the order before getting and administering the medication. A drug diversion investigation was conducted and was unsubstantiated. Resident #1 was assessed and there was no harm to the resident. Licensed Practical Nurse #10 was suspended pending investigation. Review of the Social Worker Progress Note dated 08/23/2024 documented that the nurse reported to the supervisor that resident was complaining of pain and without reading the order Licensed Practical Nurse #10 administered pain medication that was discontinued to Resident #1. Review of the Medication Treatment Error Report dated 08/18/2024 documented an error happened but didn't cause harm or potential for harm to the resident. Education done regarding medication administration narcotic policy. During an interview on 10/08/2024 at 8:39AM, Licensed Practical Nurse # 10 stated they were passing medications, and a Certified Nurse Aide reported to them that Resident #1 was in pain. They immediately administered Resident #1 1 tablet of Percocet without checking the order. Licensed Practical Nurse # 10 stated when they went to sign off on the Percocet in the Medication Administration Record, they realized that the medication was discontinued. They immediately reported the incident to the supervisor. During an interview on 10/08/2024 at 9:00 AM, the Director of Nursing stated Licensed Practical Nurse #10 did not follow the protocol. They were supposed to check the order before administering the medication. The medication should not have been in the medication room after it was stopped (discontinued). The procedure is to take the medication and the narcotic sheet from the unit to their office. All the nurses were in serviced after the incident. During a follow up interview on 10/10/2024 at 9:24 AM, the Director of Nursing stated the medication should not have been in the medication room, after it was stopped. The procedure is the medication nurse should remove the medication and the narcotic sheet and bring them to their office within 24 hours, and if it is the weekend the expectation is the medication should be in the office of the director of nursing by Monday. The Director of Nursing stated they don't know why the process was not followed and the medication was kept on the unit for seven days. All discontinued medications are bagged and given to the driver to bring to the pharmacy. Narcotics are kept in a lock box for destruction. 10 NYCRR 415.18(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification survey conducted from 10/12/23 to 10/20/23, the facility did not ensure that each resident had the right to make choices about aspects of their life in the facility that were significant to the resident for 1 of 3 residents (Resident #21) reviewed for choice. Specifically, Resident #21 was not provided a choice regarding whether to receive a bed bath or shower and the resident was not provided the opportunity to participate in activities they enjoyed including going to the public library. Findings include: Resident #21 had diagnoses including diabetes (uncontrolled blood sugar), generalized muscle weakness, and cervicalgia (neck pain). The Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was cognitively intact. Resident #21 required extensive assistance with 1 person for personal hygiene and was totally dependent with 1 person for bathing and required a 2 person assist for transfers. The MDS documented it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. The MDS also documented that it was very important to resident to do their favorite activities. Review of the Recreation Evaluation dated 9/28/23, revealed it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath; and it was very important to the resident to do their favorite activities. Review of computerized Point of Care (POC) documentation, completed by certified nurse aide (CNA) staff from 9/1/23-10/12/23 revealed the ADL (activities of daily living) section for Bathing did not specify the resident's preference. The documentation showed the resident was bathed daily except for 9/18/23, 9/28/23, 10/1/23, and 10/5/23. During the same time period it was noted that resident did not receive a shower on their assigned shower days. There was no documentation stating showers were offered or refused. During an observation and interview on 10/12/23 at 10:40 AM, Resident #21 stated they were waiting for staff to assist with cares. The resident was in bed, wearing a gown, and the breakfast tray was on the bedside table. The resident stated that they had not had a shower and would prefer a shower instead of a bed bath. The resident stated they would like to be more involved in physical activities, missed going to the library, and felt they were declining by living at the facility. During an interview on 10/13/23 at 10:10 AM, with the Ombudsman present, the resident stated that they enjoyed attending the library and had been doing so for many years. The resident stated that they enjoyed doing research and did not want to just get books. The Ombudsman stated that they had been working since August to find a way for the resident to continue with this activity and attempted to speak with facility to facilitate library visits. The resident stated that at a care plan meeting the facility discussed getting an iPad for the resident but nothing has happened yet. Resident #21 again stated their preference for a shower instead of a bed bath, and that they were not gotten out of bed every day. During an observation later that day, 10/13/23 at 1:37 PM, Resident #21 was still in bed wearing a gown. During an interview on 10/18/23 at 12:10 PM, the Activities Director stated when residents were admitted to the facility, an assessment was completed with their hobbies, activities, religion, etc. The information was documented and an individualized care plan was created and updated quarterly. They stated there had not been any outside trips since COVID and were attempting to arrange transportation to resume trips. They stated Resident #21 was offered an iPad and refused. When requested, they were unable to provide documentation regarding the refusal. During an interview 10/18/23 at 01:08 PM, CNA #1 stated that residents were assessed for bathing preference before they entered the facility, and they accommodated preferences throughout the day. CNA #1 stated if a resident refused or care was not done, they made a note at the end of the shift, and communicated to the nurse in charge and to the staff on next shift. During interview on 10/19/23 at 11:15 AM, Nurse Manager #2 reviewed the bathing/ shower documentation provided for September and October 2023. Nurse Manager #2 stated, that based on the documentation, it appeared the resident did not receive or was not offered a shower from 9/1/23 to 10/12/23. 415.5(b)(1,3)

Based on record review and interview conducted during the recertification abbreviated surveys (NY00322999) from 10/12/2023 to 10/20/2023, the facility did not ensure that an allegation of resident neglect was fully investigated. This was evident for one of two residents (Resident #372 ) reviewed for abuse. Specifically, when it was alleged that Resident #372 was left in a chair for two shifts, including over night, the facility did not conduct a thorough investigation to rule out neglect and did not report the allegation to the New York State Department of Health (NYSDOH). The findings are: A review of the facility Policy & Procedure titled Abuse, Neglect, Exploitation or Misappropriation-reporting and Investigation dated 10/2022, documents all reports of resident abuse, neglect, exploitation are reported to local, state, and federal agencies as required by current regulations, and thoroughly investigate by facility management. Findings of all investigations are documented and reported. Resident #372 had diagnoses including metabolic encephalopathy, malignant neoplasm (cancer) of the mouth, and diabetes (uncontrolled blood sugar). The Minimum Data Set (MDS an assessment tool) dated 7/23/2023, documented the resident had severely impaired cognition, and required extensive assistance with all activities of daily living. During an interview on 10/18/23 at 10:21 AM, Resident #372's family member stated they visited the resident on 8/11/23 and when they left at 3 PM the resident was in the wheelchair. When they returned the next morning the resident was in the same position and in the same clothes as the day before. They stated they spoke to the Registered Nurse Unit Manager (RNUM) #1 that morning about the resident being left in the chair all night from 8/11/2023-8/12/2023. RNUM #1 told them that they would investigate and find out what happened. On 10/18/23, a review of facility records and Resident #372's record for the time period from 8/10/2023-8/15/2023 revealed: - No documentation in the facility morning report minutes of any incidents with Resident #372. - No documented evidence in the resident's progress notes for behavioral issues or difficulty sleeping. - The Certified Nurse Aid Tasks in the resident's electronic medical record was blank for the 3 PM to 11 PM shift on 8/11/23 and for the 11 PM to 7 AM shift for 8/11-8/12/23. There was no evidence care was provided that included bathing, bed mobility, barrier cream after incontinent episodes, bladder and bowel continence, personal hygiene, skin observation, toilet use, and transfers. - The resident's Care Plan documented the resident was at risk for potential abuse and neglect related to cognitive impairment and dependence on others for activities of daily living. Interventions included investigating all allegations of abuse neglect promptly, providing support and ensuring the resident was free from abuse and neglect. On 10/19/23 at 11:58 AM during an interview, RNUM #1 stated they remembered speaking with the family member who told him the resident had been left in the wheelchair all night. RNUM #1 stated they investigated the concern with the night shift staff and the staff said the resident kept trying to get out of bed and they were concerned about the resident's safety, so they kept the resident out of bed. RNUM #1 stated they did not document the concern or get back to the family, but they did discuss it in morning report and the Director of Nursing (DON) was there. They stated, in hindsight, it could have been considered an accusation of abuse, neglect, or mistreatment. On 10/19/23 at 12:35 PM during an interview, the Director of Nursing (DON) stated they were unaware of the allegation and if it had been brought to their attention, it would have been investigated and reported it to the NYSDOH. 415.4(b)(1)

Based on interview and record review conducted during the recent recertification survey, the facility did not ensure for 1 of 2 residents (#61) reviewed for hospitalization that the resident or resident's representative were notified in writing of transfer/discharge to the hospital, including the effective date of transfer, location of transfer, and reason for transfer. The findings include: Resident #61 had diagnoses including anemia, hypertension, and schizophrenia. The annual Minimum Data Set (MDS: an assessment tool) dated 8/22/2023 documented the residents' cognition was moderately impaired for decision making. The nursing progress notes dated 10/11/2023 - 10/13/2023 documented that Resident #61 had a very abnormal Hemoglobin of 5, the resident's medical doctor was called and ordered for the resident to go to the hospital in the morning on the day shift for a transfusion. On 10/12/2023 at 8:36am Resident #61's Hemoglobin was 5.7, their medical doctor had ordered the resident to be sent to the hospital for blood transfusion; the hospital emergency room received status report, Health Care Proxy was aware of transfer, Emergency Medical Services arrived, and Resident #61 was transferred to the emergency room via ambulance. On 10/13/2023 at 2:54PMthe facility staff nurse called the hospital emergency staff, and resident had been admitted with diagnosis anemia. There was no documented evidence in the resident's clinical record that the resident or the resident's representative, had been provided with a written notice of the transfer/discharge. In an interview on 10/18/23 at 10:36 AM Resident #61 stated they did not believe they had received a written notice of the transfer/discharge. Resident #61 stated that their nephew was their designated representative. In an interview on 10/19/23 at 9:02 AM the Social Work Director (SWD) was asked if written notification of Resident #61's transfer/discharge had been provided to the resident or the residents' representative. At that time, the SWD produced a discharge/transfer notice dated 10/12/2023 which indicated that a staff social worker had notified the resident's nephew of the transfer via phone, and the staff social worker had signed the notice. There was no evidence provided to suggest that the bed hold policy had been mailed to the resident or their representative, i.e., no return receipt was found with the transfer/discharge notice. When asked what the correct process was for notification of transfer and discharge, the SWD stated that they should have spoken with the resident, if the resident was not available, they should have spoken with the next available contact, the conversation should have been documented in the chart, and a letter should have been sent out to the resident or responsible party immediately after the phone notification. In an interview on 10/20/23 at 9:05 AM the Administrator stated that they were aware that the social worker was reaching out to families regarding discharge, transfer, and bed hold, but they were not aware that the social worker had not been providing /sending written notification to residents or their responsible party. 10 NYCRR 415.3(i)(1)

Based on interview and record review conducted during the recertification survey from 10/12/23 to 10/20/23, the facility did not ensure that to the extent practicable, each resident was offered the opportunity to participate in their plan of care, or that an explanation was included in a resident's medical record if the participation of the resident and their resident representative was determined not practicable for the development of the resident's care plan for 2 (Residents #46 and #39) of 3 residents reviewed for care planning. Specifically, Residents #46 and #39 expressed interest in attending care planning meetings and reported they had not been invited. The findings are: 1) Resident #46 was admitted with diagnoses including hemiplegia and hemiparesis, psychosis, and Diabetes Mellitus. The Annual Minimum Data Set (MDS: a screening tool) dated 8/17/2023 documented that the resident had moderate cognitive impairment for decision making, usually understands verbal content, and was usually understood. The resident was interviewed on 10/13/23 at 10:29 AM and stated they did not go to the care planning meetings, but it sounded interesting. The resident stated they did not recall being invited to care planning meetings. The Social Work progress note dated 9/7/2023 documented the Interdisciplinary Care Plan (IDCP) meeting had been held that day and the resident's daughter was in attendance at the meeting via phone. There was no documented evidence that Resident #46 had been invited to the care planning meeting, and no explanation was documented in the resident's medical record indicating if the participation of the resident was determined not practicable for the development of the resident's care plan. During an interview on 10/19/2023 at about 9:40 AM the Social Work Director (SWD) reviewed the record with surveyor and stated that the resident's daughter attended care planning on 9/7/2023. There was no documentation found that the resident was invited to attend CCP, or that their attendance at the meeting was not practicable. The SWD stated that the process was that the Social Worker or SWD would speak with the resident and ask if they would like to attend CCP, and if the resident said yes to the invitation, they would inform the resident of the date and time of the meeting. The SWD offered no explanation as to why the Resident #46 had not been invited to care planning meetings. 2) Resident #39 was admitted with diagnoses traumatic subdural hemorrhage, aphasia following other cerebrovascular disease, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The annual Minimum Data Set (MDS: an assessment tool) dated 7/7/2023 documented cognitive skills for decision making were severely impaired, hearing was adequate, they had an absence of spoken words, rarely or never made themselves understood, rarely understands verbal content, and sees adequately without corrective lenses. Section F, preferences for customary routine and activities were checked yes to indicate that an interview of the resident should be conducted, and daily preferences and activity preferences were documented. Resident #39's care plan dated 7/13/2023 documented that the resident had aphasia, was non-verbal, could answer direct yes/no questions by nodding their head, they sometimes understood, and were sometimes understood. The resident was interviewed on 10/13/23 at 11:43 AM and when asked if they had been invited to attend care planning meetings, they nodded their head no. When asked if they would like to attend care planning meetings, the resident nodded their head yes. A social work progress note dated 10/18/2023 documented that IDCP had been held on that day, and the resident's fiancé was in attendance. There was no documented evidence found that the resident had been invited to the care planning meeting, and no explanation was documented in the residents' medical record indicating if the participation of the resident was determined not practicable for the development of the resident's care plan. During an interview on 10/19/23 at 9:50 AM the Social Work Director (SWD) reviewed the record with surveyor and stated that the resident's fiancé had attended the care planning meeting on 10/18/2023 via telephone. The SWD offered no explanation as to why Resident #39 had not been invited to care planning meetings. 10NYCRR 415.11(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey from 10/12/23 to 10/20/23, the facility did not ensure all residents were provided the necessary care and services for 1 of 3 residents (Resident #39) reviewed for activities of daily living (ADL). Specifically, Resident #39, who had a diagnosis of aphasia (a loss of ability to understand or express speech, caused by brain damage), was not assessed and treatment was not provided to enable the resident to communicate with others more normally including speech and/or other functional communication systems. The findings are: Resident #39 was admitted with diagnoses including traumatic subdural hemorrhage (brain bleed), aphasia following other cerebrovascular disease, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The annual Minimum Data Set (MDS: an assessment tool) dated 7/7/2023 documented cognitive skills for decision making were severely impaired, hearing was adequate, they had an absence of spoken words, rarely or never made themselves understood, rarely understands verbal content, and sees adequately without corrective lenses. Section F, preferences for customary routine and activities were checked yes to indicate that an interview of the resident should be conducted, and daily preferences and activity preferences were documented. Active diagnoses included aphasia, hemiparesis, or hemiplegia. Speech therapy (ST) was last provided 3/30/2023 - 4/19/2023. Occupational therapy (OT) was last provided 3/31/2023 - 4/25/2023, and physical therapy (PT) was last provided 3/29/2023 - 4/21/2023. Resident #39's care plan dated 6/23/2023 documented the resident had a communication problem related to a cardiovascular accident as evidenced by aphasia. The goal was the resident would improve communication function. Interventions included OT/PT/Nurse to evaluate resident ability/dexterity to use communication board, writing, use computer, or use of sign language as alternate communication to speech, and to refer to speech therapy for evaluation and treatment as ordered. A policy and procedure dated 10/2022 and titled Speech Therapy Level III documented the purpose of the procedure was to identify, assess, and treat speech and language problems. General guidelines documented the speech therapist works with other rehabilitation and medical professionals and families to provide a comprehensive evaluation and treatment program for residents with aphasia, anomia (word finding), dysarthria (muscles of the lips, tongue and other body parts used for speech are weaker than normal), and apraxia (a disorder of the nervous system that affects the ability to sequence and say sounds, syllables, and words. Speech therapy treatments included working on drills and exercises to improve specific language skills affected by damage to the brain, using a communication board, exercise of speech muscles, and teaching the resident to make use of gestures and writing to express ideas. Resident #39's care [NAME] (instructions for direct care staff) dated 10/19/2023, documented to use alternative communication techniques as needed, such as communication book/board, writing pad, gestures, signs, and pictures. During an observation and interview conducted on 10/12/23 at 10:34 AM, Resident #39 communicated by shaking their head to indicate yes and no to questions about eating and verbalizing, and their response was accurate when responding yes that they did not eat by mouth, and inaccurate when responding they could verbalize. No functional communication systems were observed. During an observation on 10/13/23 at 11:51 AM, 2 small dry erase white boards were observed on a bedside table. No dry erase markers or eraser were observed. Resident #39 was asked if they communicated with the dry erase boards and indicated no with a head shake. During an observation on 10/19/23 at 12:26 PM, 2 small dry erase boards stored in a plastic bag without a dry erase marker or eraser were observed on an overbed table located behind the resident. At that time, the resident was out of bed in their wheelchair with their back was to the overbed table and dry erase boards. A small picture board with the words I want and pictures was also observed on the overbed table located behind the resident. In an interview on 10/19/23 at 11:52 AM the Speech Language Pathologist (SLP) Therapist responsible for evaluation of speech for Resident #39 stated the last time they evaluated and treated the resident was 3/30 - 4/19/23 for swallowing related to dysphagia, and that they did not document anything about resident #39's communication at that time. The SLP stated that they have not specifically evaluated Resident #39 for communication. The SLP stated they were aware of the resident's communication deficits. The SLP stated that they could have done a more thorough communication exam or evaluation to determine if a picture board would be utilized more to communicate the residents' wants. In an interview on 10/19/23 at 12:31 PM, the certified nurse aide (CNA) #6 stated that Resident #39 communicated with them by nodding their head and communicating with their eyes. CNA #6 stated that they had seen a dry erase board, but no dry erase pen or eraser in the resident's room. CNA #6 stated that they had not seen an I want communication board in the resident's room when they provided care to the resident that morning. CNA #6 stated they were not told how the resident communicated or about the dry erase board or an I want board. In an interview on 10/19/23 at 12:51 PM CNA #7 stated they communicated with Resident #39 by verbalizing to them, the resident was able to understand, and the resident responded with shaking their head. CNA #7 stated the resident did not communicate with them in any other way. CNA #7 stated that they had not received any information from nursing about how to communicate with the resident. 10NYCRR 415.12(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, during a recertification survey from 10/12/23-10/20/23, the facility did not ensure the resident environment remained free of accident hazards to prevent accidents for 1 (Resident #28) of 6 residents reviewed for accidents. Specifically, Resident #28, who was assessed as needing a bed rail to promote independence, had the rail removed and when they awoke from a nap and reached for the rail, they fell and sustained a fractured (broken) shoulder and blunt head trauma. The findings are: Resident #28 had diagnoses which include atrial fibrillation, spinal stenosis, hypertension. The annual Minimum Data Set (MDS), an assessment tool, dated 7/16/23, documented the resident had a Brief Interview for Mental Status (BIMS) of 15/15 indicating they were cognitively intact. The resident required extensive assistance of two persons for bed mobility and transfers and extensive assistance for dressing. The resident's care plan for falls dated 4/20/2016, and updated 7/11/23 after a fall, documented the resident was at risk for falls and had interventions which included anticipating the resident's needs, and to re-educate to use the call bell for assistance. The physician orders dated 7/20/22 document ½ side rails up to both sides of bed for bed mobility and transfer participation. A side rail/grab bar review dated 7/25/23, documented the resident had demonstrated poor bed mobility and difficulty moving to a sitting position on the side of bed. The recommendation was bilateral half side rails were indicated and served as an enabler to promote independence. The Accident/Incident report dated 9/21/23 documented at 4:45 PM the resident was found on the floor next to their bed bleeding from the right side of their head. The resident stated they were trying to sit up on side of the bed and fell off bed. The box on the A/I for side rails up was not checked. The September 2023 Treatment Administration Record (TAR) documented ½ side rails up to both sides of the bed, check placement every shift, for bed mobility and transfer participation. The TAR was last signed for the ½ rails on 9/21/23 for the 7 AM to 3 PM shift. The TAR documented the resident was hospitalized [DATE] for the 3-11 PM shift. Further review of the resident's medical record revealed no documented evidence that an assessment was performed to see if the resident could safely position themselves on the side of the bed without the enabler side rail, prior to the removal. There was no documentation the resident and/or their representative received education about side rail removal. During an interview with Resident #28 and the resident's family member on 10/12/23 at 10:28 AM and 3:29 PM, both stated the side rails had been on the resident's bed for a very long time but were removed abruptly three weeks ago. The Resident stated they awoke from a nap and went reach for the rail to pull themselves up, the rail was not there, and they fell out of bed. The resident's family member stated they visited the facility every day and no one told them the rails were going to be removed. During an interview on 10/18/23 at 11:34AM, the Registered Nurse Unit Manager (RNUM) stated the facility received a letter from the State regarding side rail usage and side rails were removed. They stated all of the residents were assessed before putting rails in place but there were no plans for assessment before they were removed. RNUM#2 stated they did not provide education for staff, residents, or residents family members prior to removing the side rails. RNUM #2 stated there was a lot of confusion when the letter came out, so the facility just removed the rails without first having plans in place. During an interview on 10/20/23 at 9:23 AM, Certified Nurse Aide (CNA) #1 stated they took care of Resident #28 many times and knew the resident well. The resident was able to help staff by grabbing the rail when they were being positioned or having the bed changed. The rail gave the resident support, and they used it while they were in bed. CNA #1 stated the rails were removed on a lot of the residents' beds, there was no education or reminders to be extra cautious with the residents. During an interview on 10/19/23 at 12:24PM, the Director of Nursing (DON) stated they were at the scene on the day Resident #28 fell and the resident did not have rails on the bed. The DON stated they were not aware the resident was assessed to need the rails as an enabler, and they did not know there was a physician order for the rails. During an interview on 10/19/23 at 1:18 PM, the Administrator stated they were not aware that Resident #28 was assessed to have a need for side rails and had a physician order, but the rails were removed anyway. The Administrator stated they were unaware that assessments were not done prior to removing side rails. 10NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during the recent recertification survey, the facility did not ensure that emergency equipment was readily available for 1 of 2 residents (Resident #35) screened for respiratory care. Specifically, a resident with a tracheostomy did not have an Ambu bag (a hand-held device that provides positive pressure to residents who are not breathing) at the bedside. The findings are: Resident #35 was admitted with a diagnosis of traumatic brain injury and tracheostomy status. The resident's orders included Oxygen at 8L/min, humidification 50% via trach mask continuously every shift for respiratory care. The annual MDS dated [DATE] documented the resident was comatose, had diagnoses including respiratory failure and a tracheostomy, and received oxygen and tracheostomy care. The resident's care plan dated 11/11/2016, and revised 7/3/2023, documented the resident had tube out procedures which included keeping an extra trach tube and obturator at bedside. If tube cannot be reinserted, monitor /document for signs of respiratory distress. If able to breathe spontaneously, elevate head of bed 45 degrees and stay with resident. Obtain medical help immediately. A policy and procedure dated 12/2/2022 and titled Tracheostomy Medical Emergencies documented: Tube Occlusion: .use an Ambu bag to ventilate, Decannulation: maintain tracheal airway and ventilation with bag tracheostomy mask as best as is possible, and If the patient is not ventilating adequately, close stoma and ventilate with bag and face mask with 100% O2 until CODE team arrives. During an observation on 10/13/23 at 9:25 AM no Ambu bag was observed at bedside. An observation and interview were conducted in the residents' room on 10/13/23 at 9:35 AM with the Licensed Practical Nurse (LPN) #4 in attendance. LPN #4 was asked to show surveyor where the Ambu bag was kept. LPN #4 proceeded to check the room storage areas and stated there was no Ambu bag. When asked what the process for ensuring the Ambu bag was accessible in the room, LPN #4 stated they would find out. During an observation on 10/16/23 at 5:55 PM no Ambu bag was observed at bedside. During an interview on 10/16/2023 at 5:58 PM, LPN #5 was asked what equipment was needed in case of a respiratory emergency for Resident #35, and they responded that they would need the suction machine, the inner cannula, and a suction catheter kit. When asked if they would need an Ambu bag for the resident in the case of a respiratory emergency, LPN #5 stated there was an Ambu bag in the dining room. In an interview on 10/19/23 at 8:50 AM the Respiratory Therapist (RT #1) stated emergency equipment that should always be in the resident's room included an oxygen tank, an Ambu bag, and a spare, smaller size trach than the one the resident has. 10NYCRR 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations,interviews and record review conducted during an abbreviated survey (NY00309932) the facility failed to provide adequate supervision/monitoring/ assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed. Specifically, Resident #1 fell forward out of their wheelchair while they were been transported by a Certified Nurse Aide (CNA#1) to their room. Resident #1 sustained a close fracture of the nasal bone and a contusion of the head. The resident's feet was not positioned on the footrest during transport. Findings include: Resident #1 was admitted on [DATE] with diagnoses including Vascular Dementia, Congestive Heart Failure and Essential Hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented no Brief Interview for Mental Status (BIMS) score as the resident had severe cognitive impairment. The resident required total and extensive care for Activities of Daily Living (ADLs), including one-person physical assistance for locomotion on and off unit with a wheelchair. Resident was dependent on staff when in wheelchair to move from place to place. The comprehensive care plan (CCP) created 05/04/2022 documented that the resident requires assist with activities of daily living related to dementia. Interventions included to encourage resident to fully participate and encourage the use of call bell system for assistance. Review of security footage dated 01/14/2023 at 20:21:18 PM, Certified Nurse Aide (CNA #1) is seen pushing Resident #1 down the hall in their wheelchair. Resident #1 was seen shuffling their feet while the chair was being pushed by CNA#1. At 20:21:24 Resident #1's foot looked tangled behind the other foot and Resident #1 fell forward out of the chair to the floor face first. Resident #1's feet were not observed on the wheelchair footrest during transport. Facility incident report dated 1/14/2023 at 8:30 PM documented Resident #1 suddenly without warning put feet down on floor during active transport in wheelchair resident put their feet down on floor while wheelchair was in motion causing them to fall forward from wheelchair. Writer observed Resident #1 lying face down on the floor on their left side. Minimal bleeding noted to the nose and small break in skin at the forehead. Neuro checks initiated. Resident #1 was transferred to hospital for further evaluation. Resident #1 sustained nasal fracture because of fall however care plan was followed. Video surveillance reviewed by DON and Administrator. No environmental factors noted, no change in plan or obstructions noted in environment. No abuse, neglect or mistreatment suspected. The 1/15/23 at 2:15 PM hospital discharge record documented the resident discharge diagnosis as closed fracture of nasal bone and contusion of head. An Interview was conducted with CNA#2 on 3/15/2023 at 11:17 AM. CNA #2 stated they were following behind CNA #1 on 1/15/2023 as they transported Resident #1 to their room in a wheelchair. CNA #2 stated Resident #1 was moving their feet while CNA #1 was pushing the chair and it looked like Resident #1's foot stopped or got stuck and they fell forward out the chair. CNA #2 stated they immediately called for the nurse who came and did a head-to-toe assessment. CNA #2 stated they could not recall if CNA #1 ensured Resident #1's feet on the foot pedals but stated there were foot pedals on the residents' chair. An interview was conducted with CNA #1. on 05/25/2023 at 1:20 PM. CNA #1 stated Resident #1's wheelchair had foot pedals while they were pushing them. CNA #1 stated they believe Resident #1 moved their feet off the foot pedals during transport causing them to fall forward. CNA #1 stated they did not notice Resident #1 had removed their feet off the foot pedals otherwise they would have stopped to put them back on the pedals. During an interview conducted with the Director of Nursing (DON), on 05/25/2023 at 2:00 PM, the DON stated staff are trained on utilizing assistive devices such as ensuring breaks and foot pedals are utilized when necessary. DON stated after a review of the surveillance cameras, Resident #1 had foot pedals on their chair. DON stated Resident #1 took their feet off the pedals and the aide was unaware causing the resident to fall out the chair. DON could not tell by looking at the video if CNA #1 ensured Resident #1's feet were properly placed on the foot pedals prior to moving the resident. 415.12(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F657 Based on record review and interview conducted during a recertification survey, it cannot be ensured that the facility reviewed and revised Comprehensive Care Plans with measurable objectives, timeframes and appropriate interventions for 1 of 1 residents (#44) reviewed for prevention of further decline and/or potential restoration of urinary continence to the extent possible. The findings are: Resident #44 was admitted to the facility on [DATE] with diagnoses including Fracture, Alzheimer's Disease, and Hypertension. The 2/3/2020 Annual and 8/26/2020 Quarterly Minimum Data Set Assessment (MDS) indicated that Resident #44 had severe cognitive impairment, required supervision for toileting and had occasional incontinence of bladder. The 11/19/2019 Bowel and Bladder evaluation indicated that Resident #44 is continent of bladder. The 07/23/2020 Bowel and Bladder evaluation indicated that Resident #44 is incontinent of bladder. The 08/26/2020 Bowel and Bladder evaluation indicated resident #44 is continent of bladder. The Patient-Centered Care Plan dated 2/8/2018 and titled Resident has Potential for Bladder Incontinence Related to Disease Process, Impaired Mobility, Medication Side Effects, But Resident is Mostly Continent had a goal for the resident to be continent at all times, through the review date. The plan notes interventions including to notify nursing if incontinent during activities, ensure unobstructed path to the bathroom and the resident is to inform staff of toileting needs on the overnight shift. The care plan did not show interventions to promote continence/and or prevent further decline in continence. An interview was conducted on 10/2/2020 at 10:18AM with the Registered Nurse Unit Manager (RNUM #1) where she indicated that she thought the resident knew when she had to go to the bathroom. She stated she had not updated the bladder incontinence care plan to include individualized interventions to restore bladder function and/or to prevent further urinary function decline. An interview was conducted on 10/2/2020 at 11:15AM with Certified Nursing Assistant (CNA #3). She indicated that the resident was incontinent of urine at times. She indicated the resident wets the protective undergarments and the floor. CNA #3 also stated that sometimes Resident #44 knows when she needs to be toileted. She stated that the resident is not currently on a toileting schedule. 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F686 Based on observation, interview and record review conducted during a recertification survey, it could not be ensured that the facility reviewed 1 of 4 residents (#23) for pressure ulcer or provided the appropriate care to promote healing of an existing pressure ulcer and prevent further pressure ulcers. Specifically, bilateral heel booties were not applied at all times as per physician orders. The findings are: Resident #23 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Hip Fracture, Anemia one stage 4 pressure ulcer, one stage 3 pressure ulcer and three unstageable wounds. Review of the Medicare MDS dated [DATE] showed that Resident #23 had a stage 1 and two unstageable pressure ulcers. Review of the Physician's Orders dated 5/4/2020 indicated that heel booties are to be worn at all times, every shift for Deep Tissue Injuries (DTIs) on both heels. The Significant Change Minimum Data Set assessment (MDS) dated [DATE] indicated that Resident #23 had severely impaired cognition, received extensive total assist of 2 staff for bed mobility, transfers, toileting needs, had no functional limitation of upper or lower extremities and had multiple pressure ulcers. The Quarterly MDS dated [DATE] indicated that Resident #23 had severely impaired cognition received extensive total assist of 2 staff, had no functional limitation of upper or lower extremities and had one stage 3 pressure ulcer not present upon admission. The wound assessment record dated 9/28/2020 showed that the right heel stage 3 pressure ulcer measured 3.0 x 1.0 x 0.3. The current Care Plan addressing the treatment and prevention of pressure sores included the application of heel booties at all times, assistance with turning and positioning every 2 hours, more often as needed or requested and to apply treatments as ordered. The current Treatment Administration record (TAR) indicated heel booties to be worn at all times for DITs on both heels. During observations on 9/28/2020 at 10:28AM, Resident #23 was lying in bed on her back. On 9/29/20 at 9:15AM, Resident #23 was observed sitting in her wheel chair with both lower extremities resting on a calf board. On 10/1/20 at 8:52AM, Resident #23 was observed lying in bed on her left side. On 10/1/20 at 9:50AM Resident #23 was observed during a wound dressing change. At no time was Resident #23 observed to have the heel booties applied to her bilateral lower extremities as directed. During an interview on 10/1/2020 at 9:41AM with Certified Nursing Assistant (CNA #1), he stated that he had taken a bootie off the resident before breakfast just after 8AM. When asked if the resident was supposed to wear bilateral heel booties, CNA #1 stated he is new to floor and was unsure. During interview on 10/1/2020 at 9:50AM with LPN #1, she stated that Resident #23 should wear bilateral heel booties at all times. She further stated that she thought the CNAs had applied the bilateral heel booties but did not always check. During interview on 10/1/2020 at 9:55AM with CNA #2, she stated that the resident mostly used only 1 heel bootie. When asked if and when the resident should wear heel booties CNA #2 stated she was not sure. 415.12(c)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F690 Based on interview and record review conducted during a recertification survey, it could not be ensured that the facility provided the necessary care to promote and maintain bladder continency to the extent possible for 1 of 1 residents (#44) reviewed for urinary incontinence. Specifically, the type of urinary incontinence was not identified and a Patient-Centered Care Plan, based on the type of incontinence and maintenance versus restorative goals and interventions, was not developed. The findings are: Resident #44 was admitted to the facility on [DATE] with diagnoses including Fracture, Alzheimer's Disease, and Hypertension. The 2/3/2020 Annual Minimum Data Set (MDS; a resident assessment and screening tool) indicated that Resident #44 had severe cognitive impairment, required supervision for toileting needs and was occasionally incontinent of urine (defined in MDS as less than 7 episodes of incontinence weekly). The 8/26/2020 Quarterly MDS indicated that Resident #44 had severe cognitive impairment, occasionally incontinent of bladder and received as needed pain medications for rare complaint of mild pain. Resident #44 displayed no maladaptive behaviors, had no functional limitations in range of motion, required supervision with bed mobility and limited assist with transfers, toilet needs, personal hygiene, and ambulation. The Care Area Assessment Summary (CAAS) section of this MDS noted that the resident's urinary incontinence required further assessment. The 7/23/2020 Bowel and Bladder evaluation indicated that Resident #44 was incontinent of bladder and had no recent change in continence status. The subsequent 8/26/2020 Bowel and Bladder evaluation indicated Resident #44 was continent of bladder. There was no documented evidence in the resident's record as to why the resident was incontinent of urine or what type of incontinence the resident experienced. The Patient-Centered Care Plan dated 2/8/2018 and titled, Resident has Potential for Bladder Incontinence Related to Disease Process, Impaired Mobility, Medication Side Effects, But Resident is Mostly Continent had a goal for the resident to be continent at all times through review date. The interventions include to notify nursing if incontinent during activities, ensure unobstructed path to the bathroom, the resident is to inform staff of toileting needs on the overnight shift. The care plan did not contain interventions to promote continence/and or prevent further decline in continence. The Certified Nursing Assistant (CNA) resident task record indicated that the resident was to be toileted every shift with limited assist of 1 staff for support. The Certified Nursing Assistant (CNA) Accountability Record for the previous 30 days from the date of the survey was reviewed and showed episodes of incontinence on the following dates: 9/1, 9/5, 9/10, 9/14, 9/15, 9/20, 9/22, 9/24, 9/27, and 9/30. The review further revealed no documentation of bladder activity on the 11PM - 7AM shift on the following dates: 9/2, 9/3, 9/4, 9/8, 9/12, 9/13, 9/15, 9/16, and 9/28. The 3PM - 11PM shift had no documentation of bladder activity on the following dates 9/19, 9/20, and 9/27. The 7AM - 3PM shift had no bladder activity documentation on the following dates: 9/18 and 9/21. Observation on 10/1/2020 at 9:33AM revealed Resident #44 urinated on the bathroom floor in her room. An interview was conducted on 10/1/2020 at 9:33AM with the unit housekeeping staff. She stated that Resident #44 urinates on the floor often. She stated the staff know and are keeping an eye on the resident. An interview was conducted on 10/2/2020 at 10:18AM with the Registered Nurse Unit Manager (RNUM #1). She indicated that Resident #44 wears protective undergarments, goes to bathroom and if the protective undergarment is wet, the resident takes the it off and throws it away. She thought the resident knew when she had to use the bathroom. After checking the resident's record, she indicated that she could not locate documentation to indicate the physician was updated on the resident's incontinence status or the cause of incontinence. She stated she had not updated the Bladder Incontinence Care Plan to include individualized interventions for Resident #44. An interview was conducted on 10/2/2020 at 11:15AM with Certified Nursing Assistant (CNA #3). She indicated that the resident was incontinent of urine at times. She indicated that Resident #44 wets the protective undergarment and the floor. CNA #3 also noted that Resident #44 sometimes knows when she needs to be toileted. CNA #3 further stated that the resident is not on a toileting schedule. 415.12(d)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F695 Based on observation, record review and interview conducted during a recertification survey, it cannot be ensured that the facility provided care consistent with professional standards for 1 of 4 (Resident #35) reviewed for respiratory care. Specifically, for Resident #35, the facility did not ensure the Physician's Order for the prescribed oxygen administration was followed. The findings are: Resident #35 was re-admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Asthma, and Coronary Artery Disease. The 6/19/2020 Significant Change MDS (Minimum Data Set Assessment) indicated that Resident #35 had severe cognitive impairment and had received 7 days of antidiuretic therapy. The Comprehensive Care Plan (CCP) dated 8/2/2018 and titled, Altered Respiratory Status Related to Asthma documented a 3/3/2020 intervention that states if oxygen saturation (SPO2) is below 92%, apply oxygen (O2) at 2 liters per minute (LPM). The CCP dated 8/19/20 titled Resident Will Be Monitored for Shortness of Breath (SOB) and Desaturation Related to Asthma and as Needed (PRN) Oxygen Use had an intervention to monitor SPO2 and administer O2 as per physician's order. Review of the Physician's Orders dated 8/19/2020 showed that SP02 is to be monitored every shift and if it is less than 92%, oxygen is to be applied at 2LPM. The Treatment Administration Records (TARs) dated 9/1/2020-9/30/2020 and 10/1/2020-10/2/2020 7:00AM - 3:00PM, 3:00PM - 11:00PM, and 11:00PM - 7:00AM shifts documented staff initials indicating SP02 monitoring every shift and if less than or equal to 92%, apply oxygen at 2LPM via nasal cannula every shift for desaturation. The Weights and Vitals Summary record dated 9/21/2020-10/2/2020 indicated that on 9/28/2020, SPO2 was 96% on oxygen via nasal cannula. During an observation on 09/28/20 at 11:00AM Resident #35's 02 concentration machine displayed that the flow rate was set to 2LPM. The Weights and Vitals Summary record dated 9/21/2020-10/2/2020 indicated that on 9/29/2020 SPO2 was 95% on room air and oxygen via nasal cannula. During an observation on 9/29/20 at 08:41AM and again at 9:30AM, Resident #35's 02 concentration machine displayed that the flow rate was set at 2.5LPM. The Weights and Vitals Summary record dated 9/21/2020-10/2/2020 indicated that on 10/2/2020 SP02 was 94% on room air. During observation on 10/2/2020 at 9:00AM, Resident #35's 02 concentration machine displayed that the flow rate was set at 2LPM. During an interview on 10/2/2020 at 10:05AM with Licensed Practical Nurse (LPN #1), she stated that she had not yet checked Resident #35's SP02 this shift. When asked why Resident #35 was using O2 for an SP02 above 92%, she stated that Resident #35 would like to use the oxygen and can make simple needs known. She stated she should have let the Nurse Manager or Physician know that the resident is requesting to use 02. During an interview on 10/2/2020 at 10:10AM with the Registered Nurse Unit Manager (RNUM #1), she stated that the resident should not use 02 unless the SPO2 is lower than 92%. 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pressure Ulcer/Injury F880 Based on observation, interview, and record review conducted during a recertification survey, it could not be ensured that facility staff followed proper hand hygiene during wound care treatment for 1 of 4 residents (Resident #23) reviewed for pressure ulcers. The findings are: Resident #23 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Hip Fracture and Anemia. The Significant Change Minimum Data Set (MDS; a resident assessment tool) dated 5/16/2020 revealed that the resident has severely impaired cognition and multiple pressure ulcers. The Quarterly MDS dated [DATE] indicated that Resident #23 had severely impaired cognition and one stage 3 pressure ulcer. The current Pressure Ulcer Care Plan was initiated on 6/16/2020 to address the right heel pressure wound. Review of the 10/1/2020 Physician's Orders showed an order for Betadine solution 10% apply to right heel topically one time daily for ulcer to right heel. Cleanse with normal saline, pat dry and wipe with betadine solution. A dressing observation was conducted on 10/1/2020 at 9:50AM. During the wound care, the Licensed Practical Nurse (LPN #1) washed her hands, donned gloves and removed the dressing from the right heel. Without doffing the gloves and performing hand hygiene, LPN #1 proceeded to clean the right heel wound with normal saline, pat dry, apply betadine 10% and apply a clean dressing. LPN #1 was interviewed on 10/1/2020 at 10:00AM, following the wound care observation and stated that she was nervous and thought she had washed her hands after removing the soiled dressing. 415.19(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during a recertification survey the facility did not ensure a person-centered comprehensive care plan was developed and/or implemented to meet the resident's medical, physical, mental and psychosocial needs. Specifically, 1) a care plan was not developed for 1 of 3 residents (#53) reviewed for range of motion (ROM), and 2) the care plan was not implemented as per physician's orders for 1 of 4 residents (#35) reviewed for respiratory care. The findings are: 1. Resident #53 was admitted to the facility on [DATE] with diagnoses including Stroke, Fracture, and Non-Alzheimer's Dementia. The admission Minimum Data Set Assessment (MDS) dated [DATE] and Quarterly MDS dated [DATE] indicated that Resident #53 had cognitive impairment, received extensive assist by 2 staff for bed mobility, transfers, eating and toilet use. Furthermore, Resident #53 had an impairment on one side upper extremity, no lower extremity impairment and received occupational as well as physical therapies. Care Plans reviewed revealed there were no care plans in place to address the upper extremity impairment for resident #53. The 7/24/2020 Physician's Orders indicated Range of Motion (ROM) exercise to the right upper extremity. Interview on 10/2/20 at 12:15PM with the Registered Nurse Unit Manager (RNUM #2), she indicated she was responsible for development of care plans to address the limited range of motion care area. After checking the resident medical record she indicated a limited range of motion care plan had not been developed. The September 2020 Certified Nursing Assistant (CNA) task record indicated for Resident #53 to weight bear as tolerated on the right wrist and hand. Range of motion (ROM) is permitted on the right upper extremity (RUE). 2. Resident #35 was re-admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Asthma and Coronary Artery Disease. The 6/19/20 Significant Change and 8/18/2020 MDS indicated that Resident #35 had severe cognitive impairment. Review of the 8/19/2020 Physician Orders indicated Oxygen saturation (SPO2) every shift. If SP02 is measured to be less than 92%, apply oxygen (O2) at 2 liters per minute (LPM). The 8/2/2018 Care Plan titled, Altered Respiratory Status Related to Asthma had a 3/3/2020 intervention for the use of O2 at 2LPM via nasal cannula (n/c) if SPO2 less than 92%. The 8/19/2020 Care Plan titled, Resident Will Be Monitored for Shortness of Breath (SOB) and Desaturation related to asthma and as needed (PRN) oxygen use had an intervention for monitoring SPO2 and administration of O2 as per MD order. Review of the Treatment Administration Record (TAR) indicated that staff are to check SP02 every shift. If the SPO2 is less than/equal to 92%, apply O2 at 2LPM via N/C. Documentation on 9/29/2020 and 10/2/2020 indicated oxygen via N/C at 2LPM was administered with an oxygen saturation above 92%. Observation on 9/29/20 at 08:41AM, 12:00PM and 2:30PM and 10/2/20 at 10:00AM revealed resident #35 receiving oxygen via n/c at 2LPM. During an interview on 10/2/20 at 10:05AM with Licensed Practical Nurse (LPN #1), she stated she had not yet checked the resident O2 sat this tour. When asked why the resident was using O2 for a sat above 92% she stated the resident would like to use the oxygen and can make simple needs known. She stated she should have let the nurse manager or physician know that the resident is requesting to use oxygen have the order changed. During an interview on 10/2/20 at 10:10AM with the Registered Nurse Unit Manager (RNUM #1), she stated the resident should not use oxygen unless the O2 saturation is lower than 92%. She further stated she continues to educate the nurses on the importance of checking physician's orders. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F919 Based on observation, record review and interview conducted during a recertification survey, it could not be ensured that the facility maintained the resident call bell system in proper working order. Specifically, the call bell system on the 1st floor was unable to be heard clearly at the nurses' station when the call bells were activated from residents' rooms. Findings are: Review of the facility's Policy and Procedure for Call Bell System dated 10/2019 indicated that a system can be accessed on each unit. Items identified for correction will be entered onto TELS (Maintenance Management Program) so it can be identified and fixed. During observation on 10/2/2020 at 9:55am and 10:08am on the 1st floor, the call bell was activated in rooms [ROOM NUMBERS] by staff and could not be heard clearly in all areas of the nurse's station. Subsequently, the Director of Maintenance activated the call bell in room [ROOM NUMBER]A, and could not be heard clearly in all areas of the nurse's station. During surveyor interview with the Director of Maintenance at 10:10am, he indicated that the call bell usually rings louder. He further explained that the facility does not conduct any preventive maintenance on the call bells. He stated that if the call [NAME] malfunction, the company is contacted. He explained that he will contact the company to initiate repair of the call bells. Interview with the LPN 10:12am and 10:28am indicated that the auditory indicator of the call bell system cannot be heard clearly. She explained that that she usually uses the lights to identify when a resident activates the call bell. She further indicated that if she is on one side of the unit she can't hear or see if a resident on other side has activated the bell until she returns to the nurse's station or walks down to that side of the hall. 415.29