**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the recertification survey from 09/16/2024 to 09/23/2024, the facility did not ensure a resident right to self-determination was honored. This was evident for 1 of 3 Residents (Resident #69) investigated for Abuse out of a total sample of 35 Residents. Specifically, Certified Nursing Assistant repeatedly attempted to render care to Resident #69 despite Resident #69 refusing care. The findings are: The facility's policy titled, Resident Rights Policy and Procedures last reviewed 6/11/2024 documented this facility is committed to assuring the rights and protection of its residents as stipulated under Federal and State Laws. Resident's rights include but are not limited to the following: Treated with respect, dignity and self-determination with care. Quarterly Minimum Data Set, dated [DATE] documents that Resident #69 is cognitively intact with a BIMS score of 15. Resident is dependent with all activities of daily living care and transfers including bed mobility. Resident is frequently incontinent of urine and bowel. Resident has active diagnosis of Aphasia, Cerebral Vascular Accident and Hemiplegia. On 09/19/24 at 11:16 AM, Resident #69 who is nonverbal was interviewed and communicated to surveyor through use of an I pad, eye movements and hand gestures. Resident #69 typed into I-Pad that Certified Nursing Assistant #9 came in to the room at 4AM waking resident up from sleep. The Certified Nursing Assistant #9 turned on the lights and did not introduce themslves. Resident #69 states they were not familiar with the Certified Nursing Assistant #9. Resident #69 was motioning with their hands for Certified Nursing Assistant #9 to leave because resident did not want care at that time. The Certified Nursing Assistant #9 attempted to move the table by the residents bedside to give care, but Resident #69 held onto the table because they did not want it to be moved. Certified Nursing Assistant #9 also attempted to pull down Resident #69 bed sheet to change residents' diaper despite Resident #69 motioning no with their hands that they didn't want care. Resident #69 typed into iPad that CNA was still trying to change me and was trying to pull down the bed sheet despite Resident #69 waving no with their hands and motioning for Certified Nursing Assistant #9 to leave. On 09/20/24 at 08:26 AM, the Certified Nursing Assistant #9 was interviewed and stated that Resident #69 was observed to be sleeping when they entered the room, turned on the lights and attempted to give care. Certified Nursing Assistant #9 stated that when Resident #69 heard Certified Nursing Assistant #9 in the room then Resident #69 woke up from sleep and opened their eyes. Certified Nursing Assistant #9 stated that they said Good morning and I am going to give care but Resident #69 did not respond and was unaware Resident #69 did not speak. Certified Nursing Assistant #9 did not review Residents' chart before entering room and was not aware that Resident #69 was nonverbal. Certified Nursing Assistant #9 stated they went to Resident #69 bedside and attempted to move the table which was by the resident's bedside which had a cup of water in it. However, Resident #69 held on to the table which caused water in the cup to be spilled. Certified Nursing Assistant #9 stated, I started to give care and she kept pushing my hands. Certified Nursing Assistant #9 tried to pull down the bed sheet to start care, but Resident #69 kept pushing Certified Nursing Assistant #9 hands away at which time Certified Nursing Assistant #9 left the room and reported it to the Licensed Practical Nurse #2 on shift. On 09/20/24 at 08:52 AM, Licensed Practical Nurse #2 was interviewed and stated that they were notified by Certified Nursing Assistant #9 that Resident #69 was refusing their diaper to be changed. Then Licensed Practical Nurse #2 went back into the room with Certified Nursing Assistant #9. Licensed Practical Nurse #2 states they asked Resident #69 why they were refusing care and Resident #69 typed into iPad that they didn't want to be changed. Licensed Practical Nurse # 2 then informed supervisor that Resident #69 refused to be changed. On 09/20/24 at 11:52 AM, the Director of Nursing Service was interviewed and stated that residents can refuse care, but it is the staff's jobs to make sure residents are tidy. If a resident refuses care, the Certified Nursing Assistants are educated to back away, reapproach and inform nurse immediately. Then the nurse will go back to resident and approach them softly. If a resident refuses care, then staff are to back away and get family and doctor involved. Every staff is given information on resident's care and CNA accountability should be reviewed by Certified Nursing Assistants before they enter a resident's room to see what care the resident should be receiving. CNA accountability will also reflect how a resident communicates. 10 NYCRR 415.5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Recertification survey from 9/16/2024 to 9/23/2024, the facility did not ensure that a Comprehensive Care Plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan related to Communication: vision/hearing, was not revised based on a resident's need for a hearing aid. This was evident for 1 (Resident #207) of 3 residents reviewed for Communication' vision/hearing, out of 38 total sampled residents. The findings are: The facility's policy titled Comprehensive Care Plan, last reviewed 2/12/24, documented that each resident's comprehensive care plan shall be reviewed and updated by the interdisciplinary team as per the Minimum Data Set 3.0 schedule, quarterly, annually, significant change in condition, and if the resident's condition warrants it. Resident admitted to the facility with diagnoses that include Depression and Anxiety Disorder. On 09/16/24 at 10:58 AM, Resident #207 was interviewed and stated to the state surveyor to come closer and speak louder since Resident #207 does not hear well. Resident admitted to the facility with diagnoses that include Depression and Anxiety Disorder. The quarterly Minimum Data Set, dated [DATE] documented that resident's cognition was intact, adequate hearing, no behaviors and that resident and family participated in assessment and goal setting. A Physician's Orders dated 7/27/24 documented Audiology consult, hard of hearing, possible hearing aid. A Physician's Orders dated 8/20/24 documented Audiology consult appointment on 08/23/24 at 11:00am. A nursing note dated 7/17/24 documented that resident's family stated that they spoke with Resident #207 and noticed that hearing is more impaired and requested audiology consult. A nursing note dated 8/23/23 documented Resident #207 left the unit at 10:15AM for an audiology appointment due to hard of hearing. Audiology findings included sensorineural hearing loss with recommendations for hearing aid use to bilateral ears recommended. A Comprehensive Care Plan Titled Communication, etiology Dementia, effective 10/25/23, documented Resident #207 has a potential for alteration in communication. Goals included that Resident #207 will continue to communicate their needs with a review date of 10/22/24. Interventions included that the staff will speak slowly and clearly. A quarterly note dated 8/4/24 documented resident has no change in communication, able to verbalize needs, goals and interventions in place, plan of care continues x 90 days. There was no documented evidence that the Comprehensive Care Plan had been reviewed and revised to reflect resident's hard of hearing and the need for a hearing aid. On 09/19/24, at 11:16 AM, Certified Nursing Assistant #3 was interviewed and stated that the Resident #207 needs assistance and encouragement for activities of daily living. Certified Nursing Assistant #3 stated that Resident #207 has a hearing problem, and that Resident #207 went out last month (August) to the audiologist. Certified Nursing Assistant #3 said that Resident #207 does hear a little and that they talk loudly to Resident #207. On 09/20/24 at 10:38 AM Registered Nurse Supervisor #3 was interviewed and stated that Resident #207 is alert with periods of confusion and that when they try to speak with Resident #207, they speak closer and slower because of Resident #207 being hard of hearing. Registered Nurse Supervisor #3 stated that the doctor was notified of Resident #207 needs of the hearing aid. The Registered Nurse Supervisor #3 also stated that the communications care plan should have been updated to reflect Resident's #207 hearing loss, once they identified and saw that there was an actual hearing impairment. The Registered Nurse Supervisor #3 stated that the care plans are updated quarterly and annual, and when there is an actual change in the resident's condition. On 09/20/24 at 11:55 AM, the Assistant Director of Nursing was interviewed and stated that if the Resident #207 had gone to the Audiologist and was identified as hard of hearing, then the facility should have updated the care plan, to reflect that Resident #207 was hard of hearing. The Assistant Director of Nursing stated to the state surveyor that both the state surveyor and the Assistant Director of Nursing looked at Resident's #207 Communication care plan, and this was not addressed. On 09/23/24 at 12:22 PM, Director of Nursing was interviewed and stated that once the Registered Nurse Supervisor had identified that Resident #207 was hard of hearing, then the communications care plan should have been updated to reflect this. 10 NYCRR 415.11(c)(2) (i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that residents receive proper treatment and assistive devices to maintain hearing abilities. Specifically, Resident #160 was observed on several occasions the hearing aid in place. This was evident for 1 (Resident #160 ) of 2 residents reviewed for Communication and Hearing Care Area. The finding is: The facility policy and procedure dated, 01/05/24 titled, Hearing Impaired and Care of, documented, 'It is the policy of the facility staff will assist hearing impaired residents maintain effective communication with clinicians, caregivers and other residents. Resident #160 has diagnoses including but not limited to Hearing Loss, Hypertension and Cerebral Vascular Accident. The Quarterly Minimum Data 3.0 Assessment Reference Date of 08/08/24 documented the resident was admitted on [DATE], with minimal hearing difficulty, hearing aid appliance in use, clear speech, usually understood, usually understands with a brief interview of mental status score of 7. The Physician's Monthly Order dated 08/22/24 documented, apply Right hearing aid in AM when resident is awake and remove at every night. Review of the Nurse admission assessment dated [DATE] documented, under Prosthesis, Hearing Aid, and Minimal Difficulty. The Comprehensive Care Plan (CCP) dated 08/05/24 developed for Communication, documented, Use of Hearing Aids, as per MD order. Apply Right Hearing Aid in AM when resident is awake and remove every night. Review of the Resident Nursing Instructions, dated 01/05/24, for the Certified Nurse Aide documented, Apply Right Hearing Aid in AM when resident is awake and remove every night. On 09/17/24 at 12:40 PM no Hearing Aid was observed to the Right ear of the resident, while in the dining room having lunch. On 09/19/24 at 11:40 AM no Hearing Aid was observed on the Right ear of the resident while in the corridor sitting in their wheelchair. Attempted Interview with the resident on 09/19/24 at 11:49 AM made repeated statements, I can't hear, I have trouble hearing. The resident was gesturing with their hands and pointing to their ears, then talked about their arthritis. The assigned Certified Nurse Aide # 1 was interviewed on 09/19/24 12:00 PM in the room of the resident and stated, that the resident refuses the use of the hearing aide. The CNA # 1 retrieved a container which contained the Hearing Aid and stated that they are not sure if the Hearing Aide is functioning. Stated that this was reported by them to the nurses on the unit about a month ago. The resident was wheeled from the corridor back to their room and the Certified Nurse attempted to apply the Hearing Aid to the Right ear of the resident. The resident did not refuse nor attempt to remove the Hearing Aid at this time. The Certified Nurse Aide when asked about having received training on the application of a Hearing Aid, stated, Yes. On 09/20/24 at 11:15 AM the resident was observed sitting in the wheelchair along the corridor outside of the Day Room with a Right ear Hearing Aid. Resulting interview with the resident noted their response when asked if they were able to hear the State Agency talking to them. The resident responded said, Yes. On 09/19/24 at 12:10 PM Registered Nurse Unit Manager # 1 was interviewed and stated, I have not recalled having been made aware of issues with the resident and the Hearing Aid by staff. They stated I might have gotten a call from the residents son about needing to get batteries for the Hearing Aid. No follow up by Nurse Managers # 1 was made. Nurse Manager # 1 stated, I perform frequent rounds and observe residents and staff to ensure devices are in place as per medical orders. 415.12(3)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews during the re-certification survey, the facility did not ensure that the residents' environment was maintained in a safe, sanitary, and comfortable manner. Specifically multiple observations were made of resident equipment layered with dirt and dust, room furniture heavily worn and torn seat cushion, room walls with streaks and stains, ice machines covered with rust stains, floor corners embedded with grime and dirt, base of dining room tables heavily worn and rust stains, nurse station area floor and walls layered with dirt and dust and entangled loose wires, torn or stained privacy curtains. This was evident for 3 of 7 units. (Units: 3, 4 and 6). The findings are: The facility policy titled, Homelike Environment, dated 06/18/24 documented, It is the policy of the facility to ensure that all residents live in an environment that is clean and neat with appropriate furnishings and in good repair. Upon the initial entrance to the facility on [DATE] at approximately 9:00 AM and subsequent observations during the recertification survey the following environmental issues were observed: A) 3rd floor: 1. Patient Toilet room located across the Day Room with the right sided over the toilet seat handle bar cracked and broken. Stained and dirty bathroom wall tiles. 2. Rusty Ice Machine located in the Day Room. Rusty Ice Machine brackets 3. Dirty and dusty base of blood pressure machines. 4. Dirty and dusty base of thermometer stand. 5. 6 dining room tables base and stand heavily worn and rusty. 6. Uneven and wobbly dining room tables. 7. Air conditioners in dining room layered with dust and dirt. 8. Floor corners in dining room area embedded with dirt and debris. 9. Corridor resident scale layered with dirt and dust. B) 4th floor: Dining Room: 1. 2 of 2 air conditioners layered with dust and dirt. 2. 1 of 2 air conditioners with broken slats and exposing the filter. 3. Floor corners embedded with ground in dirt and debris 4. Wall tiles underneath sink stained and dirty Dining room door with chipped and falling orange paint. 1. room [ROOM NUMBER] a: rusty and heavily worn base to tray table. 2. Room chair with torn cracked seating. 3. Torn wall paper. 4. Bedside two drawer bedside table heavily worn and heavily stained with built in dirt and grime. C) room [ROOM NUMBER] P: 1. Loose cable wires over the inside room door. 2. Bedside two drawer bedside table heavily worn and heavily stained with built in dirt and grime. D) room [ROOM NUMBER] b: 1. Torn mesh privacy curtains. 2. Air conditioner layered in dust and dirt. 3. Rusty base to tray table heavily. 4. Floor corners embedded with dirt and debris. E.) Base of blood pressure stand and thermometer stand layered with accumulation of dirt and dust. F.) room [ROOM NUMBER] a: 1. Cracked and dirty tiles under room sink. 2. Torn wall paper. 3. Loose cable wires at base of room end table. 4. Bedside two drawer bedside table heavily worn and heavily stained with built in dirt and grime. G.) 6th Floor: 1. room [ROOM NUMBER]b: ground in dirt on floors and corners of floors. 2. Stained dirty walls by air conditioner H.) room [ROOM NUMBER]a: 1. Walls stained and streaked. 2. Floor accumulation of dirt and dust. On 09/23/24 at 10:32 AM the 4th floor Housekeeper #1 was interviewed and stated, that they have a daily routine for completion of their assigned tasks. They sweep, mop and use the buffer machine on their assigned floors, including wiping down walls, resident equipment and dining room tables if they need cleaning. As a routine they clean all room and corridor floors. However, the dining room tables are cleaned by the nursing staff. If I notice that walls are stained or dirty I will wipe them down. The nursing station is swept and mopped if the area not occupied by the nurses. If I notice that there is an area that needs repair I will notify the maintenance department. If the privacy curtains need to be replaced I first notify my supervisor before a replacement is done. On 09/23/24 at 11:12 AM 3rd floor Housekeeper #2 was interviewed and state they report on their daily routine for cleaning their assigned units. We also have a Bathroom [NAME] who is responsible for the cleaning of the toilet bowls and replenishing paper towels. If there is a maintenance problem I will let the unit nurse know and they submit an email to the department. The nurses station gets cleaned, but it is usually busy with the nursing staff and hard to get to at times. On 09/23/24 at 12:27 PM the Housekeeping Supervisor was interviewed and stated, that their role included overseeing the Housekeeping staff to ensure that their daily assigned tasks are being done. Daily rounds are made to ensure the environment is kept clean for the residents. My staff are to be dusting high and low areas, like the bedframes and the top of overhead light fixtures. I check for dust, garbage overflow in rooms and corridors. Every month the privacy curtains are automatically changed and immediately of soiled. The nurses station is swept and spot mopped if no one is sitting at the nurses station. The IV poles and feeding pumps and blood pressure machines and scales are to be wiped and cleaned. I sometimes wipe them clean myself if I see that it is needed and speak to the staff as well. Interview with the Director of Housekeeping and Maintenance Department on 09/23/24 at 01:00 PM stated that their role is to oversee the Housekeeping and Maintenance Departments to ensure that residents and staff have a clean and safe environment. I make daily rounds to ensure staff are keeping up and completing their work assignments. I speak to residents and staff from time to time about any environmental concerns they may have. We have an electronic software system in place that the nurses have access to and submit environmental concerns. I check the software system several times a day. When I make my rounds I observe for cleanliness and safety of rooms, corridors, bathrooms, common areas and dining rooms. I am responsible for the safety of the entire facility. If there are issues that I have come across when making my rounds. I will talk to my staff to correct the problem. The nurses station is difficult to clean at times because the nurses are busy at the nurses station. Floors 3, 4 , 5 and 7 have no cable access. We have only antennas therefore the TV wires in the room are extended as close to the window as possible. I have a plan to repair or replace the Lobby floor tiles. It is a big job and needs to be done mostly at night. I have a plan to fix this and we just recently just patched it up. On 09/23/24 at 01:47 PM the Administrator was interviewed and stated that proposals are being made for concealing the TV wiring in resident rooms. We are slowly replacing or upgrading air conditioners and tray tables. There is plan to continue to repaint and repair areas of concern and will continue to keep the residents environment safe clean and homelike. 10NYCRR 415.5(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, during the re-certification survey, the facility did not ensure the resident and staff physical environment was kept safe and clean. Specifically, 1.) Nurse Station 2.) Lobby Restrooms and Floor Tiles 3.) Staff Bathroom. This was evident in the Lobby area including 3 of 7 units. ( Units 3, 4 and 6). The findings are: The facility policy and procedure titled, Homelike Environment, dated 06/18/24 documented, The facility respectfully acknowledges that all residents are entitled to living in an environment that is like a homelike setting. Upon the initial entrance to the facility on [DATE] at approximately 9:00 AM and subsequent observations during the recertification survey the following environmental issues were observed: A) Lobby Area: 1. Broken floor tiles along the corridor. B) Lobby Rest Rooms: 1. Rest Room located across the out of order sign noted with unidentifiable offensive odor emitting from the bathroom. 2. Sink not firmly affixed to the wall. 3. Toilet seat loose. 4. Toilet paper dispenser broken. 5. Corners of floors embedded with dirt and dust. 6. Rest Room located across the Storage Room noted with broken toilet tank cover. C) 3rd Floor: 1. Employee Rest Room located across from the Nurse Station noted with a hole underneath the sink area surrounding the pipe running through it. D) 3rd Floor Nurse Station: 1. Accumulation of layered dirt dust and heavy debris underneath nurse desk. 2. Exposed cable wires layered with dirt dust and debris. 3. Walls behind nurse chairs with heavily streaked and stained. E) 4th Floor: 1. Employee Rest Room located across from the Nurse Station noted missing cold water faucet handle. 2. Floor tiles layered with ground in dirt dust and debris. 3. Ceramic wall tiles heavily stained and dirty. F) 4th Floor: 1. Nurse Station: a) Accumulation of layered dirt dust and heavy debris underneath nurse desk. b) Exposed cable wires layered with dirt dust and debris. c) Walls behind nurse chairs with heavily streaked and stained. G.) 6th Floor: 1. Nurse station area accumulation of dirt, dust and debris underneath the nurse desk area. 2. Accumulation of dirt and dust to the bundle of entangled wires located underneath the Nurse Station. On 09/23/24 at 01:00 PM the Director of Housekeeping and Maintenance Departments was interviewed and stated that their role is to oversee the Housekeeping and Maintenance Departments to ensure that residents and staff have a clean and safe environment. I make daily rounds to ensure staff are keeping up and completing their work assignments. I speak to resident and staff from time to time about any environmental concerns they may have. We have an electronic software system in place that the nurses have access to and submit environmental concerns. I check the software system several times a day. When I make my rounds observe for cleanliness and safety of rooms, corridors, bathrooms, common areas, dining rooms. I am responsible for the safety of the entire facility. There are issues that I have come across when making my rounds. I will talk to my staff to correct the problem. The nurse station is difficult to clean at times because the nurses are busy at the nurse station. Floors 3, 4 , 5 and 7 have no cable access. We have only antennas which need to be close to the window, therefore the TV wires in the room are extended as close to the window as possible. I have a plan to repair or replace the Lobby floor tiles. It is a big job and needs to be done mostly at night. I have a plan to fix this and we just recently just patched it up. 10NYCRR 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the Recertification Survey conducted from 6/27/22 to 7/5/22, the facility did not ensure a resident was provided with the necessary services to carry out activities of daily living (ADL). This was evident for 1 (Resident #143) of 2 residents reviewed for ADLs. Specifically, there were multiple observations of Resident #143 with long uncut toenails. The findings are: The facility policy titled ADLs last reviewed 2/28/2022 documented residents' needs are met in a timely manner and the Certified Nursing Assistant (CNA) provides care and assistance in accordance with nursing instructions. Resident # 143 had diagnoses of acute osteomyelitis and neuralgia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident # 143 had mild cognitive impairment, did not reject care, and required extensive assistance of 1 person to perform personal hygiene. On 06/27/22 at 11:25 AM, Resident # 143 was observed with toenails on both feet extending a half inch in length from the tip of the toes. Resident # 143 was interviewed and stated their toenails had not been cut for more than 2 months, they require staff assistance with cutting their toenails, and would like their toenails to be cut more frequently. On 06/28/22 at 09:48 AM, 06/29/22 at 10:36 AM, 06/30/22 at 10:59 AM, and 07/01/22 at 10:01 AM, Resident # 143 was observed with uncut toenails. The Comprehensive Care Plan (CCP) related to ADL's: Personal Hygiene initiated 11/08/2021 and last revised 5/16/2022 documented to keep Resident #143's nails trim and to have Podiatry consults as ordered by the Medical Doctor (MD). The Podiatry consult documented Resident #143 was last evaluated by the Podiatrist on 4/27/2022. The Podiatry consult schedules for May 2022 and June 2022 did not document Resident # 143 was scheduled to see the Podiatrist. On 06/30/22 at 11:43 AM CNA #2 was interviewed and stated Resident #143 required extensive assistance of 1 person for personal hygiene and grooming. CNA #2 checks the toenails of residents on their assignment to see if they grow beyond the tip of the toe and informs the nurse so that a Podiatry consult can be ordered. Resident #143 was observed with long toenails a few weeks ago and CNA #2 informed Registered Nurse #3 but a Podiatrist did not come to see Resident #143. On 07/01/22 at 10:51 AM, RN #3 was interviewed and stated they were not aware Resident #143's toenails were long and uncut and could not recall staff reporting that Resident #143 needed a Podiatry consult. RN #3 observed Resident #143's toenails and stated Resident #143 needed to be referred to the Podiatrist. On 06/30/22 at 11:29 AM, RN #4 was interviewed and stated they make rounds at least twice a day and checking a resident's toenails is part of the rounds. RN #4 did not notice that Resident #143's toenails were long and was not informed by staff that Resident #143 needed a Podiatry referral. Resident #143 was last seen by the Podiatrist approximately 2 months ago. After observing Resident #143's toenails, RN #4 stated Resident #143 had long toenails and a Podiatry consult needed to be ordered. On 07/01/22 at 09:20 AM, the MDS Coordinator (MDSC) was interviewed and stated a resident's toenails were considered long if they grew beyond the tip of the toes. The Podiatrist visits the facility once a week to address consults. The CNA is responsible for reporting long toenails to the RN so a Podiatry consult can be ordered. 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the re-certification survey, the facility did not ensure that each resident was treated with dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life. Specifically, a resident was observed wearing oversized soiled and tattered sneakers with no socks. This was evident for one (1) of one (1) resident reviewed for Dignity (Resident # 1). The finding is: The facility policy for Resident Funds - Personal Shopping dated 08/2019, documented that, The facility must ensure that all residents' personal needs are met and that their rights and dignity are respected. If a resident lacks capacity and has family .involved in his/her care, the family should be encouraged to make purchases for the resident directly. Resident #1 was admitted on [DATE] with diagnoses which included Alzheimer's Dementia. The Quarterly Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 09/10/19, documented that the resident had clear speech and was sometimes understood and sometimes understands. The resident had a brief interview mental status score of 3 out of 15, indicating severely impaired cognition. No rejection of care behaviors were identified. The resident required supervision to limited staff assistance for activities of daily living needs. On 09/17/19 at 1:08 PM, the resident was observed sitting in the dining room eating lunch. The resident got up from his seat, and began to walk out of the dining room. A thumping sound was heard as he walked, and the back of his heels lifted up from the back of the sneakers as the resident walked out of the dining room and into the corridor. His sneakers were heavily soiled, tattered and large for his feet. He wore no socks. Nursing staff were present when the resident got up and walked out of the dining room. The resident was observed again on 09/18/19 at 9:45 AM in the dining room, wearing the same soiled, tattered, and loosely fitting sneakers with no socks. Again, he was heard making a thumping sound when he walked, and the heels lifted up from the back of the sneakers. He wore no socks. Nursing staff were present in the dining room at the time. On 09/19/19 at 10:05 AM, the assigned Certified Nurse Assistant (CNA #2) was interviewed. The assigned CNA stated that he has been assigned to the resident for more than a year. The CNA stated that the resident needs help in retrieving his clothing, but he can put them on himself. The CNA stated that he also gives him his sneakers to put on. When asked about socks for the resident, the CNA stated that the resident wears socks whenever he wants to but not all the time. The SA accompanied the CNA to inspect the resident's clothing closet. There were no socks to be found in the drawers. The CNA recanted his statement about socks and stated that the resident has not had any socks. He further stated that he is supposed to inform the nurse when a resident needs any items of clothing so that they can contact the family or housekeeping for donated clothing items. He stated that he should have reported the oversized sneakers to his nurse because poor fitting shoes can result in a fall. He also stated that better fitting footwear is important because it looks good and feels good and could prevent foot problems. The Social Worker (SW) was interviewed on 09/19/19 at 10:29 AM. The SW stated that the resident does not have a personal fund account, and his family visits occasionally. The facility has a system in place where they collect clothing, shoes, and socks and distributes them as needed. This should have been reported to her by the nurse or CNA so she could follow-up. The SW stated that she had not noticed the resident's footwear before because he is usually sitting down. When clothing items are needed, she would contact the family to ask for needed items first. She would also contact the housekeeping department and ask if any of the needed items are available from the donated stock. Many times, the facility absorbs the cost of purchasing needed items. On 09/19/19 at 10:35 AM, the Registered Nurse (RN) Unit Manager, (UM) # 1 was interviewed. The UM stated that if a resident is in need of any clothing items, they contact the SW or the housekeeping department and family. She further stated the assigned CNA should communicate with the nurse to report a need for items of clothing or footwear. The facility has donated clothing that is managed and kept by the Housekeeping Department. The unit manager # 1 stated that she makes rounds and notices how residents are dressed and groomed. She stated that she had not noticed the condition of the resident's sneakers. 415.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not ensure that medically related social services to attain and maintain the highest practicable physical, mental and psychological well - being of each resident were provided. Specifically, a resident observed wearing oversized, soiled, and tattered sneakers without socks was not assisted with obtaining new footwear and socks. This was evident for one (1) of one (1) residents reviewed for Dignity (Resident # 1). The finding is: The facility policy for Resident Funds - Personal Shopping dated 08/2019, documented that, The facility must ensure that all residents' personal needs are met and that their rights and dignity are respected. If a resident lacks capacity and has family .involved in his/her care, the family should be encouraged to make purchases for the resident directly. Resident #1 was admitted on [DATE] with diagnoses which included Alzheimer's Dementia. The Quarterly Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 09/10/19, documented that the resident had clear speech and was sometimes understood and sometimes understands. The resident had a brief interview mental status score of 3 out of 15, indicating severely impaired cognition. No rejection of care behaviors were identified. The resident required supervision to limited staff assistance for activities of daily living needs. On 09/17/19 at 1:08 PM, the resident was observed sitting in the dining room eating lunch. The resident got up from his seat, and began to walk out of the dining room. A thumping sound was heard as he walked, and the back of his heels lifted up from the back of the sneakers as the resident walked out of the dining room and into the corridor. His sneakers were heavily soiled, tattered and large for his feet. He wore no socks. Nursing staff were present when the resident got up and walked out of the dining room. The resident was observed again on 09/18/19 at 9:45 AM in the dining room, wearing the same soiled, tattered, and loosely fitting sneakers with no socks. Again, he was heard making a thumping sound when he walked, and the heels lifted up from the back of the sneakers. He wore no socks. Nursing staff were present in the dining room at the time. On 09/19/19 at 10:05 AM, the assigned Certified Nurse Assistant (CNA #2) was interviewed. The assigned CNA stated that he has been assigned to the resident for more than a year. The CNA stated that the resident needs help in retrieving his clothing, but he can put them on himself. The CNA stated that he also gives him his sneakers to put on. When asked about socks for the resident, the CNA stated that the resident wears socks whenever he wants to but not all the time. The SA accompanied the CNA to inspect the resident's clothing closet. There were no socks to be found in the drawers. The CNA recanted his statement about socks and stated that the resident has not had any socks. He further stated that he is supposed to inform the nurse when a resident needs any items of clothing so that they can contact the family or housekeeping for donated clothing items. He stated that he should have reported the oversized sneakers to his nurse because poor fitting shoes can result in a fall. He also stated that better fitting footwear is important because it looks good and feels good and could prevent foot problems. The Social Worker (SW) was interviewed on 09/19/19 at 10:29 AM. The SW stated that the resident does not have a personal fund account, and his family visits occasionally. The facility has a system in place where they collect clothing, shoes, and socks and distributes them as needed. This should have been reported to her by the nurse or CNA so she could follow-up. The SW stated that she had not noticed the resident's footwear before because he is usually sitting down. When clothing items are needed, she would contact the family to ask for needed items first. She would also contact the housekeeping department and ask if any of the needed items are available from the donated stock. Many times, the facility absorbs the cost of purchasing needed items. On 09/19/19 at 10:35 AM, the Registered Nurse (RN) Unit Manager, (UM) # 1 was interviewed. The UM stated that if a resident is in need of any clothing items, they contact the SW or the housekeeping department and family. She further stated the assigned CNA should communicate with the nurse to report a need for items of clothing or footwear. The facility has donated clothing that is managed and kept by the Housekeeping Department. The unit manager # 1 stated that she makes rounds and notices how residents are dressed and groomed. She stated that she had not noticed the condition of the resident's sneakers. 415.5(g)(1)(i-xv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the Re-Certification Survey, the facility did not ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition. Specifically, a resident with wandering and elopement risk behaviors was prescribed psychotropic medications without an appropriate diagnosis. In addition, the facility did not attempt any non-pharmacological interventions targeted to address the psychosocial stressors of loss of home and family moving away that contributed to the behavior prior to starting the medication. This was evident for one (1) of five (5) residents investigated for Unnecessary Medication (Resident # 51). The finding is: The policy for, Psychotropic Drugs & GDR (Gradual Dose Reduction), dated 03/20/19, documented the following: That residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the medical record. Psychopharmacological medications will never be used for the purpose of discipline or convenience. Resident #51 is an 80 year, admitted to the facility on [DATE], who is alert, pleasant and approachable, with diagnosis which included: Alzheimer's Dementia, Diabetes Mellitus, Gout and Hypertension. The admission Minimum Data Set 3.0 (MDS) Assessment reference Date (ARD) dated 03/12/19 documented an admission date of 03/05/19. The resident was assessed as having clear speech, usually understands and usually understood, with a Brief Interview Mental Status (BIMS) score of 5 out of 15, indicating the resident had severely impaired cognition. No wandering behaviors were identified, and the resident required extensive assistance for activities of daily living needs, (adl). The diagnoses included: Alzheimer's Dementia, and the resident was on no psychotropic medications. The Quarterly MDS with an ARD of 07/13/19 documented a BIMS score of 7 out of 15, indicating the resident had severely impaired cognition. No wandering behaviors were identified, and the resident required limited assistance for ADL's. Diagnoses included: Mood Disorder due to known physiological condition with mixed features. The resident received Antipsychotic medication (AP) on a routine basis, with no Gradual Dose Reduction (GDR) attempted because the Physician documented it was clinically contraindicated on 06/10/19. Resident #51 was observed at different intervals throughout the survey, including but not limited to the following: On 09/19/19 at 08:14 AM, the resident was observed in the dining room area seated in a wheelchair (w/c) and dressed appropriately. The resident was quiet and had both hands on lap. There were no outbursts or inappropriate behaviors noted. The resident was able to wheel himself in and around the unit, and he used both feet to propel his wheelchair. When greeted, the resident smiled and nodded his head. On 09/19/19 at 09:37 AM, the resident was observed in his room. He was walking around his side of the room and closed his privacy curtains. His wheelchair was nearby. When spoken to, he nodded his head, smiled, and in broken English said ok, ok. The resident was approachable, seemed calm, and had a friendly and gentle demeanor. On 09/20/19 at 09:37 AM, the resident was observed in the dining room sitting in his w/c. A Chinese newspaper was folded next to him. No behaviors or outbursts were observed by the state agent (SA) during the survey. Review of Hospital records dated 02/24/2019 documented that the resident had a history of Alzheimer's Dementia, is alert and oriented times 2, status post (s/p) fall at home and developed swelling and redness to his right elbow and right hand. Medications included: Donepezil (Aricept) 10 milligrams (mg) by mouth (po). The Initial Admitting Physician's History and Physical note dated 03/06/19 documented the resident was an [AGE] year old with diagnosis of Alzheimer's, s/p fall, admitted to nursing home after completion of antibiotics. Current medications included Donepezil 10 mg po at bedtime. A Nursing Progress Note dated 03/07/19, timed at 11:41 PM, documented that the resident verbalized that he wanted to go home. Monitoring every 30 minutes was ongoing. A Nursing Note dated 03/08/19, timed at 12:11 AM, documented that the resident was wandering on the unit. When re-directed, stated, I am going home. A wander guard was applied. Nursing Notes entered 03/08/19 at 7:18 AM and 03/13/19 at 12:21 PM, documented that the resident was adjusting to unit, stays mostly in his room, and had no behaviors problems. Monitoring every 30 minutes. A Nursing Note entered 03/13/19 at 11:31 PM documented that the resident had episodes of blocking the room with his wheelchair and was difficult to re-direct. The initial Psychological evaluation documented that on 03/13/19 the resident was seen. The resident was diagnosed with Alzheimer Dementia, affect is not stable, continues to benefit from nursing care and No psychological follow-up was needed. The evaluation was ordered on 03/05/19 as a routine consult completed upon admission. A Care Plan Note on the Behavioral Symptoms Comprehensive Care Plan (CCP) dated 4/18/19 documented that Nursing notified Social Work (SW) about the resident's constant wandering behaviors. The resident was attempting to leave the building and refusing to wear the wanderguard. the resident was on q 30 minute monitoring for high elopement risk. The family was aware. SW spoke to the resident on 4/18/19 regarding the behavior. The resident stated his house is close by so he wishes to visit home. The resident was informed by his son that the house would be sold soon, and the family was moving. SW was supposed to provide further support if needed. An additional CCP note dated 4/22/29 documented the resident was not able to adjust to the facility's life and routines. The resident continued to wander on the unit and attempted to leave the building. The resident was also continuing to refuse to wear the wanderguard. The note documented the team was waiting for the psychiatrist to see the resident. SW would provide further support if needed. A Nursing Note entered 04/28/19 at 1:50 PM documented that the resident was found on the main floor between the inner and outdoors. The resident stated, I am going home, my home is nearby, I need to see my family. Staff told the resident that he cannot go out, and the resident became very upset. The resident was not listening and screaming at staff. The doctor was called and informed about the wandering behavior, and Quetiapine 25 mg po twice a day was ordered. The physician's interim order dated 04/28/19 documented an order for Quetiapine (Seroquel) 25 mg po twice a day for dementia with behavioral disturbance. Seroquel is a medication used to treat Schizophrenia and Bi-Polar Disorder. The Physician's Monthly renewal orders dated 5/1/19 documented orders for Quetiapine 25 mg PO BID. The Psychiatry Consult dated 05/08/19 documented the resident was being seen for an initial evaluation for capacity of medical and discharge decisions and agitation and screaming to staff. The resident's current medication was Seroquel 25 mg po BID. The chart was reviewed, and the consultant discussed the case with a nurse who reported the resident sleeps and eats good. During the exam, the resident was alert and superficially cooperative. The resident's mood was euthymic with labile and blunted affect. The resident was distracted, and had limited insight and judgment. The resident had poor cognitive function and impulse control. There was no overt agitation or irritability noted. The resident was diagnosed with Mood Disorder due to known physiological conditions with mixed features and Alzheimer's Disease by history. The psychiatrist documented the resident could not understand the consequence of his decisions regarding medical issues and discharge planning. The Plans/Recommendations were to add Depakote 250 mg po twice a day, labs in 1 week (Complete Blood Count, Liver Function Test, and Depakote level, monitor for mood and behavioral changes, and support and direct for proper ADL. There was no documentation in the psychiatry note regarding what specific targeted behaviors were being treated by the psychotropic medication and should be monitored. Also, the evaluation did not include any information regarding the psychosocial stressors occurring with the resident that could be contributing to the resident's behaviors (loss of his home and proximity to his family). There is also no documented evidence that the psychiatrist attempted to get a psychiatric history from the resident and family. The physician's interim order dated 05/08/19 documented orders for Valproic Acid (Depakote) 250 mg po twice a day for Mood Disorder. The Pharmacy Drug Regimen Review dated 05/20/19 documented, currently on Quetiapine, use is for a diagnosis other an an approved psychiatric condition (dementia). Please evaluate. An approved diagnosis such as Schizophrenia, Bipolar Disorder or other chronic enduring psychiatric condition. Medical response dated 05/20/19 documented, I agree, psych consult.' A Medical Note dated 05/20/19 documented the physician was called regarding the pharmacist's recommendation. The resident was seen and examined. The resident denied any history of psychiatric issues. The physician further documented they would call psychiatry to follow-up and specify the psychiatric disorder and attempt to taper/discontinue psych meds. The note further documented the resident had dementia with no abnormal behavior and was on Seroquel. An interim physician's order dated 6/4/19 documented orders for Quetiapine 25 mg po twice a day. The diagnosis for Quetiapine was changed to Mood disorder due to known physiological condition with mixed features, but the dosage was the same. Review of psychiatry consult dated 06/10/19 documented, follow up for medication change, current medications: Seroquel 25 mg po twice a day and Depakote 250 mg po twice a day. Specific (Targeted) Behaviors to be monitored,: last seen on 05/08/19. Depakote was added. Chart reviewed. Discussed with a nurse. He is better. Says he is sleeps and eats good. The plan was to continue with current medications. There was no documentation regarding what specific targeted behaviors should be monitored. The physician's monthly renewal orders dated 6/27/19 documented the dosages for Valproic Acid and Quetiapine remained unchanged. The Pharmacy review dated 07/14/19 documented, currently on Seroquel 25 mg po twice a day for behaviors associated with dementia. No recent behavior problems noted. Please evaluate, consider taper to once daily or document inability to do so. Physician response dated 07/16/19 documented, I agree. An interim Physician's Order dated 7/16/19 documented the dose of Quetiapine was decreased to 25 mg once daily. The Medical Note entered by the Nurse Practitioner (NP) dated 07/18/19 documented the NP was called to evaluate the resident regarding the pharmacy recommendations. The resident had mood disorder with mixed features for which he was placed on Seroquel. Psychiatry saw the patient and recommended to continue with Seroquel po daily for mood disorder. The bottom of the consult documented the plan to continue Seroquel 25 mg BID and Depakote 250 mg twice a day. The physician's monthly renewal orders dated 07/29/19 documented orders for Quetiapine 25 mg once daily for Mood Disorder. The physician's monthly order dated 08/30/19 documented, Quetiapine 25 mg po daily for Mood disorder and Valproic Acid 250 mg twice a day for Mood disorder. The Medical Note entered by the Nurse Practitioner (NP) dated 09/18/19, documented the NP was called to review the pharmacy recommendations. The NP documented the resident was currently on Zyprexa and Quetiapine. The plan was to discontinue Quetiapine, start Zyprexa 2.5 mg daily, continue Valproic Acid 250 mg BID, and a psychiatry consult secondary to medication changes. There was no documentation in the NP note regarding psychiatric symptoms or behaviors observed. The physician's order dated 09/18/19 documented orders to discontinue Quetiapine and start Zyprexa 2.5 mg daily. Valproic Acid was decreased to 250 mg once daily from twice a day. The Psychiatry note dated 09/18/19 documented that the reason for the consult was to evaluate efficacy of regimen. Current medications: Valproic Acid 250 mg po twice a day. Specific (Targeted) Behaviors to be monitored: .has a history of Dementia. Mental Status Examination: poor impulse control, inappropriate affect and anxious mood, disoriented to time, poor insight. Plan: lower Valproic Acid to 250 mg po daily. There was no mention of the Zyprexa 2.5 mg po daily in the psychiatry consult. The Medical note entered by the primary physician dated 09/18/19 documented the resident was currently on valproic acid for mood disorder. The plan documented the resident would continue valproic acid 250 mg po qd and Zyprexa 2.5 mg daily. There was no documentation from the physician regarding psychiatric symptoms and behaviors observed. There was no documentation regarding which targeted behaviors should be monitored. On 09/19/19 at 08:15 AM, the assigned Certified Nurse Aide (CNA #1) was interviewed. The CNA stated that she is familiar with the resident and has been assigned to him for the month of September. The resident at times gets around on the unit with his w/c, and when in his room, he walks. The only concern with the resident is that he, wants to go home. She stated the resident has displayed no behavior problems. The resident comes and goes as he likes on the unit. He may stay to watch activities, but he mostly keeps to himself. On 09/19/19 at 09:00 AM, the Registered Nurse Unit Manager (RNUM #1) was interviewed. The RNUM stated that the resident is mostly quiet and calm. He tends to suddenly want to leave to go home see his family. The resident can become upset and agitated when staff are attempting to prevent him from leaving the unit or facility. One time, the resident went to the lobby carrying a bag containing some clothing and had to be redirected by staff. The resident has also had to be escorted out of the elevator by staff when he gets onto it to in an attempt to leave the facility. The resident tends to wander, but he is not aggressive or abusive to others. The resident likes to keep to himself. The resident alternates between using a w/c and walking with the w/c to get around. The main issue with the resident is that he wants to go home. He is allowed to leave the unit and is monitored closely as he has refused to wear a wanderguard. The resident becomes agitated when the staff try to stop him from leaving the floor, which is why they have staff watch him in the lobby. The security guard was made aware of the resident's desire to leave, and they also keep an eye on him. The resident is in and out of activities, and, at times, they have called his son on the phone to help calm him down. The current psychiatrist was interviewed on 09/19/19 08:42 AM. He stated that the previous psychiatrist stopped working at the facility in the beginning of August 2019. He stated that yesterday (09/18/19) was his very first visit with the resident. He stated that he decreased the resident's Valproic Acid from twice a day to daily, and the resident has no signs of psychotic behaviors and was very calm and quiet. He would not prescribe Antipsychotic medications as he did not see signs of aggression, violence, hallucinations or delusions. He further stated he lowered the Valproic Acid with a plan to discontinue it altogether. Antipsychotic medications are mostly prescribed for residents with a diagnosis of Schizophrenia and/or Bipolar disorder. The dangers of prescribing AP medications to older people without an appropriate medical diagnosis is that these medications block the neurotransmitter of dopamine, which can contribute to parkinsonism like symptoms, such as tremors and walking back and forth behaviors. On 09/19/19 at 09:39 AM, the Nurse Practitioner (NP) was interviewed. She stated that she has been following the resident for roughly a month. The resident is mostly calm and is on AP medications due to agitation or impulsiveness at times, as he wants to leave to go home. She changed the medications yesterday, discontinuing Quetiapine and starting Zyprexa 2.5 mg daily. She made the medication change because Quetiapine was no longer going to be covered by the resident's insurance, and the insurance company requested an alternate medication be used. The resident does not have Schizophrenia, Bipolar disorder, or psychosis. The potential gross side effects of prescribing AP medications for residents with Dementia, include falls, an increase in mental status changes, parkinsonism-like tremors. In hind sight, and in the absence of an appropriate diagnosis, the resident should not be on AP medications. The resident's main issue was wanting to go home. On 09/20/19 at 08:37 AM, the Social Worker was interviewed and stated that she spoke to the family about the resident's desire to go home and see his grandchildren. The family may visit on weekends, and they have stated that they cannot take him back. The only behavior exhibited by the resident was attempting to go home. The resident was stopped from leaving once, while in the lobby, with a bag of clothing items in his hand. He does not exhibit aggression, psychosis, or abusive behaviors. She stated she makes rounds, and she takes about 5 minutes to speak with the resident about his need to leave. The resident stated that he just wants to see his family and that these thoughts are spontaneous. As for activities, he does not like to attend activities and has no hobbies. I have not explored further with him to try to create ideas and activities he may like. On 09/20/19 at 09:20 AM, the Recreation staff member was interviewed and stated that activity programs last 45 minutes. The resident likes musical based programs, like karaoke, name that tune, musical strolls, guitars, arts and craft, balloon throwing and volleyball. The resident also likes the newspaper. The resident is friendly, not abusive or aggressive. He knows when he wants to participate and when he wants to leave. She stated that the recreation staff receives Dementia Care inservice. There is no one special program developed for the resident. The activities are for all of the residents, and they do not offer activities designed specifically for Dementia residents. On 09/20/19 at 09:38 AM, the primary physician was interviewed. She stated that she first saw the resident upon admission to the facility, and she is able to speak his dialect. He was on Aricept for dementia and exhibited no behavior problems, is calm. A wanderguard was placed because he wanted to go home. He knows his name and where he lives. He was started on AP medications on 04/28/19 when he became agitated and started screaming at the staff for trying to prevent him from leaving the facility. We need a valid diagnosis for prescribing AP, which he does not have. He is not aggressive or psychotic. The black box warning for AP medications means there is a risk of death if the medications are used by elderly residents, and antipsychotics are not approved for dementia related cases. She stated that she went along with the psychiatrist's recommendations and understands that she is the one who ultimately makes decisions about a resident's medication regimen. The only behavior concern with the resident was his wanting to go home. On 09/23/19 at 11:12 AM, the Medical Director was interviewed. He stated that referrals are made to the psychiatrist for behaviors such as, combativeness, aggression, loss of appetite, and agitation. The psychiatrist makes recommendations, but the primary care physician has to agree or disagree. The Medical Director stated he conducts monthly board meetings with his doctors, and they discuss residents who are AP and follow-up with psychiatry. There ought to be a proper diagnosis for prescribing these types of medications, including documenting the target behaviors and effectiveness of the medications. Attempts to interview the physician who initially ordered Quetiapine and the psychiatrist who followed the resident upon admission were unsuccessful because they no longer work at the facility. 415.12(m)(1)

Based on observation and staff interviews during the recertification survey, the facility did not ensure the infection prevention and control program desgned to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections was maintained. Specifically, the consultant eye doctor did not properly clean the overbed table used or perform hand hygiene prior to completing an eye exam. This was evident for 1 random observation (Resident #199) on 1 out of 6 resident units (2nd floor). The finding is: The facility policy titled Handwashing, reviewed and revised on 7/2017, documented that handwashing should be done before and after resident contact. Proper handwashing technique includes the following steps: Wet hands with running water. Apply soap and throughtly distributed over hands. Vigorously rub hands together for 20 seconds covering all surfaces of the hands and fingers. On 09/19/19 at 10:09 AM, the Eye Doctor was observed preparing to see residents on the 2nd floor. The Eye Doctor borrowed an overbed table from a resident's room to use during the exams. He wiped off the table top with a paper towel and placed his bag containing eye exam equipment on it. The State Agent (SA) observed stains on the overbed table after it was wiped down. The Eye Doctor then wheeled the table into a resident room. After exiting one room, the Eye Doctor went to see Resident #199. He did not perform hand hygiene prior to entering the room or performing the eye exam. The Eye Doctor placed eye drops into the resident's eyes during the exam. On 09/19/19 at 10:24 AM, the Eye Doctor was observed performing hand hygiene after completing the eye exam for Resident #199. The eye doctor washed his hands for less than 10 seconds. On 09/19/19 at 11:06 AM, the Eye Doctor was interviewed. He stated that he used the overbed table to move around his equipment. He uses alcohol prep wipes to clean the overbed table tops, which are sometimes filthy. He stated that he usually sees 5 to10 patients on multiple floors. After he finishes with a patient, he washes his hands with soap and water or hand sanitizer and moves on to the next patient. He further stated that he washes his hands for 2 to 3 minutes before or after the patient is seen. If the patient has an infection or oozing eyes, he washes hands during the examination if doing a two-part exam. The Eye Doctor further stated he uses gloves when residents' eyes are oozing, or they are on contact isolation. 415.19 (b) (4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification survey, the facility did not ensure that a homelike environment was provided. Specifically, resident rooms were observed with bare white walls and lacking decor, creating a colorless, dull environment. This was observed for 3 residents (Resident #s 110, 218, and 204) on one (1) of six (6) resident units (Unit 3). The findings are: A review of the facility's policy and procedure for, 'Homelike Environment, documented: The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These include: inviting color and decor. 1.) Resident #110 was admitted on [DATE]. The resident was alert and oriented to person, place and time, with moments of confusion. During the initial unit tour, on 09/17/19 at 9:10 AM, the resident's room was observed. The room walls were painted off white and the wall space facing the resident was bare. An Activities, calendar was posted on the wall between the beds in the room. There were no other wall hangings or colors contrasting the bare walls. Resident #110, was interviewed during the observation. Resident #110 stated that yes the walls are bare, but she would not expect anything more from an institutional setting. The resident stated, it does not matter. On 09/20/19 at 08:33 AM, Resident #110 was observed having breakfast in her room. Two wall hangings with the depiction of flowers were on the wall facing her. The resident was interviewed. She stated that she that she did not realize what a big difference it made, to have something of life she can now look at. She stated that yesterday (09/19/19), she was asked how she felt about having a bare wall by staff. She said she told them that because she is in an 'institutional setting, that she doesn't expect much, and doesn't expect her room to be homelike. She stated she had not ever been asked about how she felt about her walls being bare before. She stated that having pictures of flowers on the wall really made a difference. She said she chose the flower hanging because it reminded her of life and something growing. She said it made her feel very happy, and it was better than having bare walls. 2.) Resident # 218 was admitted on [DATE]. The resident was alert and oriented with periods of confusion. On 09/17/19 at 9:45 AM, the resident's room was observed during the initial tour. The wall space in the single bedded room was bare. An off white paint color covered the walls. Resident #218 was interviewed during the observation. The resident stated she would like something colorful on her walls to look at. She stated that she had not been asked about how she felt about the bare walls by facility staff. On 09/20/19 at 8:50 AM, the resident was observed sitting on her bed eating breakfast. The room wall was decorated with two pictures depicting colorful fishes. The resident was smiling from ear to ear. The resident stated that seeing these pictures on her wall made her very happy. She again stated that this makes her room bright, and it made her very happy to see something colorful on her walls. 3.) Resident # 204 is alert, oriented with periods of confusion. On 09/17/19 at 11:23 AM, during the initial tour of the resident's room, the entire wall space was bare. The resident was asked about how she felt about her bare walls. The resident stated that she would like to have some wall decorations. She stated that having decorations or pictures on her wall is good for the soul and spirit, and it looks good too. The resident added that she has no family in this country. On 09/20/19 at 12:10 PM, the resident was observed in her room sitting in a wheelchair and staring at the wall. The resident's wall were still bare. The unit registered nurse #1 was interviewed immediately after the initial tour on 9/17/19 and on 09/23/19 at 10:42 AM. The RN stated that many rooms are bare, and it was just something she assumed that the residents liked. She stated that she would not normally ask residents about how they felt about the bare walls. On 09/23/19 at 10:45 AM, the Social Worker (Staff #4) was interviewed. She stated that residents are encouraged to bring in personal items from home. This is also mentioned in the Care Planning Meetings. She stated that she understood that not all residents attend the care plan meeting. She stated she noticed the bare walls, but had not asked residents about how they feel about having bare room wall. On 09/23/19 at 10:12 AM, the Admissions Director was interviewed. She stated that once a bed is accepted by the resident or family, she contacts them and and gives them an introduction to the facility. This introduction includes: activities, staffing, personal property, and personal belongings. She informs residents and families that they are allowed to bring personal photos, blankets and accent furniture. On 09/23/19 at 08:44 AM, the Administrator was interviewed. She stated that her role included the assurance that policies are implemented and that residents are safe and receive quality of care and quality of life services. She ensures that the policies are implemented by providing inservice's, having discussions during resident council meetings, and making rounds to ensure that residents are satisfied with their environment. She stated she asks residents about their level of satisfaction concerning the environment, specifically about safety, appearance, odor and cleanliness. The administrator stated that the first and second floor renovations began in 2018. The renovations included lots of upgrading, including creating a homelike environment. The facility staff encourage residents and families to bring in personal items from home. We also encourage residents and families to create their own personal items. It is a team effort that begins during the admission process and continues with other staff encounters. 415.29(e)(1)

Based on observation and staff interviews during recertification survey, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, potentially hazardous cold foods (sandwiches) were not maintained at the proper temperature (at or below 41 degrees Fahrenheit), and equipment used to slice meat for sandwiches was not properly cleaned after use. This was evident during the Kitchen Observation facility task. The findings are: 1) The policy and procedure titled Sandwich preparation last reviewed 6/19/18, documented: All items for sandwiches, for example Egg salad/Tuna salad and any deli meats, are held under refrigeration at 40 degrees or less prior to assembly. Sandwiches will be assembled on an appropriate cutting board, and upon completion, each sandwich is wrapped and dated. They are then placed back into the refrigerator. Sandwiches are assembled for same day use and discarded at end of the day. The policy and procedure titled Hot and Cold food holding effective 4/20/16 and reviewed 4/18/19, documented the purpose to hold food safely for resident consumption. The policy documented all cold foods (milk-juices-etc) will be held at 41 degrees or colder. On 09/20/2019 at 10:17 AM, a Dietary Aide (DA # 9) was observed making salami sandwiches for the day. The meat for the sandwiches was stored in an open metal pan on the table. DA #9 borrowed a thermometer from the [NAME] to take the temperature of a sandwich. At 10:33 AM, the temperature was 65.1 degrees Fahrenheit (F). At 10:40 AM, after 20 sandwiches were made, the sandwiches were placed on a ceramic plate, wrapped with plastic wrap, and dated with a label reading 9/20. The sandwiches were put on a rack and placed in the refrigerator at 10:43 AM. On 09/20/19 at 12:48 PM, the [NAME] (staff #13) took the temperature of the salami sandwiches stored in refrigerator. Surveyor noted that the refrigerator internal temp was 40 F. There was 1 sandwich left in the refrigerator from the salami sandwiches prepared earlier. At 12:52 PM, the temperature of the sandwich was 58.8 degrees Fahrenheit. The [NAME] asked the state agent (SA) if the temperature should be 40 degrees or less. After the SA nodded yes, the [NAME] discarded the leftover sandwich. An interview was conducted with DA #9 during the observation on 09/20/19 at 10:17 AM. The DA stated that they make 22 to 25 sandwiches per day, and this process takes her 2 to 3 ½ hours to complete. She further stated that sandwich making started at 7 o'clock this morning, and the sandwiches were for the 11 o'clock meal. DA #9 stated she takes temperatures of sandwiches sometimes. She stated she does not have a thermometer, but she borrows a thermometer from the Cook. DA #9 stated that she does not record the temperature of the sandwiches, and she was not sure what the temperature should be. 2) On 09/23/19 at 09:32 AM, a Dietary Aide (DA # 10) was observed making ham and cheese sandwiches for the day. The sandwiches were placed in the refrigerator with an internal temperature of 38 degrees F at 09:44 AM. On 9/23/19 at 1:06 PM, the Dietary Supervisor (DS #11) took the the temperature of a ham and cheese sandwich in the refrigerator. The temperature registered 62.6 degrees F. DS #11 calibrated the thermometer and took a repeat temperature of 61.2 degrees F at 01:08 PM. A second sandwich was tested, and the temperature was 60.1 F at 1:09 PM. The repeat temperature, after thermometer calibration, was 60.4 F at 1:10 PM. DS #11 then put the sandwiches in the freezer. An interview with DA #10 was conducted on 09/23/19 at 10:06 AM. DA #10 stated he did not know if temperatures of the sandwiches were taken. An interview was conducted with the Dietary Supervisor (DS #11) on 09/23/19 at 10:08 AM and. She stated that the sandwiches are refrigerated as soon as they made, and the temperatures are taken before the tray line starts. It takes about a half hour to prepare the sandwiches, on average. An additional interview with DS #11 was held at 1:12 PM after the temperatures were taken. DS #11 stated the remaining sandwiches would be thrown out and new sandwiches would be made after she checked with her supervisor. 3) The policy and procedure titled Sanitizing and cleaning slicer effective 04/20/16 and reviewed 4/18/19, documented the purpose of the policy was to maintain and sanitize the slicer in a way to ensure no cross contamination or bacteria growth. Duties include Using soapy water, clean cradle and all exposed area of the machine, use sanitizing solution on all areas of the machine, reassemble machine, and place cover over machine which indicates it is cleaned and sanitized. A kitchen observation of equipment cleaning of the meat slicer was conducted on 9/23/2019 at 09:45AM. Surveyor observed DA #10 cleaning the meat slicer after making ham and cheese sandwiches for the day. Staff wiped down table with cloth soaked in sanitizing solution (bleach, soap, water) after he unplugged the machine and he continued to break down the machine for cleaning. Surveyor noted that old food debris (dried meat) fell out of the carriage tray when the carriage tray knob was loosened. When the latch knob in the sharpener area was loosened, dried meat also fell out of the machine. There was also old dried meat debris underneath the machine on the table. The Meat slicer machine cleaning was finished at 09:53 AM, and the machine was covered with plastic bag. There was still noticeable meat debris remaining on the sharpener and carriage tray handle groove areas of the machine after cleaning. The table also still had old food debris on it. An interview was conducted with (DA #10) on 09/23/19 at 09:55 AM. He stated the meat slicer is used daily, and whoever makes the sandwiches is supposed to clean the meat slicer. He stated that when staff finish cleaning the machine, plastic is placed on top of it. The SA pointed out areas that were not clean on the meat slicer. DA #10 cleaned the table underneath the machine after the machine was moved to the right. The DA also stated that he did not know how to take off the sharpener on the meat slicer. An interview was conducted with the Dietary Supervisor (DS #11) on 09/23/19 at 10:11 AM. During the interview, the supervisor removed the plastic covering from the meat slicer and the sharpener knob fell off, exposing food debris underneath the sharpener knob. Surveyor noted there was still food debris (dried meat) left under machine, and the counter under the machine had to be wiped down again. DS #11 stated the staff has to make sure they clean the machine completely all the times. 415.14(h)