Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00355639), the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than two hours after the allegation is made to the State Survey Agency in accordance with State law through established procedures. This was evident for one out of three residents (Resident #1) sampled for abuse. Specifically, on 09/20/2024 at 7:30 AM, Resident #1 was observed with an abrasion and redness without any active bleeding on the left forearm. The facility investigated the incident and did not report the injury of unknown origin to the New York State Department of Health. The findings are: The facility Policy and Procedure entitled Abuse Investigation and Reporting, with the revision date of 09/16/2024, documented all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source (abuse) shall be promptly reported to local state and federal agencies (as defined by current regulation) and thoroughly investigated by facility management. Findings of abuse investigations will be reported. Resident #1 was admitted to the facility with diagnoses including Adult Failure to Thrive, Malnutrition, and Dementia. A Minimum Data Set (an assessment tool) dated 08/23/2024 identified that Resident #1 had severely impaired cognition. An Accident/Incident Note dated 09/20/2024 at 3:55 PM written by Unit Manager #1 documented that they were called by Certified Nursing Assistant #1 on 09/20/2024 at 7:30 AM for an injury of Unknown Origin. Resident #1 was attended by a Certified Nursing Assistant #1 when observed with an abrasion and redness without any active bleeding on the left forearm. Resident #1 was not able to say what happened. There are no changes in the upper-lower Range of Motion. No complaint of pain was voiced. The Medical Doctor was made aware and ordered Mupirocin two times a day. The family was notified. Emergency Contact #1 and Emergency Contact #2 were made aware. A review of the facility's Summary of Investigation dated 09/20/2024, documented the facility investigated and concluded that abuse did not occur. No staff witnessed any incident or fall. Resident #1 non-complaint with care. The abrasion likely occurred while Resident #1 was trying to leave the room and resist care. During an interview on 01/13/2025 at 1:26 PM, the Director of Nursing stated when the incident occurred on 09/20/2024, the incident was investigated by the former Director of Nursing. The Director of Nursing stated the staff was interviewed 72 hours back, and no one witnessed any injury or fall. The Director of Nursing stated Resident #1 had a behavior of resisting care and combative behavior. The Director of Nursing stated the incident was not reported to the New York State Department of Health because Resident #1 likely had a self-inflicted abrasion that was very superficial and with no bleeding due to movement behavior. The Director of Nursing stated they were supposed to report any allegation of abuse, including injury of unknown origin, to the Administrator and the New York Department of Health within two hours. During an interview on 01/13/2025 at 3:37 PM,, the Administrator stated they were made aware that Resident #1 sustained a laceration on 09/20/2024, but they don't recall what time. The Administrator stated they did not report the incident that occurred on 09/20/2024 to the New York State Department of Health because Resident #1 had a history of combativeness and, due to that, may have caused self-inflicted injury. The Administrator stated that the Director of Nursing and Administrator are responsible for investigation and reporting to the New York Department of Health. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews conducted during the Recertification Survey from 10/08/2024 to 10/16/2024, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services, including provision of equipment, to prevent further decline in range of motion. This was evident in 1 (Resident #52) of 2 residents reviewed for positioning / mobility. Specifically, Resident #52 has been observed on 2 occasions without the hand rolls applied in both hands as per physician orders. The findings are: The facility's policy titled Contractures with a last reviewed date of 01/12/2024 stated that braces and splints are applied by the nursing staff upon physician's order, per the plan of care, and under the direction of Physical/Occupational Therapy. Resident #52 was admitted to the facility with diagnoses of Traumatic Brain Injury, Seizure Disorder, and Paranoid Schizophrenia. The Minimum Data Set (a resident assessment tool) dated 06/14/2024 documented that Resident #52 had severely impaired cognition and was dependent in all areas of activities of daily living. A care plan for use of adaptive devices was initiated for Resident #52 on 03/15/2024. The care plan documented the use of Posey rolls for both hands at all times, remove for hygiene, skin check, and range of motion if tolerated. A physician's order dated 07/30/2024 included Posey rolls for both hands to be worn at all times, remove for hygiene, skin check, or range of motion as tolerated. On 10/09/2024 at 10:26 AM, Resident #52 was observed in bed with both hands tightly fisted in contracture without the Posey rolls in place. On 10/11/2024 at 11:33 AM, Resident #52 was observed in a geriatric chair without the Posey rolls in place. On 10/15/2024 at 10:11 AM, Certified Nursing Assistant #2 was interviewed and stated that Resident #52's hands and fingers are contracted, and that the Resident has devices to prevent their fingers from touching their palms. The devices are kept in their room relatively close to their bed and are not applied by the aide but by the therapists. On 10/15/2024 at 11:31 AM, Registered Nurse #2, who was the Nurse Manager, was interviewed and stated that Resident #52 is supposed to have the Posey Rolls in both hands at all times. They stated that the aides on the unit are supposed to apply the hand rolls on the residents when the rehabilitation services aide is not on the unit. On 10/16/2024 at 10:10 AM, the Rehabilitation Services Director was interviewed and stated that there are 2 Rehabilitation services aides who are responsible for applying the residents' hand rolls, but they are available only on days when the gym is open. The Director stated that when the rehab aides are not present, the nursing staff must apply the hand rolls since it has to be worn 24/7 to avoid further contracture. On 10/16/2024 at 10:48 AM, the Director of Nursing was interviewed and stated that the facility employs aides who work in the Rehabilitation Services department and make multiple rounds on all units every day; any resident not wearing ordered devices will have them placed by these aides. They stated that it was possible that the Resident was not able to tolerate the hand rolls. The Director of Nursing stated that the assigned aide needs education. 10 NYCRR 415.12(e)(2)

Based on record review and interviews conducted during the Recertification Survey from 10/08/2024 to 10/16/2024, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident in 3 (Residents #46, #294, and #295) of 3 residents reviewed for Beneficiary Notification. Specifically, the facility did not provide the Notice of Medicare Non-Coverage for Medicare Part A at least two calendar days before Medicare covered services ended as required, did not ensure that notices were mailed on the same day telephone notification was made, and did not provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form for residents after discharge from skilled services. The findings are: The facility policy titled Notice of Medicare Non-Coverage with a reviewed date of 01/2024 documented that in the event a patient/resident no longer qualifies for a skilled level of care, a Notice of Medicare Non-Coverage letter will be issued in accordance with federal guidelines informing the patient/resident and or representative party that they no longer qualify for Medicare payment. A Notice Of Medicare Non Coverage / Advanced Beneficiary Notice will be provided by the Social Service Department at least 2 calendar days before Medicare covered services end. The Social Service Department must inform the patient / resident / and / or representative of their appeal rights and when and how to appeal the decision, ensure that the beneficiary or representative signs and dates the Notice Of Medicare Non- Coverage to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 states that the form must be delivered at least two calendar days before Medicare covered services end and included the requirement that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. The instructions also stated that if the provider is personally unable to deliver a Notice of Medicare Non-Coverage to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise them when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. The instructions also state that when direct phone contact cannot be made, the notice should be sent to the representative by certified mail, return receipt requested. The Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2024) states that Medicare requires Skilled Nursing Facilities to provide the notice to original Medicare patients prior to providing care that Medicare usually covers but may not pay for because the care is not medically reasonable and necessary; or considered custodial. 1.) Resident #46's last covered day of skilled services was on 05/22/2024. The Notice of Medicare Non-Coverage documented that the Resident's designated representative received telephone notification of termination of coverage from the Social Worker on 05/22/2024. There was no documented evidence that the notice was mailed on the same day that telephone notification was made. 2.) Resident #294's last covered day of skilled services was on 04/17/2024. There was no documented evidence that the facility provided the resident or their designated representative with Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage. 3.) Resident #295's last covered day of skilled services was on 05/08/2024. There was no documented evidence that the facility provided the resident or their designated representative with Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage. On 10/15/2024 at 10:21 AM, the Minimum Data Set Coordinator was interviewed and stated that the Notice of Medicare Non-Coverage is given to the residents at least 2 days before the last day of service. This allows the resident or their representative time to appeal the process if they choose to. They stated that if a resident is not fully cognitive, they call the representative and then send the notice via certified letter with return receipt. The Minimum Data Set Coordinator stated it is the Social Worker's responsibility to provide the notice. However, they had a high turn over in the Social Service department. On 10/15/2024 at 11:49 AM, the Administrator was interviewed and stated that when there is a change in coverage or services, the resident or their representative must be notified in writing, with sufficient time to exercise their appeals rights. They stated that the Social Worker is responsible for ensuring that the liability and beneficiary notices were provided, and the process fully implemented. However, the Social Service department was going through multiple changes. The Administrator stated that they reassigned the task and trained ancillary staff as back up. 10 NYCRR 415.3(g)(2)(i)

Based on record review and interviews conducted during the Recertification Survey from 10/08/2024 to 10/16/2024, the facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report. The findings are: The facility was not able to provide a policy related to facility staffing. The Payroll Based Journal Staffing Data Report for the 3rd quarter of 2024 (04/01/2024 - 06/30/2024) documented that excessively low weekend staffing was triggered. The Facility assessment dated 10/2024 documented that the facility strives to maintain adequate staffing on each shift to ensure that residents' needs and services are met. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the residents' comprehensive care plan. The facility assessment documented a facility capacity of 200 with a staffing plan by shift as follows: Day shift - 12 licensed nurses (5 medication nurses, 5 Registered Nurses / Unit Managers, 2 charge nurses) and 5 Certified Nursing Assistants per unit with a total of 25; Evening shift - 9 licensed nurses (5 medication nurses, 2 Registered Nurse Supervisors, 2 charge nurses) and 4 Certified Nursing Assistants per unit with a total of 20. There was no staffing break down indicated for the night shift. A review of the actual weekend facility staffing schedule from 06/01/2024 to 09/30/2024 showed that the facility was utilizing Nurse Liaisons. The job description for Nurse Liaison documented that the minimum educational requirement was Home Health Aide Certificate. Their nursing care functions does not include providing direct resident care. A review of the actual facility staffing from 07/01/2024 - 09/30/2024 documented the following: 07/13/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 3rd floor; and 1 in 6th floor. 07/14/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 2nd floor; 1 Certified Nursing Assistant scheduled in 3rd floor; 1 Certified Nursing Assistant scheduled in 5th floor; and 1 Certified Nursing Assistant scheduled in 6th floor. 07/20/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 3rd floor; 1 Certified Nursing Assistant scheduled in 5th floor; and 1 Certified Nursing Assistant scheduled in 6th floor. 07/28/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 3rd floor; 1 Certified Nursing Assistant scheduled in 5th floor; and 1 Certified Nursing Assistant scheduled in 6th floor. 08/04/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 4th floor. 08/10/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 2nd floor; 1 Certified Nursing Assistant scheduled in 3rd floor; There was 1 Certified Nursing Assistant scheduled in 5th floor; and 1 Certified Nursing Assistant scheduled in 6th floor. 08/11/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 2nd floor; and 1 in 6th floor. 08/18/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 5th floor. 08/24/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 2nd floor; and 1 in 6th floor. 08/25/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 5th floor; and 1 in 6th floor. 09/07/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 3rd floor; 1 Certified Nursing Assistant scheduled in 4th floor; and 1 Certified Nursing Assistant scheduled in 5th floor. 09/08/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 2nd floor; 1 Certified Nursing Assistant scheduled in 3rd floor; 1 Certified Nursing Assistant scheduled in 4th floor; 1 Certified Nursing Assistant scheduled in 5th floor; and 6th floor had no scheduled Certified Nursing Assistant. 09/15/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 4th floor; and 1 Certified Nursing Assistant scheduled in 5th floor. 09/22/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 6th floor. 09/28/2024 Night Shift: There was 1 Certified Nursing Assistant scheduled in 4th floor; and 1 scheduled in 5th floor. A review of the Daily Staff Posting was compared with the actual facility staffing grid. The review revealed several inaccuracies documented as follows: 07/13/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 8. 07/14/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 6. 07/20/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 7. 07/28/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 7. 08/04/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 9. 08/10/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 7. 08/11/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 8. 08/18/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 9. 08/24/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 8. 08/25/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 8. 09/07/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 7. 09/08/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 4. 09/15/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 8. 09/22/2024: Documented 10 Certified Nursing Assistants for the night shift, the staffing grid showed 9. On 10/10/2024 at 2:33 PM, the Staffing Coordinator was interviewed and stated they were short in staff mainly during weekends due to call outs and religious reasons. They stated it is hard to find a replacement when staff calls out. On 10/16/2024 at 11:37 AM, Nurse Liaison #1 was interviewed and stated they started working in the facility in 11/2023. They stated they are not a Certified Nursing Assistant and is tasked to work in the unit when there is short staffing. They stated they help the Certified Nursing Assistants with transferring and ambulating residents. On 10/15/2024 at 4:38 PM, the Director of Nursing was interviewed and stated that there is short staffing coverage during the night shift especially during the weekends, and nurse liaisons are utilized as 2nd Certified Nursing Assistants in the unit. The Director of Nursing stated despite having contracts with different agencies, they are still struggling with their staffing. 10 NYCRR 415.13 (a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Recertification Survey from 4/3/23 to 4/11/23, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 1 (Unit 6) of 6 units. Specifically, Unit 6 was observed with wheelchairs (WC) with torn armrests, torn and frayed mesh on shower chairs, the dining room floor in disrepair, resident closets and bedside tables in disrepair, missing molding, and a bathroom door in disrepair. The findings are: The facility undated policy titled Resident WC Cleaning documented WCs shall be cleaned at least once per month for each resident. On 04/03/2023 at 10:00 AM and 4/10/23 at 11:00AM on Unit 6, the following was observed: 1.) a large shower chair in the tub room with torn and tattered black mesh; 2.) a standard shower chair in the tub room with torn and frayed blue mesh. 3.) bathroom door across from the clean linen room in disrepair with splintering wood along the bottom of the door; 4.) Resident #30 sitting in their WC with cracked and torn armrests and wheel spokes layered with dirt and dust; 5.) room [ROOM NUMBER] with a closet side panel splintered and missing wooden pieces; 6.) room [ROOM NUMBER] with loose fitting molding around the sink; 7.) room [ROOM NUMBER] with a recliner with bilateral armrests exposing their inner wood and foam; 8.) room [ROOM NUMBER]A with a bedside table with a splintered wooden corner; 9.) room [ROOM NUMBER]B with a heavily worn bedside table with a splintered wooden piece sticking out from the bottom dresser drawer; 10.) Dining room floor that was not level with missing and cracked floor tiles; 11.) room [ROOM NUMBER]B with torn and ripped floor mats; 12.) room [ROOM NUMBER]A with a recliner that had torn and tattered blue vinyl near the legrest. 13.) room [ROOM NUMBER] with loose fitting and missing molding around the sink. On 04/11/23 at 09:04 AM, Registered Nurse (RN) # 2 was interviewed and stated repairs or replacement needs are communicated via a Maintenance Logbook (MLB) located on the units. RN #2 will call maintenance directly is there is an urgent concern. Maintenance usually fixes things right away. RN #2 stated the staff need to be more mindful about reporting repair needs for resident equipment to Maintenance. On 04/11/23 at 09:07 AM, the Director of Environmental Services (DES) was interviewed and stated they schedule staff to clean rooms, floors, and WCs. The DES checks the cameras to see the location of their Housekeeping staff on the units and if they are working on their assignment. At 3PM, the DES makes rounds to check that the assignments have been completed. WC cleaning is conducted twice weekly on the night shift. On 04/11/23 at 09:34 AM, the Director of Maintenance (DM) was interviewed and stated their department has 4 Maintenance workers. One worker is assigned to address immediate repairs and replacements. Two of the workers are responsible for buffing and painting. One worker is assigned to check the MLB on the units and attend to those repair concerns. Maintenance rounds are done to ensure the safety of residents, staff, and visitors. The DM checks fire exit doors for egress, alarms, ceiling and floor tiles, lighting, stairways, and emergency exit doors. The DM follows up after their workers have completed their assignments and inspects the MLB. The DM makes rounds weekly. The floor tiles on the 6th floor need to be fixed and the flooring is too old for the DM to repair on their own. It is a big project. The Maintenance Department tries to find tiles that match the dining room floor, but they are almost non-existent. On 04/11/23 at 10:41 AM, the Administrator was interviewed and stated the facility is planning on meeting with a vendor to discuss renovations on Units 4, 5, and 6. 415.5(h)(2) 415.29(c)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey from 4/3/23 to 4/11/23, the facility did not ensure a resident and their representative were provided with a written summary of the baseline care plan (BCP). This was evident for 1 (Resident #61) of 2 residents reviewed for Discharge out of 35 total sampled residents. The findings are: The facility policy titled Care Plans - Baseline reviewed 3/18 documented a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The resident and their representative will be provided a summary of the BCP. Resident #61 was admitted to the facility on [DATE] with diagnoses of pelvic fracture and fracture of upper right humerus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #61 was cognitively intact, and the resident and family participated in the assessment and goal setting. On 4/4/23 at 9:05 AM, Resident #61 was interviewed and stated that they were admitted to the facility for short-term placement. Resident #61 stated they were not provided a copy of their BCP or invited to an interdisciplinary care plan meeting. The BCP dated 2/14/23 documented Resident #61 was cognitively intact, will participate in care plan meetings, and will be notified of updates to their plan of care. There was no documented evidence Resident #61 and/or their family was provided with a copy of the BCP. On 4/6/23 at 11:02 AM, the Director of Social Work (DSW) was interviewed and stated the BCP is completed by the interdisciplinary team (IDT) within 24 to 48 hours of resident's admission. Residents are not provided with a copy of the BCP. All residents will be given the summary of BCP going forward. 415.11 (c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #61 was admitted [DATE] with diagnoses of pelvic fracture and fracture of the upper right humerus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #61 was cognitively intact, and the resident and family participated in the assessment and goal setting. On 4/4/23 at 9:05 AM, Resident #61 stated they have not been invited to a CCP meeting with the interdisciplinary team (IDT). The Baseline Care Plan (BCP) dated 2/14/23 documented Resident #61 was alert, cognitively intact, and would participate in CCP meetings. The Social Services note dated 2/28/23 documented Resident #61's friend was invited to the CCP meeting with the IDT on 3/1/23. The Social Services note dated 3/1/23 documented Resident #61's friend attended the CCP meeting with the IDT via telephone. There was no documented evidence Resident #61 was invited to attend their CCP meeting on 3/1/23 with the IDT. On 4/6/23 at 11:06 AM, the Director of Social Work (DSW) was interviewed and stated Resident #61 is cognitively intact but was unable to participate at the time of their scheduled CCP meeting. Resident #61 wanted to be left alone, wanted to be in bed, was unstable, and was dismissive to staff. Resident #61's friend was invited to the CCP meeting instead and participated via telephone. On 4/11/23 at 10:57 AM, the Director of Nursing (DNS) was interviewed and stated Resident #61 was not invited to the meeting because the staff determined that the resident would have not been able to participate in the meeting. Resident #61 is currently stable and able to participate in the care plan meeting. Residents should be afforded the opportunity to attend the CCP meetings. 415.11(c)(2)(i-iii) Based on observation, interviews, and record review conducted during the recertification survey from 4/3/23 to 4/11/23, the facility did not ensure the participation of the resident and the resident's representative in the development of the comprehensive care plan (CCP), and the review and revision of the CCP after each assessment. This was evident for 2 (Residents #135 and #61) of 38 total sampled residents. Specifically, 1) Resident #135's CCP related to altered respiratory status was not revised to reflect the resident's oxygen use, and 2) Resident #61 was not invited to their CCP meeting. The findings are: The facility policy titled CCP Policy Statement last revised 2022 documented the facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1) Resident #135 had diagnose of asthma and aspiration pneumonia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #135 was cognitively intact and did not have shortness of breath. The CCP related to altered respiratory status initiated 9/5/22 and last updated 3/9/23 documented Resident #135 had a diagnosis of asthma. Interventions included to administer medication as ordered and to learn signs of respiratory compromise. The Physician Orders dated 3/28/23 documented Resident #135 receive oxygen 2-3 liters via nasal cannula every shift for shortness of breath. There was no documented evidence the CCP related to altered respiratory status was reviewed and revised to include Resident #135's oxygen therapy. On 4/10/23 at 10:04 AM and 10:28 AM, Registered Nurse (RN) #2 was interviewed and stated Resident #135 receives oxygen on an as needed basis. Oxygen therapy should be on the resident's respiratory CCP and the supervisor is responsible for updating the CCP. On 4/10/23 at 10:15 AM, RN #3 was interviewed and stated Resident #135's oxygen saturation is checked every shift and oxygen therapy is provided as needed. RN #3 is a new supervisor and has not updated CCPs yet. On 4/10/23 at 11:15 AM, an interview was conducted with the Director of Nursing (DNS) who stated an order for a resident to receive oxygen should be included on the resident's CCP. The DNS confirmed Resident #135 had an order for oxygen therapy that was not reflected on their respiratory CCP. The nursing supervisor staff responsible for updating CCPs are mostly new and being trained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey from 4/3/23 to 4/11/23, the facility did not ensure treatment and care were provided in accordnace with professional standards of practice. This was evident for 1 resident (Resident #84) reviewed for Infection/Transmission-Based Precautions out of 35 total sampled residents. Specifically, the facility did not ensure Resident #84 received care for a right upper arm intravenous (IV) midline. The findings are: The facility policy titled Midline Dressing changes dated April 2022 documented change the midline catheter dressing 24 hours after catheter insertion, every 7 days, and as needed if it is wet, dirty, not intact, or compromised in any way. Label the dressing with initials, date, and time. Resident #84 was readmitted to the facility 3/24/2023 with diagnoses of diabetes mellitus and anemia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #84 was cognitively intact and required extensive assistance from staff to complete activities of daily living. On 04/04/23 at 12:09 PM, Resident #84 was observed with an IV midline inserted in their right upper arm. Dressing placed on the midline site was dated 3/18, appeared dirty and brown, and the surrounding skin area was red. Resident #84 stated that the midline has been in their arm for over a month, and they did not know the purpose of it. The red skin surrounding the IV midline is itchy, the line has not been flushed, and Resident #84 cannot recall the last time the dressing was changed. The Hospital Physician Discharge summary dated [DATE] documented Resident #84 had a urinary tract infection that was treated with IV antibiotics for 7 days. The Nursing Note dated 3/24/2023 documented Resident #84 had and IV midline to the right upper arm. The Medical Doctor (MD) Note dated 3/25/23 documented a readmission evaluation of Resident #84. There is no documented evidence the MD assessed and addressed Resident #84's IV midline. A Progress note Nurse Practitioner dated 3/27/2023 documented the resident was seen and examined for current medical management. Chart reviewed. Medications reconciled. There was no documentation regarding the presence of an IV midline. There was no documented evidence nursing staff, the MD, and the Nurse Practitioner (NP) assessed and coordinated a plan of care to address Resident #84's IV midline. There were no physician's orders for the IV midline care. There was no documented evidence a Comprehensive Care Plan was created to address the care needs for the IV midline. On 04/07/23 at 10:30 AM, an interview was conducted with the Registered Nurse (RN) #1 who stated Resident #84 was transferred to the hospital 3/17/23 for abnormal lab values and re-admitted to the facility 3/24/23 with an IV midline in place. The IV midline was kept in place because staff thought it could be used again. RN #1 was not able to explain the reason there was no treatment or plan of care to address Resident #84's IV midline. On 04/10/23 at 09:36 AM, an interview was conducted with the RNS #2 who stated Resident #84 had an IV midline that was supposed to be assessed by the NP the day after the resident was readmitted . There is a risk of infection if the IV midline is not flushed, and the dressing is not changed. It was an oversight that Resident #84 did not have proper oversight and maintenance of their IV midline in place. On 04/10/23 at 11:05 AM, an interview was conducted with the Director of Nursing (DON) who stated there is risk of the resident developing infection if their IV midline is not maintained. The admission nurse and the supervisor should have checked Resident #84's IV midline plan of care. On 04/07/23 at 11:15 AM, an interview was conducted with the MD #1 who stated IV midlines are removed once antibiotic is completed. Until the line is removed, it should be flushed, and the dressing should be changed and dated by the nurses. MD #1 was covering for another MD and was not familiar with Resident #84. MD #1 was not aware Resident #84 had an IV midline without a MD order for dressing change and flushing. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey from 4/3/23 to 4/11/23, the facility did not ensure the physician reviewed the resident's total program of care, including medications and treatments, at each visit. This was evident for 1 resident (Resident #84) reviewed for Infection/Transmission-Based Precautions out of 35 total sampled residents. Specifically, the physician did not evaluate Resident #84 for the continuation of a right upper arm intravenous (IV) midline upon admission, and there were no physician's orders for care of the IV midline. The findings are: The facility policy titled Midline Dressing changes dated April 2022 documented change the midline catheter dressing 24 hours after catheter insertion, every 7 days, and as needed if it is wet, dirty, not intact, or compromised in any way. Label the dressing with initials, date, and time. Resident #84 was readmitted to the facility 3/24/2023 with diagnoses of diabetes mellitus and anemia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #84 was cognitively intact and required extensive assistance from staff to complete activities of daily living. On 04/04/23 at 12:09 PM, Resident #84 was observed with an IV midline inserted in their right upper arm. Dressing placed on the midline site was dated 3/18, appeared dirty and brown, and the surrounding skin area was red. Resident #84 stated that the midline has been in their arm for over a month, and they did not know the purpose of it. The red skin surrounding the IV midline is itchy, the line has not been flushed, and Resident #84 cannot recall the last time the dressing was changed. The Hospital Physician Discharge summary dated [DATE] documented Resident #84 had a urinary tract infection that was treated with IV antibiotics for 7 days. The Nursing Note dated 3/24/2023 documented Resident #84 had an IV midline to the right upper arm. The Medical Doctor (MD) Note dated 3/25/23 documented a readmission evaluation of Resident #84. There was no documented evidence the MD assessed and addressed Resident #84's IV midline. A Progress note Nurse Practitioner dated 3/27/2023 documented the resident was seen and examined for current medical management. Chart reviewed. Medications reconciled. There was no documentation regarding the presence of an IV midline. There was no documented evidence nursing staff, the MD, and the Nurse Practitioner (NP) assessed and coordinated a plan of care to address Resident #84's IV midline. There were no physician's orders for the IV midline care. On 04/07/23 at 10:30 AM, an interview was conducted with the Registered Nurse (RN) #1 who stated Resident #84 was transferred to the hospital 3/17/23 for abnormal lab values and re-admitted to the facility 3/24/23 with an IV midline in place. The IV midline was kept in place because staff thought it could be used again. RN #1 was not able to explain the reason there was no treatment or plan of care to address Resident #84's IV midline. On 04/10/23 at 09:36 AM, an interview was conducted with the RNS #2 who stated Resident #84 had an IV midline that was supposed to be assessed by the NP the day after the resident was readmitted . There is a risk of infection if the IV midline is not flushed, and the dressing is not changed. It was an oversight that Resident #84 did not have proper oversight and maintenance of their IV midline in place. On 04/10/23 at 11:05 AM, an interview was conducted with the Director of Nursing (DON) who stated there is risk of the resident developing infection if their IV midline is not maintained. The admission nurse and the supervisor should have checked Resident #84's IV midline plan of care. On 04/07/23 at 11:15 AM, an interview was conducted with the MD #1 who stated IV midlines are removed once antibiotic is completed. Until the line is removed, it should be flushed, and the dressing should be changed and dated by the nurses. MD #1 was covering for another MD and was not familiar with Resident #84. MD #1 was not aware Resident #84 had an IV midline without a MD order for dressing change and flushing. 415.15(b)(2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey from 4/3/23 to 4/11/23, the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. This was evident for 1 (Residents # 136) of 5 residents reviewed for Unnecessary Medications out of 35 total sampled residents. Specifically, non-pharmacological interventions were not used to address Resident #136's behaviors and an antipsychotic medication was administered without attempting a Gradual Dose Reduction (GDR). The findings are: The facility policy titled Use of Psychotropic Medication dated 2022 documented that the residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication. Resident # 136 was admitted to the facility on [DATE] with diagnoses of vascular dementia with behavioral disturbance and mood disorder. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #136 was independent in decision making had short and long-term memory impairments, felt down, exhibited no inappropriate behaviors, received antipsychotic medication, and did not have a GDR. The MDS dated [DATE] documented Resident #136 had moderate judgment impairments, short and long-term memory loss, felt down, exhibited no inappropriate behavior, received antipsychotic medications, and did not have a GDR. On 04/04/23 at 11:16 AM, 04/06/23 at 12:03 PM, 04/07/23 at 2:05 PM, and 04/11/23 at 12:07 PM, Resident #136 was observed in the unit common areas and interacting with staff in a calm and stable manner. The Comprehensive Care Plan (CCP) related to antipsychotic use initiated 12/19/21 and last updated 3/3/23 documented Resident #136 received Haldol for psychosis and the pharmacist and Medical Doctor (MD) would be consulted to consider dose reduction at least quarterly. The CCP related to behavior documented Resident #136 became easily agitated and would go to the kitchen and lobby during COVID-19 precautions. Interventions included assisting the resident with developing more appropriate methods of coping. MD Order dated 5/19/22 and last renewed 3/31/23 Resident #136 was ordered to receive 1ml of Haloperidol Lactate 2mg/ml daily for mood disorder. Psychiatry Consult dated 11/3/22 documented Resident #136 was suspicious, reported they were fine, and did not elaborate due to cognitive impairment. The chart was reviewed, and Resident #136 was noted with aggressiveness and agitation. Resident #136 had a calm and appropriate affect and had no paranoid ideations or delusions. The Psychiatrist documented a recommendation to continue Haldol 2mg to target cognitive impairment, mood swing, and agitation. Psychiatry Consult dated 1/12/23 documented Resident #136 was suspicious and became hostile and refused to be interviewed. Per staff, Resident #136 is unpredictable but recently less aggressive. The consult documented Resident #136 had paranoid ideation, had diagnoses of dementia and mood disorder, and should continue Haldol 1mg daily. Nursing Behavior Note dated 2/10/23 documented Resident #136 continued Haldol 1ml for mood disorder. Resident #136 is suspicious of anyone going to clean their room and becomes cooperative once everything is left the way the resident left it. Resident #136 becomes calm after provided with reassurance. Nursing Practitioner (NP) Note dated 2/21/23 documented Resident #136 refused blood work and displays medical noncompliance. Psychiatry Consult dated 2/23/23 documented Resident #136 had a history of dementia, was suspicious, and refused to be interviewed. Resident #136 was calm with no problem and appropriate affect, was noted with refusal of care and was on Haldol. Per staff, Resident #136 was unpredictable and aggressive at times. Resident #136 had no delusions, had paranoid ideation, was diagnosed with dementia with psychosis, mood disorder, and psychosis due to general medical condition and was recommended to continue Haldol 1mg daily. A GDR was not attempted in the last 4-6 months in accordance with relevant current standards of practice and would likely impair the resident's function. NP Note dated 2/24/23 documented Resident #136 was evaluated by the Psychiatrist on 2/23/23 and the NP agrees with the recommendation to continue Haldol 1mg daily. Nursing Behavior Note dated 2/24/23 documented Resident #136 was calm, quiet, and had no aggressive behavior. NP Note dated 3/8/23 documented Resident #136 refused blood work multiple times despite education Nursing Behavior Note dated 4/4/23 documented Resident #136 showed no episode of agitation. Resident #136 prefers their room to be cleaned while in the presence of someone familiar. There was no documented evidence the facility used non-pharmacological interventions to address Resident #136's behavior. There was no documented evidence a GDR was ordered to address Resident #136's long-term use of Haldol 1ml (2mg) daily. On 04/11/23 at 10:06 AM, Certified Nursing Assistant (CNA) #1 was interviewed and stated they have been assigned to Resident #136 for 1 month and the resident has not exhibited any behaviors. Resident # 136 follows simple directions without complaint and walks to the dining room almost daily and watch TV. Resident #136 is quiet and calm most of the time. During an interview conducted on 04/11/23 at 10:32 AM, Licensed Practical Nurse (LPN)# 1 stated Resident# 136 has not displayed any untoward behavior issue for several months. During an interview conducted on 04/11/23 at 10:41 AM, Nurse Practitioner (NP)# 1 stated Resident #136 has not had any behavioral outburst. There was no attempt to GDR Resident #136's Haldol because they are new to the facility and Resident #136 is new under their care. During an interview on 04/11/23 at 11:15 AM, MD# 2 stated they cannot remember what antipsychotic medications were ordered for Resident #136 and they will check the resident's medication list. MD #2 did not return to finish the interview. During an interview on 04/11/23 at 11:27 AM, the Director of Nursing (DON) stated they are aware that Resident # 136 has not exhibited any behaviors recently and they will have a meeting with the Psychiatrist about Resident #136's plan of care. The Consulting Pharmacist reviews the resident's medication regimen every month, and their recommendation is documented in the resident's medical record. The medical team reviews the recommendations to make sure the recommendations are addressed. There were no recent pharmacy recommendations for Resident #136. The DON stated they could not explain the reason Resident #136 did not receive a GDR. During an interview on 04/11/23 at 11:46 AM, the Medical Director stated they do not like prescribing Haldol and will reassess Resident #136. 415.12(1)(2)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during the Recertification survey and abbreviated survey (NY00252328), the facility failed to notify a resident's representative when there was a need to alter treament significantly. Specifically, a resident's representative was not informed when the resident was started on a new medication, Ambien, at bedtime. This was evident for 1 of 2 residents reviewed for Notification of Change (Resident #336). The finding is: The Facility Policy titled Change in a resident's condition dated February 2020 documented the nurse will notify the resident's representative when there is significant change in the resident's physical, mental or psychosocial status. Except in medical emergencies, notifications will be made within 24 hours of a of change occurring in the resident's medical/mental condition or status. The nurse will record in resident's medical record information relative to changes in the resident's medical, and mental condition or status. In adition, the nurse is responsible for notifying the resident or resident representative of any changes in medical treatment. Resident # 336 was admitted with diagnoses which include diabetes type 2, chronic kidney disease, heart failure, hypertension and dysphagia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident is cognitive level is severely impaired and she is totally dependent and requires two persons assist for most activities of daily living. The Physician orders from December 2019 to February 2020 documented the resident was put on Ambien 10 mg at bedtime on 12/23/19, and it was discontinued on 2/2/20. Medication Administration Record from 12/23/19 to 02/02/20 documented that the resident received Ambien 10 mg at bedtime. Physician notes from December to January documented that the resident to continue all medications including Ambien 10 MG at bedtime. There is no documentation regarding notifying the representative of the medication change. The Nursing notes from 12/23/19 to 02/11/20 documented no evidence that the resident representative was notified of the resident being prescribed Ambien. A Care plan meeting note dated 1/2/20 documented that rehabilitation service, wound care and level of assistance were discussed with resident's representative. There was no documented evidence that changes in medication was discussed during the meeting. On 4/08/21 at 11:10 AM, the Registered Nurse (RN #4) was interviewed and stated if there are any changes in condition and changes in medications, the family/representative would be notified. A Nursing note would be written. All Changes would be discussed with the team and also the oncoming shift. Family members are contacted within 24 hours. RN #4 stated that she is new, and she was not there when the resident was on the fifth floor. There is supposed to be a nursing note in the chart anytime there are any changes in condition or medication. Nursing is responsible for contacting the family of any changes in condition and any changes in medications. On 04/08/21 at 03:23 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated whenever there is a change in condition, the facility should notify the family members right away. Families are notified of changes in residents' conditions and treatments within 24 hours. The ADNS acknowledged that there was no note that documented that the resident's family member was notified when the resident was prescribed Ambien. A nursing note should have been written to show that the family was contacted. Nursing staff are responsible for contacting the family members of any changes in condition or treatment. On 04/09/21 at 11:06 AM, the Social Worker was interviewed and stated that the resident had an initial care plan meeting on January 2, 2020. They discussed Physical and Occupational therapy services and level of assistance needed by resident. Medication changes were not discussed. On 04/09/21 at 03:30 PM, the Director of Nursing (DNS) was interviwed and stated that if a resident is put on new medications, the family is supposed to be informed right after the Doctor puts in a new order, before the medication is initiated. The family will either consent or disagree before any medication can be initiated. The family members should be contacted as soon as a new medication is prescribed. The family member should have been informed that the resident was prescribed Ambien. The DNS stated that the team discussed all changes including new medications during morning report. The DNS further stated that the ADNS and the DNS check the charts to ensure the nurses and nurse supervisors are informing the family members right away. The ADNS and the DNS are responsible for ensuring that the nurses contact families immediately regarding any changes in condition or medication. 483.10(g)(14)(i)-(iv)

Based on record review and staff interview during the Recertification and Abbreviated survey (NY00273390), the facility did not ensure that all alleged violations were thoroughly investigated within 5 workdays and reported to the administrator or his or her designee. Specifically, Accident/Incident (A/I) investigations were not fully completed to rule out neglect. This was evident for 2 of 2 residents reviewed for Fall (Resident #51 and # 115). The findings are: 1) Resident #51 had diagnoses which include Non-Alzheimer's Dementia, Peripheral Vascular Disease, and Hypertension. The Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) 01/27/2021 documented that Resident #51 had severely impaired cognition with long and short-term memory problems. The MDS documented the resident required Supervision with setup help only for bed mobility, transfer, walking, and locomotion on and off the unit. The resident required limited assistance for toileting, dressing, and personal hygiene, and they were always continent of bowel and bladder. A Nursing Note documented on 03/13/2021 at 6:30pm documented that resident was observed at 5:35 pm lying on the back between beds A and B, alert. The resident was verbally responsive and stated, I wanted to go to the bathroom, get up from the bed and fell, don't know how exactly. The resident complained of pain in left hip. Left hip with swelling and tenderness. ROM (Range of Motion) in left leg limited due to pain. No loss of sensation noted. Skin intact. No other visible injury noted. Dr notified; telephone order received to transfer resident to hospital to r/o (rule out) fracture. Accident/Incident Report and Investigation Form dated 3/15/2021 documented no evidence that the investigation of the resident's fall was completed and reviewed to determine whether there was cause to believe any alleged resident abuse, mistreatment or neglect occurred regarding. A Nursing Progress note documented on 3/19/2021 at 3:40 pm documented that the resident was readmitted from hospital with Primary diagnosis: s/p slip and fall, left femur fracture. Resident post ORIF of fracture of left hip using trochanteric nail; 22 staples in place covered with dressing. Resident requires total care, incontinent of bowel and bladder. Progress note Nursing documented on 04/04/2021 at 11:46 pm documented that resident was observed sitting on the floor with head and shoulders leaning against the bathroom door, stated she wants to go to the bathroom by herself and forgot to use the call bell for help. Complained of pain to left lower extremity, more to the left hip. Placed back to bed by staff. Body check done; no visible injury noted. Dr made aware and ordered to transfer resident to hospital to rule out fracture. Accident/Incident Report and Investigation Form dated 4/5/2021 documented no evidence that the investigation of the resident's fall was completed and reviewed to determine whether there was cause to believe any alleged resident abuse, mistreatment or neglect occurred. 2) Resident #115 was admitted with diagnoses which include Cerebral Vascular Accident (CVA), Hemiplegia, and Hypertension (HTN). The Quarterly Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 02/27/2021, documented that Resident #115 had moderately impaired cognition. The MDS also documented that the resident required supervision with setup help for Bed Mobility, Extensive Assistance of 1 for transfer, dressing, toileting, and personal hygiene; Limited assistance of 1 for locomotion on unit, and total dependence of 1 off unit. On 04/05/21 at 12:04 PM, Resident #115 was observed sitting on wheelchair in the room having lunch. Resident stated they fell 2 times in the bathroom a couple of weeks ago, and they were assisted back to the chair with staff assistance. The resident stated they are able to toilet themself but will sometimes call for staff to help if needed. Progress Note Nursing dated 02/27/21 documented that resident #115 was observed on the floor in the bathroom by the unit housekeeper at 7:25 am. Resident was assisted off the floor with no visible injury and stated that after finished using the bathroom, went to sit on the wheel chair and flipped. Accident/Incident Report and Investigation Form dated 3/1/2021 documented no evidence that the investigation of the resident's fall was completed to reveal there is no cause to believe any alleged resident abuse, mistreatment or neglect has occurred regarding resident #115. On 04/08/21 at 11:05 AM, an interview was conducted with the Registered Nurse (RN#3). RN #3 is currently assigned to Resident #115 and was assigned to Resident #51 at the time of the first fall. RN #3 stated that the AI report is always completed by every staff member that worked at the time of the incident and reviewed by the RN Supervisor of the unit and by the Assistant Director of Nursing/Director of Nursing. The Assistant Director of Nursing (ADON) was interviewed on 04/08/21 at 02:44 PM. The ADON stated that the Accident/Incident Report and Investigation Form completed after residents' fall is reviewed by DON. The ADON was unable to state the reason why the investigation reports were not completely reviewed. 04/09/21 at 11:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility is trying to reinforce educating staff on the need to be more efficient on episodic care plan. The DON also stated that the facility has a list of projects, which includes re-education of staff on proper documentation of Accident and Accident report to make better AI reporting to ensure proper conclusion and recommendations are in place. 415.4(b)(1)(ii)

Based on observation, record review, and interview, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, a resident's Minimum Data Set 3.0 (MDS) assessment documented the resident had a trunk restraint used in the chair or out of bed when the resident had no restraint. This was evident for 1 of 1 resident reviewed for MDS accuracy (Resident #123). The finding is: The CMS RAI Version 3.0 Manual (Dated October 2018), titled Procedure: General Information documented The RAI, MDS 3.0 process requires input from the health care team to complete the designated areas in a timely and accurate fashion in accordance with State and Federal regulations. Resident #123 was admitted to the facility with diagnoses that included Hypertension, Peripheral Vascular Disease, and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 3/05/2021, documented the resident had severely impaired cognition with long and short-term memory problems. The MDS also documented that the resident had a Trunk restraint used in chair or out of bed. On 04/05/21 at 10:34 AM, the resident was observed in the hallway sitting in wheelchair. The resident had no type of restraint in place, contrary to MDS indicator. On 04/08/21 at 10:35 AM, an interview was conducted with the Certified Nursing Assistant, (CNA #4), who cared for the resident for over a year. CNA #4 stated no restraint has ever been used on the resident. On 04/08/21 at 11:16 AM, an interview was conducted with the Registered Nurse (RN #3). RN #3 stated that resident is very calm and cooperative and has never been displayed any behavior that may require the use of restraint. RN #3 stated that documentation of restraint in the resident's MDS might have been error from the MDS assessor. On 04/08/21 at 11:25 AM, an interview was conducted with the MDS Coordinator (MDSC) that has been working in the facility for 7 months. MDSC stated that during the assessment period, they see and assess the resident, review the CNA accountability record, speak with the CNA and the nurses giving care to the resident, and review the medical record and doctors' record. The MDSC stated that if any discrepancy is noted when reviewing the documentations and assessing the resident, the appropriate staff are interviewed to reconcile the differences. Every department is responsible for checking for accuracy of documentation, while MDS Coordinator checks for the completeness of the assessment. The Coordinator stated that documentation indicating that resident had restraint is an error, and it was corrected during the review of the MDS on 4/5/2021. The MDSC stated that the Interdisciplinary Team members responsible for assessment and documentation of MDS are trained and get certified every 2 years, and if there is an update, get it through webinars regularly. The MDSC further stated that the mistake is highly regrettable and stated that in-service will be given to the MDS assessors to be more careful and to ensure accuracy in documentation The Director of Nursing (DON) was interviewed on 04/09/21 at 02:17 PM and stated the MDS error was a mistake. The DON stated that restraint documented on MDS was accidentally checked off and submitted. DON further stated that once the MDS review was conducted and they saw that the facility flagged for restraint, it was corrected right away. DON stated that this was a mistake and will not happen again. 415.11(b)

Based on record review and staff interview during the Recertification and Abbreviated survey (NY00273390), the facility did not ensure adequate supervision and assistance was provided to a resident to prevent an accident. Specifically, a resident identified as high risk for fall/injury, with severely impaired cognition, had fall with injury while trying to use bathroom. The resident's care plan was not reviewed and revised with interventions to prevent additional falls. The resident was readmitted from the hospital and had another fall while attempting to use the bathroom. This was evident in 1 of 2 residents reviewed for Accident/Fall (Resident #51). The finding is: (1) Resident #51 had diagnoses which include Non-Alzheimer's Dementia, Peripheral Vascular Disease, and Hypertension. The Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) 01/27/2021 documented that Resident #51 had severely impaired cognition with long and short-term memory problems. The MDS documented the resident required Supervision with setup help only for bed mobility, transfer, walking, and locomotion on and off the unit. The resident required limited assistance for toileting, dressing, and personal hygiene, and they were always continent of bowel and bladder. The Comprehensive Care Plan (CCP) for Fall dated 11/01/2020 documented that resident is at risk for falls/injury related to history of falls and cognition deficit. Interventions documented include: - Complete fall assessment and review within 90 days; Maintain clutter free environment; Call bell within reach; Keep bed in low position with wheels locked; Make frequent safety check; Observe balance and safety awareness; Physical therapy consult as needed for falls or change in gait. Progress Note dated 03/13/2021 at 6:30pm documented the resident was observed at 5:35 pm lying on the back between beds A and B, alert and verbally responsive. The resident stated, I wanted to go to the bathroom, get up from the bed and fell, don't know how exactly. The resident complained of pain in left hip. Left hip with swelling and tenderness. Dr notified; telephone order received to transfer resident to hospital to r/o (rule out) fracture. Progress note dated 3/19/2021 at 3:40 pm documented that the resident was readmitted from the hospital with Primary diagnosis: s/p (status post) slip and fall, left femur fracture. Resident post ORIF (Open Reduction Internal Fixation) of fracture of left hip using trochanteric nail; 22 staples in place covered with dressing. Resident requires total care and was incontinent of bowel and bladder. Resident's assessment done after the fall identified that the resident was at higher risk for falls secondary to poor balance and severe cognitive impairment with non-compliant behavior. The post fall assessment also identified that the resident required assistance for toileting. There was no documented evidence that facility looked at the circumstances of the fall and developed interventions to address the causes of the fall to prevent additional falls. The CCP was not updated with new interventions, and there were no individualized specific interventions developed regarding monitoring frequency, supervision, or toileting assistance in efforts to eliminate or reduce the risk of an additional fall. There was no documented evidence in the medical record that the resident was on a toileting schedule. A Nursing Progress Note dated 04/04/2021 at 11:46 pm documented that the resident had another unwitnessed fall. The resident was observed sitting on the floor with head and shoulders leaning against the bathroom door. The note documented that the resident wanted to go to the bathroom but forgot to use the call bell for help. The resident hit their head against the door and was transferred to hospital to rule out fracture. The resident had another fall attempting to use the bathroom. There was no documented evidence that the Fall CCP, updated with a note on 4/5/21, was reviewed to determine the effectiveness of current interventions and revised with individualized interventions to reduce the risk further falls. On 04/07/21 at 03:27 PM, an interview was conducted with the Certified Nursing Assistant (CNA #1) assigned to the resident on a rotating basis. The CNA stated that resident was able to do most of the things by herself before the 1st fall, able to toilet self, and perform hygiene care, staff just needed to keep eye on her. CNA stated that a noise was heard from the resident's room located very close to the nursing station on the day of the accident, went into the room to notice the resident on the floor close by to the bathroom. Went to call the charge nurse who came in to check the resident and then called the supervisor. CNA stated that resident was supported with the pillow on the floor while the ambulance was called to take the resident to the hospital. CNA stated that all residents are constantly being checked by the staff to see who might need help or assistance, or to answer to residents' call bell. On 04/07/21 at 03:52 PM, an interview was conducted with CNA #2, assigned to take care of the resident whenever the regular CNA is not on duty. CNA #2 stated that resident was on her assignment the day of incident. CNA #2 stated that resident was last seen in the room sitting on the regular chair when the dinner tray was picked up and resident's bed was opened to prepare resident for bed whenever is ready. CNA #2 stated that resident was able to toilet self and perform hygiene care and would call for assistance if anything is needed. On 04/07/21 at 04:15 PM, interview was conducted with the Registered Nurse (RN #1) in charge of the unit when the resident fell on 4/4/21 at 10:40pm. RN #1 stated that a noise was heard from the resident's room while sitting at the nursing station. RN #1 went to check and observed the resident sitting on the floor with their back on the bathroom door. An assessment was done with no visible injury, and the resident was transferred to the hospital for further evaluation as per order. RN #1 stated that Resident #51 is occasionally incontinent of bowel and requires a Hoyer lift with assistance of 2 staff for toilet transfer. RN #1 stated that the resident was being given a bed pan for toileting every 2 hours or whenever in need. RN #1 stated that sometimes the resident will be constantly ringing the bell to be taken to the bathroom at night, and they always re-educated the resident that bed pan will be given as it requires Hoyer lift to transfer the resident. On 04/08/21 at 02:15 PM, an interview was conducted with CNA #3, assigned to take care of the resident on 4/8/21. The CNA stated that the resident is transferred from bed to chair and back to bed with assistance of 2 staff. The resident also requires assist of two for toileting. The resident calls for help most of the time for bowel movements, and the staff checks regularly every 1 or 2 hours to ask if resident needs to use the bathroom. On 04/08/21 at 02:24 PM, an interview was conducted with the Licensed Practical Nurse (LPN #2) who stated that resident was admitted to the unit for quarantine about 2 weeks ago, transferred to the hospital on Monday morning due to fall, and re-admitted on the evening of 4/6/21. LPN #2 stated that resident has dementia, and staff are constantly keeping eye on them to prevent falling. The resident is taken out of bed and placed close to the nursing station for close monitoring and constant re-direction. LPN #2 also stated that staff are always educated during change of shift report to keep close eye on the resident to prevent falls. On 04/08/21 at 02:33 PM, an interview was conducted with Registered Nurse (RN #2). RN #2 stated that resident was admitted to the unit after the hospitalization for the 1st fall, transferred back to the hospital on 4/5/2021, and readmitted again 4/6/21. RN stated that staff kept a very close eye on the resident after the first fall, constantly re-directed to call for help when trying to get out of bed. Staff were educated to constantly check on the resident when in the room and to ask for any help needed by the resident. RN stated that resident may now be on Q 30min visual check. The resident that was assessed as having severely impaired cognition had a fall with injury on 03/13/2021, while trying to use the bathroom and was hospitalized , re-admitted to the facility, and had another fall on 4/4/2021 (less than 1 month interval) in an attempt to use the bathroom. Record review did not contain documentation that new interventions/measures, including adequate supervision, were implemented in the resident's CCP to reduce the hazards/risks as much as possible. The facility's Accident/Incident Report and Investigation Form dated 4/5/2021 documented no evidence that the investigation of the resident's fall was completed and reviewed to determine whether there was reason to believe any alleged resident abuse, mistreatment or neglect occurred. 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** (4) The facility Policy and procedure on Care Planning-Interdisciplinary Team revised September 2020 documented that the resident, resident's family and/ or the residents legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Resident #48 was admitted with diagnoses which include Cervical Stenosis, Cervical Myelopathy status post decompression and fusion at C-3 to C5 level, and Generalized Muscle Weakness. The admission Minimum Data Set (MDS) dated [DATE] documented the resident was cognitively intact. The MDS documented that the resident participated in the assessment. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident was cognitively intact. The MDS documented that the resident participated in the assessment and no significant other participated in assessment and resident has no guardian or legally authorized representative. On 04/05/2021 at 10:31 AM, Resident #48 was interviewed and stated that since they have been in the facility, they have never been invited to a care planning meeting to discuss their care. The Comprehensive Care Plan Meeting/Signature sheet documented the signatures of persons present at the care plan meetings held on 12/30/2019, 2/24/2020, 5/20/2020 and 8/10/2020. The sheet documented that the resident could participate in his/her plan of care. The resident was not present at any of the meetings per the signatures, and there was no documentation regarding whether the resident was invited to the meetings. The Care Plan Conference meeting notes dated 05/20/2020, 08/10/2020 and 10/26/2020 documented that a care plan was held. The notes did not indicate the resident was present or invited. The Social Service Notes from 1/20/2020 to 10/20/2020 were reviewed. They was no documented evidence that the resident was invited to or refused to attend the care plan meeting. The Nursing Progress Notes and interdisciplinary notes from 12/11/19 to 4/5/21 were reviewed. There was no documented evidence in the medical record that the resident was invited to or participated in any care plan meetings. On 04/07/2021 at 02:27 PM, an interview was conducted with the Registered Nurse (RN #5) on the unit who stated the resident is alert and must have been invited to the care planning meeting. On 04/08/2021 at between 02:45PM and 04:00PM, the Social Worker (SW #2) was interviewed and stated that the resident/resident representative are invited to care planning meetings (initial and annual), and they are not invited to quarterly meetings. The SW #2 looked at the care plan letter binders from 12/31/2018, 1/02/2019 - 1/05/2021 and 1/06/2021, and they found one care planning meeting paper regarding Resident #48 which documented the resident was scheduled for a quarterly meeting 2/24/2020. On 04/09/2021 at 04:00PM, the Minimum Data Set (MDS) Coordinator was interviewed and stated that they were not responsible for inviting residents to the care plan meeting. The Coordinator stated that the resident would be invited to the annual and significant change care plan meetings. They could not locate any evidence that the resident was invited to a care plan meeting since admission. 415.11(c) (1) Based on record review and staff interview during the Recertification and Abbreviated survey (NY00273390), the facility did not ensure that: residents' Comprehensive Care Plans (CCPs) were reviewed and revised after a Fall; and the facility did not ensure cognitively intact cognitively intact residents were invited to participate in the development of their plan of care. Specifically: (1) The residents' CCPs were not reviewed and revised to determine effectiveness of interventions and include new interventions after falls (Resident #51 and #115). (2) Residents were not invited to participate in the care plan meeting (Resident #31 and #48). This was evident for 4 out of 35 residents reviewed in the investigation sample (Resident #s 51, 115, 31, and 48). The findings are: (1) Resident #51 had diagnoses which include Non-Alzheimer's Dementia, Peripheral Vascular Disease, and Hypertension. The Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) 01/27/2021 documented that Resident #51 had severely impaired cognition with long and short-term memory problems. The MDS documented the resident required Supervision with setup help only for bed mobility, transfer, walking, and locomotion on and off the unit. The resident required limited assistance for toileting, dressing, and personal hygiene, and they were always continent of bowel and bladder. The Comprehensive Care Plan (CCP) for Fall dated 11/01/2020 documented that resident is at risk for falls/injury related to history of falls and cognition deficit. Interventions documented include: - Complete fall assessment and review within 90 days; Maintain clutter free environment; Call bell within reach; Keep bed in low position with wheels locked; Make frequent safety check; Observe balance and safety awareness; Physical therapy consult as needed for falls or change in gait. Progress Note dated 03/13/2021 at 6:30pm documented the resident was observed at 5:35 pm lying on the back between beds A and B, alert and verbally responsive. The resident stated, I wanted to go to the bathroom, get up from the bed and fell, don't know how exactly. The resident complained of pain in left hip. Left hip with swelling and tenderness. ROM (Range of Motion) in left leg limited due to pain. No loss of sensation noted. Skin intact. No other visible injury noted. Dr notified; telephone order received to transfer resident to hospital to r/o (rule out) fracture. Progress note dated 3/19/2021 at 3:40 pm documented that the resident was readmitted from the hospital with Primary diagnosis: s/p slip and fall, left femur fracture. Resident post ORIF (Open Reduction Internal Fixation) of fracture of left hip using trochanteric nail; 22 staples in place covered with dressing. Resident requires total care and was incontinent of bowel and bladder. The resident's CCPs updated after the fall of 3/13/2021 and 4/5/2021 were not properly reviewed to determine effectiveness of interventions and CCPs were not immediately revised to include new interventions to prevent further falls - No documentation on the CCPs on how frequent the resident will be monitored, at what interval of time to prevent the falls. No new interventions documented in both CCPs for Fall. No documented evidence of individualized specific implemented interventions, including adequate supervision, consistent with the resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident/fall. A Nursing Progress Note dated 04/04/2021 at 11:46 pm documented that the resident had another unwitnessed fall, resident was observed sitting on the floor with head and shoulders leaning against the bathroom door. Documented that resident wanted to go to the bathroom but forgot to use the call bell for help and hit head against the door. The resident complained of pain to left lower extremity, more to the left hip. Placed back to bed by staff. Body check done; no visible injury noted. Dr made aware and ordered to transfer resident to hospital to rule out fracture. No documented evidence in the updated CCP of 4/5/2021 as to monitor the effectiveness of the interventions and modify the individualized care plan as necessary, in accordance with current professional standards of practice to reduce the risk for further fall. Resident #51, assessed as having severely impaired cognition had a fall with injury on 03/13/2021, while trying to use the bathroom and was hospitalized , re-admitted to the facility, and had another fall on 4/4/2021 (less than 1 month interval) in an attempt to use the bathroom. Record review did not contain documentation that new interventions/measures, including adequate supervision, were implemented in the resident's CCP to reduce the hazards/risks as much as possible. (2) Resident #115 was admitted with diagnoses which include Cerebral Vascular Accident (CVA), Hemiplegia, and Hypertension (HTN). The Quarterly Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 02/27/2021, documented that Resident #115 had moderately impaired cognition. The MDS also documented that the resident required supervision with setup help for Bed Mobility, Extensive Assistance of 1 for transfer, dressing, toileting, and personal hygiene; Limited assistance of 1 for locomotion on unit, and total dependence of 1 off unit. Resident #115 was observed sitting on wheelchair in the room having lunch on 04/05/21 at 12:04 PM. The resident reported to have fallen 2 times in the bathroom couple of weeks ago with no injury and was assisted back to chair by staff. The Comprehensive Care Plan (CCP) for Fall updated 2/27/2021 documented that resident is at risk for fall. Interventions documented include: - Complete fall assessment and review within 90 days; Maintain clutter free environment; Call bell within reach; Keep bed in low position with wheels locked; Make frequent safety check; Lock wheelchair prior transfer. Progress Note Nursing dated 05/16/2020 documented that resident #115 was observed at 9:35 am sitting on the floor next to wheel chair positioned near the bed; Resident states I tries to go to the bed myself, then I slide down; Resident assisted back to wheel chair, body assessment check done, no visible injury noted. Progress Note Nursing dated 02/27/21 documented that resident #115 was observed on the floor in the bathroom by the unit housekeeper at 7:25 am. Resident was assisted off the floor with no visible injury and stated that after finished using the bathroom, went to sit on the wheel chair and flipped. Record review of the resident's CCPs dated 05/16/2020 and 0227/2021 done. No documented evidence of new individualized specific implemented interventions, including adequate supervision, consistent with the resident's needs, goals, care plan in order to eliminate or reduce the resident's risk for fall noted. The resident's CCP dated 2/27/2021 was not reviewed to determine effectiveness of interventions and CCP was not immediately revised to include new interventions to prevent further falls - No documentation on CCP that resident will be monitored, and at what interval of time. Record review did not contain documentation that new interventions/measures, including adequate supervision, were implemented in the resident's CCP to reduce the hazards/risks as much as possible. On 04/08/21 at 11:05 AM, an interview was conducted with the RN Supervisor, (RN#3). RN #3 stated that the risk factors for fall or accident for resident's #115 are general weakness due to diagnosis of Hemiplegia; and resident's refusal to call for assistance when using the bathroom despite several education and encouragement. RN stated that frequent rounds are made by staff to check on the residents and ask if they need to go to the bathroom. RN #3 further stated that residents' care plan is updated quarterly or as needed when there is episodic fall or any concern. RN also stated that the residents' CCP on fall that were not updated to reflect the new interventions being carried out to prevent further falls must have been omitted and will be incorporated immediately. RN stated that staff are constantly monitored to ensure that the interventions are carried out as per the plan of care of all the residents. Assistant Director of Nursing (ADON) was interviewed on 04/08/21 at 02:44 PM. ADON stated that residents are assessed Quarterly and as needed and documented in the paper chart. ADON stated that residents' care plan is updated with new interventions based on the resident's risk factors when re-assessed after fall/incident. 04/09/21 at 11:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility is trying to reinforce staff education on the need to be more efficient and detailed on the episodic care plan. The DON also stated that the facility has a list of projects at hand, which includes re-education of staff on proper documentation of Accident and Incident (AI) report to make better AI reporting, to ensure that proper conclusion and recommendations are documented. (3) The facility Policy and Procedure titled Care Planning - Interdisciplinary Team dated 09/2020 documented: facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan (CCP) for each resident. The resident, the resident's family and/the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Resident #31 was admitted to the facility on [DATE], with diagnoses which include Cancer, Anemia, and Peripheral Vascular Disease (PVD). The Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) 03/12/2021 documented the resident had intact cognition. The MDS also documented that the resident participated in the assessment and goal setting, and family or significant other did not participate. During a Resident Interview conducted on 04/05/21 at 10:58 AM, Resident #31 stated that they had never been invited to or attended a care plan meeting, but they would have gone if they were informed or invited. The facility's attendance records for Care Plan Meetings held on 3/11/2020, 6/10/2020, and 8/26/2020 were reviewed. There was no documented evidence that Resident #31 was invited to, or attended any of the meetings. The Electronic Medical Record (EMR) was reviewed from admission date 9/12/2018 to 4/8/2021. There was no documented evidence that Resident #31 was ever invited, participated, or refused to participate in the care plan meetings. On 04/08/21 at 10:19 AM, an interview was conducted with the Registered Nurse (RN #3) who stated that the care plan meeting is usually held quarterly. The MDS staff prepares the list of the residents and gives invitation letters to the operator to be sent out to family members. The social services staff notify the alert residents of the meeting time and date so they can attend, if interested. RN #3 stated that the attendance list is always signed at the end of the meeting by the team members and the resident and/or resident representative. On 04/08/21 at 10:45 AM, an interview was conducted with the Social Services Director (SSD). The SSD stated that the MDS department puts together the list of residents' with upcoming care plan meetings so a notice can be mailed to the family members via the operator downstairs. The alert residents are directly notified by Social Services, and if the alert resident wants the family members to be part of the meeting, a notice is also sent to the family members. The meeting could be held via telephone. The director stated that record of attendance is documented in the system after the meeting. The Social Worker (Staff #10) was interviewed on 04/08/2021 at 11:15 AM. The SW stated the list of residents with an upcoming care plan meeting is prepared by the MDS department and given to the main desk to mail out invitations to the family members. The social worker will inform the alert residents of the care plan meeting date and time, and the notification and attendance documented in the resident's progress notes. The SW further stated that as a newly hired staff, they could not explain why Resident #31 was not informed of the meetings. They were in orientation during that time. A follow-up interview was conducted with the Social Services Director on 04/08/21 at 3:37 PM. The SSD confirmed there was no documented evidence that Resident #31 was notified of the any meetings or attended any care plan meetings in the electronic system. The director stated that it might have been an oversight on the part of Social Services Department. An interview was conducted with the Administrator on 04/09/21 at 11:51 AM. The Administrator stated that 2 of the social workers left at about the same time. The facility had a series of interviews and hired an interim social worker. The interim social worker quit aftier a month creating another vacuum in the facility. The Administrator stated that the facility lacks experienced social worker staff and has been getting the old social worker to come in per diem to do some supervision until the 2 current newly hired staff came, no mention was made if the facility is still making use of the per-diem Social worker. The Administrator further stated that the facility has been trying to fill the gap as much as possible with experienced staff that know how to carry out the responsibilities with proper documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) The Centers for Disease Control and Prevention (CDC) guidance titled Hand Hygiene Recommendations: Guidance for Healthcare Providers about Hand Hygiene and COVID-19, updated 5/17/20, documented: Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The facility policy on Handwashing, revised 02/2019, documented handwashing is the most effective method of preventing nosocomial infections. To prevent the transmission of pathogens among residents and employees within the facility by maintaining a program of hand washing. Facility staff will wash hands before touching, preparing or serving food, before and after direct contact with resident. On 04/05/2021 at 11:35 AM, the following was observed on the 6th Floor Unit during lunch preparation. Certified Nursing Assistant (CNA #7) was assisting three wheelchair bound residents out of the dining room wearing a face shield and surgical mask and no gloves after an activity in preparation for the lunch meal. CNA #7 was touched by Resident #71 who kissed CNA #7's hand as they stopped briefly to chat with another resident. The CNA was pushing Resident #38 in their wheelchair (w/c). CNA #7 did not perform hand hygiene after this encounter. CNA #7 proceeded down the hallway to room [ROOM NUMBER] with Resident #38. After entering room [ROOM NUMBER], CNA #7 locked the resident's wheelchair. CNA #7 proceeded to the linen cart parked outside the resident's door, retrieved a clean white towel, and placed it on Resident #38's upper body. No hand hygiene was performed before or after exiting the room. CNA #7 touched the outside of their surgical mask with bare hands and proceeded down the hallway to the dining room. They retrieved a bedside table and took it to room [ROOM NUMBER] for Resident #127 and locked Resident #127's w/c. CNA #7 proceeded to get a dining chair for another resident seated by the nurses' station. No hand hygiene was completed before or after. CNA #7 began escorting another resident in a w/c from the dining room to their room when they noticed Resident #23 was standing up without assistance in room [ROOM NUMBER]. CNA #7 entered room [ROOM NUMBER] and touched Resident #23's arm while assisting them back to the w/c. No hand hygiene was performed before or after assisting Resident #23. CNA #7 exited the room and continued to push the resident in the w/c to room [ROOM NUMBER]. After entering room [ROOM NUMBER], CNA #7 washed their hands. On 04/05/2021 at 11:56 AM, the following was observed during the lunch meal: CNA #8 was observed by the nurses' station assisting Resident #71. CNA #8 touched the inside of the resident's surgical mask with bare hands while adjusting the mask on the resident's face. No hand hygiene was performed afterwards. CNA #8 set-up the resident's tray by opening sugar packets, mixing sugar into their cup with a spoon, opening and buttering the roll, and cutting the meat. They took wrappers and trash to the trash bin. CNA #8 did not perform hand hygiene. CNA #8 walked down the hall to the meal tray rack and retrieved the tray for Resident #134. CNA #8 brought the tray to Resident #134 who was seated in the hallway in front of their room. CNA #8 assisted Resident #134 by opening utensils, opening the teacup, adding creamer and sugar substitute, opening the bread, and putting it on the plate. CNA #8 placed used items in the plastic tray top and took it to room [ROOM NUMBER] to put it in the trash. CNA #8 washed their hands in the sink and exited room [ROOM NUMBER]. On 04/05/2021 at 12:48PM, CNA #7 was interviewed and stated that they wash hands with hand sanitizer or soap and water. They should wash hands and don gloves before providing care and in between tasks. They should wash their hands after wheeling residents with hand sanitizer which is located in the hallway. CNA #7 stated they should make sure their hands are clean to maintain infection control. They should sanitize their hands after touching dirty items, before going into the clean linen cart, and after resident contact. CNA #7 stated they should not touch their facemask. They did not have time to wash their hands because multiple residents were asking to be assisted to their rooms at once. Usually, after they wheel a resident, they sanitize their hands. CNA #8 was interviewed on 04/05/2021 at 02:33 PM and stated they perform hand hygiene before and after every resident interaction. They wash their hands when the trays come to the unit and before and after feeding the residents. They also wash hands after touching the tables and before touching the trays and racks. CNA #8 stated they wash their hands to avoid the spread of infection. On 04/05/2021 at 03:02PM, the RN #5 the Unit Supervisor was interviewed and stated staff should wash their hands before and after care and feeding. They should wash their hands before assisting another resident. If staff are wheeling residents, they should wash hands with soap and water or sanitizer. Staff must wash hands frequently using soap and water or hand sanitizer to prevent infection, and they have to be more careful due to COVID-19. On 04/05/2021 at 03:05PM, the Director of Nursing (DON) was interviewed and stated that they expect everyone to wash their hands before and after contact with residents, staff, and after any procedure. Staff should follow protocol. Staff were educated on how to use alcohol hand sanitizer. They should rub hands to make sure dry they are dry before donning gloves. If they are using soap and water, staff should wash their hands for 20 seconds and dry hands for 20 second before turning off faucet. Staff were informed they can use hand sanitizer with 70% alcohol content and dry hands before putting on gloves. Staff were instructed on how to rub the sanitizer to cover all parts of the hand. Proper handwashing is one way to break the cycle of infection and prevent the spread of infection. It is important for the safety of residents and staff. 415.19 (a)(1),(b)(4); 400.2 2) Resident #64 was admitted with diagnoses which include Chronic Obstructive Pulmonary Disease, Hypertension, and Congestive Heart Failure. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident was alert and oriented. The resident required extensive assistance of one person assist with all Activities of Daily Living (ADLs). On 04/05/21 at 11:21 AM and 04/06/21 at 10:11 AM, the resident was observed seating in room and the oxygen tubing was observed touching the floor. The certified Nursing Assistant (CNA) was observed in the hallway and the Registered Nurse (RN) was observed seating at the nursing station. On 04/07/21 at 02:38 PM, the Rehab Assistant was interviewed and stated that when she goes into the resident's room, she ensures the oxygen is on and flowing. If the oxygen tubing is long, it should be positioned so that it does not touch the floor. The oxygen tubing is not supposed to be on the floor, and it should be placed in a bag. When tubings are found on the floor, staff must change it. On 04/07/21 at 02:44 PM, RN #3 stated that she makes rounds of the entire unit. She checks on all the residents. RN #3 stated that when she goes to see residents on oxygen, she ensures that the residents are not in distress. She also ensures that the oxygen is flowing, and the tubing is attached. RN #3 stated that she checks to make sure tubing is not on the floor. If the tubing is found on the floor, it would be thrown away. All the CNAs were told to let nurses know right away if tubing is found on the floor. RN #3 also stated that they go into the resident's room frequently during their shift. RN #3 further stated that they will remind all of the CNAs again to ensure that all tubings are off the floor. 3) Resident #104 was admitted with diagnoses which include Asthma, Hypertension, and Congestive Heart Failure. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident is alert and oriented. The resident required extensive assist of two persons assist with all Activities of Daily Living (ADLs). On 04/05/21 at 11:08 AM, and 04/06/21 at 09:35 AM, the resident was observed seating in room and the resident's oxygen tubing was observed touching the floor. On 04/08/21 at 11:04 AM, the Certified Nursing Assistant (CNA#6) was interviewed and stated that the residents are monitored frequently. If a resident is on oxygen, they check to ensure that the oxygen tubing is off the floor. The oxygen tubing is changed daily. If the oxygen tubing is found on the floor, it would be discarded. The oxygen tubing is not supposed to be on the floor. On 04/08/21 at 03:23 PM, the ADNS was interviewed and stated that all staff were trained on infection control prevention procedures. All staff were trained on ensuring all tubings are off the floor. If tubings are found on the floor, they should be discarded right away. If the tubing is long, it should be positioned so it does not touch the floor. On 04/08/21 at 03:41 PM, the Director of Nursing (DON) was interviewed and stated that she supervises all nursing staff. All Nursing staff were taught to follow infection control procedures. Tubing should never be on the floor. We have to reinforce that all tubing should be off the floor with all CNAs, rehab staff and nurses. All tubing should be in a bag. All staff will be retrained on keeping all tubing off the floor. Based on observations and interviews conducted during the Recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, (1) A nurse was observed administering eye drop during medication pass without wearing gloves; (2) oxygen tubing was observed on the floor; and (3) Staff were observed assisting multiple residents without performing hand hygiene between residents or after touching dirty items during the dining preparation and service. This was evident for 1 of 4 residents observed for Med Admin; 2 of out of 31 residents reviewed in the investigation Sample; and random observations on 1 out of 4 units observed for Dining (Unit 6). The findings are: (1) The facility's Policy and procedure for Instillation of Eye Drops dated December 2020 documented the eye drop administration procedure as: Wash and dry your hands thoroughly; Put on gloves (before applying eye drops); Remove gloves (after applying the eye drops), and discard into designated container. Wash and dry your hands thoroughly. The Licensed Practical Nurse (LPN #1) was observed administering medication to Resident #90 on 04/07/21 at 09:24 AM. The LPN sanitized hands after administering PO (by mouth) meds to the resident, documented the administrations, opened the cart, took out the eye drops, went back to the resident and used bare hands to apply the eye drops to both of the resident's eyes. The LPN but did not sanitize hands and don gloves prior to administering eye drops to both eyes. On 04/07/21 at 11:25 AM, an interview was conducted with the LPN #1. LPN #1 stated that hand sanitization was performed, and soft tissue used to cleanse the resident's conjunctiva after the eye drops were applied. LPN #1 stated that gloves are not worn to administer the eye drops as both hands were sanitized before administering the eye drops. An interview was conducted with the Unit Supervisor (RN #3) at 11:49 AM. The RN stated that both hands need to be sanitized before eye drops are applied as per order, and the eyes should be cleansed with tissue. RN did not state that hand gloves should be worn prior administering the eye drops. RN further stated that resident's eye could be infected, or the nurse's hand could also be infected if gloves are not properly worn while administering the eye drops, when asked on the implications of not wearing gloves while administering eye drops.