**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024, the facility did not ensure that a Pre-admission Screening and Resident Review (PASARR) was completed for each resident prior to their admission to the facility to determine that the individual requires the level of services provided by the nursing facility and whether the individual requires specialized services. This was identified for one (Resident #29) of 26 residents reviewed for Pre-admission Screening and Resident Review (PASARR). Specifically, Resident #29 was admitted to the facility in October 2023. There was no documented evidence that a Level 1 Pre-admission Screening and Resident Review (PASARR) was completed prior to Resident #29's admission. The finding is: The facility's policy and procedure titled Pre-admission Screening and Resident Review (PASSR) last revised on 6/26/2024 documented that the admission coordinator will ensure a screen is completed before admission for all new admissions. Resident #29 was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, Diabetes Mellitus, and Myalgia (muscle pain). The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderately impaired cognition. The assessment's Pre-admission Screening and Resident Review (PASARR) section documented that Resident #29 was not currently considered by the State level II Pre-admission Screening and Resident Review (PASARR) process to have a serious mental illness, intellectual disability, or other related conditions. The facility failed to provide documented evidence that a Pre-admission Screening and Resident Review (PASARR) form was completed and reviewed prior to Resident #29's admission. The Director of Admissions was interviewed on 8/29/2024 at 11:15 AM and stated they were not employed at the facility in October 2023. The Director of Admissions stated that the admission department is responsible for reviewing and ensuring that the resident's admission documents from the sending facility include a Pre-admission Screening and Resident Review (PASARR) form. The Director of Admissions stated that if a screen form was not included or was incomplete, they would reach out to the case worker from the sending facility to obtain a completed copy of the screen form. The Director of Social Work was interviewed on 8/29/2024 at 11:32 AM and stated that Resident #29's Pre-admission Screening and Resident Review (PASARR) form was not found. The Director of Social Work stated that the admission staff who admitted Resident #29 should have ensured that a Pre-admission Screening and Resident Review (PASARR) form was completed for Resident #29 by the sending facility, prior to their admission. The Director of Social Work stated that the Pre-admission Screening and Resident Review (PASARR) form was also reviewed by the Social Worker prior to the resident's admission because if a Level II referral was recommended, the Social Work Department is responsible for obtaining recommended services such as psychiatric evaluation assessment and ensuring that the facility can provide the services. The Administrator was interviewed on 8/29/2024 at 2:42 PM and stated that Resident #29's Pre-admission Screening and Resident Review (PASARR) form was not found and they were not able to obtain the copy from the sending facility. The Administrator stated that the admission department is expected to review and ensure that each resident has a completed Pre-admission Screening and Resident Review prior to their admission to the facility. The Administrator stated that the Pre-admission Screening and Resident Review (PASARR) form is essential to determine whether the facility can offer a safe placement and provide appropriate services to the resident. 10 NYCRR 415.11(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #1) of five residents reviewed for Unnecessary Medications. Specifically, Resident #1 with a diagnosis of Diabetes Mellitus had a physician's order to monitor the resident's blood glucose level as per the facility's protocol. The facility policy indicated reporting the findings to the Physician if the blood glucose levels were less than 100 milligrams/Deciliter or greater than 300 milligrams /Deciliter. Resident #1's blood glucose levels were less than 100 milligrams/Deciliter or greater than 300 milligrams /Deciliter on 27 occasions in July 2024 and on 13 occasions in August 2024 and the resident's Physician was not notified as per the facility protocol. Additionally, the insulin injection sites were not documented in the resident's medical record on 50 occasions in July 2024 and 70 occasions in August 2024. The finding is: The facility's policy titled Fingerstick Blood Glucose Level Monitoring, last revised May 2024, documented that glucose and fingerstick results with blood sugar levels of less than 100 milligrams/Deciliter or greater than 300 milligrams/Deciliter will be reported to the Primary Care Physician/Nurse Practitioner. The facility's policy titled Medication Administration, last revised May 2024, documented that when giving insulin, site rotation should be charted in the Medication Administration Record. Resident #1 was admitted with diagnoses of Diabetes Mellitus with Diabetic Polyneuropathy (nerve involvement), Hypertension, and Peripheral Autonomic Neuropathy. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The Minimum Data Set documented Resident #1 received insulin injections. The physician's order dated 7/5/2024 documented to administer 4 units of Novolog 100 unit/milliliter insulin subcutaneously three times a day and to monitor blood sugar levels as per protocol. The physician's order dated 7/5/2024 documented to administer 18 units of Lantus Solostar 100 unit/ milliliter subcutaneously once daily at bedtime and to monitor blood sugar levels as per protocol. The Comprehensive Care Plan (CCP) for Diabetes Mellitus dated 7/8/2024 documented interventions to administer antidiabetic medication as ordered, to monitor blood glucose/fingerstick levels as ordered, and to monitor for signs and symptoms of Hypoglycemia (low blood glucose) or Hyperglycemia (high blood glucose). The July 2024 Medication Administration Record documented the resident's blood sugar levels greater than 300 milligrams /Deciliter on 7/9/2024 at 5:03 PM; 7/13/2024 at 5:00 PM; 7/16/2024 at 8:28 AM and 12:07 PM; 7/17/2024 at 9:38 AM; 7/18/2024 at 10:00 PM; 7/19/2024 at 5:07 AM; 7/20/2024 at 12:41 PM; 7/21/2024 at 4:37 PM and 9:10 PM; 7/22/2024 at 8:36 AM, 12:40 PM, and 5:16 PM; 7/23/2024 at 5:11 PM and 9:45 PM, 12:33 PM, 4:33 PM and 8:59 PM; 7/25/2024 at 7:30 AM and 5:00 PM; 7/26/2024 at 11:30 AM; 7/27/2024 at 5:04 PM; 7/28/2024 at 12:18 PM and 5:03 PM; 7/29/2024 at 5:04 PM and 8:55 PM; and on 7/31/2024 at 9:09 PM. There was no documentation in the medical record that the resident's Physician was notified of the elevated blood glucose levels as per the facility's protocols. The July 2024 Medication Administration Record review also revealed that the insulin injection administration site was not documented for 50 out of 100 occasions. The August 2024 Medication Administration Record documented the blood sugar levels were either less than 100 milligrams /Deciliter or greater than 300 milligrams /Deciliter on 8/3/2024 at 7:30 AM, 11:30 AM, and 8:39 PM; 8/4/2024 at 12:35 PM, 5:00 PM, and 8:34 PM; 8/5/2024 at 12:57 PM; 8/6/2024 at 9:31 AM; 8/16/2024 at 11:30 AM; 8/19/2024 at 12:50 PM; 8/24/2024 at 9:51 AM; 8/25/2024 at 9:24 AM; 8/26/2024 at 9:45 PM. There was no documentation in the medical record that the resident's Physician was notified of these blood glucose levels. The August 2024 Medication Administration Record review also revealed that the insulin injection administration site was not documented for 68 out of 106 occasions. Licensed Practical Nurse #2 was interviewed on 8/28/2024 at 2:02 PM and stated they were the regularly assigned medication nurse on Resident #1's unit during the 7:00 AM- 3:00 PM shift. Licensed Practical Nurse #2 stated they were familiar with Resident #1 and would consider the resident's blood sugar level out of range if the blood glucose level was below 70 milligrams /Deciliter and greater than 255 milligrams /Deciliter. Licensed Practical Nurse #2 stated they would notify the unit manager if the resident's blood sugar level was out of range. Licensed Practical Nurse #2 stated Resident #1's physician's orders did not include the blood glucose parameters to indicate when a Physician should be notified and they did not know the facility protocol. Licensed Practical Nurse #2 stated that the insulin injection site should be rotated and documented to prevent insulin from being administered repeatedly at the same location. Licensed Practical Nurse #2 stated that repeated injection administration at the same site may potentially cause swelling and bruising to the area. Licensed Practical Nurse #2 did not know why they did not document the insulin injection sites after they administered the insulin to the resident. Registered Nurse #5, the unit manager, was interviewed on 8/28/2024 at 2:32 PM and stated nurses should notify their supervisor each time when a resident's blood sugar level is below 100 milligrams /Deciliter and greater than 300 milligrams /Deciliter as per the facility's protocol. Registered Nurse #5 stated they were never notified of Resident #1's unstable blood sugar results and thought the resident's blood sugar was under control. Registered Nurse #5 stated nurses should document the injection site after each insulin administration and the site should be rotated. Licensed Practical Nurse #3 was interviewed on 8/28/2024 at 3:31 PM and stated they were the regularly assigned 3:00 PM-11:00 PM medication nurse. Licensed Practical Nurse #3 stated when Resident #1's blood sugar level exceeded 300 milligrams /Deciliter, they did not inform the Physician because Resident #1's physician's order did not have parameters. Licensed Practical Nurse #3 stated they were not aware of the facility protocol regarding when to report the blood glucose levels to a medical provider. Physician #3 was interviewed on 8/30/2024 at 11:04 AM and stated they expected the nursing staff to follow the facility protocol and notify the Physician when the blood glucose levels are outside the established parameters so they can monitor the effectiveness of the resident's current diabetes management and re-adjust the resident's medication dose as necessary. The Director of Nursing Services was interviewed on 8/30/2024 at 11:23 AM and stated nursing staff should follow the facility protocol and notify the Physician each time the resident's blood sugar is below 100 milligrams /Deciliter or higher than 300 milligrams /Deciliter unless otherwise specified by the Physician. The Director of Nursing Services stated insulin injection site should be rotated and nurses should document the injection site each time insulin was administered. The Director of Nursing Services stated that repeated injections at the same site can cause swelling and redness and affect the absorption of insulin. 10NYCRR 415.12

Based on observation, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024, the facility did not ensure that each resident's environment remained as free of accident hazards as possible. This was identified for one (Third Floor) of three units observed during the initial tour. Specifically, a full oxygen E-Cylinder tank (portable oxygen tank) was observed in the third-floor day room that was not secured in a rolling safety stand or a metal rack. The finding is: The facility's policy and procedure titled Oxygen Therapy last revised on 5/2024 documented that safety devices in valves or cylinders shall never be tampered with. Cylinders shall not be chained to portable or movable apparatus such as beds and tables. Even if they are considered empty, cylinders shall never be used as rollers, supports, or for any other purpose other than that for which they are intended by the supplier. Cylinders and containers shall not be dropped, dragged, or rolled. Cylinders shall not be supported by, and neither cylinder nor container shall be placed in proximity of, radiators, steam pipes, or heat ducts. The policy did not include guidance on how to store an oxygen tank in resident units. During an observation on 8/26/2024 at 10:21 AM, a free-standing, unsecured E-cylinder tank was observed in the third-floor unit day room during an activity. The E-cylinder tank gauge needle was at 2,000 PSI (pounds per square inch) indicating that the tank was full. A Recreation Aide was present in the day room during the observation. The Recreation Aide was interviewed on 8/26/2024 at 10:22 AM and stated they did not notice the free-standing E-cylinder tank in the day room. The Recreation Aide stated they would call the nurse if they noticed the E-cylinder tank. Registered Nurse #5, the Unit Supervisor, was interviewed on 8/26/2024 at 10:25 AM and stated they did not know there was a free-standing E-cylinder tank in the day room. Registered Nurse #5 stated the oxygen tank should not be left unsecured and must be placed in a rolling cart or a metal rack to secure the E-cylinder tank. The Director of Maintenance and Housekeeping was interviewed on 8/27/2024 at 2:47 PM and stated the nurses are responsible for the oxygen tanks that are stored on the unit. The Director of Maintenance and Housekeeping stated all oxygen tanks must be secured with a rolling cart or a metal rack. The Director of Maintenance and Housekeeping stated there should not be an unsecured, free-standing E-cylinder tank on the unit. The Director of Maintenance and Housekeeping stated If the tank falls and the tank regulator and valve come off the top of the tank, the tank itself can propel like a rocket. The Director of Maintenance and Housekeeping stated an unsecured E-cylinder tank is an accident hazard. The Director of Nursing Services was interviewed on 8/30/2024 at 9:54 AM and stated the E-cylinder tank should always be secured using a rolling cart or a metal rack. The Director of Nursing Services further stated an unsecured E-cylinder tank is an accident hazard. 10 NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024, the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice. This was identified for two (Resident #5 and Resident #82) of two residents reviewed for Respiratory Care. Specifically, 1) Resident #5 had a physician's order to continuously receive oxygen therapy at 2 liters per minute. The resident was observed receiving an inaccurate amount of oxygen therapy on 8/26/2024, 8/27/2024, and 8/28/2024. 2) Resident #82 had a physician's order to continuously receive oxygen therapy at 2 liters per minute. The resident was observed receiving an inaccurate amount of oxygen therapy on 8/26/2024, 8/27/2024, and 8/28/2024. The findings are: The facility's policy titled Oxygen Therapy revised on 5/2024 documented that oxygen therapy must be ordered by a Physician or Nurse Practitioner and the flow rate of oxygen is to be set at the prescribed liters per minute. 1) Resident #5 was admitted with diagnoses that included Congestive Heart Failure, Major Depressive Disorder, and Dementia. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 99, which indicated the resident had severely impaired cognition. The resident had lower extremity impairment and was dependent on two or more helpers for chair to bed transfer. The Minimum Data Set documented that Resident #5 used oxygen therapy during the look-back period. The Comprehensive Care Plan for Oxygen Therapy last reviewed on 8/08/2024 documented to provide treatments and medications as per Physician orders. A physician's order dated 3/27/2024 last renewed on 8/03/2024 documented to administer 2 liters of oxygen continuously via a nasal cannula. Resident #5 was observed in bed sleeping on 8/26/2024 at 9:45 AM. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Resident #5 was observed in their room in a Geri chair on 8/26/2024 at 12:22 PM. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Resident #5 was observed in bed having breakfast on 8/27/2024 at 8:49 AM. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Resident #5 was observed in bed on 8/28/2024 at 9:24 AM. Nurse Supervisor #2 was also present in the room. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Nurse Supervisor #2 was interviewed on 8/28/2024 at 9:24 AM and stated the resident was supposed to receive continuous oxygen at 2 liters per minute; however, the oxygen flow rate was set at 4 liters per minute. Nurse Supervisor #2 stated only the nursing staff is responsible for changing the oxygen setting on the oxygen concentrator. Nurse Supervisor #2 stated Resident #5 was not able to reach the concentrator from their bed or the Geri chair to change the oxygen setting. The Director of Nursing Services was interviewed on 8/28/2024 at 12:56 PM and stated that the nurses on the unit should monitor the oxygen levels of each resident who is receiving oxygen during their shift. The nurses should regularly assess the resident's oxygen levels, and if an increase is needed, they should obtain an updated order from the Physician. 2) Resident #82 was admitted with diagnoses that included Dementia, Diabetes Mellitus, and Wheezing. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 99, which indicated the resident had severely impaired cognition. The Minimum Data Set documented Resident #82 used oxygen therapy during the look-back period. The Comprehensive Care Plan for Respiratory Care dated 4/01/2024 documented interventions including administering oxygen as per the physician's order. A physician's order dated 6/10/2024 and renewed on 8/26/2024 documented to administer 2 liters of oxygen continuously via a nasal cannula. Resident #82 was observed in bed on 8/26/2024 at 9:38 AM. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Resident #82 was observed in bed on 8/26/2024 at 12:21 PM. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Resident #82 was observed in bed on 8/27/2024 at 8:46 AM having breakfast. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Resident #82 was observed on 8/28/2024 at 9:29 AM in bed. Nurse Supervisor #2 was also present in the room. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 5 liters per minute. Nurse Supervisor #2 was interviewed on 8/28/2024 at 9:29 AM and stated Resident #82 has a physician's order to administer oxygen at 2 liters per minute. Nurse Supervisor #2 acknowledged that the resident was receiving oxygen at 5 liters per minute. Nurse Supervisor #2 stated only the nurses are responsible for changing the oxygen setting on the oxygen concentrator. The nurses should be monitoring the oxygen level on each shift and if the resident needs an increase, they should increase oxygen and notify the Physician. Resident #5 was not able to reach the concentrator from their bed or the Geri chair to change the oxygen setting. The Director of Nursing Services was interviewed on 8/28/2024 at 12:56 PM and stated that the nurses on the unit should monitor the oxygen levels of each resident who is receiving oxygen during their shift. The nurses should regularly assess the resident's oxygen levels, and if an increase is needed, they should obtain an updated order from the Physician. 10 NYCRR 415.12 (k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024 the facility did not ensure that it maintained an infection prevention and control program designed to help prevent the development and transmission of infectious diseases. This was identified for one (Resident #67) of three residents reviewed for tube feeding. Specifically, Resident #67 had a physician's order for Enhanced Barrier Precautions for the use of a gastrostomy tube (feeding tube inserted through the stomach for artificial feeding). During an observation, Registered Nurse Supervisor #2 was observed entering Resident #67's room without the use of Personal Protective Equipment (gown and gloves) and disconnected the tube feeding from the gastrostomy tube. The finding is: The facility policy titled Enhanced Barrier Precautions dated 5/06/2024 documented that Enhanced Barrier Precautions are indicated for residents with central lines, urinary catheters, feeding tubes, and tracheostomies. The Enhanced Barrier Precautions are employed when performing high-contact resident care activities such as device care or feeding tube use. Resident #67 was admitted with diagnoses including Type 2 Diabetes Mellitus, Cerebral Infarction (disrupted blood flow to the brain), and Dementia. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 8, indicating the resident had moderate cognitive impairment. The Minimum Data Set documented the resident utilized tube feeding. A physician's order dated 5/14/2024 and last renewed on 8/26/2024 documented Enhanced Barrier Precautions due to gastronomy tube. A Comprehensive Care Plan dated 5/14/2024 for Enhanced Barrier Precautions had interventions including the use of a gown and gloves when in contact with the gastronomy tube. Nurse Supervisor #2 was observed going into Resident #67's room on 8/26/2024 at 10:00 AM to respond to the tube feeding pump alarm. There was a sign at the door and above the resident's bed indicating the resident was on Enhanced Barrier Precautions. The sign read Everyone must clean hands before entering and leaving the room. Staff must wear gown and gloves for high-contact resident care. The sign had a list of device care including a feeding tube with directions to wear a gown and gloves when providing care. Nurse Supervisor #2 did not don (put on) a gown or gloves when they turned off the feeding pump and disconnected the tube feeding from the resident's gastronomy tube. Nurse Supervisor #2 was interviewed on 8/26/2024 at 10:05 AM and stated Resident #67 is on Enhanced Barrier Precautions for the use of a gastronomy tube. The staff needs to wear Personal Protective Equipment when coming in contact with the gastronomy tube. Nurse Supervisor #2 further stated they should have put on Personal Protective Equipment to disconnect the tube feed; however, they were nervous and wanted to promptly respond to the alarm. The Assistant Director of Nursing Services, the Infection Preventionist, was interviewed on 8/28/2024 at 1:45 PM and stated nursing staff are expected to use gowns and gloves when providing care to a resident with a feeding tube. A resident with a feeding tube is placed on Enhanced Barrier Precautions because the feeding tube can harbor organisms that can transfer to staff and then to other residents. Nurse Supervisor #2 should have put on a gown and gloves when they disconnected the tubing from the resident's gastronomy tube. The Director of Nursing Services was interviewed on 8/30/2024 at 9:52 AM and stated nursing staff should wear Personal Protective Equipment while caring for residents who are on Enhanced Barrier Precautions. 10 NYCRR 415.19 (a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024 the facility did not ensure that each resident with Pressure Ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for three (Resident #38, Resident #5, and Resident #82) of eight residents reviewed for Pressure Ulcers. Specifically, 1) Resident #38 had multiple pressure ulcers and had a physician's order to use a low-air loss mattress for pressure relief. During multiple observations, the adjustable weight setting for the air mattress, which is meant to correspond to the resident's weight, was not set accurately. 2) Resident #5 had a history of Moisture Associated Skin Damage to the left buttock. Resident #5 had an order for a low-air loss mattress. During multiple observations, the adjustable weight setting for the air mattress was not set accurately. 3) Resident # 82 had Moisture Associated Skin Damage to the sacrum area. Resident #82 had an order for a low-air loss mattress. During several observations, the adjustable weight setting for the air mattress was not set accurately. The findings are: The facility's policy titled Pressure Injury Management and Prevention revised on 5/2024, documented it is the policy of the facility to have in place all necessary interventions to prevent the development of pressure ulcers and to facilitate healing of any existing pressure ulcers acquired before admission, readmission, or hospital return. Residents at risk for pressure injuries will have a preventative plan implemented and specific preventative care interventions may include pressure-relieving mattresses. The facility's policy titled Air Mattress revised on 1/01/2024 documented that air mattresses should be used as a tool to help with alleviating pressure. The use of an air mattress is an adjunct to proper turning and positioning with other pressure-relieving devices or interventions. The air mattress should be checked daily for proper functioning by staff and any issues will be reported to the unit nurse. The nursing staff will then set up the mattress according to the manufacturer's instructions. The operation manual for the low-air mattress documented instructions that included adjusting the internal pressure of the air mattress according to the patient's weight by using the weight button on the control panel of the power unit. 1) Resident # 38 was admitted with diagnoses including Dementia, Type 2 Diabetes Mellitus, and Pneumonia. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 99, which indicated the resident had severely impaired cognition. The Minimum Data Set documented the resident had three Stage 4 Pressure Ulcers. A Comprehensive Care Plan titled Pressure Ulcer/Injury was initiated on 4/05/2024 with documented interventions that included the use of a pressure relief mattress, turning and positioning the resident every 2 hours and as needed. A Wound Care Physician consultation dated 8/20/2024 documented the resident had a left foot arterial wound measuring 2.5 centimeters in length, 0.8 centimeters in width, and 0.1 centimeters in depth. A left Ischium/buttock Stage 4 Pressure Ulcer (full thickness with an exposed underlying structure) measuring 3.5 centimeters in length, 4.5 centimeters in width, and 2.7 centimeters in depth. A right Ischium/buttock Stage 4 Pressure Ulcer (full thickness with exposed underlying structure) measuring 4.2 centimeters in length, 1.8 centimeters in width, and 2.4 centimeters in depth, with undermining (when the edges of a wound separate from the surrounding tissue creating a pocket underneath the wound surface) measuring 3.1 centimeters. A sacrum Stage 4 Pressure Ulcer (full thickness with exposed underlying structure) measuring 7 centimeters in length, 6.2 centimeters in width, 2.4 centimeters in depth, with undermining measuring 2.4 centimeters. A physician's order dated 7/08/2024 and last renewed on 8/09/2024 documented the use of a low-air loss mattress. A review of the electronic medical record indicated Resident #38's most recent weight was 85 pounds on 8/29/2024. Resident #38 was observed in bed on 8/26/2024 at 10:03 AM. The air mattress weight setting was set at 325 pounds. Resident #38 was observed in bed on 8/26/2024 at 12:19 PM, the air mattress weight setting was set at 325 pounds. Resident #38 was observed in bed on 08/27/24 at 08:50 AM. The air mattress weight setting was set at 325 pounds. Nurse Supervisor #2 was interviewed on 8/28/2024 at 9:16 AM and stated Resident #38 has multiple skin breakdowns and uses the air mattress. The air mattress weight setting should be adjusted to the resident's weight. Nurse Supervisor #2 stated the resident's air mattress weight setting was set at 325 pounds and the resident weighs 85 pounds. The wound care nurse is responsible for ensuring that the air mattress weight setting is accurately set. Nurse Supervisor #2 stated they were only responsible for ensuring that the air mattress was not deflated and was functioning properly. Wound Care Nurse #3 was interviewed on 8/28/2024 at 10:44 AM and stated they check all the air mattresses daily to ensure that the weight setting is set according to the residents' weight. Wound Care Nurse #3 stated Resident #38 weighs 85 pounds, and the air mattress weight setting should not be set at 325 pounds. Certified Nursing Assistant #1 was interviewed on 8/29/2024 at 10:00 AM and stated they are the regularly assigned 7:00 AM-3:00 PM shift Certified Nursing Assistant for Resident #38. Certified Nursing Assistant #1 stated they do not touch the setting on the air mattress and if they identify any concerns with the air mattress, they report them to the unit nurse. Wound Care Physician #2 was interviewed on 8/29/2024 at 11:19 AM and stated the purpose of the air mattress is to relieve pressure from wounds and to prevent further pressure ulcer development. The mattress weight setting should be set according to the resident's weight and the manufacturer's guidelines. If the weight setting for the air mattress is too high or too low, it can cause more pressure injury and impede the healing of the current wounds. The Director of Nursing Services was interviewed on 8/29/2024 at 11:27 AM and stated the air mattress weight setting should be set according to the resident's weight. The nurses are responsible for monitoring the air mattress weight setting when the wound nurse is not in the building. 2) Resident #5 was admitted with diagnoses that included Heart Failure, Major Depressive Disorder, and Dementia. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 99, which indicated the resident had severely impaired cognition. The Minimum Data Set documented that Resident #5 had Moisture Associated Skin Damage. A Comprehensive Care Plan titled Pressure Ulcer/Injury was initiated on 5/12/2023 and last revised on 8/08/2024 documented interventions that included the use of a pressure relief air mattress and encouraging the resident to turn in bed. A physician's order dated 3/18/2024 and renewed on 8/03/2024 documented the use of a low-air loss mattress. A Wound Care Physician's consultation dated 8/20/2024 documented Resident #5 had Moisture Associated Skin Damage to the left buttock that was now healed. A review of the electronic medical record indicated Resident #5's most recent weight was 173 pounds on 8/03/2024. Resident #5 was observed in bed on 8/26/2024 at 9:45 AM. The air mattress weight setting was set at 250 pounds. Resident #5 was observed in bed eating their breakfast on 8/27/2024 at 8:48 AM. The air mattress weight setting was set at 250 pounds. Resident #5 was observed in bed on 8/28/2024 at 9:22 AM. The air mattress weight setting was set at 250 pounds. Nurse Supervisor #2 was interviewed on 8/28/2024 at 09:22 AM and stated Resident #5's air mattress weight setting was set at 250 pounds and currently the resident weighs 173 pounds. The air mattress weight setting should be set according to the resident's weight. The Director of Nursing Services was interviewed on 8/29/2024 at 11:27 AM and stated the air mattress weight setting should be set according to the resident's weight. The nurses are responsible for monitoring the air mattress weight setting when the wound nurse is not in the building. 3) Resident #82 was admitted with diagnoses including Diabetes Mellitus, Non-Alzheimer's Dementia, and Muscle Wasting and Atrophy. The 6/30/2024 Significant Change Minimum Data Set assessment did not have a Brief Interview for Mental Status score due to the resident's severely impaired cognitive skills for daily decision-making. The Minimum Data Set assessment documented the resident was at risk for pressure ulcer development. A Comprehensive Care Plan titled Pressure Ulcer/Skin Integrity Alteration Risk, effective 10/4/2023 and last updated on 7/8/2024, documented an intervention for a low air loss mattress. An update on 7/3/2024 documented that the resident was on comfort care and was at increased risk of skin breakdown. A physician's order dated 10/3/2023 and last updated 8/26/2024 documented the use of a Low Air Loss Mattress. A physician's order dated 4/12/2024 and last updated 8/26/2024 documented under Advanced Directives: Comfort Measures Only. A physician's order dated 8/5/2024 and last updated 8/26/2024 documented cleanse sacral area with soap and water, pat dry, apply zinc oxide (topical wound treatment) and cover with dressing every shift for diagnosis of irritant contact dermatitis due to friction or contact with body fluids. A wound care weekly note dated 8/21/2024 written by Registered Nurse #3 (wound care nurse) documented: sacrum-moisture associated skin damage measuring 5 centimeters in length and 4 centimeters in width; interventions included to apply zinc oxide treatment and offloading with low air loss mattress. Resident #82's weight in the medical record as of 8/2/2024 was 122 pounds. On 8/26/2024 at 9:38 AM Resident #82 was observed in bed. The air mattress weight setting was set at 250 pounds. On 8/28/2024 at 9:08 AM Resident #82 was observed in their wheelchair in their room. The air mattress weight setting was set at 250 pounds. On 8/28/2024 at 9:21 AM Registered Nurse #2 (unit supervisor) observed Resident #82's mattress and confirmed the weight was set at 250 pounds. Registered Nurse #2 checked the resident's weight in the medical record and stated the last recorded weight was 122 pounds. Registered Nurse #2 stated the wound care nurse does daily rounds and is supposed to check the air mattress weight setting and the mattress weight setting is supposed to be set according to the resident's weight. Registered Nurse #2 stated our job as nurses on the unit is to make sure the mattress is not deflated and ensure that the air mattress is functioning properly. It is the wound care nurse's job to ensure the setting is consistent with the resident's weight. Registered Nurse #2 stated they do not check the air mattress weight setting because it has been set by the wound care nurse. Registered Nurse #4, the Clinical Supervisor, was interviewed on 8/28/2024 at 10:31 AM. Registered Nurse #4 stated the wound care nurse orders the air mattress and sets the weight setting on the air mattress based on the resident's weight. Any unit nurse can let the wound care nurse know if the weight setting is not accurate. The unit nurses do environmental checks, so checking the mattress weight setting should be a part of the environmental checks. Registered Nurse #3, the wound care nurse, was interviewed on 8/28/2024 at 10:45 AM. Registered Nurse #3 stated the weight setting on the air mattress should be consistent with the resident's weight and they check the air mattress weight setting on daily rounds, but they have not been in the building for several days. Registered Nurse #3 stated they did not know that there was no protocol for the unit nurses to check the air mattress weight setting in their absence. Physician #2, the wound care consultant, was interviewed on 8/29/2024 at 11:19 AM and stated residents with pressure ulcers should have an air mattress in place to prevent further pressure ulcer development. The purpose of the air mattress is to relieve pressure from wounds and to prevent further pressure ulcers. The mattress should be set according to the resident's weight and the manufacturer's guidelines. If a mattress weight is set too high or too low, it can cause more pressure injury and impede healing of the current wounds. The Director of Nursing Services was interviewed on 8/29/2024 at 11:27 AM and stated the air mattress weight should be set consistent with the resident's weight. The Director of Nursing Services stated the nurses on the unit are responsible for monitoring the mattress when the wound care nurse is not in the building. The nurses are aware that they are responsible for monitoring the settings on the mattress. 10 NYCRR 415.12(c)(1)

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00292723) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that all alleged violations were thoroughly investigated for one (Resident #21) of one resident reviewed for Change of Condition. Specifically, Resident #21 was identified with swelling and pain of the right lower extremity beginning on 3/8/2022. An x-ray of the right lower extremity was not ordered until 3/15/2022, upon which a fracture of the right tibia was identified. The accident and incident (A/I) investigation dated 3/18/2022 concluded that no abuse, neglect, or mistreatment had occurred; however, interviews with staff only went back to 3/14/2022, and not to when the pain and swelling initially started on 3/8/2022. The finding is: Resident #21 was admitted with diagnoses including Non-Alzheimer's Dementia, Depression, and Muscle Weakness. The 3/10/2022 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident had severely impaired cognitive decision-making skills. The MDS documented the resident required extensive assistance of two staff members for bed mobility and transfers, was non-ambulatory and had no falls. The MDS indicated the resident utilizes wheelchair for locomotion when out of bed. A nursing progress note written by Registered Nurse (RN) #1 on 3/8/2022 at 8:32 AM documented Resident #21 was alert and responsive and complained of pain in the right foot. Upon examination right foot had edema, was warm to touch, and very tender. Pedal pulses were present and equal bilaterally. Physician notified and ordered Motrin 400 milligram (mg) as a onetime dose and stat (immediate) laboratory blood work. A nursing progress note dated 3/9/2022 at 6:18 AM documented the laboratory blood work results were received and reviewed with the Physician with no new orders were obtained. A nursing note written by RN #1 dated 3/10/2022 at 2:06 PM documented the resident was alert and responsive. The resident's right foot remains swollen and tender to touch. Blood work was completed and was within normal limits. The Physician notified and ordered Tylenol 650 mg every 6 hours as needed for pain and to elevate the foot while in bed. A nursing note written by RN #1 dated 3/11/2022 at 2:15 PM documented the resident's right foot remains swollen and tender to touch. Orders were in place for Tylenol 650 mg every 6 hours as needed for pain and to elevate the foot while in bed. A nursing note written by the wound RN on 3/15/2022 at 12:02 PM documented Resident #21 was seen and examined by the wound care physician for evaluation of right lower extremity pain and tenderness. The Right ankle and right distal leg were identified with tenderness and warmth compared to the left leg. A nursing note written by RN #1 on 3/15/2022 at 12:41 PM documented resident alert and responsive. Seen today by Wound Care/Vascular Physician. Suggested ordering a right lower extremity Venous Doppler and Physician (#1) was in agreement. A STAT Portable x-ray was ordered and to be completed today. A nursing note dated 3/15/2022 at 7:56 PM documented the x-ray and venous Doppler results were received and Physician #1 was made aware. X-ray of the right ankle revealed an acute nondisplaced spiral distal tibial fracture. A new order was obtained to transfer the resident to the hospital. This fracture was reported to the New York State Department of Health on 3/16/2022 as an injury of unknown origin (NY00292723). Review of the A/I report dated 3/18/2022, and signed by the former Director of Nursing Services (DNS), documented the investigation was completed. The facility concluded that no abuse, neglect, or mistreatment regarding this resident occurred. There was no care plan violation. Review of the A/I report revealed that the interviews with staff went back to 3/14/2022, not to when the swelling and pain were first identified on 3/8/2022. Registered Nurse (RN) #4 was interviewed on 1/10/2923 at 12:49 PM and stated they are the wound care nurse, and they currently perform the accident investigations for the facility. RN #4 stated they (RN #4) were not doing the accident and incident investigations in March 2022 when the incident related to Resident #21 occurred. RN #4 stated they (RN #4) did not know why the investigation did not go back to 3/8/2022 when the pain and swelling were first identified. RN #4 further stated it was the former DNS's error for not going back to 3/8/2022. The current DNS was interviewed on 1/10/2023 at 2:20 PM and stated the investigation should have included interviews with staff going back to 48 hours before 3/8/2022 when the pain and swelling were first identified. 10NYCRR 415.4(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 1/05/2023 and completed on 1/13/2023, the facility must develop and implement a Comprehensive Person- Centered Care Plan (CCP) for each resident that includes measurable objective and time frames to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #54) of one resident reviewed for Communication and Sensory: Hearing/Vision. Specifically, Resident #54 utilized bilateral hearing aids. There was no CCP developed for the use of the hearing aids. The finding is: The facility Policy and Procedure for Comprehensive Care Plan dated 6/2017 documented that each resident must have an individualized interdisciplinary plan of care in place. Within 48 hours, there must be a baseline care plan in place. Within 21 days of admission, the Interdisciplinary Team will develop and implement the Comprehensive Care Plan. All care plans are then reviewed and revised quarterly, annually, and as needed. The facility's Resident Care Policy and Procedure for Hearing Aids dated 3/2015, documented residents with hearing aids will be assisted by the staff in application and maintenance of their devices. Resident #54 was admitted with diagnoses including Hypertension, Hyperlipidemia, and Anxiety Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS documented the resident had adequate hearing and utilized hearing aids or other hearing appliances. The Physician's order dated 8/31/2022 and last renewed on 1/6/2023 documented to apply hearing aids in the morning and remove before bedtime. The resident may keep the hearing aids at their bed side. Resident #54 was observed on 1/13/2023 at 10:55 AM lying in bed. Resident #54 was not wearing their hearing aids. Resident #54 had difficulty hearing, and voices had to be raised for them to hear. A hearing aid was observed on the resident's nightstand. Resident #54 stated they keep their hearing aids at their bedside. The Resident stated they have two hearing aids, and the second hearing aid is located in their nightstand. Resident #54 stated they charge their hearing aids in their room across from the bed with a Universal Serial Bus (USB) cord. The resident was observed to get out of their bed and placed one of the hearing aids on the USB charger. Resident #54 further stated they charge one hearing aid at a time and while one hearing aid is charging they utilize the other hearing aid. Review of the Comprehensive Care Plan on 1/13/2023 revealed that there was no CCP developed for hearing deficit, use of hearing aids, or communication deficit. The Treatment Administration Record (TAR) for January 2023, documented the hearing aids were applied and removed by the nurse from 1/1/2023 to 1/13/2023. Registered Nurse (RN) #1 Supervisor was interviewed on 1/13/2023 at 12:13 PM and stated they did not develop any care plans for Resident #54. The former Director of Nursing Services was responsible for developing CCPs. RN #1 further stated the CCP for hearing loss and use of the hearing aids was not in place for Resident #54. The current DNS was interviewed on 1/13/2023 at 1:07 PM and stated there should be a care plan developed for Resident #54's hearing and hearing aid use. The DNS stated they did not see a care plan for communication, hearing, or hearing aids in Resident #54's electronic medical record and that there should be one. 10NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00292723) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #21) of one resident reviewed for Change of Condition. Specifically, Resident #21 was identified with swelling and pain of the right lower extremity beginning on 3/8/2022. The resident continued to participate in Physical Therapy (PT), standing on both lower extremities, and was performing transfers from once surface to another (bed/chair) on the nursing unit daily. The resident was complaining of pain to the right lower extremity during the PT and during transfers. The resident was evaluated by the Physician on 3/8/2022, 3/10/2022 and 3/15/2022. An x-ray of the right lower extremity and Doppler study were ordered on 3/15/2022, seven days after the pain and swelling was first identified. The x-ray results identified a fracture of the right tibia. The finding is: Resident #21 was admitted with diagnoses including Non-Alzheimer's Dementia, Depression, and Muscle Weakness. The 3/10/2022 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident had severely impaired cognitive decision-making skills. The MDS documented the resident required extensive assistance of two staff members for bed mobility and transfers, was non ambulatory and had no falls. The MDS indicated the resident utilizes wheelchair for locomotion when out of bed. A wound care nursing note dated 3/1/2022 at 12:14 PM documented Resident #21 was seen and examined by the wound care/vascular Physician (MD) for bilateral lower extremity discoloration and dry scabs to bilateral lateral feet. Both lower extremities were examined and noted with Varicose veins, chronic Venous Insufficiency and discolorations at the ankle and dorsum (top) of both feet. There were spider reticular veins and dark dry scabs covering the lateral feet. No open wounds. Dorsalis pedis pulses positive, no cellulitis, no peripheral arterial disease. The feet and toes were warm with no leg edema present. Impression: chronic venous insufficiency, varicose veins and changes of chronic venous insufficiency with healing superficial skin ulcers. Treatment in progress with dry protective dressing and Ace wraps to bilateral lower extremities. A Rehabilitation-Physical Therapy (PT) progress note dated 3/4/2022 documented Resident #21 stood with a rolling walker and one person assistance full weight bearing on both lower extremities. The resident had no pain. A nursing progress note written by Registered Nurse (RN) #1 on 3/8/2022 at 8:32 AM documented Resident #21 was alert and responsive and complained of pain in the right foot. Upon examination right foot had edema, was warm to touch, and very tender. Pedal pulses were present and equal bilaterally. Physician notified and ordered Motrin 400 milligram (mg) as a onetime dose and stat (immediate) laboratory blood work. A Physician note (Physician #1) dated 3/8/2022 at 4:39 PM documented Resident #21 had left foot redness, pain, and swelling. The resident had no history of trauma. The resident had been evaluated by a vascular surgeon on 3/2/2022 with no clinical evidence of peripheral arterial disease. Ace wrap and dry protective dressing ordered for daytime for both lower extremities. Further work-up and prescription as per clinical course. A nursing progress note dated 3/9/2022 at 6:18 AM documented the laboratory blood work results were received and reviewed with the Physician with no new orders obtained. A PT Discharge summary dated [DATE] documented Resident #21 stood full weight bearing on both lower extremities for 20 seconds; however, now required maximum assistance of two staff members. The resident was complaining of right lower leg and right foot pain. The discharge summary recommended for the resident to get out of bed daily to the wheelchair, begin Restorative Nursing Program for active assistive range of motion to bilateral upper and lower extremities and a standing program. A nursing note dated 3/10/2022 at 7:53 AM documented Resident #21 was discharged from Occupational Therapy (OT)/PT. Recommendations were to provide a Restorative Nursing Program for Transfers/Standing Program, 20 seconds with extensive assistance of 2 persons using handrails, 6 days per week. A nursing note written by RN #1 dated 3/10/2022 at 2:06 PM documented the resident was alert and responsive. The resident's right foot remains swollen and tender to touch. The Physician was notified and ordered Tylenol 650 mg every 6 hours as needed for pain and to elevate the foot while in bed. A nursing note written by RN #1 dated 3/11/2022 at 2:15 PM documented the resident's right foot remains swollen and tender to touch. Orders were in place for Tylenol 650 mg every 6 hours as needed for pain and to elevate the foot while in bed. Physician #1's note dated 3/11/2022 at 3:55 PM documented the resident continues with right foot pain episodically. The resident was discussed with the RN and was given Tylenol with good results. The assessment/plan for the right foot included Osteo Arthritis (OA). Further adjustments as per clinical course. A nursing note written by the wound RN on 3/15/2022 at 12:02 PM documented Resident #21 was seen and examined by the wound care physician for evaluation of right lower extremity pain and tenderness. The Right ankle and right distal leg were identified with tenderness and warmth compared to the left leg. A nursing note written by RN #1 on 3/15/2022 at 12:41 PM documented resident alert and responsive. Seen today by Wound Care/Vascular Physician. Suggested ordering a right lower extremity Venous Doppler and Physician (#1) was in agreement. A STAT (immediate) portable x-ray was ordered and to be completed today. Physician #1's note dated 3/15/2022 at 3:22 PM documented the resident continues with right foot pain, no history of trauma, diffuse tenderness to the dorsal aspect of the right foot and lateral malleolar area. The plan for the right foot pain was to check x-rays and a Doppler study was already ordered by the vascular surgeon. A nursing note dated 3/15/2022 at 7:56 PM documented the x-ray and venous Doppler results were received and Physician #1 was made aware. X-ray of the right ankle revealed an acute nondisplaced spiral distal tibial fracture. A new order was obtained to transfer the resident to the hospital. A Rehabilitation evaluation dated 3/16/2022, upon the resident's return from the hospital, documented that the resident had a cast in place to the right lower extremity, was non-weight bearing to right lower extremity, and was to follow up with the Orthopedic Surgeon in one week. RN #1 (unit supervisor) was interviewed on 1/10/2023 at 12:20 PM and stated the x-ray was not considered initially because there was no trauma, like an accident or fall, and the pain was treated as arthritic pain. RN #1 stated when the pain persisted the x-ray was ordered. RN #1 stated when the resident was transferred out of bed, the resident would complain about pain to the CNA, and even when the resident was being moved in bed the resident would complain of pain to the CNA. RN #1 stated the CNA reported the pain to me (RN #1) and RN #1 reported it to the doctor. RN #1 stated on 3/15/2022 the wound care physician and the Primary Care Physician discussed Resident #21 and decided to order an x-ray. RN #1 further stated as far as they (RN #1) know transfers were not stopped when the resident complained about pain because there was no Physician's order for non-weight bearing. Review of the CNA Accountability record from 3/8/2022-3/15/2022 revealed that the resident was transferred from bed to chair and chair to bed daily with extensive assistance of two persons. Physician #1 was interviewed on 1/10/2023 at 1:22 PM and stated that an x-ray was not initially ordered because there was not a high index of suspicion of a fracture because there were no falls or accidents, and the suspicion of a fracture was remote. Physician #1 stated in the setting of trauma, an x-ray would be done, but in the absence of trauma, things were done to determine if there was something else going on like a clot, which is more significant. Physician #1 stated an order for an x-ray was made when an evaluation was made with the wound care physician on 3/15/2022. The physician acknowledged that a fracture may have been a result of routine transfers. The current Director of Nursing Services (DNS) was interviewed on 1/10/2023 at 2:20 PM and stated an x-ray should have been ordered initially to rule out a fracture. The DNS stated they (DNS) would have fought with the doctor for an x-ray order because we are all clinicians. The DNS stated transfer status is based on what the Rehabilitation Department (Rehab) assessment indicates, and Rehabilitation did not say to stop transfers after the resident was discharged from therapy. Physician #1 was reinterviewed on 1/11/2023 at 8:23 AM and was asked if a clot was a concern, why was the venous Doppler ordered on 3/15/2022 instead of 3/8/2022 when the pain and swelling started. Physician #1 stated a venous Doppler was not ordered sooner because maybe the pain and swelling were not as accentuated, but as time progressed and the pain and swelling did not resolve, or the pain worsened, that is when the venous Doppler was ordered. The Rehabilitation Director was interviewed on 1/11/2023 at 9:59 AM and stated the 3/10/2022 PT discharge note documented pain in the right lower leg. The Rehabilitation Director stated we did not know what was going on because there was no x-ray and the resident was still able to stand with extensive assist of two persons. The PT note documented that the resident stood for 20 seconds with maximum assistance of two persons. The Rehabilitation Director stated if we notice pain, we report it to nurse and nurse tells the doctor and that Rehabilitation Department does not communicate with the doctor. The Rehabilitation Director stated the pain was probably the reason why therapy was discontinued because the resident's status was not improving, and the resident reached maximum potential. The resident was placed on active assistive range of motion because the resident's pain was inconsistent, and the PT wanted to keep the resident active. The Rehabilitation Director stated we just inform the nurse about the pain by phone call; we do not say what is needed or recommended like an x-ray. Certified Nursing Assistant (CNA) #1 was interviewed on 1/11/2023 at 10:41 AM and stated they (CNA #1) were the one who reported to the nurse that the resident had pain in the right leg CNA #1 stated the resident would wince if you tried to move or touch the resident. CNA # 1 stated we just transferred the resident by having the resident step on the floor and pivot but did not do a standing program. CNA #1 could not recall if the resident complained of pain during the transfer process. PT #1 (treating therapist) and Rehabilitation Director were interviewed concurrently on 1/12/2023 at 10:30 AM. PT #1 stated the resident was not performing that well because of the pain in the right lower leg and kept on refusing to participate. PT #1 stated we did not know what was going on with the right leg. PT #1 stated the resident's pain was not consistent and they (PT #1) had documented in the therapy notes before discharge that the resident had pain. PT #1 stated they (PT #1) recommended a nursing rehab program after discharge because they (PT #1) did not want the resident to stop activities. PT #1 stated that nursing was aware of the pain in the right leg. PT #1 stated they (PT #1) did speak to a nurse on the unit regarding the resident's pain, but PT #1 did not document the conversation and did not remember who the nurse was. PT #1 stated that as long as the resident was able to tolerate the program and there was nothing excruciating, they (PT #1) did not recommend an x-ray to the nurse. 10NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00290705) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that each resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (Resident #163) of two residents reviewed for Nutrition. Specifically, Resident #163 had a 14% significant weight loss in one month, identified in December 2021, which was not addressed by the Registered Dietitian (RD) until January 2022. The finding is: The facility's policy titled, Monthly Weight and Vital Sign Policy and Procedure last reviewed on 1/2021 documented that the Nurse would notify the Physician and Dietitian of any 5 pounds (lbs)/5% weight changes. The policy also documented that once weights are completed, they will be given to the Dietitian. The Dietitian will enter the weights into the Electronic Medical Record and document the weight on the monthly weight sheet. The facility's policy titled, Unplanned Significant Weight Changes last reviewed on 11/2021 documented that a significant weight loss is defined as a 5% weight loss in one month or more and a 10% loss in 6 months. The policy also documented that the Dietitian will complete a comprehensive assessment and based on the findings, the Dietitian will determine the need for further interventions. Resident #163 has diagnoses which include Type 2 Diabetes Mellitus and Hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance of one person for eating. The resident's height was 70 inches and they weighed 180 pounds. The MDS documented the resident had loss of liquids/solids from mouth when eating or drinking; was holding food in mouth/cheeks or residual food in mouth after meals; and exhibited coughing or choking during meals or when swallowing medications. The quarterly MDS assessment dated [DATE] documented that the resident had a BIMS score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident was totally dependent on one person for eating. The resident's height was 70 inches and they now weighed 150 pounds, a decrease of 30 lbs since the 11/4/2021 MDS assessment. The MDS documented the resident had loss of liquids/solids from mouth when eating or drinking; was holding food in mouth/cheeks or residual food in mouth after meals; and exhibited coughing or choking during meals or when swallowing medications. The MDS also documented that there was a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and that the resident was not on a physician prescribed weight-loss regimen. The resident's Weight Monitoring Report documented that on 10/20/2021 the resident weighed 180 lbs and on 12/10/2021 the resident weighed 158 lbs which indicated a 22 lbs or a 14% significant weight loss in two months. The resident's current diet orders dated 12/22/2021 documented Diet: No Concentrated Sweets (NCS), Food Consistency: Ground (No Bread), and Fluid Consistency: Thin Liquids. The Speech Therapy Progress Note dated 1/12/2022 recommended a diet change from ground solids (no bread) and thin liquids to puree solids and nectar thick liquids secondary to a change in the resident's cognitive status. The resident's diet orders dated 1/12/2022 documented Diet: NCS, Food Consistency: Puree, and Fluid Consistency: Nectar Thickened. The resident's Weight Monitoring Report documented that on 1/14/2022 the resident weighed 150 lbs which indicated an additional 8 lb or 5% significant weight loss in one month. The Speech Therapy Progress Note dated 1/14/2022 at 4:26 PM recommended a diet change from nectar thickened liquids to honey thickened liquids due to an increased aspiration risk. Speech Language Pathologist (SLP) observed excessive coughing post swallow of nectar thick liquids. The resident's diet orders dated 1/14/2022 documented Diet: NCS, Food Consistency: Puree, and Fluid Consistency: Honey Thickened. The Weight Change/Quarterly Nutrition assessment dated [DATE], written by Registered Dietitian (RD) #2, documented that the resident's Current Body Weight (CBW): 150 lbs, Height: 70 inches, Ideal Body Weight Range (IBWr): 149-183 lbs, and the Body Mass Index (BMI): 21.5 (categorized as normal body weight; BMI>20 is desirable given advanced age). The evaluation by RD #2 documented that the resident presented with a weight change of (-30 lbs, -20% loss) x 3 months, and (-30 lbs, -20% loss) x 6 months; weight change (x 3 and 6 months) was clinically significant, unplanned, and undesirable, questioned the accuracy of weighs/weight status and a reweigh for the resident for January was currently pending. The weight loss was likely related to the resident's variable oral (po) intake, mechanically altered diet, disease process, Parkinson's Disease, Dementia, and recent positive COVID-19 diagnosis. The Brief Nutrition Note dated 1/17/2022, written by RD #2, documented concerns regarding the resident's weight loss and nutrition status were discussed with the resident's family, food preferences were obtained, and Glucerna shakes (a nutritional supplement) would be provided twice daily to aid in optimizing the resident's intake and weight status. The resident's diet order dated 1/17/2022 documented Supplement: Honey Thickened Glucerna 8 ounces (oz) by mouth twice daily (BID). The 3rd Floor Registered Nurse (RN) #7, Charge Nurse, was interviewed on 1/10/2023 at 3:00 PM and stated that monthly weights are started at the end of each month by the 30th or 31st and finished by the 5th of the following month. RN #7 stated that if there is a weight discrepancy, reweights are done by the 10th of the month. RN #7 stated that the weights are written on a weight worksheet, and they (RN #7) would check if they could find the old weight worksheets for 2021 to see why the resident was not weighed for November 2021 and why no reweights had been done to check the accuracy of the weights when the resident had lost 22 lbs between October and December 2021 and another 8 lbs between December 2021 and January 2022. RN #7 was re-interviewed on 1/10/2023 at 4:05 PM and stated that they (RN #7) did not see any documentation in the resident's EMR, nor were they (RN #7) able to find any weight worksheets to explain why there was no weight taken for the resident in November 2021 and why no reweights were done to address the resident's significant weight loss. RN #7 was re-interviewed again on 1/11/2023 at 10:00 AM and stated that during October, November, and December 2021 the RD would enter the weights into the EMR. RN #7 stated that if there is a discrepancy of more than 2 pounds, they (RN #7) would ask for a reweigh. If a significant weight loss was seen, they (RN #7) would notify the Primary Care Physician (PCP) with a phone call and write a progress note in the EMR. RN #7 could not explain why they (RN #7) did not write a progress note regarding the resident's weight loss and notification to the PCP. The facility's current RD (RD #1) was interviewed on 1/11/2023 at 10:45 AM and stated by looking into the resident's EMR, a weight in November 2021 was never obtained nor was there a re-weight for the December 2021 weight. RD #1 stated there should have been a note written by the RD at that time (RD #2) stating that a reweight was pending and some kind of intervention put into place in December of 2021 when the 22 lbs. weight loss was seen. RD #1 stated that the resident's family should have been called first to get food preferences and to tell them (the family) if there was a confirmed weight loss and put an intervention in place first while waiting for a reweigh such as giving a Mighty Shake (a high calorie shake) in between meals at 10:30 AM, 2:30 PM, and 8:30 PM. The facility's previous RD (RD #2) was interviewed on 1/11/2023 at 3:00 PM and stated that if they (RD #2) had known about the weight or seen the significant weight loss in December 2021, they (RD #2) would have documented the findings. RD #2 stated that they (RD #2) were in charge of putting all of the weights into the EMR. RD #2 stated that Resident #163's weight of 158 lbs. in December of 2021 was a 14% weight loss in two months, which was significant. RD #2 could not say why they (RD #2) missed the resident's initial weight loss in November 2021. RD #2 stated that had they (RD #2) seen the resident's weight loss in December 2021, they (RD #2) would have discussed meal preferences with resident's family, initiated a supplement, liberalized their (Resident #163) diet if possible, seen if there was anything they (RD #2) could work on with the speech therapist, and start Resident #163 on weekly weights. The Director of Nursing Services (DNS) was interviewed on 1/12/2023 at 10:00 AM and stated that Nursing staff communicates with the PCP when there is a weight loss. The DNS stated that the weight scale should be checked if there was something wrong, maybe the weight scale was not balanced. The DNS stated that a re-weigh for the resident should have been obtained. The DNS stated that the resident should also have been looked at to see how much the resident was eating at meals at the time and the RD should have been notified. The DNS further stated that if there was a change in the resident's weight of plus or minus 5 lbs. in a month, the resident should have been reweighed. 10 NYCRR 415.12(i)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00290705) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that the medical care of each resident was supervised by the Physician including monitoring changes in the resident's medical status. This was identified for one (Resident #163) of two residents reviewed for Nutrition. Specifically, Resident #163 had a 14% significant weight loss in one month, identified in December 2021, which was not addressed by their Primary Care Physician (PCP). Resident #163 had an additional 5% significant weight loss in one month, identified in January 2022, and there was no documentation from the PCP addressing the resident's significant weight loss in a timely manner. The finding is: The facility's policy titled, Monthly Weight and Vital Sign Policy and Procedure last reviewed on 1/2021 documented that the Nurse would notify the Physician and Dietitian of any 5 pounds (lbs)/5% weight changes. The facility's policy titled, Unplanned Significant Weight Changes last reviewed on 11/2021 documented that a significant weight loss is defined as a 5% weight loss in one month or more and a 10% loss in 6 months. The policy also documented that the Physician should review the weight loss and based on the resident's diagnosis/prognosis, determine if the weight loss is unavoidable. Resident #163 has diagnoses which include Type 2 Diabetes Mellitus and Hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance of one person for eating. The resident's height was 70 inches and they weighed 180 pounds. The MDS documented the resident had loss of liquids/solids from mouth when eating or drinking; was holding food in mouth/cheeks or residual food in mouth after meals; and exhibited coughing or choking during meals or when swallowing medications. The quarterly MDS assessment dated [DATE] documented that the resident had a BIMS score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident was totally dependent on one person for eating. The resident's height was 70 inches and they now weighed 150 pounds a decrease of 30 lbs since the 11/4/2021 MDS assessment. The MDS documented the resident had loss of liquids/solids from mouth when eating or drinking; was holding food in mouth/cheeks or residual food in mouth after meals; and exhibited coughing or choking during meals or when swallowing medications. The MDS also documented that there was a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and that the resident was not on a physician prescribed weight-loss regimen. The Physician's Order dated 7/30/2021 and last renewed on 1/12/2022 documented Do Not Resuscitate (DNR): Consent on File, Comfort Measures Only, Do Not Intubate (DNI), Do not send to the Hospital (DNH), and a trial period of Intravenous (IV) Fluids. The resident's Weight Monitoring Report documented that on 10/20/2021 the resident weighed 180 lbs and on 12/10/2021 the resident weighed 158 lbs which indicated a 22 lbs or a 14% significant weight loss in two months. The Medical Monthly Progress Note dated 12/22/2021, written by the resident's PCP (Physician #2), documented: Weight 180 lbs - No changes - observe only. The resident's current diet orders dated 12/22/2021 documented Diet: No Concentrated Sweets (NCS), Food Consistency: Ground (No Bread), and Fluid Consistency: Thin Liquids. The Speech Therapy Progress Note dated 1/12/2022 recommended a diet change from ground solids (no bread) and thin liquids to puree solids and nectar thick liquids secondary to a change in the resident's cognitive status. The resident's diet orders dated 1/12/2022 documented Diet: NCS, Food Consistency: Puree, and Fluid Consistency: Nectar Thickened. The resident's Weight Monitoring Report documented that on 1/14/2022 the resident weighed 150 lbs which indicated an additional 8 lb or 5% significant weight loss in one month. The Speech Therapy Progress Note dated 1/14/2022 at 4:26 PM recommended a diet change from nectar thickened liquids to honey thickened liquids due to an increased aspiration risk. Speech Language Pathologist (SLP) observed excessive coughing post swallow of nectar thick liquids. The resident's diet orders dated 1/14/2022 documented Diet: NCS, Food Consistency: Puree, and Fluid Consistency: Honey Thickened. The Medical Monthly Progress Note dated 1/14/2022 at 10:14 PM, written by the resident's PCP (Physician #2), documented: Weight 150 lbs - observe only. There was no further documentation in reference to the resident's weight. The Weight Change/Quarterly Nutrition assessment dated [DATE], written by Registered Dietitian (RD #2), documented that the resident's Current Body Weight (CBW): 150 lbs, Height: 70 inches, Ideal Body Weight Range (IBWr): 149-183 lbs, and the Body Mass Index (BMI): 21.5 (categorized as normal body weight; BMI>20 is desirable given advanced age). The evaluation by RD #2 documented that the resident presented with a weight change of (-30 lbs, -20% loss) x 3 months, and (-30 lbs, -20% loss) x 6 months; weight change (x 3 and 6 months) was clinically significant, unplanned, and undesirable, questioned the accuracy of weighs/weight status and a reweigh for the resident for January was currently pending. The weight loss was likely related to the resident's variable oral (po) intake, mechanically altered diet, disease process, Parkinson's Disease, Dementia, and recent positive COVID-19 diagnosis The Brief Nutrition Note dated 1/17/2022, written by RD #2, documented concerns regarding the resident's weight loss and nutrition status were discussed with the resident's family, food preferences were obtained, and Glucerna shakes (a nutritional supplement) would be provided twice daily to aid in optimizing the resident's intake and weight status. The resident's diet order dated 1/17/2022 documented Supplement: Honey Thickened Glucerna 8 ounces (oz) by mouth twice daily (BID). The Medical Progress Notes dated 1/17/2022, 1/19/2022, 1/21/2022, and 2/7/2022 written by the resident's PCP (Physician #2) documented that they were asked to see patient by staff for f/u (follow-up) eval (evaluation) with no documented evidence addressing the resident's significant weight loss. The Medical Progress note dated 3/6/2022 written by the resident's PCP (Physician #2) documented that the resident's family had taken the resident to the Emergency Department (ED) on 2/9/2022 for an undisclosed reason. The 3rd Floor Registered Nurse (RN #7) Charge Nurse was interviewed on 1/10/2023 at 3:00 PM and stated that monthly weights are started at the end of each month by the 30th or 31st and finished by the 5th of the following month. RN #7 stated that if there is a weight discrepancy, reweights are done by the 10th of the month. RN #7 stated that the weights are written on a weight worksheet, and they (RN #7) would check if they could find the old weight worksheets for 2021 to see why the resident was not weighed for November 2021 and why no reweights had been done to check the accuracy of the weights when the resident had lost 22 lbs between October and December 2021 and another 8 lbs between December 2021 and January 2022. RN #7 was re-interviewed on 1/10/2023 at 4:05 PM and stated that they (RN #7) did not see any documentation in the resident's electronic medical record (EMR), nor were they (RN #7) able to find any weight worksheets to explain why there was no weight taken for the resident in November 2021 and why no reweights were done to address the resident's significant weight loss. RN #7 was re-interviewed again on 1/11/2023 at 10:00 AM and stated that during October, November, and December 2021 the RD would enter the weights into the EMR. RN #7 stated that if there is a discrepancy of more than 2 pounds, they (RN #7) would ask for a reweigh. If a significant weight loss was seen, they (RN #7) would notify the PCP with a phone call and write a progress note in the EMR. RN #7 could not explain why they (RN #7) did not write a progress note regarding the resident's weight loss and notification to the PCP. The facility's current RD (RD #1) was interviewed on 1/11/2023 at 10:45 AM and stated by looking into the resident's EMR, a weight in November was never obtained nor was there a re-weight for the December weight. RD #1 stated there should have been a note written by the RD at that time (RD #2) stating that a reweight was pending and some kind of intervention put into place in December of 2021 when the 22 lb weight loss was seen. RD #1 stated that the resident's family should have been called first to get food preferences and to tell them (the family) if there was a confirmed weight loss and put an intervention in place first while waiting for a reweigh such as giving a Mighty Shake (a high calorie shake) in between meals at 10:30 AM, 2:30 PM, and 8:30 PM. Resident #163's PCP (Physician #2) was interviewed on 1/11/2023 at 1:13 PM and stated that the resident was on Comfort Measures since 7/30/2021 and guessed that was why they (Physician #2) were not too aggressive in treating them (Resident #163) for their weight loss. Physician #2 stated that it was very strange why they (Physician #2) did not acknowledge the resident's significant weight loss in December of 2021 and could not explain why they (Physician #2) would just observe the resident's weight in January 2022 when the resident had lost 20 lbs or 20% of their weight in 3 months. The Medical Director was interviewed on 1/11/2023 at 2:50 PM and stated that when Physician's document weights, they should refer to the weights in the EMR. The Medical Director stated that if a resident has a significant weight loss, it should be documented that it was discussed with family and in this case, that weight loss was expected because they (the resident) were on Comfort Care. The facility's prior RD (RD #2) was interviewed on 1/11/2023 at 3:00 PM and stated that if they (RD #2) had known about the weight or seen the significant weight loss in December 2021, they (RD #2) would have documented. RD #2 stated that they (RD #2) were in charge of putting all of the weights into the EMR. RD #2 stated that Resident #163's weight of 158 lbs in December of 2021 was a 14% weight loss in two months, which was significant. RD #2 could not say why they (RD #2) missed the resident's initial weight loss in November 2021. The Director of Nursing Services (DNS) was interviewed on 1/12/2023 at 10:00 AM and stated that Nursing staff communicates with the PCP when there is a weight loss. The DNS stated that the weight scale should be checked if there was something wrong, maybe the weight scale was not balanced. The DNS stated that a re-weigh for the resident should have been obtained. The DNS stated that the resident should also have been looked at to see how much the resident was eating at meals at the time and the RD should have been notified. The DNS further stated that if there was a change in the resident's weight of plus or minus 5 lbs in a month, the resident should have been reweighed. 10 NYCRR 415.15(b)(1)(i)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 1/5/2023 and completed on 1/13/2023 the facility did not ensure for influenza vaccine that each resident's medical record indicated either the resident received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. This was identified for one (Resident #104) of five residents reviewed for influenza vaccine; and for Pneumococcal vaccine the facility did not ensure that each resident's medical record indicated either the resident received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal for two (Resident #104 and #99) of five residents reviewed for pneumococcal vaccine. The findings are: The facility's policy dated 12/2021, titled Influenza Vaccination (seasonal flu), documented all new admissions will be assessed for the need for this vaccine as part of the admission medical work-up; and documentation of the vaccine will be noted in the medication administration record, 24-hour report, nurses notes and resident's immunization record. The facility's undated policy titled Immunization Specific to Pneumococcal Vaccines documented that on admission, annually, and with significant change the nursing department will review the resident's pneumococcal vaccination history; and each resident will have an immunization care plan, and this will be updated accordingly, and each resident will have all immunizations listed in the electronic medical record. 1a) Resident #104 was admitted on [DATE] with diagnoses including Diabetes Mellitus, Non-Alzheimer's Dementia, and Hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. The MDS assessment documented the influenza vaccine was not administered in the facility and was not offered in the facility. The pneumococcal vaccine was not up to date and the vaccine was not offered in the facility. Review of the nursing admission assessment dated [DATE] revealed documented that the resident/representative were not educated regarding the influenza and pneumococcal vaccines and did not receive an opportunity to consent or decline the vaccines. Licensed Practical Nurse (LPN) #1, unit charge nurse, was interviewed on 1/6/2023 at 1:05 PM. LPN #1 reviewed Resident #104's medical record and stated there was no documentation of whether the resident received the influenza vaccine. LPN #1 stated they (LPN #1) were not sure if the vaccine was offered, and that Resident #104 may have received the influenza vaccine before admission. A nursing progress note, written by Registered Nurse (RN) #1, dated 1/9/2023 at 8:29 AM documented they (RN #1) spoke to the resident's family regarding the 2022 flu shot. The family member stated the vaccine was declined upon admission because the resident was previously vaccinated by their (Resident #104) primary care physician in community. The progress note indicated that the flu shot was administered on 9/24/2022. RN #1, unit supervisor, was interviewed on 1/9/2023 at 9:05 AM. RN #1 stated whoever did the admission failed to put the vaccination status in the admission note and assessment. 1b) Review of a vaccination history document provided by a community physician for Resident #104 revealed that the resident received the pneumococcal vaccine on 10/26/2015. A nursing progress note written by RN #3 dated 1/9/2023 at 11:56 AM documented the writer spoke to the resident's family member and the family member agreed that Resident #104 can get the pneumococcal vaccine in the facility as the last pneumococcal vaccination was given on 10/26/2015. The facility physician was made aware and ordered the pneumococcal vaccine on 1/9/2023. RN #2, who was the evening RN supervisor/ admission nurse, was interviewed on 1/13/2023 at 8:27 AM. RN #2 stated the resident spoke Italian and RN #2 had left a message with the family regarding the vaccines. RN #2 stated admissions usually come in late in the day, so follow up the next day regarding vaccine status is usually needed. RN #2 stated Social Work is supposed to follow up. 2.) Resident #99 was admitted on [DATE] with diagnoses including Hypertension, Adult Failure to Thrive, and Wedge Compression Fracture of Lumbar Vertebra. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS assessment documented the pneumococcal vaccine was not up to date and the vaccine was not offered in the facility. The nursing admission assessment dated [DATE] revealed no documentation for the pneumococcal vaccine. There was no documentation in the medical record that the resident was offered and or received the pneumococcal vaccine. Registered Nurse (RN) #3 (unit supervisor) was interviewed on 1/9/2023 at 2:31 PM and stated there was nothing in the medical record regarding the status of the pneumococcal vaccine for Resident #99, so we just asked the resident today (1/9/2023) and the resident declined the vaccine. RN #1, the admission nurse, was interviewed on 1/12/2023 at 1:35 PM and stated there was no determination of the resident's pneumococcal vaccination status upon admission. RN #1 further stated sometimes the information is not available at admission and it has to be followed up. The current DNS was interviewed on 1/13/2023 at 2:09 PM and stated they (DNS) thought the former DNS followed up the resident vaccine status after an admission. The DNS stated going forward the RN supervisors will be responsible to follow up on the residents' vaccination status. 10 NYCRR 415.19(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the Recertification Survey and Abbreviated Survey (NY00306893) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not conduct COVID-19 testing individuals with known or suspected exposure to COVID-19. This was identified for one (Resident #263) of one resident reviewed for Infection Control. Specifically, Resident #263 was transferred to the hospital for low blood pressure, low heart rate and low oxygen saturation on 12/22/2022. At the hospital the resident was diagnosed with COVID-19 infection. The facility was notified of the resident's COVID-19 diagnosis by the hospital. The facility did not conduct contact tracing to identify staff that were in close contact with Resident #263 to identify transmission of COVID-19 infection and did not conduct COVID-19 testing. The finding is: The facility policy entitled Long Term Care Facility Testing/Visitation dated 9/23/2022 documented that facilities are required to test residents and staff based on parameters and frequency set forth by the Health and Human Services (HHS) Secretary. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. Close Contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. Resident #263 has diagnoses of Non-Alzheimer's Dementia, Pneumonia, and Malnutrition. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderately impaired cognition. The physician's orders dated 11/10/2022 documented to administer oxygen at a rate of 2 liters per minute as needed via Nasal Cannula. The nursing note dated 12/22/2022 at 2:09 PM documented Resident #263 was hypotensive (low blood pressure), bradycardic (low heart rate) and hypoxic (low oxygen saturation). The resident's oxygen was increased from 2 liters to 4 liters per minute. The Physician was notified and ordered to transfer the resident to the hospital. The nursing progress note written by the Registered Nurse (RN) #2 dated 12/22/2022 at 9:41 PM documented Resident #263 was admitted to the hospital with a diagnosis of COVID-19 infection. The hospital admission note dated 12/22/2022 documented the reason for the resident's admission to the hospital was Hypoxia and COVID-19 infection. The Certified Nursing Assistant (CNA) Accountability Record dated December 2022 documented CNA #4 and CNA #5 provided care for Resident #263 from 12/20/2022 to 12/22/2022. The progress note dated 12/23/2022 at 10:58 AM documented RN #1 performed a Rapid COVID-19 test for Resident #24, who was Resident #263's roommate. Resident #24 was negative for COVID-19 infection. RN #1 was interviewed on 1/10/2023 at 12:20 PM. RN #1 stated that they were assigned to Resident #263 on 12/22/2022 before the resident was transferred to the hospital. RN #1 stated that the night nurse, RN #2, called the hospital on [DATE] and was notified by the hospital that the resident was admitted with COVID-19 infection. RN #2 notified RN #1 of the resident's COVID-19 diagnosis on 12/23/2022. RN #1 stated that after the resident's diagnosis was known to the facility, they (RN #1) were not tested and were not aware if other staff members who provided care to Resident #263 were tested for COVID-19. RN #2 was interviewed on 1/11/2023 at 9:46 AM and stated that they (RN #2) informed the Director of Nursing Services (DNS) on 12/22/2022 at 9:38 PM via a text message that Resident #263 tested positive for COVID-19 infection at the hospital. CNA #4 was interviewed on 1/11/23 at 9:54 AM. CNA #4 was Resident #263's regular CNA during the day shift. CNA #4 stated that they (CNA #4) provided care for Resident #263 the week of 12/19/2022 through 12/22/2022. CNA #4 stated that during the week, Resident #263 had a cough and CNA #4 was told by RN #1 it was just Pneumonia. Resident #263 was not wearing a surgical mask and CNA #4 was wearing a surgical mask when CNA #4 provided care. Resident #263 was not on any precautions. As CNA #4 noticed Resident #263's cough worsened, CNA #4 decided to wear an N95 mask but did not wear eye protection. CNA #4 stated that they spent 30 minutes every morning with Resident #263 to assist with toileting, washing, oral swabbing, washing the dentures and combing the resident's hair. In addition to the 30 minutes spent in the morning, CNA #4 also toileted Resident #263 throughout the day which would take a minimum of 5 minutes on each occasion because they had to stay with Resident #263 during toileting activities and the resident requested to be toileted frequently. CNA #4 did not work on 12/23/2022 and returned to the facility on [DATE]. No one from the facility notified CNA #4 that they had close contact with a positive COVID-19 case and they (CNA #4) were not instructed to get tested for COVID-19. CNA #5 was interviewed on 1/11/23 at 3:20 PM. CNA #5 stated that they were the regularly assigned evening shift CNA for Resident #263. CNA #5 stated that they spent 15-25 minutes providing care to Resident #263 before bedtime each night from 12/20/2022 through 12/22/2022. In addition to the 15-25 minutes of care, CNA #5 would spend about 10 minutes with Resident #263 every 2 hours to provide incontinence care. CNA #5 stated that Resident #263 did not wear a mask. CNA #5 stated that they wore an KN95 mask but did not wear eye protection. CNA #5 stated that Resident #263 was not on any precautions. CNA #5 further stated that the facility did not contact CNA #5 about getting tested for COVID-19. The Administrator was interviewed on 1/11/23 at 3:43 PM. The Administrator stated that they were aware that Resident #263 tested positive for COVID-19 infection in the hospital on [DATE]. The Administrator stated that the DNS at that time was the Infection Preventionist. The Administrator stated that staff members who provided care for Resident #263 were not tested because the previous DNS, who was also the Infection Preventionist, did not tell them (Administrator) that the staff had to be tested. 10NYCRR 415.19

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the Recertification Survey and Abbreviated Survey (NY00306893) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not provide a functional environment for one (Resident #263) of one Resident reviewed for Environment. Specifically, when Resident #263 resided on the second floor in a three bedded room. There was insufficient space in the room to accommodate a Mechanical (Hoyer) lift between Resident #44's bed and Resident #263 bed. Resident #263 was asked to get out of bed exit the room when Resident #44 needed to be transferred in and out of bed with Hoyer lift. The finding is: The facility policy entitled Safety Management Plan dated November 2017 documented that a safe and functional environment of care is essential for delivering high quality of care to all. All staff are responsible for cooperating with all aspects of the Safety Management Program. This includes performing their duties in a safe manner and reporting any and all hazardous conditions. 1 a) Resident #44 has diagnoses including Metatarsal Fractures, Diabetes Mellitus, and Hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderately impaired cognition. Resident #44 required extensive assistance of two persons for bed mobility and transfer. The Physical Therapy (PT) evaluation dated 11/2/2022 documented that Resident #44 required assistance of two persons via mechanical lift for transfers in and out of bed to the wheelchair. 1 b) Resident #263 has diagnoses of Non-Alzheimer's Dementia, Pneumonia, and Malnutrition. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #263 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderately impaired cognition. Resident #263 required extensive assistance of two persons for bed mobility and transfer. The facility census documented that Resident #44 occupied the A bed in the three bedded Room from 11/11/22 to 12/20/22. The census also documented that Resident #263 occupied the C bed in the three room [ROOM NUMBER] from 11/16/22 to 12/22/22. Resident #263's family member was interviewed on 1/10/2023 at 10:10 AM and stated Resident #263 was moved to another unit in a private room after readmission from the hospital on 1/3/2023. Resident #263 had previously resided on the second floor in the three bedded room. The family member stated that the three bedded room was too small for three residents. Whenever the roommate needed to be transferred out of bed with the Hoyer lift, the whole room had to be rearranged. The Certified Nursing Assistant (CNAs) had to move Resident #263's bed to make room for the Hoyer to fit in between the beds. The family member and Resident #263 would have to step out of the room when visiting so that the staff could get to the roommate. The family member stated that they expressed concern to the CNAs and the nurse, but no one did anything about it. The three bedded room was observed on 1/10/2023 at 10:38 AM. The room was L shaped with the A bed located closest to the window. The C bed was parallel to the A bed and was located closest to the room door. The B bed was located on the opposite side of the room. CNA #3 was interviewed on 1/10/2023 at 10:40 AM. CNA #3 stated that they are currently assigned to the three bedded room. CNA #3 stated that it is difficult to get the Hoyer lift into the three bedded room and that whenever they assisted with the Hoyer lift transfer, they had to move the other bed closer to the door. CNA #4, who was dayshift CNA assigned to Resident #263 while the resident was in the three bedded room, was interviewed on 1/11/23 at 9:54 AM and stated that the three bedded room was small. CNA #4 stated that they had to ask Resident #263's family member and Resident #263 to step out of the room whenever they had to get Resident #44 transferred out of bed. Sometimes CNA #4 had to ask Resident #263 to get out of bed so they (CNA #4) can move Resident #263's bed to transfer Resident #44 with the Hoyer lift because the space between the beds is too small to fit the Hoyer lift. The Director of Nursing Services (DNS) was interviewed on 1/12/2023 at 10:25 AM and stated that the resident needs have to be considered when assigning a room. The DNS stated that having a small space for a Hoyer lift is not safe and could cause a resident to fall out of the Hoyer. The DNS stated that the room would have to be re-arranged or a resident who requires a Hoyer lift should be assigned to another room that can fit a Hoyer lift. 10 NYCRR 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey the facility did not ensure that care was implemented to meet each resident's medical and nursing needs for 2 (Resident #17 and Resident #88) of 2 residents reviewed for Pressure Ulcers. Specifically, 1) Resident #17 had an ulcer to the right heel and previously had a boggy area to left heel that resolved. The resident had a physician's order for booties to both feet when in bed. Resident #17 was observed on 11/18/2020 in bed with only a heel boot on the right foot and on 11/19/2020 in bed with no heel boots on; and 2) Resident # 88 has multiple Pressure Ulcers of the ankles and feet. The resident had a Physician's Order and current Wound care plan that documented Heel booties at all times, to be removed for hygiene. During two resident observations on 11/16/2020 and 11/18/2020, the Heel booties were not observed in place. The findings are: 1) Resident #17 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Peripheral Vascular Disease, and Malnutrition. The 9/1/2020 Significant Change Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The MDS documented that the resident had one Stage 2 pressure ulcer and one venous/arterial ulcer. A Physician's order dated 8/26/2020, and last renewed on 9/25/2020, ordered booties to both feet when in bed. A Physician's order dated 10/15/2020 ordered to cleanse the right heel with normal saline, pat dry, and apply Xeroform gauze. The physician's order included to Pad the heel and top of the foot with combine (a wound dressing), abdominal pads, or gauze 4 inch x 4 inch and wrap loosely with kling/rolled gauze. A Comprehensive Care Plan (CCP) dated 8/12/2020 titled Wound Care-Skin Impairment-Right Heel-Arterial/Venous/Diabetic, had an intervention for heel pads while in bed. The Resident Nursing Instructions, which provides direction to the Certified Nursing Assistant (CNA) for the resident care needs, documented booties to both feet when in bed. A nursing progress note dated 8/12/2020, written by the Registered Nurse (RN) wound care nurse, documented the following: Called by nurse to assess resident's heels. Right heel has suspected deep tissue injury (DTI) with boggy texture and reddish/purple ecchymosis measuring 3 centimeters (cm) X 3 cm. Left heel has redness and boggy texture. MD notified and orders placed for normal saline, skin prep and dry protective dressing. Float heel booties placed and offloading with rolled towel. On 11/18/2020 at 9:52 AM Resident #17's sacrum wound care was observed. The resident was in bed. T he resident had a foam heel boot on the right foot. There was no heel boot on the left foot. On 11/19/2020 at 8:40 AM Resident #17 was in bed having breakfast. An observation was made with the Licensed Practical Nurse (LPN) medication nurse. A foam boot was observed on the resident's bedside table. The resident had a dressing on the right foot. The were no heel boots on either foot. The heels were resting on the mattress. The LPN stated she was not sure if both heels should have heel boots. The LPN opened the resident's closet and there was an additional heel boot in the closet. The LPN left room and did not apply the foam heel boot to the right foot. The resident's CNA was interviewed on 11/19/2020 at 8:45 AM. She stated the foam heel boot is for the right foot only because there is a wound on the right heel. She stated the left foot does not have a wound and there is no heel boot necessary for the left foot. The Registered Nurse (RN) wound care nurse was interviewed on 11/19/2020 at 9:17 AM. She stated the resident has diabetic and vascular issues. She stated both heels were boggy and the right heel was worse with a DTI. She stated that is why there was an order for heel boots for both heels. She further stated the left heel had healed and she did not change the order to right heel boot only. The resident's CNA was re-interviewed on 11/19/2020 at 12:25 PM. She stated she was not aware the resident was not wearing the right heel boot during breakfast. She stated the resident never complained about about having the boot on when she ate breakfast. The Director of Nursing Services (DNS) was interviewed on 11/20/2020 at 8:15 AM. She stated the left heel boot was not necessary because the left heel healed and the wound care nurse made a mistake by not cancelling the order. 2) Resident # 88 has diagnoses which include Dementia and multiple Pressure Ulcers. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition and was totally dependent on staff for all activities of daily living. The MDS documented the resident had two Stage IV Pressure Ulcers and three Unstageable Pressure Ulcers, not present on admission. The Physician's Order dated 10/30/2020 and renewed on 11/10/2020 documented Protective Heel booties at all times. Remove for skin check, hygiene and dressing change. The resident's Comprehensive Care Plan (CCP) dated 6/23/2020 titled Wound Care, Pressure Ulcer, Actual-documented interventions that included booties at all times. During the initial tour on Unit 2 on 11/16/2020 at 9:50 AM, the resident was observed in bed positioned on the left side. There were no protective Heel booties in place. No resident care was being rendered. A subsequent resident observation was made on 11/18/2020 at 1: 45 PM with the Registered Nurse/Unit Manager (RN) present. The resident was positioned in a geri recliner. The Heel booties were not observed on the resident. The RN Manager was interviewed at that time and stated that the Heel booties are removed for lunch so that the resident would have some freedom of movement during the meal. The RN stated that removal of the booties during lunch should have been made part of the resident plan of care. Review of the resident's Activity of Daily Living CCP, effective 10/30/2020 and Wound Care-Actual Pressure Ulcer CCP's effective 10/30/2020, did not document the removal of the Heel booties during the resident's meals. The resident's Certified Nursing Assistant (CNA #1) was interviewed on 11/19/2020 at 11:45 AM. The CNA stated that the Heel booties are removed during morning care and for treatments. The Physician (MD) was interviewed on 11/20/2020 at 10:00 AM The MD stated that Resident # 88's Pressure Ulcers are unavoidable and the result of the severe leg contractures. The MD stated that Resident # 88 should have the Heel booties applied all times related to the need for offloading as much as possible. 415.11(c)(1)