Based on interview and record review conducted during a Complaint investigation (#NY00328230) during a Standard survey completed on 2/12/24, the facility did not ensure that a resident has the right to refuse treatment for one (Resident #137) of six residents reviewed for immunizations. Specifically, Resident #137's Health Care Proxy did not give consent for a COVID 19 vaccine, and the resident received it. The finding is: Review of the policy and procedure titled COVID 19 Vaccination dated 10/19/23 documented that residents or their representatives will be educated regarding the risks, benefits, contraindications, and potential side effects associated with the COVID 19 vaccine. Further review of the policy documented that residents or the residents' representatives must have verbal or written consent prior to receiving the vaccine. Resident #137 was admitted to the facility with cancer of the frontal lobe of the brain, dementia, and dysphagia (difficulty in swallowing food or drink). Review of the Minimum Data Set (a resident assessment tool) dated 9/15/23 documented that the resident was cognitively intact, understood by others, and understands others. Review of the Health Care Proxy dated 6/28/23 documented that the resident designated their spouse as their Health Care Proxy and that the Health Care Proxy would go into effect when the resident could not make their own health care decisions. Review of the Determination of Incapacity/Adult Without Capacity HCP (health care proxy) form for Resident #137 dated 6/29/23 documented that the cause of the resident's incapacity was dementia, and that the probable duration was permanent. Review of the COVID 19 Vaccination Consent/Declination form dated 11/1/23, documented that Registered Nurse Unit Coordinator #1 received a verbal consent from Resident #137's Health Care Proxy for a COVID 19 immunization. The consent form was signed by the Registered Nurse Unit Coordinator #1 and was not signed by the resident, their Health Care Proxy or any witnesses. The Medication Administration Record dated 11/1/23 - 11/30/23 documented that Resident #137 received the COVID 19 vaccination on 11/7/23 at 12:04 PM. The Medication Administration Record documented that Resident #137 was monitored for post COVID 19 immunization side effects every shift from 11/7/23 to 11/9/23. Review of Resident #137's care plan last updated 12/18/23, documented that the resident had a Health Care Proxy activated. The care plan documented that the resident had alterations in their decision-making ability and some difficulty making decisions in new situations. The care plan also documented that the COVID 19 vaccination was previously declined twice. Review of a Medication/Treatment Variance Report dated 11/8/23 documented that Resident #137 was given the COVID 19 vaccine without consent. The medication error report documented that Resident #137 had a slight fever and a reddened area on the injection site. The medication error report also documented a statement from Registered Nurse Unit Coordinator #1 that they gave Resident #137 the COVID 19 vaccine in error and to be more vigilant with consents. During an interview on 2/8/24 at 8:32 AM, Registered Nurse Unit Coordinator #1 stated that they received a verbal consent from Resident 137's Health Care Proxy by telephone. They stated that they gave the COVID 19 shot and the day after they administered the shot, the Health Care Proxy said they didn't want Resident #137 to receive the shot. The Registered Nurse Unit Coordinator #1 stated that they explained to the Health Care Proxy about monitoring Resident #137 after receiving the shot and that the Health Care Proxy was okay with the resident receiving the COVID 19 shot. During an interview on 2/9/24 at 9:02 AM, Resident #137's Health Care proxy stated that they did not receive a phone call from Registered Nurse Unit Coordinator #1 about consenting to a COVID 19 immunization for the resident. They stated that they found out Resident #137 received the shot the day after it was given to the resident when they came for a visit. The Health Care Proxy stated that they visited Resident #137 every day and that they could have signed the declination for the COVID 19 shot. The Health Care Proxy stated they did not sign a consent form or a declination for the COVID 19 shot. The Health Care Proxy stated that they did not receive any educational material concerning the COVID 19 immunization before or after Resident #137 received the vaccination. During an interview on 2/9/24 at 10:22 AM, the Registered Nurse Unit Coordinator #1 stated that they had 46 consents to obtain and was told they had to get them. They stated they made a phone call to Resident #137's Health Care Proxy and thought they obtained a verbal consent. The Registered Nurse Unit Coordinator #1 stated when they spoke to the Health Care Proxy after Resident #137 received the COVID 19 shot, they realized they made a mistake. The Registered Nurse Unit Coordinator #1 stated they reported to the Director of Nursing that they gave the COVID 19 immunization in error. During an interview on 2/9/24 at 10:40 AM, the Assistant Director of Nursing Registered Nurse Infection Preventionist stated the process was that we get an order for the vaccination from the resident's physician. They stated that they expected Unit Coordinators to get a verbal or written consent from the resident or the resident's representative or Health Care Proxy prior to administering the vaccination. They stated that the Unit Coordinators were told to obtain consents, verbal or written, for the flu, pneumonia, or COVID 19 shots. They stated they would not expect the Unit Coordinator to get all consents, verbal or written, in one day. They also stated that it would be difficult to obtain consents for an entire unit in one day. During an interview on 2/9/24 at 11:10 AM, the Director of Nursing stated they expected the nursing staff to obtain verbal or written consents prior to the administration of any immunization. They stated that if a resident had capacity to make healthcare decisions, the resident should sign the consent or declination. They stated that if the resident does not have capacity to make healthcare decisions, then the Health Care Proxy should sign the consent or declination. During an interview on 2/9/24 at 2:22 PM, Resident #137's Physician stated they expected nursing staff to get a consent, verbal or written, prior to giving an immunization to a resident. During an interview on 2/12/24 at 10:31 AM, the Administrator stated that at that time, the resident was cognitively intact and could have refused the COVID 19 shot. The Administrator stated that the Health Care Proxy likes to be involved with Resident #137's care and therefore nursing staff should have obtained the consent from the Health Care Proxy. During an interview on 2/12/24 at 10:56 AM, Registered Nurse Unit Coordinator #1 stated that Resident #137 could not sign a consent or a declination form because the resident had brain cancer and could not have capacity to consent, refuse, or decline any immunization. 10 NYCRR 415.3(f)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the Standard survey completed on 3/22/22, the facility did not ensure that New York SCREEN Forms DOH (Department of Health) - 695 were completed as required. One (Resident #119) of one resident reviewed with mental retardation/developmental disabilities (MR/DD) diagnosis did not have a Level II evaluation completed as required. The finding is: Resident #119 was admitted to the facility with diagnoses including spastic quadriplegic cerebral palsy (disorder that affects a person's ability to move), intellectual disabilities, and calculus of kidney (kidney stone). Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment and was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability. The facility policy Pre-admission Screening & Resident Review (PASRR) dated 11/18 documented a resident who was identified as having mental retardation/developmental disability on their admission screen Level I Review and met the criteria for Categorical Determination, requires a stay longer than the appropriate physician documented number of days, a screen and Level II evaluation must be completed. Review of the Hospital and Community Patient Review Instrument (HC/PRI) dated 12/10/20 revealed the resident had a diagnosis of intellectual disability. Review of the SCREEN Form (DOH-695) dated 12/10/20 revealed the Level I review answered Items # 24-26 no; which determined the resident had no documented history of MR/DD and no Level II referral was made. Review of the SCREEN Form (DOH-695) dated 1/13/2021 revealed the Level I review answered Items # 24-26 yes; which determined the resident had a documented history of MR/DD. Items #27-30 were answered no and the document directed screener to complete item #33 (Level II Referrals), which was blank. Review of social work Progress Notes dated 12/14/20-3/18/22 revealed no evidence a Level II referral was made to OPWDD. During an interview on 3/18/22 at 10:22 AM, the Social Worker (SW) #1 stated the resident had some developmental disability and that residents who require a Level II are usually checked prior to admission to the facility. SW #1 stated they check the SCREENs to ensure they had a valid screener number and that was it, they don't check that it was accurate. SW #1 stated they didn't know why a Level II would be done or wouldn't be done and didn't know the qualifications needed for a resident to be referred for a Level II review. During further interview on 3/18/22 at 10:55 AM, SW #1 stated they went through all the resident's screens in the chart and the screener (at the hospital) did not indicate a Level II referral was needed. The SW #1 stated the resident was initially admitted for short term rehab and that nothing changes once someone goes long term care in regard to a Level II referral. SW #1 stated the group home couldn't meet the resident's needs anymore and the resident transitioned to long term care. During an interview on 3/21/22 at 11:24 AM, SW #1 stated the resident did have a diagnosis of intellectual disability upon admission. The SW who followed the resident upon initial admission no longer worked in the facility and that SW #1 took over in May of 2021 and did not refer the resident for a Level II evaluation, had never made a referral to Office for People with Developmental Disabilities (OPWDD) and didn't know who was responsible for making the referral. SW #1 reviewed the facility policy, stated it was revised 11/2018 and said if the resident was initially here for a brief stay, but exceeded 30 days, they must make a referral for a Level II, then the Level II should be completed within 40 days from the referral. During an interview on 3/22/22 at 10:27 AM, SW #2 stated they were the resident's social worker upon the January 2021 admission and that they reviewed SCREEN forms only to make sure there was a valid screener number. SW #2 stated they would make a Level II referral if the resident had a developmental disability and was expected to remain in the facility longer than 30 days. SW #2 stated the resident was switched to another SW's case once the resident transitioned to long term care prior to the 30 days, so they did not make a Level II referral. During an interview on 3/22/22 at 11:07 AM, the Director of Nursing (DON) stated a referral to OPWDD was to be made once someone with intellectual disabilities transitioned to long term care and it was the social worker's responsibility to make the referral. 415.11 (e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 3/22/22, the facility did not ensure that each resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain grooming and personal hygiene for two (Residents #119 and 92) of five residents reviewed for ADLs. Specifically, Resident (#119) was not provided with complete AM ADL care including washing of their underarms, hands and perineal area and Resident (#92) was not provided timely incontinence care. Additionally, barrier cream was not applied following incontinence care (#119) and staff did not complete hand hygiene in-between glove change after incontinence care (#92). The findings are: The facility policy and procedure (P&P) titled Bathing and Grooming revised 2/2019 documented a partial bed bath (AM Care) included washing the resident's face, neck, underarms and under breasts. Also, to wash the resident's genitals, buttocks, and apply A&D ointment (skin protectant). The facility P&P titled Policy on Hand Washing with revised date 11/2019 documented that proper handwashing technique is used for the prevention of transmission of infectious diseases. The P&P documented that all personnel working the long-term care facility are required to wash their hands before and after assisting a resident with personal care and after removing gloves. 1. Resident #119 was admitted to the facility with diagnoses including spastic quadriplegic cerebral palsy (disorder that affects a person's ability to move), intellectual disabilities, and calculus of kidney (kidney stone). The Minimum Data Set (MDS) dated [DATE] documented Resident #119 had moderate cognitive impairment, required extensive two person assist for bed mobility and was totally dependent on staff for toileting and hygiene. The Visual Bedside [NAME] Report (used by Certified Nurse Aides (CNA) to guide care) dated 3/18/22 documented Resident #119 required two assist for side-to-side bed mobility, total care for bathing and personal hygiene, and a moisture barrier following incontinence care. During observation of morning (AM) care on 3/18/22 at 8:31 AM, Resident #119 was lying in bed, wearing the same shirt they had been wearing the day before. There were linens on the overbed table including washcloths, a towel, and an incontinence brief. There was no basin of water. CNA #2 removed the pillow that was under Resident 119's legs then removed the resident's shirt and started to put a different shirt on the resident. Resident #119 stated No, CNA #2 asked the resident if they wanted a different shirt, and Resident #119 stated, yes. CNA #2 obtained a different shirt from the resident's closet, Resident #119 approved the shirt, and the CNA put the clean shirt on the resident. CNA #2 did not wash Resident 119's underarms, chest, hands, or apply deodorant before putting on the clean shirt. CNA #2 went to the sink, applied water and soap to the washcloth and placed the washcloth directly on the resident's bed. CNA #2 unfastened Resident 119's brief and folded it down between their thighs. Resident #119 was incontinent of urine. CNA #2 turned Resident #119 onto their left side, using 1 assist and washed the resident's buttocks, gluteal folds, wiped once between the resident's thighs, placed a new brief under the resident, and positioned the resident on their back. CNA #2 did not wash Resident 119's genital and groin area or apply moisture barrier cream to the resident's buttocks. The resident said No, the CNA asked the resident if they wanted a larger brief, the resident stated yes. CNA #2 left the room to obtain a new brief and the Registered Nurse Unit Coordinator (RN UC) #1 returned to the room with CNA #2. CNA #2 and RN UC #1 turned Resident #119 to their left side and applied the new brief. CNA #2 put pants on the resident, and the two staff members transferred Resident #119 into a chair using a mechanical lift. During an interview on 3/18/22 at 10:10 AM, CNA #2 stated Resident 119 required two assist for bed mobility and they should have asked for assistance to turn the resident. The CNA stated the resident was a two assist because they required a mechanical lift and the resident sometimes had pain in their legs. The CNA stated washing underarms, chest, and hands were a normal part of morning care and didn't do it. CNA #2 stated they do look at the [NAME] but didn't look at all the details and missed that they were to apply the barrier cream, they have tubes of A&D ointment that should be used. During an interview on 3/18/22 at 10:34 AM, the RN UC #1 stated they expected that the CNA would use 2 assist to turn Resident #119 per the [NAME]. RN #1 stated morning care was supposed to include washing the resident's underarms, hands, and peri area and should be completed daily to keep the residents clean. During an interview on 3/22/22 at 11:01 AM, the Director of Nursing (DON) stated they expected the CNAs to follow the care plan to ensure resident safety and comfort. The CNA should have applied barrier cream to prevent skin breakdown. The DON stated washing underarms, hands, and peri area was part of basic morning care. 2. Resident #92 had diagnoses including hemiplegia (paralysis of one side of the body) following a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), and dementia. The MDS dated [DATE] documented Resident #92 had severe cognitive impairments, was sometimes understood, sometimes understands. The MDS documented Resident #92 required total assist for toileting, was always incontinent of bladder and bowel and was at risk for developing pressure ulcers. The visual/bedside [NAME] report dated 3/21/22 documented Resident #92 was incontinent and required total care for toileting. Interventions included to provided incontinent care every 2-3 hours and as needed. During a continuous observation on 3/21/22 from 8:41 AM through 12:31 PM Resident #92 was observed to be seated in their Geri-chair (specialized reclining chair) in an upright seated position. The resident was not checked for incontinence, provided with incontinence care or with assisted with positional changes during this time. During an observation of incontinence care in the presence of RN #5 on 3/21/22 at 1:08 PM, Resident #92 was in bed on their back with CNA #3 at bedside. The room smelled of urine. CNA #3 and CNA #5 performed hand hygiene and donned (put on) clean gloves. The CNAs positioned Resident #92 onto their left side, and removed the resident's incontinence brief. The brief was saturated with urine and a small amount of stool. CNA #3 provided urinary and bowel incontinence care. CNA #3 removed their gloves, donned new gloves and washed Resident #92 face and hands. CNA #3 did not complete hand hygiene in-between the glove change. Upon pulling up Resident #92's pants it was noted that their pants were also wet. CNA #3 changed the resident's pants. During an interview on 3/21/22 at 1:45 PM, CNA #3 stated they had gotten Resident #92 out of bed around 7:30 AM. CNA #3 stated they were floated to another unit about 8:15 AM and returned to the unit about 9:30 AM. CNA #3 stated that Resident #92 should have been put back to bed every 2-4 hours and provided with incontinence care before lunch around 11:00 AM. During an additional interview on 3/22/22 at 10:06 AM, CNA #3 stated that they did not check or provided incontinence care to Resident #92 until after lunch on 3/21/22 (1:08 PM). During an interview on 3/21/22 at 1:57 PM, CNA #5 stated Resident #92 was on their assignment while CNA #3 floated to another unit. CNA #5 stated they did not provide any ADL or incontinence care to Resident #92 during that time. During an interview on 3/21/22 at 2:00 PM, LPN #5 stated that Resident #92 should be turn and positioned every 2 hours and have incontinence care provided every three hours and did not know if that took place. During an interview on 3/21/22 at 3:04 PM, RN #5 Director of Education/Director of Quality stated that during observation of incontinence care for Resident #92, CNA #3 did not wash their hands in-between glove change and they should have. RN #5 stated the expectation was for residents to be provided with incontinence care every two hours and as needed. During an interview on 3/22/22 at 9:58 AM, RN #4 Assistant Director of Nurses /Infection Control Preventist stated that staff should wash their hands after taking off gloves and applying new gloves to prevent cross-contamination of germs and infection. During an interview on 3/22/22 at 10:52 AM, the DON stated that their expectation was a resident should be toileted per their care plan to prevent skin breakdown. 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review conducted during a Complaint investigation (Complaint #NY00281755) completed during the Standard survey on 3/22/22, the facility did not ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for two residents (#298 and #184) of four residents reviewed for indwelling catheters (tubing put into a patient's urethra to collect urine from their bladder). Specifically, the lack of adhering to professional standards of practice and infection prevention and control practices. This included the lack proper hand hygiene and glove change during catheter care (#298) and a catheter drainage bag and tubing that were observed directly on the floor during multiple observations (#184). Both residents had urinary tract infections. The findings are: The facility policy and procedure (P&P) titled Policy on Hand Washing dated 11/2019 documented that all personnel who are working in the long-term care facility are required to wash their hands before and after direct resident contact, before and after assisting a resident with toileting, before and after assisting a resident with personal care like bathing, and after handling soiled or used linens, dressing, bedpans, catheters and urinals. The facility P&P titled Incontinent Care dated 3/2022 documented that a staff member should clean the genital area first, the perineal area (the area between the genitals and the anus) second, and the anal area last; after cleansing the resident's genital area, staff are to remove their gloves and wash their hands. The facility P&P titled Catheter Drainage Bag Care documented that care should be taken to make sure the tubing does not touch or drag on the floor. Staff should wash hands before and after any manipulation of the urinary drainage apparatus. 1. Resident #298 was admitted to the facility with diagnoses of complications of the genitourinary system (urinary and genital system) and prostate cancer. The Minimum Data Set (MDS - a resident assessment tool) dated 3/9/22 documented Resident #298 was cognitively intact, understands and was understood. The MDS documented Resident #298 was taking an antibiotic for an infection. The Nursing admission Evaluation dated 3/2/22 documented that Resident #298 had a urinary catheter upon admission to the facility. The Physician's Orders dated 3/14/22 documented an order for levofloxacin (medication used to treat infections) 500 milligrams (mg) one time a day by mouth for a urinary tract infection (UTI). The order documented that the antibiotic was to be taken until 3/23/22. Resident #298's Medication Administration Record (MAR) dated March 2022 documented the resident received levofloxacin 500 mg as ordered. Review of Resident #298's care plan dated 3/2/22 documented the resident had an alteration of bladder function due to a surgical procedure, and had a urinary catheter related to prostate cancer. Documented interventions included that catheter care was to be completed every shift. The Visual/Bedside [NAME] Report (guide used by staff to provide care) dated 3/2/22 documented that the CNA was to perform urinary catheter care every shift. During an observation of urinary catheter care in the presence of Licensed Practical Nurse (LPN) Clinical Educator #3 on 3/21/22 at 3:30 PM, CNA #1 was wearing gloves and un-tabbed Resident #298's incontinence brief and asked the resident to roll onto their right side. CNA #1 proceeded to tuck the brief outside in under the hip of the resident. Resident #298 was incontinent of stool. CNA #1 completed fecal incontinence care using a basin of water and a spray cleanser. Once fecal incontinence care was completed, and without removing their gloves or washing their hands CNA #1 assisted Resident #298 onto their left side, by touching the resident's hip and bed linens. CNA #1 then removed the soiled brief completely and positioned Resident #298 onto their back. Without washing their hands and wearing the same gloves used to complete fecal incontinent care, CNA #1 then cleaned Resident 298's urinary catheter, genital area, inner thigh area, and applied a clean brief on the resident. During an interview on 3/21/22 at 3:45 PM, CNA #1 stated they should have washed their hands and changed gloves after completing fecal incontinent care. CNA #1 stated that by not washing their hands or changing gloves it could lead to an infection. During an interview on 3/21/22 at 3:46 PM, LPN #3 stated CNA #1 should have washed their hands and changed her gloves after performing fecal incontinent care, as the CNA could have caused cross contamination. During an interview on 3/21/22 at 3:50 PM, Registered Nurse (RN) Unit Coordinator #2 stated the expectation was for staff to wash their hands and change their gloves after touching a resident especially after performing fecal incontinent care. RN #1 stated the CNA should have cleaned the resident's genital area first then performed fecal incontinent care as there could be a cross contamination. During an interview on 3/21/22 at 4:10 PM, the Director of Nursing (DON) stated the expectation was for staff to wash their hands and change their gloves when performing incontinent care. The DON also stated that there was possibility of cross contamination by going from a dirty area to a clean area. They stated that staff are taught to go from front to back (from genital area to anal area) when cleaning a resident after incontinent care. 2. Resident #184 had diagnoses including pulmonary embolism (artery in the lung blocked by a blood clot), dementia and UTI. The MDS dated [DATE] documented Resident #184 was cognitively intact, usually understood, and usually understands. The MDS documented Resident #184 had an indwelling urinary catheter. The undated Comprehensive Care Plan (CCP) documented Resident #184 had alteration in their bladder function related to the use of an indwelling urinary catheter and a UTI. Documented interventions included that a leg bag (holds urine that drains from catheter and fits under clothing) was to be worn during daytime hours and that Resident #184 required total care for toileting tasks. The Telephone/Verbal Order Signature Details documented that Resident #184 had the following antibiotic medication orders: -Cefdinir 300mg every 12 hours for UTI with started date of 2/24/22 until 3/1/22. -Cefdinir was discontinued on 2/28/22 and Linezolid 600 mg every 12 hours for UTI was ordered from 2/26/22 until 3/7/22. -Cefpodoxime 200mg every 12 hours for UTI with started date of 3/16/22 until 3/19/22. Review of the Lab Results Report documented: -2/25/22 Clean catch urine culture results were positive for vancomycin resistant enterococcus (VRE- a bacterial strain). -3/14/22 Clean catch urine culture results were positive for klebsiella oxytoca (a gram-negative bacterial strain). Intermittent observations of Resident #184 during survey from 3/16/22 through 3/22/22 revealed the following: -3/16/22 at 9:20 AM, Resident #184 was seated in their wheelchair (w/c) across from the nursing station, the urinary drainage bag was attached beneath the w/c seat and the foley tubing was on the floor. -3/16/22 at 11:49 AM, Resident #184 was seated in their w/c in their room the urinary drainage bag was attached beneath the w/c seat and the foley tubing was touching on the floor. -3/16/22 at 2:54 PM, Resident #184 was in bed, the bed was in a low position and the urinary drainage bag was attached to bed frame. The drainage bag was touching the floor, and there was no barrier between the bag and the floor. -3/17/22 at 4:04 PM, Resident #184 was in bed, the bed was in a low position and the urinary drainage bag was attached to the bed frame. The drainage bag was touching the floor, and there was no barrier between the bag and the floor. -3/18/22 at 9:55 AM, Resident #184 was seated in their w/c in their room, the foley drainage bag was attached beneath the w/c seat and the foley tubing was on the floor. -3/18/22 at 11:45 AM, Resident #184 was seated in their w/c in their room, after returning from therapy, the foley bag was attached beneath the w/c seat and the foley tubing on the floor During an observation on 3/18/22 at 12:26 PM Resident #184 was observed seated in their w/c in their room. The resident's foley drainage bag was hanging beneath the w/c seat and the foley tubing was on the floor. CNA #3 took a blue privacy bag from windowsill and placed the blue privacy bag around the foley bag. CNA #3 washed their hands and exited the resident's room. The foley tubing remained directly on the floor. During an interview on 3/18/22 at the time of the observation CNA #3 stated that they do not usually put a leg bag on Resident #184 because they are usually in their room. CNA #3 stated there is a slit in the bottom of the blue privacy bags and the extra foley tubing falls out of the bottom of the bag. During an observation in the presence of the DON on 3/18/22 at 12:34 PM, LPN #4 fixed the placement of the privacy bag, urinary drainage bag and tubing, so the tubing was no longer on the floor. The DON stated Resident #184 had a shorter w/c and the foley tubing was touching the floor. The DON stated that residents, if tolerated, should be wearing foley leg bags. During an interview on 3/18/22 at 12:45 PM, LPN #4 stated that there was an opening in the bottom of the privacy bag that makes the foley bag fall through to the ground. LPN #4 stated that Resident #184 could be wearing a foley leg bag if they were to leave their room. In a further interview on 3/18/22 at 12:52 PM, the DON stated the foley tubing touching the ground could possibly result in a UTI. During an interview on 3/22/22 at 9:52 AM, RN #4 Infection Control Preventist stated that a foley leg bag should be utilized anytime a resident gets out bed that has a foley catheter. If a resident refused to wear a leg bag, the tubing should run down the resident's pant leg and if there was extra tubing then that should be placed into the privacy bag. RN #4 stated the foley bag or foley tubing touching the ground could result in cross contamination. 415.12(d)(1)

Based on observation, interview, and record review completed during the Standard survey completed on 3/22/22, the facility did not ensure that a resident who is fed by enteral means (method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements) receives the appropriate treatment and services to prevent possible complications for one (Resident #48) of two residents reviewed for feeding tubes. Specifically, the facility did not administer the tube feed formula at the flow rate as ordered by the physician. In addition, the nursing staff documented the formula was administered as ordered. The finding is: The facility policy and procedure (P&P) titled Gastrostomy Feeding Tubes revised 8/2017 documented that the purpose was to provide nourishment, hydration, and medication for residents requiring feeding through a gastric tube (g-tube) inserted into the stomach through the abdominal wall when the oral route is inaccessible and/or medically contraindicated. The procedure included that the nurse was to obtain a physician order for the type, strength, amount, time, and method of tube feeding. For continuous feeding types (uninterrupted administration of enteral formula over extended periods of time), the nurse was to allow the contents of the feeding bag to flow into the stomach at the rate ordered by the physician and regulate the flow by adjusting the flow regulator or the infusion pump. 1. Resident #48 was admitted to the facility with diagnoses of dysphagia (difficulty swallowing), adult failure to thrive, protein-calorie malnutrition. The Minimum Data Set (MDS- a resident assessment tool) dated 1/18/22 documented Resident #48 had moderately impaired cognition, sometimes understands, and was sometimes understood. Additionally, the MDS documented that the resident received 26-50% (percent) of total calories and 501 cc (cubic centimeter) per day or more fluid intake through parenteral or tube feeding. The Comprehensive Care Plan (CCP) reviewed 1/25/22 documented Resident #48 required a percutaneous endoscopic gastrostomy tube (PEG tube- most common type of g-tube) related to dysphagia. Interventions included to administer the tube feed per MD orders. Review of Physician's Orders from 1/1/22 through 3/4/22 revealed a previous order dated 1/25/21 and discontinued on 3/4/22 for Isosource 1.5 to be infused at set pump rate of 60 mL's per hour to a total daily volume of 1200 mL's. The Physician's Orders dated 3/4/22 documented to start Isosource 1.5 (tube feed formula) cyclic at 2 PM infusing 55mL's per hour infused to a total daily volume of 1100 mL's via set pump total volume and instructions for every evening and night nurse to check Isosource 1.5 is being infused at 55 cc (cubic centimeters). An additional order dated 3/4/22 documented to record end total volume of enteral feed at 10 AM, shut off enteral feed when total volume mL's of ordered formula per 24 hours are infused (total feed=1100 mL's/24 hours, total calories=1650/24 hours). Intermittent observation of Resident #48 revealed the following: - 3/16/22 at 2:52 PM, Resident #48 was lying in bed with the head of the bed elevated and the continuous enteral feed was infusing via PEG tube at the set flow rate of 60 mL (milliliters) per hour; at 3:53 PM, the feeding was observed still infusing at 60 mL per hour. - 3/17/22 at 8:45 AM, the continuous feed initiated the day prior was still infusing at 60 mL per hour. The total volume infused (TVI) was 2158 mL; at 3:42 PM, a new bag of enteral feeding formal, signed with the last name of licensed practical nurse (LPN) #1, was infusing at set rate of 60 mL per hour. - 3/18/22 at 9:19 AM, the continuous feed initiated the day prior was still infusing at 60 mL per hour. The total volume infused (TVI) was 2114 mL; at 2:45 PM, a new bag of enteral feeding formal initialed by LPN #2 was infusing at set rate of 60 mL per hour. Review of the Medication Administration Record (MAR) dated 3/1/22 through 3/31/22 documented that Isosource 1.5 infused at 55mL's per hour was administered as ordered on 3/16/22, 3/17/22, and 3/18/22. Review of a document titled Weight and Vitals Summary dated 9/9/21 through 3/31/22 for Resident #48 documented the following weights: 9/9/21 174.6 lbs. (pounds), 10/1/21 178 lbs., 11/1/21 174.6 lbs., 12/1/21 175.6 lbs., 1/6/22 175 lbs., 2/1/22 174.9 lbs., 3/2/22 192.6 lbs., 3/9/22 190.6 lbs., 3/13/22 191 lbs. Review of Medication/Treatment Discrepancy/Error Report dated 3/18/22 revealed that Resident #48's PEG tube pump rate was set at 60 cc/hour instead of 55 cc/hour as per MD orders on 3/16/22, 3/17/22, and 3/18/22. During an interview on 3/18 at 2:56 PM, Licensed Practical Nurse (LPN) #1 stated that they were assigned to Resident #48 that shift, but LPN #2 administered the resident's enteral feeding because LPN #1 was unsure of the process for tube feeding. During an interview on 3/18/22 at 3:02 PM, LPN #2 stated that they administered Resident #48's enteral feeding during the shift. LPN #2 stated they checked the resident's paper chart to verify the Physician's Orders for the enteral feeding prior to administration and that it was ordered to infuse at 55 mL's per hour. LPN #2 observed the resident's enteral feeding and stated that it was currently infusing at 60 mL's per hour and that it was not set to infuse per the MD orders. LPN #2 stated that they set it at the wrong rate and were going to reset the pump to infuse at 55 mL per hour, as ordered. LPN #2 stated that they did not go check on the Resident #48 after starting the enteral feed to ensure it was properly infusing because the resident was assigned to LPN #1 that shift. During an interview on 3/18/22 at 3:02 PM, Registered Nurse (RN) #1, Unit Coordinator (UC) stated the expectation was for the bedside LPN to check their resident's infusion rate before administration and to monitor the enteral feeding infusion throughout shift the to ensure it was running at the correct flow rate. RN #1 stated that the enteral feeding orders for Resident #48 had recently changed due to weight gain. New orders began at the beginning of March to infuse the feeding at 55 mL's per hour and feed infusing at 60 mL's was a medication error. During an interview on 3/18/22 at 3:55 PM, the Registered Dietician (RD) stated that the nursing staff were responsible to set up and ensure that a Resident #48's enteral feeding was running as order. The RD stated that they decreased Resident #48's flow rate from 60 mL per hour to 55 mL's per hour to address weight gain, with goal of the resident not gaining anymore weight and possibly losing weight. The RD stated that it would not be following current orders if the feed was being administered at 60 mL per hour. The RD further stated that Resident #48 could continue to gain weight or maintain current weight and not lose weight if being administered enteral feed at higher infusion rate. During an interview on 3/18/22 at 4:08 PM, the Director of Nursing (DON) stated that they would have expected the nurse to set Resident #48's enteral feed per orders and to monitor the feed throughout their shift. The DON stated that having more enteral feed infused than ordered would be a medication error which could result in weight gain or fluid issues for the resident. During a follow-up telephone interview on 3/22/22 at 9:13 AM, LPN #1 stated that they should have verified the flow rate on 3/18/22 after LPN #2 started the enteral feed and throughout the shift since Resident #48 was assigned to LPN #1 and did not. LPN #1 further stated that they should have looked at the flow rate prior to taking the feed down and signing it off on the MAR the next morning to verify it was the correct flow rate and did not. During a telephone interview on 3/22/22 at 10:30 AM, the Physician stated that they would have expected the tube feed formula to be running at 55mL per hour as ordered. 415.12(g)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 7/2/19, the facility did not ensure that the facility establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. One (Resident #206) of three residents reviewed for infection control during care had issues with the lack of proper infection control practices. Specifically, the Certified Nurse Aide (CNA) did not change gloves and wash hands after cleaning feces prior to washing another area on the resident. In addition, touched environmental surfaces with contaminated gloves. The finding is: The facility policies and procedures (P&P) titled Hand Washing dated 7/09 documented proper handwashing technique is used for the prevention of transmission of infectious disease. All personnel working in the long-term care facility are required to wash their hands before and after assisting a resident with toileting needs: After handling soiled bedpans and urinals: After handling soiled equipment. The facility P&P titled Perineal Care dated 10/17 documented wash perineal area from front to back to prevent contamination. The facility P&P titled Bedpans/Urinals dated 8/05 documented a bedpan or urinal is used when a resident is unable to use the bathroom. Gloves are worn when contact with body fluids and secretions are expected. Dispose of urine or stool in toilet. Rinse urinal or bedpan with water. Return to bottom shelf of bedside stand. 1. Resident #206 was admitted to the facility on [DATE] with diagnoses that include dementia, benign prostatic hyperplasia (enlarged prostate), and urinary tract infection (UTI). The Minimum Data Set (MDS- a resident assessment tool) dated 6/11/19 documented the resident was severely cognitively impaired, sometimes understands, sometimes understood, and required an extensive assist of two people for bed mobility and toileting needs. The current Visual/Bedside [NAME] Report (guide used by staff to provide care) documented the resident required total assist of one person for personal hygiene. The Hospital Discharge summary dated [DATE] documented UTI as a secondary diagnosis. During observation on 7/1/19 at 9:27 AM, CNA #1 donned gloves and removed a soiled bedpan from under the resident containing a small amount of brown stool and washed the resident's rectal area with a soapy wash cloth. On the washcloth was a small amount of brown smeared debris and placed the soiled washcloth onto a barrier cloth. She positioned the resident onto his back, removed an empty urinal from between the resident's legs and proceeded to wash the perineal area with a clean washcloth without removing her gloves and washing hands. CNA#1 then emptied and rinsed the bedpan and with the same gloves, touched the handle on the door of the bedside stand and placed the bedpan onto the bottom shelf and shut the door. She then removed the glove on her right hand, gathered soiled linens with her gloved hand and disposed the linens in the soiled utility room receptacle down the hall. Interview on 7/1/19 at 9:35 AM with CNA #1 revealed that she normally washes from front to back and would remove her gloves and wash her hands in between. CNA #1 stated, I removed the bedpan and washed the resident not thinking to change my gloves and wash my hands prior to washing the front. I was nervous. Interview on 7/1/19 at 9:38 AM with Registered Nurse (RN) #1 revealed CNA #1 should have removed her gloves and washed her hands before doing perineal care to reduce risk of infection. CNA #1 should have removed the bedpan, wiped the resident with toilet tissue then wash the perineal area then proceed to the back and wash the rectal area. Gloves are removed, and handwashing is done prior to touching and surfaces in the room to prevent cross contamination. Interview on 7/1/19 at 10:55 AM with the Director of Nursing (DON) revealed she expected her staff to perform hand hygiene after handling a resident's soiled bedpan and before touching any of the resident's care equipment. The DON stated she would expect her staff to wash from front to back when performing perineal care. 415.19(b)(4)