**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 07/31/2025 and completed on 08/06/2025, the facility did not ensure the resident's right to self-administer medications. This was identified for one (Resident #8) of six (6) residents reviewed for Accidents. Specifically, Resident #8 was observed with a souffle medication cup containing four pills on their bedside table. There was no documented evidence Resident #8 was assessed to self-administer medications, and the resident did not have a physician's order to self-administer their medications. The finding is: The facility policy titled Medication, Self-Administration, dated 2/2017, documented that each resident shall have the right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. Self-administering medications is [permitted] by physician order only. Medications kept at bedside are in a locked box. Resident #8 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Osteoarthritis (joint pain, swelling). The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The current physician's order documented Aspirin enteric-coated delayed-release 81 milligrams; take 1 tablet by mouth once daily for coronary artery disease. The current physician's order documented Metoprolol Succinate Extended Release 100 milligrams, give 1 tablet by mouth once a day for Hypertension. The current physician's order documented Glyco-lax Powder, give 17 grams by mouth mixed in 8 ounces of beverage once a day for constipation, hold for loose stool. A physician's order dated 7/26/2025, documented Hydrochlorothiazide tablet 25 milligrams, give 2 tablets by mouth, 50 milligrams one time a day for Congestive Heart Failure, Hypertension.During an observation on 07/31/2025 at 11:05 AM, Resident #8 was observed in their room sitting in a wheelchair next to their overbed table. The overbed table had a souffle medication cup containing four pills and a small disposable cup with a white powder. Resident #8 stated they told the nurse to just leave the medications on the overbed table and they would take them when they eat their breakfast. Resident #8 stated that they usually tell the nurses to leave their medication on the overbed table, and they take the medications when they are ready. Resident #8 stated the nurses frequently allow them (Resident #8) to self-administer their medications. A review of Resident #8's medical record revealed there was no physician's order, no Comprehensive Care Plan to self-administer medications, and no indication that the resident was assessed to self-administer medications. During an interview on 07/31/2025 at 11:16 AM, Licensed Practical Nurse #1 stated they were unsure if Resident #8 was assessed by the interdisciplinary team to self-administer medications and that a care plan to self-administer medications was developed. Licensed Practical Nurse #1 stated they always left the medications for Resident #8 at their bedside, and Resident #8 self-administered their medications. Licensed Practical Nurse #1 stated they were trained to leave Resident #8's medications at the bedside. Licensed Practical Nurse #1 stated the medications in the souffle medication cup were the resident's 8:00 AM medications, which included one tablet of Aspirin 81 milligrams, two tablets of Hydrochlorothiazide 25 milligrams, one tablet of Metoprolol Succinate 100 milligrams one tablet, and a plastic cup with Glyco-Lax Powder 17 grams to be mixed with 8 ounces of liquid. Licensed Practical Nurse #1 stated they should have verified if Resident #8 was assessed for self-administering medications and had a physician's order and a care plan for self-administering medications. During an interview on 08/04/2025 at 10:43 AM, Registered Nurse Manager #1 stated Resident #8 was not assessed to self-administer their medications and did not have a care plan to self-administer medications. Registered Nurse Manager #1 stated Licensed Practical Nurse #1 should not have left the medications at the bedside for a resident who did not have a physician's order to self-administer medications. Registered Nurse Manager #1 stated they should have been notified that Resident #8 wanted to self-administer medications, and an assessment should have been completed for the resident. During an interview on 08/06/2025 at 9:36 AM, the Director of Nursing Services stated Resident #8 did not have an order to self-administer medications. The Director of Nursing Services stated the resident should have been assessed by the physician to self-administer medications. The Director of Nursing Services stated the resident should demonstrate understanding of the time to take the medications, the reasons why they are taking the medications, and the nurse should ensure that the resident was not leaving the medications at the bedside. 10 NYCRR 415.3(f)(1)(vi)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey initiated on 07/31/2025 and completed on 08/06/2025, the facility did not ensure person-centered comprehensive care plans that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs were developed and implemented. This was identified for one (Resident #8) of two residents reviewed for Behavioral and Emotional Status. Specifically, Resident #8 had a Physician's order for a two-person approach in care and a Comprehensive Care Plan for Accusatory Behaviors with interventions that included a two-person approach. During an observation on 07/31/2025 at 11:05 AM, Certified Nursing Assistant #1 provided care to Resident #8 without a second caregiver in the resident's room.The finding is:Resident #8 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Osteoarthritis. The Quarterly Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status score of 15, indicating the resident is cognitively intact. The Quarterly Minimum Data Set indicated that the resident did not display any behavioral issues.A Comprehensive Care Plan titled Non-Compliance, last revised on 01/09/2025, documented interventions that included the use of a two-person approach in care. A Comprehensive Care Plan titled Accusatory and Verbally Abusive dated 06/03/2022, documented interventions that included the resident required a two-person approach for care. A revision on 01/9/2025 documented interventions that included to continue the two-person approach. A physician's order dated 10/03/2024 and discontinued on 08/1/2025 documented the resident required a two-person approach in care. A physician's order dated 08/02/2025 documented a two-person approach for care secondary to accusatory behavior. A review of the Certified Nursing Assistant Accountability record for June 2025 and July 2025 revealed no documented evidence for a two-person approach during care. The Certified Nursing Assistant Accountability record for August 2025 documented a two-person approach in care for each shift. During an observation on 07/31/2025 at 11:05 AM, the door frame to Resident #8's private room had a magnet signage displaying an icon of two people. Resident #8's room door was closed, the surveyor knocked and was told to come in. Resident #8 was seated in a wheelchair next to their over-bed table, and Certified Nursing Assistant #1 was changing the Resident #8's bed linens and collecting the laundry and soiled linens in the room. During an interview on 07/31/2025 at 11:06 AM, Resident #8 stated they like to keep the door closed. Resident #8 stated Certified Nursing Assistant #1 was their regularly assigned Certified Nursing Assistant. During an interview on 07/31/2025 at 11:22 AM, Certified Nursing Assistant #1 stated that the magnet outside the resident's room indicated that the resident within the room required a two-person approach during care. Certified Nursing Assistant #1 stated Resident #8 has accusatory behavior, but usually, the resident accepted care from them alone and allowed them to come into the room alone. Certified Nursing Assistant #1 stated the facility educated them when they were hired to provide care with a second caregiver if the resident had a two-person signage on the door frame, and the Certified Nursing Assistant Accountability instruction included a two-person approach during care. During an interview on 08/04/2025 at 9:23 AM, Registered Nurse Manager #1 stated that the two-person magnet signage on the door frame was to alert staff that the resident required a two-person approach during care. The Certified Nursing Assistants and Nurses were educated on the two-person approach. During an interview on 08/06/2025 at 9:36 AM, the Director of Nursing Services stated residents should receive care from two staff members when a two-person approach is required. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 07/31/2025 and completed on 08/06/2025, the facility did not ensure that drug records were in order and accounted for all controlled drugs. This was identified for one (Unit 3) of two units reviewed for medication storage and medication administration tasks. Specifically, during the medication storage task/medication administration task on Unit 3 on 08/01/2025 at 5:46 AM, the Controlled Substance Administration Record was not reconciled to reflect Resident #60's refusal of Tramadol hydrochloric acid medications on 07/31/2025 at 9:00 PM. The finding is: The Facility's Controlled Substances and Narcotics Policy dated January 2025 documented that when a resident refuses a controlled substance after it has been poured, the medication must be destroyed with a witness, and the back of the Controlled Drug 24-Hour Administration Record must be completed. The Nursing Supervisor must be notified. Resident #60 was admitted with diagnoses including Alzheimer's Disease, Adult Failure to Thrive, and Anxiety Disorder. The Significant Change Minimum Data Set assessment dated [DATE] documented a Brief Interview of Mental Status score of four (4), which indicated the resident had severely impaired cognition. The resident required assistance with all activities of daily living. The Minimum Data Set indicated the resident received antianxiety medication during the assessment look-back period. The Current Physician's Order documented Tramadol hydrochloric acid (pain medication) oral tablet 25 milligrams, Controlled Drug, administer 1 tablet by mouth two times a day (9:00 AM and 9:00 PM) for pain; Lorazepam (antianxiety medication that is a controlled drug) oral tablet 0.5 milligram, administer by mouth at bedtime for Anxiety. During a medication administration observation on 08/01/2025 at 5:41 AM, a Unit 3 medication cart was left unattended in the middle of the hallway. There were two medication cups on the medication cart. One cup contained two white tablets, and the other cup contained one white tablet. There was no staff in the vicinity. During an interview on 08/01/2025 at 5:55 AM, Licensed Practical Nurse #2 stated they worked a double shift, and Resident #60 refused the 9:00 PM scheduled Tramadol 25 milligram tablet and the Lorazepam 0.5 milligram. Licensed Practical Nurse #2 stated the second medication cup contained one tablet of Melatonin 3 milligrams, and they did not remember which resident refused that medication. Licensed Practical Nurse # 2 stated they kept the medications on the medication cart because they did not want to waste them. Licensed Practical Nurse# 2 stated they did not lock the medication cart and the narcotic box because they were called into a resident's room to help a Certified Nursing Assistant with a resident. Licensed Practical Nurse #2 stated they should have documented in the Controlled Drug 24 -Hour Administration Record that the resident refused the medication, notified the supervisor and wasted the controlled medications with another nurse and document in the narcotic book that the medications were wasted. During an interview on 08/01/2025 at 6:22 AM, Registered Nurse Supervisor #3 stated they were not aware that Licensed Practical Nurse #2 did not destroy the Tramadol 25 milligram 1 tablet and Lorazepam 05 milligram 1 tablet with two nurses and did not reconcile the medications in the Controlled Drug 24 -Hour Administration Record since the previous shift. Registered Nurse Supervisor #3 stated they should have been notified of the resident's refusal, the controlled medications should have been destroyed with two nurses, and the Controlled Drug 24-Hour Administration Record should have been reconciled. During an interview on 08/06/2025 at 3:00 PM, the Director of Nursing Services stated the Controlled Substance Administration Record form should be reconciled immediately after a medication is administered or destroyed. The Director of Nursing Services stated Resident #60's medication refusals should have been reported to the Nurse Supervisor, and the medication should have been destroyed. 10 NYCRR 415.18(b)(1)(2)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 7/31/2025 and completed on 8/6/2025, the facility did not ensure all drugs and biologicals were stored in locked compartments and only authorized personnel were permitted to have access. This was identified for one (Unit 3 ) of two (2) Units reviewed during the medication storage task and for one (Resident #8) of six (6) residents reviewed for accidents. Specifically, 1) during the medication administration observation on 08/01/2025 at 5:46 AM, an unattended medication cart on Unit 3 was observed to be unlocked in the hallway with an unlocked narcotic box. Additionally, there were two cups containing Resident #60's controlled medications on the medication cart. 2) Resident #8 was observed with a souffle medication cup containing four (4) medication tablets on their overbed table and did not have a Physician's order to self-administer medications. The findings are: 1) The facility's Controlled Substances and Narcotics Policy dated January 2025 documented controlled substances and narcotics are kept in a double-locked cabinet in the medication room or double-locked in the medication cart. The facility's Medication Policy dated 01/04/2025 documented that all medications shall be contained in a locked cart and/or cabinet in a locked room. Resident #60 was admitted with diagnoses including Alzheimer's Disease, Adult Failure to Thrive, and Anxiety Disorder. The Significant Change Minimum Data Set assessment dated [DATE] documented a Brief Interview of Mental Status score of four (4), which indicated the resident had severely impaired cognition. The resident required assistance with all activities of daily living. The Minimum Data Set indicated the resident received antianxiety medication during the assessment look-back period. The Current Physician's Order documented Tramadol hydrochloric acid (pain medication) oral tablet 25 milligrams, Controlled Drug, administer 1 tablet by mouth two times a day (9:00 AM and 9:00 PM) for pain; Lorazepam (antianxiety medication that is a controlled drug) oral tablet 0.5 milligram, administer by mouth at bedtime for Anxiety. During a medication administration observation on 08/01/2025 at 5:41 AM, a Unit 3 medication cart was left unattended in the middle of the hallway. There were two medication cups on the medication cart. One cup contained two white tablets, and the other cup contained one white tablet. There was no staff in the vicinity. During an interview on 08/01/2025 at 5:55 AM, Licensed Practical Nurse #2 stated they worked a double shift, and Resident #60 refused the 9:00 PM scheduled Tramadol 25 milligram tablet and the Lorazepam 0.5 milligram. Licensed Practical Nurse #2 stated the second medication cup contained one tablet of Melatonin 3 milligrams, and they did not remember which resident refused that medication. Licensed Practical Nurse # 2 stated they kept the medications on the medication cart because they did not want to waste them. Licensed Practical Nurse# 2 stated they did not lock the medication cart and the narcotic box because they were called into a resident's room to help a Certified Nursing Assistant with a resident. During an interview on 08/01/2025 at 6:22 AM, Registered Nurse Supervisor #3 stated that Licensed Practical Nurse #2 should not leave any medications on the medication cart for safety reasons. Registered Nurse Supervisor #3 stated the medication carts must be locked when unattended, and the narcotic boxes must be double locked per the facility policy. During an interview on 08/06/2025 at 1:30 PM, the Director of Nursing Services stated it was not safe to leave medications on an unattended medication cart. The Director of Nursing stated the medication cart, and the narcotic box should not be left unlocked when unattended. 2) Resident #8 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Osteoarthritis (joint pain, swelling). The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The current physician's order documented Aspirin enteric-coated delayed-release 81 milligrams; take 1 tablet by mouth once daily for coronary artery disease. The current physician's order documented Metoprolol Succinate Extended Release 100 milligrams, give 1 tablet by mouth once a day for Hypertension. The current physician's order documented Glyco-lax Powder, give 17 grams by mouth mixed in 8 ounces of beverage once a day for constipation, hold for loose stool. A physician's order dated 7/26/2025, documented Hydrochlorothiazide tablet 25 milligrams, give 2 tablets by mouth, 50 milligrams one time a day for Congestive Heart Failure, Hypertension. During an observation on 07/31/2025 at 11:05 AM, Resident #8 was observed in their room sitting in a wheelchair next to their overbed table. The overbed table had a soufflé medication cup containing four pills and a small disposable cup with a white powder. Resident #8 stated they told the nurse to just leave the medications on the overbed table and they would take them when they eat their breakfast. Resident #8 stated that they usually tell the nurses to leave their medication on the overbed table, and they take the medications when they are ready. Resident #8 stated the nurses frequently allow them (Resident #8) to self-administer their medications. A review of Resident #8's medical record revealed there was no physician's order, no Comprehensive Care Plan to self-administer medications, and no indication that the resident was assessed to self-administer medications. During an interview on 07/31/2025 at 11:16 AM, Licensed Practical Nurse #1 stated they always left the medications for Resident #8 at their bedside, and Resident #8 self-administered their medications. Licensed Practical Nurse #1 stated they were trained to leave Resident #8's medications at the bedside. Licensed Practical Nurse #1 stated the medications in the soufflé medication cup were the resident's 8:00 AM medications, which included one tablet of Aspirin 81 milligrams, two tablets of Hydrochlorothiazide 25 milligrams, one tablet of Metoprolol Succinate 100 milligrams one tablet, and a plastic cup with Glyco-Lax Powder 17 grams to be mixed with 8 ounces of liquid. During an interview on 08/04/2025 at 10:43 AM, Registered Nurse Manager #1 stated Licensed Practical Nurse #1 should not have left the medications at the bedside for a resident who did not have a physician's order to self-administer medications. During an interview on 08/06/2025 at 9:36 AM, the Director of Nursing Services stated Resident #8 did not have an order to self-administer medications, and the nursing staff should not have left the medications at the bedside. The Director of Nursing Services stated the resident should have been assessed by the physician to self-administer medications. The Director of Nursing Services stated that residents who can self-administer medications and wish to store them in their room must have the medications locked in their dresser drawer. 10 NYCRR 415.18(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 6/5/2024 and completed on 6/11/2024, the facility did not ensure an assessment was completed for each resident to accurately reflect a resident's status. This was identified for one (Resident #54) of one resident reviewed for Hospice and End of Life. Specifically, the Quarterly Minimum Data Set assessment dated [DATE] did not reflect Resident #54 received Hospice care. The finding is: The facility's policy and procedure titled MDS 3.0 Completion dated August 2020 documented residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. The facility initially and periodically conducts a comprehensive, accurate, and standardized assessment of each resident's functional capacity. Resident #54 was admitted with diagnoses including Dementia, Protein-Calorie Malnutrition, and Hypothyroidism. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status was not conducted because the resident was rarely or never understood and had severely impaired skills for daily decision-making. The Minimum Data Set assessment documented the resident received comfort care and had advanced directives that included do not resuscitate and do not hospitalize. Under Section O, Special Services, the Minimum Date Set assessment did not include that Resident #54 received Hospice Services while a resident at the facility. A Comprehensive Care Plan titled The Resident Has a Terminal Prognosis with Diagnosis of End Stage Alzheimer's effective 10/2/2023 and updated on 11/1/2023 documented the resident was admitted to the facility for Long Term Care and was on Hospice services. Interventions included to observe for pain or discomfort. Assess and encourage the resident with coping strategies and respect the resident's wishes. The current Physician's order, active as of 3/14/2024, documented the resident is receiving Hospice Services (from a Hospice agency). Registered Nurse #2, the Minimum Data Set assessment nurse, was interviewed on 6/7/2024 at 9:05 AM. Registered Nurse #2 stated they were responsible for completing the Minimum Data Set assessment dated [DATE] for Resident #54. Registered Nurse #2 stated the assessment should reflect that Resident #54 received Hospice Care. Registered Nurse #2 stated they made an error and did not document Hospice services under the Special Treatments section of the Quarterly Minimum Data Set, dated [DATE]. Registered Nurse #2 stated they will correct the assessment for Resident #54 to reflect Resident #54 received Hospice care. The Director of Nursing Services was interviewed on 6/10/2024 at 11:49 AM and stated Resident #54 was receiving Hospice services while residing in the facility. The Director of Nursing Services stated the Minimum Data Set assessment for Resident #54 should have reflected that the resident was receiving Hospice care. 10 NYCRR 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility's policy titled, Comprehensive Care Plan, dated 12/2019 documented The Comprehensive Care Plan and Discharge Plan must be initiated within one week of admission. Within fourteen days of an initial or significant change in the resident's condition, the team must initiate a Comprehensive Care Plan. Within twenty-one days of admission, the Comprehensive Care Plan must be finalized. The facility's undated policy titled, Assistive/Adaptive Devices, documented all device recommendations are entered into the computer via an [physician's] order and labeled electronically with the word device. Resident #73 was admitted with diagnoses that included, Spinal Stenosis, Sepsis, and Pneumonia. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15 which indicated the resident had intact cognition. The admission Minimum Data Set documented Resident #73 did not use a splint or brace. A Physical Therapy Communication form dated 4/13/2024 documented Resident #73 wore a Miami J Cervical Collar when out of bed and when ambulating. Resident #73 was observed seated in their wheelchair in their room on 6/5/2024 at 11:22 AM. Resident #73 was wearing a Miami J Cervical Collar (a neck brace used to prevent head and neck movement). Resident #73 stated they wore the Miami J Cervical Collar because it helped them hold up their head. Resident #73 stated they put on and took off the Miami J Cervical Collar themselves. Resident #73 stated they took the Miami J Cervical Collar off to eat and when they went to bed. Resident #73 was observed seated in their wheelchair in their room on 6/5/2024 at 12:52 PM. Resident #73 was eating lunch and was not wearing their Miami J Cervical Collar. The Miami J Cervical Collar was on the chair next to Resident #73. Resident #73 stated they took the Miami J Cervical Collar off to eat. Resident #73 was observed seated in their wheelchair in their room on 6/9/2024 at 2:07 PM. Resident #73 was wearing their Miami J Cervical Collar. Resident #73's Comprehensive Person-Centered Care for Activities of Daily Living initiated on 4/1/2024 did not include an intervention for the use of the Miami J Cervical Collar. A revision to the Comprehensive Person-Centered Care was made on 6/10/2024 after the observations. There were no Physician's orders in place for the use of the Miami J Cervical Collar until 6/10/2024. Certified Nursing Assistant #1 was interviewed on 6/10/2024 at 12:02 PM and stated they regularly provided care for Resident #73 on the 7:00 AM - 3:00 PM shift and put on Resident #73's Miami J Cervical Collar after morning care. Certified Nursing Assistant #1 stated the resident wore the Miami J Cervical Collar every day. Licensed Practical Nurse #1 was interviewed on 6/10/2024 at 12:28 PM and stated they were aware that Resident #73 wore the Miami J Cervical Collar when they were out of bed. Licensed Practical Nurse #1 stated they were not sure who was responsible for assisting the resident with putting on and taking off the Miami J Cervical Collar. Physical Therapy Assistant #1 was interviewed on 6/10/2024 at 1:35 PM and stated Resident #73 was admitted to the facility with the Miami J Cervical Collar. Physical Therapy Assistant #1 stated the Certified Nursing Assistants were responsible for putting on and removing the resident's Miami J Cervical Collar. Physical Therapy Assistant #1 stated the Miami J Cervical Collar should be removed during care and while the resident was eating or taking their medications. Physical Therapy Assistant #1 stated Resident #73 was able to put on and take off the Miami J Cervical Collar; however, sometimes required assistance. The Director of Rehabilitation was interviewed on 6/10/2024 at 1:40 PM and stated Resident #73 used the Miami J Cervical Collar for comfort. There was no physician's order or Comprehensive Care Plan in place for the use of the Miami J Cervical Collar. The Director of Rehabilitation stated nursing was responsible for developing the comprehensive care plan and obtaining the physician's order. Registered Nurse #6, the Unit Manager, was interviewed on 6/10/2024 at 2:21 PM and stated Resident #73 was admitted to the facility with the Miami J Cervical Collar and wore it for comfort. Registered Nurse #6 stated it was the Certified Nursing Assistant's responsibility to put on and take off the Miami J Cervical Collar. Registered Nurse #6 stated they should have ensured that a physician's order and a Comprehensive Care Plan were in place for the use of the Miami J Cervical Collar. Registered Nurse #7, the Nurse Supervisor, was interviewed on 6/10/2024 at 3:41 PM and stated if a resident was admitted to the facility with a Miami J Cervical Collar, a physician's order for the use of the Cervical Collar including the skin checks should have been obtained and a Comprehensive Care Plan should have been developed. The Director of Nursing Services was interviewed on 6/11/2024 at 8:48 AM and stated if a resident was admitted with a Miami J Cervical Collar in place, a physician's order for the use of the Miami J Cervical Collar including the skin checks should have been obtained and a Comprehensive Care Plan should have been developed. 3) The facility policy for Communication with Non-English Speaking Residents dated 1/2021 documented the facility shall have a system in place to ensure that residents/patients with limited English proficiency, that is anyone who does not speak, read, write, or understand the English language at a level necessary for effective communication is provided with the means to do so. Under the procedure section, the policy documented: The facility shall have the services of staff interpreters available through its Language Bank; The social worker shall identify family members who are bilingual and utilize them to communicate with their relatives; The family members shall not be utilized to act as interpreters for non-related residents/patients; The Rehabilitation Department shall assist in devising a form of communication board/ picture book for residents/patients who can use them; The Manager of Therapeutic Recreation/Volunteers shall make attempts to solicit/assign volunteers who can communicate with residents/patients; and the facility shall provide access to translation services, as needed. Resident #90 was admitted with diagnoses that included, Cerebral Infarction (Stroke), Type 2 Diabetes, and Hyperlipidemia (High Cholesterol). The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15 which indicated the resident had intact cognition and their preferred language was identified as Spanish. An interview was attempted with Resident #90 on 6/5/2024 at 2:48 PM. Resident #90 was unable to understand the questions that were asked. Resident #90's Designated Representative (Designated Representative #1) was visiting with Resident #90 and was able to interpret for Resident #90. Designated Representative #1 stated upon resident's admission, the facility was aware Resident #90 did not speak English. Designated Representative #1 stated before Resident #90's admission, they (Designated Representative #1) were told that the facility had Spanish-speaking staff available to translate. Designated Representative #1 stated they were not aware of the availability of translation services and Resident #90 often called them (Designated Representative #1) for translation assistance, but they (Designated Representative #1) were not always able to answer the phone especially when they were at work. Certified Nursing Assistant #2 was interviewed on 6/11/2024 at 11:04 AM and stated they were assigned to care for Resident #90 and did not speak Spanish. They utilized gestures and hand signals to communicate with Resident #90. Certified Nursing Assistant #2 stated there was a Spanish-speaking Certified Nursing Assistant (Certified Nursing Assistant #3) who was not always available due to the days off and because they (Certified Nursing Assistant #3) only worked from 9:00 AM - 1:00 PM shift. Certified Nursing Assistant #2 stated they also asked Registered Nurse #6 to translate; however, Registered Nurse #6 only spoke a little Spanish. Certified Nursing Assistant #2 stated Resident #90 did not have a communication board and there were no translation services available. Licensed Practical Nurse #1 was interviewed on 6/11/2024 at 11:22 AM and stated they provided medications to Resident #90. Licensed Practical Nurse #1 stated they communicated with Resident #90 in Spanish because they (Licensed Practical Nurse #1) understood some Spanish, but they were not fluent in Spanish. Licensed Practical Nurse #1 stated Resident #90 did not have a communication board and there were no translation services available. Licensed Practical Nurse #1 stated there was a Spanish-speaking Certified Nursing Assistant (Certified Nursing Assistant #3), but they were not always available due to days off or because they (Certified Nursing Assistant #3) only worked from 9:00 AM - 1:00 PM. Licensed Practical Nurse #1 stated there was a staff person in the Human Resources Department who was available to translate. Registered Nurse #6 was interviewed on 6/11/2024 at 11:34 AM and stated Resident #90 was able to communicate their needs which is why a Comprehensive Care Plan for Communication was not necessary. Registered Nurse #6 stated they did not use a communication board with Resident #90 because the resident was able to communicate their needs. Registered Nurse #6 stated there were staff members available to assist with the translation. The staff members were Certified Nursing Assistant #3, the Human Resources Supervisor, and the Finance Supervisor. The Human Resources Supervisor was interviewed on 6/11/2024 at 12:00 PM and stated they were asked to translate for Resident #90 only on two occasions. The Finance Supervisor was interviewed on 6/11/2024 at 12:03 PM and stated they never assisted as an interpreter for Resident #90. Certified Nursing Assistant #3 was interviewed on 6/11/2024 at 12:21 PM and stated they translated for Resident #90 only one time for Licensed Practical Nurse #1 when Resident #90 complained of pain. The Director of Nursing Services was interviewed on 6/11/2024 at 2:39 PM and stated there should have been a Comprehensive Care Plan for Communication in place for Resident #90. The Director of Nursing Services stated the facility has a translation service in place and they would educate the unit staff on the availability of services. 10 NYCRR 415.11(c)(1) Based on record review and staff interviews during the Recertification Survey initiated on 6/5/2024 and completed on 6/11/2024, the facility did not ensure a comprehensive person-centered care plan was generated for each resident that included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for 1) one (Resident #81) of two residents reviewed for skin conditions; 2) one (Resident #73) of two residents reviewed for positioning; and 3) one (Resident #90) of one resident reviewed for language and communication. Specifically, 1) Resident #81 had a history of a chronic skin condition and was currently experiencing symptoms that included pruritis (itching), crusting, and weeping lesions. There was no comprehensive care plan developed for the resident's chronic skin condition; 2) Resident #73 was observed on 6/5/2024 and 6/9/2024 wearing a Miami J Cervical Collar and there was no Comprehensive Person-Centered Care Plan in place for the use of the Miami J Cervical Collar; and 3) Resident #90 did not speak English as their primary language. There was no Comprehensive Care Plan developed for the resident's Communication needs. The findings are: The facility's policy titled, Comprehensive Care Plan, dated 12/2019, documented each resident will have a person-centered comprehensive care plan developed and implemented to meet their preferences and goals and address the resident's medical, physical, mental, and psychosocial needs. The Interdisciplinary Team will respond to the current plan of care and establish new goals and treatment plans as necessary, including all acute, subacute, and chronic management problems that may interfere with the ability of any one discipline to manage resident care effectively. 1) Resident #81 was admitted with diagnoses including Diabetes Mellitus, Non-Alzheimer's Dementia, and Depression. The 3/14/2024 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 3, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment documented that the resident had open skin lesions. A Nurse Practitioner note dated 3/13/2024 documented the resident was evaluated for pruritis/itching. Unknown exposure to allergen. The resident was on Benadryl (an antihistamine medication to treat allergic reactions) 25 milligrams every 6 hours with minimal relief. There were no hives noted. The resident was positive for itchiness. Visible skin was clean and dry with no rashes. Start Zyrtec (a medication to treat allergies) (10 milligrams by mouth daily) and continue Benadryl (25 milligrams) by mouth for breakthrough itching. Monitor symptoms. Possibly, a steroid may be needed if there is no relief. A comprehensive care plan titled, The resident has potential for skin tear related to decreased mobility, was initiated on 3/7/2024. The care plan did not address the resident's chronic pruritis and did not add any interventions initiated on 3/13/2024. A Nurse Practitioner note dated 3/24/2024 documented the resident was being evaluated for pruritis. The resident was seen for pruritis in the past and was started on Loratadine (an antihistamine, 10 milligrams daily) and Benadryl (an antihistamine, 50 milligrams, at hour of sleep). The resident stated they were still itching at night and requested another medication to help with the itching. Visible skin was without rashes. Currently, the resident was not itching. Recommendations were to continue Loratadine daily; discontinue Benadryl and start Vistaril (an antihistamine, 50 milligrams, at hour of sleep) for itching and monitor for relief. A Physician Assistant note dated 5/20/2024 documented the resident was seen for evaluation of skin changes. The Physician Assistant communicated with the resident's family regarding establishing a dermatology appointment. Calamine (a lotion to relieve itching) and Hydrocortisone cream (to relieve itching) are to be continued. There were no signs of infection to the skin. The resident was to be referred to the skin specialist for further evaluation and treatment. A Dermatology consult dated 5/30/2024 documented the resident has a four-month history of blistering and crusted weeping lesions pretty much all over including the neck, chest, back, and lower legs. The resident has been treated for scabies and with topical steroids for presumed Eczema. The resident has widespread Bullous Impetigo (bacterial skin infection that causes blisters). Treat with Cefdinir (an oral antibiotic) 300 milligrams twice a day for two weeks. Wash the lesions with Hibiclens (an antibacterial skin cleanser) and apply Mupirocin (an antibiotic ointment) to all lesions three times a day. A Physician Assistant progress note dated 5/30/2024 documented resident was seen for skin changes. Skin specialist consult recommendations were reviewed. The resident had Bullous Impetigo with skin rashes diffused with open areas on the resident's body. The resident had multiple open skin wounds. The resident was previously treated for scabies (at the hospital), shingles, and atopic dermatitis (Eczema) with minimal benefit. Resident #81 was observed in bed on 6/5/2024 at 10:57 AM. The resident's room had a contact precautions sign at the doorway. The resident had open wounds that were visible on the uncovered parts of the resident's body. The resident's shirt, pillow, and sheets had blood stains. The resident stated they had wounds all over their body on their skin because they were itchy and they scratched the itchy areas. Registered Nurse #1 (Unit Manager) was interviewed on 6/5/2024 at 11:00 AM and stated the resident had open wounds from Impetigo. Registered Nurse #1 stated the resident is currently being treated with antibiotics and topical creams. Registered Nurse #1 stated the resident is no longer contagious because they have been on antibiotics for more than 48 hours. A review of the medical record revealed that the comprehensive care plan for the Impetigo bacterial infection was not initiated until 6/5/2024. There was no comprehensive care plan developed for chronic pruritis or chronic skin conditions. The Assistant Director of Nursing Services was interviewed on 6/7/2024 at 8:32 AM. The Assistant Director of Nursing Services provided a copy of the Impetigo comprehensive care plan initiated on 6/5/2024 and resolved on 6/7/2024. The Assistant Director of Nursing Services stated that the resident's open wounds were crusting over which is why they (Assistant Director of Nursing Services) resolved the Impetigo care plan. The Assistant Director of Nursing Services stated Resident #81's skin condition was an ongoing issue with no definite diagnosis. The Dermatologist diagnoses the skin condition as Impetigo. The Assistant Director of Nursing Services stated the resident was always scratching and was constantly at the Dermatologist. The resident was also seen by the facility's medical providers; each time they diagnosed the resident's skin condition to be something different, We do not know what is causing the resident's symptoms of pruritis. The Assistant Director of Nursing Services We would come up with a care plan if we knew what the skin condition was. A physician's order dated 5/30/2024 documented to administer Cefdinir 300 milligrams antibiotic capsule, one capsule by mouth two times a day for infection for 14 days. The physician's order had an end date of 6/13/2024 and was still being given to the resident as of 6/7/2024. On 6/7/2024 at 9:02 AM, the Director of Nursing Services provided a comprehensive care plan titled Skin Integrity: Impaired skin integrity related to chronic rashes/scratching, initiated on 6/7/2024. The interventions included but were not limited to administering medications per the physician's order, a consult with the Infectious Disease was ordered on 6/5/2024, and a Dermatology consult as per the physician's order. The Director of Nursing Services was interviewed on 6/7/2024 at 9:03 PM and stated there should have been a care plan in place to address the resident's chronic pruritis and scratching condition. The care plan for Impetigo should not have been resolved because the resident is still taking the antibiotics for Impetigo and an evaluation of the resident's condition will have to be made after the antibiotic is completed. Resident #81 was re-interviewed on 6/7/2024 at 10:09 AM and stated that itching was still a problem and was still bothering them. The Director of Nursing Services was re-interviewed and stated the resident was still receiving antibiotics and had a history of skin conditions, therefore, the care plan developed for Impetigo should not have been discontinued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during the Recertification Survey initiated on 6/5/2024 and completed on 6/11/2024 the facility did not ensure person-centered comprehensive care plans were reviewed and revised to address each resident's needs. This was identified for 1) one (Resident #80) of one resident reviewed for hydration and 2) one (Resident #37) of one resident reviewed for Dental Services. Specifically, 1) there was no documented evidence that the comprehensive care plans for Resident #80 were reviewed and revised by the interdisciplinary team after each comprehensive and quarterly review assessment. 2) For Resident #37, the dental care plan was not reviewed and revised to reflect the resident's dental pain concerns and the need for dental X-rays as recommended by the resident's Dentist. The finding is: A facility policy titled Comprehensive Care Plan, dated 12/2019 documented that the interdisciplinary team should ensure the timeliness of each resident's person-centered comprehensive care plan and that the comprehensive care plan is reviewed and revised at intervals not to exceed 92 days. 1) Resident #80 had diagnoses of Seizure disorder, Dehydration, and Altered Mental Status. A Significant Change Minimum Data Set, dated [DATE] documented the resident's Brief Interview for Mental Status score was three indicating severely impaired cognition. The resident required substantial/maximal assistance for eating and was receiving a diuretic medication. A Quarterly Minimum Data Set, dated [DATE] documented the resident's Brief Interview for Mental Status score was three indicating severely impaired cognition. The resident required substantial/maximal assistance for eating and was receiving a diuretic medication. A Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of one, which indicated the resident had severely impaired cognition. The resident received intravenous fluids during the assessment look-back period. A comprehensive care plan titled Dehydration initiated 1/29/2024, documented the resident was at risk for Dehydration related to diuretic use. The interventions include to administer medications as ordered, monitor, document, and to report any signs or symptoms of Dehydration. Obtain and monitor laboratory and diagnostic work as ordered. There was no documented evidence that the comprehensive care plan was reviewed and or revised in conjunction with the Minimum Data Set assessment of 3/1/2024, 3/21/2024, and 4/29/2024. A comprehensive care plan titled Seizure Disorder initiated on 1/29/2024, documented the resident had a Seizure Disorder. The interventions included to administer seizure medication as ordered and to obtain and monitor laboratory and diagnostic work as ordered. There was no documented evidence that the comprehensive care plan was reviewed and or revised in conjunction with the Minimum Data Set assessment of 3/1/2024, 3/21/2024, and 4/29/2024. A Physician progress note dated 2/20/2024 documented the resident was noted with increased lethargy. The resident's comprehensive metabolic panel was reviewed and recommended to hold Lasix for three days. The resident had seizure-like activity in the hospital. Encourage oral hydration. The resident had trace edema. The physician recommended avoiding intravenous fluids due to the chance of fluid overloading. laboratory results dated [DATE] document a Keppra level of 108 (reference range 10-40). A Physician Assistant progress note dated 2/22/2024 documents the resident was seen after returning from the hospital for altered mental status. The hospital neurologist recommended increasing Keppra from 1000 milligrams twice a day to 1250 milligrams twice a day. A Physician Assistant progress note dated 2/24/2024 documented the resident was seen for Seizure management. Keppra (antiseizure medication) was recently increased. The blood level for Keppra was at 108 micrograms per milliliter (High end of normal 40 micrograms per milliliter). The resident presented with altered mental status which was likely related to Keppra toxicity: hold Keppra until Monday. A Physician's order dated 4/23/2024 documented to administer Sodium Chloride Intravenous Solution 0.9 %, use 65 milliliters per hour, intravenously one time only for hydration for two days. The registered nurse unit manager #4 was interviewed on 6/10/2024 at 10:05 AM and stated they just started working at the facility a few weeks ago and did not get a chance to update the care plans. The Registered Nurse Minimum Data Set Assessor #5 was interviewed on 6/10/2024 at 10:11 AM and stated the Nurse Managers are responsible for updating the existing care plan or creating new ones if needed. Registered Nurse Minimum Data Set Assessor #5 stated that care plans should be updated whenever a Minimum Data Set assessment is completed. The Director of Nursing Services was interviewed on 6/11/2024 at 10:23 AM and stated that care plans are updated and reviewed quarterly with the Minimum Data Set assessment schedule and whenever a significant change is identified. The Director of Nursing Services reviewed Resident #80's care plans and stated the care plans were last revised on 1/29/2024. The Director of Nursing Services stated they did not know why the care plans were not reviewed or revised as there have been three assessments completed for Resident #80 since 1/29/2024. 2) Resident #37 was admitted with diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Osteoarthritis. The Annual 1/25/2023 Minimum Data Set assessment documented a Brief Interview for Mental Status score of 10, indicating the resident had moderate cognitive impairment. There were no dental concerns documented in the Minimum Data Set assessment. A Comprehensive Care Plan titled, Oral Care: Resident has own natural teeth, initiated 7/4/2022 and last revised 1/17/2024, documented the resident will continue to have optimum oral health through the next review. The resident was last seen by a Dentist on 9/6/2022. Updates to the care plan on 5/1/2023, 7/21/2023, 11/1/2023, and 1/17/2024 documented the resident will continue to have optimum oral health through the next review. Each one of these updates was made by the Director of Nursing Services. The dental progress note, written by Dentist #1, dated 3/17/2023 documented the resident was having shooting pain in the upper left and lower left teeth upon biting. Noted several crowns have class I mobility (describes the movement of the crown). The resident needs radiographs (dental X-rays). The medical clearance and oral surgery consult sheets were submitted so the resident could be seen for evaluation. This was approved by the Dental Services Vendor (a company that contracts with the facility to provide Dentists and a company that needs to approve services before they can be provided for the resident) on 3/22/2023. A review of the progress notes from 3/19/2023 through 9/15/2023 documented multiple entries of the resident's complaint of oral pain and recommendations to obtain oral X-rays and dental consults and to administer pain medications. A Dental progress note, written by Dentist #1, dated 4/14/2023 documented the resident complaint of pain on the left side of the face/jaw. The Dentist had submitted the medical clearance and oral surgery referral for dental X-rays. A Dental consult by Dentist #2 on 5/5/2023 documented the resident had upper left jaw pain. The previous Dentist (#1) had submitted paperwork for dental X-rays. A dental consult, completed by Dentist #2, dated 7/10/2023 documented the resident had an appointment for X-rays to evaluate Crown/bridgework for any pathology due to the resident's complaint of dull aching pain. The paperwork is complete. A dental consult dated 9/15/2023 by Dentist #2 documented the resident had a pending appointment for dental X-rays. A review of the Dental comprehensive care plan revealed that the interventions recommended by the Dentists were not included in the care plan and the comprehensive care plan was not revised to reflect the resident's complaints of oral/teeth pain. The Director of Nursing Services was interviewed on 6/11/2024 at 9:48 AM and stated the unit managers are responsible for updating the care plans including adding any new interventions. The Director of Nursing Services acknowledged that they revised the Dental care plan for Resident # 37 on 5/1/2023, 7/21/2023, 11/1/2023, and 1/17/2024; however, they were unable to state why the care plan updates did not reflect the interventions that were recommended by the Dentist or the medical staff. The Assistant Director of Nursing Services was interviewed on 6/11/2024 at 11:18 AM and stated the unit managers are responsible for updating the care plan. The former unit manager, who should have updated the resident's care plan, was no longer employed at the facility. 10 NYCRR 415.11(c)(2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 6/5/2024 and completed on 6/11/2024, the facility did not ensure that each resident's medical care was supervised by a Physician throughout the resident's stay. This was identified for 1) one (Resident #45) of one resident reviewed for anticoagulant medication use and 2) one (Resident #73) of one resident reviewed for positioning/mobility. Specifically, 1) Resident #45's permanent cardiac pacemaker (a device placed in the chest that sends small electrical impulses to the heart muscles for maintaining a suitable heart rate) was supposed to be checked every three months as per the physician's order. The resident's Primary Care Physician did not ensure the pacemaker was monitored as per the physician's order. 2) Resident #73 was observed on multiple occasions wearing a Miami J Collar. The Primary Care Physician was not aware of the use of the Miami J Collar (a neck brace used to prevent head and neck movement) and therefore did not write physician's orders to apply and monitor the use of the Miami J Cervical Collar. The findings are: 1) A facility policy and procedure titled Pacemaker, effective 7/2010, documented the Primary Medical Doctor will enter an order for pacemaker checks which will include the frequency of the checks. The facility staff will arrange for a radiology company to come to the facility and perform the pacemaker checks. The Primary Medical Doctor will review the results and refer the resident to Cardiology if needed. Resident #45 was admitted with diagnoses of Hypertension, Heart Failure, and the presence of a Cardiac Pacemaker. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of zero, indicating severe cognitive impairment. A comprehensive care plan titled Cardiac/Circulatory, created on 12/10/2021, and last reviewed on 5/28/2024 documented the resident has impaired cardiac function related to Hypertension and has a cardiac pacemaker in place. The interventions included pacemaker checks as per the physician's orders. The current physician's order first initiated on 12/10/2021 documented a pacemaker check every three months for Cardiac Arrhythmia (abnormal heart rhythm). Registered Nurse Manager #1 was interviewed on 6/11/2024 at 11:54 AM and stated they did not know why Resident #45's cardiac pacemaker checks were not done for a year. Registered Nurse Manager #1 stated the resident was supposed to have their cardiac pacemaker checked every three months as per the physician's order. The Unit Secretary was interviewed on 6/11/2024 at 12:10 PM and stated the Director of Nursing Services would direct them to schedule the appointment for the cardiac pacemaker checks. The Unit Secretary stated the vendor company responsible for conducting the cardiac pacemaker checks, comes in every six months. The Unit Secretary stated in order to schedule the cardiac pacemaker check appointments, there must be between six to ten residents, or else the company will not come in to perform the cardiac pacemaker checks. The Unit Secretary stated that the vendor company was at the facility last month; however, they did not know that Resident #45 had a cardiac pacemaker in place and had orders for monitoring every three months. The Unit Secretary stated if they knew Resident #45 had a cardiac pacemaker with orders to monitor every three months, they would have scheduled an appointment. Physician #1 was interviewed on 6/11/2024 at 12:25 PM and stated the pacemaker check for Resident #45 should have been completed every three months and the scheduling for the pacemaker check is done by the facility, not the Physician. Physician #1 stated that it would be impossible for the Physician to track these schedules to ensure that the order is complied with. Physician #1 stated once the pacemaker check is completed they would review the report. Physician #1 stated Resident #45 told them a month ago that their cardiac pacemaker check had not been completed in a while. Physician #1 then spoke to the nursing supervisor to ensure the resident's pacemaker was checked. A review of the resident's medical record indicated that the resident's cardiac pacemaker was not checked after 6/26/2023 until 5/24/2024. A review of the medical progress notes from 7/18/2023 through 5/14/2024 lacked documented evidence that the resident had a cardiac pacemaker in place and that cardiac pacemaker checks were needed every three months. The Director of Nursing Services was interviewed on 6/11/2024 at 12:58 PM and stated that pacemaker monitoring is done through an outside company. It is difficult to schedule appointments with the vendor company because the vendor company requires a minimum number of residents who need cardiac pacemaker checks before the vendor company can come. The Director of Nursing Services stated the facility often does not meet the required minimum number of residents. The Director of Nursing Services stated that the unit manager should be monitoring the orders and scheduling the pacemaker checks. The Administrator was interviewed on 6/11/2024 at 1:04 PM and stated that the cardiac pacemaker checks are done based on the physician's orders. The Unit Secretary schedules the appointments with the outside vendor. The Administrator stated they could not answer why an order for monitoring every three months was not completed for one year, except that it must have been an oversight. Physician #1 was re-interviewed on 6/11/2024 at 3:17 PM and stated that quarterly monitoring of the cardiac pacemaker is needed to ensure that the cardiac pacemaker is functioning properly. 2) The facility's undated policy titled, Assistive/Adaptive Devices, documented all device recommendations are entered into the computer via a physician's order and labeled electronically with the word device. Resident #73 was admitted with diagnoses that included, Spinal Stenosis, Sepsis, and Pneumonia. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15 which indicated an intact cognition. The admission Minimum Data Set Documented Resident #73 did not have a splint or brace. A Physical Therapy Communication form dated 4/13/2024 documented Resident #73 wore a Miami J Cervical Collar when out of bed and when ambulating. Resident #73 was observed seated in their wheelchair in their room on 6/5/2024 at 11:22 AM. Resident #73 was wearing a Miami J Cervical Collar. Resident #73 stated they wore the Miami J Cervical Collar because it helped them hold up their head. Resident #73 was observed seated in their wheelchair in their room on 6/9/2024 at 2:07 PM. Resident #73 was wearing their Miami J Cervical Collar. There was no physician's order in place for the use of the Miami J Cervical Collar until 6/10/2024. The Director of Rehabilitation was interviewed on 6/10/2024 at 1:40 PM. The Director of Rehabilitation stated Resident #73 wore the Miami J Cervical Collar for comfort and that the nursing department would be responsible for obtaining an order from the Physician. Registered Nurse #6, the Unit Manager, was interviewed on 6/10/2024 at 2:21 PM. Registered Nurse #6 stated Resident #73 was admitted to the facility with the Miami J Cervical Collar and wore it for comfort. The Director of Nursing Services was interviewed on 6/11/2024 at 8:48 AM. The Director of Nursing Services stated if a resident was admitted with a Miami J Cervical Collar. The Director of Nursing Services stated there should have been a physician's order in place for the use of the Miami J Cervical Collar and for the skin checks when the Miami J Cervical Collar was removed. Physician #1 was interviewed on 6/11/2024 at 9:01 AM. Physician #1 stated all appliances, including the Miami J Cervical Collar required a physician's order, and Resident #73 should have had a physician's order for the cervical collar. A second interview was conducted with Physician #1 on 6/11/2024 at 3:14 PM. Physician #1 stated they initially assessed Resident #73 after admission and when they examined Resident #73 they did not observe Resident #73 wearing a Miami J Cervical Collar. Physician #1 stated if the resident was wearing a Miami J Cervical Collar, they would have documented the Miami J Cervical Collar in their notes. 10 NYCRR 415.15(b)(1)(i)(ii)

Based on record review and staff interviews during the Recertification Survey and Extended Survey (NY 00312849) initiated on 6/5/2024 and completed on 6/11/2024, the facility did not ensure that each resident received routine dental care. This was identified for one (Resident #37) of two residents reviewed for Pain Management. Specifically, on 3/17/2023, Dentist #1 recommended dental X-rays of the upper left and lower left teeth for Resident #37 due to a complaint of mouth pain. There was no documented evidence that the dental X-rays were ever done. The finding is: The facility's policy titled Dental and Oral Health, dated 1/2021, documented it is the policy of the facility to make routine and 24-hour emergency dental care available to its residents and to ensure the availability of these services. The dental program shall include preventive care, evaluation, and treatment, including extractions, restorative dentistry, and dental prosthetics. Resident #37 was admitted with diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Osteoarthritis. The 1/25/2023 Minimum Data Set assessment documented a Brief Interview for Mental Status score of 10, indicating the resident had moderate cognitive impairment. There were no dental concerns documented in the Minimum Data Set assessment. A Comprehensive Care Plan titled, Oral Care: resident has own natural teeth, initiated 7/4/2022 and last revised 1/17/2024, documented the resident will continue to have optimum oral health through the next review. The dental progress note dated 3/17/2023, written by Dentist #1, documented the resident was having shooting pain in the upper left and lower left teeth upon biting. Several crowns had class I mobility (describes the movement of the crown). The resident needed radiographs (dental X-rays). The medical clearance and oral surgery consult sheets were submitted so the resident could be seen for evaluation. This was approved by the Dental Service Vendor (a company that contracts with the facility to provide dentists and approved services before they can be provided) on 3/22/2023. A progress note dated 3/19/2023, written by Nurse Practitioner #1, documented the resident complained that their lower gums along the molar teeth were sensitive and wanted to see the Dentist. The resident was to follow up with the Dentist. A Dental progress note dated 4/14/2023, written by Dentist #1, documented the resident stated they were having pain on the left side of the face/jaw. Dentist #1 discussed with the resident that the medical clearance and oral surgery referral for dental X-rays and evaluation were submitted to evaluate the bridges. A progress note dated 4/23/2023, written by Nurse Practitioner #1, documented the resident was evaluated for a complaint of teeth pain. On exam, the resident had no loose teeth, and no gum redness; the recommendation was to follow up with the Dentist. A progress note dated 4/24/2023, written by Physician Assistant #1, documented the resident was still complaining of jaw and tooth pain; dentistry was consulted. Physician Assistant #1 recommended a follow-up with the Dentist. A dental consult dated 5/5/2023, completed by Dentist #2, documented the resident had upper left jaw pain. The resident had crowns that appeared to be clinically sound. There was no active infection/abscess noted. The previous Dentist (#1) had submitted paperwork for dental X-rays. A progress note dated 5/6/2023, written by Nurse Practitioner #2, documented they were asked by nursing staff to evaluate the resident for dental pain. The resident complained of left upper molar pain that started a few days ago. Nurse Practitioner #2 recommended to obtain a dental consult. A nursing progress note dated 5/9/2023, written by Registered Nurse #3, documented the resident complained of tooth pain on the left side after chewing on bread. The resident stated their pain scale was up to 20 (on a scale of 0 to 10 where 0 is the least amount of pain and 10 is the highest imaginable pain). Tramadol (pain medication) was administered. A progress note dated 6/11/2023, written by Nurse Practitioner #1, documented the resident complained of left gum and tooth pain. Upon examination, the resident had no loose teeth, and no gum redness/sensitivity. Recommended to follow up with the Dentist. A progress note dated 7/9/2023, written by Nurse Practitioner #1, documented they were asked by nursing staff to evaluate the resident for toothache. The resident complained of gum sensitivity to the left upper quadrant by the second molar. A follow-up with the Dentist was pending. A dental consult dated 7/10/2023 by Dentist #2 documented Annual Exam- there is no active infection/abscess; gingiva (gums) healthy, firm, no apparent gingivitis (gum inflammation)/swelling/ or inflammation. The resident has an appointment for dental X-rays as crown/bridgework needed to be evaluated for any pathology as the resident complains of dull aching pain. The paperwork is complete. A progress note dated 8/13/2023, written by Nurse Practitioner #2, documented the resident complained of left upper dental pain and was requesting an evaluation. The resident is awaiting a dental consult. A dental consult dated 9/15/2023, completed by Dentist #2, documented the resident had a pending appointment for dental X-rays. A review of the medical record revealed no documented evidence that the dental X-rays were ever completed. Additionally, there was no documented evidence from March 2023 to September 2023 that the resident's Dentist or the facility staff followed up on the status of the dental X-ray appointment. Dentist #2 was interviewed on 6/10/2024 at 9:47 AM and stated that on 9/14/2023 the facility that was supposed to complete the resident's dental X-rays canceled the appointment and notified the nursing home (Unit Secretary #1) that they no longer provide dental X-ray services. The original dental referral was requested in March 2023 for dental X-rays. After the dental X-ray appointment was canceled on 9/14/2023, Dentist #2 notified the Dental Service Vendor to assist in scheduling the dental X-rays. Dentist #2 stated they assumed that Unit Secretary #1 and the Dental Service Vendor were working on making another appointment to obtain the dental X-ray for Resident # 37. Dentist #2 stated they did not see the resident again until January 2024 because there were no requests for additional consults. In January 2024 the resident was asymptomatic, and the referral was finally discontinued. Unit Secretary #1 was interviewed on 6/10/2024 at 10:21 AM and stated they are not able to make an appointment for outside dental services until there is approval from the Dental Service Vendor. Unit Secretary #1 stated they received the first approval for dental X-ray on 9/7/2023 and that is when they made an appointment for the dental X-rays for Resident #37 in September 2023. Unit Secretary #1 stated that the day before the resident's appointment for the dental X-rays, the dental X-ray facility contacted them, canceled the appointment, and notified them that they no longer provide dental X-ray services. The Dental Service Vendor Representative was interviewed on 06/10/2024 at 1:25 PM and stated the Dentist is supposed to submit a medical clearance and oral surgery consult to the resident's primary physician. When the primary physician provides the medical clearance, the Dentist should contact the Dental Service Vendor for approval of the needed services. Once the Dental Service Vendor approves the services, the facility should then make the appropriate appointments. The Dental Service Vendor Representative was re-interviewed on 6/10/2024 at 02:14 PM and stated for Resident #37, the approval for services was provided to the facility on 3/22/2023, and again on 9/7/2023 when the approval was renewed. Once approval is provided by the Dental Service Vendor, it would be up to the facility to make the appointment for the dental X-rays. Unit Secretary #1 was re-interviewed on 6/10/2024 at 2:36 PM and stated they did not receive any approval for Resident #37's dental X-ray until 9/7/2023. If they had been aware of approval on 3/22/2023, they would have made the appointment. Unit Secretary #1 stated they are the only unit secretary in the facility and are responsible for scheduling all the outside appointments. The Director of Nursing Services was interviewed on 6/11/2024 at 9:48 and stated the X-rays for Resident #37 should have been done in March 2023 when they were first ordered. The Administrator was interviewed on 6/11/2024 at 2:40 PM and stated the resident's dental X-rays were originally ordered in March 2023 and they should have been done when they were first ordered. 10 NYCRR 415.17

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification and abbreviated Survey (Complaint #NY 00327627) initiated on 6/05/2024 and completed on 6/11/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for two (Unit 2 and Unit 3) of three units reviewed during the Sufficient Nursing Staffing Task. Specifically, 1) a review of the Payroll-Based Journal (PBJ) Staffing Data Report Quarter 1 2024 from October 1, 2023, through December 31, 2023, indicated excessively low weekend staffing; 2) During the survey 13 of the 26 sampled residents ( Resident # 19, # 72, #45, # 18, # 75, # 16, # 57, # 36, # 39, # 73, # 31, 50 and # 49) complained of staffing shortage causing a delay in staff response to call bells and a delay in attending to the residents' needs; and 3) During observations on the weekend of 6/8/2024 and 6/9/2024, Unit 2 and Unit 3 were staffed with fewer Certified Nursing Assistants than indicated on the Facility Assessment. The findings are: The Facility's Policy titled, Nursing Services and Sufficient Staffing dated November 2021, documented to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individual plans of care. The facility's census, acuity, and diagnoses of the resident population will be considered based on the facility assessment. The facility utilizes Resident Care Assistants who are supplemental nursing staff. Resident Care Assistants serve as ancillary staff in providing non-clinical assistance to residents. The Facility assessment dated [DATE] documented the facility had three nursing units with 120 residents (40 residents per unit). The facility assessment documented the following staffing requirement for each unit based on 120 resident capacity: -On Unit 1, during the 7:00 AM -3:00 PM shift there should be one Registered Nurse Coordinator, two Licensed Practical Nurses, and five Certified Nursing Assistants; during the 3:00 PM to 11:00 PM shift there should be one Registered Nurse Coordinator, one Licensed Practical Nurse, and five Certified Nursing Assistants; and during the 11:00 PM to 7:00 AM shift, there should be one Registered Nurse Coordinator and three Certified Nurse Assistants. -On Unit 2, during the 7:00 AM -3:00 PM shift there should be one Registered Nurse Coordinator, one Licensed Practical Nurse, and five Certified Nursing Assistants; during the 3:00 PM to 11:00 PM shift there should be one Licensed Practical Nurse and four Certified Nursing Assistants; during the 11:00 PM to the 7:00 AM shift, there should be one Licensed Practical Nurse and two Certified Nursing Assistants. -On Unit 3, during the 7:00 AM to 3:00 PM shit there should be one Registered Nurse Coordinator, one Licensed Practical Nurse, and five Certified Nursing Assistants; during the 3:00 PM to 11:00 PM shift, there should be one Licensed Practical Nurse and four Certified Nursing Assistants. During the 11:00 PM to 7:00 AM shift, there should be one Licensed Practical Nurse and two Certified Nursing Assistants. A Registered Nurse Unit coordinator is staffed for the building for each shift. 1) The Payroll-Based Journal (PBJ) Staffing Data Report for Fiscal Year (FY) Quarter one 2024 (October 1- December 31) documented the facility triggered for the Metric of excessively low weekend staffing. A review of the weekend staffing from 10/1/2023 to 12/31/2023 revealed examples that were not limited to the following: -On 10/15/2023, during the 7:00 AM-3:00 PM shift, on Unit 2 and Unit 3 there was one licensed nurse and three Certified Nursing Assistants on duty. Based on the Facility Assessment there should be one Registered Nurse Coordinator, one Licensed Practical Nurse, and five Certified Nursing Assistants on Unit 2 and Unit 3 during the 7:00 AM-3:00 PM shift. During the 3:00 PM-11:00 PM shift Unit 2 and Unit 3 had one Licensed Practical Nurse and two Certified Nursing Assistants on duty. Based on the Facility Assessment there should be one Licensed Practical Nurse and four Certified Nursing Assistants assigned to Unit 2 and Unit 3 during the 3:00 PM to 11:00 PM shift. -On 11/4/2023, during the 3:00 PM-11:00 PM shift on Unit 2 and Unit 3 there was one Licensed Practical Nurses licensed nurse and two Certified Nursing Assistants on duty. Based on the Facility Assessment there should be one Licensed Practical Nurse and four Certified Nursing Assistants assigned to Unit 2 and Unit 3 during the 3:00 PM to 11:00 PM shift. -On 11/11/23, during the 7:00 AM-3:00 PM shift, there was one Licensed Practical Nurse and two Certified Nursing Assistants assigned to each unit. Based on the Facility Assessment there should be one Registered Nurse Coordinator, one Licensed Practical Nurse, and five Certified Nursing Assistants assigned. -On 12/17/2023, during the 7:00 AM-3:00 PM shift there was one Licensed Practical Nurse and 2.5 Certified Nursing Assistants on duty for Unit 2 and Unit 3. Based on the Facility Assessment there should be one Registered Nurse Coordinator, one Licensed Practical Nurse, and five Certified Nursing Assistants assigned. -On 12/17/2023 during the 3:00 PM-11:00 PM shift there was one Licensed Practical Nurse and two Certified Nursing Assistants on duty per unit. Based on the Facility Assessment there should be one Licensed Practical Nurse and four Certified Nursing Assistants assigned to Unit 2 and Unit 3 during the 3:00 PM to 11:00 PM shift and Unit 1 was supposed to have five Certified Nursing Assistants assigned. 2) Resident interviews were conducted during the screening process. The findings included but were not limited to the following: -Resident # 19 with a Brief Interview of Mental Status score of 12, indicating moderately impaired cognition, was interviewed on 6/05/2024 at 10:44 AM and stated on Sunday (6/2/2024) evening, on Unit 3, there were only two Certified Nursing Assistants assigned for 40 residents. The resident stated they had to wait a long time to have their brief changed. -Resident # 72 with a Brief Interview of Mental Status score of 15, indicating intact cognition, was interviewed on 6/05/2024 at 11:30 AM and stated on the weekends during the evening shit it takes an hour and a half for a Certified Nursing Assistant to take them to the bathroom. - Resident # 18 with a Brief Interview of Mental Status score of 10, indicating moderately impaired cognition, was interviewed on 6/5/2024 at 10:30 AM and stated they preferred to get showers, instead they received a bed bath because of short staffing. Resident #18 resided on Unit 2. -Resident # 45 on unit 3 was interviewed on 6/05/2024 at 10:20 AM. The resident stated they prefer getting out of bed earlier; however, due to short staffing, they are getting out late due to staffing shortage. - Resident # 75, with a Brief Interview of Mental Status score of 15, indicating intact cognition was interviewed on 06/05/2024 at 11:30 AM and stated they resided on Unit 2 and preferred to get up early but some days they get to their rehabilitation appointment late because the Certified Nursing Assistants are very busy and do not get them out of bed on time. -Resident # 39, with a Brief Interview of Mental Status score of 14, indicating intact cognition was interviewed on 6/05/2024 at 10:41 AM and stated there is not enough staff on unit 3 during the 3:00 PM-11:00 PM shift, especially on the weekends. The resident stated at times they were left in a dirty brief for 4-5 hours and when the Certified Nursing Assistants came to help, they told the resident there were not enough staff. Resident # 73, with a Brief Interview of Mental Status score of 15, indicating intact cognition was interviewed on 06/05/2024 at 11:22 AM and stated they did not have consistent staff on Unit 1 on all shifts and it takes a long time to get help. Resident #73 further stated that on the 3:00 PM-11:00 PM shift there are fewer staff members, the staff members do respond to the call bell and tell the resident they would return but they do not come back to provide requested care until 45 minutes to two hours later. Resident # 49, with a Brief Interview of Mental Status score of 15, indicating intact cognition was interviewed on 6/05/2024 at 10:54 AM and stated during the 3:00 PM-11:00 PM shift the Certified Nurse Assistants on Unit 1 turned the call bell off, and then take a long time to come back to provide needed care. A Resident Council meeting was held on 6/6/2024 at 10:35 AM with eight residents in attendance. Three Residents stated that there was a delay in providing residents with care during the night shift and evening shift. The Resident council member stated the staff are overburdened on the weekend and the residents receive their care late. 3) During an observation on 6/8/2024, Saturday, at 2:30 PM, Unit 2 had three Certified Nursing Assistants, one Resident Care Associate (RCA), and one Registered Nurse Coordinator for 39 residents. Based on the Facility Assessment there should be one Registered Nurse Coordinator, one Licensed Practical Nurse, and five Certified Nursing Assistants on Unit 2 during the 7:00 AM-3:00 PM shift. During an observation on 6/8/2024 at 2:45 PM, Unit 3 had one Registered Nurse Coordinator, one Licensed Practical Nurse, and three Certified Nursing Assistants for 38 residents. Based on the Facility Assessment there should be one Registered Nurse Coordinator, one Licensed Practical Nurse, and five Certified Nursing Assistants on Unit 2 during the 7:00 AM-3:00 PM shift. During an observation on 6/9/2024, Sunday, at 2:30 PM, Unit 2 had one Registered Nurse Coordinator, one Licensed Practical Nurse, two Certified Nurse Assistants, and one Resident Care Associate (RCA) for 39 residents. Based on the Facility Assessment there should be one Registered Nurse Coordinator, one Licensed Practical Nurse, and five Certified Nursing Assistants on Unit 2 during the 7:00 AM-3:00 PM shift. Certified Nursing Assistant # 4, who was assigned to Unit 2, was interviewed on 6/9/2024 at 2:52 PM and stated Unit 2 usually has three Certified Nursing Assistants assigned; however, today there are only two Certified Nursing Assistants on duty since 7:00 AM. Certified Nursing Assistant # 4 stated they do not have enough time to complete all resident tasks even with three Certified Nursing Assistants and with only two Certified Nursing Assistants, it becomes even harder because it takes them a long time to respond to the call bells. During an observation on 6/9/2024 at 2:55 PM, Unit 3 had one Registered Nurse Coordinator, one Licensed Practical Nurse, and three Certified Nursing Assistants for 38 residents. Based on the Facility Assessment there should be one Registered Nurse Coordinator, one Licensed Practical Nurse, and five Certified Nursing Assistants on Unit 3 during the 7:00 AM-3:00 PM shift. During an observation on 6/9/2024 at 3:30 PM, Unit 2 had one Registered Nurse Coordinator, one Licensed Practical Nurse, 2.5 Certified Nurse Assistants, and one Resident Care Associate (RCA) for 39 residents. Based on the Facility Assessment there should be one Licensed Practical Nurse and 4 Certified Nurse Assistants during the 3:00 PM to 11:00 PM shift. During an observation on 6/9/2024 at 3:55 PM, Unit 3 had one Registered Nurse Coordinator and three Certified Nursing Assistants for 38 residents. Based on the Facility Assessment there should be one Licensed Practical Nurse and 4 Certified Nurse Assistants during the 3:00 PM to 11:00 PM shift. The Staffing Coordinator was interviewed on 6/09/2024 at 12:14 PM and stated that the facility is understaffed with Certified Nursing Assistants. The Nursing Supervisors are supposed to replace staff members who call out on the weekends. The Staffing Coordinator further stated that Unit 2 and Unit 3 should have five Certified Nursing Assistants assigned for a census of 39 residents during the day shift. On the evening shift, there should be four Certified Nursing Assistants assigned for a census of 39 residents. On the night shift, there should be three Certified Nursing Assistants assigned for a census of 39 residents. The Administrator was interviewed on 6/11/2024 at 1:29 PM and stated they were aware that there was a Nationwide Nursing staffing shortage. The facility has had difficulties recruiting Certified Nursing Assistants. The shortage affected the facility more on the weekends. The Administrator stated the facility used staffing agencies to recruit Certified Nursing Assistants and is having a difficult time finding Certified Nursing Assistants. The Director of Nursing Services was interviewed on 6/11/2024 at 1:20 PM and stated the facility has the most difficulty with staffing on the weekends. The actual staffing does not match the staffing projected on the facility staffing plan in the Facility Assessment because the facility has a staffing shortage. 10 NYCRR 415.13(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey initiated on 9/6/2022 and completed on 9/13/2022, 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 one (Resident #64) of seven residents reviewed for respiratory care. Specifically, Resident #64 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and was not receiving oxygen therapy as per the Physician's order. The finding is: The policy and procedure for oxygen administration dated November 2019 documented to verify there is a Physician's order for the procedure [oxygen administration], assemble equipment needed for the procedure [oxygen administration], and connect the resident tubing to the oxygen source. Resident #64 was admitted with the diagnoses of Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Section O: Special Treatments, Procedures, and Programs of the MDS documented the resident received oxygen therapy while in the facility. The physician's order dated 8/15/2022 included to administer oxygen at 3 Liters per minute (L/M) via nasal cannula (a plastic tube used to deliver oxygen to the resident) continuously. The Comprehensive Care Plan (CCP) for Impaired pulmonary function related to COPD and Pneumonia dated 8/2/2022 documented interventions that included but were not limited to administer oxygen as per the Physician's (MD) orders. Resident #64 was observed on 9/08/2022 at 12:15 PM, in the Rehabilitation Department sitting in a wheelchair with an oxygen canister attached to the wheelchair. There was no nasal cannula attached to the canister. The resident was not wearing a nasal cannula. The resident was interviewed on 9/8/2022 at 12:15 PM and stated they (Resident #64) had no difficulty in breathing. Registered Nurse (RN) # 1 was interviewed on 9/08/2022 at 1:17 PM and stated that they (RN #1) did not see Resident #64 leave the unit when the Rehabilitation staff member picked up the resident to take them (Resident #64) for therapy. RN #1 stated Resident #64 should have been wearing oxygen while in Rehabilitation therapy. Licensed Practical Nurse (LPN) #1 was interviewed on 9/08/2022 at 1:18 PM and stated Resident #64 was on oxygen when they (LPN #1) saw the resident in bed in the morning. LPN #1 stated they (LPN #1) did not see Resident #64 leaving the unit and the resident should be on continuous Oxygen as per physician orders. LPN #1 stated that Resident #64 should have received continuous oxygen therapy as per the Physician's order. Physical Therapist (PT) #1 was interviewed on 9/08/2022 at 1:30 PM and stated they (PT #1) took the resident for therapy without notifying the nurses. PT #1 signed the resident out on a Logbook maintained at the nursing station. The resident was in a wheelchair ready to go to therapy. PT #1 stated sometimes they (PT #1) did not check the physician's order to determine if the resident required oxygen. Certified Nursing Assistant (CNA) # 1 was interviewed on 9/08/2022 at 1:44 PM and stated they (CNA #1) provided morning care and transferred the resident out of their bed into a wheelchair. CNA #1 stated the resident was in the bed utilizing oxygen while in bed. When the resident was transferred to the wheelchair, the resident did not want to use oxygen therapy. CNA #1 stated they (CNA #1) did not notify the nurse of the resident's refusal to use the oxygen therapy and left the resident in the resident's room without oxygen. The Administrator was interviewed on 9/9/2022 at 11 AM and stated Resident #64 should have had oxygen administered as ordered by the Physician. If the resident did not want oxygen therapy, this should have been communicated to the nurse. PT #1 should have checked the Physician's orders and applied oxygen therapy as per the Physician's orders. The Director of Nursing Services (DNS) was interviewed on 9/13/2022 at 4:00 PM and stated the resident should have been using the oxygen as per the Physician's orders. If the resident refused to wear oxygen, the nurse should have been made aware by the CNA to then notify the physician. The DNS further stated that the CNA should have reported that the resident refused to wear the Oxygen to the nurse. 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews during the Recertification Survey initiated on 9/6/2022 and completed on 9/13/2022, the facility did not ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs safely, and in a manner that promotes each resident's rights, physical, mental and psychosocial well- being. This was identified for one (Resident #64) of seven residents reviewed for Respiratory care. Specifically, Resident #64 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and had a Physician's order to administer oxygen continuously at 3 Liters/minute. The Certified Nursing Assistant (CNA) did not report the resident's refusal to utilize the physician prescribed oxygen to the charge nurse. The finding is: The Policy and Procedure for Oxygen administration dated November 2019 documented to verify there is a Physician's order for the procedure [oxygen administration], assemble equipment needed for the procedure [oxygen administration] and connect the resident tubing to the oxygen source. Resident #64 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Section O: Special Treatments, Procedures, and Programs of the MDS documented the resident received oxygen therapy while in the facility. The physician's order dated 8/15/2022 included to administer oxygen at 3 Liters per minute (L/M) via nasal cannula (a plastic tube used to deliver oxygen to the resident) continuously. The Comprehensive Care Plan (CCP) for Impaired pulmonary function related to COPD, and Pneumonia dated 8/2/2022 documented interventions that included but were not limited to administer oxygen as per the Physician (MD) orders. Resident #64 was observed on 9/08/2022 at 12:15 PM, in the Rehabilitation Department sitting in a wheelchair with an oxygen canister attached to the wheelchair. The resident was not wearing a nasal cannula. Oxygen tubing was not connected to the oxygen tank. Registered Nurse (RN) # 1 was interviewed on 9/08/2022 at 1:17 PM and stated that they (RN #1) did not see Resident #64 leave the unit when the Rehabilitation staff member picked up the resident to take them (Resident #64) for therapy. RN #1 stated Resident #64 should have been wearing oxygen while at Rehabilitation therapy. Licensed Practical Nurse (LPN) #1 was interviewed on 9/08/2022 at 1:18 PM and stated Resident #64 was on oxygen when they (LPN #1) saw the resident in bed in the morning. LPN #1 stated they (LPN #1) did not see Resident #1 leaving the unit. LPN #1 stated Resident # 64 should be receiving continuous oxygen as per the MD order. Certified Nursing Assistant (CNA) # 1 was interviewed on 9/08/22 at 1:44 PM and stated they (CNA #1) provided morning care this morning and transferred the resident out from their bed into their (Resident # 64) wheelchair. CNA #1 stated the resident was in the bed utilizing oxygen. When the resident was transferred to the wheelchair, the resident did not want to use the oxygen therapy. CNA #1 did not notify the nurse of the resident's refusal to use the oxygen therapy and left the resident without oxygen. CNA #1 stated that they (CNA #1) were trained to report any changes in resident condition or refusal of care to the nurses on the unit. The Administrator was interviewed on 9/9/2022 at 11 AM and stated Resident #64 should have had oxygen administered as ordered by the Physician. If the resident did not want oxygen therapy, this should have been communicated to the nurse. The Director of Nursing Services (DNS) was interviewed on 9/13/2022 at 4:00 PM and stated the resident should have been using the oxygen as per the Physician's orders. If the resident refuses to wear oxygen, the nurse should have been made aware by CNA #1 so the nurse could then notify the physician. The DNS further stated that the CNA should have reported that the resident refused to wear the Oxygen to the nurse. 415.26(c)(1)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the Recertification Survey initiated on 9/6/2022 and completed on 9/13/2022, the facility failed to establish and maintain infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases. This was identified for six (Resident #77, #57, #50, #9, #43, #32) of seven residents reviewed for respiratory care. Specifically, for six (Resident #77, #57, #50, #9, #43, #32) of six residents receiving nebulizer treatment the facility did not follow their policy and procedures to change or clean the tubing, the mouthpiece, and the mask utilized to provide treatment via the nebulizer to prevent and minimize the risk of infection. Findings include but are not limited to: The Nebulizer Policy revised in May 2022, documented that after completion of nebulizer treatments, the nebulizer mask must be rinsed with normal saline and air dried. The mask can be cleanly stored in the plastic bag and stored in the nebulizer case. The nebulizer mouthpieces-unscrew the medication cup and rinse the entire apparatus with sterile water, dry and place in a plastic bag for clean storage. The nebulizers and the tubing need to be changed and discarded every 72 hours and documented on the treatment sheet. The Nebulizer tubing must be labeled with the time, date, and initials of the nurse. 1) Resident #77 was admitted with diagnoses that include Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Type 2 Diabetes Mellitus. The Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) score was 15, which indicated Resident #77 was cognitively intact. The MDS indicated that Resident #77 received oxygen while a resident at the facility. The Physician's order dated 8/20/2022 documented to administer Ipratropium-Albuterol Solution 0.5-2.5(3) milligrams (MG)/3 milliliters (ML) every 6 hours as needed and on 8/21/2022 to administer Budesonide Suspension 0.5 MG/2 ML via a nebulizer twice a day. On 9/06/2022 at 11:03 AM, Resident #77's nebulizer machine was observed uncovered on the nightstand and the nebulizer tube and the attached mouthpiece were observed hanging from the nebulizer. The tube was not dated. The nebulizer mouthpiece was observed with a dried white color substance. Registered Nurse (RN) #1 Manager was interviewed on 9/8/2022 at 12:15 PM and stated that every Sunday, the 11 PM to 7 AM shift nurse is responsible to change the nebulizer tube and date the tube. RN #1 stated they (RN #1) do not know if the nurses clean the nebulizer machine after each use. RN #1 stated that the nurses were supposed to clean and place the nebulizer mouthpiece or nebulizer face mask in the zip lock bag after each use. Resident #77 was interviewed on 9/8/2022 at 1:30 PM and stated that they (Resident #77) try to wash their nebulizer mouthpiece in the bathroom sink daily because no staff member ever cleans the mouthpiece, and the mouthpiece gets smelly and dirty. Licensed Practical Nurse (LPN) #1 was interviewed on 9/8/2022 at 2:51 PM and stated that they (LPN#1) never clean or change the nebulizer equipment. LPN#1 stated they believed the 3 PM to 11 PM shift nurses changed the nebulizer tube every 72 hours. LPN #1 stated they (LPN #1) were not in-serviced by the facility related to nebulizer care. LPN #1 stated they (LPN #1) were not aware of the facility protocol related to nebulizer mask, mouthpiece, or tubing care. RN # 2, who worked during the 3 PM to 11 PM nursing shift, was interviewed on 9/12/2022 at 3:36 PM and stated that they (RN #2) sometimes rinse the nebulizer mouthpiece with sink water after the nebulizer medication is administered. RN#2 stated that after they (RN #2) rinse the mouthpiece, they (RN #2) do not document anywhere in the medical record because there are no MD orders. RN#2 stated the medication chamber for the mouthpiece, the mask, and the tubing are supposed to be changed weekly. RN #2 stated they (RN #2) did not know the facility's policy related to nebulizer care. RN #2 further stated they (RN #2) did not know when the nebulizer tube was last changed because there was no date on the tubing. 2) Resident #57 was admitted with diagnoses of Acute and Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation and Pulmonary Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #57 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #57 was cognitively intact. The MDS indicated that Resident #57 received oxygen while a resident at the facility. The Comprehensive Care Plan (CCP) titled Pulmonary: Impaired pulmonary function related to (R/T) COPD, history of Pneumonia and Pulmonary Fibrosis, last revised on 9/3/2022, included interventions that were not limited to administer pulmonary medications per MD orders and to monitor skin on the face and around the ears for changes related to cannula/mask usage. There was no interventions related to the frequency of changing the nebulizer tubing or the mouth piece. The Physician's orders dated 8/22/2022 documented to administer Ipratropium-Albuterol Solution 0.5-2.5(3) milligrams (MG)/3 milliliters (ML) every 6 hours as needed for shortness of breath or wheezing, Budesonide Suspension 0.5 MG/2 ML inhale orally two times a day for COPD. Resident #57's nebulizer tube and mouthpiece were observed on the nightstand on 9/9/2022 at 2:30 PM. The mouthpiece was dirty with dried secretions. The resident stated the nurses do not clean or replace the mouthpiece or tubing. Registered Nurse (RN) #1, who was the Unit manager, was interviewed on 9/9/2022 at 3 PM and stated Resident #57 did not have an order for nebulizer care. RN #1 stated they (RN #1) did not know that a protocol for nebulizer care existed. RN #1 stated they (RN#1) did not recall receiving Inservice education regarding nebulizer care or the facility protocols for nebulizer care. RN# 2, who worked during the 3 PM to 11 PM nursing shift, was interviewed on 09/12/2022 at 3:36 PM and stated that they (RN #2) attempted to rinse the nebulizer mouthpiece after each nebulizer medication use with sink water; however, did not document because there were no Physician orders related to the care of the nebulizer mask or mouthpiece and the tubing. RN #2 stated that the mouthpiece or mask and the tubing are supposed to be changed weekly. RN #2 stated because there was no date on Resident #57's nebulizer tubing, they (RN #2) could not say when the tubing was last changed. 3) Resident #50 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Pulmonary Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #50 was cognitively intact. The Physician's order dated 9/7/2022 documented to administer Budesonide Suspension 0.5 milligram (MG)/2 milliliter (ML), orally two times a day for COPD for 7 days and Ipratropium-Albuterol Solution 0.5-2.5(3) MG/3 ML every 6 hours as needed for shortness of breath or wheezing. The Comprehensive Care Plan titled Pulmonary: Impaired pulmonary function related to (R/T) COPD was revised on 8/6/2022. Interventions included to administer pulmonary medications per the Physician's (MD) order. During an observation on 9/13/22 at 2:29 PM Resident # 50 was observed in their room in bed. A nebulizer was observed on the nightstand dresser. The uncovered nebulizer tubing was observed hanging from the nebulizer. The mouthpiece was observed to be dirty with dried secretions. Licensed Practical Nurse (LPN) #2 was interviewed on 9/13/2022 at 3:30 PM and stated they (LPN #2) did not clean the resident's mask after a nebulizer treatment and did not know when the tubing was last changed. LPN #2 further stated there was no record of when the resident's nebulizer tubing was last changed. The Director of Nursing Services (DNS) was interviewed on 9/13/2022 at 4:50 PM and stated nurses should follow the facility policy when providing nebulizer care after each nebulizer treatment to alleviate infection control concerns. The DNS stated they (DNS) expected Physician orders should be in place, along with a care plan regarding changing and cleaning of the nebulizer mouthpiece, mask, and tubing. The DNS was unable to state why there were no Physician's orders related to changing or cleaning of the nebulizer mask, mouthpiece, and tubing for the six residents reviewed. The Medical Director was interviewed on 9/13/2022 at 4:55 PM and stated the facility had a policy and protocol for how the respiratory equipment should be cared for. The Medical Director stated that if the nurses were not following the policy and protocol for nebulizer treatment, the residents were at risk for respiratory infections. The Medical Director stated that there should be physician orders regarding how to care for the nebulizer equipment. The MD further stated that changing the tubing including the mask and the mouthpiece every 72 hours should have a physician's order to ensure it gets carry over to the Treatment Administration Record. 415.19(a)(1-3)