**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/16/2025, the facility did not ensure that each resident was treated with respect and dignity and in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one (Resident #136) of one resident reviewed for Dignity. Specifically, on 4/8/2025, during multiple observations, Resident #136 was observed from the hallway with a Foley Catheter drainage bag half filled with yellow-colored fluid (urine). The drainage bag was not covered with a privacy bag. Additionally, Resident #35's Jackson Pratt (defined as a surgical suction drain that gently draws fluids from a wound after surgery) drain bulb containing yellowish-orange drainage was also visible from the hallway without any privacy covering. The finding is: The facility's policy titled Catheter Care, last revised on 2/2024, documented that the facility will ensure residents with catheters receive appropriate catheter care and maintain their dignity and privacy when catheters are in use. Privacy bags will be available, and catheter drainage bags will be covered at all times while in use. Resident #136 was admitted with diagnoses including Malignant Neoplasm (abnormal growth of cells that can spread to other body parts) of the Rectum, Type 2 Diabetes, and Neurogenic Bladder (Nerve problems affecting the bladder). The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #136 had intact cognition. The Minimum Data Set (MDS) assessment documented that Resident #136 had an Indwelling Catheter (a thin tube inserted into the bladder to drain urine) and had a primary medical condition category of Cancer. A Physician's Order dated 3/25/2025 documented Foley Catheter French 16 with a 100 cubic centimeters balloon. Change the catheter every month and as needed. Foley Catheter care every shift and as needed. Change the Foley Catheter bag and the privacy bag as needed for soiling and dislocation. A Physician's Order dated 3/25/2025 documented the Right Upper Quadrant Jackson Pratt (JP) Drain [abdominal surgery]. Monitor output and document every shift. Keep the Jackson Pratt (JP) Drain in negative pressure. A Comprehensive Care Plan (CCP) dated 4/2/2025 documented Resident #136 had a Foley Catheter secondary to Neurogenic Bladder (Nerve problems affecting the bladder). Interventions included changing the drainage bag weekly, observing urine for a change in color and consistency, and placing a privacy bag over the Foley Catheter bag. A Comprehensive Care Plan (CCP) dated 4/2/2025 documented that Resident #136 had a Jackson Pratt (JP) drain to the right upper quadrant of the abdomen. Interventions included ensuring negative pressure was maintained in the Jackson Pratt Drain. Notify the Physician of any changes related to drainage color, amount, and consistency. Resident #136 was observed in their room on 4/8/2025 at 10:45 AM lying in their bed with a Foley bag and catheter tubing visible from the hallway. The Foley bag was half full of urine. Resident #136 also had a Jackson Pratt (JP) drainage bulb with yellowish-orange drainage placed on the bed which was visible from the hallway. Resident #136 was observed in their room on 4/8/2025 at 2:01 PM lying in their bed with a Foley bag and tubing visible from the hallway. The Foley bag was half full of urine. Resident #136 also had a Jackson Pratt (JP) drainage bulb with yellowish-orange drainage placed on the bed which was visible from the hallway. During an interview on 4/8/2025 at 2:07 PM, Licensed Practical Nurse #1, the Charge Nurse, stated that they were not aware that the Certified Nursing Assistant assigned to Resident #136 did not use the Foley Catheter privacy bag. Licensed Practical Nurse #1 stated that there should have been a privacy bag covering the Foley catheter bag, and the Jackson Pratt (JP) drain valve should also have been covered for privacy. During an interview on 4/10/2025 at 10:26 AM, Certified Nursing Assistant #3 stated they took care of Resident #136 on 4/8/2025 during the 7:00 AM-3:00 PM shift. Certified Nursing Assistant #3 stated they had showered Resident #136 and taken off the privacy bag from the Foley Catheter drainage bag before they showered the resident and forgot to put the privacy bag covering back. Certified Nursing Assistant #3 stated the Jackson Pratt (JP) drain bulb did not have any privacy covering available since Resident #136 had returned from the Hospital. Certified Nursing Assistant #3 stated they were not aware that the Jackson Pratt (JP) drain bulb should be covered because the Nurses are responsible for the care of the Jackson Pratt (JP) drain bulb. During an interview on 4/15/2025 at 8:30 AM, the Director of Nursing Services stated the Foley Catheter drainage bags should be covered with a privacy bag to maintain the residents' dignity. The Director of Nursing Services stated that the Jackson Pratt (JP) drain bulb should at least have been covered with a plastic bag for privacy. 10 NYCRR 415.3(d)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during the Recertification and abbreviated complaint (NY 00349884) survey initiated on 4/8/2025 and completed on 4/16/2025, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately to the facility administration and were reported to the Department of Health within 24 hours. This was identified for two (Resident #6 and Resident #34) of two residents reviewed for abuse and for one (Resident #29) of one resident reviewed for Skin Conditions. Specifically, 1) a resident to resident altercation between Resident #34 and Resident #6 that resulted in a scratch to Resident #34's right arm and Resident #6's fall was not reported to the New York State Department of Health timely. 2) Resident #29 alleged that a certified nursing assistant scratched them during care. The incident was not reported to the facility administration and an investigation was not initiated to rule out abuse, neglect, and mistreatment and to identify the root cause of the incident. The findings are: The facility's policy entitled Abuse Prevention, updated on 6/2023 and 10/2024 documented that all allegations of abuse must be immediately reported to the Administrator and no later than 2 hours to other officials (including the State Survey Agency) after the allegation is made, if the events that caused the allegation involved abuse or resulted in serious bodily injury. The alleged violations must be reported no later than 24 hours to the State Survey Agency, for the events that the allegation did not involve abuse and did not result in serious bodily Injury. The policy did not include resident to resident altercation incident investigation and reporting. 1) Resident #34 was admitted with diagnoses that included Dementia with Behavioral disturbance, Delusional disorders, and Diabetes Mellitus. The Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status score of seven (7), which indicated the resident had severe cognitive impairment. The Minimum Data Set documented that the resident was independent with ambulation and had no identified behaviors. Resident #6 was admitted with diagnoses that included Vascular Dementia, Dysphagia (difficulty swallowing) following Cerebral infarction, and Schizophrenia. The Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status score of six (6), which indicated the resident had severely impaired cognition. The resident required the supervision of one staff member with limited assistance and utilized a wheelchair for locomotion. A Resident Altercation and Occurrence investigation concluded on 7/19/2024, documented that on 7/17/2024 at approximately 4:05 PM, Resident #6, while using the wheelchair as a walker, bumped into another resident's wheelchair in the dining room. Resident #34, who was in the dining room, saw the incident and walked over to help the resident. Resident #6 hit Resident #34 to get them away and Resident #34 grabbed Resident #6's left forearm. Resident #6 then swatted at Resident #34, resulting in a scratch on Resident #34's right arm. The investigation report further documented that a review of video surveillance was immediately conducted and showed that Resident #6 attempted to release their arm from Resident #34's grip, lost their balance, and fell. The report concluded that this was an isolated incident, and both residents were cognitively impaired with no intent to harm each other. A central complaint intake form from the New York State Department of Health (Complaint # NY 00349884) documented the incident between Resident #34 and Resident #6 was reported to the Department of Health on 8/1/2024, 14 days after the incident took place on 7/17/2024. During an interview on 4/14/2025 at 1:30 PM, the Director of Nursing Services stated they were responsible for reporting the reportable incidents to the New York State Department of Health. The altercation between Resident #34 and Resident #6 on 7/17/2024 was not reported timely because they were on vacation. Their designee, the former Assistant Director of Nursing Services, who no longer works at the facility, should have reported the incident within 24 hours but failed to do so. During an interview on 4/14/2025 at 1:45 PM, the Risk Manager stated that the Director of Nursing Services or the Assistant Director of Nursing Services was responsible for reporting incidents to the Department of Health. They stated that the incident between Resident #34 and Resident #6 should have been required within 24 hours. During an interview on 4/16/2025 at 11:43 AM, the administrator stated that an abuse allegation should be reported to the Department of Health within 2 hours if abuse is suspected, otherwise, an incident involving resident to resident altercation should be reported within 24 hours. 2) Resident #29 was admitted with diagnoses including Colon Cancer, Hypertension, and Osteoarthritis. The 2/12/2025 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. There was no documentation of open wounds in the Minimum Data Set assessment. On 4/8/2025 at 10:07 AM Resident #29 was observed in bed. The resident stated they had a scabbed area on their right upper arm. Upon observation the area was about two centimeters in length and one centimeter in width; the area around the scab appeared reddened. The resident's hands were contracted and due to shoulder arthritis, the resident stated they had difficulty reaching that part of their arm. The resident stated this happened about two months ago when a certified nursing assistant was providing care and scratched the resident. The resident stated the certified nursing assistant's nail broke off and went into the resident's arm. The resident stated they did not recall the name of the certified nursing assistant who was providing care, but they named another certified nursing assistant (Certified Nursing Assistant #1) who was aware of what happened and took the nail out of the resident's arm. A review of the medical record revealed that there were no treatment orders for the right upper arm wound. During an interview on 4/9/2025 at 2:23 PM, Certified Nursing Assistant #1 stated the incident happened months ago. There was a new certified nursing assistant (name not recalled) providing care to Resident #29. The resident's right upper arm was bleeding a little bit. Certified Nursing Assistant #1 stated they did not have to take the nail out from under the resident's skin. Certified Nursing Assistant #1 stated they were attending to Resident #29's roommate, and the resident called them over to look at the scratch on their arm. Certified Nursing Assistant #1 stated they reported the incident to Medication/Treatment Nurse #1, who worked as a Unlicensed Registered Nurse at the facility. During an interview on 4/9/2025 at 2:38 PM, Medication/Treatment Nurse #1 (unit medication nurse for Resident #29) denied that they were informed of the incident and were not aware of the scab on Resident #29's right upper arm. During an interview on 4/9/2025 at 2:42 PM, Registered Nurse #5 (unit charge nurse) stated they were not aware of a wound on the resident's right upper arm, or any incidents that caused the wound. During a re-interview on 4/9/2025 at 2:50 PM, Registered Nurse #5 (unit charge nurse) stated they spoke to the resident and the resident confirmed that a certified nursing assistant had scratched the resident during care. Registered Nurse #5 (unit charge nurse) stated there should be an accident and incident report. During an interview on 4/10/2025 at 9:45 AM, the Director of Nursing Services stated there were no accident or incident reports for Resident #29 related to the resident being scratched by a certified nursing assistant. During an interview on 4/10/2025 at 10:53 AM, the Assistant Director of Nursing Services/Risk Manager #1 stated they became aware of the incident yesterday (4/9/2025) and immediately initiated an investigation. The Assistant Director of Nursing Services/Risk Manager #1 stated they should have been notified of the incident when it first occurred and an investigation should have been started. During an interview on 4/10/2025 at 11:20 AM, the Director of Nursing Services stated if the resident reported to staff that a certified nursing assistant had scratched them, then the incident should have been investigated to rule out abuse or mistreatment. The Director of Nursing Services stated Certified Nursing Assistant #1 was responsible for reporting the incident to the floor nurse who then should have reported the incident to the nursing supervisor and an accident and incident report should have been initiated. 10 NYCRR 415.4 (b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/16/2025, the facility did not have evidence that all alleged violations of abuse, neglect, and mistreatment were thoroughly investigated. This was identified for one (Resident #51) of two residents reviewed for Hospitalization. Specifically, Resident #51 with a recent history of left hip replacement and was dependent on staff assistance for Activities of Daily Living, was found in their room with their left hip internally rotated (rotated inward) with leg discrepancy (one leg was shorter than the other). The facility did not obtain statements from all employees involved with resident care to determine the root cause of the incident. The finding is: The facility's policy titled Accident/Incident, last revised in December 2023, documented an accident as an unexpected, unintended event that can cause a resident bodily injury. All accidents or incidents involving residents must be thoroughly documented in the resident's medical record. Such documentation, at a minimum, must include, but not be limited to: a clear description of the accident/incident; the Certified Nursing Assistant assigned to the resident to complete an investigation statement; a statement completed by the person who found or witnessed the accident/incident; and the Assistant Director of Nursing/Risk Manager will complete the accident/incident investigation report summary, conclusion, and will formulate a root cause analysis and implement any intervention to prevent occurrence. Resident #51 has diagnoses including Schizophrenia, Aftercare Following Joint Replacement Surgery, Fracture of Unspecified Part of Neck of Left Femur, Subsequent Encounter For Closed Fracture with Routine Healing, and Presence of Left Artificial Hip Joint. The 5-Day Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severely impaired cognitive skills for daily decision-making. The resident was dependent on staff to roll left and right in bed, sit to lying in bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer. The Physician's Order dated 1/30/2025 documented Occupational Therapy and Physical Therapy Screen/Evaluation and treatment as indicated. The Physician's Order dated 1/30/2025 and last renewed 3/31/2025 documented the resident's weight-bearing status as: Weight-bearing as tolerated on the left lower extremity. The Physician's Order dated 1/30/2025 and last renewed 3/31/2025 documented: Hip precautions on the left lower extremity. The Physician's Order dated 1/30/2025 and last renewed 3/31/2025 documented transfer with the assistance of two persons Stand Pivot. The Physician's Order dated 1/30/2025 documented adaptive/assistive devices: Hip abductor wedge when in bed and a wheelchair at all times. This order was discontinued on 2/4/2025. The Rehabilitation Progress Note dated 1/30/2025 written by Physical Therapist #2 documented the resident was seen today for Physical Therapy/Occupational Therapy evaluation status post new admission. The resident presented with a decline in functional mobility and was placed on restorative Physical Therapy and Occupational Therapy to address functional limitations. Resident's one to one (Mental Health Therapy Aide) and Certified Nursing Assistant were educated on hip precautions and verbalized understanding. The Certified Nursing Assistant's [NAME] (resident care instructions provided to the Certified Nursing Assistant) as of 2/1/2025 documented for the resident to have adaptive/assistive devices: hip abductor wedge when in bed and a wheelchair at all times. The Treatment Administration Record dated February 2025 documented under Unscheduled 'Other' Orders for the resident to have adaptive/assistive devices: hip abductor wedge when in bed and when in a wheelchair at all times. The Physician's Order dated 2/4/2025 documented for the resident to have adaptive/assistive devices: Hip abductor wedge when in bed and knee separator when in a wheelchair at all times. The Nursing Progress Note dated 2/4/2025 written by Registered Nurse #6 documented Occupational Therapist #1 reported the resident was taken down for therapy via a wheelchair. Prior to going, Occupational Therapist #1 reported that the abductor wedge was put on. Upon arrival at the therapy gym, the resident's left hip was noted displaced, shortened, and internally rotated. The resident was placed back to bed and the Physician Assistant was contacted who ordered to send the resident to the Emergency Department for x-ray and evaluation by orthopedics. The Physician's Assistant Progress Note dated 2/4/2025 documented there was a concern for the resident having a possible left hip dislocation. The left hip was internally rotated and shortened. The resident was not able to bear weight and was placed back in bed. Advised to send to Emergency Department for x-ray and Orthopedic evaluation. A review of the Resident Accident and Incident Report dated 2/4/2025 revealed only one employee statement written by Occupational Therapist #1. The statement documented: This therapist went into the resident's room to bring them to the rehabilitation gym around 2:00 PM. The resident's one to one Mental Health Therapy Aide #1 was in the resident's room. Occupational Therapist #1 saw the resident's left hip internally rotated with leg discrepancy. Occupational Therapist #1 notified nursing and also brought the resident to the rehabilitation gym for Physical Therapist #2 and the Rehabilitation Director to see the resident. The Rehabilitation Director informed Occupational Therapist #1 to bring the resident to the Nursing Supervisor (Registered Nurse #6). The resident was left in their room with Mental Health Therapy Aide #1. The resident did not receive Physical Therapy/Occupational Therapy for the day. Physical Therapist #2 was unavailable for the interview. The Director of Rehabilitation at the time of the incident was unavailable for an interview. During an interview on 4/15/2025 at 2:05 PM, Occupational Therapist #1 stated on 2/4/2025, they went to the resident's room to bring them to therapy. Upon entering the resident's room, Occupational Therapist #1 stated they saw the resident's internally rotated hip. Occupational Therapist #1 stated they asked Mental Health Therapy Aide #1, who was also in the room with the resident at the time if they knew what happened to the resident and they were unable to offer any explanation. Occupational Therapist #1 stated they had to put on the resident's knee separator that they found sitting on the resident's dresser in their room. Occupational Therapist #1 stated Physical Therapist #2 and the Director of Rehabilitation both looked at the resident's left leg and agreed that the leg was internally rotated with a possible dislocation. Occupational Therapist #1 stated they then brought the resident back to their room and informed Registered Nurse #6 that the resident's leg did not look good and to possibly get an x-ray done. During an interview on 4/15/2025 at 2:40 PM, Certified Nursing Assistant #5, who cared for the resident on 2/4/2025 during the 7:00 AM-3:00 PM shift, stated they did not remember the resident, nor the incident that took place regarding the resident's left leg. During an interview on 4/15/2025 at 3:35 PM, the 7 AM-3 PM Registered Nurse Nursing Supervisor (Registered Nurse #6) stated they thought the incident had occurred in the Rehabilitation gym during therapy. Registered Nurse #6 stated that when they went to assess the resident in their room and with the help of another Nurse. The resident was placed back into bed and the Physician Assistant was notified who advised them to send the resident to the hospital for an x-ray. During an interview on 4/16/2025 at 9:10 AM, the Assistant Director of Nursing/Risk Manager stated they never got a statement from any staff other than Occupational Therapist #1 because they thought the resident's left hip dislocation happened while the resident was in therapy. The Risk Manager stated they never read the written statement provided by Occupational Therapist #1. The Risk Manager stated if they had realized the resident was found in their room with their left leg internally rotated, they would have gotten a statement from Certified Nursing Assistant #5, the one to one Mental Health Therapy Aide #1, and from all staff who had cared for the resident on the prior three shifts. During an interview on 4/16/2025 at 9:35 AM, the Director of Nursing Services stated the Risk Manager should have gotten written statements from the 7:00 AM-3:00 PM Registered Nurse Nursing Supervisor (Registered Nurse #6), Certified Nursing Assistant #5, the one to one Mental Health Therapy Aide #1, and anyone else who had contact with the resident on the shift that the resident's leg was found internally rotated and also the prior three shifts because the incident was considered an injury of unknown origin. On 4/16/2025 at 2:40 PM, one to one Mental Health Therapy Aide #1 was contacted and was unavailable for an interview. 10 NYCRR 483.12(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/16/2025, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #136) of three residents reviewed for Catheter care. Specifically, Resident #136 had a Physician's Order to monitor and document the Jackson Pratt (a closed-suction medical device used after surgery to drain fluids from a wound or incision) drain and to keep the drain bulb at negative pressure (achieved by compressing the bulb to gently pull fluids from the surgical site). During multiple observations, Resident #136's Jackson Pratt drain bulb was not compressed, which indicated that the Jackson Pratt drain was not at negative pressure. Additionally, the facility staff were not knowledgeable about the care and monitoring of the drain. The finding is: The facility's policy titled Jackson Pratt Drain Policy last revised on 3/2024, documented to ensure that closed wound drains, such as Jackson Pratt drains, are cared for and managed according to current standards of practice. Jackson Pratt is an example of commonly used drains that utilize low negative pressure to drain the fluids. Proper care and management of these drains are important to aid in healing and preventing infections and other complications. Compliance Guidelines indicated that nurses would confirm during care rounds and as needed that the drains are maintaining their suction unless otherwise instructed. Resident #136 was admitted with diagnoses including Malignant Neoplasm (abnormal growth of cells that can spread to other body parts) of the Rectum, Type 2 Diabetes, and Neurogenic Bladder (Nerve problems affecting the bladder). The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #136 had intact cognition. The Minimum Data Set (MDS) assessment documented that Resident #136 had a primary medical condition category of Cancer. A Comprehensive Care Plan (CCP) dated 4/2/2025 documented that Resident #136 had a Jackson Pratt drain to the right upper abdomen. Interventions included ensuring negative pressure is maintained in the Jackson Pratt drain. Monitor output from the Jackson Pratt drain and notify the Physician of any changes related to drainage color, amount, and consistency. A Physician's Order dated 3/25/2025 documented a Right Upper Quadrant [abdomen] Jackson Pratt drain. Monitor output and document every shift for monitoring. Keep the Jackson Pratt drain in negative pressure. Resident #136 was observed lying in bed on 4/8/2025 at 10:45 AM. The Jackson Pratt bulb was observed lying on the bed with no privacy cover. The Jackson Pratt bulb was not compressed and had a small amount of yellowish-orange drainage. Resident #136 was observed lying in bed on 4/8/2025 at 2:01 PM. The Jackson Pratt bulb was lying on the right side of the bed with no privacy cover. The Jackson Pratt bulb was not compressed and had a small amount of yellowish-orange drainage. During an interview on 4/8/2025 at 2:05 PM, Licensed Practical Nurse #1, the Charge Nurse, stated that the Jackson Pratt drain was supposed to be monitored by the Nurses. Licensed Practical Nurse #1 stated they were aware of the Physician's order regarding monitoring the output from the Jackson Pratt drain. Licensed Practical Nurse #1 stated they did not know that there was an order to maintain the Jackson Pratt drain bulb's negative pressure and were not sure how to maintain the negative pressure. During an interview on 4/9/2025 at 9:45 AM, Medication/Treatment Nurse #2, who worked as an Unlicensed Registered Nurse, stated that they checked the Jackson Pratt drain for Resident #136 at the end of their shift because they were busy with the medication administration pass. Medication/Treatment Nurse #2 stated that they should have checked the Jackson Pratt drain more often and ensured that the drain was on negative pressure. During an interview on 4/9/2025 at 11:38 AM, the Wound Care Nurse stated that on 4/8/2025, after Licensed Practical Nurse #1 had told them about the Physician's order for negative pressure, they had discontinued the negative pressure order and then informed the Physician. The Wound Care Nurse stated they discontinued the order because they (the Wound Care Nurse) had never seen an order for negative pressure with the Jackson Pratt drain. The Wound Care Nurse stated they spoke with the Medical Director who told them to reinstate the order to maintain the Jackson Pratt drain negative pressure. During an interview on 4/10/2025 at 3:00 PM, the Nurse Educator stated they had just started the role of Nurse Educator at the facility and were not able to provide documented evidence of staff education related to the Jackson Pratt drain. The Nurse Educator stated they provided education to all nurses on 4/9/2025 after the issue was identified by the Surveyor. During an interview on 4/14/2025 at 8:03 AM, the Medical Director stated that for optimal functioning of the Jackson Pratt drain, negative pressure should be maintained as per the Physician's orders. The Medical Director stated the Nurses should also monitor the Jackson Pratt drainage, document output, and report any adverse effects, including color, amount, and consistency. During an interview on 4/15/2025 at 8:30 AM, the Director of Nursing Services stated the Nurses should monitor and document the Jackson Pratt drainage periodically throughout the shift. The Director of Nursing Services stated that the Nurses should have followed the Physician's order and maintained the Jackson Pratt drain in negative pressure to ensure proper wound healing. The Director of Nursing Services stated that the Nursing staff should have been educated regarding appropriate care of the Jackson Pratt drain. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/16/2025, the facility did not ensure that each resident's environment remained free of accidents. This was identified for one (Resident #32) of five residents reviewed for Accidents. Specifically, Resident #32 resided in a unit that had three residents (Resident #24, Resident #77, and Resident #101) with wandering behaviors. During observation, one 16-ounce bottle of nail polish remover, three disinfectant spray bottles, and four air freshener spray bottles were observed in Resident #32's room on their nightstand. The finding is: The facility's undated policy, titled Accidents and Hazards, defined Hazards as elements of the resident environment that have the potential to cause injury or illness. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks, monitoring for effectiveness, and modifying interventions when necessary. All staff are to be involved in observing and identifying potential hazards in the environment while taking into consideration the unique characteristics and abilities of each resident. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. Resident #32 was admitted with diagnoses including Cirrhosis of the Liver (permanent scarring and damage of the liver), Type 2 Diabetes, and Hypertension. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #32 had intact cognition. The Minimum Data Set documented under Daily Preferences that taking care of personal belongings was very important for Resident #32, and having a place to lock things to keep them safe was not important for Resident #32. A Comprehensive Care Plan (CCP) titled Activities dated 5/16/2024 and revised on 4/9/2025, documented that Resident #32 presented as alert and oriented, able to make their needs known. Resident #32 remained independent with their leisure pursuits. Beauty parlor services and nail polishing were offered to Resident #32. During an observation on 4/8/2025 at 10:00 AM, the Resident was lying in bed. There was one bottle of a 16-fluid-ounce pink nail polish remover on the nightstand. The bottle had a sign on the back of the bottle indicating DANGER! EXTREMELY FLAMMABLE! Additionally, there were three disinfectant spray bottles, and four air freshener spray bottles were observed in Resident #32's room on their nightstand. During an interview on 4/8/2025 at 10:25 AM, Resident #32 stated when they (Resident #32) have a bowel movement, the odor in the room can be foul-smelling which is why they use the room sprays to keep their room clean. Resident #32 stated they perform their nail care by themselves and use the nail polish remover for nail care. Resident #32 stated they did not know and the facility staff had never told them that they were not allowed to keep the room sprays and nail polish remover in their room. During an interview on 4/8/2025 at 11:19 AM, Licensed Practical Nurse #1, Charge Nurse, stated that Resident #32 should not have room spray bottles and a nail polish remover bottle stored in the room unsupervised because these are hazardous items and can cause injury when ingested or inhaled. Licensed Practical Nurse #1 stated they were not aware that Resident #32 had these items in the room. Licensed Practical Nurse #1 stated that some residents (Resident #24, Resident #77, and Resident #101) are confused and sometimes wander into other residents' rooms. Licensed Practical Nurse #1 stated that staff were expected to report if any hazardous items were seen in the resident rooms. During an interview on 4/8/2025 at 1:00 PM, Medication/Treatment Nurse #2, who was working as an Unlicensed Registered Nurse, stated they did not notice that Resident #32 had room spray bottles and a nail polish remover bottle in their room. Medication/Treatment Nurse #2 stated they should have been more observant of the resident's room during medication administration. During an interview on 4/11/2025 at 10:38 AM, Certified Nursing Assistant #2 stated they did not see any room spray bottles or the nail polish remover bottle when they took care of Resident #32 on 4/7/2025 during the 7:00 AM-3:00 PM shift. Certified Nursing Assistant #2 stated that Resident #32's family member must have brought the supplies for the resident. Certified Nursing Assistant #2 stated if they had seen the nail polish remover bottle and the room sprays, they would have reported it immediately to the Charge Nurse. During an interview on 4/15/2025 at 8:34 AM, the Director of Nursing Services stated the unit staff members were responsible for maintaining residents' safety and that Resident #32 should not have any hazardous materials in their room to prevent potential injury and illness as there are some residents on the unit who are confused and might wander into the resident's room. 10 NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/16/2025, the facility did not assist each resident in making an appointment for necessary dental services. This was identified for one (Resident #39) of one resident reviewed for Dental Services. Specifically, Resident #39 had an annual dental consult completed on 2/26/2025. The Dentist documented resident had broken teeth and recommended referral to an outside oral surgeon for full mouth extraction. There was no documented evidence that the recommendations made by the Dentist were addressed by the facility until 4/15/2025 after the Surveyor brought the concern to the facility's attention. The finding is: The facility's policy and procedure titled Dental Consult revised in March 2024 documented the facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location. All action and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record. Resident #39 was admitted with diagnoses including Cocaine Abuse, Chronic Obstructive Pulmonary Disease, and Acute Respiratory Failure. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, indicating intact cognition. The Minimum Data Set assessment documented that the resident did not have any chewing or swallowing disorder and did not require a mechanically altered diet. A Physician's order dated 5/22/2024 documented Regular Texture, Thin Consistency Diet. A Comprehensive Care Plan for Dental, effective 11/2/2023, documented the resident was at risk of oral/dental health problems. The intervention included notifying the primary Physician of any signs and symptoms of infection/inflammation. A plan of care note written by Registered Nurse #1, dated 2/28/2025, documented that the resident was seen by the Dentist for an annual examination, and recommendations were placed in the resident's medical record. A Dental consult dated 2/26/2025 documented that Resident #39 was seen for an annual examination. The dentition chart indicated the resident required multiple teeth extractions. The Dentist's written recommendations were illegible. A review of the medical record from 2/28/2025 to 4/15/2025 revealed no documented evidence of clarification related to the Dentist's recommendations or any actions taken to address the recommendations. During an interview on 4/8/2025 at 1:49 PM, Resident #39 was observed with partial upper and lower dentition. The remaining teeth were observed with black stains. Resident #39 stated that they would like to see a Dentist and were waiting for the facility to arrange an appointment. During a re-interview on 4/14/2025 at 12:36 PM, Resident #39 stated that they were seen by the in-house Dentist in February 2025 and needed to go to a hospital to have all their teeth removed. Resident #39 stated that no one in the facility had followed up with them and they did not know if and when an appointment was scheduled for teeth extractions. Resident #39 stated they would like to have dentures for aesthetic reasons. During an interview on 4/15/2025 at 9:33 AM, Registered Nurse #1, the unit charge nurse, stated they were responsible for reviewing, following up, and notifying the primary Physician of the Dentist's recommendations. Registered Nurse #1 stated they did not understand the Dentist's handwriting on the consultation form completed on 2/26/2025. Registered Nurse #1 stated they did not call the Dentist to clarify and ascertain what recommendations were provided by the Dentist. Registered Nurse #1 stated they placed the completed dental consult form in the resident's medical record and did not take any other actions. During an interview on 4/15/2025 at 10:17 AM, the Director of Nursing Services stated that Registered Nurse #1 should have followed up with the Dentist to clarify the recommendations and assisted in making the appointment for Resident #39. The Director of Nursing Services stated that Registered Nurse #1 should have reached out to the Dentist if the Dentist's recommendations were incomprehensible. During an interview on 4/16/2025 at 11:14 AM, the Dentist stated that all of Resident #39's remaining dentition was nonrestorable. The Dentist stated they recommended a referral to an Oral Surgeon for a full mouth extraction and then the resident was to be fitted for dentures at the facility. The Dentist stated that the staff should have assisted Resident #39 in scheduling an appointment with the Oral Surgeon and should have contacted them (the Dentist) if there were any issues. 10 NYCRR 415.17(a-d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/16/2025, in accordance with accepted professional standards and practices, the facility did not maintain medical records on each resident that were complete. This was identified for one (Resident #151) of one resident reviewed for Dialysis. Specifically, there was no documented evidence in the treatment administration record that Resident #151's right chest Permacath (a long-term catheter used for dialysis treatment) was monitored every shift for signs and symptoms of bleeding, placement, and skin integrity. The finding is: The facility's policy titled Dialysis last reviewed in July 2023, documented that the shunt site (a surgically created connection between an artery and a vein, used for hemodialysis) or vascular access site will be checked every shift and documented on the Treatment Administration Record by the Nurse. The Nurse will check for bruit/thrill ( signs that the fistula or graft is working, and their presence is a positive indicator of healthy blood flow) at the shunt site and for any signs of infection and/or bleeding. The Nurse will check the vascular access site for any signs of bleeding or infection. Resident #151 has diagnoses including End Stage Renal Disease and Cerebral Infarction (Stroke). The 5-Day Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognitive skills for daily decision-making. The resident also received Hemodialysis while a resident of the facility and within the last 14 days. The Comprehensive Care Plan titled Hemodialysis related to End Stage Renal Disease initiated on 1/23/2025 documented as an intervention: Right chest Permacath for Hemodialysis: Monitor for signs and symptoms for bleeding, monitor for placement and check skin integrity. The Physician's Order dated 4/8/2025 documented that the resident was to receive in-house dialysis every Monday, Tuesday, Wednesday, Thursday, and Friday. The Physician's Order dated 4/8/2025 documented for the Nurse to fill out the dialysis communication book prior to dialysis and review the book after the resident returns. A review of the resident's medical record revealed there was no physician's order to monitor the right chest Permacath for signs and symptoms of bleeding, placement, and skin integrity. A review of the resident's Dialysis Communication Book revealed the Permacath site was being monitored by the facility staff before and after the resident's dialysis from Monday to Friday. A review of the Progress Notes dated Saturday 4/12/2025 and Sunday 4/13/2025 (when the resident did not receive dialysis) revealed no documented evidence that the resident's right chest Permacath was monitored for signs and symptoms of bleeding, monitored for placement, and checked for skin integrity. During an interview on 4/14/2025 at 12:30 PM, Registered Nurse # 5 stated the resident should have had Physician's Orders to monitor the right chest Permacath for signs and symptoms of infection, bleeding, and any abnormalities every shift. Registered Nurse #5 stated the admission nurse who readmitted the resident on 2/10/2025 did enter the Physician's Orders into the computer for monitoring of the Permacath site. Registered Nurse #5 stated the orders must have been overlooked. During an interview on 4/14/2025 at 12:55 PM, the Registered Nurse Supervisor (Registered Nurse #4) stated they readmitted the resident to the facility on 2/10/2025 and forgot to enter the order into the computer to monitor the resident's right chest Permacath for bleeding or signs of infection. During an interview on 4/14/2025 at 1:20 PM, the Director of Nursing Services stated the Physician Orders to monitor the resident's right chest Permacath should have been entered into the computer by Registered Nurse #4 on 2/10/2025. If there was an order present, it would have been transcribed over to the Treatment Administration Record for the nurses to document. During an interview on 4/15/2025 at 10:05 AM, Registered Nurse #2 stated they had worked the 7:00 AM - 3:00 shift on 4/12/2025 and 4/13/2025 and assessed the resident's right chest Permacath for any signs of infection, but did not document their assessment in the resident's medical record. Registered Nurse #2 stated they had seen other dialysis residents in the facility with physician orders to monitor their Permacath site, but not Resident #151. Registered Nurse #2 stated they never questioned why this resident did not have those orders. 10 NYCRR 483.70(i)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/16/2025, the facility did not ensure it established an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one (Resident #321) of one resident reviewed for Transmission-Based Precautions and for one (Resident #43) of five residents observed during the Medication Administration Task. Specifically, 1) Resident #321 had a Physician's order for Contact Precautions for Shingles (a rash caused by the virus that causes Chickenpox) with an antiviral medication; however, there was no Contact Precautions signage posted in a conspicuous location outside the resident's room that instructs staff and visitors for use of specific Personal Protective Equipment. 2) Medication/Treatment Nurse #2 did not perform hand hygiene before putting on and removing their gloves when performing a finger stick blood glucose testing for Resident #43. The findings are: The facility's policy titled Infection Control/Infection Prevention and Control Program, dated 3/2024 documented the facility will establish and maintain an infection prevention and control program under which it prevents, identifies, reports, investigates, and controls the spread of infections and communicable diseases in the facility. The facility decides when and how isolations should be applied to an individual resident. Resident #321 was admitted with diagnoses including Schizophrenia, Malnutrition, and Acute Kidney Failure. The 4/4/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 3, indicating the resident had severe cognitive impairment. A nursing progress note dated 4/4/2025 documented the resident being showered and there was a blistery rash noted on the right rib area extending to the front chest area. The physician was sent a picture (notified) and ordered Valtrex (an antiviral medication) 1 gram. The resident was placed in a private room for isolation purposes. A physician's order dated 4/4/2025 documented Contact Precautions. A physician's order dated 4/4/2025 documented Valtrex Oral Tablet 1 gram (an antiviral medication), give 1 tablet via Gastrostomy-Tube three times a day for Shingles for seven (7) days. On 4/8/2025 at 12:50 PM Resident #321 was observed in their shared room. Resident #321 occupied the window bed. There was no Contact Precautions signage posted in a conspicuous location outside the resident's room that instructs staff and visitors to use specific Personal Protective Equipment. During an interview on 4/8/2025 at 12:55 PM, Registered Nurse #5 (the unit charge nurse) observed Resident #321's room entrance and stated the resident had a physician's order for Contact Precautions and there should be a Contact Precautions sign posted outside the resident's room. Registered Nurse #5 stated on 4/4/2025 the resident was diagnosed with Shingles, was receiving Valtrex for seven days, and was moved to a private room for isolation. Yesterday (4/7/2025) the resident was moved back to their original (current) room; however, the Contact Precaution sign was not re-posted outside the resident's current room when the resident was moved. Registered Nurse #5 stated the resident was still taking the antiviral treatment and had a physician's order to remain on Contact Precautions. During an interview on 4/9/2025 at 2:47 PM, Registered Nurse Infection Preventionist #1 stated Resident #321 was started on Valtrex for seven days on 4/4/2025 for Shingles. The resident's room was changed on 4/4/2025 to be in a private room for contact isolation. On 4/7/2025 the Physician Assistant decided the resident could be moved back to their original room because the Shingles rash was dry, crusted over, and covered. Registered Nurse Infection Preventionist #1 stated the resident was supposed to remain on Contact Precautions while taking the Valtrex. Registered Nurse Infection Preventionist #1 stated the Contact Precaution sign was not moved to the resident's current room and it was an oversight. During an interview on 4/10/2025 at 2:01 PM, the Director of Nursing Services stated Resident #321 had a physician's order to be placed on Contact Precautions for Shingles and a Contact Precautions signage should have been posted outside the resident's room. The Infection Preventionist and the nursing staff are responsible for making sure the Contact Precautions sign is present. 2) The facility's policy titled Blood Glucose Monitoring, last revised on 12/2023, documented that finger stick glucose testing is ordered by the Physician. The Procedural Guidelines included performing hand hygiene and donning gloves. Clean the resident's fingertip or alternate site with alcohol preparation and allow to dry. Place the strip in the glucometer, pierce the resident's skin with a disposable lancet, and apply a drop of blood on the reagent strip. Remove gloves and perform hand hygiene. Wipe the machine surfaces, glucometer must be cleaned and disinfected between resident uses; to disinfect, wipe the glucometer with a germicidal disposable cloth and perform hand hygiene. Resident #43 was admitted with diagnoses of Type 2 Diabetes, Dorsalgia (back pain), and Altered Mental Status. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated Resident #43 had moderately impaired cognition. The Comprehensive Care Plan (CCP) dated 1/7/2025 documented that Resident #43 had Diabetes. Interventions included blood glucose monitoring as per the Physician's Order. Diabetic medication as per the Physician's order. A Physician's Order dated 1/9/2025 documented Lantus (Insulin) Subcutaneous Solution 100 units per milliliter, Inject 30 units subcutaneously two times a day for Diabetes. Hold if fasting blood sugar is below 110 milligrams per deciliter and contact the Physician if fasting blood sugar is more than 350 milligrams per deciliter and below 70 milligrams per deciliter. During a Medication Administration Task with Medication/Treatment Nurse #2, who worked at the facility as an Unlicensed Registered Nurse, on 4/9/2025 at 9:05 AM, Medication/Treatment Nurse #2 was observed conducting a finger stick blood glucose monitoring and administering insulin injection for Resident #43. Medication/Treatment Nurse #2 brought the supplies to the resident's room, put on the gloves without washing their hands, and performed the finger stick blood glucose testing. Medication/Treatment Nurse #2 administered the physician-ordered insulin to the resident, wiped the glucometer machine with a disposable germicidal cloth, and removed their gloves. Medication/Treatment Nurse #2 did not perform hand hygiene. Medication/Treatment Nurse #2 gathered the used supplies (used for fingerstick and insulin injection) in a tray and put the tray on top of the medication cart. The Medication/Treatment Nurse #2 then proceeded to open the medication cart to administer Resident #43 their oral medications when the surveyor informed Medication/Treatment Nurse #2 to perform handwashing. During an interview on 4/9/2025 at 9:15 AM, Medication/Treatment Nurse #2 stated they should have washed their hands before putting their gloves on and after they discarded the gloves to prevent the spread of any infection. During an interview on 4/11/2025 at 2:23 PM, the Infection Preventionist stated that Medication/Treatment Nurse #2 should have washed their hands before putting their gloves on and after discarding their gloves. During an interview on 4/15/2025 at 8:40 AM, the Director of Nursing Service stated that all staff must perform hand hygiene during resident care and other facility tasks. The Director of Nursing Service stated that handwashing prevents the spread of infection. 10 NYCRR 415.19(a)(1-3)(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #132 was admitted with diagnoses including Cerebrovascular Accident, Dementia, and Bipolar Disorder. The 1/23/2025 Quarterly Minimum Data Set Assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision-making. The Minimum Data Set Assessment documented that the resident was at risk for pressure ulcer development and had no pressure ulcers. The Braden Risk Evaluation (a scale for determining pressure ulcer risk) dated 1/21/2025 documented a score of 14, indicating the resident was at moderate risk for developing a pressure ulcer. A physician's order dated 10/25/2024 documented checking the air mattress placement and function and checking air pressure based on the resident's body weight every shift. A Comprehensive Care Plan titled Skin: The resident has potential for alteration in skin integrity related to immobility, incontinence, and failure to thrive dated 10/29/2024 documented interventions to provide pressure-reducing mattress as per facility protocol and provide individualized care regarding preventative measures of skin breakdown. On 4/8/2025 at 10:12 AM Resident #132 was observed in bed. The air mattress weight setting was set at 300 pounds, which was the maximum weight setting for the air mattress. The most recent resident weight in the medical record was 85.2 pounds on 3/3/2025. During an observation and interview on 4/8/2025 at 2:15 PM, Medication/Treatment Nurse #1, who worked as an Unlicensed Registered Nurse at the facility, the resident was still in bed, and the mattress weight setting was set at 300 pounds. Medication/Treatment Nurse #1 stated they would have to check the resident's weight. During an interview on 4/8/2025 at 2:20 PM, Medication/Treatment Nurse #1 returned to the resident's room with Registered Nurse #5 (the unit charge nurse). Registered Nurse #5 stated the air mattress weight setting of 300 pounds was not correct; Registered Nurse #5 tried to adjust the weight on the control panel to approximate the resident weight of 85 pounds, but the weight would not change; Registered Nurse #5 stated they would have to call the maintenance staff. Medication/Treatment Nurse #1 stated they noticed the air mattress weight setting was set to 300 pounds this morning, but they forgot to tell the charge nurse. A review of the April 2025 Treatment Administration Record revealed that nurses, including Medication/Treatment Nurse #1, documented they have been checking the air mattress weight setting every shift. During an interview on 4/10/2025 at 8:32 AM, Registered Nurse #5 (unit charge nurse) stated they could not change the weight setting on the air mattress because the mattress was in locked mode and they did not know how to unlock the control panel which is why they had to call the housekeeping staff. Registered Nurse #5 stated the medication nurses were supposed to check the weight setting during the medication pass. During an interview on 4/10/2025 at 10:04 AM, Wound Care Nurse #1 stated there should be an order in place for the nurse to check the air mattress weight setting to ensure the weight is set according to the resident's weight and then document on the treatment record. The air mattress weight setting should be in correlation with the resident weight. During an interview on 4/10/2025 at 2:01 PM, the Director of Nursing Services stated all nurses should make sure the air mattress weight setting is in alliance with the resident's weight. The medication nurse should check the weight setting, alert the supervisor if there is a problem, and then sign the treatment record. During an interview on 4/11/2025 at 8:08 AM, Wound Care Physician #1 stated the air mattress weight setting should reflect the resident's weight, otherwise, the purpose of using the air mattress for wound healing will not be achieved. Wound Care Physician #1 stated they would expect the air mattress to be set according to the resident's weight. 10 NYCRR 415.12(c)(1) Based on observations, record review, and interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/16/2025, the facility did not ensure that each resident received care, consistent with professional standards of practice, to prevent Pressure Ulcers. This was identified for two (Resident #152 and Resident #132) of four residents reviewed for Pressure Ulcers. Specifically, 1) Resident #152 with multiple pressure ulcers utilized an air mattress as a care plan intervention. During multiple observations, the adjustable weight setting for the air mattress, which is meant to correspond to the resident's weight, was not set accurately. 2) Resident #132 utilized an air mattress according to their plan of care. During observation, the air mattress weight setting was set at 300 pounds while the resident weighed 85 pounds. The findings are: The facility policy titled Wound Care/Pressure Injury Management and Prevention, dated 6/2023 documented that pressure injury care requires an interdisciplinary team approach that addresses the following areas to promote the healing of tissue: reduce or eliminate causative factors such as pressure due to immobility, friction, shear, moisture, and circulatory impairments. Establish an interdisciplinary treatment plan that promotes wound healing and addresses other conditions that may affect wound healing. The operation manual for the air mattress documented instructions that included determining the patient's weight and setting the control knob to that [resident's] weight setting on the control unit. 1) Resident #152 was admitted with diagnoses including Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves), Acute Kidney Failure, and Bradycardia (heart rate is consistently low). A Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99, which indicated that Resident #152 had severe cognitive impairment. The Minimum Data Set documented Resident #152 had unhealed pressure ulcers, was at risk for developing pressure ulcers, and had pressure-reducing devices on the chair and bed. A Physician's Order dated 1/22/2025 documented cleanse the sacrum wound with normal saline and apply Santyl (ointment used to remove damaged tissue), cover with dry protective dressing every day shift and evening shift, and as needed [Stage 3 pressure ulcer]. A Comprehensive Care Plan (CCP) dated 2/14/2025 titled Skin Impairment Sacrum Stage 3 Pressure Ulcer (full-thickness skin loss where subcutaneous tissue is visible but bone and tendon or muscle is not exposed) documented interventions including administering treatments as ordered by the Physician and monitoring for effectiveness. Provide the resident with a pressure-relieving mattress and seat cushions. Turn and position the resident every two hours and as needed. A Physician's Order dated 3/7/2025 documented cleanse the mid back wound with normal saline,apply Santyl (ointment used to remove damaged tissue), cover with dry protective dressing every day shift, and as needed [for a full thickness excoriation]. A Physician's Order dated 3/13/2025 documented to check air mattress placement and function, and check air pressure based on body weight. A Physician's Order dated 4/5/2025 documented cleanse the left heel with normal saline and apply Skin Prep (protective barrier), cover with an abdominal pad, and wrap with Kerlix (gauze roll) every day shift [Stage 4 pressure ulcer (full thickness skin and tissue loss with exposure of muscle, tendon, or bone). A review of the electronic medical record indicated that Resident #152's most recent weight dated 4/7/2025 was 145.5 pounds. During an observation on 4/8/2025 at 10:45 AM, Resident #152 was in bed. The air mattress weight setting control knob was set at 260 pounds. During an observation on 4/9/2025 at 10:00 AM, Resident #152 was in bed. The air mattress weight setting control knob was set at 260 pounds. During an interview on 4/8/2025 at 11:00 AM, Medication/Treatment Nurse #2, who was working as an Unlicensed Registered Nurse, stated that the Nurses were responsible for checking the air mattress every shift to ensure that the air mattress was not deflated and was at the correct weight setting. Medication/Treatment Nurse #2 stated they did not know why the air mattress weight setting was set at a higher value than Resident #152's weight. During an interview on 4/11/2025 at 8:03 AM, the Wound Care Physician stated the air mattress weight setting should be set according to the resident's weight to facilitate wound healing. During an interview on 4/11/2025 at 9:00 AM, Licensed Practical Nurse #1, Charge Nurse, stated they did not know why the air mattress weight setting for Resident #152 was not set according to their weight. Licensed Practical Nurse #1 stated that the Medication/Treatment Nurse was responsible for checking the air mattress setting. During an interview on 4/14/2025 at 8:51 AM, the Wound Care Nurse stated the unit Nurses were responsible for making sure that the air mattress weight setting was set according to the residents' weight. The Wound Care Nurse stated that if the air mattress was not set according to the residents' weight, the pressure could not be distributed properly. During an interview on 4/15/2025 at 8:45 AM, the Director of Nursing Services stated that the air mattress weight setting should be set according to the resident's weight to distribute the pressure evenly and for optimal wound healing.

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00359457) initiated on 4/8/2025 and completed on 4/16/2025, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, facility administration did not ensure Medication/Treatment Nurse #1, Medication/Treatment Nurse #2, Medication/Treatment Nurse #3, Medication/Treatment Nurse #4, and Medication/Treatment Nurse #6 had approved limited permit or a current New York State Registered Nurse license to work at a health care facility as Registered Nurses. Cross Reference: F839 Administration-Staff Qualifications The finding is: Executive Order Number 4.22 dated 6/8/2023 documented the Executive Order number 4 was extended until 6/22/2023 which included a temporary Suspension and Modification of Subdivision 5 of Section 6907 of the Education Law and Regulations to the extent necessary to permit graduates of registered professional nurse and licensed practical nurse licensure qualifying education programs registered by the State Education Department to be employed to practice nursing under the supervision of a registered professional nurse and with the endorsement of the employing hospital or nursing home for 180 days immediately following graduation. The facility's undated policy titled Recruitment and Hiring, last revised on 4/2025, documented that it is the facility's policy to recruit professionals, direct care staff, and employees to meet the resident's needs, clinical needs, and operational needs in accordance with the facility assessment, current recruitments, and professional standards. The policy indicated that before the candidate starts their new job, the facility will conduct a background check to verify their license/certification, education, employment history, and any other relevant information including the criminal background check following State and Federal requirements. The facility's policy titled Agency Hiring last revised in March 2023 documented the facility may engage staffing agencies to provide temporary or contract nursing personnel when internal staffing resources are insufficient to meet resident care needs. All agency nurses must meet the same standards of care, conduct, and compliance as employed staff. The policy indicated the credentialing and compliance prior to assignment, the agency must provide documentation for each nurse, and the HR/designee will verify all documentation before the nurse begins to work. The facility's Agency Nurse Job Description documented qualifications that included a current, active nursing license in the state of assignment. Key responsibilities included administering medications and treatments as prescribed, monitoring residents for changes in condition, and reporting promptly to appropriate staff. During an interview on 4/10/2025 at 12:03 PM, the Director of Human Resources/Assistant Administrator stated started working at the facility in February 2024 and had been calling the staffing agency to get the approved limited permits for the Medication/Treatment Nurses who are working at the facility as Unlicensed Registered Nurses. The Director of Human Resources/ Assistant Administrator stated Medication/Treatment Nurse #1, Medication/Treatment Nurse #2 and Medication/Treatment Nurse #3 have been working at the facility as Registered Nurses since 2021. Medication/Treatment Nurse #4 and Medication/Treatment Nurse #6 have been working at the facility as Registered Nurses since 2023. The Director of Human Resources/Assistant Administrator did not know why the facility allowed these nurses to work without a valid permit or New York State Registered Nurse license. The Director of Human Resources/ Assistant Administrator stated they continued to schedule the Medication/Treatment Nurses to work at the facility as Registered Nurses because the Nursing Department did not tell them to stop. The Director of Human Resources/ Assistant Administrator stated that the Director of Nursing Services and the Administrator were aware of the unlicensed nurses working at the facility in the capacity of Registered Nurses, as both the Director of Nursing Services and the Administrators were part of the emails that were sent to the staffing agency to obtain the nurses' license or limited permit information. The Director of Human Resources stated they were not able to continue to follow up with the employees and the employees' agency to ensure appropriate credentials were obtained because they were busy with numerous other responsibilities at the facility. During an interview on 4/10/2025 at 1:51 PM, the Director of Nursing Services stated all Medication/Treatment Nurses' job descriptions included Medication and Treatment Administration only. The Director of Nursing Services stated that Medication/Treatment Nurses who worked as unlicensed Registered Nurses should not be allowed to work at the facility without proper documentation. The Director of Nursing Services stated they have been working at the facility since 5/2023 and were aware of the unlicensed Nurses and how the Director of Human Resources/Assistant Administrator was trying to communicate with the staffing agency to obtain the approved credential for each of the nurses and was unsuccessful. The Director of Nursing Services stated they did not make it their priority to ensure the nurses had appropriate credentials available to work at the facility as Registered Nurses. They were so busy doing other things. The Director of Nursing Services stated Medication/Treatment Nurses who were identified as not having a New York State Registered Nurse license had been employed by the facility before the Director of Nursing Services was hired and they (the Director of Nursing Services) continued to schedule these Nurses as Medication and Treatment Nurses. During an interview on 4/11/2025 at 11:27 AM, the Administrator stated that Medication/Treatment Nurse #1, Medication/Treatment Nurse #2, and Medication/Treatment Nurse #3 have been working at the facility as Registered Nurses since 2021. Medication/Treatment Nurse #4 and Medication/Treatment Nurse #6 have been working at the facility as Registered Nurses since 2023. The Administrator stated the unlicensed Medication/Treatment Nurses should not have been scheduled to work at the facility without proper documentation. The Administrator stated it was an oversight on their part, and it was not intentional. The Administrator stated they were not responsible for hiring and maintaining the employee files. The Administrator stated the Director of Human Resources/Assistant Administrator was responsible for ensuring and maintaining that each employee had appropriate credentials. 10 NYCRR 415.26

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint# NY 00359457) initiated on [DATE] and completed on [DATE], the facility did not ensure professional staff were licensed, certified, or registered in accordance with applicable State laws. This was identified for five (Medication/Treatment Nurse #1, Medication/Treatment Nurse #2, Medication/Treatment Nurse #3, Medication/Treatment Nurse #4, and Medication/Treatment Nurse #6) of six employees reviewed for Licensure and Certification. Specifically, Medication/Treatment Nurse #1, Medication/Treatment Nurse #2, Medication/Treatment Nurse #3, Medication/Treatment Nurse #4, and Medication/Treatment Nurse #6 were working as Registered Nurses at the facility; however, all five employees did not have the required New York State Registered Nurse license and or approved limited permit to work as a Registered Nurse under the supervision of a licensed Registered Nurses. The finding is: The facility's undated policy titled Recruitment and Hiring, last revised on 4/2025, documented that it is the facility's policy to recruit professionals, direct care staff, and employees to meet the resident's needs, clinical needs, and operational needs in accordance with the facility assessment, current recruitments, and professional standards. The policy indicated that before the candidate starts their new job, the facility will conduct a background check to verify their license/certification, education, employment history, and any other relevant information including the criminal background check following State and Federal requirements. The facility's policy titled Agency Hiring last revised in [DATE] documented the facility may engage staffing agencies to provide temporary or contract nursing personnel when internal staffing resources are insufficient to meet resident care needs. All agency nurses must meet the same standards of care, conduct, and compliance as employed staff. The policy indicated the credentialing and compliance prior to assignment, the agency must provide documentation for each nurse, and the HR/designee will verify all documentation before the nurse begins to work. The New York State Education Department (NYSED) website indicates under limited permit: that the New York State Education Department issues limited permits to nursing school graduates who have: 1) applied to the New York State Education Department (NYSED) for licensure as a Registered Nurse and limited permit, and 2) Have met all requirements for licensure as Registered Nurse (RN) in New York State except for taking the National Council License Examination for Registered Nurses (NCLEX-RN). A limited permit holder (called a Graduate Nurse or GN) can temporarily practice nursing under Registered Nurse supervision at the health care facility noted on the limited permit. The Graduate Nurse must be employed by the health care facility, and the supervising Registered Nurse must be on the care unit with the Graduate Nurse when the Graduate Nurse provides care. A limited permit is valid for up to one (1) year or until 10 days after the Graduate Nurse is notified that they failed the National Council License Examination for Registered Nurses (NCLEX-RN), whichever happens first. A Graduate Nurse who changes employers will have to obtain a new limited permit from the New York State Education Department (NYSED) to practice nursing for the new employer. A Review of Medication/Treatment#1's personnel records indicated the employee was hired as a Registered Nurse. The limited permit application to work as a Registered Nurse in New York State was undated and incomplete. Medication/Treatment#1's personnel records did not have a current New York State Registered Nurse license or documentation for a request or approval of a Limited Permit from the New York State Education Department. The personnel file contained a Foreign Nursing School Registered Nurse Diploma dated [DATE]. The personnel record did not include evidence of an initial job application or a background check for Medication/Treatment Nurse #1 as indicated in the facility policy. A Review of Medication/Treatment#2's personnel file indicated that the employee was initially hired by the facility on [DATE]. Medication/Treatment Nurse #2's personnel file indicated application for a limited permit to work as a Registered Nurse in New York State was incomplete, unsigned, and undated. There was no evidence of a New York State Registered Nurse license for Medication/Treatment#2. A Review of Medication/Treatment #3's personnel file included an incomplete job application that was not signed and dated. There was no documentation of an approved limited permit to work as a Registered Nurse in New York State. Medication/Treatment Nurse #3's personnel file included a Diploma for a Registered Nurse from a Foreign Nursing School dated [DATE]. There was no evidence of a New York State Registered Nurse license for Medication/Treatment #3. A Review of Medication/Treatment#4's personnel file did not have any documentation for an approved limited permit to work as a Registered Nurse in New York State. There was no evidence of a current Registered Nurse license for Medication/Treatment#4. The Office of the Inspector General (OIG) search (refers to the background check against the Health and Human Services Office of the Inspector General's list of excluded individuals/ entities) was completed on [DATE] and the employee was not barred from participating in Federal healthcare programs like Medicare and Medicaid. Medication/Treatment Nurse #4's personnel file included a Diploma for a Registered Nurse from a Foreign Nursing School dated [DATE]. Medication/Treatment #4's personnel record showed a National Council License Examination for Registered Nurses (NCLEX-RN) appointment that was rescheduled dated [DATE]. A Review of Medication/Treatment #6's personnel file did not include an approved limited permit to work as a Registered Nurse in New York State. There was no evidence of a current New York State Registered Nurse license for Medication/Treatment #6. Medication/Treatment Nurse #6's personnel file included a Diploma for a Registered Nurse from a Foreign Nursing School dated [DATE]. Medication/Treatment Nurse #6's personnel file indicated they were approved to sit for the National Council License Examination for Registered Nurses (NCLEX-RN) as indicated in the email correspondence from the New York State Education Department dated [DATE]. There was no indication that Council License Examination for Registered Nurses (NCLEX-RN) was completed and passed the examination. During an interview on [DATE] at 12:03 PM, the Director of Human Resources/Assistant Administrator stated started working at the facility in February 2024 and had been calling the staffing agency to get the approved limited permits for the Medication/Treatment Nurses who are working at the facility as Unlicensed Registered Nurses. The Director of Human Resources/ Assistant Administrator stated Medication/Treatment Nurse #1, Medication/Treatment Nurse #2 and Medication/Treatment Nurse #3 have been working at the facility as Registered Nurses since 2021. Medication/Treatment Nurse #4 and Medication/Treatment Nurse #6 have been working at the facility as Registered Nurses since 2023. The Director of Human Resources/Assistant Administrator did not know why the facility allowed these nurses to work without a valid permit or New York State Registered Nurse license. The Director of Human Resources/ Assistant Administrator stated they continued to schedule the Medication/Treatment Nurses to work at the facility as Registered Nurses because the Nursing Department did not tell them to stop. The Director of Human Resources/ Assistant Administrator stated that the Director of Nursing Services and the Administrator were aware of the unlicensed nurses working at the facility in the capacity of Registered Nurses, as both the Director of Nursing Services and the Administrators were part of the emails that were sent to the staffing agency to obtain the nurses' license or limited permit information. The Director of Human Resources stated they were not able to continue to follow up with the employees and the employees' agency to ensure appropriate credentials were obtained because they were busy with numerous other responsibilities at the facility. During an interview on [DATE] at 12:53 PM, Medication/Treatment Nurse #1, who worked at the facility as an Unlicensed Registered Nurse, stated they have been working at the facility since [DATE] through an agency under a limited permit. They did not know when the limited permit application was approved. They went on an extended leave in [DATE] and came back to work at the facility in [DATE]. They have not yet obtained their New York State Registered Nurse License. Medication/Treatment Nurse #1 stated their agency told them that the limited permit had ended; however, they were not able to recall the date the permit expired. Medication/Treatment Nurse #1 stated that they did not start the process of applying for the National Council License Examination for Registered Nurses (NCLEX-RN) examination to become a New York State licensed Registered Nurse because they were too busy. Medication/Treatment Nurse #2, Medication/Treatment Nurse #3, Medication/Treatment Nurse #4, and Medication/Treatment Nurse #6 were not available for an interview. During an interview on [DATE] at 1:51 PM, the Director of Nursing Services stated all Medication/Treatment Nurses' job descriptions included Medication and Treatment Administration only. The Director of Nursing Services stated that Medication/Treatment Nurses who worked as unlicensed Registered Nurses should not be allowed to work at the facility without proper documentation. The Director of Nursing Services stated they have been working at the facility since 5/2023 and were aware of the unlicensed Nurses and how the Director of Human Resources/Assistant Administrator was trying to communicate with the staffing agency to obtain the approved credential for each of the nurses and was unsuccessful. The Director of Nursing Services stated they did not make it their priority to ensure the nurses had appropriate credentials available to work at the facility as Registered Nurses. They were so busy doing other things. The Director of Nursing Services stated Medication/Treatment Nurses who were identified as not having a New York State Registered Nurse license had been employed by the facility before the Director of Nursing Services was hired and they (the Director of Nursing Services) continued to schedule these Nurses as Medication and Treatment Nurses. During an interview on [DATE] at 11:27 AM, the Administrator stated that Medication/Treatment Nurse #1, Medication/Treatment Nurse #2, and Medication/Treatment Nurse #3 have been working at the facility as Registered Nurses since 2021. Medication/Treatment Nurse #4 and Medication/Treatment Nurse #6 have been working at the facility as Registered Nurses since 2023. The Administrator stated the unlicensed Medication/Treatment Nurses should not have been scheduled to work at the facility without proper documentation. The Administrator stated it was an oversight on their part, and it was not intentional. The Administrator stated they were not responsible for hiring and maintaining the employee files. The Administrator stated the Director of Human Resources/Assistant Administrator was responsible for ensuring and maintaining that each employee had appropriate credentials. 10 NYCRR 415.26(c)

Based on observations, record review, and interviews conducted during the Recertification survey initiated on 4/8/2025 and completed on 4/16/2025, the facility did not follow proper sanitation practices to prevent the outbreak of foodborne illness and did not store and prepare food in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, during the kitchen observation on 4/8/2025, the final rinse cycle temperature of the high-temperature dishmachine was observed to be below 180 degrees Fahrenheit. The dietary staff did not operate and monitor the dishmachine temperatures for the rinse cycle as per the manufacturer's recommendation to ensure proper sanitization of the dishes. The finding is: The facility's policy and procedure titled Dishwasher Temperature dated August 2024 documented that all items cleaned in the dishwasher will be washed in water that is sufficient to sanitize all items. Machine washing and sanitizing [procedures] should follow the manufacturer's instructions. Water temperature shall be measured. The wash temperature shall be 150 to 165 degrees Fahrenheit, and the final rinse temperature shall be 180-194 degrees Fahrenheit for high-temperature dishwasher (heat sanitization). Corrective actions shall be taken for a final temperature below the required final rinse temperatures. The Dishmachine manufacturer's instruction dated 12/2011 documented minimum temperatures of the Wash and Final Rinse cycle while using high-temperature sanitizing were 150 degrees Fahrenheit and 180 degrees Fahrenheit respectively. The undated Dishwasher (7:00 AM-3:00 PM) assignment schedule documented instructions for staff to log the dishmachine temperatures on the temperature sheet and then run dishes through the machine. During an observation on 4/8/2025 at 10:41 AM, the dishmachine was observed being operated by Dietary Aide #1, in the presence of the Food Service Director. Dietary Aide #2 was also present and was removing the washed load out of the dishmachine. The temperature gauges on the dishmachine read 150 degrees Fahrenheit for the Wash cycle and 134 degrees Fahrenheit for the Final Rinse cycle. The Final Rinse temperature of a second load also read 134 degrees Fahrenheit. Dietary Aide #1 was immediately interviewed after the observation and stated they were using the dishmachine to wash the dishes from the facility's breakfast meal. Dietary Aide #1 stated the dishmachine water temperature was checked before the run and the final rinse temperature was at 180 degrees Fahrenheit. Dietary Aide #1 stated the Final Rinse cycle temperature should be 180 degrees Fahrenheit. The April 2025 daily dishwasher temperature log was reviewed and there was no documented evidence that the water temperatures were recorded and monitored before the breakfast dishes were cleaned and sanitized. During an interview on 4/8/2025 at 2:50 PM, the Director of Food Services stated the Dietary Aide should set up the dishmachine and turn on the water heating booster which heats the water to the desired temperature for dishwashing prior to washing the dishes to ensure appropriate water temperature. The Director of Food Services stated that the dischmachine Wash cycle temperature should be maintained at 150 degrees Fahrenheit and the Final Rinse cycle temperature should be maintained at 180 degrees Fahrenheit. The Director of Food Services stated staff should notify them (the Director of Food Service) when the water temperature for the dishmachine did not reach a desirable range. 10 NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately to the New York State Department of Health, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. This was Identified for one (Resident #98) of 11 residents reviewed for Accidents. Specifically, on 11/24/2023 Resident #98 was identified with an injury of unknown origin. There was no documented evidence that the injury was reported to the New York State Department of Health as required. The facility's policy titled, Abuse Prevention effective 11/2/2022 and last revised 6/1/2023 documented that an injury of unknown origin is to be reported to the New York State Department of Health. Resident #98 was admitted with diagnoses that included Cerebral Vascular Accident (Stroke), Dementia, and Bipolar Disorder. The Annual Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status was not conducted because the resident is rarely/never understood. The Minimum Data Set documented Resident #98 required supervision/touch assistance for lying to sitting on the side of the bed, transfers, and walking. A Progress Note dated 11/24/2023 at 10:39 AM documented Resident #98 was observed with a small hematoma (bruise) on the right side of their forehead with no known origin. An Accident/Incident Report dated 11/24/2023 at 8:00 AM documented Resident #98 was noted with a hematoma (bruise) to the forehead with no known origin. The resident walked ad-lib (as desired) and was combative and aphasic (a speech disorder). The Accident/Incident Report documented Resident #98 was nonverbal and cognitively impaired. The Accident/Incident report concluded that there was no cause to believe that resident abuse, neglect, or mistreatment had occurred. A Comprehensive Care Plan dated 11/24/2023 for Skin Integrity documented the resident had a hematoma on the forehead. Interventions included to notify the nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, or discoloration noted during bath or daily care. Certified Nursing Assistant #6 was interviewed on 2/9/2024 at 2:29 PM and stated they were the regularly assigned Certified Nursing Assistant for Resident #98. Certified Nursing Assistant #6 stated they worked 7:00 AM - 3:00 PM on 11/24/2023. Certified Nursing Assistant #6 stated when they arrived on the unit Resident #98 was sleeping. Certified Nursing Assistant #6 stated they provided care to two other residents and returned to Resident #98's room to provide care and they observed a bump on the resident's right forehead. Certified Nursing Assistant #6 stated they reported the bump to Licensed Practical Nurse #1, who was the unit charge nurse. Licensed Practical Nurse #1, the unit charge nurse, was interviewed on 2/9/2024 at 2:38 PM and stated they could not recall the event that occurred on 11/24/2023 related to Resident #98. The Assistant Director of Nursing Services was interviewed on 2/14/2024 at 8:50 AM and stated they were responsible for completing the Accident and Incident reports. The Assistant Director of Nursing Services stated they should have completed an investigation that went back three shifts to rule of abuse because no one witnessed how Resident #98 sustained the bump on their right forehead. The Assistant Director of Nursing stated Resident #98 used the handrails in the hallway to ambulate and if they turned a corner, they could have hit their head on the corner of the wall therefore they did not think that the resident's injury (hematoma) was as a result of abuse. An interview was conducted with the Director of Nursing Services on 2/14/2024 at 9:02 AM. The Director of Nursing Services stated the incident should have been investigated by interviewing staff on all shifts for the seventy-two hours prior to the observation of the bump on Resident #98's forehead. The Director of Nursing Services stated they should have reported the injury of unknown origin to the New York State Department of Health within twenty-four hours and it was an oversight. 10 NYCRR 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024 the facility did not ensure that all incidents including the injury of unknown origin were thoroughly investigated . This was identified for one (Resident #98) of 11 residents reviewed for Accidents. Specifically, on 11/24/2023 at 8:00 AM Resident #98 was observed with an injury of unknown origin and the facility did not thoroughly investigate the incident to identify the root cause of the injury and to rule of Abuse, Neglect, and Mistreatment. The finding is: The facility's policy titled, Accident/Incident last revised December 2023, documented that all injuries of unknown sources will be investigated. The facility's policy titled, Abuse Prevention effective 11/2/2022 and last revised 6/2023 documented the facility will investigate all incidents of alleged and actual abuse, complaints/grievances, misappropriation, and injuries of unknown origin. The investigative process will include statements from staff, witnesses, and residents, interviews with staff witnesses, and residents, medical record review if applicable, and review of employee records. All findings of investigations will be documented. Resident #98 was admitted with diagnoses that included Cerebral Vascular Accident (stroke), Dementia, and Bipolar Disorder. The Annual Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status was not conducted because the resident is rarely/never understood. The Minimum Data Set documented Resident #98 required supervision/touch assistance for lying to sitting on the side of the bed, transfers, and walking. A Progress Note dated 11/24/2023 at 10:39 AM documented Resident #98 was observed with a small hematoma (bruise) on the right side of their forehead with no known origin. A Comprehensive Care Plan dated 11/24/2023 for Skin Integrity documented Resident #98 had a hematoma on their forehead. Interventions included to notify the nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, or discoloration noted during bath or daily care. An Accident/Incident Report dated 11/24/2023 at 8:00 AM documented Resident #98 was noted with a hematoma (bruise) on their forehead with no known origin, walks ad-lib (as desired) and was combative and aphasic (a language disorder). The Accident/Incident Reported documented Resident #98 was nonverbal and cognitively impaired. An undated written statement from Certified Nursing Assistant #6 documented Certified Nursing Assistant #6 was assigned to Resident #98 on 11/24/2023 during the 7:00 AM - 3:00 PM shift. Certified Nursing Assistant #6 noted a bump on Resident #98's right forehead when they provided care to the resident. Certified Nursing Assistant #6 documented that they notified their observation to the charge nurse. An undated written statement from the charge nurse, Licensed Practical Nurse #1, documented they (Licensed Practical Nurse #1) were called to Resident #98's room and observed a bump on the right side of Resident #98's forehead and they (Licensed Practical Nurse #1) informed their observation to their supervisor, the Assistant Director of Nursing Services. The Accident/Incident Report did not have statements from the previous shift staff to identify the root cause of the resident's hematoma, an injury of unknown origin. Certified Nursing Assistant #6 was interviewed on 2/9/2024 at 2:29 PM and stated they were the regularly assigned Certified Nursing Assistant for Resident #98. Certified Nursing Assistant #6 stated they worked 7:00 AM - 3:00 PM on 11/24/2023. Certified Nursing Assistant #6 stated when they arrived at the unit Resident #98 was sleeping. Certified Nursing Assistant #6 stated they provided care to two other residents and returned to Resident #98's room to provide care and they observed a bump on the resident's right forehead. Certified Nursing Assistant #6 stated they reported the bump to the charge nurse. The Assistant Director of Nursing Services was interviewed on 2/14/2024 at 8:50 AM and stated that no one witnessed how Resident #98 received the bump on their right forehead. The Assistant Director of Nursing Services stated they should have completed an investigation that went back three shifts to rule out abuse. The Assistant Director of Nursing stated Resident #98 used the handrails in the hallway to ambulate and if they turned a corner, they could have hit their head on the corner of the wall; however, acknowledged that no one witnessed the incident and therefore they did not know the origin of the injury. The Director of Nursing Services was interviewed on 2/14/2024 at 9:02 AM and stated the incident should have been investigated by interviewing staff on all shifts for the seventy-two hours prior to the observation of the injury of unknown origin. The Director of Nursing Services stated because the investigation was not thorough, the root cause of the injury could not be determined to rule out abuse, neglect, or mistreatment. 10 NYCRR415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024, the facility did not ensure that the Minimum Data Set (MDS) assessment accurately reflects the resident's status. This was identified for one (Resident #61) of one resident reviewed for Dialysis. Specifically, the Minimum Data Set assessment for Resident #61 did not accurately capture that the resident was receiving dialysis treatment. The finding is: The facility policy and procedure titled, MDS 3.0, last reviewed 10/2023, documented that residents are assessed, using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan. Resident #61 was admitted with diagnoses including Cancer, End-Stage Renal Disease (ESRD), and Dependence on Renal Dialysis. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Section O of the Minimum Data Set for Special Treatments, Procedures, and Programs was blank for dialysis. A quarterly Minimum Data Set assessment dated [DATE] documented under Section O: Special Treatments, Procedures, and Programs triggered dialysis. A Physician's order dated 12/19/2023 documented to provide Hemodialysis at an outside Dialysis Center facility every day shift every Tuesday, Thursday, and Saturday. Registered Nurse (RN) #5, the Minimum Data Set Coordinator, was interviewed on 2/9/2024 at 2:44 PM and stated they are responsible to check for accuracy of the Minimum Data Set assessment. Registered Nurse #5 stated that it was an oversight that the Minimum Data Set was not coded correctly. 10 NYCCR 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024 the facility did not ensure a person-centered comprehensive care plan was reviewed and revised to address each resident's needs. This was identified for one (Resident #152) of 35 sampled residents. Specifically, a quarterly Minimum Data Set assessment was completed on 12/20/2023 for Resident #152. There was no documented evidence that a care plan meeting was held after each assessment including both the comprehensive and quarterly review assessments. The resident or their representative were not provided notice of a care plan meeting for an opportunity to attend and participate. In addition, Resident #152's comprehensive care plan related to Resident/Family participation in assessment and care planning and Satisfaction with the current plan of care were not reviewed and revised upon the quarterly Minimum Data Set assessment dated [DATE]. The finding is: The facility's policy and procedure titled, Care Planning last reviewed October 2023, documented to provide each resident with an individualized interdisciplinary plan of care. The initial comprehensive care plan meeting is conducted no later than 21 days after admission. The facilitator for the meetings is the Minimum Data Set Coordinator or designee. The facilitator/clinical nurse manager will ensure that a record of team meetings is initiated and that all participating members are present and sign the Comprehensive Care Plan meeting attendance sheet. The Comprehensive care plan is reviewed/revised in conjunction with the Minimum Data Set assessment schedule to include annual reviews, quarterly reviews, and in response to a significant change and all episodic events. The policy and procedure do not address when the resident and/or their representative is invited to participate in the care plan meeting. Resident #152 was admitted with diagnoses including Depression, and Anxiety Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12 indicating the resident had moderately impaired cognition. The resident had adequate hearing with clear speech; was understood and understood others. A social services progress note dated 3/28/2023 documented that the initial care plan meeting was held today and was attended by the resident's family member. The progress documented that it was not beneficial for the resident to attend meetings due to the resident's cognitive status. The nursing and social work progress notes from 10/1/2023 to 2/7/2024 did not reveal any documentation that a care plan meeting was held or that the resident or the resident's representative was invited to attend and or that a care plan meeting was held. A record review was completed on 2/8/2024 at 9:14 AM and revealed multiple Comprehensive Care Plans (example: Cognition created 3/14/23 revision 12/26/23) were reviewed and/or revised in accordance with the Minimum Data Set assessment schedule. There was no evidence documenting that the Resident/ Family participation in assessment and care planning or the Satisfaction with the current plan of care was reviewed and/or revised in accordance with the Minimum Data Set assessment schedule. The Registered Nurse Minimum Data Set Coordinator #1 was interviewed on 2/9/2024 at 2:53 PM and stated that they are responsible for generating the care planning schedule and the Social Worker is responsible for inviting the resident and or the resident's representative. Registered Nurse Minimum Data Set Coordinator #1 further stated that care plan meetings are held upon admission, annually, and with significant change in condition. Registered Nurse Minimum Data Set Coordinator #1 stated that the team does not invite the resident and or their representative for quarterly assessment meetings. The Director of Social Work was interviewed on 2/9/2024 at 3:25 PM and stated that care plan meetings are held when a new admission, quarterly, and significant change assessments are completed. The Director of Social Work stated that ideally if the resident is capable of attending, or their designated representative attend the initial, annual, discharge, or significant change care plan meetings. The Social Work department gets a list from the Minimum Data Set Coordinator and then the Social Worker calls the resident's representative about the meeting and asks if they can attend. The facility accommodates the resident representative's schedule. The resident is also notified. The Director of Social Work stated they only invite the resident and the resident representative to initial, annual, and significant change meetings. The resident and the resident representative are not invited to a quarterly meeting; however, a call is the representative to provide updates. The Director of Social Work reviewed Resident #152's Electronic Medical Record and confirmed that there was no documentation of a care plan meeting held for Resident #152 other than the initial meeting dated 3/28/2023. The Director of Social Work also reviewed the care plans in the Electronic Medical Record and stated that the Comprehensive Care Plans titled, Resident/ Family Participation in Assessment and Care Planning and Satisfaction with the current Plan of Care were not reviewed in conjunction with the Minimum Data Set assessments. 10 NYCCR 415.11

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024 the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain personal hygiene. This was identified for one (Resident #122) of two residents reviewed for Activities of Daily Living. Specifically, on 2/6/2024 Resident #122 was observed with long, dirty, and jagged fingernails with a brown substance under the nails on both hands. The finding is: The facility's policy titled, Job Description-Certified Nursing Assistant, dated January 2015, documented the primary purpose of the Certified Nursing Assistant is to provide each of your residents with routine daily nursing care and services in accordance with the resident's assessment and care plan including assisting with nail care (clipping, trimming, and cleaning the finger/toenails). Note: does not include diabetic residents. Resident #122 was admitted with diagnoses including Diabetes Mellitus, Schizophrenia, and Depression. The 1/5/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 12, indicating the resident was cognitively intact. The Minimum Data Set documented that the resident needed set-up or clean-up assistance for Personal Hygiene. A Comprehensive Care Plan titled, Activities of Daily Living effective 5/28/2021 and last updated on 1/17/2024, documented that the resident required supervision for personal hygiene tasks. Interventions included but were not limited to provide assistance with grooming as needed. The Comprehensive Care Plan did not include specific care instructions or interventions regarding nail care. A Comprehensive Care Plan titled, Visual Function initiated on 7/7/2021 and last updated on 8/18/2023, documented the resident is at risk of impaired visual function related to presbyopia (normal age-related changes), retinal detachment, and Diabetes Mellitus; moderately impaired vision and is unable to see small print but can see larger print. The [NAME] (resident care instructions provided to the Certified Nursing Assistants) documented that Resident #122 required supervision for personal hygiene. The [NAME] did not document specific instructions regarding nail care. On 2/6/2024 at 10:05 AM during an interview with Licensed Practical Nurse #2, the charge nurse on Unit 1A, Resident #122 approached the nurse's station and stated that they needed their fingernails trimmed. Resident #122 resided on another unit (Unit C). The surveyor observed the resident's fingernails to be long and dirty. There was a brown color substance under the resident's fingernails and the nails were broken with jagged edges on both hands. Registered Nurse #1, the Minimum Data Set nurse, was present at the nurse's station at the time of the observation and escorted the resident back to their unit (Unit C). Registered Nurse #1 stated they would return Resident #122 to their unit to have the fingernails taken care of. Registered Nurse #2, the Unit C charge nurse, was interviewed on 2/8/2024 at 2:07 PM and stated Resident #122 has been on Unit C for approximately two months and the Certified Nursing Assistants are responsible for fingernail care and keeping the resident's nails clean. Registered Nurse #2 stated if a resident refuses to have their nails trimmed, the Certified Nursing Assistant is supposed to let the nurse know. Registered Nurse #2 stated the first time they were alerted about the issue with Resident #122's fingernails was on 2/6/2024 after the observation by the surveyor. Registered Nurse #2 stated as soon as they were made aware, they cut the resident's nails and the resident offered no resistance. The Registered Nurse Inservice Coordinator was interviewed on 2/9/2024 at 8:51 AM and stated that the Certified Nursing Assistants are supposed to provide nail care on shower days at least two times a week as per the facility policy. The Registered Nurse Inservice Coordinator stated that the Certified Nursing Assistants sign the skin monitoring sheet every shower day to indicate the resident received the shower and any refusals regarding shower or nail care should be reported to the nurse. The skin monitoring sheet is also signed by the floor nurse. The Registered Nurse Inservice Coordinator stated if a resident is Diabetic, the floor nurse should cut the fingernails. A review of the Skin Monitoring: Comprehensive Certified Nursing Assistant Shower Review sheet dated 2/3/2024 indicated Resident #122 received a shower on 2/3/2024. The sheet was signed by Certified Nursing Assistant #2 and Registered Nurse #3 and documented no concerns. Certified Nursing Assistant #2 was interviewed on 2/9/2024 at 2:18 PM and stated the skin monitoring sheets are filled out for every shower and signed by the Certified Nursing Assistants and the Nurse to confirm that the skin checks were performed, including checking fingernails and toenails. Certified Nursing Assistant #2 stated they would cut the residents' nails if the nails were long, and if the resident is a diabetic, they would tell the nurse. Certified Nursing Assistant #2 stated they did not see any concerns with Resident #122's nails during the 2/3/2024 shower and there was nothing to report. Registered Nurse #3 was interviewed on 2/9/2024 at 3:35 PM. Registered Nurse #3 stated even though the Certified Nursing Assistant fills out and signs the skin monitoring sheets that there are no concerns, they (Registered Nurse #3) still must go and check the resident. Registered Nurse #3 stated they could not remember if there was any problem with Resident #122's fingernails on 2/3/2024. The Director of Nursing Services was interviewed on 2/12/2024 at 10:01 AM and stated the residents' fingernails are trimmed and cleaned on shower days and as needed. The staff do not have to wait for a shower day to cut or trim resident's nails. The Director of Nursing Services stated that Resident #122 refused to get their nails cut and the Certified Nursing Assistant did not inform the nurse. The Director of Nursing Services further stated the nurse should also have checked the resident's nails. 10 NYCRR 415.12(a)(3)

Based on record review and staff interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024, the facility did not ensure sufficient nursing staff were available to provide nursing and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was identified for three (Unit 1A, Unit 2A, and Unit C) of four Units during the Sufficient Staffing Task review. Specifically, a review of the Payroll Based Journal (PBJ) Staffing Data Report, the Facility Assessment, review of weekend staffing and staffing during the Recertification Survey revealed the facility had insufficient nursing staff on numerous occasions. The finding is: The Facility's Staffing Policy and Procedure dated October 2023 documented the facility will maintain safe staffing levels and that the nursing department will schedule and arrange staff according to the acuity and census of each unit to ensure quality of care is maintained. The employees who call out sick will always be replaced at the time of incident to the highest degree possible and practical. Overtime will be used when necessary to ensure staffing levels. Additionally, the nursing department will ensure each unit is maintained at a safe staffing level. This may require nursing to shift assignments to the unit with the highest acuity and/or highest census. Licensed nurses may be assigned to complete Certified Nursing Assistant (CNA) responsibility and administrative nurses may be assigned to administer medications and treatments. The Payroll-Based Journal (PBJ) Staffing Data Report dated for Fiscal Year (FY) Quarter four 2023 (July 1-September 30) documented the facility triggered for the Metric of Excessively low weekend staffing: July 1, 2023, July 16, 2023, August 5, 2023, September 9, 2023, and September 24, 2023 The Facility Assessment for 2024 documented the facility does not take a census-based approach to staffing but looks at the acuity levels of the residents in order to provide the best staffing possible. Organizational staffing is monitored and evaluated daily for changes and required adjustments. The Facility Assessment indicated the facility would need 58 Certified Nursing Assistants on a daily (24-hour) basis and 18-24 Licensed nurses for providing direct care. The Facility Assessment did not identify the required staffing needs for each nursing shift (7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM). A review of the weekend staffing from 7/1/2023 to 9/30/2023 revealed there was insufficient nursing staff than indicated on the Facility Assessment. Examples include but are not limited to: -On July 1, 2023 (Saturday), the facility had 49 Certified Nursing Assistants on duty instead of 58 Certified Nursing Assistants. -On July 16, 2023 (Sunday), the facility had 46 Certified Nursing Assistants on duty instead of 58 Certified Nursing Assistants. -On August 5, 2023 (Saturday), the facility had 48 Certified Nursing Assistants on duty instead of 58 Certified Nursing Assistants. -On September 9, 2023 (Saturday), the facility had 48 Certified Nursing Assistants on duty instead of 58 Certified Nursing Assistants. -On September 24, 2023 (Sunday), the facility had 52 Certified Nursing Assistants on duty instead of 58 Certified Nursing Assistants. Additionally, a review of the actual Daily Staffing Assignments revealed: -On 7/1/2023 and 7/16/2023, during the 11:00 PM-7:00 AM shift Unit 1A had only one Certified Nursing Assistant on duty with a Census of 44 residents. -On 8/5/2023 during the 11:00 PM-7:00 AM shift Unit 1A and Unit C had only one Certified Nursing Assistant on duty with a census of 46 residents on Unit 1A and 57 residents on Unit C. -On 9/9/2023 during the 11:00 PM-7:00 AM shift Unit 1A and Unit 2A had only one Certified Nursing Assistant on duty with a census of 44 residents on Unit 1A and 29 residents on Unit 2A. -On 9/24/2023 during the 11:00 PM-7:00 AM shift Unit 1A had only one Certified Nursing Assistant on duty with a full census of 46 residents. The Staffing Coordinator #1 was interviewed on 2/12/2024 at 4:25 PM and stated that the staffing par level (minimum and maximum staff numbers set by the facility) for each unit was in place prior to them starting in this position. Staffing Coordinator #1 stated when there are call-outs certain staff are willing to pick up extra shifts; the facility also offers overtime to replace the call-outs. Staffing Coordinator #1 stated that, particularly on the weekends, it is difficult to get both licensed and non-licensed nursing staff to replace the staff who called in sick. Staffing Coordinator #1 stated the par levels are as follows: -On Day Shift: 7:00 AM - 3:00 PM -Unit 1A should have five Certified Nursing Assistants, one Charge Licensed Practical Nurse, and two Registered Nurses (medication nurse). -Unit 2A should have four Certified Nursing Assistants, one Charge Licensed Practical Nurse, one Licensed Practical Nurse or Registered Nurse (medication nurse). -Unit B should have seven Certified Nursing assistants, two Charge Registered Nurses, and two medication nurses. - Unit C should have seven Certified Nursing Assistants, one Charge Registered Nurse, and two Registered Nurses (medication nurses). On the Evening Shift: 3:00 PM - 11:00 PM -Unit 1A should have five Certified Nursing Assistants, one Charge Registered Nurse, and one Licensed Practical Nurse (medication nurse). -Unit 2A should have four Certified Nursing assistants, and two Licensed Practical Nurses (medication nurses). -Unit B should have five Certified Nursing Assistants, two Charge Registered Nurses -Unit C should have six Certified Nursing Assistants and two Charge Registered Nurses and there should be two Registered Nurse Supervisors on duty for the entire building. On the Night Shift: 11:00 PM - 7:00 AM -Unit 1A should have three Certified Nursing Assistants and one Registered Nurse. -Unit 2A should have two Certified Nursing Assistants and one Registered Nurse or Licensed Practical Nurse. -Unit B should have three Certified Nursing Assistants and two Registered Nurses -Unit C should have three Certified Nursing Assistants and one Registered Nurse and there should be one Registered Nurse Supervisor for the entire building. The Director of Nursing Services was interviewed on 2/24/2024 at 2:12 PM. The Director of Nursing Services stated that the par-levels for the weekends are the same as the weekdays, except, on the weekends there are no charge nurses. The Director of Nursing Services stated that if there were call-outs on the weekend the Registered Nurse Supervisors would get someone to stay or call other staff to replace the call-out. The Director of Nursing Services stated that they would expect the Staffing Coordinator to notify them if the staffing par levels are not met. The Daily Staffing Assignments for 7/1/2023, 7/16/2023, 8/5/2023, 9/6/2023, and 9/24/2024 were reviewed with the Director of Nursing Services. The Director of Nursing Services confirmed the staffing levels and stated that they were not informed by anyone that sufficient staff were not available to care for the residents on the weekends in July, August, and September 2023. The Director of Nursing Services stated that if they had been made aware the units were working with only one Certified Nursing Assistant, they would have instructed the Staffing Coordinator or the Nursing Supervisor to ensure that the staff were replaced. The Administrator was interviewed on 2/14/2024 at 3:22 PM. The Administrator stated that they were not directly involved with staffing. The Administrator stated that they did not recall anyone complaining about short staffing and that currently there have been no concerns about short staffing. The Administrator stated that the par-levels are census-based and were set up prior to them being hired at the facility. The Administrator stated that if the census was low there might not be a need for extra staff; however, if the units fell below their par levels, they expected the other staff to be called. 10 NYCRR 415.13(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024 the facility did not ensure that nurse's aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This was identified for one (Resident #48) of two residents reviewed for Choices. Specifically, Certified Nursing Assistant #8 was observed utilizing a sink as a basin to store the water for providing care to Resident #48 in a semi-private room. The sink is also utilized by other residents for handwashing and other hygiene tasks. The finding is: The facility Activity of Daily Living (ADL) Policy dated 6/2023 documented to perform a bed bath, the nursing assistant will secure the bath supplies and clean bed linens as needed and bring them to the resident/patient's bedside. Resident #48 was admitted with diagnoses that included Vascular Dementia, Adult Failure to Thrive, and Liver Cell Carcinoma. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident had short and long term memory problems. The resident had no behavior problems and required total staff assistance for bathing and personal hygiene. The Activities of Living Care Plan dated 3/24/2022 and last updated on 11/10/2023 documented that the resident was totally dependent on staff for bathing and personal hygiene. During an observation on 2/9/2024 at 12:00 PM, Certified Nursing Assistant #8 was observed in Resident #48's room. Certified Nursing Assistant #8 was standing by the sink. The water faucet was on, and a towel was placed in the water that was being collected in the sink. Certified Nursing Assistant #8 stated that they were assigned to Resident #48 and were in the process of administering a bed bath to the resident. Certified Nursing Assistant #8 stated that they were using the towel and the water in the sink to administer care to Resident #48. Certified Nursing Assistant #8 stated that they always provide hygiene care for the resident using the sink as the basin. Licensed Practical Nurse #2, the nurse in charge, then came to the resident's room and instructed Certified Nursing Assistant #8 to use the wash basin to administer care. Licensed Practical Nurse #2 was interviewed on 2/9/2024 at 3:24 PM and stated that Certified Nursing Assistant #8 should never wash residents from the sink as it is a break in infection control. Licensed Practical Nurse #2 stated that each resident has a designated wash basin and Certified Nursing Assistant #8 should have used Resident #48's basin to administer care. The Staff Educator, who was also the Infection Preventionist, was interviewed on 2/9/2024 at 3:59 PM and stated that under no circumstances should the sink be used to collect water to wash the resident. The Staff Educator stated that Certified Nursing Assistant #8 should have used a wash basin that was designated for Resident #48 to administer care. The Staff Educator further stated that the sink was a mode of transmission of infection. The Director of Nursing Services was interviewed on 2/14/2024 at 12:29 PM and stated that the Certified Nursing Assistants are educated on proper procedures for providing morning care. The Director of Nursing Services stated that Certified Nursing Assistant #8 was expected to clean the resident's wash basin with soap and water and then administer morning care by using the wash basin filled with water. The Director of Nursing Services stated that the sink in the resident's room should not be used as a mode for collecting water to administer care. 10 NYCRR 415.26(c)(1)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024 the facility did not ensure each resident received radiology services in a timely manner. This was identified for one (Resident #48) of two residents reviewed for Choices. Specifically, Resident #48 had a Physician's order for pacemaker checks every three months and there was no documented evidence that the pacemaker checks were completed as per the Physician's order since 10/4/2023. The finding is: The facility Pacemaker Policy, last reviewed on 6/2023, documented the charge nurse was responsible for ensuring that pacemaker/automated implantable defibrillator (AICD-a device inserted into the chest to help fix fast, abnormal heart rhythms) checks are conducted and reported in compliance with Physician's orders every 3 to 6 months. Resident #48 was admitted with diagnoses that included Atrial Fibrillation, Hypertension, and Presence of a Cardiac Pacemaker. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident had short and long term memory problems. The Minimum Data Set assessment did not document the use of the Pacemaker in section 18000. The Comprehensive Care Plan dated 9/29/2023 and updated 11/14/2023 documented the resident had a pacemaker to the left upper chest due to diagnoses of Atrial Fibrillation. Interventions included to observe, document, and report any signs and symptoms of altered cardiac output or pacemaker malfunction such as dizziness, syncope (fainting), difficulty breathing, pulse rate lower than programmed rate, and lower than baseline blood pressure to the Physician as needed A Physician's order dated 9/29/2023 and last reviewed 1/14/2024 documented to have the resident's pacemaker checked every 3 months. A review of the Radiology Results Report documented Resident #48's pacemaker monitoring was completed on 10/4/2023 and was reported to the facility on [DATE]. A review of the medical record lacked documented evidence that Resident #48's pacemaker monitoring was conducted after 10/4/2023. Licensed Practical Nurse #2, who was the Unit Manager, was interviewed on 2/9/2024 at 12:20 PM and stated that the last pacemaker check for Resident #48 was completed on 10/4/2023 and the next check was due in January 2024. Licensed Practical Nurse #2 stated they were responsible for following up with the Radiology company to ensure pacemaker checks were completed as ordered by the Physician. Licensed Practical Nurse #2 stated that the pacemaker check should have been done as ordered by the Physician and that it was an oversight. The Assistant Director of Nursing Services was interviewed on 2/9/2024 at 3:35 PM and stated that Licensed Practical Nurse #2 was the Unit Manager and was responsible for ensuring all required follow-up appointments for the pacemaker check were completed. The Assistant Director of Nursing Services stated that the pacemaker checks should have been completed as ordered by the Physician. The Director of Nursing Services was interviewed on 2/14/2024 at 12:24 PM and stated that pacemakers should be checked every 3 to 6 months and that the charge nurses were responsible for calling the company to make appointments for residents who required pacemaker monitoring. The Director of Nursing Services stated they expected that the pacemaker should be checked every 3 months as per the Physician's orders. 10 NYCCRR 415.21

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey, initiated on 2/6/2024 and completed on 2/14/2024, the facility did not ensure each resident received routine dental services to meet the needs of each resident. This was identified for one (Resident #147) of two residents reviewed for Dental Services. Specifically, Resident #147 was admitted to the facility with full upper and lower dentures. The resident lost the upper dentures while a resident at the facility. A dental consult dated 1/11/2023 documented that a preliminary impression for the lost dentures would take place at the next session. There was no documented evidence that the preliminary impression for the upper dentures was completed. In addition, the resident was not offered to use their lower dentures, as the lower dentures were being stored in the medication cart and the facility staff did not know the whereabouts of the resident's lower dentures. The finding is: The facility's Dental Policy dated October 2023, documented to assist residents in obtaining routine and emergency dental care. The routine includes taking impressions for dentures and fitting dentures. Oral care and denture care shall be provided in accordance with identified needs and as specified in the plan of care. Staff shall be mindful of resident dentures when providing care and alert to situations where dentures may be displaced. All actions and information regarding dental services, including any delays relating to obtaining dental services, will be documented in the resident's medical record. The resident and or representative shall be kept informed of all arrangements. Resident #147 was admitted with diagnoses including Non-Alzheimer's Dementia, Adult Failure to Thrive, and Dysphagia (difficulty swallowing). The 12/19/2023 Significant Change Minimum Data Set assessment documented the resident had a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. The Minimum Data Set assessment documented that the resident was edentulous (had no natural teeth). The nursing admission summary note dated 12/22/2022 documented resident used full upper and lower dentures. A Comprehensive Care Plan for Dental, effective 12/27/2022 and last revised 2/9/2024, documented the resident is at risk of oral/dental health problems related to poor oral hygiene, and use of dentures; edentulous, Resident has full upper dentures. Interventions included: Denture cleaning as per policy, ongoing observation for proper fit of dentures, and providing dentures as per resident's preference. A Dental consult dated 1/11/2023 documented the resident was seen for a new admission examination. The resident was fully edentulous. The resident had a full lower denture. The resident lost the upper denture and denied dental complaints. Will begin the preliminary impression next session. A speech therapy note, written by Speech Therapist #1, dated 3/14/2023 documented the resident's family requested the resident to remain on a puree diet due to missing upper dentures. Ground diet was introduced; however, the resident's family declined and requested the resident to remain on puree until the Dentist followed up regarding the upper dentures. Speech Therapist #1 documented that they consulted with nursing regarding the status of the dental consult. A nursing progress note dated 4/24/2023, written by Registered Nurse #7, documented the resident's family requested a follow-up of the resident's denture. A review of the medical record revealed there was no documented follow-up and no further sessions from the Dentist to fabricate the missing upper denture. The dental consult dated 1/3/2024 documented that the resident was seen for an annual examination. Intraoral exam: the resident was fully edentulous. The resident was not wearing dentures and declined fabrication. As per the facility staff, the resident ate well. The resident denies dental complaints and dental services were explained. The [NAME] (resident care instructions provided to the Certified Nursing Assistants), as of 2/9/2024, documented denture cleaning as per policy; provide dentures as per resident's preferences; and provide oral hygiene daily. Resident #147's assigned Certified Nursing Assistant #5 was interviewed on 2/9/2024 at 11:31 AM. Certified Nursing Assistant #5 stated Resident #147 does not wear dentures and they (Certified Nursing Assistant #5) were not aware that the resident had dentures. Registered Nurse #2, the Unit C Charge Nurse, was interviewed on 2/9/2024 at 11:34 AM. Registered Nurse #2 stated they were not aware of the resident's dental consults and the need for the new upper dentures. Registered Nurse #2 stated they would review the dental consult dated 1/11/2023. Registered Nurse #2 was re-interviewed on 2/9/2024 at 1:52 PM and stated they had just spoken to the Dentist and the Dentist informed them that the previous Director of Nursing Services had communicated to the Dentist that the resident was a short-term resident and therefore, the upper dentures were not needed. A review of the medical record revealed no documentation from the nursing staff of discussions with the Dentist that the upper denture was not needed. Dentist #1 was interviewed on 2/9/2024 at 2:09 PM and stated a follow-up session was planned after the initial visit; however, the Director of Nursing Services at that time told them that the resident was a short-term resident; therefore, the upper dentures were not necessary. Dentist #1 stated that the resident was not supposed to be staying as a long-term resident at the facility, and that is why the upper denture request was not completed. Dentist #1 stated that if they had known the resident's family had requested the denture, they (Dentist #1) would have evaluated the resident for the dentures. Resident #147 was observed having breakfast in their room on 2/12/2024 at 8:37 AM. Certified Nursing Assistant #5 was present and was setting up the resident's tray. The resident was not wearing any dentures. The Certified Nursing Assistant stated they (the Certified Nursing Assistant) were not aware of the resident having to use any dentures, upper or lower. Further review of the medical record revealed no documentation that the lower dentures were missing. Registered Nurse #2, Unit C Charge Nurse, was re-interviewed on 2/12/2024 at 8:40 AM. Registered Nurse #2 stated they have been working at the facility for about 6 months and they have not known the resident to use any dentures. Registered Nurse #2 stated they were not aware of the request made by the resident's family for dentures. Registered Nurse #7, who wrote the 4/24/2023 progress note, was interviewed on 2/12/2024 at 8:47 AM. Registered Nurse #7 stated they filled out a form requesting a follow-up dental consult in April 2023 and had sent the request form to the senior supervisor who is no longer employed at the facility. The senior supervisor was supposed to send the consult request to the Dentist. Registered Nurse #7 reviewed the medical record and stated they could not find any evidence of a follow-up by the Dentist regarding evaluating the resident for denture. On 2/12/2024 at 9:33 AM Registered Nurse #2 approached the surveyor and stated they found Resident #147's lower denture in the medication cart and showed the surveyor a denture storage container with lower dentures and Resident #147's name on the container. Registered Nurse #2 stated they could not explain why the lower dentures were not being applied to the resident. Registered Nurse #8, the regularly assigned medication nurse for Resident #147, was interviewed on 2/12/2024 at 9:41 AM. Registered Nurse #8 did not know that Resident #147's dentures were stored in the medication cart, and they were not sure why the dentures were not used by Resident #147. The Director of Nursing Services was interviewed on 2/12/2024 at 10:05 AM. The Director of Nursing Services stated it was not acceptable that the staff did not provide the lower dentures to the resident and that a follow-up for the lost upper dentures was not done. 10 NYCRR 415.17(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #383) of two residents reviewed for Transmission-Based Precautions, one (Resident #48) of two residents reviewed for Choices, and one (Resident #60) of two residents reviewed for pressure ulcers. Specifically, 1) the facility did not ensure that an employee (Certified Nursing Assistant #3) wore the appropriate Personal Protective Equipment (PPE) in Resident #383's room who was on Contact and Droplet Precautions for COVID-19 infection. 2) Certified Nursing Assistant #8 was observed using the room sink as a water basin to provide hygiene care to Resident #48. The resident shares a room with another resident who also utilizes the sink for hygiene and hand washing. 3) During a wound care observation on 2/14/2024 Registered Nurse #10 did not wash their hands with soap after cleaning the wound. During the treatment change, the resident had a bowel movement. Registered Nurse #10 cleaned the resident's bowel movement and then washed their (Registered Nurse #10) hands with water without using soap and then continued with the dressing change. The findings are: 1) The facility's policy titled, Infection Prevention and Control Program for SARS-CoV-2 (COVID-19 Infection), dated 6/2023, documented health care personnel caring for residents with confirmed SARS-CoV-2 infection will use full personal protective equipment, including gowns, gloves, eye protection, and an N95 respirator with the door closed. The facility's policy titled, Personal Protective Equipment Policy dated 10/2023, documented all staff who have contact with residents and /or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. Resident #383 was admitted with diagnoses including COVID-19 infection, a history of Cerebral Infarction, and Prostate Cancer. The hospital discharge instructions dated 2/8/2024 documented that the resident tested positive for COVID-19 infection upon hospital admission on [DATE]. The facility nursing admission note dated 2/8/2024 documented that the resident was admitted to the facility and was positive for COVID-19 infection. The resident was on respiratory isolation. The note documented that the resident was alert and oriented to person, place, and time. A physician's order dated 2/9/2024 documented single-room isolation for COVID-19 infection until 2/15/2024. Certified Nursing Assistant #3 was observed in Resident #383's room on 2/9/2024 at 8:30 AM. Signage was observed at the resident's door that included: Stop-Personal Protective Equipment Required Beyond this Point; Pick Up and Dispose Gown and Gloves at Personal Protective Equipment Station; Please [NAME] (put on) and Doff (take off) Personal Protective Equipment at Resident Room Door Only. There was a personal protective equipment cart outside the doorway. The resident was in bed, and Certified Nursing Assistant #3 was observed leaning over the resident's bed, coming in contact with the resident's bed, and preparing the resident's breakfast tray, which was on the overbed table directly in position over the resident. Certified Nursing Assistant #3 was wearing a surgical mask. Certified Nursing Assistant #3 was not wearing a gown, gloves, or eye protection. Certified Nursing Assistant #3 washed their hands prior to leaving the room and did not remove the surgical mask. Certified Nursing Assistant #3 was interviewed, after they left Resident #383's room, on 2/9/2024 at 8:35 AM. Certified Nursing Assistant #3 stated they had to rush into the resident's room to give the resident a urinal because the resident said they (Resident #383) had to urinate and they (Certified Nursing Assistant #3) thought the resident would fall; therefore, they (Certified Nursing Assistant #3) did not have time to put on a gown and gloves. The Director of Nursing Services and the Registered Nurse Infection Preventionist were interviewed concurrently on 2/9/2024 at 10:30 AM. They both stated Certified Nursing Assistant #3 was given education regarding Personal Protective Equipment usage on 2/9/2024 after being identified as not wearing the appropriate Personal Protective Equipment and will now be sent home and will have to isolate at home due to COVID-19 exposure. Certified Nursing Assistant #3 was again observed in Resident #383's room finishing providing care to the resident on 2/9/2024 at 10:54 AM. Certified Nursing Assistant #3 was wearing full personal protective equipment, including an N95 mask. Certified Nursing Assistant #3 was re-interviewed on 2/9/2024 at 10:55 AM and stated that they thought Resident #380, who had occupied Resident #383's room previously, was still in the room and had completed their isolation on 2/8/2023. Certified Nursing Assistant #3 did not realize there was a new resident (Resident #383) placed in the room on the evening of 2/8/2024. The Registered Nurse Infection Preventionist was interviewed on 2/12/2024 at 8:18 AM and stated Certified Nursing Assistant #3 should have put on appropriate Personal Protective Equipment including a gown, gloves, and eye protection. The signage was present on the resident's door. The Registered Nurse Infection Preventionist stated there should not have been any confusion because the new resident's name was on the door. The Director of Nursing Services was interviewed on 2/12/2024 at 10:02 AM. The Director of Nursing Services stated Certified Nursing Assistant #3 should have had the appropriate Personal Protective Equipment on. The fact that there was a new resident in the room should not have caused any confusion. The Director of Nursing Services further stated that Certified Nursing Assistant #3 was sent home immediately following an investigation. 2) Resident #48 was admitted with diagnoses that included Vascular Dementia, Adult Failure to Thrive, and Liver Cell Carcinoma. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident had short and long term memory problems. The resident had no behavior problems and required total staff assistance for bathing and personal hygiene. The Activities of Living Care Plan dated 3/24/2022 and last updated on 11/10/2023 documented that the resident was totally dependent on staff for bathing and personal hygiene. During an observation on 2/9/2024 at 12:00 PM, Certified Nursing Assistant #8 was observed in Resident #48's room. Certified Nursing Assistant #8 was standing by the sink. The water faucet was on, and a towel was placed in the water that was being collected in the sink. Certified Nursing Assistant #8 stated that they were assigned to Resident #48 and were in the process of administering a bed bath to the resident. Certified Nursing Assistant #8 stated that they were using the towel and the water in the sink to administer care to Resident #48. Certified Nursing Assistant #8 stated that they always provide hygiene care for the resident using the sink as the basin. Licensed Practical Nurse #2, the nurse in charge, then came into the resident's room and instructed Certified Nursing Assistant #8 to use the wash basin to administer care. Licensed Practical Nurse #2 was interviewed on 2/9/2024 at 3:24 PM and stated that Certified Nursing Assistant #8 should never wash residents from the sink as it is a break in infection control. Licensed Practical Nurse #2 stated that each resident has a designated wash basin and Certified Nursing Assistant #8 should have used Resident #48's basin to administer care. The Staff Educator, who is also the Infection Preventionist, was interviewed on 2/9/2024 at 3:59 PM and stated that under no circumstances should the sink be used to collect water to wash the resident. The Staff Educator stated that Certified Nursing Assistant #8 should have used a wash basin that was designated for Resident #48 to administer care. The Staff Educator further stated that the sink was a mode of transmission of infection. The Director of Nursing Services was interviewed on 2/14/2024 at 12:29 PM and stated that the Certified Nursing Assistants are educated on proper procedures for providing morning care. The Director of Nursing Services stated that Certified Nursing Assistant #8 was expected to clean the resident's wash basin with soap and water and then administer morning care by using the wash basin filled with water instead of using the sink as a mode for collecting water to administer care. 3) The Facility Wound Treatment Administration Policy last reviewed in October 2023, documented to practice appropriate hand hygiene and washing hands with soap and water before putting on new gloves and and after removing used gloves. Resident #60 was admitted with diagnoses that included Diabetes Mellitus, Peripheral Vascular Disease, and Coronary Artery Disease. A Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 12 which indicated the resident had moderately impaired cognition. The resident was at risk of developing pressure ulcer injuries and had pressure ulcer-reducing devices in place on the bed and chair. The Comprehensive Care Plan titled, Skin: the resident has an ACTUAL impairment of the skin integrity related to full thickness Stage 4 re-open sacral area was initiated on 2/1/2024 and documented interventions including to monitor bony prominences for redness and to monitor the ulcer for signs of progression or declination. The Comprehensive Care Plan indicated the resident was seen during wound rounds on 2/01/2024 for re-opening of a Stage IV Sacral ulcer. A Physician's order dated 2/10/2024 documented to cleanse the sacrum wound with normal saline; apply Collagen (wound dressing) and abdomen pad; and then cover with dry protective dressing every day and evening shift for Wound Care and as needed for soiling or dislocation. During a wound care dressing change observation conducted on 2/14/2024 at 10:15 AM, Registered Nurse #10 removed the soiled dressing from the resident's sacral wound and then washed their hands with water. Registered Nurse #10 did not use soap during the hand-washing procedure. Registered Nurse #10 then donned (put on) clean gloves, removed the soiled dressing, cleansed the sacral wound, and removed their gloves. Registered Nurse #10 then washed their hands with water without using the soap. After the wound was cleansed the resident was observed to have a bowel movement. Before proceeding further with the dressing change, Registered Nurse #10 was observed to clean the resident's bowel movement. After cleaning the resident, Registered Nurse #10 removed their gloves, washed their hands with water without using the soap, and proceeded to don clean gloves. Before Registered Nurse #10 donned clean gloves, the Surveyor brought to their attention that they (Registered Nurse #10) did not use soap when performing hand hygiene. Registered Nurse #10 then washed their hands with soap and water and completed the wound care. Registered Nurse #10 was interviewed on 2/14/2024 at 10:40 AM. Registered Nurse #10 acknowledged they were not using soap when performing hand hygiene and that when washing their hands they should use soap and water. Registered Nurse #10 stated they knew that they should have used soap and water to wash their hands, but they went blank. Registered Nurse #10 further stated they were inserviced on proper hand washing. The Staff Educator, who is also the Infection Preventionist, was interviewed on 2/14/2024 at 11:11 AM and stated after cleansing the wound Registered Nurse #10 should have changed the soiled gloves and washed their hands with soap and water before donning clean gloves. The Staff Educator further stated after cleaning the resident's bowel movement Registered Nurse #10 should have changed their gloves and should have washed their hands with soap and water before putting on new gloves. The Director of Nursing Services was interviewed on 2/14/2024 at 12:03 PM and stated that each time nurses change their gloves, they must wash their hands with soap and water. The Director of Nursing Services further stated that Registered Nurse #10 should have used a hand sanitizer or washed their hands with soap and water after cleansing the wound and after cleaning the resident. 10 NYCRR 415.19(a)(1-3);415.19(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records review, and interviews during Recertification Survey and Abbreviated Survey (NY 00319371) initiated on 2/6/2024 and completed on 2/14/2024, the facility did not ensure that a clean, comfortable, and homelike environment was maintained for each resident. This was identified for four (Resident #146, Resident #85, Resident #104, and Resident #93) of four residents reviewed for Environment. Specifically, 1) Resident #146's room was observed on 2/6/2024 and 2/7/2024; the room furniture and the sink vanity were not in good repair with detached base molding, missing drawers, and rusty exposed metal parts. 2) Resident #85's room was observed on 2/6/2024 and 2/7/2024. The room furniture and the sink vanity were not in good repair with missing drawers and a nonfunctioning bureau. 3) Resident #104's room was observed on 2/6/2024 and 2/7/2024. The furniture in the room was not in good repair as evidenced by drawers without a handle, drawers that could not be opened, and missing drawers. 4) Resident #93's room was observed on 2/6/2024 and 2/7/2024; the sink vanity was observed to be missing the middle drawer and a piece of wood was nailed in the place of the drawer front. The findings include but are not limited to: The facility's policy titled Routine Maintenance dated 2/2022 and last reviewed 5/2023 documented that the facility will ensure the provision of a safe, functional, sanitary, and comfortable environment for residents. The maintenance department will ensure that the physical environment, furniture, and equipment are maintained in good repair throughout the facility. 1) Resident #146 was admitted with diagnoses that include Dementia, Depression, and Chronic Obstructive Pulmonary Disease. The Annual Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status was four, which indicated the resident's cognition was severely impaired. During an environmental tour of Resident #146's room on 2/6/2024 at 10:54 AM, the bottom drawer of the nightstand, located next to the bed, was open and could not be shut. The corner base molding to the left of the sink vanity was detached. To the right of the sink vanity, the drywall was missing from the corner of the wall and the metal corner bead was exposed and rusted. The middle sink vanity drawer was missing and a piece of wood was nailed in the place of the drawer front. The sink vanity's bottom drawer was missing the handle. During an environmental tour of Resident #146's room on 2/7/2024 at 8:42 AM the bottom drawer of the nightstand next to the bed was open and could not be shut. The corner base molding to the left of the sink vanity was detached. To the right of the sink vanity, the drywall was missing from the corner of the wall and the metal corner bead was exposed and rusted. The middle sink vanity drawer was missing and a piece of wood was nailed in the place of the drawer front. The sink vanity's bottom drawer was missing the handle. Certified Nursing Assistant #6 was interviewed on 2/9/2024 at 9:45 AM and stated they are regularly assigned to work with Resident #146. Certified Nursing Assistant #6 stated they did not report the issues with the vanity, wall, or nightstand in Resident #146's room. Certified Nursing Assistant #6 stated if they saw maintenance concerns, they reported them to the charge nurse and the charge nurse would submit a maintenance request. Housekeeper #1 was interviewed on 2/9/2024 at 10:31 AM and stated they are the regularly assigned housekeeper on the unit. Housekeeper #1 stated they cleaned each room on the unit every day. Housekeeper #1 stated they did not observe maintenance problems in Resident #146's room. Housekeeper #1 stated they have not observed any broken furniture or things in disrepair. Housekeeper #1 stated if they see an issue that required maintenance they would report the problem to the charge nurse. Registered Nurse #9 was interviewed on 2/9/2024 at 10:43 AM and stated they had not observed anything in need of maintenance in Resident #146's room. Registered Nurse #9 stated they reported maintenance concerns to the charge nurse on the unit. Licensed Practical Nurse #1 was interviewed on 2/9/2024 at 10:50 AM and stated they were the charge nurse on the unit. Licensed Practical Nurse #1 stated they completed a tour of the unit and went into each room daily. Licensed Practical Nurse #1 stated Resident #146 did not report any environmental concerns with their room. Licensed Practical Nurse #1 stated they complete a maintenance request in the computer system if they saw a problem or if a problem was reported to them. Licensed Practical Nurse #1 stated they have not submitted any maintenance requests for Resident #146's room recently. Maintenance Worker #1 was interviewed on 2/9/2024 at 10:59 AM and stated they toured the unit daily and they asked the unit charge nurse if they had maintenance concerns. Maintenance Worker #1 stated they check the computer system daily for new requests. Maintenance Worker #1 stated they had fixed broken furniture and placed wooden planks in place of new drawers on the vanity. Maintenance Worker #1 stated the furniture broke frequently and they have repaired a few pieces on the unit more than once. Maintenance Worker #1 stated the sink vanities on the unit are old and replacement drawers are no longer available. Maintenance Worker #1 stated the wood planks were placed on the vanity to protect the residents from hurting themselves. The Director of Maintenance was interviewed on 2/9/2024 at 4:06 PM. The Director of Maintenance stated they tour the building once a week. The Director of Maintenance stated the facility used a computer system to report maintenance concerns to the maintenance department. The Director of Maintenance stated they have not received any complaints from the residents on the unit that Resident #146 resided on. The Director of Maintenance reported they replaced furniture if it could no longer be fixed. The Director of Maintenance stated any furniture needs were brought to the attention of the Administrator. The Director of Maintenance stated the drawer replacements for the sink vanities on the unit were no longer available and the wood planks were placed to cover up the holes left by the missing drawers. Resident #146 was interviewed on 2/12/2024 at 11:46 AM. Resident #146 stated they were not sure how long the nightstand and vanity were in disrepair. Resident #146 stated they could not remember if they reported the vanity and broken nightstand drawer to the nurse. The Administrator was interviewed on 2/14/2024 at 10:11 AM and stated they were not aware of the environmental concerns on the unit where Resident #146 resided. The Administrator stated the facility always tried to provide a home-like environment for the residents. The Administrator stated were not aware of the concerns in Resident #146's room. A second interview was conducted with the Director of Maintenance on 2/14/2024 at 1:18 PM. The Director of Maintenance stated they reviewed the computer maintenance request logs from 7/1/2023 through 2/14/2024 and there were no repairs requested for Resident #146's bureau or sink vanity. 2) Resident #85 was admitted with diagnoses that include Vascular Dementia, Schizophrenia, and Chronic Obstructive Pulmonary Disease. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status was ten, which indicated the resident's cognition was moderately impaired. During an environmental tour of Resident #85's room on 2/6/2024 at 11:01 AM the second drawer of their bureau was open and would not stay shut. The sink vanity was observed with a missing middle drawer and a plank of wood was nailed in place of the drawer front. During an observation of Resident #85's room on 2/7/2024 at 8:30 AM, the sink vanity was observed with a missing middle drawer, and a plank of wood was nailed in place of the drawer front. Certified Nursing Assistant #6 was interviewed on 2/9/2024 at 9:45 AM and stated they are regularly assigned to work with Resident # 85. Certified Nursing Assistant #6 stated they did not report the issues with the vanity or nightstand in Resident #85's room. Certified Nursing Assistant #6 stated if they saw maintenance concerns, they reported them to the charge nurse and the charge nurse would submit a maintenance request. Housekeeper #1 was interviewed on 2/9/2024 at 10:31 AM and stated they are the regularly assigned housekeeper on the unit. Housekeeper #1 stated they cleaned each room on the unit daily. Housekeeper #1 stated they did not observe maintenance problems in Resident #85's room. Housekeeper #1 stated they have not observed any broken furniture or things in disrepair. Housekeeper #1 stated if they see an issue that required maintenance they would report the problem to the charge nurse. Licensed Practical Nurse #1 was interviewed on 2/9/2024 at 10:50 AM and stated Resident #85 has not reported any environmental concerns with their room. Licensed Practical Nurse #1 stated they have not submitted any maintenance requests for Resident #85's room recently. Maintenance Worker #1 was interviewed on 2/9/2024 at 10:59 AM and stated they toured the unit daily and asked the unit charge nurse if they had maintenance concerns. Maintenance Worker #1 stated they check the computer system daily for new requests. Maintenance Worker #1 stated they had fixed broken furniture and placed wooden planks in place of new drawers on the vanity. Maintenance Worker #1 stated the furniture broke frequently and they have repaired a few pieces on the unit more than once. Maintenance Worker #1 stated the sink vanities on the unit are old and replacement drawers are no longer available. Maintenance Worker #1 stated the wood planks were placed on the vanity to protect the residents from hurting themselves. The Director of Maintenance was interviewed on 2/9/2024 at 4:06 PM. The Director of Maintenance stated they tour the building once a week. The Director of Maintenance stated the facility used a computer system to report maintenance concerns to the maintenance department. The Director of Maintenance stated they had not received any complaints from the residents on the unit that Resident #85 resided on. The Director of Maintenance reported they replaced furniture if it could no longer be fixed. The Director of Maintenance stated any furniture needs were brought to the attention of the Administrator. The Director of Maintenance stated the drawer replacements for the sink vanities on the unit were no longer available and the wood planks were placed to cover up the holes left by the missing drawers. The Administrator was interviewed on 2/14/2024 at 10:11 AM and stated they were not aware of the environmental concerns on the unit where Resident #85 resided. The Administrator stated the facility always tried to provide a home-like environment for the residents. The Administrator stated, if there were needs they were aware of, they would address them but they were not aware of the concerns in Resident #85's room. A second interview was conducted with the Director of Maintenance on 2/14/2024 at 1:18 PM. The Director of Maintenance stated they reviewed the computer maintenance request logs from 7/1/2023 through 2/14/2024 and there were no repairs requested for Resident #85's bureau or sink vanity. 3) Resident #104 was admitted to the facility with diagnoses that include Dementia, Type 2 Diabetes, and Chronic Obstructive Pulmonary Disease. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status was ten, which indicated the resident's cognition was moderately impaired. During an environmental tour of Resident #104's room on 2/6/2024 at 10:39 AM the top drawer of their bureau was open and could not be shut and the second drawer handle was missing. A second observation of Resident #104's room was completed on 2/7/2024 at 8:51 AM and the bureau drawer was shut and functional and the second drawer was missing a handle. Resident #104 was interviewed on 2/6/2024 at 10:39 AM and stated the top bureau drawer had been broken and the second drawer's handle had been missing for a while but could not say for how long. Resident #104 stated they reported the problems with the bureau but could not recall when or to whom. Certified Nursing Assistant #7 was interviewed on 2/9/2024 at 10:23 AM and stated they are regularly assigned to work with Resident #104. Certified Nursing Assistant #7 stated they did not report the issues with the bureau in Resident #104's room. Certified Nursing Assistant #7 stated if they saw maintenance concerns, they reported them to the charge nurse and the charge nurse would submit a maintenance request. Housekeeper #1 was interviewed on 2/9/2024 at 10:31 AM and stated they are the regularly assigned housekeeper on the unit. Housekeeper #1 stated they cleaned each room on the unit daily. Housekeeper #1 stated they did not observe maintenance problems in Resident #104's room. Housekeeper #1 stated they have not observed any broken furniture or things in disrepair. Housekeeper #1 stated if they see an issue that required maintenance they would report the problem to the charge nurse. Licensed Practical Nurse #1 was interviewed on 2/9/2024 at 10:50 AM and stated they were the charge nurse on the unit. Licensed Practical Nurse #1 stated they completed a tour of the unit and went into each room daily. Licensed Practical Nurse #1 stated Resident #104 had not reported any environmental concerns with their room. Licensed Practical Nurse #1 stated they completed a maintenance request in the computer system if they saw a problem or if a problem was reported to them. Licensed Practical Nurse #1 stated they have not submitted any maintenance requests for Resident #104's room recently. Maintenance Worker #1 was interviewed on 2/9/2024 at 10:59 AM and stated they toured the unit daily and asked the unit charge nurse if they had maintenance concerns. Maintenance Worker #1 stated they check the computer system daily for new requests. Maintenance Worker #1 stated they have fixed broken furniture. Maintenance Worker #1 stated the furniture broke frequently and they have repaired a few pieces on the unit more than once. The Director of Maintenance was interviewed on 2/9/2024 at 4:06 PM. The Director of Maintenance stated they tour the building once a week. The Director of Maintenance stated the facility used a computer system to report maintenance concerns to the maintenance department. The Director of Maintenance stated they had not received any complaints from the residents on the unit where Resident #104 resided. The Director of Maintenance reported they replaced furniture if it could no longer be fixed. The Director of Maintenance stated any furniture needs were brought to the attention of the Administrator. The Administrator was interviewed on 2/14/2024 at 10:11 AM and stated they were not aware of the environmental concerns on the unit where Resident #104 resided. The Administrator stated the facility always tried to provide a home-like environment for the residents. The Administrator stated if there were needs they were aware of they would address them but they were not aware of the concerns in Resident #104's room. A second interview was conducted with the Director of Maintenance on 2/14/2024 at 1:18 PM. The Director of Maintenance stated they reviewed the computer maintenance request logs from 7/1/2023 through 2/14/2024 and there were no repairs requested for Resident #104's bureau. 10 NYCRR 415.5(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility's policy titled Routine Maintenance dated 2/2022 and last reviewed 5/2023 documented the facility will ensure the provision of a safe, functional, sanitary, and comfortable environment for the resident. The maintenance department will ensure that the physical environment, furniture, and equipment are maintained in good repair throughout the facility. 2a) Resident #93 was admitted with diagnoses that included Bilateral Osteoarthritis of the hips, Dementia, and Anxiety Disorder. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status was not completed because the resident is rarely/never understood. The Minimum Data Set documented the resident used a wheelchair and needed supervision or touch assistance for mobility. The Minimum Data Set documented Resident #93 was always continent of bowel and bladder and required partial/moderate assistance during toilet transfer. During an environmental tour of Resident #93's bathroom on 2/6/2024 at 11:01 AM the handrails on both sides of the toilet were loose and unsteady. Resident #93 was observed in their room on 2/6/2024 at 11:01 AM. Resident #93 was in bed and stated they preferred to rest and chose to be in bed. Resident #93 stated they did not want to talk further. A second observation was completed on 2/7/2024 at 8:30 AM and the handrails on both sides of the toilet were loose and unsteady. Certified Nursing Assistant #6 was interviewed on 2/9/2024 at 9:45 AM and stated they are regularly assigned to work with Resident #93. Certified Nursing Assistant #6 stated they did not notice the loose handrails in Resident #93's bathroom. Certified Nursing Assistant #6 stated Resident #93 required the assistance of two people to transfer from their wheelchair to the toilet and from the toilet to the wheelchair. Certified Nursing Assistant #6 stated if they saw maintenance concerns, they reported them to the charge nurse and the charge nurse submitted a maintenance request. Housekeeper #1 was interviewed on 2/9/2024 at 10:31 AM and stated they are the regularly assigned housekeeper on the unit. Housekeeper #1 stated they cleaned each bathroom on the unit daily. Housekeeper #1 stated they had not observed loose handrails in Resident #93's bathroom. Housekeeper #1 stated if they saw an issue that required maintenance, they would report the problem to the charge nurse. Licensed Practical Nurse #1 was interviewed on 2/9/2024 at 10:50 AM and stated they were the charge nurse on the unit. Licensed Practical Nurse #1 stated they completed a tour of the unit and went into each room daily. Licensed Practical Nurse #1 stated Resident #93 has not reported any environmental concerns with their bathroom. Licensed Practical Nurse #1 stated they have not observed loose toilet handrails in any of the resident's bathrooms on the unit. Licensed Practical Nurse #1 stated they have not submitted any maintenance requests for Resident #93's bathroom recently. Maintenance Worker #1 was interviewed on 2/9/2024 at 10:59 AM and stated they toured the unit daily and they asked the unit charge nurse if they had maintenance concerns. Maintenance Worker #1 stated they checked the computer system daily for new requests. Maintenance Worker #1 stated they replaced the screws on the toilet handrails a couple of months ago but were unable to state exactly when. Maintenance Worker #1 stated the toilet handrails on the unit were loose and they frequently tightened them. The Director of Maintenance was interviewed on 2/9/2024 at 4:06 PM. The Director of Maintenance stated the toilet handrails should be secure and sturdy for resident safety. The Director of Maintenance stated they toured the building once a week to see if any environmental concerns needed to be addressed. The Director of Maintenance stated the facility used a computer system to report maintenance concerns to the maintenance department. The Director of Maintenance stated they had not received any complaints from the residents on the unit that Resident #93 resided on. The Administrator was interviewed on 2/14/2024 at 10:11 AM and stated they were not aware of the concerns with the toilet handrails on the unit where Resident #93 resided. The Administrator stated they were not aware of the concerns in Resident #93's bathroom. A second interview was conducted with the Director of Maintenance on 2/14/2024 at 1:18 PM. The Director of Maintenance stated they reviewed the computer maintenance request logs from 7/1/2023 through 2/14/2024 and there were no repairs requested for Resident #93's toilet handrails. 2 b) Resident #104 was admitted to the facility with diagnoses that included Dementia, Type 2 Diabetes, and Chronic Obstructive Pulmonary Disease. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status was ten, which indicated the resident's cognition was moderately impaired. The Minimum Data Set documented Resident #104 used a walker and wheelchair for mobility. The Minimum Data Set documented Resident #104 was occasionally incontinent of bowel and bladder and required supervision or touch assistance with toilet transfer. During an environmental tour of Resident #104's room on 2/6/2024 at 10:39 AM the toilet handrails in Resident #104's bathroom were observed to be loose and unsteady. Resident #104 was interviewed on 2/6/2024 at 10:39 AM and stated they used the toilet in their bathroom on their own and used the toilet handrails to steady themselves. Resident #104 stated they knew the handrails were loose, but they were not sure if they reported it to anyone. During an environmental tour of Resident #104's room on 2/7/2024 at 8:51 AM the toilet handrails in Resident #104's bathroom were observed to be loose and unsteady. Certified Nursing Assistant #7 was interviewed on 2/9/2024 at 10:23 AM and stated they are regularly assigned to work with Resident #104. Certified Nursing Assistant #7 stated Resident #104 was usually independent in the bathroom and had not reported loose toilet handrails. Certified Nursing Assistant #7 stated Resident #104 was sometimes unsteady on their feet and used a walker. Certified Nursing Assistant #7 stated if they saw maintenance concerns, they reported them to the charge nurse and the charge nurse submitted a maintenance request. Housekeeper #1 was interviewed on 2/9/2024 at 10:31 AM and stated they are the regularly assigned housekeeper on the unit. Housekeeper #1 stated they cleaned each room on the unit. Housekeeper #1 stated they had not observed loose handrails in Resident #104's bathroom. Maintenance Worker #1 was interviewed on 2/9/2024 at 10:59 AM and stated they toured the unit daily and asked the unit charge nurse if they had maintenance concerns. Maintenance Worker #1 stated they checked the computer system daily for new requests. Maintenance Worker #1 stated they replaced the screws on the toilet handrails a couple of months ago, but they were unable to state exactly when. Maintenance Worker #1 stated the toilet handrails on the unit were loose and they frequently tighten them. The Director of Maintenance was interviewed on 2/9/2024 at 4:06 PM. The Director of Maintenance stated the toilet handrails should be secure and sturdy for resident safety. The Director of Maintenance stated they toured the building once a week to see if any environmental concerns needed to be addressed. The Director of Maintenance stated the facility used a computer system to report maintenance concerns to the maintenance department. The Director of Maintenance stated they have not received any complaints from the residents on the unit Resident #104 resided on. The Administrator was interviewed on 2/14/2024 at 10:11 AM and stated they were not aware of the concerns with the toilet handrails on the unit where Resident #104 resided. A second interview was conducted with the Director of Maintenance on 2/14/2024 at 1:18 PM. The Director of Maintenance stated they reviewed the computer maintenance request logs from 7/1/2023 through 2/14/2024 and there were no repairs requested for Resident #104's toilet handrails. 2 c) Resident #146 was admitted to the facility with diagnoses that included Dementia, Depression, and Chronic Obstructive Pulmonary Disease. The Annual Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status was four, which indicated the resident's cognition was severely impaired. The Minimum Data Set documented Resident #146 was always continent of bowel and bladder and used a walker and wheelchair for mobility. The Annual Minimum Data Set documented that Resident #146 required partial/moderate assistance during toilet transfer. During an environmental tour of Resident #146's room on 2/6/2024 at 10:54 AM the toilet handrails in Resident #146's bathroom were loose and unsteady. During an environmental tour of Resident #146's room on 2/6/2024 at 10:54 AM and 2/7/2024 at 8:42 AM the toilet handrails in Resident #146's bathroom were loose and unsteady. Certified Nursing Assistant #6 was interviewed on 2/9/2024 at 9:45 AM and stated they are regularly assigned to work with Resident #146. Certified Nursing Assistant #6 stated they did not notice the loose handrails in Resident #146's bathroom. Certified Nursing Assistant #6 stated Resident #146 used the bathroom independently. Certified Nursing Assistant #6 stated Resident #146 used a walker and was unsteady on their feet. Certified Nursing Assistant #6 stated if they saw maintenance concerns, they reported them to the charge nurse and the charge nurse submitted a maintenance request. Housekeeper #1 was interviewed on 2/9/2024 at 10:31 AM and stated they are the regularly assigned housekeeper on the unit. Housekeeper #1 stated they clean each bathroom on the unit daily and have not observed loose handrails in Resident #146's bathroom. Housekeeper #1 stated if they saw an issue that required maintenance, they would report the problem to the charge nurse. Licensed Practical Nurse #1 was interviewed on 2/9/2024 at 10:50 AM and stated they were the charge nurse on the unit. Licensed Practical Nurse #1 stated they completed a tour of the unit and went into each room daily. Licensed Practical Nurse #1 stated they have not observed loose toilet handrails in any of the resident's bathrooms on the unit and have not submitted any maintenance requests for Resident #146's bathroom recently. Maintenance Worker #1 was interviewed on 2/9/2024 at 10:59 AM and stated they toured the unit daily and asked the unit charge nurse if they had maintenance concerns. Maintenance Worker #1 stated they check the computer system daily for new requests. Maintenance Worker #1 stated they replaced the screws on the toilet handrails a couple of months ago but were unable to state exactly when. Maintenance Worker #1 stated the toilet handrails on the unit were loose and they frequently tightened them. The Director of Maintenance was interviewed on 2/9/2024 at 4:06 PM. The Director of Maintenance stated the toilet handrails should be secure and sturdy for resident safety. The Director of Maintenance stated they toured the building once a week to see if any environmental concerns needed to be addressed. The Director of Maintenance stated the facility used a computer system to report maintenance concerns to the maintenance department. The Director of Maintenance stated they have not received any complaints from the residents on the unit that Resident #146 resided on. The Administrator was interviewed on 2/14/2024 at 10:11 AM and stated they were not aware of the concerns with the toilet handrails on the unit where Resident #146 resided. The Administrator stated they were not aware of the concerns in Resident #146's bathroom. A second interview was conducted with the Director of Maintenance on 2/14/2024 at 1:18 PM. The Director of Maintenance stated they reviewed the computer maintenance request logs from 7/1/2023 through 2/14/2024 and there were no repairs requested for Resident #146's toilet handrails. 3) The facility's policy titled Medication Storage last reviewed in October 2023, documented all drugs and biologicals would be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). Only authorized personnel would have access to the keys to locked compartments. During a tour of the facility's medication storage on Unit 1A on 2/14/2024 at 2:21 PM, the medication closet was observed to not have a lock. The closet was located behind the unit's nurse's station. The items in the unlocked closet included but were not limited to insulin syringes, Tuberculin syringes, razors for shaving, Pepcid tablets (for gastroesophageal reflux disease), Loratadine tablets (an antihistamine) bottles, Acetaminophen tablets (used to relieve pain and reduce fever) bottles, Hydrogen Peroxide (an antiseptic) bottles, Geri-Tussin liquid (used to relieve cough), Zinc tablets ( a nutritional supplement), Povidone Iodine (a disinfectant) bottles, Lidocaine pain relief patches, intravenous fluids (liquids injected into a person's veins through an intravenous tube) and, Antacid tablets (used to treat heartburn) bottles etc. Licensed Practical Nurse #2, who was the unit charge nurse, was interviewed on 2/14/2024 at 2:21 PM and stated the nurse's station was under renovation and the facility had stored medication in the unlocked closet behind the nurse's station for about two or three months. Licensed Practical Nurse #2 stated there was usually a nurse seated at the station but if the nurse was called away the closet was unsupervised and accessible to the other staff, residents, or visitors. The Director of Maintenance was interviewed on 2/14/2024 at 2:48 PM and stated the closet doors have not had locks for about two to three months. The Director of Maintenance stated the area was recently renovated and the previous doors did not have locks so they did not think they needed a lock on the medication storage area. The Director of Nursing Services was interviewed on 2/24/2024 at 3:02 PM and stated the nurse's station was recently renovated. The Director of Nursing Services stated the medicine closet is behind the nurse's station and residents do not go behind there, but the closet should be locked. 10 NYCRR 415.12(h)(1)(2) Based on observations, record review and interviews conducted during a Recertification and abbreviated Survey (NY 00318188) initiated on 2/6/2024 and completed on 2/14/2024, the facility did not ensure that the residents' environment remained as free from accident hazards as possible, and each resident receives adequate supervision to prevent accidents. This was identified for one (Resident #146) of 11 residents reviewed for Accidents/elopement, 2) for six (Resident #93, Resident #104, Resident #146, Resident #103, Resident #112, and Resident #85) of eleven residents reviewed for Accidents hazards; and 3) for one Unit 1A of four units observed during the Medication Storage Task. Specifically, 1) Resident #146, who had a diagnosis of Dementia and was identified by the facility as an elopement risk/wanderer, wandered outside of the facility on 6/11/2023 after being directed to an outdoor area by the receptionist. The resident left the facility without staff knowledge and was brought back by the local police after the resident was found knocking at the door of a private home looking for their parents. 2) On multiple observations of Resident's, #93's, #104's, #146, #103's, #112's, and #85's bathrooms, the handrails on each side of the toilet were observed loose and unsteady; 3) During the Medication Storage Task on Unit 1A, the medication storage closet was observed with no lock. The medication storage contained over the counter medications along with other medical supplies such as syringes and intravenous fluid bags. The findings include but are not limited to: 1) The facility's policy titled, Elopement and Unsafe Wandering dated 2/2022 documented staff education regarding the responsibility to identify, report, and intervene in wandering/elopement risk; such as but not limited to anticipating resident needs based upon wandering triggers and patterns, acknowledging resident's behavior as an attempt to communicate needs and encourage verbalization, identifying etiology, and recognizing feelings. Resident #146 was admitted with diagnoses that included Dementia, Chronic Obstructive Pulmonary Disease, and Emphysema. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 4 which indicated severe cognitive impairment. The Minimum Data Set documented the resident needed extensive assistance from one staff for locomotion off the unit. The resident utilized a walker and a wheelchair as per the Minimum Data Set. A Comprehensive Care Plan for Wandering dated 12/20/2022 and last revised on 1/3/2024 documented that the resident is an elopement risk/wanderer as the resident moves about aimlessly. Interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. The investigation report dated 6/11/2023 documented that at approximately 7:55 PM the resident was speaking to the receptionist while sitting in the lobby, which is their usual behavior, and verbalized they wanted to get some fresh air. The receptionist reported they directed the resident towards the patio to accommodate their request. The surveillance camera revealed that at approximately 8:12 PM Resident #146 was observed walking back towards their unit and the patio. At 8:18 PM the resident was noted walking through the dining room, entering the hub, pushing on the alarmed exterior door, and exiting the facility. At 9:15 PM the resident returned to the facility accompanied by the police department after they were found knocking on a neighbor's door looking for their parents. The investigation summary concluded that the receptionist/security did not follow policy & procedure regarding facility alarms as they did not utilize the proper notification to the Registered Nurse Supervisor with regards to Resident #146's request to leave, nor did they provide an escort. A written statement from the receptionist dated 6/11/2023 documented that they did not hear the sounding of an alarm or have any awareness of the resident exiting the building until the resident's family called asking for the resident and then entered the building accompanied by the resident and the police. The Director of Maintenance Services was interviewed on 2/7/2024 at 2:42 PM. The Director of Maintenance Services stated that the Hub (an area described as a rarely used recreation room adjacent to the first-floor dining room) is inspected by staff every Friday. They stated that the area was alarmed remotely at the front desk, and they expected that the front desk staff would notify the nursing supervisor if the alarm sounded. The Director of Maintenance Services stated that the fence enclosing the outdoor area exiting the Hub was broken. The fence may have come down because of the landscaper's equipment moving. The Director of Nursing Services (DNS) was interviewed on 2/7/2024 at 2:47 PM. The Direction of Nursing Services stated Resident #146 expressed a desire for fresh air to the front desk receptionist on 6/11/2023 and the receptionist directed the resident to the patio without conveying the request to the nursing supervisor. The resident however wandered to another area of the building referred to as the Hub and exited a remotely alarmed exit door to the outside of the building. This area outside of the building was fenced in; however, a section of the fence had collapsed and Resident #146 wandered through this breached area to a neighbor's home at which point the police were called by the neighbors. The resident was escorted back to the facility by the police. The Director of Nursing Services stated that the receptionist alleged that the alarmed door did not sound at the front desk; however, an examination of the door alarm in question was checked and was found to be operational. The receptionist was later terminated for failing to alert the nursing supervisor of the resident's intent. Resident #146 was observed in their bed on 2/9/2024 at 11:27 AM. Resident #146 was alert. Resident #146 was communicative; however, did present with impaired memory and had no recollection of the incident on 6/11/2023. Licensed Practical Nurse #1 was interviewed on 2/9/2024 at 11:41 AM. Licensed Practical Nurse #1 stated that Resident #146 is a known wanderer with periods of confusion. Licensed Practical Nurse #1 stated that Resident #146 was moved to the Dementia Unit on the second floor following the incident on 6/11/2023. Licensed Practical Nurse #1 stated that Resident #146 now wears a wander guard and is in a secured unit requiring staff assistance to exit the unit. Licensed Practical Nurse #1 stated that Resident #146 was not a known wanderer before the incident on 6/11/2023.

Based on observations, records review, and interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024 the facility did not ensure all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to the keys. This was identified for one unit (Unit 1A) of four units observed during the Medication Storage Task. Specifically, during an observation of the medication storage on 2/14/2024, the medication closet on Unit 1A was observed without a lock. The medication closet door had no locking mechanism installed on the door. The storage closet had multiple medications, syringes, and intravenous medication bags stored. The finding is: The facility's policy titled, Medication Storage last reviewed October 2023, documented all drugs and biologicals would be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). Only authorized personnel would have access to the keys to locked compartments. During a tour of the facility's medication storage on Unit 1A on 2/14/2024 at 2:21 PM, the medication closet was observed to not have a lock or a locking mechanism installed. The closet was located behind the unit's nurse's station. The medication closet had items that included but were not limited to Pepcid tablets (for gastroesophageal reflux disease), Loratadine tablets (an antihistamine), Acetaminophen tablets (used to relieve pain and reduce fever), Hydrogen Peroxide (an antiseptic), Geri-Tussin liquid (used to relieve cough), Zinc tablets ( a nutritional supplement), Povidone Iodine (a disinfectant), Lidocaine pain relief patches, intravenous fluids (liquids injected into a person's veins through an intravenous tube) and, Antacid tablet bottles (used to treat heartburn). There were no staff members present in the vicinity. Licensed Practical Nurse #2 was interviewed on 2/14/2024 at 2:21 PM and stated the nurse's station was under renovation and the facility had stored medication in the unlocked closet behind the nurse's station for about two or three months. Licensed Practical Nurse #2 stated there was usually a nurse seated at the station but if the nurse was called away the closet was not supervised and was accessible to anyone. The Director of Maintenance was interviewed on 2/14/2024 at 2:48 PM and stated the closet doors have not had locks for about two to three months. The Director of Maintenance stated the area was recently renovated and the previous doors also did not have locks so they did not think the locks were needed for the medication closet. The Director of Nursing Services was interviewed on 2/24/2024 at 3:02 PM and stated the nurse's station was recently renovated. The Director of Nursing Services stated the medication storage closet is behind the nurse's station and residents do not go behind there; however, the closet should be locked. 10 NYCRR 415.18(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey completed on 2/14/2022, the facility did not ensure that a comprehensive person- centered care plan (CCP) was developed to meet the resident's medical and nursing needs to include the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. This was identified for one (Resident #222) of three residents reviewed for Pressure Ulcers. Specifically, Resident #222 who had a Stage 3 Pressure Ulcer to the sacral area upon admission and was identified as requiring two person staff assistance for bed mobility. The resident's CCP did not have specific interventions to address turning and positioning needs. The finding is: Resident #222 was admitted to the facility on [DATE] with diagnoses including Stage 3 Pressure Ulcer to the Sacral Region. The Five-Day Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognition. Resident #222 required extensive assistance of two staff members for bed mobility and transfers. The MDS documented the resident had one Stage 3 Pressure Ulcer that was present on admission. The MDS, under section M1200 Skin and Ulcer Treatment, did not include a turning and positioning program. The CCP for Actual skin breakdown related to a Stage 3 Pressure Ulcer to the sacral area dated 2/3/2022 documented interventions which included but were not limited to encourage the resident to turn to the sides while in bed to air out /and offload back and bilateral gluteus. The Certified Nursing Assistant (CNA) [NAME] report as of February 11, 2022, documented instructions for the CNAs to encourage the resident to turn side to side while in bed to air out /and offload back and bilateral gluteus. The wound care note dated 2/8/2022 documented the resident was seen during wound rounds on 2/3/2022. The resident was noted to have a Stage 3 Pressure Ulcer to the sacral area measuring 0.2 centimeters (cm) width x 0.2 cm length x 0.1 cm depth with scant drainage. The resident was observed on 2/11/2022 at 12:07 PM in their room sitting in a wheelchair near their bed and stated they (Resident #222) cannot turn and reposition themselves in bed, however, the nursing staff assist them (Resident #222) in turning and positioning while in bed. CNA #5, who was the assigned CNA to Resident #222, was interviewed on 2/11/2022 at 12:15 PM. CNA #5 stated that Resident #222 could not turn and reposition themselves while in bed. The MDS Registered Nurse (RN) #8, who was the unit Charge Nurse, was interviewed on 02/11/2022 at 3:26 PM and stated instructions for the CNAs on how and when to turn and reposition the resident should be documented in the CCP and on the CNA [NAME] report. The Director of Nursing Services (DNS) was interviewed on 2/14/2022 at 2 PM and stated residents who require assistance with bed mobility are required to be turned and repositioned by nursing staff. The CCP and the [NAME] should reflect interventions to turn and reposition the resident every 2 -3 hours while in bed. The DNS further stated that the facility chose not to develop a baseline care plan within 48 hours and opted to develop the comprehensive care plan for Pressure Ulcers within 48 hours. 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 completed on 2/14/2022, the facility did not ensure that each resident received care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #4) of four residents reviewed for skin conditions. Specifically, during the observation of Resident #4's right plantar foot wound care the Registered Nurse (RN) #6 did not pack the wound with the Iodoform wound packing as per the Physician's order. The finding is: The facility's policy titled, Wound Treatment Administration, last reviewed 1/2022, documented to provide evidenced-based treatments in accordance with current standards of practice and physician's orders. The policy further documented that the wound treatments will be provided in accordance with physician and physician-extender orders, including cleansing method, type of dressing, and frequency of dressing change. Resident #4 was admitted with diagnoses including Peripheral Vascular Disease, Diabetes Mellitus, and Anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident had an infection of the foot and had diabetic foot ulcers. A physician's order dated 2/4/2022 documented to administer treatment to the right plantar foot. The order indicated to paint the planter foot wound with Betadine, pack the wound bed with Iodoform strip, cover with abdominal pad, and wrap with Kerlix and an ace bandage as needed (PRN). A physician's order dated 2/4/2022 documented to administer treatment to the right plantar foot. The order indicated to paint the planter foot wound with Betadine, pack the wound bed with Iodoform strip, cover with abdominal pad, and wrap with Kerlix and an ace bandage every night shift. A Comprehensive Care Plan (CCP), effective 10/7/2021, titled Resident with Actual Skin Breakdown related to Diabetic Ulcer to the right plantar foot, had interventions that included but were not limited to administer treatments as ordered and to monitor for effectiveness of the treatment. The wound treatment for Resident #4's right plantar foot wound, performed by RN #6, was observed on 2/10/2022 at 10:07 AM. RN #6 removed the dressing from the wound, cleaned the wound with normal saline, applied Betadine treatment, and then re-applied a clean dressing without packing the wound with the Iodoform strip. RN #6 was interviewed on 2/10/2022 at 11:00 AM. RN #6 reviewed the orders for Resident #4's right plantar foot wound and stated the wound care was ordered to be administered during the night shift, but they (RN #6) had performed the wound care on the PRN basis because the dressing was soiled. RN #6 stated that they (RN #6) overlooked the order to pack the wound with Iodoform stripping and would have to re-perform the wound care. The RN Infection Preventionist/Wound Care Nurse was interviewed on 2/10/2022 at 11:13 AM and stated RN #6 will have to re-perform the wound care for the right plantar foot wound because the wound required packing. The RN Infection Preventionist/Wound Care Nurse further stated that the wound care orders should have been closely reviewed before starting the wound treatment. The Director of Nursing Services (DNS) was interviewed on 2/11/2022 at 8:40 AM and stated RN #6 should have followed the orders and should have packed the wound as per the physician's orders. The DNS further stated that RN #6 will have to be re-educated. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey completed on 2/14/2022, the facility did not ensure that all resident's environment was free from accident hazards. This was identified for one (Resident #152) of eight residents reviewed for Accidents. Specifically, Resident #152, who was ambulatory, was not moved out of their room while there were repairs being made for an active leak. Staff did not ensure that signage indicating the wet floor was in place to alert the resident of the wet floor. The finding is: The Accident/Incident facility policy dated 1/2022 documented that it is the policy of the facility to maintain the safety of all residents. In compliance with the New York State Department of Health regulation, the resident environment remains free of accident hazards. Professional staff members will recommend, institute and update plan of care with preventative measures to ensure resident's safety. The policy documented hazards include wet floors that are not obviously labeled and to which access is not blocked. Resident #152 was admitted with diagnoses of Parkinson's Disease, Non-Alzheimer's Dementia, and Depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #152 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. The MDS also documented that Resident #152 required supervision and set up assistance for transfers, walking in the room, and walking in the corridor. Resident #152 was steady at all times while walking and had no impairment in the upper and lower extremities. The Comprehensive Care Plan (CCP) for Falls dated 4/9/2021 documented Resident #152 was at risk for falls related to gait/balance problems, Cerebrovascular Accident, Dementia, Parkinson's Disease, Orthostatic Hypotension and a history of an unwitnessed fall on 3/18/2021 prior to admission. The interventions included but were not limited to maintain a clutter-free environment in the residents' room. The Physician's order dated 5/10/2021 documented Resident #152 was able to ambulate independently ad lib on the unit with a rolling walker within a supervised environment. On 2/7/22 at 11:32 AM Resident #152 was observed in their room laying in bed. Water was observed leaking from the ceiling in the middle of the resident's room between Resident #152's bed and another bed. A bucket was observed on the floor collecting the water underneath the leak with towels wrapped around the base of the bucket. Water was observed on the floor in the middle of the room heading towards the bathroom, near the foot of the bed, and at the entryway to the room. An invoice dated 2/7/2022 documented that an emergency plumbing service was completed from 9:30 AM to 10:30 AM to fix the 2nd floor heating unit leak. Registered Nurse (RN) #4, the Unit Nurse Supervisor, was interviewed on 2/7/2022 at 2:28 PM. RN #4 observed the wet floor in Resident #152's room at 2:28 PM. RN #4 stated that they (RN #4) were informed by the overnight nurse that there was a leak in Resident #152's room when they (RN #4) started the day shift. RN #4 stated they (RN #4) did not offer to move Resident #152 out of their (Resident #152) room while there were repairs being done because Resident #152 was still sleeping. RN #4 stated they (RN #4) were very busy and did not re-approach Resident #152. RN #4 stated that Resident #152 was confused and fully ambulatory. RN #4 further stated that Resident #152 is able to walk to the bathroom unassisted and wet floor is an accident hazard. Resident #152 was observed on 2/8/2022 at 9:35 AM sleeping in bed. There was a leak running from the ceiling above the doorway, at the foot of the bed and to the middle of the room on the way to the bathroom. Water was observed on the floor with no wet floor signage. Certified Nurse Assistant (CNA) #4 was interviewed on 2/8/2022 at 9:38 AM and stated that they were assigned to Resident #152 on 2/7/2022 and reported the leak yesterday (2/7/2022) to the maintenance and housekeeping departments. CNA #4 stated that when they (CNA #4) offered to take Resident #152 out of the room, Resident #152 refused to leave the room and preferred to stay in bed. CNA #4 left the resident in their room and did not offer to remove the resident out of the room again. CNA #3 was interviewed on 2/8/2022 at 9:41 AM and stated that they (CNA #3) were assigned to Resident #152 today (2/8/2022). CNA #3 observed the wet floor in Resident #152's room at the beginning of their shift and stated that they did not report the water on the floor to the housekeeping or maintenance department. CNA #3 stated that they were wiping the floor with towels when they saw the wet floor. CNA #3 stated that Resident #152 refused to get out of bed this morning and was still sleeping. CNA #3 stated that Resident #152 is able to ambulate in their room and could slip on the wet floor. Housekeeper #1 was interviewed on 2/8/2022 at 9:46 AM and stated that they (Housekeeper #1) were responsible to clean the whole building and is just now making rounds on Resident #152's unit. Housekeeper #1 stated that they (Housekeeper #1) knew about the leak yesterday (2/7/2022) and was told that the leak in Resident #152's room was fixed. Housekeeper #1 stated that they (Housekeeper #1) did not know that the ceiling was still leaking today (2/8/2022). Housekeeper #1 observed water on the floor at 9:47 AM and stated that they should have put a sign that indicated the floor was wet because Resident #152 could fall on the wet floor. The Director of Nursing Services (DNS) was interviewed on 2/9/2022 at 1:28 PM and stated that the staff could have moved Resident #152 out of the room as the facility had some empty beds. The DNS stated that Resident #152 has some behavioral issues and confusion so if Resident #152 had refused to leave the room, the staff should have put additional interventions in place, such as keeping the floor dry by placing buckets under the leak, and a wet floor sign to prevent a fall. The DNS stated that the situation was potentially hazardous for Resident #152. The DNS further stated that they (DNS) were not aware of the leak in Resident #152's room until after the leak was resolved on 2/8/2022. 415.12(h)(1)

Based on observations, record review, and staff interviews during the Recertification Survey completed 2/14/2022, the facility did not ensure that each resident who needs respiratory care was provided such care, consistent with professional standards of practice, for one (Resident #17) of two residents reviewed for Respiratory Care. Specifically, Resident #17 was observed receiving oxygen therapy without a physician's order. The finding is: The facility's policy titled Oxygen Administration, last reviewed in January 2022, documented oxygen administration shall be initiated under orders of a physician or physician-extender, except in the case of an acute need. In such cases, oxygen is administered and orders for oxygen are obtained as soon as is able. Resident #17 was admitted to the facility with diagnoses including Heart Failure, Chronic Obstructive Pulmonary Disease, and Hypoxemia. The 11/7/2021 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS documented that the resident was receiving oxygen therapy while a resident. A Comprehensive Care Plan (CCP), effective 11/1/2021, titled the resident has potential risk for altered respiratory status, acute Hypoxic Respiratory Failure due to acute chronic Congestive Heart Failure and Hypoxemia. The interventions included but were not limited to administering nebulizer and oxygen treatments as ordered. A CCP titled altered Cardiovascular status, effective 11/1/2021, included interventions but were not limited to administering oxygen therapy as ordered by the Physician. A Physician's order dated 10/29/2021 documented to administer oxygen at 3 liters per minute (LPM) via nasal cannula (a plastic tubing used to administer supplemental oxygen) every shift for shortness of breath. This order was discontinued on 1/17/2022. A Physician's order dated 1/17/2022 documented to administer oxygen at 2 LPM as needed (PRN) for shortness of breath. This order was discontinued on 1/29/2022. Review of the medical record revealed there was no further Physician's order for oxygen therapy after 1/29/2022. On 2/7/2022 at 10:30 AM Resident #17 was observed in their room with a portable oxygen tank on the back of their (Resident #17) wheelchair. The resident had just finished washing up and stated they (Resident #17) were going to re-apply the nasal cannula. The resident stated they (Resident #17) need the oxygen. A review of the medical record revealed that Resident #17 did not have a current physician's order for oxygen therapy. During observation of Resident #17's wound care on 2/8/2022 at 11:04 AM, the resident was observed receiving oxygen via a nasal cannula from an oxygen concentrator. The setting on the concentrator, as confirmed by the Registered Nurse (RN #4) performing the wound care, was set at 4 LPM. The RN charge nurse (RN #7) was interviewed on 2/8/2022 at 11:17 AM and stated Resident #17 did not have a current Physician's order for oxygen therapy. RN #7 stated that they (RN #7) would have to check with the Physician about why there was no order and if the resident requires oxygen. A new order for Resident #17 dated 2/8/2022, following the interview with RN #7, documented to administer continuous oxygen inhalation via nasal cannula at 4 LPM for shortness of breath. RN #7 Charge Nurse was re-interviewed on 2/9/2022 at 9:02 AM and stated the Physician Assistant (PA) assessed Resident #17's need for oxygen therapy and determined that Resident #17 needed oxygen therapy because the resident verbalized that they (Resident #17) get short of breath without oxygen. The Nurse Practitioner (NP) was interviewed on 2/9/2022 at 10:51 AM and stated that Resident #17 had an order for oxygen therapy at 2 LPM PRN for shortness of breath on 1/17/2022 per the facility's protocol when the resident was diagnosed with COVID-19 (on 1/17/2022). The NP was not sure why the order for 2 LPM PRN replaced the previous order of 3 LPM continuous oxygen that was ordered for the resident from the time of their admission. The NP stated the order for the 2 LPM PRN oxygen was probably discontinued after the resident's COVID-19 quarantine period was completed. The NP was not sure why a new order for oxygen was not placed after the 2 LPM PRN oxygen order was discontinued. The PA was interviewed on 2/9/2022 at 11:29 AM and stated Resident #17 has been on oxygen therapy since admission. The PA stated that initially Resident #17 was much more dependent on the supplemental oxygen therapy but has improved. The PA stated the resident still needs the supplemental oxygen therapy and was not sure why the order for the oxygen therapy was discontinued. The Director of Nursing Services (DNS) was interviewed on 2/11/2022 at 8:30 AM and stated that there should be an order for oxygen therapy if the resident was using oxygen and was not sure why Resident #17 did not have an order for oxygen administration. The DNS further stated there were discrepancies in the oxygen orders and the Physician will have to review the resident's need for oxygen. 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident #154 was admitted with the diagnoses of Schizophrenia, Obsessive Compulsive Disorder, and Unspecified Open Wound to the Scalp. The five-day Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #154 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognition. The Comprehensive Care Plan (CCP) for Skin dated 5/28/2021 documented that Resident #154 had actual skin breakdown related to a self-inflicted wound on the head. Interventions included to administer treatments as ordered, monitor for effectiveness, and educate resident on compulsive behavior of scratching or picking their scalp. On 2/7/2022 a helmet to be worn at all times was an added intervention with the instructions to remove it every shift for skin check and during care. The Physician's Order dated 2/5/2022 documented to remove the Helmet during wound care and skin integrity checks every shift. Apply Iodosorb Gel 0.9 percent (%) (Cadexomer Iodine) to the resident's head topically every day and evening shift for wound care. RN #5 was observed on 2/10/22 at 1:27 PM providing wound treatment to Resident #154's head wound. RN #5 was wearing gloves when they entered the room with the treatment supply tray. RN #5 placed the treatment supplies on the over the bed table next to Resident #154's bed. RN #5 removed the treatment supplies from the packaging and then proceeded to remove Resident #154's helmet and the bandages on Resident #154's head. RN #5 stepped away from Resident #154 to discard the gauze and bandages into the trash bin under the sink. RN #5 did not wash their hands after removing the bandage from the resident's head. RN #5 then applied saline on a gauze pad then applied the saline saturated gauze pad to the resident's head wound to clean the area. RN #5 then threw out the gauze and repeated the process again. RN #5 did not change gloves and wash their hands after cleaning the wound. RN #5 applied the prescribed dressing, gauze, and the bandage to secure the gauze pad in place. RN #5 then placed the helmet back on to Resident #154's head, removed the helmet again to date the bandage with a marker, and then secured the helmet on. RN #5 was interviewed on 2/10/2022 at 2:05 PM and stated that Resident #154 is sometimes combative during wound care, and they (RN #5) have to work quickly before Resident #154 refuses the wound care. RN #5 stated that they (RN #5) should have performed hand hygiene before applying the dressing as per the facility's protocol. The Infection Control Preventionist (ICP) /Wound Nurse was interviewed on 2/10/2022 at 3:01 PM and stated that RN #5 should have discarded their gloves after cleansing the wound, washed their hands, and then put on clean gloves before applying the dressing. The ICP stated that it is the facility's protocol to perform hand hygiene while conducting wound care. The Director of Nursing Services (DNS) was interviewed on 2/14/2022 at 2:08 PM and stated that the nurses are expected to first perform handwashing, then put on gloves, remove the old dressing, and discard the gloves. The DNS stated that after discarding the old dressing and used gloves, nurses are expected to perform hand hygiene again, then put on clean gloves before cleaning the wound. The DNS stated after cleaning the wound, the nurse should change their gloves again before applying a clean dressing. The DNS further stated RN #5 should have performed hand hygiene and changed their gloves as per the facility protocol. 415.19(a)(1-3) 415.19(b)(4) Based on observations, record review, and interviews during the Recertification Survey completed on 2/14/2022 the facility failed to ensure an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections was maintained. This was identified for two (Resident #4 and Resident #154) of four residents reviewed for Skin Conditions and one (Resident #53) of three residents reviewed for Pressure Ulcers. Specifically, 1) during the wound care observation of Resident #4's right lateral leg wound, right heel, and plantar foot wounds the Registered Nurse (RN) #6 did not perform hand hygiene and did not change gloves after cleaning the leg wounds. Additionally, after cleaning the heel and plantar wounds, RN #6 allowed the wounds to come in contact with a dirty surface. 2) During an observation of Resident #53's left heel ulcer treatment, RN #6 allowed the cleansed wound to come in contact with a dirty surface; and 3) during Resident #154's head wound care observation, RN #5 did not perform hand hygiene and did not change gloves after cleaning Resident #154's wound. The findings are: The facility's policy, titled Wound Treatment Administration, last reviewed 1/2022, documented to promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician's orders; and wound treatments will be provided in accordance with physician and physician-extender orders, including cleansing method, type of dressing, and frequency of dressing change. 1) Resident #4 was admitted with diagnoses including Peripheral Vascular Disease, Diabetes Mellitus, and Anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident had an infection of the foot and had diabetic foot ulcers. A Physician's order dated 1/21/2022 ordered Ampicillin-Sulbactam (antibacterial) Sodium Solution Reconstituted, Use 3 grams intravenously every 6 hours for cellulitis of the right lower extremity until 02/24/2022. A Physician's order dated 1/21/2022 documented to apply Iodosorb Gel 0.9 % (Cadexomer Iodine) to the right lateral leg topically as needed (PRN). A Physician's order dated 1/21/2022 documented to apply Iodosorb Gel 0.9 % (Cadexomer Iodine) to the right lateral leg topically every night shift for wound care: cleanse with normal saline, apply Iodosorb gel, abdominal pad, and wrap with Kerlix and ace bandage. A Physician's order dated 1/27/2022 documented to cleanse the right heel wound with normal saline, pack the wound bed with 4-inch x 4-inch gauze, cover with an abdominal pad, wrap with Kerlix and ace bandage as needed (PRN). A Physician's order dated 1/27/2022 documented to cleanse the right heel wound with normal saline, pack the wound bed with 4-inch x 4-inch gauze, cover with an abdominal pad, wrap with Kerlix and ace bandage every night shift for wound care. A physician's order dated 2/4/2022, documented to paint the right plantar foot wound with Betadine, wound bed to be packed with iodoform strip, cover with an abdominal pad and wrap with Kerlix and an ace bandage as-needed (PRN). A physician's order dated 2/4/2022, documented to paint the right plantar foot wound with Betadine, wound bed to be packed with iodoform strip, cover with an abdominal pad and wrap with Kerlix and an ace bandage every night shift. Resident #4's wound care, performed by RN #6, was observed on 2/10/2022 at 10:07 AM. RN #6 stated the wound care is ordered to be done during the night shift, but the dressings are soiled, so the treatments are being done on a PRN basis as ordered. Resident #4 was observed laying in their bed when the treatment was performed. RN #6 performed the wound care for the right lateral leg wound first. RN #6 cleansed the leg wound with normal saline. After cleansing the wound, the gauze pad was observed to be soiled with debris and exudate from the wound. RN #6 did not remove gloves or perform hand hygiene after cleansing the leg wound. RN #6 then prepared the Iodosorb gel with an applicator and was about to apply the gel to the wound when the surveyor asked the nurse if they (RN #6) were going to perform hand hygiene and change their gloves before applying the wound gel. RN #6 stopped the treatment and then removed the dirty gloves, sanitized hands, and applied clean gloves before proceeding with the application of the wound gel. After RN #6 completed dressing the right lateral leg wound, they (RN #6) proceeded to the right heel and the right plantar foot wounds. The resident's right foot with the old dressings in place was resting on a cloth towel. RN #6 removed the dressings from both the heel and the plantar wounds and allowed the foot to come to rest on the towel with the wounds exposed. RN #6 then cleansed both of the wounds with normal saline and allowed the cleansed wounds to come in contact with the soiled towel, which was now damp from the normal saline after the cleaning process. The surveyor brought this to RN #6's attention. The RN then proceeded to get a clean barrier to place under the right foot and then re-cleansed both wounds before applying the applicable treatments. The RN Infection Preventionist/Wound Care Nurse was interviewed on 2/10/2022 at 11:13 AM and stated that hand washing and changing of gloves must be done after cleaning a wound and before proceeding to apply a clean dressing. The RN Infection Preventionist/Wound Care Nurse further stated that after a wound is cleaned, the nurse must not let the wound come in contact with a dirty surface. The Director of Nursing Services (DNS) was interviewed on 2/11/0222 at 8:40 AM and stated gloves should have been changed and handwashing should have been performed by RN #6 after cleaning the right leg wound. The DNS also stated the heel and plantar foot wounds should not have come in contact with a dirty surface. The DNS further stated RN #6 should have propped the foot on a pillow or had someone help them to support the resident's foot. 2) Resident #53 was admitted with diagnoses including Cerebrovascular Accident, Non-Alzheimer's Dementia, and Osteomyelitis. The 1/18/2022 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderately impaired cognition. The MDS documented that the resident had a Stage 4 pressure ulcer. A Physician's order dated 2/4/2022 for the left heel documented to apply Iodosorb Gel 0.9 % (Cadexomer Iodine) to the left heel topically as needed (PRN). A Physician's order dated 2/4/2022 for the left heel documented to apply Iodosorb Gel 0.9 % (Cadexomer Iodine) to the left heel topically every day and night shift. The order included to cleanse the left heel wound with normal saline, apply Iodosorb gel, abdominal pad, and to wrap the wound with Kerlix. The treatment for Resident #53's left heel wound was observed, performed by RN #6, on 2/10/2022 at 11:20 AM. The left foot was observed with a heel boot in place. The boot and the existing dressing were removed by RN #6 and the left foot was allowed to rest on a cloth towel with the left heel wound exposed. RN #6 cleansed the wound with normal saline. Serosanguinous (blood tinged) drainage was observed on the gauze pad. After cleaning the wound, RN #6 allowed the foot to rest on the soiled cloth towel, thereby allowing the heel ulcer to come in contact with the soiled surface. The RN Infection Preventionist/Wound Care Nurse was interviewed on 2/10/2022 at 11:33 AM and stated that after a wound is cleansed, the nurse must not let the wound come in contact with a dirty surface. the Director of Nursing Services (DNS) was interviewed on 2/11/2022 at 8:40 AM and stated the heel wound should not have come in contact with the dirty surface. The DNS stated RN #6 should have propped the resident's foot on a pillow or had someone help to support the foot.