**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review during the Recertification Survey initiated on 10/7/2024 and completed on 10/11/2024, the facility did not ensure that drug records were in order and accounted for all controlled drugs. This was identified for one (Unit 2) of two nursing units during the Medication Storage Task. Specifically, the Controlled Substance Administration Record form for Resident #29 for Lacosamide (Vimpat-a controlled medication) indicated there were 56 tablets available; however, the blister pack for Lacosamide only had 55 tablets remaining. The finding is: The facility policy titled Controlled Substance Handling, effective 1/2011 and last revised 12/2022, documented that after a [controlled medication] dose is administered, the licensed nurse administering the drug signs the electronic medication administration record and the controlled substance administration record sheet. Resident #29 was admitted with diagnoses including Seizures and Type 2 Diabetes Mellitus. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for a Mental Status score of 11, which indicated the resident had moderate cognitive impairment. A Comprehensive Care Plan titled Diagnosis-Neurological Status effective 2/2/2024 and reviewed on 10/1/2024 documented the resident had a Seizure disorder with interventions including administering medication as ordered, monitoring for signs and symptoms of impaired swallowing, encouraging rest periods, and assisting with activities of daily living as needed. A physician's order effective 3/6/2024 and last renewed on 10/8/2024 documented to administer Vimpat (an anti-seizure medication) 150 milligrams tablet, 1 tablet by oral route every 12 hours for Seizures. During an observation of Unit 2's medication cart on 10/10/2024 at 12:22 PM with Licensed Practical Nurse #1, Resident #29's Controlled Substance Administration Record form for Lacosamide (Vimpat) documented that 56 tablets were remaining; however, the blister pack for Lacosamide (Vimpat) only had 55 tablets remaining. During an interview conducted immediately after the observation on 10/10/2024, Licensed Practical Nurse #1 stated they had administered one tablet of Lacosamide (Vimpat) to Resident #29 at 8:40 AM; however, they forgot to document on the Controlled Substance Administration Record form. Licensed Practical Nurse #1 stated they should have signed the Controlled Substance Administration Record form immediately after administering the medication. During an interview on 10/10/2024 at 2:26 PM, Registered Nurse #2, the nurse supervisor for Unit 2, stated they expected the Controlled Substance Administration Record form to be updated at this time the controlled substance medication is administered. Licensed Practical Nurse #1 should have updated the Controlled Substance Administration Record form at the time the controlled medication was administered. During an interview on 10/10/2024 at 3:25 PM, the Director of Nursing Services stated the nurse should have signed the Controlled Substance Administration Record form for Resident #29 immediately after administering the medication. 10 NYCRR 415.18(b)(1)(2)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 10/7/2024 and completed on 10/11/2024, the facility did not ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles. This was identified for one (Unit 2 medication cart) of two units observed during the Medication Pass. Specifically, on 10/9/2024, the medications cart for Unit 2 was observed with an opened bottle of Lipopolysaccharide-Sugar Free (LPS-SF) supplement without a date indicating when the bottle was first opened for use. The finding is: The facility policy and procedure titled Supplement, last revised on 5/29/2024, documented that all oral supplements including Lipopolysaccharide-Sugar Free (LPS-SF) shall be maintained by nursing or in the nursing medication cart. Once opened, the supplement will be dated and discarded per the manufacturer's guidelines. The storage instructions on the bottle for Lipopolysaccharide-Sugar Free (LPS-SF) documented that Lipopolysaccharide-Sugar Free (LPS-SF) should be stored at room temperature in a clean hygienic manner. Reseal tightly after opening and discard after 60 days. Resident #331 was admitted to the facility with diagnoses that included Cellulitis, Multiple Rib Fractures, and Congestive Heart Failure. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderately impaired cognition. The Minimum Data Set (MDS) documented that Resident #331 was at risk for developing pressure ulcers and needed pressure-reducing devices, nutrition, and hydration. A Comprehensive Care Plan (CCP) dated 9/20/2024 titled Dietary Nutrition, documented Resident #331 had potential weight fluctuations related to fluid shifts secondary to Congestive Heart Failure, with interventions including adequate nutrition and hydration, dietary supplements, snacks, and nourishment. A physician's order dated 9/23/2024 documented Supplement: Give Lipopolysaccharide-Sugar Free (LPS-SF) 30 milliliters orally daily. During a Medication Pass observation on 10/9/2024 at 8:26 AM with Licensed Practical Nurse #1, the medication cart on Unit 2 was observed with a bottle of Lipopolysaccharide-Sugar Free that was opened and had no date to indicate when the bottle was first opened. During an interview on 10/9/2024 at 9:00 AM, Licensed Practical Nurse #1 stated the Lipopolysaccharide-Sugar Free bottle was already opened and they did not know when the bottle was first opened. Licensed Practical Nurse #1 stated they should have discarded the undated bottle. During an interview on 10/9/2024 at 1:40 PM, Pharmacist #1 stated the undated Lipopolysaccharide-Sugar Free bottle should have been discarded. As per the manufacturer's guidelines, after opening the Lipopolysaccharide-Sugar Free bottle should be discarded after 60 days. Pharmacist #1 stated to determine the 60th day, the nurses should have dated the bottle when it was first opened. During an interview on 10/9/2024 at 2:13 PM, Registered Nurse #2 stated the medication nurses are responsible for checking the medication carts for expired medications, undated opened supplements, and other medications. Registered Nurse #2 stated that Licensed Practical Nurse #1 should have discarded the undated opened bottle of Lipopolysaccharide-Sugar Free and opened a new one. During an interview on 10/10/2024 at 12:14 PM, the Director of Nursing Services stated the Lipopolysaccharide-Sugar Free supplement bottles must be dated when opened. The Director of Nursing Services stated the nurse should discard the undated open bottle, should have opened a new one, and should have indicated the date on the new bottle when it was first opened. 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 initiated on 10/7/2024 and completed on 10/11/2024, 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 #58) of three residents reviewed for Transmission Based Precautions. Specifically, Resident #58 was placed on Contact Isolation for Extended-Spectrum-Beta-Lactamases (ESBL-an enzymes that are resistant to most antibiotics) bacteria in the urine as per the physician's order. Certified Nursing Assistant #1 was observed entering Resident #58's room without wearing appropriate Personal Protective Equipment including a gown and gloves. The finding is: The facility's policy and procedure titled Transmission Based Precautions, last revised on 9/11/2024 documented the facility will use Transmission-Based Precautions to manage specific, highly transmissible, or epidemiologically important pathogens based on the mode of transmission: contact, droplet, and airborne. The Infection Preventionist/Designee will explain and inform staff members about the need for Transmission-Based Precautions and will perform periodic observations to ensure accurate implementation. Nurses will obtain appropriate Transmission Based Precautions category orders, develop a Comprehensive Care Plan, and post appropriate isolation signage outside the resident's room. Personal Protective Equipment (PPE) includes gloves, surgical mask, gown, and goggles/eye shield if splashing is expected. Contact Precautions will be used when there is evidence of multi-drug-resistant organisms (MDRO) or other epidemiologically significant organisms causing clinical symptoms. Hands should be washed with soap and water before and after each resident contact and after contact with resident's belongings, environmental surfaces, and resident care equipment. Resident #58 was admitted with diagnoses of Type 2 Diabetes, Sepsis, and Extended-Spectrum-Beta-Lactamases (ESBL) Resistance in the urine. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #58 had intact cognition. The admission Minimum Data Set (MDS) assessment documented that Resident #58 had incontinence of both bowel and bladder. Resident #58 was dependent on staff for all activities of daily living including toileting, personal hygiene, and showering. The Comprehensive Care Plan (CCP) titled Contact Isolation, dated 9/25/2024 documented interventions which included maintaining precautions as per the physician's order; maintaining single room isolation; wearing Personal Protective Equipment (PPE); and monitoring signs and symptoms of infection. A physician's order dated 9/25/2024 documented Contact Precautions/Isolation secondary to Extended-Spectrum-Beta-Lactamases (ESBL) in urine. A physician's order dated 9/25/2024 documented Meropenem (antibiotics) one gram per 50 milliliters in 0.9 percent sodium chloride. Give 1 milliliter (0.02 grams) by intravenous route every 8 hours for 5 days. A physician's order dated 10/8/2024 documented Vancomycin (antibiotics) 1,000 milligrams intravenous, infuse 1250 milligrams daily for 3 days. During an observation in Unit 1 on 10/7/2024 at 12:36 PM, a precautions sign outside Resident #58's room indicated Contact Isolation Precautions: everyone must perform hand hygiene before and after entering Resident #58's room. The sign also instructed to use Personal Protective Equipment (PPE) including wearing a gown and gloves before entering Resident #58's room and discarding the gown and gloves before exiting the room. Certified Nursing Assistant #1 was observed entering Resident #58's room with a lunch tray without using a gown and gloves. Certified Nursing Assistant #1 did not perform hand hygiene before entering Resident #58's room and when exiting the room. During an interview on 10/7/2024 at 12:40 PM, Certified Nursing Assistant #1 stated they did not wear a gown and gloves before entering Resident #58's room because they did not know that Resident #58 was on contact precautions and they were only bringing the meal tray for Resident #58. Certified Nursing Assistant #1 stated they did not read the precautions sign outside Resident #58's room. Certified Nursing Assistant #1 stated when a resident is on contact isolation, Personal Protective Equipment (PPE) should be only used for high-contact care. During an interview on 10/7/2024 at 12:45 PM, Registered Nurse #1, the Unit Supervisor stated Certified Nursing Assistant #1 should have read and followed the instructions on the signage outside Resident #58's room. Registered Nurse #1 stated that Resident #58 was on contact isolation and that everyone who entered Resident #58's room should have performed hand hygiene and put on a gown and gloves before entering the resident's room. During an interview on 10/9/2024 at 11:05 AM, the Infection Preventionist stated Certified Nursing Assistant #1 should have followed the instructions for the contact isolation precautions posted outside the resident's room. The Infection Preventionist stated all staff and visitors must perform hand hygiene, and wear a gown and gloves when entering Resident #58's room. During an interview on 10/10/2024 at 1:46 PM, the Director of Nursing Services stated that Certified Nursing Assistant #1 had breached the infection control precautions as soon as they entered the room without performing hand hygiene and without wearing the appropriate Personal Protective Equipment (PPE), as indicated on the signage outside Resident #58's room. The Director of Nursing Services stated they expect all staff to follow all infection protocols in the facility to prevent the spread of infection. 10 NYCRR 415.19(a) (1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and Interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY00272086) completed on 6/2/2021, the facility did not ensure that the Health Care Proxy (HCP) for 1 of 1 resident (Resident #139) reviewed for notification of change was promptly notified of a change in the resident's medical condition. Specifically, Resident #139 was administered Intravenous Fluids (IVF) as per the Physician's order, however, the resident's family was not notified of the change in the resident's condition. The finding is: The Facility's policy and procedure on notification of Physician of Resident change in condition dated July 2016 documented that the family of the resident will be notified of the change in condition as soon as possible. Resident #139 was admitted with diagnoses that included Dementia, Multiple Sclerosis, and Gastroesophageal Reflux Disease (GERD). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The resident required supervision and setup help for eating. A Nursing Progress Notes dated 1/28/2021 at 11:18 PM documented the Resident's Laboratory values indicated a Blood Urea Nitrogen (BUN) level of 42 milligram/deciliter (mg/dl)(normal range 5-20 (mg/dl)) and a Sodium (NA) level of 149 milliequivalents per liter (mEq/L) (normal range between 135 and 145 mEq/L)). The Physician was notified and a new order to start 0.9% Normal Saline (NS) 75 Milliliter/Hour (ml/hr.) for 24 hrs. via IV route. The IV line was inserted to the resident's left forearm. The IV fluid was in progress. There was no documentation in the medical record that the resident's family was notified of the change in the resident's condition. The physician orders dated 1/28/21 documented to start 0.9% NS 75 ml/hr. for 24 hrs. A family member was interviewed on 6/2/2021 at 2:30 PM and stated that the family member was not notified that the resident was started on an Intravenous fluids (IV) on 1/29/2021. The family member stated that they found out about the resident being placed on IV fluids during a Facetime video conducted on 1/31/2021. The Registered Nurse (RN) #7 Supervisor was interviewed on 6/2/2021 at 4:00 PM and stated they (RN#7) did not notify the family member and that the family member should have been notified. If RN #7 did call the family member, there would have been documentation that the family was notified of the resident's change in condition. The Director of Nursing Services was interviewed on 6/2/2021 at 4:20 PM and stated the family should have been notified whenever there is a change in condition. 415.3(e)(2)(ii)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the Recertification Survey completed on 6/2/2021, the facility did not ensure that each resident with pressure ulcers received necessary services consistent with standards of practices to promote healing and prevent infection for one (Resident #36) of two residents reviewed for pressure ulcers. Specifically, the weekly wound assessments performed from 3/20/2021 through 4/16/2021 did not document thorough assessments of each pressure ulcer including a complete description of the wounds. The finding is: The Policy/Procedure for Pressure Ulcer Prevention and Care dated 10/2017 documented that the measurements of the ulcer/wound must be done weekly until the area is healed. Measurements are to be done by the Wound Care Nurse and the Wound Care Physician. Resident #36 was admitted with diagnoses that include Gangrene, Right foot open wound, and Dementia. The Minimum Data Set (MDS) assessment dated [DATE] documented that a Brief Interview for Mental Status (BIMS) could not be completed. The resident required total dependence of two staff members for bed mobility, transfers, toilet use, and bathing. The resident was non-ambulatory and was always incontinent of bowel and bladder. The resident had two Stage 2 Pressure Ulcers (PU), one Stage 3 PU, and one Unstageable PU that were all present upon admission. A wound care observation of the left hip wound was conducted on 6/2/2021 at 11:00 AM with LPN #1 and no concerns were identified during the treatment. The admission physician orders dated 3/19/2021-3/20/2021 documented: 1- Clean the Left hip with Normal Saline Solution (NSS), apply Collagenase (enzymatic debriding agent) and Aquacel Foam (a cover dressing) daily (QD). 2- Clean Right elbow with NSS and apply Collagenase and Aquacel Foam QD. 3- Clean Right hip with NSS apply Collagenase and Aquacel Foam QD 4- Clean Intergluteal cleft (groove between the buttocks that runs from just below the sacrum) with NSS apply Collagenase and Aquacel Foam QD 5- Clean Right Lower buttock with NSS, apply Collagenase and Aquacel Foam bandage QD. The initial wound care consult dated 3/26/2021 documented the resident had a right hip Stage 2 pressure ulcer; a left hip necrotic unstageable wound; a right heel, and a right lateral foot ulcer (no staging). The Physician's assessment did not include wound length, width, depth, drainage, undermining (when the tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound's edge), and color. Furthermore, the consult documented a request for the Wound Care Physician to evaluate the right elbow pressure ulcer. The Wound Care Physician's documentation did not include an assessment of the right elbow. The weekly pressure ulcer/wound flow sheets were reviewed from 3/20/2021 through 4/16/2021. The assessments did not include the depth of the wounds, undermining, drainage, color, odor and pain management. The Comprehensive Care Plan (CCP) dated 4/10/2021 for the left hip, right elbow, and right hip pressure ulcers documented to administer medication/treatments as per the Physician; Weekly wound care charting/rounds; Monitor for signs and symptoms of infection (redness, increase temperature, warmth, increase drainage, inflammation); Monitor healing process; assess weekly; and to Monitor/report changes in ulcer's size, drainage and odor. The Wound Care Registered Nurse (RN #2) was interviewed on 6/1/2021 at 1:00 PM and stated they (RN #2) was off from work when the resident was admitted , and that RN # 3 completed the wound assessment. RN #2 further stated that all the wounds should have the measurements including depth, color, presence of eschar, presence of undermining, odor, and drainage. The wound care physician assessment should include a complete assessment of each of the resident's pressure ulcers. RN #3 was interviewed on 6/1/2021 at 1:30 PM and stated Resident #36's wound assessments were not thorough. RN #3 could not explain why they were not thorough and stated wounds that are Stage 3 and Stage 4 had depth that were not documented. RN #3 further stated they (RN #3) could not recall the depth of the pressure ulcers. The Wound Care Physician was interviewed on 6/2/2021 at 11:23 AM and stated that the Wound Care Physician did not have access to the Electronic Medical Record (EMR) and all of the wound assessments were documented on paper. The Wound Care Physician stated the documentation is poor and a better system will be implemented to ensure thorough assessments are documented. The Wound Care Physician stated they (the Wound Care Physician) was relying on the nursing staff to document the wound measurements, odor, drainage, undermining and color. The Wound Care Physician further stated that they did not assess the right elbow wound because this was not brought to their attention. The Director of Nursing Services (DNS) was interviewed on 6/2/2021 at 4:13 PM and stated a thorough assessment should be documented every time the resident's wounds were assessed by the Wound Care Team. 415.12(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey completed on 6/2/2021 the facility did not maintain an Infection Prevention and Control Program designed to help prevent the development and transmission of communicable diseases and infections on 1 of 2 nursing units. Specifically, during a medication pass observation for Resident #289, who was on isolation precautions for clostridium difficile (C-Diff) infection, the Licensed Practical Nurse (LPN #1) did not don (put on) appropriate Personal Protective Equipment (PPE) as indicated on the sign posted at the resident's doorway and did not perform hand hygiene. The finding is: The facility's policy titled Transmission-Based Precautions (TBP), revised on 10/28/2020, documented that nursing staff will don appropriate PPE when entering resident's room and remove all PPE before exiting the resident's room. Resident #289 was admitted to the facility with diagnoses including Malnutrition, Scoliosis, and Fusion of Spine (cervical and lumbar region). The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A physician's order dated 5/25/2021 documented Vancomycin (Antibiotic) Oral Solution 500 milligram (mg)/6 milliliter (ml), give 125 mg four times per day for 10 days for Diarrhea. A physician's order dated 5/26/2021 documented Isolation Precautions Secondary to Possible C-Diff. A laboratory report dated 5/27/2021 documented the resident was positive for C. Difficile toxin. A nursing progress note dated 5/27/2021 documented that the laboratory reported the resident was positive for C-Diff and GDH antigen (an antigen that is produced by C-Diff). During a medication pass observation on 6/2/2021 at 9:09 AM a sign was observed outside Resident #289's room that documented Contact/Droplet Precautions. The sign also indicated that providers and staff must put on gloves and a gown before entering and discard the gloves and gown before exiting the resident's room. LPN #1, medication nurse, was observed entering Resident #289's room with a plastic tray that contained a medication cup and the water cup to administer medications to the resident. LPN #1 was wearing a mask and a face shield but did not put on gloves or a gown. LPN #1 placed the plastic tray on the over-bed table; the resident consumed the medication with the water. LPN #1 then picked up the plastic tray and brought the tray outside of the room and placed the tray on top of the medication cart. LPN #1 put on gloves and sanitized the plastic tray with a germicidal wipe but did not wash their hands. LPN #1 medication nurse was interviewed on 6/2/2021 at 9:12 AM after the nurse exited the resident's room. LPN #1 stated that the resident had a C-Diff infection, and a gown and gloves should have been put on prior to entering the room. LPN #1 further stated that not having donned a gown and gloves and not washing hands was an oversight. The unit Registered Nurse (RN) Supervisors #2 and #3 were interviewed concurrently on 6/2/2021 at 1:24 PM. They stated the resident was being treated with Vancomycin for C-Diff. They stated the diarrhea has subsided; however, the resident remains on isolation precautions until the Vancomycin is completed. They stated LPN #1 should have worn gloves and a gown when conducting the medication pass. The RN Infection Preventionist (IP) was interviewed on 6/2/2021 at 1:37 PM. The IP stated full PPE is needed if coming in contact with the resident, but for giving medications to an alert resident who is on isolation precautions the gown and gloves may not be necessary if the nurse does not have direct contact. The IP stated gown and gloves would have to be put on if the resident required additional assistance that required contact. The IP stated hand washing is recommended rather than use of the hand sanitizer when working with a resident who has a C-Diff infection. The IP further stated that hand washing should have been done after LPN #1 exited the resident's room. 415.19(a)(1-3)