Based on observation, record review, and interview during the recertification survey dated 05/30/23 through 06/06/23, the facility did not ensure food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in the main kitchen. Specifically, one (1) of 2 food temperature thermometers were found to be not in calibration when tested in a standard ice-bath method, and the correct test kit to measure the concentration of chemical sanitizer used to manually sanitize food contact surfaces (sanitizer) has color graduations that do not exceed 400 parts per million (ppm) and cannot test sanitizer concentrations exceeding the manufacturer specifications (the label on the bottle of sanitizer states the sanitizer is to be diluted to between 200 ppm and 400 ppm when sanitizing food contact surfaces). This is evidenced as follows: During observations of the main kitchen on 06/05/23 at 11:49 AM, one of 2 food temperature thermometers was found not in calibration when tested in a standard ice-bath method as follows: 5 degrees Fahrenheit. The label on the bottle of concentrated sanitizer titled Barrier II Disinfectant, Sanitizer, Virucide, Deodorizer (label not dated) states the sanitizer is to be diluted to between 200 ppm and 400 ppm when sanitizing food contact surfaces. The label of the test kit titled QT 10 Hydrion with an expiration date of 06/15/23, documented color graduations that do not exceed 400 ppm and cannot test sanitizer concentrations exceeding the manufacturer specifications. During an interview with the Administrator and Dietary Manager on 06/05/23 at 12:33 PM, the Administrator stated that the correct test strips will be purchased. The Dietary Manager stated that staff will be re-trained on how to check the thermometer calibration using the ice bath method, and audits will be started for checking thermometer calibration. The Dietary Manager stated that being new to the position, the procedure for checking thermometer calibration was not known, and the vendor was relied upon for providing test papers. 10 NYCRR 415.14(h)

Based on record review, and interviews during the recertification survey, the facility did not ensure residents requiring specialized rehabilitative services were provided with services for 1 (Resident #44) of 1 residents reviewed for rehabilitation. Specifically, for Resident #44, the facility did not ensure a therapy referral entered on 05/24/2023 was addressed by the therapy department in accordance with facility policy. This is evidenced by: Resident #44 Resident #44 was admitted to the facility with diagnoses of cerebral infarction, osteoarthritis, and dementia. The Minimum Data Set (MDS - an assessment tool) dated 04/11/2023, documented the resident was able to make themselves understood, able to understand others, and was severely cognitively impaired. The Policy and Procedure (P&P) titled Therapy Services Evaluation/Referrals, revised 02/2023, documented upon receipt of a rehabilitation referral in the Electronic Medical Record (EMR), therapy staff (Physical Therapy (PT), Occupational Therapy (OT), or Speech-Language Pathologist (SLP) would have 72 hours to respond to the referral, and either complete a screen or an evaluation, and update the care plan and EMR accordingly. The Comprehensive Care Plan (CCP), titled Activities of Daily Living (ADLs), revised 05/16/2023, documented an extensive assist x 1 for transfers with a front-wheeled walker. A therapy referral, dated 05/24/2023 at 09:17 PM, documented for a PT referral for a decrease/increase in functional mobility (transfers, ambulation, bed mobility). The referral did not include the response to the referral by the PT department. During an interview on 06/06/23 at 10:05 AM, Registered Nurse (RN) #1 stated any time there was a change in a resident's ADL status, a therapy evaluation would be entered by an RN. Once the therapy evaluation was entered, the therapy department had 72 hours to respond to the referral. Sometimes there were verbal conversations between nursing and therapy once the therapy evaluations were entered, but they were not sure if there was any kind of formal oversight process to ensure these referrals were completed. They had not heard from therapy regarding Resident #44's referral since it was entered on 5/24/2023. There was no documentation in the EMR that therapy had addressed the referral. This should have been addressed and documented by therapy by 5/27/2023. During an interview on 06/06/23 at 10:52 AM, Physical Therapist (PT) #1 stated PT and OT referrals were entered into the EMR by nursing and reviewed daily by the therapy department. The therapy department was aware of the PT referral made on 5/24/2023 for Resident #44 on 5/25/2023, but the resident was not seen until 5/31/2023; they were not sure why it took so long to see the resident. On 5/31/2023, they and Occupational Therapist (OT) #1 evaluated the resident, but neither of them documented the results of their evaluation. They both should have done this on 5/31/2023 after their evaluations were completed, they were not sure why they did not do this. OT #1 was currently unavailable due to illness. During an interview on 06/06/23 at 11:34 AM, the Director of Nursing (DON) stated on 5/24/2023, Resident #44 seemed to be having increased difficulty with transfers, which was why the therapy referral was entered. Once the therapy referral was entered, the therapy department should have responded and documented the results of their evaluation within 72 hours; this was not done. There was no formal process to monitor therapy referrals to ensure they were being completed in a timely manner once they were entered. If PT and OT evaluations were completed on 5/31/2023, there needed to be corresponding documentation in the EMR with the results. 10 NYCRR 415.16(a)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure the personal privacy and confidentiality of personal and medical records for 1 (East Unit) of 2 units reviewed for privacy and confidentiality. Specifically, the facility did not ensure resident rights to personal privacy and confidentiality of their personal and medical records were maintained on 5/31/2023, 6/2/2023, and 6/6/2023, when facility staff left computer screens unattended on the East Nursing Unit Nursing Station. This is evidenced by: East Nursing Unit: The Policy and Procedure (P&P) titled Confidentiality/Health Insurance Portability and Accountability Act (HIPAA), dated 02/2023, documented health care providers may not use or disclose Protected Health Information (PHI), except as permitted by privacy regulations. PHI was any individually identifiable health insurance information in any form or medium, including names, social security numbers, medical record numbers, date of birth , or Medicaid number. This included written, oral, and electronic communications and records. During an observation on 05/31/23 at 09:09 AM, a list of resident names and images was visible on a computer monitor screen at an unattended medication cart near the East Unit Nursing Station. There were no staff within view of the medication cart. During an observation on 06/02/23 at 08:46 AM, a resident Electronic Medical Record (EMR) profile was visible on the monitor screen of an unattended medication cart near a wall by the East Unit Nursing Station. There were no staff visible near the cart. During an observation on 06/02/23 at 02:13 PM, a list of resident names and images was visible from the hallway on an unattended facility computer monitor screen at the East Unit Nursing Station. There were no staff at the nursing station at the time of the observation. During an observation on 06/06/23 at 08:19 AM, a resident profile was observed from the East Nursing Unit hallway on an unattended computer monitor screen at the nursing station. There were no staff present at the nursing station. During an observation on 06/06/23 at 11:31 AM, a resident profile was observed from the East Nursing Unit hallway on an unattended computer monitor screen at the nursing station; there were no staff present at the nursing station. During an interview on 06/02/23 at 08:48 AM, Licensed Practical Nurse (LPN) #1 stated prior to leaving a medication cart, staff needed to ensure the computer screen was locked, so no resident personal information was visible. They were currently assigned to the medication cart that had resident personal information displayed on the monitor screen. Prior to leaving the medication cart unattended, they should have locked the monitor screen or signed out of the EMR to ensure there was no resident personal information displayed. During an interview on 06/06/23 at 08:20 AM, the Director of Nursing (DON) stated the monitor screen at the East Unit Nursing Station should have been locked out prior to being left unattended by the staff member, as the information on the screen was easily visible from outside the nursing station in the hallway. Prior to leaving any computer, including at the nursing station or at a medication cart, staff were responsible for either logging out of the EMR or locking the monitor screens to ensure no resident information was visible. During an interview on 06/06/23 at 10:05 AM, Registered Nurse (RN) #1 stated before leaving any computer, staff were responsible for signing out of the EMR, or locking the monitor screen, to make sure there was no resident personal information present and left unattended. During an interview on 06/06/23 at 11:32 AM, the DON stated the resident profile observed at the East Unit Nursing Station at 11:31 AM should not have been left unattended. This was a HIPAA and resident privacy concern. This was addressed with the staff after the incident that occurred earlier in the day on the East Unit, they were not sure why this was happening again. 10 NYCRR 415.3(e)(1)

Based on observations, interviews and record review during a recertification survey, the facility did not ensure that based on the comprehensive assessment, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #14) of 2 residents reviewed for pressure sores. Specifically, for Resident #14, who was at risk for developing pressure sores, the facility did not ensure interventions were developed and provided to prevent the development of pressure sores. This is evidenced by: A facility policy titled Alteration in Skin Integrity: Management and Tracking revised 6/1/2020, documented the facility will identify, monitor and treat all new skin areas according to best practice and CMS regulations to promote healing and prevent further skin breakdown. A new Braden Score Risk Assessment (an assessment tool to determine risk of developing a pressure sore - 18 or less is considered at risk for developing a pressure ulcer) should be completed, and the Registered Dietitian will be notified of any new pressure injury stage 2 or higher. Resident #14: The resident was admitted to the facility with diagnoses of Parkinson's disease, dementia, and hypertension. The Minimum Data Set (MDS- an assessment tool) dated 12/17/2020, documented the resident had moderately impaired cognitive skills for daily decision making; required extensive assistance of one staff for transfers, toileting, and personal hygiene and limited assist of one person for bed mobility and walking; and had no pressure ulcers but was at risk of developing a pressure ulcer. Section V of the MDS (used to make decisions on what care planning is needed) documented that the resident triggered as being at risk for pressure ulcer development and that it was addressed in a Comprehensive Care Plan (CCP). Review of the resident's Braden scales documented the following: - on 12/14/2020, 12/30/2020, and 3/9/2021, the resident had no sensory perception impairment - (ability to respond meaningfully to pressure related discomfort); Moisture (degree to which the skin is exposed to moisture) - occasionaly moist, Activity - walked occasionally during the day but for very short distances; spends a majority of each shift in bed or a chair, Mobility (ability to change body position) - slightly limited made frequent though slight changes in body or extremity position independently. This gave the resident a score of 18. - on 4/30/21, the resident had slightly limited sensory perception; Sensory Perception - slightly limited: cannot communicate discomfort or the need to be turned, Moisture- very moist, Activity - walks occasionally during the day but for very short distances; spends a majority of each shift in bed or a chair, Mobility- very limited: makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently, Nutrition- probably inadequate, and Friction and Shear - requires moderate to maximum assistance in moving, complete lifting without sling against sheets is impossible, frequently slides down in bed or chair requiring frequent repositioning. This gave the resident a score of 13. The Comprehensive Care Plans (CCP) were as following: -Skin Intergrity dated 12/15/2020 and last reviewed on 4/17/2021, did not include interventions to prevent pressure sores. -Alteration in skin integrity related to an Actual PU dated 4/23/2021, documented a stage 3 Sacral measuring 4 cm x 38 cm x 0.2 cm. obtain orders, refer to weekly skin tracking for weekly wound assessments, standard pressure reducing, rehab as needed for ROM, mobility and positioning if indicated, ongoing evaluation of alternative pressure reducing cushion, evaluate for changes to current Turning and Positioning (T&P) schedule per skin care at risk, refer to wound care consultant as indicated. A Personal Care Profile (a care plan for Certified Nursing Assistants (CNA)) to let them know what care they are to deliver to the resident), last reviewed 4/13/2021, documented that on 1/27/2021, comfort (standard) cushion in w/c and leg rests. A CCP for Alteration in Skin Integrity related to an Actual PU dated 4/23/2021, documented a stage 3 Sacral measuring 4 cm x 38 cm x 0.2 cm. obtain orders, refer to weekly skin tracking for weekly wound assessments, standard pressure reducing, rehab as needed for ROM, mobility and positioning if indicated, ongoing evaluation of alternative pressure reducing cushion, evaluate for changes to current Turning and Positioning (T&P) schedule per skin care at risk, refer to wound care consultant as indicated. The CCP for At Risk for Alteration in Skin Integrity dated 12/15/21, did not include a turning and positioning, toileting schedule, or referral to the wound care consultant. A Personal Care Profile (a Care plan for Certified Nursing Assistants (CNA) to let them know what care they are to deliver to the resident), last reviewed 4/13/21, documented that on 1/27/21, comfort (standard) cushion in w/c and leg rests. The resident was an extensive assist of 1 for ambulation, bed mobility, transfers, and toileting The current Personal Care Profile obtained from the resident's room and copied for surveyor on 5/5/2021, last reviewed 4/29/2021, documented that on 1/27/2021, comfort (standard) cushion in w/c and leg rests. There were offloading interventions added. The following observations were made: -05/03/2021 at 10:10 PM -11:35 AM, 05/05/2021 at 09:42 AM, 10:43 AM - 10:47 AM, and 03:07 PM, 05/06/21 at 03:07 PM, and 05/07/21 from 09:21 AM - 9:28 AM, the resident was sitting in a chair across from the nursing station. The resident did not attempt to get up or to reposition. -05/04/2021 at 10:30 AM - 12:50 PM, the resident did not attempt to get up or change position. At 11:40 AM, the Activity Aid (AA) attempted to toilet the resident but the resident would not stand so she was not toileted. A Progress Note dated 4/22/2021 at 8:15 AM, written by Registered Nurse Manager (RNM) #1, documented the resident was noted with 2 circular open areas to the sacrum, 2 centimeters (cm) x 2 cm on the lower sacral area. The site was cleaned and Medi-honey alginate (a pressure ulcer treatment) and a dry dressing was applied. The resident's medical record did not include further documentation of this area from 04/22/2021 till the date of survey. During an interview on 05/06/2021 at 09:30 AM, Certified Nursing Assistant (CNA) #1 stated the resident could not walk and could not turn and position themselves in bed. During an interview on 05/07/2021 at 11:39 AM, Registered Nurse Manager (RNM) #1 stated she was responsible for care planning and there should have been a care plan in place for the resident's risk for pressure ulcer (PU) development prior to the resident developing the pressure ulcer. RNM #1 stated it was hard to get things done sometimes as staffing was an issue and she sometimes has to take a medication cart. During an interview on 05/07/2021 on 12:02 PM, Physical Therapist (PT) #9 stated she became aware the resident had a pressure sore today when nursing asked for a ROHO cushion. PT usually assessed for an offloading cushion and nursing for a Turning and Positioning (T&P) and toileting schedule. During an interview on 05/07/2021, at 09:38 AM, the Director of Nursing stated there should have been an at risk for a PU care plan in place prior to the development of a PU, and this could have contributed to the pressure sore. Based on what she was seeing now the pressure sore could have been avoidable. 10 NYCRR 415.12(c)(1-2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews during a recertification survey, the facility did not ensure residents received adequate supervision to prevent accidents for 1 (Resident #3) of 4 residents reviewed for accidents. Specifically, for Resident #3, who was at high risk for choking, the facility did not ensure the resident was not kept in their room with the door closed. This is evidenced by: Resident #3: The resident was admitted to the facility with diagnoses of dysphasia, dementia, and Wernicke's encephalopathy. The Minimum Data Set (MDS- an assessment tool) dated 9/30/2020, documented the resident had moderately impaired cognitive skills for daily decision making. The following observations were made: -05/03/2021 at 10:00 AM and 11:35 AM, the resident was in his/her room with the room door closed. -05/03/2021 at 12:31 AM, the resident's tray was delivered to his room and the door was closed. -05/05/21 at 08:40 AM, and 05/07/21, at 09:18 AM, the resident was in his/her room with his /her meal tray. The resident room door was shut. 05/04/2021 at 12:35 PM, staff delivered the residents tray to his/her room, set it up, and left the room. -05/05/2021 at 09:08 AM, the resident was in the hall eating breakfast, was coughing frequently during the meal and staff were heard telling the resident to slow down. -05/06/2021 at 03:06 PM, the resident was in their room and the door shut. Finding #1: The facility did not ensure the resident who was at risk for choking was not left alone in his/her room with the door shut during meals. A Speech Therapy SLP Discharge summary dated [DATE], documented the resident required close supervision for oral intake. The CCP for Swallowing Problem related to coughing during meals or with medications and swallowing evaluation results 10/22/2019, documented the resident had a hospital stay for aspiration pneumonia and interventions were as follows; small bites and sips, alternate between bites and sips and close supervision for meals. A Medical Doctor Order dated 4/24/2021, documented; diet pureed texture and honey thick consistency. The Certified Nursing Assistant Care Card obtained from the resident's room and copied for the surveyor on 5/5/2021, documented the resident required setup and supervision. regular honey thick liquids, close supervision for the meal small bites and sips alternate bites and sips. During an interview on 05/06/2021 at 03:25 PM, Certified Nursing Assistant (CNA) #4 stated they give the resident their meal tray in the room and shut the door; the resident eats by himself. During an interview on 05/06/2021 at 03:37 PM, Registered Nurse Manager (RNM) #1 stated the resident was at risk for choking and should not be in his room alone while eating. During an interview on 05/07/2021 at 10:22 AM, the Director of Nursing (DON) stated Speech Therapy recommended close supervision, which means the resident needed to be in a placed where he/she could be seen during meals. It was not appropriate to have the resident in his/her room alone while the resident was eating. He/she should be out in the common area or have someone with him//her if eating in his/her room. Eating alone in their room put the resident at risk for choking. 10 NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey and an abbreviated survey (Case #NY00268487), the facility did not ensure comprehensive person-centered care plans were developed and implemented for each resident that included measurable observations and time frames to meet a resident's medical, nursing, mental and psychosocial needs for five (5) (Resident #'s 3, #14, #86, #87, and #285) of nineteen (19) residents reviewed. Specifically for Resident #3, the facility did not ensure the comprehensive care plan (CCP) for swallowing was implemented, for Resident #14, that a CCP was developed and implemented for at risk for pressure ulcers, for Resident #86, the facility did not ensure a CCP was developed for cast care, for Resident #87, the facility did not ensure the intervention for oxygen administration on the comprehensive care plan was consistently implemented. Additionally for Resident #285 the facility did not ensure it implemented the care plan to offer the resident to get out of bed before lunch and dinner. This is evidenced by: The facility Policy and Procedure titled, Interdisciplinary Care Plans last reviewed 4/21, documented the care plan would be person centered and reflective of the needs and goals of the individual residents that are served. Resident #86 The resident was admitted to the facility with diagnoses of non displaced fracture of the head of the left radius, impacted cerumen and acute vaginitis. The Minimum Data Set (MDS-an assessment tool) was not yet completed. The resident was alert and oriented. The Comprehensive Care Plan did not include a care plan for the presence or care of the residents left arm cast. During an interview on 05/06/21 at 11:32 AM, Certified Nursing Assistant (CNA) #2 stated the cast does not come off. There is no instructions to the CNAs on their Care Cards regarding the residents cast. During an interview on 05/06/21 at 03:32 PM, Registered Nurse Manager (RNM) #1 stated she was responsible for the care planning. and did not know why there was no care plan in place but there should have been. Resident #87 The resident was admitted to the facility with diagnosis of cerebral infarction, major depressive disorder and essential (primary) hypertension. The Minimum Data Set (MDS - an assessment tool) dated 3/25/2021, documented the resident was cognitively intact, able to make self-understood and able to understand others and required oxygen therapy. During observations on 5/3/2021 at 9:50 AM, 5/4/2021 at 10:30 AM, and 5/5/2021 at 10:25 AM, Resident #87 was seated in a common area with an oxygen canister attached to their walker without oxygen tubing connected to the cannister or attached to the resident. A Medical Doctor's order dated 3/17/2021 documented to administer oxygen at 3 liters per minute via nasal cannula continuously every shift and to check liter flow and placement. The CCP for Potential for Alteration in Respiratory Function related to COPD (chronic obstructive pulmomary disease) Interventions/Approaches, reviewed on 3/30/2021 included an intervention to administer oxygen as ordered. A Medication Administration Record dated May 2021, documented the resident received oxygen 3 liters per minute via nasal canula continuously for the day shift on 5/3/2021, 5/4/2021, and 5/5/2021. During an interview on 5/5/2021 at 11:08 AM, Licensed Practical Nurse (LPN) #1 stated Resident #87 only received oxygen while in their room. LPN #1 stated the resident would remove their oxygen when out in the common area as they felt embarrassed with it in place. LPN #1 stated she did not make the Unit Manager or MD aware of the resident's refusal to wear oxygen continuously. During an interview on 5/5/2021 at 11:11 AM, Nurse Practitioner (NP) #7 stated she was not made aware Resident #87 was not wearing oxygen continuously. During an interview on 5/5/2021 at 12:02 PM, Registered Nurse Unit Manager (RNUM) #1 stated she was aware Resident #87 only used oxygen at nighttime. RNUM #1 stated the NP or MD should have been made aware the resident was not receiving oxygen per MD orders, staff should not sign for medication that was not administered and the care plan should followed. Resident #285 Resident #285 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, depression, osteoarthritis and pain. The Minimum Data Set (MDS-an assessment tool) dated 1/15/2021, documented the resident required two-person physical assistance for bed mobility and transfers. Resident #285 was observed in bed on 5/3/2021 at 12:10 PM, 5/4/2021 at 10:01 AM, 5/5/2021 at 10:40 AM 5/7/2021 at 10:05 AM, 5/7/2021 at 11:15 AM, and at 5/10/2021 at 12:15 PM. A facility document titled Resident/ Resident Representative Grievance Form, documented the resident and resident representative verbalized concerns over the resident being in a recliner for extended periods of time. A resolution/ outcome documented the resident would be scheduled out of bed for lunch and dinner and be placed back to bed in two hours for comfort as allowed. The Comprehensive Care Plan for Alteration in Comfort/ Pain, updated 11/18/2020, documented the resident would be scheduled out of bed for lunch and dinner and placed back to bed in two hours for comfort as the resident allowed. A facility document titled, Personal Care Profile, used to direct care given to residents by CNAs, did not include getting the resident out of bed for lunch or dinner, or ensuring the resident was returned to bed within two hours. An evaluation date of 11/19/2020 documented the resident was pleased with the new intervention in place and voiced no concerns. During an interview on 5/3/2021 at 12:10 PM, Resident #285 stated they do not regularly get out of bed. The resident stated the staff are extremely busy and therefore are not always available to get her back to bed in a reasonable timeframe. Resident #285 stated the staff do not offer them to get out of bed daily, and not before lunch and dinner regularly. Resident #285 stated they have not been out of bed in a couple of weeks. During an interview on 5/7/2021 at 11:00 AM, CNA #3 stated they only get Resident #285 out of bed when they ask to get up. CNA #3 stated the resident does not have a specific intervention to get out of bed for meals, or to be put back in bed within a certain time frame. During an interview on 5/10/2021 at 12:28 PM, the Director of Nursing (DON) stated they would expect staff to offer the resident to get out of bed before lunch and dinner. The DON would expect the care plan on paper, the care plan in the electronic medical record and the personal care profile to match. The DON stated if the resident refused to get out of bed, this should be documented in the medical record. 10NYCRR415.4(b)(1)(i)

Based on observation, interview and record review during a recertification survey, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases, and infection. Specifically, for 1 (West Unit) of 2 Units, which was on contact and droplet precautions, the facility did not ensure staff consistently wore gowns and gloves prior to direct contact with residents; for 2 (West and East Units) of 2 units, the facility did not ensure staff performed hand hygiene after assisting a resident to ambulate, after administering injectable medications, or after checking a blood glucose level, before touching clean multi-resident areas; and did not disinfect multi-resident use glucometers (machine used to check a blood glucose level) after resident use and before returning the glucometer to the clean multi-resident use medication cart. Additionally, the facility did not ensure it maintained a system of surveillance to identify, investigate or control infections and communicable disease for all residents in the facility. This is evidenced by: The Centers for Disease Control and Prevention (CDC) Guidance titled Transmission-Based Precautions (undated), provides: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal Protective Equipment (PPE) upon room entry and properly discarding before exiting the patient room is done to contain pathogens. The Centers for Disease Control and Prevention (CDC) guidance titled Using Personal Protective Equipment (PPE), updated 08/19/2020, further documents that gloves and gown shall be removed (doffed) before exiting a patient's room. The Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, dated 2/23/2021, recommended the following additional strategies to minimize chances for exposure to COVID-19: Hand Hygiene: HCP [healthcare personnel] should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. The Centers for Disease Control and Prevention (CDC) guidance titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated on 3/29/2021 provides: Because of the high risk of unrecognized infection among residents, a single new case of SARS-CoV-2 infection in any HCP (healthcare provider), or a nursing home-onset SARS-CoV-2 infection in a resident should be evaluated as a potential outbreak and although most care activities require close physical contact between residents and HCP, when possible, maintaining physical distance between people (at least 6 feet) is an important strategy to prevent SARS-CoV-2 transmission. The CDC guidance also documented: -HCP should care for residents using an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. -Residents should generally be restricted to their rooms and serial SARS-CoV-2 testing performed. -Consideration should be given to halting social activities and communal dining; if these activities must continue for uninfected residents, they should be conducted using source control and physical distancing for all participants. The New York State Department of Health (NYSDOH) Revised Health Advisory entitled COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and updated 7/10/2020, documented that if there are confirmed cases of COVID-19 in a Nursing Home, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The facility Policy and Procedure, Amended Droplet Precautions for COVID-19- Surveillance undated, documented: Gowns will be worn when providing direct care, when close contact with a resident when they are not wearing a mask is anticipated, and anytime in the resident's room. During an interview on 5/3/21 at 11:30 AM, the Director of Nursing (DON) stated a Certified Nurse Assistant (CNA) that worked on both units in the facility tested positive for COVID-19 on 4/20/21. The DON stated all residents in the facility were on contact and droplet precautions through 5/4/21. Finding #1 The facility did not ensure staff on 1 (West Unit) of 2 units on contact and droplet precautions consistently wore gowns or gloves prior to coming into contact with residents. During an observation on of the [NAME] Unit 5/3/2021 at 11:41 AM, Licensed Practical Nurse (LPN) #7 entered Resident #135's room with a glucometer in her hand. LPN #7 did not don (put on) a gown prior to checking the blood glucose level of Resident #135. LPN #7 exited the resident's room, obtained insulin from the medication cart, entered Resident #135's room and administered insulin to the resident. LPN #7 did not don a gown prior to entering the resident's room either time. During an observation of the [NAME] Unit on 5/4/21 at 9:34 AM, Certified Nurse Assistant (CNA) #5 took a resident by the hand and assisted the resident to walk to a chair in the common area. CNA #5 placed her arm around the resident to sit in the chair. CNA #5 did was not wearing a gown or gloves while coming into contact with the resident. During an interview on 5/3/2021 at 11:45 AM, LPN #7 stated all residents in the facility were on contact precautions. LPN #7 stated staff were expected to don a gown prior to providing personal care to residents. The LPN stated a gown was not needed prior to checking a blood glucose or administering insulin to a resident. During an interview on 5/4/2021 at 9:38 AM, CNA #5 stated staff were expected to wear a gown when toileting or bathing a resident only. CNA #5 stated she was not expected to wear a gown when assisting a resident to ambulate. During an interview on 5/4/2021 at 9:53 AM, the Infection Control Practitioner (ICP) stated all residents were on amended droplet and contact precautions due to a staff testing positive for COVID-19 on 4/20/2021. The ICP stated staff were expected to don a gown and gloves at all times prior to coming into contact with a resident and or their environment. The ICP stated staff were expected to wear a gown and gloves when checking a blood glucose level, administering insulin, or when assisting a resident to ambulate. Finding #2: The facility did not ensure staff performed hand hygiene after direct contact with residents and prior to coming into contact with clean multi-resident use equipment and surfaces in the environment. The facility Policy and Procedure titled Standard Precautions for Infection Control last reviewed on 2/2/2021, documented hands would be washed after gloves are removed and between resident contacts. During an observation of the [NAME] Unit on 5/3/2021 at 11:43 AM, LPN #7 exited Resident #135's room with a glucometer in one hand and gloves in another. LPN #7 placed the gloves in the garbage and placed the glucometer on top of a multi-resident medication cart, opened the top drawer of the medication cart and removed an insulin pen and a needle from the drawer. The LPN did not perform hand hygiene. During an observation of the [NAME] Unit on 5/4/2021 at 9:34 AM, CNA #5 assisted a resident to ambulate to a chair in the hallway while holding the resident's hand. The CNA walked to a clean linen cart and removed a towel and washcloths, walked down the hall and lifted a cover from a different clean linen cart and touched several items without removing anything. CNA #5 did not perform hand hygiene after coming into contact with a resident and prior to touching a clean multi-resident use linen cart. The CNA walked back up the hallway and picked up a crumbled tissue from the floor and discarded the tissue in the trash. The CNA placed the towel and washcloths on the nurse's station and entered a resident's room to answer the call bell. CNA #5 did not perform hand hygiene after picking up a discarded tissue from the floor and prior to entering the resident's room. During an observation of the [NAME] Unit on 5/6/2021 at 12:20 PM, LPN #5 prepared and administered oral medication to a resident. LPN #5 exited the resident's room carrying a food tray, placed the food tray on a table and proceeded to prepare another resident's medications. LPN #5 did not perform hand hygiene after exiting the resident room and before preparing medications for administration. During an interview on 5/3/2021 at 11:44 AM, LPN #7 stated she should have performed hand hygiene after testing the resident's blood glucose and removing her contaminated gloves and prior to entering the medication cart. During an interview on 5/4/2021 at 9:39 AM, CNA #5 stated she should have performed hand hygiene after coming into contact with the resident and prior to touching the clean linen cart. The CNA stated she should have donned gloves before picking up the soiled tissue on the floor, doffed (remove) the gloves and performed hand hygiene prior to answering the residents call bell. During an interview on 5/4/2021 at 9:53 AM, the ICP stated staff were expected to perform hand hygiene before and after coming into contact with a resident, a resident's environment and prior to contact with a clean multi-resident use area. During an interview on 5/6/2021 at 12:20 PM, LPN #5 stated hand hygiene should be done prior to exiting a resident's room or if unable then prior to touching anything. Finding #3: The facility did not ensure a multi-resident use glucometer (machine used to check a blood glucose level) was disinfected after resident use and before returning it to the multi-resident use medication cart on 2 (East and [NAME] Unit) of 2 Units. In 2010, the FDA and CDC issued clinical reminders and public health notifications highlighting the risk of transmission of disease from shared use of fingerstick (lancing) devices and point of care blood testing devices; see e.g.: FDA Public Health Notification: Use of Fingerstick Devices on More than One Person Poses Risk for Transmitting Bloodborne Pathogens: Initial Communication (Original publication: 8/26/2010; Updated: 11/29/2010), and CDC Clinical Reminder: Use of Fingerstick Devices on More than One Person Poses Risk or Transmitting Bloodborne Pathogens (Issued: 8/23/2010) . The aforementioned CDC guidance states, for example: [F]ingerstick devices should NEVER be used for more than one person. This is not a safe practice for several reasons. Improper use or device malfunction can lead to the use of a contaminated lancet blade on more than one patient. POC blood testing devices can also be a source of bloodborne infections if used on multiple patients, because it is difficult for healthcare staff to ensure that all blood has been removed from these devices and the reusable portions of the fingerstick device. If contaminated blood is left on them, this could result in bloodborne pathogen transmission among patients. Failure of healthcare personnel to change gloves between patients could also result in bloodborne pathogen transmission. In 2017, the FDA issued updated guidance on this topic, titled Letter to Manufacturers of Blood Glucose Monitoring Systems Listed With the FDA (updated: 11/27/2017), providing: The disinfection solvent you choose should be effective against HIV, Hepatitis C, and Hepatitis B virus. Please note that 70% ethanol solutions are not effective against viral bloodborne pathogens. And: Point of care blood testing devices such as blood glucose meters should be used only on one patient and not shared. If dedicating blood glucose meters to a single patient is not possible, the meters must be properly cleaned and disinfected after every use. The manufacturer's instructions for the blood glucose meter used by the facility did not include instructions for multi-patient use. East Unit During an East Unit medication administration observation on 5/6/2021; at 12:12 PM Licensed Practical Nurse (LPN) #5 was observed to perform blood glucose testing on a resident and placed the testing device on the multi-patient use medication cart without cleaning the device. When asked, LPN #5 stated, I usually clean it with an alcohol wipe after each use, but I did not, I will now. During an interview on 05/07/2021 12:24 PM, LPN #6 stated, the glucometer should be cleaned before and after each use with a sanitizing wipe. West Unit During an observation on 5/3/2021 at 11:43 AM, LPN #7 exited Resident #135's room with a glucometer in one hand and gloves in the other. LPN #7 discarded the gloves in the garbage and placed the glucometer on top of the clean multi-resident use medication cart. LPN #7 opened the top drawer of the medication cart, removed 2 items placed them on-top of the medication cart, and removed a pair of gloves from a box. LPN #7 donned gloves removed a tissue from a box on-top of the medication cart, squirted hand sanitizer on the tissue and wiped the glucometer off. LPN #7 placed the glucometer in the top drawer of the medication cart. During an interview on 5/3/2021 at 11:46 AM, LPN #7 stated disinfectant wipes are available in the facility, however she did not have any stocked in her medication cart and thought hand sanitizer was an acceptable replacement as it contained alcohol. LPN #7 stated she did not know CDC's guidance on cleansing multi-resident use glucometers. During an interview on 5/7/2021 at 1:10 PM, the ICP stated the expectation was that staff would use Sani-wipes for disinfecting glucometers after each resident use. The ICP stated hand sanitizer was not an acceptable replacement to disinfect a multi-resident use item. Finding #4: The facility did not ensure it maintained a system of surveillance to identify, investigate or control infections and communicable disease for all residents in the facility. The facility Policy and Procedure, Surveillance of Nosocomial Infections last reviewed 2/2/2021, documented each unit would maintain a line list with a new line listing beginning each month. Infections would be tabulated according to body site, geographic locations, and type of pathogen. During an interview on 5/7/2021 at 1:12 PM, the ICP stated the expectation was that the ICP would keep a list of all infections in the facility. The ICP stated there was an incomplete list on the East Unit from April 2021, but this had not been updated and did not contain all of the identified infections on that unit. The ICP stated the ICP was previously the Unit Manager for the East Unit and took over the ICP position last week. During an interview on 5/10/2021 at 12:12 PM, the DON stated the facility was aware that the previous ICP was not accurately tracking communicable diseases for the facility. The DON stated the expectation was that the ICP would have an ongoing updated list of all infections that occurred within the facility. The DON stated the [NAME] Unit did not have a tracking list since January of 2021. The DON stated the facility did not have a system to track and monitor infections. 10 NYCRR 415.19 (a)(1-3); (b)(4); 10 NYCRR 400.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure that written notice of transfer or discharge was provided to the Office of the State Long-Term Care Ombudsman for 2 (Resident #'s 33, and #51) of 2 residents reviewed for hospitalization. Specifically, the facility did not provide written notice to the Ombudsman when residents were transferred to the hospital from the facility. This was determined by: Resident #33: The resident was admitted to the facility on [DATE], with the diagnoses of dementia, dysphagia, and pneumonia. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition, could rarely or never understand others and could rarely or never make himself understood. During a record review on 04/16/19 at 02:30 PM, nursing progress notes documented the resident was sent to the hospital on [DATE] and returned to the facility on [DATE]. There was no documentation that written notification was provided to the Ombudsman regarding the resident's transfer to the hospital. Resident #51: The resident was admitted to the facility on [DATE] with the diagnoses of atrial fibrillation, diabetes mellitus, and osteoporosis. The Minimum Data Set (MDS) dated [DATE], documented the resident had severe cognitive impairment and was sometimes able to understand others and was usually able to make herself understood. The nursing progress notes documented the resident was sent to the hospital on [DATE] and returned to the facility on [DATE]. There was no documentation that written notification was provided to the Ombudsman regarding the resident's transfer to the hospital. During an interview on 4/17/19 at 2:26 PM, the Director of Resident and Family Services stated he did not send the Ombudsman written notice of a resident's transfer or discharge to the hospital. He stated he would only notify the Ombudsman's office when a resident was discharged from the facility against medical advice (AMA) or when the discharge was initiated by a resident or family. He stated the Ombudsman was not notified of facility initiated discharges. 10NYCRR415.3(h)(1)(v)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it conducted initially and periodically, a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for one (Resident # 9) of one resident reviewed for dental, one (Resident #62) of two residents reviewed for Range of Motion (ROM) and one (Resident #50) of four residents reviewed for nutrition. Specifically, the facility did not ensure that they coded Resident #9 as having broken teeth, Resident #62 as having a limited ROM, and Resident #50 as having a significant weight loss. This is evidenced by: Resident #9: The resident was admitted to the nursing home on 9/26/19 with diagnoses of diabetes, hypertension, depression, post poliomyelitis syndrome, general anxiety disorder, panic attacks, CAD (coronary artery disease). The Minimum Data Set (MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. During an observation on 1/14/19 at 12:15 PM, the resident was noted with natural teeth. A comprehensive MDS, Section L, dated 1/14/19 documented the resident had no natural teeth. Dental Consult Notes documented the following; 2/9/18 - The resident had a chipped tooth repaired 7/15/18 - The resident was seen for a broken tooth (#23) that was previously repaired. The tooth was stable and a repair would be scheduled. 8/4/18 - Tooth #23 was repaired. The resident was told to be careful chewing hard foods. 9/21/18 - The resident was seen per request for a fracture in tooth #20. 10/19/18 - tooth #20 was repaired. The resident was told to be careful chewing hard foods. During an interview on 4/15/19 at 12:15 PM, the resident stated she has problems with her teeth breaking. During an interview on 4/17/19 1:42 PM, the MDS Coordinator stated that she looked over dental consults and would have CNAs update information every quarter. There is an issue with the accuracy of this part of the MDS. Resident #50: The resident was admitted to the nursing home on 1/18/16 with diagnoses of hypertension, diverticulosis, and dementia. The Minimum Data Set (MDS) dated [DATE], assessed the resident had severely impaired cognitive skills for daily decision making. It documented that the resident usually understood and was usually understood by others. Monthly Weight Records documented the following weights: 1/16/19 - 106 pounds (lbs). 2/1/19 - 105.5 lbs. 3/12/19 - 98.5 lbs, which was a 7.1 % weight loss in 1 month. The MDS, Section K, dated 3/15/19, documented the resident weighed 99 lbs., and that the resident did not have a loss of 5% or more in the last month. During an interview on 4/17/19 at 1:42 PM, the MDS Coordinator stated at the time of the resident's review the Dietary Service Manager was doing Section K. The Registered Dietician does them now and the significant weight loss should have been captured on the MDS. Resident #62: The resident was admitted to the facility on [DATE] with diagnoses of depression, seizures, and hypertension. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition, could rarely or never understand others and could rarely or never make herself understood. The MDS documented the resident did not have functional limitation in range of motion to her lower extremities. During an observation on 04/15/19 at 12:12 PM, the resident was observed to have a right knee contracture. A Comprehensive Care Plan (CCP) for mobility, dated 1/2/19, documented the goal was to address the contractures of the resident's bilateral lower extremities, to increase Active Range of Motion (AROM) and Passive ROM (PROM) of bilateral knees to facilitate easier transfers from and into bed by care givers. The MDS Section G, dated 3/21/19, documented the resident had no impairment in the functional limitation in Range of Motion of the lower extremities. During an interview on 4/17/19 at 01:42 PM, the MDS Coordinator stated to complete the section of the MDS for ROM she would look at the resident's chart and ask therapy for input. She stated there was an issue with the accuracy of the MDS if the resident has a contracture and the MDS documents that she does not have a functional limitation to her lower extremities. She stated she is not sure how the inaccuracies occurred and it must have just been missed. During an interview on 04/18/19 at 09:36 AM, Physical Therapist #9 stated the resident's right leg had limited range of motion due to contracture. She stated it would be inaccurate if the resident was coded to have no functional limitation in her lower extremity. 10NYCRR 415.11(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during a recertification survey the facility did not ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable for one (Resident #33) of two resident reviewed for limited mobility. Specifically, for Resident #33, the facility did not ensure positioning devices were applied when the resident, who was dependent for positioning and mobility, was in bed. This is evidenced by: Resident #33: The resident was admitted to the facility on [DATE] with the diagnoses of dementia, dysphasia, and pneumonia. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition, could rarely or never understand others and could rarely or never make himself understood. The MDS documented the resident was an extensive assist of two persons (staff provide weight bearing support and physical assistance) for bed mobility. The Policy and Procedure titled Positioning last updated 04/2019, documented to maintain the resident's proper body alignment through positioning techniques and devices such as splints, braces, slings, pillows, wheelchair cushions, etc and to report any intolerance or refusal of the positioning devices to the charge nurse and supervisor. The Comprehensive Care Plan (CCP) for positioning, last revised 02/18/19, documented the resident had an alteration in positioning related to the diagnoses of pneumonia, congestive heart failure, and dementia. The goal documented to maintain optimal positioning to allow the resident to participate with activities of choice. CCP interventions included two positioning devices while the resident was in bed; an off-loading device for the resident's heels and a wedge shaped off-loading device for turning and positioning the resident in bed. The 24 Hour Shift Report dated 02/18/19, documented therapy issued a positioning wedge for the resident. The Resident Care Card, last reviewed 2/20/19, documented the resident was total assistance for bed mobility and had two off-loading positioning devices for bed mobility: A cushion for his heels and a wedge for positioning. During an observation on 04/16/19 from 9:08 AM to 11:15 AM, the resident was laying on his back without positioning devices in place and did not receive assistance or repositioning from staff. Both off-loading positioning devices were on the floor in the resident's room next to the closet. During an observation on 04/16/19 at 02:15 PM, the resident was laying on his back without positioning devices in place. During an interview on 04/16/19 at 02:20 PM, the Certified Nursing Assistant (CNA) #5 stated the resident was totally dependent on staff for all care. She stated the resident was unable to reposition himself and that staff turned and positioned him every 2 hours when he was in bed. She stated she was not aware the two positioning devices were in the resident's room and that the devices were supposed to be used when positioning the resident in bed. She stated she would normally be made aware when devices were being implemented during shift to shift report or by reading the resident's care card in the closet. She stated the devices should be written on the resident's care card for staff to know. During an interview on 04/16/19 at 02:23 PM, CNA #4 stated she was familiar with the resident's care needs, but was not aware the resident was supposed to have a positioning device in place to off load his heels while in bed. She stated she knew the wedge had been in the resident's room, but was not sure it was consistently being used. During an interview on 04/16/19 at 02:35 PM, Registered Nurse (RN) #1 stated the resident was scheduled to be turned and positioned every 2 hours due to his incontinence and his immobility. She was not aware the resident was supposed to have positioning devices in place when he was in bed. She stated, as the RN Unit Manager, she was responsible for the follow up to ensure devices were in place for all residents, but she had not been made aware the devices were put into place by therapy. She stated she should have been aware and she should oversee that positioning devices were being implemented by the staff. During an interview on 04/16/19 at 03:20 PM, Physical Therapist #10 stated she issued the positioning devices for off-loading in bed due to the resident's immobility and limited range of motion in his lower extremities. She stated therapy determined how the resident tolerated the positioning devices while on therapy program and then educated staff about the devices. She stated she updated the resident's care plan, card card, and wrote any changes on the 24 hour report to communicate the changes to staff. She stated the heel cushion should be used when the resident was on his back in bed and the wedge was to be used when positioning the resident on his side in bed. She stated once the resident was discharged from therapy, it was the responsibility of the unit staff to implement the devices and monitor that the devices were being applied. During an interview on 4/18/19 at 10:27 AM, the Director of Nursing stated all nursing staff should be checking the resident's care cards and care plans to be as familiar as possible with the resident's specific care needs. She stated the CNA's should be putting the positioning devices in place and the RN was responsible to ensure that was happening. She stated when therapy recommended an intervention, it was for the benefit of the resident, and should be implemented. She stated she did not want want a resident to get skin breakdown or pressure areas because offloading devices were not implemented. 10NYCRR415.12(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that resident were as free from accident hazards as possible and that each resident received adequate supervision to prevent accidents, for one (Resident #33) of two resident reviewed for accident hazards. Specifically, for Resident #33, the facility did not ensure the resident received the recommended swallowing precautions, potentially increasing his risk of aspiration pneumonia. This is evidenced by: Resident #33: The resident was admitted to the facility on [DATE] with the diagnoses of dementia, dysphasia (difficulty swallowing), and pneumonia. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition, could rarely or never understand others and could rarely or never make himself understood. The MDS documented the resident required extensive assist (staff provide weight bearing support and physical assistance) of one person for eating. The Policy and Procedure titled Consistency Alterations, last revised 11/2016, documented residents with observed indicators of dysphasia would be referred to the speech therapist for evaluation and meal patterns would take into account the specific recommendations of the speech therapist regarding individual foods. The Policy and Procedure did not address the use of swallowing precaution cue cards when implemented by the Speech Language Pathologist. The Comprehensive Care Plan (CCP) for swallowing function dated 1/30/19, documented the resident had a potential for alteration in swallowing related to holding food in mouth or residual (remaining) food in his mouth after meals and coughing or chocking during meals. The CCP goal was for the resident to remain free from signs and symptoms of choking and aspiration (food or liquids swallowed poorly and going into the lungs). The interventions included feeding the resident at a slow rate, providing small bites and sips, checking for residue in the resident's mouth, using a dry swallow, not using straws and to provide one on one for meals. Physician order date 02/01/19, documented the resident's diet as mechanical soft with nectar thick liquids. The Resident Care Card, updated on 1/31/19, documented the use of a swallowing precaution cue card during meals when feeding the resident. The care card documented swallowing strategies for staff use that included; a dry swallow when needed, to alternate bites and sips, to check the resident's mouth for pocketing, to provide small bites and sips, and not to use straws when feeding the resident. During an observation on 04/16/19 at 12:00 PM, the resident's lunch tray was set up for lunch by dietary in the unit dining room and did not have a swallowing precaution cue card on the tray. During an observation on 04/17/19 at 07:58 AM, a nurse was feeding the resident in his room. The swallowing precaution cue card was not on the resident's food tray for the nurse to use. During an interview on 04/17/19 at 07:58 AM, Licensed Practical Nurse (LPN) #4 stated the resident did not have a cue card with instructions for feeding. She stated she knew how to feed the resident because she was the one who normally fed him when she worked on that unit. She stated she offered the resident a sip of liquid in between bites of food, but was not aware of a swallowing precaution cue card for the resident. During an interview on 4/17/19 at 09:54 AM, the Speech Language Pathologist (SLP) stated when she determined that a resident required a swallowing precaution cue card, she was responsible for attaching the cue card to the white (table) meal cards that dietary placed on the resident meal trays. She stated dietary was responsible for placing the cards on the resident's meal tray for each meal. She stated the resident should have had a cue card on his tray and was unaware it was missing. During an interview on 04/18/19 at 09:55 AM, the Registered Nurse #1 stated she had never seen a cue card for the resident and did not recall that he was supposed to have one. She stated staff fed him in his room. During an interview on 04/18/19 at 10:27 AM, the Director of Nursing stated she was not aware the resident had a cue card issued from speech therapy. She stated it was extremely important the cue card was in place because the resident was at risk for aspiration pneumonia. During an subsequent interview on 04/18/19 at 01:49 PM, the SLP stated the resident should have a swallowing precaution cue card in place as he was at a higher risk to aspirate due to holding food in his mouth. She was not aware that the resident's cue card had gone missing and should have been made aware. She stated she initiated the swallowing precaution cue card when the resident returned from the hospital in January 2019 based on her evaluation and the resident's diagnosis of dysphasia. She stated the resident required swallowing precautions and cueing related to holding food in his mouth and not clearing his mouth of food. She stated when she implemented the cue card she also updated the care plan, care card, and wrote it on the 24 hour (shift to shift) report. She provided education to staff since the resident required one to one assistance for feeding and ate in his room. She stated the resident had a long history of pneumonia and that was why it was so important staff made sure his mouth was cleared of food due to his risk of aspiration. 10NYCRR415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey the facility did not ensure that a resident who needed respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals for 2 (Resident #'s 4 and #53) of 2 residents reviewed for respiratory care. Specifically, for Resident #4, the facility did not ensure the resident was provided with and received the physician ordered number of liters per minute (lpm) of oxygen (O2) on 4 occasions and for Resident #53, the facility did not ensure the resident was provided with and received the physician ordered number of lpm of O2 on 2 occasions. This was evidenced by: Resident #4: The resident was admitted to the facility on [DATE], with the diagnoses of coronary artery disease (CAD), congestive heart failure (CHF) and diabetes mellitus. The Minimum Data Set (MDS) dated [DATE], documented the resident had moderate cognitive impairment and was able to make herself understood and usually able to understand others. The physician (MD) orders dated 9/21/18, documented oxygen (O2) at 2 liters via nasal cannula (lightweight tube used to deliver supplemental oxygen into the nostrils). The Treatment Administration Record (TAR) dated April 2019, documented Oxygen at 2 liters via nasal cannula. The TAR documented nurses initials indicating the oxygen was delivered as ordered for each shift . The comprehensive care plan (CCP) dated 3/28/18 and titled Potential for Alteration in Respiratory and Cardiac Function related to CHF, CAD, and Atrial Fibrillation documented an interventions to administer oxygen as ordered. During an observation on 04/15/19 at 10:59 AM, the resident was lying in her bed with a nasal cannula in her nostrils. The resident's O2 was set on 0.5 lpm via an oxygen concentrator. During an observation on 04/16/19 at 08:35 AM, the resident was sitting up in her bed eating her breakfast, with a nasal cannula in her nostrils and O2 set on 3 lpm via an oxygen concentrator. During an observation on 04/16/19 at 03:10 PM, the resident was sitting up in chair at the nursing station, with a nasal cannula in her nostrils and O2 set on 3 lpm via an oxygen concentrator. During an observation on 04/17/19 at 09:19 AM, the resident was sitting up in bed with a nasal cannula in her nostrils and O2 set on 3 lpm via an oxygen concentrator. Licensed Practical Nurse (LPN) #3 adjusted the resident's O2 from 3 lpm to 2 lpm. During an interview on 4/17/19 at 9:45 AM, LPN #3 stated that the lpm might get changed from staff bumping into the concentrator. The nurses are not supposed to change the lpm without an MD order. The nurses sign the MAR every shift after looking at the O2 concentrator to make sure it is set at the correct lpm. She did not know that the resident's O2 lpm was not correct, it should have been set at 2 lpm. Resident #53: The resident was admitted to the facility on [DATE], with the diagnoses of chronic obstructive pulmonary disease (COPD), dementia and anxiety. The MDS dated [DATE], documented the resident had moderately impaired cognition and was usually able to make himself understood and could understand others. The MD orders dated 3/12/19, documented O2 at 3 lpm via nasal cannula The TAR dated April 2019, documented O2 at 3 lpm via nasal cannula. The TAR documented nurses initials indicating the O2 was delivered as ordered for each shift . The comprehensive care plan (CCP) dated 3/12/19 and titled Potential for Alteration in Respiratory and Cardiac Function related to COPD, CHF, and CAD inc Interventions included, administer oxygen as ordered. During an observation on 04/15/19 at 10:30AM, the resident was sitting in a wheelchair by the nursing station with the nasal cannula in his nares and his O2 was set on 4 lpm. During an observation on 04/16/19 at 11:00 AM, the resident was sitting in a wheelchair by the nursing station with the nasal cannula in his nares and his O2 was set on 2 lpm. During an interview on 4/16/19 at 3:39 PM, LPN #6 stated the Treatment Nurse is in charge of looking at the oxygen of residents and the Medication Nurse passes medications. If there is no Treatment Nurse, the Medication Nurse does both. The nurse should look at the concentrator to make sure the lpm is correct before signing the TAR. During an interview on 4/18/19 at 12:26 PM, Registered Nurse Manager (RNM) #2 stated her expectation of the nurses is that they should be looking at the liter flow on the O2 concentrators to ensure the resident is getting the correct flow. If a nurse finds the resident O2 lpm is wrong they need to get an O2 Saturation and have an RN assess the resident. There needs to be more education and monitoring to ensure the nurses are completing their treatments and medications correctly. During an interview on 4/17/19 at 9:46 AM, the Director of Nursing (DON) stated the treatment nurses should be looking at the O2 lpm throughout the day, and they should not be signing the TAR until after they ensure the O2 is set at the correct lpm. Other nurses on the unit should also be looking at the O2 lpm when they are near the residents with O2. The residents ordered lpm for O2 should always be set at the correct lpm. 10NYCRR415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 (Resident #14) of 5 residents reviewed. Specifically, the facility did not ensure that Resident #14 did not receive an as needed medication without a physician order. This was evidenced by: Resident #14: The resident was admitted to the facility on [DATE] with the diagnoses of dementia, anxiety and depression. The Minimum Data Set (MDS) dated [DATE], documented the resident had moderately impaired cognition. It documented the resident was usually able to understand others and usually able to make herself understood. The MAR dated April 2019 documented the resident was to receive APAP (N-acetyl-para-aminophenol, acetaminophen) 650 mg every 6 hours for mild/moderate pain. The MAR documented APAP was administered on 4/5/19, 4/7/19, 4/9 -4/11/19, 4/14 - 4/18/19. A review of the MD orders signed on 4/9/19, did not include documentation of a physician order for APAP. During an interview on 04/18/19 at 12:02 PM, LPN #2 stated that the APAP documented on the MAR was probably copied from the standing medical orders (SMO), and should not have been. The SMO medications are to used for a 48 hour period only and then the physician has to be notified. During an interview on 04/18/19 at 12:16 PM, Registered Nurse Manager (RNM) #2 stated the APAP should not have been written on the MAR. The resident's Tramadol (pain medication) was recently increased and the resident also had a physician order for prn Ibuprofen. The APAP was unnecessary. During an interview on 04/18/19 at 01:04 PM, the Director of Nursing (DON) stated APAP was given without a doctors order. The DON stated she would talk to the nurses and will complete a medication error report. During an interview on 4/18/19 at 3:00 PM, the Medical Director stated that APAP should not have been documented on the MAR. The Medical Director stated that the doseage of the pain medication Tramadol (can treat moderate to severe pain) was increased to 50 mg four times per day on 4/9/19. The resident should not have been receiving Ibuprofen, Tramadol and Tylenol for pain. 10NYCRR415.12(I)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during a recertification survey, the facility did not ensure each resident's drug regimen was free from unnecessary psychotropic drugs for two (Resident #14 and #52) of five residents reviewed for unnecessary medications. Specifically, for Resident #14, the facility did not ensure an order for as needed (PRN) antianxiety medication was limited to 14 days. Additionally, the facility did not ensure that non-pharmacologic interventions, documentation of behaviors, effect of medication, and documentation to justify extending a PRN order beyond 14 days. Specifically, for Resident #52, the facility did not ensure adequate documentation of a clinical indication to support the use of an antipsychotic medication (Seroquel) and did not ensure the medical record included documentation to support an increase in the frequency of Seroquel from once a day to twice a day. This is evidenced by: The Policy & Procedure titled Psychotropic Medication Use and dated 04/2018, documented Psychotropic medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use. This will be documented in the medical record in addition to symptoms being exhibited and the post-medication effect. PRN (as needed) psychotropic medications are limited to no more than 14 days, except when the practitioner has documented their rationale in the medical record and indicates the duration for the PRN order. Resident #14: The Resident was admitted to the facility on [DATE] with the diagnoses of Dementia, Anxiety and depression. The Minimum Data Set (MDS) dated [DATE] documented the resident had moderately impaired cognition and was usually able to understand others and usually able to make herself understood. The Comprehensive Care Plan (CCP) titled Alteration in Mood related to trouble concentrating, fidgety/restless, short-tempered, flat affect, anxious, repetitive questions/concerns, paranoid thoughts, foul language, fixated on medical concerns, physical complaints. Diagnosis of Anxiety and Depression. The Physician's (MD) order dated 4/3/19 documented, Ativan 0.5 mg two time per day as needed (PRN). There was no 14 day stop date documented, (14th day was 4/16/19). The Medication Administration Record (MAR) dated April 2019, documented Ativan 0.5 mg two times per day, prn. The MAR documented the Ativan was administered on 4/7/19, 4/10/19, 4/11/19, 4/14/19, 4/15/19, 4/16/19, and 4/17/19. There was no documentation of non-pharmacological interventions, documentation of behaviors and the effect of the medication on the date and time the medication was administered. During an interview on 04/18/19 at 12:02 PM, Licensed Practical Nurse (LPN) #2 stated that the protocol for giving PRN medications was to document the resident symptoms, the non-pharmacological interventions attempted before medicating, and the effectiveness of the medication. The nurse should document in the nurse notes and on the 24-hour report. During an interview on 04/18/19 at 12:16 PM, the Registered Nurse Manager (RNM) #2 stated the PRN Ativan should only have been ordered for 14 days. The RNM's expectation of the nurses was that the Ativan PRN use would be documented in the nurse notes. They should be trying non-pharmacological interventions before administering the Ativan. The documentation should include the behaviors, the interventions attempted and the effect of the medication. During an interview on 04/18/19 at 01:04 PM, the Director of Nursing (DON) stated the Ativan should be documented with the 14 day limit and the reason for the medication. Ativan PRN should be used after non-pharmacological interventions had been attempted first. The nurses should be documenting in the nurse notes or the back of the MAR. During an interview on 4/18/19 at 3:00 PM, the Medical Director (MD) stated the PRN Ativan should have a 14 day cut off. The MD stated he did not tell them the order for Ativan was for 14 days, it was the protocol for the facility and it should have been done automatically. Staff should be making him aware if they were using a PRN medication often and he would deal with it. The nurses should be documenting why they are giving the medication and if it was effective. Resident #52: The resident was admitted to the facility on [DATE], with the diagnosis of dementia, depression, and atrial fibrillation. The Minimum Data Set, dated [DATE], documented the resident had severely impaired cognition, could usually understand others and could usually make himself understood. It documented the resident received an antipsychotic medication 7 out of 7 days. The Comprehensive Care Plan for Psychotropic Drugs, last revised 3/26/19, documented the potential for adverse side effects related to the use of Celexa (antidepressant) and Seroquel (antipsychotic) as evidenced by drowsiness. Interventions included to monitor and assess for effectiveness and/or adverse reactions, to evaluate any change in functional and/or mental status, and to monitor and evaluate for changes in behavior related to drug reduction. Physician order dated 02/19/19 documented Seroquel 25 mg 1 tablet by mouth at bedtime. The order did not include an indication for use. Physician order dated 03/26/19 documented a new order for Seroquel 25 mg 1 tablet by mouth in the morning and in the evening. The order did not include an indication for use. During a record review on 04/16/19 at 8:30 AM, the medical chart did not include documentation of a clinical indication for the increase in the frequency of Seroquel from once a day to twice a day Seroquel. A pharmacy review note to the physician dated 02/26/19, documented the resident was receiving an antipsychotic medication upon admission and the ICD-10 (International Statistical Classification of Diseases and Related Health Problems) code needed to be updated to support the administration of the medication. The pharmacy note also documented that nursing documentation was required to provide evidence that one of the following existed: symptoms are identified as being due to mania or psychosis; behavioral symptoms present a danger to the resident or others; the symptoms are significant enough that the resident is experiencing persistent distress, decline in function, or substantial difficulty receiving care needed. The physician responded to the pharmacy note that he disagreed as the resident was combative during care and physically aggressive. The Mobile Geriatric Outreach Program (MGOP) note dated 03/18/19, documented the resident was quietly sitting in a wheelchair with no obvious distress and was easily aroused. A physician note dated 03/26/19, documented the resident was alert, oriented, and pleasant with no changes in his sleep pattern or in his activities of daily living. The note documented a new order for Seroquel 25 mg by mouth in the morning and evening. The note did not document a clinical indication for the increase in the frequency of Seroquel. A nursing note dated 03/26/19, documented the physician saw the resident for a monthly review and due to falls. The note documented a new order per the physician for Seroquel 25 mg by mouth in the morning and evening. A review of nursing notes from 03/27/19 - 04/15/19, did not include documentation that the resident was monitored and evaluated for changes in functional status, mental status, and/or behaviorally to assess the effectiveness or adverse reactions related to the increase in frequency of Seroquel. The MGOP note dated 04/15/19, documented the resident was sleeping in the recliner at the nurses station with some difficulty to arouse. The resident was confused with no agitation. During an interview on 4/17/19 at 02:28 PM, the Director of Resident and Family Services stated he was not sure if he was aware when the Seroquel was changed from once a day to twice a day. He was normally made aware of medication changes in morning report. He stated when the resident was first admitted he was aggressive and a little combative with care. He stated in the last couple of weeks, the resident had gotten better with not as many behaviors. He stated the interdisciplinary team (IDT) should be monitoring for positive or adverse effects of the medication in nursing progress notes, on the 24-hour report, and on the care plan. He stated his interactions with the resident were pretty good but could vary depending on the time of the day. He stated he did not know what non-pharmacological interventions were attempted prior to changing the Seroquel from once a day to twice a day. During an interview on 04/17/19 at 02:55 PM, Certified Nursing Assistant (CNA) #4 stated she was the resident's regular caregiver and the resident had never been combative or tried to hit her. She stated she was always able to care for the resident and stated, It is all about approach. She stated the resident's behavior seemed to depend on how he was approached by staff. She stated the resident did not want to be in the facility and was kind of depressed. She stated if the resident seemed agitated she would talk to him calmly and would tell him it was going be ok. During an interview on 04/18/19 at 09:16 AM, Licensed Practical Nurse (LPN) #1 stated the Seroquel was increased to twice a day due to increased behaviors. She stated the resident kept trying to stand up, put his fist in the air, and was mean. She stated it was taking the resident awhile to adjust because he was angry with placement in the facility. She thought the resident's behaviors were related to dementia and agitation and he was a lot better since the Seroquel was changed to twice a day. She stated prior to medication change the staff tried taking the resident to activities, providing 1:1 visit, and redirecting him. She stated when there was an increase in psychotropic medication nursing should be documenting whether the medication change was effective. She stated the increase in the frequency of Seroquel was effective for the resident as he was more controllable and was adjusting better to the facility. She stated she was not aware of non-pharmacological interventions on the resident's care card for staff to use when the resident was exhibiting behaviors. She stated the staff just knew different techniques because they have dealt with residents in the past who had similar behaviors. She stated the staff was still trying to learn about the resident and what he liked. During an interview on 04/18/19 at 9:50 PM, Registered Nurse #1 stated prior to the increase in the frequency of Seroquel the resident was falling, yelling out, was uncontrollable, and needed constant attention. She stated the increase in Seroquel had changed the resident quite a bit and he was like a different person. He seemed happy and he was eating better. She stated she did not know if other interventions were tried prior to changing the Seroquel from once a day to twice a day. She stated the nurses monitored the effectiveness of the medication in the nursing notes. She stated the reason the Seroquel was ordered was for the diagnosis of dementia. During an interview on 04/18/19 at 10:13 AM, the Director of Nursing (DON) stated prior to increasing the Seroquel to twice a day the resident was falling and agitated. She stated interventions attempted prior to the change included a toileting schedule, having the resident lay down in the afternoon, and redirecting the resident by talking about military. The DON reviewed the physician's note and stated there was not a rationale documented in the note for changing the Seroquel from once a day to twice a day and there was not a clinical indication as to why the Seroquel was ordered. She stated the diagnosis should be included in the medication order and it was not acceptable to have an order for a medication without a supporting diagnosis. She stated staff needed to know why the resident was on the medication and the rationale for an increase or decrease in medication. She stated when a medication was changed, there should also be daily progress notes, if not every shift, by nursing to document the effectiveness or any adverse effects of the change. She reviewed the nursing documentation and stated the nursing notes were not adequate in monitoring the effectiveness of the change in Seroquel from once a day to twice a day. She stated the progress notes should address the fact that the Seroquel was increased and should have included staff observations of the resident to determine if he was improving or not. 10NYCRR 415.12(1)(2)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during a recertification survey the facility did not ensure that residents were free from significant med errors for one (Resident #9) of five residents reviewed for medications. Specifically, for Resident #9, the facility did not ensure the resident's medication orders included an active sliding scale orders for insulin use. This is evidenced by: Resident #9: The resident was admitted to the nursing home on 9/26/19 with diagnoses of diabetes, HTN, depression, post poliomyelitis syndrome general anxiety disorder, panic attacks, CAD. The Minimum Data Set (MDS) dated [DATE] assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A handwritten admission Medical Doctor (MD) Orders dated 1/7/19, documented Novolog sliding scale 1-13 units of insulin every 4 hours subcutaneous (sc). for Fingerstick Blood Sugar (FSBS): <66 follow hypoglycemic protocol 66-140 give no insulin 141 - 180 give 2 units 181 - 210 give 3 units 211 - 250 give 5 units 251 - 299 give 7 units >300 give 11 units >400 contact MD. A Medication Administration Record (MAR) for January 2019 did not include the sliding scale. The hand written MAR for 1/2019 documented that insulin coverage was administered on 6 occasions. The printed MD Orders dated 1/31/19 and 4/9/19 did not document any orders for a sliding scale. The MARs dated from 2/1/19 - 4/16/19, included the following sliding scale: 0 - 200 give no insulin 201 - 250 give 2 units 251 - 300 give 4 units 301 - 350 give 6 units 351 - 400 give 8 units >400 give 10 units and re-check FSBS in 2 hours If recheck FSBS is <400 give no insulin. If recheck FSBS is >400 give 10 units and recheck in 2 hours If 2nd recheck is >400 call MD The MARs dated from 2/1/19 - 4/16/19 documented that insulin coverage was administered on 2 occasions. During an interview on 4/16/19 at 3:43 PM, the Registered Nurse Manager (RNM) stated that when orders came in staff compared them to the most current orders. There should be three checks and at least on of those checks needs to be an RN. She was not aware that there was no order for the resident's sliding scale. During an interview on 4/17/19 at 9:17 AM, Licensed Practical Nurse (LPN) #2 stated that the MARs got checked monthly by 3 nurses one is an RN. The resident frequently refuses FS and insulin. She has given insulin coverage before and was not aware there was no order for the sliding scale because she was not the nurse who checked the orders. She assumed that after 3 checks the information on the MAR was correct. She was not know who wrote the sliding scale on the MAR. 10NYRR 415.12(m)(2)

Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in all areas with gas operated equipment. Specifically, carbon monoxide detection was not installed in areas with gas fuel fired equipment. This is evidenced as follows. Observations on 04/15/2019 at 1:30 PM revealed that carbon monoxide detection was not present in the area of the fuel burning equipment in the laundry or the main kitchen. The Director of Environmental Services stated in an interview on 04/15/2019 at 3:05 PM that he was unaware that it was a requirement to provide carbon monoxide protection in these areas. 483.70 (b); 2015 International Fire Code, Section 915

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not maintain an infection prevention and control program (IPCP) to prevent the development and transmission of disease and infection. Specifically, the facility did not ensure the IPCP policies were reviewed annually. Specifically, for 1 (Resident #4) of 3 residents reviewed for pressure ulcers, the facility did not ensure standard precautions were maintained during a dressing change to the resident's right heel. This was evidenced by: Finding #1 The facility did not ensure that the following IPCP policies and procedures were reviewed annually: 1. Infection Prevention and Control Manual: does not include documentation of the policy's implementation date or a date that the policy was reviewed or revised. 2. Antibiotic stewardship: Guidelines for Prescribing Antibiotics, documented a date of 11/2017 and Progress notes - Antibiotic Use, date of 11/2017. During an interview on 04/18/19 at 01:11 PM, the Director of Nursing (DON) and the Infection Prevention Nurse (IPN) stated they were aware that their policies are outdated and need to be reviewed and/or updated. Finding #2 Resident #4: The resident was admitted to the facility on [DATE], with the diagnoses of coronary artery disease (CAD), congestive heart failure (CHF) and diabetes mellitus. The Minimum Data Set (MDS) dated [DATE], documented the resident had moderate cognitive impairment, was able to make herself understood and usually able to understand others. A physician order dated 4/11/19 documented; Cleanse right heel with Dakins (dilute solution of sodium hypochlorite (0.4% to 0.5%) and other stabilizing ingredients, traditionally used as an antiseptic, e.g. to cleanse wounds in order to prevent infection). Apply Wound Gel and Calcium Alginate (a highly absorbent, biodegradable alginate dressing derived from seaweed) to the wound bed. Cover with ABD pad and wrap with kling every day. The wound assessment dated [DATE] documented the resident had a full thickness wound of the right posterior heel measuring 0.5 x 0.7. The wound base presented with 100% pale granular tissue (new tissue). The wound edges were semi adherent to the wound base with scattered areas appearing to be lifting where the wound edges were dried. There was a low to moderate amount of serous drainage that was semi mal-odorous. During an observation of the dressing change to the right heel on 04/16/19 at 09:30 AM, Licensed Practical Nurse (LPN) #3 was observed entering the resident room with the packaged supplies in her hands and laid the supplies on the overbed table. The table was not cleansed prior to placing the dressing supplies on it. LPN #3 removed the blanket from the resident's foot and removed the old dressing. The resident's heel was put back onto the pillow on the bed without a barrier between the foot and the pillow. LPN #3 donned gloves without washing her hands first, opened a gauze package, wet the gauze with the Dakins solution and lifted the resident's heel to wipe the wound at the bottom of the heel with the gauze and put the resident's heel back down onto the pillow. LPN #3 did not change her gloves or wash her hands, prior to dipping a Q Tip into the wound gel. The resident's heel was lifted off the pillow and wound gel was applied to the wound with the qtip. The LPN unwrapped a gauze package and placed the gauze over the wound; then wrapped the foot with rolled gauze. During an interview on 4/17/19 at 10:13 AM, LPN #3 stated she was very nervous having a surveyor watch her do the dressing change. She should have washed her hands and changed her gloves between cleaning the wound and applying the new treatment. She should have cleaned the overbed table and set up a dressing change field. She would not have normally set her foot down on the pillow after cleaning the wound. During an interview on 04/18/19 at 12:32 PM, the Registered Nurse Manager (RNM) stated the dressing change was not appropriate. The RNM did not know if the facility did dressing change audits to monitor the nurses practice. She stated that education regarding wounds and dressing changes would be needed as well as monitoring. During an interview on 04/18/19 at 01:00 PM, the Director of Nursing (DON) stated the dressing change done by LPN #3 was not appropriate. The nurse should wash her hands, change her gloves and set up a dressing change field. She should not have placed the resident's foot back on the bed after cleansing the wound. She stated she will look into providing education for dressing changes. 10NYCRR415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it developed and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for six (Resident #'s 15, 33, 50, 52, 55, & #58) of fifteen residents reviewed. Specifically: for Resident #15 the facility did not insure that the comprehensive Care Plan (CCP) included finger foods that were recommended by the Registered Dietitian (RD), that Resident #33's care planned swallowing precautions were implemented, that Resident #50 received the care planned assistance with feeding, and that Resident #52, who had pain, had a CCP to address pain management. Additionally, the facility did not ensure that Resident #55's care planned double portions of meat at meals were implemented and that Resident #55 received nutritional supplements at meals per the CCP. This is evidenced by: Resident #15: The resident was admitted to the facility on [DATE] with diagnoses of dementia, non-Hodgkin's lymphoma, and osteoarthritis. The Minimum Data Set (MDS) dated [DATE] documented the resident had severely impaired cognition, rarely/never understood others and could rarely/never make themselves understood. The New Jersey Dietitians in Health Care Facilities Diet Manual, dated 2008, documented finger foods were a modification used for feeding problems. A Comprehensive Care Plan (CCP) for Nutritional Status, last revised 2/8/19, did not include documentation of finger foods. The CCP documented the resident was on comfort care, and to monitor intake and weight loss. A nutrition assessment dated [DATE], documented the resident does best with finger foods, and had poor intake. Physician notes dated 3/26/19, 3/12/19, 2/26/19, 2/5/19, 1/29/19, 12/11/18, and 11/27/18 documented the resident had a poor appetite. A review of intake records dated 4/1/19 - 4/8/19 documented the resident ate less than 50% on average at meals. The white (table) meal cards and the yellow (server) meal cards did not include documentation of finger foods. During an observation on 4/16/19 at 12:35 PM, the resident was observed eating the cheese off the pizza with her fingers. During an observation on 4/17/19 at 8:21 AM, the resident was observed eating bacon and toast with her fingers. During an interview on 4/17/19 at 8:55 AM, Food Service Director (FSD) #1 stated if a resident needs finger foods, it will be written on the white (table) and yellow (server) cards. The resident should have had finger foods written on her cards. During a phone interview on 4/17/19 at 2:00 PM, the Registered Dietitian (RD) #2 stated the finger food modification should be on the resident's yellow (server) card and nutrition care plan. Resident #55: The resident was admitted to the facility on [DATE] with diagnoses of pressure ulcers, diabetes, and peripheral vascular disease. The Minimum Data Set (MDS) dated [DATE] documented the resident was cognitively intact, understood others and could make themselves understood. A Comprehensive Care Plan (CCP) for Nutritional Status, last revised 3/29/19, documented the resident was to receive double portions of meat and high-quality protein. A nutrition review dated 11/2/18 documented the resident was to be offered larger meat portion at lunch and supper to be sure all nutritional needs are met. A nutrition review dated 1/29/19 documented the resident was receiving large meat portions and lunch and supper. A nutrition assessment dated [DATE] documented the resident was receiving double portions of meat at lunch and supper. A wound note dated 4/4/19 documented the resident had a stage 2 pressure ulcer of the left heel, with a recommended treatment to monitor nutritional intake, and a stage 3 pressure ulcer/injury of the right heel with a recommended treatment to monitor nutritional intake. The white (table) meal cards and the yellow (server) meal cards did not include documentation of double meat portions at lunch and dinner. During an interview on 4/15/19 at 9:39 AM, the resident stated she is on a special diet and does not always receive the foods she should. During a phone interview on 4/17/19 at 2:00 PM, the Registered Dietitian (RD) #2 stated the double portions of meat should be documented on the resident's yellow (server) card. During an interview on 4/18/19 at 10:35 AM, Unit Manager #1 stated the double portions of meat should be indicated on the white and yellow meal cards. Resident #52: Specifically, for Resident #52, the facility did not ensure a care plan was developed to address the resident's pain. The resident was admitted to the facility on [DATE] with the diagnosis of dementia, depression, and atrial fibrillation. The Minimum Data Set, dated [DATE] documented the resident had severely impaired cognition, could usually understood others and could usually make himself understood. It documented the resident received a scheduled pain medication regimen. During a record review on 04/16/19 at 9:00 AM, the comprehensive care plan did not include a care plan to address pain management. During an interview on 04/18/19 at 9:50 AM, Registered Nurse # 1 stated the resident should have a care plan in place for generalized pain. She stated the resident had generalized pain and it was being addressed by the interdisciplinary team. She stated the resident received Mobic (nonsteroidal anti-inflammatory drug) for his pain. During an interview on 04/18/19 at 10:13 AM, the Director of Nursing stated a care plan for pain should have been developed to address the resident's pain. She stated the resident experienced generalized pain and received Mobic for pain. 10NYCRR 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, the facility did not ensure a therapeutic diet was offered for a nutritional problem and that acceptable parameters of nutritional status were maintained for 4 (Resident #'s 15, 50, 55, and #58) of 6 residents reviewed. Specifically, for Resident #15, the facility did not provide finger foods consistent with the resident's annual nutrition assessment; for Resident #50, the facility did not ensure interventions were implemented for a resident with severe weight loss; for Resident #55, the facility did not provide additional protein consistent with the resident's comprehensive assessment; and for Resident #58, the facility did not provide supplements consistent with the resident's comprehensive assessment. This is evidenced by: The Policy and Procedure (P&P) titled Resident Meal Service dated 10/03/17, documented the physician, nursing staff, and dietitian were responsible for determining the nutritional and dietary needs for each individual based on clinical assessment. The P&P titled Weights (Admission/Weekly/Monthly) dated 2/19, documented all residents will be weighed monthly except for residents on comfort care. The policy documented that any resident who has a large discrepancy in weights will be reweighed within a 24 hour period and verified by professional staff. The policy documented if a significant change is noted in a resident's weight, weekly weights will be initiated. Resident #15: The resident was admitted to the facility on [DATE] with diagnoses of dementia, non-Hodgkin's lymphoma, and osteoarthritis. The Minimum Data Set (MDS) dated [DATE] documented the resident had severely impaired cognition, rarely/never understood others and could rarely/never make themselves understood. The New Jersey Dietitians in Health Care Facilities Diet Manual (facility selected) dated 2008, documented finger foods were a modification used for feeding problems. An interim nutrition assessment written by the Registered Dietitian (RD) #2, dated 11/2/18, documented the resident does best with finger foods, and had poor intake. A review of the resident's medical record from 11/2/18 - 4/16/19 did not include documentation of the implementation of finger foods. A Comprehensive Care Plan (CCP) for Nutritional Status, last revised 2/8/19, did not include documentation for the use of finger foods. The CCP documented the resident was on comfort care, and to monitor intake and weight loss. Physician notes dated 3/26/19, 3/12/19, 2/26/19, 2/5/19, 1/29/19, 12/11/18, and 11/27/18 documented the resident had a poor appetite. A review of intake records dated 4/1/19 - 4/8/19 documented the resident ate less than 50% on average at meals. The white (table) meal cards and the yellow (server) meal cards did not include documentation of finger foods. During an observation on 4/16/19 at 12:35 PM, the resident was eating the cheese off the pizza with her fingers. During an observation on 4/17/19 at 8:21 AM, the resident used her fingers to eat bacon and toast. During an interview on 4/17/19 at 8:37 AM, Food Service Director (FSD) #1 stated nutrition assessments written by the RD #2 are placed in a file in her office, and she is responsible for making the changes to the meal cards that are recommended by the RD #2. She stated she is also responsible for updating the resident's care card. She stated if a resident needed finger foods, it would be written on the white (table) and yellow (server) cards. The resident should have had finger foods written on her cards. During a phone interview on 4/17/19 at 2:00 PM, the Registered Dietitian (RD) #2 stated the finger food modification should be on the resident's yellow (server) card and nutrition care plan. Resident #50: The resident was admitted to the nursing home on 1/18/16 with diagnoses of hypertension (high blood pressure), diverticulosis, and dementia. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition, usually understood others, and could usually make themselves understood. The MDS documented staff provide guided movement of limbs and other non-weight bearing assistance. A Comprehensive Care Plan (CCP) for Nutritional Status last revised 3/28/19 documented the resident's goals included improve protein status and maintain weight around 100 lbs. The CCP interventions included monitor at mealtime, follow via meal rounds, and follow weight and intakes as available. The weight record documented the following: 04/19 = 95 lbs (3.7% weight loss over past 30 days, 11.6% severe weight loss over the past 90 days) 03/19 = 98.5 lbs (reweight was not obtained) 02/19 = 105.5 lbs 01/19 = 106 lbs The resident's care card, last updated 3/25/19, documented the resident required encouragement, set up, and limited assist at meals. A quarterly nutrition review written by the Registered Dietitian (RD) #2, dated 3/29/19, documented the resident consumed approximately 25% at meals, and had a weight loss of 7 lb over the last month. The nutrition review documented the resident's intake had decreased since last review and the resident had been sleeping through meals. No changes were recommended. The Certified Nursing Aide (CNA) accountability record, dated 4/1/19 - 4/16/19, documented the resident was independent with set up at meals (0,1). The 24 hour shift report dated 4/1/19-4/7/19 documented to monitor the resident's intake. Poor intake and poor appetite were documented on each day. During an observation on 4/15/19 at 12:43 PM, the resident was served an open-faced pork sandwich. The resident was not being assisted by staff to eat during the surveyor observation. The resident was asleep. During an observation on 4/16/19 at 9:15 AM, the meal period had ended, and the resident was no longer in dining room. Her tray was still at the table with no solids consumed. There was an empty coffee cup and 2 empty 4 ounce drinking glasses. During an interview on 4/16/19 at 2:37 PM, CNA # 7 stated the resident eats pretty well, and sometimes she will refuse to eat. She stated she does not try to assist the resident with meals. During an interview on 4/16/19 at 2:46 PM, CNA # 8 stated the resident is hit or miss with her meals and she does not try to assist her with feeding. She stated the nurses are aware she is not assisted with meals. During an interview on 4/17/19 at 1:59 PM, CNA #2 stated the resident feeds herself. sometimes she won't want to eat other times will yell or sleep during meals a lot she sleeps during the meal. She stated the resident does not get assisted at meals. During an interview on 4/18/19 at 9:19 AM, CNA #2 stated weights are done when the resident gets up or on the night shift before or after toileting. She stated we look in the weight book to find out who we have to weigh. She stated if there is a change in the resident's weight, we tell the nurse. During an interview at 4/18/19 at 9:25 AM, Licensed Practical Nurse (LPN) #2 stated weights are obtained once a month and are entered into the weight book. If someone loses 5lbs, we let the physician know by putting the weight change on their visit sheet, and we document the weight change on the 24-hour sheet. The CNA will obtain the weight and use a sheet to communicate any changes to the LPN. She stated sometimes a reweight will be obtained, if there is a 3lbs or 5lbs difference. She stated the communication sheets are in the weight book, and both the CNA and LPN review the weight book. She stated the dietitian looks at the weight book when she is here and may catch a weight change nursing staff did not. During an interview on 4/18/19 at 9:45 AM, the Director of Nursing (DON) stated the unit manager should be monitoring and assessing the resident's weights and intakes. She stated any change in weight or intake should be discussed with the interdisciplinary team, nurse manager and physician. She stated she would expect a resident care planned for limited assistance at meals would be given cues and observed during the meal. She stated she would expect more assistance than set up to be provided and would expect an intervention to be in place based on the resident's weight loss trend. During an interview on 4/18/19 at 10:00 AM, Occupational Therapist (OT) #6 stated she would expect the resident's food would be set up, someone would be close by if needed. She stated based on the resident's care card, the level of assistance provided should have been documented as 2,1 according to the assistance categories key. During an interview on 4/18/19 at 3:01 PM, the Physician stated he was not aware of the weight loss, would have done something if he was. He stated he should have been notified. Resident #58: The resident was admitted to the facility on [DATE] with diagnoses of congestive heart failure, dementia, and generalized weakness. The Minimum Data Set (MDS) dated [DATE] documented the resident had severely impaired cognition, could sometimes understood others and could sometimes make themselves understood. A Comprehensive Care Plan (CCP) for Nutritional Status, last updated 4/10/19, documented the resident was to be offered mighty shakes after meals and pureed food when needed. The CCP documented the resident is totally fed by staff in the dining room. A Physician order dated 1/29/19 documented the resident was to receive mighty shakes (nutrition supplement) with meals. Physician notes dated 1/29/19 documented the resident was to receive high calorie shakes (nutrition supplement). Physician notes dated 3/26/19 documented the resident was a total assist at meals, mechanical soft diet with pureed meat and thin liquids, no added salt. The physician note also documented that if the resident was tired, the diet was to be altered to pureed consistency. A quarterly nutrition review written by the Registered Dietitian (RD) #2, dated 3/29/19, documented the resident's intake was less than 1/2 solids at meals, and the resident had steady weight loss (15% over the last 6 months). The weight record documented the following: 04/19 weight = 116.5 lbs 03/19 weight = 116.5 lbs 02/19 weight = 118 lbs 01/19 weight = 121.5 lbs 12/18 weight = 122.5 lbs 11/18 weight = 124 lbs 10/18 weight = 128.5 lbs 9/18 weight = 132 lbs The white (table) meal cards and the yellow (server) meal cards documented the resident was to receive a 4 oz milkshake with breakfast, lunch, and dinner. During an observation on 4/17/19 at 8:21 AM, the resident was removed from the dining room after breakfast with minimal beverage intake noted. The milkshake (nutrition supplement) was not offered. During an interview on 4/17/19 at 9:14 AM, FSD #1 stated she was aware the resident was not drinking the supplement shake. She stated she would write a note to the dietitian in the communication book if a resident was not drinking a supplement. The communication book did not include documentation to the dietitian that the resident was not drinking the supplement shake. During an interview on 4/17/19 on 9:46 AM, CNA # 1 stated the resident has had poor intake lately and has not been drinking the supplement shake. She stated she reported the change in intake to Licensed Practical Nurse (LPN) #1 a few weeks ago. During an interview on 4/17/19 at 9:49 AM, LPN #1 stated she was not aware of a change in the resident's intake or supplement acceptance. During a telephone interview on 4/7/19 at 2:00 PM, RD #2 stated supplements were prepared, labeled, and brought to the unit by the dietary staff. She stated the supplements were passed to the residents by the staff member who pours the beverages or sets up the resident's meal. She stated supplements were tracked by observation and communication from dietary and nursing staff, and if weight is stable, the assumption is made that the resident is consuming the supplement. She stated she was not aware the resident was not receiving the supplement at meals. She stated the resident should have been receiving the supplement per the care plan. During an interview on 4/18/19 at 10:41 AM, Nurse Manager #1 stated the resident was probably not being offered the shakes. During an interview on 4/18/19 at 12:18 PM, the DON stated she would expect a resident's supplement refusal would be documented. 10NYCRR415.12(i)(1)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure diets were provided to meet resident needs. Specifically, the facility did not ensure that residents who required pureed diets received the correct pureed diet consistency and mechanical soft diets were served in accordance with the facility diet manual. This is evidenced by: A Policy and Procedure (P&P) titled Consistency Alterations dated 11/2016, documented: Upgrading a diet is not acceptable without a doctor's order. Finding #1 The New Jersey Dietitians in Health Care Facilities Diet Manual (facility's choice for a diet manual) dated 2008, documented pureed foods should have a mashed potato or pudding consistency. The facility menu documented the pureed diet served to residents on Tuesday (Week 1) lunch was to include pureed pizza. During an observation on 4/16/19 at 12:25 PM, the main dining room was serving pureed pizza to residents in a bowl. The surveyor tested the puree consistency after the completion of the trayline. The consistency of the pureed pizza was sticky with a peanut butter consistency. During an interview on 4/16/19 at 1:42 PM, [NAME] #4 stated the cook is responsible for pureeing the food. She stated it should be a smooth consistency, not too thick, formed but not runny. She stated the cheese pizza was pureed and served for the lunch meal. During an interview on 4/17/19 at 9:59 AM, the speech language pathologist (SLP) #5 stated she would expect the pureed food to be an applesauce or pudding consistency. She stated there was a concern regarding a pureed food item served to residents that had a sticky texture like peanut butter. During an interview on 4/17/19 at 9:03 AM, the food service director (FSD) #1 stated cheese pizza was served because pepperoni doesn't go over well. She stated the consistency of the pureed pizza should not be the texture of peanut butter, it should be the texture of pudding or applesauce. During an interview on 4/17/19 at 2:00 PM, the Registered Dietitian (RD) #2 stated the puree pizza should have had an extra sauce and should have not been sticky like peanut butter. Finding #2: The New Jersey Dietitians in Health Care Facilities Diet Manual, dated 2008, documented that foods like hummus or pureed legume spreads were recommended for a mechanical soft. The facility menu documented the mechanical soft diet served to residents on Tuesday (Week 1) lunch was to include three bean salad. During an observation on 4/16/19 at 12:25 PM, the three bean salad served to residents contained wax, green, and kidney beans (a legume) (approximately 1/2 cup) in a disposable ramekin. During an interview on 4/17/19 at 10:04 AM, the SLP #5 stated the three bean salad should not be served to residents on a mechanical soft diet, as it is a mixed consistency. She stated dietary should be aware not to serve the three bean salad to residents on a mechanical soft diet. During a telephonic interview on 4/17/19 at 2:00 PM, RD #2 stated the mechanical soft diet could be served a 3 bean salad. 10NYCRR415.14

Based on record review and interview during the recertification survey, the facility did not ensure a policy was in place regarding use and storage of foods brought to residents by family and other visitors. Specifically, the facility did not have a policy regarding food brought to residents by family and other visitors that: ensured facility staff assisted dependent residents in accessing and consuming the food, and ensured food brought in by family or visitors was stored in a way that was either separate or easily distinguishable from facility food. This is evidenced by: The facility Policy and Procedures (P&P) did not include a policy for foods brought to residents by family and other visitors. During an interview 4/17/19 at 9:03 AM, Food Service Director #1 stated there is no policy regarding providing residents the food brought in by family and other visitors. 10NYCRR415.14(h)