Based on record review and interviews during the recertification and abbreviated survey (Case #NY00277034) on 8/14/2023 through 8/18/2023, the facility did not ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were thoroughly investigated for 1 (Resident #425) of 5 residents reviewed. Specifically, for Resident #425, the facility did not ensure that alleged abuse by Certified Nurse Aide (CNA) #5, reported on 6/1/2021 at 4:18 PM, was thoroughly investigated and documented to rule out abuse, mistreatment, or neglect. Also the facility did not ensure the results of all investigations were reported to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident. This is evidenced by: The facility policy titled Freedom from Abuse, Neglect and Exploitation last reviewed 4/28/2022, documented in response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: 1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse, and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 2) Have evidence that all alleged violations are thoroughly investigated. 3) Prevent further potential abuse, neglect, exploitation, or mistreatment, while the investigation is in progress. 4) Report the results of all investigations to the Administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Resident #425: Resident #425 was admitted to the facility with diagnosis of vascular dementia, hypertension, restlessness, and agitation. The Minimum Data Set (MDS- an assessment tool) dated 3/16/2021, documented the resident had severe cognitive impairment, usually understood and was sometimes able to make their needs known. A facility Incident and Accident Report dated 6/1/2021 at 5:20 AM, documented Resident #425 kicked a Certified Nurse Aide (CNA) during care and the resident's leg became painful and swollen with inward rotation. The x-ray report dated 6/1/2021 at 6:28 AM, documented a displaced fracture of the right mid to distal femoral shaft. The document titled Investigation Summary dated 6/4/2021 did not include a conclusion that documented the facility's findings or determination of the allegation of abuse, mistreatment or neglect by CNA #5. During an interview on 8/18/2023 at 11:15 AM, the previous Director of Nursing (DON) #2 said they had completed the investigation and determined there was no evidence that CNA #5 had done anything wrong. However, the previous Administrator had suspended CNA #5 indefinitely and to error on the side of caution, they reported the incident to the NYSDOH and the Attorney General. The DON #2 did not know why a conclusion wasn't documented in the investigation summary. When asked what the outcome was, they said the facility was unable to determine what happened. During an interview on 8/18/2023 at 11:20 AM, the DON said they were not the DON at the time of this incident and were not involved in the investigation. Upon review of the investigation on file, the DON said the investigation did not document that the allegation of abuse was thoroughly investigated; without a conclusion summary the investigation was incomplete. 10 NYCRR 415.4(b)(3)

**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 the development and implementation of comprehensive person-centered care plans, that included measurable objectives and time frames to meet the resident's medical, nursing, mental and psychosocial needs for 3 (Resident #s 77, 135 and #78) of 34 residents reviewed for Comprehensive Care Plans (CCP). Specifically, for Resident #77, the facility did not ensure the CCP included a care plan to address the resident's hearing deficit and use of hearing aids; for Resident #135, the facility did not ensure the CCP included interventions related to the use of a splint. Specifically, for Resident #78 the facility did not ensure a CCP included a care plan to address alterations in urinary elimination to include an indwelling catheter and ongoing infection requiring contact isolation and treatment of that infection. This is evidenced by: Resident #77 Resident #77 was admitted to the facility with the diagnoses of chronic atrial fibrillation, chronic kidney disease and hypoxemia. The Minimum Data Set (MDS - an assessment tool) dated 7/13/23 documented Resident #77 was able to be understood, was able to understand others, had moderate difficulty hearing others and had a moderate cognitive impairment. During an observation on 8/14/23 at 12:31 PM, Resident #77 was noted to be wearing hearing aids in both ears. A Physician's Order dated 6/3/23 documented the staff to check placement of hearing aid every four hours. A Physician's Order dated 4/18/22 documented the resident's hearing aid to be inserted in the morning and removed at hour of sleep. During an interview on 8/17/23 at 10:56 AM, Certified Nursing Assistant (CNA) #2 stated the nurse kept the hearing aids in the medication room on a charger and the nurse would put them in during the morning. CNA #2 stated Resident #77 had their hearing aids in place. During an interview on 8/18/23 at 10:23 AM, Registered Nurse (RN) #2 stated the care plan should correspond with a resident's diagnoses and conditions. The care plans should be monitored and revised as needed. RN #2 stated a resident with a hearing deficit and hearing aids, like Resident #77, should have that care plan in place. During an interview on 8/18/23 at 10:44 AM, the Director of Nursing (DON) stated that every diagnosis should have a care plan, though the diagnoses may be grouped so a resident doesn't have multiple care plans that state the same thing. Any appliances such as splints and hearing aids should be in a care plan. Resident #135 Resident #135 was admitted to the facility with the diagnoses of immunodeficiency, dementia and cerebral ischemia. The Minimum Data Set (MDS - an assessment tool) dated 7/21/23 documented that Resident #135 could be understood, could understand others and had a moderate cognitive impairment. During an observation on 8/15/23 at 10:40 AM, Resident #135 was noted to wearing a splint on their left hand and wrist. The Comprehensive Care Plan (CCP) titled Musculoskeletal - Fracture did not include the use and monitoring of a splint. The CCP titled Activities of Daily Living did not include the use and monitoring of a splint. During an interivew on 8/17/23 at 10:51 AM, Registered Nurse (RN) #2 stated the resident was decent about keeping the splint on but could remove it independently. During an interview on 8/18/23 at 10:25 AM, RN #2 stated the splint should be on the comprehensive care plan. During an interview on 8/18/23 at 10:44 AM, the Director of Nursing (DON) stated that every diagnosis should have a care plan, though the diagnoses may be grouped so a resident doesn't have multiple care plans that state the same thing. Any appliances such as splints and hearing aids should be in a care plan. Resident #78 Resident #78 was admitted to the facility with the diagnoses of Cerebral vascular accident, neurogenic bladder requiring a catheter, and multiple sclerosis. The MDS dated [DATE], documented Resident #78 was able to be understood, was able to understand others, and had intact cognition for daily decision making. During an observation on 8/15/23 at 10:19 AM, Resident #78 was observed in bed. The foley catheter collection bag was hanging at the side of the bed. The resident had a sign outside the room notifying people entering that the resident was on contact precaution. A nursing progress note date 04/03/2023 at 3:12 PM, documented Resident #78 continues contact precautions for MRSA (Methicillin-resistant Staphylococcus aureus, a resistive contagious infection) in the urine. A Nurse Practitioner note dated 4/09/2023 at 9:42 PM, documented urology consultation was completed regarding recurrent symptomatic urinary tract infections with recommendations for suppression therapy with nitrofurantoin or cephalexin nightly and consider foley catheter changes A Physician's Order dated 04/10/2023, documented give nitrofurantoin macrocrystal 50 mg (milligrams), 1 capsule by oral route once daily at bedtime with food for personal history of urinary tract infections. The electronic medication administration record (eMAR) for August 2023 documented the following give nitrofurantoin macrocrystal 50 mg (milligrams), 1 capsule by oral route once daily at bedtime with food for personal history of urinary tract infections. Start date 4/10/2023 A Nurse Practitioner note dated 4/09/2023 at 9:42 PM, documented urology consultation was completed regarding recurrent symptomatic urinary tract infections with recommendations for suppression therapy with nitrofurantoin or cephalexin nightly and consider foley catheter changes The electronic treatment administration record (eTAR) for August 2023 documented the following: Foley Catheter, change every 4 weeks and prn (as needed). Start date 4/10/2023 for diagnosis of Multiple Sclerosis. The CCP titled Alteration in Urinary Elimination did not include care and monitoring of a urinary catheter and medication and care for isolation of the resident on contact isolation. The CCP titled Neuromuscular Disease related to MS did not include loss of bladder function and care and monitoring of a catheter. During an interview on 8/17/23 at 12:06 PM, Certified Nursing Assistant (CNA) #6 stated the resident had an indwelling catheter and was on contact isolation. During an interview on 8/17/2023 at 2:26 PM, Licensed Practical Nurse #2 (LPN) stated the resident had medication for suppression of MRSA. During an interview on 8/17/23 at 10:23 AM, Registered Nurse (RN) #3 stated the care plans are generated by the MDS and the focus of the CCP's was determined by a resident's diagnoses and conditions and care needs. The care plans should be monitored and revised as needed and all diagnoses need to be addressed. After review of the CCP's for Neuromuscular disease and alteration of urinary elimination when the addition of the foley catheter and urinary infection occurred in April 2023, areas of concern requiring goals and interventions had not been addressed in the current CCP's for adequate monitoring. This would need to be addressed. During an interview on 8/18/2023 at 10:45 AM, the DON stated CCP's were an area the facility and nurses needed to focus on. The MDS coordinator had been behind, and an outside company was helping to catch up and this had affected the on time completion of the CCP's. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure care plans were reviewed and revised in a timely manner for 2 (Resident #'s 45, and 78) of 34 residents reviewed for Comprehensive Care Plans (CCP). Specifically, for Resident #45, the facility did not ensure the Comprehensive Care Plan (CCP) for Sensory Deficit (At Risk for Visual Deficit), Musculoskeletal Disorder (Vitamin D Deficiency), and Sleep Pattern Disturbance were reviewed at least quarterly. Specifically, for Resident #78, the facility did not ensure the CCP for Resident #78 for Neuromuscular disease related to Multiple Sclerosis and Altered Urinary Elimination were updated quarterly with goals and interventions as treatment was changed. This is evidenced by: The Policy and Procedure (P&P) titled Baseline Care Plans, Resident Care Plans, dated 11/2022, documented the Interdisciplinary Team (IDT) must review and update each CCP at least quarterly. Resident #45 Resident #45 was admitted to the facility with diagnoses of bipolar disorder, pain, and osteoporosis. The Minimum Data Set (MDS - an assessment tool) dated 3/15/2023, documented the resident was able to make themselves understood, understand others, and moderately cognitively impaired. The CCP, titled: Sensory Deficit (At Risk for Visual Deficit), documented a review date of 06/03/2022; Sleep Pattern Disturbances, documented a review date of 06/10/2022; and Musculoskeletal Disorder (Vitamin D Deficiency), documented a review date of 08/17/2022. During an interview on 08/18/23 at 12:55 PM, the Director of Nursing (DON) stated they were currently covering the [NAME] Crossing (EC) Unit since there was no full-time Nurse Manager there. The Nurse Managers or DON was responsible for reviewing each resident's CCP at least quarterly. The CCP for Resident #45 for Sensory Deficit (At Risk for Visual Deficit) and Sleep Pattern Disturbances had not been reviewed since June 2022, and Musculoskeletal Disorder (Vitamin D Deficiency) had not been reviewed since August 2022. These CCP should have been reviewed quarterly since these dates, they were not sure why this had not been done. Resident #78 Resident #78 was admitted to the facility with the diagnoses of Cerebral Vascular Accident, neurogenic bladder requiring a indwelling catheter, and Multiple Sclerosis (MS). The MDS dated [DATE], documented Resident #78 was able to be understood, was able to understand others, and had intact cognition for daily decision making. The CCP, titled: Altered Urinary Elimination related to UTI with MRSA, did not include medication and other changes that were in place with new orders from 4/10/2023. Neurological Disease, related to Multiple Sclerosis documented the CCP was last reviewed and updated on 2/27/2023. During an interview on 8/16/2023 at 2:24 PM, Registered Nurse Unit Manager (RNUM) #3 stated the resident had an indwelling catheter and was on contact precautions. The CCP's for the resident needed to be updated to ensure goals and interventions were added to the care plan. This hadn't happened. The CCP should be updated quarterly, and the RN's were responsible to do this but that doesn't always get done. The RNUM stated they would fix the CCP to reflect the goals and interventions needed for care of Resident #78's current conditions. 10 NYCRR 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #NY00308435), the facility did not ensure each resident was treated with respect and dignity for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure Resident #1 was treated with respect and dignity by the facility staff on 4/4/2023 at 3:00 AM, when assisting the resident after they had fallen on the floor. This is evidenced by: Refer to F684 Resident #1: Resident #1 was admitted to the facility with diagnoses of unstable burst fracture of first lumbar vertebra, Crohn's disease (inflammatory bowel disease that causes inflammation of the gastrointestinal tract) and dementia. The Minimum Data Set (MDS) dated [DATE], documented the resident's cognitive skills for daily decision making were severely impaired. The Policy and Procedure (P&P) titled Resident Rights dated 1/23, documented Federal and State laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to a dignified existence, and to be treated with respect, kindness, and dignity. Review of a video file named EEED5F22-D935-42C8-B733-9ED88FF717E0 dated 4/4/2023 at 3:02 AM showed the following: -Resident #1 was laying on their right side, on the floor between the bedroom and the bathroom. The resident was laying close to the left side of the bathroom doorway and the resident's legs were visible in the bedroom area. The resident had socks on both feet and the resident's undergarment was down and wrapped around their left foot. Certified Nurse Aides (CNAs) #1 and #2 were in the bedroom. -As RNS #1 entered the resident's room RNS #1 stated, I have to zip my mouth right now. I really have to zip it and be nice. RNS #1 saw that the resident was on the floor, walked over to Resident #1 and RNS #1 stated, Resident #1, what are you doing? You're stark naked. What are you doing? -RNS #1 then turned on the bathroom light and stepped inside the bathroom. RNS #1 stated, Oh, poo. Poo everywhere. -Licensed Practical Nurse (LPN) #1 entered the resident's room. The camera view was then partially obstructed by where LPN #1 was standing in the room. -RNS #1 then told Resident #1, Ok, here we go [NAME]. CNA #1 then removed the resident's undergarment from their left foot. RNS #1 then stated, Come on. This is ridiculous and appeared to be moving the resident onto their back since the resident's feet were now both flat on the floor. -CNA #1 then walked over to the resident's right side and RNS #1 then stated, You gotta stay your ass in bed. You know that. This is ridiculous. Stand up., as RNS #1 and CNA #1 assisted the resident to stand. -RNS #1 then stated, Ridiculous, as they and CNA #1 began to walk the resident towards their bed. LPN #1 then stepped to left and the camera view was no longer obstructed. -RNS #1 then looked at the back of the resident who was naked and stated, She's got poop all over her. -CNA #2 then pointed to their forehead and RNS #1 then pointed to Resident #1's forehead and stated, Oh, she's got stitches in her head from another fall. RNS #1 then stated, Honey, you are in such big trouble. Let's get you over here to sit down. You are in such big trouble. Big trouble. Big, big as RNS #1 and CNA #1 walked the resident over to their bed. The undated facility investigation report by the Administrator (ADMIN #1), documented they reviewed the videos dated 4/4/2023. The ADMIN #1 documented that during the process of assisting Resident #1, the RN Supervisor (#1) stated, You gotta stay your ass in bed, this is ridiculous. RNS #1 then went on to state, Honey you are in big trouble. The ADMIN #1 documented the facility was not aware of the behavior of RNS #1 until 4/11/2023 at approximately 12:45 PM. During an interview on 4/13/2023 at 8:35 AM, the Administrator (ADMIN) #1 stated they reviewed the video footage dated 4/4/2023 at 3:00 AM and stated RNS # 1 spoke to Resident #1 in a derogatory manner. The ADMIN stated they were mortified that the resident was naked and was not covered. The ADMIN stated RNS #1 had violated facility policy and was suspended on 4/11/2023. The ADMIN #1 stated the facility was going through the process of terminating RNS #1. During an interview on 4/14/2023 at 12:26 PM, RNS #1 stated they were aware of the camera that the family had in the Resident's room. RNS #1 stated that when they went to the resident's room, the resident was laying on the floor was without clothing. RNS #1 stated they did not review the video footage dated 4/4/2023 at 3:00 AM. RNS #1 stated, I am animated, but it wasn't done in a negative manner. I'm sure it looks very unprofessional. RNS #1 stated that their behavior was inappropriate and stated, I was wrong. During an interview on 4/18/2023 at 2:19 PM, the Director of Nursing (DON) #1 stated they reviewed the video footage dated 4/4/2023 at 3:00 AM. The DON stated RNS #1 did not treat Resident #1 respectfully and stated staff could have put a gown over the resident. During an interview on 4/18/2023 at 3:25 PM, the Assistant Director of Nursing (ADON) stated they reviewed the video footage dated 4/4/2023 at 3:00 AM. The ADON stated the facility started educating staff right away about what they saw on the video and to tell a resident they were in trouble was not good. The ADON stated staff might not have wanted to get the resident fully dressed at that point in time, but they could have put something over the resident to cover them up. The ADON stated the facility did have gowns. During an interview on 4/20/2023 at 3:47 PM, CNA #1 stated they did not recall what RNS #1 said to Resident #1 on 4/4/2023 at 3:00 AM, when the resident had fallen. During an interview on 4/21/2023 at 12:53 PM, CNA #2 stated they recalled RNS #1 saying it's ridiculous and stated they thought RNS #1 said that because Resident #1 had fallen so many times. 10 NYCRR 415.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case # NY00308435), the facility did not ensure each resident received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure that their policy for Falls Protocol and Incident and Accident Reporting was followed when Resident #1, who had a history of falls and chronic compression fractures (small breaks in the bones of the spine), was found on the floor in their room on 4/4/2023 at 3:00 AM and was not assessed for injury by the Registered Nurse before the resident was moved onto their back and then assisted to a standing position. This is evidenced by: Refer to F550 Resident #1: Resident #1 was admitted to the facility with diagnoses of unstable burst fracture of first lumbar vertebra, Crohn's disease (inflammatory bowel disease that causes inflammation of the gastrointestinal tract) and dementia. The Minimum Data Set (MDS) dated [DATE], documented the resident's cognitive skills for daily decision making were severely impaired. The Policy and Procedure (P&P) titled Falls Protocol dated 7/22/16, documented steps to be taken with all falls. The first step documented a Registered Nurse (RN) was to assess the resident before the resident was moved. The (P&P) titled Incident and Accident Reporting dated 6/2022, documented a nursing assessment would be completed for all incidents by the Registered Nurse Supervisor/RN Charge Nurse/RN On-Call. It documented a RN assessment was required for all observed and unobserved falls prior to the resident being moved. The Comprehensive Care Plan (CCP) for Risk for Falls related to Crohn's and dementia last revised 4/6/2023, documented the resident was at high risk for falls secondary to spontaneous personality and non-compliance. The resident was impulsive and had poor safety awareness. The CCP documented 9 incidents of falls from 1/17/2023 to 4/1/2023. The CCP for Musculoskeletal Disorder: History of Fracture last revised 4/4/2023, documented the resident had a history of fracture of L1 compression fracture. The resident was being followed by the bone and joint specialist and had osteoporotic compression fractures. The CCP for Pain Management last revised 4/6/2023, documented the resident had pain related to L1 compression fracture, history of osteoporosis, and osteoporotic compression fractures. Review of a video file named EEED5F22-D935-42C8-B733-9ED88FF717E0 dated 4/4/2023 at 3:02 AM showed the following: -Resident #1 was laying on their right side, on the floor between the bedroom and the bathroom. The resident was laying close to the left side of the bathroom doorway and the resident's legs were visible in the bedroom area. The resident had socks on both feet and the resident's undergarment was down and wrapped around their left foot. Certified Nurse Aides (CNAs) #1 and #2 were in the bedroom. -As RNS #1 entered the resident's room and saw that the resident was on the floor. RNS #1 walked over to Resident #1 and RNS #1 stated, Resident #1 what are you doing? You're stark naked. What are you doing? -RNS #1 then turned on the bathroom light and stepped inside the bathroom. -Licensed Practical Nurse (LPN) #1 entered the resident's room. The camera view was then partially obstructed by where LPN #1 was standing in the room. -RNS #1 then told Resident #1, Ok, here we go [NAME]. CNA #1 then removed the resident's undergarment from their left foot. RNS #1 then stated, Come on and appeared to be moving the resident onto their back since the resident's feet were now both flat on the floor. -CNA #1 then walked over to the resident's right side and RNS #1 then stated, This is ridiculous. Stand up, as RNS #1 and CNA #1 assisted the resident to stand. -RNS #1 and CNA #1 began to walk the resident towards their bed. LPN #1 then stepped to left and the camera view was no longer obstructed. RNS #1 did not assess the resident for injury prior to turning Resident #1 onto their back or prior to assisting the resident to stand. The Nursing Progress Note dated 4/4/2023 at 4:18 AM by RNS #1, documented that at 3:00 AM, they found the resident on the floor between the bathroom and bedroom. The resident had removed their clothes and was laying on their right side and the walker was on the floor in the bathroom. The resident was rolled over to back position and stood with two-assist. Resident was walked back to bed and then requested to go back to the toilet. The undated facility investigation report by the Administrator (ADMIN #1), documented that after reviewing the videos dated 4/4/2023, it appeared that Resident #1 fell on the floor in their bathroom on 4/4/2023 at approximately 3:00 AM. There were two nurse aides that entered the room and waited for the RNS (#1) to come into the room before moving the resident. The RNS (#1) entered the room and assisted the resident with one of the nurse aides. RNS #1 was asked if they conducted an assessment of the resident prior to moving the resident. RNS #1 stated they conducted a visual assessment and it appeared that the resident's hips and legs were in alignment. RNS #1 stated the resident was placed in bed and that they completed a more thorough assessment. It was documented that after discussing the entirety of the incident, it did not appear that RNS #1 did a complete assessment before moving the resident from the floor to the bed. During an on 4/14/2023 at 12:26 PM, RNS #1 stated Resident #1 fell at 3:00 AM. RNS #1 stated they did not assess the resident prior to moving the resident. RNS #1 stated they were not disputing that the resident should have gotten a thorough assessment when they were on the floor but did not remember saying that they finished assessing the resident when they were put back to bed. RNS #1 stated they did not assess the resident when the resident was on the floor or when they were put back to bed. During an interview on 4/18/2023 at 2:19 PM, the Director of Nursing (DON) #1 stated they reviewed the videos dated 4/4/2023. The DON #1 stated it did not appear that an assessment of the resident was done. The DON #1 stated a full body assessment with neurological checks should have been done while the resident was still on the floor, to assess for injury. The DON #1 stated the whole purpose of the RN supervisor was for them to do an assessment of the resident. During an interview on 4/18/2023 at 3:25 PM, the Assistant Director of Nursing (ADON) #1 stated when a resident falls, the facility policy was for the RN to do a basic assessment; check range of motion and assess for pain and do a neurological check before the resident is moved. The ADON #1 stated RNS #1 said they assessed the resident after the resident used the bathroom and was put back to bed. The ADON #1 stated they watched the videos dated 4/4/2023 and did not see RNS #1 assess the resident for injury. During an interview on 4/20/2023 at 3:47 PM, CNA #1 stated they could not recall if RNS #1 assessed Resident #1 for injury after they had fallen on 4/4/2023 at 3:00 AM. During an interview on 4/21/2023 at 12:53 PM, CNA #2 stated RNS #1 did not do an assessment of Resident #1 when they had fallen on the floor on 4/4/2023. CNA #2 stated RNS #1 was supposed to assess the resident and then tell the CNAs when they could move the resident. CNA #2 stated that instead, RNS #1 and CNA #1 stood the resident up. CNA #2 stated the reason they call the supervisor and do not move a resident when they fall is so that the resident can be assessed for injury prior to moving the resident. During an interview on 4/21/2023 at 3:31 PM, LPN #1 stated whenever a resident falls, the RN does an assessment of the resident for injury. LPN #1 stated the moving of the resident was based on what the RN does and finds during the assessment. LPN #1 stated staff were aware they were not to move a resident before an assessment was done by the RN. 10 NYCRR 415.12

Based on observation, record review and interview during a recertification survey, the facility did not ensure residents received care to prevent avoidable pressure ulcers, and that residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #49) of 3 residents reviewed for pressure ulcers. Specifically, for Resident #49, the facility did not ensure a mechanical wound treatment (wound vac) was applied correctly. Additionally, the facility did not ensure the care plan developed for a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) contained interventions for an infected wound or for suspected deep tissue injuries (DTI: localized area of discolored intact skin or blister due to damage of underlying soft tissue) to the resident's bilateral great toes. This is evidenced by: Resident #49 Resident #49 was admitted to the facility with diagnoses of local infection of the skin and subcutaneous tissue, pressure ulcer of the sacral region stage 4 and type 2 diabetes mellitus with unspecified complications. The Minimum Data Set (MDS - an assessment tool) dated 3/1/2021 documented the resident was cognitively intact, was usually understood and can usually understand others. It documented the resident was at risk for developing pressure ulcers, had one stage 4 pressure ulcer. Finding #1 The facility did not ensure facility staff applied a mechanical wound treatment correctly. During an observation on 5/17/2021 at 11:10 AM, Registered Nurse Unit Manager (RNUM) #3 placed a cut sponge onto the Stage IV pressure ulcer on the resident's sacrum. RNUM #3 used a sterile cotton swab to place the sponge into the wound cavity. The sponge was not placed completely within the wound cavity. The sponge overlapped onto intact skin at the wound border. RNUM #3 placed a large transparent medical dressing to cover the wound and the sponge. The Policy and Procedure (P&P) titled Medela Invia Liberty Negative Pressure Wound Therapy dated 5/6/2021, documented to follow the dressing application guide attached. The manufacturer's Dressing Application Guide, documented to not allow foam to overlap onto intact skin. During an interview on 5/17/2021 at 11:36 AM, RNUM #3 the sponge should be placed within the wound bed and not on intact skin. The RNUM stated she did not realize the sponge was overlapping onto intact skin as the resident's wound has decreased in size since she previously completed wound care on the resident. Finding #2 The facility did not ensure the care plan developed for Wound Care included the care and treatment of the infection of the stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) on the resident's sacrum and the At risk for Skin Breakdown Care Plan did not include the pressure relieving device that was in use on the day of survey for the suspected deep tissue injury (DTI: localized area of discolored intact skin or blister due to damage of underlying soft tissue) to both great toes. The Comprehensive Care Plan (CCP) for Wound Care created 2/22/2021, documented wound treatment as ordered for stage 4 pressure ulcer. The CCP did not include the care and treatment of the resident's bilateral great toe DTI's. Review of Resident #49's CCPs did not include the care and treatment for an active infection in the stage 4 pressure ulcer on the resident's sacrum. A Nursing Progress Note dated 5/14/2021 at 2:47 PM, documented the presence of a DTI on both great toes. A Medical Doctor order dated 5/5/2021, documented ertapenem (antibiotic) 1 g solution for injection: Infuse 1 gram by intravenous route once daily for 40 days via PICC. A document titled Wound Tracking Flow Sheet documented the presence of stage 2 pressure ulcer on (the resident's) left bunion below the big toe on 5/8/2021. A document titled Wound Tracking Flow Sheet documented the presence of a DTI on the resident's right bunion on 5/12/2021. During an interview on 5/19/2021 at 12:33 PM, the Director of Nursing (DON) #1 stated the expectation was that a CCP would be in place for a resident with an infected wound or suspected deep tissue injuries. 10NYCRR 415.12(c)(1)(2)

Based on observation, interview, and record review during a recertification survey, the facility did not ensure adequate pain management was provided to residents who required such services, consistent with professional standards of practice for 2 (Resident #'s 24 and #131) of 2 residents reviewed. Specifically, for Resident #24, the facility did not ensure the residents pain was consistently monitored before and after receiving a routine pain medication and did not ensure there was an ongoing assessment of the pain the resident experienced during compression boot (inflatable sleeves for the legs that go up to thighs, fill with air and squeeze the legs to increase blood flow) therapy and for Resident #131, the facility did not ensure staff monitored the effectiveness of scheduled pain medication for the resident who received Tramadol (pain medication) and Tylenol (pain medication) on a routine basis for a diagnosis of chronic pain. This is evidenced by: Resident #24: Resident #24 was admitted to the facility was the diagnoses of osteoporosis, chronic pain, and stage 2 pressure ulcer to the right buttock. The Minimum Data Set (MDS - an assessment tool) dated 2/6/2021, documented the resident was cognitively intact, received scheduled pain medications and had pain frequently at a numeric rating of 7. The facility Policy and Procedure titled Pain Management Protocol dated 4/13/2018, documented that a pain assessment will be completed upon resident complaint, staff observation or report and after family/visitor observation or report of pain. Pain will be monitored and documented by the medication nurses in the electronic medical record (EMR) using the pain scales before and after pain medication. The Comprehensive Care Plan (CCP) documented the following: -Pain Management dated 11/12/2020, documented an Alteration in Comfort due to Chronic Pain and Moisture Associated Skin Damage (MASD). The resident would have pain managed to tolerate level of 4 or less, and ongoing assessment of pain with emphasis on the onset, location, description, intensity of pain and alleviation of the aggravation factors. -At Risk for Skin Breakdown dated 11/12/2020, documented decreased mobility, edema, malnutrition; apply treatment as ordered, Braden scale (scale used for pressure ulcer risk) review quarterly and prn (as needed). The resident had a pressure sore on the buttocks which healed, buttocks still with Moisture Associated Skin Damage (MASD) and appear cracked like chapped skin, using Zinc and A&D at this time. The resident had a cushion from occupational therapy (OT) for chair issued on 3/19/2021. Finding #1: The facility did not ensure it consistently monitored the resident's pain before and after receiving a routine pain medication. During an observation on 05/17/21 at 09:58 AM, Licensed Practical Nurse (LPN) #9 and Registered Nurse Manager (RNM) #7 toileted the resident. The resident stated that their bottom really hurt. The resident was observed wincing in pain while the nurse washed off the area on the residents bottom that was covered with zinc oxide . The nurse did not assess the resident's pain. Physician Orders documented the following: -12/18/2020 Tylenol Extra Strength 500 mg; 2 tablets three times a day for chronic pain; monitor pain 30 minutes after administration. The Medication Administration Records dated from 4/1/2021 - 4/27/2021, documented Tylenol 500 milligrams (mg): 2 tablets three times a day for pain. It did not include pre or post pain scales for the administration of Tylenol at 2:00 PM on 4/1, 4/3, 4/6, 4/8, 4/12, 4/13/2021, and 4/27/2021, and at 10:00 PM on 4/1, 4/2, 4/6, 4/8, 4/11, 4/15, and 4/25/2021; pre pain scales for the administration at 10:00 PM on 4/21/2021; and post pain scales for the administration of Tylenol at 6:00 AM on 4/4/2021, at 2:00 PM on 4/5, 4/8, 4/7, and 4/25/2021, and at 10:00 PM on 4/1, 4/7, 4/9, 4/12 - 4/16, 4/18 - 4/20, and 4/24/2021. The Medication Administration Records dated from 5/2/2021 - 5/15/2021, documented Tylenol 500 mg: 2 tablets three times a day for pain. It did not include pre or post pain scales for the administration of Tylenol at 6:00 AM on 5/15/2021, at 2:00 PM on 5/6 and 5/13/2021 and the 10:00 PM dose on 5/14/2021; did not include pre administration pain scale for administration of Tylenol at 2:00 PM on 5/16/2021; and did not include a follow up pain scale for the administration of Tylenol at 2:00 PM on 5/2, 5/5, 5/11/2021, and at 10:00 PM on 5/10, and 5/13/2021. During an interview on 05/19/2021 at 08:19 AM, Registered Nurse Mnager (RNM) #7 stated that when a pain medication was given the level and location of pain are documented on the EMR. There is a spot on the EMR to document pre and post pain scales before and after each administration time. It is set up so the computer would prompt a response. She was not aware that it was not consistently documented as done. During an interview on 05/19/2021 at 10:53 AM, the Director of Nursing (DON) stated that usually when pain medication is ordered, the monitoring is also added (to the EMR). The computer prompts the nurse for the pain scale. The facility policy was to monitor for pain before and after pain medication was administered and it was the RNMs' responsibility to follow up to ensure documentation is completed. Finding #2: The facility did not ensure it assessed and addressed the pain the resident experienced during compression boot (are inflatable sleeves for the legs that go up to thighs, fill with air and squeeze the legs to increase blood flow) therapy. A Physician Orders dated 11/17/2020, documented compression boots to bilateral lower extremities (BLE) daily x 1 hour. During an interview on 05/13/21 at 12:17 PM, the resident stated he had a lot of pain on his bottom from the sore on his bottom, especially when he had the compression boots on because he could not move. During an observation on 05/17/21 at 09:58 AM, Licensed Practical Nurse (LPN) #9 and Registered Nurse Manager (RNM) #7 toileted the resident. He/she stated his/her bottom was really hurt. When the nurse was washing off the area that was covered with zinc oxide the resident was wincing in pain. The resident's pain was not assessed by the nurse. Progress notes documented the following: -2/27/21, the resident stated due to COVID restrictions his/her bottom hurts because it was the only thing, he/she could do. -3/22/21, the chafing to buttocks has improved but was still present and causing discomfort. -3/25/21 daughter called reporting that the resident had called a few times this week complaining and crying due to pain issues related to wounds and the compression boots. -3/25/ 21- the resident complained of sore buttocks stating he/she has a lot of discomfort. Currently using zinc and A&D. Encouraged to lay side to side in bed and stay off his bottom as he sits up in a chair all day. -5/17/21, RN checked the resident's skin. The resident's bilateral buttocks remain red and uncomfortable for him/her. A review on the medical record dated from 2/18/21 - did not include any documentation from the nurses or the physician of pain during the compression boot treatment. During an interview on 05/17/21 at 10:20 AM, Certified Nursing Assistant (CNA) #6 stated the resident complained a couple times a day and she told Licensed Practical Nurse #9 every day that the resident's bottom hurt. During an interview on 05/17/2021 at 11:30 AM, Licensed Practical Nurse (LPN) #9 stated the resident usually complained after sitting for an hour with the leg pumps on. She had not received any reports from the CNAs that the resident was in pain nor did not report when the resident complained to her of pain. The resident was on Tylenol three times a day. During an interview on 05/18/2021 at 10:10 AM, Registered Nurse Manager (RNM) #7 stated the resident complained about pain mostly when sitting still. No one had reported any complaints recently. It was not reported it to the physician because he got Tylenol. During an interview on 05/19/2021 at 08:19 AM, RNM #7 stated when she saw the resident with the surveyor on 5/17/21, she did not do pain assessment and should have. They just added pain monitoring today while the compression boots are in use, because of his/her complaints of pain during the compression treatment. During an interview on 05/19/21 at 10:53 AM, the Director of Nursing (DON) stated if the resident experienced pain any time during the day, it should be reported, the nurse should assess the pain, including a pain level, where it is located, the cause of the pain if known, and the physician notified. Resident #131: Resident #131 was admitted to the facility with the diagnoses of chronic pain, a right femur fracture (2019), and osteoarthritis. The Minimum Data Set (MDS - an assessment tool) dated 4/6/2021 documented the resident had moderately impaired cognition, could usually understand others and could usually make self understood. The Policy and Procedure (P&P) titled Pain Management Protocol dated 4/13/2018, documented pain would be monitored and documented by the medication nurses in the EMR (electronic medical record) using the pain scales before and after pain medication [administration]. The P&P documented follow up in the EMR should occur within one hour of administration supported by a progress note reflecting administration and the effect for each dose administered. During an observation and interview on 5/14/2021 at 10:13 AM, Resident #131 was lying in bed with their eyes closed. Resident #131 stated they did not want to get out of bed this morning and did not feel like moving because they ached all over. Resident #131 stated Resident #131 had a fall a couple years ago and hurt Resident #131's right leg and it was still painful and made the rest of Resident #131's body hurt all over. Resident #131 stated Resident #131 was receiving pain medications for the pain but continued to have pain. The Comprehensive Care Plan (CCP) for Pain Management dated 7/23/2019, documented the resident had pain related to osteoarthritis. The goal was the resident would have pain managed to a tolerable level of pain as evidenced by a pain rating of 4 or less on a scale 1-10. The care plan interventions included: on-going assessment of the resident's pain with emphasis on the onset, location, description, intensity of pain and alleviating and aggravating factors, administer medication as ordered by the physician, and monitor side effects and adverse reactions resulting from interventions rendered. A Physician Order dated 1/12/2021, documented Acetaminophen (Tylenol) 500 milligrams (mg) 2 times a day for chronic pain. A Physician Order dated 1/15/2021, documented Tramadol 50 mg 3 times a day for chronic pain. A Nurse Practitioner (NP) progress note dated 5/14/2021, documented the resident had complained of chronic left sided hip and knee pain that was managed with routine Tylenol and Tramadol. The note documented to continue the resident's current drug regimen and to monitor for signs and symptoms of pain and adjust the plan of care (POC) as needed. The note documented to consider a lidocaine patch (an anesthetic that produced a local or general loss of sensation, including pain) with continued pain. During a record review from 4/18/2021 to 5/18/2021, Resident #131's medical record did not include documentation of pain monitoring before or after Resident #131 received scheduled pain medications or the effectiveness of the medications in relieving Resident #131's chronic pain. During an interview on 5/19/2021 at 9:08 AM, License Practical Nurse (LPN) #2 stated Resident #131 had pain and received Tramadol. LPN #2 stated the nurses monitored pain with every administration of pain medication, including Tylenol. LPN #2 stated pain scales were completed before and after administering a pain medication to a resident and the pain scales were documented in the EMR. LPN #2 stated the effectiveness of a pain medication was monitored with a follow up pain scale to determine if the pain medication was working for the resident. LPN #2 stated the EMR should prompt the nurse to complete the pre-administration pain scale and a follow up pain scale within 20-45 minutes after administering the pain medication. During an interview on 5/19/2021 at 9:31 AM, Registered Nurse (RN) #1 stated when the medication nurses signed off that a pain medication was administered in the EMR, the nurses had to document a pre-pain scale, which was usually a numerical scale (1-10), to determine the resident's pain level before the administration of the pain medication. RN #1 stated the EMR would prompt the nurses to do a follow up pain scale in 30 minutes. RN #1 stated, the RN would notify the doctor if a pain management intervention was not effective, for example if the Tylenol was not working to relieve a resident's pain. RN #1 stated the use of pain scales was how the effectiveness of the pain medication was monitored. RN #1 reviewed the EMR for Resident #131 and stated RN #1 did not know why the pre and post pain scales were not showing up on the computer for the nurses to complete with the pain medication administration. RN #1 reviewed the resident's medical record for pain monitoring for the month of May 2021 and could not find a completed pain scale prior to today, 5/19/2021. RN #1 stated it did not look as if Resident #131 had pre and post pain scales completed with the administration of pain medications. RN #1 stated the pain medication order should have pain monitoring with it for the nurses to complete. During an interview on 5/19/2021 at 10:00 AM, RN #2 stated there should be a pre and post pain scale completed with the administration of pain medications. RN #2 stated if the resident had persistent, unrelenting pain that the medication was not relieving as indicated by the pain scales or as reported by the resident, the RN would notify the physician. During an interview on 5/19/2021 at 10:52 AM, the Director of Nursing (DON) stated yesterday, 5/18/2021, pain monitoring was added to Resident #131's pain medication orders. The DON stated prior to yesterday, pain monitoring had not been added in the EMR to prompt the nurses to obtain and pre and post pain scales when administering pain medications to Resident #131. The DON stated it was the Head Nurses responsibility to ensure pain monitoring was added in the EMR when a resident had an order for pain medication. The DON stated the nurses on the unit should have noticed there was no pain monitoring completed for Resident #131. The DON stated the nurses should have been monitoring to see if the pain medication was effective for the resident. The DON stated the nurses utilized the pain scale to determine the effectiveness of pain medications. The DON stated pain monitoring should be done every day and pain should be monitored before and after every pain medication was administrated. 10NYCRR 415.12

Based on observations, record reviews and interviews conducted during the recertification survey, it was determined that the facility did not ensure that it was free of medication error rates of 5 percent or greater for two (Residents #88 and #165) out of six residents reviewed for medication administration with 26 total observations resulting in a 34.62 percent error rate. Specifically, the facility did not ensure medication was administered as ordered by the medical doctor for Residents #88 and #165. This is evidenced by the following: The facility Policy and Procedure (P&P) titled Glendale Nursing Home Medication Administration Schedule Protocol dated 2/6/2012 stated drugs must be administered no more than sixty minutes before or after the scheduled time. Resident #88: Resident #88 was admitted to facility with hypertension, major depressive disorder and Alzheimer's disease. The Minimum Data Set (MDS - a resident assessment tool) dated 3/10/2021 documented resident was cognitively impaired, sometimes was understood and usually understood others. During an observation on 5/17/21 at 9:36 AM, Licensed Practical Nurse (LPN) #5 administered medications escitalopram 10 mg by mouth, propranolol 40 mg by mouth and divalproex 125 mg delayed release sprinkle by mouth. The Medical Doctor ordered escitalopram 10 mg every day at 8:00 AM for major depressive disorder (renewed 2/25/21), propranolol 40 mg every day at 8:00 AM for hypertension (renewed 5/7/21), and divalproex 125 mg delayed release sprinkle every day at 8:00 AM for bipolar disorder (renewed 5/7/21). Medical record reviewed with no documentation of contact with Medical Doctor regarding late administration of medications. Resident #165 Resident #165 was admitted to facility with presence of cardiac pacemaker, unspecified mononeuropathy of bilateral lower limbs and rheumatoid arthritis of right hand with involvement of other organs and systems. The Minimum Data Set (MDS - a resident assessment tool) documented resident was cognitively impaired, was rarely/never understood and sometimes understood others. During an observation on 5/17/2021 at 9:49 AM, LPN #5 administered medications gabapentin 100 mg 2 capsules by mouth, omeprazole 20 mg delayed release by mouth, acetaminophen 325 mg by mouth, folic acid 1 mg by mouth, apixaban 2.5 mg by mouth and prednisone 2.5 mg two tablets by mouth. The Medical Doctor ordered gabapentin 100 mg capsule 2 capsules twice daily at 8:00 AM and 7:00 PM for unspecified mononeuropathy of bilateral lower limbs (renewed 2/25/2021), omeprazole 20 mg delayed release capsule once daily before meals every day at 8:00 AM (renewed 2/25/2021), acetaminophen 325 mg twice daily at 8:00 AM and 7:00 PM for pain due to cardiac device (renewed 2/25/2021), folic acid 1 mg once daily every day at 8:00 AM for psoriatic juvenile arthropathy (renewed 2/25/2021), apixaban 2.5 mg twice daily at 8:00 AM and 7:00 AM for phlebitis and thrombophlebitis of right femoral vein (renewed 2/25/2021), and prednisone 2.5 mg two tablets every day at 8:00 AM (renewed 2/25/2021). Medical record reviewed with no documentation of contact with Medical Doctor regarding late administration of medications. During an interview on 5/17/2021 at 9:50 AM, LPN #5 stated they won't bother a resident during breakfast or will try to give medications before breakfast. LPN #5 stated the facility's medication policy is if the medication is scheduled for 8:00 AM it can be given between 7:00 AM and 9:00 AM. During an interview on 5/18/2021 at 1:12 PM, Registered Nurse Unit Manager (RNUM) #5 stated that they hadn't been told medications were being administered late by the LPNs. RNUM #5 had only been told about medications not given. The LPNs should tell RNUM #5 before giving a late medications so they can obtain MD instructions. Then it would be documented in the chart. It is the LPN's responsibility to inform RNUM #5 if medications are given late. During an interview on 5/18/2021 at 1:27 PM Director of Nursing (DON) #1 stated the expectation for medication administration was one hour before and one hour after a medication was scheduled. DON #1 stated they had not been informed by Unit Manager of late medications. 10NYCRR 415.12(m)(1)

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Specifically, non-food contact equipment were not clean in the main kitchen and in 5 of 5 unit kitchenettes. This is evidenced by: The main kitchen and the kitchenettes were inspected on 05/13/2021 at 9:45 AM. In the main kitchen, the sides of both convection ovens, the stovetop, and the electric outlets under the food preparation tables were covered in food debris. In 5 of 5 unit kitchenettes, the gaskets and the exhaust fans in the refrigerators were covered in food particles and dust, and the underside of the juice machines were covered in a black syrup like substance. The Director of Food Services stated in an interview on 05/17/2021 at 11:30 AM. that the non-food contact surfaces in the main kitchen and unit kitchenettes will be cleaned. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.90, 14-1.110, 14-1.170

Based on record review and staff interview during the recertification survey, the facility did not ensure the policy regarding foods brought in to residents by visitors is in accordance with adopted regulations. Specifically, the facility policy does not have provisions to ensure facility staff assist dependent residents in accessing and consuming food brought to them by visitors. This is evidenced is as follows. Record review of the facility policy for food brought in by visitors was reviewed on 05/13/2021. This policy did not include a method by which staff assist residents in accessing and consuming food if the resident is not able to do so on their own. The Director of Food Service stated in an interview on 05/13/2021 at 3:05 PM, that the policy for food brought to residents does not include guidelines on how residents will access and consume food brought to them if they are not able to do so on their own. 10NYCRR 483.60(i)(3)

Based on observation and interview during a recertification survey conducted on 5/26/2021, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not ensure facility staff members changed gloves and performed hand hygiene during the process of collecting specimens via nasal swabbing for COVID-19 testing for 4 (Certified Nurse Assistant (CNA) #5, Resident Support Worker (RSW) #5, Human Resource (HR) #6, and [NAME] #7) of 5 staff members swabbed. This is evidenced by: The Centers for Disease Control and Prevention (CDC) Infection Control guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel [(HCP)] During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/23/2021, documents HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE [(Personal Protective Equipment)], 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 NYSDOH Health Advisory titled COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities dated 3/13/2020 revised 7/10/2020, documented that if there are confirmed cases of COVID-19 in a NH, 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. A facility document titled COVID TESTING COMPETENCY signed and dated by CNA #2 on 5/14/21, documented when completing staff, visitor, or contract COVID testing proper Personal Protective Equipment (PPE) must be worn, including: N95 mask, eye protection, gown, and gloves. The competency did not address hand hygiene before or after performing COVID-19 testing collection. During observation of staff testing for COVID-19 on 5/18/2021 at 9:59 AM, CNA #2 performed nasal swab testing for COVID-19 on CNA #5. After the swab was obtained, CNA #2 wore gloves to hold the swab, the Binax NOW COVID-19 AG test card, and the reagent solution, inserted the swab and sealed the card closed, placed the card on the counter and set the timer for 15 minutes. CNA #2 used hand sanitizing gel on their gloved hands and performed nasal swab testing for COVID-19 on RSW #5, HR #6, and [NAME] #7. CNA #2 did not perform hand hygiene or change gloves throughout the observation. During an interview on 5/18/2021 at 10:00 AM, CNA #2 stated they were told that gloves did not need to be changed after testing each staff member, the hand sanitizing gel must be used on gloved hands between every test and to change gloves if they become damaged or their hands are sweaty. During an interview on 5/19/2021 at 1:38 PM, Registered Nurse (RN) #6 stated that they were told that it was acceptable to use hand sanitizing gel on gloved hands if the gloves were not damaged. During an interview on 5/19/21 at 1:38 PM, the Director of Nursing (DON)/ Infection Control Preventionist (ICP) agreed with RN# 6's statement it was acceptable to use hand sanitizing gel on gloved hands between tests. During an interview on 5/19/2021 at 1:40 PM, the Assistant Director of Nursing (ADON) stated staff should change gloves and perform hand hygiene between each person being swabbed. 10NYCRR415.19(a)(1); 400.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan (CCPs) for each resident, consistent with the residents rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 (Resident #'s 20, 24, 34, 43, 118, and # 141) of 29 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #20, 34, and #43 the facility did not ensure a CCP was developed for the use of psychotropic drug use for residents who were receiving psychotropic medication, for Resident #24, the facility did not ensure a CCP was developed for the resident with obstructive and reflux uropathy (a condition in which the flow of urine is blocked and causes the urine to back up and injure one or both kidneys), and for Resident #118, the facility did not ensure a CCP was developed for the care and management of an indwelling urinary catheter and did not ensure the CCP for skin integrity, for the resident with impaired mobility and pressure ulcers, included interventions to heal/prevent pressure ulcers, and, for Resident #141, the facility did not ensure the CCP for falls included person-centered interventions after the resident had a fall with injury. This is evidenced by: The facility Policy and Procedure (P&P) Comprehensive Care Plans (CCP) dated 5/12/2017, documented each resident would have an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. Resident #34: The resident was admitted to the facility with the diagnoses of rheumatoid arthritis, major depressive disorder, and pain. The Minimum Data Set (MDS - an assessment tool) dated 2/9/2021, documented the resident was cognitively intact, could usually understand others and could usually make self understood. A Physician Order dated 4/28/2021, documented Lexapro (antidepressant medication) 10 milligrams (mg) daily for major depressive disorder. A review of the CCP did not include a care plan to address the use of psychotropic medication, specifically the use of Lexapro. During an interview on 5/19/2021 at 9:25 AM, Registered Nurse (RN) #1 stated Resident #34 did not have a psychotropic drug care plan and the resident was receiving Lexapro that was recently increased from 5 mg to 10 mg. RN #1 stated the resident should have psychotropic drug care plan since the resident was receiving a psychotropic medication. RN #1 stated RN #1 was responsible for the care planning on the unit. During an interview on 5/19/2021 at 11:02 AM, the Director of Nursing (DON) stated there was not a specific care plan for psychotropic drug use. The DON stated the DON did not know if having a psychotropic drug use care plan was a requirement but the behavior care plans addressed the medications because the behavior care plan documented to administer medications as ordered by the physician. Resident #43: Resident #43 was admitted to the facility with the diagnoses of Alzheimer's disease, depression, and spinal stenosis. The Minimum Data Set (MDS-an assessment tool) dated 2/18/2021 documented the resident had severe cognitive impairment and was rarely able to make self understood or understand others. The MDS documented the resident received antipsychotic and antidepressant medications for seven days. A review of the Physician Orders with an original date of 10/27/2021 and a renewal date of 4/30/2021 documented Quetiapine (antipsychotic medication) 25 mg (milligrams) to be administered once per day; Sertraline (antidepressant medication) 100 mg to be administered once per day. A Nurse Practioner note dated 10/28/2020, documented Depression/Agitation continue with Quetiapine, continue with Sertraline. A Physician note dated 10/28/2021, documented Dementia-continue Quetiapine, Sertraline. A review of the CCPs did not include a care plan to address the antipsychotic medication or the antidepressant medication. During an interview on 5/19/2021 at 11:16 AM, the Registered Nurse Manager (RN) #4 stated the normal protocol when a resident was admitted on psychotropic medications, was to put a care plan in place. Resident #43 was admitted to a different unit initially and when the resident moved to this unit RN #4 missed that a psychotropic care plan was not in place. There should have been a psychotropic care plan when a resident was on psychotropic medications. Resident #118: Resident #118 was admitted to the facility with diagnosis of cerebella stroke syndrome, benign prostatic hyperplasia (enlarged prostate), and major depression. The Minimum Data Set (MDS- an assessment tool) dated 3/30/2021 documented the resident had severe cognitive impairment, sometimes understands others, and was sometimes understood by others. During an observation on 5/13/2021 at 12:53 PM, the urine in the resident's foley catheter bag was cloudy and brownish in color, with thick sediment (gritty particles) in the bag and in the tubing. Reviiew of the physician orders documented the following; 3/12/2021, documented foley catheter care every shift and as needed. 3/12/2021, documented change foley catheter collection bag weekly on Wednesday 11:00 PM- 7:00 AM shift. 3/12/2021, documented ensure foley collection bag cover is in place every shift. 3/12/2021, documented foley output every shift. 3/12/2021, documented flush catheter with 50 ml of sterile water weekly on Tuesday 7:00 AM- 3:00 PM shift. 3/12/2021, documented change foley catheter every 6 weeks on Tuesday 7:00 AM- 3:00 PM shift. Review of the medical record on 5/17/2021, did not include a CCP for the care and management of an indwelling urinary catheter. During an interview on 5/19/2021 at 9:47 AM, Licensed Practical Nurse (LPN) #6 stated the resident had a history of refusing care and to have the catheter flushed. LPN #6 stated staff would have to reapproach the resident multiple times before providing catheter care. LPN #6 stated the staff were not aware who was responsible to develop and review the CCPs, or if the CCP should include interventions related to the resident refusing catheter care. During an interview on 5/19/2021 at 11:15 AM, the Registered Nurse Unit Manager (RNUM) #5 stated the interdisciplinary team (IDT) reviewed and revised CCPs quarterly and as needed, and the RNUM was responsible to develop and implement a CCP for the care and management of an indwelling urinary catheter for Resident #118. The CCP should have been developed based on the admission MDS dated [DATE] and should have been revised to include person centered interventions for the resident with a history of refusing care. During an observation on 5/13/2021 at 12:54 PM, the resident was in bed and eating lunch. There was an air mattress on the bed, the head of bed was elevated, the resident's legs were bent at the knees, with the resident's feet against the foot board and knees against the overbed table with the lunch tray on it. A Physicians Order dated 3/30/2021 at 7:44 PM documented, collagenase clostridium histolyticum 250 unit/gram topical ointment (an enzyme that works by helping to break up and remove dead skin and tissue), apply by topical route to the affected area once daily: Dimensions of wound; 10.2 centimeters (cm) x 6.5cm, cover with dry dressing and wrap with kling, change daily and as needed. Diagnosis: pressure ulcer right heel; unstageable. A facility document titled Wound Tracking Flow Sheet documented, wound location: Right heel #1; unstageable, date of origin: 3/30/2021, wound size: 1.7 cm x 1.6 cm, dated 5/12/2021. A facility document titled Wound Tracking Flow Sheet documented, wound location: Right heel #2; unstageable, date of origin: 3/30/2021, wound size: 4.0 cm x 5.0 cm, dated 5/12/2021. A CCP titled Skin Integrity: Risk for Skin Breakdown dated 2/13/2021 did not include person centered interventions for prevention of pressure ulcers. A CCP titled Skin Integrity: Presence of Skin Breakdown dated 3/31/2021 did not include person centered interventions for the care of the resident with pressure ulcers. During an interview on 5/19/2021 at 9:47 AM, LPN #6 stated the resident had a history of refusing care and did not like to get out of bed. The resident should be turned and positioned every 2-4 hours with feet elevated on pillows while in bed. LPN # 6 stated they did not know if these interventions were documented in the CCP. LPN #6 stated they were not aware of who was responsible to develop and review the CCPs. During an interview on 5/19/2021 at 11:08 AM, RNUM #5 stated a CCP for Skin Integrity did not include person centered interventions. The CCP should have included person centered interventions for prevention and treatment of pressure ulcers. RNUM #5 also stated that as the RNUM it was their responsibility to review and revised the CCPs. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey the facility did not ensure it provided services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans for 3 (Resident #'s 94, 7, and #15) on 3 (Dutch Hallow, Pine Plains and [NAME] Crossing) of 5 units. Specifically, for Resident #94, the facility did not ensure the resident was transferred out of bed and/or transferred to the toilet due to inadequate staffing on the weekends, for Resident #7, the facility did not ensure the resident was transferred out of bed on the weekends and for Resident #15, did not ensure incontinence care was provided every 4 hours, in accordance with the Comprehensive Care Plan (CCP) due to inadequate staffing on the weekends. This is evidenced by: During an observation of the unit layout on 5/13/2021 at 10:15 AM, the units were very large and spread out into 3 separate self contained pods consisting of a long hallway with rooms on both sides. The hall opens into a large area with an open day room at the end and rooms around its sides. Due to the layout of the units, it would be impossible for staff in one pod to see what was going on in another pod. The Facility Census and Condition dated 5/13/2021 documented the current facility census was 190. Of those 190 residents, 142 required 1-2 person assistance with bathing and 34 were total dependent on staff; 147 required 1-2 person assistance with dressing and 15 were total dependent on staff.; 120 required 1-2 person assistance with transfers from one surface to another and 31 were total dependent on staff; 141 required 1-2 person assistance for toileting and 14 were total dependent on staff; and 50 required 1 person assistance with eating and 20 were total dependent on staff. Resident #94: Resident #94 was admitted to the facility with the diagnoses of Multiple Sclerosis (MS), lymphedema (excess fluid collection/swelling) and major depressive disorder. The Minimum Data Set (MDS - an assessment tool) dated 3/16/2021, documented the resident was cognitively intact, could understand others and could make self understood. The resident resided on the [NAME] Crossing Unit. During an interview on 05/13/2021 at 11:18 AM, Resident #94 stated there was not enough staff on the weekends to get all the residents out of bed. Resident #94 stated Resident #94 had to stay in bed on the weekends because there was not enough staff to get Resident #94 out of bed. Resident #94 stated the staff should be putting Resident #94 on the toilet, but the staff did not put the resident on the toilet when there was not enough staff, especially on the weekends. Resident #94 stated Resident #94 had to go to the bathroom in the resident's brief while in bed, and then the staff would change the brief. Resident #94 stated Resident #94 did not get out of bed on Sunday, 5/9/2021. During a subsequent interview on 05/18/2021 at 10:03 AM, Resident #94 stated Resident #94 did not get out of bed this weekend, 5/15/2021 or 5/16/2021. Resident #94 stated Resident #94 no longer expected to get out of bed on the weekends because there was not enough staff on the weekends to get the resident out of bed. Resident #94 stated it was not Resident #94's preference to remain in bed all weekend long and stated Resident #94 had to go to the bathroom in the resident's brief while in bed this weekend. The staff would change the brief. The Comprehensive Care Plan (CCP) for ADLs, dated 11/28/2017, documented the resident required assistance with ADL task performance for ambulation, toileting, grooming, bathing, and dressing. The CCP documented to assist with toileting as necessary to promote continence and to provide ADL assistance according to Nurse Instructions/Certified Nursing Assistant (CNA) care card. The CCP for Constipation, dated 3/8/2018, documented the resident had an alteration in elimination related to constipation due to multiple sclerosis and immobility. The CCP documented to monitor redness or broken areas during toileting/diaper change every 2-4 hours. The Certified Nursing Assistant (CNA) Assignment Summary (resident care instructions) with a print date 5/18/2021, documented Resident #94 preferred to be an early get up before 10:00 AM. The CNA Assignment Summary also documented the resident was a 2-person physical assist with a mechanical lift for transfers and toilet use. A review of progress notes for Sunday, 5/9/2021, Saturday, 5/15/2021 and Sunday, 5/16/2021 did not include documentation the resident declined or refused to be transferred out of bed or to use the toilet. ADL documentation for Resident #94's included: Sunday, 5/9/2021: -Transfer: Day Shift- no documentation the resident was transferred; Evening Shift- documented Activity did not occur; Night Shift- documented not performed -Toilet Use: Day Shift- no documentation the resident was toileted; Evening Shift- documented the resident's toilet type as incontinence briefs at 10:46 PM; Night Shift- documented the resident's toilet type as incontinence briefs on 5/10/21 at 12:23 AM. Saturday 5/15/2021: -Transfer: Day Shift and Night Shift- no documentation the resident was transferred; Evening Shift- documented not performed -Toilet use: Day Shift and Night Shift- no documentation the resident was toileted; Evening Shift- documented the resident's toilet type as incontinence briefs at 7:59 PM. Sunday 5/16/2021: -Transfer: Day Shift, Evening Shift, Night Shift- no documentation the resident was transferred -Toilet Use: Day Shift, Evening Shift, Night Shift- no documentation the resident was toileted During an interview on 5/19/2021 at 8:59 AM, CNA #1 stated CNA #1 worked every other weekend and stated the weekends did not have enough staff to get all the residents out of bed. CNA #1 stated when there were 2 or 3 CNAs on the day or evening shift, the CNAs could not get the residents out of bed and could not get the residents toileted according the residents' care plans. CNA #1 stated it was very hard to get all residents toileted every 2-4 hours and when there were only 2 or 3 CNAs, the residents were not toileted every 2-4 hours. CNA #1 stated Resident #94 would stay in bed on the weekends when there were 2 CNAs on the unit because Resident #94 knew if Resident #94 got out of bed, Resident #94 would not get toileted timely or get back to bed timely since there was not enough staff to put the resident on the toilet or put the resident back to bed before it got late in the evening. During an interview on 5/19/2021 at 9:48 AM, Registered Nurse (RN) #1 stated RN #1 had heard residents were not gotten out of bed when there are 2 or 3 CNAs working on the unit. RN #1 was aware Resident #94 had to stay in the bed on the weekends when staffing numbers were low on the unit. RN #1 stated residents stayed in bed and were not being checked and changed like the residents should be. RN #1 stated the staff were doing the best they could, but it was not physically possible to get all the residents out of bed and toilet all the residents as there should be. RN #1 stated the staff probably got through their assigned side of the unit once a shift and it just was not possible to do toileting every 2-4 hours like the residents' care plans documented with the amount of staff that they had. RN #1 stated when there were 2 CNAs and each CNA had 20 residents, and some of the residents required a 2 staff for assistance, it was not physically possible a lot of times to provide the needed care. RN #1 stated RN #1 reported it to the Director of Nursing (DON) and staffing concerns were discussed during morning meeting with the Administrator and the DON present. RN #1 stated the staff could not follow the care plans when there were only 2 CNAs on the day and evening shifts. RN #1 stated this unit was a long-term care unit and was not a priority for staffing. RN #1 stated the sub-acute Rehab Unit and the Dementia Care Unit were priorities for staffing. The 3 long term care units, Dutch Hallow, Pine Plains and [NAME] Crossing, were not a priority and were often left with less staff than the Rehab and Dementia Units. During an interview on 5/19/2021 at 10:58 AM, the DON stated the DON was aware staffing did not always meet the facility's minimum staffing numbers. When the DON was asked if the DON was aware that residents were not gotten up from bed on weekends or when there were 2 or 3 CNAs on the unit, the DON stated if residents refuse to get out of bed, it should be documented. The DON stated staffing had been a challenge with COVID-19 and the facility was always trying to recruit new staff. The DON stated the facility uses agency staff and the staffing scheduler tried to get staff to stay for overtime. The DON stated the nurses would drop down to be aides and RNs would cover when there were not enough medication nurses for the medication carts. During an interview on 5/19/2021 at 12:22 PM, the Administrator stated the Administrator was aware of issues with staffing. The Administrator stated it had been mentioned in morning report that the weekends were a little short for staff and that residents did not get out of bed on the weekends. The Administrator stated it was safe to assume that things were not getting done when the facility was short staffed. The Administrator stated the facility had open positions and was trying to hire. The Administrator stated the Administrator was aware that the facility staffing fell below the minimum staffing numbers the facility used to staff the building but tried to make it as safe as possible. The Administrator stated the facility used agency as much as they could, had just hired new CNAs for the night shift and was constantly recruiting for staff. Resident #7: Resident #7 was admitted to the facility with the diagnoses of Diabetes, hypertension and major depressive disorder. The Minimum Data Set (MDS - an assessment tool) dated 1/28/21 documented the resident had moderately impaired cognitive skills for daily decision making, could usually understand others and could usually make self-understood. The resident was an extensive assistance of 2 people for transfers. The resident resided on the Dutch Hollow Unit. During an interview on 05/17/2021 at 09:13 AM, the resident stated when they were short staffed they keep him in bed but he wanted to get up. He was in bed all day yesterday. A Comprehensive Care Plan for Activities of Daily Living dated 12/19/2018, documented to provide ADL care assistance according to the Nurse instruction/CNA care card. The CNA Assignment Summary documented the resident was totally dependent on 2 people for transfers and is lifted using a mechanical lift A review of progress notes for Saturday, 5/1/2021, and 5/8/2021, and Sunday, 5/9/2021, and 5/16/2021 did not include documentation the resident declined or refused to be transferred out of bed. ADL documentation for Resident #7 included: Saturday 5/1/2021: -Transfer: Day Shift and Evening shift- no documentation the resident was transferred, Night Shift- documented not performed Saturday 5/8/2021: -Transfer: evening shift- no documentation the resident was transferred, Night Shift- documented not performed Sunday, 5/9/2021: -Transfer: Evening Shift- no documentation the resident was transferred, Night Shift- documented not performed Sunday 5/16/2021: -Transfer: Day Shift, Evening Shift, Night Shift- no documentation the resident was transferred During an interview on 05/13/21 at 12:33 PM, Licensed Practical Nurse (LPN) #1 stated staffing has been bad for quite a while. They worked all week with 3 CNAs, and on weekends usually 2 CNAs for the day shift; Evenings sometimes worked with 1. She tried to help when she could, but her medication pass is her main priority. She told the CNAs to leave any residents that are 2 person assists in bed. Resident #7 is a two person assist and gets left in bed when they are short staffed. Resident #7 got upset because they did not understand why they had to stay in bed. They don't report it to administration anymore because nothing is done. During an interview on 05/17/2021 at 10:26 AM, Certified Nursing Assistant #6, stated the past few months has been pretty bad. They usually have 2 - 3 CNAs on the weekends. They leave residents that are 2 assist in bed on weekends. If they are not able to get someone out of bed they usually report it to the nurse. Last night there was only 1 CNA on the entire unit for the 11:00 PM - 7:00 AM (night shift). They were not positioned properly and were soaking wet. During an interview on 05/18/2021 at 12:57 PM, the Staffing Coordinator stated she tried to staff a minimum of 21 CNAs on the Day Shift and 19 on the Evening Shift. There were 2 CNAs per unit on the weekends more often than not. During an interview on 05/19/2021 at 08:51 AM, Registered Nurse Unit Manager (RNUM) #7 stated there were 13 residents that required assistance of 2 staff members for transfer, and was aware that when they were short staffed the residents who required 2 persons for assistance with transfers were left in bed. They try to rotate them so the same residents are not left in bed. Additionally, she was aware that when they were short staffed, residents were not being ambulated, showers were not done, and turning and positioning (T&P) and toileting was probably not being done as many times as they are supposed to be. The Day Shift staff have reported that when the Night Shift was short staffed, residents were soaked in the AM. Administration was aware and it was discussed at morning meetings with Department Heads; During an interview on 05/19/2021 at 09:20 AM, CNA #7 stated they work with 2 CNAs a majority of weekends or 2.5 CNAs. There unit gets pulled from a lot. If one of the units has 3 and one unit has 2 CNAs, they split the 3rd person so that they do 4 hours on each of the 2 units. They always get their half in the morning and the 3rd person leaves at 11:00 AM, leaving them with 2 CNAs for lunch and check and change. Ambulation was impossible. They try their hardest but sometimes they can't get all the care done. Usually the residents that required a 2 person assist were left in bed unless have to be up for meals. If they did no not do something, they either documented the activity was not performed or they did not document at all. Resident #15: The resident was admitted to the facility with diagnosis of neurogenic bladder, fibromyalgia, and hypertension. The Minimum Data Set (MDS- an assessment tool) dated 3/3/2021, documented the resident was cognitively intact and understands and is understood by others. The resident resided on the Pine Plains Unit. During an interview on 5/17/2021 at 10:39 AM, Resident #15 stated that on 5/16/2021 at 12:45 PM, the Nursing Supervisor told the CNA to float to another unit. Resident #15 reported calling the Nursing Supervisor at 2:07 PM to request a diaper change related to urinary incontinence and was told to use the call bell and wait for someone to respond. Resident #15 stated they required assistance of 2 to transfer back to bed to be changed, was on a every 4-hour toileting plan and was last toileted at 10:00 AM. The call bell was turned was on at 2:07 PM and answered by the next shift at 3:25 PM. During an interview on 5/17/2021 at 10:42 AM, CNA #3 stated when there are only 3 CNAs scheduled for the 7-3 shift each CNA has 13 or 14 residents on their assignment and the residents who require 2 person assistance for transfers do not get out of bed unless they are at high risk for falls. CNA #3 stated the care provided is prioritized based on the resident's care needs, fall risks, or level of incontinence, feeding assistance needed. The weekends are when there are only 2 or 3 CNAs scheduled. During an interview on 5/17/2021 at 12:02 PM, RNUM #5 stated the staff have not reported having difficulty completing their assignments, or not being able to get residents who require assistance of 2 person to get out of bed. RNUM #5 also stated that when the staffing levels are low everybody works together to get things done. During an interview on 5/19/2021 at 10:40 AM, CNA #3 stated that when floated to another unit in the middle of the shift the CNA is expected to report to the charge nurse and the charge nurse will re-assign the residents on that assignment. During an interview on 5/19/2021 at 10:47 AM, RNUM #5 stated when a staff member is floated to another unit after the shift has started the charge nurse is expected to reassign the resident care and document the changes on the assignment sheet. During an interview on 5/19/2021 at 10:47 AM, RNUM #5 stated there have been 3 CNAs and sometimes only 2 CNAs scheduled on the weekends for the past month. RNUM #5 stated that they had not been made aware of residents not receiving care or not getting out of bed. During an interview on 5/19/2021 at 11:26 AM, Staffing Coordinator #4 stated the unit staffing schedule is based on the unit census and residents care needs. Staff may be asked to work on a different unit to balance out the staffing levels. During an interview on 5/19/2021 at 11:35 AM, Nursing Supervisor #1 stated on 5/16/2021 on the 7:00 AM- 3:00 PM shift there were 3 CNAs scheduled on each unit and at 12:15 PM, a CNA from the Union Station Unit went home sick and a CNA from the Pines Plains unit was floated to cover her assignment. The decision to float a CNA in the middle of the shift was related to the acuity of the residents on each unit. During an interview on 5/19/2021 at 11:35 AM, Nursing Supervisor #1 stated that Resident # 15 called the supervisors phone and reported that they had been incontinent and needed to be changed. Nursing Supervisor #1 stated that the resident was instructed instructed to turn on their call light and that someone would be there as soon as possible. 10NYCRR 415.16(a) .

Based on record review and interview during a recertification survey, the facility did not ensure it conducted and documented a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. Specifically, the facility did not ensure their facility assessment included an evaluation of the overall number of facility staff needed to ensure that a sufficient number of qualified staff were available to meet each resident's needs. This was evidenced by: The Facility Assessment last reviewed on 1/14/2021, did not include an evaluation of the minimum staff required to ensure a sufficient number of qualified staff were available to meet each resident's needs. During an interview on 05/19/21 at 12:21 PM, the Administrator stated they looked through the Facility Assessment and there was no formal staffing plan. They reviewed the Facility Assessment on 1/14/2021, but had not assessed staffing levels since COVID-19 started. The Administrator stated they use a facility form titled Census for Licensed Practical Nurses (LPNs) and form titled Staffing Census for Certified Nursing Assistants (CNAs) to determine their minimum staffing, but that it was not a part of their Facility Assessment. 10 NYCRR 483.70(e)(1)-(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infection determined for 1 of 3 dressing changes observed for Resident #156. Specifically, the facility did not ensure standard precautions were maintained during a dressing change. Also, standard precautions were not maintained during installation of eye drops for Resident #65. Additional, a face mask was not properly worn by an employee while on a resident unit. This is evidenced by: Finding #1: Resident #156: The resident was admitted on [DATE] and readmitted on [DATE] with diagnoses of history of mini strokes (TIA) and a stroke (CVA) with right hemiplegia; unstageable pressure ulcer of right heel and cellulitis of right lower limb. The Minimum Data Set (MDS) dated [DATE] documented the resident was moderately impaired for cognition and was rarely/never understood and sometimes understood others. A Policy and Procedure for Dry/Clean Dressings dated 8/8/17 documented: -wash hands and put on clean gloves. Remove soiled dressing. -discard gloves and wash hands. -open dressing packages -pour cleansing solution over dry clean gauze -put on clean gloves A Physician's Order dated 3/14/19, documented the resident was to receive Santyl (an enzymatic debriding ointment) and cover with a border gauze every day and as needed (PRN). A Physician's Order dated 3/19/19 documented the resident was to receive Betadine every day to the wound on the resident's right thigh. During an observation on 3/21/19 at 09:36 AM, Licensed Practical Nurse (LPN) #1 placed a towel barrier on the resident's bed side table without first washing the table. She then placed the unopened dressing supplies on the barrier. She took the bootie off the resident's right foot and took off the old dressing. She did not wash her hands or change her gloves. She opened the gauze package, opened the bottle of saline and wet the gauze. She cleansed and dried the wound with another piece of gauze she had just opened. She then changed her right glove only. She did not wash her hands. She opened the tube of Santyl and opened the dressing package. She dated and initialed the border gauze dressing. She held the Santyl tubing with the same gloved hands and squeezed enough medication to cover the wound. She applied it to the wound. She removed her gloves but did not wash her hands. She then covered the wound with the border gauze. During an observation on 03/21/19 at 09:42 AM, LPN #1 was observed donning new gloves without washing her hands. She opened the gauze and wet the gauze with normal saline. She then cleansed the wound to the resident's right thigh. She did not wash her hands and donn new pair of gloves after opening the gauze package. After cleansing the wound she removed her gloves and donned a new pair of gloves without washing her hands. She opened the package containing the Betadine swab and then applied the Betadine to the right thigh wound. During an interview on 03/21/19 at 09:36 AM, LPN #1 stated she had worked one year at the facility and had attended inservices during orientation. She did not realize the outside of the dressing packages were considered contaminated and that she needed to wash her hands and change gloves before proceeding with the dressing change. She also did not realize she needed to wash her hands after removing gloves. During an interview on 03/21/19 at 09:53 AM, Registered Nurse Manager (RNM) #1 stated the LPN should have washed her hands whenever she removed her gloves. She also should have removed her gloves and washed her hands after touching the outside of the dressing packages. She stated the LPN will be re-inserviced. Finding #2: Resident #65: This resident was admitted on [DATE] with diagnoses of glaucoma, dry eye syndrome and aortic stenosis. The MDS dated [DATE] documented the resident had moderate cognitive impairment and was able to be understood and was able to understand others. A Physician's Order dated 7/17/17, documented the resident was to receive Timolol Maleate 0.5% eye drops, one drop in each eye two times per day. A Physician's Order dated 6/22/18, documented the resident was to receive Alphagan 0.1% eye drops one drop in each eye 2 times per day. During an observation on 3/20/19 at 09:45 AM, prior to administering Alphagan and Timolol eye drops, LPN #2 gave the resident one tissue to hold. She gave one drop of the Alphagan eye drops in each eye. The resident wiped both eyes with the one tissue. LPN #2 then gave Timolol eye drops, one drop in each eye. After she gave the eye drops, she handed the resident one unused tissue. The resident started to wipe her eyes with the used tissue, before the nurse gave her one new tissue. The resident wiped her eyes again with the new tissue. During an interview on 03/20/19 at 09:37 AM, LPN #2 stated she was inserviced to give the resident one tissue for each eye to prevent cross contamination. She stated she should have given the resident two tissues, one for each eye. During an interview on 03/21/19 at 02:32 PM, the RNM #1 stated LPN #2 should have given the resident two tissues, one for each eye. Staff are inserviced once a year during medication audit. Finding #3: During an observation on 03/19/19 at 11:04 AM, CNA #2's face mask was not covering her nose while she was walking in the hallway of the resident unit. During an interview CNA #2 stated the mask was not covering her nose because she was taking a breather. During an interview on 03/21/19 at 02:34 PM, RN #1 stated the CNA's face mask was supposed to be pinched at the nose. She stated the CNA cannot wear her mask without covering her nose. 10NYCRR415.19(a)(1-3)