**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE] the facility did not ensure a person-centered comprehensive care plan was reviewed and revised to address each resident's needs. This was identified for one (Resident #73) of one resident reviewed for Advanced Directives. Specifically, Resident #73 had a Do Not Resuscitate (the resident does not want cardiopulmonary resuscitation (CPR) the person has no heartbeat and is not breathing) Advance Directive in place in [DATE], which was later rescinded in February 2022 by the resident's representative; however, the resident's comprehensive care plan was not revised to accurately reflect interventions for the resident's current Advance Directive, full code status (full support which includes cardiopulmonary resuscitation (CPR), if the patient has no heartbeat and is not breathing). The finding is: The facility's policy and procedure titled Comprehensive Care Plans (CCP) and Resident/Patient Meeting, effective [DATE], documented that the comprehensive care plans will be revised, or new care plans will be developed quarterly, annually, and as needed, within seven days of the Minimum Data Set Assessment completion. Resident # 73 had diagnoses including Diabetes Mellitus, Seizure Disorder, and Major Depressive Disorder. A Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status of 11 which indicated the resident had moderately impaired cognition. The Minimum Data Set documented the resident had behavioral symptoms of rejection of care for one to three days during the assessment period. A comprehensive care plan titled Advance Directive, effective [DATE] and last reviewed on [DATE] documented No Advance Directives in place; however, the interventions in the care plan included to ensure the resident's face sheet and armband reflect Do Not Resuscitate, obtain necessary physician orders to conform to residents wishes, and provide and review information regarding Advance Directives with resident/ family/designated representative. The Physician's orders as of [DATE] did not indicate that Resident #73 had Advance Directives in place. Social Worker #2 was interviewed on [DATE] at 4:02 PM and stated that the social workers are responsible for developing and updating the Advance Directives care plans. Social Worker #2 stated that Resident #73 did not have advance directors upon admission in 2015. In December of 2021, Advance Directives for Do Not Resuscitate and Do Not Intubate and comfort measures (no invasive life-sustaining procedures) were instituted. The resident's surrogate rescinded the comfort measures in February 2022 and requested the resident become a full code. Social Worker #2 stated that the interventions should have been changed in February 2022 to reflect the resident's full code status and they did not know why the interventions in the Advance Directives care plan were not corrected to remove the Do Not Resuscitate status. The Minimum Data Set Director was interviewed on [DATE] at 9:41 AM and stated that the comprehensive care plans should be updated along with the Minimum Data Set assessment schedule and as needed as changes occur. The Minimum Data Set Director further stated that the interdisciplinary team is responsible for ensuring the care plans are timely updated and accurate. The Minimum Data Set Director stated the Social Work department was primarily responsible for developing and updating the Advance Directives care plans. The Minimum Data Set Director stated that the interventions on Resident #73's Advance Directive care plans should have been revised to reflect that the resident was a full code. 10 NYCRR 415.11

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 6/17/2024 and completed on 6/26/2024, the facility did not ensure that each resident's environment remained as free of accident hazards as possible. This was identified for one (Resident #301) of two residents reviewed for Accident Hazards. Specifically, Resident # 301 had a physician's order for Premarin (a cream containing a mixture of estrogen hormones to treat menopause symptoms) vaginal cream to be applied to the vaginal area by the facility staff. During an observation on 6/17/2024, a tube of conjugated (joined together) Premarin vaginal cream was observed on the resident's overbed table. The resident was using the Premarin vaginal cream daily and was applying the cream to their abdominal folds and groin areas themselves. The resident did not have a physician's order to self-administer their medications. The finding is: The facility Medication Administration and Documentation-General policy and procedure, last revised on 6/7/2024, documented that only Physicians or Licensed Nurses may administer medications unless the resident is permitted to administer their medications on the order of the Physician. The Licensed Nurse is responsible for ensuring that medications are not left unattended and are kept secured in a locked area or visible control at all times. Resident # 301 was admitted with diagnoses of Postmenopausal Atrophic Vaginitis, Diabetes, and Asthma. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, which indicated Resident #301 had intact cognition. Resident # 301 was receiving antibiotics, diuretics (a medication used to reduce fluid buildup), and hypoglycemic (lowers blood sugar) medications. A physician's order dated 4/23/2024 documented to apply conjugated (joined together) Premarin (estrogen) 0.625 milligrams per gram vaginal cream; Insert one applicator (2 grams) by vaginal route once daily. The Comprehensive Care Plan for Vaginitis dated 4/23/2024 documented interventions including administering medications as per physician's orders and monitoring the resident for any adverse reactions. A review of the Electronic Medication Administration Record (EMAR) revealed conjugated Premarin vaginal cream was administered to Resident #301 daily by the nurses, as evidenced by nurses' signatures. During an observation on 6/17/2024 at 10:30 AM, Resident # 301 was sitting in a wheelchair in their room, next to the overbed table. A tube of half-used conjugated Premarin vaginal cream was observed on the overbed table. The conjugated Premarin vaginal cream tube did not have a label with the resident's name or administration directions. There was no staff member present in Resident # 301's room at the time of the observation. Resident # 301 was interviewed on 6/17/2024 at 10:45 AM and stated they have been applying the Premarin vaginal cream daily to their abdominal fold and groin area. Resident #301 did not recall how they got the conjugated Premarin vaginal cream. A review of the physician's orders from 4/23/2024 to 6/17/2024 revealed that Resident # 301 did not have an order to self-administer any of their medications. A review of the electronic medical record from 4/23/2024 to 6/17/2024 revealed that Resident #301 was not assessed to self-administer their medications. Registered Nurse #2 was interviewed on 6/17/2024 at 10:50 AM and stated Resident #301 was not supposed to have any medications in their room. The conjugated Premarin vaginal cream should have been stored and locked in the treatment cart. Registered Nurse #2 stated that Resident #301 did not have any order to self-administer any medications. Licensed Practical Nurse #2 was interviewed on 6/18/2024 at 11:28 AM and stated they administered the conjugated Premarin vaginal cream to Resident #301 when they worked as a medication nurse on the resident's unit. Licensed Practical Nurse #2 stated they did not observe the conjugated Premarin vaginal cream on Resident #301's overbed table during their shift. Licensed Practical Nurse #2 stated that Resident #301 should not have any medications in their room. The Pharmacist was interviewed on 6/21/2024 at 8:55 AM and stated conjugated Premarin vaginal cream is considered a hazardous drug because the medication contains estrogen and when applied topically, the medication can cause darkening of the skin, redness, irritation, burning, and itching. The Pharmacist stated Premarin vaginal cream can also cause mood changes, fatigue, insomnia (problems falling and staying asleep), irritability, and hair loss therefore, the medication should be administered as per the Physician's Order. The Director of Nursing Services was interviewed on 6/25/2024 at 9:31 AM and stated that all medications should be stored in the medication or the treatment carts. The medications should not be left in the resident's room without proper supervision. The Director of Nursing Services stated the unit staff should notify the unit nurse when they observe unattended medications in the resident rooms. 10 NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 6/17/2024 and completed on 6/26/2024, the facility did not ensure that the attending physician documented in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. This was identified for one (Resident #136) of five residents reviewed for Unnecessary Medications. Specifically, the Medication Regimen Review for Resident #136 dated 5/15/2024 documented a recommendation from the consultant Pharmacist to evaluate Rozerem (a sedative to treat sleeplessness) and to consider trial taper to as needed (PRN) for one week then discontinue, if appropriate. The Physician agreed with the recommendation; however, did not address the recommendation and did not document the plan in Resident #136's medical record. The finding is: The facility's policy and procedure titled Pharmacy Drug Regimen Reviews last revised on 7/25/2017 documented that the Consultant Pharmacist shall review the medical record of each resident and perform a Drug Regimen Review at least once each calendar month. The Attending Physician or licensed designee shall respond to the Drug Regimen Review within seven days of the receipt. The Physician must document on the Drug Regimen Review Sheet if in agreement or disagreement with the recommendation and provide a brief clinical rationale if no change is to be made. Resident #136 was admitted with diagnoses of Insomnia (difficulty falling and staying asleep), acute Respiratory Failure, and Diabetes. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The Quarterly Minimum Data Set (MDS) documented Resident # 136 received high-risk medications that included anti-anxiety and hypnotic (drug for sleep disorder) medications. The Insomnia Comprehensive Care Plan dated 2/4/2024 included interventions to administer medications as per the physician's order, monitor for adverse effects, and notify the Physician of any changes in the sleep pattern. A physician's order dated 4/8/2024 documented to administer Rozerem 8 milligrams one tablet by oral route once daily at bedtime for Insomnia. A Medication Regimen Review (MRR) dated 5/15/2024, completed by the consultant Pharmacist, documented Resident #136 was receiving Ramelteon (Rozerem) at bedtime for Insomnia. The consultant Pharmacist recommended that the Physician evaluate the current need and consider a trial to taper the medication to as needed (PRN) for one week, then discontinue, if appropriate. The report indicated that the Physician agreed with the consultant Pharmacist's recommendations; however, the Medication Regimen Review form was not signed or dated by the Physician. A Medical Progress Note from the Attending Physician dated 5/16/2024 at 1:28 PM documented that a review of medication management was performed. The note did not include a plan to address recommendations made by the consultant Pharmacist regarding Rozerem medication. Registered Nurse #4 was interviewed on 6/24/2024 at 10:30 AM and stated the Physician's note did not document or address recommendations made by the consultant Pharmacist regarding Resident #126's Rozerem medication use. Registered Nurse #4 stated the Physician saw Resident #136 on 5/16/2024 and documented that a review of the medication management was performed; however, the Physician did not make changes to the Rozerem medication use as recommended by the Pharmacist. A physician's order dated 6/24/2024 documented to administer Rozerem 8 milligrams one tablet by oral route once daily for seven days at bedtime as needed. The Attending Physician #1 was interviewed on 6/25/2024 at 8:10 AM and stated they reviewed and agreed with the recommendation made by the consultant Pharmacist on the Medication Record Review (MRR) on 5/16/2024 and did not document the plan to taper the Rozerem from 8 milligrams per day to as needed. The Director of Nursing Services was interviewed on 6/25/2024 at 9:17 AM and stated Attending Physician #1 should have documented their plan for Rozerem dose reduction in the progress notes. The Consultant Pharmacist was interviewed on 6/25/2024 at 1:54 PM and stated that medications for Insomnia are reviewed periodically. The Consultant Pharmacist stated long-term use of Rozerem causes drowsiness which is why they recommended tapering of the medication use. 10 NYCRR 415.18(c)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 6/17/2024 and completed on 6/26/2024, the facility did not ensure that all drugs were stored in accordance with professional standards. This was identified for three (Carnation, Broadway, and Azaelia) of seven units reviewed for the medication storage task. Specifically, 1) The Carnation unit medication storage Room was observed on 6/21/2024 with four bottles of Aspirin (blood thinner) 325 milligrams with an expiration date of 4/2024; 2) The Broadway Unit medication storage room was observed on 6/21/2024 with nine bottles of Aspirin 325 milligrams and three bottles of Vitamin B12 (a vitamin supplement) with an expiration date of 4/2024; and 3) The Azaelia Unit medication storage room was observed on 6/21/2024 with three bottles of Aspirin 325 milligrams with an expiration date of 4/2024. The findings are: The facility's Storage of Medicine policy last reviewed on 2/2024 documented the facility shall not use outdated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The nursing staff shall be responsible for maintaining medication storage. 1) During the medication storage task on 6/21/2024 at 6:11 AM, the Carnation Unit medication storage room was observed accompanied by Licensed Practical Nurse #4. There were four bottles of Aspirin 325 milligrams with an expiration date of 4/2024. Licensed Practical Nurse #4 was interviewed on 6/21/2024 at 6:11 AM and stated they were not sure who was responsible for removing the expired medications from the medication room. Licensed Practical Nurse #4 stated the expired Aspirin bottles should not remain on the unit. Unit Manager #10 was interviewed on 6/26/2024 at 11:20 AM and stated they checked the medication storage room every day and it was an oversight on their part that they did not identify the expired medications. 2) During the medication storage task on 6/21/2024 at 6:32 AM, the Broadway Unit medication storage room was observed accompanied by Licensed Practical Nurse #5. There were nine bottles of Aspirin 325 milligrams and three Vitamin B12 bottles with an expiration date of 4/2024. Licensed Practical Nurse #5 was interviewed on 6/21/2024 at 6:32 AM and stated they did not deal with expired medications because they work during the overnight shift. The day shift Unit Managers are responsible for checking the expiration dates for medications that are stored in the medication room. Unit Manager #11 was interviewed on 6/26/2024 at 11:23 AM and stated they checked for expired medications in the medication room every day. Unit Manager #11 stated they did not know how the expired Aspirin and Vitamin B12 bottles remained in the medication room because the Pharmacist also checks for expired medications every month. Unit Manager #11 stated the expired medications are expected to be removed from the medication room and placed in the Nursing Supervisor's office for proper disposal. 3) during the medication storage task on 6/21/2024 at 6:50 AM, Azaelia Unit medication storage room was observed accompanied by Licensed Practical Nurse #6. There were two bottles of Aspirin 325 milligrams with an expiration date of 4/2024. Licensed Practical Nurse #6 was interviewed on 6/21/2024 at 6:50 AM and stated they did not know there were expired Aspirin bottles in the medication storage room. Licensed Practical Nurse #6 stated all nurses are responsible for checking the expiration dates on all medications. Unit Manager #3 was interviewed on 6/26/2024 at 11:28 AM and stated they check for expired medications every day and did not know how the expired Aspirin bottles were left in the medication storage room. Unit Manager #3 stated they are expected to place the expired medications in the supervisor's office. Pharmacist #2 was interviewed on 6/26/2024 at 12:04 PM and stated they assist the facility in reviewing the medication storage areas monthly to ensure the expired medications are removed from the storage areas. Pharmacist #2 stated either the nurse or the Pharmacist is supposed to remove expired medications from the units. Pharmacist #2 stated they did not know why Carnation, Broadway, and Azaelia units still had expired medication bottles in the medication storage rooms. The Director of Nursing Services was interviewed on 6/26/2024 at 1:55 PM and stated the Pharmacist is expected to visit each unit every month to discard the expired medications. The Director of Nursing Services stated it was not acceptable to have expired medication in the medication storage areas. 10 NYCRR 415.18(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 10/25/2022 and completed on 11/2/2022, the facility did not ensure each resident has the right to receive services in the facility with reasonable accommodation of resident needs and preferences. This was identified for one (Resident #307) of four residents reviewed for choices. Specifically, Resident #307 requested an extended shower hose to facilitate and maintain independence during the shower activity. Resident #307's request was not addressed by the facility. The finding is: Resident # 307 has diagnoses of Multiple Sclerosis, and Femur Fracture. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition. The MDS indicated the resident required total assistance of one staff member for bathing. The Comprehensive Care plan (CCP) for Activities of Daily Living dated 8/1/2022 documented that Resident #307 required assistance/supervision of one staff member for bathing. Resident #307 was observed on 10/25/2022 at 11:17 AM lying in their bed. Resident #397 was interviewed on 10/25/22 at 11:17 AM and stated they have Multiple Scoliosis (MS). Resident #307 stated they know that one day they would not be able to bathe themselves, so they wanted to enjoy taking a bath by themselves as much as possible until the MS progresses. Resident #307 stated they were not able to wash their private area by themselves during the shower because the shower hose was not long enough to reach their perineal area. Resident #307 stated that their (Resident #307) Certified Nurse Assistant (CNA), the Unit Nurse Manager, and the Maintenance Director were aware of their (Resident #307) request. CNA #10 was interviewed on 11/01/2022 at 3:29 PM and stated they (CNA #10) prepare the supplies for Resident #307's shower, and they (CNA #10) stay outside of the shower stall in case Resident #10 needed something. CNA #10 stated they wash Resident #307 perineal area since the shower hose is not long enough for the Resident to use. CNA #10 stated they normally put a bucket of water on the Resident's lap and the Resident opens their (Resident #307) legs to allow the water to drain onto their perineal area. CNA #10 stated a couple of months ago they reported to Registered Nurse (RN) Unit Manager #7 that Resident #307 was requesting a longer shower hose. RN Unit Manager #7 was interviewed on 11/1/2022 at 1:13 PM and stated Resident #307 required supervision and one staff member assistance with bathing. RN Unit Manager #7 stated that a couple of months ago CNA #10 and Resident #307 requested a longer shower hose so the resident could wash their (Resident#307) perineal area themselves during the shower. RN Unit Manager #7 stated that they (RN Unit Manger #7) documented Resident #307's request for a longer hose in the maintenance order book in August 2022. RN Unit Manager #7 reviewed the maintenance order book with the surveyor; however, they (RN Unit Manager #7) could not find the documented request in the maintenance order book. The Maintenance Director was interviewed on 11/2/2022 at 11:25 AM and stated that they checked the maintenance work [order] book every morning and they do not remember a documented request for the longer shower hose. The Maintenance Director stated that they were approached by Resident #307 a couple of months ago and were asked to provide a longer shower hose. The Maintenance Director stated they did not provide the longer shower hose to the resident because they thought the longer shower hose would be an accidental hazard and infection control hazard as the longer shower hose would be touching the shower floor. The Maintenance Director stated that they did not discuss Resident # 307's request with anyone and did not explore other options to accommodate the resident's request. The Director of Nursing Services (DNS) was interviewed on 11/02/2022 at 2 PM and stated that they did not know Resident #307 requested to have a longer shower hose to wash their (Resident #307) perineal area themselves during the shower. They expected the nurses to document the resident's request in the maintenance work order book. The DNS stated they expected the Maintenance Director to communicate any concerns related to the longer shower hose with the DNS so other options could be explored to accommodate the resident's request. 415.5(e)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated survey (NY 00301536) initiated on 10/25/2022 and completed on 11/2/2022, the facility did not ensure that Comprehensive Care Plans (CCP) were reviewed and revised by the interdisciplinary team after each assessment. This was identified for one (Resident #712) of seven residents reviewed for accidents. Specifically, Resident #712 fell on 8/9/2022 and sustained a hip fracture. The resident was hospitalized and re-admitted back to the facility on 8/16/2022. The CCP for falls was not reviewed and revised to address the resident's hip fracture after the resident's return from the hospital. The finding is: The Accident prevention policy dated February 2018 documented to identify specific risk factors that may indicate the resident is at risk for falls upon admission, readmission, quarterly, annually and with any significant change. Based on the assessment the resident will have a preventative plan of care initiated as well as revised, monitored, and evaluated throughout their stay at the facility. The interdisciplinary team will collaborate in developing, evaluating, and revising the fall/injury prevention plan of care to prevent falls/injury, or to minimize injury and/or complications of a fall. Resident #712 was admitted to the facility on [DATE] with the diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and muscle weakness. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #712 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS documented the resident required extensive assistance of one person for transfers, dressing, personal hygiene, and toilet use. The resident was non-ambulatory and was occasionally incontinent of urine. A Fall risk assessment dated [DATE] documented the resident's score was 8 (if the total score is 10 or greater, the resident should be considered at high risk for potential for falls) indicating that the resident was not at high risk for falls. The fall risk assessment documented that the resident had a balance problem while standing/walking and was on Antipsychotics, Antianxiety Agents, Antidepressants, Hypnotics, Cardiovascular Medications, Diuretics, Narcotic Analgesics, Narcoleptic, and other Medications that also would cause lethargy or confusion. The resident's assessment did not include the resident's ambulation/incontinence status that would place the resident in a high-risk category for falls. The nursing progress note dated 8/9/2022 at 6:39 AM documented that Resident #712 stated they were standing at the bedside using the urinal when they got dizzy and fell. Resident #712 helped themselves back to bed before staff could assist. The resident complained of Left hip pain. The Physician was made aware, and X-rays were ordered. A nursing progress note dated 8/09/2022 at 1:59 PM, documented Hip, Femur and Pelvic X-ray reviewed with physician. X- ray results showed an acute impacted left femoral neck fracture. The resident was sent to Hospital emergency room (ER) for evaluation. The nursing progress note dated 8/10/2022 at 1:14 AM documented Resident #712 was admitted to the hospital with a diagnosis of closed fracture of the shaft of the left femur. The CCP for falls was reviewed on 10/28/2022 by the Surveyor. The CCP was developed on 8/2/2022 and documented Resident #712 was at high risk for Falls related to Unsteady Gait, Immobility/Limited Mobility, and Cardiac Medications. The interventions included to wear proper footwear, locking the wheelchair, keep areas clean, clutter-free, and well lit; keep bed in the lowest position; utilize low bed; keep personal items within reach; orient to environment/placement of items and call bell within reach. On 8/9/22, the CCP was updated to include slippers socks with non-skid tread to be worn in bed. On 8/18/22, the CCP was updated Sent to Hospital for evaluation, status post fall, X ray results show a fracture. The Nursing progress notes dated 8/19/2022 at 7:01 PM documented floor mats in place, secondary to safety; however, this intervention was not added to the resident's CCP. The Registered Nurse (RN) Manager #7 was interviewed on 10/31/22 at 10:52 AM and stated that the falls CCP interventions should have been revised upon re-admission following the resident's fall to determine if additional interventions were required to prevent the resident from falls. The Assistant Director of Nursing Services (ADNS) # 1 was interviewed on 10/31/22 at 11:30 AM and stated the resident's falls CCP should have been revised upon re-admission to ensure all prior interventions are effective to prevent further falls. 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated survey (NY 00301536) initiated on 10/25/2022 and completed on 11/2/2022, the facility did not ensure that each resident's drug regimen remained free from unnecessary drugs and residents who use psychotropic drugs receive behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. This was identified for one (Resident #712) of six residents reviewed for unnecessary medications. Specifically, Resident #712 was prescribed Ativan (antianxiety medication) 0.5 milligrams (mg) and Ambien (hypnotic medication) 10 mg as needed (PRN). There was no documented evidence that the facility staff provided non- pharmacological interventions to the resident prior to administering Ativan 0.5 mg or Ambien 10 mg. The finding is: The Antipsychotic Medication policy dated 4/2019 documented prior to the use of a PRN (as needed basis) Anti-Psychotic medication administration non-pharmacological interventions should be implemented. Antipsychotic medications will not be used unless behavioral symptoms are not sufficiently relieved by non- pharmacological interventions. Resident #712 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Insomnia, and Anxiety Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #712 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident's cognitive function was intact. The MDS documented the resident received antianxiety and hypnotic medications during the 7 of 7 days during the assessment look back period. The Psychotropic Drug Use Comprehensive Care Plan (CCP) dated 8/04/2022 documented Resident #712 was on psychotropic medications secondary to Depression and Anxiety. There were no documented interventions for this CCP. The Insomnia CCP dated 8/03/2022 documented interventions including to administer medications as per the Physician's (MD) order, monitor for adverse effects, monitor for desired effect, monitor the resident's sleep pattern, and notify the MD of changes in the resident's sleep pattern. The physician orders dated 8/2/2022 documented to administer lorazepam 0.5 milligrams (mg) tablet, give 1 tablet (0.5 mg) by oral route every 8 hours and Zolpidem 10 mg tablet by oral route once daily at bedtime for 7 days as needed (PRN). The Medication Administration Record dated 8/2/2022 through 8/9/2022 documented Resident #712 was administered the psychotropic medications daily. The readmission physician orders dated 8/16/2022 documented to administer lorazepam 0.5 milligrams (mg) tablet, give 1 tablet (0.5 mg) by oral route every 8 hours and Zolpidem 10 mg tablet by oral route once daily at bedtime for 7 days as needed (PRN). The physician orders dated 8/25/2022 documented to administer Zolpidem 10 mg tablet by oral route once daily at bedtime for 7 days as needed for sleep. The physician orders dated 9/4/2022 and 9/13/22 documented to administer Zolpidem 10 mg tablet by oral route once daily at bedtime for 14 days as needed for sleep. The physician orders dated 9/14/2022 documented to administer Lorazepam 0.5 mg tablet, give 1 tablet (0.5 mg) by oral route every 8 hours for 14 days as needed. The Medication Administration Record dated 8/16/2022 through 9/27/2022 documented Resident #712 was administered the psychotropic medications daily. A review of the medical record from 8/2/2022 to 9/27/2022 revealed that the facility did not ensure that non- pharmacological interventions were implemented prior to administration of the psychotropic medications. Pharmacy review dated 9/14/2022 documented- receiving Zolpidem (Ambien) 10 mg at bedtime PRN for Insomnia. Please note that the maximum recommended dose in geriatrics is 5 mg at bedtime. Please evaluate, consider trial taper to 5 mg at bedtime PRN, if appropriate. The Physician documented they disagreed- the resident had COPD and will re-evaluate in 2 to 4 weeks. The Assistant Director of Nursing Services (ADNS) #1 was interviewed on 10/28/2022 at 10:58 AM and stated the Psychotropic CCP should have included interventions to direct nurses to use non-pharmacological interventions, obtain Psychiatry consult, monitor the resident, and watch for signs and symptoms of drowsiness/lethargy. The ADNS could not explain why the interventions were not developed. The Registered Nurse (RN) Manager # 4 was interviewed on 10/31/2022 at 10:52 AM and stated the Psychotropic medication CCP should have listed interventions to address the resident's use of psychotropic medications. RN Manager #4 further stated Resident #712 was on these medications prior to admission and non-pharmacological interventions were not implemented. The RN # 5 was interviewed on 10/31/22 at 3:52 PM and stated the resident was very alert and instructed nursing to come in at certain times to administer Ativan and other times to administer Ambien. The resident should have had a CCP developed to include interventions to address the use of Ativan. The resident was on these medications prior to admission and non- pharmacological interventions were not considered. 415.12(l)(2)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review during the Recertification Survey initiated on 10/25/2022 and completed on 11/2/2022, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified on one of seven nursing units during the medication storage task. Specifically, on the [NAME] unit, Resident #302's Lantus insulin pen was erroneously stored in a plastic bag that was labeled for Resident #60's Lantus insulin pen. The finding is: The facility's policy titled Storage of Medications, dated 8/2021, documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding areas to prevent the possibility of mixing medications of several residents. Resident #302 has a physician's order dated 10/14/2022 for Lantus Solostar U-100 Insulin 100 unit/mL (3 mL) subcutaneous pen, inject 15 units by subcutaneous route once daily at bedtime, for Type 2 Diabetes Mellitus. Resident #60 has a physician's order dated 10/18/2022 for Lantus Solostar U-100 Insulin 100 unit/mL (3 mL) subcutaneous pen, inject 20 units by subcutaneous route every 12 hours at 9:00 AM and 9:00 PM, for Type 1 Diabetes Mellitus. A medication storage observation was conducted on the [NAME] unit with Licensed Practical Nurse (LPN) #1 (medication nurse) on 11/1/2022 at 10:54 AM. A review of insulin pens in LPN #1's medication cart revealed that a Lantus insulin pen with Resident #302's name and medical label was in a plastic bag that had Resident #60's name and medical label. There were no other insulin pens in the bag. LPN #1 stated it was a mistake that Resident #302's insulin pen was in Resident #60's plastic bag. LPN #1 stated they (LPN #1) had administered Resident #60's 9 AM dose of Lantus this morning and then threw out the insulin pen and storage bag that had Resident #60's name on it. LPN #1 did not know how Resident #302's Lantus insulin pen was placed in a bag with Resident #60's name and medical label. The Director of Nursing Services (DNS) was interviewed on 11/2/2022 at 8:53 AM. The DNS stated it was an error to have one resident's insulin pen or medications in another resident's medication storage bag. The DNS stated the facility staff is trained to check the medication labels before administering a medication, especially injectable medications, to prevent medication errors. The DNS further stated they (DNS) will again provide in-service education to staff to ensure that the residents' medications are stored appropriately. LPN #2 (In-service coordinator) was interviewed on 11/2/2022 at 9:27 AM and stated that the initial training for nurses upon hire includes education on appropriately storing the medications. LPN #2 stated it sounds like Resident #302's insulin pen was put in the wrong storage bag. LPN #2 stated all medications should be stored appropriately to prevent medication errors. 415.18(e)(1-4)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 10/25/2022 and completed on 11/2/2022 the facility did not ensure an infection prevention and control program was established to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified on one of seven nursing units. Specifically, 1) a training toilet room currently used by residents on the Carnation unit did not have a means for residents to sanitize their hands before leaving the room; and 2) on the Carnation unit two Certified Nursing Assistants (CNA)s were not wearing appropriate Personal Protective Equipment (PPE) while providing care to Resident #47, who was placed on contact and droplet precautions as per their Physician's order. The findings are: The facility's undated policy titled Room Readiness and Unit Cleanliness for Housekeeping Staff, documented to check that all dispensers are properly filled, and the bathroom must be disinfected from top to bottom. The facility's policy titled Infection Control Surveillance, dated 9/14/2020, documented effective measures are in place to prevent, identify, and control acquired infection or infection brought into the facility from the community. The responsibility of the Infection Control Preventionist is to detect and record all nosocomial infections and to institute proper, effective control measures. 1) On 10/26/2022 at 11:48 AM an observation of the training toilet room on the Carnation unit was made. The room has an entrance door from the hallway with only a toilet in it. There was no sink or alcohol-based hand sanitizer in the training toilet room. On 10/27/2022 at 8:25 AM Registered Nurse (RN) #2-unit supervisor was interviewed. RN #2 stated the training toilet is currently used by unit residents. RN #2 observed the training toilet room and that there was no means to sanitize hands prior to leaving the room. RN #2 stated the toilet is used by people who are ambulatory on the unit and also by residents who need assistance. RN #2 stated residents can sanitize their hands either at the hallway alcohol-based sanitizer, at their room sink, or in the shower room next door. On 10/27/2022 at 9:31 AM CNAs #3 and #4 were interviewed concurrently. CNA #3 and #4 stated the training toilet is used by alert ambulatory residents. When asked where residents sanitize their hands after using the training toilet, both CNAs chuckled and then stated at the hallway alcohol-based sanitizer or at the residents' room sink. RN #1, who was the Infection Preventionist and the Assistant Director of Nursing Services, was interviewed on 11/1/2022 at 12:20 PM. RN #1 stated there should be a hand sanitizer in the training toilet room, and that as soon as they (RN #1) heard that there was no hand sanitizer in the training toilet room, they (RN #1) got in touch with the maintenance department to have one installed. RN #1 stated the housekeeping and maintenance departments do their rounds and should have noticed that there was no hand sanitizer in the training toilet room. The Housekeeping Director was interviewed on 11/1/2022 at 1:14 PM and stated that the unit housekeeper is supposed make sure the hand sanitizer containers are full. The unit housekeeper is also responsible to do a quick visual check of the training toilet room to make sure nothing is out of order or missing, and, if so, log it in the maintenance logbook. Housekeeper #1 was interviewed on 11/1/2022 at 1:22 PM and stated they (Housekeeper #1) are the housekeeper for the unit. Housekeeper #1 stated if the hand sanitizer was not in the training toilet room, they (Housekeeper #1) would log it in the maintenance logbook. An observation of the maintenance logbook was made with Housekeeper #1 and there were no entries for a missing hand sanitizer. 2) The facility's policy titled Transmission Based Precautions, dated 10/17/2022, documented for droplet precautions when providing care personal protective equipment (PPE) should include mask, gloves, gown, and eye protection. For contact precautions wear a gown when entering the room if you anticipate substantial contact with the resident, environmental surfaces, or items in the patient's room. Resident #47 was admitted with diagnoses including Seizure Disorder, Cerebral Infarction, and Schizophrenia. The 8/1/2022 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. The MDS documented that the resident required total assistance of two staff members for transfers. Review of nursing progress notes revealed that on 10/28/2022 at 12:11 PM RN #2 documented that Resident #47's roommate (Resident #72) had presented with a sore throat, and a rapid COVID-19 test was administered with a positive result. Resident #72 was moved to the Emerald unit for isolation. Observation on 11/1/2022 at 08:30 AM revealed Resident #47's room had a yellow contact/droplet sign at the doorway. The sign documented that everyone must clean hands when entering the room, wear a face mask, wear eye protection, and a gown and gloves at the door. There was no PPE supply outside the room. CNA #1 and CNA #2 were observed in the room with a Hoyer lift preparing to transfer Resident #47, who was in their bed and was visible from the hallway. The CNAs had gloves and surgical masks on, but no eye protection or gowns and had come in contact with the resident's bed in positioning the Hoyer lift. Both CNAs approached the doorway and were asked by the surveyor about the sign at the doorway indicating contact/droplet precautions. Both CNAs stated they did not know that Resident #47 was on contact/droplet precautions. RN #1, who was the Infection Preventionist and the Assistant Director of Nursing, was interviewed on 11/1/2022 at 12:25 PM and stated Resident #47's room is on contact and droplet precautions for 10 days from 10/28/2022 because Resident #72 tested positive for COVID-19 and was a close contact of Resident #47, who currently resides in the room. RN #1 stated both CNAs should have been wearing gowns and eye protection as the sign indicated and there should have been a PPE cart outside the room. RN #1 stated staff have previously been in-serviced about PPE usage and precaution signs. RN #1 stated they (RN #1) explained to the CNAs, whenever you see a sign, if you are not sure, just ask. RN #1 stated there should also be a Physician's order for contact and droplet precautions for Resident #47 and will be added. A physician's order for Resident #47 dated 11/1/2022 at 1:09 PM documented Droplet/Contact Precautions. Licensed Practical Nurse (LPN) #2, who was the in-service coordinator, was interviewed on 11/1/2022 at 12:33 PM. LPN #2 first stated the yellow contact/droplet sign means the residents in the room are COVID-19 negative, but under watch to see if any symptoms develop. LPN #2 stated technically the CNAs did not have to wear gowns because Resident #47 is COVID-19 negative. LPN #2 was asked by the surveyor to clarify why the contact/droplet sign is at the doorway. LPN #2 stated a sign is necessary if the resident is COVID-19 positive. LPN #2 stated a sign should not be there if the COVID-19 positive resident is not in the room. The Director of Nursing Services (DNS) was interviewed on 11/1/2022 at 2:02 PM and stated that the CNAs were probably not aware that they should have been wearing the appropriate PPE. The DNS stated if the resident was exposed to a positive COVID-19 roommate, the resident is placed on contact and droplet precautions for 10 days. The CNAs caring for Resident #47 should have been wearing gowns and eye protection. LPN #3, the unit medication nurse, was interviewed on 11/2/2022 at 8:44 AM and stated there was confusion yesterday (11/1/2022) because the unit supervisor was not in and we were not sure if Resident #47's was on contact and droplet precautions because we have been doing serial COVID testing and Resident #47 was negative. LPN #3 stated the infection Preventionist clarified with us that Resident #47's room is on contact/droplet precautions for 10 days until 11/7/2022. 415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) room [ROOM NUMBER] of the Petal Unit was observed on 10/25/2022 at 11:33 AM. The floor was observed with yellow, brown, and black spots in the center of the room and blackened accumulated debris under and around residents' beds. The RN Unit Manager #10 was interviewed on 10/25/2022 at 11:33 AM and stated that they reported the dirty floor concerns to the housekeeping department a month ago. The RN Unit Manager #10 stated the room [ROOM NUMBER] floor needs to be cleaned and waxed. Housekeeper #4 was interviewed on 10/25/2022 at 12:35 PM and stated that even though the room has been cleaned every day, the floor still feels sticky. Housekeeper #4 further stated the stains on the floor were not coming off with daily mopping. The Housekeeping Director was interviewed on 10/25/2022 at 12:39 PM and stated that they (Housekeeping Director) were aware of the room's stained floor condition and that the stains were because of dirt buildup. 415.5(h)(2) Based on observation, record review, and interviews during the Recertification Survey initiated on 10/25/2022 and completed on 11/2/2022 the facility did not ensure that housekeeping and maintenance services were provided to maintain a sanitary, orderly, comfortable, and homelike environment on 4 of 7 residential units and the main kitchen area. Specifically, 1) On the [NAME] unit, in room [ROOM NUMBER], there were water stains on the ceiling, patched areas of wall that were not painted, floor molding missing from the sink area, a hole in the wall behind the room entrance door, and broken wood covering radiator pipes; 2) On the Broadway unit, in room [ROOM NUMBER] a dry dirt-like substance was observed on the floor and in the grout at the resident's bedside, in the corners of the room, and in front of the sink area; 3) On the Petal unit, in room [ROOM NUMBER], the floor was observed with yellow, brown, and black spots in the center of the room and blackened accumulated debris under and around residents' beds; 4) The walls and ceilings in the corridors of the Diamond, [NAME], and Broadway nursing units were noted with unpainted spackling throughout; 5) The [NAME] unit dayroom walls and ceiling were noted with unpainted spackling; 6) The Broadway nursing unit was noted with peeling paint; and 7) The ceiling in the main kitchen in the basement was noted with unpainted spackling by the dishwasher room and by the food preparation area. The findings include but are not limited to: The facility's policy titled Internal Work Orders (Maintenance Requests), dated 12/2021, documented maintenance mechanic/designee will collect all maintenance requests daily. Work orders will be prioritized and distributed to maintenance staff daily in order to ensure a proper mechanism for residents, staff, and family members to report maintenance issues that require repair. The facility's undated policy titled Room Readiness and Unit Cleanliness for Housekeeping Staff documented any maintenance-related concerns should be placed in the maintenance book that is located at every unit nursing station. 1) On 10/25/2022 at 11:36 AM an observation of [NAME] unit room [ROOM NUMBER] was made. The resident who resided in the room complained about environmental conditions in the room. There were rusty, brown water damage areas on the ceiling, multiple wall areas that were patched but not painted, missing floor molding by the sink, a hole in the wall behind the room entrance door (this was not a spot where the door handle makes contact), and broken wood that was covering the radiator pipes. The Maintenance Director and Maintenance Engineer were interviewed concurrently on 10/27/2022 at 8:38 AM and the conditions in room [ROOM NUMBER] were observed, which had not been repaired yet. They (Maintenance Director and Maintenance Engineer) stated they were not aware of the hole behind the door. The resident who resided in the room was also present in the room. The resident stated that the hole in the wall was not new and had been there since the resident was admitted . Regarding the missing molding by the sink and the multiple patched areas in the wall by the sink, the Maintenance Director stated the old-style sink with the platform was replaced with a new sink and that is why the molding is missing and the walls are patched up. The Maintenance Director could not identify when the sink replacement took place. Regarding the rusty, brown water-damaged areas on the ceiling, the Maintenance Engineer stated the damage was from a water leak that occurred a few weeks ago and was fixed, and the room is slated to be repainted. Regarding the broken wood covering the radiator pipes, the Maintenance Director stated the facility has the material to replace the broken wood and it would be done today. Housekeeper #2 was interviewed on 10/27/2022 at 9:36 AM and stated they (Housekeeper #2) clean room [ROOM NUMBER] daily. Housekeeper #2 stated the wall was broken by a past resident who is no longer in the facility. Housekeeper #2 stated they (Housekeeper #2) had documented the broken wall concern in the maintenance logbook. Housekeeper #2 reviewed the maintenance book and could not identify where or when they (Housekeeper #2) had logged the concern of the hole in the wall in room [ROOM NUMBER]. The Maintenance Director was re-interviewed on 11/1/2022 at 8:30 AM. The Maintenance Director stated all staff can enter maintenance issues in the maintenance logbook. The Maintenance Director stated painting should be done within a few days after walls are patched or water damage has occurred, and the leak is fixed. The Maintenance Director stated the painting had not been done yet because the staff were busy patching other areas in the facility. 2) During an initial tour conducted on 10/25/2022 at 11:38 AM on the Broadway nursing unit, a resident who resided in room [ROOM NUMBER] complained that the floor in their room was not mopped frequently. On observation, a dry dirt-like substance was observed on the floor and in the grout at the resident's bedside, in the corners of the room, and in front of the sink area. Housekeeper #3 was interviewed on 11/2/2022 at 11:13 AM. Housekeeper #3 stated the rooms are swept daily and mopped every other day. Housekeeper #3 stated they were not aware of the condition of the floor in room [ROOM NUMBER]. The Housekeeping Director was interviewed on 11/2/2022 at 3:16 PM. The Housekeeping Director stated that the rooms are mopped every other day and upon request. The Housekeeping Director stated that they were never informed that room [ROOM NUMBER] was not being mopped every other day. The Housekeeping Director stated that the floor in the resident's room should never be in such condition. The Housekeeping Director stated that they do make rounds; however, they did not go into room [ROOM NUMBER].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the Recertification Survey initiated on 10/25/2022 and completed on 11/2/2022, the facility did not ensure that the resident environment remains as free of accident hazards as possible. This was identified for 2 (Resident #307 and Resident #159) of 7 residents reviewed for accidents and in the Carnation/Broadway unit dining room. Specifically, 1) A bottle of Pharma [NAME] Cannabidiol (CBD) Oil, a bottle D-Mannose capsules (Supplement for urinary tract), a bottle of Acidophilus 100 million organism tablets, and a bottle of Cranberry 4200 milligram (mg) with vitamin C soft gels, were observed unattended on Resident #307 bedside table, 2) Two Acetaminophen tablets were observed in a soufflé cup on Resident #159's bedside table, 3) On 10/25/2022 during an initial tour in the shared Carnation and Broadway unit dining room, the ice machine was observed to be leaking with a tray under the ice machine that contained water. Two wet blankets and a wet towel were observed on the floor near the ice machine. The ice machine cord was unplugged and hanging over a garbage pail which was positioned under the ice machine table. The findings are: 1) The Facility Protocol for prohibited substances and unprescribed medications dated June 2018 documented that all unprescribed medications found in the resident's room will be removed pending physician evaluation. Resident # 307 has diagnoses of Multiple Sclerosis and Femur Fracture. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition. On 10/25/2022 at 1:23 PM, Resident #307 was observed in their bed. The bedside table had a bottle of Pharma [NAME] CBD oil, a bottle of D-Mannose capsules, a bottle of Acidophilus 100 million organism tablets, Cranberry 4200 mg, and vitamin C soft gels. A review of the current Physician's orders dated 9/25/2022 did not include any of the supplements observed on the bedside table by the surveyor on 10/25/22. The Certified Nursing Assistant (CNA) #10 was interviewed on 11/01/2022 at 3:26 PM. CNA #10 stated they (CNA #10) never observed the resident's supplements on the Resident's bedside table. The Licensed Practical Nurse (LPN) # 7 was interviewed on 11/02/2022 at 11:11 AM and stated that they (LPN #7) never observed the supplements or oil stored on the resident's bedside table. They (LPN #7) further stated that the resident is not allowed to have any supplements on their bedside table without a Physician's order. On 11/1/2022 at 12:07 PM Resident #307 was observed in their bed. The bedside table had a bottle of Pharma [NAME] CBD oil, a bottle of D-Mannose capsules, a bottle of Acidophilus 100 million organism tablets, Cranberry 4200 mg, and vitamin C soft gels. The Unit Registered Nurse (RN) Manager #7 was interviewed on 11/1/2022 at 12:07 PM and stated they did not know that Resident #307 had supplements in their possession. RN #7 stated that Resident #307 was not allowed to have any supplements in their possessions without a Physician's order since the Resident had a history of pocketing medications. RN #7 stated that they (RN #7) did not know if any of these supplements would interfere with the medications the resident was taking. The resident's Primary Care Physician was not available for an interview. The covering Physician (MD#1) was interviewed on 11/02/2022 at 12:15 PM and stated that they (MD #1) were the covering doctor for Resident #307's Primary Care Physician. MD #1 stated they (MD #1) did not know the resident's medical history, but it was not safe for any resident to have these supplements in their possession as consumption of the supplements may interfere with the prescribed medications. MD #1 stated they (MD#1) will have a team meeting including the resident to see if it was safe for the resident to keep these supplements in their possession. The Director of Nursing Services (DNS) was interviewed on 11/02/2022 at 2:00 PM and stated that since the covering doctor did not think to give Resident #307 permission for self-medication administration, we took the supplements away from the resident. The DNS stated they (DNS) did not know Resident #307 had the supplements in their possession and it is not okay because of potential interaction with the prescribed medications. The DNS stated the resident has a history of using supplements inappropriately, but they did not know all the details. The DNS further stated they (DNS) will have a care plan meeting with the interdisciplinary team, and they will include Resident #307 in the meeting to discuss the resident having the supplements in their possession and self-administration of the supplements. 2) The facility Administration of Medication Policy and Procedure updated 4/20/2019 documented that medications are administered in accordance with Prescriber orders, including any required time frame. The policy did not address medication being left at the bedside without a Physician's order for self-administration. Resident #159 was admitted with diagnoses that included Bell's Palsy, Congestive Heart Failure, and Hypertension. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition. The resident required assistance for all activities of daily living. A Physician's order dated 10/9/2022 documented Acetaminophen 500 milligram (mg) 2 tablets by oral route every 12 hours for right shoulder pain. During an observation on 11/2/2022 at 10:55 AM a soufflé cup containing two white round tablets was observed on Resident #159's bedside table. Resident #159 was interviewed on 11/2/2022 at 10:55 AM, immediately after the observation was made. Resident #159 stated that they had two Tylenol tablets in a souffle cup that were given to them (Resident #159) during the medication administration pass. Resident #159 stated that they usually take the Tylenol with apple sauce and would take them soon. Licensed Practical Nurse (LPN) #6 was interviewed on 11/2/2022 at 11:01 AM and stated they (LPN #6) had administered Tylenol to Resident #159 and that they (LPN #6) thought the resident had taken the medication. LPN #6 and the state surveyor entered Resident #159's room and LPN #6 confirmed there were two Tylenol tablets in the souffle cup. Resident #159 then took the Tylenol tablets. LPN #6 stated that medications should not be left at the resident's bedside, and they (LPN #6) should have ensured that the resident had taken all their medications prior to leaving the resident's room. Registered Nurse (RN) #4 was interviewed on 11/2/2022 at 11:09 AM and stated at no time should medications be left at the resident's bedside. RN #4 stated that the medication nurse must ensure that all medications are taken by the resident before leaving the resident's room. RN #4 further stated that LPN #6 should not have left the Tylenol tablets at the resident's bedside. The Director of Nursing Services (DNS) was interviewed on 11/2/2022 at 2:27 PM and stated that LPN #6 should have waited until Resident #159 took all their medications before leaving the resident's room. The DNS stated medications are left at the resident's bedside for residents who had a Physician's order for self-administration of medication. A review of the resident's Physician orders was conducted by the DNS. The DNS stated that Resident #159 did not have an order for self-administration of Tylenol, therefore, LPN #6 should not have left the Tylenol at the resident's bedside. The DNS stated that leaving the Tylenol at the bedside put the resident at risk of pocketing the Tylenol and potentially taking more than the ordered dose of Tylenol at a later time. 3) On 10/25/22 at 11:21 AM during an initial tour in the shared Carnation and Broadway unit dining room an ice machine was observed to be leaking. There were two wet blankets and a wet towel observed on the floor, a tray with water was observed on a rack under the ice machine table, the ice machine was unplugged, and the cord was hanging over a garbage pail that was also under the table. Several residents were sitting in wheelchairs in the dining room and residents were ambulating in the hallway outside the dining room. There was no signage observed that indicated the presence of a wet floor. The Maintenance Director was interviewed on 11/2/2022 at 3:09 PM and stated they (Maintenance Director) were not aware that the ice machine was leaking until it was brought to their attention by the Surveyor. The Maintenance Director stated the staff that identified that the ice machine was leaking should have placed a wet sign in the area to alert others of the wet floor and to prevent accidents. The Maintenance Director stated that the housekeepers always have a wet sign on their cart in case of an emergency and that any staff could have placed the wet sign in the dining room. The Maintenance Director stated a wet sign should have been placed immediately in the dining room by the ice machine to prevent accidents. 415.12 (h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident #252 has diagnoses of Sleep Apnea, Social Pragmatic Communication Disorder, and Leigh's Disease. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated that the resident was cognitively intact. The MDS documented the resident required extensive assistance of one person for bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS documented the resident utilized a wheelchair for mobilization, had no limitation in range of motion, and was frequently incontinent of bladder and occasionally incontinent of bowel. The Comprehensive Care Plan (CCP) for vision dated 9/7/2022 documented adequate vision. The intervention including to keep objects in the visual field. The CCP for communication dated 9/21/2022 documented interventions including to keep the call bell within reach. During an observation on 10/25/2022 at 2 PM, Resident #252 was observed sitting in a wheelchair in their room by the room entrance door. Resident #252 asked for assistance to retrieve their call bell. Resident #252's bed was observed against the wall and the call bell was not visible. The Assistant Director of Nursing (ADNS) was asked to locate Resident #252's call bell. The ADNS found Resident #252's call bell underneath the upper corner of the resident's mattress and was out of the resident's reach. The ADNS was interviewed on 10/25/2022 at 2 PM immediately after the observation and stated that the call bell was out of Resident #252's reach. The ADNS further stated the call bell should always be available and within the resident's reach. Resident #252 was interviewed on 10/25/2022 at 2:01 PM and stated that the call bell was wrapped on the side rail overnight but during the day shift the staff did not place the call bell on their bed where Resident #252 could reach the call bell when needed. Resident #252 further stated they want to be able to utilize the call bell during the day. The 6 AM-2 PM shift Certified Nursing Assistant (CNA) #12 was interviewed 11/01/2022 at 12:18 PM and stated that they (CNA #12) remembered they placed the call bell within Resient#252 reach when they got the resident out of the bed in the morning. CNA #12 stated they (CNA #12) do not know how the call bell ended up under the mattress. CNA #12 further stated that Resident #252 utilizes the call bell to call for assistance. The ADNS was interviewed on 11/01/2022 at 11:31 AM and stated that Resident #252 preferred their (Resident#252) call bell attached to the left side of the bed on the side rail at night, and preferred the call bell placed on the bed during the day time. The ADNS stated maybe the day shift CNA forgot to place the call bell on the bed in the morning. The ADNS stated that it was not possible for the resident to have placed the call bell under the mattress as observed on 10/25/2022. The ADNS further stated that it was not acceptable that Resident #252's call bell was not within their reach. The RN Unit Manager #7 was interviewed on 11/01/2022 at 1:36 PM and stated that Resident #252's call bell should have been within reach, and it should be clipped on the bed. The Unit Manager further stated that they will educate the CNAs to make sure they are placing the call bells on the bed during the day. The Director of Nursing Services (DNS) was interviewed on 11/2/2022 at 2 PM and stated that Resident #252's call bell should always be within the resident's reach. 415.29 Based on observations, record review, and staff interviews during the Recertification Survey initiated on 10/25/2022 and completed on 11/2/2022, the facility did not ensure that residents are adequately equipped to call for staff assistance through a communication system directly to a staff member or centralized staff work area from each resident's bedside. This was identified for 3 (Resident #137 #240 and #252) of 11 residents in the initial pool reviewed for Environmental Task. Specifically, 1) Resident #137 was observed in bed on 10/25/2022 and the call bell was observed on the floor out of the resident's reach; 2) Resident #240 was observed in bed on 10/25/2022 and 10/26/2022 with the call device out of the resident's reach; 3) Resident #252 was observed in their room on 10/25/2022 with the call device out of the resident's reach. The findings are: The facility Accident Prevention Policy dated 2/26/2018 documented, in the safety measures section, call bells and personal items should be within the resident's reach. 1) Resident #137 was admitted with diagnoses that included Parkinson's Disease, Chronic Obstructive Pulmonary Disease, and Schizophrenia. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 13 which indicated intact cognition. The resident had no behavioral symptoms and required assistance of staff for all activities of daily living. During an observation on the Broadway Nursing Unit on 10/25/2022 at 2:00 PM, Resident #137 was observed in bed with the head of the bed elevated. The resident was awake and responded appropriately to greetings. The resident's call bell was not visible at the resident's bedside. Certified Nursing Assistant (CNA #7) was notified of the observation. Upon entering the resident's room CNA #7 was unable to find the call bell next to the resident. CNA #7 observed the call bell on the floor behind the head of the resident's bed. The call bell was observed without a clip to attach the cord to the resident's sheet. CNA #7 was interviewed on 10/25/2022 at 2:09 PM and stated that they (CNA #7) were the assigned CNA for Resident #137 on 10/25/2022 from 12 PM through 10 PM. CNA #7 stated they (CNA #7) could not recall when they last saw Resident #137. CNA #7 stated that the resident's call bell should have been next to the resident and within the resident's reach. CNA #7 stated the call bell must have fallen. CNA #7 stated that the CNAs were responsible for ensuring the resident's call bell is always within reach. The Registered Nurse (RN) #4, who was the RN Manager, was interviewed on 10/26/2022 at 10:45 AM. RN #4 stated that all staff were responsible for ensuring that the residents' call bells are within reach at all times. RN #4 stated that there should have been a clip attached to the call bell cord to secure the call bell next to the resident. 2) Resident #240 was admitted with diagnoses that include Mild Cognitive Disorder, Convulsion, and Mood Disorder. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderately impaired cognition. The resident had no mood or behavioral symptoms and required assistance for all Activities of Daily Living. During an initial tour of the Broadway Nursing Unit on 10/25/22 at 11:29 AM Resident #240 was observed in bed asleep. The resident's call bell was observed draped over the night table and was resting on the floor under a chair on the left side of the resident's bed. A second observation was conducted on 10/26/2022 at 10:30 AM. The resident was awake in bed and was observed wearing a left-hand roll. The call bell cord was observed lodged between the mattress and the left side rail and was out of the resident's reach. Licensed Practical Nurse (LPN) #6 was interviewed on 10/26/2022 at 10:40 AM. Upon entering the resident's room LPN #6 acknowledged the call bell tucked between the resident's mattress and the left side rail. The resident was unable to reach the call bell and was wearing a left-hand roll. LPN #6 stated that it was the responsibility of all the staff to ensure that the resident's call bell is within reach at all times. LPN #6 stated that the call bell should have been at the resident's bedside on the unaffected side in the resident's reach. LPN #6 placed the call bell on the right side of the bed next to the resident and the resident demonstrated ability in using the call bell CNA #6, who cared for Resident #240 on 10/26/2022, was interviewed on 11/2/2022 at 10:22 AM. CNA #6 stated the resident uses a left-hand roll and is able to use the call bell with their right hand. CNA #6 stated that they were responsible for ensuring that the resident's call bell was within reach at all times. CNA #6 stated that they (CNA #6) usually place the resident's call bell within reach and did not know how the call bell got between the mattress and the side rail. CNA #6 stated that at no time should the resident be without their call bell. The Director of Nursing Services (DNS) was interviewed on 11/2/2022 at 2:35 PM and stated that it was the responsibility of all staff to ensure that the resident's call bell is within reach. The DNS stated that the resident moves around in the bed and probably dislodged the call bell; however, staff should make frequent rounds to ensure the resident's call bell was at their bedside within reach. The DNS further stated that there should be a clip on the call bell cord to keep the resident's call bell in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey, the facility did not ensure that an allegation of abuse was reported to the State Agency not later than 24 hours when the allegation determination did not involve abuse and did not result in an injury. This was identified for one (Resident #136) of one resident reviewed for Abuse. Specifically, Resident #136 made an allegation of abuse by a Certified Nursing Assistant (CNA) during a Resident Council meeting. An investigation for potential abuse was completed; however, without notification to the State Agency about the allegation. The facility Policy and Procedure on Abuse Investigation dated 10/29/19, documented that .#2- For all alleged violations, the DOH (Department of Health) should be notified two hours if the alleged violation involved abuse or results in serious bodily injury, 24 hours if it does not involve abuse and does not result in serious injury. The finding is: An interview was held with a representative from the Ombudsman program on 1/17/20 at 10:15 AM. The Ombudsman stated that during the resident council meeting held on 1/6/20 Resident #136 stated that he had been struck by a staff member, a Certified Nursing Assistant (CNA). A review of the resident council minutes dated 1/6/90 documented that Resident #136 stated that a CNA (named) tried to hit him over the weekend. Resident # 136 has diagnoses including Cerebral Palsy and Depression. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) Score of 12, indicating the resident had moderate cognitive impairment. The MDS documented the resident had no behavior problems during the assessment period. A Comprehensive Care Plan (CCP) titled Psychosocial Well-Being, effective 5/19/14 and last updated on 1/9/20, documented that the resident had a potential risk for victimization related to Cerebral Palsy. The interventions included to encourage the resident to express feelings and provide emotional support. The CCP updated on 1/9/20 did not include the allegation of abuse as reported on 1/6/20. The review of the Progress Notes from 1/6/20 to 1/21/20 did not include the incident of alleged abuse. Resident #136 was interviewed on 1/17/20 at 2:11 PM. The resident stated that a CNA went to hit him by raising a hand to him. The resident stated that he had reported this to the Nurse. The Director of Nursing Services (DNS) was interviewed on 1/17/20 at 3:32 PM. The DNS stated that it seemed as though the resident was not serious. The DNS stated the accusation was investigated and it was determined that it was not abuse and therefore, it was not necessary to call it in to the Department of Health (DOH). The DNS stated that after reviewing the information and talking about the allegation with the team it was determined that this did not have to be called in. The incident was discussed and a determination was made that no contact was made. During a subsequent interview with the Ombudsman on 1/21/20 at 12:37 PM the Ombudsman stated that following the Resident Council Meeting on 1/6/20 the Ombudsman immediately reported the allegation of abuse to the Administrator, at that time, and the Assistant Administrator. The Ombudsman stated that during the resident council meeting the resident stated that he was struck by the CNA. The Ombudsman stated that during a follow up meeting with the DNS and the Assistant Director of Nursing (ADNS) on 1/13/2020, the DNS stated that she had already investigated the allegation made by Resident #136. The Assistant Administrator was interviewed on 1/21/20 at 4:37 PM. The Assistant Administrator stated that they were waiting to determine whether this was an actual abuse concern before the facility called it in. He stated that the facility was going to investigate the allegation and then make the determination. 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during a Recertification survey the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident. This was identified for one (Resident #64) of eight residents reviewed for Unnecessary medications. Specifically, Resident #64 did not have a Comprehensive Care Plan (CCP) developed to address the resident's frequent refusal to take medications. The finding is: Resident #64 was admitted to the facility with diagnoses including Acute Kidney Failure, Psychosis and Mood Disorder. An admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) Score of 99, indicating that the resident was unable to complete the assessment. A review of the Medication Administration Record (MAR) from 9/17/19 to 1/21/20 revealed the resident was refusing medications frequently. The resident refused to take medications on the following dates: September 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28 and 29 of 2019. October 1, 2, 3, 4, 5, 19, 22, 24, 27, 28 and 31 of 2019. November 7, 8, 9, 21, 23, 24, 28, 29, 30 of 2019. December 1, 3, 5, 7, 8, 19, 21, 24, 25 of 2019. January 3, 4, 5, 7, 9, 10, 11, 16, 17, 18, 19, 21 of 2020. A review of CCPs from 9/17/19 to 1/21/20 revealed that no CCP was developed for the resident's refusal of medications. The unit Charge Registered Nurse (RN) was interviewed on 1/21/20 at 10:00 AM and stated that she was responsible for developing the CCPs. The RN stated that she did not develop a CCP for the resident's non-compliance of taking medications because she was not aware that the resident was frequently refusing medications. The Unit Desk RN was interviewed on 1/21/20 at 10:05 AM and stated that she was aware of a one-time refusal of medications by the resident through a report from the Medication Licensed Practical (LPN) when the resident was just admitted . She stated she was not aware that the resident had been refusing medications so frequently. The unit 7:00 AM-3:00 PM Medication Licensed Practical Nurse (LPN #1) was interviewed on 1/21/20 at 11:00 AM and stated that when the resident refused to take medications she informed either the Desk RN, the Charge RN, or both of them. The unit 7:00AM-3:00 PM Medication LPN #2 was interviewed on 1/22/20 at 9:51 AM and stated that when the resident refused medications he told the RN Supervisor. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #117 has diagnoses including Dementia, Schizoaffective Disorder/Bipolar Type, and Anxiety Disorder. An Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 15 which indicated intact cognition. The resident had no behavior symptoms and was documented as a current tobacco user. A Comprehensive Care Plan (CCP) dated 6/29/17 for smoking documented the resident was deemed a dependent smoker and was unable to smoke safely due to hoarding/hiding smoking material, and was aggressive when redirected about smoking. The goals included that the resident will be able to smoke safely under supervision for three months, and will comply with the facility smoking policy times (x) 3 months. The interventions included to assess the resident's ability to smoke safely, check bags /clothing/pocketbook for smoking contraband upon return from out on pass, conduct room search if necessary and with the resident's consent. The monitoring/evaluation section of the CCP documented on 1/7/2020 that the resident's smoking status was unchanged. A Smoking assessment dated [DATE] and last updated 1/7/2020 documented the resident was an independent smoker. The Registered Nurse (RN) Supervisor was interviewed on 1/21/2020 at 10:18 AM. The RN Supervisor stated the resident does not have a smoking schedule as the resident was an independent smoker. The RN stated the resident has a Physician's order for out on pass (OOP) privileges. The RN further stated when the resident wishes to go out to smoke, she would go to the parking lot at the designated area to smoke. Resident #117 was interviewed on 1/23/2020 at 11:45 AM and stated that she has no smoking schedule and that she was an independent smoker. The resident stated when she chooses to go cut to smoke, she signs an out on pass form and then smokes in the designated area in the parking lot. The Director of Recreation was interviewed on 1/23/2020 at 1:15 PM. The Director of Recreation stated that either she or her assistant is responsible to update the CCP and that the CCPs are updated quarterly with the smoking assessment. The Director of Recreation stated the resident is an independent smoker with OOP privileges and that the resident smokes outside in the parking in the designated area. The Director of Recreation stated that there was one occasion when the resident was found with an electronic cigarette in 2018, and that the resident has been in compliance since that time. The Director of Recreation stated that her evaluation assessed the resident as independent in smoking. The Director of Recreation further stated it was an oversight that the CCP was not updated to reflect the resident's current status of being an independent smoker. 3) Resident #111 has diagnoses including Urinary Tract Infection and Dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) Score of 9 which indicated moderately impaired cognition. The resident had no mood or behavior problems. The Quarterly MDS assessment dated [DATE] documented the resident had short and long term memory problems, was severely impaired for daily decision making, and had no mood or behavior problems. A Comprehensive Care Plan (CCP) dated 9/11/19 for Cognitive loss/Dementia documented the resident had moderate cognitive impairment. The goal was for the resident to maintain her current level of cognition. The interventions included to monitor for mood disorder, provide reorientation aids and verbal reminders and to monitor for changes or decline in cognition. Review of the monitoring and evaluation section of the CCP lacked documented evidence that the resident's current cognitive status was updated on the CCP when the Quarterly MDS completed 11/2/19 identified a decline in the resident's cognition. The Social Service Assessment created on 11/1/19 was reviewed on 1/23/2020 and revealed the Assessment was not completed. The Unit Social Worker (SW) was interviewed on 1/23/20 at 1:30 PM. The SW stated she was responsible for completing Section C (Cognitive Pattern) of the MDS and for updating the cognition CCP. The SW stated that the CCP should have been updated with the quarterly review; however, she was a little behind in completing the quarterly assessment. She stated that she would complete a new BIMS for the resident to ensure the resident's correct cognition was captured. 415.11(c)(2)(i-iii) Based on observations, record review, and staff interviews during the Recertification Survey, the facility did not ensure that Comprehensive Care Plans (CCP) were reviewed and revised to reassess the effectiveness of interventions and reflect each resident's current status. This was identified for one (Resident #78) of four residents reviewed for falls, one (Resident #117) of one resident reviewed for smoking, and one (Resident #111) of four residents reviewed for mood and behavior. Specifically, 1) Resident #78, who was identified as at risk for falls and had actual falls, had no interventions added or revisions to the CCP developed for falls since 2016. Additionally, educating the resident to use the call bell was identified as an intervention in 2016 and was no longer applicable based on the resident's current cognitive status; 2) Resident #117 was assessed to be an independent smoker and the care plan was not updated to reflect the resident's current independent status: and 3) Resident #111 had a change in cognition and the care plan was not updated to reflect the resident's current cognitive status. The findings are: 1) Resident #78 was admitted to the facility in July of 2019 with diagnoses including Parkinson's Disease, Peripheral Vascular Disease, and Bipolar Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and had severely impaired cognition. The resident transferred with total assistance of two staff members and was non-ambulatory. The resident was observed on 1/16/20 at 12:05 PM in the TV recreation area, staring at the TV, and was verbally unresponsive when greeted by the surveyor. A review of the medical progress notes revealed that on 9/12/19 at 8:50 PM, the resident was found sitting on the floor at the foot of the bed, with a bleeding laceration to the top of his head and a hematoma to the front right side of the head. The resident was unable to give an account of what happened. The resident was assessed by the Registered Nurse (RN) and the Physician was notified. A telephone order was obtained to send the resident to the hospital for a Computerized Axial Tomography (CAT) scan of the head. The resident returned to the facility early the next morning. The care plan for falls, dated 6/5/16, documented the identified fall which occurred on 9/12/19. An update on 12/30/19 documented that the resident continued to put himself on the floor and thrash in bed. The most recent intervention documented in the care plan was implemented on 11/24/16. The intervention documented to educate the resident on the use of the call bell when in need of assistance. The Registered Nurse (RN) Manager was interviewed on 1/22/20 at 11:44 AM. The RN stated that she was responsible for updating the care plan. She stated that the educational intervention for the use of the call bell was no longer applicable due to the resident's poor cognitive status and that the intervention should have been changed. She stated that interventions were discussed in the care plan meetings but were never documented on the care plan itself.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews during the Recertification survey, the facility did not 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, 1) During a medication pass observation, the Licensed Practical Nurse (LPN) medication nurse was observed placing medication cups directly on the bathroom sink for two (Resident #228 and Resident #85) of three residents during the medication administration observation; and 2) a Certified Nursing Assistant (CNA) was observed wearing a mask improperly in resident areas on [DATE]. The findings are: 1a) Resident #228 was admitted to the facility with diagnoses that includes Depression and Cerebral Vascular Accident. A Physician's order dated [DATE] documented Vitamin C 500 milligram (mg) 1 tablet oral route (po) once daily, Multiple Vitamin 1 tablet po once daily, Liquid Protein Supplement (LPS) Critical Care Sugar Free 30 milliliters (ml) by po twice daily, Citalopram 20 mg po once daily, Aspirin 81 mg po once daily. 1b) Resident #85 was admitted to the facility with diagnoses that included Atrial Fibrillation, Coronary Artery Disease and Hypertension. A Physician's order dated [DATE] documented Aspirin 81 mg 1 tablet po once daily; Ferrous Sulfate 325 mg po 2 times daily; Isosorbide Mononitrate Extended Release (ER) 60 mg, 1/2 tab (30 mg) po once daily; Miralax 17 gram 1 packet po daily; Ramipril 2.5 mg 1 capsule po once daily; and Visine-AC 0.05%-0.25% instill 2 drops in each eye 3 times daily. A medication administration observation was conducted on the Spring Unit on [DATE] at 9:15 AM with the LPN #1 medication nurse. LPN#1 was observed to pour medication for Resident #228 then entered the resident's bathroom, placed the medication cups with the resident's medication on the sink counter below the paper towel dispenser. LPN #1 then washed her hands, and with water dripping from her hands over the medication cups the LPN removed paper towels from the dispenser to dry her hands. The LPN then administered the medication to the resident. LPN #1 then washed her hands and poured medications for Resident #85. LPN # 1 entered the resident's bathroom, placed the medication cups with the resident's medication on the sink counter, washed her hands, then administered the medications to the resident. LPN #1 was immediately interviewed on [DATE] at 9:30 AM. LPN #1 stated that she was a new nurse and that she was inserviced upon hire, about one year ago, regarding medication administration. LPN #1 stated that she was inserviced to wash her hands before and after medication administration and that she was not clear regarding what to do with the cup containing medication when she washed her hands before administering the medication to the residents. The Director of Nursing Service (DNS)/Infection Control Nurse was interviewed on [DATE] at 10:00 AM. The DNS stated that the staff educator was responsible for educating the nurses regarding handwashing and proper infection control practices. The LPN #2 Staff Educator was interviewed on [DATE] at 10:16 AM and stated that on hire, based on experience, the nurses are given a Medication Skill list and are buddied with another nurse for five days. LPN #2 stated that during the buddy period the nurse that was assigned to LPN #1 should have observed the medication pass to ensure proper infection control practices were followed during medication administration. LPN #2 stated LPN #1 should have washed her hands before pouring the medication, then administered the medication to the resident and washed her hands after the medication was administered to the resident. 2) During a tour of the Emerald unit on [DATE] between 10:45 AM -11:13 AM a Certified Nursing Assistant (CNA) was observed walking in the unit hallways and going in and out of multiple resident rooms. Residents were present in the hallway and in the rooms. The CNA was observed wearing a mask which covered her mouth; however, her nose was uncovered. The CNA was interviewed on [DATE] at 11:00 AM and stated that she wore the mask because she did not take the influenza vaccine this season. The CNA was observed on [DATE] at 1:05 PM walking in and out of resident rooms wearing a mask which covered her mouth; however, her nose was uncovered. The CNA's wearing of the mask was brought to the attention of the unit Registered Nurse (RN) Charge Nurse on [DATE] at 1:05 PM. The RN observed the CNA and stated that the mask should cover both the nose and mouth. The RN further stated that the CNA was assigned to assist with call bell responses and to obtain the resident's weight. The CNA was interviewed on [DATE] at 1:06 PM and stated that she did not notice that the mask had slid down her nose. The Director of Nursing Services (DNS) was interviewed on [DATE] at 2:00 PM and stated that all employees are trained on the proper use of personal protective equipment (PPE), including wearing a mask. 415.19(a)(1-3)