**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024 the facility did not provide each resident access to personal and medical records pertaining to themselves, upon an oral or written request, in the form and format requested by the individual. This was identified for one (Resident #222) of one resident reviewed for Dignity. Specifically, Resident #222 was readmitted to the facility from the hospital on 7/13/2024 and requested a copy of their hospital Discharge Summary, which was received by the facility upon the resident's return from the hospital. The facility did not make the requested discharge summary available to Resident #222 within the required timeframe. The finding is: The facility policy titled, Medical Record Request Policy last revised on 3/2023 documented that if an individual should request a release of medical records from the facility, the individual shall be referred to the Social Worker who shall provide the Health Insurance Portability and Accountability Act (HIPAA) authorization form. The Social Worker will review the request to determine the individual's capacity and the validity of the request. The Social Worker will forward the request with any supporting documentation to the Medical Record Clerk. The Medical Record Clerk will send the medical record request and all supporting documents to the Legal Department for final review and approval. A resident or qualified person/personal representative has the right to request access to patient information. The facility shall allow access to inspect medical records to individuals and their legal representatives within 24 hours or provide copies of medical records within 48 hours after receipt of a valid request for medical records. Resident #222 was admitted with diagnoses including Traumatic Subarachnoid Hemorrhage (brain bleed), Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #222 had intact cognition. Resident #222 was interviewed on 8/5/2024 at 3:00 PM and stated they had requested a copy of the hospital discharge summary and hospital recommendations after they were readmitted from the hospital to the facility in July 2024. Resident #222 stated they needed the discharge summary recommendation information to schedule their follow-up appointments with the specialists from the hospital. Resident #222 stated they requested the discharge summary from Social Worker #3 and were told that they (Resident #222) could request the documents directly from the hospital. A review of the hospital Discharge Instructions dated 7/13/2024 documented that Resident #222 needed a follow-up consultation with a Neurosurgeon in one week due to a diagnosis of Traumatic Subarachnoid Hematoma (brain bleed). Social Worker #3 was interviewed on 8/6/2024 at 11:04 AM and stated that Resident #222 had requested a copy of their hospital discharge summary for the July 2024 hospital stay. Social Worker #3 stated they gave Resident #222 a copy of the Health Insurance Portability and Accountability Act (HIPAA) authorization form and told Resident #222 that they could also obtain the requested records directly from the hospital. Social Worker #3 stated they did not follow up with Resident #222 to ascertain if the resident received the requested records. A review of Resident #222's electronic medical record revealed there was no documented evidence of the Health Insurance Portability and Accountability Act (HIPAA) authorization form present in the resident's medical record. The Medical Record Clerk was interviewed on 8/6/2024 at 12:03 PM and stated they did not receive the Health Insurance Portability and Accountability Act (HIPAA) authorization form from Resident #222. The Medical Record Clerk stated Social Worker #3 did not follow up with their department regarding Resident #222's medical record request. Resident #222 was re-interviewed on 8/7/2024 at 10:54 AM and stated they did not receive the Health Insurance Portability and Accountability Act (HIPAA) authorization form from the facility. Resident #222 stated they asked the facility staff for the hospital discharge summary for the July 2024 hospital stay numerous times and were told to request the record from the hospital. The Director of Nursing Services was interviewed on 8/7/2024 at 11:30 AM and stated that Resident #222 should not have difficulties obtaining their medical record. The Director of Nursing Services stated that Social Worker #3 should have assisted Resident #222 in obtaining the medical records. The Administrator was interviewed on 8/7/2024 at 2:39 PM and stated that Resident #222 should have been assisted by Social Worker #3 in obtaining the requested medical records. The Administrator stated that Resident #222 did not have to request their (Resident #222) medical record from the hospital. 10 NYCRR 415.3(c)(1)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00339563) initiated on [DATE] and completed on [DATE], the facility did not ensure each resident transferred to the hospital and discharged from the facility had documentation in the medical record of the attempts made by the facility to meet the needs of the resident before the resident was discharged to the hospital. This was identified for one (Resident #413) of three residents reviewed for death and the facility did not ensure each resident had documentation from a Physician of the necessity to transfer or discharge the resident. This was identified for two (Resident #413 and #414) of three residents reviewed for death. Specifically, Resident #413 suffered a cardiac arrest (occurs when the heart suddenly and unexpectedly stops pumping) in the facility and attempts of cardiopulmonary resuscitation and the use of an automated external defibrillator were not documented in the resident's medical record. Additionally, Resident #413 and Resident #414 suffered a cardiac arrest and were transferred to the hospital. There was no discharge note written by the Physician for both residents. The finding is: The facility's policy titled Cardiopulmonary Resuscitation-Emergency Response Code Blue, dated 6/2013 documented that the staff responding (to Code Blue) is responsible for documenting the interventions and outcome of the emergency response in the resident's medical record. The facility's policy titled Hospital Transfers, effective 7/2014, documented that when nursing staff notices a change in the resident's condition indicating medical intervention, the charge nurse/nursing supervisor shall evaluate the resident and report their findings to the attending/covering physician. The Registered Nurse will document findings and actions in the medical record using the Situation, Background, Assessment, and Recommendation (SBAR) note or progress note. In addition, the Physician/Nurse Practitioner shall document the present medical condition in the space provided on the institutional transfer form. Registered Nurse/Nursing Supervisor shall document a transfer note in the Situation, Background, Assessment, and Recommendation (SBAR) form. Resident #413 was admitted to the facility with diagnoses including End Stage Renal Disease, Diabetes Mellitus, and Depression. The [DATE] Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. A Comprehensive Care Plan titled Resident Does Not Have Advanced Directives (legal documents to make provisions for future health care decisions in the event the individual is unable to make such decisions for themselves) in place, initiated on [DATE] documented to educate the resident on advanced directives and give the resident an opportunity to enact an advanced directive. A Situation, Background, Assessment, and Recommendation (SBAR) note dated [DATE] at 2:15 PM, created by Registered Nurse #3, documented Resident #413 had a cardiac arrest and respiratory arrest (no breathing). The resident was unresponsive. The resident was a full code (cardiopulmonary resuscitation can be used). Nurse Practitioner #1 was notified with an order to call Emergency Medical Services (911) and transfer the resident to the hospital. The section titled Nursing Notes in the Situation, Background, Assessment, and Recommendation (SBAR) form was blank. There was no documentation in the medical record that cardiopulmonary resuscitation was initiated for Resident #413. Additionally, there was no documentation from the Physician regarding the resident's transfer/discharge or disposition after the resident was transferred to the hospital. Registered Nurse #3 was interviewed on [DATE] at 11:57 AM and stated they were no longer employed at the facility and did not recall Resident #413. Registered Nurse #3 stated if the resident was a full code, the facility staff would have initiated cardiopulmonary resuscitation and documented it in the resident's medical record. Assistant Director of Nursing #1, the Nurse Educator, was interviewed on [DATE] at 12:34 PM and stated there should absolutely be notes written detailing what actions were taken by facility staff during a full code. If staff initiated cardiopulmonary resuscitation and used an automatic external defibrillator, this should be documented. Licensed Practical Nurse #2, the medication nurse, was interviewed on [DATE] at 1:37 PM and stated on [DATE], they found Resident #413 unresponsive and called Code Blue; a lot of staff responded, and they (Licensed Practical Nurse #2) initiated the cardiopulmonary resuscitation. Staff also attempted to use the automatic external defibrillator but there was no shock advised. Cardiopulmonary resuscitation was continued until the emergency medical services arrived and then they took over. The emergency medical services transported the resident to the hospital. Licensed Practical Nurse #2 stated they did not write a progress note because the nursing supervisor usually writes the notes. The Registered Nurse is responsible for completing the Situation, Background, Assessment, and Recommendation (SBAR) form which should include all interventions that were applied before the resident's transfer to the hospital. If a resident is pronounced dead at the hospital, the nursing supervisor gets a call from the hospital and should then write a progress note to document the resident's disposition. Nurse Practitioner #1 was interviewed on [DATE] at 8:15 AM and stated they did not write a transfer/discharge note for Resident #413 because they (Nurse Practioner #1) were not there at the time the Emergency Response Code was called. Nurse Practitioner #1 stated they would not write a note if they were not present. Physician #3, the attending Physician, was interviewed on [DATE] at 10:30 AM and stated they did not write a discharge summary or note in Resident #413's medical record because they did not see the resident and were not involved with the Emergency Response Code. Physician #3 stated the emergency room called them and told them that the resident expired in the emergency room. If they were present during the Emergency Response Code, they would have written a note. Physician #3 stated that a discharge note is more important when a resident is being discharged to the community. The facility has a protocol for when a resident is being discharged home, I am not sure about a discharge to the hospital. The Director of Nursing Services was interviewed on [DATE] at 12:10 PM and stated they did not know if the facility protocol requires the doctor to write a note when a resident is transferred to the hospital. The Medical Director was interviewed on [DATE] at 8:30 AM and stated that doctors should write a note when a resident is transferred or discharged to the hospital. Any resident who gets discharged from the facility must have a discharge summary. Resident #414 was admitted with diagnoses including End Stage Renal Disease, Diabetes Mellitus, and Hypertension. The [DATE] Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. A Comprehensive Care Plan titled Resident Does Not Have Advanced Directives (legal documents to make provisions for future health care decisions in the event the individual is unable to make such decisions for themselves) in Place, initiated [DATE] documented to educate the resident on advanced directives and give the resident an opportunity to enact an advanced directive. A nursing progress note for Resident #414 dated [DATE] at 9:55 AM documented the resident was found unresponsive to verbal and tactile stimuli, no pulse, and no respiratory movement. The resident was a full code. Code Blue was initiated at 8:40 AM and 911 was called. An automated external defibrillator was applied, and shock was advised one time. Emergency medical technicians arrived at the facility at approximately 8:51 AM. The resident left the facility via ambulance at 9:30 AM. A nursing progress note dated [DATE] at 10:56 AM documented writer called the hospital and spoke with a Physician who stated the resident arrived at the hospital in cardiac arrest and was pronounced dead at 9:52 AM. There was no documentation in Resident #414's medical record from the resident's physician regarding the resident's transfer/discharge. Physician #1, Resident #414's attending physician, was interviewed on [DATE] at 12:02 PM and stated they were away in February 2024 when Resident #414 expired. Physician #2 was covering their residents. Physician #1 stated there should be a Physician discharge note in place that includes the reason the resident went to the hospital and the outcome. The Director of Nursing Services was interviewed on [DATE] at 12:10 PM and stated they did not know if the facility protocol requires the doctor to write a note when a resident is transferred to the hospital. Physician #2 was interviewed on [DATE] at 12:36 PM and stated they usually write discharge summaries for residents who are under their care. Resident #414 was not their resident and perhaps Physician #1 missed documenting the discharge summary since they (Physician #1) were away. The Medical Director was interviewed on [DATE] at 8:30 AM and stated that doctors should write a note when a resident is transferred or discharged to the hospital. Any resident who gets discharged from the facility must have a discharge summary. 10 NYCRR 415.3(i)(1)(ii)(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that a person-centered care plan for each resident that includes measurable objectives and timeframes to meet each resident's medical and nursing needs was implemented as identified in the comprehensive assessment. This was identified for one (Resident #71) of five residents reviewed for Respiratory Care. Specifically, Resident #71 had a physician's order to drain fluids from the abdominal cavity on the 7:00 PM - 7:00 AM shift via a Peritoneal (abdominal) Pleurex catheter (a thin, flexible tube that is inserted into the abdominal cavity to drain fluid) due to the diagnosis of Ascitis (a condition where fluid builds up in the abdomen between the lining of the abdomen and the abdominal organs). A review of the resident's medical record from 7/1/2024 to 7/12/2024 and from 8/1/2024 to 8/3/2024 revealed no documented evidence that the abdominal fluid was drained as per the physician's orders for a total of 11 out of 15 opportunities. The finding is: The facility's policy for Peritoneal Drainage System- Pleurex Catheter dated 4/2023 documented to chart the resident's response to the procedure and the volume of Ascites fluid drained. Resident #71 was admitted with diagnoses that included Cirrhosis of the Liver and Ascites. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 14, which indicated the resident had intact cognition. The resident had no behavioral problems and did not reject care. A Comprehensive Care Plan dated 4/7/2023 and last reviewed on 7/31/2024 documented alteration in gastrointestinal status related to the disease process. Interventions included to discuss with the resident, family, or caregivers any concerns, fears, or issues related to gastrointestinal distress. Drain Ascites fluid via peritoneal drain every 12 hours, no more than 500 milliliters of fluid each drain, elevate the head of the bed to semi-Fowler's (patient lies on their back with their head and upper body raised at a 30-45 degree angle on the bed) position as needed. A physician's order dated 6/28/2024 documented to drain of the Peritoneal (abdominal) Pleurex Catheter up to 500 milliliters of fluid every day for abdominal discomfort and distension. The Treatment Administration Record for July 2024 was reviewed on 8/7/2024 and revealed there was no documented evidence of the amount of fluid drained from the Peritoneal Pleurex Catheter on 7/1/2024, 7/2/2024,7/5/2024, 7/6/2024, 7/7/2024, 7/8/2024, 7/9/2024, and 7/11/2024. A review of the medical record revealed that Resident #71 went to the hospital on 7/26/2024 and returned on 7/31/2024. A Physician's order dated 8/1/2024 documented to drain Left Chest Pleurex Catheter up to 500 cubic centimeters daily in the evening for Pleurex Catheter. A Treatment Administration Record for August 2024 was reviewed on 8/7/2024 and revealed there was no documented evidence of the amount of fluid drained from the Pleurex Catheter from 8/1/2024 to 8/3/2024. Physician #2 was interviewed on 8/8/2024 at 11:37 PM and stated they have been caring for Resident #71 for the past three years. The resident has Ascites due to Cirrhosis of the Liver. Physician #2 stated that if too much fluid was drained from the Pleurex Catheter, the resident could develop Hypotension (low blood pressure). Registered Nurse #16, who was assigned to Resident #71 on 7/5/2024, 7/9/2024, and 7/11/2024, was interviewed on 8/8/2024 at 12:27 PM. Registered Nurse #16 stated they usually document the amount of fluid drained from the Pleurex Catheter on the Treatment Administration Record. Registered Nurse #16 stated they were supposed to document the amount of fluid drained from the Pleurex Catheter on the Treatment Administration Record. Registered Nurse #17, who was assigned to Resident #71 on 7/2/2024, 7/6/2024, 7/7/2024, 7/8/2024, and 8/3/2024, was interviewed on 8/8/2024 at 1:48 PM. Registered Nurse #17 stated Resident #71 had a Pleurex Catheter and they had drained no more than 500 cubic centimeters of fluid from the Pleurex Catheter daily during the 7:00 PM to 7:00 AM shift. Registered Nurse #17 stated they did not know why the drainage amount was not documented on the Treatment Administration Record on 7/2/2024, 7/6/2024, 7/7/2024, 7/8/2024, and 8/3/2024. The Director of Nursing Services was interviewed on 8/8/2024 at 1:52 PM and stated that the nurses must document the amount of fluid drained from the Pleurex Catheter on the Treatment Administration Record. 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 initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (Resident #116) of two residents reviewed for Communication. Specifically, Resident #116's comprehensive care plan for Communication documented that the resident was hard of hearing in the left ear. The comprehensive care plan was not updated to indicate the resident used a hearing aid and preferred keeping the hearing aid at the bedside. The finding is: The facility's policy titled Care Planning Process, effective 7/2022 documented the facility shall have a care planning process that is person-centered, which includes integrating assessment findings in care planning, providing services to attain or maintain the resident's highest physical, mental, and psychosocial well-being, and regularly reviewing and revising the care plan. The comprehensive care plan shall include the resident's preferences and is revised by members of the interdisciplinary team based on changing goals, preferences, and needs of the resident and in response to current interventions. Resident #116 was admitted with diagnoses including Morbid Obesity, Bipolar Disorder, and Chronic Obstructive Pulmonary Disease. The 5/1/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident had moderate difficulty with hearing and did not use a hearing aid. A Comprehensive Care Plan, titled Communication Problem Related to Deafness, effective 10/27/2023 and last updated 8/5/2024, documented the resident was was hard of hearing in the left ear and was able to lip read. the interventions included audiology consult as ordered. The care plan did not include use of a hearing aid. Certified Nursing Assistant #1 was interviewed on 8/5/2024 at 10:41 AM and stated they did not know the resident used a hearing aid. Certified Nursing Assistant #1 stated they have to speak loudly with the resident for the resident to understand them. The [NAME] (nursing care instructions for Certified Nursing Assistant) dated 8/4/2024 instructed the Certified Nursing Assistant to assist the resident with the hearing aid and keep the hearing aid in the medication cart. Resident #116 was observed on 8/5/2024 at 10:45 AM with Certified Nursing Assistant #1 present. The resident was in bed sleeping and was awakened by Certified Nursing Assistant #1. A message (communication) board was used to help communicate with the resident. The resident stated they use a hearing aid for their left ear and keep the hearing aid in their bag at the bedside. The resident stated they are completely deaf in the right ear. The resident stated they put the hearing aid in themselves and do not need staff assistance. Registered Nurse #5, the medication nurse, was interviewed on 8/5/2024 at 11:07 AM and stated the resident was very hard of hearing; however, they did not know if Resident #116 used a hearing aid. Registered Nurse #6, the Minimum Data Set assessor, was interviewed on 8/5/2024 at 11:41 AM and stated they completed the 5/1/2024 Quarterly Minimum Data Set assessment, for Resident #116 and the resident was able to read lips and was able to understand what was being said to them. Registered Nurse #6 stated they had to speak loudly and clearly. Registered Nurse #6 stated the resident had a hearing aid but did not use the hearing aid during the assessment. Registered Nurse #6 stated any nurse involved with the resident's care, including the Minimum Data Set nurses, can update care plans. Registered Nurse #6 reviewed the resident's communication care plan and the [NAME] and stated that the care plan and the [NAME] were not consistent with the resident's communication status and preferences. The Director of Nursing Services was interviewed on 8/6/2024 at 12:00 PM and stated the comprehensive care plan and [NAME] should reflect the resident's preferences, goals, and needs and everything should be consistent and current. 10 NYCRR 415.11(c)(2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00333364) initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain grooming, personal, and oral hygiene. This was identified for one (Resident #5) of five residents reviewed for pressure ulcers and one (Resident #132) of two residents reviewed for activities of daily living. Specifically, 1) on 8/7/2024, Resident #5's fingernails on both hands were observed to be long and dirty, with a brown substance under the nails and 2) on 8/2/2024, Resident #132's right palm was observed with dark crusty flakes and a musty odor was detected coming from their right hand. The findings are: The facility's policy titled Activities of Daily Living, effective 11/2018, documented the facility will provide the necessary care and services based on the comprehensive assessment of a resident and consistent with the resident's needs, choices, and preferences, to maintain or improve, the resident's ability to perform activities of daily living and to prevent decline unless it is unavoidable. Activities of daily living include hygiene, such as bathing, dressing, grooming, and oral care; individualized care plans are based on an accurate assessment of the resident's self-performance and the amount and type of support being provided. When a resident refuses to comply with activities of daily living, nursing staff shall solicit assistance from other disciplines to determine the cause for refusal, offer options and alternatives, and document refusal in the medical record. 1) Resident #5 was admitted with diagnoses including Schizophrenia, Parkinson's Disease, and Diabetes Mellitus. The 7/10/2024 significant change Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident had mood concerns, including feeling down, depressed, and feeling bad about themselves nearly every day. The resident was dependent on staff for personal hygiene tasks. A comprehensive care plan titled Activities of Daily Living Self-Care Performance Deficit Related to Aggressive Behaviors, Limited Range of Motion, initiated 5/24/2024, documented the resident was dependent on staff for Personal Hygiene needs and will remain clean, neat, dressed appropriately, and free of body odor and that. The [NAME] (nursing care instructions for Certified Nursing Assistants), as of 8/7/2024, documented that the resident was dependent on staff for personal hygiene needs and to observe the resident for proper hand hygiene. Under the Personal Hygiene heading, oral care was the only care area listed. Resident #5 was observed in bed on 8/7/2024 at 9:47 AM. The resident's fingernails on both hands were excessively long and dirty, with a brown substance under the nails. The resident stated they would like their nails trimmed. During an observation on 8/7/2024 at 9:53 AM with Certified Nursing Assistant #2 and Registered Nurse #7 (acting unit charge nurse) Resident #5's fingernails were observed to be long and dirty. Certified Nursing Assistant #2, who was the resident's regularly assigned Certified Nursing Assistant, was interviewed on 8/7/2024 at 9:54 AM. Certified Nursing Assistant #2 stated the nurses were supposed to cut Resident #5's fingernails because the resident was Diabetic. Certified Nursing Assistant #2 stated the nurses see the resident every day, which is why they (Certified Nursing Assistant #2) did not report the resident's long fingernails to the nurse. Registered Nurse #7 was interviewed on 8/7/2024 at 9:55 AM and stated the nurses were responsible for cutting Resident #5 nails because the resident was Diabetic and any nurse could have cut the resident's fingernails. Registered Nurse #8, the medication nurse, was interviewed on 8/7/2024 at 10:03 AM and stated they administered the morning medications to Resident #5 and did not notice the resident's fingernails. Registered Nurse #8 then proceeded to check the resident's fingernails and stated the fingernails needed to be trimmed and cleaned. Registered Nurse #8 asked the resident if they wanted their fingernails trimmed and the resident responded yes. Assistant Director of Nursing Services #1, the nurse educator, was interviewed on 8/7/2024 at 11:06 AM and stated the staff members have to ask the resident if they want the fingernails cut; sometimes the resident refuses and gets aggressive. Assistant Director of Nursing Services #1 stated the refusals should be documented in the medical record. Assistant Director of Nursing Services #1 stated the resident's fingernails should be clean and neatly trimmed. A review of nursing progress notes from 8/1/2024 to 8/7/2024 revealed no documentation that Resident #5 refused to have their fingernails trimmed. The Director of Nursing Services was interviewed on 8/7/2024 at 12:54 PM and stated they had never heard that Resident #5 refused care. The Director of Nursing Services stated if the resident was refusing care, there should have been a care plan in place, and the staff should have determined how to maintain the resident's hygiene including nail care. 2) Resident #132 was admitted with diagnoses that included Coronary Artery Disease, Peripheral Vascular Disease, and Non-Alzheimer's Dementia. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 00, which indicated severely impaired cognition. The resident had no behavioral symptoms, had impairment on both sides of upper and lower extremities, and was totally dependent on staff for all aspects of Activities of Daily Living. A Comprehensive Care Plan dated 9/13/2023 and last revised on 6/7/2024 documented the resident had a deficit in Activities of Daily Living, cognitive Impairment, Dementia, limited mobility, and limited range of motion. Interventions included for staff to maintain personal hygiene including combing the resident's hair, shaving, washing, and drying the resident's face and hands. The [NAME] (nursing care instructions for the Certified Nursing Assistants), from 8/1/2024 to 8/10/2024 documented to observe the resident for proper hand hygiene. Under the Personal Hygiene heading, oral care was the only care listed. During an observation on 8/1/2024 at 3:09 PM the resident was observed out of bed in their room resting in a Geri chair. The Therapy Carrot was observed on the resident's chest and not appropriately positioned in the resident's right hand. During an observation on 8/2/2024 at 3:15 PM, with the Wound Care Registered Nurse (acting Nurse Manager) and the Director of Rehabilitation Services, the resident's right hand Therapy Carrot was observed resting on the resident chest. The palm of the resident's right hand was observed with dark crusty flakes and a musty odor was detected from the resident's right hands. The Director of Rehabilitation Services stated that the Therapy Carrot should be appropriately placed in the resident's palm at all times to prevent contractures. The Director of Rehabilitation Services stated if the Certified Nursing Assistants were having difficulty placing the Therapy Carrot in the resident's hand, they should have reported the concern to the charge nurse or them (Director of Rehabilitation Services). The 7:00 AM - 3:00 PM assigned Certified Nursing Assistant #11 was interviewed on 8/5/2024 at 1:51 PM and stated they were having difficulty opening the resident's right hand but did not report it to the charge nurse. Certified Nursing Assistant #11 stated they asked another Certified Nursing Assistant (could not recall the name) to assist them with opening the resident's hand and the other Certified Nursing Assistant also could not open the resident's hand. Certified Nursing Assistant #11 stated they washed the outside of the resident's hand but were unable to wash the palm of the resident's right hand. The Director of Nursing Services was interviewed on 8/8/2024 at 12:59 PM and stated that after caring for the resident the Certified Nursing Assistant was responsible for ensuring that the Therapy Carrot was appropriately in the resident's right hand and that the nurses should monitor to ensure that the device was in place. The Director of Nursing Services stated if Certified Nursing Assistant #11 was having difficulty opening the resident's right hand, they (Certified Nursing Assistant #11) should have asked the nurse for assistance. The Director of Nursing Services stated that the resident's right hand should not have been left dirty. 10 NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility's policy and procedure titled, Air Mattress last revised in 10/2023 documented that the selection of the air mattress will be based on the individual's specific needs, including mobility levels, weight, and any pre-existing medical condition. The Wound Care Coordinator will conduct a monthly audit of the resident's weight and assessment of the staff's knowledge of operating the equipment. The operation manual for the low air loss alternating pressure relief air mattress documented instructions that included determining the patient's weight and setting the control knob to that weight setting on the control unit. -Resident #94 was admitted with diagnoses including End Stage Renal Disease, Acute Respiratory Failure, and Type 2 Diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #94 had moderately impaired cognition. Resident #94 had one Stage 4 (defined as full-thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer on the sacrum and an Unstageable (defined as full-thickness tissue loss in which the actual depth of the ulcer is completely obscured by an eschar [tan, brown or black] in the wound bed) wound on the right heel. A Comprehensive Care Plan (CCP) dated 6/15/2024 documented that Resident #94 had pressure ulcers on the sacrum and right heel related to immobility. Interventions included the use of an air mattress, offloading both heels with pillows when in bed, monitoring nutritional status, and administering medications as ordered. A physician's order dated 6/17/2024 documented the use of a Low Air Loss Alternating Pressure Mattress. A physician's order dated 6/17/2024 and renewed on 7/26/2024 documented cleaning the sacrum wound with DermaKlenz (a wound cleanser) and applying DermaBlue Foam (an anti-microbial, absorbent wound dressing) every Tuesday, Thursday, and Saturday and as needed everyday shift and cleaning the right heel with DermaKlenz (a wound cleanser) and applying Sting-Free Skin-Prep (a barrier between skin and adhesive) to the area everyday shift. A review of the electronic medical record indicated that Resident # 94's most recent weight dated 7/26/2024 was 134 pounds. On 8/1/2024 at 12:10 AM, Resident #94 was observed in bed. The air mattress control knob was set at 300 pounds. On 8/2/2024 at 7:16 AM, Resident #94 was observed in bed. The air mattress control knob was set at 300 pounds. On 8/5/2024 at 11:00 AM, Resident #94 was observed in bed. The air mattress control knob was set at 300 pounds. -Resident #201 was admitted to the facility with Diagnoses including Hypertension, Muscle Weakness, and Alcohol Dependence with Intoxication. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #201 had intact cognition. The admission Minimum Data Set (MDS) assessment documented that Resident #201 had one Unstageable (defined as full-thickness tissue loss in which the actual depth of the ulcer is completely obscured by an eschar (tan, brown, or black) in the wound bed) wound on the right hip. A Comprehensive Care Plan (CCP) dated 7/16/2024 documented that Resident #201 had a right hip pressure ulcer related to immobility and had interventions that included an air mattress, turning and positioning every two hours, and monitoring for changes in skin condition every shift. A physician's order dated 7/18/2024 documented cleaning the right hip with normal saline and applying Santyl Collagenase (an enzymatic debriding agent) ointment, then covered with bordered gauze daily. A physician's order dated 7/28/2024 documented an order for a Low Air Loss Alternating Pressure Mattress. A review of the electronic medical record indicated that Resident #201's most recent weight dated 7/18/2024 was 124 pounds. On 8/1/2024 at 10:42 AM, Resident #201 was observed in bed. The air mattress control knob was set at 250 pounds. On 8/2/2024 at 6:52 AM, Resident #201 was observed in bed. The air mattress control knob was set at 250 pounds. On 8/5/2024 at 8:00 AM, Resident #201 was observed in bed. The air mattress control knob was set at 250 pounds. Certified Nursing Assistant #6 was interviewed on 8/5/2024 at 11:15 AM and stated that when they took care of Resident #94 and #201, they did not touch the air mattress control knob. Certified Nursing Assistant #6 stated the weight setting was the responsibility of the nurses. Certified Nursing Assistant #6 stated they were only responsible for checking if the air mattress was deflated or unplugged. Registered Nurse #11, the Medication Nurse, was interviewed on 8/5/2024 at 11:30 AM and stated they did not check the air mattress weight setting for Resident #94 and #201. Registered Nurse #11 stated that the Wound Care Coordinator was responsible for checking and monitoring the air mattresses. The Wound Care Coordinator was interviewed on 8/5/2024 at 11:51 AM and stated when the air mattress is first installed, they set up the air mattress control knob according to the resident's weight and then spot-check the air mattress weight calibration occasionally. The Wound Care Coordinator stated they did not remember the last time they checked Resident #94 and Resident #201's air mattresses. The Wound Care Coordinator stated they did not have any documentation of the air mattress monitoring. The Wound Care Physician was interviewed on 8/5/2024 at 3:54 PM and stated the facility was responsible for monitoring the air mattresses. The Wound Care Physician stated the weight setting on the air mattress should correspond with the resident's weight. The Wound Care Physician stated the correct weight setting was essential otherwise the air mattress would be either too hard or too soft and could affect wound healing. The Director of Nursing Service was interviewed on 8/7/2024 at 11:30 AM and stated the Wound Care Coordinator was responsible for monitoring the air mattress and that the air mattress weight setting should correspond with the resident's actual weight. The Director of Nursing Service stated the Wound Care Nurse should have monitored Resident #94 and Resident #201's air mattress weight setting during wound care rounds. 10 NYCRR 415.12(c)(1) Based on observations, record review, and interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for three (Resident #5, Resident #94, and Resident #201) of five residents reviewed for Pressure Ulcers. Specifically, 1) Resident #5 had a Stage 4 pressure ulcer (full-thickness tissue loss with exposed bone, tendon, or muscle) at the sacrum (triangular bone in between the two hips). A comprehensive care plan intervention required that the resident be turned and positioned every two hours to offload (relieve pressure) from the sacra; ulcer. The resident was observed on multiple occasions on 8/6/2024 from 7:50 AM to 11:21 AM, lying flat on their back. The certified nursing assistant assigned to the resident stated the resident did not like to be on their side. The medical record lacked documented evidence that Resident #5 refused to turn and position or that the clinicians were notified of the resident's behavior to determine new interventions to offload the sacral region. 2) Residents #94 and Resident #201 had a physician's order for a low air loss alternating air mattress. During multiple observations, the adjustable weight setting for the air mattresses, which is meant to correspond to the resident's weight, was not set accurately. The finding is: The facility's policy titled Pressure Injury/Pressure Ulcer Assessment, Prevention, and Management, effective 3/24/2023 documented the facility shall provide care and services consistent with professional standards of practice to promote the healing of existing pressure injury/ulcer. Develop a positioning schedule and avoid positioning residents on existing pressure injuries; notify the wound care coordinator of any skin conditions or injuries. The Certified Nursing Assistant should report any changes or areas of concern to a nurse; redistribute pressure when in bed and position at least every two hours, and as needed. 1) Resident #5 was admitted with diagnoses including Schizophrenia, Parkinson's Disease, and Diabetes Mellitus. The 7/10/2024 Significant Change Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident had one unhealed Stage 4 pressure ulcer and was dependent on staff for moving from side to side in bed. The nursing admission assessment dated [DATE] documented the resident had an unstageable (the wound is covered with dead tissue and the depth cannot be determined) pressure ulcer to the sacrum. The resident's Braden Scale (a scale used to predict pressure ulcer risk) score was documented as 16, which indicated the resident was at mild risk for developing pressure ulcers. A Comprehensive Care Plan titled Pressure Ulcer Related to Impaired Mobility, Stage 4 to Sacrum (post debridement), initiated on 5/27/2024, had an intervention to turn and position the resident every two hours and when needed. The [NAME] (nursing care instructions for Certified Nursing Assistants) documented the resident has a pressure ulcer to the sacrum and to turn and position the resident every two hours and when needed. A wound physician consultation dated 5/29/2024 documented the resident had a sacrum Stage 4 pressure ulcer measuring 10.5 centimeters in length, 12.5 centimeters in width, and 4 centimeters in depth. The bone was palpable. Negative pressure wound therapy (wound vacuum) was started. A physician's order dated 6/28/2024 documented to cleanse the sacral ulcer with normal saline, pat dry, and then apply the wound vacuum at 125 millimeters of mercury, every Tuesday, Thursday, and Saturday. A wound physician consult dated 7/16/2024 documented that offloading the sacral area was difficult due to Parkinson's Disease. The resident was always on their back when the wound physician saw the resident. The Physician documented that the sacrum pressure ulcer was a Stage 4 ulcer, measuring 10 centimeters in length, 8 centimeters in width, and 2.5 centimeters in depth. During an observation on 8/6/2024 at 7:50 AM, Resident #5 was observed in bed on their back. During an observation on 8/6/2024 at 9:27 AM Resident #5 was observed in bed on their back. During an observation on 8/6/2024 at 10:45 AM Resident #5 was observed in bed on their back. During an observation on 8/6/2024 at 11:21 AM Resident #5 was observed in bed on their back. A review of the Certified Nursing Assistant Accountability for 8/6/2024 for the 7:00 AM- 3:00 PM shift revealed that Certified Nursing Assistant #2 documented they had turned and positioned the resident every 2 hours. There was no documentation in the accountability record indicating which side the resident was turned. Certified Nursing Assistant #2, the assigned Certified Nursing Assistant for Resident #5, was interviewed on 8/6/2024 at 11:29 AM. Certified Nursing Assistant #2 stated Resident #5 did not like to turn on their side. Certified Nursing Assistant #2 lifted the resident's sheet to show two pillows, one on the resident's left side torso and one on the resident's right side torso, and stated these pillows provided offloading. Upon observation, these pillows were keeping the resident positioned on their back and the resident's sacrum was directly placed on the bed, not offloaded. Wound Care Registered Nurse #1 was interviewed on 8/6/2024 at 11:46 AM and stated the resident was on a turning and positioning schedule and should be re-positioned every two hours on their left side, right side, and back. Wound Care Registered Nurse #1 stated there are times when the resident will be on their back but should not be on their back all the time. On 8/7/2024 at 9:03 AM Resident #5 was observed in bed. The resident was positioned on their left side with the sacrum completely offloaded from the mattress. Wound Care Registered Nurse #1 was re-interviewed on 8/7/2024 at 9:07 AM and stated they spoke to Certified Nursing Assistant #2 and educated them about turning and positioning. Wound Care Registered Nurse #1 stated the resident needs to spend time off their back for optimal wound healing. Wound Care Registered Nurse #1 stated if the resident does not want to be on their side, or is uncomfortable, we have to keep encouraging and turning and positioning while keeping them as comfortable as possible, so the resident is not flat on their back. On 8/7/2024 at 9:47 AM Resident #5 was interviewed. Resident #5 stated they do not mind being on their side and staying on their back sometimes bothers them. The Director of Nursing Services was interviewed on 8/7/2024 at 3:11 PM and stated the staff must offload the affected areas using pillows to help the wound heal and determine how to make the residents comfortable if they are expressing discomfort. The Director of Nursing Services stated certified nursing assistants needed to be re-educated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00333364) initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease of range of motion. This was identified for one (Resident #132) of three residents reviewed for positioning and mobility. Specifically, Resident #132 had a physician's order for right hand Therapy Carrot (a nonsurgical device that helps position contracted hands) to be worn at all times. On 8/1/2024 and 8/2/2024 the resident was observed not wearing the right-hand Therapy Carrot as ordered by the Physician. The finding is: The facility's policy for Application and Management of Splint/Brace/Immobilizer dated 11/2017 documented the nursing staff is responsible for following the wearing schedule for the device and must complete a skin inspection every shift at a minimum unless ordered otherwise. Resident #132 was admitted with diagnoses that included Coronary Artery Disease, Peripheral Vascular Disease, and Non-Alzheimer's Dementia. A Quarterly Minimum Data Set assessment dated [DATE] documented the Brief Interview for Mental Status score was 00, which indicated the resident had severely impaired cognition. The resident had no behavioral symptoms, had impairment on both sides of upper and lower extremities, and was totally dependent on staff for all aspects of Activities of Daily Living. A physician's note dated 3/14/2024 documented Splint/Brace: Therapy Carrot to be applied to the right hand at all times by the Certified Nursing Assistant. The nurse is to spot-check for the placement of the Therapy Carrot every shift. A Comprehensive Care Plan for Activities of Daily Living dated 9/13/2023 and revised on 6/7/2024 documented interventions that included right-hand Therapy Carrot at all times to be applied by the Certified Nursing Assistant. Remove every shift for skin checks and hygiene. The [NAME] (nursing care instructions for the Certified Nursing Assistants) from 7/1/2024 to 8/10/2024 documented Therapy Carrot to be applied to the right hand at all times by the Certified Nursing Assistant. The nurse is to spot-check for the placement of a Therapy Carrot every shift. Resident #132 was observed out of bed to a Geri-Lounge chair on 8/1/2024 at 3:09 PM. The resident's right hand was observed in a closed-fisted position and the resident was not able to open their right hand on command. The Therapy Carrot was observed not in the resident hand but was resting on top of the resident's torso. A subsequent observation was made on 8/2/2024 at 2:54 PM. The Therapy Carrot was observed on the resident's chest and not appropriately positioned in the resident's right hand. Licensed Practical Nurse #5, who was assigned to Resident #132, was interviewed on 8/2/2024 at 3:04 PM. Licensed Practical Nurse #5 stated that the Therapy Carrot is used for the resident to keep the fingernails from pressing into the resident's palm. Licensed Practical Nurse #5 stated that Certified Nursing Assistant #11 was responsible for ensuring the Therapy Carrot was appropriately placed in the resident's right hand. During an observation on 8/2/2024 at 3:15 PM, with the Wound Care Registered Nurse (acting Nurse Manager) and the Director of Rehabilitation Services, the resident's right hand Therapy Carrot was observed resting on the resident chest. The palm of the resident's right hand was observed with dark crusty flakes and a musty odor was detected from the resident's right hands. The Director of Rehabilitation Services stated that the Therapy Carrot should be appropriately placed in the resident's palm at all times to prevent contractures. The Director of Rehabilitation Services stated if the Certified Nursing Assistants were having difficulty placing the Therapy Carrot in the resident's hand, they should have reported the concern to the charge nurse or them (Director of Rehabilitation Services). The Wound Care Registered Nurse was interviewed on 8/2/2024 at 3:20 PM and stated that they supervised the unit on 8/1/2024 and 8/2/2024. The Wound Care Registered Nurse stated they were not sure how to properly position the Therapy Carrot and would have to follow up with the Director of Rehabilitation Services to learn to properly position the Therapy Carrot in the resident's right hand. The 7:00 AM - 3:00 PM assigned Certified Nursing Assistant #11 was interviewed on 8/5/2024 at 1:51 PM. Certified Nursing Assistant #11 stated they were assigned to Resident #132 on 8/1/2024 and 8/2/2024. Certified Nursing Assistant #11 stated that the resident should use the Therapy Carrot device in the right hand at all times. Certified Nursing Assistant #11 stated that they were having difficulty opening the resident's right hand to insert the Therapy Carrot but did not report it to the charge nurse. The Director of Nursing Services was interviewed on 8/8/2024 at 12:59 PM and stated that after caring for the resident the Certified Nursing Assistant was responsible for ensuring that the Therapy Carrot was appropriately positioned in the resident's right hand at all times and that the nurses should monitor to ensure that the device was in place. 10 NYCRR 415.12(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey initiated on 8/01/2024 and completed on 8/08/2024, the facility did not ensure that each resident's receives adequate supervision and the resident's environment remained as free of accident hazards as possible to prevent accidents. This was identified for one (Resident #28) of seven residents reviewed for accidents. Specifically, Resident #28 was observed on 8/1/2024 with an Albuterol inhaler on their overbed table. There was no staff present in the vicinity. Additionally, Resident #28 did not have a physician's order for the use of the Albuterol inhaler or an order to self-administer medications. The finding is: Resident #28 was admitted to the facility with diagnoses including Multiple Sclerosis, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated that Resident #28 had intact cognition. The Quarterly Minimum Data Set documented that Resident #28 received antibiotic and antidepressant medications. A Comprehensive Care Plan (CCP) dated 2/26/2024 titled Chronic Obstructive Pulmonary Disease (COPD) documented interventions including medications as per physician's order and to monitor signs and symptoms of acute respiratory distress. The physician's order dated 2/2/2024 documented to administer Ipratropium-Albuterol Inhalation Solution 0.5-2.5 Milligrams/3 Milliliters (Ipratropium-Albuterol) 3 Milliliters inhale orally via nebulizer every 6 hours as needed for Chronic Obstructive Pulmonary Disease. During an observation on 8/1/2024 at 9:45 AM, Resident #28 was sitting in their bed with an overbed table in front of them. An Albuterol inhaler (medicine in an inhaler form used to treat Asthma) was observed on the overbed table. The Albuterol inhaler label was faded and hard to read. There was no staff member present in Resident #28's room at the time of the observation. A review of the resident's medical record indicated there was no physician's order for the Albuterol inhaler use prior to 8/1/2024 at 10:24 AM. Resident #28 was interviewed on 8/1/2024 at 10:00 AM and stated they got the Albuterol inhaler from home and have been using the Albuterol inhaler for a long time for their Asthma. Resident #28 stated they had the inhaler since they were admitted to the facility and were using the inhaler at least three times a day. A review of the physician's orders revealed Resident #28 did not have an order to self-administer their medications. A review of the electronic medical record revealed that Resident #28 was not assessed to self-administer their medications. Registered Nurse #12, the medication nurse, was interviewed on 8/1/2024 at 11:26 AM and stated they did not see any inhalers on the resident's over-bed table or the nightstand during the morning medication administration for Resident #28. Registered Nurse #12 stated that Resident #28 should not have medications stored in their room. The Assistant Director of Nursing Services was interviewed on 8/1/2024 at 11:45 AM and stated they did not know why Resident #28 had the Albuterol inhaler in their room. The Assistant Director of Nursing Services stated unless Resident #28 had a physician's order and was assessed by the facility to safely self-administer their medications, they should not have any medications left in their room. The Director of Nursing Services was interviewed on 8/7/2024 at 11:15 AM and stated that medications should not be left unattended in the resident's room. The Director of Nursing Services stated that Resident #28 had hoarding issues and the staff must have overlooked the Albuterol inhaler that Resident #28 was using. 10 NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 8/01/2024, and completed on 8/08/2024 the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice. This was identified for two (Resident #42 and Resident #71) of five residents reviewed for Respiratory Care. Specifically, 1) Resident #42 had a physician's order to continuously receive oxygen therapy at 2 liters per minute. The resident was observed receiving an inaccurate amount of oxygen on 8/1/2024 and 8/7/2024. 2) Resident #71 had a physician's order for oxygen to be administered at 2 liters per minute via a nasal cannula. The resident was observed receiving an inaccurate amount of oxygen on 8/1/2024 at 10:30 AM and 2:34 PM. This is a repeat deficiency. The findings are: The facility's policy titled Oxygen Therapy dated 6/2017, documented the physician's order specifies the concentration, type, and duration of the (oxygen) therapy. The nursing staff will set up, check, and supervise all treatments. 1) Resident #42 was admitted with diagnoses including Parkinson's Disease with Dyskinesia (involuntary neurological movements), Osteoporosis, and Type Two Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 15, which indicated the resident was cognitively intact. The Minimum Data Set documented Resident #42 used oxygen therapy during the look-back period. The Comprehensive Care Plan for Oxygen Therapy dated 7/11/2024 documented interventions that included administering oxygen therapy as ordered and checking the oxygen tank every shift. The current physician's orders documented to administer oxygen at 2 liters per minute via a nasal cannula continuously for shortness of breath. During an observation on 8/01/2024 at 11:11 AM, Resident #42 was observed in their bed. The resident was receiving 4 liters of oxygen per minute via a nasal cannula from an oxygen concentrator. Resident #42 was interviewed on 8/01/2024 at 11:11 AM and stated they used oxygen therapy daily. Resident #42 stated they did not change the oxygen flow rate setting because they were not able to access the oxygen concentrator. Resident #42 was observed in bed on 8/07/2024 at 10:18 AM. The resident was receiving 3 liters of oxygen a nasal cannula, from an oxygen concentrator. Registered Nurse #13 was interviewed on 8/07/2024 at 10:19 AM and stated Resident #42 should receive oxygen at 2 liters per minute as per their physician's orders. Registered Nurse #13 stated they did not change the resident's oxygen flow rate and did not feel that Resident #42 was able to change the oxygen settings either. Registered Nurse #7, the unit Charge Nurse, was interviewed on 8/07/2024 at 10:35 AM and stated nurses are expected to follow the physician's orders. If a resident needs an increased oxygen flow rate, the Physician should be notified. The Director of Nursing Services was interviewed on 8/07/2024 at 10:47 AM and stated they were unsure why the oxygen flow rate for Resident #42 was set at 3 liters today (8/7/2024) and 4 liters on 8/01/2024. If the resident requires more oxygen, nursing staff should call the Physician and follow the physician's orders. 2) Resident #71 was admitted with diagnoses that included Cirrhosis of the Liver and Ascites (a condition in which fluid collects in spaces within your abdomen). A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 14, which indicated the resident had intact cognition. The resident had no behavioral problems and did not reject care. A Comprehensive Care Plan dated 7/31/2024 documented the resident received oxygen therapy related to shortness of breath. Interventions included to administer medications as ordered by the Physician, monitor for signs and symptoms of respiratory distress, and report to the Physician as needed. A physician's order dated 7/31/2024 documented to administer oxygen at 2 liters per minute continuously. During an observation on 8/1/2024 at 10:30 AM, Resident #71 was observed in bed asleep. The resident was receiving oxygen at 3 liters per minute via a nasal cannula from the oxygen concentrator. A subsequent observation was made on 8/1/2024 at 2:34 PM. The resident was in bed asleep and was receiving oxygen at 3 liters per minute via a nasal cannula. Licensed Practical Nurse #1 was interviewed on 8/1/2024 at 2:40 PM and stated they were responsible for checking that the oxygen was delivered to the resident as per the physician's orders. Licensed Practical Nurse #1 stated they should have checked the flow rate at the start of the shift to ensure Resident #71 was receiving the prescribed 2 liters of oxygen. The Director of Nursing Services was interviewed on 8/8/2024 at 1:05 PM and stated that the nurses were responsible for checking the oxygen flow rate to ensure the residents were receiving the correct oxygen flow rate as ordered by the Physician. The Director of Nursing Services stated the nurses should check that all residents are receiving the correct oxygen amount at the beginning of the shift and periodically throughout the shift. 10 NYCRR 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024 the facility did not ensure that outside professional services were furnished timely. This was identified for one (Resident #222) of one resident reviewed for Dignity and for one (Resident #150) of five residents reviewed for Unnecessary Medications. Specifically, 1) Resident #222 was readmitted from the hospital on 7/13/2024 with a diagnosis of Traumatic Subarachnoid Hematoma (brain bleed). The hospital discharging physician recommended a follow-up with a Neurosurgeon within a week. The recommended consult was not completed as of 8/7/2024 when it was brought to the facility's attention by the Surveyor. 2) Resident #150 was admitted to the facility in November 2023. A physician's order dated 11/14/2023 documented that the resident was to be seen by the Psychiatrist for the Initial Evaluation. The Psychiatry consult/evaluation was not completed until 8/6/2024 when it was brought to the facility's attention by the State Surveyor. The findings are: The facility's policy titled Medical and Dental Consults last revised on 5/2023, documented that the facility will arrange services of qualified professional personnel to render specific medical services. An order for a consultation shall be placed in the electronic medical record (EMR) with the reason for consultation. For new admissions or readmissions, the Registered Nurse Supervisor will reconcile all hospital-scheduled outpatient appointments with the resident's attending physician and log in to the Hospital Consult Reconciliation Form. The attending physician will determine the need for further follow-up (agree, disagree, or use an in-house consultant). The Consult Coordinator will schedule the outpatient consults and arrange for transportation and escort if indicated. 1) Resident #222 was admitted with diagnoses including Traumatic Subarachnoid Hemorrhage (brain bleed), Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #222 had intact cognition. The Minimum Data Set (MDS) assessment documented Resident #222 received anticoagulant (blood thinner) medications. A Comprehensive Care Plan (CCP) titled, Anticoagulant Therapy dated 7/18/2024, documented the resident was at risk for bleeding, The interventions included reinforcing safety measures to prevent injury/bleeding and to administer medications ordered by the Physician. A review of the hospital Discharge Instructions dated 7/13/2024 documented that Resident #222 needed a follow-up consultation with a Neurosurgeon in one week due to a diagnosis of Traumatic Subarachnoid Hematoma (brain bleed). A review of the electronic medical record indicated no physician's order for a Neurosurgery consultation. A review of the electronic medical record revealed Resident #222 did not have a follow-up appointment or consult with the Neurosurgeon as recommended by the hospital. Licensed Practical Nurse #4 was interviewed on 8/5/2024 at 12:02 PM and stated they were one of the nurses who assisted in readmitting Resident #222 on 7/13/2024. Licensed Practical Nurse #4 stated they (Licensed Practical Nurse #4) only reviewed the medication list on the discharge summary from the hospital. Licensed Practical Nurse #4 stated it was Registered Nurse Supervisor #10 who reviewed the consult instructions for Resident #222. The Unit Clerk was interviewed on 8/5/2024 at 2:06 PM and stated they made appointments for any consultations needed for the residents after they received the consultation form from the nurses. The Unit Clerk stated they did not receive a consultation form to schedule a follow-up appointment with the Neurosurgeon for Resident #222. Registered Nurse #10, the nursing supervisor, was interviewed on 8/5/2024 at 2:21 PM and stated they admitted Resident #222 from the hospital on 7/13/2024; however, they did not see any recommendations from the hospital for a follow-up consult with a Neurosurgeon. Registered Nurse #10 stated they must have missed the recommendations documented on the discharge instructions from the hospital. Physician #2 was interviewed on 8/6/2024 at 10:30 AM and stated a Neurosurgery consult should have been completed for Resident #22 as per the hospital's recommendations. Physician #2 stated the facility was responsible for arranging for the consultation. The Director of Nursing Services was interviewed on 8/7/2024 at 11:30 AM and stated the nurses should have thoroughly checked the hospital discharge instructions for Resident #222 and ensured that the consultation form was completed and provided to the Unit Clerk to set up an appointment with the Neurologist as per the hospital discharge summary recommendations. 2) Resident #150 was admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease, Hypertension, and Major Depressive Disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognitive skills for daily decision-making. The Minimum Data Set assessment documented that the resident had been receiving an antidepressant medication for the last 7 days. The Physician's Order dated 11/11/2023, obtained by Licensed Practical Nurse #1, documented for the resident to receive Remeron (an antidepressant medication) 7.5 milligrams tablet- give 1 tablet by mouth at bedtime for Major Depressive Disorder. (This order was discontinued on 12/4/2023.) A review of the Psychiatry Consultation Form dated 11/11/2023, initiated by Licensed Practical Nurse #1, revealed that the Consultation Form was never completed by the Psychiatrist. The Physician's Order dated 11/14/2023, obtained by Registered Nurse #1, documented to obtain a Psychiatry Consult Initial Evaluation and follow-up. The Physician's Order dated 12/15/2023 last revised on 3/22/2024 documented to administer Mirtazapine (Remeron) 7.5 milligram - give one tablet by mouth at bedtime for Depression. A review of the Psychiatry Consultation Form dated 7/25/2024, initiated by the Registered Nurse Consultant (Registered Nurse #2), revealed that the Consultation Form was never completed by the Psychiatrist. Registered Nurse #1 was interviewed on 8/6/2024 at 3:05 PM and stated after they (Registered Nurse #1) receive a Physician's Order for a Psychiatric Consultation, they are supposed to initiate a Psychiatry Consultation Form in the resident's Electronic Medical Record, print the resident's face sheet, and place the resident's face sheet in the Psychiatrist's folder which is kept at the reception desk in the lobby of the facility. Registered Nurse #1 stated when the Psychiatrist comes to the facility, they (Psychiatrist) take the face sheets of the residents needing Psychiatric Consultations out of the folder and go see them. Registered Nurse #1 stated that the Psychiatrist comes weekly to the facility, and they (Registered Nurse #1) did not know why Resident #150 was never seen by the Psychiatrist. Registered Nurse #1 stated they may not have opened another Psychiatry Consultation Form after obtaining the Physician's Order on 11/14/2023 because Licensed Practical Nurse #1 had already initiated one on 11/11/2023. Licensed Practical Nurse #1 was interviewed on 8/7/2024 at 9:35 AM and stated that when a resident is admitted to the facility on psychiatric medications, the Physician automatically orders a Psychiatric consultation request. Licensed Practical Nurse #1 stated that Resident #150's Physician must have given a verbal order for the resident to have a Psychiatric Consult, but they (Licensed Practical Nurse #1) must have forgotten to enter the Physician's Order into the computer on 11/11/2023 when the resident was admitted to the facility. The Psychiatrist was interviewed on 8/7/2024 at 10:45 AM and stated they usually do not see a newly admitted resident unless ordered to by the Physician. The Psychiatrist stated that either a Nurse calls them (Psychiatrist) or the resident's face sheet is left at the reception desk for them (Psychiatrist) when a resident needs a Psychiatric Consultation. The Psychiatrist stated that once they see a resident, they (Psychiatrist) will keep track of when the resident needs to be seen for a follow-up. The Psychiatrist stated they would not know when a Psychiatric Consultation Form was initiated unless the resident's face sheet was placed in their folder at the reception desk. The Psychiatrist stated they were never notified to see the resident for their initial Psychiatric Consultation. The Director of Nursing Services was interviewed on 8/7/2024 at 10:50 AM and acknowledged that Resident #15's initial Psychiatric Consultation was never done. The Director of Nursing Services stated that a Psychiatry Consultation should be completed as per the physician's orders. 10 NYCRR 415.26(e)(1)(i-iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure medical records for each resident were complete and accurately documented. This was identified for one (Resident #90) of three residents reviewed for Choices. Specifically, Resident #90 had a physician's order for a finger stick blood glucose monitoring every morning. The Medication Administration Record did not include the finger stick blood glucose level results and the Vital Signs record had inconsistent documentation of the finger stick blood glucose level results. The finding is: The policy titled Blood Glucose Monitoring dated 7/2013 documented findings (of finger stick blood glucose levels) shall be documented in the medical chart. Resident #90 was admitted with diagnoses including Spinal Stenosis, Dementia, and Type two Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 12, which indicated the resident had moderately impaired cognition. The Comprehensive Care Plan for Diabetes Mellitus dated 5/20/2021 and last revised on 5/17/2024 documented interventions including monitoring finger stick blood glucose as ordered by the Physician. A physician's order dated 7/14/2024 documented to obtain finger stick blood glucose level every morning one time a day. The Vital Sign documentation record for July and August 2024 was reviewed. The Vital Sign record lacked documented evidence of finger stick blood glucose results on 7/15/2024, 7/19/2024, 7/20/2024, 7/21/2024, 7/23/2024, 7/24/2024, 7/25/2024, 7/26/2024, 7/27/2024, 7/28/2024, 7/30/2024, 7/31/2024, 8/01/2024, and 8/02/2024. The Medication Administration Record for July 2024 and August 2024 did not document morning finger stick glucose levels. The Assistant Director of Nursing Services #1, the Nurse Educator, was interviewed on 8/05/2024 at 10:43 AM and stated there should be a section on the Medication Administration Record to document the morning finger stick glucose levels. The Assistant Director of Nursing Services #1 stated Resident #90's Medication Administration Record did not include a space to document the finger stick blood glucose level and should have. The Director of Nursing Services was interviewed on 8/07/2024 at 10:49 AM and stated that the nurses are responsible for the resident's care and for documenting the finger stick blood glucose level in the Medication Administration Record to monitor the blood glucose level trends. 10 NYCRR 415.22(a)(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 8/1/2024 and completed on 8/8/2024 the facility did not ensure that an infection prevention and control program designed to help prevent the development and transmission of infections was maintained. This was identified for one (Resident #6) of five residents reviewed for Pressure Ulcers. Specifically, during a dressing change observation of Resident #6's sacral wound, Registered Nurse #15 did not change their gloves and did not wash their hands after cleansing the sacral wound and before applying the treatment. The finding is: The facility's Hand Washing Protocol dated 11/2017 documented to perform hand hygiene before and after each resident/patient contact. The facility's Clean Dressing Change policy and procedure dated 5/2024 documented to cleanse the wound while maintaining an aseptic technique, pat dry with a clean gauze, and then perform hand hygiene. [NAME] (put on) clean gloves before applying a dressing as ordered. Resident #6 was admitted with diagnoses that included Non-Alzheimer's Dementia, Coronary Artery Disease, and Diabetes Mellitus. A Significant Change Minimum Data Set assessment dated [DATE] documented the resident had short and long term memory problems. The resident had impairment on both lower extremities and was dependent on staff for bed mobility and transfer. The resident had one unhealed Stage III Pressure Ulcer (a full-thickness loss of skin that extends to the subcutaneous tissue but does not cross the fascia beneath it) that was not present on admission. A Comprehensive Care Plan for Pressure Ulcer dated 1/11/2024 and revised on 6/14/2024 documented that the resident has a Pressure Ulcer to the sacrum. Interventions included the use of an air mattress, turning, and positioning the resident every two hours and as needed. A Physician's order dated 7/19/2024 documented to apply Santyl Collagenase (an enzymatic debriding agent) Ointment 250 Unit/Gram. Clean the wound first by using Normal Saline. Apply Sting Free Skin Prep to peri-wound (surrounding skin) and allow to dry. Apply Santyl Collagenase ointment to the wound bed, then cover with bordered foam every day shift for diagnoses of Pressure Ulcer/Injury. A wound care observation was conducted on 8/8/2024 at 8:52 AM, with Registered Nurse #15. The Assistant Director of Nursing Services #1, the Nurse Educator, was also present in the room. Registered Nurse #15 washed their hand and donned (put on) clean gloves. Registered Nurse #15 cleansed the wound two times from the center of the wound to the outer area of the wound, using saline-soaked gauze. After cleansing the wound Registered Nurse #15 applied skin prep to the peri-wound area, then applied the Santyl Collagenase ointment to the wound bed without changing their gloves and washing their hands. Registered Nurse #15 was interviewed immediately after the observation on 8/8/2024 at 9:20 AM and stated they knew they were supposed to change their gloves and wash their hands after they cleaned the wound bed, and before they applied the treatment to the wound. Registered Nurse #15 stated they should have changed their gloves after cleansing the wound and applying the treatment. The Assistant Director of Nursing Services #1, the Nurse Educator, who was present during the wound care observation, was interviewed on 8/8/2024 at 9:28 AM and stated they educate nurses to change gloves and wash their hands after cleansing a wound. The Assistant Director of Nursing Services #1 stated after Registered Nurse #15 cleansed the wound they should have changed their gloves and performed hand hygiene before applying the treatment. The Director of Nursing Services was interviewed on 8/8/2024 at 10:48 AM and stated after Registered Nurse #15 cleansed the resident's sacral wound, they should have changed gloves, performed hand hygiene, and applied clean gloves before the wound treatment was applied. 10 NYCRR 415.19(a)(1-3) (b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the recertification Survey and Abbreviated Survey (NY 00332930) initiated on 8/01/2024 and completed on 8/08/2024, the facility did not provide a safe, functional, sanitary, and comfortable environment. This was identified for two (Resident #131, Resident #5) of three residents reviewed for Environment. Specifically, the toilets that were mounted to the walls in Resident #131 and Resident #5's bathroom did not have appropriate support and reinforcement. The toilets were observed with wooden blocks underneath the toilet to provide support and reinforcement. The findings are: The facility policy titled Room and Unit Maintenance dated 9/2021 documented to maintain rooms and units within the facility in a manner that provides a safe, homelike environment. -Resident #131 was admitted with diagnoses of Morbid Obesity, Type Two Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 15, indicating the resident had intact cognition. Resident #131 had no impairment in functional ability for toileting needs and utilized a wheelchair or walker for mobility. The Comprehensive Care Plan for Activities of Daily Living dated 7/25/2024 documented the resident required partial/moderate assistance with toileting. On 8/06/2024 at 11:15 AM Resident #131 was observed in a wheelchair coming out of their room. The resident's room had a bathroom with a toilet mounted to the wall. The toilet was supported by wooden blocks. Resident #131 was interviewed on 8/01/2024 at 10:50 AM and stated the wooden blocks holding up the toilet bowl had been there for months. -Resident #5 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease, Type Two Diabetes Mellitus, and Schizophrenia. The Quarterly Minimum Data Set assessment, dated 7/10/2024, documented the resident had a Brief Interview for Mental Status score of 14, indicating the resident had intact cognition. Resident #5 was dependent and required 2 persons' assistance for toileting needs. During an observation on 8/01/2024 at 11:04 AM, Resident #5 was observed in their bed resting with the television on. The resident's room had a bathroom with a toilet mounted to the wall. The toilet was supported by wooden blocks. Resident #5 was interviewed on 8/01/2024 at 11:04 AM and was unaware of the wooden blocks underneath the toilet. Housekeeper #1 was interviewed on 8/06/2024 at 11:29 AM and stated they did not know why Resident #131, and Resident #5's bathrooms have wooden blocks supporting the toilet. Housekeeper #1 stated they cleaned around the wooden blocks but did not move the blocks. The Director of Facility Management was interviewed on 8/07/2024 at 12:01 PM and stated the wooden blocks were placed under the toilet to provide support, due to the resident's weight. The Director of Facility Management stated they had ordered a bracket (wall-mounted toilet support) for properly supporting the toilet, but they were unsure why the brackets were not yet installed. The Director of Facility Management further stated that using the wooden blocks to support a toilet was unsafe for the residents, posed infection control issues, and was not a home-like environment. The Administrator was interviewed on 8/07/2024 at 2:38 PM and stated the wooden blocks were used to support the toilets. The Administrator stated as far as they knew, all wooden blocks were removed after the toilets were repaired. The Administrator stated using the wooden blocks in the resident's bathroom could pose an infection control issue, was unsafe for the residents, and was not a home-like environment. 10 NYCRR 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00292215) initiated on 12/12/2022 and completed on 12/16/2022, the facility did not develop and implement a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This was identified for one (Resident #399) of one resident reviewed for Tube Feeding. Specifically, Resident #399 was admitted to the facility on [DATE] and the baseline care plan developed for the Gastrostomy (G) tube did not include use of an abdominal binder. A baseline care plan for the use of the abdominal binder was not developed until 3/3/2022. The finding is: The policy titled: Baseline Care Plan, effective date 11/2016, documented that the facility will develop and implement a baseline care plan within 48 hours of a resident's admission, which include, but is not limited to, initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and Pre-admission Screening and Resident Review (PASARR) recommendation if applicable. The baseline care plan for each resident includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Resident #399 has diagnoses which include Profound Intellectual Disabilities and status post Peg (percutaneous endoscopic gastrostomy[G]) tube Placement on 2/17/2022. The 5 Day Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognitive skills for daily decision making with long and short-term memory problems. The MDS documented the resident utilized a feeding tube. The admission Progress Note dated 2/28/2022 documented the resident arrived to the facility at 3:30 PM. The resident required an abdominal binder in place for protection of their G-tube. The Progress Note dated 3/1/2022 at 3:34 AM documented that the resident was observed with their G-tube dislodged from their abdomen. The resident was transferred to hospital. The Progress Note dated 3/1/2022 at 9:55 PM documented that the resident returned from the hospital with replacement of their G-Tube and an abdominal binder was in place. The Progress Note dated 3/2/2022 at 12:33 AM documented that the resident was observed with their G-Tube dislodged. The resident was sent to the hospital for replacement of the G-tube. The Progress Note dated 3/2/2022 at 11:41 AM documented that as per the hospital Emergency Department (ED), the resident was being scheduled for a surgical repair of the G-tube replacement. The Registered Nurse (RN) Supervisor Progress Note dated 3/2/2022 at 7:28 PM documented that the resident returned to the facility at approximately 5:00 PM status post G-tube replacement. An abdominal binder was in place for protection. The RN Supervisor Progress Note dated 3/3/2022 at 7:28 PM documented that the resident was noted to pull out their G-tube. The abdominal binder was in place at the time. The Physician was called, made aware, and ordered Resident #399 to be transferred to the hospital. The Comprehensive Care Plan (CCP) titled The resident uses physical restraints Abdominal binder to prevent from pulling PEG Tube was initiated on 3/3/2022. The Director of Nursing Services (DNS) was interviewed on 12/16/2022 at 12:00 PM and stated that they (DNS) could not see who initiated the CCP for the resident's abdominal binder and that an error was made when the abdominal binder was referred to as a restraint because the resident was still able to access the binder and remove it. The DNS was interviewed again on 12/16/2022 at 2:30 PM and stated that the CCP for the abdominal binder should have been developed within 48 hours of the resident's admission to the facility since the resident was admitted with the abdominal binder. 10NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 12/12/2022 and completed on 12/16/2022, the facility did not ensure that a comprehensive person-centered care plan was implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was identified for one (Resident #105) of three residents reviewed for Choices. Specifically, Resident #105 had documented Physician's Orders on 6/6/2022, 8/16/2022, and 10/22/2022 to have a bilateral breast mammogram which was never completed. The finding is: The facility's policy titled: Laboratory, Radiology and Other Diagnostic Services, last revised in August 2018, documented to provide, or obtain radiology and other diagnostic services only when ordered by a medical provider. Resident #105 has diagnoses which include Peripheral Vascular Disease and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 10 which indicated that the resident had moderately impaired cognitive skills for daily decision making. The resident was totally dependent on two persons for transfers. The Progress Note dated 6/6/2022, written by Registered Nurse (RN) #2, documented the resident was complaining of bilateral (B/L) breast discomfort. The Nurse Practitioner (NP) #1 was made aware, and an order was received for a mammogram. The Physician's Order dated 6/6/2022 documented for the resident to receive a mammogram. The Physician Progress Note dated 6/7/2022, written by NP #1, documented the resident was seen for B/L breast pain. The assessment indicated non-tender breasts, no palpable lump, and no discharge. The resident requested a breast mammogram. Nursing (staff) was made aware and an order was placed. The Health Status Progress Note dated 8/15/2022, written by Licensed Practical Nurse (LPN) #3, documented the resident complained of sore and tender bilateral breasts. NP #1 was made aware and ordered a mammogram for the resident and a message was left for the Nursing Secretary. The Physician's Order dated 8/16/2022 documented for the resident to receive a mammogram due to complaints of B/L breast pain. The Health Status Progress Note dated 10/22/2022, written by LPN #3, documented the resident complained of B/L breast pain and was requesting a mammogram. NP #1 was made aware and agreed for the resident to have mammogram and a communication note was sent to the Nursing Secretary (NS) to make an appointment. The Physician's Order dated 10/22/2022 documented for the resident to receive a mammogram as per the resident's request. The Physician Progress Note dated 10/27/2022 documented the resident was seen for a follow-up for breast pain. No palpable mass, no discharge, no palpable adenopathy (swelling of the glands). Mammogram had been ordered in the past; however, nursing unable to find facility to accommodate the resident. Breast ultrasound will be ordered. The Physician's Order dated 10/27/2022 documented for the resident to receive a B/L breast ultrasound due to breast pain and to rule out a mass. The Health Status Progress Note dated 10/30/2022 documented that the bilateral breast ultrasound was still pending. The Health Status Progress Note dated 11/1/2022 documented that the bilateral breast ultrasound was rendered today with results pending. The Health Status Progress Note dated 11/2/2022 documented that the resident's bilateral breast ultrasound results were negative. The Nursing Secretary (NS) was interviewed on 12/14/2022 at 10:30 AM and stated that they (NS) got the request several times for the resident to have a mammogram and several times they (NS) tried to work on getting the resident an appointment. The NS stated that the hospital where the resident had mammograms in the past could not accommodate the resident now because the resident was in a lounge chair in a lying position and was unable to sit safely in a wheelchair. The NS stated that every time they called the hospital to set up an appointment for Resident #105, they (NS) were told that the hospital staff would get back to them (NS). The NS stated that finally in November 2022, the resident got an ultrasound by the facility's radiology company because the hospital could not accommodate the resident's mammogram. The NS stated that they (NS) had spoken to a few Nurses in the facility about not being able to get the mammogram done for Resident #105 but could not remember who they (NS) had spoken to. LPN #3 was interviewed on 12/14/2022 at 10:45 AM and stated that they (LPN #3) float (work) on different units in the facility. LPN #3 stated that they put the order in for the resident to receive a mammogram in August and when they (LPN #3) came back to the resident's unit in October, they (LPN #3) found out that the mammogram was never done. Resident #105 brought it to their (LPN #3) attention that the mammogram was never done, and that they (Resident #105) were still experiencing some discomfort in both breasts. LPN #3 stated that they (LPN #3) looked into the resident's medical record and saw that the mammogram was not done and then got another order for a mammogram and sent another communication to the NS. The Director of Nursing Services (DNS) was interviewed on 12/14/2022 at 11:00 AM and stated that the NP was informed that multiple attempts were made to get the resident a mammogram appointment. The DNS stated that the resident could not be accommodated on a stretcher. The DNS stated that normally a mammogram appointment would be gotten as soon as possible; however, they (DNS) did not know why it had taken almost 5 months to have the diagnostic testing completed related the resident's complaint of bilateral breast pain. The NS was interviewed again on 12/14/2022 at 11:05 AM in the presence of the DNS and stated that they (NS) had found in their (NS) scheduling book that the resident had an appointment scheduled on 9/6/2022 to go to the hospital for the mammogram and it was at that time the ambulette company told them (NS) that they could not accommodate the resident because the resident was lying down in a lounge chair. The NS stated that when they (NS) called to cancel the appointment in the hospital, the hospital staff said they could not accommodate the resident's lounge chair either. The resident's Physician (#1) was interviewed on 12/14/22 at 1:10 PM and stated that they (Physician #1) they would have expected that when the first order for the mammogram was given, the mammogram should have been done. 10NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility policy entitled, Laboratory, Radiology and other diagnostic services, dated 8/2018 documented that the facility will provide radiology services only when ordered by a medical provider. The licensed nurse must ensure to pick up orders made by the Physician/Physician extenders. A stat order must be transcribed as soon as the nurse is made aware of the request. The licensed nurse will ensure to properly fill out the requisition form and must call the appropriate service provider immediately. A follow up call must be made by the licensed nurse to the appropriate service provider to ensure that stat order was received and acknowledged. The licensed nurse must document in the medical record any communication made with the appropriate provider. Resident #186 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease, Respiratory Failure and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #186 had a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. A care plan entitled, Resident is at high risk for pneumonia related to age and weakened immune system, dated 8/10/2022 documented interventions to monitor for any signs and symptoms of Pneumonia (fever, chills, cough, shortness of breath, fatigue, chest pain). The Nursing Progress Note dated 12/7/2022 documented that Resident #186 had a productive cough and phlegm. The Nurse Practitioner was made aware, and Licensed Practical Nurse (LPN) #1 was awaiting a response. The Physician's Progress Note dated 12/8/2022 at 11:59 AM documented that the Nurse Practitioner (NP) #1 evaluated Resident #186 for complaints of cough and vomiting. Resident #186 was noted with cough, congestion, and bilateral crackles (lung sounds). NP #1 documented that they (NP #1) spoke with nursing and an abdominal x-ray and chest x-ray were ordered. Review of the physician's orders revealed that there were no orders for an abdominal and chest x-ray. The Physician's order dated 12/8/2022 documented Guaifenesin Extended-Release 12-hour 600 milligrams (mg) tablet. Give 1 tablet by mouth every 12 hours for cough for 7 days. The Physician's order dated 12/9/2022 documented Ipratropium-Albuterol solution 0.5-2.5 (3) mg/milliliter (ml). One Application inhale every 6 hours for cough for 7 days. The Radiology Report dated 12/11/2022 documented an abdominal and chest x-ray were completed on 12/11/2022. The impression of the abdominal x-ray was unremarkable. The impression of the chest x-ray noted bilateral infiltrates which were increased from the previous study on 8/11/2022. The Physician's order dated 12/12/2022 documented to administer Amoxicillin-Potassium Clavulanate (Antibiotic) tablet 875-125 mg, give one tablet by mouth every 12 hours for Pneumonia for 7 days. LPN #1, who worked on 12/7/2022 on the 7 AM to 7 PM nursing shift, was interviewed on 12/14/2022 at 2:34 PM. LPN #1 stated that they left a voice message and text for NP #1 to inform the NP about Resident #186's cough and abnormal lung sounds on 12/7/2022 but NP #1 never got back to them (LPN #1). Resident #186 was observed sitting in a recliner chair with a non-productive cough in the dining room on 12/15/2022 at 1:45 PM. LPN #2, who worked on 12/8/2022 on the 7 AM to 7 PM nursing shift was interviewed on 12/15/2022 at 3:00 PM. LPN #2 stated that during the morning report on 12/8/2022, LPN #2 was told that Resident #186 was coughing, and then a voice message was left for NP #1 by LPN #2. LPN #2 stated that they heard Resident #186 coughing and listened to Resident #186's lungs. LPN #2 heard wheezing and crackles. LPN #2 stated that they (LPN #2) did not remember seeing NP #1 on 12/8/2022. NP #1 usually notifies the nurse to enter the orders in the medical record, but LPN #2 did not remember NP #1 telling LPN #2 to write an order for the abdominal and chest x-ray. LPN #2 stated that they (LPN #2) normally review the NP notes, but LPN #2 did not see notes. LPN #2 stated they (LPN #2) forgot to write a nursing note on 12/8/2022. On Monday, 12/12/2022, the night shift Registered Nurse (RN) gave LPN #2 the x-ray results for Resident #186. NP #1 was at the facility on 12/12/2022 and LPN #2 notified NP #1 of the resident's x-ray results around 10 AM. NP #1 was interviewed on 12/16/2022 at 3:28 PM. NP #1 stated that they instructed the nurse on duty to enter the orders for the x-rays on 12/8/2022. NP #1 stated that they were not sure which nurse they spoke to on 12/8/2022. NP #1 stated that they expected the x-ray orders to be entered in the medical record on 12/8/2022 and it was a stat order. NP #1 stated that they did not enter the order themselves. NP #1 told the nurse to enter the x-ray order because the nurse has to call the x-ray company and give the resident's insurance information. NP#1 stated there were x-ray results when they came to the facility on [DATE]. NP #1 was not sure when the x-ray results first became available and when the x-rays were ordered. The x-ray indicated that Resident #186 had Pneumonia and NP#1 started a 7-day treatment of antibiotics on 12/12/2022. LPN #1 was re-interviewed on 12/16/2022 at 4:14 PM. LPN #1 stated that they (LPN #1) did not work again at the facility after 12/7/2022 until 12/11/2022. On 12/11/2022, LPN #1 saw a requisition form for Resident #186's x-ray taped to the nurse's station and noticed that the x-ray was not done. Since the requisition form was a few days old, LPN #1 called the x-ray company to follow up on the status. The x-ray company agreed to come in on 12/11/2022. LPN #1 stated that if they (LPN #1) had received the x-ray order from NP #1, they would have entered the order in Resident #186's medical record and called the x-ray company the same day. LPN #1 further stated they (LPN #1) did not enter the x-ray orders in the medical record. The Director of Nursing Services (DNS) was interviewed on 12/16/2022 at 4:49 PM. The DNS stated that either the Physician or the nurse is expected to enter the radiology orders directly into the Electronic Medical Record. The orders are verbally given by the Physician, or the Physician extenders and staff are expected to enter the orders into the medical record and ensure the orders are followed through on the same shift. The DNS was re-interviewed on 12/16/22 at 5:06 PM. The DNS stated that they reviewed Resident #186's medical record and could not find the Physician's order for an abdominal and chest x-ray. The DNS stated that there should have been an order in Resident #186's medical record. 10NYCRR 415.12 Based on observations, record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00292215) initiated on 12/12/2022 and completed on 12/16/2022, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan that will meet each resident's physical, mental, and psychosocial needs. This was identified for one (Resident #399) of one resident reviewed for Tube Feeding and one (Resident #186) of six residents reviewed for respiratory care. Specifically, 1) Resident #399 was admitted to the facility on [DATE] with a recent insertion of a Peg (percutaneous endoscopic gastrostomy[G]) tube on 2/17/2022 and the use of an abdominal binder. The resident had demonstrated behaviors of manipulating the abdominal binder and pulling their G-tube. The resident's G-tube was dislodged on three occasions: 3/1/2022, 3/2/2022 and 3/3/2022 requiring hospitalization for replacement of the G-tube. The facility did not assess the use of the abdominal binder and did not determine the root cause of the recurrent G-tube dislodgment. Additionally, the facility did not implement measures to prevent the resident from pulling out their G-tube multiple times after the first incident. 2) Resident #186 exhibited a productive cough with phlegm on 12/7/2022. Resident #186 was assessed by the Nurse Practitioner (NP) #1 on 12/8/2022 and documented in their progress note to obtain an abdominal and chest x-ray; however, no Physician Orders were written. The facility did not obtain x-ray services for Resident #186 until four days later on 12/11/2022. The x-ray results dated 12/12/2022 indicated the resident had Pneumonia and subsequently was prescribed antibiotic therapy for Pneumonia five days after the symptoms were first identified. The findings are: Resident #399 has diagnoses which include Profound Intellectual Disabilities and status post Peg Placement on 2/17/2022. The 5 Day Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognitive skills for daily decision making with long and short-term memory problems. The MDS documented the resident utilized a feeding tube. The Nursing admission Progress Note dated 2/28/2022 documented that the resident arrived at 3:30 PM. The resident required an abdominal binder in place for protection of their G (Gastrostomy)-tube. The Physician's Order dated 2/28/2022 documented for the resident to receive Glucerna 1.5 via G Tube/PEG (Peg) and to verify the patency and placement of the tube every evening shift. Review of Physician's Order throughout the resident's stay revealed no Physician Orders for the use of the abdominal binder. The Comprehensive Care Plan (CCP) titled, the resident requires tube feeding related to Dysphagia and history of Aspiration, initiated on 3/1/2022 made no mention of the resident using an abdominal binder. The CCP titled, the resident uses physical restraints Abdominal binder to prevent from pulling the Peg Tube was initiated on 3/3/2022. The Progress Note dated 3/1/2022 at 3:34 AM documented that the resident was observed with their G-tube dislodged from their abdomen. The resident was transferred to hospital. The Progress Note dated 3/1/2022 at 9:55 PM documented that the resident returned from the hospital with replacement of their G-Tube and an abdominal binder was in place. The Progress Note dated 3/2/2022 at 12:33 AM documented that the resident was observed with their G-Tube dislodged. The resident was sent to the hospital for replacement of the G-tube. The Progress Note dated 3/2/2022 at 11:41 AM documented that as per the hospital Emergency Department (ED), the resident was being scheduled for a surgical repair of the G-tube replacement. The Registered Nurse (RN) Supervisor Progress Note dated 3/2/2022 at 7:28 PM, written by Registered Nurse (RN) #1, documented that the resident returned to the facility at approximately 5:00 PM status post G-tube replacement. An abdominal binder was in place for protection. The RN Supervisor Progress Note dated 3/3/2022 at 7:28 PM, written by RN #1, documented that the resident was noted to pull out their G-tube. The abdominal binder was in place at the time. The Physician was called, made aware, and ordered Resident #399 to be transferred to the hospital. The Progress Note dated 3/4/2022 at 3:36 AM documented that the resident was admitted to the hospital with diagnosis of Dislodgement of the G-tube. Certified Nursing Assistant (CNA) #4 was interviewed on 12/16/2022 at 2:00 PM and stated that they (CNA #4) had found the resident's G-tube pulled out on one occasion. CNA #4 stated that they (CNA #4) notified the Nurse when they (CNA #4) found the resident's G-tube out, but they did not remember which Nurse it was. CNA #4 stated that they (CNA #4) would check the resident on hourly rounding. CNA #4 stated that when they (CNA #4) check on a resident they (CNA #4) would lift up the resident's blanket to see if they needed incontinence care. CNA #4 stated that Resident #399 got agitated a lot and would reposition or remove the abdominal binder. CNA #4 stated that the resident would mess around with the abdominal binder in different ways and would get the abdominal binder off. CNA #4 stated that the abdominal binder has velcro which closes in the back and sometimes they (CNA #4) would find the closure in the front of the resident. CNA #4 stated that they made the Nurse aware that the resident was doing this and that the Nurse did not tell them (CNA #4) anything to do to prevent it. CNA #4 stated that they (CNA #4) did not remember which Nurse they (CNA #4) spoke with. RN #1 was interviewed on 12/16/2022 at 9:40 AM and stated that they (RN #1) knew that Resident #399 had a G-tube and they (Resident #399) had removed the G-tube multiple times since their admission to the facility. RN #1 stated sometimes no matter what staff does the resident could still get at their G-tube even if they had an abdominal binder. RN #1 stated that an abdominal binder was the only thing that could be used to prevent the resident from pulling out their G-tube. RN #1 stated that a resident would be put on more frequent monitoring when there was harm done, but the resident's G-tube was replaced without physical harm to the resident. The Director of Nursing Services (DNS) was interviewed on 12/16/2022 at 10:05 AM and stated that all Nurses and Certified Nursing Assistants (CNAs) should have ensured that the resident's abdominal binder was properly in place. The DNS stated that to prevent the resident's G-tube from being pulled out again, either they (DNS) or the Assistant Director of Nursing (ADNS) would look for the root cause analysis of why it was coming out, for example if the resident was pulling it out; however, a root cause analysis was not done. The DNS stated that they (DNS) were aware that the resident pulled out their G-tube on more than one occasion, but they (DNS) thought it was just a behavior of the resident. The DNS further stated that there was no Physician's Order for the abdominal binder and there should have been. The DNS was interviewed again on 12/16/22 at 12:00 PM and stated that the resident's abdominal binder was implemented by the hospital, not by the facility. The DNS stated that there should have been a Physician's Order for the placement of the abdominal binder, and it was the responsibility of the admitting Nurse to put the order into the computer. The DNS stated that there was no documentation in the resident's medical record if the abdominal binder was on or not when the G-tube was found dislodged and since there was no documentation it was unclear how the tube became dislodged since there was no nursing assessment. The resident's Physician (#1) was interviewed on 12/16/2022 at 1:40 PM and stated that no one told them (Physician #1) that the resident had an abdominal binder. Physician #1 stated that if the resident came from the hospital with the abdominal binder, the hospital would give a reason why because one would worry about the resident pulling out their G-tube. Physician #1 stated that they (Physician #1) should have been told about the resident's abdominal binder when they were admitted from the hospital. Physician #1 stated that any devices that the resident comes with, they (Physician #1) should be made aware of it. Physician #1 stated that they (Physician #1) have never encountered a resident with an abdominal binder. The Medical Director (MD) was interviewed on 12/16/2022 at 2:15 PM and stated that some residents have mental health issues, and they are tugging at these G-tubes and the abdominal binder should be part of the medical management of the resident. The MD stated that someone should have looked at the resident and what was going on and have at least done an assessment why the pulling out of the resident's G-tube was a reoccurrence. The MD stated that once is an accident, but not two or three times of the G-tube being dislodged. The MD stated that this was a conversation that should have taken place between the Attending Physician or NP and the Nurse to get a better understanding of why this was happening. The MD stated that abdominal binders are uncommon, so there must have been a reason for the resident to have one and then it should have been documented as such. The MD stated that abdominal binders are not really restraints, more medical management, and that no Physician's Order was needed for one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 12/12/2022 and completed on 12/16/2022, the facility did not ensure that a resident who needs respiratory care, is provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #57) of four residents reviewed for Respiratory Care. Specifically, Resident #57 had a diagnosis of Chronic Obstructive Pulmonary Disease and was observed receiving four liters of oxygen via a nasal cannula without a Physician's order. The finding is: Resident #57 was admitted with diagnoses that include Pneumonia, Chronic Obstructive Pulmonary Disease and Congested Heart Failure. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated the resident had intact cognition. The resident had no behavioral symptoms. The MDS documented the resident received oxygen while being a resident in facility. During an initial tour conducted on 12/12/2022 at 11:30 AM on the Legrange Nursing Unit Resident #57 was observed in bed. The resident was receiving 4 Liters of oxygen per minutes via a nasal cannula (N/C). The resident stated that they (Resident #57) always used oxygen and that they (Resident #57) can only tolerate a half hour without oxygen. A Comprehensive Care Plan (CCP) dated 11/24/2022 documented the resident has altered Cardiovascular status related to Atrial Fibrillation, Congestive Heart Failure, and Hypertension. Interventions included to administer oxygen as ordered by the Physician. A review of all Physician's orders dated from 11/24/2022 to current indicated there was no documented evidence that a Physician's order was obtained to administer oxygen to Resident #57. The Treatment Administration Record (TAR) for 11/2022 and 12/2022 lacked documented evidence of oxygen administration for Resident #57. The Skilled Observation notes dated 11/25/2022, 11/29/2022, 11/30/2022 documented the resident receives oxygen via nasal cannula. The Skilled Observation notes dated 12/3/2022 to 12/15/2022 documented the resident was on oxygen at 2 liters per minutes via nasal cannula. A Health Status note dated 12/14/2022 and 12/15/2022 documented the resident was receiving oxygen at 2 liters per minutes via nasal cannula. During an observation on 12/16/2022 at 10:30 AM Resident #57 was observed sitting in a wheelchair. The resident was receiving oxygen at 2 liters per minute via a nasal cannula from an oxygen tank. Registered Nurse (RN) #3 was interviewed on 12/16/2022 at 2:00 PM and stated that they (RN #3) do not usually work on the Legrange unit. A review of the Physician's order by RN #3, with the surveyor present, revealed there was no documented evidence of a Physician's order for the use of oxygen for Resident #57. RN #3 stated the nurses were responsible for ensuring a Physician's order for the use of oxygen was obtained for residents who utilize oxygen therapy. RN #3 stated the nurses are expected to document the use of oxygen therapy and sign the TAR every shift to ensure monitoring of oxygen administration. RN #3 further stated that there should have been an order in place for the use of oxygen for Resident #57. Physician #2, who cared for Resident #57, was interviewed on 12/16/2022 at 2:15 PM. Physician #2 stated they knew Resident #57 was receiving oxygen. Physician #2 stated that the resident should not have been receiving oxygen without a Physician's order and there should have been a Physician's order for the oxygen. The Director of Nursing Services (DNS) was interviewed on 12/16/2022 at 2:31 PM and stated that the admission nurse should have ensured there was a Physician's order in place for the use of oxygen therapy. 10NYCRR 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 12/12/2022 and completed on 12/16/2022, the facility did not ensure that Radiology services to meet the resident's needs were provided timely as ordered by a Physician. This was identified for one (Resident #105) of three residents reviewed for Choices. Specifically, 1) Resident #105 had documented Physician's Orders dated 6/6/2022, 8/16/2022, and 10/22/2022 to have a bilateral breast mammogram which was never completed; and 2) as a result of the mammogram not being completed, a Physician's order for bilateral breast ultrasound due to breast pain and to rule out breast mass was obtained on 10/27/2022. The bilateral breast ultrasound was not performed until 5 days later on 11/1/2022. The findings are: The facility's policy titled: Laboratory, Radiology and Other Diagnostic Services, last revised on August 2018, documented to provide or obtain radiology and other diagnostic services only when ordered by a medical provider. Resident #105 has diagnoses which include Peripheral Vascular Disease and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderately impaired cognitive skills for daily decision making. The resident was totally dependent on two persons for transfers. 1) The Progress Note dated 6/6/2022, written by Registered Nurse (RN) #2, documented the resident was complaining of bilateral (B/L) breast discomfort. The Nurse Practitioner (NP) #1 was made aware and an order was received for a mammogram. The Physician's Order dated 6/6/2022 documented for the resident to receive a mammogram. The Physician Progress Note dated 6/7/2022, written by NP #1, documented the resident was seen for B/L breast pain. The assessment indicated non-tender breasts, no palpable lump, and no discharge. The resident requested a breast mammogram. Nursing (staff) was made aware, and an order was placed. The Health Status Progress Note dated 8/15/2022, written by Licensed Practical Nurse (LPN) #3, documented the resident complained of sore and tender bilateral breasts. NP #1 was made aware and ordered a mammogram for the resident and a message was left for the Nursing Secretary (NS). The Physician's Order dated 8/16/2022 documented for the resident to receive a mammogram due to complaints of B/L breast pain. The Health Status Progress Note dated 10/22/2022, written by LPN #3, documented the resident complained of B/L breast pain and was requesting a mammogram. NP #1 was made aware and agreed for the resident to have a mammogram and a communication note was sent to the NS to make an appointment. The Physician's Order dated 10/22/2022 documented for the resident to receive a mammogram as per the resident's request. The Physician Progress Note dated 10/27/2022 documented the resident was seen for a follow-up for breast pain. No palpable mass, no discharge, no palpable adenopathy (swelling of the glands). Mammogram had been ordered in the past; however, nursing unable to find facility to accommodate the resident. Breast ultrasound will be ordered. The NS was interviewed on 12/14/2022 at 10:30 AM and stated that they (NS) got the request several times for the resident to have a mammogram and several times they (NS) tried to work on getting the resident an appointment. The NS stated that the hospital where the resident had mammograms in the past could not accommodate the resident now because the resident was in a lounge chair in a lying position and was unable to sit safely in a wheelchair. The NS stated that every time they called the hospital to set up an appointment for Resident #105, they (NS) were told that the hospital staff would get back to them (NS). The NS stated that finally in November 2022, the resident got an ultrasound by the facility's radiology company because the hospital could not accommodate the resident's mammogram. The NS stated that they (NS) had spoken to a few Nurses in the facility about not being able to get the mammogram done for Resident #105 but could not remember who they (NS) had spoken to. LPN #3 was interviewed on 12/14/2022 at 10:45 AM and stated that they (LPN #3) float (work) on different units in the facility. LPN #3 stated that they put the order in for the resident to receive a mammogram in August and when they (LPN #3) came back to the resident's unit in October, they (LPN #3) found out that the mammogram was never done. Resident #105 brought it to their (LPN #3) attention that the mammogram was never done, and that they (Resident #105) were still experiencing discomfort in both breasts. LPN #3 stated that they (LPN #3) looked into the resident's medical record and saw that the mammogram was not done and then got another order for a mammogram and sent another communication to the NS. The Director of Nursing Services (DNS) was interviewed on 12/14/2022 at 11:00 AM and stated that NP #1 was informed that multiple attempts were made to get the resident a mammogram appointment. The DNS stated that the resident could not be accommodated on a stretcher. The DNS stated that normally a mammogram appointment would be gotten as soon as possible; however, they (DNS) did not know why it had taken almost 5 months to have the diagnostic testing completed related to the resident's complaint of bilateral breast pain. The NS was interviewed again on 12/14/2022 at 11:05 AM in the presence of the DNS and stated that they (NS) had found in their (NS) scheduling book that the resident had an appointment scheduled on 9/6/2022 to go to the hospital for the mammogram and it was at that time the ambulette company told them (NS) that they could not accommodate the resident because the resident was lying down in a lounge chair. The NS stated that when they (NS) called to cancel the appointment in the hospital, the hospital staff said they could not accommodate the resident's lounge chair either. The resident's Physician (#1) was interviewed on 12/14/2022 at 1:10 PM and stated that they (Physician #1) would have expected that when the first order for the mammogram was given, the mammogram should have been done. The Assistant Director of Nursing Services (ADNS) was interviewed on 12/14/22 at 2:15 PM and stated that they (ADNS) just happened to overhear the NS and NP #1 speaking that there was difficulty getting a mammogram for Resident #105 and then they (ADNS) called the x-ray vendor (radiology) company and verified that a breast ultrasound at the bedside could be done. The ADNS stated that the request for the ultrasound was made on 10/27/2022. 2) The Physician Progress Note dated 10/27/2022 documented that the resident was seen for breast pain. There was no palpable mass, no discharge, no palpable adenopathy (swelling of the glands). Mammogram had been ordered in the past, however nursing unable to find facility to accommodate the resident. Will order breast ultrasound and follow-up. The Physician's Order dated 10/27/2022 documented for the resident to receive a B/L breast ultrasound due to breast pain and to rule out a mass. The Health Status Progress Note dated 10/30/2022 documented that the bilateral breast ultrasound was still pending. The Health Status Progress Note dated 11/1/2022 documented that the bilateral breast ultrasound was rendered today with results pending. The Health Status Progress Note dated 11/2/2022 documented that the resident's bilateral breast ultrasound was negative. The ADNS was interviewed on 12/14/22 at 2:15 PM and stated that they (ADNS) did not know how long it would take the radiology company to come to the nursing home to do the ultrasound after they (ADNS) put in the request for it. The ADNS stated that the radiology company had told them (ADNS) that because of COVID-19, they (radiology company) are backed up and will get there as fast as they can. The ADNS stated that the radiology company makes this frequent excuse and has told them (ADNS) that it is related to staffing issues within the radiology company. The ADNS stated that since COVID the facility does not see the same production from the radiology company even when it comes to an x-ray being done. 10NYCRR 415.21

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Recertification Survey initiated on 12/12/2022 and completed on 12/16/2022, the facility did not ensure that radiology services were obtained only when ordered by a Physician, Physician Assistant, or Nurse Practitioner. This was identified for one (Resident #186) of six residents reviewed for respiratory care. Specifically, Resident #186 received radiology services of an abdominal and chest x-ray without a Physician/Physician Assistant/Nurse Practitioner's order. The finding is: The facility policy entitled Laboratory, Radiology, and other diagnostic services dated 8/2018 documented that the facility will provide radiology services only when ordered by a medical provider. The licensed nurse must ensure to pick up orders made by the Physician/Physician extenders. A stat order must be transcribed as soon as the nurse is made aware of the request. The licensed nurse will ensure to properly fill out the requisition form and must call the appropriate service provider immediately. A follow-up call must be made by the licensed nurse to the appropriate service provider to ensure that the stat order was received and acknowledged. The licensed nurse must document in the medical record any communication made with the appropriate provider. Resident #186 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease, Respiratory Failure, and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #186 had a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. A care plan entitled, Resident is at high risk for pneumonia related to age and weakened immune system, dated 8/10/2022 documented interventions to monitor for any signs and symptoms of Pneumonia (fever, chills, cough, shortness of breath, fatigue, chest pain). The Nursing Progress Note dated 12/7/2022, written by LPN #1, documented that Resident #186 had a productive cough and phlegm. The Nurse Practitioner (NP) was made aware and Licensed Practical Nurse (LPN) #1 was awaiting a response. The Physician's Progress Note dated 12/8/2022 at 11:59 AM documented that NP #1 evaluated Resident #186 for complaints of cough and vomiting. Resident #186 was noted with cough, congestion, and bilateral crackles (lung sounds). NP #1 documented that they (NP #1) spoke with nursing and an abdominal x-ray and chest x-ray were ordered. A review of the physician's orders revealed that there were no orders for an abdominal and chest x-ray. The Physician's order dated 12/8/2022 documented Guaifenesin Extended-Release 12-hour 600 milligrams (mg) tablet. Give 1 tablet by mouth every 12 hours for cough for 7 days. The Physician's order dated 12/9/22 documented Ipratropium-Albuterol solution 0.5-2.5 (3) mg/milliliter (ml). one Application inhale every 6 hours for cough for 7 days. The Radiology Report dated 12/11/2022 documented an abdominal and chest x-ray were completed on 12/11/2022. The impression of the abdominal x-ray was unremarkable. The impression of the chest x-ray noted bilateral infiltrates which was increased from the previous study on 8/11/2022. LPN #1 who worked on 12/7/2022 on the 7 AM to 7 PM nursing shift was interviewed on 12/14/2022 at 2:34 PM. LPN #1 stated that they left a voice message and text for NP #1 on 12/7/2022 but NP #1 never got back to them (LPN #1). The Physician's order dated 12/12/2022 documented to administer Amoxicillin-Potassium Clavulanate (Antibiotic) tablet 875-125 mg, give one tablet by mouth every 12 hours for Pneumonia for 7 days. LPN #2, who worked on 12/8/2022 on the 7 AM to 7 PM nursing shift was interviewed on 12/15/2022 at 3:00 PM. LPN #2 stated that during the morning report on 12/8/2022, LPN #2 was told that Resident #186 was coughing, and then a voice message was left for NP #1 by LPN #2. LPN #2 stated that they heard Resident #186 coughing and listened to Resident #186's lungs. LPN #2 heard wheezing and crackles. LPN #2 stated that they (LPN #2) did not remember seeing NP #1 on 12/8/2022. NP #1 usually notifies the nurse to enter the orders in the medical record, but LPN #2 did not remember NP #1 telling LPN #2 to write an order for the abdominal and chest x-ray. LPN #2 stated that they (LPN #2) normally review the NP notes, but LPN #2 did not see notes. LPN #2 stated they (LPN #2) forgot to write a nursing note on 12/8/2022. On Monday, 12/12/2022, the night shift Registered Nurse (RN) gave LPN #2 the x-ray results for Resident #186. NP #1 was at the facility on 12/12/2022 and LPN #2 notified NP #1 of the resident's x-ray results around 10 AM. LPN #1 was re-interviewed on 12/16/2022 at 4:14 PM. LPN #1 stated that they (LPN #1) did not work again at the facility after 12/7/2022 until 12/11/2022. On 12/11/2022, LPN #1 saw a requisition form for Resident #186's x-ray taped to the nurse's station and noticed that the x-ray was not done. Since the requisition form was a few days old, LPN #1 called the x-ray company to follow up on the status. The x-ray company agreed to come in on 12/11/2022. LPN #1 stated that if they (LPN #1) had received the x-ray order from NP #1, they would have entered the order in Resident #186's medical record and called the x-ray company the same day. LPN #1 further stated they (LPN #1) did not enter the x-ray orders in the medical record. NP #1 was interviewed on 12/16/2022 at 3:28 PM. NP #1 stated that they instructed the nurse on duty to enter the orders for the x-rays on 12/8/2022. NP #1 stated that they were not sure which nurse they spoke to on 12/8/2022. NP #1 stated that they expected the x-ray orders to be entered in the medical record on 12/8/2022 and it was a stat order. NP #1 stated that they did not enter the order themselves. NP #1 told the nurse to enter the x-ray order because the nurse has to call the x-ray company and give the resident's insurance information. NP#1 stated there were x-ray results when they came to the facility on [DATE]. NP #1 was not sure when the x-ray results first became available and when the x-rays were ordered. The x-ray indicated that Resident #186 had Pneumonia and NP#1 started a 7-day treatment of antibiotics on 12/12/22. The Director of Nursing Services (DNS) was interviewed on 12/16/2022 at 4:49 PM. The DNS stated that either the Physician or the nurse is expected to enter the radiology orders directly into the Electronic Medical Record. The orders are verbally given by the Physician or the Physician extenders, and the staff are expected to enter the orders into the medical record and ensure the orders are followed through on the same shift. The DNS was re-interviewed on 12/16/2022 at 5:06 PM. The DNS stated that they reviewed Resident #186's medical record and could not find the Physician's order for an abdominal and chest x-ray. The DNS stated that there should have been an order in Resident #186's medical record. 10NYCRR 415.21

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification initiated on 12/12/2022 and completed on 12/16/22 the facility failed to maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and COVID-19 infection. This was identified on 1 of 5 units. Specifically, 1) On the Legrange Unit, a Transmission Based Precautions (TBP) sign was not observed for a resident who was COVID-19 positive; 2) a Certified Nursing Assistant (CNA #5) did not utilize appropriate Personal Protective Equipment (PPE) when entering a COVID-19 positive resident's room and did not discard all of the used PPE prior to leaving the COVID-19 positive resident's room. The finding is: The facility policy titled Cohorting for COVID-19 last updated 9/10/2021 documented that for positive cohorts full PPE is required, including gloves, gown, N-95 mask, and eye protection. The policy further documents Transmission-Based Signage for Droplet and Contact precautions will be posted on the doors of residents that are confirmed for COVID-19. An entrance conference was conducted with the Administrator and the Director of Nursing Services (DNS) on 12/12/22 at 8:43 AM. They both stated that there was one COVID-19 positive resident that resides in the Legrange Unit and one COVID-19 positive resident who had completed the TBP and would be moved to the [NAME] Unit. 1) Resident #169 has diagnoses that includes COVID-19 infection as of 12/6/22, Pleural Effusion and Chronic Embolism/Thrombosis. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A Physician's order dated 12/7/22 documented Droplet and Contact precautions for COVID -19 for 14 days every shift. A nursing progress note dated 12/6/2022 at 2:44 PM documented the resident's COVID-19 swab (test) was positive and the resident was now on Contact and Droplet Precautions. A Comprehensive Care Plan (CCP) dated 4/19/2021 and last updated on 12/11/2022 documented the resident was at risk to be positive for COVID-19 infection due to the pandemic outbreak. The CCP was updated on 12/11/2022 and documented the resident tested positive for COVID-19 infection and was placed on Droplet and Contact Isolation. A tour of the LeGrange Unit, the COVID-19 wing, was conducted on 12/12/2022 at 11:20 AM. There was one COVID-19 positive resident in the area. There was no signage indicating the resident was on Droplet and Contact Precaution posted on the resident's door or the unit. A second observation on the Legrange unit, the COVID-19 wing, was conducted on 12/12/2022 at 3:00 PM with the Assistant Director of Nursing Services (ADNS). There was no Droplet and Contact Precaution sign posted on the resident's door or the unit. The ADNS was immediately interviewed on 12/12/2022 at 3:05 PM and stated that they thought the Droplet and Contact Precaution sign was posted on the resident's door. The ADNS stated that a sign should have been initiated at the time the resident was confirmed COVID-19 positive and was transferred to the COVID-19 wing. The Infection Control Preventionist (ICP) was interviewed on 12/15/2022 at 3:50 PM and stated once the resident tested COVID-19 positive the resident was transferred to the COVID-19 unit and was placed on Droplet precaution for 10 days. The ICP stated a stop sign and the Droplet Precaution sign should have been placed on the resident's door to alert staff of the resident's positive COVID-19 status. The ICP stated the appropriate signs are initiated as soon as a resident is identified to be COVID-19 positive and that the ICP, the unit Registered Nurse (RN), or the RN Supervisor were responsible for ensuring all necessary precautions and signage are put in place. The DNS was interviewed on 12/16/2022 at 12:22 PM. The DNS stated once the resident was identified COVID-19 positive the ICP should initiate all appropriate precautionary signs. The DNS stated if the ICP was not available the RN Supervisor would initiate the signs on the appropriate door. The DNS further stated that there should have been a stop sign and a Droplet Precaution sign placed on the resident's door at the time the resident was identified COVID-19 positive. 2) During a Lunch meal observation on 12/12/2022 at 12:30 PM Certified Nursing Assistant (CNA) #5 was observed prepping a meal tray. CNA #5 verified that the meal was for the resident who was COVID-19 positive. CNA #5 was wearing a surgical mask then donned (put on) a gown, and gloves. CNA #5 then asked a peer to hand them (CNA #5) the resident's tray. CNA #5 then entered the COVID-19 positive resident's room. After leaving the resident's room CNA #5 doffed (took off) the gown and gloves, sanitized their hands then proceeded down the hall towards the lunch truck that was in the hallway. CNA #5 did not wear an N95 mask when entering a COVID-19 positive resident's room and did not change their surgical mask after leaving the resident's room. CNA #5 who worked on the 7:00 AM - 3:00 PM shift was interviewed on 12/12/2022 at 12:40 PM. CNA #5 stated during the morning report the charge nurse informed them Resident #169 was COVID-19 positive. CNA #5 stated when entering a COVID-19 positive resident's room full PPE which includes a gown, face shield or goggles, gloves, and an N95 mask covered with a surgical mask is required prior to entering the room. CNA #5 stated they did not have an N95 mask and that there were no N95 masks on the PPE cart. CNA #5 stated that they were fit tested and usually receive extra N95 masks from the nursing office and that they (CNA #5) did not stop to obtain an N95 mask at the beginning of the shift before going to the unit. CNA #5 stated prior to entering the COVID-19 positive resident's room they (CNA #5) should have been wearing an N95 mask. CNA #5 further stated they (CNA #5) should have changed their surgical mask after leaving the resident's room. The Infection Control Preventionist (ICP) was interviewed on 12/15/2022 at 3:50 PM. The ICP stated when entering a COVID-19 positive resident's room an N95 mask must be worn at all times and there should be a surgical mask covering the N95 mask. The ICP stated that CNA #5 should have been wearing an N95 mask prior to entering the resident's room and should have changed their surgical mask before coming out of the COVID-19 resident's room. The DNS was interviewed on 12/16/2022 at 12:22 PM and stated that N95 masks were available on the units for the staff and CNA #5 could have obtained an N95 Mask from the charge nurse. The DNS stated CNA #5 should have been wearing an N95 mask before entering the COVID-19 positive resident's room and should have changed their surgical mask before coming out of the COVID-19 positive resident's room. 10NYCRR 415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for 1 (Resident #488) of one resident reviewed for Pressure Ulcer (PU) Injuries. Specifically, the resident was identified with a Deep Tissue Injury (DTI) to the right heel and there was no documented evidence that a Comprehensive Care Plan (CCP) was developed for the DTI. The finding is: The resident was admitted to the facility with diagnoses that included Fracture Neck of Right Femur, Muscle weakness, and Type II Diabetes Mellitus (DM). An admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score as 15 indicating intact cognition. The resident had one or more unhealed unstageable Pressure Ulcers (PU) that were present on admission. A CCP dated 1/13/2020 documented the resident has the potential for PU development related to DM and the Right Hip Fracture. The interventions included to offload the heels with a pillow to reduce pressure on the heels to prevent a wound, pressure reducing mattress, assess changes in skin condition every shift, and turn and position the resident every two hours. The physician's order dated 1/23/2020 documented to cleanse the right heel with normal saline, pat dry and apply skin prep (a liquid film-forming dressing that forms a protective film). The medical record lacked documented evidence of an individualized CCP for the right heel DTI. The Registered Nurse (RN), Wound Care Nurse was interviewed on 1/31/2020 at 9:20 AM and stated that the resident was admitted with pressure ulcers and was at risk for developing pressure ulcers. The RN stated that the resident had a right femur fracture and was refusing the suggested intervention to offload the right leg. The resident was then provided with pillows to offload the heels. The RN Supervisor was interviewed on 1/31/2020 at 11:26 AM and stated that the resident was transferred from another unit with a right heel pressure ulcer. The RN stated that she was not aware that the resident did not have a CCP related to the right heel DTI and if she knew there was no CCP developed, she would have initiated one. The RN further stated that a CCP should have been initiated for the right heel pressure ulcer when it was identified. The Director of Nursing Services (DNS) was interviewed on 1/31/2020 at 11:36 AM and stated that the unit RNs are responsible to initiate the CCPs. The DNS stated that a CCP should have been developed for the DTI to the right heel the moment it was found by the RN covering the unit at that time. 415.11(c)(1)

**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 ensure that each resident receives treatment and care in accordance with professional standards of practice. This was noted for one (Resident # 51) of five residents reviewed for skin conditions. Specifically, for Resident #51, there was no documented evidence that the Physician was notified and no orders were received for skin tears on the resident's bilateral hands. The finding is: Resident # 51 had with diagnoses including Rhabdomyolysis, Dementia with Behavior Disturbance, and Major Depressive Disorder. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99 indicating severely impaired cognition. The resident required extensive assist of two persons for bed mobility and toilet use and extensive assist of one person for locomotion, dressing and personal hygiene. A Comprehensive Care Plan (CCP) dated 6/7/19 documented the resident had a potential for skin tears due to fragile skin and purpura (discoloration of the skin or mucous membranes due to hemorrhage from small blood vessels). The CCP documented interventions including, if skin tear occurs, treat per facility protocol and notify Physician, family. Resident #51 was observed on 1/27/20 at 8:52 AM sleeping in her room. The resident was observed with multiple purpura on bilateral hands. The resident was observed on 1/30/20 at 11:06 AM in the unit hallway sitting in a Recliner chair. The resident was observed with two comfort foam bandages on the back of each hand. A review of Physician's orders, Medication and Treatment Administration Records from September 2019 through January 2020 revealed Physician orders dated September 28, 2019 for Bacitracin to the left elbow abrasion for 7 days and dated October 15, 2019 for Bacitracin to the right forearm abrasion for 7 days. There was no current treatment order in place for treatment to both hands. A review of the medical record including the integrated progress notes and the comprehensive care plan for January 2020 revealed no documented evidence of current skin treatments. The unit Licensed Practical Nurse (LPN) Charge Nurse was interviewed on 1/30/20 at 11:10 AM and stated that currently Resident # 51 has fragile skin with no open areas or treatment orders. She observed the comfort foam bandages on the back of the resident's hands. The LPN lifted one foam bandage and stated that there is a small skin tear. The unit 7:00 AM-3:00 PM Medication and Treatment LPN was interviewed on 1/30/20 at 11:19 AM. The LPN stated she was on this unit since January 2020 and no one has reported any skin opening to her for Resident #51. She also stated she did not administer any medication to the resident this morning and the resident might have had new skin tears last night that were not communicated to her. Resident #51's Certified Nursing Assistant (CNA) was interviewed on 1/30/20 at 11:33 AM. The CNA stated that she had cared for Resident #51 for 6 months and the resident needs two persons for assistance, was very resistive, and can be combative during care. The CNA stated that there were two tiny band aids on each hand and one band aid on the forearm this morning. The CNA also stated that she cared for the resident yesterday (1/29/20) and today (1/30/20) and did not recall if the band aids were in place yesterday. The unit Charge LPN was interviewed on 1/30/20 at 11:46 AM. The Charge LPN stated that a complete body check on Resident # 51 revealed that she has purpura, discolorations, and skin openings. The Charge LPN also stated that she will get a Doctors order for treatment. The Charge LPN further stated that the CNAs are supposed to report when they see something, the Nurse should have called the doctor and obtained an order, and should have written a note. The Charge LPN stated that the CCP was in place for potential for skin tears due to fragile skin and purpura and is updated by her or by any other Nurse on the unit. She reviewed the CCP and stated that the CCP had not been updated for the current skin tears nor the skin abrasions that were treated on September 28, 2019 and October 15, 2019. A Nurse's note dated 1/30/20 documented that a full body check was completed and the resident had 2 small superficial open purpuras on each hand. The left outer hand measured 0.7 centimeters (cm), the top portion of the left hand measured 0.5 cm, the top portions of the right hand measured 0.3 and 0.5 cm. A physician's order dated 1/30/2020 at 2:28 PM documented to provide comfort foam border to the left hand, check for signs/symptoms of infection, once a day, for the open purpura. The treatment order instructed the staff to wash the area with normal saline, pat dry, and apply (comfort foam border). The resident's Physician was interviewed on 1/31/20 at 10:19 AM and stated that he was made aware of skin tears only yesterday (1/30/20). He stated he expects to be called when there is a new treatment required. The 3:00-11:00 PM LPN who worked on Monday, 1/27/20, and Wednesday, 1/29/20, was interviewed on 1/31/20 at 11:25 AM. The LPN stated that she had seen the bandages on the resident's hands on Monday and Wednesday. She stated that the bandages looked intact and she did not touch or examine them. The LPN further stated she thought that the treatments might have been done on other shifts. The 3:00 PM-11:00 PM CNA was interviewed on 1/31/20 at 12:00 PM and stated she worked on Wednesday, 1/29/20, and Thursday, 1/30/20. The CNA stated she saw that the resident had square bandages on both her hands on both days. 415.12