**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 6/3/2025 and completed on 6/10/2025, the facility did not ensure that a comprehensive patient-centered care plan was implemented to include measurable objectives and timeframes to meet a resident's medical and nursing needs. This was identified for one (Resident #143) of one resident reviewed for the environment (Call Bell). Specifically, Resident #143 was admitted with diagnoses that included Legal Blindness and Glaucoma and there was no documented evidence that a care plan was developed to address the resident's visual impairment. The finding is: The facility's Comprehensive Care Plan Policy revised on 11/2019 documented a Comprehensive Care Plan for resident's needs shall be developed within 14 days of admission. The Comprehensive Care Plan meeting (with the inclusion, by invitation, of the resident and /or family) will be conducted within 21 days from admission. Within 14 days of the resident's admission, a comprehensive assessment of the resident's needs will be prepared and developed by the interdisciplinary team. The resident was admitted with diagnoses that included Legal Blindness and Glaucoma. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 10, which indicated the resident had moderately impaired cognition. The Minimum Data Set assessment documented the resident's vision was impaired, and the resident utilized corrective lenses. The hospital Patient Review Instrument (a screening to determine appropriate placement for the resident) dated 4/07/2025 documented the resident was legally blind. The Nurse Practitioner's progress note dated 6/3/2025 at 8:12 PM documented the resident was legally blind. The resident had laser eye surgery to the left eye. A review of the resident's Electronic Medical Record revealed there was no documented evidence of a care plan developed to address the resident's visual impairment. During an interview on 6/10/2025 at 10:23 AM, Registered Nurse Unit Manager #2 stated the resident was legally blind and had vision difficulties. Registered Nurse Unit Manager #2 stated they did not know that the resident did not have a care plan to address the vision problem. Registered Nurse Unit Manager #2 stated the admission Nurse was responsible for developing the care plan. Registered Nurse Unit Manager #2 stated if the admission Nurse does not initiate the care plan, then the Unit Manager should have ensured all the care plans were in place. During an interview on 6/10/2025 at 11:36 AM, the Director of Nursing Services stated the admission nurse should have initiated the care plan for visual impairment due to the resident's legally blind status upon admission. The Director of Nursing Services stated the Registered Nurse Unit Manager should have also ensured all the care plans were in place to meet the resident's needs. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 6/3/2025 and completed on 6/10/2025, the facility did not ensure that all biologicals were stored in locked compartments in accordance with accepted professional principles. This was identified for one (Resident #12) of one resident reviewed for Dental Services. Specifically, on multiple occasions, Resident #12 was observed with Flonase (Fluticasone) (nasal spray with steroids) 50 micrograms Nasal Spray at their bedside and there was no staff in the vicinity on both occasions. The Flonase order was discontinued by the resident's Physician on 12/9/2024. Resident #12 did not have a physician's order and was not assessed to self-administer their medication. The finding is: The facility's Self-Administration of Medication Policy and Procedure revised in 9/2020 documented that upon determining the resident's desire and ability to self-medicate an order from the attending should be obtained. This order must be specific to the medication(s) the resident may self-administer, the dosage, interval, route of administration, and the amount of time over which the medication is to be taken. The facility's Medication Administration policy revised in 9/2020 documented the nurse will ensure that medications are not left unattended. Medications will be secured in a locked area or in visible control at all times. Resident #12 was admitted with diagnoses that included Shortness of Breath and Congestive Heart Failure. A Quarterly Minimum Data Set assessment dated [DATE] documented that the resident's Brief Interview of Mental Status score (BIMS) was 15, which indicated the resident's cognition was intact. The resident had impairment on one side of the upper extremities and required supervision or touch assistance for oral hygiene. A Physician's order dated 9/18/2024 documented Fluticasone Propionate Suspension 50 Microgram 1 spray in each nostril in the morning related to Nasal Congestion. The order was discontinued on 12/9/2024. During an initial tour on 6/3/2025 at 2:26 PM, Resident #12 was observed with Flonase (Fluticasone Propionate) Nasal Spray at the bedside. The resident stated they self-administer the Flonase Nasal spray once daily in the morning, and they have been self-administering the nasal spray for some time. During a second observation on 6/10/25 at 11:30 AM, Flonase (Fluticasone Propionate) Nasal Spray was observed on Resident #12's overbed table. There was no staff present in the vicinity. A review of the resident's medical record revealed the resident was not assessed for self-administration and did not have a physician's order to self-administer any medications. During an interview on 6/10/2025 at 11:31 AM, Registered Nurse #3 stated they were not aware that Resident #12 had Flonase Nasal Spray at the bedside and that the resident was administering the Flonase Spray daily by themselves. Registered Nurse #3 stated Resident #12 did not have orders to self-administer medications and had no current physicians' orders for Flonase Nasal Spray. Registered Nurse #3 stated the physicians' orders for Flonase Nasal Spray were discontinued on 12/9/2024. Registered Nurse #3 stated a physician's order was required for self-administration of medication and that there should be no medications left at the resident's bedside. During an interview on 6/10/2025 at 11:48 AM, Licensed Practical Nurse #2 stated Resident #12 did not have orders to self-administer medications and had no current physicians' orders for Flonase Nasal Spray. Licensed Practical Nurse #2 stated that medications should not be left at the bedside. During an interview on 6/10/2025 at 2:44 PM, the Director of Nursing Services stated that an assessment must be completed to determine if the resident could self-administer the Flonase nasal spray with or without supervision. The Director of Nursing Services stated there should be a physician's order in place for self-administration. The Director of Nursing Services further stated that the Flonase nasal spray should not have been left at the resident's bedside. During an interview on 6/10/2025 at 3:06 PM, the Attending Physician stated the nasal spray should not have been left in the resident's room, as the order for the nasal spray was discontinued a long time ago. The Attending Physician stated the facility should be aware of all medications being taken by the resident and there should be an order in place for all medications being administered to the resident. 10 NYCRR 415.18(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 6/3/2025 and completed on 6/10/2025, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #88) of three residents reviewed for Transmission-Based Precautions. Specifically, Resident #88 had a physician's order for Contact Precautions due to Methicillin Resistant Staphylococcus Aureus (antibiotic-resistant bacteria) and Osteomyelitis (bone infection) to the right great toe. During the initial tour on 6/3/2025, the Contact Precautions signage was not posted in a conspicuous location outside the resident's room. A visitor was observed in the resident's room without the use of Personal Protective Equipment and was coming in contact with the resident's bed. The finding is: The facility policy and procedure titled Transmission-Based Isolation, dated October 2024, documented that contact transmission can occur by directly touching the patient and through contact with the patient's environment. Contact isolation requires ensuring that appropriate signage and Personal Protective Equipment are at the entrance to the patient's room. The resident was readmitted to the facility with diagnoses including Osteomyelitis and Methicillin Resistant Staphylococcus Aureus to the right great toe. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status Assessment score of 14, which indicated the resident had intact cognition. The Minimum Data Set documented that the resident had two venous/ arterial ulcers. The hospital Discharge summary dated [DATE] documented that Resident #88 had a diagnosis of the right great toe Osteomyelitis. The resident's wound culture tested on [DATE] was positive for Methicillin Resistant Staphylococcus Aureus. A Physician's order dated 5/30/2025 documented a hold order for the Enhanced Barrier Precautions. The nursing progress note dated 5/30/2025 documented Contact Precautions maintained secondary to Methicillin Resistant Staphylococcus Aureus/Osteomyelitis of the right great toe. The review of the resident's Electronic Medical Record indicated no orders for Transmission-Based Precautions until 6/3/2025. The Physician's Orders dated 6/3/2025 documented Contact Precautions: Methicillin Resistant Staphylococcus Aureus/ Osteomyelitis right great toe every shift. During an initial tour on 6/3/2025 at 11:24 AM, an Enhanced Barrier Precaution signage was observed on the doorframe of Resident # 88's room. The door was opened, and a visitor was inside Resident #88's room without Personal Protective Equipment. The visitor's lunch bag was observed on the resident's bed. The visitor was kneeling on the bed with one foot on the floor, and Resident #88 was seated in their wheelchair at the foot of the bed. Licensed Practical Nurse #1 came to the door and asked the visitor to put on Personal Protective Equipment because the resident was on Contact Precautions for Methicillin Resistant Staphylococcus Aureus. Licensed Practical Nurse #1 stated the visitor should be wearing Personal Protective Equipment. The visitor asked for assistance with putting on the gown. While Licensed Practical Nurse #1 assisted the visitor with putting on the gown, the visitor stated, I didn't know. Licensed Practical Nurse #1 was immediately interviewed and stated the contact precaution signage was on the other side of the door and was not visible because the resident prefers the door to be fully opened. During an interview on 6/3/2025 at 12:32 PM, Registered Nurse Manager #1 stated Resident #88 has a Methicillin Resistant Staphylococcus Aureus infection in the right toe and was supposed to be placed on Contact Precautions to prevent the spread of infection. Registered Nurse Manager #1 stated that the Contact Precautions signage was posted on the resident's room door and could only be seen if the door was closed. Registered Nurse Manager #1 stated Resident #88 requested the door remain open because they were claustrophobic (have a fear of confined spaces). Registered Nurse Manager #1 stated they need to add a second Contact Precautions sign for the signage to be visible to all staff and visitors. During an interview on 6/5/2025 at 11:43 AM, Infection Preventionist #1 stated that Contact Precautions signage must always be visible to visitors and staff members to prompt them to go to the nurse for assistance. Infection Preventionist #1 stated that Personal Protective Equipment must be worn to prevent the spread of Methicillin Resistant Staphylococcus Aureus infection. During an interview on 6/5/2025 at 12:17 PM, the Director of Nursing Services stated a resident with Methicillin-Resistant Staphylococcus Aureus infection should be placed on Contact Precautions, and the precautions signage should be placed in a conspicuous area outside the resident's room. The Director of Nursing Services stated that staff or visitors entering the room must wear appropriate Personal Protective Equipment to prevent the spread of infection. 10 NYCRR 415.19(a)(1-3)

Based on observation, record review and interviews during the recertification survey initiated on 6/3/2025 and completed on 6/10/2025, the facility did not ensure that food was stored and/or served in accordance with professional standards for food safety. This was identified during the Kitchen task observation on 6/6/2025. Specifically, there was no system in place to monitor the temperatures of cold food items. The finding is: A facility policy and procedure titled Food Temperature (effective 1/2024), documented How to Keep Cold Food Cold: cold holding equipment (i.e. refrigerator, serving station, salad bar, deli bar) must keep food temperature at 40 degrees Fahrenheit or lower; check product temperature often, as directed. The facility policy contained a Hot Food Temperature Chart that did not include a space to record cold temperatures for food items other than milk. The chart documented All items must be held at 40 degrees or lower/141 degrees or higher. During an interview on 6/6/2025 at 11:44 AM, [NAME] #1 stated they take the food temperature when they set the items on the steam table on the tray line. [NAME] #1 stated they record the temperatures of the food on the Food Temperature Log. [NAME] #1 stated they do not take the temperature of the cold food items that are not part of the main entrée. During an observation and interview on 6/6/2025 at 11:49 AM, the Food Service Director reviewed the Hot Food Temperature Log and stated there was no space on the form to document the temperatures for cold food items other than milk. The Food Service Director further stated that if the temperatures are not monitored and the food is out of the safe range (below 41 degrees Fahrenheit), there is an increase in the potential for foodborne illness. During an interview on 6/6/2025 at 1:33 PM, the Administrator stated that both hot and cold food temperatures should be monitored before the food is served to the residents. The Administrator stated that the kitchen staff should monitor food temperatures and record temperatures on a Temperature Log Sheet. The Administrator stated that they were not aware that the cold food items were not being monitored. 10 NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification survey initiated on 1/3/2024 and completed on 1/11/2024, the facility did not ensure that each resident was cared for in a manner that maintained or enhanced his or her dignity. This was identified for one (Resident #12) of one resident reviewed for Dignity. Specifically, Licensed Practical Nurse (LPN) # 2 was observed responding to Resident # 12's call bell in an undignified manner. The finding is: The facility's policy titled Resident Rights dated September 2019 documented the resident has the right to be treated with respect and dignity. Resident # 12 has diagnoses that include Morbid (severe) Obesity, Generalized Chronic Pain Syndrome, and Osteoarthritis of both knees. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderately impaired cognition. The resident had no verbal or physical behavior problems identified. During an observation on 1/3/2024 at 12:10 PM, Resident #12 was observed in their room in their wheelchair. Resident #12 complained of pain in the legs to the surveyor. Resident #12 stated the pain was a 10 on a scale of 1-10 with 10 being the worst pain one can experience. The surveyor notified Licensed Practical Nurse (LPN) # 2 of the resident's complaint of pain. Resident #12 also pressed their Call Bell for assistance. Licensed Practical Nurse # 2 responded to the call bell and was observed knocking on the door and speaking to the resident saying what in a very loud tone then told the resident, I just medicated you with Oxycodone. I cannot help you. Resident # 12 told Licensed Practical Nurse # 2, The heel booties are hurting me. I don't want them on. Licensed Practical Nurse # 2 stated, You have to wear the heel booties. I cannot remove them. Licensed Practical Nurse #2 did not explain why Resident #12 needed to wear the heel booties and walked out of the room. When Licensed Practical Nurse #2 left the room, Resident #12 was upset and appeared in pain as evidenced by squinting their eyes and pursing their lips. In lieu of Resident #12's response, the surveyor requested Registered Nurse #4 to intervene. Registered Nurse (RN) # 4, who was the charge nurse, was interviewed on 1/3/2024 at 12:20 PM. Registered Nurse #4 stated the resident has a right to not wear heel booties and to be treated in a dignified manner. The pain has to be assessed to determine if there are alternate treatments that can be provided. Registered Nurse #4 then assessed Resident # 12 and removed the resident's heel booties. Resident # 12 was very thankful and expressed immediate relief from discomfort. Registered Nurse #4 educated the resident on the importance of wearing heel booties. Resident # 12 stated the heel booties do not bother them when they are in bed but are uncomfortable while in the wheelchair and they should not be forced to wear them. Registered Nurse # 4 stated this will be care planned and the Licensed Practical Nurse will be re-educated. The Director of Nursing Services was interviewed on 1/10/2024 at 2:36 PM and stated Licensed Practical Nurse # 2 should not enter a resident's room and address the resident with what. Licensed Practical Nurse # 2 should have been more courteous. The Director of Nursing Services stated the resident has a right to refuse treatment and the heel booties should have been removed. 10NYCRR415.3(d)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, conducted during the Recertification survey initiated on 1/3/2024 and completed on 1/11/2024, the facility did not ensure that it promoted and facilitated resident self-determination through support of resident choice. This was identified for one (Resident #12) of one resident reviewed for Choices. Specifically, Resident #12 was observed complaining of pain in their legs to Licensed Practical Nurse # 2 and requested that their heel booties be removed. Licensed Practical Nurse #2 denied the resident's request and walked out of the resident's room without providing an explanation or exploring alternate interventions. Resident #12 was upset and appeared in pain as evidenced by squinting their eyes and pursing their lips. In lieu of Resident #12's response, the surveyor requested Registered Nurse #4 to intervene, who then assessed the resident and removed the resident's heel booties. The finding is: The facility's policy titled Resident Rights dated September 2019 documented the resident has the right to refuse treatments. Resident # 12 has diagnoses that include Morbid (severe) Obesity, Generalized Chronic Pain Syndrome, and Osteoarthritis of both knees. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderately impaired cognition. The resident had no verbal or physical behavior problems identified. The Comprehensive Care Plan (CCP) for Refusal Behavior dated 11/29/2022 last updated on 11/29/2023 documented the resident has a behavior problem of refusing to wear Bilevel positive airway pressure (BIPAP) machine (machine to treat sleep apnea), removing oxygen tubing, placing the bed in a supine position, smearing feces, accusatory towards staff, and calling 911. The Comprehensive Care Plan did not document the resident's refusal of the heel booties. The interventions included to assist the resident to develop more appropriate methods of coping and interacting and to encourage the resident to express feelings appropriately. The Skin Integrity Comprehensive Care Plan dated 11/29/2023 documented the resident has the potential for impaired skin integrity related to impaired mobility. Interventions included to elevate legs as tolerated, to encourage the resident to wear appropriate socks when in and out of bed, to provide pressure relief interventions, to float the heels off of the mattress, and to use pillows to elevate legs/heels/arms. The Comprehensive Care Plan did not document the use of the heel booties to be worn when out of bed. During an observation on 1/3/2024 at 12:10 PM, Resident #12 was observed in their room in their wheelchair. Resident #12 complained of pain in the legs to the surveyor. Resident #12 stated the pain was a 10 on a scale of 1-10 with 10 being the worst pain one can experience. The surveyor notified Licensed Practical Nurse (LPN) # 2 of the resident's complaint of pain. Resident #12 also pressed their Call Bell for assistance. Licensed Practical Nurse # 2 responded to the call bell and was observed knocking on the door and speaking to the resident saying what in a very loud tone then told the resident, I just medicated you with Oxycodone. I cannot help you. Resident # 12 told Licensed Practical Nurse # 2, The heel booties are hurting me. I don't want them on. Licensed Practical Nurse # 2 stated, You have to wear the heel booties. I cannot remove them. Licensed Practical Nurse #2 did not explain why Resident #12 needed to wear the heel booties and walked out of the room. When Licensed Practical Nurse #2 left the room, Resident #12 was upset and appeared in pain as evidenced by squinting their eyes and pursing their lips. In lieu of Resident #12's response, the surveyor requested Registered Nurse #4 to intervene. Registered Nurse (RN) # 4, who was the charge nurse, was interviewed on 1/3/2024 at 12:20 PM. Registered Nurse #4 stated the resident has a right to not wear heel booties and to be treated in a dignified manner. The pain has to be assessed to determine if there are alternate treatments that can be provided. Registered Nurse #4 then assessed Resident # 12 and removed the resident's heel booties. Resident # 12 was very thankful and expressed immediate relief from discomfort. Registered Nurse #4 educated the resident on the importance of wearing heel booties. Resident # 12 stated the heel booties do not bother them when they are in bed but are uncomfortable while in the wheelchair and they should not be forced to wear them. Registered Nurse # 4 stated this will be care planned and the Licensed Practical Nurse will be re-educated. The Director of Nursing Services (DNS) was interviewed on 1/10/2024 at 2:36 PM and stated Licensed Practical Nurse # 2 should have notified Registered Nurse # 4 that the resident refused to wear the heel booties. If the pain was due to the heel booties, the use of heel booties should have been assessed. The Director of Nursing Services stated if the resident refused to wear the heel booties then they should have been removed and the care should have been updated. 10 NYCRR 415.5 (b)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00319951) initiated on 1/03/2024 and completed on 1/11/2024, the facility did not ensure that the resident or designated representative was notified when the need to discontinue a treatment was identified. This was identified for one (Resident #149) of one resident reviewed for Notification of Change. Specifically, Resident #149 had a physician's order to administer Heparin (blood thinner medication) 5000 units every 12 hours and Aspirin (blood thinner) 81 milligrams one time daily. The vendor pharmacy identified a drug to drug interaction and a medical alert was generated in the Electronic Medical Record. The Heparin 5000 unit was discontinued as per the resident's physician's orders. There was no documented evidence that the resident or the resident's representatives were notified of the change in the resident's medication regimen. The finding is: The facility's Policy and Procedure titled, Notification Policy effective July 2019 documented to ensure that every resident's change of condition is assessed and documented properly. To ensure that every resident's change of condition is reported to the Physician and the resident's family. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) a need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences. (e.g., an adverse drug interaction). Resident #149 has diagnoses of Pneumonia, Coronary Artery Disease, Cardiomyopathy. The 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 hospital Medication Administration Record dated 6/13/2023 documented the resident was receiving Heparin 5000 units every 12 hours since 6/7/2023. A Physician's order dated 6/13/2023, documented to administer Heparin Sodium 5000 units/Milliliter (ML) inject 5000 units Subcutaneously (SC) every 12 hours related to Atrioventricular Block. The order was discontinued on 6/14/2023 by Physician #1. A Medication Administration Record dated 6/13/2023 documented Heparin Sodium 5000 units/milliliter give Subcutaneously every 12 hours. The Medication Administration Record was signed on 6/13/2023 at 9:00 PM, indicating that the Heparin was administered as prescribed. A progress note dated 6/13/2023 at 3:17 PM documented the order you entered Heparin Sodium 5000 units/Milliliter (ML) inject 5000 units Subcutaneously (SC) every 12 hours related to Atrioventricular block has triggered the following drug protocol alert/warning. Drug to drug interaction. The system has identified a possible drug interaction with the following orders: Aspirin oral capsule 81 mg give 1 tablet by mouth one time a day. Severity-Severe. The risk of bleeding in Heparin Sodium injection 5000 units/milliliter treated in patients may be increased by aspirin oral capsule 81 mg. Registered Nurse #1 was interviewed on 1/08/2024 at 12:33 PM. Registered Nurse #1 stated the nurse assigned to the resident would notify the resident and or the resident's family of any medication changes and document the notification in the resident's medical record. Registered Nurse #1 stated they are no longer employed by the facility and could not recall if the resident or the family member were notified of any change in the resident's medications. The Director of Nursing Services was interviewed on 1/10/2024 at 11:29 AM. The Director of Nursing Services stated any licensed nurse can notify the resident or family regarding changes in resident care or medications. If a resident is alert, the resident should be made aware, along with the resident's representative, and document the notification in the resident's medical record. Physician #1 was interviewed on 1/10/2024 at 1:19 PM. Physician #1 stated they notify their patients themselves. Physician #1 stated when they document the resident's admission assessment, there is a box on the admission note indicating if the resident is able to understand and has the capacity. If the resident has capacity, they (Physician #1) communicate with the resident and if they (Physician #1) feel that the resident does not have capacity, they then will speak to the appointed care giver or the resident's representative. Physician #1 stated Resident #149 was alert, and they should have discussed with the use of Heparin with the resident. Physician #1 stated they might not always document the conversation they had with the resident. 10 NYCRR 415.3(f)(2)(ii)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 1/03/2024 and completed on 1/11/2024, the facility did not implement a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (Resident #81) of one resident reviewed for Dementia Care. Specifically, Resident #81 with a diagnosis of Diabetes Mellitus, had a Physician's order to monitor blood sugar via finger sticks every morning and to notify a Physician of blood sugar results of less than 60 milligrams per deciliter (mg/dL) or greater than 350 milligrams per deciliter (mg/dL) . There was no documented evidence that Resident #81's finger sticks were performed from 12/15/2023 through 1/08/2024 to obtain the blood sugar levels as per the physician's orders. The finding is: The facility's policy titled, Diabetic Finger Stick Parameters Policy last reviewed in July 2019, documented that all diabetic residents will receive proper blood sugar monitoring and treatment of fluctuation as needed. Resident #81 has diagnoses that include Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Dementia. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 5 which indicated the resident had severe cognitive impairment. The Minimum Data Set documented Resident #81 had a diagnosis of Diabetes Mellitus. The Physician's order dated 12/09/2023 documented to monitor the resident's blood sugar level one time a day and to notify the Physician for blood sugar levels less than 60 milligrams per deciliter (mg/dL) or greater than 350 milligrams per deciliter (mg/dL) . The Comprehensive Care Plan for Diabetes Mellitus dated 12/08/2023 documented interventions including to monitor blood work as ordered and to monitor and report signs and symptoms of Hyperglycemia (high blood sugar) or Hypoglycemia (low blood sugar). A review of the December 2023 Medication Administration Record indicated no documentation of the blood glucose levels from 12/15/2023 through 12/31/2023. A review of the January 2024 Medication Administration Record indicated no documentation of blood glucose levels from 1/01/2024 through 1/08/2024. Licensed Practical Nurse #1 was interviewed on 1/09/2024 at 11:03 AM and stated Resident #81 has an order for blood sugar to be checked one time a day in the morning. Licensed Practical Nurse #1 stated they could not find documentation of the blood sugar levels in the Medication Administration Record for Resident #81. When the resident returned from the hospital on [DATE] the admitting nurse should have ensured that the blood sugar monitoring order was transcribed onto the Medication Administration Record. Licensed Practical Nurse #1 stated if the order is entered into the Electronic Medical Record as other order then that order has to be manually entered into the Medication Administration Record. Licensed Practical Nurse #1 stated Resident #81 has not had their blood sugar checked from 12/15/2023 through 1/8/2024. The Director of Nursing Services was interviewed on 1/10/2024 at 11:35 AM and stated Resident #81 had a physician's order to monitor their blood sugar daily. The Director of Nursing Services stated they expected nursing staff to follow the physician's orders. The Director of Nursing Services stated a resident can become Hyperglycemic or Hypoglycemic when their blood sugars are not monitored. The Director of Nursing Services stated that nurses are responsible for monitoring and documenting the residents' blood sugar results. The Director of Nursing Services further stated that the admission nurse did not designate and add supplemental documentation to the blood sugar order which resulted in the transcription error. Physician #1 was interviewed on 01/10/2024 at 1:30 PM and stated they expected nursing staff to follow the Physician's order. Physician #1 stated they are not a fan of finger sticks but if an order is prescribed the nurse should follow the order. Physician #1 stated that if the blood sugar was not monitored as per the physician's order the resident may have possible adverse outcomes and experience clinical signs of Hypoglycemia or Hyperglycemia. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during a Recertification survey initiated on 1/3/2024 and completed on 1/11/2024, the facility did not ensure each resident received treatment and care in accordance with professional standards of practice in accordance with the resident's plan of care. This was identified for one (Resident #136) of one resident reviewed for Intravenous (IV) access. Specifically, Resident #136 had a Peripherally Inserted Central Catheter (PICC) line. The physician's orders included measuring the Peripherally Inserted Central Catheter length and the resident's arm circumference weekly and changing the injection cap of the Peripherally Inserted Central Catheter line access weekly. There was no documented evidence that the physician orders were followed for three of four weeks on the December 2023 Treatment Administration Record. The finding is: The policy and procedure for the Peripherally Inserted Central Catheter line dated July 2019 documented procedures and assessments to include - assessment of peripheral catheter sites during dressing changes and before and after administration of intermittent intravenous medications. The policy and procedure also documented the length of the external catheter and upper arm circumference is obtained during dressing changes. At each dressing change, a measurement of the external catheter length should be taken and compared to the initial external length to verify that the catheter tip has not migrated (moved). In addition, the circumference of the resident's arm will be measured 10 centimeters above the Peripherally Inserted Central Catheter insertion site upon admission and weekly with dressing changes. Injection cap changes will be done each week upon the dressing change and as needed. Resident #136 was admitted with diagnoses including Acute Osteomyelitis of the left ankle and foot, and local infection of the skin and subcutaneous tissue. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 8, which indicated the resident had moderately impaired cognition. The Physician's admission orders dated 11/16/2023 documented the care instructions for the Peripherally Inserted Central Catheter line as follows: -Registered Nurse (RN) to flush the Peripherally Inserted Central Catheter line before and after each infusion with 10 milliliters of Normal Saline followed by 5 cubic centimeters of Heparin (blood thinner). - Registered Nurse to measure the circumference of the arm 10 centimeters above the Peripherally Inserted Central Catheter insertion site upon admission, 24 hours after insertion, weekly with dressing changes, and as needed. -Registered Nurse to measure external catheter length on admission, weekly with each dressing change, and as needed. -Registered Nurse to flush the Peripherally Inserted Central Catheter line before and after each infusion with 10 milliliters of Normal Saline. -Registered Nurse to change the Peripherally Inserted Central Catheter dressing on admission, 24 hours after insertion, weekly, and as needed. The Physician's orders also included antibiotics to be administered via the Peripherally Inserted Central Catheter. The Comprehensive Care Plan (CCP) for Peripherally Inserted Central Catheter dated 11/16/2023 documented potential for catheter-related bloodstream infection, Phlebitis (inflammation of a vein near the surface of the skin), Deep Vein Thrombosis, catheter occlusion, catheter migration, and Infection. The interventions included to assess the site every two hours during continuous infusion, before and after each intermittent use, and every shift when not in use. Measure the circumference of the arm 10 centimeters above the insertion site upon admission, 24 hours after insertion, weekly with dressing changes, and as needed. Measure external catheter length on admission, weekly with each dressing change, and as needed. A review of the Treatment Administration Record (TAR) for December 2023 documented: -On 12/1/23- the Treatment Administration Record documented the resident's arm circumference was 27 centimeters and the Peripherally Inserted Central Catheter length was 8 centimeters. -On 12/8/2023, and 12/15/2023 there were no signatures or initials recorded to indicate that the Peripherally Inserted Central Catheter care was completed as per the physician's orders. -On 12/29/2023, there were no measurements of the Peripherally Inserted Central Catheter line length or the arm circumference documented. A Nursing progress note dated 12/8/2023 at 9:25 PM documented Resident #136 had left ankle Osteomyelitis. Daptomycin (antibiotic) intravenous was in progress as ordered until 12/29/2023. The Left upper extremity (LUE) Peripherally Inserted Central Catheter line was in place and was patent. The site dressing was changed. The progress note did not indicate the Peripherally Inserted Central Catheter length or the left extremity arm circumference. The Registered Nurse (RN) #5 Supervisor was interviewed on 1/8/2024 at 1:00 PM and stated that they provided Peripherally Inserted Central Catheter line care on 12/15/2023 and 12/29/2023; however, they forgot to document in the Treatment Administration Record on 12/15/2023 and 12/29/2023 that Peripherally Inserted Central Catheter line care was provided. Registered Nurse #5 stated as they recall the measurements for the arm circumference was 25 centimeters (cm) and the length of the Peripherally Inserted Central Catheter was 0 centimeters. Registered Nurse #5 stated they did not check the previous measurement to determine if the Peripherally Inserted Central Catheter line migrated (moved). Registered Nurse #5 stated that the changes in the Peripherally Inserted Central Catheter line length should have been reported to the physician but this was not done. The Director of Nursing Services (DNS) was interviewed on 1/8/2024 at 12:45 PM and stated the nurses should document the Peripherally Inserted Central Catheter length and the arm circumference measurements in the Treatment Administration Record to monitor the Peripherally Inserted Central Catheter site for dislodgement, infection, and complications. Physician# 2 was interviewed on 1/11/2024 at 11:53 AM and stated that it was important to measure and document the measurement of the Peripherally Inserted Central Catheter area to monitor for infiltration or thrombosis. If the catheter length or arm circumference changed, this should have been reported to them. Changes in the length of the Peripherally Inserted Central Catheter can cause complications. If the cap is not changed weekly, an infection can occur. 10 NYCRR 415.12

Based on observations, record review and interviews conducted during a Recertification Survey initiated on 1/3/2024 and completed on 1/11/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen observation conducted on 1/3/2024. Specifically, the reach-in refrigerator was observed with multiple trays of assorted desserts and nourishments that included three trays of vanilla pudding, one tray of applesauce, two trays of crushed pineapple, one tray of strawberry applesauce, and one tray of butterscotch pudding. The items on the trays were not labeled and dated. The finding is: Facility's policy titled Dating Food last reviewed on 1/5/2023 documented that all refrigerator items will be placed in the refrigerator with labels that identify the items and are dated. All prepared foods will be identified as to the date of preparation. Facility policy titled Food Storage last reviewed on 1/5/2023 documented that all containers of food will be stored covered, labeled, and dated. All potentially hazardous food prepared and held for more than 24 hours shall be clearly marked at the time of preparation to indicate the date by which the food shall be consumed. All potentially hazardous food prepared and held for more than 24 hours shall be consumed within seven calendar days or less from the day that the food is prepared if the food is maintained at a temperature of 41 degrees Fahrenheit (F) or less. A tour of the kitchen was conducted on 1/3/2024. A reach-in refrigerator located by the trayline area was inspected at 11:16 AM with the Director of Food Services present. A sheet pan rack was observed holding eight trays of assorted desserts and nourishment including three trays of vanilla pudding, one tray of applesauce, two trays of crushed pineapple, one tray of strawberry applesauce, and one tray of butterscotch pudding. All desserts and nourishments were stored in undated and unlabeled clear plastic cups. There were approximately 20-30 cups on each tray. The Director of Food Services (FSD) was interviewed immediately after the observation and stated that none of the desserts or nourishments seen in the refrigerator were prepared for today's (1/3/2024) meal. The Director of Food Services stated they (FSD) could not immediately indicate the exact dates when each dessert or nourishment item was prepared and how long the observed items have been in the refrigerator. The Director of Food Services believed that the items were leftovers from meal preparations since the previous week. The Director of Food Services stated that leftover desserts were typically stored in this refrigerator and could be used for 24 hours from the time the items were stored in the refrigerator and then discarded. The Director of Food Services checked the menu and stated that the crushed pineapples were likely prepped for dinner meal two days ago on 1/1/2024. The Director of Food Services stated that the desserts and nourishments without dates should be discarded because there was no way to establish how long those items had been in the refrigerator. The Director of Food Services stated that any dietary aide should re-date the leftover desserts indicating when the items were stored away in the refrigerator and should check and discard any items that were stored in the refrigerator for more than 24 hours. The Director of Food Services stated they and the supervisors should also check the refrigerators and make sure items are discarded on time. Dietary Aide #1, who was assigned to prepare dessert on 1/3/2024, was interviewed on 1/3/2024 at 11:17 AM. Dietary Aide #1 stated they did not prepare any of the desserts or nourishments that were found in the refrigerator. Dietary Aide #1 stated that those desserts were not prepared today. Dietary Aide #1 stated that they would always date the items on the trays. Dietary Aide #1 stated that sometimes there were leftovers after the resident's meal and the desserts would just be put back into the refrigerator without a re-date. Dietary Aide #2 was interviewed on 1/3/2024 at 11:23 AM. Dietary Aide #2 stated they did not assemble any of the dessert and nourishments that were found in the refrigerator. Dietary Aide #2 stated that the trays were already in the refrigerator before their shift started. Dietary Aide #2 stated if they were assigned to prepare dessert they (Dietary Aide #2) would place a completed tray into the refrigerator and would not date the desserts, especially the fruits, because they get used up so fast. Dietary Aide #2 stated that if they worked at the trayline and required a certain dessert or nourishment, they would check the nourishment refrigerator and take anything they needed. Dietary Aide #2 stated if the items were not dated, then they would not know how long these items were in the refrigerator. The refrigerator was inspected again on 1/4/2024 at 1:47 PM with the Director of Food Services. The Director of Food Services stated that they discarded all the desserts and nourishments for which they were unable to identify the date of preparation. The Director of Food Services stated moving forward, leftover desserts and nourishments must be discarded on the 4th day from the time the items were stored in the refrigerator. 10 NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00277754) completed on 1/18/2022 the facility did not ensure that each resident's representative was immediately informed when there was a need to alter treatment significantly. This was identified for one (Resident #314) of one resident reviewed for choices. Specifically, Resident #314's family member was not informed when the facility staff initiated a gradual dose reduction of the antipsychotic medication, Seroquel, on 5/5/2021. The finding is: The facility Family Notification policy dated 7/2019 documented that the facility must immediately notify the resident's interested family member when there is a need to alter treatment significantly. Resident #314 was admitted on [DATE] with the diagnoses of Non-Alzheimer's Dementia, Major Depressive Disorder with Psychotic Features, and Functional Quadriplegia. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #314 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated Resident #314 had severely impaired cognition. Resident #314 received an antipsychotic medication 6 of 7 days and a gradual dose reduction was done on 5/5/2021. The Hospital Discharge summary dated [DATE] documented to continue Seroquel 25 milligrams (mg) orally (PO) at bedtime and Seroquel 12.5 mg PO in the morning for a total of 37.5 mg daily. The admission Summary note dated 5/4/2021 at 23:02 (11:02 PM) documented Registered Nurse (RN) #2 reconciled medications with Resident #314's family member and reviewed Resident 314's medications with the Physician Assistant (PA). The Facility Physician's Orders dated 5/4/2021 documented to administer Quetiapine Tablet 25 mg 1 tablet by mouth at bedtime related to Unspecified Dementia without Behavioral Disturbance. The order was discontinued on 5/5/2021. The Physician's Orders dated 5/5/2021 documented to administer Quetiapine 25 mg 0.5 tablet (for a dose of 12.5 mg) in the evening for Mood Disorder. The Nurse's Note dated 5/5/2021 at 19:41 (7:41 PM) by Licensed Practical Nurse (LPN) #5 documented Resident #314 was on Seroquel gradual dose reduction day 1 of 7 days. Psychiatric consultation dated 6/1/2021 documented that Resident #314 had a history of combativeness, aggressive behavior towards staff. Current psychoactive medication included Seroquel 25 mg, half a tablet, and Haldol 2.5 mg intramuscular injection. The psychiatrist documented Resident #314 physically attacked staff and there was a concern for Resident #314 and other Residents' safety. The recommendation was to add Depakote 125 mg twice a day if not medically contraindicated and to continue other medications. The Medical Director's note dated 6/1/2021 documented that Resident #314's chart was reviewed, and the case was discussed with the unit nurse. Resident #314 returned from the emergency room after evaluation for ongoing agitation and combativeness. A recent Seroquel gradual dose reduction was initiated by the attending physician. The Medical Director documented that they will attempt to better manage combative and aggressive behaviors with Depakote to start at 125 mg in the morning and 250 mg in the evening with increased dosing if needed. The Seroquel at 12.5 mg will be discontinued. The attending physician was updated with the plan. The medical record lacked documented evidence of notification to Resident #314's family regarding the Seroquel dose reduction. Resident #314's Family member was interviewed on 1/12/2022 at 1:38 PM. The Family member stated that they did not get any updates from the facility until Resident #314's behavior was out of control in June 2021. The Family member stated that on 6/1/2021 they called the facility and spoke with LPN #4. The Family member asked LPN #4 what medications Resident #314 was receiving because Resident #314 was stable on Seroquel at home. The Family member stated they were informed by LPN #4 that Resident #314 was no longer on Seroquel. The Family Member stated that they were never informed of any adjustments to Resident #314's psychotropic medications and were not aware that Resident #314 had received Psychiatric evaluations at the facility. The attending physician or psychiatrist never reached out to them about the dosage adjustments nor to obtain a history regarding Resident #314's medication use. RN #2, the admission Nurse, was interviewed on 1/12/2022 at 2:04 PM. RN #2 stated that they reconciled the medication for Resident #314 with PA #1 by going over the hospital discharge list. RN #2 stated that they did not review the prescribed amount of Seroquel with Resident #314's family member. The Attending Physician was interviewed on 1/12/2022 at 2:12 PM and stated that the Medical Director and the Psychiatrist managed all the resident's psychotropic medication regimens. The Attending Physician further stated that they did not have a conversation with Resident #314's Family member regarding the gradual dose reduction of Seroquel. LPN #5 was interviewed on 1/12/2022 at 3:51 PM and stated that they did not call Resident #314's family member to inform them of the change in treatment orders for Seroquel. LPN #6 was interviewed on 1/12/2022 at 4:15 PM and stated that they entered the order into the medical record on 5/5/2021 and did not call the family member to inform them of the change in the Seroquel orders. LPN #4, Unit Manager, was interviewed on 1/13/2022 at 10:14 AM and stated that they (LPN #4) had previously spoken to the family member, however, did not discuss Seroquel dose reduction until 6/1/2021. PA #1 was interviewed on 1/13/2022 at 10:55 AM and stated that typically they reconcile the hospital medications with what was received at home and what was recommended by the hospital. PA #1 stated that they did not discuss a gradual dose reduction of Seroquel with Resident #314's family member on 5/4/2021. RN #4 was interviewed on 1/13/2022 at 3:55 PM. RN #4 stated that they were the RN Supervisor for the building overnight on 5/5/2021 and did not inform the family member of the change in Seroquel dosage. RN #4 stated that nurses are expected to document family notification of change in treatments in the medical record. The Director of Nursing Services (DNS) was interviewed on 1/14/2022 at 10:26 AM and stated that the nursing staff are expected to notify family members of changes in treatment. The DNS further stated the nursing staff should have called Resident #314's family member to update them on the Seroquel dose reduction. 415.3(e)(2)(ii)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00276066) completed on 1/18/2022, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health (NYSDOH) for one (Resident #364) of four residents reviewed for Accidents. Specifically, Resident #364 was care planned for two-person assistance for bathing. however, the resident was showered only by one Certified Nursing Assistant (CNA) and was not properly secured with a safety belt while sitting on the shower chair. Subsequently, Resident #364 fell to the floor and sustained a head injury resulting in a Subdural Hematoma. The facility did not report the incident to the NYSDOH. The finding is: The facility's policy titled Abuse Mistreatment and Neglect dated July 2019 documented the term neglect shall mean failure to provide timely, consistent, safe, adequate, and appropriate services, treatment, and/or care. All evidence is reviewed by the Administrator, Director of Nursing Services (DNS), and a decision is made to notify the NYSDOH. The facility's policy titled Showering a Resident using the Shower Chair dated July 2019, documented to secure the resident with a safety belt in the shower chair to transport the resident. Resident #364 was admitted with diagnoses including Metabolic Encephalopathy, Asthma, and Chronic Obstructive Pulmonary Disease. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident was rarely or never understood and the Brief Interview for Mental Status (BIMS) was not conducted. The MDS documented that Resident #364 required extensive assistance of two persons for bed mobility, transfer, dressing, toilet use, and personal hygiene; and total dependence of two persons for bathing. A Comprehensive Care Plan (CCP) for Activity of Daily Living (ADL) dated 3/19/2021 documented Resident #364 required assistance with ADLs as evidenced by confusion, Dementia, and limited mobility. The interventions included but were not limited to providing the assistance of two staff members for bathing/showering twice weekly and as necessary; assistance of two staff members for dressing; and assistance of two staff members for transfers from the wheelchair to the bed with a rolling walker. The Accident/Incident (A/I) Investigation dated 5/5/2021 documented that at 6 PM, CNA #5 reported that Resident #364 was on the ground in the bathroom. CNA #5 who was assigned to the resident stated that Resident #364's shower was just completed. CNA #5 turned around to get a pair of gloves so they (CNA #5) could apply lotion to the resident and when CNA #5 turned back around the resident was on the ground. CNA #5 notified the Registered Nurse (RN) Supervisor (RN #4). RN #4 went into the bathroom and observed the resident on the floor laying on the right side in front of the shower chair. RN #4 assessed the resident and noted a large hematoma to the right side of the head and a small reddened area to the upper back. The floor was wet from the shower. An investigative summary dated 5/6/2021 documented that upon investigation it was determined that the safety belt was not used when the resident was in the shower chair. The facility ruled out abuse, neglect, or mistreatment. There was no documentation that the NYSDOH was notified of the resident's injury. The Director of Nursing Services (DNS) was interviewed on 1/18/2022 at 11:05 AM and stated they (DNS) had reviewed and investigated the incident related to Resident #364's fall. The DNS stated that the CNAs were expected to use the safety belt to secure the resident while the resident was sitting in the shower chair and through re-enactment, it was discovered that the CNAs did not use the safety belt. The DNS stated that Resident #364 sustained a head injury and was found to have a Subdural Hematoma. The DNS further stated that the incident did not need to be reported to NYSDOH because there was a breach of the facility's policy and not of the resident's plan of care. The Administrator and the DNS were interviewed concurrently on 1/18/2022 at 2:03 PM and stated that the original manufactured shower chairs did not have a safety belt feature. The facility had re-designed the shower chairs and added safety belts for extra safety. They both stated that the staff were educated and expected to use the safety belt when providing a shower. 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY00277754) completed on 1/18/2022 the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice for one (Resident #314) of one Resident reviewed for choices. Specifically, Resident #314 had a history of receiving Seroquel (an antipsychotic medication) 25 milligrams (mg) per day in the community. Resident #314 was hospitalized after a fall at home and was discharged to the facility with recommendation to receive Seroquel 37.5 mg total daily. The facility Physician prescribed Seroquel 12.5 mg daily without obtaining Resident #314's history for Seroquel usage and did not obtain a psychiatry consult until 20 days after the gradual dose reduction when the resident started to exhibit behavioral changes. The finding is: The facility's Gradual Dose Reduction and Psychoactive Medication policy dated 7/2019 documented all residents on psychoactive medications must have a psychiatric consultation and follow up as per the attending Physician's recommendations and orders. When the order is written for a psychoactive drug, an appropriate diagnosis must be written and documentation must exist that states all other means have been attempted to modify the behavior. Resident #314 was admitted with the diagnoses of Non-Alzheimer's Dementia, Urinary Tract Infection and Functional Quadriplegia. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #314 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognitive function. The MDS documented that Resident #314 had no signs and symptoms of Delirium, no indicators of psychosis, no physical behaviors directed towards others and no verbal behaviors directed towards others during the assessment period. The MDS further documented Resident #314 exhibited wandering behavior 1 to 3 days of the assessment period. Resident #314 received an antipsychotic medication 6 of 7 days and the gradual dose reduction was done on 5/5/2021. The Hospital admission History and Physical dated 4/26/2021 documented that Resident #314 had presented to the hospital after a fall at home. Home medications included Quetiapine (Seroquel) 25 milligram (mg) tablet daily at bedtime. Resident #314's behavior was documented as appropriate and cooperative. The plan of care documented to continue home medications including Seroquel 25 mg. The Hospital Discharge summary dated [DATE] documented to continue Seroquel 25 mg orally (PO) at bedtime and Seroquel 12.5 mg PO in the morning (a total of 37.5 mg daily). The Facility Physician's admission orders dated 5/4/2021 documented to administer Quetiapine Tablet 25 mg, 1 tablet, by mouth at bedtime related to Unspecified Dementia without Behavioral Disturbance. The order was discontinued on 5/5/2021. The Physician's Orders dated 5/4/2021 documented to obtain a psychiatry evaluation to determine the effectiveness of medications and evaluation for gradual dose reduction of the psychotropic medication. The admission Summary note dated 5/4/2021 at 23:02 (11:02 PM) documented Registered Nurse (RN) #2 reconciled medications with Resident #314's family member and reviewed the medications with the Physician Assistant (PA). The Physician's orders dated 5/5/2021 documented to administer Quetiapine 25 mg, half a tablet (for a dose of 12.5 mg) in the evening for Mood Disorder. The Nurse's Note dated 5/5/2021 at 19:41 (7:41 PM) by Licensed Practical Nurse (LPN) #5 documented Resident #314 was on Seroquel gradual dose reduction day 1 of 7 days. The Nursing Progress Note dated 5/9/2021 documented Resident #314 was self ambulating, calling out, and cursing at staff. Resident #314 was redirected several times. Activities, snacks and toileting provided with little effect. Gradual dose reduction of Seroquel was in progress. The Nursing Progress Notes dated 5/10/2021 documented Resident #314 was on day 6 of 7 of the gradual dose reduction of Seroquel. Resident #314 was noted to stand up from the wheelchair multiple times unassisted and was encouraged to ask staff for help prior to standing alone. Resident #314 was noted to become argumentative towards staff. The Physician's progress note, written by the attending Physician, dated 5/10/2021 at 14:58 (2:58 PM) documented Resident #314 was aggressive with staff at times as witnessed by the Physician. The plan was to monitor the resident's behaviors. The Physician documented that the resident had a recent gradual dose reduction which may need adjustment. The Nursing Progress Note dated 5/11/2021 documented Resident #314 was on day 7 of 7 for the gradual dose reduction. Resident #314 was alert, pleasantly confused, non-compliant and frequently got out of bed unassisted. The nursing progress note dated 5/12/2021 documented that bloodwork was unable to be obtained this morning by the technician. Resident #314 was screaming out and yelling at the technician. The Nursing Progress Note dated 5/12/2021 documented Resident #314 was verbally aggressive during care and was screaming at the staff. The Physician's progress note dated 5/12/2021 at 14:52 (2:52 PM) documented that Resident #314 was seen with variable mentation and Dementia and associated combative behaviors. The attending Physician documented a recent gradual dose reduction of Seroquel and the plan was to address the variable mentation and to follow the resident's clinical status. The physician's progress note dated 5/14/2021 at 14:30 documented that Resident #314 was seen for deconditioning, unsteady gait, Advanced Dementia, a decrease of awareness of limitations, and inherent non-adherence to staff direction. The plan was to follow the clinical status on the recent Seroquel gradual dose reduction. The Nursing Progress Note dated 5/16/2021 documented Resident #314 was noted to self ambulate into other resident rooms. Redirected multiple times with no effect. Resident #314 noted to become aggravated at times. The Nursing Progress Note dated 5/18/2021 documented Resident #314 was restless with attempts to self transfer. Resident #314 became aggressive several times this shift with staff redirection. The Social Work note dated 5/18/2021 at 11:54 AM documented Resident #314 would benefit from a room change onto the secure unit to ensure the resident's safety as Resident #314 required additional oversight. The Nursing Progress Note, written by the Licensed Practical Nurse (LPN) #4, dated 5/19/2021 documented Resident #314 ambulated with staff in the hallway, was extremely resistive to care despite a gentle approach. A two-person approach was utilized with no effect. Resident #314 was swinging fists at staff. The attending Physician was notified and no new orders were obtained. The attending Physician instructed to send the resident to the hospital if the resident (behavior) can not be managed (at the facility). Resident #314 remains irritable but no longer physically combative. The nursing progress note dated 5/25/2021 documented Resident #314 exhibited with increased agitation and aggressive behaviors. Resident #314 was walking into other residents rooms, yelling at their roommate to get out of bed, and yelling at staff when being redirected. The Psychiatric Evaluation dated 5/25/2021 documented the nursing staff reported that Resident #314 was combative and physically aggressive towards staff but was easily redirected. Resident #314's behavior was unpredictable. The primary medical history diagnosis included Major Depressive Disorder with psychotic symptoms and Dementia with behavioral disturbance. Resident #314 was noted to be uncooperative with poor insight/judgment during the interview. The plan was to recommend the continuation of current medications which included Seroquel 12.5 mg and a follow-up in 3 months. On 5/31/2021 LPN #4 documented that the attending Physician was called. The Physician stated to LPN #4 if the staff cannot handle Resident #314, send Resident #314 to the hospital. Resident #314 was extremely unpredictable and aggressive. Resident #314 continued to be combative with staff despite a gentle approach. Resident #314 got out of bed and ran at staff, yelling with fists up to threaten staff. The resident was beginning to swing fists at staff again. As per the attending physician's order, 2.5 mg of Haldol was administered intramuscularly and Resident #314 was sent to the hospital for evaluation. The Skilled Nursing Facility to Emergency Department Communication Form (Transfer Form) dated 5/31/2021 documented Resident #314 was combative and aggressive and needed psychiatric evaluation. Resident #314's mental status was documented as anxious, combative, agitated, and alert with Dementia. Resident #314's Family member was interviewed on 1/12/2022 at 1:38 PM. The Family member stated that they did not get any updates from the facility until Resident #314's behavior was out of control in June 2021. The Family member stated that on 6/1/2021 they called the facility and spoke with LPN #4. The Family member asked LPN #4 what medications Resident #314 was receiving because Resident #314 was stable on Seroquel at home. The Family member stated they were informed by LPN #4 that Resident #314 was no longer on Seroquel. The Family Member stated that they were never informed of any adjustments to Resident #314's psychotropic medications and were not aware that Resident #314 had received Psychiatric evaluations at the facility. The attending physician or psychiatrist never reached out to them about the dosage adjustments nor to obtain a history regarding Resident #314's medication use. RN #2, the admission Nurse, was interviewed on 1/12/2022 at 2:04 PM. RN #2 stated that they reconciled the medication for Resident #314 with PA #1 by going over the hospital discharge list. RN #2 stated that they did not review the prescribed amount of Seroquel with Resident #314's family member. The Hospital Discharge Medication List dated 5/4/2021 documented Resident #314 was prescribed Quetiapine (Seroquel) 25 mg tablet 1 tablet oral daily at bedtime and Quetiapine (Seroquel) 25 mg 0.5 tablet oral (PO) daily for a total of 37.5 mg per day. The medication list had handwritten check marks next to the medications listed. The Attending Physician was interviewed on 1/12/2022 at 2:12 PM and stated that the Medical Director directed them (Attending Physician) to globally taper Seroquel in the facility for all residents. The Attending Physician stated that they (Attending Physician) were following the Medical Director's orders and was not involved in managing Resident #314's psychotropic medication regimen throughout Resident #314's stay at the facility. The Physician was not aware of the resident's historical use of Seroquel for behavior management. The Attending Physician stated the Medical Director managed the resident's psychotropic medication regimen. The Physician stated that the dosage was so low that it was atypical to be effective but anecdotally has observed residents in the past who became unstable like Resident #314. The Attending Physician stated that they did not have a conversation with Resident #314's Family Member, hospital physicians or community physician regarding the use of Seroquel and history of mental health diagnosis. The Attending Physician further stated that they did not review the hospital records to further assess Resident #314's psychotropic regimen. PA #1 was interviewed on 1/13/2022 at 10:55 AM and stated that they reconciled the hospital medications with what was received at home and what was recommended by the hospital. PA #1 stated that the Attending Physician would review the medication regimen again and make the final adjustments. PA #1 stated that they did not recall initiating a gradual dose reduction of Seroquel for Resident #314. LPN #3 (Unit Manager of unit 5) was interviewed on 1/3/2022 at 9:51 AM. LPN #3 stated they worked with Resident #314 when they covered various shifts on Unit 5 in May 2021. Resident #314 was very restless and wandered through the hallways in the beginning of Resident #314's stay. LPN #3 stated that Resident #314's room was changed to the Dementia locked unit to maintain Resident #314's safety. LPN #4, Unit Manager of Unit 3, was interviewed on 1/13/2022 at 10:14 AM and stated that on 5/18/21, they received Resident #314 on Unit 3. LPN #6 (the Unit 5 Manager on that day) told them that the gradual dose reduction for Resident #314 was not working and the Attending Physician had directed Resident #314 to be moved to the Dementia Unit as an alternative to adjusting the psychiatric medication. LPN #4 stated that Resident #314 was very erratic from the first day they were transferred to Unit 3. Initially, Resident #314 would visit the activities but eventually refused them. Resident #314 would then stay in the room and place their bed sheets over their head. Throughout the course of Resident #314's stay, Resident #314 became more aggressive, unpredictable and too confused to respond appropriately to interventions. Resident #314 would yell at others, wander into other resident's rooms and make them feel unsafe by putting up fists and using threatening language. Redirection was totally ineffective, and Resident #314 was suspicious of everyone who was around them. LPN #4 stated that they (LPN #4) sustained bruising from the physical attacks Resident #314 would inflict. LPN #4 stated that staff tried diversional activities for Resident #314 with no success. LPN #4 stated that they regularly communicated the challenges with the attending Physician. LPN #4 stated that they expressed concern for Resident #314 and the ineffectiveness of the gradual dose reduction, but the Attending Physician told them to just continue to redirect Resident #314. LPN #4 stated that the Attending Physician did not take any consideration for the nurses expressed concerns that Resident #314 was a danger to themselves and others and the Physician refused to adjust Resident #314's psychotropic medication. LPN #4 stated that they spoke with Resident #314's family member about the violent behaviors and the family member informed LPN #4 the that Resident #314 did not have these behaviors at home and was stable on 25 mg of Seroquel per day. PA #2, the consulting psychiatric physician's assistant, was interviewed on 1/13/2022 at 11:18 AM. PA #2 stated that they received a referral from the social worker for an evaluation and reviewed the case with nursing regarding Resident #314's combative behavior on 5/24/2021. PA #2 stated that they reviewed the medical history in the record, and the nursing notes when they evaluated Resident #314. Resident #314 was a poor historian and PA #2 did not speak with the family member bout the resident's history. PA #2 was not aware that Resident #314 received Seroquel prior to admission and of the resident's historical mental health diagnosis. PA #2 stated that they refrain from using Seroquel without a known history and will try to utilize other medications. PA #2 stated that they were not aware of any psychiatric history for Resident #314 and thought that mood stabilization would be better treated with Depakote. PA #2 stated that they never worked with the Medical Director regarding Resident #314 and did not speak with the Attending Physician. PA #2 further stated that the attending Physician makes the final determination regarding the prescription recommendations. Certified Nursing Assistant (CNA) #3, the regularly assigned Unit 3 Dayshift CNA for Resident #314, was interviewed on 1/13/2022 at 11:47 AM. CNA #3 stated that Resident #314 was very pleasant and wandered around the unit in the beginning of the stay on Unit 3. Resident #314 would participate in activities and interact with the other residents. Resident #314 later refused to get out of bed and accept assistance from CNA #3. Resident #314 became combative towards others and was aggressive with staff. Redirection and reapproaching was not working with Resident #314. The Medical Director was interviewed on 1/13/2022 at 1:28 PM. The Medical Director stated that they were not involved with Resident #314's care until they were reviewing medical records for antipsychotic medication usage on 6/1/2021. The Medical Director stated that they observed Resident #314's order for Seroquel which was 12.5 mg daily and thought it was unnecessary because it was so low. The Medical Director then reviewed Resident #314 with the nursing staff and was informed of Resident #314's decline and worsening behaviors. The Medical Director stated they were surprised that Resident #314 was doing poorly and was not informed by either the attending physician, the psychiatrist, or nursing prior to 6/1/2021. The Medical Director stated that they did not direct the staff to lower Seroquel dose for Resident #314. However, the staff follows the facility protocol for dose reduction if the resident did not have a history of significant mental illness. The Medical Director stated that they would not have made a drastic reduction from 37.5 mg to 12.5 mg and would have instead reduced the medication to 12.5 mg twice a day for a total of 25 mg daily. The Medical Director stated that had they been informed of Resident #314's instability, they would have added Depakote sooner, prior to 6/1/2021, to help with mood stabilization. 415.12

Based on observation, record review, and interviews during the Recertification Survey completed on 1/18/2022 the facility failed to ensure an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases including COVID-19 infection was implemented on 2 of 5 nursing units. Specifically, 1) during the medication pass observation on Unit 2 on 1/11/2022, the Licensed Practical Nurse (LPN) #1 did not wear appropriate personal protective equipment (PPE) when providing medications and checking blood sugar for Resident #26 who was on contact and droplet precautions; in addition, LPN#1 did not wear gloves while administering insulin; 2) on Unit 2 two certified nursing assistants (CNA #1 and #2) did not wear appropriate PPE when adjusting Resident #68 in bed, who was on contact and droplet precautions; 3) on Unit 4, a family member of Resident #55, who was on contact and droplet precautions, was observed exiting the resident's room and walking down the hallway wearing a disposable gown. The findings were: The facility's policy titled Administration and Preparation of Insulin Injection, dated September 2019, documented to don (put on) gloves prior to insulin administration. The facility's policy titled Personal Protective Equipment-Gowns, Aprons, Other Protective Coverings, dated March 2020, documented that personnel must wear a gown, apron, or other protective covering when performing tasks that will likely soil the employee's clothing with blood, body fluids, secretions, or excretions. The facility's policy titled Transmission-Based Precautions, dated November 2020, documented that healthcare personnel caring for patients on contact precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning (putting on) upon room entry and discarding before exiting the patient room is done to contain pathogens; and healthcare personnel caring for patients on droplet precautions wear a gown, gloves, mask, and goggles. 1) Resident #26 was admitted with diagnoses including Diabetes Mellitus, Cerebrovascular Accident, and Depression. The 10/18/2021 Annual Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A physician's order for Resident #26, dated 1/1/2022, documented droplet/contact precautions secondary to COVID-19 exposure. On 1/11/2022 at 8:15 AM on Unit 2, an observation was made of Resident #26's medication administration. Signs affixed to Resident #26's door included Contact Precautions, Droplet Precautions, and Stop and Report to Nurse Before Entering Room and there was a sign showing how to put on PPE. The LPN medication nurse (LPN #1) was wearing an N95 mask and a surgical mask on top of the N95. LPN #1 entered Resident #26's room and performed a fingerstick to check the resident's blood sugar. LPN #1 put gloves on but did not put on a gown or goggles. After LPN #1 performed the fingerstick they (LPN #1) exited the room and were asked by the surveyor if a gown and goggles should have been used as the resident was on contact and droplet precautions. LPN #1 stated that they (LPN #1) probably should have put a gown and goggles on. LPN #1 then proceeded to prepare Resident #26's medications at the medication cart, including oral medications, eye drops, and an insulin pen, and then re-entered the resident's room and administered these same medications. LPN #1 did not put on a gown, eye goggles, or gloves upon room entry and did not wear gloves when administering the insulin to the resident's abdomen. LPN #1 was observed coming in contact with the resident's bedsheets and clothing during the medication administration. The only time LPN #1 put on gloves was to administer the eye drops. LPN #1 was asked by the surveyor if gloves should have been worn when administering insulin and LPN #1 stated they (LPN #1) probably should have. The Director of Nursing Services (DNS) was interviewed on 1/11/2022 at 9:30 AM and stated that LPN #1 definitely should have been wearing full PPE, including a gown, gloves, and goggles, when caring for a resident in a room that is on contact and droplet precautions and should have been wearing gloves when administering insulin. The DNS stated whenever staff go in the rooms with contact and droplet precaution signs the staff are supposed to wear full PPE. The Infection Preventionist (IP) was interviewed on 1/12/2022 at 10:36 AM and stated if staff are touching a resident who is on contact and droplet precautions, this is considered providing care. The staff must put on full PPE, including gowns, gloves, and eye goggles when entering the room, and then remove the PPE before exiting the room. The IP further stated that LPN #1 was supposed to wear gloves when administering insulin. The Inservice Coordinator (IC) was interviewed on 1/12/2022 at 10:44 AM and stated that for residents on contact and droplet precautions all PPE must be put on at the resident's doorway, including gowns and goggles, and then the PPE must be removed before leaving the room. The IC further stated LPN #1 should have worn gloves when administering insulin. The Administrator was interviewed on 1/14/2022 at 12:21 PM and stated all staff are supposed to adhere to the infection control guidelines and wear PPE appropriately. 2) Resident #68 was admitted with diagnoses including Non-Alzheimer's Dementia, Depression, and Heart Failure. The 11/13/2021 Annual Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. A physician's order for Resident #68, dated 1/1/2022, documented droplet/contact precautions secondary to COVID-19 exposure. Two Certified Nursing Assistants (CNA #1 and #2) were observed positioning Resident #68 in the bed (the resident had slid down in bed) on 1/11/2022 at 8:27 AM. Signs affixed to Resident #68's door included Contact Precautions, Droplet Precautions, and Stop and Report to Nurse Before Entering Room. Both CNAs were wearing N95 masks and surgical masks on top of the N95 masks and had put on gloves. Both CNAs were not wearing eye goggles or gowns. CNA #1 and CNA # 2 were interviewed concurrently on 1/11/2022 at 11:23 AM. The CNAs stated they (CNA #1 and #2) were in a rush, and were supposed to wear gowns and goggles. Both CNA #1 and CNA #2 stated they had made a mistake. The Director of Nursing Services (DNS) was interviewed on 1/11/2022 at 9:30 AM and stated the staff are supposed to wear full PPE whenever they are in the rooms with contact and droplet precaution signs when providing care to the residents. The DNS stated the two CNAs (CNA #1 and CNA #2) should have had gowns and goggles on when coming in contact with Resident #68. The Infection Preventionist (IP) was interviewed on 1/12/2022 at 10:36 AM and stated if staff are touching a resident who is on contact and droplet precautions, this is considered providing care. The staff must put on full PPE, including gowns, gloves, and eye goggles when entering the room, and then remove the PPE before exiting the room. The IP stated this is to protect the staff and the residents. The Inservice Coordinator (IC) was interviewed on 1/12/2022 at 10:44 AM and stated that for residents on contact and droplet precautions all PPE must be put on at the resident's doorway, including gowns and goggles, and then the PPE must be removed prior to leaving the room. The Administrator was interviewed on 1/14/2022 at 12:21 PM and stated all staff are supposed to adhere to the infection control guidelines and wear PPE appropriately. 3) Resident #55 was admitted with diagnoses including Heart Failure, Renal Insufficiency, and Morbid Obesity. The 11/5/2021 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A physician's order for Resident #55, dated 1/4/2022, documented droplet/contact precautions secondary to COVID-19 exposure. Review of the Visitors Expectations Fact Sheet, which was located at the reception desk in the lobby Revised on 1/3/2022, documented: If your loved one is on isolation precautions you must wear all necessary PPE while visiting a resident room. There is signage on the resident room doors indicating isolation precautions and to see the nurse before entering. Instructions on how to apply and remove PPE, including a gown, were taped to the resident room doors. PPE must be removed before exiting the room. LPN #2 was observed preparing medications for administration outside of Resident #55's room on 1/11/2022 at 9:04 AM. Signs affixed to Resident #55's door included Contact Precautions, Droplet Precautions, and Stop and Report to Nurse Before Entering Room. The door was closed. While the nurse was preparing the medications, a family member came out of Resident #55's room wearing a disposable gown, asked LPN #2 to untie the gown from the back, and then walked down the hallway with the gown still on in full view of LPN #2. Moments later another staff member noticed the family member walking down the hallway with the gown on, asked the family member to remove the gown, and reminded the family member that the gown has to be removed before exiting the resident's room. LPN #2 was interviewed on 1/11/2022 at 10:43 AM and stated gowns are not to be worn in the hallway. The Infection Preventionist (IP) was interviewed on 1/12/2022 at 10:36 AM and stated that staff have to educate and remind families to remove gowns when a family member exits the resident's room. The IP stated LPN #2 should have asked the family member to remove the gown before walking down the hallway. The IP stated families are educated about wearing PPE and there are signs on the doors that instruct how to put on and remove PPE. Resident #55's family member was interviewed on 1/13/2022 at 10:14 AM and stated that they (the family member) did not know the protocol and no staff member had explained the protocols to them. The family member stated they (the family member) were not given instructions in the lobby when being screened. The receptionist was interviewed on 1/14/2022 at 10:11 AM and stated that the family members are given the fact sheet and are told there are precautions on certain units and there are signs on doors to see the nurse for help to put on PPE. The Administrator was interviewed on 1/14/2022 at 12:21 PM and stated families have to be continually reminded about the proper use of PPE. 415.19(a)(1-3)