Every finding on record at Harlem Center for Nursing and Rehabilitation, L L

Based on observations, interviews, and record review during an on-site abbreviated survey (457794), it was determined that for five (Second, Third, Fourth, Fifth, and Sixth Floors) of five resident-occupied floors, the facility did not maintain a comfortable environment. Issues included residents feeling uncomfortable and resident room temperatures ranging from 46 F to 57 F, from approximately 3:00 AM on 12/16/2025 through approximately 4:00 PM on 12/17/2025.Observations in the presence of the Director of Maintenance during an initial tour of the facility on 12/17/2025, between 9:30 AM and 10:30 AM, included but were not limited to the following: Utilizing an infrared temperature gun, the temperatures in resident rooms on the Sixth Floor were recorded at 49.4 F in resident room [ROOM NUMBER], with the highest temperature 54.6 F in resident room [ROOM NUMBER]. The corridor temperature was 54.6 F, and the Day Room was 60.2 F.Utilizing an infrared temperature gun, the temperatures in resident rooms on the Fifth Floor were recorded at 51.7 F in resident room [ROOM NUMBER], with the highest temperature 55.5 F in resident room [ROOM NUMBER]. The corridor temperature was 57.8 F, and the Day Room was 57.9 F.Utilizing an infrared temperature gun, the temperatures in resident rooms on the Fourth Floor were recorded at 52.5 F in resident room [ROOM NUMBER], with the highest temperature 58.5 F in resident room [ROOM NUMBER]. The corridor temperature was 58.7 F, and the Day Room was 62.8 F.Utilizing an infrared temperature gun, the temperatures in resident rooms on the Third Floor were recorded at 52.9 F in resident room [ROOM NUMBER], with the highest temperature 57.6 F in resident room [ROOM NUMBER]. The corridor temperature was 60.4 F, and the Day Room was 62.8 F.Utilizing an infrared temperature gun, the temperatures in resident rooms on the Second Floor were recorded at 46.9 F in resident room [ROOM NUMBER], with the highest temperature 58.3 F in resident room [ROOM NUMBER]. The corridor temperature was 58.4 F, and the Day Room was 59.2 F.Utilizing the facility's digital cooking thermometer, fourteen (14) water temperatures in resident bathroom sinks and three (3) Day Room sinks were measured. The temperatures were as low as 48 F and as high as 52 F. On 12/17/2025 at 4:20 PM, it was noted that the rental heating units were arriving at the facility. In an interview on 12/17/2025 at approximately 12:00 PM, the Administrator stated the facility did not report the loss of heat to the Department of Health because she thought it was not necessary to call unless it lasted longer than 4 hours. In an interview on 12/17/2025 at approximately 9:30 AM, the Director of Maintenance stated their boiler vendor was at the facility the day before (12/16/2025), changed a pump, and the boiler began to run in the evening of 12/16/2025. The Director of Maintenance further stated that the fix was short-lived, and the vendor returned on 12/17/2025 to assess that the supply line was clogged and needed to be cleaned. The Director of Maintenance further stated that he expected the heat to be running within an hour or two. Record review of the facility's policy titled Extreme Weather-Cold, reviewed 12/17/2025, revealed that the facility is to take immediate actions when the facility's heating systems are inoperable to maintain temperatures within the facility at 71 F - 81 F. General Procedures for loss of heating: provide blankets, warm beverages, establish warming centers, consider evacuation, and notify the New York State Department of Health.

Based on record review and interviews conducted during the Abbreviated Survey (Complaint #2634618) the facility failed to ensure that one (1) (Resident #1) of three (3) residents reviewed for quality of care, received treatment and care in accordance with professional standards of practice. Specifically, an order for comprehensive metabolic panel and complete blood count was made for Resident #1 but was not carried out. There was no documentation available in the medical record to explain why the test was not completed. The findings include:The undated facility policy titled Physician Services documented the resident's Attending Physician is responsible for prescribing new therapy, ordering a transfer to the hospital, conducting required routine visits, delegating and supervising follow-up visits from Nurse Practitioners or Physician Assistants, etc., to ensure that the resident receives quality care and medical treatments.Resident #1 had diagnoses of Diabetes Mellitus, Hypertension, and Urinary Tract Infection.The admission Minimum Data Set assessment dated [DATE] documented that Resident #1 had moderately impaired cognition.A nurse's progress note dated 09/20/2025 at 3:22 PM documented the registered nurse was called to assess Resident #2 with complaints of headache, abdominal pain, and chest pain. The note documented that telehealth was consulted and that they spoke with the nurse practitioner who ordered chest x-ray, comprehensive metabolic panel, and complete blood count. A physician's order dated 09/20/2025 documented Comprehensive Metabolic Panel and Complete Blood Count with Auto Differential one time only related to Chest pain, stat (immediately).A telehealth notes by Nurse Practitioner #1 dated 9/20/2025 at 2:52 PM documented Resident #1 reported having headache, mild chest pain, and abdominal pain. The resident's last bowel movement was yesterday, and the resident was not passing gas. Orders were placed for laboratory and imaging to evaluate for infection, constipation, or other abdominal process. Comprehensive metabolic panel and complete blood count were ordered to assess metabolic and infectious status.There was no documented evidence in Resident #1's medical record that the complete blood count and comprehensive metabolic panel were drawn. There was no documentation available in the medical record to explain why the tests were not completed.A progress note by Physician #1 dated 09/22/2025 documented that Resident #2 was seen and examined for abnormal urine. There was no documentation in the progress note stating that comprehensive metabolic panel and complete blood count were no longer necessary. On 10/24/2025 at 12:20 PM, Registered Nurse #2 who was the nursing supervisor, was interviewed and stated they do not recall Resident #1's stat labs that were ordered on 09/20/2025. Registered Nurse #2 stated they cannot explain what happened and why the blood work was not done and followed up. On 10/22/2025 at 2:35 PM, Physician #1 was interviewed and stated the telehealth note on 09/20/2025 was from a weekend on call provider. Resident #1 was having headaches and abdominal pain. The note documented on their plan that they wanted to do a chest x-ray and blood work. Physician #1 stated that the chest x-ray was completed, and a urine sample was obtained to rule out an infection. Physician #1 stated they do not think that blood work was necessary when they returned to work on Monday, 09/22/2025, since the findings from 09/20/2025 confirmed a urinary tract infection which explained Resident #1's symptoms.On 10/24/2025 at 1:47 PM, the Director of Nursing was interviewed and stated they think that the order was not completed because the resident refused blood drawing. The Director stated that if a laboratory order was not completed, the reason should be documented in the medical record. On 10/24/2025 at 11:16 AM, the Medical Director was interviewed and stated when the primary physician comes back in after the weekend, they follow up on any telemedicine orders and either continues the orders or makes necessary changes based on the physical assessment of the resident. Any critical issues that occurred over the weekend that need attention are communicated on the dashboard for the physician to review on Monday. In an ideal situation progress notes should document why the laboratory work was not done. On 10/24/2025 at 2:12 PM, the Administrator was interviewed and stated if a resident refuses to have their blood drawn, the laboratory technician would communicate this with nursing. On Mondays, physicians should review the dashboard and follow up and agree or not agree with the telehealth orders. The Administrator stated they believe the laboratory technician came because the confirmation number is in the progress notes. It could have been that Resident #1 refused to have their blood drawn, stating that Resident #1 had history of refusals. The Administrator also stated that if a resident refused blood draw, the nurse should have communicated this with the physician and documented in the medical record. 10 NYCRR 415.12

Based on observation, record review, and interviews during an abbreviated survey (NY00375711), the facility did not ensure each resident received adequate supervision to prevent an elopement. This was evident for one (1) of four (4) residents (Resident #1),sampled for elopement. Specifically, the facility's video surveillance footage dated 03/19/2025 at 4:04:06 PM showed Resident #1 walked past Security Guard #1, who was sitting at the front desk in the lobby with their head down. Security Guard #1 did not stop Resident #1 from leaving the facility. Resident #1 exited the automatic front doors and left the facility. Staff interviews and the facility's investigative report revealed that the facility was not aware Resident #1 was missing until 7:30 PM. To date, Resident #1 has not been located. This resulted in the potential for serious harm to Resident #1 that was determined to be Immediate Jeopardy Past Noncompliance. The findings are: The facility's Policy and Procedure titled Elopement, dated 02/24/2024, states if an employee observes a resident leaving the premises, he/she should: attempt to prevent the departure in a courteous manner; get help from other staff members in the immediate vicinity, if necessary; instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. The facility's Policy and Procedure titled Front Desk and Security, dated 02/28/2024, stated that the purpose was to enhance visitor tracking, ensure compliance with sign-in/sign-out procedures, and to improve security measures to prevent unauthorized resident departures. Resident #1 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a type of schizophrenia characterized by persistent delusions and hallucinations with paranoia) and dementia (a brain condition that affects thinking, memory, and behavior.) The Minimum Data Set (an assessment tool) dated 03/12/2025 documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 12 indicating moderately impaired cognition. Resident #1 ambulated without assistive devices. An Elopement Risk Assessment from 05/23/2023 to 03/06/2025 documented Resident #1 was not identified at risk for elopement; therefore, an elopement care plan was not implemented. The facility's video surveillance footage dated 03/19/2025 showed Resident #1 with a coat on exited the elevator from the unit into the lobby at 4:04.06 PM. Resident #1 walked past Security Guard #1 at the front desk and exited through the automatic front door. Security Guard #1 was observed sitting at the front desk with their head down. Security Guard #1 did not stop Resident #1 from exiting the facility. Security Guard #2 was observed exiting the bathroom at 4:04:21 PM. The facility's Incident Investigative Report dated 03/26/2025 documented on 03/19/2025 at 4:00 PM, Resident #1 left the building. At the time of the report, a full facility-wide search had been initiated and staff were already searching the surrounding neighborhood and Staff searched Resident #1's former apartment building. Hospitals and surrounding shelters were called but the resident was not identified in these places. On 03/19/2025 at 11:00 PM, local law enforcement was called and arrived at the facility at approximately 2:00 AM on 03/20/2025. A review of the video surveillance footage confirmed Resident #1 exited the facility at 4:00 PM on 03/19/2025. The facility concluded that Resident #1 eloped from the facility at 4:00 PM. A nursing progress note dated 03/19/2025 at 10:10 PM by Assistant Director of Nursing #1 documented that on 03/19/2025 at 9:30 PM, Registered Nurse Supervisor #1 contacted them to report Resident #1 had eloped from the facility. The nursing staff did not notice Resident #1's absence until 7:30 PM. Registered Nurse Supervisor #1 was alerted at 7:30 PM. A Code Grey (elopement code) was activated facility-wide, a neighborhood search was conducted, and the Administrator and Director of Nursing were informed. During an interview on 03/31/2025 at 4:25 PM, Certified Nursing Assistant #1 stated they worked on the evening shift of 03/19/2025 from 3:45 PM - 11:45 PM. Certified Nursing Assistant #1 stated they observed Resident #1 at the unit elevator at 4:00 PM; Resident #1 stated they were going downstairs to get snacks from the vending machine. Certified Nursing Assistant #1 stated they did not stop Resident #1 from going downstairs because the Resident was allowed to do this. Certified Nursing Assistant #1 stated Resident #1 had never verbalized wanting to leave the facility and was never observed packing their belongings. Certified Nursing Assistant #1 stated they took their dinner break from 6:30 PM - 7:30 PM after serving dinner to the residents, and they returned to the unit at 7:30 PM. Certified Nursing Assistant #1 stated when they returned from their break and made rounds, Resident #1's dinner tray was in their room, untouched. Certified Nursing Assistant #1 stated they immediately informed Licensed Practical Nurse #1 and began to search for Resident #1 but was unable to locate them. During an interview on 03/31/2025 at 4:19 PM, Licensed Practical Nurse #1 stated they worked on the evening shift of 03/19/2025 from 3:30 PM - 11:45 PM. Licensed Practical Nurse #1 stated they performed rounds on the unit at 3:30 PM and Resident #1 was observed sitting in their room. Licensed Practical Nurse #1 stated they were notified by Certified Nursing Assistant #1 at approximately 7:30 PM that Resident #1 was not in their room. Licensed Practical Nurse #1 stated it was normal for Resident #1 to leave the unit unsupervised to go to the vending machine prior to dinner, which is served between 6:00 PM and 6:30 PM. Licensed Practical Nurse #1 stated Resident #1 usually returned to the unit after getting their snacks and that Resident #1 had no known exit- seeking behavior. Licensed Practical Nurse #1 stated after they searched the lobby and unit, they notified Registered Nursing Supervisor #1 at approximately 7:30 PM and a Code Grey was called at 8:00 PM. During an interview on 03/31/2025 at 1:31 PM Registered Nursing Supervisor #1 stated they were informed by Licensed Practical Nurse #1 at approximately 7:30 PM - 8:00 PM on 03/19/2025 that they were unable find Resident #1. Registered Nursing Supervisor #1 stated they called a Code Grey at approximately 8:00 PM and the search for Resident #1 was unsuccessful. Registered Nursing Supervisor #1 stated they called the Director of Nursing and the Administrator and notified them Resident #1 was missing. Registered Nursing Supervisor #1 stated local law enforcement was called on 03/19/2025 at 11:00 PM and they arrived at the facility on 03/20/2025 at 2:00 AM. Registered Nursing Supervisor #1 stated Resident #1 was not at risk for elopement and had never verbalized or attempted to leave the facility. Registered Nursing Supervisor #1 stated all residents are on 30-minute visual monitoring for safety, that was not documented. They only document monitoring for Residents who are at risk for elopement. During an interview on 04/01/2024 at 1:53 PM, Security Guard #1 stated 03/19/2025 was their first day on the job and they were receiving training. Security Guard #1 stated they were left alone at the front desk by Security Guard #2, who was training them. Security Guard #1 stated they did not know Resident #1, and they did not know the people leaving the facility. Security Guard #1 stated they became aware a week later that a resident walked out of the facility while they were sitting at the front desk. During an interview on 04/02/2025 at 4:39 PM, Security Guard #2 stated they worked on the morning shift on 03/19/2025 from 9:00 AM - 5:00 PM. Security Guard #2 stated they were training Security Guard #1 but left them and went to the bathroom for approximately 2-3 minutes. Security Guard #2 stated when they returned to the front desk, neither Security Guard #1 nor any other staff members notified them that Resident #1 had left the building. Security Guard #2 stated they became aware of the elopement two days later when they returned to work. Security Guard #2 stated Resident #1 usually came down to the vending machine in the lobby during the evening to get snacks. Security Guard #2 also stated Resident #1 normally sat in the lobby for a while before returning to their unit. Security Guard #2 stated Resident #1 never attempted to leave nor verbalized wanting to leave the facility. During an interview on 03/31/2025 at 1:17 PM, the Director of Nursing stated they were notified that Resident #1 was missing on 03/19/2025 at 9:00 PM by Registered Nursing Supervisor #1 The Director of Nursing stated they instructed Registered Nursing Supervisor #1 to search the entire building and surrounding areas. The Director of Nursing stated a Code Grey was called at 8:00 PM and staff members continued searching for Resident #1. The Director of Nursing stated Resident #1 had been living in the facility for nearly two years and had never exhibited any exit-seeking behavior, and never attempted to nor verbalized wanting to leave the facility. The Director of Nursing stated they called the surrounding hospitals and shelters, and they went to Resident #1's previous home address but was unsuccessful in locating Resident #1. During an interview on 03/31/2025 at 11:03 AM, the Administrator stated they were made aware of the elopement at 9:30 PM on 03/19/2025. The Administrator stated there were two security guards at the front desk; Security Guard #1 was being trained by Security Guard #2. The Administrator stated Resident #1 walked past Security Guard #1 shortly after Security Guard #2 got up from the front desk to go to the restroom. The Administrator stated it was Resident #1's routine to purchase snacks from the vending machine in the lobby and then return to their unit. The Administrator stated all visitors entering the building must sign in; however, they were not required to sign out. The Administrator stated they reviewed the video surveillance footage, which showed Resident #1 left the facility at 4:00 PM without anyone knowing. The Administrator stated the police were still looking for Resident #1 and would keep them updated. The Administrator stated they provided staff members with elopement in-service and elopement drills. The Administrator stated they have also implemented new measures to prevent resident elopement. During an interview on 04/01/2025 at 1:42 PM, the Medical Doctor stated they have been providing care to Resident #1 for over a year, and during their interactions Resident #1 had never verbalized wanting to leave the facility. The Medical Doctor stated they were informed by the facility that Resident #1 was missing on 03/19/2025. The Immediate Jeopardy was determined to have begun on 03/19/2025. The Administrator was informed of the Immediate Jeopardy and provided with the Past Noncompliance Immediate Jeopardy Template on 04/01/2025 at 4:32 PM. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to the start (03/31/2025) of this survey. As such, a Plan of Correction is not required for this citation. The facility took immediate corrective actions and was found to be in substantial compliance on 03/24/2025 prior to surveyor entrance on 03/31/2025 at 9:00 AM. Facility initiated an investigation 03/19/2024 at 9:30 PM. 03/19/2025 at 11:00 PM - Reported to Department of Health. 03/19/2025 at 11:00 PM - 911/police notified and responded on 03/20/2025 at 2:00 AM. 03/20/2025 - All staff in-serviced on the elopement policy. Topics: Hand-Off-Report - Rounding with Incoming Staff, Elopement, Effective Rounding, Timely Reporting Significant Elopement -Significant issues. 03/20/2025 - An Audit Tool initiated to assess Residents who may be at risk for elopement. Audit is ongoing. 03/20/2025 - Unit staff were given verbal counseling regarding proper reporting, effective rounding. 03/20/2025 - An Elopement Risk Tool developed. Three Residents who wander on the unit were re-assessed for elopement risk. 03/24/2025 - Quality Assurance Meeting with department heads and Medical Director. Attendance sheet reviewed. 03/20/2025 - Security Guard #1 was terminated. 03/31/2025 - Policy and Procedure for Front Desk and Security dated 02/28/2024 revised to add visitors must sign in and out in the Kiosk. Front desk staff must monitor the Kiosk, stop/ensure visitor returns Kiosk Pass, if visitor does not have a pass, security calls supervisor. Security will be present in the vestibule during shift change to monitor staff exit to ensure no residents exit the building. 03/31/2025 - Policy and Procedure on Elopement reviewed with no revisions. In-service of all staff was initiated on 03/31/2025. 91% Certified Nursing Assistants, 95% Licensed Practical Nurses, 95% Registered Nurses, 80% Dietary staff, 100% Activities staff, 100% admission staff, 100% Maintenance staff, 100% Rehab staff, 71% Housekeeping staff, 100% Social Worker staff, 80% Security Guards, and 100% Administrative staff. 10NYCRR415.12(h)(2)

Based on record review and interview conducted during the Recertification Survey from 02/05/2025 to 02/12/2025, the facility did not ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committee consisted at a minimum of the Medical Director, or their designee attended quarterly meetings. Specifically, the Medical Director has not participated in Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) meetings for 4 out of the four meetings as required. The findings are: The facility Quality Assurance and Performance Improvement (QAPI) policy, last revised on August 31, 2022, documented that the Quality Assessment and Assurance Committee consists of, at minimum, the director of nursing services, the medical director or designee, and at least one other member of the facility staff. One of them must be the administrator, the owner, a board member, or another individual in a leadership role. Meetings will be held quarterly. The facility policy and procedure titled Medical Director, with the last revised date of January 2025, documented that the Medical Director will be responsible for improving the performance of medical services as an integral part of performance improvement activities. A review of the Quarterly Meeting Attendance Sheets entitled Quality Assurance and Performance Improvement revealed that the Medical Director did not sign the attendance sheets for the following meetings: 01/31/2024, 04/08/2024, 08/29/2024, and 12/19/2024. There is no documented evidence that the Medical Director attended the Quality Assurance & Performance Improvement meeting via Microsoft Teams or in person for 4 of the four quarterly meetings. On 02/12/2025 at 1:59 PM, the Director of Nursing was interviewed and stated that the Quality Assessment and Assurance Committee comprises the director of nursing, the administrator, the medical director, and all the department heads. They meet quarterly, but we have been meeting every week since November on different topics. The Medical Director only comes to the quarterly meetings. The department heads attend the weekly meeting. On 02/12/2025 at 2:53 PM, the Medical Director was interviewed and stated that the protocol of the Quality Assurance and Performance Improvement meeting is to discuss different topics requiring improvement. The Administrator shares the meeting, and it covers everything that is a potential risk. I attend some of the meetings. The Administrator informs me on the phone that they are having a meeting. I do attend the meeting, and my name might be in the minutes. I do not sign the attendance record. On 02/12/2025 at 3:00 PM, the Administrator was interviewed and stated that they meet every quarter. All the department heads and corporate representatives attend the meeting. We hold a medical board meeting for the physicians. The Medical Director does not physically attend the quality assurance meeting. After the meeting, I would have a one-on-one meeting with the Medical Director to explain what we discussed and any new performance improvement plan. 10 NYCRR 415.15(a)

Based on observation, record review, and interviews conducted during the Recertification Survey from 02/05/2025 - 02/12/2025, the facility did not ensure that infection control practices and procedures were maintained. This was evident for 2 Residents (Resident # 389 and Resident #63) of 12 residents observed for medication administration and 1 Resident (Resident #389) observed for Pressure Ulcer Injury out of a total of 35 sampled residents. Specifically, 1.) Licensed Practical Nurse #2 failed to follow Enhanced Barrier Precautions by not donning a gown while administering intravenous medications for a Resident with a Peripherally Inserted Central Catheter. 2.) Licensed Practical Nurse #3 failed to follow Enhanced Barrier Precautions by not donning a gown while administering medications for a Resident with a Gastrostomy tube. 3.) Licensed Practical Nurse #1 did not establish a clean field for the placement of wound supplies while performing a dressing change and did not perform hand hygiene after removing the soiled dressings. The findings are: The facility policy titled Enhanced Barrier Precautions reviewed/revised 02/2025, documented that Enhanced Barrier Precautions are implemented for residents who are at high risk of both acquisition of and colonization with multi-drug-resistant organisms. Enhanced Barrier Precautions expands the risk of personal protective equipment and refers to the use of gowns and gloves during high contact resident care activities. Enhanced Barrier Precautions should be applied to the residents with wounds, indwelling medical devices and infection or colonization with a multi-drug-resistant organisms. The facility policy titled Wound Care reviewed/revised 02/2025, documented steps in the wound care procedure: Establishment of a clean field on the resident's over the bed table for the placement of the clean items used while performing the dressing change. Hands should be washed and dried thoroughly after tape is loosened and the dressing is removed. 1) On 02/06/25 at 9:06AM, during observation of medication administration for Resident #389, Licensed Practical Nurse # 2 was observed a) Administering 5 milliliters of 0.9% Sodium Chloride Flush Solution into the Peripherally Inserted Central Catheter b) Preparing and Administering the antibiotic solution of Daptomycin Sodium Chloride 350-0.9 milligrams/50mililiters to be administered at a rate of 100ml/hr. into the Peripherally Inserted Central Catheter without wearing a gown. On 02/06/25 at 9:30AM, Licensed Practical Nurse #2 was Interviewed and stated that they were not sure if the Intravenous Line for administration of medication for Resident #389 was a Central Catheter. Licensed Practical Nurse #2 was then observed looking in the Electronic Medical Record and stated that they then determined that the Resident's intravenous line is a Peripherally Inserted Central Catheter. Licensed Practical Nurse #2 further stated that they did not wear a gown because the resident is not on contact precautions. After reading the signage that was posted for Enhanced Barrier Precautions, Licensed Practical Nurse #2 stated that they were not knowledgeable on the topic because they have not received any education on Enhanced Barrier Precautions. 2.) On 02/10/25 at 9:33AM, during observation of medication administration for Resident #63, Licensed Practical Nurse # 3 was observed administering medications into the Gastrostomy tube without wearing a gown. Resident #63 was admitted to the facility with diagnoses that include Cerebral Vascular Accident and Malnutrition The Quarterly Minimum Data Set assessment dated [DATE], documented that Resident #63 had severely impaired cognition and required 51% or more of the total caloric intake to be administered through a feeding tube On 02/10/25 at 9:45AM, Licensed Practical Nurse #3 was interviewed and stated that they did not wear a gown during medication administration because the Resident is not on contact precautions. Enhanced Barrier Precautions signage was posted on the resident's door. Licensed Practical Nurse #3 was observed reading the signage and afterwards stated they did not wear a gown for medication administration through the Gastrostomy tube because they did not see the signage. The signage was also posted on the personal protective equipment cart. 3.) On 02/07/25 at 11:47AM during wound care observation for Resident #389, Licensed Practical Nurse # 1 was performing wound treatments to the left foot and bilateral hips and was observed placing wound care supplies and gauze dressings on an over the bed table that was not cleaned nor covered with a barrier to establish a clean field. After removal of the soiled dressings from the 3 wounds, it was observed that Licensed Practical Nurse # 1 did not perform hand washing or change gloves. Resident #389 was admitted to the facility with diagnoses that include Osteomyelitis of the left ankle and foot and Diabetes Mellitus. The Admission Minimum Data Set assessment dated [DATE], documented Resident # 389 had severely impaired cognition, the presence of 2 venous and arterial ulcers, skin and ulcer/injuries and required medication administration intravenously A Readmission nursing assessment dated [DATE], documented that the readmitting diagnosis for Resident #389 was aftercare following a surgical amputation with wounds to the left foot and pressure ulcers to the left and right Trochanter/hips. A Physician Order dated 01/22/2025, documented a treatment order of Xeroform gauze application to bilateral Trochanter topically two times a day for pressure ulcers. A Physician Order dated 01/22/2025, documented a treatment order of Calcium alginate to left lateral foot topically two times a day for arterial ulcer. On 02/07/25 at 12:20, Licensed Practical Nurse #1 was Interviewed on the wound procedure related to infection control measures. Licensed Practical Nurse #1 stated that they were nervous during the wound observation and that is why they omitted critical steps including establishing a clean field for placement of the wound supplies and hand washing and change of gloves after removal of the soiled dressings. On 02/07/25 at 12:30, Registered Nurse #1 was interviewed and stated that Licensed Practical Nurse #1 should not have omitted any infection control steps or processes while performing the wound treatment as they were educated, and they will be reeducated on the procedures. On 02/07/25 at 9:06 AM, The Assistant Director of Nursing/ Infection Control Preventionist, was interviewed and stated that all the nurses have been oriented on Enhanced Barrier Precautions and infection control procedures, medication administration and treatments. Inservice agendas and attendance sheets were received. The Assistant Director of Nursing/ Infection Control Preventionist also stated that they round daily, to ensure that the correct infection control signage is posted, and that the staff is administering medications correctly and following infection control and enhanced barrier precautions. On 02/07/25 at 09:47 AM The Director of Nursing was interviewed and stated that when a resident is admitted they are notified by email of those with indwelling devices, and they advise the staff on postings for Precautions and PPE to ensure compliance. The Director of Nursing further stated that walking Rounds with the Registered Nurses and the Licensed Practical Nurses for accountability has been initiated daily and for every shift and the Assistant Director of Nursing will report on the findings. 10 NYCRR 415.19 (a) (1-3)

Based on observations, record reviews, and staff interviews conducted during the Recertification survey from 02/05/2025 to 02/12/2025, the facility did not ensure that care and services were provided according to accepted standards of clinical quality and practice. This was evident for 1 (Resident #389) of 2 residents reviewed for Intravenous medication administration out of a total of 35 sampled residents. Specifically, Intravenous antibiotics for Resident #389 were administered through a Peripherally Inserted Central Catheter by a Licensed Practical Nurse. The findings are: The facility Policy and Procedure titled Administering Medication by Central Line Access, reviewed and or revised 01/02/2025, documented guidelines for safe administration of medications intravenously through a central line access: 1) An LPN may Not Flush any venous central line for patency including a Peripherally Inserted Central Catheter. 2) An LPN may Not administer any intravenous solutions through a central venous line including a Peripherally Inserted Central Catheter. Resident #389 was admitted to the facility with diagnoses that include: Osteomyelitis of the left ankle and foot and Diabetes Mellitus. The Admission Minimum Data Set assessment dated [DATE] documented Resident #389 with severely impaired cognition and they required medication administration intravenously. On 02/06/25 at 9:06AM, during observation of medication administration of Resident #389, Licensed Practical Nurse #2 was observed 1) Administering 5 milliliters of 0.9% Sodium Chloride Flush Solution into the Peripherally Inserted Central Catheter 2) Preparing and Administering the antibiotic solution of Daptomycin Sodium Chloride 350-0.9 milligrams/50mililiters to be administered at a rate of 100ml/hr. into the Peripherally Inserted Central Catheter. A Hospital Surgical Progress Note/discharge summary dated 01/21/2025, documented that Resident #389 is undergoing antibiotic treatment for Osteomyelitis with a Peripherally Inserted Central Catheter in place. A Facility Physician Order dated 01/22/25, documented that Resident #389 had a left arm Central Venous Peripherally Inserted Central Catheter Line to be observed every shift for signs and symptoms of infection. A Facility Physician Order dated 01/22/25, documented the use of Daptomycin Sodium Chloride 350-0.9 milligrams/50mililiters. 360 milligrams to be administered intravenously once daily for 14 days. A Facility Physician Order dated 01/22/25, documented the use of Saline Flush 0.9% 5 milliliters to be administered for Central Venous / Peripherally Inserted Central Catheter Line maintenance before and after antibiotic administration. A Facility Medication Administration Record dated February 2025, documented that Licensed Practical Nurse #2 administered intravenously the antibiotic solutions of Daptomycin Sodium Chloride and Ceftriaxone Sodium Dextrose on 2/4 and 2/5. On 02/06/25 at 9:30AM, Licensed Practical Nurse #2 was Interviewed and stated, that they were not sure if the Intravenous Line for administration of medication for Resident #389 was a Central Catheter. Licensed Practical Nurse #2 was then observed looking in the Electronic Medical Record and stated that they then determined that the Resident's intravenous line is a Peripherally Inserted Central Catheter. Licensed Practical Nurse #2 further stated that they have been employed by the facility for 1 month and has not yet been in-serviced on intravenous administration. On 02/06/25 at 12:34PM, Registered Nurse #1, the unit supervisor, was Interviewed and stated that Licensed Practical Nurses do not give medications through a central line. Medication administration is monitored as new medication orders are reviewed. If an antibiotic is to be given through a Peripherally Inserted Central Catheter, the Licensed Practical Nurses are reminded not to give the medication as the Registered Nurse on duty will. Registered Nurse #1 further stated that it will take some investigation to determine how the Licensed Practical Nurse has been administering medications through the Peripherally Inserted Central Catheter and that they will have to speak with the Assistant Director of Nursing regarding this and additional education for Licensed Practical Nurses. On 02/07/25 at 09:06AM, The Assistant Director of Nursing was interviewed and stated that Licensed Practical Nurse #2 was hired on 12/17/2025 as a new nurse who has been assigned to work the night shift and has passed orientation education on infusion therapy. An agenda and attendance sheet were provided. The Assistant Director of Nursing also stated that the facility admission nurse reviews the medication orders, enters the details into the Medication Administration Record, communicates with the next shift and the Registered Nurse who performs that admission or the additional Registered Nurse who is rounding will administer the medications that are ordered to be infused through a central line. The Assistant Director of Nursing then stated that the Licensed Practical Nurse who is administering the medications should contact the Registered Nurse if the Medication Administration Record documents for medications to be administered through a Peripherally Inserted Central Catheter. The Assistant Director of Nursing further stated that they can also administer the medications as they round daily and communicate with the staff to ensure that the nurses are administering medications correctly but they did not check the medication administration for Resident #389. They don't audit the Medication Admission Records for signatures of nurses who are performing intravenous medication administration but will start. On 02/07/25 at 09:47 AM, The Director of Nursing was interviewed and stated that when a resident is admitted they are notified by email of residents with indwelling devices, and they advise the staff on postings for Precautions and Personal Protective Equipment to ensure compliance. The Director of Nursing also stated that the Licensed Practical Nurse should look at the Medication Administration Record and notify the Registered Nurse if the resident has a central line for medication administration. The Director of Nursing further stated that the Registered Nurse should be rounding and that's how they would know there is a central line medication administration. Walking Rounds with the Registered Nurses and the Licensed Practical Nurses for accountability has been initiated daily and for every shift and the Assistant Director of Nursing will report on the findings. 415.11(c)(3)(i)

Based on observation, interview and record review conducted during a Recertification survey from 02/5/2025 to 02/12/2025, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing. This was evident for 1 of 4 residents (Resident #389) reviewed for Pressure Ulcer Injury out of a total of 35 sampled residents. Specifically, Resident #389 did not receive pressure relieving devices and preventative measures to promote wound healing. The findings are: The Facility Policy titled Prevention of Pressure Ulcers reviewed/revised 01/02/025, documented the purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors, interventions for specific risk factors, and preventative measures. General preventive measures include 1) Identify risk factors for pressure ulcer development 2) For a person in bed: Change position at least every two hours or more frequently if needed, determine if resident needs a special mattress, if a special mattress is needed, use one that contains foam, air, gel, or water, as indicated. Use pillows or wedges to keep bony prominences such as knees or ankles from touching each other. When in bed, every attempt should be made to float heels (keep heels off the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician. Resident #389 was admitted to the facility with diagnoses that include Osteomyelitis of the left ankle and foot and Diabetes Mellitus. The Admission Minimum Data Set assessment dated [DATE], documented Resident # 389 had severely impaired cognition, the presence of 2 venous and arterial ulcers, and skin and ulcer/injury treatments that included pressure reducing devices for the chair, the bed, and a turning and positioning program. Resident #389 was dependent for all bed mobility and transfers. On 02/06/25 at 8:47 AM, Resident #389 was observed out of bed sitting. No heel booties were applied to cover the left foot surgical site and there was no pressure reducing device present in the wheelchair. On 02/06/2024 at 9:06 AM, During medication administration observation, Resident #389 was observed in bed. There was no heel booties applied, no offloading of the heels and there was no pressure reducing mattress present. On 02/07/25 at 11:47 AM, During wound observation, Resident #389 was observed in bed. There was no heel booties applied, no offloading of the heels and there was no pressure reducing mattress present. A Readmission nursing assessment dated [DATE], documented that the readmitting diagnosis for Resident #389 was aftercare following a surgical amputation with wounds to the left foot and pressure ulcers to the left and right trochanters/hips. A Braden Scale for Predicting Pressure Sore Risk dated 01/03/2025 and 01/22/2025, documented that Resident #389 was at a moderate risk of developing pressure ulcers. A Physician Order dated 01/22/2025, documented a treatment order of Xeroform gauze application to bilateral trochanters topically two times a day for pressure ulcers. A Physician Order dated 01/22/2025, documented a treatment order of Calcium alginate to left lateral foot topically two times a day for arterial ulcer. A Wound Assessment Progress Note dated 01/28/2025, documented that Resident #389 has significant contributors for increased risk of wound incidence and/or impede healing including impaired mobility. Education was provided regarding pressure relief, general offloading and frequent repositioning with offloading orders to avoid direct pressure to wound sites. A Wound Assessment Progress Note dated 01/30/2025, documented recommendations for nursing to continue to monitor skin integrity/wound progression and provide preventative measures. The Certified Nursing Assistant Accountability Record for January 2025 documented the intervention/task to turn and reposition Resident #389. There was no intervention/task for turning and repositioning on the Certified Nursing Assistant Accountability Record for February 2025. There was no documented evidence that measures were implemented to promote wound healing and prevent additional skin breakdown. On 02/12/25 at 9:24 AM, An Observation was performed with Registered Nurse #1 that Resident #389 did not have any pressure ulcer preventative measures in place including an air mattress, a seat cushion, heel booties, nor were his heels/surgical site off loaded. Registered Nurse #1 was interviewed and stated that the Protocol for residents prone to pressure ulcers and or who currently have a wound is that a Braden scale risk assessment is performed at admission and the admission nurse should report the at-risk residents findings to the Assistant Director of Nursing and or the Director of Nursing and they will arrange with maintenance for the resident to get an air mattress. Registered Nurse #1 also stated that a care plan should be entered for turning and positioning every 2 hours and entered in the CNA Accountability. Registered Nurse #1 further stated that foam dressings and heel booties are also used for prevention of skin breakdown and for the promotion of wound healing and all these measures should have been entered in orders. The Electronic Medical Record was reviewed by Registered Nurse #1 who stated that there were no orders entered for pressure relieving measures or devices. On 02/12/25 at 12:56 PM, the Director of Nursing was interviewed and stated that Corporate wants new forms implemented so the turning and positioning has been performed but not documented in the record. the Director of Nursing also stated that the unit manager who rounds daily should have picked up on the fact that there was no preventative measures or equipment in place for pressure ulcers prevention and wound healing and the admission nurse should have also documented to have these measures put in place. 10 NYCRR 415.12(c)(1-2)

Based on observation, record review and staff interviews conducted during the Complaint (NY#00347998) and Recertification survey from 2/5/2025 to 2/12/2025, the facility did not ensure a resident with limited range of motion received treatment and services to maintain and/or to prevent further decrease in range of motion. This was evident for 1 (Resident #66) of 2 residents reviewed for Limited Range of Motion out of 37 total sampled residents. Specifically, Resident #66 was not provided with range of motion exercises in accordance with a Physician's Order. The findings are: The facility's policy and procedure titled Rehabilitative Nursing Care undated documented rehabilitative nursing care is performed daily for those residents who require such service include assisting residents with their routine range of motion exercises, floor ambulation, standing and transfer. Resident #66 was admitted to the facility with diagnoses that included Multiple Sclerosis, Hemiplegia, and Osteoarthritis. The Minimum Data Set, dated dated dated [DATE] documented Resident #66 is cognitively intact and requires partial/moderate assistance for upper body dressing, personal hygiene and dependent for lower body dressing, putting footwear. The New York State Department of Health Complaint Intake received 7/12/2024 documented that Resident #66 no longer receives physical therapy and was ordered to receive stretches in bed. However, staff are not providing any exercises. On 2/6/2025 9:59 AM, Resident #66 was interviewed who stated they are ordered to receive upper/lower extremity exercises in bed after therapy was discontinued. Initially, the nursing staff were doing the exercises daily for Resident #66. It later stopped completely and has not been getting any exercise for few months already. The Physician Order initiated 11/6/2024 documented Resident #66 to receive Active Range of Motion to both upper extremities and Active/Passive Range of Motion to both lower extremities 3 sets x 10 reps daily as tolerated. The Comprehensive Care Plan for Resident #66 placed on Range of Motion initiated 11/6/2024 and last reviewed 1/23/2025 documented resident will maintain to participate in range of motion during care and will not develop any contracture or limitation in movements during care until next review date. The interventions included active range of motion to both upper extremities and active/passive range of motion to both lower extremities 3 sets x 10 reps in all available planes of motion daily as tolerated. The Certified Nursing Assistant Documentation Record for Resident #66 dated 1/1/2025 to 2/6/2025 documented Resident #66 to receive range of motion to both upper/lower extremities 3 sets x 10 reps once daily for 15 minutes during 7:30AM to 3:30PM shift. The review of the record revealed that the AROM/PROM exercises were being provided/was tolerated. On 2/7/2025 at 10:14 AM, Certified Nursing Assistant #9 stated they are currently regular assigned staff during the day shift for Resident #66. Certified Nursing Assistant #9 stated Resident #66 is cognitively intact, requiring total care for most of ADLs except for eating. Resident #66 is also limited in their mobility/functional level so resident utilizes the call bell when help is needed. Certified Nursing Assistant #9 stated Resident #66 prefers to stay in their room, mostly in bed. Certified Nursing Assistant #9 recalled Resident #66 on range of motion some time last year, but stated resident is not currently on any program. Therefore, Certified Nursing Assistant #9 stated they are not performing any range of motion exercises for Resident #66. Certified Nursing Assistant #9 stated nursing instructions/therapy binder were checked to confirm that Resident #66 was not on any restorative nursing program. Certified Nursing Assistant #9 stated they don't remember completing any documentation related to range of motion in the electronic medical record for Resident #66. Therefore, they could not explain why there is documentation indicating Resident #66 was provided with range of motion exercises. On 2/11/2025 at 11:43 AM, Certified Nursing Assistant #11 stated they are per diem who worked during the day shift on 2/6/2025. Certified Nursing Assistant #11 recalled that Resident #66 was added to their assignment because staff had called out on that day. Certified Nursing Assistant #11 stated they didn't provide any range of motion exercises for any residents including Resident #66 on that day. Certified Nursing Assistant #11 stated they did not know why documentation reflected that resident was provided with range of motion exercises. It was an error and should have not been documented as completion. On 2/11/2025 at 11:22 AM, Physical Therapist stated Resident #66 last received therapy from 10/17/2024 to 11/6/2024 and was placed on maintenance restorative nursing program. Resident #66 is provided with daily range of motion exercises for 15 minutes by nursing staff. Range of motion can be incorporated/performed during ADL care but it requires time to complete 10 reps x 3 sets for both upper/lower extremities. On 2/10/2025 at 8:25 AM, Registered Nurse #3 stated certified nursing assistant during the day shift is responsible to provide range of motion during ADL care daily. Nursing staff is rotated monthly, so they are responsible to check resident's individual plan of care in the electronic medical record. Registered Nurse #3 stated they were not aware that Resident #66 was not getting their range of motion exercises daily. On 2/12/2025 at 12:05 PM, Director of Nursing Service stated that unit nurse supervisor is responsible to review resident's individualized plan of care with assigned nursing staff and to conduct rounding on the unit to ensure the care is being provided. Director of Nursing Service stated the staff will need more training about performing range of motion and documenting accurately in the electronic medical record. 10 NYCRR 415.12(e)(2)

Based on the observations and staff interviews conducted during the Recertification survey from 2/5/2025 to 2/12/2025, the facility did not ensure garbage and refuse were disposed properly. This was evident during kitchen observation. Specifically, the facility garbage bins did not have a lid or cover to prevent the harborage and potential feeding of pests. The findings: The facility's policy and procedure titled Disposal of Garbage and Refuse revised 1/2025 documented all garbage and refuse will be disposed of in a safe and efficient manner throughout the day. The exterior dumpster area shall be maintained and free of rubbish and other debris. All waste shell be kept in lined containers that are covered with lids, leak-proof and non-absorbent prior to disposal. On 2/10/2025 at 1:02PM, an observation was made of the garbage disposal room. The garbage bins all containing garbage were observed without a lid or cover. On 2/10/2025 at 1:13 PM and 2/11/2025 at 3:40PM, the garbage bin located in the garbage pickup area was observed without lid or cover, exposing garbage piled high in the bin. On 2/11/2025 at 12:04PM, Director of Food Service stated garbage bins are not equipped with a lid so they are not able to keep waste covered at this time. On 2/11/2025 at 3:27PM, Housekeeping Director stated they have been working in the facility for [AGE] years and the waste company has never provided garbage bins equipped with lids. Therefore, the garbage taken out to the pick-up area are always left exposed in the bin. On 2/12/2025 at 11:31 AM, Administrator was interviewed and stated they contacted the vendor to address the issue. 10 NYCRR 415.14(h)

Based on observation, record review and staff interviews conducted during the Complaint (NY#00347998) and Recertification Survey from 2/5/2025 to 2/12/2025, the facility did not ensure that the resident records were accurately documented in accordance with professional standards of practice. This was evident for 1 (Resident #66) of 2 residents reviewed for Limited Range of Motion out of 37 total sampled residents. Specifically, Resident #66 was not provided with Range of Motion exercises, but documentation reflected that resident was provided with Range of Motion exercises. The findings are: The facility's policy and procedure titled Charting and Documentation undated documented all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Resident #66 was admitted to the facility with diagnoses that included Multiple Sclerosis, Hemiplegia, and Osteoarthritis. The Minimum Data Set, dated dated dated [DATE] documented Resident #66 is cognitively intact and requires partial/moderate assistance for upper body dressing, personal hygiene and dependent for lower body dressing, putting footwear. The New York State Department of Health Complaint Intake received 7/12/2024 documented that Resident #66 no longer receives physical therapy and was ordered to receive stretches in bed. However, staff are not providing any exercises. On 2/6/2025 9:59AM, Resident #66 was interviewed who stated they are ordered to receive upper/lower extremity exercises in bed after therapy was discontinued. Initially, the nursing staff were doing the exercises daily for Resident #66. It later stopped completely and has not been getting any exercise for few months already. The Physician Order initiated 11/6/2024 documented Resident #66 to receive Active Range of Motion to both upper extremities and Active/Passive Range of Motion to both lower extremities 3 sets x 10 reps daily as tolerated. The Comprehensive Care Plan for Resident #66 placed on Range of Motion initiated 11/6/2024 and last reviewed 1/23/2025 documented resident will maintain to participate in range of motion during care and will not develop any contracture or limitation in movements during care until next review date. The interventions included active range of motion to both upper extremities and active/passive range of motion to both lower extremities 3 sets x 10 reps in all available planes of motion daily as tolerated. The Certified Nursing Assistant Documentation Record for Resident #66 dated 1/1/2025 to 2/6/2025 documented Resident #66 to receive range of motion to both upper/lower extremities 3 sets x 10 reps once daily for 15 minutes during 7:30AM to 3:30PM shift. The review of the record revealed that the AROM/PROM exercises were being provided/was tolerated. On 2/7/2025 at 10:14 AM, Certified Nursing Assistant #9 stated they are currently regular assigned staff during the day shift for Resident #66. Certified Nursing Assistant #9 stated Resident #66 is cognitively intact, requiring total care for most of ADLs except for eating. Resident #66 is also limited in their mobility/functional level so resident utilizes the call bell when help is needed. Certified Nursing Assistant #9 stated Resident #66 prefers to stay in their room, mostly in bed. Certified Nursing Assistant #9 recalled Resident #66 on range of motion some time last year, but stated resident is not currently on any program. Therefore, Certified Nursing Assistant #9 stated they are not performing any range of motion exercises for Resident #66. Certified Nursing Assistant #9 stated nursing instructions/therapy binder were checked to confirm that Resident #66 was not on any restorative nursing program. Certified Nursing Assistant #9 stated they don't remember completing any documentation related to range of motion in the electronic medical record for Resident #66. Therefore, they could not explain why there is documentation indicating Resident #66 was provided with range of motion exercises. On 2/11/2025 at 11:43 AM, Certified Nursing Assistant #11 stated they are per diem who worked during the day shift on 2/6/2025. Certified Nursing Assistant #11 recalled that Resident #66 was added to their assignment because staff had called out on that day. Certified Nursing Assistant stated they didn't provide any range of motion exercises for any residents including Resident #66 on that day. Certified Nursing Assistant #11 stated they did not know why documentation reflected that resident was provided with range of motion exercises. It was an error and should have not been documented as completion. On 2/11/2025 at 11:22 AM, Physical Therapist stated Resident #66 last received therapy from 10/17/2024 to 11/6/2024 and was placed on maintenance restorative nursing program. Resident #66 is provided with daily range of motion exercises for 15 minutes by nursing staff. Range of motion can be incorporated/performed during ADL care but it requires time to complete 10 reps x 3 sets for both upper/lower extremities. On 2/10/2025 at 8:25 AM, Registered Nurse #3 stated certified nursing assistant during the day shift is responsible to provide range of motion during ADL care daily. Nursing staff is rotated monthly, so they are responsible to check resident's individual plan of care in the electronic medical record. Registered Nurse #3 stated they were not aware that Resident #66 was not getting their range of motion exercises daily. On 2/12/2025 at 12:05 PM, Director of Nursing Service stated that unit nurse supervisor is responsible to review resident's individualized plan of care with assigned nursing staff and to conduct rounding on the unit to ensure the care is being provided. Director of Nursing Service stated the staff will need more training about performing range of motion and documenting accurately in the electronic medical record. 10 NYCRR 415.22(a)(1-4)

Based on observations, record reviews, and interviews conducted during the Recertification Survey from 02/05/2025 to 02/12/2025, the facility did not ensure the daily nurse staffing was posted. Specifically, there was no indication of the daily nurse staffing information with the total number of staff and total number of hours posted. This was evident during the review of the Staffing task. The findings include: The facility policy and procedure titled Posting Daily Nurse Staffing Information, last revised 01/02/2025, documented that the facility's policy is to ensure that nurse staffing information is always readily available in a readable format to residents and visitors. The facility will post daily nurse staffing information in a prominent place in each unit and in common areas that are readily accessible to residents and visitors. During multiple observations conducted on 02/05/2025 through 02/11/2025, there was no indication of the daily nurse staffing information being posted in the lobby or the nursing unit. The daily schedule was posted in the lobby inside a bulletin board. On 02/11/2025 at 9:39 AM, the Staffing Coordinator was interviewed and stated that the daily staffing schedule with the staff names and units assigned is posted on the bulletin board in the lobby. The daily nurse staffing with the total number of staff and total number of hours is not posted; it is attached to the schedule at the end of the day. On 02/11/2025 at 9:55 AM, the Director of Nursing was interviewed and stated that the staffing schedule is posted daily in the lobby. It contains where the staff are assigned to work. The daily staffing with the total number of staff and hours is supposed to be posted. I am not aware that it is not being posted. I do not check to see if it is posted; the director of nursing is responsible for ensuring that daily staffing is posted. On 02/11/2025 at 10:17 AM, the Administrator was interviewed and stated that staffing is posted in the lobby on the bulletin board. The schedule and the daily staffing are supposed to be posted. I usually check every morning but have not looked at it since the survey. I did not know that the daily staffing with the total number of staff and hours was not posted. 10 NYCRR 415.13

Based on observation, interview, and record review conducted during the Recertification Survey from 3/9/23 to 3/16/23, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evidenced for 2 of 5 units (Unit 5 and Unit 2). Specifically, 1) Unit 5 had multiple rooms with dirty and stained bathroom disinfectant tanks (DT) in disrepair, a wheelchair in disrepair, and a missing closet door in resident's room, and 2) Unit 3 contained wheelchairs in disrepair, a rusty shower chair, torn mesh on a large shower chair, torn mesh covering the clean linen carts, and heaters in the dining room area littered with dirt and debris. The findings are: The facility policy titled Equipment - General Use for All Residents last reviewed 2/2023 documented wheelchairs are maintained by the facility for general use of all residents. The facility policy titled Building Services last reviewed 2/2023 documented the Building Services employees maintain restrooms and toilets. Broken equipment is reported immediately to the Maintenance Department for repair. On 03/09/23 at 09:36 AM, Resident #11 was observed in the Unit 5 day room seated in a wheelchair with torn and missing leather from bilateral armrests. The cushion and stuffing under the leather was visible. The leather covering the back of the wheelchair was cracked and creased at the top, in the middle. The rubber wheel treads were cracked and several sections were missing. On 03/09/23 at 10:43 AM, an interview was conducted with Resident #64 and their designated representative (DR) in the resident's room. The DR stated Resident #64's closet door has been missing for approximately 1 month and was informed by the Maintenance Department (MNT) a replacement is not available. During the interview, SA observed Resident #64's closet door was missing and the resident's clothing was visible. The bottom closet door hinge was missing and splintered damaged wood was in its place. On 03/09/23 at 10:21 AM and 03/13/23 at 11:48 AM, resident bathrooms were observed with the following: 501 - Disinfectant Tank (DT) made of clear plastic, stained brown on the inside, sitting on the back of the toilet bowl seat, and connected to the toilet bowl by a dark brown stained tube. A square metal vent on the bottom of the wall adjacent to the toilet bowl was covered in rust and dust. 504 - DT stained brown on the inside and connected to the toilet bowl by a dark brown stained tube. 505 - Large amount of water leaking from the metal pipe attached to the back of the toilet bowl when flushed. 506 - DT stained brown on inside and connected to the toilet bowl by a dark brown stained tube. 509 - DT observed sitting on the back of the toilet partially filled with yellow substance, white calcification and green oxidation on metal cap, dark brown substance covering the piping that connected the DT to the toilet bowl. The toilet was flushed and the metal pipes at the back of the toilet dripped water onto the back of the toilet bowl. 510 - DT stained brown on inside and connected to the toilet bowl by a dark brown stained tube. The toilet was flushed and the metal pipes at the back of the toilet dripped water onto the back of the toilet bowl. 513 - DT metal top was observed in the corner of the bathroom on the floor with no bottle of tubing connected. The stained brown and black tubing was connected to the metal pipe at the back of the toilet bowl. 514 - The metal pipes at the back of the toilet bowl were rusted and dusty. The area where the toilet bowl seat attaches to the wall was missing a 4 inch piece of wall with plaster exposed. 515 - DT stained brown on inside and connected to the toilet bowl by a dark brown stained tube. The toilet did not flush. 516 - DT stained brown on inside and connected to the toilet bowl by a dark brown stained tube. 521 - DT stained brown on inside with dark brown stained tubing that is not connected to the toilet bowl. Black electrical tape was loosely wound around the metal pipe at the back of the toilet bowl several times until it rested at the base where the pipe connected to the toilet bowl. Water leaked out of the base of the pipe when the toilet was flushed. The 5th floor Maintenance Safety Log (MSL) from 2/12/23 through 3/14/23 documented a maintenance request for room [ROOM NUMBER] on 3/2/23 due to a leaking toilet. The date of repair was 3/3/23. There were no documented requests to address Resident #11's wheelchair or Resident #64's missing closet door. On 03/14/23 at 10:53 AM, Certified Nursing Assistant (CNA) #5 was interviewed and stated they began working with Resident #64 on 3/1/23 and verbally told the MNT that the resident was missing their closet door. Normally repair requests are placed in the MSL. CNA #5 did not place the closet door repair request in the MSL and does not recall informing the charge nurse. If MNT does not address the repair request, CNA #5 makes the charge nurse aware and the repair request is placed in the book again. The charge nurse then reinforces the repair request with MNT. On 03/15/23 at 03:36 PM, Licensed Practical Nurse (LPN) #4 was interviewed and stated they could not recall when Resident #64's closet door went missing. LPN #4 reported the missing closet door to MNT via telephone and should have logged it into the MSL. LPN #4 could not recall documenting the report into the MSL. Usually, MNT addresses repair requests in the MSL daily, but Resident #64's missing closet door took awhile for them to address and they needed to be reminded several times. The DR complained about the missing door and that is one of the times I spoke with MNT. On 3/15/23 at 03:52 PM, LPN #5 was interviewed and stated they do rounds daily and look for anything messy. After observing the resident bathroom in room [ROOM NUMBER] with SA, LPN #5 stated they were unaware there was black electrical tape and water dripping from the toilet bowl. MNT did not inform LPN #5 the bathroom was under repair or not functional. LPN #5 did not observe the stained and dirty DT in the resident bathrooms and did not report their condition to MNT. On 03/16/23 at 11:15 AM, Maintenance Worker (MW) #1 was interviewed and stated the CNAs or Physical Therapist inform the MW when wheelchairs need to be repaired. MW #1 observed Resident #11's wheelchair with SA and stated it is not appropriate for a Resident #11's wheelchair to have cracked leather. The staff did not make MW #1 aware that Resident #11 had cracked missing leather and the leather can be replaced. MW #1 check the MSL and conducted rounds by going from room to room every day to address any repair issues. Usually repair issues are addressed right away if the parts are available. If parts are not available, MW #1 will document this in the MSL. MW #1 stated they became aware Resident #64 was missing their closet door approximately 2 weeks ago. The repair request for the closet door was written in the MSL. MW #1 attempted to fix the door but there was a piece of wood required to complete the repair because the wooden board MW #1 used kept splitting. MW #1 spoke to and informed the Director of Maintenance (DM). It is not appropriate for Resident #64 to go without a closet door and other ways to address the situation should have been found. The DT attached to the resident toilet bowls are old and MW #1 does not know their function or if they are in use. MW #1 is not responsible for cleaning them and is only responsible for toilet bowls that are broken or leaking. MW #1 did not know what the dark brown substances and stains were in the DT and the attached tubing. On 03/16/23 at 11:42 AM, the DM was interviewed and stated they receive an email every week from the Director of Building Services detailing resident wheelchairs in need of repairs including torn armrests. The Rehab Department and Nursing staff also inform the DM of wheelchair repair needs. The DM cannot recall if they were informed Resident #11's wheelchair required repairs. The DM became aware Resident #64 was missing a closet door as of yesterday. The hinge near the floor was completely eroded. The DM stated someone on the night crew probably took down the door and didn't tell anyone. The parts were obtained and the closet door was fixed immediately once the DM became aware the closet door was missing. The DM is not aware of a MSL repair request for the missing closet door. The DM stated the DT attached to the toilet bowls in resident rooms are old and not in use since the DM began working with the facility. They should not be filled with anything. The DTs are still attached to the toilet bowls because, if removed, the whole faucet system would need to be replaced. MNT replaces the DT as they get broken. The facility is renovating and have replaced the flushometer (faucet system) on other floors. The DT should not be brown or soiled looking. MNT checks the MSL on every unit, rounds are done every morning, and the DM receives verbal reports from staff if there is a problem. The DM checks the resident toilet bowls but never noticed the color of the DT attached to them. 19546 2) On 03/13/2023 at 9:30 AM the following was observed on the Unit 3: 1). Two torn mesh coverings on the clean linen carts 2). A small shower chair with rusty legs, inside the Toilet/Shower Room near room [ROOM NUMBER]. 3). A large shower chair with torn and heavily worn back mesh, inside the Toilet/Shower Room, near room [ROOM NUMBER]. 4). Torn/cracked backside and torn seat cushion of a wheelchair in room [ROOM NUMBER]A. 5). Torn/cracked backrest of a wheelchair in room [ROOM NUMBER]A. 6). Torn/cracked left armrest of a wheelchair in room [ROOM NUMBER]B. 7). Torn backrest of a wheelchair in room [ROOM NUMBER]A. 8). Torn right upper back rest, underneath the right handle, of a wheelchair in room [ROOM NUMBER]B. 9). Two heaters located in the dining room area, with the inside of the grills littered with an accumulation of dirt and debris. On 03/16/23 at 10:20 AM, the Director of Building Services (DBS) was interviewed and stated that weekly wheelchair cleaning is done for each floor. We have an audit tool that is used by the housekeeping staff who is cleaning the wheelchairs to indicate if they need repairs, are torn, are missing parts. This audit tool is collected by me and I then notify the Maintenance Department or Rehabilitation Department for the replacement or wheelchair repair. The DBS follows up after wheelchair cleaning and is responsible for ensuring they are clean. The wheelchairs with torn and cracked cushions pose a safety issue for residents. On 03/16/23 at 10:30 AM the Director of Maintenance (DM) was interviewed and stated that they receive email from the Housekeeping Department when there are wheelchairs that need repair. The wheelchairs are then removed from the units and returned immediately once repair is done. As for the heater/air conditioner located in the dining room, the DM would have to remove the grill so that the Housekeeping Department can clean inside the core of the unit. The DM stated debris fell into the grill of the units when renovations to the unit were done. The Registered Nurse #3 was interviewed on 03/16/23 at10:50 AM and stated that resident equipment needs to be safe and in good condition. 415.5(h)(2) 415.29(c)(4)

Based on observations, interview, and record review conducted during the Recertification Survey from 3/9/23 to 3/16/23, the facility did not ensure a resident remained free of physical restraints. This was evidenced for 1 (Resident #94) of 1 resident(s) reviewed for Physical Restraints out of 40 total sampled residents. Specifically, Resident #94 was observed with bilateral upper 1/3 siderails (SR) in place on multiple occasions. The findings are: The facility policy titled Physical Restraint Application last reviewed 2/2023 documented the definition of restraint is based on the functional status of the resident and not the device. If the resident cannot mentally and physically self-release, then the device is considered a restraint. Resident #94 had diagnoses of dementia and hemiplegia and hemiparesis following non-traumatic intra-cerebral hemorrhage affecting the right dominant side. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #94 was severely cognitively impaired, required extensive assistance of 1 person for bed mobility and transfers, and bed rails and restraints were not used. On 03/10/23 at 10:09 AM, 03/13/23 at 11:48 AM, and 03/15/23 at 03:12 PM, Resident #94 was observed in bed sleeping calmly with bilateral upper 1/3 SR raised. On 03/10/23 at 12:55 PM, Resident #94 was observed alert in bed eating lunch with bilateral 1/3 SR raised. The Comprehensive Care Plan (CCP) related to falls initiated 5/7/19 last reviewed 3/10/23 documented Resident #94's fall risk was related to confusion with fall incidents occurring on 11/13/22 and 11/23/22. Interventions included a Physical Therapy (PT) evaluation and treatment. The CCP related to self-care deficit and Activities of Daily Living (ADL) initiated 5/8/19 documented 1/3 SR was a bed enabler and used during care provision to assist with turning and positioning every 2 hours. The CCP related to behavior initiated 9/13/19 last reviewed 3/10/23 documented Resident #94 had a history of verbal and physical aggression during ADL care and attempting to come out of bed. The Siderail Rationale Screen dated 11/28/22 documented Resident #94 was non ambulatory, had alteration in safety awareness due to cognitive decline, had a history of falls, was on medications that require safety precautions, and was using the SR for positioning and or support. Bilateral 1/3 SR indicated to improve mobility and increase independence. A Communication with Rehab note dated 3/6/23 documented a Rehab screen was completed. Resident #94 was not oriented, was unable to follow commands, and was able to perform bed mobility with the limited assistance from 1 person. The note documented Resident #94 was not a candidate for SR. An Informed Consent for Use of SR form dated 3/6/23 documented SRs were used with Resident #94 for safety due to medical condition. Verbal consent was obtained from the family. The form did not document Resident #94's specific medical need, possible benefits of, and/or possible risks of SR use. There was no documented evidence the facility obtained a Medical Doctor Order (MDO) with instruction for use and clinical rationale for bilateral 1/3 upper SR use with Resident #94. On 03/15/23 at 03:13 PM, CNA #4 was interviewed and stated they are assigned to and familiar with Resident #94. The bilateral SR were already raised when CNA #4 arrived at work today. CNA #4 did not know the size of the SR. Resident #94 used to throw themselves out of the wheelchair onto the floor but no longer comes out of bed and is not a fall risk any longer. CNA #4 stated Resident #94 helped a lot by grabbing the SR while turning in bed during washing or bowel movement. Resident #94 follows commands intermittently. CNA #4 stated SR were not listed on the CNA Point Of Care system that provides care instructions for Resident #94. SR are implemented as a standard for all residents in the facility and do not have to be listed in the POC. There are no risks or dangers with SR because the residents need them. Nursing Supervisors tell the CNAs that SR are in place for safety. On 03/15/23 at 03:52 PM, Licensed Practical Nurse (LPN) #5 was interviewed and stated it is not standard for all residents to have SR in place. The Rehab Department (RHD) completes a SR assessment to determine if a resident can turn to the side and hold onto the SR. The RHD communicates their recommendation verbally or via the communication log in the electronic medical record, and writes an order for SR. The nursing supervisor requests for the Maintenance Department (MNT) to bring the SR and checks they are the right size. LPN #5 does not know whether MNT conducts a SR assessment for risk of entrapment and improper sizing. CNAs and other staff learn about changes in SR use verbally during their daily morning report. Resident #94 had a SR assessment on 11/28/22 recommending use of SR. LPN #5 was not aware of the Rehab Communication note dated 3/6/23 documenting that SR use for Resident #94 was not recommended. LPN #5 observed Resident #94 lying in bed with no care in progress and bilateral 1/3 SR raised. LPN #5 stated Resident #94 had SR for bed mobility and they should only be raised during ADL care. The MDO for Resident #94's SR use was dated today, 3/15/23. SRs are not being used to prevent falls with Resident #94 and are not a restraint. On 03/15/23 at 05:25 PM, the Director of RHD (DOR) was interviewed and stated a SR assessment is completed for each resident quarterly and as needed. The RHD cannot recommend SR use for safety because then the SR would be considered a restraint. The RHD only assesses the resident's cognition, bed mobility, and ability to follow instructions when turning in bed. The RHD assessed and determined Resident #94 was not a candidate for SR on 3/6/23 and should not have SR in place. The DOR stated the Nursing Department did not communicate with the RHD that SR were being used for Resident #94 following the RHD assessment on 3/6/23. Resident #94 was discharged from the Physical and Occupational Therapy program on 3/10/23 and there was no recommendation for SR use. On 03/16/23 at 12:23 PM, the Director of Nursing Services (DNS) was interviewed and stated the Registered Nurse completes the initial SR assessment, communicates to the RHD, RHD completes their evaluation of bed mobility in the medical record, Nursing reviews the RHD recommendation, MNT brings the SR to the unit, and Nursing contacts the family for consent for SR use. Nursing deems whether a resident has an appropriate diagnosis for SR use. The final determination for SR use is made by the Interdisciplinary Team (IDT). If the RHD and Nursing disagree on recommendation for SR use, alternative interventions are discussed. Once SR are recommended, the family is contacted for consent, the Medical Doctor (MD) is made aware, and an order is written. Resident #94 needed SR because of the diagnosis of seizures and not for falls. Resident was assessed on 11/28/22 and should have had a MD order for the SR following this assessment. Restraint impedes a resident movement and restricts. SR are not used as a restraint. It is for mobility and to help with diagnosis. If the SR are ordered for mobility, they should only be up when ADL care is being provided and should be lowered when not in use. On 03/16/23 at 03:09 PM, the Administrator was interviewed and stated the facility identified SR as a topic for Quality Assurance Performance Improvement (QAPI) Committee in 10/2022. Assessing residents and communication between the RHD and Nursing were part of the focus. The facility does not use SR as a restraint. A full or 1/2 SR is considered a restraint and a 1/3 SR is not considered a restraint. 415.4(a)(2-7)

Based on record review and staff interviews conducted during a recertification and complaint survey (NY00298773, NY00295726), the facility did not ensure an alleged violation involving resident to resident physical abuse was and allegations that did not involve serious bodily injury to the New [NAME] State Department of Health (NYSDOH) within a timely manner. This was evident for 2 (Resident #246 and #119) of 3 residents reviewed for Abuse and 1 (Resident #25) of 7 resident reviewed for Accidents out of 40 total sampled residents. Specifically, the facility did not report a resident-to-resident altercation involving Resident #246 and Resident #119 to the NYSDOH within 2 hours of occurrence, and 2) the facility did not report an incident resulting in Resident #25 sustaining a leg laceration requiring 11 staples and hospital intervention within 24 hours of occurrence. The findings include: The facility's current Policy and Procedure, titled Abuse Prevention Policy and Procedure stated that all reports of resident abuse shall be reported immediately or within two hours to the New [NAME] State Department of Health. Resident #246 had diagnoses of depression and schizophrenia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #246 's cognitive status was moderately impaired. Resident # 246 required extensive assistance from staff for most activities of daily living (ADL). Resident #119 had diagnoses of dementia and osteoarthritis. The MDS dated [DATE] documented that Resident #119 's cognitive status was moderately impaired. Resident # 119 required extensive assistance from staff for ADLs. The facility's Incident Report documented that on 07/09/22 at approximately 6:50 PM, resident #246 punched resident #119 on the nose. Resident # 119 was observed with nosebleed. Nursing note dated 07/09/22 documented at 6:50 PM Resident #119 was observed sitting in the dayroom watching television. Resident #246 raised their arm and punched Resident #119 in the face. Staff immediately separated both residents. The Aspen Complaint Tracking System Intake dated 07/11/22 documented that the facility reported the incident on 07/10/22 at 03:08 PM, more than 2 hours after occurrence. On 03/14/23 at 03:56 PM, the Director of Nursing Services (DNS) stated Resident #119 and Resident #246 had a resident-to-resident altercation. Both residents had to be sent to the hospital. An internal investigation was completed and reported to the NYSDOH. The incident report was completed over the weekend. The incident was reported to the NYSDOH the next day. The facility reports all incidents within 24 hours of occurrence and the incident involving Resident #119 and Resident #246 was reported within the right time frame. The DNS stated that there was no injury and so the incident did not need to be reported within two hours. The DNS stated that she was not aware that resident-to-resident altercations had to be reported within two hours. On 03/15/23 at 10:32 AM, the Administrator stated incidents involving substantial injury need to be reported to the NYSDOH within two hours of occurrence. At the time of the incident involving Resident #119 and Resident #246, there were no injuries noted. Both residents were sent to the hospital to rule out injuries. The incident was not reported because Resident #119 had a nose x-ray and there were no injuries. 40686 2) Resident #25 had diagnoses of dementia and osteoporosis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] and 2/9/23 documented Resident #25 had severe cognitive impairments, required total assistance of 2 people for transfers and bed mobility, and did not document any other wounds or skin problems. Nursing Note dated 4/26/22 documented Resident #25 was heard crying in pain and was observed alone in their room with right leg positioned between the GC seat and armrest. Resident #25's right leg was bleeding, pressure was applied to the wound, and Resident #25 was assessed and hospitalized with a 7cm x 1cm x 1cm right leg laceration. The Hospital After Visit Summary dated 4/26/22 documented Resident #25 to have staple removal in 8-10 days, dressing change in 24 hours, and antibiotic prophylaxis for 3-5 days. The summary documented laceration care for an adult includes keeping the wound clean and dry, change the bandage once daily, clean the wound daily and apply a layer of antibiotic ointment daily. The Accident/Incident (A/I) Report initiated 4/26/22 and completed 4/28/22 documented Resident #25 sustained a skin tear because of a screw located on the bottom of the GC armrest. An External Consultation Request dated 4/27/22 documented the Rehab Department (RHD) found GC to be in good working condition with all parts intact. There was no documented evidence the incident involving Resident #25's right leg laceration was reported to the NYSDOH. On 03/14/23 at 05:09 PM and 05:27 PM, Licensed Practical Nurse (LPN) #6 was interviewed and stated Resident #25 was hospitalized on [DATE] due to right leg laceration requiring 11 staples and nursing staff documented an assessment of the wound and treatment plan when the resident was readmitted to the facility. On 03/16/23 at 12:46 PM, the Director of Nursing was interviewed and stated Resident #25 was hospitalized after assessment and had 11 staples to their leg. This was not reported to the NYSDOH and was not considered an injury of unknown origin because the supervisor assessed and saw a screw from the armrest caused the incident. 415.4(b)(2)

Based on observation, interview, and record review conducted during the Recertification and Complaint (NY00295726) Survey from 3/9/23 to 3/16/23, the facility did not ensure a comprehensive person-centered care plan (CCP) was developed and implemented for each resident to meet the resident's needs. This was evident for 1 ( Resident #25) of 7 residents reviewed for Accidents out of 40 total sampled residents. Specifically, a CCP was not developed to address Resident #25's right leg laceration requiring 11 staples. The findings are: The facility policy titled Care Planning-Interdisciplinary Team last reviewed 2/2023 documented the care plan is based on the resident's comprehensive assessment. Resident #25 had diagnoses of dementia and osteoporosis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] and 2/9/23 documented Resident #25 had severe cognitive impairments, required total assistance of 2 people for transfers and bed mobility, and did not document any other wounds or skin problems. On 03/14/23 at 10:22 AM, Resident #25 was observed asleep in bed. A Geriatric Chair (GC) labeled with Resident #25's name was observed against the wall in the room with surgical tape and gauze wrapped around the ends of bilateral armrests. On 03/15/23 at 11:10 AM, Certified Nursing Assistant (CNA) #1 was interviewed and stated Resident #25 received care and is ready for transfer to the GC. Observation was made of 2-person Hoyer lift transfer with CNA #1 placing Resident #25 in the GC with surgical tape and gauze still wrapped around the ends of bilateral armrests. After transferring Resident #25, CNA #1 stated they referred to the CNA Point of Care (POC) electronic medical record prior to transferring Resident #25 to the GC. There are no special instructions, devices, or cushions assigned to Resident #25 in the POC. CNA #1 did not know the reason for the surgical tape and gauze wrapped around the armrest ends and stated the plastic knobs with the screws have never been used. CNA #1 does not know of any incidents involving Resident #25's leg being injured by a GC. The CCP related to self-care performance deficit initiated 5/24/2018 and last reviewed 2/21/23 documented a Hoyer lift was used to transfer Resident #25 out of bed to their GC. The CCP related to fall risk initiated 8/8/2018 and last reviewed 2/10/23 documented interventions to prevent Resident #25 from falling included Physical Therapy (PT) and Occupational Therapy (OT) evaluation as needed. The CCP related to potential for skin integrity impairment initiated 12/29/20 and last updated 2/10/23 documented to keep Resident #25's skin clean and dry. Nursing Note dated 4/26/22 documented Resident #25 was heard crying in pain and was observed with right leg positioned between the GC seat and armrest. Resident #25's right leg was bleeding, pressure was applied to the wound, and Resident #25 was assessed and hospitalized with a 7cm x 1cm x 1cm right leg laceration. The Hospital After Visit Summary dated 4/26/22 documented Resident #25 to have staple removal in 8-10 days, dressing change in 24 hours, and antibiotic prophylaxis for 3-5 days. The summary documented laceration care for an adult includes keeping the wound clean and dry, change the bandage once daily, clean the wound daily and apply a layer of antibiotic ointment daily. The Accident/Incident (A/I) Report initiated 4/26/22 and completed 4/28/22 documented Resident #25 sustained a skin tear because of a screw located on the bottom of the GC armrest. An External Consultation Request dated 4/27/22 documented the Rehab Department (RHD) found GC to be in good working condition with all parts intact. Medical Doctor Orders (MDO) dated 4/27/22 and renewed 2/18/23 documented Resident #25 was ordered out of bed to a GC with Hoyer lift. NN dated 4/27/22 documented Resident #25 returned from the hospital with suturing of laceration to right leg. Medical Doctor (MD) Note dated 4/27/22 documented Resident #25 was noted with laceration to right leg, was sent to the hospital, and returned with 11 staples on the lateral aspect of the middle 3rd of the right leg. Tetanus toxoid vaccine was ordered. NN dated 4/27/22 documented hospital instructions to remove staples in 8-10 days and Keflex in place as prophylaxis. MD Note dated 5/16/22 documented 10 staples safely removed and wound healed. NN dated 5/16/22 documented Resident #25 had staples removed by MD, cleansed with betadine solution, and left open to air. CNA Documentation Survey Report for 3/2023 documented observations of Resident #25's skin every shift. There was no documented evidence a CCP was developed and implemented to treat and prevent further laceration to Resident #25 due to the GC. On 03/14/23 at 05:09 PM and 05:27 PM, Licensed Practical Nurse (LPN) #6 was interviewed and stated Resident #25 was hospitalized on [DATE] due to right leg laceration requiring 11 staples and nursing staff documented an assessment of the wound and treatment plan when the resident was readmitted to the facility. LPN #6 referred Resident #25's GC to the Maintenance Department (MNT) and was told the GC could not be fixed. The intervention was to give Resident #25 another GC. LPN #6 stated the surgical tape on the GC armrests is soft and cushioned and if there is anything like a screw or other sharp object, then Resident #25 would not be injured. but was told they could not fix the GC. On 03/15/23 at 12:47 PM, LPN #3 was interviewed and stated Resident #25 had a past incident with a cut on their leg and the CCP should have been updated. The LPN is not responsible for updating the CCPs. The CCP should have precautions to prevent the incident from happening again. On 03/15/23 at 04:55 PM, the Director of Rehabilitation (DOR) was interviewed and stated the Rehabilitation Department (RHD) screened Resident #25 upon return from the hospital and determine their GC was in good working condition. The Nursing Department determined Resident #25 was injured by a screw under their armrest. The RHD could not support that theory because it was unrealistic for Resident #25 to move their leg to that position. The RHD decided to wrap Resident #25's armrests in surgical tape and gauze. The RHD did not document use of surgical tape and gauze on the resident's medical record and they are not considered interventions to prevent reoccurrence. The RHD had to do something to address Resident #25's injury and did their part by checking the GC. The original GC from 4/26/22 was never switched out and Resident #25 continues to use the same GC today. On 03/16/23 at 12:46 PM, the Director of Nursing Services (DNS) was interviewed and stated after Resident #25 was injured on 4/26/22, the interdisciplinary team (IDT) discussed and the RHD placed the surgical tape and gauze on the GC armrests to prevent reoccurrence of the incident. The team plan was to monitor mobility of the lower extremities, reassess, reposition the resident every 2-4 hours, and fragile skin care. The RNs complete and update the CCPs. 415.11(c)(1)

Based on record review and interviews conducted during the Recertification survey from 3/09/2023 through 03/16/2023, the facility did not ensure that each resident's person-centered comprehensive care plan (CCP) was reviewed and revised. This was evident for 1 (Resident #68) of 1 resident reviewed for Behavior out of a sample of 40 residents. Specifically, the Resident #68's CCP related to hoarding behavior was reviewed and revised to include person-centered interventions to address clutter in the resident's room. The findings are: The facility policy and procedure titled Problematic Behavior Management- Clinical Protocol dated 02/2023 documented staff and the physician will identify problematic behavior and interventions to address the nature and causes of problematic behavior. The staff and physician will document reassessments of positive or negative changes in the individual's behavior. Resident #68 with diagnoses that included unspecified dementia without behavioral disturbance and anxiety. The Minimum Data Set 3.0 dated 12/13/2022 documented that the resident was cognitively intact and did not display inappropriate behaviors. On 3/13/2023 at 10:02 AM, Resident #68's room was observed with stacked food trays, papers, magazines books, 17 boxes stacked behind the door, 1 box under bed footboard and cardboard boxes stacked 6 high to the right of the resident's bed, perishable food including sandwiches, milk, sealed juices, and 1 pink suitcase to left of door. Resident #68 was observed taking food off of the used breakfast trays and took the food back to their room. The CCP related to Resident #68's hoarding behavior initiated 2/24/2017 and last reviewed 6/7/22 documented interventions including anticipate resident needs, approach in a clam manner, monitor behavior episodes, and intervene as necessary to protect the rights of others. The most recent intervention was documented 5/15/2020. The Plan of Care note dated 9/13/2022 documented Resident #68 will have fewer episodes of hoarding by review day and resident has an ability to properly organize objects/discards during their time in the facility. The Plan of Care note dated 9/29/2022 documented the Resident #68 continues to hoard stuff in their room and is redirected as needed. The Psychiatrist Note dated 1/19/2023 documented the plan to address Resident #68's hoarding behavior included setting firm limits, encouraging participation in activities, and reconsultation with the psychiatrist. Resident #68 will work on decluttering the room with staff. There was no documented evidence Resident #68's CCP related to hoarding behavior was reviewed and revised at least quarterly to include person-centered interventions. On 03/14/2023 at 3:17 PM, an interview was conducted with Certified Nursing Assistant (CNA #6) who stated Resident #68 has a lot of clutter that staff cannot touch because the resident raises their voice and will not allow staff to touch their belongings. The nurse is aware. Staff discuss the resident's room periodically. On 03/14/2023 at 3:31 PM, Licensed Practical Nurse (LPN) #8 was interviewed and stated they try to remove items from Resident #68's room during daily rounds. The Social Worker (SW) writes notes. The Registered Nurse (RN) revises resident CCPs. On 03/14/2023 at 5:26 PM, RN #1 was interviewed and stated they try to limit the clutter in Resident #68's room and it does not pose a hazard. RN #1 has not documented the behavior. The RN charge nurse or night supervisor modifies the CCP. The morning RN completes the scheduled CCP reviews. On 03/15/2023 at 12:07 PM, RN #3 was interviewed and stated Resident #68 was a hoarder and is encouraged to get rid of items they don't need. RN #3 is aware Resident #68 removes food items from meal trays and keeps food in their room. The Assistant Director of Nursing (ADON) does the CCPs for the unit. On 03/15/2023 at 12:34 PM, an interview was conducted with the Director of Social Work (DSW) who stated Resident #68 has hoarding behavior and care planning is a collaboration between SW and Nursing. It should trigger for review quarterly and annually. The DSW could not provide a reason the CCP was not updated more recently. On 03/15/2023 at 12:54 PM, an interview was conducted with the ADON who stated they think there have been changes to Resident #68's CCP related to hoarding. CCPs should be reviewed quarterly. On 03/16/2022 at 02:20 PM, an interview was conducted with the Director of Nursing who stated the Resident #68's behaviors are ongoing and not specifically when care plan is scheduled to be reviewed. It is a team effort. Nursing and social work make intervention recommendations for the resident. Interventions are updated when changed. Resident #68 had a known hoarding behavior and Interventions remain the same unless there is an episode of hoarding behavior. Staff maximize all interventions from the CCP. 415.11(c)(2)(i-iii)

Based on observation, interviews, and record review during the Recertification Survey initiated on 3/9/23 and completed on 3/16/23, the facility failed to ensure residents who had a prosthesis (artificial limb) were provided care and assistance consistent with resident preferences to use the prosthetic device. This was evident for 1 (Resident #24)of 1 resident reviewed for Mobility out of 40 total sampled residents. Specifically, Resident #24 did not receive assistance applying a cosmetic prosthetic limb. The findings are: The facility policy titled Artificial limb, care of, reviewed February 2023, documented guidelines for use of artificial limbs, including reviewing care plans and assembling equipment, ensuring cleanliness, checking for changes or complaints, reporting on skin conditions, and documenting if the resident refuses. Resident #24 had diagnoses of acquired absence of the left leg above the knee (AKA) and depression. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #24 had moderate cognitive impairment and was totally dependent on staff for bed mobility, transfer, toilet use and dressing. On 03/09/23 at 10:25 AM, Resident #24 was interviewed and stated they have a prosthetic limb sitting in their room for approximately 2 months. The Rehab Department (RHD) was supposed to show staff on the unit how to apply the prosthesis to Resident #24's left AKA but no one came to the unit and staff have not applied the prosthesis. A prosthetic leg was observed wrapped in plastic and propped up by the resident's window. On 03/13/23 at 12:03 PM, 03/14/23 at 10:33 AM and 12:22 PM, and 03/15/23 at 12:45 PM and 03:01 PM, Resident #24 was observed out of bed without their prosthesis applied to their left AKA. A Physician Assessment for Prosthetic Device dated 8/15/22 documented Resident #24 requested a prosthetic leg for cosmetic purposes. A Medical Doctor Order dated 11/16/22 documented Resident #24 was provided with left above knee cosmetic prosthesis ordered to be worn when out of bed and out on pass. A comprehensive care plan (CCP) related to prosthesis use was created 11/16/22 and last revised 1/20/23 and documented intervention to assist Resident #24 with applying prosthesis. A Physical Therapy/Occupational Therapy screen dated 1/16/23 documented Resident #24 had left above knee cosmetic prosthesis to be worn out of bed and when out on pass. There was no documented evidence the prosthesis was applied to Resident #24's left AKA and no documented evidence Resident #24 refused to have the prosthesis applied. On 03/15/23 at 11:05 AM, Certified Nursing Assistant (CNA) #1 was interviewed and stated that Resident #24 told CNA #1 the Physical Therapist had to explain to the CNA how to use the prosthetic leg. CNA #1 did not attempt to apply the leg and did not report prosthesis use to their supervisor. On 03/16/23 at 09:57 AM, CNA #2 was interviewed and stated Resident #24 asked Rehab to help with prosthesis use. The Physical Therapist said they would teach Resident #24 and the staff how to use it but never came back. On 03/15/23 at 11:52 AM, Licensed Practical Nurse (LPN) #1 was interviewed and stated that Resident #24 has a prosthesis but refuses to wear it. The CNAs are supposed to put it on. LPN #1 stated they tried to put it on Resident #24 and the resident didn't want it. Refusals are normally documented and LPN #1 could not explain the reason Resident #24's refusal to wear the prosthesis was not documented. LPN #1 also did not attempt to apply the device again. On 03/15/23 at 12:34 PM LPN #2 was interviewed and stated they have taken care of Resident #24 and have never seen them use their prosthesis. The order is not in the Point Of Care system that lists resident care. LPN #2 stated they have not received an in-service on how to apply Resident #24's prosthetic leg and that is why they had not attempted to apply it. On 03/15/23 at 12:06 PM and on 03/16/23 at 10:10 AM, the Rehab Director was interviewed and stated the CNA assigned to Resident #24 received an in-service when the prosthesis was delivered and the CNA was expected to teach other staff and call the Rehab Department with any questions. The Rehab Director stated Resident #24 refused the device or was not available at the time it was offered. Resident #24 was forgetful and had not complained about the prosthesis. The Rehab director stated the prosthetic leg had been in the room for a while and the nursing staff should have called the Rehab Department if they didn't know how to use it. The prosthesis is only for cosmetic purposes. On 03/16/23 at 01:41 PM, the Director of Nursing (DNS) was interviewed and stated that usually, CNAs put on prosthetic devices when they provide care, and document when the devices are on and if they are refused. The Rehab Department in-services the staff on proper use. The DNS stated that Resident #24 has periods of confusion and refusals should have been documented. The DNS could not confirm if the prosthesis was applied and if there were any refusals. The DNS stated that documentation needs to be improved. 415.12

Based on observations, interview, and record review conducted during the Recertification Survey from 3/9/23 to 3/16/23, the facility did not ensure a resident remained free of physical restraints. This was evidenced for 1 (Resident #94) of 1 resident(s) reviewed for physical Restraints. Specifically, Resident #94 was observed with bilateral upper 1/3 siderails (SR) in place on multiple occasions. The findings are: The facility policy titled Bed Safety last reviewed 2/2023 documented to prevent deaths, maintenance staff inspect beds for entrapment risks. The review shall consider resident weight and movement. Identify safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g. altered mental status, restlessness, etc.) Siderail use shall be in consultation with the Attending Physician. Resident #94 had diagnoses of dementia and hemiplegia and hemiparesis following non-traumatic intra-cerebral hemorrhage affecting right dominant side. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #94 was severely cognitively impaired, required extensive assistance of 1 person for bed mobility and transfers, and bed rails and restraints were not used. On 03/10/23 at 10:09 AM, 03/13/23 at 11:48 AM, and 03/15/23 at 03:12 PM, Resident #94 was observed in bed sleeping calmly with bilateral upper 1/3 SR raised. On 03/10/23 at 12:55 PM, Resident #94 was observed alert in bed eating lunch with bilateral 1/3 SR raised. The Comprehensive Care Plan (CCP) related to falls initiated 5/7/19 last reviewed 3/10/23 documented Resident #94's fall risk was related to confusion with fall incidents occurring on 11/13/22 and 11/23/22. Physical Therapy to evaluate and treat as ordered. The CCP related to self-care deficit and Activities of Daily Living (ADL) initiated 5/8/19 documented 1/3 SR was a bed enabler and used during care provision to assist with turning and positioning every 2 hours. The CCP related to behavior initiated 9/13/19 last reviewed 3/10/23 documented Resident #94 had a history of verbal and physical aggression during ADL care and attempting to come out of bed. The Siderail Rationale Screen dated 11/28/22 documented Resident #94 was non ambulatory, had alteration in safety awareness due to cognitive decline, had a history of falls, was on medications that require safety precautions, and was using the SR for positioning and or support. Bilateral 1/3 SR indicated to improve mobility and increase independence. A Communication with Rehab note dated 3/6/23 documented a Rehab screen was completed. Resident #94 was not oriented, was unable to follow commands, and was able to perform bed mobility with the limited assistance of 1 person. The note documented Resident #94 was not a candidate for SR. An Informed Consent for Use of SR form dated 3/6/23 documented SRs were used with Resident #94 for safety due to medical condition. verbal consent from the family. The form did not document Resident #94's specific medical need, possible benefits of, and/or possible risks of SR use. There was no documented evidence Resident #94 was assessed for risk of entrapment prior to bilateral 1/3 upper SR use. On 03/15/23 at 03:13 PM, CNA #4 was interviewed and stated they are assigned to and familiar with Resident #94. The bilateral SR were already raised when CNA #4 arrived at work. CNA #4 did not know the size of the SR. Resident #94 used to throw themselves out of the wheelchair onto the floor but no longer comes out of bed and is not a fall risk any longer. CNA #4 stated Resident #94 helped a lot by grabbing the SR while turning in bed during washing or cleaning of bowel movement. Resident #94 follows commands intermittently. CNA #4 stated SR were not listed on the CNA POC system for Resident #94. SR are implemented as a standard for all residents and do not have to be listed in the POC. There are no risks or dangers with SR because the residents need them. Nursing Supervisors tell the CNAs that SR are in place for safety. On 03/15/23 at 03:52 PM, Licensed Practical Nurse (LPN) #5 was interviewed and stated it is not standard for all residents to have SR in place. the Rehab Department (RHD) completes a SR assessment to determine if a resident can turn to the side and hold onto the SR. The RHD communicates their recommendation verbally or via the communication log in the electronic medical record, and writes an order for SR. The nursing supervisor requests for the Maintenance Department (MNT) to bring the SR and checks they are the right size. LPN #5 does not know whether MNT conducts a SR assessment for risk of entrapment and improper sizing. CNAs and other staff learn about changes in SR use verbally during their daily morning report. Resident #94 had a SR assessment on 11/28/22 recommending use of SR. LPN #5 was not aware of the Rehab Communication note dated 3/6/23 documenting that SR use for Resident #94 was not recommended. LPN #5 observed Resident #94 lying in bed with no care in progress and bilateral 1/3 SR raised. LPN #5 stated Resident #94 had SR for bed mobility SR should only be raised during ADL care. The MDO for Resident #94's SR use was dated today, 3/15/23. SRs are not being used to prevent falls and are not a restraint. On 03/15/23 at 05:25 PM, the Director of RHD (DOR) was interviewed and stated SR assessment is completed for each resident quarterly and as needed. The RHD cannot recommend SR use for safety because then the SR would be considered a restraint. The RHD only assess the resident cognition, bed mobility, and the resident's ability to follow instructions when turning in bed. The RHD assessed and determined Resident #94 was not a candidate for SR on 3/6/23 and should not have SR in place. The DOR stated the Nursing Department did not communicate with the RHD that SR were being used for Resident #94 following the RHD assessment on 3/6/23. Resident #94 was discharged from Physical and Occupational Therapy program on 3/10/23 and there was no recommendation for SR use. On 03/16/23 at 01:11 PM, the Director of Maintenance was interviewed and stated they are told by the Nursing Department when a resident requires SR and the Maintenance Department brings the SR to the unit. Approximately 90% of the beds already come with SR attached. There is no SR assessment. The Maintenance Department just makes sure the SR can hold a 200 lb person and that the resident cannot remove it. A drill is used to screw the SR in very tightly. On 03/16/23 at 12:23 PM, the Director of Nursing Services (DNS) was interviewed and stated the Registered Nurse completes the initial SR assessment, communicates to the RHD, RHD completes their evaluation of bed mobility in the medical record, Nursing reviews the RHD recommendation, MNT brings the SR to the unit, and Nursing contacts the family for consent for SR use. Nursing deems whether a resident has an appropriate diagnosis for SR use. The final determination for SR use is made by the Interdisciplinary Team (IDT). If the RHD and Nursing disagree on recommendation for SR use, alternate interventions are discussed. Once SR are recommended, the family is contacted for consent. The consent is obtained and documented on the siderail form. Usually In progress notes also. (Requested example of consent form). The MD is made aware, and an order is written. Resident needed SR because of the diagnosis of seizures. The safety is from seizures not from falls. 415.12(g)(2)

Based on observation, record review, and interviews conducted during the recertification survey from 3/9/23 to 3/16/23, the facility did not ensure menus were followed. This was evident for 1 (Resident #64) of 40 sampled residents. Specifically, Resident #64 did not receive a sandwich on their tray in accordance with the meal ticket. The findings are: The facility policy titled Resident Food Preference last reviewed 2/2023 documented the Dietician will discuss resident food preferences and will visit residents periodically to determine if revisions are needed. The Nursing staff will inform the kitchen about resident requests. The facility policy titled Tray Identification last reviewed 2/2023 documented tray tickets are placed on the tray to ensure the correct diet is being served and food preferences are being honored. Resident #64 had diagnoses of chronic kidney disease and major depressive disorder. The Minimum Data Set 3.0 dated 12/8/22 documented Resident #64 had mild cognitive impairment and had a mechanically altered diet. On 03/09/23 at 10:47 AM, Resident #64's daughter was interviewed and stated Resident #64 does not like the hot food from the facility and prefers to have sandwiches on her lunch and dinner tray. The sandwiches are often missing and the Dietician is aware. On 03/09/23 at 12:31 PM, Resident #64 was observed being served a meal tray with a meal ticket that read Tuna Sandwich on Tray. The meal tray was observed with no tuna sandwich. On 03/10/23 at 12:22 PM, Resident #64 was observed being served a meal tray with a meal ticket that read Tuna Sandwich on Tray. At 12:47 PM, the staff member returned to the resident's room with a new meal tray. The Nutritional assessment dated [DATE] documented Resident #64 had a current diet order of ground texture and soft sandwiches and was able to tolerate the current diet without chewing or swallowing difficulty. Resident likes ham and cheese sandwiches. On 03/14/23 at 10:53 AM, Certified Nursing Assistant (CNA) #5 was interviewed and stated Resident needs anything, Resident asks for the CNA to lift the lid to see if they like the meal. If Resident #64 does not have a sandwich on the tray, the CNA will request for a sandwich from the kitchen. Resident #64 normally gets a sandwich every day but sometimes it does not come up on th tray and then Resident #64 requests to have a sandwich. The sandwich is listed on the resident's meal ticket. Resident #64 reported they now want ham and cheese instead of tuna sandwich. The CNA reported sandwich preference to the nurse who then informed the Dietician. The Dietician said sandwiches will be added to the resident's meal ticket. The kitchen still did not send up sandwiches for Resident #64 and staff have to go down to pick up a sandwich from the kitchen when it is not delivered on the tray. CNA #5 stated they went to get Resident #64 a ham and cheese sandwich yesterday. On 03/15/23 at 03:36 PM, Licensed Practical Nurse (LPN) #4 was interviewed and stated Resident #64 always wanted a tuna sandwich on their tray. If it is not there, LPN #4 calls the kitchen for it. LPN #4 does not know the reason the kitchen has not provided the tuna sandwich and has reported it to the kitchen supervisor. Other residents have sandwiches delivered without issue. LPN #4 only spoke with the head of the kitchen about Resident #64's sandwich preferences and cannot recall speaking with the Dietician. On 03/16/23 at 09:30 AM, the Dietician was interviewed and stated Resident #64 was able to tolerate soft sandwiches and the tuna sandwich was their preference. The Dietician has not checked whether trays are accurate according to meal tickets. There have not been any reports from unit staff that trays do not follow the meal tickets. On 03/16/23 at 09:54 AM, the Director of Dietary (DD) was interviewed and stated they and the Dietician input food preferences for residents into the meal tracker system. The DD checks the trays and ensures the meals match the meal ticket. If the DD gets called away from the tray line, the Dietary Supervisor covers the tray line and checks accuracy. The DD heard of some residents that did not have accurate trays but this was an issue that was fixed approximately 3 months ago by having the DD check all the trays. The nurse told the kitchen to stop sending tuna sandwiches for Resident #64 but the DD is not sure when this took place. The nurse from Resident #64's unit has been coming down to get tuna sandwiches for Resident #64 and the meal ticket was not changed. Changes to the meal ticket can only come from the Dietician or Speech Therapist. If tuna sandwich was on the meal ticket, it should have been served. On 03/16/23 at 10:17 AM, the Dietary Supervisor (DS) was interviewed and stated they were responsible for checking the trays for accuracy on 3/9/23 and 3/10/23. The DD checks some too. The DS does not check every meal ticket. Sometimes a sample of trays are checked from each unit. The DS checked Resident #64's tray and there were tuna sandwiches on the tray. The DS could not explain the tuna sandwiches not being on the trays when delivered to the unit. There was one day, the nurse came to th kitchen, requested ham and cheese for the resident, and then took a tuna sandwich for the resident. On 2 occasions, the nurse called the kitchen and informed the kitchen the tuna sandwich was not there. 415.14(c)(1-3)

Based on record review and interviews conducted during the Recertification Survey initiated on 3/9/23 and completed on 3/16/23, the facility did not implement policies and procedures to ensure that staff who were granted an exemption to the Covid-19 vaccine requirement adhere to additional precautions that are intended to mitigate the spread of Covid-19. This was evident for 1 of 1 medical exemptions provided by the facility. Specifically, an unvaccinated staff member providing direct care for residents had a valid medical exemption, but no additional precautions were in place. The findings are: The facility policy titled Mandatory Covid-19 vaccination for covered personnel, undated, documented when reasonable accommodations have been granted to personnel with a medical exemption, additional precautions that are intended to mitigate the spread of Covid-19 should be in place. These include but are not limited to reassigning staff to non-patient care areas or duties, requiring at least weekly testing for exempted personnel regardless of level of community transmission, and requiring exempted staff to use N95 or equivalent higher-level respirator regardless of whether they are providing direct care to residents. The Staff Vaccination Matrix documented that there was one unvaccinated staff with a medical exemption, CNA #3. The Request for medical exemption from Covid-19 vaccine for CNA #3, dated 9/23/21, specified the recognized clinical contraindications to COVID-19 vaccines and was signed by a health care practitioner. The staffing Schedule for CNA #3 for February and March 2023 documented CNA #3 was scheduled to work 6 days a week on the day and evening shifts. The Assistant Director of Nursing Services (ADNS)/Infection Preventionist (IP) was interviewed on 03/14/23 at 03:06 PM and stated that the facility has no additional precautions in place for unvaccinated staff. CNA #3 follows the same procedures as the rest of the staff and is required to mask continuously throughout their shift and utilize standard precautions such as hand hygiene. CNA #3 wears a surgical mask and is not required to wear an N95 or equivalent. N95 masks are used by staff when they care for Covid-19 positive residents. CNA #3 is not required to undergo regular testing. The IP also stated that they'd try not to assign CNA #3 to residents who are considered high-risk. The risk is determined by the resident's diagnosis, but this process is not stipulated nor documented. On 03/16/23 at 01:41 PM, an interview was conducted with the Director of Nursing Services (DNS) who stated that the infection preventionist is the one who really manages the Covid-19 vaccination efforts. The DNS further stated that unvaccinated staff have no additional precautions to prevent the spread of Covid-19. They follow the same measures as rest of the staff, such as use of masks at all times. They are to report to the administration immediately if they feel any symptoms. 415.19