Every finding on record at The Grand Rehabilitation and Nursing at Great Neck

Based on observations, record review, and interviews during the survey, the facility failed to ensure it maintained an infection control program to help prevent the development and transmission of communicable diseases and infections. This was identified for (1) one (Resident #219) of six (6) residents observed during the medication administration task, for one (1) (first floor medication cart) of four (4) medication carts observed during the medication storage task; and for one (1) (Resident #95) of four (4) residents reviewed for respiratory care. Specifically, 1) Resident #219 had a physician's order for contact precautions for conjunctivitis (a contagious eye infection). During a medication administration observation on 05/27/2026, Licensed Practical Nurse #3 did not wear a gown or gloves when entering Resident #219's room and was touching the resident's hands and wrists; 2) during an observation of a medication cart on the first floor nursing unit, Licensed Practical Nurse #2 sanitized the blood glucose glucometer (a device for testing blood sugar) with alcohol prep pads rather than the manufacturer-required germicidal wipes; and 3) After Resident #95 refused the physician ordered chest x-ray and skin test to rule out tuberculosis (lung disease) infection, there was no documented evidence that the facility completed a tuberculosis symptom screening and risk assessment.The findings include:The facility policy titled Isolation-Notices of Transmission-Based Precautions, reviewed 01/2026, documented when transmission-based precautions are implemented, the infection preventionist determines the appropriate notification to be placed on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions. Notices will be used to alert personnel and visitors of transmission-based precautions. The facility policy titled Contact Precautions, reviewed 01/2026, documented all personnel, including visitors, that have direct contact with a resident on contact precautions shall be required to follow all procedures as outlined within this policy in addition to standard precautions. Contact precautions are to be used for specific residents known or suspected of being infected with epidemiologically important microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. A medical order is required for initiation of precautions and discontinuation of precautions. The order should include the reason and site. As soon as precautions are implemented, a contact precaution sign shall be placed on the resident's door and remain in place until precaution procedures have been discontinued.The facility policy titled Cleaning and Disinfection of Glucometer, reviewed 01/2026, documented glucometer cleaning should take place prior to and immediately after each use to prevent the spread of pathogens from blood or body fluids. In cases where the manufacturer has no cleaning recommendations, use of an Environmental Protection Agency-registered high-level disinfectant is the standard. The meter must be disinfected between patient uses by wiping it with an Environmental Protection Agency -registered disinfecting wipes in between the tests.The facility policy titled Screening Residents for Tuberculosis, reviewed 01/2026, documented the facility shall screen all residents for tuberculosis infection and disease. Individuals identified with active tuberculosis disease shall be isolated from other residents and staff and transported to an appropriate care facility as soon as possible. The nurse will screen referrals for admission and readmission for information regarding exposure to or symptoms of tuberculosis.1) Resident #219 was admitted with diagnoses including cerebrovascular accident, fracture of spine and pelvis, and muscle weakness. The 02/15/2026 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 6, indicating the resident had severe cognitive impairment.A nursing progress note dated 05/21/2026 documented the resident was noted with redness to the left eye and complained of itching. The resident was seen by the nurse practitioner and was diagnosed with left eye conjunctivitis. Recommendations were to start polytrim (antibiotic) ophthalmic eye drops three times a day. The resident was placed on contact precautions.A physician's order dated 05/21/2026 documented contact precautions for bacterial conjunctivitis to the left eye for seven days.A physician's order dated 05/21/2026 documented polytrim ophthalmic solution 10,000-0.1 unit / milliliter, instill one drop in both eyes three times a day for conjunctivitis for seven days.During a medication pass observation on 05/27/2026 at 8:45 AM, Licensed Practical Nurse #3 began preparing the medication administration for Resident #219. There was a contact precautions sign at Resident #219's doorway, which documented: Contact Precautions, everyone must clean their hands, including before entering and when leaving the room; providers and staff must also put on gloves before room entry; discard gloves before room exit; put on gown before room entry; discard gown before room exit. Licensed Practical Nurse #3 went into Resident #219's room; the resident was sitting in their wheelchair beside their bed. Licensed Practical Nurse #3 did not put on gown or gloves and touched the resident's wrists and hands to check the resident's identification bracelet. Licensed Practical Nurse #3 came out of the room, did not perform hand hygiene, and then touched the medication cart and the computer that was mounted on the medication cart. When the surveyor pointed to the contact precaution sign Licensed Practical Nurse #3 stated Resident #219 was on contact precautions and they did not touch anything in the room. Licensed Practical Nurse #3 then sanitized their hands and went to the nursing station. Seconds later, Licensed Practical Nurse #3 returned from the nursing station with the Registered Nurse Infection Preventionist. The Registered Nurse Infection Preventionist stated Resident #219 has conjunctivitis and cellulitis of the orbital (eye) area and is on antibiotics for both. The resident is on contact precautions for one more day. The Registered Nurse Infection Preventionist stated Licensed Practical Nurse #3 was supposed to wear a gown and gloves when entering Resident #219's room and should have sanitized their hands when they left the room.During an interview on 05/29/2026 at 1:40 PM, the Director of Nursing Services stated that nurses and staff are supposed to read the transmission-based precautions signage, put on appropriate personal protective equipment and perform hand hygiene as per the facility policy.2) During the inspection of a medication cart on 05/27/2026 at 11:40 AM, on the first-floor nursing unit, Licensed Practical Nurse #2 stated they used alcohol prep pads to sanitize the glucometer and then demonstrated sanitizing the glucometer by using two alcohol prep pads. Licensed Practical Nurse #2 stated there are two glucometers in the medication cart. While one glucometer is drying, the nurse could use the other glucometer to check residents' blood sugars. Licensed Practical Nurse #2 stated they had used the glucometer earlier in the morning to check the blood sugars for Resident #230 and Resident #107. There was a container of germicidal wipes on the medication cart. Licensed Practical Nurse #2 stated they used germicidal wipes to sanitize the blood pressure cuffs.The glucometer manufacturer's user guide documented: Disinfection Instructions: The meter must be disinfected between patient uses by wiping it with an Environmental Protection Agency-registered disinfecting wipe in between tests. The disinfection process reduces the risk of transmitting infectious diseases if it is performed properly.During an interview on 05/27/2026 at 11:45 PM, the Registered Nurse Infection Preventionist stated alcohol is not effective against the blood borne pathogens and the nurses should use the germicidal wipes to clean the glucometer.During an interview on 05/29/2026 at 1:40 PM, the Director of Nursing Services stated the nurses are not supposed to use alcohol wipes to clean the glucometer, because the alcohol is not effective against blood borne pathogens.3) Resident #95 was admitted with diagnoses including diabetes mellitus, pulmonary edema (excess fluid accumulating in the lungs), and cancer. The 05/14/2026 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 9, indicating the resident had moderately impaired cognition.A physician's order dated 05/09/2026 documented Tubersol Solution 5 unit/0.1 milliliter (tuberculin skin test), inject 0.1 ml intradermally (under the skin) one time only for admission-immunization, to be read in 72 hours post implantation.A review of the May 2026 medication administration record revealed the resident refused the tuberculin skin test injection on 05/09/2026.A nursing progress note dated 05/09/2026 documented the resident's family refused the tuberculin skin test.A nursing progress note dated 05/12/2026 documented family repeatedly interrupted and interfered with x-ray technician and phlebotomist while they were attempting to perform ordered imaging and bloodwork, preventing completion of both tasks at this time.A comprehensive care plan dated 05/14/2026 titled Resident is at risk for infection related to need for immunization from communicable diseases (influenza, pneumonia, tuberculosis) documented interventions including to administer the tuberculin skin test as per physician orders. There were no notes or updates added to the care plan following the refusal of the tuberculin skin test injection.During an interview on 05/28/2026 at 1:48 PM, the Registered Nurse Infection Preventionist stated there is questioning related to tuberculosis during the resident admission process, like history, symptoms, potential exposure, and contacts; however, they were not sure where the responses to the tuberculosis screening are documented. The Registered Nurse Infection Preventionist stated that any registered nurse involved in admitting the resident can ask these questions.Review of the medical record revealed no documentation in the medical or nursing progress notes related to tuberculosis screening or interventions following the resident's refusal for the tuberculin skin test and the chest x-ray.During a re-interview on 05/29/2026 at 12:25 PM, the Registered Nurse Infection Preventionist stated the facility used to have a tuberculosis screening form and they did not know why the form was not being used anymore. The Registered Nurse Infection Preventionist stated that the facility policy directs that tuberculosis screening would be completed for new admissions; however, the policy will be revised to include the actual (tuberculosis screening) form be completed. The Registered Nurse Infection Preventionist stated that since Resident #95 refused both the tuberculin skin test and the chest x-ray, the tuberculosis screening should have been completed to rule out active infection. During an interview on 05/29/2026 at 1:40 PM, the Director of Nursing Services stated they were working on updating the tuberculosis screening policy. The tuberculosis screening should be documented, and the facility will be incorporating a tuberculosis screening form in the electronic medical to provide evidence that the screening was done.10 New York Code Rules and Regulations 415.19(a)(1-3), 415.19(b)(4)

Based on observations, record review, and interviews during the survey, the facility failed to ensure that a comprehensive person-centered care plan was developed for each resident that included measurable objectives and timeframes to meet each resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (1) (Resident #119) of three (3) resident reviewed for communication and sensory problems. Specifically, Resident #119 was assessed with moderate hearing difficulty. There was no documented evidence that a comprehensive person-centered care plan was developed for Resident #119's impaired hearing.The findings are: A facility policy titled Care Plans, Comprehensive Person-Centered, documented a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Resident #119 was admitted with diagnoses of non-Alzheimer's dementia, anxiety disorder, and adult failure to thrive (a decline in overall health). An admission Minimum Data Set assessment with dated 05/12/2026 documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The resident had moderate difficulty hearing (speaker has to increase volume and speak distinctly) and had no behaviors. The nursing admission/readmission evaluation dated 05/06/2026 documented the resident had moderate difficulty hearing. The nursing admission note dated 05/06/2026 documented the resident was cognitively intact and had moderate difficulty hearing. During an interview on 05/26/2026 at 12:07 PM, Resident #119 stated that they have difficulty hearing, it is best to speak closely in their left ear for them to hear better. They further stated that they did not have a hearing aid. During an interview on 06/01/2026 at 1:55 PM, Resident #119 stated that a family member had brought in the hearing aids from home, but they had not tried using them as of yet. Resident #119 was not certain if nursing staff knew that the hearing aids had been placed in the nightstand drawer. During an interview on 06/01/2026 at 2:09 PM, Certified Nursing Assistant #1 stated that Resident #119 was hard-of-hearing, so they need to face them directly or speak closely into their left ear and the resident did not use any hearing devices. During an interview on 06/01/2026 at 2:19 PM, Registered Nurse Unit Manager #2 stated that Resident #119 was hard of hearing. The admitting Registered Nurse should have initiated a care plan related to the residents' hard of hearing status based on the admission assessment. If the admission nurse did not initiate the care plan, then it should have been initiated by the interdisciplinary team when the care plan meeting was conducted, and the residents' concerns were discussed. During an interview on 06/01/2026 at 3:14 PM, Registered Nurse Supervisor #3 stated they admitted Resident #119 to the facility. At the time of admission, Resident #119 told them that they could not hear well, and the staff had to adjust the tonal quality and speak closer to the resident's left ear. Registered Nurse Supervisor #3 stated on admission they only initiate the baseline care plans, then it is up to the nurse manager to complete the comprehensive care plans. During an interview on 06/02/2026 at 1:16 PM, the Director of Nursing Services stated when a resident is identified with hearing issues, a care plan should be developed. It was probably overlooked because Resident #119 was able to communicate their basic needs. 10 New York Code Rules and Regulations 415.11(c)(1)

Based on observations, record review, and interviews during the survey, the facility failed to ensure that drugs and biologicals were stored and labeled in accordance with accepted professional principles. This was identified for one (1) (Resident #159) of one (1) resident reviewed for pain management; and one (1) (Unit 2 medication cart) of four (4) medication carts reviewed during the medication storage task. Specifically, 1) on 05/26/2026, Resident #159 had a box of lidocaine (a local anesthetic) pain patches at their bedside and there were no staff in the vicinity. 2) A medication cart in unit two (2) had an undated opened liquid protein bottle (a concentrated, ready-to-drink nutritional protein supplement). The findings include: The facility policy titled Storage of Medications, reviewed 01/2026, documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medications storage. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. The facility's policy titled, Labeling of Medication Containers dated 01/2026 documented that all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Labels for each floor's stocks medications shall include all necessary information such as the name and strength of the drug, the expiration date when applicable, and the date that the medication was dispensed. The facility's policy titled, Storage of Medications dated 01/2026 documented that nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Medications must be stored separately from food and must be labeled accordingly. 1) Resident #159 was admitted with diagnoses including cerebrovascular accident, major depressive disorder, and hypertension. The 03/16/2026 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The resident received a scheduled pain medication regimen over the last five days and had mild pain. A physician's order dated 04/25/2026 documented Aspercreme Lidocaine Patch 4%, apply to left lower back topically one time a day for pain relief, leave on for 12 hours, remove for 12 hours. During an observation on 05/26/2026 at 11:35 AM, Resident #159 was in their room sitting on the edge of their bed. There was a box of lidocaine 4% pain relief patches on the resident's bedside table. The medication pharmacy label had the resident's name; however, the pharmacy that dispensed the medication was not the facility's vendor pharmacy. Resident #159 stated that most days the facility did not have pain patches, so they kept their own supply. Resident #159 stated the patches are applied on their back by the nurses. During an interview on 05/28/2026 at 09:10 AM, Licensed Practical Nurse #1 stated the nurses apply the lidocaine patch to the resident's back and that they had no idea why and for how long the resident had the box of lidocaine patches at the bedside. The lidocaine patches are always available at the facility. During an interview on 05/29/2026 at 11:45 AM, Registered Nurse Staff Educator #1 stated that medications should not be left at the resident's bedside, even if the resident could self-administer their medications. The medications must be stored in the medication cart. Registered Nurse Staff Educator #1 stated if staff notices a medication at the resident's bedside, they should remove the medication, notify the supervisor, educate the family and the resident, and notify the social worker. During an interview on 05/29/2026 at 01:40 PM the Director of Nursing Services stated Resident #159 did not have an order to self-administer medications and that the medications were not supposed to be left unattended or unlocked in the resident's room. 2) During an observation on 06/01/2026 at 11:05 AM, one (1) medication cart on Unit two (2) was observed with an undated, opened bottle of active liquid protein. During an interview on 06/01/2026 at 11:08 AM, Licensed Practical Nurse #4 stated that they did not notice that the active liquid protein bottle did not have a date when it was first opened. Licensed Practical Nurse #4 stated they were not sure when the active liquid protein bottle should be discarded after the it was first opened. During an interview on 06/01/2026 at 11:16 AM, Registered Nurse #1, the unit manager, stated that they were not sure when the active liquid protein bottle should be discarded after the it was first opened. During an interview on 06/01/2026 at 2:01PM, the Director of Nursing Services stated that the medication bottles should be labeled with the date they were first opened to ensure that a discard date can be established. During an interview on 06/02/2026 at 9:47 AM, the Pharmacist stated that active protein supplement should be discarded two to three (2-3) months after opening even if the expiration date on the bottle is beyond that timeframe. The Pharmacist stated that liquid medications are prone to contamination, once exposed to the air. The Pharmacist stated that Nurses should date the bottle after opening to determine the discard date. 10 New York Code Rules and Regulations 415.18(e) (1-4)

Based on observations, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that a comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment. This was identified for one (Resident #71) of three residents reviewed for skin conditions. Specifically, Resident #71 was observed with tissues and rubber bands wrapped around two fingers on multiple occasions and Nursing staff did not revise the comprehensive care plan to address the resident's behavior. The finding is: The facility's policy, titled Behavioral Assessment, Intervention, and Monitoring, last reviewed in January 2024, documented behavior symptoms will be identified using a facility-approved behavior screening tool and a comprehensive assessment. The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice. The facility's policy titled Care Planning, last reviewed in January 2024, documented the facility's care planning/interdisciplinary team is responsible for the development of an individualized Comprehensive Care Plan for each resident. Resident #71 was admitted with diagnoses including Dementia, Chronic Kidney Disease, and Chronic Atrial Fibrillation. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #71 had a Brief Interview for Mental Status score of 12, indicating the resident had moderate cognitive impairment. The Impaired Cognitive Function related to Dementia Comprehensive Care Plan initiated on 2/15/2022 and last revised on 4/28/2023 documented interventions for the Certified Nursing Assistant to report any changes in cognitive function to the Nurse and notify the Physician of inappropriate behavior. The Potential to Exhibit Behavior Symptoms Comprehensive Care plan initiated on 4/28/2022 and last revised on 5/10/2023 documented Resident #71 had the diagnoses of Psychosis and Dementia. The interventions included to administer psychotropic medications as ordered and notify the Physician of inappropriate behavior. A review of Resident #71's Comprehensive Care Plans revealed there were no updates or revisions to address the resident's behavioral symptoms including the habit of wrapping tissues and rubber bands around two fingers. Resident #71 was observed in their room sitting in a chair on 7/11/2024 at 11:02 AM. Resident #71 had tissues and rubber bands wrapped around their left thumb and right middle finger. Resident #71 removed the rubber bands and tissues, in the presence of the Surveyor, and no cuts or bruises were observed on the resident's fingers. Resident #71 stated facility staff cut their fingernails and when doing so, cut their fingers. The resident stated they had a treatment in place to their fingers for three days. A review of the resident's Physician's Orders and Progress Notes revealed Resident #71 did not require skin treatments to their fingers. Resident #71 was observed in their room sitting in a chair on 7/11/2024 at 12:54 PM with tissues and rubber bands wrapped around the same two fingers, their left thumb and right middle finger. Resident #71 removed the rubber bands and tissues, in the presence of the Surveyor, to expose their fingers, and nothing unusual was observed. Resident #71 stated they put the tissues and rubber bands on their fingers because facility staff cut their fingernails too short. Resident #71 was observed in their room sitting in a chair on 7/12/2024 at 9:27 AM with their two fingers wrapped in tissues and rubber bands. Resident #71 stated they prefer to leave their fingers covered so they do not hurt and they must do this for three days. Resident #71 was observed in their room coming out of the bathroom and then sitting in a chair on 7/15/2024 at 10:09 AM with the Registered Nurse Manager (Registered Nurse #5) present. The resident had tissues and medical tape wrapped around their two fingers (the left thumb and the right middle finger). Resident #71 stated that Certified Nursing Assistant #1 put the tissues and tape on their (Resident #71's) fingers for them. Registered Nurse #5 stated they would remove the tissues and tape from Resident #71's fingers. Registered Nurse #5 stated the Certified Nursing Assistant should not have wrapped the resident's fingers and should have reported the behavior of Resident #71 to the Nurse for them to assess the resident's fingers. Registered Nurse #5 stated Resident #71's behavior of wrapping their fingers should have been documented in a progress note and the Comprehensive Care Plan for Behavior should have been updated. Certified Nursing Assistant #1 was interviewed on 7/15/2024 at 10:11 AM and stated they regularly provide care for Resident #71. Certified Nursing Assistant #1 stated Resident #71 was distressed because their (Resident #71) fingers were not wrapped and asked if Certified Nursing Assistant #1 could help the resident wrap their fingers. Certified Nursing Assistant #1 stated they calmed Resident #71 down and did not put the tissues and tape on Resident #71's fingers and the resident must have done it themself. Certified Nursing Assistant #1 stated they should have told the Nurse about the resident wrapping their fingers. Certified Nursing Assistant #1 stated everyone has seen Resident #71 with wrapped fingers and the resident always wraps their fingers with tissues and tape or rubber bands. The Director of Nursing Services was interviewed on 7/17/2024 at 12:02 PM and stated they were unaware of Resident #71's behavior of wrapping their fingers which should have been monitored and documented accordingly. The Director of Nursing Services stated Resident #71 should have had their behavior of wrapping their fingers added to their Behavior Comprehensive Care Plan. The Director of Nursing Services further stated Certified Nursing Assistant #1 should have brought this behavior to the attention of the Nurse on duty or the Nurse Supervisor. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #260) of three residents reviewed for Choices. Specifically, Resident #260 was admitted on [DATE] after a Micra Leadless Pacemaker Implantation (electronic device that is implanted in the body to monitor heart rate and rhythm) and required pacemaker remote monitoring. The facility did not initiate the pacemaker remote monitoring until 7/11/2024 and there was no documented Physician Order for the monitoring until 7/15/2024, seven days after Resident #260 was admitted to the facility. The finding is: The facility's Admission Notes policy dated 1/2022 documented preliminary resident information shall be documented upon a resident's admission to the facility including a brief description of any disabilities, prosthesis required, nursing history, and a preliminary assessment, the presence of a catheter, dressings, etc., Physician's orders that were received and verified and the general condition of the resident upon admission. There was no documented evidence that the facility had a policy and procedure that addressed Pacemaker monitoring. Resident #260 was admitted with diagnoses of the Presence of Cardiac Monitor, Atrial Fibrillation, and Fracture of the Left Acetabulum (hipbone). The Minimum Data Set assessment was not available as the resident was newly admitted . A Comprehensive Care Plan dated 7/8/2024 documented Resident #260 had an Alteration in Cardiovascular Function and the Presence of a Cardiac Pacemaker. An intervention dated 7/9/2024 documented to check the Medtronic pacemaker monitoring device (a device that sends information on the pacemaker battery status, heart rhythm and heart rate to the Physician) was connected to the resident and was plugged in every shift. The care plan instructed to report if the device is not connected and if there are any changes to the resident's condition. Additionally, the care plan instructed to monitor blood the resident's blood pressure and vital signs. The hospital discharge instructions dated 7/8/2024 at 10:08 AM documented to schedule a follow-up to evaluate Resident #260's pacemaker and to check the pacemaker battery. A Baseline Care Plan dated 7/9/2024 documented that Resident #260 was alert and oriented to time, place, and person, cognitively intact, and could communicate with staff. A review of the medical and nursing progress notes revealed routine checks of Resident #260's pacemaker monitoring device were not performed from 7/8/2024 to 7/11/2024. Resident #260 was observed lying in bed on 7/11/2024 at 10:35 AM. A pacemaker monitoring device was observed on Resident #260's nightstand and plugged into the wall. Resident #260 was subsequently interviewed and stated they (Resident #260) had a procedure for pacemaker implantation at the hospital and was admitted to the facility on [DATE]. Resident #260 stated they were concerned because the Registered Nurse Unit Manager (Registered Nurse #1) just came into their room [on 7/11/24] and set up the pacemaker monitoring device. Resident #260 stated that since their admission, the pacemaker monitoring device was not set up and was not transmitting any data to their Physician at the Cardiac Clinic. Registered Nurse #1 was interviewed on 7/12/2024 at 3:12 PM and stated they (Registered Nurse #1) completed the admission intake for Resident #260 on 7/8/2024 when the resident was admitted from the hospital. Registered Nurse #1 stated the pacemaker monitoring device came with Resident #260 upon admission. Registered Nurse #1 stated they plugged the monitor into the wall on 7/8/2024 and did not know they had to set up the machine for the Physician to receive a transmission. Registered Nurse #1 stated they did not call the Physician to verify if a transmission was received. Registered Nurse #1 stated they went to Resident #260's room to check the pacemaker monitoring device on 7/11/2024 at around 10:00 AM and they noticed the panel of the device was not set up. Registered Nurse #1 stated they (Registered Nurse #1) read the setup instructions for first-time transmission on 7/11/2024. Registered Nurse #1 stated they should have read the instructions when they completed the admission intake for Resident #260 on 7/8/2024. Physician #1 was interviewed on 7/15/2024 at 12:09 PM and stated they expected nursing staff to monitor Resident #260's vital signs. Physician #1 stated the Nurses should report if Resident #260 had abnormal vital signs or Atrial Fibrillation symptoms, including a pulse rate of more than 90 rate per minute or less than 60 rate per minute. Physician #1 stated that on 7/15/2024 they (Physician #1) ordered to monitor the pacemaker monitoring device's connection to the resident and ensure that the device was plugged in every shift. Physician #1 stated it was an error that the order was not placed upon admission on 7/8/2024. Physician #1 stated they entered the order on 7/15/2024 after it was brought to their attention [by the surveyor] that the physician's order was not in place. Registered Nurse #2 (Nurse at the Cardiac Clinic) was interviewed on 7/16/2024 at 9:10 AM and stated the Cardiac Clinic received the first transmission from Resident #260's pacemaker monitoring device on 7/11/2024 at 10:00 AM. Registered Nurse #2 stated the facility is expected to set up the pacemaker monitoring device immediately after admission to ensure that the Cardiac Clinic Physician receives transmissions after the pacemaker implantation procedure. The Director of Nursing Services was interviewed on 7/16/2024 at 10:22 AM and stated that when the facility received pacemaker monitoring devices, the Nurses would just plug it on the wall because they assumed the device was already set up. The Director of Nursing Services stated it was unfortunate that Resident #260's pacemaker monitoring device was not set up. The Director of Nursing Services stated the facility did not know the device was not functioning until Registered Nurse #1 had called the Cardiac Clinic on 7/11/2024 to confirm the data transmission. The Director of Nursing Services stated that Registered Nurse #1, who admitted Resident #260, should have called the Cardiac Clinic to confirm the transmission was received and should not have assumed that the pacemaker monitoring device did not need any setup. The Director of Nursing Services stated the facility does not usually enter a Physician's Order for a pacemaker monitoring device; however, an order was entered for Resident #260 to ensure that the nurses check the device's functioning. 10 NYCRR 415.12

Based on observation, record review, and staff interviews during the Recertification Survey, initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. This was identified for one (Resident #135) of two residents reviewed for Rehabilitation Services. Specifically, the Rehabilitation Department recommended a floor ambulation program for Resident #135, however, the floor ambulation program was not completed. The finding is: The facility's Restorative Nursing Rehab Program Floor Ambulation policy, last reviewed on 1/2023, documented each resident will receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care including but not limited to restorative services. The ambulation program refers to the activity of walking that provides weight-bearing that promotes bone health and joint mobility. Recommendations for nursing rehabilitation such as floor ambulation will be transcribed to the tasks in the resident's chart. The task should include frequency, distance, and assistive devices recommended for ambulation. After a successful ambulation session, the aide should document the resident's ambulation, and any concerns that occurred during the event should be reported to the nurse. Resident #135 was admitted with diagnoses including Non-Alzheimer's Dementia, Difficulty in Walking, and Congestive Heart Failure. The 6/16/2024 quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 9, indicating the resident had moderate cognitive impairment. The Minimum Data Set assessment documented the resident needed partial/moderate assistance of one person to walk 10 feet and could not walk 50 feet due to a medical condition. A progress note from the Rehabilitation Department dated 7/3/2024 recommended a Nursing Floor Ambulation Program twice a day for Resident #135 to walk 30 feet with a rolling walker with partial/moderate assistance of one person. The facility Task List Report (Certified Nursing Assistant Instructions) as of 7/18/2024 documented a Floor Ambulation Program for Resident #135 to walk 30 feet with a rolling walker with partial/moderate assistance of one person twice a day. The seven-day lookback of the resident's Certified Nursing Assistant Accountability Record documented a Floor Ambulation Program was performed on eight of ten opportunities from 7/12/2024 to 7/17/2024. Resident #135 was observed lying in bed in their room on 7/11/2024 at 10:23 AM with their Private Aide (Private Aide #1) seated at the bedside. Resident #135 stated that they had been receiving therapy from the facility's Rehabilitation Department, but their therapy had ended. Resident #135 stated that they (Resident #135) wanted to walk more, but could not, since their Rehabilitation Therapy had been discontinued. Private Aide #1 stated that they have cared for Resident #135 for the past [AGE] years and the resident used to be very active. The Director of Rehabilitation was interviewed on 7/18/2024 at 9:04 AM and stated Resident #135 started Physical Therapy on 3/18/2024 and was discharged from Physical Therapy on 7/3/2024 due to reaching their (Resident #135) therapy goals. The Director of Rehabilitation stated the resident was discharged from therapy with a recommendation for a Nursing Floor Ambulation Program to walk a distance of 30 feet twice a day. The Director of Rehabilitation stated rehabilitation staff educate the Certified Nursing Assistants and the Nurses when a resident is discharged from therapy and placed on a Floor Ambulation Program. The Director of Rehabilitation stated rehabilitation staff are expected to add the floor ambulation program task to the Certified Nursing Assistant Accountability Record and the Certified Nursing Assistant Care Instructions to ensure the task is done on a daily basis. The Director of Rehabilitation stated the facility does not use Physician's orders to implement a Nursing Floor Ambulation program. Private Aide #1 was interviewed on 7/18/2024 at 9:30 AM and stated they are with Resident #135 from 7 AM to 5 PM every day and have not seen anyone perform floor ambulation with the resident. Certified Nursing Assistant #2, regularly assigned to Resident #135 on the 7 AM to 3 PM shift, was interviewed on 7/18/2024 at 10:25 AM and stated that they had not completed floor ambulation with the resident and the documentation on the Certified Nursing Assistant Accountability Record of them doing so was a mistake. Certified Nursing Assistant #2 stated they have never walked with the resident on the unit when caring for them during the 7 AM to 3 PM shift. Certified Nursing Assistant #3 was interviewed on 7/18/2024 at 10:40 AM and stated they have never provided floor ambulation for Resident #135. Certified Nursing Assistant #3 stated they were not regularly assigned to Resident #135 and covered various units. Certified Nursing Assistant #3 stated they documented that they had completed that task on 7/15/2024 and 7/16/2024 because they thought the resident walked with a Rehabilitation Therapist. Registered Nurse Unit Manager #1 was interviewed on 7/18/2024 at 10:48 AM and stated they were not aware of Resident #135's Floor Ambulation Program. Registered Nurse Unit Manager #1 stated that if the Floor Ambulation Program was part of the Certified Nursing Assistant's instructions, the Certified Nursing Assistants were expected to perform the task and report if it was not completed. Registered Nurse Unit Manager #1 stated the Rehabilitation Department educates and informs the Nursing Staff which residents are on a Floor Ambulation Program. Licensed Practical Nurse #2 (Resident #135's Medication Nurse) was interviewed on 7/18/2024 at 11:03 AM and stated the resident was not on a Floor Ambulation Program and the resident goes to Rehabilitation Therapy every day. The Director of Rehabilitation was re-interviewed on 7/18/2024 at 11:41 AM and stated the Rehabilitation Staff provides education to the Nursing Staff using a paper lesson plan that outlines the material being taught and the nursing staff then signs off on it. The Director of Rehabilitation stated they could not find the lesson plan for Resident #135's Floor Ambulation Program. The Director of Nursing Services was interviewed on 7/18/2024 at 12:02 PM and stated Certified Nursing Assistants should not document that they provided Floor Ambulation to a resident if they did not do it. The Director of Nursing Services stated there was a clear disconnect between Nursing and Rehabilitation Staff in regards to Resident #135's Floor Ambulation Program. The Director of Nursing Services stated Resident #135 should have received Floor Ambulation as per the program recommended by the Rehabilitation Department. 10 NYCRR 415.12(e)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that residents who are incontinent of bowel and bladder received the appropriate treatment and services to prevent Urinary Tract Infection. This was evident for one (Resident #117) of three residents reviewed for Activities for Daily Living. Specifically, Resident #117 required total assistance from one caregiver for toileting and was frequently incontinent of bowel and bladder. Resident #117 was observed wearing a urine-soaked brief and had wet linens underneath them on 7/11/2024 at 11:11 AM. The resident was last changed on the 11:00 PM to 7:00 AM shift before the observation. The findings is: The facility Resident Care with Activities of Daily Living policy and procedure, last updated on 1/2024, documented the resident will be offered toileting assistance or incontinent care twice per shift and as needed. The policy documented that staff must report any changes in the resident prior to, during or after toileting or incontinence care such as refusal to the Charge Nurse/Supervisor. Resident #117 was admitted with diagnoses that included Dementia with Agitation, Insomnia, and Major Depressive Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 10, indicating the resident had moderately impaired cognition. The resident had no mood symptoms and did not reject care. The resident was not on a toileting program, was frequently incontinent of bowel and bladder, and required total assistance from one caregiver for toileting. A Comprehensive Care Plan for Activities of Daily Living dated 11/8/2023 and last updated on 5/6/2024 documented Resident #117 required assistance with self-care and mobility due to impaired mobility. The interventions included to encourage the resident to participate to the fullest extent possible with each interaction. The care plan documented the resident was dependent on the care of one staff member for toileting and personal hygiene. A Comprehensive Care Plan for Resident Choice dated 11/9/2023 and last revised on 4/12/2024 documented Resident #117 refused activities of daily living care. The interventions included to assess the underlying reason for the resident's choices. There were no instructions for staff to report refusal of care to the Charge Nurse and/or Supervisor. The Certified Nursing Assistant Task Report (Certified Nursing Assistant Instructions) last revised on 3/23/2024 documented the resident required incontinence care, used a large-sized brief, and depended on one caregiver for toileting hygiene. There were no instructions for Certified Nursing Assistants to report refusals of care to the Charge Nurse and/or Supervisor. Review of Resident #117's progress notes on 7/11/2024 revealed there were no documented care refusals before 11:00 AM. Resident #117 was observed in their room lying in bed while awake and wearing sleepwear on 7/11/2024 at 11:11 AM. There was a strong urine odor in the resident's room. Resident #117 stated that their Certified Nursing Assistant had not come in to perform morning care all morning. Resident #117 stated they were wet, needed to be changed and assisted out of bed. At 11:12 AM, the resident was observed ringing the call bell and Certified Nursing Assistant #5 responded within one minute. Certified Nursing Assistant #5 stated that they (Certified Nursing Assistant #5) were assisting another resident and would help Resident #117 after they were finished. The resident stated they were last changed on the 11 PM to 7 AM shift. Certified Nursing Assistant #5 was observed assisting the resident with morning care on 7/11/2024 at 12:26 PM. There was a strong odor of urine in the hallway, and upon entering the resident's room, the pungent urine odor permeated the resident's room. The resident's soiled brief was observed to be saturated with urine and the inner lining of the diaper was balled up. The resident's bed linen was also observed to be wet and smelled of urine. Certified Nursing Assistant #5 was interviewed on 7/11/2024 at 12:53 PM and stated they had not cared for Resident #117 all morning and that the resident was last changed on the 11 PM to 7 AM shift. Certified Nursing Assistant #5 stated that they regularly worked with the resident, and they (the resident) were difficult to work with. Certified Nursing Assistant #5 stated the resident refused morning care on 7/11/2024. Certified Nursing Assistant #5 was re-interviewed on 7/16/2024 at 2:32 PM and stated Resident #117 usually gets out of bed around 11:00 AM daily. Certified Nursing Assistant #5 stated that the resident was incontinent of bowel and urine and had frequent urination. Certified Nursing Assistant #5 stated that on 7/11/2024, they (Certified Nursing Assistant #5) served the resident their breakfast tray after 8 AM and the resident did not complain about being wet. Certified Nursing Assistant #5 stated that they went into the resident's room after breakfast, at around 9:30 AM, and after 11:00 AM, and the resident stated that they were not ready to get out of bed. Certified Nursing Assistant #5 stated that they did not report to the Nurse that the resident was refusing care. Certified Nursing Assistant #5 stated that at 11:25 AM, they went to the resident and informed them (Resident #117) that they were with another resident and would come in after they had completed the other resident's care. Certified Nursing Assistant #5 stated when they returned to care for Resident #117 at around 11:45 AM, the resident's brief was soaked with urine and the bed linen was also wet. Certified Nursing Assistant #5 further stated they should have report to the Charge Nurse when a resident refuses care and encourage the resident to accept care. Certified Nursing Assistant #7, who cared for the resident on the 11:00 PM to 7:00 AM shift on 7/10/2024 into 7/11/2024, was unavailable for an interview. Registered Nurse #7, the Nurse Manager for the second floor Nursing Unit, was interviewed on 7/16/2024 at 3:03 PM and stated they were not made aware that Resident #117 was refusing care. Registered Nurse #7 stated Certified Nursing Assistant #5 should have checked the resident at the beginning of the shift to ensure they were dry. Registered Nurse #7 stated that the Certified Nursing Assistants are instructed to check the residents every two hours to ensure timely and appropriate incontinence care is rendered. Registered Nurse #7 stated if a resident refuses care, the Certified Nursing Assistant should re-approach the resident. Registered Nurse #7 stated if the resident continues to refuse care, the Certified Nursing Assistant should go to the Charge Nurse. The Charge Nurse and the Certified Nursing Assistant should report to the Nurse Manager if they were unable to encourage the resident to accept care and document the refusal in the progress notes. The Director of Nursing Services was interviewed on 7/17/2024 at 12:08 PM and stated Certified Nursing Assistant #5 should have reported to the Charge Nurse that Resident #117 refused care after they (Certified Nursing Assistant #5) approached the resident twice. The Director of Nursing Services stated the Charge Nurse should report to the Registered Nurse Manager that the resident continued to refuse care and document the incident in a progress note. The Director of Nursing Services stated they expect Certified Nursing Assistants to check and change a resident's brief every two to three hours. 10 NYCRR 415.12 (d)(2)

Based on observations, record review, and interviews conducted during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. This was identified for one (Resident #57) of four residents reviewed for Respiratory Care. Specifically, Resident #57 had a Physician's Order to receive 4 liters of oxygen therapy per minute via mist collar to a tracheostomy continuously. However, on multiple occasions, Resident #57 was observed receiving 6 liters of oxygen per minute via mist collar to their tracheostomy. The finding is: The facility's Assessing Oxygen Saturation Policy, last revised in January 2024, documented to assess the resident for the following signs and symptoms of impaired oxygen saturation: altered respirations, difficulty breathing, and abnormal breath sounds. The policy further documented to notify the Physician if the oxygen saturation level is less than an acceptable level for the resident's condition. Resident #57 was admitted with diagnoses including Acute Respiratory Failure with Hypoxia, Quadriplegia, and Cerebral Infarction. The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 99, which indicated the resident had severe cognitive impairment. The Minimum Data Set further documented the resident received oxygen therapy. The Alteration in Respiratory System Care Plan, last revised on 3/21/2024, documented interventions which included to provide oxygen therapy via humidified air at 4 liters per minute via tracheostomy collar at all times, as per Physician's Orders. A Physician's Order dated 7/11/2024 documented oxygen therapy to be administered at 4 liters per minute via a tracheostomy collar continuously. Resident #57 was observed sleeping in a Geri chair (a large padded chair with wheeled bases designed to assist individuals with limited mobility) in their room with a mist collar delivering 6 liters of oxygen per minute to their tracheostomy on 7/11/2024 at 1:08 PM. Resident #57 was observed lying in bed in their room with a mist collar delivering 6 liters of oxygen per minute to their tracheostomy on 7/12/2024 at 8:53 AM. Resident #57 was observed sleeping in a Geri chair in their room with a mist collar delivering 6 liters of oxygen per minute to their tracheostomy on 7/12/2024 at 11:56 AM. Resident #57 was observed in their room in a Geri chair with Nurse Manager #5 on 7/16/2024 at 10:42 AM. The display window on the oxygen concentrator indicated the resident was receiving 6 liters of oxygen per minute via a mist collar to their tracheostomy. Registered Nurse #3 was interviewed on 7/16/2024 at 10:46 AM and stated they just checked the oxygen level and thought it was set to 4 liters per minute. Registered Nurse #3 stated that the oxygen therapy setting was checked on each shift by a Nurse. Registered Nurse #3 stated they would speak to the Physician about the Oxygen order. Registered Nurse #3 stated they would set the oxygen therapy to 4 liters per minute and check Resident #57's oxygen saturation level (measurement of the amount of oxygen in your blood). Registered Nurse #3 stated they would continue to monitor the resident's oxygen saturation level during the 7 AM - 3 PM shift and if Resident #57's oxygen dropped, they would increase the oxygen and call the Physician. The Registered Nurse Manager (Registered Nurse #5) was interviewed on 7/16/2024 at 10:49 AM and stated the Nurse caring for Resident #57 should monitor the resident's oxygen saturation levels and notify the Physician that the resident required more oxygen. Registered Nurse #5 stated the Nurse caring for Resident #57 was responsible for monitoring and documenting the resident's oxygen level every shift. Registered Nurse #5 checked Resident #57's Physician's Orders and verified the resident should have received 4 liters per minute and not 6 liters per minute as observed. Physician #2 was interviewed on 7/17/2024 at 11:22 AM and stated they expect the Nursing staff to follow their Physician Orders as they were written for Resident #57. Physician #2 stated when a resident is not receiving enough oxygen, they can become hypoxic (a condition in which the body does not have enough oxygen at the tissue level), have difficulty breathing, and have a rapid heart rate. Physician #2 stated too much oxygen therapy can cause problems with vision and dizziness. Physician #2 stated they expect the Nursing staff to monitor the respiratory levels of the residents and to notify them (the Physician) if a resident continues to be hypoxic. Physician #2 stated they would then put in an order for an increase in oxygen therapy if needed. Physician #2 further stated that they expected the nursing staff to continue monitoring the resident's oxygen saturation level after the increase in oxygen therapy was made. The Director of Nursing Services was interviewed on 7/17/2024 at 12:00 PM and stated they expect the Nursing staff to frequently monitor the oxygen levels and the settings of oxygen therapy as per the Physicians' Orders. The Director of Nursing Services stated if a Nurse observes changes in the oxygen level of a resident, they are expected to notify the resident's Physician. 10 NYCRR 415.12(k)(6)

Based on observation, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure it obtained laboratory services to meet the needs of each resident. This was identified for one (Resident #41) of three residents reviewed for Transmission-Based Precautions. Specifically, Resident #41 was receiving the antibiotic Vancomycin for Methicillin-Resistant Staphylococcus aureus (a bacteria that causes serious infection) in the urine and mastoid bone (the bone behind the ear) and the Physician ordered a Vancomycin trough level (a laboratory test used to determine therapeutic dosage) to be drawn on 7/9/2024. There was no documented evidence in the resident's medical record that the laboratory order was completed. The finding is: The facility's Laboratory and Diagnostic Test Results Clinical Protocol, last reviewed 1/2024, documented the Physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory will report test results to the facility. Nursing staff are expected to review all results and relay results to the medical professional. A nurse will identify the urgency of communicating with the Attending Physician based on the Physician's request, the seriousness of any abnormality, and the individual's current condition. Nursing staff will consider the following factors to help identify situations requiring prompt Physician notification concerning lab or diagnostic test results: High or toxic drug levels. A Physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. If the Attending or Covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. Resident #41 was admitted with diagnoses including Cancer, Acute Mastoiditis, and Infection with Multi-Drug Resistant Organism. The 6/19/2024 significant change Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented that the resident was taking an antibiotic. A Physician's Order dated 6/12/2024 documented Resident #41 required Strict Contact Precautions for an Active Methicillin-Resistant Staphylococcus Aureus Infection in Urine. The physician's order directed all services to be completed in the resident's room. A Comprehensive Care Plan effective 6/15/2024 documented Resident #41 was on Contact Precautions due to a Methicillin-Resistant Staphylococcus Aureus Infection to Mastoid Bone and Urinary Tract. The interventions included administering medications or treatments as per the Physician's Order. A Physician's Order dated 6/15/2024 documented to administer Vancomycin Hydrochloride in Sodium Chloride Intravenous Solution 750-0.9 milligram per 150 milliliter, use 750 milligram intravenously every 12 hours for Methicillin-Resistant Staphylococcus Aureus until 7/19/2024. Bloodwork for Resident #41's Vancomycin trough level was collected on 7/5/2024 and the result was reported to the facility on [DATE]. The result was 35.7 micrograms per milliliter and was flagged by the laboratory as critically high (meaning above peak levels as the normal reference range is between 10.0 and 20.0). A Progress Note written by Physician #1 dated 7/6/2024 documented a high Vancomycin level of 35.7 on the Vancomycin trough test. Physician #1 recommended decreasing the Vancomycin to once a day and repeating the Vancomycin laboratory test in three days. A Physician's Order dated 7/6/2024 documented to give Vancomycin Hydrochloride in Sodium Chloride Intravenous Solution 750-0.9 milligram per 150 milliliter, use 750 milligrams intravenously in the evening for Methicillin-Resistant Staphylococcus Aureus for 13 days. A Physician's Order dated 7/6/2024 documented to obtain a Vancomycin trough level on 7/9/2024. A review of Resident #41's medical record revealed no documented evidence of bloodwork collection for a Vancomycin trough level test on 7/9/2024. Resident #41 was observed in their room in their wheelchair on 7/12/2024 at 10 AM. There was a contact precaution sign at the doorway and a full personal protective equipment cart outside the resident's room door. The Registered Nurse Unit Manager (Registered Nurse #1) was interviewed on 7/15/2024 at 9:24 AM and stated they were not sure if the 7/9/2024 Vancomycin trough level had been ordered. A review of the resident's medical record revealed that another order for a Vancomycin trough level was entered on 7/15/2024 at 9:34 AM. The Registered Nurse Unit Manager (Registered Nurse #1) and Licensed Practical Nurse #2 were interviewed concurrently on 7/15/2024 at 10:38 AM. Licensed Practical Nurse #2 stated the order for the 7/9/2024 Vancomycin trough was entered in the laboratory-ordering system and for some reason, the laboratory did not collect it. Registered Nurse #1 stated an immediate (STAT) order for a Vancomycin trough level was just placed today (7/15/2024) to be collected as it was never done on 7/9/2024 and should have been. Registered Nurse #1 stated the Vancomycin trough level for Resident #41 was last collected on 7/5/2024. Physician #1 was interviewed on 7/15/2024 at 11:25 AM and stated the Methicillin-Resistant Staphylococcus Aureus infection was in Resident #41's urinary tract and mastoid bone. Physician #1 stated they did not follow up on the Vancomycin trough level they ordered on 7/9/2024 because they were addressing another health issue Resident #41 had. Physician #1 stated that monitoring the Vancomycin trough level was important to ensure the resident received a therapeutic dose. The Registered Nurse Unit Manager (Registered Nurse #1) was re-interviewed on 7/15/2024 at 12:41 PM and stated the Laboratory Technician may have missed the resident when coming in to draw the blood. Registered Nurse #1 stated the Nurse who entered the laboratory work order or the Physician should have followed up on the status of the order. The Laboratory Technician (Laboratory Representative #1) was interviewed on 7/15/2024 at 1:36 PM and stated they did not see Resident #41's order for the 7/9/2024 Vancomycin trough level. Laboratory Representative #1 stated they only saw an order for the Vancomycin trough from today, 7/15/2024, and another from 7/5/2024. Licensed Practical Nurse #2 was interviewed on 7/16/2024 at 9:47 AM and stated they entered the Vancomycin trough level order on 7/9/2024 via the laboratory's website. Licensed Practical Nurse #2 stated they could not explain why the bloodwork was not collected and they did not follow up with the laboratory. The Director of Nursing Services was interviewed on 7/16/2024 at 10:49 AM and stated that they (the Director of Nursing Services) were unable to determine why Resident #41's Vancomycin trough level was not collected on 7/9/2024. The Director of Nursing Services stated that the facility ordered Resident #41's laboratory work, so there may have been an issue on the laboratory's side in not completing it. The Director of Nursing Services stated the Nurse on the unit and the resident's Physician were supposed to follow up the next day to ensure that laboratory work was completed. 10 NYCRR 415.20

Based on observation, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #112) of six residents reviewed in the Medication Administration Task. Specifically, Resident #112 had a physician's order for Strict Contact Precautions for Pseudomonas Aeruginosa (a type of bacteria) in the urine which required the use of Personal Protective Equipment including a gown and gloves. The Licensed Practical Nurse (Medication Nurse) #1 was observed on 7/12/2024 entering the room without wearing a gown and gloves and administered medications to Resident #112. The finding is: The facility's Initiation of Transmission-Based Precautions policy, last revised on 1/2024, documented it is the policy of the facility to prevent the spread of infection within the facility through the use of isolation precautions. Contact Precautions in addition to standard precautions are used for residents known or suspected to be infected with microorganisms that can easily be transmitted by direct or indirect contact such as handling environmental surfaces or resident care items. Special instructions are to be explained to all staff involved. Education will be provided to the resident if applicable, and visitors/family members regarding the use of isolation precautions. Resident #112 was admitted with the diagnoses of Urinary Tract Infection, Epilepsy, and Schizoaffective Disorder. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13 which indicated Resident #112 had intact cognition. The Annual Minimum Data Set assessment documented that Resident #112 was incontinent of both bowel and bladder. Resident #112 was dependent on staff for all activities of daily living including toileting, personal hygiene, and bathing. A Urinary Culture Report dated 7/7/2024 documented Resident #112 had Pseudomonas Aeruginosa (a bacteria) of 10,000 to 49,000 colony-forming units per milliliter and needed Ciprofloxacin (an antibiotic). The Comprehensive Care Plan for Urinary Tract Infection dated 7/8/2024 documented interventions which included implementing Transmission-Based Precautions as per Physician Order, specifically contact precautions; performing hand hygiene before and after contact with residents; using Personal Protective Equipment; and encouraging fluid intake and diet compliance. A Physician's Order dated 7/11/2024 documented to implement Strict Contact Precautions for an active infection and to complete all services in the resident's room. A Physician's Order dated 7/11/2024 documented to administer Ciprofloxacin Hydrochloride (an antibiotic) 500 milligrams one tablet by mouth once a day for one day and one tablet by mouth every 12 hours for 7 days to treat a Urinary Tract Infection. A sign posted outside Resident #112's room on Unit 2 that read Contact Precautions was observed on 7/12/2024 at 8:49 AM in Unit 2 during the Medication Administration task. The sign instructed everyone must clean their hands before and after entering and when leaving the room. The sign also instructed to use Personal Protective Equipment including wearing a gown and gloves. Licensed Practical Nurse #1 was subsequently observed entering Resident #112's room to administer medications to the resident without a gown and gloves. Licensed Practical Nurse #1 proceeded to administer medication to Resident #112, who was lying in bed. Licensed Practical Nurse #1 was interviewed on 7/12/2024 at 9:00 AM and stated they (Licensed Practical Nurse #1) did not wear gloves and a gown when entering Resident #112's room because Resident #112 had an infection in the urine. Licensed Practical Nurse #1 stated they were not providing care at the time and were just giving medications to Resident #112. Licensed Practical Nurse #1 stated they read the signage outside Resident #112 room, but thought it only pertained to high-contact care such as toileting. Licensed Practical Nurse #1 stated they were not aware that a gown and gloves were needed for medication administration. The Registered Nurse Infection Preventionist was interviewed on 7/12/2024 at 3:38 PM and stated Licensed Practical Nurse #1 should have worn a gown and gloves before entering Resident #112's room. The Registered Nurse Infection Preventionist stated that Resident #112 was on Contact Isolation and the signage was very specific that everyone who entered the room must wear a gown and gloves. The Director of Nursing Services was interviewed on 7/16/2024 at 10:35 AM and stated Licensed Practical Nurse #1 should have worn gloves and a gown as indicated on the Contact Precautions signage outside Resident #112's room. The Director of Nursing Services stated that all the staff and visitors should follow the Contact Precautions signage outside Resident#112's room and wear a gown and gloves when entering the resident's room. 10 NYCRR 415.19 (a) (1-3)

Based on observation, record review, and staff interviews during the Recertification and Abbreviated (NY00323936) Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not maintain medical records on each resident that were complete and accurate for one (Resident #91) of one resident reviewed for Abuse. Specifically, Resident #91's family member reported bruising to Resident #91's left eye on 9/13/2023. However, the resident's skin assessment and medical evaluation to rule out trauma were not documented in the medical record. The finding is: The facility's Charting and Documentation policy, last reviewed in 1/2024, documented objective observations, treatments or services performed, events, incidents or accidents involving the resident are to be documented in the medical record. Resident #91 was admitted with diagnoses including Unspecified Dementia, Type 2 Diabetes Mellitus, and Venous Insufficiency. The 7/21/2023 annual Minimum Data Set assessment documented a Brief Interview for Mental Status score of 99, indicating the resident was unable to complete the interview. The staff assessment for mental status documented the resident had impaired short-term memory and long-term memory as well as moderately impaired cognitive skills for daily decision-making. Resident #91's family member was interviewed on 7/15/2023 at 11:58 AM and stated during a virtual videoconferencing meeting on 9/13/2023, they observed Resident #91 with a discoloration under their left eye. The family member reported the discoloration to the Director of Nursing Services and the Administrator on 9/13/2023. The family member stated they were informed that the Director of Nursing Services assessed the resident and concluded the skin condition was an old discoloration. The family member alleged the Director of Nursing Services compared the resident's discoloration to an admission photograph from 2016. A review of Resident #91's medical records for September 2023 revealed no documented evidence of any evaluation of the left or right eye areas for discoloration. Resident #91 was observed with the Director of Nursing Services present in the second-floor main dining room on 7/16/2024 at 1:15 PM. The resident's complexion showed varying pigmentation across different areas of the face, with no signs of bruising. The Director of Nursing Services was interviewed on 7/16/2024 at 1:20 PM and stated they spoke to Resident #91's family member on 9/13/2023 and immediately assessed Resident #91's eye area. The Director of Nursing Services stated they concluded that the discoloration was related to a birthmark or pigmentation. The Director of Nursing Services stated they did not document the skin assessment or the communication with the family member in the resident's medical record. The Director of Nursing Services stated they should have documented the family member's allegation and Resident #91's skin assessment. The Physician Assistant was interviewed on 7/18/2024 at 12:24 PM and stated the Director of Nursing Services reported the family member's allegation to them immediately on 9/13/2023. The Physician Assistant stated they assessed Resident #91 the next day (9/14/2023) and concluded that the discoloration around the resident's eye was not the result of trauma, but rather a birthmark or pigmentation. The Physician Assistant stated they did not feel it was necessary to document their evaluation in Resident #91's medical record because it was a verbal concern expressed by the Director of Nursing Services. The Physician Assistant did not report the family member's allegation to the attending Physician because they did not observe a change in Resident #91's condition. The Administrator was interviewed on 7/18/2024 at 12:51 PM and stated they were made aware of the family member's allegation but could not recall the exact date. The Administrator stated licensed providers are expected to document all medical assessments in the resident medical records. 10 NYCRR 415.22(a)(1-4)

Based on observation, record review and interviews during a Recertification Survey and Abbreviated Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility failed to Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; the facility failed to reassess the resident after the weight loss was identified and failed to notify the Physician and the Dietician to implement interventions to address and monitor the unplanned weight loss. The facility's failure to implement an existing weight monitoring policy and failure to monitor each residents' nutritional intake was identified for two (Resident #45 and Resident #80) of seven residents reviewed for Nutrition. Specifically, 1) Resident #45 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility staff were not accurately monitoring the resident's food consumption and failed to reassess the resident after a significant weight loss was identified. The resident had a 23.5 % unplanned weight loss in one month. The facility also failed to notify the physician and the dietician of the significant weight loss to implement interventions to address and monitor the unplanned weight loss. Additionally, the facility failed to have an effective system in place to monitor residents with significant weight loss. 2) Resident #80 (NY 462) had a significant weight loss after being admitted to the facility; the resident was not reweighed timely and was not assessed by the Dietician after the weight loss was identified. This resulted in actual harm and Immediate Jeopardy to the resident's health and safety with Substandard Quality of Care for Resident #45. The findings are: The Weight Assessment and Interventions policy, last revised on 1/2022, documented the nursing staff will measure the resident's weight on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted, weights will be measured monthly thereafter. Weights will be recorded in each unit weight record chart or notebook and in the individual residents' medical record. The policy further documented any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight loss is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. The policy documented the dietitian will respond within 24 hours of receipt of written notification. The dietitian will review the unit weight record by the 15 th of the month to follow individual weight trends overtime. The policy documented the interventions for undesirable weight loss shall be based on careful consideration of resident choice and preferences, nutrition and hydration need of the resident, functional factors that may inhibit independent eating, environmental factors that may inhibit appetite or desire to participate in meals, chewing and swallowing abnormalities and the need for diet. The Nutritional Assessment policy last revised on 1/2022 documented the dietitian, in conjunction with the nursing staff and health care practitioners, will conduct nutritional assessment for each resident upon admission and as indicated by changes in condition that places the resident at risk for impaired nutrition. The policy documented the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for impaired nutrition. The policy further documented that the Physician is to assess the presence of chewing or swallowing abnormalities, conditions of the mouth, teeth, gums, pharynx, or esophagus that affects the residents' ability to chew or swallow food. 1) Resident #45 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #45 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had severely impaired cognition. The resident had moderately impaired vision. The MDS documented Resident #45 did not reject care and required supervision with set up help only for eating. The MDS documented the resident had no broken or loosely fitting full or partial dentures or pain. The resident was 60 inches tall, weighed 99 pounds, and no weight loss was identified. The resident was not on a Physician prescribed weight loss regimen. The Comprehensive Care Plan (CCP) dated 7/21/2019, titled Risk for weight change/Malnutrition due to underlying medical condition included advanced age, Alzheimer's Disease, hearing loss, Poor oral intake, low Body Mass Index (BMI), and vitamin deficiency. The interventions included to identify and honor food preferences, monitor meal consumption records, monitor weights monthly or as frequently as resident will allow. The CCP was revised on 1/30/2022 documented interventions to include to feed self with supervision, observe for chewing and swallowing problems and to provide regular diet, chopped texture with thin liquid consistency. The CCP did not have revised interventions related to monitoring of the weights due to poor intake. The Dietary progress note dated 1/12/2022 documented resident's supplements adjusted to 120 cubic centimeter (cc) Health Shake. There was no Physician's order for the Health Shakes that were recommended by the dietician on 1/12/2022 until 1/30/2022. The quarterly dietary progress notes by Dietician #1 on 1/30/2022 at 3:11 PM documented Resident #45 weighed 97 pounds and was 60 inches tall. The resident's BMI was 19.3, indicating borderline underweight. There was no significant weight change noted this quarter however, progressive weight gain would be beneficial due to the resident being borderline underweight. The resident was receiving regular diet, regular texture with thin Liquid consistency and was consuming mostly 26%-50% of their meals which indicated poor to fair oral intake with no difficulty chewing or swallowing. The dietician recommended to continue Health Shakes 4 ounces (oz), 120 cubic centimeter (cc) five times a day as a supplement. The Physician orders dated 1/30/2022 documented to administer Health Shakes 4 oz, 120 cubic centimeter (cc) five times a day as a supplement. Speech evaluation by the Speech Language Pathologist (SLP) #3 dated 2/1/2022 at 1:27 PM documented Resident#45 comprehension likely impacted by language barrier in addition to their visual impairment and Hard of Hearing (HOH). Speech therapist recommended to downgrade the diet to a soft-chopped with thin liquid diet. Resident #45 typically avoids regular hard solids at baseline. The resident has mild to moderately prolonged oral prep and anterior to posterior (AP) transit for regular solids likely impacted by edentulous (toothless) status and visual impairment. Resident would likely benefit from a soft-chopped diet to promote ease of mastication (chewing) and increased intake. The Physician's order dated 2/1/2022 documented to provide Regular diet, chopped/soft texture with thin liquid consistency. The primary Physician's progress note dated 3/11/2022 at 3:08 PM documented Resident #45 had normal age-related changes and was at risk for Malnutrition. The progress note documented that the resident weighed 98.0 pounds on 2/25/2022. Speech evaluation by SLP #1 dated 3/18/2022 at 1:50 PM documented Resident #45 was screened for the appropriate and safest diet consistency. Resident #45 was previously tolerating a soft-chopped diet with thin liquids. Recommended to continue diet with Chopped consistency and thin liquids. The Registered Dietician (RD) and nursing were informed. There was no documented evidence related to the resident's weight loss. The Physician's order dated 3/18/2022 documented regular diet, chopped texture with thin liquid consistency. The Certified Nursing Assistant Accountability Record (CNAAR) from December 2021 to March 2022 was reviewed. In December 2021 there were 93 meal opportunities. The resident consumed 0-25% of their meals on 29 occasions; 26-50% on 29 occasions; 51-75 % on 4 occasions; 76-100% on one occasion. The resident refused meals on 4 occasions and there were 26 occasions the staff did not document the resident's meal consumption and the CNAAR was left blank. In January 2022 there were 93 meal opportunities. The resident consumed 0-25% of their meals on 28 occasions; 26-50% on 26 occasions; 51-75 % on 3 occasions; 76-100% on zero occasion. The resident refused meals on zero occasions and there were 36 occasions the staff did not document the resident's meal consumption and the CNAAR was left blank. In February 2022 there were 84 meal Opportunities. The resident consumed 0-25% of their meals on 19 occasions; 26-50% on 12 occasions; 51-75 % on 6 occasions; 76-100% on zero occasion. The resident refused meals on zero occasions and there were 47 occasions the staff did not document the resident's meal consumption and the CNAAR was left blank. The March 2022 CNAAR from March 1st through March 30 th had 90 meal opportunities. The resident consumed 0-25% of their meals on 32 occasions; 26-50% on 12 occasions; 51-75 % on 2 occasions; 76-100% on zero occasion. The resident refused meals on 12 occasions and there were 32 occasions the staff did not document the resident's meal consumption and the CNAAR was left blank. There was no documented evidence of additional interventions in the resident's medical record for poor meal consumption. Resident #45 was observed in bed on 03/23/22 at 12:50 PM with their lunch meal tray that was opened and untouched on the resident's overbed table. The meal tray was out of the resident's reach. There were no staff members observed in the resident's room. The staff did not document the resident's meal consumption and the CNAAR was left blank on 3/23/2022 for the breakfast and the lunch meal. Resident #45 was observed on 3/25/2022 at 1:00 PM lying in bed in their room with a sheet covering the resident's face with. The lunch meal tray was opened and untouched on the resident's overbed table. The meal tray was within the resident's reach. The resident was not eating the meal. There were no staff members observed in the resident's room. Resident #45 was re-weighed on 3/25/2022 after the lunch meal. The resident's weight was 75 pounds. The unit weight book was reviewed on 3/25/2022 at 3:00 PM with the RD #2. RD #2 stated that the weight book was last updated in 2020. Resident #45's name was not listed in the weight book. -On 2/25/2022 the resident's weight was recorded as 98.0 pounds with a Hoyer (Mechanical Lift) scale. -On 3/12/2022 the resident's weight was recorded as 85.6 pounds with a Hoyer (Mechanical Lift) scale. -On 3/25/2022 the resident's weight was recorded as 75 pounds with a Hoyer (Mechanical Lift) scale LPN #1, who was the 7 AM to 3 PM medication and treatment nurse on Unit 2 and was assigned to Resident #45, was interviewed on 3/25/2022 at 11:36 AM and stated they (LPN #1) knew Resident #45 was a picky eater and requires only setup help and does not require assistance with meals. LPN #1 stated Resident #45 receives mighty shakes 4 oz 5 times a day and the resident was alert and eats what they want, when they want. LPN #1 stated they (LPN #1) encouraged Resident #45 to eat throughout the day. RD #2 was interviewed on 03/25/2022 at 12:03 PM and stated they started working at the facility on 3/14/2022 and were not made aware of Resident #45's weight loss. The resident weighed 98 pounds on 2/25/2022 and weighed 85.6 pounds on 3/12/2022. RD #2 stated that they should have been made aware of the weight loss. RD #2 stated the nurses are supposed to notify the RD if a resident loses 5 percent of their body weight in one month. RD #2 stated reporting the weight loss is nurse's job. RD #2 stated it is hard to track the weights because of room changes, and the facility always have staffing issues since the facility is short staffed. RD #2 stated residents' weights have not been tracked since 2020 in the weight book. RD #2 stated that the facility does not have a system to identify and track the residents with weight loss. Nurse Practitioner (NP) #1 was interviewed on 3/25/2022 at 4:03 PM and stated they were not notified about Resident #45's weight loss until 3/25/2022. NP #1 stated there were no progress notes regarding Resident #45 weight loss in the resident's medical record. NP #1 stated they if they were notified of the weight loss on 3/12/2022 they (NP #1) would have notified the dietitian and ordered blood work. NP #1 stated they (NP #1) would have asked the nurses to feed Resident #45 every meal. NP #1 stated they (NP #1) do not know if other residents have had a significant weight loss. NP #1 stated the facility should have a protocol for reporting weight loss and all staff should know what to do in case weight loss is identified. NP #1 stated as soon as a weight loss is identified the nurses should notify the NP, the MD, and the Dietician. NP #1 stated they will order intravenous fluids for 24 hours for Resident #45 for possible dehydration and order to obtain daily weights. NP #1 further stated that they will instruct staff that Resident #45 be fed by staff. LPN #2 the 3 PM-11 PM shift medication and treatment nurse was interviewed on 3/25/2022 at 4:22 PM and stated they (LPN #2) did not know if Resident #45 was eating their meals as no one made them aware of the resident's poor meal intake. They (LPN #2) stated if they knew Resident#45 not eating the meals and lost weight they would have called the doctor, dietitian, and the family. LPN #2 stated they (LPN #2) put all residents' weights in the Electronic Medical Record (EMR) but do not check the weights previously entered to identify if any residents had changes in weights. LPN #2 stated they do not know if there are other residents who have weight loss because the LPNs are not responsible to monitor weight loss. LPN #2 stated the Dietitian and the Registered Nurse (RN) managers, or the RN Supervisors are supposed to monitor the residents' weights. Certified Nursing Assistant (CNA) #1, who was the regularly assigned 7 AM-3PM CNA for Resident #45, was interviewed on 3/25/2022 at 4:44 PM and stated they (CNA#1) set up Resident #45's meal tray, but they do not have to feed the resident because the resident eats independently. CNA #1 stated for a couple weeks, Resident #45 has been refusing to eat their meals and was not eating like before. CNA #1 stated they (CNA #1) notified LPN #4 that Resident #45 was not eating and LPN #4 tried to feed the resident by giving the resident oatmeal and shakes. CNA #1 stated Resident #45's meal intake did not improve after LPN # 4 was notified. CNA #1 stated they would have reminded Resident #45 to drink and eat if they (CNA #1) knew the resident was losing weight. CNA #1 stated they (CNA #1) did not let other nurses know Resident #45 was not eating because LPN #4 was the regular nurse. CNA #1 stated they (CNA #1) do not know if there are any other residents that have weight loss because the nurses record the weights in the EMR and can see the previous weights. During an observation on 3/28/2022 at approximately 10 AM Resident #45 was weighed in their room with a Hoyer lift with two CNAs present. The resident weighed 75 pounds. The Dietary progress note dated 3/28/2022 documented as per speech evaluation downgrade diet to puree consistency. The Physician's order dated 3/28/2022 documented to provide Resident #45 a regular diet, puree texture with thin liquid consistency. Assistant Nurse Aide (ANA) #1 was interviewed on 3/29/2022 at 10:12 AM and stated Resident #45 was an independent eater and they (ANA #1) only set up Resident #45's meal trays. ANA #1 stated the LPNs knew Resident #45 was not a good eater. ANA #1 stated after they weigh the residents, they (ANA #1) give the resident's weight results to the nurses on a piece of paper and the nurses put the weights in the EMR. ANA #1 stated their responsibility is to report to the nurses when they see residents refusing to eat or eating less; however, they (ANA #1) did not report the resident's poor intake to the nurses because it was normal for the resident to not eat their meals and all the nurses knew that the resident was not eating. LPN #4, who is the regularly assigned medication nurse on Unit 2, was interviewed on 03/29/2022 at 11:08 AM and stated Resident #45 has been on their floor since January 2022. They stated they received a report from the 4th floor where Resident #45 previously resided and were informed that Resident #45 was not a good eater. LPN #4 stated Resident #45 needs assistance to eat, and LPN #4 has to go back and forth to encourage the resident to eat but, was busy passing medications and administering treatments. LPN #4 stated CNA#1 did not report that Resident #45 was not eating their meals therefore LPN #4 did not report to the Dietitian or the Physician that Resident #45 was not a good eater. LPN #4 stated the Registered Nurse Manager (RNM) was usually responsible to monitor the CNAAR for meal intake recording. LPN #4 stated Unit 2 does not have a full time RNM assigned for a while now. LPN #4 stated they expected CNAs to report Resident #45's meal intake to them (LPN #4). LPN #4 stated there is a weight sheet on the Unit and the CNAs were responsible to record the residents' weights on that sheet. LPN #4 stated the Dietician was responsible for checking the residents' weight every month and collecting the weight sheets and then recording the residents' weights in the EMR. If a resident loses or gains 5 pounds, the Dietitian will then request a reweigh. LPN #4 stated that the Dietician (RD #1) did not request a reweigh for Resident #45 from LPN #4. SLP #1 was interviewed on 3/29/2022 at 12:18 PM and stated in March 2022, the facility's corporate office changed the names of diets. SLP #1 stated they wrote a note on 3/18/2022 to reflect that change in Resident #45's medical record, however, there were no changes made to the diet consistency that the resident was already receiving. SLP #1 stated it was the same consistency but with a different name. SLP #1 stated they were not made aware of the resident's weight loss. If there was a weight loss, SLP #1 should have been notified by the Dietitian and nurses to evaluate the resident for difficulty swallowing and to perform a full evaluation to rule out dysphasia (difficulty swallowing). The Director of Nursing Services (DNS) was interviewed on 3/29/2022 at 12:00 PM and stated Unit 2 does not have an assigned unit manager. If there are any emergencies the DNS, wound nurse, and RN #8 Unit Manager chip in to help. The DNS stated the facility is short of staff. The Wound Nurse, RN # 7, was interviewed on 03/29/22 at 1:18 PM and stated they (RN #7) help out on the 2nd floor as needed because Unit 2 does not have an RNM. RN #7 only goes to Unit 2 when the unit staff members call them (RN #7) for an emergency. RN #7 stated CNAs are responsible for weighing the residents and the Dietitian and nurses are responsible to review the weights. Each unit has a full time RN to complete the weight task however, there is no full time RN on Unit 2. RN #7 does not know which RN is responsible for checking the resident's weights on that unit. RN #7 stated they were not made aware of Resident #45's weight loss. RN #7 stated they (RN #7) do not know who is responsible to review the CNAAR for completion and monitoring of meal intake. RN # 8, the Unit Manager from the first floor, was interviewed on 3/29/2022 at 2:09 PM and stated they (RN #8) have been working at the facility for 4 months. RN #8 stated the second floor staff calls them when there is a fall or a resident requires medications to be administered by an RN. RN #8 stated they did not know who monitors the residents' weights on the second floor since the second floor does not have an RNM. RN #8 stated they were not made aware of Resident #45's weight loss. RN #8 stated that they checked the CNA accountability to make sure they complete the tasks on their own unit but did not know who checks the second floor CNAARs. RN #9, who was a per-diem Nursing Supervisor, was interviewed 03/29/2022 at 2:39 PM and stated they (RN #9) were the RN Supervisor for the entire building and works various shifts. RN #9 stated that RN #9 received a list of residents to weigh or reweigh from the DNS on 3/10/2022. The list was given to the DNS by the previous Dietitian (RD #1). RN #9 stated that the weights were completed on 3/10/2022 and the completed list was placed in the DNS's mailbox. RN #9 stated they received a call from the DNS on 3/12/2022 requesting the residents' weights. RN #9 stated they observed the weight list was still in the DNS's mailbox on 3/12/2022. RN #9 stated they (RN #9) updated the weights in the EMR on 3/12/2022 and then noticed Resident# 45 had a weight loss however, RN #9 did not notify any one of the weight loss because they (RN #9) assumed the DNS and the Dietitian would follow up with Resident #45's weight loss. RN #9 stated they (RN #9) do not check the CNAAR or the weight records because the Unit RN managers are responsible to check the CNAAR and the weight records. CNA #5 who usually works on the 3 PM to 11 PM nursing shift, was interviewed on 3/29/2022 at 6:00 PM and stated Resident #45 does not like the food that is served to them (Resident #45). CNA #5 stated Resident #45 required only set up help for meals. Resident #45 could not chew their meals and liked soup. The resident's family used to come and feed the resident with their ethnic food, however, since COVID-19 started Resident #45's family does not come to feed the resident. CNA #5 stated they reported Resident#45's decreased appetite to the Unit nurse (Could not recall to who and when) a while ago. CNA #5 stated if this facility provided Resident #45 with their own cultural food the resident would have eaten. On 3/29/2022 at 6:00 PM, Resident #45 was observed in bed in their room with the bedside table out of the resident's reach. The bedside table contained an Ensure carton that was opened and was half full and one cup of water. There was no staff member present. RD #2 was re-interviewed on 3/30/2022 at 10:35 AM and stated the facility did not provide them (RD #2) a list of residents with significant weight loss and a list of residents who were at risk for weight loss when they first started on 3/14/2022. They stated the facility and nurses failed to alert the Doctor of any residents who had a weight change of over 5 pounds in a month. RD #2 stated nurses are the core for weight monitoring. RD #2 stated if they were made aware of Resident #45's weight loss when they started working at this facility Resident #45 would have benefited from the interventions they would have initiated. RD #2 stated the facility failed to have a structure in place and have consistency of weight monitoring. RD #2 stated they do not know if there are other residents with significant weight loss. RD #2 stated the facility's EMR cannot capture the weight loss. The weight loss has to be calculated manually one resident at a time. RD #2 stated if they were made aware of Resident#45's weight loss they would have talked to the primary Physician to discuss the possibility of a feeding tube insertion. RD #2 stated had they known Resident #45 lost a significant amount of weight they would have started a three-day calorie count, reviewed laboratory reports, increased supplements and asked the SLP to evaluate the resident for swallowing issues or problems to determine if anything was preventing the resident from eating. The Primary Physician (MD) was interviewed on 3/30/22 at 12:34 PM and stated they (MD) do not remember when they last saw Resident #45. The MD stated they (MD) were not made aware of Resident #45's weight loss and if they were aware they (MD) would have ordered blood work. The MD stated that they would expect the facility staff to inform them (MD). The MD further stated that Resident #45 would have benefited from dietary interventions if they (MD) were made aware of Resident #45's weight loss on 3/12/2022. The DNS was re-interviewed on 3/30/2022 at 1:22 PM and stated since 2019 every unit has had a unit manager assigned, however, the second-floor unit manager left in January 2022. The DNS stated RN managers are responsible to monitor weights. The DNS stated the Dietitian is in control of monitoring the residents' weights. They stated the Dietitian would make a list of residents needing to be weighed at the beginning of month. The CNAs would weigh the residents and the Dietitian would pick up the list to update the EMR. The DNS stated they were not made aware of the weight loss for Resident #45. The DNS stated RN #9 should have notified the RD after identifying the weight loss for Resident #45. The DNS stated they were not aware that Resident #45's intake was poor and that the CNAs were not documenting the resident's food intake on the CNAAR. The DNS further stated that the RNMs should be reviewing the CNA accountability record, however, Unit 2 does not have an RNM. RD #1 was interviewed on 3/30/2022 at 2:10 PM and stated they (RD #1) was a temporary Dietitian started on January 24, 2022, until March 10, 2022. RD #1 stated they (RD #1) sent an email to the DNS, Nurse Managers, RN Supervisors, and the Administrator on March 10 2022, at 2:55 PM with list of residents that needed to be weighed (could not recall why). RD #1 stated in that email they informed the recipients that RD #1 will not conduct a follow up on the weights because it was their last day to work at the facility. RD #1 would expect the nursing staff get the weights, record the weights in the EMR and to notify the Dietitian and the doctor of any weight changes. SLP #2 was interviewed on 4/01/2022 at 2:17 PM and stated they screened Resident #45 on 3/28/2022 and completed the evaluation on 3/30/2022 to rule out if the resident had a decline in swallowing or had Dysphagia upon the request from the DNS and the Director of Rehabilitation. SLP #2 stated Resident #45's diet was downgraded to puree consistency on 3/28/2022 because of the resident's prolonged chewing and complaint of pain when they chewed. SLP #2 stated that Resident #45 reported to the nurse who spoke their language that they (Resident #45) had pain when they chewed the food. SLP #2 stated the pain in Resident #45's mouth when they chew could be the reason for the weight loss. The Medical Director was interviewed on 4/01/2022 at 4:52 PM and stated they (Medical Director) did not know about Resident # 45's weight loss. The Medical Director stated the staff did not follow the system. The Medical Director stated they did not follow the facility's policy for weight loss. The Medical Director stated it was not acceptable that Resident #45's significant weight loss was not captured in a timely manner. The Medical Director stated they are very happy this issue was identified. The Administrator was interviewed on 4/01/2022 at 5:55 PM and stated they (Administrator) would expect caregivers to complete their tasks as directed. The Administrator stated that they (Administrator) was not aware of a list provided to them by RD #1 and was not aware of Resident #45's weight loss. The Administrator stated that they (Administrator) was not aware of the issues related to monitoring of residents' weights and meal intake or staffing issues on Unit 2; however, they (Administrator) knew they needed to hire more staff. The Immediacy was removed on 4/3/2022 when the facility provided evidence of: -Dietary reassessment of Resident #45 including increasing the assistance needed for feeding, downgraded the diet to puree consistency. The facility initiated a calorie count to identify resident's intake and also increased weight monitoring. The facility updated the resident's Comprehensive Care Plan to address the dietary need. -The facility weighed all residents and compared the current weight to the most recent previous weight to identify significant weight loss. The facility identified 10 additional residents with Significant weight loss. The newly identified residents with Significant weight loss were evaluated by the Dietician and the Physician by 04/03/2022 to update the residents plan of care and address the nutritional needs. -The Facility revised the policies and procedure related to monitoring and reporting of weights and the residents' food intake. -Inservice education was provided to 96% of the facility staff that included the Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nurse Assistants (CNAs), Nurse Assistants (NAs) and the Dieticians. -16 facility staff were interviewed during the 1st PSR visit. All interviewed staff were knowledgeable of the changes in the facility's revised Policies and Procedures including changes implemented related to resident food intake and weight monitoring and reporting. 2) Resident #80 was admitted on [DATE]th 2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 3 which indicated the resident had severely impaired cognition. The resident had mood symptoms of poor appetite or overeating 2-6 days during the two -week look back period. The resident had no behavioral symptoms, did not reject care, and required the assistance of one staff member for eating. The MDS documented the resident had no swallowing problems and had a documented Height of 63 inches and weight of 130 pounds. The resident did not have significant weight loss or gain identified on the MDS and was not on a physician prescribed weight loss program. Resident #80 was observed on 3/23/2022 at 1:10 PM in their room sitting in a wheelchair at the bedside during the lunch meal with a meal tray on the overbed table in front of the resident. The resident's family member was observed verbally encouraging the resident to eat. The Comprehensive Care Plan (CCP) for at Risk for Weight Shift dated 1/7/2022 and last updated on 3/12/22 documented the resident was at risk for weight shifts and malnutrition due to underlying medical conditions that included advanced age, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included the resident feeds self with limited assist of one staff, encourage meal intake and completion, monitor oral (PO) intake and appetite, monitor meal consumption record, monitor weights monthly, and report significant weight loss to the Physician (MD) and the Interdisciplinary Team (IDT) team. The Physician's progress note signed by a Physician's Assistant (PA) dated 1/7/2022 documented the resident's medical records were reviewed; the note did not document the resident's weights. The Physician's order dated 1/8/2022 documented daily weight x 3 then weekly weight x 4. The resident's weight record documented the following weights: on 1/7/2022-130 pounds (lbs) There was no documented evidence of weights on 1/8/2022, 1/9/2022 and 1/10/2022 on 1/11/2022-89.2 lbs a weight loss of 40.8 lbs since 1/7/2022 There were no documented weights between 1/12/2022 through 1/30/2022 on 1/31/2022-84.2 lbs a weight loss of 5 lbs since 1/11/2022 on 2/8/2022-82.0 lbs a weight loss of 2.2 lbs since 1/31/2022 on 3/13/2022-91 lbs a weight gain of 9 lbs since 2/8/2022 A Dietary Note written by RD #3 dated 1/7/2022 at 3:08 PM documented the resident's current weight was 130 pounds with a Body Mass Index (BMI) of 23. The resident required limited assistance with meals and was at risk for malnutri [TRUNCATED]

Based on observation, interviews, and record review during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident as determined by resident assessment and individual plans of care. This was identified through staff interviews, resident council task, review of facility assessment and staffing assignments. Specifically, 1) The facility nursing staffing assignments did not reflect the staffing needs as indicated in the facility assessment; 2) Resident #136 did not receive wound care treatment as prescribed by the Physician on multiple occasions 3) Resident #358 received 6 medications and 1 supplement 3 hours later than the prescribed time to be administered; 4) Resident #99 did not have a Certified Nursing Assistant (CNA) assigned on the 7-3 shift to care for their needs on 3/25/2022; 5) during the resident council meeting held on 3/24/2022, 3 of 10 residents indicated delay in staff response to resident needs due to staffing shortage. The findings include but were not limited to: 1) The Facility assessment dated [DATE] documented that based on the facility's resident population and their needs for care and support, the general plan for staffing is Licensed Nurses (Registered Nurses (RN), and Licensed Practical Nurses (LPN), providing direct care) 1 to 20-23 residents on the day shift, 1 to 30-33 residents on the evening shift, 1 to 50-55 residents on the night shift. Certified Nursing Aides 1 to 7-10 residents on the day shift, 1 to 9-12 residents on the evening shift, 1 to 18-22 residents on the night shift. Other staff includes 1 Director of Nursing, 1 Assistant Director of Nursing, 1 Admission Nurse, 1 Wound Care Nurse, 1-2 Minimum Data Set (MDS) nurses, 1 Staff Development Nurse, 1 Evening RN Supervisor and 1 Night RN Supervisor. The facility has a total bed capacity of 214. The Facility Staffing Sheets from 3/19/2022 to 3/28/2022 were reviewed. The staffing sheets provided documentation that there was 1 CNA or Assistant Nurse Aide (ANA) for the whole unit for the following dates and units: Day shift: (Facility assessment indicated each CNA is to be assigned 7-10 residents on their assignment and each Licensed Nurse is to be assigned 20-23 residents on the day shift) -1st floor on the 3/20/22 Day shift with a census of 29/49 -4th floor on the 3/21/22 day shift with a census of 32/37 -4th floor on the 3/24/22 day shift with a census of 29/47 On 3/25/22 during the day shift there was 1 Licensed Nurse for the 4th floor unit with a census of 27/47. Night Shift: (Facility assessment indicated each CNA is to be assigned 18-22 residents on their assignment) -1st floor (Census 29/49) and 2nd floor (Census 56/59) on the 3/19/2022 night shift -2nd floor on the 3/20/22 night shift with a census of 56/59 -2nd floor on 3/23/22 night shift with a census of 57/59 -4th floor on the 3/23/22 night shift with a census of 28/47 -1st (Census of 29/49) and 2nd floor (Census 56/59) on the 3/24/22 night shift -2nd floor on the 3/25/22 night shift with a census of 56/59 The Director of Nursing Services (DNS) and the Assistant Administrator were interviewed concurrently on 4/1/2022 at 3:38 PM. The Assistant Administrator stated that the Staffing Coordinator had quit on 3/31/2022 and the facility is currently in the process of interviewing to fill the position. The Assistant Administrator stated that they (Assistant Administrator) were covering for the Staffing Coordinator. The DNS stated that the facility does have staffing problems. The Assistant Administrator and the DNS both stated they were not aware of the Dear Administrator Letter from the New York State Department of Health advising about the Surge and Flex Center to inform the Department of Health of critical staffing levels. The Assistant Administrator stated that the facility did not have any success with staffing agencies that they reached out to. The DNS stated that they were aware of the facility assessment and took part in the assessment meeting but did not realize that the nursing staffing ratios were specified in the assessment. The DNS reviewed the staffing assignment from 3/19/2022 through 3/25/2022 and stated that the CNAs were not assigned the number of residents as indicated on the facility assessment and had been assigned an excessive number of residents to care for. The DNS stated that if the RNs and the LPNs cannot complete their assignments, they are expected to inform the nursing Supervisor and to pass on the assignments to the next shift. 2) Resident #136 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #136 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. Resident #136 was interviewed on 4/1/22 at 12:20 PM. Resident #136 stated that the wound care is inconsistent but could not recall specific dates or times. The March 2022 Treatment Administration Record (TAR) documented to cleanse the right buttock with normal saline, pat dry, apply Hydrogel, and cover with a dry protective dressing every day and evening shift for abscess. The treatment was not signed for as administered on the evening shift on 3/19/22, 3/25/22 and 3/28/22. The treatment was also not signed for as administered on the day shift on 3/20/22, 3/21/22, and 3/26/22. RN #3 was interviewed on 4/1/2022 at 11:20 AM and stated that on 3/21/2022 during day shift, they (RN #3) were working at the facility, but did not work on the resident's unit as a medication and treatment nurse. RN #3 stated that LPN #1 was the medication and treatment nurse. RN #9 an RN Supervisor, was interviewed on 4/1/22 at 11:35 AM. RN #9 stated that they (RN #9) worked on 3/26/2022 and administered medication because there was no nurse assigned to Unit 4. RN #9 stated they (RN #9) did not get to the wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 was interviewed on 4/1/22 at 11:57 AM and stated that they (RN #2) worked on 3/19/22 during the evening and had to leave at 10 PM due to an emergency. RN #2 stated that they did not administer the wound care for Resident #136, that is why there is no signature. RN #2 stated that they told the DNS who took over as the Supervisor. RN #8, an RN Supervisor, was interviewed on 4/1/22 at 12:41 PM. RN #8 stated that they (RN #8) worked 3/20/2022 during the day shift. RN #8 stated that when there is a bad shortage, RN #8 comes in to help for medication administration and wound care. RN #8 stated that on 3/20/2022, a nurse called out and RN #8 had to do medication administration on the 4th floor. RN #8 stated that 3/20/22 was a very hectic day and they did not get a chance to do the wound care because there were other resident emergencies. LPN #1 was interviewed on 4/1/2022 at 1:24 PM and stated that they (LPN #1) worked on 4th floor on 3/21/22, but they only administered medications and not the treatments. LPN #1 stated that RN #3 was supposed to do the treatments. The DNS and the Assistant Administrator were interviewed concurrently on 4/1/2022 at 3:38 PM. They both stated that the RNs and the LPNs should not have skipped Resident #136's wound care treatments. The DNS stated that the facility does have staffing problems and if the nurses had trouble completing their assignments, the nurses are expected to inform the DNS or their supervisor and endorse the unfinished tasks to the next shift. 3) Resident #358 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #358 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented Resident #358 received anticoagulant medication 2 of 7 days in the MDS look back period. On 3/25/2022 at 12:05 PM RN #3 was observed outside Resident #358's room preparing medications. RN #3 stated the medications were due to be given to Resident #358 at 9 AM. RN #3 further stated that they (RN #3) were the only nurse on Unit 4. The following 9 AM medications that were ordered and the corresponding administration times on 3/25/2022 are as follows: [MEDICATION(S)] Aerosol 110 microgram (mcg) 1 puff inhale orally every 12 hours for Asthma. The medication was administered at 12:03 PM; [MEDICATION(S)] Tablet 5 milligram (mg) Give 1 tablet by mouth every 12 hours for [CONDITION(S)]. The medication was administered at 12:03 PM; [MEDICATION(S)] Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for supplement. The medication was administered at 12:03 PM; Pepcid Tablet 20 mg (Famotidine) Give 1 tablet by mouth two times a day for Gastro [CONDITION(S)] Reflux Disease (GERD). The medication was administered at 12:03 PM; [MEDICATION(S)] Tablet 50 mg ([MEDICATION(S)]) Give 1 tablet by mouth one time a day for Hypertension. The medication was administered at 1:02 PM; [MEDICATION(S)] Tablet 10 mg Give 1 tablet by mouth one time a day for Hypertension. The medication was administered at 12:35 PM. Budesonide-[MEDICATION(S)] Aerosol 160-4.5 mcg two puff inhale orally two times a day for Asthma. The medication was administered at 12:35 PM. RN #3 was re-interviewed on 3/28/2022 at 12:17 PM and stated the 9 AM medications for Resident #358 were late on 3/25/2022 because things were hectic, and they (RN #3) were the only nurse on the unit. RN #3 stated that being the only nurse on the unit is how it usually is. RN #3 stated it was not normal to deliver the 9 AM medications after 12 PM, and the medications should be administered one hour before or one hour after the prescribed time. The Director of Nursing Services (DNS) was interviewed on 3/30/2022 at 8:45 AM and stated the medications are to be administered within one hour before or one hour after the ordered due time. The DNS stated the nurse could have asked for help. 415.13(a)(1)(i-iii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure resident rights to be free from neglect. This was identified for one (Resident #99) of five residents reviewed for Activity of Daily Living (ADL). Specifically, Resident #99 required staff assistance for ADL and incontinence care. The resident did not receive ADL and incontinence care on 3/25/2022 from 6:14 AM until 12:15 PM. The resident was observed in bed with a strong urine odor in their room. Resident #99 was visibly upset, clenching their lips and stated with an elevated loud tone that no one took care of them today. The resident stated they were wet and had been asking for staff assistance all morning; however, no staff came to assist. The finding is: The Abuse Prohibition policy last updated January 2022 documented Neglect is defined as the failure of the facility and its employees and service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect typically means the refusal or failure to provide a resident with such life necessities as food, water, clothing, shelter and personal hygiene. The Urinary Incontinence policy dated January 2022 documented, As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. Resident # 99 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition. The resident was frequently incontinent of bowel and bladder and required extensive assistance of one person for bed mobility and dressing, extensive assistance of two persons for transfers and limited assistance of one person for personal hygiene. The Comprehensive Care Plan (CCP) dated 12/30/2021 documented the resident had bowel incontinence related to the aging process. Interventions included to check the resident every two hours and to assist with toileting as needed; Provide bedpan/bedside commode and provide perineal care after each incontinent episode. The CCP dated 9/11/2021 documented the resident had bladder incontinence related to the aging process. Interventions included to apply incontinence devices as identified as appropriate for the resident. The CCP dated 9/13/2021 for at risk for Pressure Ulcer development related to actual swelling and [CONDITION(S)] to the left hip and the left hand; impaired mobility; incontinence and fragile skin included interventions to turn and reposition the resident every two hours and as needed. On 3/25/2022 at 10:30 AM, Resident #99 was observed in their room in their bed. On 3/25/2022 at 11:20 AM, Resident #99 was again observed in their bed. A strong urine odor was detected. Resident #99 appeared upset as evidenced by the resident clenching their lips. Resident #99 stated they were upset and angry. Resident #99 stated in a loud tone that they have been waiting all morning to get changed and to be taken out of bed. Resident #99's concern was brought to the Unit clerk's attention. The Unit clerk stated CNA #2 was the assigned CNA for Resident #99. On 3/25/2022 at 11:30 AM CNA #2 was interviewed and stated that they (CNA #2) were not assigned to the resident. The CNA assignment sheet dated 3/25/2022 documented five CNA assignments for the 7 AM-3PM nursing shift (assignment A, B, C, E and F) with corresponding CNA names, except for assignment C. Resident # 99's room number was included under assignment C. On 3/25/2022 between 11:20 AM and 12:00 PM there were no nursing staff present at the nurses' station. At 12:00 PM the unit clerk was asked who the RN Manager or Supervisor was assigned to the resident's unit. The unit clerk stated they will call the supervisor. The Director of Nursing Services (DNS) arrived on the Unit 10 minutes later at 12:10 PM. The DNS stated there was no RN manager or Supervisor assigned to the resident's Unit. The DNS reviewed the CNA staffing sheet and could not determine who the assigned CNA was for Resident #99. The DNS then stated that CNA #1 was the assigned CNA for Resident #99. Between 12 PM to 12:20 PM, CNA #1 could not be located on the Unit. At 12:15 PM CNA # 2 was observed providing care to the resident. The CNA accountability record for March 2022 documented the resident was toileted and last received hygiene care on 3/25/2022 at 6:14 AM. The bed mobility section documented the resident last received assistance with bed mobility at 6:14 AM. There was no documented evidence that Resident #99 was turned and positioned every two hours and as needed. CNA # 1 was interviewed on 3/25/2022 at 12:30 PM and stated that they were not assigned to Resident # 99. CNA #1 stated that although Resident #99 was on their assignment on the unit assignment sheet, they (CNA #1) traded off Resident # 99 with CNA # 3 who is normally assigned to assignment F. CNA #1 stated they (CNA #1) did not inform Licensed Practical Nurse (LPN) # 2, who was responsible for the assignments, of the trade off of Resident #99. LPN # 2, who was the Unit charge nurse, was interviewed on 3/25/2022 at 3:35 PM and stated they (LPN #2) were responsible to make the CNA assignments. CNA #1 was supposed to be assigned to Resident #99. LPN #2 stated that the CNA assignment did not have a CNA's name assigned for assignment C and it was an oversight. LPN #2 stated the assignment sheet should reflect CNA # 1 for assignment C. LPN #2 further stated that they (LPN #2) were not aware that CNA # 1 and CNA # 3 were trading residents on their assignments. CNA # 3 was not available to interview. The DNS was re-interviewed on 3/25/2022 at 4:10 PM and stated no resident should have to wait till 12 noon to be provided AM care and to be taken out of their bed. 415.4(b)(1)(i)

Based on record review and staff interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that the comprehensive person-centered care plan (CCP) for each resident was implemented. This was identified for one (Resident #110) of seven residents reviewed for nutrition. Specifically, Resident #110 had a Physician's (MD) order for daily weights for 3 days and weekly weights every 7 days for four weeks for weight monitoring. There was no documented evidence the weights were completed according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The finding is: The facility Weight Assessment and Intervention policy reviewed on 1/2022 documented the nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weight will be measured monthly thereafter. Resident #110 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short- and long-term memory problems and had no behavioral symptoms. The resident utilize a gastric feeding tube. The resident weighed 224 pounds. A Quarterly MDS assessment dated [DATE] documented the resident had short- and long-term memory problems. The MDS documented the resident The resident's weight was 176 and had no weight loss or gain. A Comprehensive Care Plan (CCP) for risk for weight shift dated 1/28/2022 and last updated on 3/12/2022 documented the resident was at risk for weight changes due to underlying medical conditions. Intervention included to monitor caloric intake. There were no interventions related to weight monitoring, A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident weight record documented the following weights: -1/28/22 224.0 pounds (lbs), There was no documented evidence that the resident was weighed on 1/29/2022, 1/30/2022 and on 1/31/2022. -2/1/22 weight recorded as 224.0 lbs, A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident weight record documented the following weights: there was no documented evidence that the resident was weighed on 3/11/2022 and 3/12/2022. -3/13/22 weight recorded as 224.0 lbs. -3/14/22 weight recorded as 176.0 lbs. -3/21/22 weight recorded as 176 lbs. -3/28/22 weight recorded as 176.3 lbs. The Dietary note dated 3/12/2022 documented the weight recorded on the Patient Review Instrument (PRI-a hospital record) was 164 pounds on 3/10/2022. The Dietary note dated 3/29/2022 documented the weight on the PRI-hospital record was 183 pounds on 1/28/2022. Registered Nurse (RN #2), Nurse Manager, was interviewed on 3/29/2022 at 12:11 PM and stated that the Certified Nursing Assistant (CNA)s were responsible for weighting the residents. RN #2 stated that residents are weighed on the day of admission then daily for 3 days and weekly for four weeks as per the facility protocol. RN #2 stated the weights should have been taken as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Registered Dietitian (RD #2) was interviewed on 3/29/2022 at 2:09 PM and stated that in their professional opinion, the resident's initial weight of 224 pounds was not a true weight. RD #2 reviewed both PRIs information dated 1/28/2022 and 3/10/2022 and stated that they (RD #2) did not believe the resident was weighed on admission. RD #2 stated that the resident could not have lost 48 pound in one day and that staff might have just entered random numbers on the weight sheet. RD #2 further stated when the resident was weighed on 3/14/2022 the weight of 176 pounds was the resident's true weight. Additionally, RD #2 stated that they witnessed a reweight of Resident #110 on 3/29/22 and the resident weighed 178 pounds. Physician#1 was interviewed on 4/1/2022 at 2:53 PM and stated that the expectation is that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing Services (DNS) was interviewed on 4/1/2022 at 6:15 PM and stated if there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 415.11(c)(1)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADL) receive the necessary services to maintain grooming and personal hygiene. This was identified for one (Resident #99) of five residents reviewed for ADLs. Specifically, Resident #99, who was alert and oriented and required staff assistance for ADL care, did not receive morning care on 3/25/2022 during the 7 AM-3 PM nursing shift until 12:15 PM because no Certified Nursing Assistant (CNA) was assigned to provide care for the resident. The resident was observed in bed with a strong urine odor in their room. Resident #99 was visibly upset, clenching their lips and stated with an elevated loud tone that no one took care of them today. The resident stated they were wet and had been asking for staff assistance all morning; however, no staff came to assist. The finding is: The Urinary Incontinence policy dated January 2022 documented, As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. Resident # 99 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition. The resident was frequently incontinent of bowel and bladder and required extensive assistance of one person for Bed Mobility and Dressing, Extensive Assistance of two persons for transfers and Limited assistance of one person for personal hygiene. The Comprehensive Care Plan (CCP) dated 12/30/2021 documented the resident had bowel incontinence related to the aging process. Interventions included to check the resident every two hours and to assist with toileting as needed; Provide bedpan/bedside commode and provide perineal care after each incontinent episode. The CCP for Activities of Daily Living dated 9/11/2021 related to swelling and pain to the left hip and left hand; Left distal Humeral fracture; and Fracture of left Femur related to a fall included interventions to encourage the resident to use the call bell for assistance. The CCP dated 9/11/2021 documented the resident had bladder incontinence related to the aging process. Interventions included to apply incontinence devices as identified as appropriate for the resident. The CCP dated 9/13/2021 for at risk for Pressure Ulcer development related to actual swelling and [CONDITION(S)] to left hip and left hand; impaired mobility; incontinence and fragile skin included intervention to turn and reposition the resident every two hours and as needed. On 3/25/2022 at 10:30 AM, Resident #99 was observed in their room in their bed. On 3/25/2022 at 11:20 AM, Resident #99 was again observed in their bed. A strong urine odor was detected. Resident #99 was upset as evidenced by the resident clenching their lips. Resident #99 stated they (Resident #99) were very upset and angry. Resident #99 stated in a loud tone that they have been waiting all morning to get changed and to be taken out of bed. Resident #99's concern was brought to the Unit clerk's attention. The Unit clerk stated CNA #2 was the assigned CNA for Resident #99. On 3/25/2022 at 11:30 AM CNA #2 was interviewed and stated that they (CNA #2) were not assigned to the resident. The CNA assignment sheet dated 3/25/2022 documented five CNA assignments for the 7 AM-3PM nursing shift (assignment A, B, C, E and F) with corresponding CNA names, except for assignment C. Resident # 99's room number was included under assignment C. On 3/25/2022 between 11:20 AM and 12:00 PM there were no nursing staff present at the nurses' station. at 12:00 PM the unit clerk was asked who the RN Manager or Supervisor was assigned to the resident's unit. The unit clerk stated they will call the supervisor. The Director of Nursing Services (DNS) arrived on the Unit 10 minutes later at 12:10 PM. The DNS stated there was no RN manager or Supervisor assigned to the resident's Unit. The DNS reviewed the CNA staffing sheet and could not determine who the assigned CNA was for Resident #99. The DNS then stated that CNA #1 was the assigned CNA for Resident #99. Between 12 PM to 12:20 PM, CNA #1 could not be located on the Unit. AT 12:15 PM CNA # 2 was observed providing care to the resident. The CNA accountability record for March 2022 documented the resident was toileted and last received hygiene care on 3/25/2022 at 6:14 AM. The Bed Mobility section documented the resident last received assistance with bed mobility at 6:14 AM. There was no documented evidence that Resident #99 was turned and positioned every two hours and as needed. CNA # 1 was interviewed on 3/25/2022 at 12:30 PM and stated that they were not assigned to Resident # 99. CNA #1 stated that although Resident #99 was on their assignment on the unit assignment sheet, they (CNA #1) traded off Resident # 99 with CNA # 3 who is normally assigned to assignment F. CNA #1 stated they (CNA #1) did not inform Licensed Practical Nurse (LPN) # 2, who was responsible for the assignments, of the trade off of Resident #99. LPN # 1 was interviewed on 3/25/2022 at 3:30 PM and stated they were assigned to Resident #99 this morning. LPN #1 stated they (LPN #1) were a float LPN and were not regularly assigned to the unit. LPN #1 stated that they (LPN #1) were not aware of Resident #99's routines. LPN # 2, who was the Unit charge nurse, was interviewed on 3/25/2022 at 3:35 PM and stated they (LPN #2) were responsible to make the CNA assignments. CNA #1 was supposed to be assigned to Resident #99. LPN #2 stated that the CNA assignment did not have a CNA's name assigned for assignment C and it was an oversight. LPN #2 stated the assignment sheet should reflect CNA # 1 for assignment C. LPN #2 further stated that they (LPN #2) were not aware that CNA # 1 and CNA # 3 were trading residents on their assignments. CNA # 3 was not available to interview. The attending Physician was interviewed on 4/01/2022 at 11:33 AM and stated that their expectation would be that the resident would receive timely ADL care as planned. The Physician was unaware that Resident #99 had not received morning ADL care on Friday, 3/25/2022. The DNS was re-interviewed on 3/25/2022 at 4:10 PM and stated CNAs should not be trading residents amongst each other by crossing out names on assignments. LPN #2 also made a mistake by not assigning a CNA to Assignment C. The DNS stated that LPN # 2 told the DNS that CNA # 1 was assigned to Resident #99 in error. A better system of ensuring the CNAs are assigned to each resident will be implemented. No resident should have to wait till 12 noon to be provided AM care and to be taken out of their bed. 415.12(a)(3)

Based on observation, interviews and record review during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that all residents received adequate supervision to prevent Accidents. This was identified for one (Resident #85) of three residents reviewed for Accidents. Specifically, Resident #85 was observed shaving themselves with a razor without supervision and had blood on their face. The finding is: The facility Hazardous Areas, Devices and Equipment Policy dated July 2017, documented all hazardous devices in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to: sharp objects that are accessible to vulnerable residents. Monitoring to ensure that recommendations are implemented consistently and correctly will be a component of the safety and accident prevention program. Resident #85 was admitted with diagnoses of Alzheimer's Disease, Depression and Sensorineural Bilateral Hearing Loss. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #85 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also documented that Resident #85 required Supervision with setup help for personal hygiene including shaving. The Skin Integrity care plan dated 1/21/2022 documented that Resident #85 is at risk for impaired skin integrity related to fragile skin and Peripheral Vascular Disease. The interventions documented to avoid mechanical trauma, including improper shaving. The Activities of Daily Living care plan dated 1/21/2022 documented that Resident #85 required Supervision for Activities of Daily Living secondary to generalized muscle weakness, impaired cognition, history of Multiple fractures of ribs and falls, and Alzheimer's Disease. The interventions included to provide Resident #85 with supervision and setup help for personal hygiene. On 3/25/22 at 12:27 PM, Resident #85 was observed sitting in a chair in their room dry shaving their (Resident #85's) face with a disposable razor. Resident #85 was observed to dab their face with a tissue with frank blood spots on the tissue and face. When approached, Resident #85 refused to state how they obtained the disposable razor. Resident #85 repeatedly stated What do you want? and refused to respond. Registered Nurse (RN) #2, the Unit 1 Manager, was immediately informed by the surveyor of Resident #85's possession of the disposable razor on 3/25/22 at 12:27 PM. RN #2 approached Resident #85 and observed Resident #85 facial bleeding and shaving. Resident #85 became angry, refused to answer RN #2 and repeatedly said What do you want? RN #2 stepped out of the room and stated that Resident #85 did not want to give up the razor. RN #2 stated that Resident #85 should not have the razor and the Certified Nursing Assistant (CNA) should be supervising the resident for shaving. Resident #85 usually gets shaved after the shower, but the CNA was busy showering another resident at the time of the observation. RN #2 stated that they would re-approach the resident with the CNA to remove the razor and tend to the facial cuts. RN #2 further stated that they (RN #2) would also document the incident and the resident skin assessment. CNA #13 was observed walking to Resident #85's room with RN #2 five minutes later at 12:32 PM after the observation. CNA #13 was interviewed on 3/25/22 at 12:48 PM and stated they (CNA #13) did not give Resident #85 the razor. CNA #13 stated that they would not normally give Resident #85 a razor because shaving the resident is their (CNAs) task to do with Resident #85. CNA #13 stated that they did not know where the razor came from. CNA #13 stated that the family often visits Resident #85, and the razor may have come from a visitor. The Director of Nursing Services (DNS) was interviewed on 3/28/2022 at 11:42 AM and stated that Resident #85 should have had a caregiver present to provide supervision so that Resident #85 can shave safely. Resident #85's care plan should also be revised to provide Resident #85 with an electric razor so that the resident could maintain independence. Resident #85's medical record did not document the 3/25/2022 shaving incident, the cut to the resident's face or how the resident obtained the razor until 3/29/2022. RN #2 was re-interviewed on 3/29/2022 at 9:35 AM and stated that they did not document the occurrence but did inform the Director of Nursing Services on 3/25/2022 of the incident. The DNS was re-interviewed on 3/29/2022 at 10:15 AM and stated that an investigation was not completed, and the facility should initiate an investigation to determine how the resident had obtained the razor. 415.12(h)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that residents who are incontinent of Bowel and Bladder receive appropriate treatment and services to prevent Urinary Tract Infections ([CONDITION(S)]) and that a resident who enters the facility with an indwelling catheter is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary. This was identified for one (Resident #99) of five residents reviewed for ADLs and one (Resident #356) of three residents reviewed for Urinary Catheter. Specifically, 1) Resident #99, who was alert and oriented and required staff assistance for incontinence care, did not receive morning care on 3/25/2022 during the 7 AM-3 PM nursing shift until 12:15 PM because no Certified Nursing Assistant (CNA) was assigned to provide care for the resident. The resident was observed in bed with a strong urine odor in their room. Resident #99 was visibly upset, clenching their lips, and stated with an elevated loud tone that no one took care of them today. The resident stated they were wet and had been asking for staff assistance all morning; however, no staff came to assist. 2) Resident #356 was admitted to the facility with a chronic long term Foley catheter; however, the catheter was not documented in the nursing admission assessment or the physician's history and physical, there was no physician's order in place for the catheter, there was no comprehensive care plan, and there was no documentation that catheter care was completed. The findings are: 1) The Urinary Incontinence policy dated January 2022 documented, As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. Resident # 99 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition. The resident was frequently incontinent of bowel and bladder and required extensive assistance of one person for Bed Mobility and Dressing, Extensive Assistance of two persons for transfers and Limited assistance of one person for personal hygiene. The Comprehensive Care Plan (CCP) dated 12/30/2021 documented the resident had bowel incontinence related to the aging process. Interventions included to check the resident every two hours and to assist with toileting as needed; Provide bedpan/bedside commode and provide perineal care after each incontinent episode. The CCP dated 9/11/2021 documented the resident had bladder incontinence related to the aging process. Interventions included to apply incontinence devices as identified as appropriate for the resident. The CCP dated 9/13/2021 for at risk for Pressure Ulcer development related to actual swelling and [CONDITION(S)] to left hip and left hand; impaired mobility; incontinence and fragile skin included intervention to turn and reposition the resident every two hours and as needed. On 3/25/2022 at 10:30 AM, Resident #99 was observed in their room in their bed. On 3/25/2022 at 11:20 AM, Resident #99 was again observed in their bed. A strong urine odor was detected. Resident #99 was upset as evidenced by the resident clenching their lips. Resident #99 stated they (Resident #99) were very upset and angry. Resident #99 stated in a loud tone that they have been waiting all morning to get changed and to be taken out of bed. Resident #99's concern was brought to the Unit clerk's attention. The Unit clerk stated CNA #2 was the assigned CNA for Resident #99. On 3/25/2022 at 11:30 AM CNA #2 was interviewed and stated that they (CNA #2) were not assigned to the resident. The CNA assignment sheet dated 3/25/2022 documented five CNA assignments for the 7 AM-3PM nursing shift (assignment A, B, C, E and F) with corresponding CNA names, except for assignment C. Resident # 99's room number was included under assignment C. On 3/25/2022 between 11:20 AM and 12:00 PM there were no nursing staff present at the nurses' station. at 12:00 PM the unit clerk was asked who the RN Manager or Supervisor was assigned to the resident's unit. The unit clerk stated they will call the supervisor. The Director of Nursing Services (DNS) arrived on the Unit 10 minutes later at 12:10 PM. The DNS stated there was no RN manager or Supervisor assigned to the resident's Unit. The DNS reviewed the CNA staffing sheet and could not determine who the assigned CNA was for Resident #99. The DNS then stated that CNA #1 was the assigned CNA for Resident #99. Between 12 PM to 12:20 PM, CNA #1 could not be located on the Unit. AT 12:15 PM CNA # 2 was observed providing care to the resident. The CNA accountability record for March 2022 documented the resident was toileted and last received hygiene care on 3/25/2022 at 6:14 AM. The Bed Mobility section documented the resident last received assistance with bed mobility at 6:14 AM. There was no documented evidence that Resident #99 was turned and positioned every two hours and as needed. CNA # 1 was interviewed on 3/25/2022 at 12:30 PM and stated that they were not assigned to Resident # 99. CNA #1 stated that although Resident #99 was on their assignment on the unit assignment sheet, they (CNA #1) traded off Resident # 99 with CNA # 3 who is normally assigned to assignment F. CNA #1 stated they (CNA #1) did not inform Licensed Practical Nurse (LPN) # 2, who was responsible for the assignments, of the trade off of Resident #99. LPN # 1 was interviewed on 3/25/2022 at 3:30 PM and stated they were assigned to Resident #99 this morning. LPN #1 stated they (LPN #1) were a float LPN and were not regularly assigned to the unit. LPN #1 stated that they (LPN #1) were not aware of Resident #99's routines. LPN # 2, who was the Unit charge nurse, was interviewed on 3/25/2022 at 3:35 PM and stated they (LPN #2) were responsible to make the CNA assignments. CNA #1 was supposed to be assigned to Resident #99. LPN #2 stated that the CNA assignment did not have a CNA's name assigned for assignment C and it was an oversight. LPN #2 stated the assignment sheet should reflect CNA # 1 for assignment C. LPN #2 further stated that they (LPN #2) were not aware that CNA # 1 and CNA # 3 were trading residents on their assignments. CNA # 3 was not available to interview. The attending Physician was interviewed on 4/01/2022 at 11:33 AM and stated that their expectation would be that the resident would receive timely ADL care as planned. The Physician was unaware that Resident #99 had not received morning ADL care on Friday, 3/25/2022. The DNS was re-interviewed on 3/25/2022 at 4:10 PM and stated CNAs should not be trading residents amongst each other by crossing out names on assignments. LPN #2 also made a mistake by not assigning a CNA to Assignment C. The DNS stated that LPN # 2 told the DNS that CNA # 1 was assigned to Resident #99 in error. A better system of ensuring the CNAs are assigned to each resident will be implemented. No resident should have to wait till 12 noon to be provided AM care and to be taken out of their bed. 2) The facility's policy, titled Urinary Incontinence-Clinical Protocol, last revised in 1/2022, documented as part of the physical examination, the physician will look for findings related to continence, such as a prolapsed uterus, prostate enlargement, use of a urinary catheter, evidence of abdominal or urologic surgery, and/or diuretic use. The physician will identify situations where an indwelling urethral or suprapubic catheter are indicated and will document why other alternatives are not feasible. If a long-term indwelling catheter is needed, staff will monitor for and report complications such as evidence of a symptomatic infection. Virtually all individuals with indwelling urinary catheters eventually have bacteriuria. The staff and physician will monitor the individual for complications of an indwelling catheter such as a symptomatic urinary tract infection, urosepsis, or urethral erosion or pain, and for complications of medications used to treat urinary incontinence. Resident #356 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Section H of the MDS was completed on 3/25/2022 at 1:50 PM indicating the use of the indwelling catheter. The Patient Review Instrument (PRI), hospital record, dated 3/9/2022 documented the resident had a 16 French urinary catheter in the hospital. The admission nursing assessment dated [DATE] documented the resident was incontinent of bladder related to an acute condition; however, there was no documentation regarding the resident having a urinary catheter. The Physician History and Physical dated 3/11/2022 documented deferred under the Genitalia/Bowel/Bladder section. There is no documentation related to the use of the urinary catheter. Resident #356 was observed laying in bed on 3/23/2022 at 11:18 AM with a urinary catheter drainage bag hanging from the side of bed containing yellow urine. A family member was present in the room Review of the medical record from 3/11/2022 through 3/23/2022 revealed there were no physician's orders and no care plan developed for the urinary catheter for Resident #356. In addition, there was no documentation in the medical record that catheter care was being performed. Resident #356 was observed laying in bed on 3/25/2022 at 8:23 AM. RN #3 who was the assistant unit manager, was present. RN #3 stated they (RN #3) would review the record to see if an order was in place. The drainage bag containing yellow urine was observed laying on the floor. There was no privacy bag present. RN #3 stated the bag should not be laying on the floor. Resident #356's family member was interviewed on 3/25/2022 at 8:31 AM. The family member stated that the resident has been using the Foley catheter due to a blockage and has had the catheter for about seven years. RN #3 was re-interviewed on 3/25/2022 at 10:51 AM. RN #3 stated the order for urinary catheter and care plan have just been initiated for Resident #356's urinary catheter. RN #3 stated they (RN #3) did not realize there was no order for the urinary catheter for Resident #356 and that the admitting nurse is supposed to enter the order for the urinary catheter. RN #4 (Admission RN) was interviewed on 3/25/2022 at 12:50 PM and stated when a resident is admitted with a urinary catheter, the use of the urinary catheter should be documented in the medical record, physician's orders should be obtained, and a care plan should be initiated for catheter use and care. If the admission nurse misses the catheter, the nurses on the following shifts should obtain the Physician's orders and initiate the care plan for the use of the urinary catheter. RN #4 further stated that they (RN #4) were only human. Physician #1 was interviewed on 3/25/2022 at 1:05 PM and stated that the deferred comment in the History and Physical for the bladder and bowel assessment meant that the resident or family refused examination. The Physician stated they (Physician) were aware the resident had a catheter. The physician stated that if a Foley urinary catheter was just placed in hospital for a short-term basis, then an order will be placed for the catheter with a date for a trial void to be done. The physician further stated if the Foley urinary catheter is for a chronic condition or suprapubic and is long term, then the facility policy is just to continue the catheter and the order was not needed. The Director of Nursing Services (DNS) was interviewed on 3/28/2022 at 10:33 AM and stated, we dropped the ball. The DNS stated different nurses were involved with different parts of the admission process and the nurses assumed the other nurses were documenting and care planning for the catheter. The DNS stated they (DNS) were in the resident's room a couple of days before the survey started and saw the catheter and assumed the order was in place. RN #5 (MDS Assessor) was interviewed on 3/30/2022 at 3:50 PM and stated 3/25/2022 was when they first learned that the resident had a urinary catheter. RN #5 stated after they learned that Resident #356 had a urinary catheter, they completed Section H of the MDS indicating use of the urinary catheter. 415.12(d)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022 the facility did not ensure that pharmaceutical services including administration of all medications was provided to meet the needs of all residents. This was identified for one (Resident #358) of one resident reviewed for Pharmacy Services. Specifically, on 3/25/2022 Registered Nurse (RN) #3 did not administer 9 AM Physician-ordered medications to Resident #358 timely. The finding is: The facility's policy titled Administering Medications, revised on 1/2022, documented medications must be administered in accordance with the [Physician's] orders, including any required time frame, and medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. As per the Physician's History and Physical dated 3/21/2022, Resident #358 was admitted with diagnoses including Asthma, Chronic [CONDITION(S)], and Hypertension. As per the Nursing Admission assessment dated [DATE], Resident #358 had intact cognition and was oriented to person, place, and situation. A Comprehensive Care Plan (CCP) effective 3/27/2022 documented the resident has an Alteration in Cardiovascular Function related to [CONDITION(S)] (Hypertension, [CONDITION(S)], status post-acute symptomatic [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], history of sinus [CONDITION(S)], and Pulmonary Embolism, with an intervention to administer medications as prescribed. A CCP effective 3/27/2022 documented the resident has an alteration in respiratory system related to Asthma, [CONDITION(S)], history of lung disease, and oxygen dependence, with an intervention to administer treatments (nebulizer) and medications as per physician orders. On 3/25/2022 at 12:05 PM RN #3 was observed outside Resident #358's room preparing medications. RN #3 stated the medications were due to be given to Resident #358 at 9 AM. RN #3 further stated that they (RN #3) were the only nurse on the unit. The following 9 AM medications that were ordered and the corresponding administration times on 3/25/2022 are as follows: [MEDICATION(S)] Aerosol 110 microgram (mcg) 1 puff inhale orally every 12 hours for Asthma. The medication was administered at 12:03 PM; [MEDICATION(S)] Tablet 5 milligram (mg) Give 1 tablet by mouth every 12 hours for [CONDITION(S)]. The medication was administered at 12:03 PM; [MEDICATION(S)] Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for supplement. The medication was administered at 12:03 PM; Pepcid Tablet 20 mg (Famotidine) Give 1 tablet by mouth two times a day for Gastro [CONDITION(S)] Reflux Disease (GERD). The medication was administered at 12:03 PM; [MEDICATION(S)] Tablet 50 mg ([MEDICATION(S)]) Give 1 tablet by mouth one time a day for Hypertension. The medication was administered at 1:02 PM; [MEDICATION(S)] Tablet 10 mg Give 1 tablet by mouth one time a day for Hypertension. The medication was administered at 12:35 PM. Budesonide-[MEDICATION(S)] Aerosol 160-4.5 mcg two puff inhale orally two times a day for Asthma. The medication was administered at 12:35 PM. RN #3 was re-interviewed on 3/28/2022 at 12:17 PM and stated the 9 AM medications for Resident #358 were late on 3/25/2022 because things were hectic and they (RN #3) were the only nurse on the unit. RN #3 stated that being the only nurse on the unit is how it usually is. RN #3 stated they (RN #3) called the physician to report the medications being late. RN #3 stated it was not normal to administer the 9 AM medications after 12 PM, and the medications should be administered one hour before or one hour after the prescribed time. Physician #1 was interviewed on 3/29/2022 at 8:54 AM and stated that they (Physician #1) were made aware of Resident #358 medications for being late on 3/25/2022. The Director of Nursing Services (DNS) was interviewed on 3/30/2022 at 8:45 AM and stated the medications are to be administered within one hour before or one hour after the ordered due time. The DNS stated the nurse could have asked for help. 415.18(a)

Based on observation, interviews, and record review, during the Recertification survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure all medications and tube feedings were accurately labeled and medications were safely stored in 1 of 4 medication carts reviewed for Medication Storage Task and for 1 (Resident #110) of 3 residents reviewed for Tube Feeding. Specifically, 1) an unopened bottle of [MEDICATION(S)] ([CONDITION(S)] medication) eye drops was not refrigerated as per the pharmacy instructions; and an opened pro-source bottle was not labeled with the opened date. Additionally, two unmarked tablets were observed in the medication cart in an unlabeled souffle cup. 2) on 3/23/2022 Resident #110's tube feeding bottle was not labeled with the start time, the feeding rate, and the signature of nurse who initiated the feeding. Additionally, the feeding tube was not dated to indicate when the feeding tube was changed. The findings are: 1) The facility Storage of Medication Policy and Procedure dated 1/2022 documented that medications requiring refrigeration must be stored in a refrigerator located in the medication room at the nurses' station or other secured location. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The Pfizer [MEDICATION(S)] ([MEDICATION(S)]) Label Storage instructions document to store unopened bottle(s) under refrigeration at 2° to 8°Celcius (C) (36° to 46°F). Once a bottle is opened for use, it may be stored at room temperature up to 25°C (77°F) for 6 weeks. The Medication Label Storage instructions for ProSource No Carb Liquid Protein document to discard after 3 months of opening. Resident #408 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #408 had a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition. The MDS documented that Resident #408 received antidepressant medication 2 of the 7-day of the MDS look back evaluation period. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/25/2022 at 11:00 AM, the Unit 3 medication cart was observed with RN #1. RN #1 stated that they (RN #1) were the Medication Nurse on the unit on the 7AM-3PM shift. In the top drawer, RN #1 pulled out a dark plastic bag with a red warning label indicating to refrigerate until open. The enclosed medication was an unopened bottle of [MEDICATION(S)] Eye Drop solution 0.005% for Resident #408 to be administered at bed-time. RN #1 stated that eye drops were on the cart when they arrived on their shift this morning and the eye drops should have been refrigerated and not in the medication cart as per the pharmacy instruction label. RN #1 was then observed to move unmarked small paper souffle cup containing two tablets. RN #1 stated that the tablets in the cup were Setraline 50 mg and Lisonopril 10 mg for Resident #408. RN #1 stated that Resident #408 refused the medication and that they (RN #1) will not throw out the medication. RN #1 stated that instead, they will store the medication cup in between the blister packs to re-approach the resident at a later time. RN #1 then opened the supplement drawer which revealed an undated opened bottle of ProSource No Carb Liquid Protein. RN #1 stated that the supplement drink was used amongst multiple residents on the unit and that without an opened date, they would not know when to discard it. The label on the bottle indicated to discard after 3 months after opening. The Director of Nursing Services (DNS) was interviewed on 3/28/2022 at 2:25 PM. The DNS stated that the nurses are expected to discard the refused medications and to retrieve a new pill if the resident is willing to take the medication. The DNS also stated that opened medications are not to be stored in the medication cart and that was not a standard practice. Nurses are also expected to follow the pharmacy's storing instructions and any medication that requires refrigeration should be kept in the refrigerator until needed. The Pro-Source supplement should be clearly labelled with the opened date so that staff would know when to discard it. 2) The facility Enteral Feeding - Safety Precaution policy dated 1/2022 documented to prevent errors in administration: on the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. Resident #110 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems. The MDS documented the resident had a feeding tube. During an initial tour conducted on 3/23/2022 on the 3rd floor nursing unit Resident #110 was observed at 10:45 AM and at 12:45 PM with the tube feeding (Glucerna 1.2) infusing. The tube feeding bottle was not labeled with the feeding rate, the time the feeding was started, nor the signature of the nurse that started the feeding. The tubing utilized to administer the feeding was also not labeled. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Registered Nurse (RN) #2 was interviewed on 3/23/2022 at 12:50 PM and stated that the feeding tube label should have been filled out with the information that is required on the tube feeding label including the date, flow rate and the nurse's initials who had initiated the feeding. The 3:00 PM-11:00 PM shift RN #6 was interviewed on 3/30/2022 at 6:50 PM and stated that they (RN #6) hung the tube feeding on 3/22/2022 for Resident #110 and forgot to fill out the tube feeding label. RN #6 further stated they (RN #6) were not aware that the tubing also had to be labeled because the tube is changed daily. The Director of Nursing Service (DNS) was interviewed on 4/1/2022 at 4:31 PM and stated the nurses are supposed to date the tubing and sign the label on the feeding bottle, however, the DNS was not sure if the feeding rate should be documented on the feeding bottle. 415.18(d); 415.18(e)(1-4)

Based on record review and staff interview during the Recertification survey the facility did not ensure that each resident's drug regimen was free from unnecessary medications for 1 of 3 residents reviewed for Accidents from a total Stage 2 sample of 55 residents. Specifically, Resident #340 was admitted to the facility on [DATE] from the hospital with no previous documentation that he received antipsychotic medications. The resident was prescribed a standing dose of [MEDICATION NAME] two times per day on 1/12/2016 following wandering, noncompliance, and aggressive behaviors. The [MEDICATION NAME] dosage was increased to three times per day on 1/19/2016 as the behaviors continued. Following the dosage increase on 1/19/2016 nursing notes documented that the resident was sleeping in bed and there were no behavior problems. A nursing note on 1/27/2016 documented that the resident had very poor appetite. On 1/28/2016 the resident was found lifeless in bed by nursing staff. This resulted in actual harm to Resident #340 that is not immediate jeopardy. The finding is: Resident #340 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/14/2016 Admission Minimum Data Set (MDS) Assessment documented a Brief Interview of Mental Status (BIMS) score of 3, which indicated that the resident had severely impaired cognition. The MDS documented that the resident's preferred language was Mandarin, was sometimes understood, and sometimes understands. In addition, the MDS documented no [MEDICAL CONDITION], but physical behavioral symptoms and rejection of care were present for 4 to 6 days, but less than daily. On 1/7/2016 the Physician ordered [MEDICATION NAME] Acid 250 milligram (mg) capsule, give 1 capsule by oral route every 12 hours. The [DIAGNOSES REDACTED]. On 1/7/2016 the Physician ordered [MEDICATION NAME] 0.25 mg tablet, give 1 tablet by oral route as one dose. The [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. An admission Nurse's Note (NN), dated 1/7/2016, documented that the resident was non-compliant and combative with staff and speaks primarily Mandarin. This was the only NN dated 1/7/2016. A Comprehensive Care Plan (CCP) for Psychopharmalogical Medications, effective 1/8/2016, documented that the resident was on [MEDICAL CONDITION] medications due to behavior and mood. Interventions included medicating per physician's orders [REDACTED]. On 1/8/2016 the Physician ordered a Psychiatric evaluation for Advanced Dementia with Behavioral Disturbance. The Physician's Admission Note, dated 1/9/2016, documented that the resident had behavioral problems, [MEDICAL CONDITION], and planned for a psychiatric evaluation. On 1/10/2016 the Physician ordered [MEDICATION NAME] 2 mg tablet, give 1 tablet by oral route as one dose. The [DIAGNOSES REDACTED]. The MAR indicated [REDACTED]. A NN dated 1/10/2016 documented that the resident became combative when an attempt was made to try to guide the resident from entering other residents' rooms. There is no other documentation on 1/10/2016 that non-pharmacological interventions were attempted prior to the administration of the [MEDICATION NAME]. The hospital records prior to Resident #340's admission to the facility were reviewed. The resident did not receive [MEDICATION NAME] or [MEDICATION NAME] in the hospital. A Psychiatry consult was done in the hospital and [MEDICATION NAME] intravenous (IV) was recommended on an as needed basis. However, the hospital record documented that the resident never required [MEDICATION NAME]. The hospital record also stated that if [MEDICATION NAME] is used check Electrocardiogram (EKG) for QTC--patient's family educated about side effects of stroke, sudden [MEDICAL CONDITION], but due to behavioral problems requiring it. A CCP for Behavior Problem, effective 1/11/2016, documented that the resident had physical behaviors of hitting and kicking. Interventions included medication as ordered, psychiatric consult as needed, utilizing family caregivers, providing support, and assisting to activities. A NN dated 1/11/2016 at 6:08 PM, documented that the resident only speaks Mandarin, offered resident books to read, TV. The Physician was called and ordered [MEDICATION NAME] 0.25 mg by oral route (that evening) and [MEDICATION NAME] 0.25 mg by oral route twice a day. The MAR indicated [REDACTED]. The Physician's Medical Note, dated 1/12/2016, documented that the physician evaluated the resident for [MEDICAL CONDITION] and delusional behavior, and that the resident was hitting out at staff. The plan was to add [MEDICATION NAME] twice per day. On 1/12/2016 the physician's orders [REDACTED]. The [DIAGNOSES REDACTED]. A Social Work (SW) noted dated 1/13/2016 documented that the Psychiatrist was in to see the resident but could not speak to the resident due to the language barrier. The SW sought out help from the daughter and the daughter offered to speak to the Psychiatrist for any information that could be provided about her father. The SW made the Psychiatrist aware of conversation with resident's daughter. Nursing notes from 1/12/2019 through 1/19/2016 documented that the resident was wandering around unit and into resident rooms and was demonstrating agitation and aggressive behaviors. A NN dated 1/16/2016 at 2:44 PM documented that Resident #340 had a fall and was found on the floor in the hall. There were no injuries documented. The Physician's Medical note, dated 1/19/2016, documented that the physician evaluated the resident for paranoid behavior, combativeness, punching and kicking. The plan was to increase [MEDICATION NAME] to 0.25 mg three times per day. On 1/19/2016 the physician's orders [REDACTED]. The [DIAGNOSES REDACTED]. A Pharmacist Review was done on 1/20/2016. There were no irregularities found. Nursing notes from 1/20/2016 and 1/21/2016 (only documentation from the 11PM-7AM shift) documented the resident was sleeping in bed and there were no behavior problems. A NN dated 1/25/2016 at 1:20 PM documented that Resident #340 completed Physical Therapy on 1/21/2016 and that the resident was currently able to transfer and ambulate independently on a supervised unit without assistive device. There are no nursing notes documenting Resident #340's condition between 1/21/16 and 1/27/2016. A NN dated 1/27/2016 documented that the resident had a poor appetite in spite of much encouragement. A NN dated 1/28/2016 documented that the resident was found in bed lifeless and the resident was pronounced dead after ambulance services had arrived. On 2/23/2016 at 9:07 AM the Registered Nurse (RN) Charge Nurse on Resident #340's former unit was interviewed. He stated that non-pharmacological interventions are the first thing to be done before giving a antipsychotic medication. He stated the staff try to toilet residents, give snacks, provide music, and change location and that if that does not help the physician is called for a medication. He added that he has told the nurses that non-medicated interventions are done first and notes must be documented. The RN Charge Nurse was unable to find non-pharmacological interventions in the nurses' notes dated 1/7/2016 and 1/10/2016. On 02/23/2016 at 11:21 AM the Director of Nursing Services (DNS) was interviewed. She stated she would have expected non-pharmacological interventions to be provided before administering the one-time antipsychotic medications. She added that the nurse that administered the one-time [MEDICATION NAME] on 1/10/2016 was an agency nurse and was no longer working at the facility. She stated she was not sure if the agency nurses get the same training as the staff nurses regarding providing non-pharmacological interventions before administering a one-time antispsychotic medication. On 02/23/2016 at 11:41 AM the Attending Physician was interviewed. She stated that the nurses reported to her that the resident was very aggressive and that she was told that non-pharmacological interventions were done. She stated that she would expect non-pharmacological interventions to be done before giving the one-time [MEDICATION NAME] and [MEDICATION NAME]. On 2/23/2016 at 11:50 AM the Psychiatrist was interviewed. He stated that he could not communicate with Resident #340 due to the language barrier and that the resident was unable to use the language-line translation service due to dementia. He stated that he did not get a chance to meet with Resident #340's family. He also stated that he did not review the medical record and that it was not a normal part of the consult process. There was no documented evidence that a Psychiatric consult was done. The Food and Drug Administration's (FDA) Black Box Warning, issued in 2005, states that the FDA has determined that patients with dementia-related [MEDICAL CONDITION] treated with atypical (second generation) antipsychotic medications are at an increased risk of death. Based on currently available data, the FDA has requested that the package insert for [MEDICATION NAME] be revised to include a black box warning describing this risk and noting that this drug is not approved for this indication. 415.12(l)(1)