**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification survey from 4/17/2023 to 4/24/2023, the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made to the State Survey Agency. This was evident for 1 (Resident # 197) of 5 residents reviewed for Falls out of 38 sampled residents. Specifically, the facility did not report an injury of unknown source for Resident #197 to the New York State Department of Health (NYSDOH). The findings are: The facility policy titled Abuse Prohibition Program with effective date March 2003 and last reviewed date 12/2022 documented it was the policy of the facility to maintain an environment free of abuse and neglect. The policy documented that abuse and neglect definitions included physical abuse, verbal abuse, sexual abuse, emotional abuse, mental abuse, neglect, misappropriation, and involuntary seclusion. The Reporting section documented that substantiated and/or confirmed abuse is to be reported to New York Department of Health as well as licensing/certification boards if applicable for further action. The Procedure section documented that confirmed cases of abuse will be reported to Center of Complaints Intake Program within 24 hours of completion of investigation. The policy did not mention how concerns involving injuries of unknown source would be reported. Resident #197 was admitted to the facility with diagnoses which included Unspecified Dementia, Altered Mental Status, and Other reduced mobility. The Quarterly Minimum Data Set (MDS) 3.0 dated 12/31/22 documented Resident #197 had severely impaired cognition, did not walk in the room and corridor, and was total dependent with 1 person for locomotion on unit and off unit. The MDS also documented that Resident #197 had no fall since admission/entry or reentry or the prior assessment. The Accident Report dated 3/11/23 documented the CNA (Certified Nursing Assistant) responded to the bed alarm at about 5:00 AM on 3/11/23 and found Resident #197 lying on the floor to the left side of bed. The report also documented that Resident # 197 was observed with a swelling to the forehead and that the physician ordered Resident #197 be transferred to the emergency room for a head scan. The report further documented that Resident #197 was confused and not able to tell what happened. The hospital Discharge summary dated [DATE] documented Resident # 97's CT c-spine showed Resident #197 had a transverse oriented fracture through the dens (cervical bone). The Comprehensive Care Plan related to Falls/Injury initiated on 3/20/2023 documented interventions which included keep bed in low position and locked, visual check to assess comfort and toileting needs hourly, and keep immediate necessities within easy reach. Resident # 197's Face Sheet documented Resident # 197 had new diagnoses included Unspecified nondisplaced fracture of second cervical vertebra, Unspecified displaced fracture of first cervical vertebra, and Unspecified injury of head with onset date 3/20/23. The medical note dated 3/21/23 documented Resident # 197 was found lying on floor by nursing staff at the facility and the hospital CT of c-spine showed Resident had a transverse oriented fracture through the dens, type II. There was no HERDS report or other documented evidence in the medical chart that the facility reported the injury of unknown source that occurred on 3/11/2023 to NYS DOH. On 04/20/23 at 10:14 AM, Registered Nurse (RN) #1 was interviewed and stated Resident # 197 was found lying on the floor in their room on 3/11/23 and the incident was not witnessed. RN #1 further stated Resident #197 was not able to verbalize what happened and was observed with a bump on the forehead and the physician ordered Resident #197 be transferred to the hospital for a CT scan. RN #1 also stated they notified the DON and ADON of the incident immediately. On 04/21/23 at 09:58 AM, the Director of Nursing (DON) was interviewed and stated they were notified by the unit nursing supervisor that Resident # 197 was found lying on the floor on the day and had a bump at the forehead. The DON also stated Resident #197 had a history of falls and they thought Resident #197 had fallen again in their room. The DON stated the fall was not witnessed by anyone and Resident #197 was not able to verbalize what happened. Resident #197 had a bump on the forehead and the hospital discharge paper documented Resident #197 had a fracture to their neck. The DON also stated that a discussion is held with the Assistant Director of Nursing (ADON), Medical Director, Administrator, Director of Social Services to determine if an incident is reportable to the New York State Department of Health (NYSDOH) and they did not think that they had to report this fall incident to NYSDOH. The DON further stated the Administrator, ADON and themselves had access to HCS for reporting to NYSDOH and the ADON was responsible for submitting the report through HCS to NYSDOH. The DON then stated that based on the fall being unwitnessed, they should have reported this incident to NYSDOH within 2 hours of their awareness as it was an injury of unknown source. On 04/21/23 at 11:56 AM, the Assistant Director of Nursing (ADON) was interviewed and stated they were responsible for reporting incidents to NYSDOH through HCS or hotline. The ADON also stated they knew they had to report incidents involving injury of unknown source to NYSDOH within 2 hours of awareness, and they did not report the incident with Resident #197 to NYSDOH as they believed Resident #197 had fallen when they tried to get out of bed. The ADON further stated they did not think Resident #197 had an unknown source of injury at that time. The ADON stated the incident was unwitnessed and Resident #197 was cognitively impaired and unable to tell what happened. The ADON further stated they should report this incident to NYSDOH within 2 hours as it was considered as an injury of unknow source. 415.4 (b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during a Recertification survey from 4/17/2023 to 4/24/2023, the facility did not ensure that baseline care plan was completed within 48 hours and the resident and/or their representative were provided with a written summary of the baseline care plan. This was evident for 1 (Resident #129) of 2 residents reviewed for Care Planning out of 38 sampled residents. The findings are: The facility policy titled Baseline Care Plan (BCP) with effective date 1/17/2019 and last reviewed date 1/16/2023 documented that the baseline care plan will be completed within 48 hours of the residents admission. The policy did not document that the facility will provide a written summary of BCP to residents and/or their designated representatives. Resident #129 was admitted to the facility on [DATE] with diagnoses that included Altered Mental Status, Unspecified Dementia, and Unspecified Depression. The admission Minimum Data Set (MDS) dated [DATE] documented Resident #129 had Brief Interview of Mental Status (BIMS) score 12 out of 15, had no behavioral symptoms, and did not reject care. The MDS also documented only Resident #129 participated in the assessment. On 04/17/23 at 11:37 AM, Resident #129 was interviewed and stated they had been admitted to the facility for about 5 to 6 months now. Resident #129 also stated they made decision themselves. Resident #129 further stated they did not recall if they were provided a hard copy of a baseline care plan since their admission to the facility. The Baseline Care Plan (BCP) was documented as created on 12/30/2022 and the sections for the Social Worker, Speech Therapy, and OT were completed on 1/2/2023, 1/5/2023, and 4/18/2023 respectively and were beyond 48 hours of admission. There was no acknowledgement of receipt section in the BCP for Resident #129 and /or their designated representative. Review of progress notes from 1/2/2023 to 4/10/2023 in the EMR and the hard copy chart revealed no documented evidence that Resident #129 and/or their designated representative were provided with a copy of or signed the baseline care plan. On 04/20/23 at 12:18 PM, Registered Nurse (RN) #2 was interviewed and stated the EMR created the baseline care plan (BCP) for all disciplines when the residents were admitted , and they were responsible to complete the nursing section in the BCP within 48 hours of admission. RN #2 also stated they were not sure which staff was responsible to provide the residents and/or their designated representative the hard copy of baseline care plan and oversees the completion of whole baseline care plan. On 04/20/23 at 12:38 PM, the Social Worker (SW) was interviewed and stated they were not sure which staff was responsible to provide the hard copy of baseline care plan to residents and/or their designated representatives. The SW also stated they had to complete the BCP within 48 hours of admission. The SW further stated they did not do the BCP for Resident #129 and was not able to explain why the social worker section of BCP was not completed within 48 hours of admission. On 04/20/23 at 02:23 PM, the Director of Social Services (DSS) was interviewed and stated each department head was responsible to make sure their staff completed their respective section in the baseline care plan within 48 hours of admission. The DSS also stated the MDS department was responsible to oversee the completion of whole BCP and give a hard copy of BCP to the residents and/or their designated representatives. The DSS completing the social worker section in the BCP for Resident #129 stated they were not able to explain why it was completed on 1/2/23 and not within 48 hours of admission. On 04/20/23 at 02:34 PM, the MDS Coordinator (MDSC) was interviewed and stated the floor RN supervisor was responsible to make sure the whole BCP was completed in 48 hours of admission. The MDSC also stated the medical record staff was responsible to provide the resident and/or their designated representative the copy of baseline care plan only if they requested it. The MDSC stated they did not know that they had to provide the residents and/or their designated representatives the hard copy of the BCP without their request of it. The MDSC also stated they did not provide a hard copy of the BCP to Resident #129 and/or their designated representative because they did not request it. On 04/24/23 at 10:23 AM, the Director of Rehab (DR) was interviewed and stated they assigned staff to complete the therapist sections including OT and SLP in the BCP when the EMR created the assessments. The DR also stated they checked the census and made the assignments for the BCP daily. The DR further stated they monitored once a month if the BCP assessments were completed or not. The DR stated they knew the BCP had to be completed within 48 hours of resident admission to the facility. The DR also stated they were not able to explain for the late completion of therapist sections in the BCP. On 04/21/23 at 09:48 AM, the Director of Nursing (DON) was interviewed and stated each department head was responsible to make sure their discipline completed their respective sections in the BCP within 48 hours of admission. The DON also stated the MDS coordinator was responsible to make sure the whole BCP was completed within 48 hours. The DON further stated they did not know they had to provide a hard copy of BCP to the residents and/or their designated representatives and therefore they did not provide Resident #129 and/or their representative a hard copy of BCP. The DON stated they were not able to explain why the BCP for Resident #129 was not completed within 48 hours. 415.11 (c) Based on record review and staff interviews conducted during a Recertification/Complaint Survey from 4/17/2023 to 4/24/2023, the facility did not ensure that baseline care plan was completed within 48 hours and the resident and/or their representative were provided with a written summary of the baseline care plan. This was evident for 1 (Resident # 129) of 2 residents reviewed for Care Planning out of 38 sampled residents. The findings are: The facility policy titled Baseline Care Plan (BCP) with effective date 1/17/2019 and last reviewed date 1/16/2023 documented that the baseline care plan will be completed within 48 hours of the residents admission. The policy did not document that the facility will provide a written summary of BCP to residents and/or their designated representatives. Resident # 129 was admitted to the facility on [DATE] with diagnoses that included Altered mental status, Unspecified dementia, and Unspecified Depression. The admission Minimum Data Set (MDS) dated [DATE] documented Resident # 129 had Brief Interview of Mental Status (BIMS) score 12 out of 15, had no behavioral symptoms, and did not reject care. It also documented only Resident # 129 participated in the assessment. On 04/17/23 at 11:37 AM, Resident # 129 was interviewed and stated they had been admitted to the facility for about 5 to 6 months now. Resident # 129 also stated they made decision themselves. Resident # 129 further stated they did not recall they were provided a hard copy of baseline care plan since their admission to the facility. The Baseline Care Plan (BCP) was documented as created on 12/30/2022 and the sections for the Social Worker, Speech Therapy, and OT were completed on 1/2/2023, 1/5/2023, and 4/18/2023 respectively and were beyond 48 hours of admission. There was no acknowledgement of receipt section in the BCP for Resident # 129 and /or their designated representative. Review of progress notes from 1/2/2023 to 4/10/2023 in the EMR and the hard copy chart revealed no documented evidence that Resident # 129 and/or their designated representative were provided with a copy of or signed the baseline care plan. On 04/20/23 at 12:18 PM, Registered Nurse (RN) # 2 was interviewed and stated the EMR created the baseline care plan (BCP) for all disciplines when the residents were admitted , and they were responsible to complete the nursing section in the BCP within 48 hours of admission. The RN # 2 also stated they were not sure which staff was responsible to provide the residents and/or their designated representative the hard copy of baseline care plan and oversees the completion of whole baseline care plan. On 04/20/23 at 12:38 PM , the Social Worker (SW) was interviewed and stated they were not sure which staff was responsible to provide the hard copy of baseline care plan to residents and/or their designated representatives. The SW also stated they had to complete the BCP within 48 hours of admission. The SW further stated they did not do the BCP for Resident # 129 and was not able to explain why the social worker section of BCP was not completed within 48 hours of admission. On 04/20/23 at 02:23 PM, the Director of Social Services (DSS) was interviewed and stated each department head was responsible to make sure their staff completed their respective section in the baseline care plan within 48 hours of admission. The DSS also stated the MDS department was responsible to oversee the completion of whole BCP and give a hard copy of BCP to the residents and/or their designated representatives. The DSS completing the social worker section in the BCP for Resident # 129 stated they were not able to explain why it was completed on 1/2/23 and not within 48 hours of admission. On 04/20/23 at 02:34 PM, the MDS Coordinator (MDSC) was interviewed and stated the floor RN supervisor was responsible to make sure the whole BCP was completed in 48 hours of admission. The MDSC also stated the medical record staff was responsible to provide the resident and/or their designated representative the copy of baseline care plan only if they requested it. The MDSC stated they did not know that they had to provide the residents and/or their designated representatives the hard copy of BCP without their request of it. The MDSC also stated they did not provide a hard copy of BCP to Resident # 129 and/or their designated representative because they did not request it. On 04/24/23 at 10:23 AM, the Director of Rehab (DR) was interviewed and stated they assigned staff to complete the therapist sections including OT and SLP in the BCP when the EMR created the assessments. The DR also stated they checked the census and made the assignments for the BCP daily. The DR further stated they monitored once a month if the BCP assessments were completed or not. The DR stated they knew the BCP had to be completed within 48 hours of resident admission to the facility. The DR also stated they were not able to explain for the late completion of therapist sections in the BCP. On 04/21/23 at 09:48 AM, the Director of Nursing (DON) was interviewed and stated each department head was responsible to make sure their discipline completing their respective sections in BCP within 48 hours of admission. The DON also stated the MDS coordinator was responsible to make sure the whole BCP was completed within 48 hours. The DON further stated they did not know they had to provide a hard copy of BCP to the residents and/or their designated representatives and therefore they did not provide Resident # 129 and/or their representative a hard copy of BCP. The DON stated they were not able to explain why the BCP for Resident # 129 was not completed within 48 hours. 415.11 (c)