**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during the Recertification survey from 3/9/23 to 3/16/23, the facility did not ensure that comprehensive person-centered care plans were developed and implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment for 2 of 10 residents (Resident #26, Resident #29) reviewed for Accidents out of a total sample of 38 residents. Specifically, a Comprehensive Care Plan (CCP) had not been developed for safety measures related to smoking for Resident #26 and Resident #29. The findings are: The facility's policy and procedure titled Comprehensive Care Planning reviewed 1/23 documented Comprehensive Care Plan (CCP) shall be developed through an interdisciplinary team approach and CCP team review each resident's own unique personal needs in an integrated and coordinated manner. 1. Resident #26 was admitted to the facility with diagnoses of Depression, Non-Alzheimer's Dementia, and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #26 had severely impaired cognition and required supervision for locomotion on and off unit. The Social Services progress note dated 6/20/22 documented that the Social Worker reviewed the facility's smoking policy with Resident #26 and resident's signature was obtained. Family was contacted and notified via voicemail. Review of the electronic medical record revealed that there was no documented evidence that a CCP for smoking was developed. 2. Resident #29 was admitted to the facility with diagnoses of Non-Alzheimer's Dementia, Schizophrenia, and Diabetes Mellitus. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented cognition was moderately impaired and required supervision with locomotion on and off the unit. The Social Service progress note dated 7/20/22 documented Social Worker met with Resident #29 who stated that resident previously smoked years ago and wished to resume smoking again. Smoking policy was reviewed and signed by the resident. Review of the Comprehensive Care Plan (CCP) revised 12/26/22 revealed there was no documented evidence that CCP for smoking was developed. On 3/14/23 at 11:36 AM, Social Worker (SW) #1 was interviewed and stated that they are responsible for initiating and updating care plans for cognition, mood, advance directives, discharge planning, COVID-19, and abuse. For a resident who is identified as a smoker, they will also have a smoking care plan that is initiated and updated by the social worker. SW #1 also stated that when a resident is identified as a smoker, the social worker will review the smoking policy and obtain a signature from the resident to ensure resident agrees to the smoking policy. SW #1 further stated that there are not too many smokers in the facility and therefore, SW #1 did not realize that a care plan had not been created and this was an oversight. On 3/13/23 at 12:50 PM, the Director of Social Work (DSW) was interviewed and stated the care plan for smoking is to be initiated when a resident is identified as a smoker. The resident and their family are educated on the facility's smoking policy and once they agree, signatures are obtained. The DSW was asked to review the smoking care plan for Resident #26, Resident #29 and after reviewing the medical record, the DSW acknowledged that a CCP for should have been developed for both residents once they were identified as smokers. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during a Recertification and Complaint survey (NY#00301808) conducted 3/9/23 to 3/16/23, the facility did not ensure that resident remained free of accident hazards. Specifically, a Certified Occupational Therapist Assistant (COTA) applied a hot pack to Resident #104's right shoulder, resulting in a second degree burn. This was evident for 1 of 10 residents reviewed for Accidents out of total sample of 38 residents. (Resident #104). The findings are: The facility policy and procedure titled Hydrocollator Packs (Hot Packs) revised 2/1/22 documented the physical/occupational therapist and therapy assistant will use hydrocollator packs as an adjunct to therapy. The hydrocollator is thermostatically controlled with the water temperature being maintained at 144 to 160F. The unit is checked monthly by the Rehab/Maintenance Department. Procedure as follows: remove hot pack from hydrocollator and place in hot pack cover, then cover with another 4 to 8 layers of toweling. Apply to the area for 10 to 20 minutes, periodically inspect area(every 3 to 5 minutes), inspect the skin upon removal. The facility policy and procedure titled Risk Management Program - Accidents/Incidents revised 2/23 documented that an individualized care plan of care will be formulated in conjunction with the Interdisciplinary Team that identify risk factors and interventions for prevention of accidents/incident. Resident #104 was admitted to the facility with diagnosis of Essential Hypertension, Multiple Ischemic Stroke with Right Sided Hemiparesis, and Central Pain Syndrome. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented cognition is intact and required extensive assistance of one staff for bed mobility and personal hygiene, and extensive assistance of two staff for transfer. The MDS also documented that resident had a burn of unspecified degree of right shoulder and was receiving application of nonsurgical dressings. The Comprehensive Care Plan (CCP) for Impaired Skin Integrity related to actual second-degree burn on 9/4/22, reviewed 2/15/23 documented interventions which included to provide good skin care daily, skin check every shift, report any abnormality to MD and use draw sheet to turn and position. The undated Accident/Incident Report documented the date of occurrence was 9/4/22 at 9 AM when Certified Nursing Assistant (CNA) observed Resident #104 with a red area on the right shoulder. CNA immediately notified the supervisor who notified the family and MD (Doctor) about the burn on the right shoulder. The Nursing note dated 9/4/22 documented resident was noted with a 6.0 cm x 4.0 cm skin opening on the right shoulder, raw skin exposed with slight bleeding on the edges. Resident #104 verbalized that they got it on Friday (9/2/22) after they were given a heat pad while in rehab. NOK (Next of Kin) and attending physician were made aware. Resident was offered pain medication and ordered Bacitracin for wound treatment. The physician note dated 9/5/22 documented resident was seen 9/4/22, noted to have skin wound at the right shoulder. Resident stated it occurred after physical therapy two days prior. The skin injury with no blister, treat wound with Silvadene cream. The physician note dated 9/6/22 documented resident seen again for right shoulder burn, noted that it is a 2nd degree burn. The Investigation Summary dated 9/7/22 concluded that there is reasonable cause to believe that an accident related to heating pad took place. It documented that the COTA who applied the heat pad and Certified Nursing Assistant (CNA) who failed to report the redness observed on 9/3/22 were given disciplinary action. The facility also initiated competency for use of heating pad, re-initiated Stop and Watch program to staff for plan of actions to prevent occurrence. The application of heating pad was discontinued and used therapeutic massage as an alternative treatment for Resident #104. The Employee Disciplinary Action dated 9/7/22 documented COTA who applied hot moist pack, leading to burn on Resident #104's right shoulder, was given disciplinary action for unsatisfactory work. The Employee Disciplinary Action dated 9/9/22 documented CNA who observed redness on the right shoulder following the day after rehab, was given disciplinary action for failure to report change in skin condition while providing care. On 3/16/23 at 9:16 AM, Certified Nurse Assistant (CNA) #2 was interviewed and stated Resident #104 was observed with redness on their shoulder in the morning of 9/3/22. CNA #2 also stated that Resident #104 did not complain of pain or discomfort related to the redness. CNA #2 acknowledged that it was not reported to the nurse on the day when Resident #104 was observed with redness and that they were working short staffed on this day therefore, it was missed by mistake. During an interview with Licensed Practical Nurse (LPN) #2 on 3/16/23 at 9:25 AM, they stated that they were notified by the CNA regarding Resident #104's burn on 9/4/22. Resident #104 did not have any pain related to the burn and was able to verbalize that the burn was from the heat pack used during rehab. LPN #2 notified the supervisor on duty who initiated the incident report. Resident #104's burn was treated and dressed as per physician's order. On 3/14/23 at 9:05 AM, the Director of Rehab (DR) was interviewed and stated that the Certified Occupational Therapy Assistant (COTA) no longer works in the facility. The DR also stated that the Hot Moist Pack (HMP) was used for Resident #104 on an as needed basis and that this was an isolated incident. As per COTA, the HMP was used on that day as it is normally applied and was applied correctly. The DR was first made aware of the burn injury on 9/5/22. The DR stated that they are responsible to oversee all rehab staff including COTA and that COTAs are professionally trained to use hot packs as an adjunct to therapy. New COTAs will be introduced to different modalities used in the facility and instructions for proper applications are provided. The DR further stated that staff were not evaluated for competency for the use hot pack prior to this incident and that competency for the use of heat packs was initiated post resident's burn as a plan of correction. The DR stated that they were no other incidents of burns related to heating pad and re-emphasized that it was an isolated incident. On 3/14/23 at 11:58 AM, an attempt was made to contact the Registered Nurse Supervisor (RNS #2) who was the nurse on duty at the time of the incident and completed the occurrence report, however RNS #2 did not answer or return the call. On 3/16/23 at 12:02 PM, the Director of Nursing (DON) was interviewed and stated the facility was first made aware of Resident #104's injury on 9/4/22 when a CNA notified the nurse. The nurse supervisor immediately assessed the injury and obtained information from Resident #104, who verbalize that the injury was from the heating pad used during a rehab session. The DON also stated that the injury was not related to abuse since resident verbalized that the burn was from the heating pad used in rehab, therefore, it was not reported immediately to the New York State Department of Health (NYS DOH). 415.12(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, the facility did not effectively monitor a resident that was at risk for weight loss and weight fluctuations with a weight loss of 19.08 % in 6 months, and 5.09% in less than 1 month. This was evident for 1 of 6 residents reviewed for Nutrition out of a sample of 38 residents investigated. (Resident # 22). The findings are: The facility's policy titled Weights dated 05/06, last revised 01/2023 documented: A loss or gain of 3lbs a week and 5lbs a month will be communicated by CNA to the Charge Nurse and a reweigh will be done in the presence of the Charge Nurse for validation. A confirmed weight loss or gain will be communicated to MD/NP, RD, NOK and documented in the CCP (Comprehensive Care Plan) with corresponding intervention. Resident #22 was admitted with diagnoses that included Cerebrovascular Accident (CVA), Non-Alzheimer's Dementia, and Depression. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS also documented that the resident was extensive assistance of staff for most activities of daily living including eating. The MDS further documented that Resident #22 holds food in mouth/cheeks, and had a loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on a physician-prescribed weight-loss regimen. The Comprehensive Care Plan (CCP) for Nutritional Status dated 12/16/2013, last updated 2/17/2022, documented that Resident is on therapeutic diet secondary to Significant weight loss: x 3 months. Goals included that Resident will be adequately nourished as evidenced by absence of significant weight loss, resident's laboratory report(s) will be clinically stable per MD, and resident will continue to consume >75% of meals served x 90 days. Interventions included check lab values on a routine basis, monitor intake and tolerance to diet, monitor weight, observe for visual signs and symptoms of poor nutrition or hydration status, and provide diet per MD order (NAS diet, with chopped consistency and honey thick liquids). The Long Term Care Survey Process (LTCSP) weight calculator documented On 09/13/2022, the resident weighed 152 lbs. On 03/06/2023, the resident weighed 123 pounds which is a 19.08 % loss. This weight loss occurred over a 6 month period. The LTCSP weight calculator also documented On 02/22/2023, the resident weighed 129.6 lbs. On 03/06/2023, the resident weighed 123 pounds which is a -5.09 % loss. This weight loss occurred over a 12-day period. Progress Notes Dietary dated 12/24/2022 documented: Quarterly Assessment: .Current nutritionally pertinent medication includes . mirtazapine, Prilosec. Note: Mirtazapine - may increase appetite. There are no current nutrition related labs.Current Wt:131.5 (12/5) Ht: 66 in, Past weight: 126.6 lbs. (11/14), 138 lbs. (10/14), 138 lbs. (9/30), 157.8 lbs. (8/16), 157.4 lbs. (7/19), 156 lbs. (6/21), 154.2 lbs. (5/31). Current BMI: 21.2 - WNL - low for geriatric age. Continues to trigger for unplanned/undesirable weight loss in 3 months ~12.37% and 6 months ~14.62% Progress Note Medical dated 12/20/2022 documented that resident was seen and examined secondary to exposure to COVID-19, weights documented by MD are 131.5lbs (12/05/22); 126.6lbs (11/14/22); 138lbs (10/14/22, and 157.8lbs (8/16/22). This was a 16.67 % loss between 8/16/22 and 12/5/22. There was no documented evidence of interventions to address the resident's significant weight loss of over 16% in 4 months. Progress note Medical -Physician's Monthly Progress dated 3/13/2023 documented that Resident seen and examined 3/13/2023 for monthly follow up. Weight loss, Aphasia, dementia; At risk for malnutrition secondary to multiple comorbidities, weight 123 pounds. There was no documented evidence of interventions to address the resident's significant weight loss and risk for malnutrition. On 03/14/23 at 11:08 AM, an interview was conducted with Certified Nursing Assistant (CNA) #1 who stated that Resident #22 can feed self with tray set up and has been completing between 25% and 75% of meals served. CNA #1 also stated that resident has been noted with some weight loss when transferred to the unit a few months ago and this was reported to the nurse. On 03/14/23 at 11:41 AM, an interview was conducted with the Charge Nurse, Licensed Practical Nurse (LPN) #1 who stated that Resident #22's meal intake is documented by CNA in the CNA Accountability Record (CNAAR). If a resident consumes less than 25% for 3 days, the dietician is notified to do a calorie count and weekly weights are recommended. LPN #1 also stated that based on the resident's weight, Resident #22 was noted with some weight loss when transferred to the unit. LPN #1 further stated that they do not remember doing a calorie count for the resident recently, and weekly weights had not been recommended by the dietician or by the Physician. On 03/14/23 at 12:03 PM, an interview was conducted with the Registered Dietitian (RD) who stated that per documentation reviewed, resident requires assistance of staff for eating and has been consuming over 75% of the meals based on the data generated from the CNAAR. The RD also stated that they had never observed the resident eating during meals, and the first assessment and quarterly evaluation was done in December. The RD further stated that as per the assessment, resident was triggered for undesired weight loss, probably due to the worsened dementia, as at that time, it was documented that resident was consuming only about 25% of food. The RD stated that they planned to re-assess the resident at the next quarter, which is currently due. On 03/16/23 at 08:55 AM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1. RNS #1 stated that monthly weight is done for a stable resident, and any resident observed with weight loss of 5% from the previous weight is reported to the dietician and the doctor so necessary interventions can be given. The resident's weight will be monitored weekly until the weight is stabilized. RNS #1 also stated that the dietician should have communicated the significant weight change of the resident to the doctor for new interventions to address the resident's weight loss. RNS #1 stated that they believe that the resident's weight loss was discussed with the dietician by nursing staff, but they did not know why the dietician had not implemented necessary interventions for the weight loss. On 03/16/23 at 09:21 AM, an interview was conducted with the Director of Nursing (DON) who stated that if a resident is observed with significant weight loss, the nursing staff will notify the doctor and the dietician. A calorie count will be recommended and ordered, and depending on the physician, the resident may be given an appetite stimulant, along with weekly weight monitoring. It will also be discussed by the interdisciplinary team. The DON also stated the care plan must be updated by the dietician. The DON further stated that every discipline is required to update their care plan based on their clinical areas. The DON stated that they were not aware that the resident's significant weight loss was not appropriately addressed. On 03/16/23 at 11:53 AM, an interview was conducted with the Medical Director (MD) who stated that when a resident is observed with significant weight loss, we ask dietary to see if we need to offer supplements and appetite stimulant, and to continue monitoring the weight weekly until the resident is stable. The MD also stated that based on the record review, the former dietician had documentation regarding the resident's weight loss in November last year but Resident #22's weight loss had not been properly followed up on by the current dietician and the Attending Physician. The MD further stated that they were surprised that this was not done and the issue will be discussed with the staff and the attending physicians to prevent reoccurrence. 415.12(i)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the Recertification survey from 3/9/23 to 3/16/23, the facility did not ensure that the medical care of each resident was supervised by a physician. Specifically, there was no documented evidence that the physician monitored changes in the resident's health status and provided interventions to address a resident's undesired significant weight loss over the period of 6 months. This was evident for 1 of 6 residents reviewed for Nutrition out of a sample of 38 residents investigated. (Resident # 22) The finding is: The facility's policy titled Physician dated 09/2016, last revised 02/2023, documented: Resident will be seen by Primary Physician/ Nurse Practitioner on Admission/ Readmission; Monthly (every 28-30 days); Significant Change; PRN/ as requested by resident/NOK The facility's policy titled Weights dated 05/06, last revised 01/2023, documented: A loss or gain of 3lbs a week and 5lbs a month will be communicated by CNA to the Charge Nurse and a reweigh will be done in the presence of the Charge Nurse for validation. A confirmed weight loss or gain will be communicated to MD/NP, RD, NOK and documented in the CCP (Comprehensive Care Plan) with corresponding intervention. Resident #22 was admitted with diagnoses that included Cerebrovascular Accident (CVA), Non-Alzheimer's Dementia, Hemiplegia, and Depression. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS also documented that Resident #22 required extensive assistance of staff for most activities of daily living including eating. The MDS further documented that Resident #22 holds food in mouth/cheeks, and had a loss of 5% or more in the last month or loss of 10% or more in last 6 months, and was not on a physician-prescribed weight-loss regimen. The Comprehensive Care Plan (CCP) for Nutritional Status dated 12/16/2013, last updated 2/17/2022, documented that Resident is on therapeutic diet secondary to Significant weight loss: x 3 months. Goals included that Resident will be adequately nourished as evidenced by absence of significant weight loss, resident's laboratory report(s) will be clinically stable per MD, and resident will continue to consume >75% of meals served x 90 days. Progress Notes Dietary dated 12/24/2022 documented: Quarterly Assessment: .Current nutritionally pertinent medication includes . mirtazapine, Prilosec. Note: Mirtazapine - may increase appetite. There are no current nutrition related labs.Current Wt:131.5 (12/5) Ht: 66 in, Past weight: 126.6 lbs. (11/14), 138 lbs. (10/14), 138 lbs. (9/30), 157.8 lbs. (8/16), 157.4 lbs. (7/19), 156 lbs. (6/21), 154.2 lbs. (5/31). Current BMI: 21.2 - WNL - low for geriatric age. Continues to trigger for unplanned/undesirable weight loss in 3 months ~12.37% and 6 months ~14.62% Progress Note Medical dated 12/20/2022 documented that resident was seen and examined secondary to exposure to COVID-19, weights documented by physician were 131.5lbs (12/05/22); 126.6lbs (11/14/22); 138lbs (10/14/22, and 157.8lbs (8/16/22) which represented a 16.67 % loss between 8/16/22 and 12/5/22. There was no documented evidence of interventions to address the resident's significant weight loss of over 16% in 4 months. The Long Term Care Survey Process (LTCSP) weight calculator documented On 09/13/2022, the resident weighed 152 lbs. On 03/06/2023, the resident weighed 123 pounds which is a -19.08 % Loss. This weight loss occurred over a 6 month period. The LTCSP weight calculator also documented On 02/22/2023, the resident weighed 129.6 lbs. On 03/06/2023, the resident weighed 123 pounds which is a -5.09 % loss. This weight loss occurred over a 12-day period. Progress note Medical -Physician's Monthly Progress dated 3/13/2023 documented that Resident seen and examined 3/13/2023 for monthly follow up. Weight loss, Aphasia, dementia; At risk for malnutrition secondary to multiple comorbidities, weight 123 pounds. There was no documented evidence of interventions to address the resident's significant weight loss and risk for malnutrition. On 03/14/23 at 11:41 AM, an interview was conducted with the Charge Nurse, Licensed Practical Nurse (LPN) #1 who stated that Resident #22's meal intake is documented by CNA in the CNA Accountability Record (CNAAR). If a resident consumes less than 25% for 3 days, the dietician is notified to do a calorie count and weekly weights are recommended. LPN #1 also stated that based on the resident's weight, Resident #22 was noted with some weight loss when transferred to the unit. LPN #1 further stated that they do not remember doing a calorie count for the resident recently, and weekly weights had not been recommended by the dietician or by the Physician. On 03/14/23 at 12:03 PM, an interview was conducted with the Registered Dietitian (RD) who stated that per documentation reviewed, resident requires assistance of staff for eating and has been consuming over 75% of the meals based on the data generated from the CNAAR. The RD also stated that they had never observed the resident eating during meals, and the first assessment and quarterly evaluation was done in December. The RD further stated that as per the assessment, resident was triggered for undesired weight loss, probably due to the worsened dementia, as at that time, it was documented that resident was consuming only about 25% of food. The RD stated that they planned to re-assess the resident at the next quarter, which is currently due. On 03/16/23 at 08:55 AM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1 who stated that monthly weight is done for a stable resident, and any resident observed with weight loss of 5% from the previous weight is reported to the dietician and the doctor so necessary intervention can be done. The resident's weight will be monitored weekly until the weight is stabilized. RNS #1 also stated that the dietician should have communicated the significant weight change of the resident to the doctor for new interventions to address the resident's weight loss. The RNS stated that they believe that the resident's weight loss was discussed with the dietician by nursing staff, but they did not know why the dietician had not implemented necessary interventions for the weight loss. On 03/15/23 at 12:47 PM, an interview was conducted with the Attending Physician (AP) #1 who stated that Resident #22 was seen regularly. Resident #22's labs were reviewed, the most recent labs were normal, and resident was stable metabolically. AP #1 also stated that Resident #22's weight loss is due to multiple comorbidities and the last time the resident was seen, the resident was talking, and was noted to be clinically stable. AP #1 was unable to explain why there was no documented evidence of any planned interventions to address the resident's significant weight loss. On 03/16/23 at 09:21 AM, an interview was conducted with the Director of Nursing (DON) who stated that if a resident is observed with significant weight loss, the nursing will notify the doctor and the dietician, calorie count will be recommended and ordered, and depending on the physician, the resident may be given appetite stimulant, and weekly weight monitoring. It will also be discussed by the interdisciplinary team. The DON stated the care plan must be updated by the dietician. The DON further stated that every discipline is required to update their care plan based on their assigned care areas. On 03/16/23 at 11:53 AM, an interview was conducted with the Medical Director (MD) who stated that when a resident is observed with significant weight loss, we ask dietary to see if we need to offer supplements and appetite stimulant, and to continue monitoring the weight weekly until the resident is stable. The MD also stated that based on the record review, the former dietician had documentation regarding the resident's weight loss in November last year but Resident #22's weight loss had not been properly followed up on by the current dietician and the Attending Physician. The MD further stated that they were surprised that this was not done and the issue will be discussed with the staff and the attending physicians to prevent reoccurrence. 415.15(b)(1)(i)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the Recertification survey conducted from 3/9/23 to 3/16/23, the facility did not ensure that a Medication Regimen Review (MRR) performed by the Consultant Pharmacist was reviewed and acted upon by the attending physician or medical director in a timely manner. This was evident for 2 of 5 residents (Resident #26 and Resident #71) reviewed for Unnecessary Medications Review out of a total sample of 38 residents. Specifically, 1). the physician did not act upon the consultant pharmacist's recommendations to attempt a gradual dose reduction (GDR) for residents receiving antidepressant medication, and 2). A pharmacy consultant recommendation for a Psychiatry consult to evaluate symptoms of depression and the therapeutic goals of Cymbalta was not completed. The findings are: The facility's policy and procedure titled Pharmacy Services with last revised date 2/2023 that the medication regimen of each resident must be reviewed at least once a month by licensed pharmacist. The pharmacist must report any irregularities to the Attending Physician, the facility Medical Director and the Director of Nursing and these reports must be acted upon. 1. Resident #26 was admitted to the facility with diagnosis of Depression, Non-Alzheimer's Dementia, and Diabetes Mellitus. The medical order initiated 2/9/22, renewed 2/14/23 documented resident to receive Cymbalta 1 capsule (20 mg) once daily at 10 AM and Cymbalta 1 capsule (60 mg) once daily at 10 PM for Major Depressive Disorder. Medical Order initiated 3/11/22 documented Mirtazapine 15 mg tablet once daily which was discontinued on 8/24/22. The medical order initiated 8/24/22, renewed 2/14/23 documented resident to receive Mirtazapine 7.5 mg tablet by oral route once daily at bedtime at 10 PM for major depressive disorder, recurrent, mild. The Medication Administration Record dated February and March 2023 documented Resident #26 received Cymbalta 1 capsule (20 mg) at 10 AM, Cymbalta 1 capsule (60 mg) at 10 PM, Mirtazapine 0.5 tablet (7.5mg) at 10 PM, during the entire month of February and to current date of March 2023. The pharmacy's Medication Regimen Review (MRR) dated 2/15/23 documented resident has two psychotropic medication orders (Cymbalta, Remeron) for at least 3-12 months that are now potentially due for a Gradual Dose Reduction (GDR) based on CMS guidelines. Recommended to evaluate if resident is a candidate for GDR and consider reduction in the total daily dose of either of the two psychotropic medication orders. The physician's response dated 2/16/23 documented to order a psychiatric consult and have psychiatrist evaluate if resident is a candidate for GDR. Review of the interdisciplinary notes from 2/16/23 to 3/13/23 revealed there was no documented evidence that resident was evaluated by psychiatrist for Gradual Dose Reduction for the two psychotropic medication orders. On 3/13/23 at 2:15 PM, Pharmacist was interviewed and stated that Resident #26 receives two antidepressant medications. Pharmacist stated last GDR recommendation was made back in August 2022 and it was agreed to decreased Remeron from 15 mg to 7.5 mg. Pharmacist stated the monthly pharmacy reviews are emailed immediately to Director of Nursing, Assistant Director of Nursing, Medical Director, and the Administrator. Pharmacy stated that another GDR was recommended for Resident #26's MRR dated 2/15/23. Pharmacist did not know if it was considered and ordered since March Medication Regimen Review was not done as of 3/13/23. On 3/14/23 at 10:56 AM, Attending Physician (AP #2) was contacted and stated that they will call back but did not return the call. On 3/15/23 at 11:05 AM, the Psychiatric Nurse Practitioner (PNP) was interviewed and stated that once they receive a referral, the referred resident will be seen and evaluated within 3 days of receiving referral. It is electronically submitted and recorded in the electronic medical record. The PNP also stated that Resident #26 was referred to evaluate capacity on 1/14/23 and the resident was seen/evaluated on 1/16/23 according to their record. The PNP further stated that there was no other pending consult for Resident #26 since 1/16/23. On 3/14/23 at 9:57 AM, the Medical Director (MD) was interviewed and stated that they also provide care for residents and was the physician responsible to review the MRR for month of February for Resident #26. The MD stated that they reviewed the pharmacist's recommendation on 2/16/23 and planned to discontinue Remeron for Resident #26. The MD further stated that it was an oversight and that Remeron was just discontinued as an attempt for GDR on 3/14/23. 2. Resident #71 was admitted to the facility with diagnoses that include Anxiety Disorder, Bipolar Disorder, and Major Depressive Disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #71 had severely impaired and received antidepressants on five of seven days. A Medical Doctor Order (MDO) dated 04/28/22 documented that Resident #71 was to receive Cymbalta 30 mg capsule, delayed release, give one tablet (30 mg) by oral route once daily for Anxiety Disorder. A Pharmacy Consultant Note to Attending Physician/Prescriber dated 10/5/22 documented that Resident #71 has been on their current dose of Cymbalta since 4/8/22 and recommended to order a psychiatric consult and have the psychiatrist evaluate if the resident symptoms of depression and therapeutic goals are being adequately met by their current dose of Cymbalta. An MDO dated 11/10/22 documented a psychiatric consult was ordered to evaluate if the resident symptoms of depression and therapeutic goals are adequately met by their current dose of Cymbalta. Review of the medical records dated 11/11/22 to 3/16/23 revealed no documented evidence that Resident # 71 had received a psychiatric evaluation. On 03/15/23 at 12:35 PM, an interview was conducted with the Psychiatric Nurse Practitioner (PNP). The PNP stated that they have not seen Resident # 71 since they started working in the facility in November of last year. The PNP had a referral to see the Resident #71, but there was no consent, so they could not see them. The consent is obtained from the family or the resident if the resident has the capacity. They need new consent for the new year. An order to evaluate the use of the Cymbalta was received on 1/15/23 and 2/22/23. The Director of Nursing has been informed about the PNP's need for consent before they can see Resident #71. On 03/16/23 at 11:39 AM, an interview was conducted with the Attending Physician #3 (AP #3). AP #3 stated that they signed off on the recommendation but were unaware that the psychiatric provider had not seen Resident #71. AP #3 was not sure what had happened. AP # 3 was not aware that the psychiatric provider was waiting for a consent. On 03/16/23 at 11:11 AM, an interview was conducted with the Medical Director (MD). The MD does not know why the psychiatrist has not seen Resident # 71. They use an agency for psychiatry and psychology consults. If the psychiatric provider needs consent, they are responsible for obtaining it themselves. Any specialist must obtain their consent. The MD did not know that the NP did not see the resident because of consent. The PNP should have informed them they were waiting for consent before seeing the resident. On 03/16/23 at 10:01 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they have a new PNP who started last year, in November. The PNP is asking for consent before they see the resident. The PNP informed them in January that they need consent for the resident. Resident # 71's Next of Kin (NOK) had been called about eleven times for a consent, but they had not yet responded. 415.18(c)(2)

Based on observations, record review, and staff interviews conducted during the Recertification survey from 3/9/23 to 3/16/23, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, blood pressure (BP) cuffs were not cleaned/disinfected after use between residents. This was evident for 2 out of 6 licensed nurses observed during the Medication Administration task. The findings are: The facility's policy and procedure titled Cleaning and Disinfecting of Non-critical Medical Devices dated 03/17/2011, last revised 02/2023 documented: disinfect the blood pressure machine/cuff before each resident use by cleaning the blood pressure/cuff and wiping it with germicidal wipes. Always wear gloves when using germicidal wipes. On 03/13/23 at 09:26 AM, while observing Medication Administration on the 6th Floor, Licensed Practical Nurse (LPN) #1 was observed assessing Resident #147's blood pressure (BP) with a wrist BP cuff without sanitizing the cuff prior to use. LPN #1 then placed the cuff on the medication cart without sanitizing it. At 09:33 AM, LPN #1 approached Resident #50 and proceeded to check the resident's BP with the same BP cuff which had not been sanitized after use on the previous resident. On 03/13/23 at 9:40 AM, LPN #1 was interviewed and stated that the cuff is supposed to be sanitized before use on other residents but they forgot to sanitize it. On 03/13/23 at 09:59 AM, LPN #2 was observed during Medication Administration for Resident #24 on the 5th floor. LPN #2 checked the resident's BP with a wrist BP cuff without sanitizing the cuff prior to use on Resident #24 and placed the BP cuff on the medication cart after use without sanitizing it. At 10:10 AM, LPN #2 moved on to Resident # 94 and proceeded to check the resident's BP with the same BP cuff without sanitizing the cuff. On 03/13/23 at 10:15 AM, LPN #2 was interviewed and stated that the cuff should be sanitized between residents use but was not sanitized because they were nervous. On 03/16/23 at 08:46 AM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1 who stated that the purple top sanitizer wipe is used to sanitize the BP cuff prior to use on the resident and in between resident's use. RNS #1 also stated that rounds are made around 5 times daily to monitor that staff are performing proper infection control practices while giving care to the residents and if any staff is observed not following proper protocol, in-service is given to ensure compliance. RNS #1 further stated that they have new nurses in the facility, and they will have to reinforce the education to ensure compliance. On 03/16/23 at 09:33 AM, an interview was conducted with the Director of Nursing (DON) who stated that the supervisors on the units are supposed to be monitoring the staff to ensure that the staff are practicing proper infection control. The DON also stated that they are surprised that the supervisors are not identifying these problems. The DON further stated that any staff observed not practicing the proper protocol is re-inserviced. 415.19 (b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #22 was admitted to the facility with diagnoses that included Coronary Artery Disease, Cerebrovascular Accident, Non-Alzheimer's Dementia, and Depression. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS documented the resident is required extensive assistance of staff for most activities of daily living including eating and that the resident holds food in mouth/cheeks. The Annual MDS dated [DATE] and Quarterly MDS dated [DATE] documented that Resident #22 had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months documented, and was not on a physician-prescribed weight-loss regimen. The Comprehensive Care Plan (CCP) for Nutritional Status dated 12/16/2013, last updated 2/17/2022, documented that Resident is on the therapeutic diet secondary to Significant weight, loss: x 3 months (~ -12.37%), 6 months (~-14.62%). Goals included: - Resident will be adequately nourished as evidenced by absence of significant weight loss; Resident laboratory report(s) will be clinically stable per MD. Resident will continue to consume >75% of meals served x 90 days. The Long Term Care Survey Process (LTCSP) weight calculator documented On 09/13/2022, the resident weighed 152 lbs. On 03/06/2023, the resident weighed 123 pounds which is a -19.08 % Loss. This weight loss occurred over a 6 month period. The LTCSP weight calculator also documented On 02/22/2023, the resident weighed 129.6 lbs. On 03/06/2023, the resident weighed 123 pounds which is a -5.09 % loss. This weight loss occurred over a 12-day period. Progress Notes Dietary dated 12/24/2022 documented: Quarterly Assessment: .Current nutritionally pertinent medication includes . mirtazapine, Prilosec. Note: Mirtazapine - may increase appetite. There are no current nutrition related labs.Current Wt:131.5 (12/5) Ht: 66 in. Past Weight: 126.6 lbs. (11/14), 138 lbs. (10/14), 138 lbs. (9/30), 157.8 lbs. (8/16), 157.4 lbs. (7/19), 156 lbs. (6/21), 154.2 lbs. (5/31). Current BMI: 21.2 - WNL - low for geriatric age. Continues to trigger for unplanned/undesirable weight loss in 3 months ~12.37% and 6 months ~14.62% There was no documented evidence that the nutrition care plan was reviewed and revised since 2/17/2022 after MDS assessments or to reflect the documented weight loss or interventions to address the weight loss. On 03/14/23 at 11:08 AM, an interview was conducted with the Certified Nursing Assistant (CNA) #1 who stated that Resident #22 had been noted with some weight loss when transferred to the unit a few months ago and this was reported to the nurse. On 03/14/23 at 11:41 AM, an interview was conducted with the Charge Nurse, Licensed Practical Nurse (LPN) #1 who stated that the Resident's meal intake is documented by the CNAs in the CNA Accountability Record (CNAAR). LPN #1 also stated that Resident #22 was noted with some weight loss when transferred to the unit. LPN #1 further stated that any weight loss is discussed with the dietician who is responsible for reviewing and updating the resident's nutrition care plan. On 03/14/23 at 12:03 PM, an interview was conducted with the Registered Dietitian (RD) #1 who stated that the first assessment and quarterly evaluation was done in December 2022. RD #1 stated that when the nurses document the weight in the electronic medical record, at the end of the month, it is checked, and the weight is put in the meal tracker to generate a report. When the meal tracker was checked at the end of January, no changes were identified with Resident 22's weight loss. RD #1 further stated that they had planned to re-assess the resident at the end of the next quarter, which is currently due, and then update the CCP. RD #1 stated that they were not aware that the resident's care plan should be updated at every assessment. On 03/16/23 at 08:55 AM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1. RNS #1 stated that monthly weight is done for a stable resident, and any resident observed with weight loss of 5% from the previous weight is reported to the dietician and then reported to the doctor for further intervention. The resident's weight will be monitored weekly until the weight is stabilized. RNS #1 stated that it is the responsibility of the dietician to update the nutrition care plan whenever there is significant weight change. RNS #1 further stated that they did not know that the resident's CCP for nutrition was not being updated. On 03/16/23 at 09:21 AM, an interview was conducted with the Director of Nursing (DON) who stated that if a resident is observed with significant weight loss, nursing staff will notify the doctor and the dietician. A calorie count will be recommended and ordered, and depending on the physician, the resident may be given appetite stimulant, and weekly weight monitoring. It will also be discussed by the interdisciplinary team. The DON also stated that the care plan must be updated by the dietician. The DON further stated that every discipline is required to update their care plan based on their clinical areas. 415.11(c)(2)(i-iii) Based on record review and interview conducted during the Recertification survey from 3/9/23 and 3/16/23, the facility did not ensure that resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Specifically, the Comprehensive Care Plans (CCPs) for residents with significant weight loss were not updated and revised. This was evident for 3 of 6 residents reviewed for Nutrition out of 38 sampled residents. (Residents #18, #17, and #22,). The finding is: The facility Policy for Comprehensive Care Planning dated 11/1997, last revised 01/2023 documented that A Comprehensive Care Plan for each resident shall be developed through an interdisciplinary team approach. A Comprehensive Care Plan (CCP) team has been established to review each resident's own unique personal needs in an integrated and coordinated manner. Reviews are conducted on initial admission, readmission, hospital return, significant change of status and quarterly thereafter. 1. Resident #18 was admitted to the facility with diagnoses including Coronary Artery Disease and Dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #18 was severely cognitively impaired, had a weight loss of 5% or more in the last month or a loss of 10% over the previous six months, and was not on a physician prescribed weight loss program. A Dietary Progress Note dated 10/12/22 at 1:16 PM documented that Resident #18 was triggered for undesired/unplanned significant weight loss for three months. The Quarterly MDS assessment dated [DATE] documented that Resident #18 was severely cognitively impaired, had a weight loss of 5% or more in the last month or a loss of 10% in the previous six months, and was not on a physician prescribed weight loss program. The Dietary Progress Note dated 12/28/22 documented that Resident #18 is triggered for unexpected/undesirable significant weight loss for six months. There was no documented evidence that the CCP for nutrition had been reviewed and revised after the MDS assessments on 10/7/22 and 12/30/22 which indicated that resident had a significant weight loss. 2. Resident #71 was admitted to the facility with diagnoses that include Anxiety Disorder, Bipolar Disorder, and Dementia The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident # 71 was severely cognitively impaired, had a weight loss of 5% or more in the last month or a loss of 10% over the previous six months, and was not on a physician prescribed weight loss program. A Dietary Note dated 10/8/22 at 12:59 PM documented that Resident #71 is triggered for undesired/unplanned significant weight loss x 3 month. The Quarterly MDS assessment dated [DATE] documented that Resident #71 was severely cognitively impaired, had a weight loss of 5% or more or loss of 10% or more in last 6 months and was not on a physician-prescribed weight-loss regimen. A Dietary Progress Note dated 12/27/22 at 2:04 PM documented that Resident #71 weight loss is possibly related to disease progression. A Comprehensive Care Plan titled Nutrition Status was initiated on 2/28/17 and was last revised on 2/10/22. There was no documented evidence that the CCP for nutrition had been reviewed and revised when resident was identified with significant weight loss and after MDS assessments on 10/1/22 and 12/21/22. On 03/15/23 at 2:45 PM, an interview was conducted with the Registered Dietician (RD) who stated that care plans are updated after every assessment and when there is a significant nutritional change. The RD also stated Resident #71 was triggered for significant weight loss, so the care plan was updated on 3/13/23 with no new interventions added. On 03/16/23 at 9:55 AM, an interview was conducted with the Director of Nursing (DON) who stated that the Dietician is responsible for updating the nutrition care plan. The DON also stated that the regional consultant is responsible for overseeing the Dietician and the care plans are supposed to be updated every quarter, and after a significant change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during the recertification survey, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected the resident's current medical status. Specifically, a resident who had been on hemodialysis 3 times per week since 07/18/19 was not coded as a dialysis resident. This was evident for 1 of 38 sampled residents (Resident # 115). The finding is: Resident #115 had diagnoses which include End Stage Renal Disease. The MDS assessment dated [DATE] did not identify that the resident was receiving dialysis. Section O (Special Treatments, procedures, and programs), item J was left bank. The Physician's orders, initiated 7/18/19 and last renewed 2/16/20, documented orders for Hemodialysis 3 times per week on Monday-Wednesday-Friday. The Comprehensive Care Plan for Renal Function/End Stage Renal Disease dated 7/18/19 documented that the resident is on hemodialysis 3 times per week. On 02/25/20 at 12:17 PM, an interview conducted with the Registered Nurse (RN # 6) who completed the MDS. She stated that maybe that section of the MDS was overlooked. When she completes the assessment, she reviews the medical record from the last review date and the previous MDS for changes. She stated that the dialysis was not captured. It was an oversight. 415.11 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility policy and procedure for Accident/Incident Reporting dated 02/2020 documented the following: It is the policy of the facility to promote resident safety through staff education and provide a safe environment by identifying and eliminating risk without compromising independence. The facility shall ensure the that environment remains free of accident hazards as possible and each resident receives adequate supervision. All accidents/falls must be reported to the nurse or physician and their family member as soon as possible. The facility policy and procedure for accident/incident further documented that the Certified Nursing Assistant (CNA) must notify a charge nurse of any fall or accident immediately. The Registered Nurse (RN) must respond immediately and remove the resident from danger and/or assure resident safety. The RN should assess the resident's condition, render emergency treatment, and notify the nursing supervisor and physician. Resident #71 was admitted with diagnoses which include Dementia, Parkinson's disease, and Cerebrovascular Accident (CVA). The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had moderately impaired cognition (Brief interview of Mental Status score 9 out of 15). The resident had unclear speech and usually understands and sometimes understood. The MDS further documented the resident required the total assist of two persons for transfers. The MDS documented the resident did not ambulate and required total assist for locomotion on the unit. The resident weighed 147 pounds (lbs). On 02/25/20 at 09:59 AM, Resident #71 was observed in bed fully dressing with divider in between the legs, left and right-hand rolls in place, bilateral heel pads in place. On 02/26/20 at 12:15 PM, the resident was observed sitting in a lounge chair in the dining room with a divider cushion in between the legs, bilateral hand rolls, and bilateral heel floats in place. The Comprehensive Care Plan (CCP) for Falls, effective 02/07/14 and last reviewed 01/02/20, documented the resident was at risk for falls secondary to vision impairment, impaired memory/cognition, and gait/balance problems. The CCP included the intervention to provide assistance with Activities of Daily Living (ADLs). The CCP for ADLs: All Tasks, effective 02/07/2014 and last reviewed 01/02/20, documented the resident was dependent on staff for transfer, bathing, toileting, and dressing. The CCP included the intervention to use the Hoyer-lift properly and according to the manufacturer's operating manual. The Certified Nursing Assistant Accountability Record (CNAAR) dated December 2019 documented that the resident required total assist of 2 persons using a Hoyer lift for transfers. On 12/29/19, the CNA documented that the resident was provided with total assist of 2 persons for transfer and physical help of two persons for bathing. The CNA assignment sheet dated 12/29/19 documented CNA #1 was assigned to Resident #71 on the evening shift. A Nursing Note dated 12/29/19 at 10:30pm, documented that the charge nurse was called to the unit because when CNA #1 was providing care, pain was noted during movements of the right hip. Per the CNA, no pain was observed when she transferred the resident back to bed at 4:30pm. The resident was assessed, and the resident's pain increased during movement/turning. The resident had a pained facial expression described as a 6 out of 10 on the [NAME] pain scale. There was no bruise/discoloration/swelling on the right hip. The resident was asked what happened using staff as an interpreter, and the resident replied, I don't know. The Nurse Practitioner was notified, and orders for an X-ray to bilateral hips secondary to pain to r/o (rule out) fracture and Tylenol 1000mg PO (by mouth) x 1 dose were obtained. The Radiology report dated 12/30/19 documented x-rays of the right hip and femur were done, and the results showed a mildly displaced intertrochanteric fracture. On 12/30/19, Progress notes documented that the primary doctor was notified of R hip x-ray results and ordered hospital transfer for eval of fracture. The resident returned to the unit at 11 PM. The hospital discharge summary recommended toe touch weight-bearing on the right leg, pain control, avoid pressure to the Right hip, and follow up in 3-4 weeks. The resident was placed on bedrest as of 12/31/19. The Accident/Incident CNA Statement dated 12/29/19, written by CNA #1, documented the CNA noticed the resident had facial grimacing when she provided incontinent care around 10:30 PM. The CNA documented she transferred the resident to bed alone, using the Hoyer lift, around 4pm. The Accident/Incident Report Nursing Supervisor Investigation form dated 12/29/19 documented there was reasonable cause to believe abuse, mistreatment, or neglect occurred, and the Director of Nursing (DON) was informed. The Investigation Summary, written by the DON, dated 12/31/19 documented the case was reported to NYSDOH. CNA #1 was suspended for 3 days and reassigned to another unit because she used the Hoyer lift to transfer the resident alone. Staff were also given in-services on Hoyer lift transfers and Abuse Prevention and Prohibition. On 02/26/20 at 12:10 PM, the CNA #1 was interviewed via telephone. She stated that she transferred the resident safely to the bed alone. CNA #1 denied any fall or accident/incident (A/I) occurred with the resident during the transfer. She further stated that there four CNAs assigned to the unit during that evening, and the unit was not short-staffed. She stated that she transferred Resident #71 by herself using the Hoyer lift in the past. She stated that was a poor judgement on her part. She received numerous in-services on safely transferring residents via Hoyer lift, but she still practiced poor judgment. On 02/25/20 at 11:05 AM, an interview was conducted with the DON. The DON stated that she investigated the case the same day it was reported to her. CNA #1 reported to the nurse that Resident #71 complained of pain during positioning. The charge nurse assessed the resident and reported it to the NP. The NP ordered 2 tablets of Acetaminophen, which was given to the resident. The resident was examined by the NP/MD, and after the X-ray results showed a right hip fracture, the resident was transferred to the hospital. The DON stated that CNA #1 was suspended for 3 days for transferring the resident to bed without assistance on 12/29/19, using the Hoyer lift. The DON stated that she reported this incident/accident to DOH on 12/31/2019. 415.11(c)(1) Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure a comprehensive person-centered care plan for each resident, consistent with needs identified in teh comprehensive assessment, was developed and implemented. Specifically, (1) there was no care plan developed for a resident with Limited Mobility to bilateral lower extremities; (2) and a resident who required a Hoyer lift with 2-person assist for transfers was tranferred with one person. This was evident for 2 of 38 sampled residents (Resident #57 and Resident #71). The findings are: 1) Resident # 57 had diagnoses which include Generalized Osteoarthritis and Depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident required total assistance with transfer and toilet use, and extensive assistance with bed mobility, dressing, and personal hygiene. The MDS also documented that resident had Range of Motion (ROM) impairment of the lower extremities. The Physician's Order dated 12/18/19 documented orders for Active Range of Motion (AROM) on Bilateral Upper Extremities and Passive Range of Motion (PROM) on Bilateral Lower Extremities for 5-6 times per week for 15 minutes. On 2/26/20, a review of the Comprehensive Care Plan revealed there was no documented evidence that a CCP was developed for to address the care needs for ROM limitations. On 02/27/20 11:18 AM an interview was conducted with the Charge Nurse (RN #3). She stated that she was responsible for developing and updating the care plan, however, she started here not too long ago. She was unable to explain reason why the care plan was missed. The charge nurse also stated that she did not know the resident was receiving ROM services. 02/27/20 at 11:32 AM, an interview was conducted with RN #4, a supervisor. She stated that she was responsible for ensuring residents with nursing rehab receive services. She also described nursing rehab protocol as follows: Once a resident has completed their rehab services, the rehab staff will notify her if there is a need to continue nursing rehab. The rehab director will create an order and in-service the C.N.A. on what to do. The charge nurse is responsible for ensuring that the orders for ROM exercises are carried out. Based on observation, record review and interview conducted during the Recertification survey and abbreviated survey (NY00250178), the facility did not ensure that a resident received adequate supervision to prevent accidents. Specifically, a resident who required a Hoyer lift with 2-person assist for transfers was transferred with one-person assist. The resident sustained a hip fracture. This was evident for 1 out of 4 residents reviewed for accidents within a total sample of 39 (Resident #71). The findings are: The facility policy and procedure for Accident/Incident Reporting dated 02/2020 documented the following: It is the policy of the facility to promote resident safety through staff education and provide a safe environment by identifying and eliminating risk without compromising independence. The facility shall ensure the that environment remains free of accident hazards as possible and each resident receives adequate supervision. All accidents/falls must be reported to the nurse or physician and their family member as soon as possible. The facility policy and procedure for accident/incident further documented that the Certified Nursing Assistant (CNA) must notify a charge nurse of any fall or accident immediately. The Registered Nurse (RN) must respond immediately and remove the resident from danger and/or assure resident safety. The RN should assess the resident's condition, render emergency treatment, and notify the nursing supervisor and physician. Resident #71 was admitted with diagnoses which include Dementia, Parkinson's disease, and Cerebrovascular Accident (CVA). The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had moderately impaired cognition (Brief interview of Mental Status score 9 out of 15). The resident had unclear speech and usually understands and sometimes understood. The MDS further documented the resident required the total assist of two persons for transfers. The MDS documented the resident did not ambulate and required total assist for locomotion on the unit. The resident weighed 147 pounds (lbs). On 02/25/20 at 09:59 AM, Resident #71 was observed in bed fully dressing with divider in between the legs, left and right-hand rolls in place, bilateral heel pads in place. On 02/26/20 at 12:15 PM, the resident was observed sitting in a lounge chair in the dining room with a divider cushion in between the legs, bilateral hand rolls, and bilateral heel floats in place. The Comprehensive Care Plan (CCP) for Falls, effective 02/07/14 and last reviewed 01/02/20, documented the resident was at risk for falls secondary to vision impairment, impaired memory/cognition, and gait/balance problems. The CCP included the intervention to provide assistance with Activities of Daily Living (ADLs). The CCP for ADLs: All Tasks, effective 02/07/2014 and last reviewed 01/02/20, documented the resident was dependent on staff for transfer, bathing, toileting, and dressing. The CCP included the intervention to use the Hoyer-lift properly and according to the manufacturer's operating manual. The Certified Nursing Assistant Accountability Record (CNAAR) dated December 2019 documented that the resident required total assist of 2 persons using a Hoyer lift for transfers. On 12/29/19, the CNA documented that the resident was provided with total assist of 2 persons for transfer and physical help of two persons for bathing. The CNA assignment sheet dated 12/29/19 documented CNA #1 was assigned to Resident #71 on the evening shift. A Nursing Note dated 12/29/19 at 10:30pm, documented that the charge nurse was called to the unit because when CNA #1 was providing care, pain was noted during movements of the right hip. Per the CNA, no pain was observed when she transferred the resident back to bed at 4:30pm. The resident was assessed, and the resident's pain increased during movement/turning. The resident had a pained facial expression described as a 6 out of 10 on the [NAME] pain scale. There was no bruise/discoloration/swelling on the right hip. The resident was asked what happened using staff as an interpreter, and the resident replied, I don't know. The Nurse Practitioner was notified, and orders for an X-ray to bilateral hips secondary to pain to r/o (rule out) fracture and Tylenol 1000mg PO (by mouth) x 1 dose were obtained. The Radiology report dated 12/30/19 documented x-rays of the right hip and femur were done, and the results showed a mildly displaced intertrochanteric fracture. On 12/30/19, Progress notes documented that the primary doctor was notified of R hip x-ray results and ordered hospital transfer for eval of fracture. The resident returned to the unit at 11 PM. The hospital discharge summary recommended toe touch weight-bearing on the right leg, pain control, avoid pressure to the Right hip, and follow up in 3-4 weeks. The resident was placed on bedrest as of 12/31/19. The Accident/Incident CNA Statement dated 12/29/19, written by CNA #1, documented the CNA noticed the resident had facial grimacing when she provided incontinent care around 10:30 PM. The CNA documented she transferred the resident to bed alone, using the Hoyer lift, around 4pm. The Accident/Incident Report Nursing Supervisor Investigation form dated 12/29/19 documented there was reasonable cause to believe abuse, mistreatment, or neglect occurred, and the Director of Nursing (DON) was informed. The Investigation Summary, written by the DON, dated 12/31/19 documented the case was reported to NYSDOH. CNA #1 was suspended for 3 days and reassigned to another unit because she used the Hoyer lift to transfer the resident alone. Staff were also given in-services on Hoyer lift transfers and Abuse Prevention and Prohibition. On 02/26/20 at 12:10 PM, the CNA #1 was interviewed via telephone. She stated that she transferred the resident safely to the bed alone. CNA #1 denied any fall or accident/incident (A/I) occurred with the resident during the transfer. She further stated that there four CNAs assigned to the unit during that evening, and the unit was not short-staffed. She stated that she transferred Resident #71 by herself using the Hoyer lift in the past. She stated that was a poor judgement on her part. She received numerous in-services on safely transferring residents via Hoyer lift, but she still practiced poor judgment. On 02/25/20 at 11:05 AM, an interview was conducted with the DON. The DON stated that she investigated the case the same day it was reported to her. CNA #1 reported to the nurse that Resident #71 complained of pain during positioning. The charge nurse assessed the resident and reported it to the NP. The NP ordered 2 tablets of Acetaminophen, which was given to the resident. The resident was examined by the NP/MD, and after the X-ray results showed a right hip fracture, the resident was transferred to the hospital. The DON stated that CNA #1 was suspended for 3 days for transferring the resident to bed without assistance on 12/29/19, using the Hoyer lift. The DON stated that she reported this incident/accident to DOH on 12/31/2019. 415.12(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews conducted during the re-certification survey, the facility did not ensure a resident with limited range of motion received treatment and services to increase and/or to prevent further decrease in range of motion. Specifically, a resident with physician's orders for Range Of Motion (ROM) exercises to Bilateral Upper Extremities 5-6 times per week for 15 minutes and Bed mobility exercises 6 times per week for 15 minutes were not provided. This was evident for 1 of 2 residents reviewed for Limited Range of Motion (Resident #57). The finding is: The facility policy and procedure titled Specific protocols and Guidelines for performing Range of Motion (ROM) dated 2/2019 documented that the Active Range of Motion exercise (AROM) is conducted by staff giving directions, cues, and/or demonstration to residents. The Passive Range of Motion (PROM) exercise is performed by staff moving resident extremities as tolerated. The policy also documented that the Physical or Occupational therapists should be consulted for instructions/clarification on movements not described in the policy guidelines. Resident # 57 had diagnoses which include Generalized Osteoarthritis and Depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident required total assistance with transfer and toilet use, and extensive assistance with bed mobility, dressing, and personal hygiene. The MDS also documented that resident had Range of Motion (ROM) impairment of the lower extremities. On 02/24/20 at 10:56 AM, during the initial visit to the resident, the resident was observed in bed, alert and awake with intact memory. The resident reported that staff had stopped performing bedside exercises. She stated that she is no longer receiving exercise on her extremities. She further stated that two rehab staff used to come and give her exercises while in bed, but that is not happening again. The resident was asked if she received hand and leg exercises from the Certified Nursing Assistant (C.NA), she replied, no. The resident stated she does not want to get out of bed, but she needs exercise on her extremities to prevent contractures. The Physician's Order dated 12/18/19 documented the following: Active Range of Motion (AROM) on Bilateral Upper Extremities and Passive Range of Motion (PROM) on Bilateral Lower Extremities for 5-6 times per week for 15 minutes. Bed mobility exercises 6 times per week for 15 minutes. A review of Certified Nursing Assistant (CNA) Documentation History Detail, dated from 12/18/19 to 2/26/19 documented the following: Nursing Rehab AROM/PROM. The CNA record also documented that the AROM/PROM exercises were provided and resident well tolerated. On 02/26/20 at 10:53 AM, an interview was conducted with CNA #4. She stated she has been taking care of the resident for over a year now. She stated that she does not perform ROM on the resident because, a while back, the resident began refusing ROM. The resident will only allow her to rub her lower legs with lotion. She further stated that the resident preferred the rehab staff to assist her with ROM exercises. CNA #4 stated she never informed the charge nurse that the resident was refusing ROM exercises. On 02/26/20 at 11:19 AM, an interview was conducted with the Director of Rehab, who stated that the resident was discharged to nursing rehab a while ago. He also stated that after residents is discharged from rehab, a notice is sent to the nursing, indicating that the resident needs nursing rehab services. In-service will also be provided to the CNAs on how to perform ROM exercises on residents. The rehab director stated the resident refused to transfer out of bed to wheelchair in order to be able to receive additional rehab services. The resident preferred to do the exercises in bed. As a result, we had to discharge the resident from our program to nursing rehab. He stated that the nursing staff were made aware through the weekly meeting. On 02/27/20 at 11:18 AM, an interview was conducted with the Charge Nurse (RN #3) who stated that she was not aware the resident refused ROM services. When she was asked about the protocol for nursing rehab for residents with contractures and limited range of motion exercises, she was unable to explain. She stated that she is a new nurse on the unit. 02/27/20 at 11:32 AM, an interview was conducted with RN #4, a supervisor. She stated that she was responsible for ensuring residents with nursing rehab receive services. She also described nursing rehab protocol as follows: Once a resident has completed their rehab services, the rehab staff will notify her if there is a need to continue nursing rehab. The rehab director will create an order and in-service the C.N.A. on what to do. The charge nurse is responsible for ensuring that the orders for ROM exercises are carried out. 415.12(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during an survey the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices that were complete and accurately documented for each resident. Specifically, Nursing Staff documented completion of Range of Motion exercises on several occasions in the medical record when they were not being provided. This was evident for 1 of 2 residents reviewed for Limited Range of Motion (Resident #57) The finding is. Resident # 57 had diagnoses which include Generalized Osteoarthritis and Depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident required total assistance with transfer and toilet use, and extensive assistance with bed mobility, dressing, and personal hygiene. The MDS also documented that resident had Range of Motion (ROM) impairment of the lower extremities. On 02/24/20 during the initial visit to the resident, the resident was observed in bed, alert and awake with intact memory. The resident reported that staff stopped performing bedside exercises with her for a while She further stated that two rehab staff used to come and give her exercises while in bed, but that is not happening again. When the resident was asked if she received hand and leg exercises from the CNA, she replied, no. The resident stated she does not want to get out of bed, but she needs exercise on her legs to prevent further contractures. The Physician's Order dated 12/18/19 documented the following: Active Range of Motion (AROM) on Bilateral Upper Extremities and Passive Range of Motion (PROM) on Bilateral Lower Extremities for 5-6 times per week for 15 minutes. Bed mobility exercises 6 times per week for 15 minutes. A review of Certified Nursing Assistant (CNA) Documentation History Detail, dated from 12/18/19 to 2/26/19 documented the following: Nursing Rehab AROM/PROM. The CNA record also documented that the AROM/PROM exercises were provided and resident well tolerated. On 02/26/20 at 10:53 AM, an interview was conducted with CNA #4. She stated she has been taking care of the resident for over a year now. She stated that she does not perform ROM on the resident because, a while back, the resident began refusing ROM. She stated that resident has been refusing ROM for a long time. She acknowledged that the documentation on the C.N.A accountability was incorrect, and it was an error. 415.22(a)(1,2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey the facility did not ensure that a resident received necessary services to prevent new ulcers from developing. Specifically, a resident with a physician's order for heel lifts while in bed was observed on multiple occasions without heel lifts in place. This was evident for 1 of 3 residents reviewed for Pressure Ulcer/Injury out of a total sample of 41 residents (Resident #39). The finding is: Resident #39 is severely cognitively impaired with a diagnosis of Alzheimer's disease and a history of facility acquired unstageable pressure ulcers (PU) to bilateral heels. The resident's most recent Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had no unhealed PUs, and the resident is at risk for developing PUs. On 11/15/18 at 9:10 AM and 11/16/18 at 9:38 AM, Resident # 39 was observed sleeping in bed. On both occasions, there were no heel lifts or heel booties observed on the resident's feet or in the resident's room. On 11/19/18 at 3:07 PM the charge nurse for the unit, Registered Nurse (RN) #1, was present when SA observed that there were no heel lift devices present in the resident's room or personal closet. The Pressure Ulcer Comprehensive Care Plan (CCP) dated 8/14/18 documented Resident #39 has a potential for alteration in skin integrity as the result of having a history of PUs on bilateral heels. The right heel PU was resolved on 5/29/18 and the left heel PU was resolved on 8/14/18. Interventions included assessing resident, identifying risk factors using the Braden Scale, initiating protocol for PU treatment upon identification of PU, skin care daily, and skin checks every shift. The Impaired Skin Integrity CCP initiated 2/6/14 and most recently updated on 11/8/18 documented the resident was at high risk for skin breakdown due to impaired mobility, incontinence, and fragile skin. Interventions included administering medications and treatments as ordered, Certified Nursing Assistant (CNA) evaluation of skin condition daily, and completion of the Braden Scale. A Nursing Note dated 8/14/18 documented the resident's left heel PU had healed. The resident had very fragile skin and the heel lift order was to be continued. The Physicians Orders, renewed on 11/1/18, documented that the resident is to have bilateral heel lifts when in bed. This order was originated on 3/6/18. The Braden Scale initiated on 11/7/18 documented the resident as having a score of 13 indicating that the resident is at moderate risk for PU development. The resident's risk factors include very limited sensory perception, occasionally moistness, being chairfast, having very limited mobility, and friction and shearing. A review of the resident's Medication Administration Record (MAR), Treatment Administration Record (TAR), and CNA Documentation Record for the month of 11/2018 do not document the physician's order for bilateral heel lifts while in bed. An interview was conducted with the resident's CNA, CNA #1, on 11/19/18 at 11:58 AM. CNA #1 has worked for the facility for 8 months and with resident #39 for approximately 2 months. The resident requires total assistance with all activities of daily living. She usually takes the resident out of bed later in the morning, and the resident usually does not go back to bed throughout the day unless she has an accident or bowel movement. CNA #1 was aware the resident has a wedge cushion for positioning while in bed, but she was not aware of any other devices or equipment ordered for resident while she is in bed. CNA #1 is also unaware of the resident having any skin conditions or history of PUs. The resident is provided with lotion every day and periguard to the feet, sacrum, and groin area as preventative measures to ensure that her skin remains in good condition. The CNA is made aware of all devices and equipment orders for the resident by looking at her chart on the computer and by looking at what devices are currently present in her room. If the CNA notices that a device has been ordered for the resident but is not in her room, CNA #1 will let the nurse know. CNA #1 is aware of what heel booties are but was unsure of what would be considered heel lifts. On 11/19/18 at 2:54 PM, an interview was conducted with the charge nurse for the unit, RN #1. She has worked in the facility and on the resident's unit for approximately 8 months. RN #1 is aware that Resident #39 had a PU on her heel but states that it was healed. The resident continues to have a pressure relieving mattress. She had a physician's order for heel booties, but they were no longer needed since the resident's wounds have been resolved. Upon checking the resident's chart and reviewing the current Physician's Orders, RN #1 stated that the resident does have an order for bilateral heel lifts while in bed. RN #1 stated that heel lifts differ from heel booties. According to RN #1, heel lifts are made of foam and have circular cutouts so that when it is placed under the resident's heels, there is less pressure on the area while sleeping. The CNA is responsible for putting the heel lift in place for the resident. The charge nurse at night should do a visual check to ensure that devices are in place. RN #1 stated that she was not aware of whether the heel lifts and/or booties were documented on any type of accountability or treatment record. The physician's order for a device is only documented under instructions for the CNA but there is no area for the CNA to sign that it is present and being used. After observing that there were no heel lifts in the resident's room, the RN stated that she would contact the Rehabilitation (Rehab) Department to obtain a new device. An interview was conducted with the Director of Rehabilitation (DOR) on 11/20/18 at 10:27 AM. The DOR stated that the wound care nurse will recommend that a pressure relieving device, such as heel lifts, are needed for a resident. The wound care nurse will then secure an order from the Medical Doctor (MD), fill out an interim communication sheet and collaborate with the rehab department to ensure that the device is distributed. The Rehab Department will clarify the order to ensure that the device has been issued but does not complete an actual Rehab Assessment. Heel lifts are actually heel booties, which are cushioned individual booties that cover the entire foot and heel area and that are held in place with a Velcro strap. The facility does not have a separate device identified as heel lifts and does not utilize a foam device with heel impressions in them. The CNA accountability record is utilized to ensure that devices are in place. Part of the facility's Quality Assurance and Performance Improvement (QAPI) plan is that the Rehab Department checks the physician's monthly orders on a regular basis and ensures that the device that is ordered for the resident is in place and being utilized. The Rehab Department is not responsible for monitoring the presence and usage of heel lifts. On 11/20/18 at 12:04 PM, an interview was conducted with RN/Wound Care Nurse, RN #2. RN #2 has worked in the facility for approximately 6 years. Any pressure relieving devices ordered for a resident (heel booties/lifts) are documented on the CNA Documentation Record; and, the CNAs are the primary staff that are responsible for tracking the devices and ensuring that they are in place. The CNA would be the one to report any missing devices to the charge nurse. As of right now, there is no formal log or schedule for audits/spot-checks of pressure relieving devices. Spot-checks for pressure relieving devices are done sporadically, and there is no set schedule. Most of the time, the charge nurses on the unit are responsible for conducting spot-checks. 415.12(c)1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records reviewed, and interviews conducted during the refortification survey, the facility did not ensure that the residents who were assessed for elopement risk were adequately supervised. Specifically, Resident #33 was not provided with wander guard according to the physician order. In addition, there was no proper documentation by the Certified Nursing Assistant (CNA) in the resident's CNA documentation Record indicating that the resident's wander guard is in place and being monitored by staff to prevent accident, unsafe wandering and/or elopement. This was evident for 1 of 2 residents reviewed for accident/elopement risk out of a Sample of 41 residents. The Findings are: The facility's policy and procedure for Prevention of Elopement and Unsafe Wandering dated 6/2018 documented: Once determined as at risk for elopement, the resident' at risk for elopement status is reflected on the resident's clinical record. i.e. progress notes. MD/NP will be notified and an order for Watchmate (wander guard) will be obtained. The policy also stated that Watchmate is placed on resident's wrist or ankle and that the Watchmate is checked to ensure its functioning before placement. The Policy further stated that the CNA instructions is updated to reflect the placement of Watchmate; The CNA checks the placement of the Watchmate every shift, if found missing, it must be reported to the nurse using the stop and watch form and must be replaced immediately. The Resident Accountability form/Census is completed by the CNA each shift. Resident #33 is [AGE] years old admitted to the facility on [DATE]. Active diagnoses include Hypertension, Diabetes Mellitus, Non-Alzheimer's Disease, Seizure Disorder, Schizophrenia. On 11/14/18 at 10:20 AM, and 11:17 AM, the State Surveyor observed Resident #33 wandering around the floor and toward the exit door, and at 11:19 AM, towards the elevator doors. The resident appeared confused and was unable to engage in conversation with the State Surveyor. There was no wander guard observed either on the ankles or wrists. There was no staff monitoring resident at this time 1 staff was observed in the day room and other staff were observed providing care for residents in their rooms. On 11/15/18 from 11:211 AM to 11:31 AM the resident was also observed wandering in the elevator and on the unit unsupervised with no wander guard in place. On 11/16/18 at 10:30 AM Resident was observed wandering in the hall-way - unsupervised, noted with wet pant. No wander guard observed on the resident. The Quarterly Minimum Data Set (MDS) - Version 3.0, dated 08/16/2018 documented that the resident cognitive status is moderately impaired, on antipsychotic medication. The MDS also indicated that resident is occasionally incontinent of bowel and bladder. The MDS further indicated that the resident requires supervision for Bed mobility, transfer, walk in room/corridor, Locomotion on/off unit, and eating, and is extensive assistance of 1 staff for dressing, toilet use, personal hygiene, and bathing. No wandering behavior documented on MDS. The revised Comprehensive Care Plan (CCP) dated 12/27/2016 documented elopement as an identified risk as evidenced by resident observed wandering to another floor. Watchmate (wander guard) in place and functioning. The revised (CCP ) for elopement dated 05/03/2017 documented that resident's Elopement risk assessment score is 10. Watchmate intact. Physician's Order - original date 03/08/2018, renewed date 11/15/2018 documented that resident has Watchmate secondary to risk for elopement; Modes of Locomotion: Ambulation On and Off Unit without Assistive Device, with Supervision; Regular chair on and off unit. The revised elopement care plan dated 08/04/2018 documented that resident is at risk for elopement, noted with behavior of wandering, and has Wander guard in place. Review of Nursing behavior/elopement monitoring notes between 11/01/2018 and 11/16/2018 documented that resident continues to wander and is being re-directed by staff. There is no documentation that resident's wander guard is checked. There is also no documentation that resident has ever been observed removing the wander guard. The revised elopement care dated 11/05/2018 documented that the resident is at risk for elopement, continue to wander in hallway, redirected as needed. There was no documentation that resident has wander guard in place. A review of the Resident CNA Documentation Records dated between 11/01/2018 and 11/16/2018 did not indicate that the resident's wander guard was checked for placement and functionality. There is no documentation that the wander guard was being monitored by CNA every shift. On 11/16/18 at 12:30 PM the CNA #3 was asked if resident had wander guard. CNA #3 checked both wrists and ankles. No wander guard was found. On 11/16/18 at 12:42 PM an interview was conducted with CNA #3. CNA #3 stated that sometimes resident removes the wander-guard, but could not recall the the last time the wander guard was observed on the resident. CNA stated that there is no place to document the wander-guard placement in the CNA accountability record, and that they just report to the nurse if the wander guard is not found on the resident. On 11/19/18 at 09:33 AM an interview was conducted with the Licensed Practical Nurse LPN #1. LPN #1 stated that the resident sometimes wander around to other floor and is always re-directed by the staff. LPN stated that Wander guard should be checked every shift by the CNA and to report to the charge nurse if not found on the resident. LPN further stated that the resident likes to take it off and hide it sometimes and also stated that the wander guard monitoring is documented in the CNA accountability record every shift. On 11/19/18 at 12:35 PM an interview was conducted with the social worker SW #5. SW stated that the resident is always seen in the nursing station and is constantly monitored and re-directed if noted with inappropriate behavior like putting on dirty cloth or putting on shoes incorrectly. SW also stated that the resident follows direction most of the time, and that the resident was moved to a private room on the unit because he was not getting on with other residents on the previous unit where he was sharing a room. 415.12(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that nutrition and hydration were provided in a manner consistent with the resident's assessment. Specifically, a resident with a physician's order for a chopped diet and for adaptive dietary devices (a sippy cup and lip plate) during meal times was observed on multiple occasions with a regular consistency diet and without the dietary devices in place. This was evident for 1 of 8 residents reviewed for Nutrition out of a sample of 41. (Resident #110) The findings are: Resident #110 has severely impaired cognition and is diagnosed with Alzheimer's diseases, cerebral vascular accident (CVA), and hemiplegia. The most recent Annual Minimum Data Set (MDS) dated [DATE] documents that the resident requires the extensive assistance of one person for eating and requires a mechanically altered diet. On 11/16/18 at 12:42 PM, Resident #110 was observed in the Floor Day Room (FDR) with his lunch tray in front of him. The resident's meal ticket on his tray listed that the resident is to receive chopped fish, chopped cornbread, sippy cup, and lip plate. The resident was observed to have a full filet of fish on his tray and a large square piece of cornbread. No sippy cup or lip plate was observed on the resident's tray. The resident was observed picking up full fish filet with his hands and biting into it. The fish tore apart in the resident's hands and was left hanging out of his mouth while he attempted to chew it. After several minutes, an aide was observed going to the resident and using a knife to chop up the cornbread on the resident's tray. On 11/19/18 at 12:39 PM, the resident was again observed with no sippy cup or lipped plate present. A standard circular plate and plastic cup with a straw was present on the tray. The Physician's Orders for Resident #110 and renewed on 11/13/18 document that the resident is to receive a chopped consistency diet and nectar thickened liquids with meals. The Rehab Orders list that the resident is to use a lip plate and sippy cup for each meal. The resident's Nutrition Comprehensive Care Plan (CCP) active since 10/2/13 and last updated on 10/05/18 document that the resident is on a chopped diet with nectar thick liquids and requires a mechanically altered diet due to impaired swallowing related to diagnosis of CVA. An undated list of Special Devices - Delivery and Pickup Sign Sheet lists Resident #110 as having a sippy cup and lip plate ordered. The CNA Documentation Record - Resident Nursing Instructions for 11/2018 documents under Eating/Toileting that the resident has a chopped consistency diet and requires lip plate and sippy cup for each meal. An interview was conducted with the resident's Certified Nursing Assistant (CNA), CNA #2 on 11/19/18 at 12:53 PM. CNA #2 has worked in the facility for 27 years and with Resident #110 for approximately 6 months. The resident requires total assistance of one person. The CNA is not aware of any special dietary device orders for the resident. On 11/20/18 at 10:04 AM an interview was conducted with Regional Clinical Manager for Dietary (RCMD). Once a resident has been ordered adaptive dietary devices (lip plate and sippy cup), the dietician is made aware by the occupational therapy and/or speech therapy department and the order is communicated by the Nursing Department to the Kitchen. The Kitchen then inputs the order into the meal tracker system and the order is then printed onto the residents'' meal tickets. The dietary staff who puts together the meal trays are responsible for ensuring that dietary devices on the meal ticket are present. The RCMD is not aware of any auditing or rounds that are specifically done to ensure that the special dietary devices are on a resident's tray. There are extra devices on hand if they are thrown out or misplaced. Spot checks are conducted by the Dietary Department; however, the RCMD is not aware of any log that is kept re: the outcome of these spot checks. Dietary devices are sent back down to the kitchen after each meal to be washed before the next meal. An interview was conducted with Regional Food Service Director (RFSD) on 11/20/18 at 10:13 AM. The Dietary Department is responsible for ensuring that the resident's meal ticket is updated to indicate that a dietary device has been ordered. A list of residents on adaptive devices is checked by dietary staff during tray line service. All kitchen staff, especially those on the tray line, check the list to ensure they are aware of residents who should be receiving adaptive dietary devices. The list is also checked after every meal to ensure that items come back down to the kitchen and do not go missing. There are extra devices kept in the kitchen and the Rehabilitation Department is made aware in the event a device goes missing and needs to be replaced. RFSD is unaware that Resident #110 had any adaptive dietary devices missing from his tray on 11/16 and 11/19/18. He will be checking with kitchen staff to determine the reason that the resident did not have the sippy cup and lip plate on his tray. On 11/20/18 at 10:51 AM, an interview was conducted with the Charge Nurse for the resident's unit, Registered Nurse (RN) #1. She has worked in the facility and on the resident's unit for 8 months. The RN checks the trays for devices and then hands the tray to CNA to provide to the resident during each meal time. The RN cannot recall if there was a sippy cup and/or lip plate on the resident's tray during the last few meal times observed by the SA. If the RN notices that items are missing from a resident's meal tray, the RN calls down to the kitchen to have them replaced. She is not aware of any documentation that is kept regarding whether an adaptive device is present or missing. An interview was conducted with RN/Assistant Director of Nursing (ADNS) on 11/20/18 at 11:47 AM. ADNS stated that when the meal trucks are delivered to the unit during meal time, the dietary devices should already be on the tray. The Nursing staff will then place the used dietary devices in the pantry and dietary aides will pick them up at the completion of each meal to wash them for the next meal. The Charge Nurse is responsible for ensuring that the dietary devices are placed on the tray. The CNAs are also responsible since devices are on their CNA Documentation Record. No Quality Assurance audits or spot checks are currently being done to ensure that adaptive dietary devices are in place. 415.12(i)(1)