Based on record review and staff interview conducted during the Recertification survey from 06/13/2024 to 06/21/2024, the facility did not ensure that resident right to manage his or her financial affairs was maintained. This was evident for 1 (Resident #9) of 1 resident reviewed for Personal Funds. Specifically, the facility did not provide Resident #9 with quarterly statements advising of the balance in their personal fund account. The finding is: The facility policy and procedure titled Residents Funds with revision date of 06/18/2024 states that the facility manages the personal funds of residents who request the facility to do so. The policy also stated that should the resident elect to have the facility manage their personal funds, it is authorized in writing by the resident or the resident's representative, and a copy of such authorization is documented in the resident's medical record. Copies of all financial transactions are filed in the residents' permanent record. Resident #9 was admitted to the facility with diagnoses that included Hypertension, Multiple Sclerosis and Bipolar Disorder. The Quarterly Minimum Data Set 3.0 dated 06/16/2024 documented that Resident #9 was cognitively intact with a Brief Interview for Mental Status score of 13. During an interview on 06/17/2024 at 11:30 am, Resident #9 stated they did not know if they have an account, and it would be nice to know if they have. On 06/21/2024 at 12:37 PM, Resident # 9 was re-interviewed and stated they have not received any bank statement from the facility and was not aware if there was an account in their name. The Patient Trust Fund PNA Quarterly Statement from 06/02/2024 thru 06/20/2024 documented that Resident #9 had a balance of $5357.28 in their account. On 06/21/2024 at 1:18 PM, a telephone interview was conducted with Medicaid/Finance Coordinator who stated that Resident #9 has an account in their name, however the quarterly statements have been sent to the Resident's representative. The Medicaid/Finance Coordinator also stated that they were told that the Resident's representative was in charge of everything concerning the Resident #9, so they did not inform Resident #9 about their account or provide them with any statements even though Resident #9 was cognitively intact. 10 NYCRR 415.3(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Complaint (NY00337375) survey from 06/13/2024 to 06/21/2024, the facility did not ensure that residents were free from misappropriation of property. This was evident for 2 (Resident #232 and #334) of 2 residents reviewed for Abuse out of 38 total sampled residents. Specifically, Licensed Practical Nurse #3 diverted narcotic medication ordered and delivered for use with two residents. Licensed Practical Nurse #3 hid the medication in their personal bag and removed it from the facility. The findings are: The facility policy titled Abuse Neglect and Exploitation of resident dated 6/24/2024 documented each resident has the right to free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation, and misappropriation of property. The policy further documented exploitation/misappropriation of resident property is an act or improper course of conduct, including misrepresentation or failure to obtain informed consent which results in monetary, personal, or other benefits, gain or profit for the perpetrator to monetary loss for the resident. This includes deliberate misplacement, exploitation or wrongful (temporary or permanent) use of resident belongings or funds without the resident consent. 1. Resident #232 was admitted to facility 2/22/2024 with diagnosis including Malignant Neoplasm of the Bone, Malignant Neoplasm of the Prostate, Pain in Joint, and Low Back Pain. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #232 was cognitively intact. The Physician Order dated 3/5/2024 documented Percocet Oral Tablet 5-325 mg (Oxycodone with Acetaminophen) give two tablets every six hours as needed for pain. The Pain assessment dated [DATE] documented Resident #232 had occasional pain in last 5 days with a score of 0. Resident #232 received Percocet 5/325 mg every 6 hours as needed, Fentanyl Patch 75mcg every 72 hours, and received pain medication. Review of facility unit assignment documented Licensed Practical Nurse #3 worked on Unit 2 on 3/23/2024 and 3/24/2024. The Narcotic Logbook Sheet dated 3/24/2024 documented 60 Oxycodone-APAP (Percocet) 5/325 mg tablets were delivered to the unit and was signed and received by Licensed Practical Nurse #3. The Controlled Drug Record Sheet for Resident #232 revealed Licensed Practical Nurse #3 documented that they received only 30 tablets Percocet 3/525 mg on 3/24/2024 instead of 60 tablets as documented on the Narcotic Logbook Sheet. The facility Investigation Report dated as completed on 4/1/2024 documented that on March 28th, 2024, at 8:50 AM, Licensed Practical Nurse #2 reported to the Nurse Manager that while doing the narcotic count, they noticed that a blister pack containing twenty-six (26) Oxycodone-APAP 5/325 mg tablets were missing for Resident #232. Licensed Practical Nurse #2 also reported that the medication had not been discontinued and that was the number of pills remaining at the end of their shift on the previous day. Licensed Practical Nurse #2 reported they searched the unit, and the medication was not found. The facility Investigation Report also documented as per the 7am- 3 pm nurse, a blister pack of 26 Oxycodone-APAP 5/325 mg tablets which was left upon the completion of the shift, belonging to Resident #232 was now missing. The Director of Nursing was made aware, the medication carts, medication room, and narcotic cabinet on the unit were thoroughly searched by the Director of Nursing and the Administrator. The Controlled Drug Record Sheet for Resident #232 for Oxycodone-APAP 5/325 mg was noted to be absent from the book. The medication cart, the medication room, and narcotic boxes throughout the entire facility were searched. The narcotic sheets were also cross referenced with Resident #232's medication orders, and Medication Administration Record. Footage from facility cameras was reviewed dated back to 3/27/2024, and the Licensed Practical Nurse who worked the 3pm to 11pm shift was observed removing medications from the locked box on the medication cart. The nurse initially denied any knowledge of this medication, but later admitted upon interview that the nurse did in fact take the medication for the nurse's own personal use. Resident #232 was interviewed and denied pain or missing doses of medication. The New York City Police Department was called to the facility and a police report was filed. During interview with the Director of Nursing Services, the Administrator, and the New York City Police Department, the nurse initially denied any knowledge of the medication. The nurse was terminated immediately and taken into custody by the New York City Police Department. An order to replace the missing medication was called in to the Pharmacy and Resident #232 was provided with medication from the emergency box pending delivery of the new order. The result of the investigation revealed that Resident #232's medication were misappropriated; however, Resident #232 endured no physical, emotional, or mental harm as a result. Resident #232 received as needed pain medication as per the Medical Doctor orders. The case was reported to the New York City Police Department, the Department of Health, the Bureau of Narcotics Enforcement, and the Office of the Professions. The Loss of Controlled Substances Report dated 3-28-24 documented that on 3/27/24 at 10:42pm known diversion of 56 tablets Percocet: 5mg-325 mg and 30 Oxycodone 10mg tablets had occurred. Licensed Practical Nurse #3's statement dated 3/28/2024 documented that they administered Percocet 5/325 mg to Resident #232 on the 3pm-11pm shift. Licensed Practical Nurse #3 stated 9 pills were left at the end of the shift. Licensed Practical Nurse #3 then took the blister pack of Percocet and put it with the garbage that night and took the pills home. Licensed Practical Nurse #3 also stated they did not tell the Director of Nursing and Administrator the truth because of fear of losing their job and apologized for lying and taking the pills. Review of the facility camera footage of the incident dated 3/27/2024 showed that at 22:42 (10:42pm), Licensed Practical Nurse #3 left the nurse's station, turned off some the lights on the unit and walked toward the medication cart parked just across from the nurse's station. Licensed Practical Nurse #3 opened the narcotic box in the medication cart and removed one blister pack, placed the blister pack in the regular medication cart, and closed the cart. Licensed Practical Nurse #3 then cleaned the top of the medication cart of debris which they placed in the garbage bag and returned to the nurse's station where they removed a small personal bag from the nurse's station and went into a room opposite to the nurse's station. Licensed Practical Nurse #3 left the room at 22:44 (10:44 pm) with no bag in hand and went to the medication cart. Licensed Practical Nurse #3 then took a clear plastic bag containing garbage from the medication cart, opened the medication cart and removed a blister pack which they placed behind the garbage bag. Licensed Practical Nurse #3 then returned to the nurse's station and pick up another bag of garbage and then entered the room opposite the nurse's station. The Licensed Practical Nurse #3 then exited the room at 22:46 (10:46 pm) with the small personal bag which they placed on top of the medication cart, went to another food and discarded the garbage bag. Licensed Practical Nurse #3 then returned to the medication cart, picked up their small personal bag which they then placed in the nurse's station. 2. Resident #334 was admitted to the facility on [DATE] with diagnosis including Polyarthritis, Osteoarthritis left knee, and Neuropathy. Resident #334 was discharged to the community on 5/13/2024. The admission Minimum Data Set, dated [DATE] documented Resident #334 was cognitively intact. Physician order dated 3/11/2024 documented order for Oxycodone 10 mg every 6 hours as needed for pain. The PharMerica Pharmacy Electronic Shipping Manifest documented 60 Oxycodone tablets were received by the facility on 3/24/2024 for Resident #334. The Narcotic Logbook Sheet dated 3/24/2024 documented 60 Oxycodone 10 mg tablets were delivered to the unit and signed received by Licensed Practical Nurse #3. The Controlled Drug Record Sheet for Resident #334 revealed Licensed Practical Nurse #3 documented that they received only 30 tablets Oxycodone 10 mg tablets on 3/24/2024 instead of 60 tablets as documented on the Narcotic Logbook Sheet. The facility investigation dated completed 4/1/2024 documented a review of the Narcotic log sheets for Resident #334 revealed that Licensed Practical Nurse #3 documented they received 30 Oxycodone 10 mg tablets, instead of 60 Oxycodone 10 mg tablets that was delivered to Licensed Practical Nurse #3. The New York City Police Department Form for Complaint #2024-061-001871 dated 3/28/2024 documented employee arrested for Petit Larceny, theft from building. The police report narrative also documented that a quantity of 56 Percocet (Oxycodone-APAP 5/325 mg) oral tablets and 30 Oxycodone oral tablets which are controlled substances were removed by the nurse without authority or permission. On 06/18/2024 at 09:32 AM, an interview was conducted with the Director of Nursing Services who stated they came to work on the morning of 3/28/2024, when Licensed Practical Nurse #2 who worked the day shift on 3/27/2024 reported that they left approximately 26 Percocet 5/325 mg tablets for Resident #232, and when they counted that morning, the Percocet was missing. The Director of Nursing Services also stated the searched the unit, and the entire building wherever narcotics were kept but did not find the missing Percocet tablets. The nurse that worked the night shift and the night Supervisor were called, and they reported no missing narcotics. Licensed Practical Nurse #3 was contacted and denied seeing the missing Percocet. The Director of Nursing Services further stated that they discovered that the narcotic sheets for Resident #232 were also missing and so they decided to view the video footage for the unit which showed Licensed Practical Nurse #3 counting the Percocet with the outgoing day shift nurse. The footage also showed Licensed Practical Nurse #3 removing the Percocet from the narcotic box on the medication cart and placing it among the other medications on the cart before subsequently placing the medication in their personal bag on the unit. The Director of Nursing Services stated the investigation was expanded and missing narcotics for Resident #334 was also identified. The police were called and Licensed Practical Nurse #3 was arrested, reported to the Narcotic Bureau and the Licensing Board, and terminated immediately. The Director of Nursing Services stated no other narcotics was observed missing in the investigation. On 06/18/24 at 02:38 PM, an interview was completed with the facility Administrator who stated the video in the facility is not continuous and can be reviewed by going back and looking at the footage. The Administrator also stated there are no monitors and they only review the cameras if something happens, as in the case of the missing medications. The Administrator provided copy of footage saved to the Surveyor. On 06/19/24 at 09:01 AM, a telephone interview was completed with Licensed Practical Nurse #2, who stated there were only two residents on the unit receiving narcotics at that time. Licensed Practical Nurse #2 stated they left the faciity on 3/27/24 after working the day shift and signed off 26 Percocet tablets to Licensed Practical Nurse #3. They returned to work the next day, and while counting narcotics from the night nurse found that there were no narcotics for Resident #232, and the narcotic log sheet was missing. They looked in the Electronic Medical Record and there was no note or an order that stated that the medication had been discontinued. Licensed Practical Nurse #2 also stated they looked among the regular medications on both carts, in the narcotic box and searched the medication room but did not find the medication so they alerted their supervisor who informed the Director of Nursing. Licensed Practical Nurse #2 stated they have not received narcotics because the medications are always delivered on the evening shift, with duplicate forms which are both given to the nurse when the nurse accepts the narcotics. Licensed Practical Nurse #2 a nurse could possibly throw out or keep one of the forms and document whatever they want on the other form. On 06/20/24 at 08:53 AM, an interview was conducted with the Director of Nursing Services who stated they conducted and reported immediately the investigation missing narcotics for Resident #232, but during the investigation found that there was also missing narcotics for Resident #334. On 06/20/24 at 11:20 AM, a telephone interview was conducted with Registered Nursing Supervisor #1 who worked the evening shift on 3/27/2024 who stated that on 3/27/2024 they received narcotics from the pharmacy and gave Licensed Practical Nurse #3 60 Percocet 5/325 mg tablets and 60 Oxycodone 10 mg tablets, two blister packs each for Resident #232 and #334. Registered Nursing Supervisor #1 also stated that after ensuring that the narcotic was locked in the narcotic box, they left Licensed Practical Nurse #3 and did not see what the nurse documented on the resident's narcotic sheets on the unit. Registered Nursing Supervisor #1 further stated they worked with Licensed Practical Nurse #3 before and there were no complaints from staff or residents. Registered Nursing Supervisor #1 stated they are the only supervisor in the building, and they monitor the staff by making rounds on each unit, and staff calls them if there are any issues. On 06/21/24 at 04:34 PM, a telephone interview was completed with Licensed Practical Nurse #3, who stated they are the regular nurse for the evening shift. Licensed Practical Nurse #3 stated they were called downstairs on 3/28/2024 by the Director of Nursing and was shown video footage but they did not take any pills home and the garbage bag was tied and so they may have thrown the blister pack out with the garbage. Licensed Practical Nurse #3 also stated they have never taken the medication home from the facility. Licensed Practical Nurse #3 further stated no one saw Licensed Practical Nurse #3 leave the facility with any blister pack or put a blister pack in Licensed Practical Nurse #3's bag. Licensed Practical Nurse #3 stated may have thrown out the blister pack with the garbage. Licensed Practical Nurse #3 denies in pain and kept repeating I did not take any pills. Licensed Practical Nurse #3 stated they did get arrested and was let go by the facility. Licensed Practical Nurse #3 did not respond when asked why they documented 30 pills were received instead of 60. 10 NYCRR 415.4(b)

Based on record review and interviews conducted during the Recertification and Complaint (NY00337275) survey from 06/13/2024 to 06/21/2024, the facility did not ensure that misappropriation of property was reported to the Department of Health. This was evident for 1 (Resident # 334) of 2 residents reviewed for abuse out of 38 total investigated sampled residents. Specifically, during another investigation a Licensed Practical Nurse was found to have diverted narcotic medication for Resident #334 and this was not reported to the Department of Health. The findings are: The facility policy titled Abuse Neglect and Exploitation of Resident dated 6/24/2024 documented should the investigation revealed that an abuse occurred the Administrator will report the findings to the local police department, the ombudsman, and state licensing certification agency within such licensing agency within 24 hours of the results of the completion of the investigation, as indicated, and to the state survey and certification agency within five (5) days of the completion of the investigation. Resident #334 was admitted to the facility with diagnosis that included Polyarthritis, Osteoarthritis left knee, and Neuropathy. The Physician's Order dated 3/11/2024 documented order for Oxycodone 10 mg every 6 hours as needed for pain. The Loss of Controlled Substances Report dated 3-28-24 documented that on 3/27/24 at 10:42pm known diversion of 30 Oxycodone 10mg tablets had occurred. The PharMerica Pharmacy Electronic Shipping Manifest documented 60 Oxycodone tablets were received by the facility on 3/24/2024 for Resident #334. The Narcotic Logbook Sheet dated 3/24/2024 documented 60 Oxycodone 10 mg tablets were delivered to the unit and signed received by Licensed Practical Nurse #3. The Controlled Drug Record Sheet for Resident #334 revealed Licensed Practical Nurse #3 documented that they received only 30 tablets Oxycodone 10 mg tablets on 3/24/2024 instead of 60 tablets as documented on the Narcotic Logbook Sheet. The facility investigation dated completed 4/1/2024 documented a review of the Narcotic log sheets for Resident #334 revealed that Licensed Practical Nurse #3 documented they received 30 Oxycodone 10 mg tablets, instead of 60 Oxycodone 10 mg tablets that was delivered to Licensed Practical Nurse #3. The New York City Police Department Form for Complaint #2024-061-001871 dated 3/28/2024 documented employee arrested for Petit Larceny, theft from building. The police report narrative also documented that a quantity of 56 Percocet (Oxycodone-APAP 5/325 mg) oral tablets and 30 Oxycodone oral tablets which are controlled substances were removed by the nurse without authority or permission. There was no documented evidence that the diversion of 30 tablets of Oxycodone 10 mg tablets had been reported to the Department of Health. On 06/20/24 at 08:53 AM, an interview was conducted with the Director of Nursing Services who stated they conducted and reported immediately the investigation missing narcotics for another resident but during the investigation found that there was also missing narcotics for Resident #334. On 06/21/24 at 03:54 PM, an interview was conducted with the Director of Nursing who stated that the incident report completed on 4/1/24 did not include information regarding Resident #334. The Director of Nursing further stated that this information was included in the Bureau of Narcotic Enforcement and was not provided to the State Surveyor. On 06/21/24 at 03:56 PM, the facility Administrator was interviewed and stated that at the time they submitted the initial report to the Department of Health on 3/27/24 they were only aware of diverted medication for one resident. The Administrator also stated that the information regarding the second resident was not reported because they received notification from the Department of Health stated no additional reporting needed on the initial report. The Administrator further stated that based on that notification they did not think that they needed to report the diversion of medication intended for Resident #334 although it was included in the Bureau of Narcotic Enforcement report. 10 NYCRR 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification Survey from 6/13/2024 to 6/21/2024, the facility did not ensure a person-centered comprehensive care plan was developed and implemented to meet a resident's needs. This was evident for 1 (Resident #6) of 6 residents reviewed for Pain Management and 1 (Resident #22) of 2 residents reviewed for Respiratory Care out of 38 total sampled residents. Specifically, 1). a comprehensive care plan related to pain was not developed to address Resident #6 chronic pain and 2). there was no care plan created for a resident receiving Oxygen therapy. The findings include: The facility policy titled Care Plan-Comprehensive created 3/2022 and revised 6/2024 stated that comprehensive care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functions needs is developed and implemented. The care planning process will include an assessment of the residents' strengths and needs. The Comprehensive Care person centered care plan will incorporate identified problem areas and areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 1. Resident #6 had diagnoses of Heart Failure, Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting unspecified side. The admission Minimum Data Set 3.0 assessment dated [DATE] documented Resident #6 had intact cognition. A Medical Doctor's Order dated 3/11/2024 documented Resident #6 was ordered Gabapentin 100MG capsule (2 capsule by mouth two times a day for neuropathic pain). A Medical Doctor's Order dated 5/28/2024 documented Resident #6 was ordered Acetaminophen Oral Tablet 325 MG (2 tablet by mouth every 6 hours as needed for pain.) A Medical Doctors Order dated 6/14/2024 documented Resident #6 was ordered Gabapentin 400 MG Capsule (1 capsule by mouth at bedtime for neuropathic pain). Pain Level Summary dated 3/11/2024 -6/19/2024 documented pain assessment twice daily. Most of the dates rated 0, 1 rating 3, 1 rating of 4, 3 ratings of 2. Review of the Electronic Medical Record revealed that there was no Comprehensive Care Plan created to address Resident #6's pain concern. On 06/21/24 at 10:18 AM, Licensed Practical Nurse #4 was interviewed and stated that the Registered Nurse supervisors are responsible for putting in all resident's care plans. On 06/21/24 at 11:12 AM, Registered Nurse Supervisor #2 was interviewed and stated that during morning staff meetings, care plans for residents are reviewed. Registered Nurse Supervisor #2 stated that all staff have access to care plans and while Licensed Practical Nurses cannot put in care plans, they do have access to see interventions and goals. Registered Nurse Supervisor #2 confirmed there was no pain care plan for Resident #6 despite seeing an as needed order for Tylenol and an order for Gabapentin in the Electronic Medical Record. Registered Nurse Supervisor #2 stated that Resident #6 should have had a care plan in place to address pain. On 06/21/24 at 11:43 AM, Registered Nurse Manager and Clinical Educator #1 was interviewed and stated that when a new resident comes into the facility, the nursing supervisors create care plans. Care plans are based on the residents' diagnosis, medications and anything else going on with resident. Social work, Minimum Data Set Director, Recreation and Dieticians have access to care plan with the purpose being to direct care for residents within facility. With new residents, care plans are reviewed during staff morning report to ensure all care plans are in place. Registered Nurse Manager and Clinical Educator #1 stated that a pain care plan for Resident #6 was not listed in Electronic Medical Record and that it was missed. On 06/21/24 at 01:32 PM, the Director of Nursing #1 was interviewed and stated that Nurse Managers and supervisor's enter residents care plans in upon admission. Care plans for residents are reviewed when residents come in and the day after. The Director of Nursing stated #1 that the Nurse Manager should have checked the care plans and a care plan for pain should have been in place for Resident #6. 2. Resident #22 was readmitted to the facility with diagnoses that included Atrial Fibrillation, Heart Failure and Hypertension. The Minimum Data Set 3.0 assessment dated [DATE] documented that resident was receiving oxygen. On 06/18/2024 at 12:06 PM, Resident #22 was observed in their room in bed receiving with oxygen by nasal cannula delivered through an Oxygen concentrator at 2 liters per minute. Review of the Physician's order dated 06/14/2024 documented oxygen by nasal cannula 2 liters per minute, check oxygen saturation every shift and change tubing every week. There was no documented evidence that a Comprehensive Care Plan last updated on the use of oxygen was initiated for Resident #22. On 06/20/2024 at 1:37 PM, the Assistant Director of Nursing was interviewed and stated that resident's care plans are done by the Registered Nurse Supervisor on admission, significant change, quarterly and as needed if there are new care areas that needed to be addressed and care planned for. The Assistant Director of Nursing also stated that upon review of the medical record, they could not locate a care plan addressing the use of oxygen for Resident #22. The Assistant Director of Nursing further stated that there had been no regular Registered Nurse Supervisor on this unit, and they started a month ago and are trying to organize and keep everything up to date. 10 NYCRR 415.3(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Abbreviated (NY00337375) survey from 6/13/2024 to 6/21/2024, the facility did not ensure services provided met professional standards. This was evident for 2 (Resident #232 and #334) of 2 residents reviewed for Abuse out of 38 total sampled residents. Specifically, Licensed Practical Nurse #3 diverted narcotics intended for use with two residents. Licensed Practical Nurse #3 documented on 3/24/2024 that 30 Percocet 5/325 mg tablets were received instead of 60 Percocet 5/325 mg tablets for Resident #232 and that 30 Oxycodone 10 mg tablets were received instead of 60 Oxycodone 10 mg tablets for Resident #334. The Registered Nursing Supervisor #1 who delivered the medications to the unit did not monitor the quantity of narcotics the Licensed Practical Nurse #3 documented on the resident's narcotics sheets used on the unit. The findings are: The facility's policy titled Nursing Standards of Care dated 6/24/2024 documented members of the Departments who provide direct care will do so in accordance with professional and legal standards, physicians orders, the Resident/patient's plan of care and the facility policies. The facility policy titled Controlled substances with no initiated, review or revised date documented the facility complies with all laws, regulations, and other requirements to handling, storage disposal and documentation of controlled substances. The policy further documented the nurse receiving the medication and the individual delivering the medication verify the name dose and quantity of each controlled substance record of receipt. Both individuals sign the controlled substance receipt. An individual Resident-controlled substance record is made for each Resident who is receiving controlled substance. The record contains name of the Resident, name and strength of the medication, quantity received, number on hand, name of physician, prescription number name of issuing pharmacy and the date and time received. 1. Resident #232 was admitted to facility 2/22/2024 with diagnosis including Malignant Neoplasm of the Bone, Malignant Neoplasm of the Prostate, Pain in Joint, and Low Back Pain. The Physician Order dated 3/5/2024 documented Percocet Oral Tablet 5-325 mg (Oxycodone with Acetaminophen) give two tablets every six hours as needed for pain. The Pain assessment dated [DATE] documented Resident #232 had occasional pain in last 5 days with a score of 0. Resident #232 received Percocet 5/325 mg every 6 hours as needed, Fentanyl Patch 75mcg every 72 hours, and received pain medication. Review of facility unit assignment documented Licensed Practical Nurse #3 worked on Unit 2 on 3/23/2024 and 3/24/2024. The Narcotic Logbook Sheet dated 3/24/2024 documented 60 Oxycodone-APAP (Percocet) 5/325 mg tablets were delivered to the unit and was signed and received by Licensed Practical Nurse #3. The Controlled Drug Record Sheet for Resident #232 revealed Licensed Practical Nurse #3 documented that they received only 30 tablets Percocet 3/525 mg on 3/24/2024 instead of 60 tablets as documented on the Narcotic Logbook Sheet. The facility Investigation Report dated as completed on 4/1/2024 documented that on March 28th, 2024, at 8:50 AM, Licensed Practical Nurse #2 reported to the Nurse Manager that while doing the narcotic count, they noticed that a blister pack containing twenty-six (26) Oxycodone-APAP 5/325 mg tablets were missing for Resident #232. Licensed Practical Nurse #2 also reported that the medication had not been discontinued and that was the number of pills remaining at the end of their shift on the previous day. Licensed Practical Nurse #2 reported they searched the unit, and the medication was not found. The Director of Nursing was made aware, the medication carts, medication room, and narcotic cabinet on the unit were thoroughly searched by the Director of Nursing and the Administrator. The Controlled Drug Record Sheet for Resident #232 for Oxycodone-APAP 5/325 mg was noted to be absent from the book. The medication cart, the medication room, and narcotic boxes throughout the entire facility were searched. The narcotic sheets were also cross referenced with Resident #232's medication orders, and Medication Administration Record. Footage from facility cameras dated back to 3/27/2024 was reviewed and showed the Licensed Practical Nurse who worked the 3pm to 11pm shift removing medications from the locked box on the medication cart. The nurse initially denied any knowledge of this medication, but later admitted upon interview that they did in fact take the medication for the nurse's own personal use. Resident #232 was interviewed and denied pain or missing doses of medication. The New York City Police Department was called to the facility and a police report was filed. During interview with the Director of Nursing Services, the Administrator, and the New York City Police Department, the nurse initially denied any knowledge of the medication. The nurse was terminated immediately and taken into custody by the New York City Police Department. The result of the investigation revealed that Resident #232's medication were misappropriated. The case was reported to the New York City Police Department, the Department of Health, the Bureau of Narcotics Enforcement, and the Office of the Professions. The Loss of Controlled Substances Report dated 3-28-24 documented that on 3/27/24 at 10:42pm known diversion of 56 tablets Percocet 5mg-325 mg and 30 Oxycodone 10mg tablets had occurred. Licensed Practical Nurse #3's statement dated 3/28/2024 documented that they administered Percocet 5/325 mg to Resident #232 on the 3pm-11pm shift. Licensed Practical Nurse #3 stated 9 pills were left at the end of the shift. Licensed Practical Nurse #3 then took the blister pack of Percocet 5/325 mg tablets and put it with the garbage that night and took the pills home. Licensed Practical Nurse #3 also stated they did not tell the Director of Nursing and Administrator the truth because of fear of losing their job and apologized for lying and taking the pills. Review of the facility camera footage of the incident dated 3/27/2024 revealed that at 22:42 (10:42pm), Licensed Practical Nurse #3 left the nurse's station, turned off some the lights on the unit and walked toward the medication cart parked just across from the nurse's station. Licensed Practical Nurse #3 opened the narcotic box in the medication cart and removed one blister pack, placed the blister pack in the regular medication cart, and closed the cart. Licensed Practical Nurse #3 then cleaned the top of the medication cart of debris which they placed in the garbage bag and returned to the nurse's station where they removed a small personal bag from the nurse's station and went into a room opposite to the nurse's station. Licensed Practical Nurse #3 left the room at 22:44 (10:44 pm) with no bag in hand and went to the medication cart. Licensed Practical Nurse #3 then took a clear plastic bag containing garbage from the medication cart, opened the medication cart and removed a blister pack which they placed behind the garbage bag. Licensed Practical Nurse #3 then returned to the nurse's station and pick up another bag of garbage and then entered the room opposite the nurse's station. The Licensed Practical Nurse #3 then exited the room at 22:46 (10:46 pm) with the small personal bag which they placed on top of the medication cart, went to another food and discarded the garbage bag. Licensed Practical Nurse #3 then returned to the medication cart, picked up their small personal bag which they then placed in the nurse's station. 2. Resident #334 was admitted to the facility on [DATE] with diagnosis including Polyarthritis, Osteoarthritis left knee, and Neuropathy. Resident #334 was discharged to the community on 5/13/2024. The admission Minimum Data Set, dated [DATE] documented Resident #334 was cognitively intact. Physician order dated 3/11/2024 documented order for Oxycodone 10 mg every 6 hours as needed for pain. The PharMerica Pharmacy Electronic Shipping Manifest documented 60 Oxycodone 10mg tablets were received by the facility on 3/24/2024 for Resident #334. The Narcotic Logbook Sheet dated 3/24/2024 documented 60 Oxycodone 10 mg tablets were delivered to the unit and signed as received by Licensed Practical Nurse #3. The Controlled Drug Record Sheet for Resident #334 revealed Licensed Practical Nurse #3 documented that they received only 30 tablets Oxycodone 10 mg tablets on 3/24/2024 instead of 60 tablets as documented on the Narcotic Logbook Sheet. The facility investigation dated completed on 4/1/2024 documented a review of the Narcotic log sheets for Resident #334 revealed that Licensed Practical Nurse #3 documented they received 30 Oxycodone 10 mg tablets, instead of 60 Oxycodone 10 mg tablets that was delivered to Licensed Practical Nurse #3. The New York City Police Department Form for Complaint #2024-061-001871 dated 3/28/2024 documented employee arrested for Petit Larceny, theft from building. The police report narrative also documented that a quantity of 56 Percocet (Oxycodone-APAP 5/325 mg) oral tablets and 30 Oxycodone oral tablets which are controlled substances were removed by the nurse without authority or permission. On 06/18/2024 at 09:32 AM, an interview was conducted with the Director of Nursing Services who stated that on the morning of 3/28/2024, Licensed Practical Nurse #2 who worked the day shift on 3/27/2024 reported that they left approximately 26 Percocet 5/325 tablets for Resident #232, and when they counted that morning, the Percocet 5/325 mg tablets were missing. The Director of Nursing Services also stated they searched the unit, and the entire building wherever narcotics were kept but did not find the missing Percocet 5/325 tablets. The nurse that worked the night shift and the night Supervisor were called, and they reported no missing narcotics. Licensed Practical Nurse #3 was contacted and denied seeing the missing Percocet 5/325. The Director of Nursing Services further stated that they discovered that the narcotic sheets for Resident #232 were also missing and so they decided to view the video footage for the unit which showed Licensed Practical Nurse #3 counting the Percocet 5/325 mg tablets with the outgoing day shift nurse. The footage also showed Licensed Practical Nurse #3 remove the Percocet 5/325 mg tablets from the narcotic box on the medication cart and place it among the other medications on the cart before subsequently placing the medication in their personal bag on the unit. The Director of Nursing Services stated the investigation was expanded and missing narcotics for Resident #334 was also identified. The police were called and Licensed Practical Nurse #3 was arrested, reported to the Narcotic Bureau and the Licensing Board, and terminated immediately. The Director of Nursing Services stated no other narcotics was observed missing in the investigation. On 06/18/24 at 02:38 PM, an interview was completed with the facility Administrator who stated the video in the facility is not continuous and can be reviewed by going back and looking at the footage. The Administrator also stated there are no monitors and they only review the cameras if something happens, as in the case of the missing medications. On 06/19/24 at 09:01 AM, a telephone interview was completed with Licensed Practical Nurse #2, who stated there were only two residents on the unit receiving narcotics at that time. Licensed Practical Nurse #2 stated they left the faciity on 3/27/24 after working the day shift and signed off 26 Percocet 5/325 mg tablets to Licensed Practical Nurse #3. They returned to work the next day, and while counting narcotics from the night nurse found that there were no narcotics for Resident #232, and the narcotic log sheet was missing. They looked in the Electronic Medical Record and there was no note or an order that stated that the medication had been discontinued. Licensed Practical Nurse #2 also stated they looked among the regular medications on both carts, in the narcotic box and searched the medication room but did not find the medication so they alerted their supervisor who informed the Director of Nursing. Licensed Practical Nurse #2 stated they have not received narcotics because the medications are always delivered on the evening shift, with duplicate forms which are both given to the nurse when the nurse accepts the narcotics. Licensed Practical Nurse #2 a nurse could possibly throw out or keep one of the forms and document whatever they want on the other form. On 06/20/24 at 08:53 AM, an interview was conducted with the Director of Nursing Services who stated they conducted and reported immediately the investigation missing narcotics for Resident #232, but during the investigation found that there was also missing narcotics for Resident #334. On 06/20/24 at 11:20 AM, a telephone interview was conducted with Registered Nursing Supervisor #1 who worked the evening shift on 3/27/2024 who stated that they when they receive narcotics from the Pharmacy they count the narcotics, log the date, time medications received, the name and dosage of the medications, the number pills received, and the amount of blister packs received into the narcotic logbook in the nursing office, and then they sign the book. They then take the narcotic book and the narcotics to the nurse on duty on the unit. The nurse on the unit will sign that they received the narcotics in the book and include the amount and the number of blister packs received. After handing over the medications and the book is signed, the Registered Nursing Supervisor #1 stated they will ensure that the nurse places the narcotics into the double locked narcotic box on the unit. Registered Nursing Supervisor #1 stated on 3/27/2024 they received narcotics from the pharmacy and gave Licensed Practical Nurse #3 60 Percocet 5/325 tablets and 60 Oxycodone 10 mg tablets, two blister packs each for Resident #232 and #334. Registered Nursing Supervisor #1 also stated that after ensuring that the narcotic was locked in the narcotic box, they left Licensed Practical Nurse #3 and did not see what the nurse documented on the resident's narcotic sheets on the unit. Registered Nursing Supervisor #1 further stated they worked with Licensed Practical Nurse #3 before and there were no complaints from staff or residents. Registered Nursing Supervisor #1 stated they are the only supervisor in the building and monitors the staff by making rounds on each unit, and staff calls them if there are any issues. On 06/21/24 at 04:34 PM, a telephone interview was completed with Licensed Practical Nurse #3, who stated they are the regular nurse for the evening shift. Licensed Practical Nurse #3 stated they were called downstairs on 3/28/2024 by the Director of Nursing and was shown video footage but they did not take any pills home and the garbage bag was tied and so they may have thrown the blister pack out with the garbage. Licensed Practical Nurse #3 also stated they have never taken the medication home from the facility. Licensed Practical Nurse #3 further stated no one saw Licensed Practical Nurse #3 leave the facility with any blister pack or put a blister pack in Licensed Practical Nurse #3's bag. Licensed Practical Nurse #3 stated may have thrown out the blister pack with the garbage. Licensed Practical Nurse #3 denies in pain and kept repeating I did not take any pills. Licensed Practical Nurse #3 stated they did get arrested and was let go by the facility. Licensed Practical Nurse #3 did not respond when asked why they documented 30 pills were received instead of 60. 10 NYCRR 415.11(c)(3)(i)

Based on record reviews and interviews conducted during the Recertification and Abbreviated (NY00337375) Survey from 6/13/2024 to 6/21/2024, the facility did not ensure pharmaceutical services was provided to including procedures that assure accurate, receiving of narcotics, establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records are in order; and that an account of all controlled drugs is maintained. Specifically, Licensed Practical Nurse #3 diverted narcotics delivered for two residents. Licensed Practical Nurse #3 documented on 3/24/2024 that they received 30 Percocet 5/325 mg tablets instead of 60 Percocet 5/325 mg tablets and 30 Oxycodone 10 mg tablets instead of 60 Oxycodone10 mg tablets. The Registered Nursing Supervisor#1 who delivered the narcotic medications to Licensed Practical Nurse #3 did not observe the quantity of narcotics Licensed Practical Nurse #3 documented received on the narcotics sheets used on the unit. The findings are: The facility policy titled Controlled Substances with no initiated, review or revised date documented the facility complies with all laws, regulations, and other requirements to handling, storage disposal and documentation of controlled substances. The policy further documented the nurse receiving the medication and the individual delivering the medication verify the name dose and quantity of each controlled substance record of receipt. Both individuals sign the controlled substance receipt. An individual Resident-controlled substance record is made for each Resident who is receiving controlled substance. The record contains name of the Resident, name and strength of the medication, quantity received, number on hand, name of physician, prescription number name of issuing pharmacy and the date and time received. Review of the facility unit assignment documented Licensed Practical Nurse #3 worked on Unit 2 on 3/23/2024 and 3/24/2024. The Narcotic Logbook Sheet dated 3/24/2024 documented 60 Oxycodone-APAP (Percocet) 5/325 mg tablets were delivered to the unit and was signed and received by Licensed Practical Nurse #3. The Controlled Drug Record Sheet for Resident #232 revealed Licensed Practical Nurse #3 documented that they received only 30 tablets Percocet 3/525 mg on 3/24/2024 instead of 60 tablets as documented on the Narcotic Logbook Sheet. The facility Investigation Report dated as completed on 4/1/2024 documented that on March 28th, 2024, at 8:50 AM, Licensed Practical Nurse #2 reported to the Nurse Manager that while doing the narcotic count, they noticed that a blister pack containing twenty-six (26) Oxycodone-APAP 5/325 mg tablets were missing for Resident #232. Licensed Practical Nurse #2 also reported that the medication had not been discontinued and that was the number of pills remaining at the end of their shift on the previous day. Licensed Practical Nurse #2 reported they searched the unit, and the medication was not found. The Director of Nursing was made aware, the medication carts, medication room, and narcotic cabinet on the unit were thoroughly searched by the Director of Nursing and the Administrator. The Controlled Drug Record Sheet for Resident #232 for Oxycodone-APAP 5/325 mg was noted to be absent from the book. The medication cart, the medication room, and narcotic boxes throughout the entire facility were searched. The narcotic sheets were also cross referenced with Resident #232's medication orders, and Medication Administration Record. Footage from facility cameras was reviewed dated back to 3/27/2024, and the Licensed Practical Nurse who worked the 3pm to 11pm shift was observed removing medications from the locked box on the medication cart. The nurse initially denied any knowledge of this medication, but later admitted upon interview that the nurse did in fact take the medication for the nurse's own personal use. Resident #232 was interviewed and denied pain or missing doses of medication. The New York City Police Department was called to the facility and a police report was filed. During interview with the Director of Nursing Services, the Administrator, and the New York City Police Department, the nurse initially denied any knowledge of the medication. The nurse was terminated immediately and taken into custody by the New York City Police Department. The result of the investigation revealed that Resident #232's medication were misappropriated. The case was reported to the New York City Police Department, the Department of Health, the Bureau of Narcotics Enforcement, and the Office of the Professions. The Loss of Controlled Substances Report dated 3-28-24 documented that on 3/27/24 at 10:42pm known diversion of 56 tablets Percocet 5mg-325 mg and 30 Oxycodone 10mg tablets had occurred. Review of the facility camera footage of the incident dated 3/27/2024 revealed that at 22:42 (10:42pm), Licensed Practical Nurse #3 left the nurse's station, turned off some the lights on the unit and walked toward the medication cart parked just across from the nurse's station. Licensed Practical Nurse #3 opened the narcotic box in the medication cart and removed one blister pack, placed the blister pack in the regular medication cart, and closed the cart. Licensed Practical Nurse #3 then cleaned the top of the medication cart of debris which they placed in the garbage bag and returned to the nurse's station where they removed a small personal bag from the nurse's station and went into a room opposite to the nurse's station. Licensed Practical Nurse #3 left the room at 22:44 (10:44 pm) with no bag in hand and went to the medication cart. Licensed Practical Nurse #3 then took a clear plastic bag containing garbage from the medication cart, opened the medication cart and removed a blister pack which they placed behind the garbage bag. Licensed Practical Nurse #3 then returned to the nurse's station and pick up another bag of garbage and then entered the room opposite the nurse's station. The Licensed Practical Nurse #3 then exited the room at 22:46 (10:46 pm) with the small personal bag which they placed on top of the medication cart, went to another food and discarded the garbage bag. Licensed Practical Nurse #3 then returned to the medication cart, picked up their small personal bag which they then placed in the nurse's station. The PharMerica Pharmacy Electronic Shipping Manifest documented 60 Oxycodone 10mg tablets were received by the facility on 3/24/2024 for Resident #334. The Narcotic Logbook Sheet dated 3/24/2024 documented 60 Oxycodone 10 mg tablets were delivered to the unit and signed as received by Licensed Practical Nurse #3. The Controlled Drug Record Sheet for Resident #334 revealed Licensed Practical Nurse #3 documented that they received only 30 tablets Oxycodone 10 mg tablets on 3/24/2024 instead of 60 tablets as documented on the Narcotic Logbook Sheet. The facility investigation dated completed on 4/1/2024 documented a review of the Narcotic log sheets for Resident #334 revealed that Licensed Practical Nurse #3 documented they received 30 Oxycodone 10 mg tablets, instead of 60 Oxycodone 10 mg tablets that was delivered to Licensed Practical Nurse #3. The New York City Police Department Form for Complaint #2024-061-001871 dated 3/28/2024 documented employee arrested for Petit Larceny, theft from building. The police report narrative also documented that a quantity of 56 Percocet (Oxycodone-APAP 5/325 mg) oral tablets and 30 Oxycodone oral tablets which are controlled substances were removed by the nurse without authority or permission. There was no documented evidence that the Pharmacy was notified that narcotics had been diverted from the facility. On 06/18/2024 at 09:32 AM, an interview was conducted with the Director of Nursing Services who stated that on the morning of 3/28/2024, Licensed Practical Nurse #2 who worked the day shift on 3/27/2024 reported that they left approximately 26 Percocet 5/325 tablets for Resident #232, and when they counted that morning, the Percocet 5/325 mg tablets were missing. The Director of Nursing Services also stated they searched the unit, and the entire building wherever narcotics were kept but did not find the missing Percocet 5/325 tablets. The nurse that worked the night shift and the night Supervisor were called, and they reported no missing narcotics. Licensed Practical Nurse #3 was contacted and denied seeing the missing Percocet 5/325. The Director of Nursing Services further stated that they discovered that the narcotic sheets for Resident #232 were also missing and so they decided to view the video footage for the unit which showed Licensed Practical Nurse #3 counting the Percocet 5/325 mg tablets with the outgoing day shift nurse. The footage also showed Licensed Practical Nurse #3 remove the Percocet 5/325 mg tablets from the narcotic box on the medication cart and place it among the other medications on the cart before subsequently placing the medication in their personal bag on the unit. The Director of Nursing Services stated the investigation was expanded and missing narcotics for Resident #334 was also identified. The police were called and Licensed Practical Nurse #3 was arrested, reported to the Narcotic Bureau and the Licensing Board, and terminated immediately. The Director of Nursing Services stated no other narcotics was observed missing in the investigation. On 06/19/24 at 09:01 AM, a telephone interview was completed with Licensed Practical Nurse #2, who stated there were only two residents on the unit receiving narcotics at that time. Licensed Practical Nurse #2 stated they left the faciity on 3/27/24 after working the day shift and signed off 26 Percocet 5/325 mg tablets to Licensed Practical Nurse #3. They returned to work the next day, and while counting narcotics from the night nurse found that there were no narcotics for Resident #232, and the narcotic log sheet was missing. They looked in the Electronic Medical Record and there was no note or an order that stated that the medication had been discontinued. Licensed Practical Nurse #2 also stated they looked among the regular medications on both carts, in the narcotic box and searched the medication room but did not find the medication so they alerted their supervisor who informed the Director of Nursing. Licensed Practical Nurse #2 stated they have not received narcotics because the medications are always delivered on the evening shift, with duplicate forms which are both given to the nurse when the nurse accepts the narcotics. Licensed Practical Nurse #2 a nurse could possibly throw out or keep one of the forms and document whatever they want on the other form. On 06/20/24 at 08:53 AM, an interview was conducted with the Director of Nursing Services who stated they conducted and reported immediately the investigation missing narcotics for Resident #232, but during the investigation found that there was also missing narcotics for Resident #334. On 06/20/24 at 11:20 AM, a telephone interview was conducted with Registered Nursing Supervisor #1 who worked the evening shift on 3/27/2024 who stated that they when they receive narcotics from the Pharmacy they count the narcotics, log the date, time medications received, the name and dosage of the medications, the number pills received, and the amount of blister packs received into the narcotic logbook in the nursing office, and then they sign the book. They then take the narcotic book and the narcotics to the nurse on duty on the unit. The nurse on the unit will sign that they received the narcotics in the book and include the amount and the number of blister packs received. After handing over the medications and the book is signed, the Registered Nursing Supervisor #1 stated they will ensure that the nurse places the narcotics into the double locked narcotic box on the unit. Registered Nursing Supervisor #1 stated on 3/27/2024 they received narcotics from the pharmacy and gave Licensed Practical Nurse #3 60 Percocet 5/325 tablets and 60 Oxycodone 10 mg tablets, two blister packs each for Resident #232 and #334. Registered Nursing Supervisor #1 also stated that after ensuring that the narcotic was locked in the narcotic box, they left Licensed Practical Nurse #3 and did not see what the nurse documented on the resident's narcotic sheets on the unit. Registered Nursing Supervisor #1 further stated they worked with Licensed Practical Nurse #3 before and there were no complaints from staff or residents. Registered Nursing Supervisor #1 stated they are the only supervisor in the building and monitors the staff by making rounds on each unit, and staff calls them if there are any issues. On 06/20/24 at 11:54 AM, a telephone interview was completed with The Director of PharMerica Pharmacy, who provides medication for the facility. The Director of Pharmacy stated once the facility placed an order for prescription, example a narcotic, it is received by the Pharmacy electronically. the Pharmacist will look at the order and then fill the order. The Director of Pharmacy stated then the medication is picked up by the courier, and the courier will deliver the medication to the facility. The courier is instructed to look for the Nursing Supervisor, who will count the medication and signed that they received the medications as ordered. The Director of Pharmacy stated that once the medication delivered to the facility and the signature is received, the courier's job is completed. The Director of Pharmacy stated they were not made aware of any diversion of narcotics or missing narcotics from this facility and the State Surveyor's call is the first time they are hearing about any diversion from the facility. On 06/21/24 at 04:34 PM, a telephone interview was completed with Licensed Practical Nurse #3, who stated they are the regular nurse for the evening shift. Licensed Practical Nurse #3 stated they were called downstairs on 3/28/2024 by the Director of Nursing and was shown video footage but they did not take any pills home and the garbage bag was tied and so they may have thrown the blister pack out with the garbage. Licensed Practical Nurse #3 also stated they have never taken the medication home from the facility. Licensed Practical Nurse #3 further stated no one saw Licensed Practical Nurse #3 leave the facility with any blister pack or put a blister pack in Licensed Practical Nurse #3's bag. Licensed Practical Nurse #3 stated may have thrown out the blister pack with the garbage. Licensed Practical Nurse #3 denies in pain and kept repeating I did not take any pills. Licensed Practical Nurse #3 stated they did get arrested and was let go by the facility. Licensed Practical Nurse #3 did not respond when asked why they documented 30 pills were received instead of 60. 10 NYCRR 415.18(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility did not ensure a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and includes the resident's goals, desired outcomes, and preferences was developed. Specifically, a comprehensive care plan was not developed for a resident with a diagnosis of diabetes mellitus. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a sample of 35 residents. (Resident #77) The findings are: The facility policy and procedure titled Care Plans - Preliminary dated 12/20/2021 documented a preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. The facility policy and procedure titled Care Plans - Comprehensive Care Planning dated 12/20/2021 documented the facility will develop a comprehensive, person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs which are identified in the comprehensive assessment and lead to the resident's highest obtainable level of independence. The Care Planning/Interdisciplinary Team is responsible for the development of the comprehensive care plan. An initial care plan will be developed within 48 hours of admission to the facility and will include initial Discharge Planning. A comprehensive and interdisciplinary care plan will be developed within 7 days of admission. Resident #77 was admitted to the facility with diagnoses that included Diabetes Mellitus, Atrial Fibrillation, and Atherosclerotic heart disease. The admission Minimum Data Set (MDS) dated [DATE] documented resident was cognitively intact and had an active diagnosis of Diabetes Mellitus. Physician Orders dated 3/12/2022 renewed on 5/16/2022 documented Metformin 1,000 mg tablet give 1 tablet (1,000 mg) by oral route 2 times per day with morning and evening meals for diabetes mellitus. Documentation History documented that medication was administered as ordered and was last received on 5/20/2022. Physician's Orders dated 3/11/2022 and renewed on 5/16/2022 documented Blood Sugar Monitoring three times daily. Review of vital signs monitoring from 3/12/2022 - 5/20/2022 documented that blood sugar monitoring was done as ordered. There was no Comprehensive Care Plan for Diabetes Mellitus in place in the medical record. On 05/24/22 at 03:56 PM, an interview was conducted with the RN Manager (RN) #2. RN #2 stated that upon admission a care plan is initiated by the supervisor that is on shift. All supervisors from other shifts revise and update the care plan. Care plans are done based on the resident's medication, diagnoses, and other concerns. RN #2 also currently RNs on the floor are not responsible for initiating care plans and only do revisions as they are new to the unit. RN #2 stated that Resident #77 should have had a care plan for Diabetes care but they may have missed creating one. RN #2 further stated that there was a discharged Diabetes Care Plan from a previous admission which this would not be acceptable because it is no longer active. On 05/25/22 at 12:23 PM, an interview was conducted with the Director of Nursing (DON). The DNS stated that nursing is supposed to initiate care plans and review them quarterly, annually, and with change of condition or acute condition. Care plans are done according to disciplines and only RNs can initiate nursing a care plan. The DON also stated Nurses communicate with nursing supervisor for care plan initiation and if a resident is missing a care plan, then the RN is responsible for initiating the care plan. The DON further stated that she thought there was already an active care plan for diabetes in addition to the inactive one and that staff informed them that the care plan was not there because the resident was no longer receiving insulin. 415.11(c)(1)

Based on observations, record review, and interviews conducted during the Recertification survey from 5/18/2022 to 5/25/2022, the facility did not ensure safe food handling and storage were practiced to prevent food-borne illness. This was evident during observation of the facility Kitchen. Specifically, several expired food items were observed in the Kitchen refrigerators. The findings are: The facility policy titled Food Storage revised 2/15/2022 documented foods removed from original packaging must be dated with expiration dates, and leftover food is used within 3 days or discarded. On 05/18/2022 at 09:17 AM, the Kitchen reach-in refrigerator was observed with the following labeled items: one honey thick orange juice cup expiration 5/4/2022; one nectar thick water cup expiration 5/6/2022; five nectar thick water cups expiration 5/10/2022; two cottage cheese cups, two nectar thick water cups, and two nectar thick apple juice cups expiration 5/15/2022; one nectar thick apple juice cup, three 4-ounce Lactaid milk containers, and three 4-oz cottage cheese cups expiration 5/17/2022. The dairy refrigerator was observed with a 5-pound unopened container of cottage cheese with an expiration date of 4/21/2022. On 5/18/2022 at 10:03AM, the Dietary Aide (DA) was interviewed and stated the DA is responsible for preparing 4-ounce cups of thickened liquids and cottage cheese. The DA checks the expiration dates on prepared items in the fridge every other day and last checked 3-4 days ago. Expired items are disposed to promote food safety. On 05/18/2022 at 10:05AM, the Assistant Food Service Director (AFSD) was interviewed and stated the AFSD checks the expiration dates on prepared food items every evening at the end of their shift. The AFSD did not check the refrigerators yesterday or today. On 05/18/2022 at 10:12AM, the Food Service Director (FSD) was interviewed and stated the FSD makes daily rounds in the morning, afternoon, and evening and checks the expiration dates of prepared food in the fridge. It is everyone's responsibility to dispose of expired food in the kitchen. 415.14 (h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review and interview during the Recertification Survey, the facility did not ensure that a person-centered care plan with measurable goals and time frames and interventions was developed to address a resident's medical needs identified in the comprehensive assessment. Specifically, there was no documented evidence that the comprehensive care plan included measurable goals, objectives and interventions to address for a resident with a Urinary Catheter. This was evident for one (1) of two (2) Residents investigated for Catheter Care. (Resident # 165). The finding is: Resident # 165 is a [AGE] year old admitted on [DATE] with diagnosis that included 'Retention of Urine. The Annual MDS ARD of 05/26/19 documented the resident has being able to be understood and understands, with moderate to severe cognition. The resident requires extensive assistance from staff with activities of daily living. The It is alsot documented that the resident at the time of the assessment had an indweling urinary catheter with a diagnosis of Retention of Urine. Several observations made on 06/18/19 at 12:07 PM during lunch and on 06/20/19 at 10:58 AM during activities, found sediment urine from inside the catheter tubing, which extended out from inside of his right bottom pants leg, as he sat in the dining room area. There was no documented evidence for a Care Plan with measurable goals and interventions for Catheter Use. The Registered Nurse Manager (RNM) # 1 for the unit was interviewed on 06/21/19 at 9:13 AM and stated that she is responsible for ensuring that the car plans are developed. The care plans are important because that is what drives the care and treatment of the residents. We update the care plans as needed and we also review and revise them quarterly during the care planning meetings. The RNM stated that she does not know how she missed, but that the care of monitoring the output and staff reporting changes including maintaining catheter care protocol, including visits made by the Genitourinary physician are maintained. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review and interview the facility did not ensure that infection control practices were maintained. Specifically, a resident who has an physician order to be on contact precautions did not have clear signage to the resident's room either identifying the category of transmission-based precautions, instructions for use of Personal Protective Equipment (PPE), and/or instructions to see the nurse before entering. This was evident for one (1) resident investigated for Infection. (Resident # 65). The finding is: Review of the facility policy and procedure for, Infection Control, dated 03/28/19 documented that, When Transmission Based Precautions are implemented, the designee shall, Post the appropriate notice on the room entrance door . Observations on 06/20/19 at 12:04 PM found a visitor in the the room of the resident who was on contact precautions. The visitor was observed sitting close to the resident, talking with the resident, both were eating a sandwich. The visitor did not have on a gown or gloves. The signage was not on the residents room door. The signage was observed on top of the cart outside the residents room, behind a large container of antibacterial wipes. The signage was not visible and partially blocked by the antibacterial container. The signage on the cart read, 'Attention see nurse before entering room. The cart contained Personal Protective Equipment including gloves, and gowns. Resident is a [AGE] year old admitted on [DATE] with an initial admission on [DATE]. Review of the Minimum Data Set (MDS) Assessment Reference Date (ARD) 04/07/19, documented clear speech, understood, understands with a Brief Interview of Mental Status (BIMS ) of 15/15. Diagnosis included Multi-drug Resistant Organism (MDRO), and Wound Infection of Left Hip. Review of the current physician orders dated 06/12/19 documented Contact Precautions -Methicillin- Resistant Staphylococcus Aureus (MRSA)- in the wound of the left hip. On 06/20/19 at 12:14 PM the visitor was interviewed and she stated that she did not see a sign on the door, but if she had, she would have gone first to the nurse. The visitor stated that she has now been instructed to wash her hands, and put on a gown and gloves before entering her friends room. She stated that she had not seen her friend for some time and was sharing a sandwich with her and catching up on things. The visitor stated that she is to remove her gown gloves and wash her hands before leaving the room. The signage was observed on the door of the resident at 12:15 PM on 06/20/19. On 06/20/19 at 12:20 PM the Licensed Practical Nurse (LPN) # 1 was interview and stated that the sign must have fallen from the door. The sign should have been placed back up where it is visible to all visitors and staff. Its an infection control prevention procedure for residents on who are contact precautions. I make rounds to ensure that my residents are 'OK, and that the Personal Protective Equipment (PPE) supplies are accessible and that signs are posted and visible. She stated that the nasal swab results are pending. On 06/21/19 at 11:08 AM the resident was interviewed and she stated that the sign that is currently on her door is not always there, its on and off, she further stated her wound to her hip is now closed. She attends the infectious disease doctor. She was told a while ago that her wound was infected which is why the sign on the door was placed (sometimes). She stated that her visitor yesterday did not know that she had to wear gown and gloves and was very upset about this. I too was upset because the sign is not always visible so I was not sure what to think. On 06/21/19 at 12:45 PM the Registered Nurse Unit Manager (RNM) # 1 was interviewed and stated that the resident is on contact precautions from her recent re-admission because of her open hip wound. She is followed up by the Infectious Disease doctor and currently awaiting nasal swab results. She stated that she makes her rounds to ensure the unit and residents on contact precautions and staff and maintaining infection control protocols. We have to minimize the spread by ensuring residents, staff and visitors are educated on prevention protocols. 415.19(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification Survey, the facility did not ensure that a resident was cared for in a manner that maintained or enhanced his or her dignity. Specifically, residents with a catheter were observed in common areas with visible urine-filled catheter tubing. This was evident for 2 of 2 residents reviewed for Catheter Care (Residents #162 and #165). The findings are: Review of the facility policy and procedure, titled, Foley & Suprapubic Care, dated 07/11/2018, documented the use of a dignity bag when out of bed. 1) Resident #162 was re-admitted on [DATE] with diagnoses which include Neurogenic Bladder. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had clear speech and understands. The resident had a Brief Interview of Mental Status (BIMS) score of 09/15, indicating moderately impaired cognition. Several observations made on 06/18/19 at 12:24 PM and on 06/20/19 at 11:39 AM found the resident in the dining room, during a lunch meal and during activities, with cloudy urine visible through the clear catheter tubing. The tubing was seen coming from out underneath the bottom of the the right leg pants and connected to a urine bag, which was covered. The tubing was observed in this manner during both dates of observations. On 06/20/19 at 11:39 AM, the resident was interviewed. The resident stated that he has never had a leg bag placed on him when he is out of bed. The resident could not clearly state how he felt about having his urine exposed through catheter tubing. The Care Plan for Catheter Use dated 03/20/2017 documented that a leg bag should be used when the resident is out of bed as one of the interventions. The CNA Accountability Record dated June 2019 documented no instructions for a leg bag to be placed on resident. On 06/20/19 at 12:07 PM, the assigned Certified Nurse Aide (CNA #2) was interviewed. She stated that Resident #162 has been assigned to her for some time. She stated that she had never placed a leg bag on the resident before today. She stated that she placed a leg bag on the resident today because she was instructed to do so by her nurse. She later stated that she should know to place a leg bag on the resident when they are out of bed because no one wants to have their urine being seen out in public. 2.) Resident #165 was admitted on [DATE] with the diagnosis of Retention of Urine. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented a BIMS of 07/15, indicating the resident had moderately to severely impaired cognition. The resident had clear speech and was usually understood and understands. Several observations made on 06/18/19 at 12:07 PM, during lunch, and on 06/20/19 at 10:58 AM, during activities, in the dining room. There was sediment urine visible inside the catheter tubing that extended out from the inside of the right bottom pants leg. The CNA Accountability Record dated June 2019 documented no instructions for a leg bag to be placed on resident. On 06/21/19 at 11:30 AM, the assigned the Certified Nurse Aide (CNA #1) was interviewed. She stated that she has been assigned to Resident #165 for a long time. She stated that the resident has always had a Foley catheter in place. The CNA stated that she has never had a leg bag to place on the resident when he is out of bed. She stated a leg bag would be better because it would allow for more privacy. She further stated that she had asked for a leg bag from the a nurse who is no longer employed at the facility about a year ago. She was told at that time that leg bags are not being used. The CNA stated that she did not pursue the issue. A later interview with the CNA on 06/24/19 at 9:09 AM stated that she should have known to use a privacy bag when catheters are in use. On 06/21/19 at 8:45 AM, the Licence Practical Nurse (LPN #1) was interviewed. She stated that privacy bags are kept in stock and that the CNAs should know that leg bags are to be applied when a resident is out of bed. The LPN stated that she makes random rounds and looks her her residents for cleanliness, odor, grooming and treatment by staff. She has not observed the urine in the tubing while in the dining room area before. She stated that this is a dignity issue which should be maintained. The Registered Nurse Manager (RNM #1) on the unit was interviewed on 06/21/19 at 9:13 AM. The RNM stated that she reviews the CNA Accountability Record on a quarterly basis together with the Care Plans to ensure continuity of care and planning, during the care planning meetings. Information on the CNA accountability should match the needs of the residents, otherwise how would the CNAs know. It is the facility protocol to apply leg bags on residents with catheters to maintain their dignity and existence as humans beings. She further stated that she makes random rounds on her two units to ensure residents are being cared for and treated well. She stated that she had not noticed exposed catheter tubing when making her rounds. On 06/21/19 at 11:37 AM, the Director of Nursing (DON) was interviewed. She stated that her role is to ensure that the State and Federal requirements are met. She attends monthly corporate meetings that keeps her informed as to the trends and changes with outside agencies, such as the New York State Department of Health; Centers for Medicaid and Medicare; Infection Control requirements; Education for the CNAs and more. She makes facility rounds throughout the building, going room to room using an audit tool she developed. She checks to see what the environment looks like, if it is clean, with odors. The audit tool, titled Environmental Rounds Audit Tool, is a tool that she developed to ensure that the residents and the environment are in good shape. The facility protocol is to provide residents with catheters with dignity bags when they are out of their rooms, including the use of leg bags. The CNAs know to use these as this is part of their training,and they provide in-services on this as well. The residents are to be provided with dignity and the facility must preserve this right. 415.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification Survey, the facility did not ensure that residents' privacy and confidenciality were maintained. Specifically, residents with a catheter were observed in common areas with visible urine-filled catheter tubing. This was evident for 2 of 2 residents reviewed for Catheter Care (Residents #162 and #165). The findings are: Review of the facility policy and procedure, titled, Foley & Suprapubic Care, dated 07/11/2018, documented the use of a dignity bag when out of bed. 1) Resident #162 was re-admitted on [DATE] with diagnoses which include Neurogenic Bladder. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had clear speech and understands. The resident had a Brief Interview of Mental Status (BIMS) score of 09/15, indicating moderately impaired cognition. Several observations made on 06/18/19 at 12:24 PM and on 06/20/19 at 11:39 AM found the resident in the dining room, during a lunch meal and during activities, with cloudy urine visible through the clear catheter tubing. The tubing was seen coming from out underneath the bottom of the the right leg pants and connected to a urine bag, which was covered. The tubing was observed in this manner during both dates of observations. On 06/20/19 at 11:39 AM, the resident was interviewed. The resident stated that he has never had a leg bag placed on him when he is out of bed. The resident could not clearly state how he felt about having his urine exposed through catheter tubing. The Care Plan for Catheter Use dated 03/20/2017 documented that a leg bag should be used when the resident is out of bed as one of the interventions. The CNA Accountability Record dated June 2019 documented no instructions for a leg bag to be placed on resident. On 06/20/19 at 12:07 PM, the assigned Certified Nurse Aide (CNA #2) was interviewed. She stated that Resident #162 has been assigned to her for some time. She stated that she had never placed a leg bag on the resident before today. She stated that she placed a leg bag on the resident today because she was instructed to do so by her nurse. She later stated that she should know to place a leg bag on the resident when they are out of bed because no one wants to have their urine being seen out in public. 2.) Resident #165 was admitted on [DATE] with the diagnosis of Retention of Urine. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented a BIMS of 07/15, indicating the resident had moderately to severely impaired cognition. The resident had clear speech and was usually understood and understands. Several observations made on 06/18/19 at 12:07 PM, during lunch, and on 06/20/19 at 10:58 AM, during activities, in the dining room. There was sediment urine visible inside the catheter tubing that extended out from the inside of the right bottom pants leg. The CNA Accountability Record dated June 2019 documented no instructions for a leg bag to be placed on resident. On 06/21/19 at 11:30 AM, the assigned the Certified Nurse Aide (CNA #1) was interviewed. She stated that she has been assigned to Resident #165 for a long time. She stated that the resident has always had a Foley catheter in place. The CNA stated that she has never had a leg bag to place on the resident when he is out of bed. She stated a leg bag would be better because it would allow for more privacy. She further stated that she had asked for a leg bag from the a nurse who is no longer employed at the facility about a year ago. She was told at that time that leg bags are not being used. The CNA stated that she did not pursue the issue. A later interview with the CNA on 06/24/19 at 9:09 AM stated that she should have known to use a privacy bag when catheters are in use. On 06/21/19 at 8:45 AM, the Licence Practical Nurse (LPN #1) was interviewed. She stated that privacy bags are kept in stock and that the CNAs should know that leg bags are to be applied when a resident is out of bed. The LPN stated that she makes random rounds and looks her her residents for cleanliness, odor, grooming and treatment by staff. She has not observed the urine in the tubing while in the dining room area before. She stated that this is a dignity issue which should be maintained. The Registered Nurse Manager (RNM #1) on the unit was interviewed on 06/21/19 at 9:13 AM. The RNM stated that she reviews the CNA Accountability Record on a quarterly basis together with the Care Plans to ensure continuity of care and planning, during the care planning meetings. Information on the CNA accountability should match the needs of the residents, otherwise how would the CNAs know. It is the facility protocol to apply leg bags on residents with catheters to maintain their dignity and existence as humans beings. She further stated that she makes random rounds on her two units to ensure residents are being cared for and treated well. She stated that she had not noticed exposed catheter tubing when making her rounds. On 06/21/19 at 11:37 AM, the Director of Nursing (DON) was interviewed. She stated that her role is to ensure that the State and Federal requirements are met. She attends monthly corporate meetings that keeps her informed as to the trends and changes with outside agencies, such as the New York State Department of Health; Centers for Medicaid and Medicare; Infection Control requirements; Education for the CNAs and more. She makes facility rounds throughout the building, going room to room using an audit tool she developed. She checks to see what the environment looks like, if it is clean, with odors. The audit tool, titled Environmental Rounds Audit Tool, is a tool that she developed to ensure that the residents and the environment are in good shape. The facility protocol is to provide residents with catheters with dignity bags when they are out of their rooms, including the use of leg bags. The CNAs know to use these as this is part of their training,and they provide in-services on this as well. The residents are to be provided with dignity and the facility must preserve this right. 415.3(d)(1)(ii)

Based on observation and interview during the Recertification survey, the facility did not ensure that housekeeping and maintenance services were maintained. Specifically: 1.) chairs in resident room and in dining room were soiled, faded, tattered and torn, with duck tape to armrests. 2.) hole in wall, peeling plaster, soiled dusty curtains hanging off their hooks. 3) Dining room windows missing vertical blind slats. 4.) the 4th floor nurse station counter top with its edges with exposed inner wood material and missing pieces of the Formica covering. 5) Hoyer lift with accumulation of dirt and dust. This was evident for two (2) of (5) five resident units. (units 4 and 5). The findings are: The following was observed during the initial unit observations and subsequent date on 06/18 /19 at 10:37 AM on the 4th floor (fl) and on 06/19/19 at at 9:01 AM on the 5th fl. 4th floor unit: The Nurse Station desk top with its corners frayed exposing the inner material and missing Formica covering. The dining room area: Five (5) crimson colored chairs with torn arm rest, soiled and heavily worn fabric observed in the dining room. one (1) beige colored wooden framed chair with torn vinyl on the back of the right side of the chair. One (1) beige colored wooden framed chair with torn vinyl on the back of the right side of the chair. All windows were missing slabs from the vertical blinds. Rooms: 402: crimson colored chair with masking tape to both armrest, fabric soiled and color faded and heavily worn, 407b: soiled crimson colored chair with torn and tattered armrest. Laundry bins without lid. Windows off hook. Curtains dusty stained lining, 411: upon entrance to room, left side of wall with holes and glove bracket hanging off one hook, and broken plaster. Window curtains dusty dirty lining hanging of hooks, 414b: peeling plaster, hole in hole by head of bed, 417: Window curtains with dusty stained window curtains hanging off hook. 5th floor unit: Dining Room Area: . crimson colored chair with masking tape. . four (4) crimson colored chair with torn armrest, fabric soiled and faded. . Windows missing slabs from the vertical blinds. Rooms: 507 crimson colored chair with masking tape to both arm rest. Wooden legs stained streaked, fabric heavily faded and worn. On 06/24/19 at 9:18 AM the Director of Facility Services was interviewed and he stated that he oversees the housekeeping and maintenance and security for the building. I have many roles and am responsible for many departments. Housekeeping and Maintenance services are important for all residents/families/visitors and staff. An orderly and clean place makes us feel good and is important for infection control purposes and for the quality of life of all who reside here work here and those who visit. It is very important to have a clean comfortable and safe environment. I perform daily vertical rounds to ensure that we are meeting our objectives. I inspect rooms, units and follow up on my staff to ensure that the work assignments are being done. We currently have a electronic system which allows nursing to submit a ticket should a housekeeping or maintenance issue arise. These tickets are completed and logged. We currently are remodeling all units and in the process of replacing the blinds. The window curtains are changed monthly to be washed. I have one lead porter including one on each unit. My staff are to be reporting these issues as do nursing. Sometimes its difficult to bring all departments together but I will continue to make this my goal. On 06/24/19 at 1:33 PM the Administrator was interviewed. the Administrator stated that he is currently working with an outside contractor to remodel all units. They have completed the 2nd floor and commence again , next week. We have fired and hired new housekeeping staff. The vision is for the employees to feel like they want to be here. They will be replacing the furnitur and curtains in the rooms. He was aware of some units not meeting the standards of cleanliness, which is why he let some people go. This project will take time, but will get done. Every room will have its own look and style. 415.5(h)(4)