**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 10/1/24, the facility did not ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #41) of one resident's reviewed. Specifically, Resident #41 was not provided with a right hand and right elbow splint as planned by Occupational Therapy. Additionally, staff lacked knowledge regarding the correct application of the right elbow splint. The finding is: The policy and procedure titled Community Based Care: Contractures with effective date 4/2/24 documented that a plan of care would be developed regarding contracture management. Approaches to prevent or treat contractures may include positioning, range of motion, ambulation, application of a splint/brace, and /or therapy treatment programs. The policy and procedure titled Community Based Care: Minimum Data Set, Comprehensive Care Planning, and [NAME] Utilization with effective date 11/30/21 documented that prior to providing hands on care, staff will review the content of the [NAME] and will then provide care in accordance with [NAME] guidelines/instructions. Resident #41 had diagnoses of cerebral infarction with right sided hemiplegia (stroke with paralysis on one side of body), contracture to right elbow (loss of joint mobility), and aphasia (absence or difficulty with speech). The Minimum Data Set (MDS - an assessment tool) dated 9/6/24 documented Resident #41 had severe cognitive impairment, was rarely understood, and rarely understands, dependent on staff for all activities of daily living, and had no refusals care. The comprehensive care plan revised on 10/18/23 documented that Resident #41 had ADL self-care performance deficit related to weakness. Interventions included a right resting hand splint and right elbow extension splint to be donned (put on) by the certified nursing assistant after morning care, and doffed (to take off) before evening care. Review of the Visual/Bedside [NAME] Report (a guide used by staff to provide care) dated 9/27/24 documented under dressing/splint care Resident #41 was to have right resting hand splint and right elbow extension splint to be donned by the certified nursing assistant after morning care, doffed before evening care. Review of the occupational therapy note dated 6/13/22 documented that occupational therapy educated certified nursing assistants on proper donning technique for Resident #41's right elbow and resting hand splint. The Occupational Therapist updated Resident #41's care plan to include: right resting hand splint and right elbow extension splint to be donned by Certified Nurse Assistant after morning care, doffed before evening care. Review of the nursing progress notes dated 9/1/24 - 9/30/24 revealed there was no documented evidence that Resident #41 had refused application of the right hand and right elbow splints. During an observation on 9/25/24 at 9:57 AM, Resident #41 was lying in bed, there were no splints visualized to their right hand and right elbow. Resident #41's right thumb was touching their right index finger, and their pinky finger was bent towards the palm of the hand. During an observation on 9/25/24 at 2:53 PM, Resident #41 was observed lying in bed without their right resting hand splint or right elbow extension splint in place. Resident #41's right arm was resting to their side in a bent position. During an observation of morning care on 9/27/24 at 9:26 AM, Certified Nursing Assistant #1 provided morning care to Resident #41. Certified Nursing Assistant #1 completed care, gathered soiled items, and exited the room without applying Resident #41 splints to their right hand and elbow. During an observation and interview on 9/27/24 at 9:45 AM, Certified Nursing Assistant #1 stated Resident #41 does not get out of bed, morning care had been completed, and the resident did not need anything additional for care to be completed. Certified Nursing Assistant #1 re-entered Resident #41's room to review the closet care plan ([NAME] - guide used by staff to provide care) and stated Resident #41 was to have splints on their right hand and elbow. Certified Nursing Assistant #1 was unable to locate the right-hand splint. Certified Nursing Assistant #1 attempted to apply the right elbow splint, and stated they were unsure how to properly apply the splint and would have to get the nurse. During an observation and interview on 9/27/24 at 9:50 AM, Licensed Practical Nurse #2 entered Resident #41's room and brought in a right-hand splint. Licensed Practical Nurse #2 assisted Certified Nursing Assistant #1 with Resident #41's right elbow extension splint. Licensed Practical Nurse #2 stated they believed the elbow splint was applied correctly. Licensed Practical Nurse #2 then applied the resident's right hand splint. They stated they had not received any education on splint application. Licensed Practical Nurse #2 stated the Certified Nursing Assistant providing care to Resident #41 would be responsible for applying splints. Licensed Practical Nurse #2 stated if certified nursing assistants needed help, they would notify them, and they would assist. During an observation and interview on 9/27/24 at 10:03 AM, the Director of Rehabilitation stated Resident #41's right elbow splint had been incorrectly applied and was backwards. The Director of Rehabilitation took the elbow splint off and reapplied the splint without any difficulty. They stated Resident #41 would not get the full benefit of the splint without it being applied correctly. The Director of Rehabilitation stated Resident #41 utilized the right hand and elbow splints due to a spastic arm (stiff or rigid muscles) and the resident was at risk for further decline due to the lack of mobility. They stated the splints were utilized to reduce the risk of decline. The Director of Rehabilitation stated the nurses and certified nursing assistants were trained by therapy staff when a resident was issued a new splint/device and that annual mandatory in-services were completed. They stated the certified nursing assistants would be responsible for splint application. During an interview on 9/27/24 at 2:52 PM, Licensed Practical Nurse Manager #1 stated that Resident #41 was dependent on staff for all care needs and was unable to their make needs known. They stated the resident has had both splits for approximately two years, and they would expect that staff knew how to apply the devices correctly. Licensed Practical Nurse Manager #1 stated it was the certified nursing assistant and restorative nursing aides' responsibility to apply splints. The nurses were responsible to ensure sure the splints were on, and the care plan was followed. They stated there were no physician orders for splint application, splints were listed on the care plan, and they expected staff would follow the care plan. During an interview on 9/30/24 at 12:24 PM, the Director of Nursing stated the certified nursing assistants and licensed practical nurses were responsible for putting on splints and that the restorative nursing aides could assist if working on the floor. They stated all splints were listed on the closet care plan/[NAME], and they would expect staff to review their closet care plan before providing care. The Director of Nursing stated if certified nursing assistants were unsure how to apply splints they should ask the nurse for assistance. They stated that both the nurses and certified nursing assistants received training on splint application when a new splint was ordered and would expect staff to contact therapy for additional training if needed. They stated they would have expected staff to follow the care plan and apply devices/splints per plan of care. During an interview on 9/30/24 at 2:50 PM, Certified Nursing Assistant #2 stated splints would be listed on the resident's care plan and they would review the plan prior to providing care. They stated they had not received education on applying splints. During an interview on 9/30/24 at 3:24 PM, Certified Nursing Assistant #3 stated the restorative nursing aides applied Resident #41's splints and the nurse would remove them in the evening. Certified Nursing Assistant #3 stated they would notify the nurse or therapy if a resident did not have their splints on and was unsure how to apply them. They stated they have not received any training on splint application. During an interview on 9/30/24 at 3:46 PM, Licensed Practical Nurse #4 stated the nurse team leaders and supervisors were responsible to ensure certified nursing assistants were following the care plan and applying splints. They stated that the nurses and therapy department should make sure splints were applied correctly. Licensed Practical Nurse #4 stated they would contact therapy or their supervisor if they were unsure how to apply a splint/device. During an interview on 10/1/24 at 9:01 AM, the Administrator stated that they would expect staff to visualize and read the care plan before providing care. They stated they would expect staff to review all details of the care plan to provide safe care, they would expect staff to follow the care plan and report any discrepancies. 10 NYCRR 415.12 (e)(2)

Based on interview and record review conducted during a Standard survey completed 2/14/23, the facility did not inform the resident's representative of a need to alter treatment significantly for one (Resident #29) of one resident reviewed for notification of change. Specifically, Resident #29 developed an unstageable pressure ulcer (a skin injury due to pressure where the wound base cannot be visualized due to slough or eschar [dead tissue]) to the coccyx (tail bone) and there is no documented evidence the responsible party was not notified of the development, status or treatment to the wound. Additionally, the resident had an order for an antibiotic medication for the wound and there is no documented evidence the responsible party was notified of the need for the antibiotic use. The finding is: The policy and procedure (P&P) titled Notification of a Significant Change in Condition effective date of 1/2023 documented the resident/responsible party should be informed of provider notification related to a significant change in condition. The P&P documented that communication should be reflected in the medical record and will include date, time, person notified, the time the calls were returned, a description of the information communicated to the provider, and the actions requested by the provider. The P&P further documented that if unable to contact the responsible party this information should be communicated during the hand off and should be documented. 1.Resident #29 had diagnoses including hemiplegia (weakness or paralysis on one side of the body) following a cerebral infraction (a lack of blood supply to the brain), aphasia (disorder affectioning the ability to communicate) and dementia. The Minimum Data Set (MDS-a resident assessment tool) dated 5/10/22 documented Resident #29 was absent of spoken words, rarely/never understood, rarely/never understands and had severe impairment of cognitive skills. The MDS documented that Resident #29 had one unstageable pressure ulcer due to slough or eschar. The Comprehensive Care Plan (CCP) with a revised date of 3/11/22 documented Resident #29 had skin impairment of an unstageable area to the coccyx on 3/10/22. Interventions included that the resident was to have two incontinent pads in bed, administer treatments as per the medical provider's orders, heel booties while in bed, notify the nurse if the dressing to the coccyx was loose or off, keep skin clean and dry, turn and position every 2-4 hours and as needed and place a wedge under back to hold resident to a side laying position. Review of the Daily Wound UDA dated 3/9/22 at 10:14 PM, documented that Resident #29 was noted to have a bleeding, black, gray and white open wound to their sacrum. Review of the Weekly RN (Registered Nurse) Wound notes documented Resident #29 had an unstageable area to their coccyx: -3/10/22 at 4:30 PM, measured 4.0 centimeters (cm) by 5.0 cm by less than 0.1 cm. -4/11/22 at 5:10 PM, measured 5.0 cm by 5.0 cm by less than 0.1 cm. The note documented that the area was larger in size and an antibiotic medication was started. -4/14/22 at 2:27 PM, measured 4.6 cm by 6.8 cm by less than 0.1 cm. The note documented that the Nurse Practitioner (NP) attempted to debride slough. -4/28/22 at 11:29 PM, measured 5.4 cm by 6.5 cm. The notes documented that the area was assessed with the NP present and there was no documented evidence that Resident #29's family was notified of the initial visualization or worsening in the measurements of the wound or the attempted debridement of the wound by the NP. Review of the Medication Administration Record (MAR) documented that Resident #29 had an order for a brand named ointment to that removes dead tissue to coccyx topically every day shift and as needed for wound care from 3/11/22 until 6/15/22. The MAR documented that Clindamycin (an antibiotic medication) 300mg three times a day was ordered from 4/11/22 until 4/16/22 for the unstageable wound. Review of the Progress Notes dated 3/8/22 through 5/3/22 revealed no documented evidence that Resident #29 family was notified of the resident's unstageable pressure ulcer or the need for antibiotic medication. Review of the Medical Provider Notes date 3/10/22 through 5/3/22 revealed no documented evidence that Resident #29's family was notified of the resident's unstageable pressure ulcer or need for antibiotic medication. During a telephone interview on 2/8/23 at 3:11 PM, Resident #29's Health Care Proxy (HCP) stated they were not notified that Resident #29 had a pressure ulcer. The HCP stated that Resident #29 developed a pressure ulcer in March of 2022 and the facility did not notify them. Resident #29 had a pressure ulcer until approximately May or June when they came into town to visit the resident. During a telephone interview on 2/14/23 at 9:17 AM, RN #2, former unit manager of the second floor, stated they could not answer any questions due to that they had not worked at the facility in six months, and they did not have access to any of their nursing notes. During an interview on 2/14/23 at 10:24 AM, RN Care Coordinator (CC) #1 stated that they were responsible for rounding with the NP for skin rounds weekly and as needed. RN CC #1 stated that when a resident had a new or worsening skin wound the residents responsible party would be notified either by the unit manager or themselves. RN CC #1 stated that the conversation with the responsible party should also be documented in the medical record. RN CC #1 stated they had never spoke to Resident #29's HCP on the telephone but they had discussed Resident #29 wound status with the HCP while they were visiting Resident #29 in person. During an interview on 2/14/23 at 10:56 AM, the Director of Nursing (DON) stated that they could not locate any documented evidence that the HCP was notified of the new, worsening or treatment for Resident #29's pressure ulcer. The DON stated that the HCP should have been notified by the nurse manager, RN or NP. The DON stated that the notification should have been documented in the medical record and did not know why it was not. During an interview on 2/14/23 at 1:29 PM, the Administrator stated a new, worsening, improving skin wound or a skin wound that had treatment change would be considered a change in condition. The Administrator stated that if a resident had a change in condition they would expect the family to be notified by supervisor, unit manager or the staff member that discovered the change. 10 NYCRR 415.3(f)(2)(ii)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 2/14/23, the facility did not ensure that the resident is free from physical restraints for the purposes of discipline or convenience, and that are not required to treat the resident's medical symptoms when the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. Specifically, for one (Resident #14) of one resident reviewed, staff did not release the seat belt restraint every 2 hours and perform passive range of motion (PROM- exercises performed on the resident by nursing staff) to bilateral extremities on 2/13/23 as ordered by the physician and per the plan of care. The finding is: The facility policy and procedure (P&P) titled Community Based Care: Restraints effective 11/18/21, documented the purpose was to provide restraint free care while protecting resident safety, comfort, and well-being. Restraints will only be used when all other interventions have been exhausted and the patient/resident posed harm to self and/or others. If restraints are used, they must be the least restrictive for the least amount of time, and an on-going evaluation of need for use will occur. If a resident is restrained, resident status and ongoing evaluation of need will be conducted and documented every (q) two (2) hours (hr). The State Operations Manual issued 10/21/22 defined a physical restraint as any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body and cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to their body. Examples of the facility practices that mean the definition of physical restraint include but not limited to using devices in conjunction with a chair, such as belts, that the resident cannot remove and prevents the resident from rising. 1. Resident #14 had diagnoses which included dementia, repeated falls, and diabetes. The Minimum Data Set (MDS-a resident assessment tool) dated 12/12/22 documented the resident had severe cognitive impairment, required extensive assistance of one staff for transfer and toileting and had no falls since the prior assessment. The MDS was not coded for restraint use during the look back period. The Comprehensive Care Plan (CCP) documented the following: -On 12/16/21, the resident was a high risk for falls r/t gait/balance problems. Interventions included do PROM to bilateral lower extremities (BLE) for 10 minutes when releasing the seat belt q2hrs. -On 4/13/22, the resident used physical restraints (seat belt in Broda-a positioning chair that prevents skin breakdown) related to (r/t) wandering, and history of falls with fractures. Interventions included release restraint q2hr and ambulate using walker. The Visual/Bedside [NAME] Report (guide used by staff to provide care) dated 2/14/23 and identified as current by the Assistant Director of Nursing/Infection Preventionist (ADON/IP), documented to do PROM to BLE for 10minutes when releasing seat belt q2hrs; keep in broda chair at all times (AATs) when out of bed (OOB), keep at nurses station for monitoring as able with opportunities to ambulate as needed (PRN); release restraint q2hrs and ambulate using a walker, per physical therapy, seat belt when OOB in broda chair, document and release every 2hrs while OOB and for toileting. Review of the physician Order Listing Report documented the following: -1/25/23, Release of restraint q2hrs and as needed. Ambulate 10-15 minutes with release q2hrs for frequent falls. The order was discontinued on 2/8/23. -2/8/23, Release seat belt q2hrs, certified nurse aide (CNA) to perform PROM to BLE x10 minutes each time q2hrs when OOB. During observations on 2/10/23 at 8:56 AM and 11:41 AM, Resident #14 was sitting in their broda chair next to the nurse's station. A black seat belt was attached to the broda chair with the fastened buckle observed around Resident #14's waist. During a continuous observation of Resident #14 on 2/13/23 between 8:30 AM and 2:05 PM the following was observed: -2/13/23 at 8:30 AM, Licensed Practical Nurse (LPN) #2 came out of a room with the resident. The resident sat in their broda chair next to the nurse's station. A black seat belt attached to the broda chair with a fastened buckle was observed around the resident's waist. -2/13/23 at 8:45 AM, the resident was leaning forward trying to scoot in their chair but stopped and leaned back into chair. A black seat belt attached to the broda chair with a fastened buckle was observed around the resident's waist. -2/13/23 from 9:47 AM to 11:41 AM, the resident sat near nurse's station in the broda chair, rested with their eyes closed at times. The seat belt remained intact around their waist. -2/13/23 at 11:42 AM, the resident was wheeled in their broda chair by staff to the unit dining room for lunch. The seat belt remained intact around their waist. -2/13/23 at 11:53 AM, LPN #1 placed a clothing protector on the resident. The seat belt was not released and remained intact around their waist. -2/13/23 at 12:10 PM, Registered Nurse (RN) #4 MDS Coordinator sat next to the resident, assisted them with lunch. The seat belt remained intact around their waist during the lunch meal. -2/13/23 at 12:41 PM, the resident was wheeled back into the hall next to the nurse's station. The seat belt remained intact. -2/13/23 at 12:44 PM, the resident was fidgeting with the seat belt buckle, and called out non sensical words to staff walking by and other residents sitting nearby. -2/13/23 at 12:48 PM, CNA #2 stopped and asked the resident if they were cold. The CNA came out of the resident's room with a blanket and placed it on the resident's lap. -2/13/23 from 12:49 PM to 2:05 PM, the resident was sitting at the nurse's station in their broda chair. The seat belt remained intact around their waist. There was no release of the resident's seat belt buckle, toileting or PROM performed by staff for the resident during this continuous observation. During an interview on 2/13/23 at 1:57 PM, CNA #1 stated they were familiar with Resident #14 and their [NAME]. CNA #1 stated Resident #14 CCP was just changed from ambulation to PROM to BLE last week. Resident #14 should have had their seatbelt released and had PROM for 10 minutes q2hrs, additionally they should be checked for incontinence and/or toileted/changed. CNA #1 stated they had not had a chance to release the seat belt, toilet or do PROM, but they would have or wanted to but they were short staffed today and they all just worked together to get everything done. CNA #1 stated they had not told anyone that they were unable to release the belt, toilet or provide PROM to the resident. During an observation on 2/13/23 at 3:00 PM, Resident #14 was sitting in their broda chair next to the nurse's station. A black seat belt attached to the broda chair with a fastened buckle was observed around Resident #14's waist. During interview on 2/13/23 at 3:01 PM, LPN #6 stated the nurse was responsible for making sure Resident #14's seat belt was being released and PROM and/or toileting was being done because they are signing it off on the Medication/Treatment Administration Record (MAR/TAR). LPN #6 stated they asked CNA #1 if the belt was released, and they said yes. LPN #6 stated CNA #1 didn't tell them that they were unable to get it (their work) done. During interview on 2/13/23 at 3:10 PM, the ADON/IP reviewed Resident #14's CCP and [NAME] in the electronic medical record (EMR) and stated PROM intervention was the current plan and the responsibility of releasing Resident #14's seat belt and doing PROM for 10 minutes was a group effort. The ADON/IP stated they were not aware that Resident #14 had not had their seal belt released with PROM for 10 minutes to BLE q2hrs, nor been toileted. The ADON/IP stated they expected the CCP be followed and if staff were unable, would expect them to let someone know so they could get some help. During an observation on 2/13/23 at 3:26 PM, the ADON/IP released Resident #14's seat belt and provided PROM to BLE. The ADON/IP asked CNA #3, who was assigned to Resident #14, and if they could toilet the resident. During observation on 2/13/23 at 3:36 PM, CNA #3 took Resident #14 to their room. Resident #14 was unable to unfasten the seat belt buckle on command. During an interview on 2/14/23 at 10:00 AM, LPN #7 stated Resident #14 had a seat belt restraint because they were high risk for falls. LPN #7 stated the CNAs were responsible for releasing the belt and performing PROM. LPN #7 stated they would expect the CNAs to release the seat belt, perform PROM and offer toileting/incontinent care q2hrs, at least three times per shift. During an interview on 2/14/23 at 10:08 AM, RN #5 Unit Manager (UM) stated the resident was trialed without the use of a seat belt for some time. It was going well but then they fell again and it was reordered. RN #5 UM stated they were not aware Resident #14 had not had their seat belt released, PROM or toileting offered for greater than 6 hours on 2/13/23. RN #5 UM stated CNAs would be responsible and they would expect staff to follow the physician orders and the resident's plan of care to release the seatbelt and toilet the resident at least two to three times per shift. During interview on 2/14/23 at 12:11 PM, the Director of Nursing (DON) stated Resident #14 had a history of frequent falls with multiple fractures and had used the restraint on and off. The DON reviewed the camera footage at the nurse's station on 2/13/23 of Resident #14 as per the continuous observation documented above. The DON stated the staff should be releasing the belt and performing PROM as ordered and per the plan of care and that was not done on 2/13/23. During interview on 2/14/23 at 1:10 PM, the Nurse Practitioner (NP) stated Resident #14 had used the seat belt restraint off and on due to history of falls with fractures. The NP stated the expectation was the seat belt should be released per facility protocol and that is what staff should follow. On follow up interview 2/14/23 at 1:40 PM, in the presence of the facility Administrator, the DON stated they had completed reviewing the camera footage from 2/13/23 from 2:00 PM until 3:36 PM and Resident #14 did not have release of seat belt buckle, toileting or PROM performed by staff q2hrs as ordered by the physician and per the plan of care. The DON stated they would have expected all of that to be done. 10 NYCRR 415.4(a)(5)(i)(ii)

Based on interview and record review conducted during a Standard survey completed 2/14/23, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown source are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for one (Resident #44) of two residents reviewed. Specifically, the facility did not report an injury of unknown origin (fracture of the distal left femur) to the State Agency within the two-hour time frame, as required. The finding is: The policy titled Identification, Prevention, Investigation and Reporting of Victims of Potential Abuse, Neglect or Exploitation effective date 11/1/22 all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and no not result in serious bodily injury, to the administrator of the facility and to other officials including to the NYS Department of Health (DOH) through established procedures. 1.Resident #44 had diagnoses including fracture of the left lower end of the femur, Alzheimer's disease and chronic ischemic heart disease (narrowed arteries in the heart). The Minimum Data Set (MDS-a resident assessment tool) dated 10/24/22 documented Resident #44 was absent of spoken words, rarely/never understood, rarely/never understands and had severe impairment of cognitive skills. The MDS documented Resident #44 was a total assist of two staff members for bed mobility, transfers, dressing and toileting; a total assist of one staff member for eating and personal hygiene; and was non ambulatory. The Comprehensive Care Plan (CCP) with a revised date of 10/17/22 documented Resident #44 had self-care performance deficit and limited functional mobility related to Alzheimer's and a sacral wound infection. Interventions included that the resident was a total assist of two staff for bathing, dressing and toileting, was a total assist of one staff member for rolling in bed, a total assist of two staff for boosting with a slide sheet in bed, and a mechanical lift of two staff for transfers. Review of the Acute Progress Note dated 10/28/22 at 10:53 AM, the Nurse Practitioner (NP) documented that Resident #44's initial lab work was normal but recent lab work revealed an elevated alkaline phosphatase (enzyme found in the blood indicating if there is damage to the liver or bone). The NP documented that on 10/17/22, Resident #44 had significant edema along with bruising to the left knee. The NP documented an x-ray of the left knee was performed on 10/27/22 and revealed a fracture involving the distal femur and an orthopedic evaluation was recommended. The NP documented they spoke with the MD and NP at the resident's previous nursing facility, and they denied any history of prior recent fall or incidents. Review of the Progress Notes revealed: -On 10/28/22 at 3:25 AM, LPN #5 documented that Resident #44 x-ray report in with the Registered Nurse (RN) supervisor. See results. -On 10/28/22 at 9:25 AM, the Assistant Director of Nursing documented that Resident #44 x-ray result was positive for left distal fracture, the NP was notified, and received a new order to transfer Resident #44 to the Emergency room. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Facility Summary revealed that no report from the facility had been filed regarding the injury of unknown origin for Resident #44 on 10/28/22. During an interview on 2/14/23 at 10:41 AM, the Director of Nursing (DON) stated that they were notified of Resident #44's fracture when the x-ray was received. The DON stated that the Administrator was notified, and the fracture was discussed with the interdisciplinary team. The DON stated that they did not know how the fracture occurred to Resident #44 but after their investigation they felt it could have occurred where the resident resided prior to admission. The DON stated that any potential abuse, neglect or mistreatment should be reported to the DOH. The DON stated that they did not suspect abuse, neglect, or mistreatment due to Resident #44 had swelling and bruising to the left leg upon admission. The DON stated Resident #44 had an injury of unknown origin and a fracture would be considered a significant injury and therefore it should have been reported to the DOH. During an interview on 2/14/23 at 1:16 PM, the Administrator stated that they were notified of the Resident #44 facture and an SBAR (Situation-Background-Assessment-Recommendations) was completed as an investigation. The Administrator stated that from the SBAR investigation, Resident #44 was lowered to the floor in another nursing facility where they previously resided. The Administrator stated that the fracture likely was obtained prior to admission. The Administrator stated that if there was an injury of unknow origin they would look at the reporting manual to see if injury needed to be reported to the DOH. The Administrator stated that they did not report the fracture to the DOH because abuse, neglect or mistreatment was not suspected. 10 NYCRR 415.4(b)(2)

Based on interview and record review conducted during a Standard survey completed 2/14/23, the facility did not have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (Resident #44) of two residents reviewed. Specifically, the facility did not complete a thorough investigation of a significant injury of unknown origin (fracture of the left femur) by obtaining statements from staff members who would have transferred or cared for the resident. The finding is: The facility policy and procedure (P&P) titled Identification, Prevention, Investigation and Reporting of Victims of Potential Abuse, Neglect or Exploitation with effective date of 11/1/22, documented all cases of suspected or actual abuse, neglect, exploitation, injury of unknown origin and/or misappropriation of resident property will be reported to the immediate supervisor and an investigation will begin immediately. The P&P documented that the Director of Nursing (DON) or designee will coordinate the investigation and is responsible for maintaining and ensuring completion of all investigative documentation, including but not limited to the Occurrence Investigation Summary and Occurrence Investigation Checklist, occurrence reports, assessments, statements, and other supporting documentation. All statements gathered through investigation will be kept confidential and all evidence found during assessment/investigation will be safeguarded. 1.Resident #44 had diagnoses including fracture of the left lower end of the femur, Alzheimer's disease and chronic ischemic heart disease (narrowed arteries in the heart). The Minimum Data Set (MDS-a resident assessment tool) dated 10/24/22 documented Resident #44 was absent of spoken words, rarely/never understood, rarely/never understands and had severe impairment of cognitive skills. The MDS documented Resident #44 was a total assist of two staff members for bed mobility, transfers, dressing and toileting; a total assist of one staff member for eating and personal hygiene; and was non ambulatory. The Comprehensive Care Plan (CCP) with a revised date of 10/17/22 documented Resident #44 had self-care performance deficit and limited functional mobility related to Alzheimer's and a sacral wound infection. Interventions included that the resident was a total assist of two staff for bathing, dressing and toileting, was a total assist of one staff member for rolling in bed, a total assist of two staff for boosting with a slide sheet in bed, and a mechanical lift of two staff for transfers. Review of the Medical Provider Note dated 10/17/22 at 8:35 PM, the Nurse Practitioner (NP) documented that Resident #44 was seen for admission history and physical and had bilateral pitting edema of the lower limbs, a 17-centimeter (cm) surgical scar of the right knee and a 12-centimeter surgical scar of the left knee. Review of the Medical Provider Note dated 10/18/22 at 6:34 PM, the Medical Doctor (MD) documented Resident #44 was seen for admission history and physical and has left knee edema that was not warm to touch. Review of the Acute Progress Note dated 10/28/22 at 10:53 AM, the NP documented that Resident #44's initial lab work was normal but recent lab work revealed an elevated alkaline phosphatase (enzyme found in the blood indicating if there is damage to the liver or bone). The NP documented that on 10/17/22 Resident #44 had significant edema along with bruising to the left knee. The NP documented an x-ray of the left knee was performed on 10/27/22 and revealed a fracture involving the distal femur and an orthopedic evaluation was recommended. The NP documented they spoke with the MD and NP at the resident's previous nursing facility, and they denied any history of prior recent fall or incidents. The previous nursing facility did obtain a venous doppler (diagnostic test to check the circulation in a vein) of the bilateral lower extremities that was negative. Review of the Progress Notes revealed: -on 10/17/22 at 12:13 PM, Register Nurse (RN) #3 documented Resident #44 was transferred from another nursing facility and was nonverbal. RN #3 documented Resident #44 was sitting in a wheelchair in the hallway and had +1 pitting edema (up to 2 millimeter of depression in swelling) to left leg/foot. -on 10/18/22 at 1:41 AM, Licensed Practical Nurse (LPN) #5 documented that Resident #44's left foot had slight pitting edema and left knee appeared greater than the right with lower leg nonpitting edema. At 6:16 AM, LPN #5 documented that Resident #44 left posterior knee and thigh area had dark purple bruises. -on 10/28/22 at 9:25 AM, Assistant Director of Nursing documented that Resident #44's x-ray result was positive for the left distal fracture. The NP was notified and received new order to transfer Resident #44 to the emergency room. The note also documented that the family was notified. Review of the SBAR (Situation-Background-Assessment and Recommendations-the facility's investigation) dated 11/1/22 and signed by the DON, documented that Resident #44's x-ray on 10/27/22 revealed a comminuted and displaced left femur fracture. The SBAR documented that while Resident #44 was at their previous nursing facility their progress notes documented on 10/4/22 that their knees buckled during a transfer and on 10/6/22 a left lower venous doppler was completed due to swelling. The assessment documented that upon admission, assessments by the medical doctor and nursing that Resident #44 left knee was edematous, larger than the right and had dark purple bruising. The recommendations documented that Resident #44 was currently in the hospital. The investigation did not contain any statements/interviews from staff that would have transferred or cared for Resident #44 since their admission to the current nursing facility. During an interview on 2/14/23 at 10:04 AM, RN #3 (Director of Adult Day Care) stated that they did the admission assessment for Resident #44. They stated that they did not transfer Resident #44 and they completed the admission assessment while the resident was sitting in a wheelchair. RN #3 stated their assessment revealed that Resident #44 had +1 pitting edema to their left leg and foot. RN #3 stated that Resident #44 family members were present during the admission assessment, and their family stated that Resident #44 did not have any previous falls. During an interview on 2/14/23 at 10:24 AM, RN Care Coordinator (CC) #1 stated that along with the NP they performed a skin assessment on Resident #44 the evening Resident #44 was admitted to the facility. RN CC #1 stated that Resident #44 was laying in bed upon their assessment, and they did not transfer the resident into bed. RN CC #1 stated that Resident #44 left knee was swollen and larger than their right knee. They stated Resident #44 did not display any nonverbal signs of pain. During an interview on 2/14/23 at 10:41 AM, the DON stated that they were notified of Resident #44 fracture when the x-ray report was received. The DON stated that the Administrator was notified, and the fracture was discussed with the interdisciplinary team. The DON stated Resident #44 had an injury of unknown origin and a fracture would be considered a significant injury. The DON stated they completed an SBAR for the investigation. The DON stated that Resident #44 had been transferred to their facility from another nursing facility and Resident #44 had documented edema of their left leg upon admission. The DON stated that the Director of Therapy had access to the previous nursing facility medical record and noted Resident #44 had an incident at that nursing facility earlier that month. The DON stated that they did not know who performed a transfer for Resident #44 and they did not obtain any interviews or statements of the staff members. The DON stated that they talked to staff in general but did not obtain any staff statements but probably should have obtained statements from staff who had completed care for Resident #44. The DON stated that they concluded that the cause of the fracture was undetermined due to bruising and edema to the left leg and a fall prior to admission. During an interview on 2/14/23 at 11:15 AM, the Director of Therapy stated they were notified of the facture when the x-rays results were received. The Director of Therapy stated that Resident #44 had edema of the left leg since admission and did not have any signs and symptoms of pain during their therapy treatments. The Director of Therapy stated they performed standing exercises to Resident #44 during their therapy treatments. They stated they after review of the previous nursing facility medical record they noted there was an incident at that facility, and they stated they cannot know for sure that the fracture happened at that time. The Director of Therapy stated they talked about Resident #44 fracture as a group but that they did not obtain any statements from the therapy staff. During an interview on 2/14/23 at 1:16 PM, the Administrator stated that they were notified of the Resident #44 facture and an SBAR was completed for investigation. The Administrator stated that there may not be any written staff statement, but the fracture was discussed at morning report. The Administrator stated that from the SBAR results the fracture was likely obtained prior to admission. The Administrator stated that Resident #44 was lowered to the floor at another nursing facility, and it was likely the fracture resulted there. 10 NYCRR 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 2/14/23, the facility did not ensure that each resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain personal hygiene for one (Resident #14) of four residents reviewed for ADLs. Specifically, the lack of timely toileting/changing of an incontinent resident. The finding is: The facility policy and procedure (P&P) titled ADL Care effective 7/19/22 documented the purpose was to ensure a resident who is unable to care out ADL's receives the necessary services to maintain good nutrition, grooming, and personal hygiene. ADL's include elimination/toileting. The resident's care plan (CP) will be updated as needed (PRN) in accordance with the resident's assessed needs, goals for care, preferences, and recognized standards of practice that address the identified limitations in their ability to perform ADL's. Facility P&P titled Perineal/Incontinence Care in Subacute/LTC effective 2/25/22 documented the purpose was to provide guidelines for the performance of incontinence care. The goal being to maintain patient comfort and dignity and improve skin care status/integrity. Perineal care should be performed daily but not limited to; as part of daily bathing, after use of the bed pan and following any episode of urinary and/or fecal incontinence. All residents with incontinence will receive perineal care as per agency guidelines to promote maintenance of skin integrity and help prevent urinary tract, bladder, and kidney infections. 1. Resident #14 had diagnoses including dementia, repeated falls, and diabetes. The Minimum Data Set (MDS-a resident assessment tool) dated 12/12/22 documented the resident had severe cognitive impairment, required extensive assistance of one staff for transfer and toileting and was always incontinent of bowel and bladder. The Comprehensive Care Plan (CCP) documented the following: -On 3/8/21, had a history of urinary tract infection r/t history of incontinence, diabetes, dementia. Interventions included the nurse and Certified Nurse Aide (CNA) were to check on the resident q (every) 2 hrs (hours), turn and position (T&P) and provide incontinent care. -On 3/8/21, the resident had a history of actual impairment to skin integrity r/t fragile skin, diabetes, and incontinence. Interventions included to keep skin clean and dry. - On 3/8/21, the resident had urinary incontinence r/t dementia. Interventions included check and change for incontinence q2hrs and PRN. The Visual/Bedside [NAME] Report (guide used by staff to provide care) dated 2/14/23 and identified as current by the Assistant Director of Nursing/Infection Preventionist (ADON/IP), documented the nurse and CNA were to check on resident q2hrs, turn and position (T&P) and provide incontinent care. During a continuous observation of Resident #14 on 2/13/23 between 8:30 AM and 2:05 PM the following was observed: -2/13/23 at 8:30 AM, Licensed Practical Nurse (LPN) #2 came out of a room with the resident. The resident sat in their broda chair next to the nurse's station. A black seat belt attached to the broda chair with a fastened buckle was observed around the resident's waist. Dressed and well groomed. -2/13/23 at 8:45 AM, the resident was leaning forward trying to scoot in their chair but stopped and leaned back into chair. A black seat belt attached to the broda chair with a fastened buckle was observed around the resident's waist. -2/13/23 from 9:47 AM to 11:41 AM, the resident sat near nurse's station in the broda chair, rested with their eyes closed at times. -2/13/23 at 11:42 AM, the resident was wheeled in their broda chair by staff to the unit dining room for lunch. The resident was not offered toileting or incontinent care. -2/13/23 at 11:53 AM, LPN #1 placed a clothing protector on the resident. -2/13/23 at 12:10 PM, Registered Nurse (RN) #4 MDS Coordinator sat next to the resident, assisted them with lunch. -2/13/23 at 12:41 PM, the resident was wheeled back into the hall next to the nurse's station. -2/13/23 at 12:44 PM, the resident was fidgeting with the seat belt buckle, and called out non sensical words to staff walking by and other residents sitting nearby. -2/13/23 at 12:48 PM, CNA #2 stopped and asked the resident if they were cold. The CNA came out of the resident's room with a blanket and placed it on the resident's lap. The resident was not offered toileting or incontinent care. -2/13/23 from 12:49 PM to 2:05 PM, the resident was sitting at the nurse's station in their broda chair. The resident was not toileted or provided incontinent care during this continuous observation. During an interview on 2/13/23 at 1:57 PM, CNA #1 stated they were familiar with Resident #14 and their [NAME]. Resident #14 should be checked for incontinence and/or toileted/changed q2hrs. CNA #1 stated they had not had a chance to check for incontinence and/or toilet the resident since getting them OOB this morning, but they would have, or wanted to, but they were short staffed today. CNA #1 stated they had not told anyone that they were unable to check the resident for incontinence or toilet the resident since they got the resident OOB after morning care. During observation on 2/13/23 at 3:00 PM, Resident #14 was sitting in their broda chair next to the nurse's station. A black seat belt attached to the broda chair with a fastened buckle was observed around Resident #14 waist. During interview on 2/13/23 at 3:01 PM, LPN #6 stated the nurse was responsible for making sure Resident #14 was checked and provided incontinent care q2hrs to prevent skin breakdown because they are signing it off on the Medication/Treatment Administration Record (MAR/TAR). LPN #6 stated CNA #1 didn't tell them that they were unable to get it (their work) done. During interview on 2/13/23 at 3:10 PM, the ADON/IP reviewed Resident #14 CCP and [NAME] in the electronic medical record (EMR) and stated the nurse and CNA were to check on the resident q2hrs, turn and position (T&P) and provide incontinent care. The ADON/IP stated they were not aware that Resident #14 had not been toileted. The ADON/IP stated they expected that the plan of care be followed and if staff were unable, would expect them to let someone know so they could get some help. During an observation on 2/13/23 at 3:36 PM, CNA #3 took Resident #14 to their room. At 3:42 PM, the CNA #3 transferred Resident #14 to their bed using the sit to stand lift. While they were removing Resident #14 pants the CNA #3 stated Oh, (Resident #14) pants are wet and placed them in the hamper. The resident's brief was noted to be heavily saturated with urine, from front to back, and a small amount of brown stool was noted in the brief. CNA #3 stated they had just come in for second shift, today, but the resident should be toileted, per their [NAME], q2hrs. During an interview on 2/14/23 at 10:00 AM, LPN #7 stated the CNAs were expected to toilet incontinent residents. LPN #7 stated they would expect the CNAs to release the seat belt and offer toileting/incontinent care q2hrs. At least three times per shift. During an interview on 2/14/23 at 10:08 AM, RN #5 Unit Manager (UM) stated they were not aware toileting or incontinent care was not offered to Resident #14 for greater than 6 hours on 2/13/23. RN #5 UM stated CNAs were responsible and would expect staff to follow physician orders and the resident's plan of care, to toilet the resident at least two to three times per shift. During an interview on 2/14/23 at 12:11 PM, the Director of Nursing (DON) reviewed the camera footage at the nurse's station from 2/13/23 of Resident #14 as per the continuous observation documented above. The DON stated staff should be toileting the resident q2hrs as ordered and per the plan of care and that was not done on 2/13/23. On follow up interview 2/14/23 at 1:40 PM, in the presence of the facility Administrator, the DON stated they had completed reviewing the camera footage from 2/13/23 from 2:00 PM until 3:36 PM and Resident #14 did not have release of seat buckle, toileting or PROM performed by staff q2hrs as ordered by the physician and per the plan of care. The DON stated they would have expected all of that to be done. 10 NYCRR 415.12 (a)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 2/14/23, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #15) of three residents reviewed. Specifically, staff did not perform hand hygiene after they completed wound care to the left gluteal (buttock) unstageable (full thickness tissue loss where base of ulcer is covered by slough-yellow, tan, grey, green, or brown tissue and or eschar (black, dead tissue) pressure ulcer with a current methicillin resistant staphylococcus aureus (MRSA- an antibiotic resistant bacteria) infection, then performed wound care to the gluteal cleft unstageable pressure ulcer. Additionally, the staff used their gloved finger, not an applicator, to apply Santyl (sterile ointment to remove dead tissue) to the gluteal cleft (deep groove that lies between the two gluteal regions) pressure ulcer. The finding is: The facility policy and procedure (P&P) titled Community Based Care Handwashing/Hand Hygiene dated 9/9/20 documented a definition to decontaminate hands was to reduce bacterial and viral counts on hands by performing antiseptic hand rub or antiseptic hand wash. Indications for hand washing included after removing gloves or any physical barrier and when moving from a contaminated site to a clean site on the same resident. 1. Resident #15 had diagnoses including neurogenic bladder (bladder with diminished sensation), epilepsy, and hypertension. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 12/6/22 documented Resident #15 was cognitively intact and had four pressure ulcers, including an unstageable pressure ulcer present on admission. The comprehensive care plan dated 11/30/22 documented Resident #15 was at risk for further alteration in skin integrity, had an unstageable pressure ulcer to their left gluteal fold and gluteal cleft (as of 1/30/23). Interventions included to administer treatments per the medical provider's order. The culture report (lab test to confirm a bacterial infection) final result dated 2/7/23 at 6:15 AM, documented the left buttock swab specimen had multiple mixed flora (a community of bacteria that exists on or in the body) including moderate colonies of MRSA and may be an isolation risk. The Order Summary Report dated 2/14/23 documented an order started 2/9/23 to cleanse the unstageable pressure ulcer on the gluteal cleft included with Dakin's (topical antiseptic used to clean infected wounds) dry, apply Santyl and cover with Allevyn (absorbent dressing). An active order dated 2/1/23 for the unstageable pressure ulcer on the left gluteal fold included to cleanse with Dakin's, dry, apply skin prep (topical application that toughens skin and enhances adherence of dressing to border), pack with Dakin's soaked gauze and cover with Allevyn. During an observation on 2/10/23 at 10:25 AM, with Registered Nurse (RN) Care Coordinator (CC) #1 present, Licensed Practical Nurse (LPN) #2 washed their hands and donned (applied) gloves. LPN #2 removed the soiled dressing from the left gluteal pressure ulcer and removed the packing; the ulcer had a moderate amount of bleeding. The LPN removed their gloves, did not perform hand hygiene, donned new gloves, and cleaned the ulcer with Dakin's soaked gauze, skin prepped the skin around the ulcer, placed Dakin's soaked gauze into the ulcer and covered it with Allevyn. The LPN #2 removed their gloves, did not perform hand hygiene, donned new gloves, and removed the dressing from the gluteal cleft ulcer. LPN #2 removed their gloves, did not perform hand hygiene, donned new gloves, cleansed the ulcer with Dakin's, applied Santyl to their gloved fingertip and directly applied the Santyl to the ulcer. LPN #2 then placed the Allevyn to the ulcer. During an interview on 2/10/23 at 10:56 AM, LPN #2 stated the pressure ulcer that was packed (left gluteal fold) had the MRSA infection. LPN #2 stated they performed the left gluteal treatment before the coccyx treatment because it was harder, but it did make sense to start with the cleaner area before the dirtier area. LPN #2 stated the order didn't say to do one treatment prior to the other one. LPN #2 stated they thought as long as they changed their gloves between ulcers it was fine and didn't think they had to wash their hands between sites. During an interview on 2/10/23 at 11:01 AM, RN CC #1 stated the left gluteal fold pressure ulcer had MRSA and that ulcer should have been completed last because you don't want to infect the other ones with MRSA. The RN CC #1 stated LPN #2 should have also washed their hands between ulcer sites and not just change their gloves. During an interview on 2/14/23 at 9:02 AM, the Director of Nursing (DON) stated they would have expected the LPN #2 to wash their hands as well as change their gloves when moving from the ulcer with MRSA to the other site because you never know if there were pinpoint holes in gloves and want to start fresh with every ulcer. The DON stated they would have expected the LPN #2 to use an applicator to apply Santyl to the ulcer and not the glove. During an interview on 2/14/23 at 1:24 PM, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) stated the LPN #2 should have performed hand hygiene between the two pressure ulcer treatments because they went from a dirty area to a clean area and wouldn't want to contaminate the other ulcer. The ADON/IP stated the nurse should have used a tongue depressor or q- tip, besides their gloved finger to apply the Santyl. 10 NYCRR 415.12 (c)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 2/14/23, the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; PRN (as needed) orders for psychotropic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication for one (Resident #61) of four residents reviewed for antipsychotic (AP) medications. Specifically, PRN Haldol (an AP medication) was ordered longer than 14 days for dementia with behaviors and there was no documentation the practitioner evaluated the resident for appropriateness of the medication used beyond 14 days, there was lack of documented specific behaviors and non-pharmacological interventions attempted prior to the administration of PRN Haldol, and the Seroquel (an AP medication) dose was increased with lack of supporting behavioral documentation and rationale for the increase. Additionally, there was no care plan developed for use of antipsychotic medications to include targeted behaviors and individualized non-pharmacological interventions. The finding is: The facility policy and procedure (P&P) titled Psychotherapeutic Drug Review dated 3/5/19 documented antipsychotic medications may be indicated if multiple non-pharmacological approaches have been attempted, but did not relieve symptoms which present a danger or significant distress, identified target behaviors will be monitored each shift along with individualized interventions as well as supporting documentation in the clinical record, the goals of psychotropic medication and non-pharmacologic approaches will be addressed in the resident's care plan. The care plan will include the type of psychotropic drugs to be monitored for side effects daily. A PRN antipsychotic medication will be limited to 14 days and not renewed unless the provider evaluates the resident for appropriateness of the medication and documents in the medical record. 1. Resident #61 had diagnoses including peripheral vascular disease (PVD-decreased circulation of the lower extremities), chronic obstructive pulmonary disease (COPD), and dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 12/9/22 documented Resident #61 had moderately impaired cognition, had no behavioral symptoms and received antipsychotic medications on a routine basis. Review of the undated comprehensive care plan, identified as current by the Licensed Practical Nurse Unit Manager (LPN UM) #2, revealed there was no documented evidence Resident #61 used antipsychotic medications. During a morning care observation on 2/10/23 at 7:10 AM, Resident #61 had no behaviors and was cooperative with care. a. Review of the Clinical Physician Orders revealed an order for Haldol 5mg (milligrams)/mL (milliliter) inject 5mg intramuscularly (IM) every 8 hours PRN for restlessness/agitation started on 12/26/22 and ended on 1/9/23. An order or Haldol 5mg IM every 8 hours PRN for agitation and restlessness started on 1/11/23 and ended on 1/25/23. Review of the Medication Administration Record (MAR) revealed the following: -From 12/1/22-12/31/22 Resident #61 received Haldol IM on 12/29/22 at 10:55 PM -From 1/1/23-1/31/23 Resident #61 received Haldol IM on 1/11/23 at 7:36 PM, 1/12/23 at 8:19 PM, 1/17/23 at 5:57 PM, 1/22/23 at 2:02 AM, 1/23/23 at 1:30 AM and 10:46 PM, and 1/25/23 at 5:57 PM. Review of medical provider Progress Notes revealed the following: - 12/19/22 at 12:03 PM, there was no documentation about AP drug use or behaviors - 12/28/22 at 9:38 PM, there was no documentation about AP drug use or behaviors - 1/2/23 at 9:48 PM, there was no documentation about AP drug use or behaviors - 1/11/23 at 4:40 PM, there was no documentation about AP drug use or behaviors There was no documentation a medical provider evaluated Resident #61 for the appropriateness of the PRN AP medication when it was started on 12/26/22 or when it was renewed 1/11/23. Review of the nursing Progress Notes for Resident #61 revealed the following: - 12/29/22, there was no documentation of behaviors or that PRN Haldol was administered - 1/11/23 at 7:17 PM, LPN #4 documented the resident had increased agitation with self-transfer, attempted to hit another resident, difficulty to give care to, notified the RN supervisor, will monitor. - 1/12/23 at 9:39 PM, LPN #4 documented difficult to give care, restless, agitation self-transfer risk fall, Haldol PRN with effect. - 1/17/23 at 7:42 PM, LPN #4 documented resident was restless with agitation, self-transfer out of wheelchair, risk for fall, Haldol PRN with positive effect - 1/22/23 at 3:41 AM, LPN #4 documented the resident was restless with agitation, several times attempted to self-transfer out of bed, risk for fall, Haldol PRN with positive effect - 1/23/23 at 4:26 AM, LPN #4 documented the resident self-transferred out of bed, risk for falls, restless with agitation, rude to the staff, Haldol PRN with positive effect. - 1/25/23 at 4:56 PM, LPN #4 documented at 4:30 PM the resident attempted to self-transfer out of the wheelchair, risk for falls, refused care, resident took their shirt off, wanted to go home and was verbally abusive. There was no documentation of non-pharmacological interventions attempted prior to the administration of the PRN Haldol. Review of 24-Hour Reports dated 1/12/23, 1/17/23, 1/22/23, 1/23/23, and 1/25/23 revealed there was no documented non- pharmacological interventions attempted prior to the administration of PRN Haldol. b. Review of the Clinical Physician Orders revealed an order for Seroquel 25mg 1 tablet at bedtime started on 10/13/22 and was discontinued on 12/15/22, Seroquel 25mg give 2 tablets (50mg) in the evening was started 12/16/22 and discontinued on 1/20/23. Review of the MAR dated 12/1/22-12/31/22 revealed Resident #61 received Seroquel 25mg from 12/1/22 until 12/14/22 and received Seroquel 50mg in the evening from 12/16/22 to 12/31/22. The MAR dated 1/1/23-1/31/23 revealed the resident received Seroquel 50mg in the evening from 1/1/23 to 1/19/23. Review of the Psychotropic Drug Review dated 11/13/22 revealed Resident #61 received Seroquel 25mg at bedtime for dementia with behaviors, was on the medication since admission and had a GDR on 8/11/22. The reason for using the AP drug was sleep induction, depression, and organic mental syndrome (i.e., dementia and other cognitive disorders with associated psychotic and/or agitated behaviors. Symptom description included restlessness and self-transfers. There was no documentation whether the behaviors were persistent, caused by preventable reasons or if the behaviors were causing the resident to present danger to themselves or others. The Psychotropic Drug Review dated 12/20/22 revealed the resident received Seroquel 50mg in the evening for dementia with behaviors, which was increased on 12/16/22. The reason for using the AP drug was sleep induction, agitation, and organic mental syndrome. The behavior section documented no concerns reported or noted. Review of medical provider Progress Notes for Resident #61 revealed the following: - 12/12/22 at 10:07 PM, no documentation about AP drug use or behaviors - 12/19/22 at 12:03 PM, no documentation about AP drug use or behaviors There was no documentation of a rationale for the increase in Seroquel medication. Review of the nursing Progress Notes for Resident #61 revealed the following: - From 12/15/22 to 12/31/22 there was no documentation about the increase in Seroquel dose and no documentation of any behaviors. Review of the Consultant Pharmacist Review: Nursing Communication dated 1/9/23 documented Resident #61 was on Seroquel 50mg daily and was recently increased to the current dose. Recommended to monitor and document their mood/behavior with changes to the medication regimen for 14 days. During a telephone interview on 2/10/23 at 4:25 PM, LPN #4 stated Resident #61 was ok during the day but in the evening their behavior changed. Sometimes it was hard to provide care. LPN #4 stated they didn't like to use Haldol but for the resident's and caregivers' safety they had to use it. LPN #4 stated the resident's behaviors were agitation, was verbally abusive, tried to hit and kick staff when they gave care. LPN #4 stated they would try to toilet the resident, give food or drinks, and call family. The LPN #4 stated maybe their documentation didn't include all their actions they tried for the resident, and they should document more. During an interview on 2/13/23 at 9:52 AM, the LPN UM #2 stated Resident #61 was admitted on AP medication for depression and anxiety, and dementia with behavior concerns that happened more at nighttime with hands on care. LPN UM #2 stated staff should always reapproach the resident or try more therapeutic things like one on one before they used AP medication. LPN UM #2 reviewed progress notes in the EMR (electronic medical record) and stated they only saw wound treatment notes documented by the medical provider in December when the Seroquel was increased. LPN UM #2 stated usually the nurse practitioner (NP) documented about medication changes, on 12/14/22 it was documented the resident self-transferred, but AP medication shouldn't be used for self-transfers. LPN UM #2 stated they didn't see anything in the care plan about use of AP medications and usually the Director of Nursing (DON) deals with the care planning. The LPN UM #2 stated staff should be documenting specific interventions they tried prior to giving the PRN AP medication and the behaviors that required using the medications. During an interview on 2/13/23 at 1:08 PM, the Nurse Practitioner (NP) stated Resident #61 became irate in the evening, combative with hands on care mostly. The NP stated they order Haldol when residents are a risk to themselves or others, if striking at other residents or trying to harm themselves by getting out of their wheelchair and walk. Also stated orders for PRN AP medications were limited to 14 days and they physically examine the resident in the 14 days. The NP stated after 14 days the PRN AP wouldn't get reordered unless behaviors were escalating. The NP stated they were in the facility daily including evenings and had witnessed the resident's behaviors and the staff interventions. The NP stated they knew they needed to document better. During an interview on 2/13/23 at 1:17 PM, the Consultant Pharmacist stated the resident was on Seroquel for dementia with behaviors including combativeness with hands on care. They had reviewed the resident monthly in BMARC (behavior modification assessment record committee) and had reduced other psychoactive medications that were ordered, recently ordered a different AP medication and were trying to figure out the best medication regimen. During an interview on 2/14/23 at 9:07 AM, the DON stated they would expect staff to document the specific behaviors a resident had prior to giving a PRN AP medication. The DON stated non-pharmacological interventions vary depending on the resident. Resident #61 was very combative with care for a while, has since calmed down and sometimes it was hard for staff to try other things for a resident prior to giving Haldol because they were uncontrollable. The DON stated they would expect the NP to document the reason for extending any 14-day PRN AP medication. The DON stated would expect the care plan to address AP medication use and interventions should include monitoring for side effects. The DON stated the December BMARC documented no concerns because the medication was working for the resident. During further interview on 2/14/23 at 12:40 PM, the Consultant Pharmacist stated they recommended behavior charting because of the increased dose of Seroquel in December and wanted to make sure if the resident had behaviors they were documented. The Consultant Pharmacist stated the NP did see the resident during the medication changes, however notes were mostly about their wound. The Consultant Pharmacist stated they review so many residents at the BMARC meetings, especially focusing on AP use, that the notes of those meetings weren't very complete, and they were trying to streamline that process. 10 NYCRR 415.12(l)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 9/10/21, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one (Resident #9) of one resident reviewed. Specifically, there were no physician's orders for tracheostomy (an opening in the neck to put a tube into a person's windpipe allowing air to enter the lungs) care. The finding is: The facility policy titled Community Based Care/TLC Resident Tracheostomy Care dated 10/2020 documented a physician's order was necessary to perform tracheostomy care. 1. Resident #9 was admitted to the facility with diagnoses which included chronic respiratory failure with hypoxia (absence of enough oxygen to sustain bodily functions), tracheostomy and anoxic (complete loss of oxygen supply) brain damage. The Minimum Data Set (MDS- a resident assessment tool) dated 5/28/21 documented Resident #9 was cognitively impaired and totally dependent with care needs. The Comprehensive Care Plan (CCP) dated 1/15/21 documented Resident #9 had a tracheostomy related to chronic respiratory failure with hypoxia. Interventions included to provide trach care as ordered. Review of the Medication Administration Records (MARs) and the Treatment Administration Records (TARs) for Resident #9 from 1/15/2021 to 9/9/2021 revealed no there were no physician's orders for tracheostomy care. Review of an Order Listing Report for active, completed, and discontinued orders showed there were no active orders for tracheostomy care since 1/15/2021. During an observation and interview on 9/10/2021 at 9:02 AM, Licensed Practical Nurse (LPN) #1 was observed providing tracheostomy care to Resident #9. LPN #1 stated that Resident #9 received tracheostomy care daily and they knew this because they have worked with Resident #9 before. LPN #1 stated once tracheostomy care was completed it was signed out on the TAR. LPN #1 stated there was no tracheostomy care order on the TAR or MAR and there should be an order. During an interview on 9/10/21 at 9:29 AM, LPN #2 stated tracheostomy care was done every shift. LPN #2 stated, they knew trach care had to be done on Resident #9 because the resident had a tracheostomy and I just automatically do trach care if a resident has a trach. After looking at MARS, TARS and standing orders LPN #2 stated, I don't understand why there isn't an order. During an interview on 9/10/21 at 9:37 AM, Registered Nurse (RN) Unit Manager (UM) stated tracheostomy care should be completed with an order. Tracheostomy care was usually ordered every shift and as needed for excess secretions. RN UM stated, I don't know why there isn't an order. During an interview on 9/10/21 at 9:49 AM, the Director of Nursing (DON) stated an order should have been in place for basic tracheostomy care. The order would have been on the TAR in the electronic medical record (EMR). If there was not an order, then the nurses would not know that trach care needed to be provided. The DON, also stated that the facility utilizes float and agency nurses. During a follow up interview on 9/10/21 at 1:21 PM, the DON stated the nurse manager should have reviewed the physician's orders to ensure the proper orders were in place. During an interview on 9/10/21 at 1:12 PM, Nurse Practitioner (NP) stated there should be an order for tracheostomy care so that it populated to the MAR and TAR. It was the responsibility of the provider who sees that resident to review orders every month to ensure medical orders were correct and current. This was important so the staff caring for the residents were aware of the care to provide. 415.12 (k)(4)