Based on observation, interview, and record review conducted during the Standard Survey completed on 8/26/24, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (Resident #314) of six residents reviewed. Specifically, Resident #314 was observed with dark brown debris under their fingernails on both hands and eating with their hands. The finding is: The policy titled Activities of Daily Living with an effective date of 2/2024, documented individual care plan interventions will be developed and implemented to encourage self-performance at the resident's highest functional level. The policy titled Grooming, AM (morning) and PM (evening) Care with an effective date of 1/2024 documented the caregiver assigned was responsible to see that care has been given in accordance with the resident's individual plan of care. Any deviation will be reported to the nurse. AM care includes nail care. The policy titled Nail Care, effective 8/2021, documented nail care is provided weekly on bath days and as needed. Resident #314 had diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), alcohol abuse, and neutropenia (abnormally low white blood cell count). The Minimum Data Set) a resident assessment tool) dated 7/20/24 documented Resident #314 was moderately cognitively impaired, was sometimes understood and sometimes understands. Additionally, the Minimum Data Set documented that Resident #314 required supervision of one staff for personal hygiene and a moderate assist of one staff for bathing. The closet care plan (a guide used by staff to provide care) dated 5/14/24, documented Resident #314 required assistance from staff with grooming. Additionally, the closet care plan documented Resident #314 eats with their fingers intermittently. Review of nursing behavior notes dated 7/12/24 to 8/21/24 documented Resident #314 had no behaviors pertaining to hands on care. During an observation on 8/20/24 at 9:36 AM, Resident #314 was lying in bed eating a hardboiled egg with their hands. there was dark brown debris was observed under all nails on both hands. During an observation on 8/22/24 at 12:27 PM, Resident #314 was sitting at a table in the dining room eating vegetables with their hands. Resident #314's fingers went into their mouth while taking bites. Dark brown debris remained under nails on both hands. During an interview on 8/22/24 at 1:08 PM, Certified Nurse Aide #2 stated they were assigned as Resident #314's Certified Nurse Aide that morning. Certified Nurse Aide #2 stated Resident #314's morning care included nail care, but they had not provided it to them on this date. Certified Nurse Aide #2 stated nail care was provided as needed and on shower days. Certified Nurse Aide #2 then observed Resident #314's nails with dark brown debris under them and stated their nails needed to be cleaned. Certified Nurse Aide #2 stated nails should be kept clean for infection control reasons, especially if the resident eats with their hands. During an interview on 8/2/24 at 1:13 PM, Licensed Practical Nurse #4 stated Certified Nurse Aides were responsible for trimming and cleaning nails on shower days and as needed. Licensed Practical Nurse #4 stated Resident #314's nails should be cleaned every day, especially if the resident eats with their hands. It is a huge infection control issue. During a telephone interview on 8/23/24 at 10:15 AM, Registered Nurse #1 stated Resident #314 had no history of refusing nail care. Registered Nurse #1 stated they expected the Certified Nurse Aides to do nail care on shower days and as needed. Registered Nurse #1 stated it was an infection control issue to have debris under the nails, especially if the resident eats with their hands. During an interview on 8/26/24 at 10:34 AM, the Director of Nursing stated they expected staff to perform basic activities of daily living based on each resident's care plan, such as nail care. The Director of Nursing stated that if residents eat with their hands, they expected staff to wash the resident's hands and nails prior to eating. Having debris under nails while eating puts that resident at risk for developing an infection. NYCRR 415.12 (a)(3)

Based on interview, and record review conducted during a Complaint investigation (Complaint #NY00321223) during the Standard survey completed on 8/26/24, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #73) of seven residents reviewed. Specifically, Certified Nurse Aide #3 did not provide/utilize a calf board per the plan of care and the resident sustained an injury to their toe/s. The finding is: The policy and procedure titled Closest Care Plan with an effective date of 11/2019, documented the purpose of the closet care plan was to provide care instructions, ready and available in the resident's room, to any caregiver based on the comprehensive care plan team. The policy documented that all caregivers were trained to check the closet care plan prior to assisting any resident. All caregivers assigned to care for residents were responsible for following the closet care plan and to report any concerns with the appropriateness of or need for changes to the nurse. Resident #73 had diagnoses including diabetes mellitus, paraplegia (loss of motor function in the lower half of the body), and traumatic brain injury. The Minimum Data Set (MDS- a resident assessment tool) dated 7/12/23 documented the resident had moderate cognitive impairment, usually understands, and was usually understood. The Minimum Data Set documented that Resident #73 required an assist of one a few times during the 7-day look back period for locomotion. The Comprehensive Care Plan initiated on 1/11/14 documented Resident #73 documented that Resident #73 had self-care deficit and interventions included therapy screens, evaluations, and discharge summaries. The closet care plan (a guide used by staff to provide care) dated 5/9/23 documented Resident #73 was non-ambulatory and required a staff assist for wheelchair mobility in a reclining wheelchair. The closet care plan documented that Resident #73 was to have a calf support, bilateral extending leg rests when in their wheelchair. The Incident/Accident form dated 8/1/23, Licensed Practical Nurse #6 documented at 3:10 PM Resident #73 was rolling self in their wheelchair as their foot fell off the wheelchair pedal. That resulted in Resident #73's toenail to become dislodged from the big toe. It was documented that Resident #73's big toe, and second toe were bleeding. The form documented that an occupational therapy order was requested for a calf board. Review of a Progress Note dated 8/1/23 at 4:04 PM, Licensed Practical Nurse #6 documented Resident #73 was moving forward in their wheelchair as their foot fell off the pedal simultaneously resulting in the nail on their big toe to become dislodged and then bleed. Review of the OT COC Screen note dated 8/2/23 at 10:33 AM, the Director of Rehab Services documented that Resident #73 was assessed due to an incident and accident from a toe bleed. It was documented that Resident #73 was re-issued a blue foot board and black calf support. Review of an untitled investigation report dated 8/8/23 at 12:53 PM, documented that Resident #73 had an injury to the nail on their left great toe that was lifted from their nail bed causing it to bleed. The investigation documented on 8/1/23 Resident #73 self-propelled to the nursing station stating they were bleeding. The investigation documented that Resident #73's great toe was bleeding and it appeared that their left leg had fallen in-between their wheelchair leg rests. The investigation documented after Resident #73 foot fell from the foot pedal, they continued to self-propelled their wheelchair, dragging their left foot under the wheelchair. The investigation documented that the facility employee assigned to Resident #73 did not notice the resident was care planned for a calf support and that employee reported that there was not a calf support in Resident #73's room the day of the incident. The investigation documented that the incident was a care plan violation. During an interview on 8/23/24 at 4:13 PM, Certified Nurse Aide #3 stated they were the staff member assigned to Resident #73 on 8/1/23 when the resident sustained an injury to their toe. Certified Nursing Assistant #3 stated when they got Resident #73 out of bed and placed them into their wheelchair, the wheelchair did not have a calf board. They stated they applied blue booties to Resident #73's feet. They stated at the time of the incident they were not aware that Resident #73 was to have a calf board in place and would have had they read Resident #73's care plan posted on their bathroom door prior to getting them out of bed. During an interview on 8/26/24 at 8:12 AM, the Director of Rehab Services stated they completed a wheelchair evaluation on Resident #73 on 8/2/23 due to an incident report on 8/1/23. The Director of Therapy stated that at the time of the incident Resident #73's wheelchair did not have on calf board as planned. They stated the purpose of Resident #73's calf board was to prevent their feet from falling off their wheelchair pedals. The Director of Therapy stated they expected staff to read the care plan prior to the start of care. During a telephone interview on 8/26/24 at 9:47 AM, Licensed Practical Nurse #6 stated that Resident #73 was in their wheelchair wheeling themselves down the hallway and they noted a trail of blood on the carpet. Licensed Practical Nurse #6 stated that Resident #73 did not have the calf board in place and their foot fell off the wheelchair pedal. They stated the calf board lays across both foot pedals to prevent the feet from falling in-between the pedals. Licensed Practical Nurse #6 stated they were not sure why the calf board was not in place. Licensed Practical Nurse #6 stated staff were to read a resident's care plan when they are assigned to a resident. During an interview on 8/26/24 at 11:37 AM, Registered Nurse #7 Team Leader of the unit stated on 8/1/23 it appeared that Resident #73 ran over their own right foot while in the wheelchair and there was a lot of active bleeding. Registered Nurse #7 stated that Resident #73 did not have their planned foot board in place at the time of the incident and if it was, the injury would have been prevented. Registered Nurse #7 stated they would have expected Certified Nurse Aide #3 to read Resident #73 closet care plan and alert the nurse if their specialty equipment was not in their room. Registered Nurse #7 stated that Certified Nursing Assistant #3 should have not gotten Resident #73 out of bed until they had the proper equipment. During an interview on 8/26/24 at 12:25 PM, the Director of Nursing stated upon investigation of Resident #73's incident on 8/1/23, Certified Nursing Assistant #3 did not implement the residents care planned calf board. The Director of Nursing stated they did not know why the calf board was not in place but that they would expect the staff to review the closet care plan prior to care. The Director of Nursing stated it was important for staff to follow a resident care plan and ensure devices were in place to avoid any injury. 10 NYCRR 415.12(h)(2)

Based on observation, interview, and record review conducted during a Compliant investigation (Complaint # NY00339904) during the Standard survey completed on 8/26/24 the facility did not ensure that its residents were free of significant medication errors for one (Resident #260) of three residents reviewed for anti-seizure medications. Specifically, Resident #260 was not administered 5 doses of their anti-seizure medication. This resulted in a significant medication error for Resident #260. The resident had seizure activity and was transferred hospital for evaluation and treatment. The finding is: Refer to F 755 Pharmacy Services/procedures, scope and severity F. The facility policy titled Medication and Treatment Administration Record with an effective date of 7/2023 documented the purpose is to assure accurate administration of medication and treatments. The policy titled Physician Services and Philosophy with an effective date of 8/2019, documented the licensed nursing staff notifies the Attending Physician/Nurse Practitioner/Physician Assistant for required, issuance/review of medical orders; when emergency orders are necessary, or if the plan of care is creating adverse reactions. A Licensed Nurse records notification of the Physician/Nurse Practitioner/Physician Assistant in the resident's medical record. Resident #260 had diagnoses that included cerebral infarction (stroke), epilepsy (seizure disorder), and metabolic encephalopathy (chemical imbalance in the blood that affects the brain). The Minimum Data Set (a resident assessment Tool) dated 3/28/24 documented Resident #260 was severely cognitively impaired, usually understands and was sometimes understood. The active physician's orders dated 12/19/23 documented Resident #260 was to receive Briviact (controlled anti-seizure medication) 50 milligrams (mg) 1 tab twice daily. Resident #260's medication, treatment, and task administration record report for April 2024 documented that Briviact 50 milligrams was not administered as ordered and scheduled on 4/19/24 at 4:03 PM, 4/20/24 at 9:04 AM, 4/20/24 at 4:54 PM, 4/21/24 at 9:43 and on 4/21/24 at 4:28 PM because the medication was unavailable. Review of 24-Hour Interdisciplinary Report dated 4/22/24 documented Resident #260 was sent out to emergency room for seizure activity at 9:20 AM. Review of Nursing progress note dated 4/22/24 at 12:08 PM, Registered Nurse #1 documented at 8:40 AM Resident #260 was being provided hands on care when they started to have emesis described as clear mucous and became sweaty. This writer entered the room and Resident #260 appeared to be actively seizing, residents body stiffened, started convulsing, and resident was unresponsive to name. This lasted for approximately 90 seconds. Resident #260 started to return to baseline, and the provider was contacted, per provider no Ativan was needed because Resident #260 was returning to baseline. Approximately 2 minutes later Resident #260 then appeared to be in distress, was no longer responsive and began to tremor. The Physican was again contacted with an order given to send tote hospital. Review of Physician progress note dated 4/23/24, Physician Assistant #1 documented Resident #260 was sent to emergency department yesterday for breakthrough seizure activity. On review, the resident reportedly had not received their Briviact since April 19th, 2024. They received 10 mg Versed (antiseizure medication) during transportation via emergency medical services. On initial evaluation they were responsive to painful stimuli only. They had 1 gram of Keppra (antiseizure medication) and 1 liter of fluids intravenously. Review of facility submitted Investigation 5 Day Report, dated 4/29/24 at 4:17 PM, documented Resident #260 had active seizure activity on 4/22/24 at 8:40 AM causing them to be sent to the emergency room for further evaluation and treatment. On 4/19/24, Resident #260 was completely out of their seizure medication. During an interview on 8/23/24 at 8:32 AM, Licensed Practical Nurse #1 stated they worked the 7-3 shift on 4/19/24 and administered the last dose of Briviact to Resident #260. Licensed Practical Nurse #1 stated the medication was written on the re-order form on Tuesday 4/16/24 so they were expecting it to come from pharmacy. They called pharmacy on 4/19/24 and pharmacy stated it was an insurance and provider issue. They reported this to the team leader, Registered Nurse #1. It was out of their hands now. Licensed Practical Nurse #1 stated they returned to work on Saturday 4/20/24, and the medication still had not been delivered. The overnight staff said, it was being handled, the doctor had said something I think. Licensed Practical Nurse #1 stated they assumed the doctor did what they needed to do, and that pharmacy was sending the medication. Licensed Practical Nurse #1 stated Resident #260 was stable throughout the weekend and had no changes in their vital signs. Licensed Practical Nurse #1 stated Briviact was an important medication and there was a communication issue that led to Resident #260 not receiving it as ordered. During a telephone interview on 8/23/24 at 9:51 AM, Registered Nurse #1 stated they were never made aware prior to Resident #260 having a seizure that they were out of the medication. Registered Nurse #1 stated Briviact was an important medication and Resident #260 was at risk for having a seizure if they missed any doses. During a telephone interview on 8/23/24 at 10:21 AM, Pharmacy Consultant stated if a resident had epilepsy and missed a few doses of the medication it would not be ideal, they could have refractory seizures. Pharmacy Consultant stated it was not ideal for seizure medications to abruptly stop and Resident #260 missing 5 doses of their Briviact put them at risk for having a seizure. Even if someone has never had a seizure and was on a seizure medication and missed doses, they could have a rebound seizure. During a telephone interview on 8/23/24 at 10:45 AM, Medical Director stated a seizure medication was one that was important and should be given as ordered. Missed doses of a seizure medication puts any person at risk for having seizures. During a telephone interview on 8/23/24 at 10:58 AM, Physician Assistant #1 stated Briviact was an important medication and without it a person was at risk for break through seizures. Physician Assistant #1 stated they would expect to be updated if a resident missed a dose of their seizure medication as soon as possible. Any more than 2 days maximum without receiving the seizure medication would be too far. In the incident with Resident #260, there was a miscommunication issue. Physician Assistant #1 stated Resident #260 experienced a seizure from missing doses of their seizure medication and was sent out to the hospital appropriately. Physician Assistant #1 stated because Resident #260 had a history of stroke and seizure disorder, missing doses of their seizure medication could be potentially harmful, but not life threatening. During a telephone interview on 8/23/24 at 11:08 AM, the Pharmacist stated the half-life (how long a drug remains in the blood) of Briviact for people 65 and younger was 9.0 hours. If someone were to miss 5 doses of their Briviact they were at risk for a partial onset seizure. If someone was on a seizure medication and missed any dose they were at risk for seizures. They're in the possibility of having a seizure, whether they have had one or not. During a telephone interview on 8/23/24 at 11:41 AM, Registered Nurse #2 stated they worked the 3:00 PM-11:00 PM shift on April 20th and 21st, 2024. When they received report from the 7-3 shift on April 20th, they were told the medication Briviact was unavailable in the facility. Registered Nurse #2 stated Licensed Practical Nurse #1 told them they had called pharmacy, and the medication was on its way. Registered Nurse #2 stated they should not have taken the day shift nurse word for it and should have called the provider themselves. Registered Nurse #2 stated Resident #260 was at risk for having seizures without the medication. During a telephone interview on 8/23/24 at 3:35 PM, Registered Nurse #4 stated they were the nursing supervisor on Sunday 4/21/24 from 7:00 AM to 11:00 PM and they should have been made aware that the medication was unavailable. Registered Nurse # stated a seizure medication is very important and puts the resident at risk for having a seizure if they miss a dose. During a telephone interview on 8/23/24 at 4:00 PM, Registered Nurse #5 stated they were the nursing supervisor on Saturday 4/20/24 from 3:00 to 11:00 PM. Registered Nurse #5 stated they were never made aware that Resident #260 was out of their seizure medication and should have been. Registered Nurse #5 stated a seizure medication was very important and puts that person at risk for having a seizure if they miss a dose. During an interview on 8/26/24 at 10:29 AM, the Director of Nursing stated they were aware Resident #260 had missed a few doses of their seizure medication and that resulted in Resident #260 having a seizure and being sent out to the hospital. The Director of Nursing stated even one dose of a seizure medication was too many to miss, it puts the patient at risk for having a seizure. Based on the following corrective actions it was determined the facility implemented corrective actions to correct the non-compliance prior to the start of survey teams' entrance to the facility on 8/20/24 at 8:30 AM: -On 4/23/24 a Special Quality Assurance Performance Improvement meeting was held to determine the root cause and to put a prevention plan into place. - Director of Nursing completed a facility wide audit on all controlled medications being readily available to the residents. - Briviact was added to the facilities emergency Pyxis system (automated dispensing system) - Policies and Procedures were reviewed and revised - As of 6/21/24 facility wide nurse education was completed along with facility wide competency quizzes, and specific staff counseling completed. During the Standard survey completed on 8/26/24 it was verified through observations, staff interviews and record review the facility implemented their plan, re-educated their nursing staff on the process for notifications to pharmacy and providers, acquiring medications, process for medications that maybe unavailable. NYRCC 415. 12 (m)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 8/26/24, it was determined the facility did not ensure residents received routine dental services to meet the needs of each resident for two (Residents #10, #112) of three residents reviewed. Specifically, Resident #10 had been missing dentures since 10/28/20 and was not provided with timely follow up appointments for denture replacement. There were no dental consults completed after 10/20 through 08/24. Additionally, Resident #112 had a delay in receiving routine dental services on admission, there was no physician order for dental consults and had not received a dental consult until 1/3/24. The findings are: The policy and procedure titled Dental Services dated 8/2021 documented that it was the responsibility of nursing staff, vendor dental services and the medical team to coordinate dental care for residents. All residents are referred to the Dental Clinic and seen within 30 days of admission. Recommendations for dental care and follow up are documented in the Vendor Dental Service's electronic medical record. A paper copy of this documentation will be kept in the resident's paper medical record. 1. Resident #10 had diagnoses that included cerebral palsy (condition that affects movements and posture), epilepsy (seizure disorder), and neuromuscular dysfunction of bladder (nerves and muscles of urinary system don't work together causing urinary tract dysfunction). The Minimum Data Set (a resident assessment tool) dated 6/12/24 documented Resident #10 was cognitively intact, was understood and understands. The assessment documented the resident was edentulous (without teeth). The Minimum Data Set Care Area assessment dated [DATE] had a note which documented Resident #10 was noted as edentulous but had full upper and lower dentures. Dental consult per policy and as needed. The comprehensive care plan dated 4/28/23 (current) documented Resident #10 required supervision with oral hygiene, removing/placing dentures in mouth, and managing denture soaking and rinsing. Additionally, the comprehensive care plan documented Resident #10 was on a modified diet of soft consistency food due to dysphagia (difficulty swallowing). The closet care plan (a guide used by staff to provide care) dated 8/22/24 documented Resident #10 had no dental appliances. The active physician's order dated 10/16/17 documented Resident #10 was to have a dental consult as needed. The dental consult note dated 10/28/20 documented Resident #10 was seen for a periodic oral exam. Resident had lost complete maxillary (upper) denture and had not worn mandibular (lower) complete denture. Primary impressions were to be taken at next visit. Review of the schedule list of residents to be seen by the onsite dentist from 11/9/22 to 7/17/24, provided by the Administrative Control Clerk Supervisor on 8/26/23 at 10:30 AM, revealed Resident #10 was not seen by the dentist between those dates. During an observation and interview on 8/23/24 at 8:47 AM, Resident #10 was sitting up in their bed with no dentures present. Resident #10 stated they have issues with chewing and were unable to eat properly due to missing dentures. Resident #10 stated they had a pair of dentures (uppers/lowers) when they arrived at the facility, but the dentures were lost at some point. Resident #10 stated they had seen the dentist and had a sore in their mouth, so impressions were not taken at that visit, and they were supposed to follow up but has not yet. During a telephone interview on 8/23/24 at 10:08 AM, Registered Nurse #1 stated Resident #10 had dentures at one point but could not remember when they were lost. Registered Nurse #1 stated Administrative Control Clerks were responsible for scheduling appointments and follow ups. Registered Nurse #1 stated there was an in-house dentist and residents go on a list to be seen by the dentist when needed. During an interview on 8/23/24 at 12:12 PM, the Administrative Control Clerk Supervisor reviewed Resident #10's electronic medical record and was unable to find any dental consults. Administrative Control Clerk Supervisor stated they were going to look for Resident #10's dental consults. During a telephone interview on 8/26/24 at 9:16 AM, the Director of Ambulatory Services for the Dental Clinic stated Resident #10 was last seen by the dentist on 10/28/20. The Director of Ambulatory Services for the Dental Clinic stated there were not any dental consults for Resident #10 after 10/28/20. During an interview on 8/26/24 at 9:24 AM, the Administrative Control Clerk Supervisor stated Resident #10's chart may have been thinned and they would check in medical records for any more dental consults. Administrative Control Clerk Supervisor returned and stated they were unable to locate any dental consults for Resident #10 after 10/28/20. During an interview on 8/26/24 at 10:30 AM, the Administrative Control Clerk Supervisor stated that on admission the nurses would be responsible for obtaining an order for dental consults and would then enter the order in the electronic medical record. The Administrative Control Clerk Supervisor stated that once the order was placed in the electronic medical record it would automatically print to their office and they would be responsible to schedule residents on the dental list to be seen. During an interview on 8/26/24 at 10:36 AM, the Director of Nursing reviewed the dental policy and stated all residents should be seen upon admission and annually by the dentist. The Director of Nursing stated they expected Team Leaders and Administrative Control Clerks to work together and make sure all residents were being seen by the dentist appropriately. Nursing staff should follow up and contact the dentist as needed. The Director of Nursing stated Resident #10 should be seen immediately by the dentist due to them not being seen since 2020. It was important for dental hygiene and dignity. 2. Resident #112 was admitted to the facility on [DATE] with diagnoses of dementia, epilepsy (disease that causes seizures), and glaucoma (eye disease that causes vision loss). The Minimum Data Set, dated [DATE] documented Resident #112 had moderate cognitive impairment was usually understood and usually understands. The assessment documented the resident required partial/moderate assistance (staff provides less than half the effort) from staff for oral hygiene. Additionally, review of Resident #112's Minimum Data Set, dated [DATE] revealed that Resident #112 was edentulous, at risk of altered nutritional status related to missing teeth and did not wear dentures. Review of the comprehensive care plan with a last review date 2/27/24 and identified as active documented dental care with interventions that included nursing to provide/encourage oral hygiene and assess condition of oral cavity. There was no documented evidence resident had dental services as needed. Review of the closet care plan dated 6/13/24 documented Resident #112 had no dental appliances, required minimum assistance with oral care, and received a regular consistency diet. The electronic and paper medical record for Resident #112 dated 11/8/22 through 8/22/24 documented they had been seen by the dental clinic for a comprehensive oral exam on 1/3/24. There was no evidence of any prior dental evaluations documented in the medical record, and no evidence Resident #112 refused dental consults. Review of Resident #112's physician orders from 11/8/22 through 8/22/24 revealed there was no physician order in place for dental consults. Additionally, the electronic and paper medical record lacked dental consents, declinations, and/or refusals for dental services. Review of the schedule list of residents to be seen by the onsite dentist from 11/9/22 to 12/27/23 provided by the Administrative Control Clerk Supervisor on 8/26/24 at 10:30 AM, revealed that Resident #112 was not seen for an admission dental consult. During an interview on 8/21/24 at 9:36 AM, Resident #112 stated they had some difficulty chewing certain foods and was not aware if they were on a special diet. Resident #112 stated they had dentures at home and would like to have them at the facility. During a telephone interview on 8/26/24 at 9:16 AM, the Director of Ambulatory Services for the Dental Clinic stated that Resident #112 had not been seen in 2022 or 2023 for a routine dental exam. They stated if a resident had refused, refusals would be documented in their medical record under dental consults. During an interview on 8/26/24 at 10:30 AM, the Administrative Control Clerk Supervisor reviewed Resident #112's electronic medical record and stated that Resident #112 did not have a dental consult order upon admission and did not have a dental consult order in place when the resident was seen and should have. During an interview on 8/26/24 at 10:45 AM, Registered Nurse #8 stated that on admission dental consults were a part of the ancillary orders and would be entered into the electronic medical record. They stated the registered nurse or nurse completing the admission would be responsible for entering those ancillary orders. Registered Nurse #8 stated that the Administrative Control Clerks would be responsible for scheduling dental visits. Registered Nurse #8 stated there should be a physician's order for dental consults. During an interview on 8/26/24 at 12:00 PM, the Assistant Director of Nursing #1 stated they were unaware of the process for obtaining dental consents and declinations. They were not aware of any resident dental care concerns and was unsure if there should be a physician order for dental consults. During an interview on 8/26/24 at 12:03 PM, the Operations Manager stated an order for dental consults were part of the standing admission orders that the providers would sign. They stated that all residents would be scheduled to be seen by dentist for admission, annually, and for any concerns. They stated that resident refusals should be documented in the medical record. During an interview on 8/26/24 at 12:35 AM, the Director of Nursing stated Resident #112 should have been seen by the dentist within 30 days of admission and annually. The Director of Nursing stated that dental consults were part of the batch orders entered on admission by the nurses. Resident #112 should have had a physician order for dental consult on admission and for the dental consult received on 1/3/24. NYCRR10 415.17 (c)

Based on interview, and record review conducted a Compliant investigation (Complaint # NY00339904) during the Standard survey completed on 8/26/24, the facility and pharmacy services did not effectively implement processes to acquire, dispense and administer medications to meet the needs of each resident. Specifically, one (Resident #260) of four residents reviewed for controlled substances was not administered a regularly scheduled controlled antiseizure medication as ordered and missed a total of 5 doses. Subsequently, the resident experienced seizure activity was transferred to the hospital. Additionally, facility staff did not notify the provider of the unavailability of the medication, and the pharmacy provider did not notify the medical provider that only a 14-day supply of the mediation was dispensed versus the 30-day as ordered. The finding is: The policy titled Controlled Substances with an effective date of 9/2021 documented an official NYS (New York State) triplicate script must state the number of tabs or the number of days and number of refills. The 11:00 PM -7:00 AM shift nurse will check all controlled substances for needed re-fills weekly. Any controlled substances with less than one week supply will be placed on the Controlled Substance Re-Order Form. The 11:00 PM -7:00 AM shift supervisor will collect the forms and bring them to the Nursing Administration Office. The Assistant Director of Nursing (ADON)/designee will give them to the prescriber so that prescriptions will be written. The prescriber will bring the prescriptions to the Nursing Supervisor who will make copies of the controlled substance prescriptions and will enter in the Nursing Supervisor Logbook. The pharmacy courier will pick up the signed prescriptions from the Nursing Supervisor with the next controlled substance delivery. The policy titled Physician Services and Philosophy with an effective date of 8/2019, documented the licensed nursing staff notifies the Attending Physician/Nurse Practitioner/Physician Assistant for required, issuance/review of medical orders; when emergency orders are necessary, or if the plan of care is creating adverse reactions. A Licensed Nurse records notification of the Physician/Nurse Practitioner/Physician Assistant in the resident's medical record. The policy titled Medication and Treatment Administration Record with an effective date of 7/2023 documented the facilities purpose is to assure accurate administration of medications and treatments. The policy titled Medication Ordering, Credits and Delivery of Prescription Medication and Treatments with an effective date of 9/2021 documented the purpose is to ensure that orders for prescription medications are faxed or sent to the Vendor Pharmacy and the prescribed medications are obtained and administered in a timely manner. If the medication is not available from the pharmacy but the time the next scheduled dose, the nurse must contact the Nursing Supervisor to review if the medication can be obtained from the Emergency Box. If the medication cannot be obtained from the Emergency Box and is not available from the Vendor Pharmacy, the nurse will contact the Medical Team for orders. Additionally, each nurse passing medication daily is responsible for the reordering of prescriptions medications. The nurse must be aware of the remaining doses when punching out the doses to be administered. The EMAR (electronic medical record) will indicate if the reorder is accepted or if it is too soon to order. The system will also indicate If medication has already been re-ordered. Resident #260 had diagnoses that included cerebral infarction (stroke), epilepsy (seizure disorder), and metabolic encephalopathy (chemical imbalance in the blood that effects the brain). The Minimum Data Set (a resident assessment tool) dated 3/28/24 documented Resident #260 was severely cognitively impaired, usually understands and was sometimes understood. Review of facility submitted Investigation 5 Day Report, dated 4/29/24 at 4:17 PM, documented Resident #260 had active seizure activity on 4/22/24 at 8:40 AM causing them to be sent to the emergency room for further evaluation and treatment. Facility Investigation documented Resident #260 ran out of seizure medication awaiting it to arrive from pharmacy. The medication, Briviact (controlled antiseizure medication), was ordered through the electronic medication administration record on 4/16/24. The provider received the renewal order that was placed on 4/16/24 but did not renew the prescription due to ordering 60 tablets of this medication on 4/2/24. On 4/3/24, pharmacy sent a 14-day supply (28 tablets) due to insurance stipulations. On 4/19/24, Resident #260 was completely out of their seizure medication. The active physician's orders dated 12/19/23 documented Resident #260 was to receive Briviact 50 milligrams (mg) 1 tab twice daily. Review of electronic pharmacy receipt provided by the Director of Nursing documented Resident #260's Briviact was for a 30-day supply (28 tablets), and on 4/3/24 a 14-day supply (28 tablets) was sent. Review of medication administration record dated 4/19/24 through 4/21/24 revealed over a period of 2.5 days a total of 5 doses of Briviact were not administered as ordered by the medical provider due to its unavailability. Review of 24 Hour Interdisciplinary Report dated 4/19/25, 4/20/24, and 4/21/24 revealed there was no evidence that Resident #260 was added to the report sheet regarding the unavailability of the Briviact, to monitor for seizure activity or that the provider and pharmacy were notified. The 24- Hour Interdisciplinary Report dated 4/22/24 documented Resident #260 was sent out to emergency room for seizure activity at 9:20 AM. The resident returned from the hospital on the 3:00 PM to 11:00 PM shift with an order to continue taking Briviact 50 milligrams by mouth twice a day. Review of the Nursing progress note dated 4/22/24 at 12:08 PM, Registered Nurse #1 documented at 8:40 AM Resident #260 was being provided hands on care when they started to have emesis described as clear mucous and became sweaty. This writer entered the room and Resident #260 appeared to be actively seizing, the resident's body stiffened, started convulsing, and resident was unresponsive to name. This lasted for approximately 90 seconds. Resident #260 started to return to baseline, and the provider was contacted, per provider no Ativan (medication that acts on the brain and nerves to produce a calming effect that relieves symptoms of anxiety) was needed because Resident #260 was returning to baseline. Resident #260 then appeared to be in distress, was no longer responsive and began to tremor. The provider was contacted again, and an order was given to send Resident #260 out to emergency room for evaluation. Emergency medical services were contacted, and upon arrival administered an injection. Resident #260 was transferred by ambulance to the emergency room for evaluation. Upon retrieving residents' packet to be sent out, a review of medication administration record showed Resident #260 had missed 5 doses of seizure medication. Review of Physician progress note dated 4/23/24, Physician Assistant #1 documented Resident #260 sent to emergency department yesterday for breakthrough seizure activity. On review patient reportedly had not received their Briviact since April 19th, 2024. On review of (mobile prescription software), a 30-day supply (60 tabs) was on April 3rd with anticipated coverage through 5/3/24. Investigation unearthed that pharmacy had sent over a 14-day supply due to medication being a brand name. This had not been reported to me previously. Does not appear that a call out was placed to notify provider (myself) or supervising physician of this discrepancy or to notify that their final doses had been utilized. During an interview on 8/23/24 at 8:32 AM, Licensed Practical Nurse #1 stated they worked the 7:00 AM to 3:00 PM shift on 4/19/24 and administered the last dose of Briviact to Resident #260. Licensed Practical Nurse #1 stated the medication was written on the re-order form on Tuesday 4/16/24 so they were expecting it to come from pharmacy. Licensed Practical Nurse #1 stated they called pharmacy and pharmacy stated it was an insurance and provider issue. They reported this to the team leader, Registered Nurse #1 and It was out of their hands now. Licensed Practical Nurse #1 stated they returned to work on Saturday 4/20/24, and the medication still had not been delivered. The overnight staff said, it was being handled, the doctor had said something I think. Licensed Practical Nurse #1 stated they assumed the doctor did what they needed to do, and that pharmacy was sending the medication. Licensed Practical Nurse #1 stated Resident #260 was stable throughout the weekend and had no changes in their vital signs. Licensed Practical Nurse #1 stated there was a communication issue that led to Resident #260 not receiving it as ordered. Licensed Practical Nurse #1 stated any nurse can put a call out to the provider regarding medication. During a telephone interview on 8/23/24 at 9:51 AM, Registered Nurse #1 Team Leader stated they were never made aware prior to Resident #260 having a seizure that they were out of Briviact. Registered Nurse #1 stated it was the nurse passing the medication who was responsible for contacting the pharmacy and/or the provider if it was unavailable. If the Licensed Practical Nurses were unable to get a hold of the provider, then they should report it to the Nursing Supervisor. During a telephone interview on 8/23/24 at 10:21 AM, Pharmacy Consultant stated Briviact was a brand name medication and only sent in a 14-day supply. The physician would have to write a script and between nursing and pharmacy, they would communicate and get refills. During a telephone interview on 8/23/24 at 10:45 AM, the Medical Director stated the procedure for when a medication was unavailable in the facility the nurse should notify the provider and then the provider will respond with a new order, a substitution in the interim, or tell them to call the pharmacy. If it was an insurance issue, there was a team that deals specifically with that. The provider cannot give an order if they were not aware the medication was unavailable. During a telephone interview on 8/23/24 at 10:58 AM, Physician Assistant #1 stated if a medication was a controlled substance or as needed, they were sent in 14-day supplies. The nurse will send a notification and the provider will determine if the order was okay to be renewed. Sometimes controlled substances were sent in a 14-day supply for insurance reasons. This is something pharmacy needs to articulate to them so that the providers can refill appropriately. Physician Assistant #1 stated the nurse were responsible for determining the count for controlled substances and should reach out and let the provider know when a refill was needed. Physician Assistant #1 stated they most definitely expect to be updated when a resident is out of a controlled substance, especially one like Briviact. In the incident with Resident #260, there was a miscommunication issue. Physician Assistant #1 stated if they would have been made aware Resident #260 hadn't received their seizure medication, they would have put an order in themselves and had pharmacy send it over urgently and would have had Ativan on board in case they developed a seizure in the interim. During a telephone interview on 8/23/24 at 11:08 AM, the Pharmacist stated Briviact was a brand name medication. Since the original order date of 12/19/23, Briviact had been sent in a 14-day supply for Resident #260. Pharmacist stated a prescription was written on 4/3/24 for a 30-day supply but the system only allowed a 14-day supply to be provided. The Pharmacist stated there were no notes indicating the facility attempted to call and no refill requests were received between 4/2/24 and 4/22/24. The Pharmacist stated usually a 30-day prescription will be written and then they provider will replenish the prescription every 14 days. The facility will usually call or send a refill sheet when a refill was needed. The Pharmacist stated there were no alerts to the provider from the pharmacy to let them know a 14-day supply was sent instead of a 30-day supply that was ordered. During a telephone interview on 8/23/24 at 11:41 AM, Registered Nurse #2 stated they worked the 3:00 PM to 11:00 PM shift on April 20th and 21st, 2024. When they received report from the 7:00 AM to 3:00 PM shift on April 20th, they were told the medication Briviact was unavailable in the facility. Registered Nurse #2 stated Licensed Practical Nurse #1 told them they had called pharmacy, and the medication was on its way. When it did not arrive on the run that night, Registered Nurse #2 stated they called pharmacy and was told it was on its way. Registered Nurse #2 stated they wrote on the report sheet that they were waiting for the medication. Registered Nurse #2 stated they came in Monday, April 22nd, and was informed Resident #260 had a seizure and was sent out to the hospital because their seizure medication never came. Registered Nurse #2 stated they should not have taken the day shift nurse word for it and should have called the provider themselves. During a telephone interview on 8/23/24 at 3:35 PM, Registered Nurse #4 Nursing Supervisor stated they were the supervisor on Sunday 4/21/24 from 7:00 AM to 11:00 PM and was not made aware that Resident #260 was out of their seizure medication. Registered Nurse #4 stated if they were made aware then they would have notified the on-call provider and got an order right away. Registered Nurse #4 stated they should have been made aware that the medication was unavailable. During a telephone interview on 8/23/24 at 4:00 PM, Registered Nurse #5 Nursing Supervisor stated they were the supervisor on Saturday 4/20/24 from 3:00 PM to 11:00 PM. Registered Nurse #5 stated they were never made aware that Resident #260 was out of their seizure medication. Registered Nurse #5 stated they should have been aware that the seizure medication was not available. Registered Nurse #5 stated that if they were made aware they would have contacted the on-call provider and sent out an urgent notification to them. During an interview on 8/26/24 at 10:29 AM, the Director of Nursing stated they were aware Resident #260 had missed a few doses of their seizure medication which resulted in Resident #260 having a seizure and being sent out to the hospital. The Director of Nursing stated the process for when a medication was not available in the facility was to call pharmacy. The Director of Nursing stated they expect staff to report off to the next shift if a medication was not available and have them follow up with pharmacy. If pharmacy cannot give a reason, notify the Nursing Supervisor who would make a call to the provider for further guidance. During an interview on 8/26/23 at 10:52 AM, Licensed Practical Nurse #3 stated they worked Monday 4/22/24 7:00 AM to 3:00 PM and was Resident #260's nurse. Licensed Practical Nurse #3 stated that morning the Certified Nurse Aide alerted to them, and Registered Nurse #1, that Resident #260 wasn't quite themselves. Registered Nurse #1 went in to Resident #260's room to assess them. Licensed Practical Nurse #3 stated when they entered the room, Resident #260 wasn't talking and was not at their baseline. Resident #260 was then sent out to the hospital. Based on the following corrective actions it was determined the facility implemented corrective actions to correct the non-compliance prior to the start of survey teams' entrance to the facility on 8/20/24 at 8:30 AM: -On 4/23/24 a Special Quality Assurance Performance Improvement meeting was held to determine the root cause and to put a prevention plan into place. - Director of Nursing completed a facility wide audit on all controlled medications being readily available to the residents. - Briviact was added to the facilities emergency Pyxis system (automated dispensing system) - Policies and Procedures were reviewed and revised - As of 6/21/24 facility wide nurse education was completed along with facility wide competency quizzes, and specific staff counseling completed. During the Standard survey completed on 8/26/24 it was verified through observations, staff interviews and record review the facility implemented their plan, re-educated their nursing staff on the process for notifications to pharmacy and providers, acquiring medications, process for medications that maybe unavailable. NYRCC 415.18 (a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey started 10/25/2022 and completed on 11/1/2022, the facility did not ensure they immediately consulted with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #343) of two residents reviewed. Specifically, there was a delay in notification to the medical provider when a peripheral intravenous line (PIV-a tiny flexible tube that is inserted into a vein for the delivery of fluids/medications) access was unable to be obtained for antibiotic (ABT) administration. The finding is: The facility policy and procedure (P&P) titled Physician/Provider Notification for Change in Patient Condition, dated 2/2022, documented that the registered nurse (RN) assigned to the patient or supervising the care of the patient was responsible for notification of and communication to the Physician/Provider regarding significant changes or significant deterioration in the patient's condition, and for assuring that there was a physician/provider response/intervention. The P&P documented that the changes in the condition of the patient are determined by assessments utilizing parameters defined in standards of care, physician/provider orders, and the patient's previous condition. The P&P documented that the physician/provider notification was to be documented in the medical record with pertinent information, which includes date, time, need, name of each physician/provider notified, actions taken, and/or patient's response to treatment. The facility P&P titled Intravenous Therapy, dated 9/2021 documented the purpose of intravenous (IV) therapy was to provide intravenous access for the administration of specified medications. If the nurse cannot restart the IV line, the medical team was to be notified. 1. Resident #343 had diagnoses including necrotic (dead tissue) arterial wound of the right heel, peripheral artery disease (poor circulation of the lower extremities) and dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 10/11/22 documented that the resident was sometimes understood and rarely/never understands and had severely impaired cognitive skills. The MDS documented that Resident #343 had received IV therapy in the last 14 days. Review of Resident #343's physician telephone orders revealed RN #9 received the following orders: -On 10/13/22 at 12:30 PM, the Physician Assistant (PA) ordered to send the resident to the interventional radiology catheter lab to replace a PICC line (peripherally inserted central catheter-a catheter that is inserted through a vein and advanced until the tip enters the central venous system) to the left arm and to hold intravenous (IV) Cefazolin (an antibiotic medication) until the PICC was replaced. -On 10/15/22 at 12:00 PM, Physician #1 ordered to attempt PIV insertion and if able to gain access continue cefazolin IV order as scheduled. -On 10/19/22 at 9:50 AM, the PA ordered to send the resident to the emergency department for PICC placement. Review of the Medication, Treatment and Task Administration Record Report dated October 2022 revealed Resident #343 received Cefazolin 2 grams via PICC every 8 hours (at 5:00 AM, 1:00 PM and 9:00 PM). The report documented from 10/13/22 at 9:00 PM thru 10/15/22 at 5:00 AM that the Cefazolin was on hold. The report further documented from 10/15/22 at 1:00 PM thru 10/19/22 at 9:00 PM Cefazolin was not administered. Review of the LTC Acute Visit written by the PA on 10/17/22, documented that Resident #343 incidentally pulled out the PICC line from their right arm on 10/13/22 and orders were given to have interventional radiology place a new PICC. The PA documented the Cefazolin was placed on hold and over the weekend the PICC was still unable to be placed, therefore new recommendations were given to administer the Cefazolin via PIV until a PICC could be placed. The PA further documented that it was okay to give the Cefazolin via PIV in the interim. There was no documentation that the PA was notified the resident didn't have PIV access for the ABT administration. Review of a LTC Acute Visit note dated 10/19/22, the PA documented that Resident #343 was sent to the emergency room for new PICC placement. Review of the nursing notes, behavioral notes and 24 Hour Interdisciplinary Report from 10/15/22-10/19/22 revealed no documented evidence that a medical provider was notified of the inability to gain PIV access or to obtain further orders. During an interview on 10/31/22 at 11:06 AM, RN #9 (Team Leader (unit manager)) stated that Resident #343 self-removed their PICC on 10/13/22. RN #9 stated they received an order to hold the Cefazolin and to have the PICC reinserted by interventional radiology. RN #9 stated that they contacted Physician #1 on 10/15/22 and received an order to attempt to access of a PIV to administer the IV antibiotic due to interventional radiology needing a prior authorization from the insurance company for insertion of a PICC line. RN #9 stated on 10/15/22 they attempted twice to access a PIV, but it was unsuccessful. RN #9 stated they wrote on the unit report sheet to attempt PIV access the next shift. During a further interview on 11/1/22 at 9:11 AM, RN #9 stated when they worked 10/16/22, Resident #343 still did not have PIV access. RN #9 stated they did not contact a medical provider on 10/15/22 or 10/16/22 that the PIV access was unsuccessful and that they should have. RN #9 stated that Resident #343 was sent to the emergency room on [DATE] for PICC line placement. RN #9 stated they did not document a nursing note regarding communication that they had with any medical provider and that they should have. During an interview on 10/31/22 at 11:12 AM, the PA stated that Resident #343 originally pulled out their PICC line and they ordered a new PICC line to be place through radiology. The PA stated radiology needed a prior authorization and the on-call physician (Physician #1) was contacted by the facility on 10/15/22. The PA stated Physician #1 ordered a PIV to be placed. The PA stated their expectation would be that a provider be notified that the PIV placement was unsuccessful so the resident could have been sent to the emergency room earlier. During a telephone interview on 11/1/22 at 12:28 PM, Physician #1 stated they ordered a PIV to be placed for Resident #343. Physician #1 stated they do not recall being notified that the PIV was not obtainable, and their expectation would be a return phone call for further orders. During a telephone interview on 11/1/22 at 1:24 PM, RN #18 (3-11 nursing supervisor) stated that on 10/15/22 Resident #343 had an unsuccessful attempt at PIV access on the day shift by RN #9. RN #18 stated that it was not reported to them that another attempt needed to be completed and that they did not contact a medical provider that the PIV was not obtainable. During an interview on 11/1/22 at 2:17 PM, the Acting Director of Nursing (DON) stated their expectation would be for a medical provider to be notified if a PIV was ordered and the nurse could not access the line as soon as possible for further orders. The Acting DON stated they expected all MD notifications to be documented in the resident's medical record. 415.3 (f)(2)(ii)(b)(c)

Based on interview and record review conducted during the Standard survey started on 10/25/22 and completed on 11/1/22, the facility did not ensure that grievances were resolved in a timely manner for one (Resident #240) of four residents reviewed for personal property. Specifically, there was lack of a thorough investigation and resolution into a resident's report of missing property. The finding is: Review of the facility policy and procedure (P&P) titled Prevention of Resident Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 10/19, revealed all staff were trained annually and on orientation regarding misappropriation of resident property. Complaints regarding resident property required an investigation. Review of the facility P&P titled Resident/Family Concerns revised 10/19, revealed it was the policy of the facility to assure timely investigation and resolution of all resident concerns. When a complaint is received, the Grievance Officer will write the complaint into the log, assign complaint to applicable department director and or management staff. The individual assigned will investigate the complaint and provide a summary to applicable Grievance Officer. All complaints will be monitored by the Facility QAPI Committee and concerns will be responded to in writing. The Grievance Officer will forward the letter to the resident/designated representative and the letter would be maintained for three years. 1. Resident #240 was admitted to the facility with diagnoses which included cerebrovascular accident (CVA), hemiplegia, and diabetes mellitus DM. The Minimum Data Set (MDS - a resident assessment tool) dated 9/17/22 documented the resident was cognitively intact, was understood and understands. During an interview on 10/26/22 at 10:36AM, Resident #240 stated they were missing two blue totes full of miscellaneous personal items. The items included a $20.00 gift card, multiple bottles of body spray, multiple sticks of deodorant, and three shirts. Resident #240 stated the missing items were reported to the Operations Manager. The Operations Manager helped pack the totes prior to a room change, then they went missing. There was no resolution reported back to the resident. Review of facility grievances from 2/12/20 to 10/31/22 revealed no concern forms for Resident #240's missing totes that contained personal items. During an interview on 10/31/22 at 11:13AM, the Operations Manager stated they packed Resident #240's personal items into two blue totes which contained multiple body sprays, multiple deodorant, some clothing, soda, bottled water, and multiple personal care items. The Operations Manager stated they were not aware of the $20.00 gift card. Resident #240 had changed rooms from 1/19/21 to 2/14/21 and the totes went missing. The Operations Manager stated a concern form was filed and logged on 3/8/21 for the missing totes. A letter of acknowledgment should have been sent to the resident. The letter informed the resident when an investigation was started. At the end of the investigation an additional letter was sent to the resident informing them of the resolution if there was one. The Operations Manager stated I don't believe the totes with the missing items were found, there were no letters sent to the resident, and no resolution occurred. The Operations Manager stated the investigation was incomplete. Review of the facility's untitled concern form log revealed a missing tote for Resident #240 was logged and referred to the team leader on 3/8/21. There was no documented evidence the missing totes were investigated. During an interview on 11/1/22 at 9:24AM, the Secretary to the Administrator stated complaints or grievances were logged into a binder. A letter of acknowledgment was sent to the resident. The appropriate department head would be notified and was responsible in conducting the investigation. Resolution letters stating the outcome were sent to the resident. In this case, the Team Leader would be responsible for the investigation. I'm not sure what happened, the concern was logged in on 3/8/21. The Team Leader never sent a response and should have. There was no follow up. During a telephone interview on 11/1/22 at 10:10 AM, Registered Nurse, (RN) #7 Team Leader (TL) stated the missing totes were reported to the Operations Manager and the Social Worker. The Social Worker was responsible and filed the concern form. The totes contained personal care items purchased by Resident #240's family member and were labeled with the resident name. The RN #7 TL stated the items were never found. During a telephone interview on 11/1/22 at 11:02 AM, RN #15 stated Resident #240 had transferred to their unit during COVID-19 and then returned to their original room. RN #15 stated the blue totes were never located and they didn't know what happened to them. RN #15 stated they just kept telling the resident, they were looking for them. During an interview on 11/1/22 at 11:44 AM, the Social Work Assistant stated a concern form was filed, the team leader should have followed up on the missing items. Typically, residents received a letter before and were notified after of the outcome of the investigation. Resident #240 never received a follow up letter and should have. The Social Work Assistant stated the missing totes with the missing items were never found. The resident was not notified. During an interview on 11/1/22 at 2:13 PM, the Administrator stated internal investigations were completed to determine if the facility was at fault. The team leader should have completed follow through on the missing totes with personal items on the log form. A conclusion should have been determined and reported to the resident. The resident should have been reimbursed for the missing items or arrangements made to the satisfaction to the resident. 415.3(c)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review completed during a Standard survey started 10/25/22 and completed on 11/1/22, the facility did not ensure that the resident is free from physical restraints imposed for purposes of convenience, that are not required to treat the resident's medical symptoms, and 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 for one (Resident #51) of one resident reviewed. Specifically, the resident had a merry walker (a seated rolling walker used to assist ambulation) with no doctor's order in place and no re-evaluation of the need for continued use of the restraint. In addition, Resident #51 had chair and bed alarms with no on-going re-evaluation of the need for the restraint and supporting clinical documentation to warrant the use of the restraint. The finding is: Review of the policy and procedure titled Physical Restraint Use last reviewed 9/2022 documented it is the policy of the facility to respect the resident's right to be free from physical restraints. Utilize restraints in accordance with the medical order, only when other options to enable the resident to reach their highest practicable level of function have failed. Purpose to provide resident centered care and services to ensure that the resident's right to freedom from physical restraint is respected by all staff, if a resident must have a restraint that the least restrictive restraint is utilized and that all restraint use is appropriately assessed prior to applying a restraint, and that all staff in the facility are oriented to the policy and procedure for physical restraint use. Restraints will only be used when all reasonable less restrictive alternatives have been considered and rejected based on the resident's well-being. Recommendations will be reviewed with the medical team and if restraints are ordered, they will be applied per order until the Comprehensive Care Plan Team (CCP) completes a full assessment within 14 days. Orders will contain the type of restraint, reason for the restraint, and frequency of removal. The Director of Nursing (DON)/ designee will monitor the use of restraints to assure compliance with facility policy and report to the Quality Assurance Committee. The State Operational Manual issued 10/21/22 defines position change alarms are alerting devices intended to monitor a resident's movement. The devices emit an audible signal when a resident moves in certain ways. Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to their body. Examples of facility practices that meet the definition of a physical restraint include but not limited to: placing a resident in an enclosed framed wheeled walker, in which the resident cannot open the front gate or if the device has been altered to prevent the resident from exiting the device and using a position change alarm to monitor resident movement, and the resident is afraid to move to avoid setting off the alarm. 1. Resident #51 had diagnoses including dementia, osteoarthritis, and hypertension (HTN- high blood pressure). The Minimum Data Set (MDS- a resident assessment tool) dated 8/10/22 documented Resident #51 was sometimes understood, sometimes understands and was moderately cognitively impaired. The resident had bed and chair alarms that were used daily indicated under restraints. There was no indication of the use of a merry walker. Review of the General Care Plan dated 5/17/22 revealed in the physical restraint section, the resident was to be out of bed (OOB) to the merry walker. The resident was to sit in a stationary chair with an alarm for meals, and the merry walker was to be released every (q) 2 hours (h) and reapplied. Review of untitled certified nurse aide (CNA) care guide dated 10/24/22 documented under safety/ restraints high fall risk- yes, no clutter around bed alarm, box out of reach. Low bed, bed wedges, landing mat, and bed alarm. Restraint location: merry walker, every 2 hours removed and reapplied. Under ambulation assistive devices: merry walker. Supervision in merry walker. Encourage to sit in merry walker when tired. Under transfer: remove from merry walker for meals (chair with chair alarm at table) hand held assist for transfers. Must be in sight at all times in merry walker. Dycem (non-slip, self-adhesive mat) to top of merry walker seat to prevent sliding out. The following observations were made: On 10/25/22 at 10:20 AM, Resident #51 was noted to be in a merry walker with a seatbelt wandering around the unit going up and down the halls. When the resident was asked if they could unlock the device they stated, I think so, but then was unable to complete the task and then said, I guess I can't do it. On 10/25/22 at 12:20 PM, during the lunch meal, Resident #51 was in a straight back chair with a chair alarm and Dycem on the seat under them. The resident stood up several times during the meal and was setting the alarm off which was making a high pitch alarming sound. Staff would then turn towards the resident and tell the resident to sit down. On 10/27/22 at 1:53 PM, Resident #51 was in their merry walker walking/rolling around the unit and approached the nursing station. At that time with Registered Nurse (RN) #16, the resident was asked to unlock the seatbelt and was unable to release it. RN #16 then demonstrated that the resident would need to unlock the seatbelt and then have to unlock the arm to the merry walker and lift it to get out. On 10/31/22 at 11:09 AM, Resident #51 was in the merry walker wandering around the unit going up and down the hallways. Resident was asked to release the seat belt and they stated, I am not able to unlock it. Resident did not even try to release the seat belt. On 10/31/22 at 1:09 PM, Resident #51 was seated in a straight back chair with the chair alarm under them in the dining room during the lunch meal. The resident stood up multiple times during the meal and the alarm kept sounding. Resident #51 stated, The alarm does scare me sometimes or startles me at times as I forget it is there. a. The Physician's Orders dated from 9/1/22-9/30/22 and 10/1/22-10/31/22 documented no order for the merry walker. The Physician's orders dated 8/1/22-8/31/22 documented for a merry walker- have resident demonstrate self-release from merry walker upon request Q week. No documented diagnosis. Initiated date of 11/3/21. Review of the Medication and Treatment Administration Record Report (MAR/ TAR) dated September 2022 and October 2022 documented nothing regarding the use of the merry walker. Review of the Acute Visit for interval visit dated 9/28/22 and completed by the Medical Director documented Resident #51 used a merry walker, had frequent falls, and was able to ambulate independently with the merry walker. Review of Annual Visit dated 8/9/22 documented reason for visit annual history and physical. Resident uses a walker when OOB. No indication for the use of the merry walker. Review of Nurse Notes dated 11/1/21 documented at 3:56 PM, the resident was sitting in their merry walker in front of the nurses' station. They slid off the seat of the merry walker to the floor sitting on their buttocks. They remained inside the walker. The resident did not hit their head and said they were not hurt with no complaints of discomfort offered when asked. The strap to the walker was noted to be very slack and it was tightened and Dycem would be applied to the merry walker seat to prevent sliding. Review of Nursing Comprehensive Care Plan Assessments dated 7/7/21, 9/27/21, 11/24/21, and 2/23/22 documented the resident did not use a physical restraint and the restraint decision tree completed was marked N/A (not applicable). Assessments dated 9/27/21, 11/24/21, and 2/23/22 documented the resident utilized a merry walker to enhance mobility and prevent falls. The 5/19/22 and 8/10/22 Assessments documented the resident utilized a merry walker to enhance mobility and prevent falls. Resident was unable to demonstrate self-removal of merry walker. Restraint decision tree and quarterly done. b. Review of the Physician's Orders dated 9/1/22-9/30/22 and 10/1/22-10/31/22 documented to check the bed alarm Q shift. Ensure the bed alarm was in place and functioning Q shift for diagnosis: high risk for falls. Initiated date of 12/23/20. Check chair alarm (uses in dining room, while at table) with no documented diagnoses. Initiated date of 9/22/21. Review of the MAR and TAR dated August 2022, September 2022 and October 2022 documented the bed and chair alarm were being checked per the order. Review of the Acute Visit for interval visit dated 9/28/22 and completed by the Medical Director documented Resident #51 had a bed and chair alarms with no documented indication for the use. Review of Annual Visit for annual history and physical dated 8/9/22 and completed by the Physician Assistant revealed no documentation regarding the use of the bed and chair alarm. Review of the Nursing Comprehensive Care Plan assessment dated [DATE], 9/27/21, 11/24/21, and 2/23/22 documented the resident did not use a physical restraint and that chair and bed alarms were used. The Assessments dated 5/19/22 and 8/10/22 documented the resident had chair and bed alarms but were not indicated as restraints. Review of the nurses notes, provider notes, and therapy notes between 9/2021 through 10/29/22 documented no on-going re-evaluation of the need for the bed and chair alarm and supporting clinical documentation to warrant the use of the chair and bed alarm. During an interview on 10/31/22 at 11:14 AM, RN #16 stated Resident #51 was falling a lot when they were first admitted and has had the merry walker since 2/11/21 for status post fall. A doctor's order was needed for a merry walker as it was considered a restraint and they needed to have the resident show they can release it. The order for the merry walker was discontinued on 8/25/22 because the resident had not been able to release the seatbelt themselves. There was no order for the merry walker for September 2022 and October 2022. RN #16 stated Resident #51 had a chair and bed alarm and they were also considered restraints. They have the bed and chair alarm to alert the staff when the resident was either standing up or was trying to get out of their bed. RN #16 stated they really do not want us to be using them because they are considered restraints. At 2:03 PM, RN #16 stated the unit secretary was unable to locate the original order for the merry walker from February 2021. During an interview on 10/31/22 at 12:42 PM, RN #11 stated a merry walker was considered a restraint if the resident was unable to release it. An order was needed for restraints like the merry walker. When Resident #51 came to their unit in May 2022, the resident was unable to release the merry walker and that was when it was considered to be a restraint. The merry walker was discontinued on 8/25/22 because the resident was no longer able to release the seatbelt and there wasn't a need to check if they could release it. A new order for the use of the merry walker should have been written at that time as the resident continued to use the merry walker. Resident #51 has the merry walker because of their poor safety awareness and was at high risk for falls and it helped them to be able to ambulate by themselves. RN #11 stated the bed and chair alarms were not considered restraints. The reason Resident #51 had them was for their safety as they were at risk for falls. The alarms alerted the staff that the resident may be attempting to ambulate or get out of their bed. Resident #51 sometimes stands up abruptly and if they do not have a staff member right there, the resident would get up and walk. The bed alarm was used so that staff heard the resident trying to get up while they were in bed. If the resident had a restraint, they reassessed the need for the restraints quarterly and as needed. During an interview with the Director of Therapy, Physical Therapist (PT) #1 and PT #2 on 11/1/22 at 8:58 AM, it was stated Resident #51 was first assessed for the use of the merry walker between 2/1/21- 2/15/22 because of prior falls that the resident had due to self-transferring. The resident would be re-assessed quarterly or on an as needed basis for their physical ability of walking in the device, not for the assessment of being able to release the device. Resident #51 needed assistance to get in and out of the walker but could negotiate the merry walker themselves. It was stated that the merry walker was not a restraint if the resident can unhook it themselves. If they cannot, at that point someone should walk with them or be 1:1 (one on one). They stated the resident was recently added to therapy on 10/24/22 and were working with Resident #51 regarding the merry walker. During an interview on 11/1/22 at 10:26 AM, the Medical Director stated they would consider the merry walker a restraint if the resident was unable to get out of it or if they were locked in it. The Medical Director stated, I guess a restraint would need a doctor's order. The Medical Director stated they do not consider chair or bed alarms restraints as they do not stop residents in any way from moving. Chair and bed alarms alerted the staff that a resident might be getting up and moving and would help prevent residents from falling. During an interview on 11/1/22 at 10:41 AM the Acting DON stated a merry walker was considered a restraint if the resident was not able to self-release the merry walker on demand. The Acting DON stated that if the merry walker was considered a restraint they would expect a doctor's order for it. They stated they did not know why Resident #51 was in the merry walker but expected the nursing staff to be releasing the resident from the merry walker q2h and to be continually assessing the need for the merry walker. The Acting DON stated that they would not consider a chair or bed alarm a restraint. 415.4(a)(2-7)

Based on observation, interview, and record review conducted during a Standard survey started on 10/25/2022 and completed on 11/1/22, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for three (Residents #58, #150 and #279) of seven residents reviewed for ADLs. Specifically, there was lack of hand hygiene and glove changes during morning (AM) care and staff did not wash the residents face, hands, and underarms (Resident #58), Resident #150 had greasy, long, and unkempt hair, with no access to a barber, and Resident #279 had long fingernails with brown debris under their thumb nails. Additionally, Resident #279 did not have rolled washcloths to both hands as ordered. The findings are: Review of the facility Policy and Procedure (P&P) titled Grooming, AM & PM Care, revised 9/2022 includes grooming, hair combed, daily shave for men/PRN (as needed) for women, oral care, application of deodorant after washing under torso, and nail care. The Certified Nurse's Aide (CNA) is to document completion of ADLs or if unable to complete ADLs. Review of the facility's undated The Resident Handbook (part of the admission packet) documented there was a beauty shop located on the ground floor. Services available included haircuts, styling, and perms. Charges can be deducted from the resident's account. Residents should see the Administrative Control Clerk (ACC) to make an appointment or call the beauty shop directly. The facility P&P titled Nail Care last revised 8/2021, documented to provide nail care weekly on bath days and as needed. Assure resident's nails are kept clean without jagged edges which could lead to injury. 1.Resident #150 was admitted to the facility with diagnoses including: heart failure, hypertension, peripheral vascular disease. The Minimum Data Set (MDS, a resident assessment tool) dated 8/26/22 documented the resident was cognitively intact and required extensive assistance of one staff member for personal hygiene. The closet care plan dated 10/20/22 documented Resident #150 needed assistance for grooming and was to be offered shaving and grooming daily. During an observation and interview on 10/26/22 at 8:59 AM, Resident #150 had greasy, long and unkempt hair. Resident #150 stated that they had been trying to get a haircut for about two months but haven't been able to because the hairdresser left. Further observations on 10/27/22 at 12:52 PM and 10/28/22 at 8:11 AM, revealed Resident #150's hair was long and unkempt. During an interview on 10/28/22 10:59 AM, Certified Nurse Aide (CNA) #2 stated the facility used to have a hairdresser but they left a while ago and they didn't have one now. During an interview on 11/1/22 9:54 AM, Resident # 150 stated that their family would take them out for a haircut the next day, although they would have preferred to have one at the facility, if a hairdresser was available. During an interview on 11/1/22 9:57 AM, the Administrative Control Clerk stated that the facility did not have a hairdresser and hasn't had one since July. The Administrative Control Clerk stated if a resident wanted a haircut, the family could arrange for a hairdresser and that it was a problem for some residents. During an interview on 11/1/22 at 10:00 AM, Registered Nurse (RN) #1 stated that the facility used to have a beautician but has not had one for many months now. RN #1 stated that to get appointments for the residents, the family would have to come in and do it or do the hair themselves since the nursing staff cannot cut the hair. During an observation and interview together with RN #1 on 11/1/22 10:04 AM, RN#1 stated that Resident #150's hair was long, and that the resident should have a haircut as they wanted to. During an interview on 11/1/22 10:51 AM, Acting Director of Nursing (DON), stated that they usually provided hairdresser services but the last hairdresser had resigned, and there is none now. The Acting DON stated residents and staff were aware the facility did not have one now, and the position had been posted, and they were trying to hire one. The Acting DON stated if a resident wanted a haircut, they would have to reach out to families to arrange it. 2. Resident #58 was admitted to the facility with diagnoses including: Depression, chronic pain, Parkinson's, pyoderma gangrenosum (skin disorder). The Minimum Data Set (MDS, a resident assessment tool) dated 8/11/22 documented resident # 58 had moderately impaired cognition, required extensive to total assistance of one person for ADLs. Review of the closet care plan dated 10/20/22 documented Resident #58 needed total assistance of one staff for bathing and oral care. During an observation of morning care on 10/31/22 at 10:37 AM, CNA #3 provided perineal-care (area between the genitalia and anus) and did not change their gloves, wash hands, and replace the water in the basin, before they wet a washcloth and cleaned brown debris off, in and around the resident's mouth. CNA #3 did not provide oral care, clean the resident's back, armpits, or brush the resident's hair. CNA #3 disposed of the used water from the basin in the single sink of the bathroom the resident shared with another resident. During an interview on 10/31/22 at 10:49 AM, CNA #3 stated Resident #58 needed total assistance with all morning care and that the resident's back, feet, armpits should have been cleaned, the resident's hair combed and brushed, and oral care should have been done during morning care. CNA #3 stated they should have changed their gloves and washed hands, before they cleaned the chocolate pudding off, in and around the resident's mouth and should have disposed of the used water from the basin into the toilet and not the single sink of the bathroom the resident shared with another resident to avoid cross contamination. During an interview on 10/31/22 at 1:23 PM, Licensed Practical Nurse (LPN) #1 stated that morning care for Resident #58 included, brushing hair, washing upper and lower body, peri-care and oral care. LPN #1 stated that CNA #3 was made aware of these guidelines this morning. LPN #1 stated CNA #3 should have washed their hands and changed gloves before cleaning the resident's mouth and should have dumped the used water into the toilet. During an interview on 11/1/22 at 11:08 AM, the Acting DON, stated that morning care included oral care, washing face, combing hair and staff should complete care as outlined by the resident's care plan. The Acting DON stated that nurses were responsible for ensuring that staff follow the care plan. The Acting DON stated that it was not acceptable that the CNA breached infection control protocols by not changing the gloves after peri-care, prior to cleaning the resident's mouth and did not carry out complete morning care for the resident as per resident's care plan. The Acting DON stated that they would have expected CNA #3 to have changed her gloves and dump the dirty water into the toilet and not the sink. During an interview on 11/1/22 at 12:06 PM, In -Service Coordinator #1 stated CNAs were taught to check the care plans and follow them and were provided infection control and other competency during orientation, and trainings before they hit the floors. In-Service Coordinator #1 stated they would have expected staff to wash hands and change gloves between dirty and clean sites of the body during care, and to dispose of the water after care in the toilet and not the sink. During an interview on 11/1/22 at 12:10 PM, In -Service Coordinator #2 stated CNA #3 should have worked from clean to dirty sites and changed gloves while moving from one task area to the other, when providing morning care to the resident. The In-Service Coordinator #2 stated that morning care included washing the resident's hands, face, underarms, peri area, and providing oral care. 3. Resident #279 had diagnoses that included unspecified dementia, contracture (loss of joint mobility) of left hand, and adult failure to thrive. The Minimum Data Set (MDS-a resident assessment tool) dated 10/18/22 documented Resident #279 had severe cognitive impairment, was rarely/never understood, and sometimes understands. In addition, Resident #279 had functional limitation in ROM (range of Motion-normal range of motion for a joint) on both sides UE (upper extremities) and LE (lower extremities). Also, required extensive to total assistance for ADL's. Review of the closet care plan dated 10/20/22 revealed Resident #279 required total assistance with grooming and required rolled washcloths to left (L) and right (R) hand(s) on as tolerated, at all times except care. Review of physician's orders printed 11/1/22, revealed an order dated 4/5/22 to cleanse Resident #279's left and right hand with soap and water, dry thoroughly and place a rolled washcloth daily and PRN (as needed) for contracture care. Another physician's order dated 4/5/22 documented to check for placement of hand rolls to bilateral hands, if not present complete PRN. Review of Medication, Treatment, and Task Administration Record Report for October 2022 documented no refusals of treatment orders for rolled washcloth and handrolls to bilateral hands. Review of nurse's notes dated from 9/13/22-10/26/22, documented no refusal of nail care or placement of bilateral hand rolls. Observations of Resident #279 revealed: -On 10/25/22 at 9:46 AM and 10:00 AM, visible fingernails on both hands were long (over the tips of the fingers), thumb fingernail on the left hand was dirty with dark debris, and jagged. Fingers on the left hand were curled into the palm of their left hand with their left index fingernail visibly pressing into the palm of their left hand. No rolled washcloth was present in their left hand. -On 10/31/22 at 10:33 AM, bilateral fingers/hands curled into fist position with no rolled washcloths present. At 1:29 PM, bilateral hands were clenched in fist position with fingernails curled into palm of hands. Bilateral thumb nails visible and were noted to be long, jagged with dark debris present. No rolled washcloth present to bilateral hands as ordered. -On 11/1/22 at 7:37 AM, a rolled washcloth was in their left hand only. During an interview on 10/31/22 at 11:45 AM, CNA #6 stated they were responsible for applying splints per the care plan so residents do not lose their ability to move. At 1:29 PM, CNA #6 stated they should have noticed Resident #279 did not have rolled washcloths to bilateral hands and they should have had them in place. Additionally, CNA #6 stated rolled washcloths were needed so Resident #279 contractures didn't get worse. During an interview on 10/31/22 at 11:59 AM, LPN #8 stated all nursing staff were responsible to ensure residents are wearing adaptive equipment as care planned. During further interview and upon observation at 1:36 PM, LPN #8 stated Resident #279 nails needed to be cut and cleaned because they were long and had dried debris under the nails. Additionally, dried skin were noted to palm of hands with nail indentation noted to palm of left hand. During an interview on 11/1/22 at 7:37 AM, RN #5 stated every shift was to make sure rolled washcloths were in place to bilateral hands. During observation at this time RN #5 confirmed that Resident #279, only had a rolled washcloth in their left hand and should have had one present in their right hand as well so their hand doesn't contract anymore. During an interview on 11/1/22 at 11:36 AM, Certified Occupational Therapy Assistant (COTA) #2 stated Resident #279 was care planned for a rolled washcloth to both hands for skin integrity and to maintain what movement they had. During an interview on 11/1/22 at 11:11 AM, the Acting DON stated they expected CNAs to perform nail care on residents unless they were diabetic then the nurse would be expected to complete. Nail care was expected to be completed on shower/bath day or anytime it was needed to prevent scratching, skin tears and infection. Additionally, the Acting DON stated rolled washcloths to hands were utilized for hand hygiene, and for contractures to help with joint mobility. Refusals of care should be reflected in the resident's plan of care. 415.12 (a) (3) (e) (2)

Based on observation, record review and interview conducted during the Standard survey started on 10/25/22 and completed on 11/1/22, the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for three (Units 2B, 2D, and 3D medication carts) of 11 medication carts reviewed for medication storage. Specifically, there was an open insulin pen not labeled with a resident's name (Unit 2B medication cart), and opened and outdated multidose vials of insulin (Units 2D and 3D medication carts). In addition, three blister packs of medications were left unattended on the 2B medication cart. Residents #32, 81, and 266 were involved. The findings are: The facility policy and procedure (P&P) titled Medication: Labeling Policy last revised on 2/2021, documented all medications specifically dispensed to an individual resident shall be appropriately labeled for that resident. Labels shall be permanently affixed to the outside of the container. The facility P&P titled Medication: Cart System last revised on 9/2019, documented that the medication cart is always locked when not in view and no medications are to be left on top of the cart when not in view. Discontinued medications should be removed from the cart and returned to pharmacy for credit if they have been punched in sequence. Liquids, Multi dose injectables, eye drops etc. cannot be returned and are disposed of in the appropriate biohazard container for destruction. 1. On 10/31/22 at 9:22 AM, the 2D Unit medication cart was observed with Registered Nurse (RN) #4. One multidose vial of Lantus insulin glargine (100 units (u)/milliliter (ml)) had date opened on vial and brown storage bag as 7/29 for Resident #32. During an interview on 10/31/2022 at 9:22 AM, RN #4 stated the Lantus insulin vial should have been discarded after 28 days of opening. RN #4 stated they utilized the opened Lantus insulin dated 7/29 for Resident #32 that morning and that they should not have. 2. On 10/31/22 from 9:48 AM until 9:52 AM, the 2B Unit medication cart was observed unattended in hallway with 3 blister packs of medication on top of medication cart for Resident #81. The medications observed were cymbalta (antidepressant) 60 milligrams (mg), 30 caps, pioglitazone (anti-diabetic medication) 45mg, 30 tablets and januvia (anti-diabetic medication) 50mg, 14 tablets. LPN #2 returned to the medication cart at 9:52 AM, and a Lantus Solostar insulin glargine 100u/ml, 3ml prefilled pen was observed in the top drawer of the medication cart not labeled with a resident's name. During an interview on 10/31/2022 at 9:55 AM, LPN #2 stated they had no idea who the insulin pen belonged to because it was not labeled and there was no storage bag with a label noted. LPN #2 stated they would discard it and obtain a new one with a label indicating name on it. LPN #2 stated medications should not be left on top of medication cart because anyone could grab them. During an interview on 10/31/2022 at 1:53 PM, RN #9 Team Leader stated Lantus insulin was good for 28 days after opening and the nurse opening the insulin vials and pens were responsible to place the date when it was opened on them. RN #9 stated after 28 days the effectiveness of the medication could change and insulin should be discarded. RN #9 stated each insulin pen should be individually labeled, so staff knew who it belonged to. 3. On 11/1/22 at 7:54 AM, the 3D medication cart was observed with LPN #5. One multidose vial of Lispro insulin 100u/ml, 10ml vial for Resident #266 was observed opened and dated 9/13/22 at 9:00 PM, the vial was in a brown storage bag that was dated 9/30 as the date the vial was opened. The sticker on the vial documented discard the medication after 28 days. During an interview on 11/1/22 at 7:54 AM, LPN #5 stated they would have to ask the manager if they could still utilize Resident #266's insulin. During an interview on 11/1/22 at 10:50 AM, the Pharmacy Consultant stated the insulin ordered for Residents #32, and 266 were only guaranteed stability for 28 days per manufactures recommendations once opened. The Pharmacy Consultant stated they would expect the date when opened to be placed on the medication, so staff knew when it would expire and needed to be discarded. Additionally, the Pharmacy Consultant stated that all insulin pens should be labeled with at least the residents' name because insulin pens cannot be shared. During an interview on 11/1/22 at 11:11 AM, the Acting Director of Nursing (DON) stated all insulin vials and pens were to be labeled so staff knew who it belonged to. The Acting DON stated opened insulin was only good for 28 days and that the nurses were responsible to date insulin when opened. Additionally, the Acting DON stated they would expect the nurse who opened the insulin and every nurse thereafter to be checking for labels and the date when opened during medication administration. During further interview at 2:17 PM, the Acting DON stated medications should not be stored on top of medication carts because anybody including a resident could take them off the cart. 415.18(d)

Based on observation, interview, and record review conducted during a Standard survey started 10/25/22 and completed 11/1/22, the facility did not follow the prepared menus. One (Unit 4D) of four test tray lunch meals on 10/31/22 did not provide broccoli slaw portion on the test tray and to the residents on Unit 4D as planned. The finding is: The Current Menus 2022 Week 2 Monday documented the following lunch meal: oven fried chicken thigh, mashed potatoes, broccoli slaw, dinner roll, rice Krispie treat, 2% milk, and coffee. The Resident Council Minutes dated 7/12/22 documented that missing items continue to be an issue and the concern was sent to the Food Service Director (FSD). During an interview on 10/25/22 at 10:09 AM, Resident #43 stated they were not getting what is on the menu. During an interview on 10/26/22 at 9:14 AM, Resident #150 stated ninety percent of what was on the meal list/slip you don't get. During a lunch observation on 10/31/22 between 12:30 PM - 1:10 PM Dietary Aide #1 was serving the lunch meal for the residents on unit 4D. During the entire meal service, no residents were served or received the broccoli slaw that was posted on the menu. Observation of the servery area revealed there was no broccoli slaw available. At 1:10 PM the dietary aide provided a test tray, and the meal tray did not have broccoli slaw. Further observation of the unit servery revealed in the refrigerator there was a container of food that looked like broccoli slaw. During an interview on 10/31/22 at 1:17 PM Dietary Aide #1 stated, No, I did not serve any broccoli slaw to any of the residents as I did not have any to pass out. I called down to the kitchen and they told me it was not on the menu. I do not remember who I spoke to. When Dietary Aide #1 was shown the broccoli slaw in the refrigerator they stated, that is probably it and they did not tell me it was in the refrigerator. During an interview on 10/31/22 at 1:26 PM, Food Service Supervisor #1 stated the container in the refrigerator was the broccoli slaw, and Dietary Aide #1 should have served it with the lunch meal. During an interview on 10/31/22 at 1:34 PM, the FSD stated broccoli slaw was part of today's (10/31) lunch meal and it was on the posted menus. The FSD stated Dietary Aide #1 should have served it to unit 4D and did not know why they didn't. If Dietary Aide #1 could not find an item that was on, they were to call the diet office. During further interview on 11/1/22 at 10:25 AM the FSD stated after looking in the diet office call down book there was nothing documented regarding not having the broccoli slaw available from the previous day (10/31). During an interview on 11/1/22 at 9:43 AM, The Registered Dietitian (RD) stated the broccoli slaw would have been considered the vegetable for the lunch meal on 10/31/22. They stated they would expect the servers to serve what was listed on the menus. It was also stated that the menus were designed to be nutritionally complete, and if the residents were not served what was on the menu, they could potentially not be getting the necessary nutrients. During an interview on 11/1/22 at 10:20 AM, FSD stated they did not have any policies regarding following posted menus/ proper food portions. 415.12(c)(1-3)

Based on observation, interview, and record review conducted during a Standard survey started 10/25/22 and completed 11/1/22, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. One of one main kitchen and one (Unit 4D) of four units had issues with safe food handling. Specifically, dietary staff (Cook #1 and Dietary Aide #1) did not change gloves in accordance with professional standards, touched multiple surfaces, and did not use appropriated utensils to prepare pureed food (Cook) and to serve ready to eat food items (Dietary Aide). The findings are: The policy and procedure (P/P) titled Production, Purchasing, Storage revision date 1/22 documented use sanitized equipment and food contact surfaces (e.g., knives, sinks, utensils, table surfaces, slicers, multipurpose cutting boards, bowls, etc.) for each task. Gloves are changed between tasks or if punctured or ripped. Hands are washed after gloves are removed. Minimize hand contact with ready-to-eat food by use of utensils, disposable gloves, or individual wax paper. Review of the P/P titled Sanitation and Infection Prevention/ Control revision date 1/20 documented disposable gloves must be changed and hands washed when moving from one task to another, such as moving from handling dirty dishes to handling clean dishes. Hands must be washed with soap and water before putting on or after use of gloves for food plating on the resident units. a. During an observation on 10/31/22 at 9:59 AM with the Assistant Food Service Director (AFSD) present, [NAME] #1 proceeded to puree cooked pork dijonnaise. The cook had plastic gloves on their hands and lifted the pan with the pork in it and placed 10 servings of the pork in the robo coupe (style of blender) by pouring it into the mixer. With the same gloved hands, they then grabbed a large measuring container, turned on the facet and filled it with approximately 2 cups (c) of hot water and placed the water it in the robo coupe. The cook then with the same gloved hands grabbed a plastic cup out of a stack which was wrapped in clear plastic wrap and filled it with ½ c of thickener and poured it in the robo coupe, covered it and turned it on. While the pork was being blended the cook touched their face mask and lifted it up over their exposed nose. Once blended the cook open the blender looked at it and stated the pork was too thick. They then grabbed the large measuring cup, walked over to the faucet, turned it on and added more water to it. They turned off the faucet and added the water into the pork, covered it and turned the blender back on. The cook's mask once again fell under their nose, they touched the mask, adjusted it and placed it back over their nose. The cook did not change their gloves. The cook then stopped the blender and opened it up. The puree pork was then tasted with clean plastic spoons to make sure the consistency was good. The cook while still wearing the same gloves took a spoonful of the puree pork, pulled down their mask, tasted the pork, took a paper towel, spit the pork out in it and put their mask back on; and still did not change their gloves. While wearing those same gloves the cook then began to pour the puree pork into a clean pan. Approximately half- way of pouring the puree pork the cook placed their hand into the blender and proceeded to scoop the rest of the puree meat out with their gloved hand. Scrapping the sides of the mixer bowl to get it all out. The cook then took their gloves off and threw them away, put clean gloves on, and covered the puree pork with clear plastic wrap. At that time [NAME] #1 was asked why they used their gloved hands and not a spatula. They stated all the utensils were dirty and did not have any to use and pointed to the sink where there was one dirty spatula. They were asked why they did not go clean that spatula and stated they didn't have time to do that. When asked if there were any other clean utensils around the cook pointed out a rack with multiple clean utensils hanging on it. The rack was approximately 20-30 feet away from where they were prepared the puree meat. [NAME] #1 stated they should not have used their hands and they should have gone and got a clean utensil to use to scrap the food out of the bowl. During an interview on 10/31/22 at 10:13 AM, the assistant Food Service Director stated, I knew that using their gloved hand to scoop the puree pork out was not proper. The cook should have used a rubber spatula or a spoon to scoop out the food. What the cook did was not correct. The staff are all in-serviced on using proper procedures when handling food. b. During an observation on 10/31/22 between 12:28 PM - 1:10 PM Dietary Aide #1 was serving lunch in the unit 4D dining room. The food that was being plated consisted of chicken, mashed potatoes with gravy, cornbread, and a rice krispie treat. The dietary aide throughout the meal service used their gloved hand to pick up the corn bread and rice krispie treat from the containers and placed the items on the residents' plates. During the meal service while wearing the same gloves used to touch and plate food, Dietary Aide #1 also touched the counter, drawer handles, sink faucets, the refrigerator door, grabbed items from the refrigerator, and the microwave. During an interview at 10/31/22 at 1:17 PM, Dietary Aide #1 stated they did not us a utensil to serve the corn bread and the rice krispie treat because there were none on the unit, so they just used their hands. They stated they did not know they were supposed to change their gloves after each time they touched other surfaces. During an interview on 10/31/22 at 1:26 PM, Food Service Supervisor #1 stated the corn bread and the rice krispie treat should have been served using some type of utensil. During an interview on 10/31/22 at 1:34 PM, the Food Service Director stated when serving any kind of food item, they should always be using a utensil to serve it. Taking your gloved hand and scooping food out of a bowl was just not a standard procedure. The FSD stated [NAME] #1 should have gone and got a clean spatula or spoon, and Dietary Aide #1 should have also used a utensil to serve the food items. If they are using their gloved hands, they need to wash and change the gloves each time they do another task. If there wasn't a utensil on the unit to use, they needed to call down and ask that some be brought up to the unit servery. 415.14 14-1.80(b)

Based on observation, interview and record review conducted during a Standard survey started 10/25/22 and completed 11/1/22, the facility did not employ sufficient staff with the appropriate competencies and skill sets to carry out the necessary functions of the food and nutrition service to carry out the functions of the food and nutrition service safely and effectively. Specifically, the facility did not ensure sufficient support personnel resulting in extended meal wait times, accuracy of foods, and proper food safety with preparation and serving of foods. This included Residents #35, 230, 239 and 296. The findings are: Refer to: F 803 Menus Meet Resident Needs/ Prep in Advanced/Followed- scope and severity (S/S) = D Refer to: F 812 Food Procurement, Store/ Prepare/Serve- Sanitary- S/S = D Review of the undated Meal Times sheet provided upon entrance of facility the following mealtimes are documented to start at: 2A MLK: Breakfast- 7:45 AM, Lunch-12:00 PM 2D Delaware: Breakfast- 7:45 AM 3B Botanical Gardens: Lunch- 12:30 PM 4C Niagara Square: Breakfast- 8:15 AM Observations of the following meals are as follows: -During unit 2A lunch meal on 10/25/22 tray passing started at 12:39 PM and was completed at 1:00 PM. Posted across from the servery was a sign that documented: Breakfast: 7:45 AM, Lunch: 12:00 PM, and Dinner: 4:30 PM. Please allow a 15-minute window for service. -During unit 2D breakfast meal on 10/26/22 tray passing started at 8:53 AM and was completed at 9:40 AM. -During unit 2A breakfast meal on 10/31/22 tray passing started at 8:30 AM and was completed at 8:51 AM. -During unit 4C breakfast meal on 10/31/22 tray passing started at 10:15 AM and was completed at 10:45 AM. -During unit 4D lunch meal on 10/31/22 tray passing started at 12:35 PM and was completed at 1:10 PM. -During unit 3B lunch meal on 10/31/22 tray passing started at 1:30 PM and was completed at 1:48 PM. Review of Resident Council Minutes dated 7/12/22 documented members stated that mealtimes were inconsistent, especially on weekends for lunch and dinner. Review of Resident Council Minutes dated 8/9/22 documented members stated that mealtimes were inconsistent, especially on weekends. Food Service Director (FSD) stated they are having staffing challenges and they continue to recruit new staff to fill gaps. Review of Resident Council Minutes dated 9/13/22 documented members stated that mealtimes are inconsistent, especially on weekends. Concern form sent to FSD and Assistant Food Service Director (AFSD). Review of Resident Council Minutes dated 10/11/22 documented members stated that mealtimes are inconsistent, causing residents to be late or miss special services and activities. Dinner times are close to 7 PM. Concern form sent to FSD and AFSD. Review of Resident Concern Form dated 7/18/22 documented Resident #239 on 7/17/22 stated, I was served breakfast at 10:20 AM on Sunday- cold cream of wheat. Form forwarded to dietary. FSD reviewed camera footage as unit was notified at 7:00 AM that we would need to send up meals via tray line. Food was delivered at 9:17 AM, nursing didn't start passing food until 10:00 AM. Director of Nursing (DON) notified, and staffing was educated. During an interview on 10/26/22 at 12:44 PM, the facility Ombudsman stated the residents have been complaining about the food and the times of when the food is being served. During an interview on 10/31/22 at 10:43 AM, Resident #296 stated It bothers me that the meals come late a lot. Wouldn't it bother you? During an interview on 10/31/22 at 10:43 AM, Resident #230 stated It bothers me the meals always come late. My mother always said if you are late for dinner, you will get nothing, so I am never late and have to sit and wait. It doesn't matter which meals they are all late. During an interview on 10/31/22 at 10:51 AM, Registered Nurse (RN) #11 stated trays often come late. Today they were extremely late for breakfast. It was discovered before 10:00 AM that the food cart was up here but no one from dietary had come to serve it. That is when dietary was called, and they came over about 10:15 AM and started serving up the breakfast meal. During an interview on 11/1/22 at 10:24 AM, Resident #239 stated that they did file a grievance back in July 2022 regarding breakfast being late. They stated meals come late all the time. They stated what resident wouldn't be upset if their meals come late. They have schedules for a reason. There are times because the meal was late causing other things not to get done, like treatments or appointments. Yes, I am upset that the meals do not come on time. During an interview on 10/31/22 at 12:01 PM, the FSD stated they have been having staffing issues as they have been 40 staff members down since 7/2021 and currently were short 14-16 staff either full time or part time positions, especially the servers. They were not able to get the meals out in timely manner. When they are short servers there will only be two servers assigned to 4 units. Optimal number of servers would be 3 per floor or 4 units and we would need a total of 12 servers per meal. There are times when the facility only has 1-2 servers per floor which causes meal service to take longer as they would not serve upstairs in the unit serveries, but from down in the kitchen. When they do this, disposable containers are used as the plates and utensils are all up on the servery. This was usually done on the weekends as that was when they are really short staffed. There have been multiple discussions with the Administrator, DON and Acting DON and they have implemented meal audits. It has to be a team effort for this serving style. During an interview on 11/1/22 at 10:20 AM, FSD stated they did not have any policies regarding staffing or meal serving times. 415.14(b)(1)(2)

Based on interview and record review conducted during the Standard survey completed on 2/12/20, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, one (Employee #4) of six personnel files reviewed for background checks had not been screened through the New York State Nurse Aide Registry prior to their employment. The finding is: The facility's policy and procedure titled Drug/Alcohol Test and Background Check, reviewed 3/2019, documented all Skilled Nursing Facility employees must be cleared through the NYS Nurse Aide Registry verification system and the Central Registry. All information will be kept in the Employee Criminal Background Check folder. Record review of the personnel file for Employee #4 (Catering Attendant) on 2/7/20 revealed Employee #4 first worked at the facility on 11/20/19 and Employee #4's file contained a Nurse Aide Registry verification dated 2/7/20. Record review of the automated time and attendance record revealed Employee #4 worked in this facility 36 days between 11/20/19 and 1/7/20. During an interview on 2/7/20 at 11:42 AM, the Labor and Employee Relations Coordinator stated Employee #4 worked in the facility as an employee of an outside food service vendor. She also stated she usually checks the Nurse Aide Registry for all facility employees before hire, including employees of the outside food service vendor, but this one was accidentally missed. During an interview on 2/7/20 at 1:50 PM, the Assistant Food Service Director stated Employee #4 worked full-time in this facility as a Catering Attendant mainly on the Third Floor Resident Servery, but also floated to other Resident Floor Serveries as needed. 415.4(b)(1)(ii)(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 2/12/20, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #371) of six residents reviewed for accidents. Specifically, the lack of supervision/cueing during meals for a resident with a diagnosis of dysphagia (difficulty swallowing). The finding is: 1. Resident #371 had diagnoses including dementia, hypertension (HTN, high blood pressure), and heart failure. The MDS (minimum data set-resident assessment tool) dated 1/20/20 documented the resident had severe cognitive impairment and was on a mechanically altered diet. The speech therapy swallow evaluation dated 1/14/20 documented the resident had moderate to severe swallowing impairment and dysphagia. Swallow precautions/strategies included sitting upright 90 degrees, small bites/sips, alternate liquids/solids, and to provide verbal cues. The speech therapy Discharge summary dated [DATE] documented the resident benefits from alternating liquids and solids. Review of the closet care plan (guide used by staff to provide care) dated 2/4/20 revealed the resident's feeding ability is assist and is an aspiration (breathing in a foreign object) risk. During a continual observation of Resident #371 on 2/10/20 from 8:31 AM to 9:07 AM revealed the following: - 8:31 AM the resident was lying in bed with the head of bed at approximately 45 degrees; at this time CNA (Certified Nurse Aide) #1 entered the room with the resident's breakfast tray, she woke the resident up, and asked the resident if they wanted breakfast - 8:32 AM CNA #1 left the room - 8:33 AM the resident was heard coughing - 8:35 AM the resident was heard coughing again, when the surveyor entered the resident's room, the resident was holding a bowl of grits and a spoon in their hands, feeding themselves. A few bites were taken of the grits and the resident stated they tasted good. The head of bed (HOB) was up at 45 degrees, the breakfast tray was on an overbed table that was against the wall at the foot of the bed which was not in reach of the resident - 8:39 AM the facility administrator entered the room and left - 8:45 AM the resident stated ok two times, there were no nursing staff in the area - 8:49 AM a CNA entered the room with roommate's breakfast tray - 8:52 AM the resident's tray was in same position against the wall - 8:57 AM the surveyor entered the room; the resident ate 100 % (percent) of the grits. The CNA was assisting the roommate and was not in eyesight of Resident #371 due to the room set up (with a wall between the beds). The resident stated, I could eat a little more grits. - 9:00 AM another CNA entered the room and asked if the resident was finished with breakfast, the CNA who was assisting the roommate stated she was going to order the resident more food - 9:07 AM the RN (Registered Nurse) Team Leader #1 brought in a bowl of grits; at 9:13 AM the RN Team Leader #1 was observed sitting in a chair next to the resident assisting with eating the grits Review of the resident's tray ticket located on the meal tray and dated 2/10/20 revealed they were on a pureed diet with pudding thick liquids. The ticket included instructions for small bites and sips, to alternate liquids and solids and the word aspiration in capital letters and bold font were also printed on the ticket. During an interview on 2/10/20 at 9:13 AM, the RN (Registered Nurse) Team Leader #1 stated the staff assist the resident as the resident will allow. The resident is on aspiration precautions, which means staff should be watching the resident eat and they would never just leave a tray here. The resident should be watched during meals, usually up in the dining room but sometimes refuses to get out of bed. During an interview on 2/10/20 at 9:32 AM, CNA #1 stated the resident was blind and was able to feed themselves. The resident is on thickened liquids and can spill things, that's why she didn't put the tray in front of the resident. The CNA thought if someone was on aspiration precautions but had pureed food and thickened liquids, they could be by themselves. The CNA did not know she had to stay in the room with the resident and usually the resident was in the dining room for breakfast. During an interview on 2/12/20 at 11:19 AM, Speech Language Pathologists #1 stated the resident should be positioned upright as close to 90 degrees as tolerated and as the resident allows. This resident is on their most restrictive diet, pureed with pudding thick liquids. When staff are passing trays, they should ensure that the diet is correct per the tray ticket. They should also be watching to make sure the resident is taking small bites, not eating too fast, and alternating liquids and solids. The resident should be in eyesight of a staff member. They have tried to upgrade the diet, but the resident hasn't passed the assessments. During an interview on 2/12/20 at 11:25 AM, the Occupational Therapist (OT) Director of Rehabilitation stated they put the speech recommendations directly on the meal tickets so if a staff member isn't familiar with the residents, they will know what assistance and instructions the resident needs at the time the meal is delivered; instead of having to check the care plan. 415.12(h)(2)