**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 12/15/2024 and completed on 12/23/2024, the facility did not ensure that each resident had the right to participate in the development and implementation of their person-centered plan of care. This was identified for one (Resident #93) of four residents reviewed for Choices. Specifically, Resident #93, a cognitively intact resident with no known family or designated representative, was not invited to their Comprehensive Care Plan meeting. The finding is: The Care Planning-Interdisciplinary Team Policy and Procedure last reviewed in January 2024 documented that the resident, the resident's family, and/or legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of day for the resident and family. The Care Plans, Comprehensive Person-Centered Policy and Procedure last reviewed in January 2024, documented that the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care including, but not limited to, the right to participate in the planning process. Resident #93, who has no known family or designated representative, has diagnoses that include Schizophrenia, Anxiety Disorder, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The Minimum Data Set assessment documented Resident #93 was feeling down, depressed, hopeless, had trouble falling or staying asleep, had little energy, felt bad about themselves, and had trouble concentrating on things. The assessment documented Resident #93 received Antipsychotic and Antidepressant medications during the 7-day lookback period. The Social Services Progress Note dated 11/18/2024, written by Social Worker #1, documented the resident had no family contact and that the (Comprehensive Care Plan) meeting would convene with the Interdisciplinary Team. The Care Plan Meeting Progress Note dated 11/20/2024, written by Social Worker #1, documented the resident had no family contact and was not able to represent themselves due to periods of confusion. The Interdisciplinary Team members present were Social Worker #1 and a representative from Dietary. It was a quarterly care plan meeting. The resident's plan of care was reviewed and all concerns were addressed. Staff would continue to provide support to the resident, as they remained stable at this time. The resident would remain in the facility for long-term care. During an interview on 12/17/2024 at 12:30 PM, Social Worker #1 stated Resident 93's Brief Interview for Mental Status score was 13 (intact cognition); however, Social Worker #1 did not invite Resident #93 to their care plan meeting that was held on 11/20/2024 because the resident was confused at times. Social Worker #1 stated they should have visited the resident on the day of the care plan meeting to determine the resident's mental status and if the resident was able to participate in their care plan meeting that day. During an interview on 12/17/2024 at 1:50 PM, the Director of Social Services stated Resident #93 should have been invited to their care plan meeting to participate and discuss their wishes. During an interview on 12/17/2024 at 3:20 PM, the Administrator stated it is a resident's right to be invited to their care plan meeting especially if they are cognitively intact. During an interview on 12/18/2024 at 10:00 AM, Resident #93 stated they would like to be invited to participate in their care plan meetings. 10 NYCRR 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 12/15/2024 and completed on 12/23/2024, the facility did not develop and implement an effective discharge planning process that focused on the resident's discharge goals. This was identified for one (Resident #93) of four residents reviewed for Choices. Specifically, Resident #93, a cognitively intact resident with no known family or designated representative, requested a transfer to another nursing facility; however, the facility did not address the resident's request to meet the resident's discharge goals. The finding is: The Discharge Summary and Plan Policy and Procedure last reviewed in January 2024 documented that when the facility anticipates a resident's discharge to a private residence, or another nursing care facility, a discharge summary, and the post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and their family. Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, they will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the decision. Resident #93, who has no known family or designated representative, has diagnoses that include Paranoid schizophrenia and Depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated that the resident had intact cognitive skills for daily decision-making. Section Q0310 A, the resident's overall goal for discharge established during the assessment process was left blank. The Psychiatry Consultation dated 10/21/2024 documented the resident felt unhappy, lonely, and had no primary support. Recommendations included for Social Services to discuss with the resident their nursing home options in Suffolk County and for the resident to receive Behavior Therapy or counseling. The Psychiatry Consultation dated 12/06/2024 documented the resident reported they would like to move to a facility in Suffolk County. The recommendations included but were not limited to providing social work support to discuss nursing home options in Suffolk County as per the resident's request and for the resident to receive Behavior Therapy or counseling. The Physician's Order dated 12/8/2024 documented for the resident to receive Social work support to discuss nursing home options in Suffolk County as per the resident's request. A review of the resident's Electronic Medical Record on 12/17/2024 at 11:30 AM revealed no documented evidence that Social Services had discussed discharge planning options with the resident to a nursing home in Suffolk County. During an interview on 12/17/2024 at 12:30 PM, Social Worker #1, who was the resident's assigned Social Worker, stated discharge planning was not their responsibility. The facility has a Discharge Planner, who was also a Social Worker responsible for discharge planning. Social Worker #1 stated they discussed the possibility of the resident being discharged to another nursing home in Suffolk County with the facility's Discharge Planner and they both agreed the resident was not a candidate due to the resident being confused at times. Social Worker #1 stated that they should have documented their discussion with the Discharge Planner. Social Worker #1 stated that they never went to the resident to discuss discharge planning because the resident was confused at times. During an interview on 12/17/2024 at 1:50 PM, the Director of Social Services stated Social Worker #1 should have met with the resident to discuss the options for transferring to another nursing home in Suffolk County. The Director of Social Services stated Social Worker #1 should have also met with the resident to know why they no longer wanted to live in this facility so that their experience in this facility could be a better one. During an interview on 12/17/2024 at 3:10 PM, the Discharge Planner stated if a resident was requesting to transfer to another facility, the resident's Social Worker should speak with the resident, and then relay the information to the Discharge Planner. The Discharge Planner stated they were not aware of the Physician's Order for Resident #93's discharge request to a Suffolk County nursing home and did not recall discussing the resident's request with Social Worker #1. The Discharge Planner stated they should have met with the resident to discuss why the resident wanted a transfer to another facility and to facilitate the transfer. During an interview on 12/17/2024 at 3:20 PM, the Administrator stated it is a resident's right to be invited to their care plan meetings. The Administrator stated the Physician's Order to explore Suffolk County nursing home options for Resident #93 should have been followed. During an interview on 12/18/2024 at 10:00 AM, Resident #93 stated before coming to this facility they had lived in a group home. The resident stated they wanted to be placed in a group home in Suffolk County because they thought they could be placed in a facility faster in Suffolk County, but they would be okay being placed in [NAME] County as well. 10 NYCRR 415.11(d)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification Survey completed on 12/23/2024, the facility did not ensure that residents received proper assistive devices to maintain hearing abilities. This was identified for one (Resident #59) of two residents reviewed for Communication. Specifically, Resident #59, with highly impaired hearing had a Physician's order to use the hearing aids for both ears. The facility staff did not recharge the hearing aids consequently Resident #59 was not able to use the hearing aids to effectively communicate with staff and peers. The finding is: The facility's Policy titled Hearing Aid; Rechargeable Type dated 1/2024 documented guidelines including: storing the resident's hearing aids in the charger, away from direct sunlight or very warm temperatures when not in use. Check specific manufacturer's instructions for care of the hearing aid and charger. It is recommended to charge the hearing aids every night. Resident #59 was admitted with diagnoses of Type 2 Diabetes Mellitus, Atrial Fibrillation, and Bilateral Hearing Loss. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderately impaired cognition. The Minimum Data Set (MDS) documented the resident had highly impaired hearing and utilized a hearing aid. The Physician's order dated 8/22/2024 documented an order for the hearing aids to the left and right ears. Remove the hearing aids and place on the charger at Sleeping Hours ( HS). Place the hearing aids in both ears in the Morning (AM). The Medication and Treatment Administration record for August 2024 to December 2024 did not indicate the resident was provided with their hearing aids every day, and that the hearing aids were recharged as per the Physician's order. The Comprehensive Care Plan (CCP) for Hearing Deficit/Hearing Loss dated 6/19/2024 and revised on 8/22/2024 documented the resident will wear hearing aids as indicated. The interventions included but were not limited to anticipating resident needs and applying the hearing aid ( left/right) and care of the hearing aids. During an observation on 12/15/2024 at 10:58 AM, Resident#59 was observed sitting in a wheelchair in the hallway without the hearing aids. Resident#59's family member was observed reporting to Registered Nurse #3 that Resident#59 often did not have their hearing aids on. During an interview on 12/15/2024 at 11:10 AM, Resident#59's family member stated they regularly visited the resident and found them without their hearing aids and always notified the staff that the resident did not have their hearing aids on. During an interview on 12/15/2024 at 11:15 AM, Resident #59 stated the staff do not give them their hearing aids often. Resident #59 stated it was difficult to communicate without their hearing aids. During an interview on 12/15/2024 at 11:30 AM, Registered Nurse Unit Manager #3 stated the overnight nurses were supposed to recharge the hearing aids. Licensed Practical Nurse #8, the overnight nurse, forgot to recharge the resident's hearing aids. Registered Nurse Unit Manager#3 stated they realized that the Physician's order for the hearing aids was never transcribed to the Medication or the Treatment Administration Record to direct the nurses to apply and recharge the hearing aids for Resident #59. During an interview on 12/20/2024 at 8:00 AM, Licensed Practical Nurse #8 stated they were the overnight nurse assigned to Resident #59. Licensed Practical Nurse #8 stated they never recharged Resident #59's hearing aids because the Medication or the Treatment Administration Record did not indicate the Physician's order for the use of the hearing aids. Licensed Practical Nurse #8 stated they did not know Resident #59 had hearing aids until 12/15/2024 when Registered Nurse Unit Manager #3 educated them regarding recharging the resident's hearing aids. During an interview on 12/20/2024 at 11:00 AM, the Director of Nursing Services stated Resident #59 had a Physician's order for bilateral hearing aids and to charge the hearing aids at night. The Director of Nursing Services stated for some unexplained technical issues, the order for the hearing aids did not get transcribed onto either the Treatment Administration Record or Medication Administration Record. The Director of Nursing Services stated the nurses should have charged the hearing aids and placed the hearing aids on the resident as per the Physician's order. 415.12(a)(3)(b)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 12/15/2024 and completed on 12/23/2024, the facility did not ensure that the medical care of each resident was supervised by the Physician including monitoring changes in the resident's medical status. This was identified for one (Resident #93) of four residents reviewed for Choices. Specifically, The Psychiatrist's consultation dated 10/21/2024 included recommendations to explore options with the resident for transfer to another facility of the resident's choice and for the resident to receive behavior therapy and counseling. Nurse Practioner #1 reviewed the recommendations provided by the Psychiatrist; however, did not agree, disagree, or implement the recommendations. The finding is: The Consultation Policy and Procedure, last reviewed in January 2024 documented the Physician will approve any orders they agree with on the consultation. The Physician will document the reason if they disagree with the consultant. Resident #93, who has no known family or designated representative, has diagnoses that include Schizophrenia, Anxiety Disorder, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The Minimum Data Set assessment documented Resident #93 was feeling down, depressed, hopeless, had trouble falling or staying asleep, had little energy, felt bad about themselves, and had trouble concentrating on things. The assessment documented Resident #93 received Antipsychotic and Antidepressant medications during the 7-day lookback period. The Psychiatry Consultation dated 10/21/2024 documented the resident felt unhappy, lonely, and had no primary support. Recommendations included for Social Services to discuss with the resident their nursing home options in Suffolk County and for the resident to receive behavior therapy or counseling. The Physician's Consult Review Note dated 10/22/2024, written by Nurse Practitioner #1, documented that they reviewed the Psychiatry Consultation dated 10/21/2024. Nurse Practitioner #1 rewrote all the recommendations made by the Psychiatrist in the Psychiatry Consultation dated 10/21/2024; however, did not document whether they agreed or disagreed with the recommendations. The Physician's Order dated 12/8/2024 documented for the resident to receive Social work support to discuss nursing home options in Suffolk County as per the resident's request. During an interview on 12/17/2024 at 5:00 PM, Nurse Practitioner #1 stated they were a remote (does not physically work in the facility) Medical Provider who only reviews the recommendations made by the Psychiatrist. Nurse Practitioner #1 stated they had strict instructions from their Supervisor to not write Physician Orders. Nurse Practitioner #1 stated the in-house Medical Providers are the ones to either agree or disagree with the recommendations made by the Psychiatrist. Nurse Practitioner #1 stated if an in-house Medical Provider agrees with the recommendations made by the Psychiatrist, they would be the one to place the Physician's Orders in the resident's Electronic Medical Record. During an interview on 12/17/2024 at 5:25 PM, the resident's Primary Physician (Primary Physician #1) stated a remote Medical Provider can also enter Physician's Orders in the resident's Electronic Medical Record after reviewing a resident's Psychiatry Consultation. Primary Physician #1 stated that a resident cannot receive behavioral (Psychological) counseling without a Physician's Order. Primary Physician #1 stated they were not aware of the Psychiatrist's recommendation for Resident #93 to receive behavioral counseling. During an interview on 12/17/2024 at 6:00 PM, the Medical Director stated that whenever a Medical Provider, either remote or in-house, reviews a Psychiatry Consultation they are to document whether they agree or disagree with the recommendations. The Medical Director stated that the facility has remote Medical Providers to add an extra layer of supervision so that areas of concern related to the resident's medical care are not missed. The Medical Director stated Nurse Practitioner #1 should have referred the resident to Social Services to discuss their nursing home options in Suffolk County and should have also entered a Physician's Order into the resident's Electronic Medical Record for the behavioral (Psychological) counseling services. During an interview on 12/18/2024 at 10:00 AM, the resident stated they had lived in a group home prior to coming to live in this facility. The resident stated they wanted to be placed in a group home specifically in Suffolk County because they thought they could be placed in a facility faster in Suffolk County. The resident stated they received psychological services when they had lived in their group home and talked about their feelings, and thoughts, and could talk to someone about what was bothering them physically, emotionally, and mentally. 10 NYCRR 415.15(b)(1)(i)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 12/15/2024 and completed on 12/23/2024, the facility did not ensure each resident received the necessary behavioral health care and services according to the resident's comprehensive assessment and plan of care to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This was identified for one (Resident #93) of four residents reviewed for Choices. Specifically, Resident #93 was not offered behavioral or psychological counseling when the resident expressed feeling down, depressed, and hopeless to Social Worker #1. Additionally, the Psychiatrist's consultation dated 10/21/2024 recommended providing behavior therapy. Nurse Practioner #1 reviewed the recommendations provided by the Psychiatrist; however, did not agree, disagree, or implement the recommendations. The finding is: The Consultation Policy and Procedure, last reviewed in January 2024 documented the Physician will approve any orders they agree with on the consultation. The Physician will document the reason if they disagree with the consultant. Resident #93, who has no known family or designated representative, has diagnoses that include Schizophrenia, Anxiety Disorder, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The Minimum Data Set assessment documented Resident #93 was feeling down, depressed, hopeless, had trouble falling or staying asleep, had little energy, felt bad about themselves, and had trouble concentrating on things. The assessment documented Resident #93 received Antipsychotic and Antidepressant medications during the 7-day lookback period. The Level I Preadmission Screening and Resident Review (PASRR) Screen dated 2/29/2024 documented that Resident #93 had a serious mental illness and required a referral for Level II evaluation by the designated mental health review entity. The Preadmission Screening and Resident Review (PASRR) Level II Screen dated 3/12/2024 documented Resident #93 had a diagnosis of Schizophrenia, Anxiety Disorder, Depressive Disorder, and Bipolar Disorder. The screen documented the nursing facility was required to provide Resident #93 with a person-centered psychiatric plan of care, ongoing psychiatric consultations, medication management by a Psychiatrist or licensed prescriber, recovery-oriented clinical counseling focused on goal achievement by overcoming mental illness barriers, and therapeutic group interventions. The screen documented Resident #93 would benefit from professional counseling to help process feelings within a supportive setting and help learn healthy coping skills to calm themselves when experiencing difficult emotions. The counseling can effectively address the resident's symptoms which include sadness, worry, and Paranoia (a mental state where a person has an irrational and persistent fear of being harmed or deceived by others). The screen documented Resident #93's symptoms led to the need for ongoing psychiatric care and medication management and it is likely Resident #93's daily life has been impacted by the mental illness. The Psychiatry Consultation dated 10/21/2024 documented the resident felt unhappy, lonely, and had no primary support. Recommendations were for the resident to receive behavior therapy or counseling. The Physician's Consult Review Note dated 10/22/2024, written by Nurse Practitioner #1, documented they reviewed the Psychiatry Consultation dated 10/21/2024. Nurse Practitioner #1 rewrote all the recommendations made by the Psychiatrist in the Psychiatry Consultation dated 10/21/2024; however, Nurse Practitioner #1 did not document whether they agreed or disagreed with the recommendations. A review of Resident #93's Physician's Orders revealed no orders for behavior therapy or counseling. The Care Plan Notes (progress note) dated 11/20/2024, written by Social Worker #1, documented the resident displayed or reported the following: Feeling down, depressed, hopeless, tired, or having little energy. Sleep pattern issues: trouble falling asleep or sleeping too much. The resident has a diagnosis of Anxiety and Depression. The was admitted with a Level 2 PASRR evaluation indicating serious mental illness including Bipolar Disorder, Schizophrenia, Anxiety Disorder, and Depressive Disorder. The Care Plan Meeting Progress Note dated 11/20/2024, written by Social Worker #1, documented Resident #93 had no family contact and the resident was not able to represent themselves due to periods of confusion. The Interdisciplinary Team members present for a quarterly care plan meeting were Social Worker #1 and a representative from the Dietary Department. The resident's plan of care was reviewed and all concerns were addressed. The resident would remain in the facility for long-term care. A review of the resident's Electronic Medical Record on 12/17/2024 at 11:30 AM revealed no documented evidence that Resident #93 was referred to behavior therapy or counseling services by the Social Worker. During an interview on 12/17/2024 at 12:30 PM, the assigned Social Worker #1 stated Resident 93's Brief Interview for Mental Status score was 13; however, Resident #93 was not invited to their care plan meeting, because the resident was confused at times. Social Worker #1 stated Resident #93 had reported feeling down, depressed, and hopeless and Social Worker #1 reported the resident's mood to the nursing staff (could not recall who); the nursing staff was supposed to report and obtain Physician's orders for behavior counseling. Social Worker #1 stated they did not document their communication with the nursing staff in the resident's medical record. During an interview on 12/17/2024 at 1:50 PM, the Director of Social Services stated after Social Worker #1 asked Nursing staff to obtain a Physician's Order for the resident to receive behavioral or psychological counseling, Social Worker #1 should have documented the conversation and followed through and made sure a Physician's Order was obtained for counseling services. During an interview on 12/17/2024 at 3:20 PM, the Administrator stated Social Worker #1 should have ensured a physician's order for psychological services was in place to address the resident feeling down, depressed, and hopeless and documented the interventions they put in place. During an interview on 12/17/2024 at 5:00 PM, Nurse Practitioner #1 stated they were a remote (does not physically work in the facility) Medical Provider who only reviews the recommendations made by the Psychiatrist. Nurse Practitioner #1 stated they had strict instructions from their Supervisor to not write Physician Orders. Nurse Practitioner #1 stated the in-house Medical Providers are the ones to either agree or disagree with the recommendations made by the Psychiatrist. Nurse Practitioner #1 stated if an in-house Medical Provider agrees with the recommendations made by the Psychiatrist, they would be the one to place the Physician's Orders in the resident's Electronic Medical Record. During an interview on 12/17/2024 at 5:25 PM, the resident's Primary Physician (Primary Physician #1) stated a remote Medical Provider can also enter Physician's Orders in the resident's Electronic Medical Record after reviewing a resident's Psychiatry Consultation. Primary Physician #1 stated that a resident can not receive behavioral (Psychological) counseling without a Physician's Order. Primary Physician #1 stated they were not aware of the Psychiatrist's recommendation for Resident #93 to receive behavioral counseling. During an interview on 12/17/2024 at 6:00 PM, the Medical Director stated that whenever a Medical Provider, either remote or in-house, reviews a Psychiatry Consultation they are to document whether they agree or disagree with the recommendations. The Medical Director stated Nurse Practitioner #1 should have entered a Physician's Order into the resident's Electronic Medical Record for the resident to receive behavioral (Psychological) counseling services. During an interview on 12/18/2024 at 10:00 AM, the resident stated they had lived in a group home before coming to live in this facility. The resident stated they wanted to be placed in a group home specifically in Suffolk County because they thought they could be placed in a facility faster in Suffolk County. The resident stated they received psychological services when they had lived in their group home and talked about their feelings, and thoughts, and could talk to someone about what was bothering them physically, emotionally, and mentally. 10 NYCRR 415.12(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 12/15/2024 and completed on 12/23/2024, the facility did not ensure that drug records were in order and accounted for all controlled drugs. This was identified on one (Unit 1 East) of seven units reviewed during the Medication Storage Task. Specifically, the Pharmacy delivered 56 tablets of Oxycodone 10 milligrams for Resident #162 on 12/17/2024; however, the Individual Resident's Controlled Substance Record documented that 46 tablets were received. Additionally, on 12/18/2024, the Individual Resident's Controlled Substance Record documented that 41 tablets of Oxycodone 10 milligrams were available, although the blister packs contained 50 tablets due to an inaccurate reconciliation of the total medication received from the Pharmacy on 12/17/2024. The finding is: The facility policy titled Controlled Substance/Narcotic Management Protocol dated 2/2021 and revised 1/2024 documented that all narcotics will be counted and reconciled at the beginning of every shift with the outgoing and oncoming nurse. Both nurses must sign the controlled substance log attesting to the presence of the narcotic as stated from the previous shift. Any discrepancies in the count must be reported to the unit manager and the nursing supervisor immediately. Staff responsible for narcotic administration will not leave their shift until the narcotic count is reconciled. Resident #162 was admitted with diagnoses including Pain, Osteomyelitis of the Sacral and Sacrococcygeal (tailbone) Region, and Stage 4 Pressure Ulcer. The Quarterly Minimum Data Set assessment dated [DATE] documented the Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident received a scheduled pain medication regimen and did not have pain within the last 5 days. A Comprehensive Care Plan titled Alteration in Comfort dated 9/7/2023 and revised 2/6/2024 documented interventions including administering medications as ordered, monitoring, and documenting for side effects of pain medications. A Physician's Order effective 12/16/2024 documented Oxycodone 10 milligrams tablet; give one tablet by mouth every 6 hours for moderate to severe pain for 14 days. The Medication Administration Record for December 2024 documented the resident received each dose of Oxycodone 10 milligrams tablet as per the physician's orders. Unit 1 East's Medication Storage Room was observed with Licensed Practical Nurse #4 on 12/18/2024 at 1:32 PM. Resident #162's Individual Resident's Controlled Substance Record for Oxycodone 10 milligrams documented 46 tablets were received from the Pharmacy on 12/17/2024. The Individual Resident's Controlled Substance Record documented that 41 Oxycodone 10 milligram tablets were remaining at 6:00 AM on 12/18/2024. There were two blister packs of Oxycodone 10 milligrams labeled with Resident #162's name. One of the two blister pack labels indicated 26 of 56 tablets were delivered by the Pharmacy. There were 20 tablets present in that blister pack. The second blister pack label indicated that 30 of 56 tablets were delivered by the Pharmacy. There were 30 tablets present in that blister pack for a total of 50 tablets remaining in the two blister packs. During an interview on 12/18/2024 at 1:33 PM, Licensed Practical Nurse #4 stated they prior to today, they were not aware of the observed discrepancy and that they were not the assigned medication nurse for Resident #162. During an interview on 12/18/2024 at 2:01 PM, Licensed Practical Nurse #5 stated they administered medication to Resident #162 on 12/18/2024 during the day shift. They reconciled the controlled substances for the residents with the outgoing night-shift Licensed Practical Nurse #6 on the morning of 12/18/2024 and did not notice any discrepancy. Licensed Practical Nurse #5 stated the Individual Resident's Controlled Substance Record documented that 46 tablets were received from the Pharmacy; however, the accurate number should have been 56 tablets and no one noticed the discrepancy including themselves. Licensed Practical Nurse #5 further stated they administered a dose of Oxycodone to Resident #162 at lunchtime on 12/18/2024 and forgot to update the Individual Resident's Controlled Substance Record. During an interview on 12/18/2024 at 2:34 PM, Licensed Practical Nurse #6 stated they worked the previous night shift from 11:00 PM to 7:00 AM and reconciled the Individual Resident's Controlled Substance Record with Licensed Practical Nurse #5. Licensed Practical Nurse #6 stated they may have overlooked the number of tablets available. During an interview on 12/18/2024 at 2:49 PM, the Assistant Director of Nursing Services stated the total amount of Oxycodone tablets that were received for Resident #162 from the Pharmacy was documented incorrectly. This discrepancy should have been picked up by the unit nurses immediately and the nursing supervisor should have been notified. Licensed Practical Nurse #5 should have updated the controlled substance record at the time of the medication administration. During an interview on 12/18/2024 at 3:53 PM, the Director of Nursing Services stated when a controlled substance is delivered by the Pharmacy, the nursing supervisor and the unit nurse, who receives the controlled substance, must ensure the accuracy of the amount and correctly document the amount on the Individual Resident's Controlled Substance Record for accurate reconciliation. The discrepancy for Resident #162's Oxycodone should have been picked up by the unit nurses and reported to the unit supervisor. 10 NYCRR 415.18(b)(1)(2)(3)

Based on record review and interviews during the Recertification Survey initiated on 12/15/2024 and completed on 12/23/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for seven of seven units reviewed for the Sufficient Nursing Staffing Task. Specifically, 1) a review of the Payroll-Based Journal (PBJ) Staffing Data Report Quarter Three, 2024 (April 1- June 30) indicated excessively low weekend staffing and One Star Staffing Rating 2) a review of the daily staffing sheets revealed the facility did not provide sufficient numbers of Certified Nursing Assistants as indicated in the Facility Assessment. This is a repeat deficiency. The finding is: The Payroll-Based Journal Staffing Data Report for Fiscal Year Quarter Three, 2024 (April 1- June 30) indicated the facility triggered for excessively low weekend staffing and One Star Staffing Rating. The Facility Assessment, last updated June 2024, documented the average daily census was 265-275 residents. The facility consisted of seven resident units. The Facility Assessment indicated staffing plan for the weekends as follows: -Unit 1 East: During the 7:00 AM-3:00 PM Shift there should be three Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be two Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be two Licensed Practical Nurses and three Certified Nursing Assistants available. -Unit 2 East: During the 7:00 AM-3:00 PM Shift there should be 2.5 Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be 1.5 Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be one Licensed Practical Nurses and two Certified Nursing Assistants available. -Unit 2 West: During the 7:00 AM-3:00 PM Shift there should be 2.5 Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be 1.5 Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be one Licensed Practical Nurses and two Certified Nursing Assistants available. -Unit 3 East: During the 7:00 AM-3:00 PM Shift there should be 2.5 Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be two Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be 1.5 Licensed Practical Nurses and three Certified Nursing Assistants available. Unit 3 West: During the 7:00 AM-3:00 PM Shift there should be 2.5 Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be two Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be 1.5 Licensed Practical Nurses and two Certified Nursing Assistants available. -Unit 4 East: During the 7:00 AM-3:00 PM Shift there should be 2.5 Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be two Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be 1.5 Licensed Practical Nurses and three Certified Nursing Assistants available. -Unit 4 West, the Dementia Unit: During the 7:00 AM-3:00 PM Shift there should be 2.5 Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be two Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be 1.5 Licensed Practical Nurses and three Certified Nursing Assistants available. A review of weekend staffing sheets for April 2024 through June 2024 and during the Recertification Survey the facility was had low staffing levels based on the numbers specified in the Facility Assessment. The staffing concerns were identified including but not limited to the following: During the 7:00 AM to 3:00 PM Shift: -Unit 1 East had one Licensed Practical Nurse assigned on 4/6/2024, 5/5/2024, 5/12/2024, 6/15/2024, and 6/23/2024. -Unit 2 East had one Licensed Practical Nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/15/2024, and 6/23/2024. -Unit 2 [NAME] had one Licensed Practical Nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, and 6/23/2024. -Unit 3 East had one Licensed Practical Nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/15/2024, and 6/23/2024. -Unit 3 [NAME] had one Licensed Practical Nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/25/2024, 6/1/2024, 6/2/2024, and 6/15/2024. -Unit 4 East had one Licensed Practical Nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/15/2024, and 6/23/2024. - Unit 4 west had one Licensed Practical Nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/15/2024, and 6/23/2024. During the 7:00 AM to 3:00 PM Shift: -Unit 1 East had three Certified Nursing Assistants on 4/14/2024, -Unit 2 East had three Certified Nursing Assistants on 6/9/2024, -Unit 2 [NAME] had three Certified Nursing Assistants on 4/7/2024, 4/13/2024, 6/2/2024, 6/8/2024, -Unit 3 [NAME] had three Certified Nursing Assistants on 4/28/2024, 6/9/2024, -Unit 4 East had three Certified Nursing Assistants on 4/13/2024, 4/28/2024, 6/2/2024, - Unit 4 west had three Certified Nursing Assistants on 4/6/2024, During an interview on 12/23/2024 at 2:35 PM, the Staffing Coordinator stated the facility has staffing shortage on the weekends for a long time. The Staffing Coordinator stated the facility utilizes one agency; however, the staffing issues have not been resolved. The Staffing Coordinator stated they have informed both the Director of Nursing Services and the Director of Human Resources with no resolution. During an interview on 12/23/2024 at 2:53 PM, the Director of Nursing Services stated they were not familiar with the Payroll-Based Journal or that the facility triggered for the low weekend staffing on the Payroll-Based Journal. The Director of Nursing Services stated the Facility Assessment is updated by them and the Administrator. The Director of Nursing Services acknowledged the facility had staffing concerns on weekends because the facility has not been successful in hiring enough staff for the weekends despite their efforts and has been challenged with a high staffing turnover rate. During an interview on 12/23/2024 at 3:30 PM, the Administrator stated the facility is committed to meeting the staffing levels identified in the Facility Assessment; however, they have been unsuccessful in doing so at this time which because of difficulty in attracting and retaining nursing staff. 10 NYCRR 415.13(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the abbreviated survey (NY00307264), the facility did not ensure that each resident had a Comprehensive Care Plan (CCP) developed that included measurable objectives and interventions to meet the resident's medical and nursing needs to attain or maintain the resident's highest practicable well-being. This was identified for 2 of 3 residents (Resident #2 and Resident #3) reviewed for falls. Specifically, Resident #2 experienced multiple falls and there was no CCP developed with goals and interventions to address the falls, and Resident #3 had multiple falls without goals or interventions to address the falls. The findings are: Resident #2 had diagnoses including Alzheimer's Disease, Hypertension and Cerebral Infarction. The 7/29/23 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment with a Brief Interview Mental Score (BIMS) of 12 and required extensive assistance of 2 for toileting and transfers and extensive assistance of 1 for bed mobility. The comprehensive care plan (CCP) created 6/6/23 documented Resident #2 had an actual fall (no date) related to unassisted transfer activity and impaired cognition. Interventions included: call light in reach, educate the resident on safety precautions, ensure resident is wearing appropriate footwear: pain evaluation. There are no subsequent updates. The fall risk evaluation dated 9/3/23, 9/12/23 and 10/2/23 documented Residen t #2 is at moderate risk for fall as evident by fall score 15. The Nurses Progress Note (PN) dated 9/2/23 documented Resident #2 was observed sitting on the floor on the left side of the bed in front of his wheelchair. The Nurses Progress Note (PN) dated 9/12/23 documented Resident #2 fell at 5:30PM in his room and was found siting on the floor. Supervisor was notified. Resident #2 was able to move all extremities and denied pain. The Nurses Progress Note 9/15/23 documented Resident # 2 was observed on the floor with blood. Resident #2 was unable to state what happened and was noted with a skin tear to right elbow. The Nurses Progress Note dated 10/2/23 documented Resident #2 was observed sitting on floor with wheelchair behind him. The facility was unable to provide an Accident/Incident report for falls on 9/2/23 or 9/12/23. The 9/15/23 Accident/Incident (A&I) report documented Resident # 2 was observed in a sitting position on the floor at the right side of his bed. The A&I report documented new interventions, staff to assist Resident #2 to monitored area when awake, staff to provide ongoing reminders regarding transfers and toileting, bed alarm. The 10/2/23 Accident and Incident (A&I) report documented Resident #2 placed themself onto the floor while in the day room. The A&I report documented staff to offer rest period after noon meal. Psychiatry/psychology evaluations were ordered. The Certified Nursing Assistant Instructions dated October 2023 has no documented evidence of fall risk, or interventions. Resident # 3 has a medical diagnosis including Parkinson's Disease, Diabetes Mellitus and Osteoarthritis. Resident #3 is a recent admission to the facility. An MDS has not yet been completed. The admission assessment documented Resident #3 is at moderate risk for fall with a score of 13. The gait analysis documents Resident #3 is unable to independently come to a standing position. The base line care plan documents risk for fall related to (undocumented) and that Resident #3 will be free from injury through the review date (no documented date). The interventions include anticipate Resident #3's needs and bed in lowest position. The Nurses Progress Note dated 10/5/23 at 1:01 PM documented Resident #3 was observed lying on the floor with his body against the bed. No apparent injuries. The Nurses Progress Note dated 10/5/23 at 3:38 PM documented Resident #3 was observed lying on the floor in the dining room and the right side of his forehead had an open laceration that was bleeding. Resident #3 was nonverbal and unable to follow commands. Resident #3 was transferred to the hospital. Hospital discharge records dated 10/8/23 documented Resident #3 was admitted on [DATE] and treated for concussion. Resident #3 was readmitted to the facility on [DATE]. The physician progress note dated 10/5/23 at 3:10 PM documented Resident #3 was in the dining room and tried to stand up and fell, striking his head with bleeding from right forehead. Resident #3 on Xarelto (blood thinner) for AFIB. The PN further documented Resident #3 had a change in mental status and was hypotensive. 911 was called. Resident #3 was transferred to the hospital for evaluation. The Facility admission discharge and transfer documentation reflected that resident #3 was readmitted to the facility on [DATE]. The Nurses Progress note dated 10/9/23 documented Resident #3 was in the dining room and slid themself out of the wheelchair with the assistance of the Certified Nursing Assistant to the floor. The Accident/Incident summary documented that on 10/5/2023 at 11:30AM Resident #3 was observed on the floor in the Resident room Interventions and recommendations included staff remain with Resident #3 to maintain constant vigilance for unpredicted movement or unsafe transfer attempts. The Accident/Incident summary documented that on 10/5/2023 at 2:45 PM Resident #3 was observed on the floor in the day room. New interventions included staff remain with Resident #3 to maintain constant vigilance for unpredictable movement or unsafe transfer attempts, and to assist and supervise Resident #3 while they are awake. There is no documented evidence of care plan update for either falls on 10/5/2023. On 10/12/2023 an interview was conducted with the Director of Nursing (DON) who stated when an incident occurs the resident is assessed, and notification is completed by the floor staff. DON stated the supervisor initiates an incident report and ADON #1 is responsible for reviewing and closing out the incident. DON stated interventions are sometimes done immediately, and in morning meeting interventions are discussed and initiated and all nurses are responsible for care plan updates. The DON stated all Registered Nurses (RNs) are responsible for care plan updates. The DON further stated that a new electronic medical record was implemented with which staff are still struggling. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the abbreviated survey (NY00307264), the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for two of three residents (Resident #2 and Resident #3) reviewed for falls. Specifically, the facility failed to identify issues that placed Resident #2 and Resident #3 at risk for falls and implement steps to address those risks in a manner that enabled Resident #2 and Resident #3 to achieve or maintain their highest practicable physical, mental, and psychosocial well-being. As a result, Resident #2, and Resident #3 experienced multiple falls. Findings include: The Fall Policy and Procedure dated 1/2023 documented the reports will be reviewed by the safety committee for trends related to accidents or safety hazards in the facility to analyze any individual resident vulnerabilities. Resident #2 had diagnoses including Alzheimer's Disease, Hypertension and Cerebral Infarction. The Minimum Data Set (MDS) dated [DATE] documented the resident had moderate cognitive impairment with a Brief Interview Mental Score (BIMS) of 12 and required extensive assistance of 2 for toileting and transfers and extensive assistance of 1 for bed mobility. The comprehensive care plan (CCP) created 6/6/2023 documented Resident #2 had an actual fall (no documented date) related to unassisted transfer activity and impaired cognition. Interventions included: call light in reach, educate the resident on safety precautions, ensure resident is wearing appropriate footwear: pain evaluation. There are no subsequent updates. The fall risk evaluation dated 9/3/2023, 9/12/2023 and 10/2/2023 documented Residen t #2 is at moderate risk for fall as evident by fall score 15. The Nurses Progress Note (PN) dated 9/2/2023 documented Resident #2 was observed sitting on the floor on the left side of the bed in front of his wheelchair. The Nurses Progress Note (PN) dated 9/12/2023 documented Resident #2 fell at 5:30PM in his room and was found siting on the floor. Supervisor was notified. Resident was able to move all extremities and denied pain. The Nurses Progress Note dated 9/15/2023 documented Resident #2 was observed on the floor with blood. Resident #2 was unable to state what happened and was noted with a skin tear to right elbow. The Nurses Progress Note dated 10/2/2023 documented Resident #2 was observed sitting on floor with wheelchair behind him. The facility was unable to provide an Accident/Incident report for the fall on 9/2/2023 or 9/12/2023. The 9/15/2023 Accident/Incident (A&I) report documented Resident # 2 was observed in a sitting position on the floor at the right side of his bed. The A&I report documented new interventions, staff to assist Resident #2 to monitored area when awake, staff to provide ongoing reminders regarding transfers and toileting, bed alarm. The 10/2/2023 Accident and Incident (A&I) report documented Resident #2 placed themself onto the floor while in the day room. The A&I report documented staff to offer rest period after noon meal. Psychiatry/psychology evaluations were ordered. The Certified Nursing Assistant Instructions dated 10/2023 has no documented evidence of fall risk, or interventions. Resident # 3 has a medical diagnosis including Parkinson's Disease, Diabetes Mellitus and Osteoarthritis. Resident #3 is a recent admission to the facility. An MDS has not yet been completed. The admission assessment documented Resident #3 is at moderate risk for fall with a score of 13. The gait analysis documents Resident #3 is unable to independently come to a standing position. The base line care plan documents risk for fall related to (undocumented) and that Resident #3 will be free from injury through the review date (no date documented). The interventions include anticipate Resident #3's needs and bed in lowest position. The Nurses Progress Note dated 10/5/2023 at 1:01 PM documented Resident #3 was observed lying on the floor with his body against the bed. No apparent injuries. The Nurses Progress Note dated 10/5/2023 at 1:38 PM documented Resident #3 was observed lying on the floor in the dinning room and the right side of his forehead had an open laceration that was bleeding. Resident #3 was nonverbal and unable to follow commands. Resident #3 was transferred to the hospital. Hospital discharge records dated 10/8/2023 documented Resident #3 was admitted on [DATE] and treated for concussion. Resident #3 was readmitted to the facility on [DATE]. The physician progress note dated 10/5/2023 at 3:10 PM documented Resident #3 was in the dining room and tried to stand up and sustained a fall witnessed by staff. Resident #3's head struct the floor and was observed with bleeding from right forehead. Resident #3 on Xarelto (blood thinner) for AFIB. The PN further documented Resident #3 had a change in mental status and was hypotensive. 911 was called. Resident #3 was transferred to the hospital for evaluation. The Nurses Progress note dated 10/9/23 documented Resident #3 was in the dinning room and slid themself out of the wheelchair with the assistance of a Certified Nursing Assistante to the floor. The Accident/Incident summary documented that on 10/5/23 at 11:30AM Resident #3 was observed on the floor in the bedroom . Interventions and recommendations included staff to remain with Resident #3 to maintain constant vigilance for unpredicted movement or unsafe transfer attempts. The Accident/Incident summary documented that on 10/5/23 at 2:45 PM Resident #3 was observed on the floor in the day room. New interventions included staff remain with Resident #3 to maintain constant vigilance for unpredictable movement or unsafe transfer attempts, and to assist and supervise Resident #3 while they are awake. There is no documented evidence of care plan update for either falls on 10/5/23 or the incident on 10/9/2023. The CNA instructions dated 10/2023 has no documented evidence of fall intervention on 10/5/2023. On 10/12/2023 an interview was conducted with CNA #1 who stated that they are aware that Resident #2 is a risk for falls. CNA #1 stated Resident #2 is taken to the dinning room when awake, but they do not like to be in there and they leave. CNA #1 stated that Resident #2's plan of care is on the computer. CNA #1 is not aware of interventions to prevent falls. On 10/12/2023 an interview was conducted with the Licensed Practical Nurse #1 who states that she is not responsible to update care plans. LPN #1 stated Resident #2 is confused and gets up unassisted, and when awake they are taken to the dining room to be monitored. LPN #2 stated she is not aware of how many falls Resident #2 has had over the last month, but knows he falls often. LPN #1 also stated they are not aware of any new intervention after the fall. On 10/12/2023 an interview was conducted with the Assistant Director of Nursing (ADON #1) who states when an incident occurs on the floor the nurse manager and supervisor complete the incident report and bring it to the nursing office. ADON #1 stated during morning clinical meeting the team discuss incidents and a summary is completed with new interventions. The interventions are documented in the summary. ADON #1 stated that the care plan should be updated by the unit manager or supervisor. The ADON #1 further stated that since May 2023 they have been using a new electronic medical record which the staff are still learning. On 10/12/2023 an interview was conducted with the Director of Nursing (DON) who stated when an incident occurs the resident is assessed, and notification is completed by the floor staff. DON stated the supervisor initiates an incident report and ADON #1 is responsible for reviewing and closing out the incident. DON stated interventions are sometimes done immediately, and in morning meeting interventions are discussed and initiated. The DON further stated the 24-hour report is brought up in morning meeting and if an incident report was not initiated, they would initiate during morning meeting. The DON stated the facility is in the process of looking at the falls for patterns and implementing a fall program . 10 NYCRR 415.12(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY00309735) initiated on 4/24/2023 and completed on 4/28/2023, the facility did not ensure that a person-centered care plan for each resident that includes measurable objectives and timeframes was developed. This was identified for one (Resident #126) of twelve residents reviewed for Activities of Daily Living (ADLs). Specifically, Resident #126 was admitted to the facility in May of 2022 and there was no Comprehensive Care Plan (CCP) developed for the resident's ADLs as of 4/27/2023. The finding is: The facility's Person Centered Care Plan policy and procedure last revised on 1/2023 documented the comprehensive person-centered care plan is developed within seven (7) days of the completion of the required comprehensive Minimum Data Set (MDS) assessment. The policy also documented the Interdisciplinary team must review and update the care plan at least quarterly in conjunction with the required quarterly MDS assessment. Resident #126 was admitted with diagnoses that included Difficulty Walking, Unstable Angina, and Stage IV Pressure Ulcer. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognition. The MDS documented the resident required extensive assist of two staff members for bed mobility, transfers, dressing and toileting. The resident required extensive assist of one staff member for locomotion on and off he unit and was non ambulatory. A review of the medical record was completed on 4/27/2023 and there was no documented evidence that a Comprehensive Care Plan (CCP) for ADLs was developed. An undated Resident Care Profile (provide directions to the Certified Nursing Assistants (CNA) regarding resident care needs) documented the resident utilized a wheelchair and required extensive assistance of two staff members for bed mobility, transfers, dressing and toileting, and required extensive assist of one staff member for locomotion on and off the unit. The Associate Director of Nursing Services (DNS) was interviewed on 4/26/2023 at 10:00 AM. The Associate DNS stated that they did a thorough search of the resident's electronic medical record (EMR) and were unable to locate the CCP for ADLs. The Associate DNS stated that the admission nurse was responsible to initiate CCPs on admission. The Associate DNS further stated that the CCP should have been completed by the initial care plan meeting. Registered Nurse (RN) #10, who was the Unit Manager, was interviewed on 4/26/2023 at 10:20 AM and stated there are some CCPs that should be initiated on admission which include the ADLs, Falls, Pain, Elopement Risk, and a behavior CCP if the resident was admitted with behaviors. RN #10 stated that the CCPs are initiated by the admission nurse and followed up by the RN Manager the next day to ensure that all documents are completed. RN #10 stated they were responsible for ensuring that a CCP for ADLs was initiated. RN #10 further stated that the CCP for ADLs should have been developed and that it was an oversight. The MDS Director was interviewed on 4/27/2023 at 1:45 PM. The MDS Director stated on admission the admitting RN was responsible for the assessment of the resident and to initiate the needed care plans based on nursing judgement. The MDS Director stated that they do not initiate or review CCPs. The MDS Director stated that they were responsible for the MDS schedule, and the unit manager is responsible to review and revise the resident's CCPs. The Director of Nursing Services (DNS) was interviewed on 4/27/2023 at 2:15 PM. The DNS stated the CCP for ADLs should be initiated on admission; however, the CCP can be initiated any time up to the first twenty-one days after admission. The DNS stated that the CCP for ADLs should have been completed by the initial CCP meeting and that the RN completing the quarterly MDSs should have identified that the CCP for ADLs was not developed. 10NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00307520) initiated on 4/24/2023 and completed on 4/28/2023, the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living (ADLs) do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This was identified for one (Resident #59) of nine residents reviewed for ADLs. Specifically, Resident #59 was not assisted out of bed on 12/2/2022, 12/3/2022 and 12/4/2022 due to their Hoyer pad being wet and having to wait for it to dry. The finding is: The facility's policy titled, Activities of Daily Living last reviewed January 2021 documented that based on the comprehensive resident assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out ADLs. The facility will provide care and services for the following ADLs: hygiene, mobility (transfer and ambulation), toileting, dining, and communication. Resident #59 has diagnoses which include Transient Cerebral Ischemic Attack and Hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] and the annual MDS assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognitive skills for daily decision making. The resident was totally dependent on two persons for transfers, toilet use, and bathing and totally dependent on one person for locomotion on and off the unit. The resident required extensive assistance of two staff members for bed mobility and extensive assistance of one person for dressing and personal hygiene. The ADL Functional/Rehabilitation Potential Comprehensive Care Plan (CCP) dated 7/6/2021 documented under Ambulation: Transfer - The resident is currently a Hoyer lift for bed to and from wheelchair, transfers with assistance of two. Resident #59 was interviewed on 4/24/2023 at 8:50 AM and stated that they (Resident #59) could not be taken out of bed on 12/2/2022, 12/3/2022, and 12/4/2022 because staff told them that their Hoyer pad was wet, and they would have to wait for the pad to dry. Resident #59 stated that it is important for them (Resident #59) to get out of bed every day because they like to get out of their room and go to activities. The resident's current Certified Nursing Assistant (CNA) #3 was interviewed on 4/27/2023 at 11:35 AM and stated that Resident #59 was not on their assignment on 12/2/2022, 12/3/2022, and 12/4/2022. CNA #3 stated that they (CNA #3) always make sure that the resident has a Hoyer pad to be taken out of bed with by hiding an extra Hoyer pad just for Resident #59 in case the resident's Hoyer pad is not available. CNA #4 was interviewed on 4/27/2023 at 3:05 PM and stated that they (CNA #4) worked on Saturday 12/3/2022 and Sunday 12/4/2022 but did not work on Friday 12/2/2022. CNA #4 stated that they (CNA #4) could not take the resident out of bed because their Hoyer pad was wet. CNA #4 stated that someone had washed the Hoyer pad and hung the Hoyer pad in the resident's bathroom to dry. CNA #4 stated that for the two days, the resident's Hoyer pad had remained wet, and that the resident had asked them (CNA #4) to put the Hoyer pad on the heater in the resident's room to try and get the pad to dry faster. CNA #4 stated that they (CNA #4) were unable to take the resident out of bed because their Hoyer pad did not dry. CNA #4 stated that there are not many Hoyer pads on the Unit. CNA #4 stated that sometimes you might be able to get another Hoyer pad by the evening shift, but there are very few extra ones, and every resident has their own. CNA #4 stated that Housekeeping is told when another Hoyer pad is needed, but they (Housekeeping) do not bring one immediately, especially on the weekends because the extra ones may be in the washer or in the dryer. CNA #4 stated that no one from Housekeeping responds on the weekends. LPN #6 was interviewed on 4/28/2023 at 10:05 AM and stated that they (LPN #6) did not remember CNA #4 ever telling them (LPN #6) that the resident's Hoyer pad was wet, and that Resident #59 could not be taken out of bed. LPN #6 stated that if a resident's Hoyer pad is wet, the Hoyer pad is sent downstairs to be washed and then Housekeeping brings the Hoyer pad back up when the pad is clean. The Associate Director of Nursing Services (DNS) was interviewed on 4/28/2023 at 10:30 AM and stated that they (Associate DNS) did not recall ever being made aware of the resident not being able to be taken out of bed due to their Hoyer pad being wet for three days. The Associate DNS stated that if a Hoyer pad is unavailable, a replacement pad should be brought to the nursing unit. The Associate DNS stated that during the week, they (Associate DNS) would call the Director of Housekeeping and they would provide the Hoyer pad. The Associate DNS stated that they (Associate DNS) have heard that there are not enough extra Hoyer pads and the facility has put in orders for extra Hoyer pads to be purchased. The Director of Housekeeping was interviewed on 4/28/2023 at 10:50 AM and stated that it was never brought to their attention that an extra Hoyer pad could not be obtained on a weekend if a resident's Hoyer pad became wet or soiled. The Director of Housekeeping stated that there are two lead porters on the weekends that can be paged or called to ask for an extra Hoyer pad and can also retrieve messages from their (Director of Housekeeping) phone. The Director of Housekeeping stated that there are new Hoyer pads that are kept in the basement and any Housekeeper can get a new one and exchange the pad. CNA #5 who cared for the resident on Friday 12/2/2022 on the 7AM-3PM shift was interviewed on 4/28/2023 at 2:35 PM. CNA #5 stated they could not remember Resident #59's Hoyer pad being wet. 10 NYCRR 415.12(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the Recertification survey and Abbreviated survey (NY00308230), the facility did not ensure that each resident receives adequate supervision to prevent accidents. This was identified for one (Resident #245) of three residents reviewed for Accidents. Specifically, Resident #245 with moderately impaired cognition was admitted on [DATE] and was assessed as high risk for elopement. The facility staff did not initiate interventions related to the identified high risk of elopement. On 1/6/2023 Resident # 245 exited the facility undetected by the facility staff and was found approximately 45 minutes later at approximately one mile away from the facility. The finding is: The facility's Wandering, Unsafe Resident policy and procedure dated 1/2023 documented the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The policy documented that resident will be assessed on admission for wandering behavior and the potential for elopement. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety such as detailed monitoring plan will be included. The care plan includes having name band on the resident, having their picture taken and placed in the wandering/elopement binder as well as the placement of a wander guard. The Elopements with Addendum (Search Assignments) policy and procedure dated 1/2023 documented that if the resident is not located, notify the Administrator, DNS, resident representatives, Attending Physician, Law Enforcement officials and as necessary volunteer agencies. Resident #245 was admitted to the facility with the diagnosis of Schizophrenia, Malnutrition and Hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #245 had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderately impaired cognition. The MDS documented that Resident #245 exhibited wandering behavior 1 to 3 days in the 7 days look back period and the behavior placed Resident #245 at significant risk of getting to a potentially dangerous place (ex. Stairs, outside of the facility). The MDS further documented that Resident #245 had no impairments in the upper or lower extremities and did not use any mobility devices. Resident #245 received antipsychotic medication seven of seven days in the look-back period. The elopement risk assessment dated [DATE] documented Resident #245 was alert and oriented, able to express desires/needs, independent in locomotion, expressed interest in exit doors, and wished to see family/friends through appropriate channels. Resident #245 had contributing medical conditions including Depression, Paranoid Behavior, Delusions, and refusal to take medications. Resident #245 had a total score of 10, out of 16 which indicated High Risk for elopement as per the assessment scale. The Wandering/Elopement Care plan dated 1/6/2023 documented Resident #245 left the building without supervision or assistive device. The interventions included to assess the resident for elopement risk on admission/readmission, quarterly and episodically, place the resident on 30-minute monitoring, place the resident's picture on the medication administration record and unit profile book at security, and place a wander guard and monitor for removal. The nurse's progress note written by Licensed Practical Nurse (LPN) #5 dated 1/6/2023 at 11:43 AM documented that Resident #245 was alert, verbal with confusion and nonsensical verbalizations. Resident #245 came to the nursing station stating, I am pregnant and have morning sickness. LPN #5 offered emotional support and reality orientation. Resident #245 was receptive, went back to their room to lay down. LPN #5 offered ginger ale and a snack. Resident #245 received medications as ordered, was continent of bowel and bladder, and ambulated with supervision. The Accident/Incident report dated 1/11/2023 documented that on 1/6/2023, Resident #245 exited the facility unescorted. At approximately 12:15 PM, Resident #245 was observed to be not in her room and an immediate search was conducted on the resident's unit and adjacent unit. Resident #245 was not observed at those locations and the facility Code M was initiated. Resident #245 was located outside of the facility on ambulating along the sidewalk on a [busy roadway]. Resident #245 was dressed in a blue hooded jogging outfit with the hood covering most of their face. Resident #245 was escorted back to the facility via car without incident. A full body assessment was done by the Registered Nurse (RN) #6 with no signs of injury or trauma. Resident #245 was evaluated by the Psychiatrist and Zyprexa (Medication used to treat Schizophrenia) 5 milligrams (mg) twice a day was ordered, and Risperdal (Medication to treat Schizophrenia) was discontinued. The Incident Report documented that a wander guard and 30-minute rounds were implemented to prevent a similar incident from occurring. Resident #245's statement documented that Resident #245 was going to the Gynecologist. RN #6's statement documented that the resident was last seen by RN #6 at 11:40 AM. Resident #245 approached the nurse's station and stated that they (Resident #245) were pregnant and was having heartburn. RN #6 had a short conversation and Resident #245 went back to their room. The investigative summary dated 1/11/2023 documented that Resident #245's admission elopement assessment on 1/3/2023 indicated Resident #245 scored a 10 (at high risk) for elopement upon admission; however, Resident #245 did not initially attempt to wander off the unit and not initially attempt to elope from the building. The immediate plan of correction included initiation of the wander guard. RN #7, who completed the initial elopement risk assessment, received educational counseling regarding follow through of initiating a wander guard whenever a resident is identified at risk for elopement. The Physician's orders dated 1/6/2023 documented to apply a Wander guard to the left ankle for safety and to prevent elopement, check skin integrity where wander guard is placed every shift, check function every night by 11PM-7AM shift, 30-minute observation for potential wandering every shift. Resident #245 was interviewed on 4/24/2023 at 10:43 AM. Resident #245 was observed lying in bed watching television. Resident #245 was observed with a wander guard applied to the left ankle under their sock. Resident #245 stated that they (Resident #245) told RN #6 on 1/6/2023 that they were going out to see the Gynecologist and went outside. RN #6 found Resident #245 by a local hotel and told Resident #245 that they were not allowed to leave the facility. Resident #245 stated that they (Resident #245) did not know the rules before but now they do. Resident #245 stated that they received the wander guard when they came back to the facility and did not have one before. Certified Nursing Assistant (CNA) #2 was interviewed on 4/27/2023 at 12:09 PM. CNA #2 stated that they were the assigned CNA to Resident #245 on 1/6/2023 during the 7 AM to 3 PM shift. CNA #2 stated that they last observed Resident #245 speaking with RN #6 at the Nurses station but could not recall exactly when. CNA #2 stated that when they last saw Resident #245, it was time for lunch and they (CNA #2) had to assist with serving the lunch meal. CNA #2 went into the dining room and as they (CNA #2) were serving lunch, they noticed that Resident #245 did not come into the dining room. CNA #2 went to look for Resident #245 to give Resident #245 their meal tray. CNA #2 went to Resident #245's room and Resident #245 was not there. CNA #2 then informed RN #6 that Resident #245 was missing and they began the search for the resident on the unit. CNA #2 stated that Resident #245 was new to the facility and was just there for a few days. CNA #2 stated that Resident #245 did not have a wander guard on and was not on 30-minute checks on 1/6/2023. CNA #2 stated that they were not aware that Resident #245 was at high risk for elopement. RN #6 was interviewed on 4/27/2023 at 1:41 PM. RN #6 stated that they were the 7AM-3PM shift Supervisor on 1/6/2023. Resident #245 was a new admission and came to the facility on 1/3/2023. RN #6 stated that on 1/6/2023 Resident #245 told them (RN #6) that they (Resident #245) were pregnant and needed to see the doctor. RN #6 stated that they (RN #6 and Resident #245) had a conversation exploring why Resident #245 believed they (Resident #245) were pregnant. RN #6 stated that when they (Resident #245 and RN #6) were finished discussing Resident #245's belief, Resident #245 appeared to understand that Resident #245 did not need to see the doctor and went back to Resident #245's room. RN #6 stated that the lunch meal arrived on the unit, so they (RN #6) went with LPN #5 and the CNAs to the dining room while Resident #245 was in their room. RN #6 stated that CNA #2 went to give Resident #245 lunch in their room and reported to RN #6 that Resident #245 was not in the room. RN #6 and CNA #2 searched for Resident #245 and could not find Resident #245. RN #6 then alerted the facility that Resident #245 was missing. RN #6 stated that the admission nurse identified that Resident #245 was at high risk for elopement on 1/3/2023 but the wander guard was not issued, and 30-minute checks were not initiated on 1/3/2023. RN #6 stated that Resident #245 did not present with exit seeking behaviors and did not express wanting to leave the unit prior to 1/6/2023 so they (RN #6) did not issue a wander guard. RN #6 stated that they did not think Resident #245 was at high risk for elopement prior to 1/6/2023. RN #7 was interviewed on 4/27/2023 at 2:35 PM. RN #7 stated that they (RN #7) were a per diem RN Supervisor for the facility. RN #7 stated that they completed the admission elopement assessment on 1/3/2023 for Resident #245 and that during the assessment, Resident # 245 stated they (Resident #245) wanted to go home. RN #7 stated that Resident #245 also had a history of elopement. RN #7 stated that the total score of 10 for elopement risk was considered high risk. RN #7 stated that when someone scores with a high-risk score, the protocol is to issue a wander guard. RN #7 stated that they did not issue a wander guard because they thought that Resident #245's unit was a locked unit. RN #7 stated that they later learned that Resident #245 eloped on 1/6/2023, the unit was not locked, and that they should have given Resident #245 a wander guard. LPN #5 was interviewed on 4/27/2023 at 3:24 PM. LPN #5 stated they were the regular 7AM-3PM LPN for Resident #245's unit. On 1/6/2023, LPN #5 was down the hallway overhearing Resident #245 telling RN #6 that they (Resident #245) were pregnant just before lunch time, about 11:45 AM. After Resident #245 went back to their room, RN #6 told LPN #5 to check on Resident #245 and RN #6 said maybe Resident #245's stomach was bothering them (Resident #245). LPN #5 went to Resident #245's room and Resident #245 was in the bathroom. Resident #245 called out when LPN #5 asked to come in. LPN #5 told Resident #245 that they (LPN #5) would return when Resident #245 was done. LPN #5 stated that they moved on to assist with lunch tray pass in the dining room. LPN #5 stated that CNA #2 went to Resident #245's room to give Resident #245 their lunch. CNA #2 then reported Resident #245 was not in their room and they assisted with the search on the unit. LPN #5 stated that Resident #245 was not on any monitoring and did not have a wander guard on the days leading up to 1/6/2023. LPN #5 stated that they (LPN #5 and RN #6) did not think Resident #245 was a high risk for elopement because Resident #245 would mostly stay in their room. Resident #245 did not express any desire to leave the facility from admission on [DATE] to 1/6/2023. RN #6 was re-interviewed on 4/27/2023 at 3:35 PM. RN #6 stated that they (RN #6) assisted with searching for the resident outside of the facility. RN #6 drove their car in the neighborhood and found Resident #245 on [a busy road] a little after 1 PM. Receptionist #1 was interviewed on 4/27/2023 at 3:59 PM. Receptionist #1 stated that they were working until 12 PM and did not observe Resident #245 in the lobby area prior to that time. Receptionist #1 stated that any resident who is observed in the lobby has to present an out on pass form and sign a book to leave the building. If they do not have a pass, they are sent back to the unit to get one. Receptionist #1 stated that Resident #245 was not in the elopement book on 1/6/2023. Receptionist #1 stated that they (Receptionist #1) did not see Resident #245 until Resident #245 returned with RN #6 at around 1:30 PM. Receptionist #2 was interviewed on 4/27/2023 at 4:02 PM. Receptionist #2 stated that they did not observe Resident #245 in the lobby area when they covered for Receptionist #1 at 12 PM. Receptionist #2 stated that they were not sure if Resident #245 was in the elopement book on 1/6/2023. Receptionist #2 stated that if they observed Resident #245, they would have redirected the resident and checked for a pass to go out of the facility. The Associate Director of Nursing Services (ADNS) was interviewed on 4/28/2023 at 8:55 AM. The ADNS stated that they (ADNS) conducted the investigation for Resident #245's elopement on 1/6/2023. The ADNS stated that Resident #245 was reported missing during lunch time at 12:15 PM. The ADNS stated that Resident #245 was found within 30 minutes, so they did not call the police to assist with the search. The ADNS stated that Resident #245 was found just outside of the facility on [a busy road]. The ADNS stated that RN #7 identified Resident #245 as a high risk for elopement and as per facility policy RN #7 should have applied the wander guard to Resident #245 on 1/3/2023. The ADNS stated that if a wander guard was applied to Resident #245 on 1/3/2023, the elopement could have been prevented. The ADNS stated that they (ADNS) speculated that because Resident #245 was wearing a hoodie, Resident #245 was concealed and left through the front of the building with other people. The ADNS stated that the surveillance cameras were not operating on 1/6/2023 and were not reviewed as a result. The Director of Nursing Services (DNS) was interviewed on 4/28/2023 at 9:35 AM. The DNS stated that they (DNS) started employment with the facility on 1/9/2023 and reviewed the investigation on 1/11/2023. The DNS stated that when they interviewed RN #7, RN #7 stated that they did not apply the wander guard because Resident #245 mostly stayed in their room. The DNS stated that RN #7 should have applied the wander guard on 1/3/2023 based on the elopement assessment which indicated Resident #245 was at high risk for elopement. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/24/2023 and completed on 4/28/2023 the facility did not ensure that each resident with an indwelling urinary catheter received appropriate care and services. This was identified for one (Resident #122) of two residents reviewed for Urinary Catheter. Specifically, Resident #122 had an indwelling urinary catheter inserted in the facility on 3/21/2023; however, there was no physician order obtained for insertion of the catheter or catheter care until 4/24/2023. Additionally, there was no documented evidence in the medical record of an assessment and plan for the removal of the catheter as soon as possible. The finding is: The facility's undated policy and procedure titled Foley Catheters documented catheter care is done at least once daily, the Foley catheter drainage bag is changed weekly on Wednesday, and a doctor's order is needed to place a Foley catheter and/or change the catheter as needed (PRN). The facility's policy, titled Foley Catheter Removal, last reviewed 1/2023, documented all residents admitted with a Foley catheter or who have had a Foley catheter inserted post admission will be assessed on admission or as soon as possible for the appropriateness of the Foley catheter including size, type, and indication for use. If deemed appropriate, the resident will be assessed for the discontinuation of the Foley catheter by the medical provider and orders will be obtained. Resident #122 was admitted with diagnoses including Diabetes Mellitus, Chronic Osteomyelitis, and Retention of Urine Unspecified. The 3/24/2023 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident had a urinary catheter in place. A nursing progress note dated 3/21/2023 at 3:25 AM documented the resident was complaining of pain and fullness in the suprapubic area. The resident stated they did not urinate all evening. Toileting record showed the resident had two wet diapers. Resident was straight catheterized with 400 milliliters (ml) of urine obtained. The Foley bag was left in place for the night. A physician note dated 3/21/2023 at 11:30 AM documented the resident was seen and was examined with family present at the resident's bedside. Resident #122 had urinary retention overnight and a Foley catheter was inserted. The plan included the use of the Foley catheter. A Comprehensive Care Plan (CCP) effective 3/22/2023 titled, Catheters documented the resident has an indwelling catheter, size 16 French, for retention of urine. Interventions included replacing the drainage bag as per the facility protocol, monitoring for signs and symptoms of Urinary Tract Infection, and protective/preventive skin care as needed. Review of the physician's orders revealed no orders for the use of the Foley catheter. Resident #122 was observed lying in bed on 4/24/2023 at 8:48 AM. The resident had a urinary catheter draining clear, yellow urine to a drainage bag. The resident stated the urinary catheter was inserted after they (resident) were admitted to the facility. Physician's orders dated 4/24/2023 documented the following: Foley catheter 16 French. Foley catheter care every shift. Replace Foley catheter every month. Apply leg bag daily when out of bed. Change drainage bag every week. Irrigate Foley catheter with 50 ml sterile water/normal saline if clogged/pressure to suprapubic area if present (every shift) as needed. Review of the Treatment Administration Record (TAR) for April 2023 documented those orders related to the resident's Foley catheter began on April 24, 2023. Review of the TAR revealed no documentation regarding the Foley catheter prior to April 24, 2023. Review of nursing progress notes from 3/22/2023 the day after Foley catheter was initiated, to 4/24/2023 revealed no documented evidence of catheter care. The CCP for Catheter was updated on 4/24/2023 and documented the family was explained the risks and benefits of Foley catheter use and was in agreement. A Physician's order dated 4/25/2023 documented trial void, reinsert Foley if no urine output in 6-8 hours. Review of the medical record revealed that prior to 4/25/2023 there were no physician progress notes regarding a plan for a trial void or assessments to remove the catheter. A nursing progress note dated 4/25/2023 documented the resident was seen and examined by a Physician, who ordered a trial void and to remove the Foley catheter tonight (4/25/2023) and re-insert the Foley Catheter in 6-8 hours if there was no urine output. Licensed Practical Nurse (LPN) #1 was interviewed on 4/25/2023 at 2:44 PM. LPN #1 stated nurses who perform catheter care every shift should document the care on the TAR. Registered Nurse (RN) #1 was interviewed on 4/25/2023 at 2:55 PM and stated catheter care should be documented in the Electronic Medical Record (EMR). RN #1 was not able to locate any documentation related to Resident #122's Foley catheter care. Certified Nursing Assistant (CNA) #1 was interviewed on 4/26/2023 at 8:38 AM and stated the CNAs are responsible to empty the drainage bag, change the drainage bag to the leg bag in the morning, and document the amount of urine output in the computer on the CNA Accountability Record (CNAAR). CNA #1 stated when the CNA signs for Catheter in the CNAAR, that just means that the resident has a catheter, not that catheter care was done. CNA #1 further stated the nurses are responsible to provide catheter care. Physician #1 was interviewed on 4/26/2023 at 10:35 AM and stated they spoke to the resident regarding the use of the catheter. Physician #1 further stated they did not recall if they documented a plan for the Foley catheter removal or a re-assessment for the clinical necessity of the Foley catheter. Resident #122 was re-interviewed on 4/26/2023 at 11:09 AM and stated they did not have a catheter in the hospital. Resident #122 stated the issue of not being able to urinate happened in the facility. Resident #122 stated they needed the catheter because they could not urinate, and it was painful. Resident #122 stated they just asked the doctor yesterday about the catheter and how long the catheter has to stay in. The doctor told them they (Physician) would initiate a trial void. Resident #122 stated before 4/25/2023 they did not have any conversation with the physician regarding the catheter being removed. The Director of Nursing Services (DNS) was interviewed on 4/26/2023 at 2:40 PM. The DNS stated the nurse and the doctor both forgot to put in the orders when the catheter was first inserted on 3/21/2023, and that is why there is no documentation related to the catheter care rendered prior to 4/24/2023. 10NYCRR 415.12(d)(1)

Based on record review and staff interviews during the Recertification Survey initiated on 4/24/2023 and completed on 4/28/2023, the facility did not ensure that each resident who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences. This was identified for one (Resident #121) of one resident reviewed for Dialysis. Specifically, 1) a recommendation by the Registered Dietician (RD) to discontinue a liquid supplement was not addressed. 2) A laboratory report forwarded by the Dialysis Center was not addressed by the resident's Physician. 3) Resident #121 was on a fluid restriction of 1,200 cubic centimeters (cc) of fluid per day, with 900 ccs of fluid to be provided by the dietary department and 300 ccs of fluid to be provided by nursing staff. The facility did not have documented evidence of the resident's fluid intake. The finding is: The facility's policy, titled Restricting Fluids, last reviewed 1/2023, documented to follow specific instructions concerning fluid intake or restrictions, be accurate when recording fluid intake, record the amount (in milliliters) of fluids consumed by the resident during the shift, and record fluid intake in the intake and output record. The facility's policy, titled Dialysis Communication, last reviewed 1/2023, documented upon return from dialysis, the nurse will review the communication book from the dialysis center regarding the resident's treatment, laboratory reports taken at dialysis, vital signs and post dialysis weight, or any other changes for continuation of care. Any adverse events will be reported to the medical professional. The nurse will document pertinent information in the medical record and relay resident's condition upon return to the medical professional if not within the resident's baseline. Resident #121 was admitted with diagnoses including End Stage Renal Disease, Hypertension, and Coronary Artery Disease. The 2/17/2023 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented the resident received dialysis treatment while a resident in the facility. A Comprehensive Care Plan, titled Hemodialysis, established 8/10/2021 documented an intervention to keep an open line of communication between the facility and the dialysis center. There were no updates or evaluations in the care plan. A physician's order dated 3/21/2023 and last renewed 4/9/2023 documented: -1,200 cc fluid restriction/day, -2 grams (gm) low potassium, 2-4 gm sodium; regular consistency diet with thin liquids -4-ounce yogurt at 10 AM -renal bag (lunch bag) on hemodialysis days -dietary to provide 900 ml of fluid with meals and nursing to provide 300 ml of fluid with medications. A facility dietician note dated 3/21/2023 documented they (Dietician) received a call from the Dialysis Center Registered Dietician (RD) who reported there has been an overload of fluids between pre and post hemodialysis (HD) weights. The resident's pre-HD weight was 67 kilograms (kg) and the post HD weight was 64.6 kg, indicating 3 kg of intradialytic fluid. The resident was currently on a 1,200 ml fluid restriction. Per dialysis recommendation, will discontinue Nepro (dietary supplement) and monitor laboratory blood work. The Dietician who wrote the 3/21/2023 note was no longer employed at the facility. A physician's order dated 1/15/2023 and last renewed 4/9/2023 documented Nepro Carb Steady (supplement) 8 ounce by mouth daily. Review of the medical record revealed no further dietician progress notes. A physician's progress note, dated 3/28/2023, documented medical renal follow-up-1,200 cc fluid restriction ordered. The physician did not address the dialysis center RD's recommendation to discontinue Nepro. The dialysis center RD was interviewed on 04/28/2023 at 12:07 PM. The dialysis center RD stated they did not know the facility RD no longer worked at the facility. The RD stated that April laboratory results were sent to the facility's RD on approximately 4/7/2023-4/11/2023, through an email. The RD stated they never got a response from the facility RD. The dialysis center RD stated they prefer to email the laboratory reports to the facility RD rather than place the reports in the communication book. The dialysis center RD stated they (the dialysis center RD) only communicates laboratory results to the facility dietician, not to any other facility staff members. Review of the dialysis communication book for the dates of 4/6/2023 to 4/11/2023 revealed no information regarding laboratory reports. The communication book contained only the resident's vital signs and weights. Licensed Practical Nurse (LPN) #3, the medication nurse, was interviewed on 4/28/2023 at 1:09 PM. LPN #3 stated the nurses do not document how much water the resident is taking with medications. Physician #2 was interviewed on 4/28/2023 at 2:06 PM and stated they (Physician #2) have not communicated with the dialysis center. Physician #2 stated the facility dietician and the dialysis center dietician communicate about laboratory results and the facility dietician will then communicate with them. A review of the Electronic Medical Record (EMR) lacked documented evidence of the resident's fluid intake. Registered Nurse (RN) #4, the Inservice Coordinator, RN #5, the unit supervisor, and LPN #3, the medication nurse reviewed the EMR concurrently on 4/28/2023 at 2:20 PM and they could not locate any documentation related to Resident #121's fluid intake. The Administrator was interviewed on 4/28/2023 at 3:15 PM. The Administrator stated the facility dietician who was communicating with the dialysis center was employed at the facility until 4/14/2023 and should have responded to the dialysis center RD's recommendations. The Director of Nursing Services (DNS) was interviewed on 4/28/2023 at 3:23 PM. The DNS stated the nurses know that the resident has a fluid restriction, and they can only give 300 cc fluid per day. The DNS stated each shift gives 100 cc although the fluid intake is not recorded. 10NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 4/24/2023 and completed on 4/28/2023, the facility did not ensure that the medical care of each resident was supervised by the Physician including monitoring changes in the resident's medical status. This was identified for one (Resident #16) of six residents reviewed for Nutrition. Specifically, Resident #16 had an 8.0% significant weight loss in 30 days and a 9.5% significant weight loss in 90 days identified in March 2023. The significant weight loss was not addressed by the resident's Primary Care Physician (PCP) in their Monthly Progress Notes. The finding is: The facility's policy titled, Weight Assessment and Intervention last reviewed in 1/2023 documented that the threshold for significant unplanned and undesirable weight loss will be based on the following criteria: 1 month - 5% weight loss is significant/greater than 5% is severe; 3 months - 7.5% weight loss is significant/greater than 7.5% is severe; 6 months - 10% weight loss is significant/greater than 10% is severe. The Physician and the multidisciplinary team will identify conditions and medications that may be causing Anorexia, weight loss or increasing risk of weight loss. Resident #16 has diagnoses which include Type 2 Diabetes and Congestive Heart Failure. The annual Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognitive skills for daily decision making. The resident required supervision and setup help only for eating. The resident's height was 61 inches and they weighed 193 pounds. The resident's weight did not reflect a loss of 5% or more in the last month or 10% or more in the last 6 months. The quarterly MDS assessment dated [DATE] documented that the resident had a BIMS score of 12 which indicated the resident had moderately impaired cognitive skills for daily decision making. The resident required supervision and setup help only for eating. The resident's height was 61 inches and they weighed 193 pounds. The resident's weight reflected a loss of 5% or more in the last month or 10% or more in the last 6 months and the resident was on a physician-prescribed weight-loss regimen. The resident's Weight Monitoring Report documented that on 12/1/2022 the resident weighed 193.2 pounds (lbs) and on 3/7/2023 the resident weighed 174.8 lbs which indicated an 18.4 lb or a 9.5% significant weight loss in 3 months. On 2/2/2023 the resident weighed 190.2 lbs and on 3/7/2023 the resident weighed 174.8 lbs which indicated a 15.4 lb or 8% significant weight loss in 1 month. The Physician's Orders dated 2/15/2023 and last renewed on 4/3/2023 documented the resident's diet orders as Diet Type: 2-4-gram Sodium (Na), No Concentrated Sweets (NCS), Consistency: Chopped/Thin Liquids, and 4-ounce diet pudding at bedtime. The Dietary Progress Note dated 3/7/2023, written by Registered Dietitian (RD) #3, documented that the resident's monthly weight of 174.8 lbs was collected and the resident lost a significant amount of weight, 18.4 lbs/9.5% x 3 months and 15.4 lbs/8% x 1 month. The resident remained obese with a Body Mass Index (BMI) of 33. Goal: weight maintenance at this time. Weekly weights to follow. The MD Monthly Progress Note dated 3/7/2023 written by Physician #2 documented that the resident's most recent weight was 174.8 lbs on 3/7/2023. The section for Comment on weight change of 5% in 1 month or 10% in 6 months was left blank. The Registered Nurse (RN) Unit Manager (RN #2) was interviewed on 4/25/2023 at 1:45 PM and stated that the RD gets the weight sheet from the unit and puts the weights into the residents' Electronic Medical Record (EMR). RN #2 stated that the RN Unit Manager or the RD would notify the Physician of the significant weight loss. RN #2 stated that they (RN #2) could not remember if they had notified the resident's Primary Care Physician (Physician #2). RN #2 stated that Physician #2 did not document about the resident's significant weight loss and neither did they (RN #2). RN #2 stated that they (RN #2) should have documented the resident's significant weight loss and so should have Physician #2. RN #2 stated that it was an oversight on their part and they (RN #2) would write a late note today. The resident's Primary Care Physician (Physician #2) was interviewed on 4/25/2023 at 2:45 PM and stated that they (Physician #2) knew the resident had lost some weight, but they (Physician #2) did not think it was that much. Physician #2 stated that they (Physician #2) should have documented the change in the resident's weight in their Monthly Progress Note written on 3/7/2023. Physician #2 stated that they (Physician #2) did not look at the resident's February weight. Physician #2 stated that usually the resident's physical appearance prompts them (Physician #2) to look at a resident's weight to determine if the resident had a significant weight loss. Physician #2 stated that the resident did not appear different to them (Physician #2). Physician #2 stated that about two weeks ago they (Physician #2) were told that the resident's weight was being monitored more closely. The Regional RD (RD #2) was interviewed on 4/26/2023 at 10:10 AM and stated that the facility's two RDs had both resigned and both of their last day of employment was 4/14/2023. RD #2 stated that they (RD #2) work for a company who employs dietitians to works in healthcare facilities. RD #2 stated that this company just started in the facility on 4/17/2023 and they (RD #2) were still getting familiar with the policies of the facility and could not comment on who should have contacted the Physician regarding the resident's significant weight loss in March of 2023. The Director of Nursing Services (DNS) was interviewed on 4/26/2023 at 11:35 AM and stated that based on their records, Resident #16's weight loss was discussed at the Friday Weight Change Meeting on 3/10, 3/17, and 3/24/2023. The DNS stated that RN #2 was present at the meetings and that they (RN #2) could have called Physician #2 to make them aware of the resident's significant weight loss, but primarily when a resident has a significant weight loss, it is a dialogue between the RD and the Physician. The Medical Director was interviewed on 4/26/2023 at 12:00 PM and stated that Physician #2 should have absolutely documented the resident's significant weight loss in the Monthly Progress Note dated 3/7/2023. The Medical Director stated that after a significant weight change is seen, loss or gain, the Physician has to look at the resident's laboratory reports, especially their thyroid level to see if it is something that can be reversed. The Medical Director stated that maybe the resident was not eating, and the family should have been called to discuss the resident's food intake. 10 NYCRR 415.15(b)(1)(i)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00307520) initiated on 4/24/2023 and completed on 4/28/2023, the facility did not ensure that there was sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. This was identified for one (Resident #59) of nine residents reviewed for Activities of Daily Living (ADLs). Specifically, on 12/10/2022 and 12/11/2022 on the 3 [NAME] Unit the facility did not have sufficient nursing staffing and Resident #59, who resides on the 3 [NAME] Unit, was not assisted out of bed due to insufficient staffing. The finding is: The facility's policy titled, Activities of Daily Living last reviewed January 2021 documented that based on the comprehensive resident assessment of and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out ADLs. The facility will provide care and services for the following ADLs: hygiene, mobility (transfer and ambulation), toileting, dining, and communication. Resident #59 has diagnoses which include Transient Cerebral Ischemic Attack and Hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] and the annual MDS assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognitive skills for daily decision making. The resident was totally dependent on two persons for transfers, toilet use, and bathing and totally dependent on one person for locomotion on and off the unit. The resident required extensive assistance of two staff members for bed mobility and extensive assistance of one person for dressing and personal hygiene. The ADL Functional/Rehabilitation Potential Comprehensive Care Plan (CCP) dated 7/6/2021 documented under Ambulation: Transfer - The resident is currently a Hoyer lift for bed to and from wheelchair, transfers with assistance of two. Resident #59 was interviewed on 4/24/2023 at 8:50 AM and stated that when they (Resident #59) were not taken out of bed on 12/10/2022 and 12/11/2022, they (Resident #59) were told the staff was working short that day and did not have the time to take them (Resident #59) out of bed. Resident #59 stated that it is important for them (Resident #59) to get out of bed every day because they like to get out of their room and go to activities. The Facility Assessment Tool dated 9/30/2022 documented under the Staffing Plan that there should be one Licensed Practical Nurse (LPN) and five Certified Nursing Assistants (CNAs) working on the 7AM-3PM shift on the 3 [NAME] Unit. The Staffing Schedule dated 12/10/2022 (Saturday) and 12/11/2022 (Sunday) documented that there was one LPN and three CNAs working on the 7AM-3PM shift on the 3 [NAME] Unit. The Daily Census Sheet dated 12/10/2022 and 12/11/2022 documented that there was a total of 40 residents (full capacity) on the 3 [NAME] Unit on both days. The resident's current CNA (CNA #3) was interviewed on 4/27/2023 at 11:35 AM and stated that Resident #59 was not on their assignment back on 12/10/2022 and 12/11/2022, the resident was on CNA #4's assignment. CNA #3 stated that there used to be five CNAs working on the 3 [NAME] Unit, but now there are only four CNAs who work on the unit. CNA #3 stated at times on the weekends there are only three CNAs assigned to the 3 [NAME] Unit. CNA #3 stated that it is very difficult to get all the residents out of bed when there are only three CNAs caring for 40 residents. CNA #3 stated that Resident #59 refuses to understand when the unit is short staffed and does not want to stay in bed. CNA #3 stated that Resident #59 told them that getting out of bed every day was important to them (Resident #59). CNA #4 was interviewed on 4/27/2023 at 3:05 PM and stated that when there are only three CNAs instead of the usual four, there is not enough time to take all the residents out of bed. CNA #4 stated that Resident #59 was on their assignment on 12/10/2022 and 12/11/2022 and they were unable to take the resident out of bed because there were only three CNAs working on the 3 [NAME] Unit on both those days. CNA #4 stated that Resident #59 required a Hoyer lift to transfer and they (CNA #4) needed the help of another CNA to take the resident out of bed. CNA #4 stated that if one CNA was at lunch and the other CNA was busy taking care of another resident, there was no one else on the Unit to help them (CNA #4) get the resident out of bed. CNA #4 stated that they (CNA #4) have told Nurses in the past when they cannot get a resident out of bed and the Nurse will just tell them to do the best they can. The Nursing Staffing Coordinator (NSC) was interviewed on 4/28/2023 at 1:30 PM and stated that they (NSC) are not the one who determines the number of staff documented in the Facility Assessment Tool. The NSC stated that they (NSC) fill each unit with nursing staff according to the Unit's census and par level. The NSC stated that the 1 East, 3 West, and 4 [NAME] Units should have five CNAs on the 7AM-3PM shift and the 2 East, 2 West, 3 East and 4 East Units should have four CNAs on the 7AM-3PM shift. The NSC stated that sometimes on the weekends the facility is short staffed, and they (NSC) do their best to staff the Units according to who is available. The NSC stated that they offer CNAs over-time and used per diem CNAs, however, the facility did not have a lot of per diem staff to choose from. The NSC stated that they (NSC) also use agency staff, but there are not many. The NSC stated that in December 2022 the facility did not have agencies to call. The Director of Nursing Services (DNS) was interviewed on 4/28/2023 at 3:10 PM and stated that three CNAs taking care of 40 residents can be dealt with if the staff works together, depending on how you structure the unit. The DNS stated that the LPN could certainly help the CNAs take care of the residents after they (LPN) give the residents their medications. The DNS stated that staffing each unit depends on the acuity levels of the residents on each unit. The DNS stated that some Units require five CNAs, and some Units require four CNAs because some residents require less assistance than others. The DNS further stated that the facility was constantly trying to staff the units by offering overtime, using agencies staff, and trying to hire new CNAs. The Administrator was interviewed on 4/28/2023 at 3:30 PM and stated that even when working short staffed on a Unit, CNAs should try to accomplish all the appropriate tasks for each resident, such as getting them out of bed. The Administrator stated that some Units have four CNAs and some with a high acuity have five CNAs. The Administrator stated that the facility has hired a full-time recruiter, offers referral bonuses, offers significant sign on bonuses, has developed relationships with Nursing schools, has gone to job fairs, held open houses, advertised online, used social media, promoted from within, worked with unemployment case workers, and offered flexible schedules to try to gain more nursing staff for the facility. 10 NYCRR 415.13(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #98 was admitted with diagnoses including Osteoarthritis, Hypertension, and Rheumatoid Arthritis. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. Resident #98 had an order for Gabapentin Oral Capsule 100 milligram (mg) with a start date of 7/16/2018 and an end date of 5/03/2023. The Medication Regimen Review dated 1/14/2023 documented recommendations for an evaluation of the benefits and risks for Gabapentin. The Pharmacist requested that the physician clarify the indication for use of Gabapentin for Osteoarthritis. The physician documented: disagreed. Medical Doctor (MD) #1 was interviewed on 4/27/2023 at 10:28 AM and stated that they do not remember why they disagreed on the Medication Regimen Review without providing reasoning. MD #1 stated that Gabapentin medication is not of a high concern to them and that may be why they did not document their rationale for disagreement on the drug regimen review. 10NYCRR 415.18(c)(2) Based on record review and staff interviews during the Recertification Survey initiated on 4/24/2023 and completed on 4/28/2023 the facility did not ensure that for each resident the attending physician reviewed and responded to the recommendations made by the Pharmacist on the medication regimen reviews. This was identified for two (Resident #122 and Resident #98) of five residents reviewed for Unnecessary Medications. Specifically, 1) Resident #122's pharmacy medication regimen review dated 3/19/2023 recommended to add parameters for when to administer as needed (PRN) pain medications. The resident's attending physician did not review and respond to the recommendation; and 2) Resident #98 was seen by the Pharmacy Consultant on 1/14/2023 and recommended a benefit/risk evaluation for Gabapentin (an anticonvulsant medication). The physician disagreed with the recommendation and did not provide rationale for their disagreement. The findings are: The facility's policy titled Monthly Drug Regimen Reviews dated 11/28/2016 documented the consultant pharmacist shall review the drug regimen of each resident at least monthly and report any irregularities via written report to the Medical Director, the Director of Nursing, and the Attending Physician. The pharmacist will enter see report or no irregularities in the electronic medical record. The pharmacist forwards all communications to the Director of Nursing for review and distribution to the Attending Physician or designee for medical matters or proper Registered Nurse (RN) Supervisor for nursing matters. The policy titled Medication Therapy/Drug Regimen Review, last revised 1/2023, documented that in the event issues are found with a resident's medication review, the physician will be contacted and will complete prescribed/recommended actions in the same timeframe they were notified. The Medical Director and Consultant Pharmacist shall collaborate to address issues of medication prescribing and monitoring with the practitioners and staff. 1) Resident #122 was admitted with diagnoses including Diabetes Mellitus, Chronic Osteomyelitis, and Chronic Inflammatory Demyelinating Polyneuritis. The 3/24/2023 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident had occasional pain level of 4 out of 10, with zero being no pain and 10 being the worst pain. The resident had the following pain medication order: -Tramadol oral tablet 50 milligram (mg), 0.5 tablet by mouth every 6 hours as needed, dated 3/18/2023. A New admission Medication Regimen Review form dated 3/19/2023 documented no issues found during drug review; however, the pharmacist documented, Resident has multiple PRN orders for pain. Please specify type of pain (i.e., mild, moderate, severe) or pain scale number in each order to clarify when to administer each. The medication regimen review was signed by the Director of Nursing Services (DNS). There was no response documented from the resident's physician regarding their agreement or disagreement with the Pharmacist's recommendations. The medication regimen review was not dated by the DNS and was not signed by the resident's Physician or the Medical Director. Physician #1 was interviewed on 4/26/2023 at 10:35 AM and stated they (Physician #1) did not see the pharmacy review dated 3/19/2023. If they (Physician #1) had seen the pharmacy review, they (Physician #1) would have ordered the parameters and pain scale as recommended by the Pharmacist. The DNS was interviewed on 4/26/2023 at 2:30 PM and stated when they (DNS) reviewed Resident #122's drug regimen review dated 3/19/2023, they (DNS) saw the box that indicated no issues, so the review was filed away. The DNS stated they did not look further to the comments section. The DNS stated if they saw the comments, the drug regimen review would have been given to the unit Supervisor who would have given the drug regimen review form to the doctor for review. The Consultant Pharmacist was interviewed on 4/28/2023 at 10:48 AM and stated the medication regimen review form has a box that indicates if any potential clinically significant issues are identified. They checked the NO option that meant no issues found during the drug review. However, the Consultant Pharmacist stated they did document their recommendations in the comment section regarding PRN pain medications. The comment section is used for less urgent matters. The Consultant Pharmacist stated the form was discussed with the facility in the past and they were not sure where the miscommunication was.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 4/24/2023 and completed on 4/28/2023 the facility did not ensure that resident records were accurately documented in accordance with professional standards of practice. This was identified for one (Resident #69) of three residents reviewed for position and mobility. Specifically, the Occupational Therapist did not accurately document in the resident's medical record a failed trial and reversal of the recommendation for a hand splint. The finding is: Resident # 69 was admitted with diagnoses that include Adult Failure to Thrive, Type 2 Diabetes Mellitus and Osteoarthritis. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long-term memory problems and was severely impaired for daily decision-making. The resident required extensive assistance of two persons for transfer and had limitations in range of motion to bilateral upper and lower extremities. The Physician (MD) order dated 1/11/2023 documented a Request for Occupational Therapy (OT) evaluation. The MD order dated 1/12/2023 documented to provide skilled Occupational Therapy for 30 days. An OT evaluation dated 1/12/2023 documented a recommendation for a resting hand splint for the right hand to maintain skin integrity. The medical record lacked documented evidence of a physician's order for the right-hand splint. Resident #69 was observed in their room on 4/26/2023 at 10:27 AM with Registered Nurse (RN) #7 present. The resident's right hand appeared to be contracted and without a hand roll or splint in place. RN#7 stated that the resident was admitted with a contracture to their right hand. RN#7 stated that they were unaware of any splint ordered or provided to the resident since admission. The Director of Occupational Therapy (OT) #1 was interviewed on 4/26/2023 at 1:25 PM and stated that an evaluation was completed on 1/12/2023 with a recommendation for a right-hand splint. The OT Director stated that a trial of the right-hand splint was attempted; however, the resident was not able to tolerate the splint. The OT Director stated they were unable to locate any documentation related to the splint trial. An Occupational Therapy note dated 4/26/2023 documented a right-hand splint trial was conducted on 1/12/2023 by OT#2. OT#2 documented that the resident was not able to tolerate the splint secondary to pain and therefore was not a candidate for the splint. OT #2 was interviewed on 4/27/2023 at 1:30 PM and stated they (OT#2) evaluated the resident on 1/12/2023. OT#2 stated that the resident had a trial for splint use on 1/12/2023. The splint trial failed because the resident experienced pain. OT#2 stated that they forgot to document the splint trial. The splint however was never ordered. The Medical Director was interviewed on 4/27/2023 at 2:23 PM and stated that their expectation would be to have the Rehabilitation department evaluate the residents as ordered by the attending physician, make recommendations, and document findings and outcomes in the medical records. 10NYCRR 415.22(a)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 4/24/2023 and completed on 4/28/2023, the facility did not ensure that within 14 days after the facility completes a resident's Minimum Data Set (MDS) assessments, the facility must electronically transmit encoded, accurate, and complete MDS data to the Center for Medicare and Medicaid System (CMS). This was identified for 10 (Resident #170, #75, #94, #2, #78, #74, #70, #60, #76, and #151) of 11 residents reviewed during the Resident Assessment Facility Task. The findings include, but were not limited to: The facility policy titled Comprehensive MDS Policy dated January 2023 documented that the facility transmits data, per CMS regulations, after the facility completes a resident assessment. 1) Resident #170 has diagnoses which include Coronary Artery Disease and Hypertension. Resident #170 had an admission MDS dated [DATE] which was completed on 12/25/2022, and transmitted on 3/8/2023, 73 days after the completion date. Resident #170 had a quarterly MDS dated [DATE] which was completed on 3/27/2023, and submitted on 4/18/2023, 22 days after the completion date. 2) Resident #75 has diagnoses which include Hypertension and Hyperlipidemia. Resident #75 had a quarterly MDS dated [DATE] which was completed on 1/2/2023, and submitted on 3/8/2023, 65 days after the completion date. Resident #75 had a quarterly MDS dated [DATE] which was completed on 3/28/2023, and submitted on 4/24/2023, 27 days after the completion date. 3) Resident #94 has diagnoses which include Depression and Cardiac Pacemaker. Resident #94 had an annual MDS dated [DATE] which was completed on 12/29/2022, and submitted on 3/8/2023, 69 days after the completion date. Resident #94 had a quarterly MDS dated [DATE] which was completed on 3/26/2023, and submitted on 4/18/2023, 23 days after the completion date. The Registered Nurse (RN) MDS Director was interviewed on 4/26/2023 at 10:45 AM and stated that the changes in the facility ownership, Director of Social Service and Rehabilitation Department affected MDS submissions to be late because the Social Service and Rehabilitation sections were not completed on time. The MDS Director stated that they (MDS Director) were trying to submit MDS data after they pulled the validation report on 3/29/2023. The MDS Director stated that they could not submit the required MDSs because there were incomplete sections. The MDS Director stated that all MDSs must be submitted within 14 days of their completion date. The Director of Nursing Services (DNS) was interviewed on 4/27/2023 at 2:20 PM and stated that the MDS Director had mentioned to them (DNS) that some MDSs were not submitted on time because some departments were late in completing their sections. The DNS stated that all MDSs should be submitted within 14 days of their completion date. 10NYCRR 415.11