Based on observation, record review and interviews during the recertification survey, the facility did not ensure preadmission screening for individuals with a mental disorder and individuals with intellectual disability was performed for 1 (Resident #13) of 2 residents reviewed for Preadmission Screening and Resident Review (PASRR). Specifically, for Resident #13, the facility did not ensure a comprehensive Level 2 assessment and determination/recommendations were completed prior to admission to the facility, following a positive Level 1 determination on the DOH-695 Preadmission Screen form on 11/16/2021. This was evidenced by: Resident #13 Resident #13 was admitted to the facility with diagnoses of bipolar disorder, schizoaffective disorder, and chronic kidney disease. The Minimum Data Set (MDS - an assessment tool) dated 11/22/2021, documented the resident was able to make themselves understood, able to understand others, and was cognitively intact. The undated Policy and Procedure (P&P) titled PASRR Review, documented it was the policy of the facility to screen all individuals for new admission for serious mental illness or mental retardation/developmental disability per New York State Department of Health (NYSDOH) regulations. All applicants who were positive for Level 1 criteria will have a comprehensive Level 2 assessment and determination/recommendations completed prior to admission to the facility. If no Level 2 referral was indicated, the resident could be admitted to the facility. The DOH-695 Preadmission Screen form, dated 11/16/2021, documented: - Question #23 (Level 1 Review for Possible Mental Illness (MI) Does this person have a serious mental illness?: Answer - Yes - Guideline: If item 23 or any of the Items 24 - 26 were marked Yes, proceed to Categorical Determinations (Items 27 - 30). Answers to Items 27 - 30 were not documented. - Guideline: If any of the Items 27 - 30 were marked Yes, proceed to Danger to Self or Others Qualifiers (Item 31). If all were marked No, proceed to Level 2 referrals (Item 33). Answers to either Items 31 or 33 were not documented. During an interview on 03/21/23 at 02:44 PM, the Director of Social Work (DSW) stated prior to admission, the SW department performed a brief review of preadmission screens. If the screen was incomplete, or there was information missing, they would report this to the Director of Nursing (DON). The preadmission screen for Resident #13, dated 11/16/2021, documented the resident had a serious mental illness for Item 23. Based on the screen instructions, Items 27 - 30 should have been completed to determine whether the resident was a danger to themselves or others, or if a Level 2 screen was required; this was not done. That should have been caught by whomever reviewed the screen and reported to the DON. During an interview on 03/22/23 at 10:14 AM, the DON stated the Clinical Evaluator (CE) was responsible for initially reviewing preadmission screens; when social work reviewed the screens, they would be secondary reviewers. The preadmission screen for Resident #13 from 11/16/2021 should have been reviewed by the CE, and it should have been identified that there were questions on the screen that had not been addressed. The hospital should have been contacted, and any incomplete questions should have been completed prior to the resident's admission. They had not been informed of any issues related to the screen at the time it was received. During an interview on 03/22/23 at 3/22/2023 at 10:49 AM, CE #1 stated they were responsible for initial review of preadmission screens for residents prior to admission. This review typically consisted of a conversation with the hospital screener, and if they were told that the screen was completed they did not always review the screens themselves. When they do review the preadmission screens, they did not typically review all the questions on the preadmission screen forms for completion. If there was an issue with a preadmission screen form, or the form was incomplete, they would need to have a conversation with the care manager responsible for completing the form. They did not recall the specific screen for Resident #13 from 11/16/2021 but was familiar with the screener who signed the form. Whenever they told them they completed a screen, they did not question them or conduct any further review of their preadmission screens. During an interview on 03/22/23 at 11:04 AM, the DON stated the CE was responsible for reviewing all preadmission screens, whether they were informed by hospital screener they were completed or not. During an interview on 03/22/23 at 12:00 PM, the Administrator stated the CE should have reviewed and addressed any issues related to completion of the preadmission screen for Resident #13 on 11/16/2021, to ensure the resident was appropriate for admission and going to receive all the necessary services they required. At the time Resident #13's screen dated 11/16/2021 was received, no issues or concerns were reported to them regarding the screen. 10 NYCRR 415.11(e)

Based on observation and interviews during the recertification survey dated 03/16/23 through 03/22/23, the facility did not ensure garbage and refuse was disposed properly. Specifically, the metal plate back piece and metal plate bottom piece of the large dumpster was pulled away creating two 2-foot by 3-inch holes and the drain plug was missing in the small dumpster. This is evidenced as follows: During observations on 03/16/23 at 11:44 AM, the metal plate back piece and metal plate bottom piece of the large dumpster was pulled away creating two 2-foot by 3-inch holes; the drain plug was missing in the small dumpster. During an interview on 03/16/23 at 11:47 AM, the Administrator stated that the vendor will be contacted to replace the large dumpster and to provide a drain plug for the small dumpster. 10 NYCRR 415.14(h)

Based on observation and interviews during the recertification survey dated 03/16/23 through 03/22/23, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for three (3) of 3 resident unit kitchenettes and the main kitchen. Specifically, in the main kitchen, the microwave oven, slicer, mixer, thermometer holder, ceiling and ceiling lights, wall by kitchen door, and fire extinguishers were soiled with food particles; the framing around the window by the 3-compartment sink was peeling; and the walls behind and around the dishwashing machine were peeling and soiled with black mold. In the 2nd floor, 3rd floor, and 4th floor kitchenettes, the refrigerator door gaskets were soiled with food particles. In the 2nd floor kitchenette, the cabinets, wall by sink, and floor below refrigerator were soiled with food particles; the windows had cobwebs; one spray bottle of disinfectant, a toxic cleaning substance, was stored on top of the refrigerator; and the laminate on the cabinets was peeling. This is evidenced as follows: During observations on 03/16/23 at 10:24 AM, in the main kitchen, the microwave oven, slicer, mixer, thermometer holder, ceiling and ceiling lights, wall by kitchen door, and fire extinguishers were soiled with food particles; the framing around the window by the 3-compartment sink was peeling; and the walls behind and around the dishwashing machine were peeling and soiled with black mold. In the 2nd floor, 3rd floor, and 4th floor kitchenettes, the refrigerator door gaskets were soiled with food particle. In the 2nd floor kitchenette, the cabinets, wall by sink, and floor below refrigerator were soiled with food particles; the windows had cobwebs; one spray bottle of disinfectant, a toxic cleaning substance, was stored on top of the refrigerator; and the laminate on the cabinets was peeling. During interviews on 03/16/23 at 11:27 AM, the Administrator and Food Service Director stated that the items found will be cleaned, the walls will be repaired, the mold will be addressed, and staff will be re-educated on calibrating thermometers and the cleaning checklist. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14

Based on interviews and record review conducted during the recertification survey, the facility did not provide proper treatment and assistive devices to maintain the hearing ability for 1 (Resident #34) of 1 resident reviewed for communication. Specifically, for Resident #34, the facility did not ensure the resident, who had impaired hearing, was provided with an audiologist consultation to be evaluated for hearing aids. This is evidenced by: Resident #34: Resident #34 was admitted to the facility with the diagnoses of cerebral infarction, schizoaffective disorder and epilepsy. The Minimum Data Set (MDS - an assessment tool) dated 8/19/20, documented the resident had moderately impaired cognition, could usually understand others and could make self understood. The Minimum Data Set (MDS) documented the resident had moderate difficulty hearing. The facility did not provide a Policy and Procedure related to communication or hearing impaired residents. The Comprehensive Care Plan for a Communication Problem, last revised 5/21/20, documented the resident was deaf in the left ear. The interventions included; to be conscious of resident's position when in groups, activities, dining room to promote proper communication with others, to allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, and use alternative communication tools as needed. A review of progress note entries by the Physician Assistant (PA) documented: -7/31/2020 - that the PA was asked to see the resident regarding left ear pain and difficulty hearing. The resident stated intermittently losing hearing in left ear for no reason and thought there was wax in it. The resident reported being deaf in the right ear due to a history of acoustic neuroma on that side. The resident reported having hearing aids before but got frustrated because they were not working right so he/she threw them in the garbage. The resident was wondering about getting new ones. The PA documented hearing loss; had hearing aids in the past, not anymore, wants to see audiologist to get new ones, will refer. -8/10/20 - left side hearing loss. The resident still had cerumen impaction on left side and will try Debrox (ear wax removal treatment) and ear flush again. Audiology referral placed. -9/11/20 - the PA was asked to see the resident regarding continued hearing loss and concern for ear wax. The PA documented she had seen the resident several times lately for concerns over hearing loss and ear wax, most recently on 8/10/20. The note documented at that visit she again ordered Debrox for 3 days and then ear flush, however this had not helped and the resident still could not hear well. The PA documented the resident had been referred to audiologist for consideration of hearing aids, but it had not been set up yet. During a record review, the medical record did not include documentation that an appointment had been made for the resident to seen an audiologist. During an interview on 11/05/2020 at 12:05 PM, Resident #34 stated he/she had hearing loss in the left ear and was supposed to see audiologist, but the appointment had not been arranged yet. The resident stated the appointment was supposed to be arranged a while ago. During an interview on 11/12/20 at 10:11 AM, Registered Nurse #1 (RN) stated an audiology appointment was not made for the resident. She stated it never got conveyed to her that the resident needed an audiology appointment. She stated the PA wrote a note on 7/31/20, 8/10/20 and 9/11/20, but she was unaware the PA had documented a referral for an audiology appointment. The RN stated she did not regularly review the PA progress notes. She stated when the RN Supervisor received the orders from the PA, the RN Supervisor should have put a physician order in the electronic medical record (EMR) for the audiology referral and should have filled out an appointment sheet for the Unit Secretary, but that did not happen. She stated if an order had been put in the EMR, she would have seen a referral had been made by the PA and would have filled the appointment sheet out for the Unit Secretary to follow through on. During an interview on 11/12/20 at 11:53 AM, the Director of Nursing DON stated the RN Supervisor who received the orders from the PA was not aware the orders for the audiologist referral needed to be put in the EMR under physician orders and that a consultation form had to be filled out so the Unit Secretary could follow up with transportation to have an appointment made. The audiologist appointment was not made for the resident. She stated the same RN Supervisor received the orders from the PA for an audiologist referral in July, August, and September and did not make the connection that an appointment still had not been made for the resident. 10NYCRR415.12(3)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey, the facility did not ensure acceptable parameters of nutrition were maintained for 1 (Resident # 87) of 4 residents reviewed for nutrition. Specifically, for Resident #87, the facility did not ensure re-weights were obtained per facility protocol, the physician was notified of the resident's significant change in weight, and the nutrition care plan included person-centered approaches to maintain acceptable parameters of the resident's nutritional status. This is evidenced by: Resident #87: Resident #87 was admitted to the facility with the diagnoses of intestinal obstruction, atrial flutter, and dysphagia. The Minimum Data Set (MDS - an assessment tool) dated 9/29/20 documented the resident was cognitively intact, could understand others and could make self understood. The Policy and Procedure titled Weight, last revised 8/2018, documented new admissions would be weighed weekly for 4 weeks and if weight remained stable the resident would be weighed monthly. Weights would be obtained and recorded per physician order. If a weight loss was noted (5% in one month, or 3 pounds in one week and weight loss was not planned or anticipated) the charge nurse would notify the nursing supervisor, physician, dietician, and responsible party. If there was a 3 pound weight difference from the last weight, a re-weight was to be done the next day with the nurse or dietician present. The Comprehensive Care Plan for Nutrition, last revised 10/22/20, documented the resident had an actual/potential nutritional problem: Increased nutrient needs r/t increased demand for calories as evidenced by recent diagnosis. The goal was the resident would maintain adequate nutritional status as evidenced by maintaining weight, no signs or symptoms of malnutrition, and consuming at least 50% of at least 2 meals daily through review date. Interventions included: To provide and serve diet as ordered; monitor intake and record every meal; RD to evaluate and make diet change recommendations PRN; and to weigh as ordered by MD/physician. The care plan did not include person-centered goals or approaches to maintain acceptable parameters of resident's nutritional status. Physician orders did not include an order to obtain the resident's weight. A review of the resident's weight record documented: 9/28/20- 113.4 pounds (lbs.) (this weight was subsequently struck out by RN #1 on 10/28/20) 10/05/20- 101.5 lbs. (10.49% weight loss x 1 week) (this weight was subsequently struck out by RN #1 on 10/28/20) 10/12/20- 95 lbs. (6.40% weight loss x 1 week) 10/13- 97 lbs. 10/14- 99 lbs. (this weight was subsequently struck out by RN #1 on 11/10/20) 10/19- 95 lbs. 10/20- 93 lbs. 10/28- 96.5 lbs. The Patient Review Instrument (PRI) completed in the hospital dated 9/24/20, documented the resident weighed 53 kg (116.6 pounds). The hospital Discharge summary dated [DATE], documented no leg edema. A nursing admission note dated 9/28/20, documented the resident stated his/her legs were very swollen; some edema noted to legs and bilateral ankles. The facility admission history and physical dated 9/29/20, documented the resident had no edema. A Nutrition assessment dated [DATE], documented the resident weighed 113.4 lbs. The resident reported his/her usual body weight was approximately 100 pounds. The assessment documented the resident had significant weight gain and the resident reported the weight gain was from increased edema in his/her legs. Weight loss was expected from fluid shifts. A nursing note on 10/3/20 documented while assisting the resident into bed, noted that his/her bilateral legs were shiny, with plus 2 edema. During a record review on 11/10/20, the medical record did not include documentation that re-weights were obtained when there was a weight difference of 3 or more pounds in accordance with the facility policy. The medical record did not include documentation the physician was notified of the resident's significant changes in weight since admission on [DATE]. During an interview on 11/12/20 at 10:22 AM, Registered Nurse (RN) #1 stated Resident #87 was admitted to a different unit and was moved up to her unit, but when any resident was admitted to the facility they were weighed weekly for 4 weeks, then it was up to the physician how frequently to weigh the resident. She stated the resident was currently being weighed weekly. She reviewed the resident's physician orders and stated there was not an order to weigh the resident and there should be. The RN stated she crossed out the weights dated 9/28 and 10/5 in the resident's medical record because the resident told her on 10/28 the weights were not accurate. She stated she weighed the resident on 10/28 to get an accurate weight. The RN stated when there was a 3 pound or greater difference in a resident's weight, the protocol was re-weigh the resident within 24 hours. She stated because a re-weight was not obtained, she did not know if the admission weight of 113 lbs. was accurate at the time of admission. She stated on her unit, the staff obtained the weights and brought the weights to her to review and to input into the medical record that way she reviewed all the weights and could determine if a re-weight was needed. She stated when the resident was weighed at 101 pounds after a weight of 113lbs last week, there should have been a re-weight. The resident should be re-weighed any time there is a 3 pound discrepancy in weight. She stated the RD and physician should have been made aware, but based on the documentation in the medical record it did not appear either had been notified of the resident's weight loss. During an interview on 11/12/20 at 10:47 AM, the RD stated she was not the RD at the facility when the resident was admitted . She stated she would have done a re-weight because a lot of times after a hospitalization residents were admitted with excess fluid or edema but with a drastic weight loss like this resident had, a re-weight should have been obtained to determine if the admission weight was an error. She stated the RD should have been made aware when the resident's weight went from 113 lbs. to 101 lbs. and then to 95 lbs. She stated the team had weekly weight meetings so discrepancies in weight could be picked up. She was unsure if this resident had been discussed in the weekly weight meeting. She stated the Nurse Managers also reviewed weights weekly and ordered re-weights as needed. She stated after the weekly weight meeting, if there was a concerning weight change the nurse would notify the Doctor of the weight change and the Nurse and Doctor would document if there was edema and visually verify if edema was present. She stated she would have tried to find information on the resident's normal weight and stated she did not know if she could say the resident's weight change was related to edema since the change in weight was so significant. She stated the team needed to determine if the admission weight was incorrect at the time of admission, and if it was determined to be incorrect, then it would get crossed out in the medical record after a re-weight was obtained. The RD reviewed the resident's nutrition care plan. She stated the care plan needed to be more person centered and to include nutritional interventions such as supplements, unintended risk for fluid, and weekly weights. She stated the care plan needed to be more individualized and specific to the resident. During an interview on 11/12/20 at 11:59 AM, the Director of Nursing (DON) stated the facility protocol for a weight discrepancy was to obtain a re-weight in order to determine if the initial weight was accurate. She stated if the resident was weighed at 113 pounds and then weighed at 101 pounds, the staff should have gotten the physician and RD to review the weights and to see the resident. She stated she would expect there to be a dietary note addressing the discrepancy in the resident's weight and there was not a note from the RD until 10/23/20. She stated she would expect the unit manager to write a progress note that the physician was notified of the weight discrepancy if the physician had been notified. She reviewed the resident's physician orders and stated she would expect to see an order for weights, but there was not an order. 10NYCRR415.12(i)(1)

Based on record review and interview during a recertification survey, the facility did not ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days, unless the attending physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #28) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #28, the facility did not ensure a PRN antianxiety medication (lorazepam) was not ordered for more than 14 days without a documented rationale from the attending physician or prescribing practitioner. This is evidenced by: Resident #28: Resident #28 was admitted to the facility with the diagnoses of end stage renal disease, diabetes, and congestive heart failure. The Minimum Data Set (MDS - an assessment tool) dated 10/21/20, documented the resident had moderately impaired cognition, could usually understand others and could usually make self understood. The Policy and Procedure titled PRN Psychotropic Medications, dated 3/2018, documented residents did not receive PRN psychotropic medications unless the medication was necessary to treat a specific condition that was documented in the clinical record and all PRN orders for psychotropic medications would not exceed 14 days, including those residents on Hospice. The Comprehensive Care Plan for Psychotropic Medications, last updated 9/23/20, documented the resident received psychotropic medications related to anxiety before dialysis- lorazepam. The care plan interventions included: To administer medications (lorazepam) as ordered by physician; monitor for side effects and effectiveness; monitor/document/report PRN any adverse reactions; and discuss with physician and family regarding ongoing need for use of medication. A physician order dated 9/26/20, documented lorazepam 1 mg; give 1mg by mouth every 8 hours as needed for anxiety. A physician re-admission note dated 9/24/20, documented the resident had dementia with agitation including aggressive behaviors towards the physician and nursing staff and to continue Seroquel (antipsychotic medication) and Ativan (lorazepam). The note documented to consult with psychiatrist if the resident accepted. A Psychiatry Diagnostic Evaluation dated 9/28/20, documented to consider routine Ativan (lorazepam) prior to dialysis treatment and to continue Seroquel. The medical record did not include a medical justification documented by the attending physician or prescribing practitioner for continuing the PRN lorazepam order for more than 14 days after it was ordered on 9/26/20. During an interview on 11/12/20 at 9:37 AM, Registered Nurse (RN) #2 stated he was aware of the regulation for PRN psychotropic medication orders and stated the PRN psychotropics were ordered for 14 days with review by the physician on the 13th or 14 day to determine whether or not to extend the order. He stated the resident's PRN lorazepam order had been reviewed by the physician and the rationale for extending the order past 14 days should be written in the provider progress notes. RN #2 reviewed the progress notes and stated there were physician notes dated 9/24/20 and 11/11/20, but there was not a provider note documenting a rationale to extend the PRN use past 14 days after the PRN lorazepam was ordered on 9/26/20. He stated the resident typically received the PRN lorazepam before dialysis since the resident's anxiety seemed to revolve around going to dialysis. During an interview on 11/12/20 at 11:49 AM, Director of Nursing (DON) for PRN psychotropic medication orders there needed to be a 14-day review. She stated all PRN orders were looked a couple times a week and a provider justification should be written in a provider progress notes. She stated the Unit Manager should let the providers know when a PRN medication order needs to be reviewed then the providers write a justification for extending for extending the order. She stated the provider should have written a note 14 days after the PRN was ordered. She stated Nurse Managers and the facility providers were aware of the regulation. 10NYCRR 415.12(1)(2)(ii)

Based on observation, staff interview, and record review during the recertification survey, the facility did not adhere to adopted food safety regulations. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Automatic dishwashing machines are to operate in accordance with manufacturer specifications, and floors are required to be kept clean and in good repair. Specifically, the automatic dishwashing machine was not operating within the manufacturer's specifications required to sanitize food contact surfaces, and floors were covered in food debris and missing grout. This is evidenced as follows. The main kitchen was inspected on 11/05/2020 at 09:48 AM, revealing the automatic dishwashing machine final rinse was 160 Fahrenheit (F) at 28 pounds per square inch (psi) water pressure, and the kitchen floors were missing grout and covered in food debris. Record review on 11/05/2020 revealed that the automatic dishwashing machine information plate stated that the minimal final rinse water temperature is to be 180 F at 20 psi. The Director of Food Services stated in an interview on 11/05/2020 at 10:24 AM that he was unaware that the high temperature automatic dishwashing machine's final rinse was only reaching 160 F, and he will contact the service company. Additionally, he stated that the kitchen floor will be cleaned and re-grouted. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.32, 14-1.85, 14-1.110, 14-112(c), 14-1.170

Based on observation, record review and interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 (Resident #'s 29, 34, 60, 71, 78 and #91) of 22 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #29, the CCP for anticoagulation therapy did not include an indication or diagnosis for the therapy and the CCP for psychotropic medications did not include person-centered, non-pharmacological interventions; for Resident #34, the CCP for a communication problem did not include the services needed for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being related to hearing loss; for Resident #60, the CCP did not include safety interventions for the resident with Parkinson's Disease following a hot food spill; for Resident #71, the facility did not ensure a CCP titled PICC included indication for use and interventions for the IV antibiotic use for infection; for Resident #78, the CCP for anticoagulation therapy did not include an indication or diagnosis for the therapy; and for Resident #91, the CCP did not include a care plan for urinary tract infection (UTI). This was evidenced by: The Policy & Procedure (P&P) undated and titled Care Planning Instructions documented, care plans are initiated upon a resident's admission, with change in status or condition, medications, etc. Care plan process included: Care plans are labeled with resident's name, unit and room number; date of care plan initiated; problem/need/strength; measurable goal for resident; interventions individualized for resident; care plans must be updated with any change in plan of care. Resident #71: Resident #71 was admitted to the facility with the diagnosis of diabetes mellitus, fibromyalgia and malignant neoplasm of uterus. The Minimum Data Set (MDS-an assessment tool) dated 10/15/20, documented the resident had severely impaired decision making and received IV medications. The physician's order dated 10/12/20, piperacillin sodium-tazobactam sodium solution (PIP/Tazo, antibiotic) reconstituted 4-0.5 grams (GM), use 3.375 gram intravenously (IV) three times a day for osteomyelitis (infection in a bone). The order was continued on 11/4/20 to continue through 12/9/20. The CCP for a PICC line was not individualized to the resident, did not include indication for use, and did not include interventions specific to the use and care of administering medications and/or flushes. During an interview on 11/12/20 at 11:17 AM, Registered Nurse Unit Manager #4 stated Resident #71's left heel wound had worsened from a stage 2 or a deep tissue injury. The PICC line in her right chest was placed on 9/25/20. The care plan should have been updated to address the PICC line and the IV medications. During an interview on 11/12/20 at 1:45 PM, the Director of Nursing stated the care plan should have been updated to include the PICC line and antibiotic administration. Resident #78: Resident #78 was admitted to the facility with the diagnoses of acute ischemia of the large intestine, acute kidney failure, and chronic pain syndrome. The Minimum Data Set (MDS - an assessment tool) dated 9/22/20, documented the resident was cognitively intact, could understand others and could make self understood. The CCP for anticoagulation therapy dated 4/21/20, documented the resident had the potential for untoward effects due to anticoagulation therapy- Xarelto (a blood thinner medicine- anticoagulant). The CCP did not include an indication or diagnosis for the use of anticoagulation therapy. During an interview on 11/12/20 at 9:37 AM, Registered Nurse (RN) #2 stated the admission nurse initiated the care plans when residents were admitted , and the RN Unit Manager helped to maintain and build on the care plans throughout the resident's stay in the facility. He stated he could certainly add the diagnosis or indication for use for clarity as to why the resident was receiving anticoagulation therapy, but the indication for use could be found in the physician progress notes. Resident #91: Resident #91 was admitted to the facility with the diagnosis of chronic kidney disease, retention of urine, and dementia. The Minimum Data Set (MDS-an assessment tool) dated 9/20/20 documented, the resident had moderate cognitive impairment. The physician's progress note dated 10/12/20 documented; Foley in place, milky white urine in bag, pyuria (elevated number of white blood cells in the urine, which can cause the urine to appear cloudy or contain pus), start Fluconazole (treat and prevent fungal infections) 100 mg x 7 days and repeat C&S (culture and sensitivity), change Foley (a sterile tube that is inserted into your bladder to drain urine) today. A nursing progress note dated 11/6/20 documented; resident noted to be confused overnight and this morning. Urine in resident's Foley bag is noted to be creamy yellow in color. Physician updated and new order to change Foley catheter and collect urinalysis and culture and sensitivity. The CCP for indwelling catheter dated 6/22/18, documented the resident had chronic kidney disease and obstructive reflux uropathy. The CCP did not include a care plan for urinary tract infection (UTI). During an interview on 11/12/20 at 11:17 AM, Registered Nurse Unit Manager #4 stated the resident had a urinary tract infection in October 2020. A urine was collected on 11/9/20 and we are waiting for the culture and sensitivity to come in. The care plan should have been updated to include the urinary tract infection. During an interview on 11/12/20 at 1:45 PM, the Director of Nursing stated the care plan should have included urinary tract infection. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey, the facility did not ensure two (2) (Resident #45 and #65) of five (5) residents reviewed for hospitalization, received written notice of transfer. Specifically, the facility did not ensure written notice of transfer was provided to family representative in writing for Resident #45 and #65 when transferred to the hospital. This evidenced by: Resident #45: This resident was admitted on [DATE] and readmitted on [DATE] with diagnoses of chronic kidney disease, stage 3, hemiplegia and hemiparesis from intracerebral hemorrhage affecting right dominant side and chronic obstructive pulmonary disease. The Minimum Data Set (MDS) dated [DATE] documented the resident was severely impaired for cognition and sometimes was understood by others and usually understood others. Hospital Discharge summary dated [DATE], documented diagnoses of sepsis related to urinary tract infection caused by Escherichia coli. Resident had been admitted on [DATE] after having four days of nausea, vomiting, diarrhea and fever. She was admitted for initiation of IV antibiotics. During an interview on 4/04/19, Social Worker (SW) #2 stated she did not send out a letter to the family concerning the transfer to the hospital. She was not sure if nursing sent the transfer letter and that they may have a transfer form. During an interview on 04/04/19 10:42 AM, Registered Nurse Manager (RNNM) #1 stated the nurses will call the family that the resident is being transferred to the hospital but that it is the social worker's ultimate responsibility to follow up. Resident #65: The resident was admitted on [DATE] with diagnoses of obstructive uropathy, diabetes and dysphagia. The MDS dated [DATE] documented the resident had severely impaired cognition. A Nursing Progress Note dated 3/8/19, documented the resident was sent to the hospital for respiratory distress and diagnosed with pneumonia on 3/7/19. The resident was admitted to the hospital on [DATE] and returned to the facility 3/14/19. During an interview on 4/4/19 at 11:15 AM, SW #2 stated she was not aware of the regulation requiring the facility to notify the resident or resident representative in writing of a resident's transfer from the nursing home. She stated the family was verbally notified of the reason for transfer and of the facility the resident was being transferred to, however there was nothing provided in writing to the resident or resident representative. During an interview on 4/5/19 at 10:50 AM, the Director of Nursing stated she was not aware of the regulation requiring the facility to notify the resident or resident representative in writing of a resident's transfer from the nursing home. 10NYCRR415.3(h)(1)(iii)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey, the facility did not ensure written notice was provided to the resident's representative of the bed hold and return policy for three (3) (Resident #'s 45, 65 and #101) of five (5) residents reviewed for hospitalization. Specifically, there was no documented evidence the resident and the resident's representative received written notice of the bed hold policy when the residents were admitted to the hospital. This evidenced by: Resident #45: This resident was admitted on [DATE] and readmitted on [DATE] with diagnoses of chronic kidney disease, stage 3, hemiplegia and hemiparesis from intracerebral hemorrhage affecting right dominant side and chronic obstructive pulmonary disease. The Minimum Data Set (MDS) dated [DATE], documented the resident was severely impaired for cognition and sometimes was understood by others and usually understood others. The Hospital Discharge summary dated [DATE], documented the resident was admitted to the hospital on [DATE] for the diagnosis of sepsis related to a urinary tract infection. During an interview on 4/04/19, Social Worker (SW) #2 stated she had never called the family concerning the bed hold policy when the resident was transferred to the hospital. It was probably not sent in writing to the family. SW #2 stated that going forward she will send the bed hold policy letter the family. Resident #65: The resident was admitted on [DATE], with diagnoses of obstructive uropathy, diabetes and dysphagia. The MDS dated [DATE], documented the resident had severely impaired cognition. A Nursing Progress Note dated 3/8/19, documented the resident was sent to the hospital for respiratory distress and diagnosed with pneumonia on 3/7/19. The resident was admitted to the hospital on [DATE] and returned to the facility 3/14/19. During an interview on 4/4/19 at 11:15 AM, SW #2 stated she was not aware of the new regulation requiring the submission of the bed hold policy in writing to the resident's representative when the resident is discharged to a hospital. She stated the only residents/ residents' representatives that are verbally notified of the bed hold policy, are the ones she feels it is applicable to. Resident #101: This resident was admitted on [DATE] and readmitted on [DATE] with diagnoses of chronic obstructive pulmonary disorder, anxiety, depression, atrial fibrillation, chronic pain, and dysphagia. The MDS dated [DATE], documented the resident was without cognitive impairment. The medical record documented Resident #101 was transferred to the hospital via ambulance and admitted on [DATE]. The resident returned to the facility on 3/10/19. During an interview on 4/5/19 at 10:50 AM, the Director of Nursing stated the bed hold policy was not being provided in writing to the resident or resident's representative when a resident was transferred to the hospital. 10NYCRR415.3(h)(4)(i)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, during a recertification survey the facility did not ensure that comprehensive person-centered care plans were developed and implemented for each resident consistent with the resident rights set forth that include measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for three (3) (Residents #'s 6, 10 and #65) of twenty-four (24) residents reviewed. Specifically; for Resident #'s 6 and 65, the facility did not ensure that the Comprehensive Care Plan (CCP) for positioning was implemented, for Resident #10, the facility did not ensure a CCP for Pain associated with a Stage 4 pressure ulcer to the resident's coccyx was implemented, and that the CCP for positioning included an intervention for not positioning the resident on her back due to a Stage IV pressure ulcer to the coccyx. This is evidenced by: Resident #6: The resident was admitted on [DATE], with diagnoses of a left foot fracture, muscle weakness, unsteadiness on feet following a motor vehicle accident. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition and required extensive assistance for all mobility, he did not ambulate, and only was transferred out of bed one to two times per week. During an observation on 4/1/19 at 9:30 AM at 2:53 PM, the resident was laying on his back in bed, with both feet pushed against the footboard of the bed and heels on the mattress. During an observation on 4/3/19 at 8:58 AM, 10:22 AM, 12:10 PM, 1:44 PM, and 3:28 PM, the resident was laying on his back, with a pillow under his right and left elbow, as well as a pillow under his knees, with his heels on the mattress. His position was unchanged with each observation noted above. A Nursing Braden Scale Assessment completed on 2/5/19 documented the resident was at risk for skin breakdown. A Comprehensive Care Plan (CCP) for actual skin impairment, documented an intervention to elevate the resident's heels. A CCP for ineffective gas exchange, documented an intervention for the resident to be turned and positioned every 2 hours. A CCP for potential for skin breakdown, documented an intervention that the resident was to be placed back to bed or in recliner chair in her room after lunch daily. The Certified Nurse Assistant (CNA) documentation report, documented the CNA completed all care per the standard of care [NAME] by 8:23 AM on 4/3/19. This report documented CNA initials on 4/3/19 at 8:23 AM and twice at 11:52 AM, indicating that the resident was turned and positioned every 2 hours, During an interview on 4/3/19 at 1:58 PM, CNA #4 stated the resident was to be turned and positioned every two hours, and that his heels were to always be floating. CNA #4 stated she repositioned this resident at 6:30 AM, before lunch, after lunch and just prior to this interview. CNA #4 stated she was unsure how the resident position and pillows remained unchanged throughout the day. During an interview on 4/5/19 at 9:48 AM, Registered Nurse Unit Manager #1 stated the expectation is that all staff will follow the CCP, and they will only sign for care after it was provided to the resident. During an interview on 4/5/19 at 10:38 AM, the Director of Nursing (DON) stated the expectation is that all staff will follow the care plan as written and only sign for care once it has been provided. Resident #65: The resident was admitted on [DATE] with diagnoses of obstructive uropathy, diabetes and dysphagia. The Minimum Data Set, dated [DATE], documented the resident had severely impaired cognition. The resident required extensive assistance with all mobility tasks and did not ambulate. During an observation on 4/3/19 at 1:36 PM, 3:35 PM and 4:34 PM, the resident was sitting in her wheelchair in the main dining room. The resident remained in the dining room after lunch. During an observation on 4/4/19 at 11:29 AM, 11:57 AM, 2:34 PM, and 3:35 PM, the resident was sitting in her wheelchair in her room, in the main hallway and in the dining room. The resident remained in the dining room after lunch. A CCP for potential for skin breakdown, documented an intervention that the resident was to be placed back to bed or in recliner chair in her room after lunch daily. During an interview on 4/4/19 at 12:08 PM, CNA #3 stated the resident was to be repositioned while in bed every two hours. CNA #3 stated she puts the resident back to bed when she notices the resident starts to lean in her chair. CNA #3 stated the resident is never in her chair for longer than one to two hours at a time. During an interview on 4/5/19 at 9:47 AM, RNUM #1 stated the expectation is that all care plans would be followed as written. She stated the resident is care planned to be placed in bed or in the recliner in her room after lunch to aide in relieving pressure. RNUM #1 stated she was aware that resident remained in the dining room in her wheelchair after lunch this week. During an interview on 4/5/19 at 10:38 AM, the DON stated the expectation is that all staff will follow the care plan as written and only sign for care once it has been provided. Resident #10: The resident was admitted on [DATE] with diagnoses of Stage IV pressure ulcer to sacrum/coccyx area, end stage renal disease and congestive heart failure (CHF). The Minimum Data Set (MDS) dated [DATE], documented the resident was severely impaired for cognition and sometimes was understood by others and usually understood others. The CCP for Stage 4 Pressure Injury revised on 2/11/19, documented an intervention to treat pain as per orders prior to doing a treatment or turning to ensure the resident's comfort. The CCP initiated on 1/11/17, documented the resident has a history of stage 4 pressure injuries to her coccyx due to disease process, immobility, poor intake and incontinence. An intervention documented to avoid positioning the resident flat on her back and to use 2 persons to assist for turning and positioning the resident at least every 2 hours, more often as needed or requested. During observation of a dressing change on 4/03/19 at 01:35 PM, the resident complained of pain throughout the dressing change to her stage 4 pressure ulcer to her coccyx. She cried when turned from left to right side. The resident was crying that it hurt so bad while RN #2 was irrigating the wound with normal saline. The resident continued to complain of pain. RN #2 told her she would give her pain medication when she was finished with the dressing change. Observations of resident positioned in bed with head of bed (HOB) at 30 degrees are as follows: 04/01/19 at 10:02 AM - resident is lying on her back. 04/01/19 at 11:57 AM - resident is lying on her back. 04/01/19at 03:01 PM - resident is turned to the right side. 04/02/19 at 08:57 AM - resident is lying on her back. 04/02/19 at 10:43 AM - resident is lying on her back. 04/02/19 at 11:38 AM - resident is lying on her back. 04/02/19 at 01:05 PM - resident is lying on her back. 04/02/19 at 03:52 PM - resident is lying on her right side. 04/03/19 at 08:55 AM - resident is lying on her back. 04/03/19 at 09:30 AM - resident is lying on her left side. 04/03/19 at 12:01 PM - resident is lying on her left side. 04/03/19 at 01:36 PM - resident is lying on her left side. 04/03/19 at 01:52 PM - turned to her right side after the dressing change. 04/04/19 at 08:37 AM - resident is lying on her right side. 04/04/19 at 10:30 AM - resident is lying on her right side. 04/04/19 at 11:35 AM - resident is lying on her right side. 04/04/19 at 03:38 PM - resident is lying on her left side. 04/05/19 at 09:16 AM - resident is lying on her right side. 04/05/19 at 10:02 AM - resident is lying on her right side - slouched down to almost the middle of the bed. During an interview on 04/02/19 at 09:16 AM, CNA #1 stated the resident used to get up out of bed but her bedsores are so bad, staying in bed is more comfortable for her. She now gets repositioned in bed on an hourly basis. He stated he was not sure if it was every one or every two hours the resident should be turned. During an interview on 04/04/19 at 11:40 AM, CNA #2 stated the resident is always in pain when she is turned. She stated she does not know if the resident is actually in pain or if it is a behavior. She has reported the resident's pain upon turning to nursing. The resident says she is in pain whenever she is turned, she does not want to be touched. She has booties on her feet but does not like them and has kicked them off. She crosses her legs in a different way because of the booties. She will place pillows underneath the resident's bottom so she is not lying on her wound. The resident has been fed in bed for the last 2 to 3 months and has visibly lost weight. She eats more food being fed in bed because she is more comfortable. During an interview on 04/04/19 at 12:39 PM, Registered Nurse Manager (RNM) #1 stated that CNA #5 is good about turning the resident every hour side to side except during meals. It is on the [NAME] not to place the resident on her back. All CNAs should be letting the nurse know if the resident is in pain prior to positioning. The resident should not be seen on the same side for extended periods of time. Meetings are held daily on proper care of the residents including making sure they turn and position the residents on a regular basis. During an interview on 04/04/19 at 01:45 PM, RNM #1 stated, she reviewed the pain evaluation which is to be filled out by the nurses every shift. The NM reviewed the pain evaluation for March and April which contained numerous 0s indicating the resident had no pain. The RNM stated there is never a time the resident will say she is not in pain, she is never a 0. When the nurses are doing the pain scale every shift, they are asking for that specific time only. On April 3 during 6-2 shift, the nurse had documented a 0 even though the resident was observed to be in pain during the dressing change on that shift. The RNM stated the PRN Morphine is ordered to be given before wound treatments though it is not on the physician orders or on the electric Medication Administration Record (eMAR). There is no set time to pre-medicate the resident prior to the dressing change which is usually done early morning. There are float nurses and nurses doing split shifts where pre-medicating may be difficult to do. The RNM added to the eMAR that the resident is to be pre-medicated prior to the pressure ulcer dressing change if not within 30 minutes of standing pain morphine every day shift on 4/04/19. During an interview on 04/03/19 at 03:38 PM, the resident's daughter stated her mother has been in the nursing home for 2 years in December. In that time her pressure ulcer never went away. After being in the nursing home for two months she acquired a pressure sore which has never healed completely. The pressure sore now has an odor with the physician being notified. She stated every time the staff got her up the pain was so bad. She has not gotten up out of bed for 3 to 4 months. Her mother is crying whenever they go into her room because she is in pain. After the Fentanyl patch was started, she came in and found her mother in terrible pain. Morphine had not been given that day and the physician was called, She stated that if she had not visited her mother that day she would not have received any morphine to tide her over until the Fentanyl took effect. Her mother continued to complain of pain and last week her order was changed to 10 mg of Morphine every 4 hours. She is a little more comfortable. The resident has told her daughter she wants to die because of the pain. Sometimes she refuses to eat because she is in too much pain. The resident's daughter stated that her mother should not be in this much pain. She thinks her mother is supposed to be repositioned every hour but she does not want to be moved. She cries the whole time she is being repositioned. Staff should wait till the morphine takes effect before moving her. Her daughter stated that if she did not come in and advocate for her mother she would be in more pain than she already is experiencing. She is told that the staff turn her but she has never seen staff reposition her mother even though she has visited for up to two hours. In her more lucid moments her mother has said that she had to move but was unable to on her own. Her daughter will then find staff who tell her they will reposition the resident if they can find two staff to help with the repositioning. 10 NYCRR 415.11(c)(1) NYCRR10 483.21(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure an ongoing resident centered activities program that incorporated the resident's interests, hobbies and cultural preferences was implemented for two (2) (Resident #'s 8 and 65) of twenty-four (24) residents reviewed. Specifically, the facility did not ensure that there were individual activities available and offered to residents that chose not to or could not participate in group activities. This is evidenced by: Resident #8: This resident was admitted to the facility on [DATE], with diagnoses of right and left knee contractures and chronic venous hypertension with ulcer of the lower extremity and major depressive disorder. The Minimum Data Set (MDS) dated [DATE], documented the resident was without cognitive impairment and required extensive assistance with mobility. During several observations on 4/1/19, 4/2/19 and 4/3/19, the resident was in his room alone, with staff interaction with care only. A Comprehensive Care Plan (CCP) for Social Needs last updated on 7/10/17, documented a goal that the resident would maintain involvement in cognitive stimulation and an intervention that included to provide a program of activities that interested and empowered the resident. A behavioral health progress note dated 2/28/19, documented the resident had an ongoing lack of stimulation and feelings of isolation and loneliness. During an interview on 4/4/19 at 12:05, Certified Nurse Assistant (CNA) #3 stated the resident requires a lot of encouragement to get out of bed. CNA #3 stated the resident enjoys playing cards, watching television and reading. CNA #3 stated the resident declines participation in group activities outside of his room. During an interview on 4/4/19 at 1:19 PM, Activity Aide (AA) #1 stated the resident declined to participate in group activities. AA #1 stated the activities department does not have enough staff to provide individual activities to residents and because the resident did not come out of his room it was hard to engage him. During an interview on 4/4/19 at 2:17 PM, the Director of Activities (DOA) stated the CCP was not resident specific and did not include ways to interact with this resident on a one to one basis. The DOA stated room visits are completed intermittently and include offering magazines, games or snacks. During an interview on 4/5/19 at 11:50 AM, the Administrator stated the expectation is that the resident's CCP would be updated and resident specific. The Administrator stated activities for residents that cannot or choose not to participate in group activities have been identified as an area they need to improve on. Resident #65: The resident was admitted on [DATE], with diagnoses of obstructive uropathy, diabetes and dysphagia. The MDS dated [DATE], documented the resident had severely impaired cognition. The resident required extensive assistance with all mobility tasks and did not ambulate. During an observation on 4/1/19 at 11:09 AM, the resident was sitting alone at a table in the dining room with a magazine in front of her. During an observation on 4/2/19 at 3:05 PM, the resident was seated in the dining room at a table alone with magazines in front of her. During observations on 4/3/19 at 1:36 PM, 3:35 PM, and 4:34 PM, the resident was observed seated at a table alone in the dining room with magazines in front of her. A CCP for meeting emotional, intellectual, physical and social needs, last updated on 3/21/2018, documented activities should be compatible with individual needs and abilities. During an interview on 4/4/19 at 11:57 AM, CNA #3 stated the resident often spent time sitting alone at a table in the dining room. CNA #3 stated staff get busy and are unable to provide the resident with individual activities. During an interview on 4/4/19 at 1:19 PM, AA #1 stated the resident had a decline in her participation of group activities since a hospitalization earlier this year. AA #1 stated the resident was often occupied by her family for individual activities. AA #1 stated staff do not have time to sit with residents for individual activities. During an interview on 4/4/19 at 2:04 PM, the DOA stated the resident's activities CCP should be reviewed and updated as needed at a minimum of quarterly and with significant changes. The DOA stated the resident's CCP was not resident specific, and that it was not updated when the resident had a significant change in condition affecting her ability to participate in group activities. During an interview on 4/5/19 at 11:55 AM, the Administrator stated the expectation is that the CCP will be updated and resident specific. The Administrator stated activities for residents that cannot or choose not to participate in group activities had been identified as an area they need to improve on. 10NYCRR415.5(f)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey and abbreviated survey (Case #NY00235153), the facility did not ensure that residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) (Resident #10) of three (3) residents reviewed. Specifically, for Resident #10, the facility did not ensure the intervention for repositioning (turn and position the resident from side to side every 2 hours) while in bed was implemented and monitored. This is evidenced by: Resident #10: The resident was admitted on [DATE] with diagnoses of Stage IV pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) to sacrum/coccyx area, end stage renal disease and congestive heart failure (CHF). The Minimum Data Set (MDS) dated [DATE], documented the resident was severely impaired for cognition and was sometimes understood by others and usually understood others. The Comprehensive Care Plan (CCP) initiated 1/11/17, documented the resident had a history of stage 4 pressure injuries to her coccyx due to disease process, immobility, poor intake and incontinence. The CCP documented that the pressure ulcer healed on 9/08/17, reopened as a stage 2 on 9/25/17, healed on 10/13/17, and reopened on 11/14/18. It documented the intervention to avoid positioning the resident flat on her back and to use 2 persons to assist for turning and positioning the resident at least every 2 hours, more often as needed or requested. The CCP for Stage 4 Pressure Injury revised on 2/11/19, documented an intervention to treat pain as per orders prior to doing a treatment or turning to ensure the resident's comfort. A Physician's Orders for pain management documented the following: 3/09/19 - Fentanyl patch 75 mcg/hr every 72 hours. Apply one patch transdermally one time a day every 3 days for pain. 3/28/19 - Morphine Sulfate 20 mg/5 ml. Give 10 mg sublingually every 4 hours for pain. 3/10/19 - Morphine Sulfate 20 mg/5ml. Give 5 mg every 1 hour as needed for comfort care. 4/04/19 - Morphine Sulfate 20 mg/5 ml. Give 10 mg every 1 hour as needed for comfort care. A Physician's Order dated 4/04/19, documented instructions for a dressing to the resident's left buttocks/coccyx pressure ulcer. Weekly Wound Observation Tool dated 3/26/19, documented the wound was acquired on 10/25/18, was originally staged as a Stage 3 and was currently a Stage 4. Overall impression was that it was worsening - moist with granulation (pink-red moist tissue that fills an open wound) and slough (non-viable yellow, tan, gray, green or brown tissue) tissue present with an odor this The wound bed had ten percent necrosis (dead tissue). The wound drained a large amount of serosanquinous drainage. The wound measured 5.5 centimeters (cm) x 4 cm, x 3 cm. Undermining (destruction of tissue or ulceration extending under the skin edges) was noted at 10:00 to 5:00 and measured between 3 cm and 4 cm. Wound progress was slightly worse due to slough in the wound bed and odor. The resident had pain at the wound/ulcer site. The physician and family were notified. Observations of resident positioned in bed with head of bed (HOB) at 30 degrees are as follows: 04/01/19 at 10:02 AM - resident is lying on her back. 04/01/19 at 11:57 AM - resident is lying on her back. 04/01/19 at 03:01 PM - resident is turned to the right side. 04/02/19 at 08:57 AM - resident is lying on her back. 04/02/19 at 10:43 AM - resident is lying on her back. 04/02/19 at 11:38 AM - resident is lying on her back. 04/02/19 at 01:05 PM - resident is lying on her back. 04/02/19 at 03:52 PM - resident is lying on her right side. 04/03/19 at 08:55 AM - resident is lying on her back. 04/03/19 at 09:30 AM - resident is lying on her left side. 04/03/19 at 12:01 PM - resident is lying on her left side. 04/03/19 at 01:36 PM - resident is lying on her left side. 04/03/19 at 01:52 PM - turned to her right side after the dressing change. 04/04/19 at 08:37 AM - resident is lying on her right side. 04/04/19 at 10:30 AM - resident is lying on her right side. 04/04/19 at 11:35 AM - resident is lying on her right side. 04/04/19 at 03:38 PM - resident is lying on her left side. 04/05/19 at 09:16 AM - resident is lying on her right side. 04/05/19 at 10:02 AM - resident is lying on her right side - slouched down to almost the middle of the bed. Documentation Survey Report V2 for April 2019 - Under Intervention/Task -Turning and Reposition documented by the Certified Nursing Assistants (CNAs) are as follows: 04/01/19 at 10:00 AM - entered 1:34 PM - resident turned to right side-observed on back. 04/01/19 at 1200 PM - entered 1:34 PM - resident turned to left side-observed on back. 04/01/19 at 2:00 PM - entered 2:45 PM - resident turned to right side-not observed. 04/01/19 at 4:00 PM - entered 3:34 PM - resident turned to left side-not observed. 04/02/19 at 0800 AM - entered 10:48 AM - resident turned to her back-same as observation. 04/02/19 at 1000 AM - entered 10:48 AM - resident turned to left side-observed on back. 04/02/19 at 12:00 PM - entered 1:30 PM - resident turned to her back-same as observation. 04/02/19 at 2:00 PM - entered 2:00 PM - resident turned to her right side-not observed. 04/03/19 at 0800 AM - entered 1:56 PM - resident turned to left side-observed on back 04/03/19 at 1000 AM - entered 1:56 PM - resident turned to right side-observed on left side 04/03/19 at 1200 PM - entered 1:56 PM - resident turned to left side-same as observation 04/03/19 at 2:00 PM - entered 9:52 PM - resident turned to right side-same as observation 04/04/19 at 0800 AM - entered 07:25 AM - resident turned to right side same as observation 04/04/19 at 1000 AM - entered 1:56 PM - resident turned to her back-observed on right side 04/04/19 at 1200 PM - entered 1:56 PM - resident turned to her back-observed on right side 04/04/19 at 2:00 PM - entered 3:13 PM - resident turned to left side-same as observation During an interview on 04/02/19 at 09:16 AM, Certified Nursing Assistant (CNA) #1 stated the resident no longer gets out of bed because her bedsores are so bad. Staying in bed is more comfortable for her. He stated he was not sure if the resident was to be turned every hour or every two hours. During an interview on 04/04/19 at 11:40 AM, CNA #2 stated the resident is always in pain when she is turned and has reported this to nursing. She stated she does not know if the resident is actually in pain or if it is a behavior. The resident is getting more contracted. The resident says she is in pain whenever she is turned, she does not want to be touched. She will place pillows underneath the resident's bottom so she is not lying on her wound. During an interview on 04/04/19 at 12:39 PM, the Registered Nurse Manager (RNM) #1 stated that CNA #5 is good about turning the resident every hour side to side. It is on the [NAME] not to place the resident on her back. All CNAs should be letting the nurse know if the resident is in pain prior to positioning. The resident should not be seen on the same side for extended periods of time. Meetings are held daily on proper care of the residents including making sure they turn and position the residents on a regular basis. During an interview on 04/05/19 at 10:06 AM, RNM #1 reviewed the CNAs' turning and positioning documentation and stated the exact times the CNAs charted are in computer. The CNAs are documenting they are turning the resident at least every two hours. After reviewing observation times for monitoring the resident's position in bed, RNM #1 stated the CNAs were not turning the resident at the times they are documenting that they are. She stated it appears they are not turning and positioning the resident but are signing that they are. During an interview on 04/03/19 at 03:38 PM, the resident's daughter stated that her mother has been a resident at the nursing home for 2 years. She had been a resident for 2 months when she developed the pressure sore to her coccyx which has never really healed. She thinks her mother is supposed to be repositioned every hour but her mother does not want to be moved, She cries continuously when repositioned, because the pressure sore causes her so much pain. Staff should wait until the pain medication takes effect before moving her. The staff have told her that they turn and reposition her mother but she has never seen it occur. She has visited for up to two hours. In her more lucid moments, her mother has told her that she has to move but cannot. The daughter will then tell staff mom needs to be repositioned and will be told it will be done if two staff members can be found to assist. 10NYCRR415.12(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey and abbreviated survey (Case #NY00235153), the facility did not ensure adequate pain management was provided to residents who require such services, consistent with professional standards of practice for one (1) (Resident #10) of three (3) residents reviewed. Specifically, for Resident #10, the facility did not ensure the resident's complaints of pain from a Stage 4 pressure ulcer to her coccyx was adequately managed. This is evidenced by: Pain Management Policy and Procedure dated 09/2005 documented it is the policy to monitor residents for symptoms of pain and when identified, provide a detailed pain evaluation and develop a care plan to provide treatment and services to prevent, minimize and alleviate pain. Resident #10: The resident was admitted on [DATE], with diagnoses of Stage 4 pressure ulcer to sacrum/coccyx area, end stage renal disease and congestive heart failure (CHF). The Minimum Data Set (MDS) dated [DATE], documented the resident was severely impaired for cognition and sometimes was understood by others and usually understood others. The Comprehensive Care Plan (CCP) for pain related to disease process and a pressure ulcer on the resident's coccyx initiated 3/21/19, documented that the resident would be free of any discomfort through the review date. The CCP for Stage 4 Pressure Injury revised on 2/11/19, documented an intervention to treat pain as per orders prior to doing a treatment or turning to ensure the resident's comfort. A Physician's Orders for pain management documented the following: 3/09/19 - Fentanyl patch 75 mcg/hr every 72 hours. Apply one patch transdermally one time a day every 3 days for pain. 3/28/19 - Morphine Sulfate 20 mg/5 ml. Give 10 mg sublingually every 4 hours for pain. 3/10/19 - Morphine Sulfate 20 mg/5ml. Give 5 mg every 1 hour as needed for comfort care. 4/04/19 - Morphine Sulfate 20 mg/5 ml. Give 10 mg every 1 hour as needed for comfort care. During observation of a dressing change on 4/03/19 at 01:35 PM, the resident complained of pain throughout the dressing change the stage 4 pressure ulcer on her coccyx. The resident stated that it hurt so bad and cried when RN #2 irrigated the pressure ulcer with normal saline. RN #2 told the resident she would give her pain medication when she was finished with the dressing change. During an interview on 04/02/19 at 09:16 AM, Certified Nursing Assistant (CNA) #1 stated the resident used to get up out of bed, but her bedsores are so bad, staying in bed is more comfortable for her. She now gets repositioned in bed on an hourly basis. CNA #1 stated he was not sure if it was every one or every two hours the resident should be turned. During an interview on 04/04/19 at 10:48 AM, Licensed Practical Nurse (LPN) #1 stated the resident receives a scheduled dose of pain medication. She complains of pain as soon as she wakes up and will ask for pain medication even though she has already received it. Whenever she walks into the resident's room, the resident complains of pain as she anticipates she will be in pain. If the resident is really adamant that she is in pain, LPN #1 will give the resident her PRN pain medication. The resident also needs extra doses of PRN Morphine when her Fentanyl patch has been on for 3 days as she is experiencing more pain. LPN #1 will wait a few minutes after pain medication is given before starting her treatment to the coccyx. During an interview on 04/04/19 at 11:40 AM, CNA #2 stated the resident is always in pain when she is turned and has reported this to nursing. She stated she does not know if the resident is actually in pain or if it is a behavior. The resident is getting more contracted. The resident says she is in pain whenever she is turned, she does not want to be touched. She will place pillows underneath the resident's bottom so she is not lying on her wound. During an interview on 04/04/19 at 01:45 PM, RNM #1 reviewed the pain evaluation for March and April which was filled out by the nurses every shift. It contained numerous 0s indicating the resident had no pain. The RNM stated there is never a time the resident will say she is not in pain, she is never a 0. When the nurses are doing the pain scale every shift, they are obtaining the level of pain for the specific time that they are asking the resident. On April 3, during the 6:00 AM-2:00 PM shift, the nurse documented a 0 even though the resident was observed to be in pain throughout the dressing change. The RNM stated the PRN Morphine is ordered to be given before wound treatments though it is not on the physician orders nor on the electric Medication Administration Record (eMAR). There is also no set time to pre-medicate the resident prior to the dressing change which is usually done early morning. There are float nurses and nurses doing split shifts where pre-medicating may be difficult to do. On 4/04/19 the RNM added to the eMAR that the resident is to be pre-medicated prior to the pressure ulcer dressing change if not within 30 minutes of the standing pain Morphine every day shift. During an interview on 04/03/19 at 03:38 PM, the resident's daughter stated that her mother has been a resident at the nursing home for 2 years. She had been a resident for 2 months when she developed the pressure sore to her coccyx which has never really healed. She thinks her mother is supposed to be repositioned every hour but her mother does not want to be moved, She cries continuously when repositioned, because the pressure sore causes her so much pain. Staff should wait until the pain medication takes effect before moving her. The staff have told her that they turn and reposition her mother but she has never seen it occur. She has visited for up to two hours. In her more lucid moments, her mother has told her that she has to move but cannot. The daughter will then tell staff mom needs to be repositioned and will be told it will be done if two staff members can be found to assist. 10NYCRR415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey, the facility did not ensure one (1) (Resident #45) received food in the appropriate dietary consistency as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his her goals and preferences. Specifically, the facility did not ensure the resident received the correct diet consistency for meat during a noon meal. This is evidenced by: Dining Policies and Procedures (not dated), documented under Restaurant Standards of Excellence, to double check the system: Dietary server and waitress/waiter both chck to ensure meal is served per geri-ticket. Resident #45: This resident was admitted on [DATE] and readmitted on [DATE], with diagnoses of chronic kidney disease, stage 3, hemiplegia and hemiparesis from intracerebral hemorrhage affecting right dominant side and chronic obstructive pulmonary disease. The Minimum Data Set (MDS) dated [DATE] documented the resident was severely impaired for cognition and sometimes was understood by others and usually understood others. A Physician's Order dated 2/23/18, documented the resident was to receive a ground general diet (dysphagia level 2) texture, honey thick consistency for liquids, and ground with pureed meat. During a dining observation on 04/01/19 at 12:27 PM, the resident received ground meat on her lunch tray instead of pureed meat per Physician's Order. Diet Aide #13 had made up the tray and Licensed Practical Nurse (LPN) #1 had carried the tray over to the resident and was preparing to feed her. A Certified Nurse Assistant (CNA) sitting at the same table told LPN #1, that the resident was supposed to have pureed meat. The CNA replaced the ground meat with pureed meat before it was consumed by the resident. During an interview on 04/01/19 at 02:18 PM, Diet Aide #13 stated she always looked to see what the meal ticket said prior to serving the food. She stated she was a substitute server that day. Whichever staff member took the food was also supposed to read the meal ticket to ensure the correct consistency of food had been served. Both she and LPN #1 missed it. She reviewed the resident's meal ticket which had ground meat entered at the top of the ticket. In bold letters toward the bottom of the ticket, pureed meat was entered. She realized she should have but did not see that the resident was supposed to receive the pureed meat because it was printed on the bottom of the ticket. During an interview on 04/04/19 at 11:54 AM, LPN #1 stated she thought she looked at the meal ticket but stated she must have missed it. She stated she works every shift and works on every unit. The staff are inserviced all the time. During an 04/04/19 at 08:22 AM, Food Service Director #9 stated at the top of the meal ticket is the resident's name and directly below is the diet texture. Toward the bottom of the ticket pureed meat is printed. The server is supposed to read the ticket thoroughly. It is supposed to be double checked when the resident receives the meal. He works closely with the staff and holds annual training on dining service and therapeutic diets. The food service worker should have read the entire meal ticket and the nurse should have done a double check when she received the resident's meal. 10NYCRR415.14 (e)

Based on record review and interview during the recertification survey, the facility did not ensure it had a policy regarding use and storage of foods brought to residents by family and visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not provide information for family and visitors on safe food preparation and handling practices. This was evidenced as follows: Review of the facility's policy on Food Brought in from the Outside on 04/04/19 at 08:37 AM documented that the policy required families and visitors to be educated on safe preparation and handling practices for food brought in from the outside (Procedure #1). Review of the facility's Welcome Packet for residents and families stated that bringing in foods from the outside, other than non-perishable items, was discouraged. A letter sent to families stated that personal refrigerators were discouraged. If refrigerators are brought in, the resident or resident's family was expected to record daily temperatures of the refrigerator, although the facility will take temperatures if necessary. No educational handout was provided about the use and storage of foods brought in from the outside to ensure safe and sanitary storage, handling, and consumption. During an interview on 04/03/19 at 10:30 AM, the Registered Dietitian stated she doubted there was a policy for Foods Brought In. Nutrition did not teach families/visitors on safe and sanitary storage, handling, and consumption of foods. During an interview on 04/04/19 02:05 PM, the Assistant Director of Nursing stated that she thought she had heard about the policy, but didn't know who taught families and visitors about safe preparation and handling practices for food brought in from the outside. She thought nursing discussed appropriate food choices with families when a resident with therapeutic needs was admitted and the family started bringing in food for the resident. In an interview on 04/04/19 at 02:27 PM, the Activities Director stated she knew about the Food Brought in from the Outside Policy. If the issue of bringing in foods comes up at a care meeting she can discuss it, but the Activities Department did not educate families about safe preparation and handling practices for food brought in from the outside. 10 NYCRR 415.14(h)

Based on observation, record review and interview during a recertification survey, the facility did not ensure it developed and implemented an ongoing infection prevention and control program (IPCP) which was reviewed and updated annually and as necessary. This would include revision of the IPCP as national standards change. This is evidenced by: Infection Control Policies and Procedures were dated as followed: - Surveillance Definitions of Infections in Long Term Care Facilities- dated January 2018. - Clinical Services Subject: Infection Prevention & Control Policy - dated November 2017. - Prevention of Influenza Transmission by Healthcare and Residential Facility and Agency. Personnel - dated 11/19/2014. - Influenza Vaccination of Residents - dated January 2015. - Clinical Services Subject: Antibiotic Stewardship Policy - dated November 2017. - Isolation- not dated. - Transmission Based Precautions Guidelines - dated October 31, 2017. During an interview on 04/05/19 at 10:36 AM, Registered Nurse/ Infection Control Nurse/ Minimum Data Set Coordinator #5 reviewed the Infection Control Policies and Procedures and noted they had not been updated within the past year. She was also unable to provide documentation that the policies had been reviewed within the year. She stated she would check with the home office. 10NYCRR415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews during recertification survey, the facility did not ensure baseline care plans were developed with a summary provided to the resident and/or representative within 48 hours of admission for 12 (Resident #'s 21, 32, 65, 70, 82, 87, 101, 102, 110, 218, 223, and #225) of 12 residents reviewed. Specifically, for Resident #'s 21, 32, 65, 70, 82, 87, 101, 102, 110, 218, 223, and #225, the facility did not provide a summary of the baseline care plan to the residents and/or representatives within 48 hours of admission. This is evidenced by: Resident #21: The resident was admitted to the facility on [DATE], with diagnoses of anemia, hypertension and Non-Alzheimer's Dementia. The Minimum Data Set (MDS) dated [DATE], documented the resident understands, is understood and has moderate cognitive impairment. During record review on 4/05/19 at 10:55 AM, the medical record did not include documentation that a baseline care plan had been developed and that a summary had been provided to the resident and/or representative. Resident #82: The resident was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Dementia with Behavioral Disturbance, and hypertension. The MDS dated [DATE], documented the resident sometimes understands, is sometimes understood and has severe cognitive impairment. During record review on 4/3/19 at 10:39 AM, the medical record did not include documentation that a baseline care plan had been developed and that a summary had been provided to the resident and/or representative. Resident #110: The resident was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), hypertension and generalized anxiety. The MDS dated [DATE], documented the resident understands, is understood and is cognitively intact. During record review on 4/03/19 at 5:30 PM, the medical record did not include documentation that a baseline care plan had been developed and that a summary had been provided to the resident and/or representative. Interviews: During an interview on 4/3/19 at 3:50 PM, the Administrator stated the 48 hour baseline care plans were not being completed. During an interview on 4/3/19 at 5:44 PM, the Assistant Director of Nursing stated the 48 hour baseline care plan is included in the regular care plan. During an interview on 4/03/19 at 5:45 PM, admission Nurse #2 stated that she was not aware of the regulation and that she had not provided baseline care plan summaries to residents and/or their representatives. During an interview on 4/5/19 at 11:00 AM, Registered Nurse Unit Manger #3 reported that she did not provide a summary of a baseline care plan to the residents and/or their representatives within 48 hours of admission. During an interview on 04/05/19 11:04 AM, the Director of Social Work #2 stated that the facility did not provide a summary of the baseline care plan to the residents and/or their representatives within 48 hours of admission. 10NYCRR415.11