Based on record review and interview during an abbreviated survey (NY00383402), the facility did not ensure that residents representative, for one of three residents reviewed for notification (Resident #1), who was designated as the emergency contact person was notified, provided education and given an opportunity to consent or decline prior to performing a treatment change/medical procedure. Specifically, Resident #1 was stated on intravenous antibiotic and Family Member#1 was not notified, additionally Resident #1 developed a facility acquired wound to left toe and Family Member #1 was not notified.The findings are:Resident #1 was admitted to the facility with diagnoses including Stroke, Hypertension, Diabetes and non-Alzheimer's dementia. The Minimum Data Set assessment, dated 6/6/2025 documented a Brief Interview Mental Score of 9 indicating the resident had moderately-impaired cognitive skills for daily decision making.The resident's medical record included the resident face sheet which listed Family member #1 as the emergency contact person for making decisions for the resident.The Policy regarding notification dated 01/2017 documented it is the policy of Beach Care Center to document any change in a resident's condition and to inform designated representative and physician in a timely fashion. The Policy further document Registered Nurse Supervisor and charge nurse or Medical Doctor notifies designated representative if a condition deteriorates, individual notifying designated representative documents same in medical records.A Nursing progress note dated 5/27/2025 documented Resident #1 was seen and examined by Primary Medical Doctor for redness to left foot, new order for Zosyn (antibiotic) 3/375 milligram intravenous every 8 hours for 5 day and Augmentin (antibiotic) 500 milligram by mouth three times a day for 5 days after zosyn is completed. The note further documented a heplock (catheter placed intravenously for infusion) was placed on right hand with 22 gauge needle and the1st dose was given. There was no documented evidence the family was notifiedA Medical Doctor progress note dated 5/27/2025 at 4:43 PM documented Resident was seen for redness on the left foot. No complaint of fever or chills complains of mild pain. On exam resident afebrile (without fever) and hemodynamically stable focal left foot erythema (redness) and edema (swelling) extending to the ankle and area of dark tissue necrotic second toe with tip of toe. No calf tenderness, neurovascular intact. Assessment indicated cellulitis of left foot. The plan was Zosyn 3.375 intravenous every 8 hours for 5 days after that start Augmentin 500mg 3 times a day. There was no documented evidence the family was notified.A review of the wound notes initiated 6/5/2025 documented Resident #1 had a facility acquired unavoidable wound located on left 2nd toe measuring 2.5x2.0 centimeters 100% eschar (dry harden skin) and the treatment order betadine. There is no documented evidence the family was notified.A review of the wound notes dated 7/18/2025 documented wound bed 30% slough 70 granulation measurement 1x1.5x.3 treatment order changed to meta honey. There is no documented evidence the family was notifiedDuring an interview conducted on 8/13/2025 at 2:38PM with Family member #1 they stated they arrived to the facility to find resident #1 in the dining room bleeding from removing the intravenous catheter. They stated the supervisor responded and cleaned the resident. Family member #1 stated they were never notified that Resident #1 would be started on intravenous medication or antibiotic. Family member #1 stated they would have refused the intravenous antibiotic because Resident #1 would not tolerate it. Family member #1 further stated she was not made aware on 6/5/2025 that Resident #1 had developed a wound on the left toe and was receiving treatment. Family member #1 state she is listed on the face sheet and wants to be notified of any changes in treatment or in Residents condition. During an interview conducted on 8/11/20205 at 2:30PM with the evening supervisor they stated they responded to the unit to observe resident #1 in the dinning room and had dislodged the intravenous catheter. Evening supervisor stated they cleaned the site and ensured the residents safety and reassured the family. Evening Supervisor stated that Family Member #1 stated they did not want medication administered intravenously so they notified the physician who ordered oral antibiotics. Evening supervisor stated the family member should have been notified by the unit coordinator on the previous shift.During an interview conducted on 8/6/2025 at 2PM with the unit coordinator they stated they worked as the unit coordinator on 5/27/2025 they further stated they do not recall notifying the daughter when the intravenous antibiotics were initiated.During an interview conducted on 8/6/2025 at 3PM with the Director of Nursing they stated when there is a change, and the resident is cognitively impaired the family is informed by the unit coordinator or the nursing supervisor. They were unable to locate any further evidence the family had been notified.415.3(e)(2)(ii)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility's policy titled Resident Accident/Significant Event dated 06/17/2019 documented that any identified neglect or abuse relating to the accident will be promptly reported to the Department of Health. Resident #83 was admitted with diagnoses including Dementia, Type 2 Diabetes Mellitus, and Anxiety. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 3, which indicated the resident had severely impaired cognition. The Falls Comprehensive Care Plan dated 7/25/2022 and revised on 9/27/2023 documented Resident #82 had a history of falls. The interventions included bed alarm and monitoring for increased confusion, agitation, or behavior changes. A nursing progress note, written by Registered Nurse #3 on 6/22/2024 at 8:05 AM, documented Certified Nurse Assistant #3 reported the resident had a blue/purple discoloration to the right eye. The resident was unable to verbalize or recall what happened. A nursing progress note, written by Registered Nurse Supervisor #4 on 6/22/2024 at 8:30 AM, documented Resident #83 was noted with discoloration to the right eye and right forehead. The resident was unable to describe what happened. Resident #83's family member declined to transfer the resident to the emergency room for a Computerized Tomography (CT) scan. The Accident and Incident report dated 6/22/2024 at 7:30 AM documented that Resident #83 had a discoloration to the right eye and right forehead. The resident was unaware of what happened and the incident was unwitnessed. The written statements obtained from nursing staff during the day shift indicated no one observed a fall or an incident that may have resulted in the identified discoloration. The Accident Investigation Report, Summary of investigation, dated 6/27/2024 documented the nature of the incident: Fall- Discoloration to Right Eye and Forehead. The summary documented there was no sufficient evidence of resident abuse, mistreatment, or neglect. The summary was signed by the facility Administrator and the Director of Nursing Services. Certified Nursing Assistant #3 was interviewed on 7/1/2024 at 2:11 PM and stated they were not assigned to care for Resident #83. They saw Resident #83 in the hallway walking to the dining room on 6/22/2024 during the 7:00 AM to 3:00 PM shift. They noticed the resident had discoloration on the right eye and reported the discoloration to the Nurse. Certified Nursing Assistant #2 was interviewed on 7/1/2024 at 2:19 PM and stated that they were assigned to care for Resident #83 on 6/22/2024 but they did not see Resident #83 until after Certified Nurse Aide #3 reported the bruise on the resident's right eye. Registered Nurse #3 was interviewed on 7/3/2024 at 10:14 AM and stated they observed Resident #83 in bed sleeping when they conducted their morning rounds on 6/22/2024. Registered Nurse #3 stated they were unable to see the resident's face and did not observe the bruise to the resident's right eye. Registered Nurse Supervisor #4 was interviewed on 7/3/2024 at 8:41 AM and stated that when they were notified of the discoloration to the resident's forehead on 6/22/2024, they called the Director of Nursing and investigated the incident. Registered Nurse Supervisor #4 stated they assumed Resident #83 fell. Registered Nurse Supervisor #4 stated they obtained statements from the nursing staff on the day shift. Registered Nurse Supervisor #4 stated the incident occurred on the weekend and they left the report documents in the Risk Manager's mailbox. The Risk Manager was interviewed on 7/3/2024 at 8:52 AM and stated they reviewed Resident #83's incident report on 6/24/2024. The Risk Manager stated they usually do not investigate the previous shift staff and did not know if the previous shift staff should have provided statements related to the resident's injury. The Risk Manager stated the Director of Nursing Services was responsible for reporting injuries of unknown origin to the New York State Department of Health. The Director of Nursing Services was interviewed on 7/3/2024 at 9:14 AM and stated they were informed of Resident #83's injury on the morning of 6/22/2024. The Director of Nursing Services stated the resident's assigned nursing staff from the previous shifts should have been interviewed to rule out abuse for the injury of unknown origin. The Director of Nursing stated they were responsible for reporting an injury of unknown origin to the New York State Department of Health. The Director of Nursing further stated they should have reported Resident #83's injury of unknown origin to the New York State Department of Health because the cause of the injury was unknown and they were unable to determine how the resident sustained bruises. 10 NYCRR 415.4(b)(2) Based on record review and staff interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024 the facility did not ensure that all alleged violations, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in a serious bodily injury, to the New York State Department of Health. This was identified for one (Resident #48) of three residents reviewed for skin conditions and one (Resident #83) of seven residents reviewed for Accidents. Specifically, 1) Resident #48 sustained a scrotal avulsion (a forcible tearing off the skin of the scrotum) on 1/25/2024 requiring surgical intervention. The cause of the injury was unknown, and the facility did not report the injury of unknown origin to the New York State Department of Health. 2) Resident #83 sustained a discoloration to the right eye and right forehead on 6/22/2024. Resident #83's injury was of unknown origin and was not reported to the New York State Department of Health. The findings are: The facility's Resident Accident/Significant Event policy dated 6/17/2019 documented that a significant event shall be defined as an unintended event resulting in serious bodily harm, such as fracture, laceration that requires closure, second or third-degree burns, or any injury requiring hospital admission. If an accident causes injury or presents the potential for injury or recurrence, the facility will investigate in conjunction with the facility's quality improvement program within five calendar days. Any identified neglect or abuse relating to the accident will be promptly reported to the New York State Department of Health. All accident reports will be screened for evidence of failure to follow the care plan, delay in assessment/treatment, and injuries of unknown origin. The policy did not specifically state the incident must be reported within 2 hours if the event involved suspected abuse or caused serious bodily injury. Resident #48 was admitted with diagnoses including Cerebrovascular Accident, Non-Alzheimer's Dementia, and Psychotic Disorder. The 1/15/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 99, indicating the resident could not complete the interview. The Minimum Data Set assessment documented the resident had behavior symptoms that were not directed toward others. A Comprehensive Care Plan for Behavioral Symptoms-Disruptive or Dangerous to Self or Others effective 6/23/2014 and last updated 7/1/2024 documented the resident has a history of self-injurious behavior. A care plan update on 1/22/2024 documented that Resident #48 was verbally and physically aggressive and was kicking and punching staff during evening care. The interventions included utilizing behavior management strategies, monitoring early warning signs of problem behaviors, and escorting the resident to a less stimulating environment as needed. A nursing progress note dated 1/25/2024 at 8:10 PM, written by Registered Nurse #1, documented Resident #48 was noted with a scrotal wound; the skin came off the sack with moderate bleeding. The nurse cleaned the wound with normal saline, applied bacitracin, and then covered the wound with a dry sterile dressing. The Physician was made aware, and the resident was transferred to the hospital. A nursing progress note dated 1/26/2024 at 10:04 AM, written by Registered Nurse #5, documented Resident #48 was admitted to the hospital and was transferred to the operating room for the surgical repair of the Scrotal Avulsion. A nursing progress note dated 1/26/2024 at 9:34 PM, written by Registered Nurse #1, documented the resident returned from the hospital with a diagnosis of Scrotal Avulsion. The resident's scrotal wound area was noted with sutures. Certified Nursing Assistant #1, the assigned Certified Nursing Assistant, was interviewed on 6/28/2024 at 11:52 AM. Certified Nursing Assistant #1 stated the resident has aggressive behaviors and would fight with caregivers by hitting, kicking, and punching the caregivers during care. Certified Nursing Assistant #1 stated that the resident also has a behavior of fondling themselves. Registered Nurse #1, the 3:00 PM-11:00 PM supervisor, was interviewed on 7/1/2024 at 12:26 PM. Registered Nurse #1 stated Resident #48's scrotal wound was identified during care in the evening shift on 1/25/2024. Certified Nurse Assistant #2 reported there was blood in the resident's brief. Upon assessment, the scrotal area had opened skin and was bleeding. Registered Nurse #1 notified the Physician, and the resident was transferred to the hospital for evaluation. Registered Nurse #1 stated they did not initiate an investigation to identify how the resident sustained the scrotal injury. Registered Nurse #1 stated that Resident #48 occasionally placed their hand in their brief, which they believed to be the cause of the injury. There were no reports of the resident being aggressive during care on 1/25/2024. Certified Nursing Assistant #2, who was assigned to Resident #48 on 1/25/2024 during the 3:00 PM-11:00 PM shift, was interviewed on 7/1/2024 at 2:24 PM. Certified Nursing Assistant #2 stated on 1/25/2024, they transferred Resident #48 back to bed via a mechanical lift with another Certified Nursing Assistant and provided care. The resident did not exhibit aggressive behaviors on 1/25/2024 during the evening shift. Certified Nursing Assistant #2 stated when they removed the resident's brief, they saw blood in the brief. Certified Nurse Assistant #2 denied incident or injury during care. There were no problems with the mechanical lift transfer. Certified Nursing Assistant #2 immediately reported the injury to Registered Nurse #1. The Director of Nursing Services was interviewed on 7/2/2024 at 8:30 AM. The Director of Nursing Services stated I never saw anything like this kind of injury. I cannot imagine this kind of injury could be caused by the resident just putting their hands in their pants. The Director of Nursing Services stated an investigation was not initiated because there were no known falls or accidents. The Director of Nursing Services stated they did not consider abuse as a possible cause of Resident #48's injury at the time. The Director of Nursing Services stated the resident's injury was of unknown origin and should have been reported to the New York State Department of Health. Registered Nurse Risk Manager #1 was interviewed on 7/3/2024 at 8:10 AM and stated an investigation related to the resident's injury was not completed because Resident #48 had a history of fondling their (Resident #48's) scrotum which could have caused the injury. Registered Nurse Risk Manager #1 stated that an investigation should have been completed to rule out abuse and the incident should have been reported to the New York State Department of Health within two hours because the injury sustained by the resident was a significant injury of unknown origin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #83 was admitted with diagnoses including Dementia, Type 2 Diabetes Mellitus, and Anxiety. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 3, which indicated the resident had severely impaired cognition. The Falls Comprehensive Care Plan dated 7/25/2022 and revised on 9/27/2023 documented Resident #82 had a history of falls. The interventions included bed alarm and monitoring for increased confusion, agitation, or behavior changes. A nursing progress note, written by Registered Nurse #3 on 6/22/2024 at 8:05 AM, documented Certified Nurse Assistant #3 reported the resident had a blue/purple discoloration to the right eye. The resident was unable to verbalize or recall what happened. A nursing progress note, written by Registered Nurse Supervisor #4 on 6/22/2024 at 8:30 AM, documented Resident #83 was noted with discoloration to the right eye and right forehead. The resident was unable to describe what happened. Resident #83's family member declined to transfer the resident to the emergency room for a Computerized Tomography (CT) scan. The Accident and Incident report dated 6/22/2024 at 7:30 AM documented that Resident #83 had a discoloration to the right eye and right forehead. The resident was unaware of what happened and the incident was unwitnessed. The written statements obtained from nursing staff during the day shift indicated no one observed a fall or an incident that may have resulted in the identified discoloration. The Accident Investigation Report, Summary of investigation, dated 6/27/2024 documented the nature of the incident: Fall- Discoloration to Right Eye and Forehead. The summary documented there was no sufficient evidence of resident abuse, mistreatment, or neglect. The summary was signed by the facility Administrator and the Director of Nursing Services. Certified Nursing Assistant #3 was interviewed on 7/1/2024 at 2:11 PM and stated they were not assigned to care for Resident #83. They saw Resident #83 in the hallway walking to the dining room on 6/22/2024 during the 7:00 AM to 3:00 PM shift. They noticed the resident had discoloration on the right eye and reported the discoloration to the Nurse. Certified Nursing Assistant #2 was interviewed on 7/1/2024 at 2:19 PM and stated that they were assigned to care for Resident #83 on 6/22/2024 but they did not see Resident #83 until after Certified Nurse Aide #3 reported the bruise on the resident's right eye. Registered Nurse #3 was interviewed on 7/3/2024 at 10:14 AM and stated they observed Resident #83 in bed sleeping when they conducted their morning rounds on 6/22/2024. Registered Nurse #3 stated they were unable to see the resident's face and did not observe the bruise to the resident's right eye. Registered Nurse Supervisor #4 was interviewed on 7/3/2024 at 8:41 AM and stated that when they were notified of the discoloration to the resident's forehead on 6/22/2024, they called the Director of Nursing and investigated the incident. Registered Nurse Supervisor #4 stated they assumed Resident #83 fell. Registered Nurse Supervisor #4 stated they obtained statements from the nursing staff on the day shift. Registered Nurse Supervisor #4 stated the incident occurred on the weekend and they left the report documents in the Risk Manager's mailbox. The Risk Manager was interviewed on 7/3/2024 at 8:52 AM and stated they reviewed Resident #83's incident report on 6/24/2024. The Risk Manager stated they usually do not investigate the previous shift staff and did not know if the previous shift staff should have provided statements related to the resident's injury. The Director of Nursing Services was interviewed on 7/3/2024 at 9:14 AM and stated they were informed of Resident #83's injury on the morning of 6/22/2024. The Director of Nursing Services stated the resident's assigned nursing staff from the previous shifts should have been interviewed to rule out abuse for the injury of unknown origin. 10 NYCCR 415.4(b)(3) Based on record review and staff interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024 the facility did not ensure that each allegation of abuse, neglect, exploitation, mistreatment, or injury of unknown origin was thoroughly investigated. This was identified for one (Resident #48) of three residents reviewed for skin conditions and one (Resident #83) of seven residents reviewed for Accidents. Specifically, 1) Resident #48 sustained a scrotal avulsion (a forcible tearing off the skin of the scrotum) that required surgical intervention on 1/25/2024. The cause of the injury was unknown. There was no investigation to determine the root cause of the injury. 2) Resident #83 sustained a discoloration to the right eye and right forehead on 6/22/2024. Resident #83's injury was of unknown origin. There was no investigation to determine the root cause of the injury. The findings are: 1) The facility's Accident/Significant Event policy dated 6/17/2019 documented that a significant event shall be defined as an unintended event resulting in serious bodily harm, such as fracture, laceration that requires closure, second or third-degree burns, or any injury requiring hospital admission. If an accident occurs that causes injury or presents the potential for injury or recurrence, the facility will investigate in conjunction with the facility's quality improvement program within five calendar days. All accidents, unexplained bruises, or injuries are reported to the charge nurse immediately. The charge nurse informs the Registered Nurse Supervisor. The policy then describes each step of the investigation process. Resident #48 was admitted with diagnoses including Cerebrovascular Accident, Non-Alzheimer's Dementia, and Psychotic Disorder. The 1/15/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 99, indicating the resident could not complete the interview. The Minimum Data Set assessment documented the resident had behavior symptoms that were not directed toward others. There were no skin conditions documented. A Comprehensive Care Plan for Behavioral Symptoms-Disruptive or Dangerous to Self or Others effective 6/23/2014 and last updated 7/1/2024 documented the resident has a history of self-injurious behavior. A care plan update on 1/22/2024 documented that Resident #48 was verbally and physically aggressive; the resident was kicking and punching staff as the Certified Nursing Assistant was performing evening care. The interventions included utilizing behavior management strategies, monitoring early warning signs of problem behaviors, and escorting the resident to a less stimulating environment as needed. A nursing progress note dated 1/25/2024 at 8:10 PM, written by Registered Nurse #1, documented Resident #48 was noted with a scrotal wound; the skin came off the sack with moderate bleeding. The nurse cleaned the wound with normal saline, applied bacitracin, and then covered the wound with a dry sterile dressing. The physician was made aware and the resident was transferred to the hospital. A nursing progress note dated 1/26/2024 at 10:04 AM, written by Registered Nurse #5, documented Resident #48 was admitted to the hospital and transferred to the operating room for surgery to repair the Scrotal Avulsion. A nursing progress note dated 1/26/2024 at 9:34 PM, written by Registered Nurse #1, documented the resident returned from the hospital with the diagnosis of Scrotal Avulsion. The resident's scrotal wound area was noted with sutures. Certified Nursing Assistant #1, Resident #48's assigned Certified Nursing Assistant, was interviewed on 6/28/2024 at 11:52 AM. Certified Nursing Assistant #1 stated the resident has aggressive behaviors during care. The resident would fight, hit, kick, and punch the caregivers and also kick the wheelchair. Certified Nursing Assistant #1 added that the resident also has a history of fondling (their scrotal area) themselves. Registered Nurse #1, the 3:00 PM-11:00 PM supervisor, was interviewed on 7/1/2024 at 12:26 PM. Registered Nurse #1 stated Resident #48's scrotal wound was identified during care in the evening shift on 1/25/2024. Certified Nurse Assistant #2 reported there was blood in the resident's brief. Upon assessment, the scrotal area had opened skin and was bleeding. Registered Nurse #1 notified the Physician and the resident was transferred to the hospital for evaluation. Registered Nurse #1 stated they did not initiate an investigation to identify how the resident sustained the scrotal injury. Registered Nurse #1 stated that Resident #48 occasionally placed their hand in their brief, which they believed to be the cause of the injury. There were no reports of the resident being aggressive during care on 1/25/2024. Certified Nursing Assistant #2, who was assigned to Resident #48 on 1/25/2024 during the 3:00 PM-11:00 PM shift, was interviewed on 7/1/2024 at 2:24 PM. Certified Nursing Assistant #2 stated on 1/25/2024, they transferred Resident #48 back to bed via a mechanical lift with another Certified Nursing Assistant and provided care. The resident did not exhibit aggressive behaviors on 1/25/2024 during the evening shift. Certified Nursing Assistant #2 stated when they removed the resident's brief, they saw blood in the brief. Certified Nurse Assistant #2 denied incident or injury during care. There were no problems with the mechanical lift transfer. Certified Nursing Assistant #2 immediately reported the injury to Registered Nurse #1. Physician #1, the Medical Director, was interviewed on 7/1/2024 at 2:59 PM and stated they could only speculate the cause of Resident #48's scrotal injury; the injury was most likely self-inflicted because the resident had a behavior of putting their hands in their brief I never saw anything like this, and I was surprised by the [scrotal avulsion] diagnosis. Physician #1/Medical Director stated they evaluated Resident #48 on 1/28/2024 after the resident returned from the hospital; however, they did not document the cause of injury. The Director of Nursing Services was interviewed on 7/2/2024 at 8:30 AM. The Director of Nursing Services stated the resident sustained Scrotal Avulsion and had to be transferred to the hospital for sutures. The resident had a history of putting their hands in their brief; however, I never saw anything like this kind of injury. I cannot imagine this kind of injury could be caused by the resident just putting their hands in their pants. The Director of Nursing Services stated an investigation was not initiated because there were no known falls or accidents. The Director of Nursing Services stated they did not consider abuse as a possible cause of Resident #48's injury at the time. The Director of Nursing Services stated the resident's injury was of unknown origin and should have been investigated to rule out abuse, neglect, and mistreatment. Registered Nurse Risk Manager #1 was interviewed on 7/3/2024 at 8:10 AM and stated an investigation related to the resident's injury was not completed because Resident #48 had a history of fondling their (Resident #48's) scrotum which could have caused the injury. Registered Nurse Risk Manager #1 stated that an investigation should have been completed to rule out abuse, neglect, and mistreatment because the injury sustained by the resident was a significant injury of unknown origin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure the comprehensive care plan was reviewed and revised to meet each resident's current needs. This was identified for one (Resident #62) of two residents reviewed for Environment. Specifically, Resident #62, who resided on the second floor of the facility, had behaviors of stuffing the toilet with objects that clogged the toilet resulting in a leaked ceiling in other residents' rooms residing on the first floor. A comprehensive care plan was developed for the resident's behavior in 2014 with interventions to manage the resident's behavior. The resident continued to exhibit the behavior; however, the interventions on the comprehensive care plan remained unchanged since 2014. The finding is: The facility's policy and procedure titled Comprehensive Care Plan, last revised on 11/28/2017, documented each resident will have an individualized interdisciplinary plan of care in place. The Interdisciplinary Team will review and revise the Comprehensive Care Plan on a quarterly basis, with a significant change in condition, on readmission from in-patient hospital stay, and as requested by the Resident/Representative. The Comprehensive Care Plan will be ongoing, constantly evolving, focusing on each individual as a unitary being, constantly changing, and interacting with the environment/energy fields. The Comprehensive Care Plan will address all real/potential problems, needs, strengths, and individual preferences of the resident. Each discipline will be responsible for the initiation and ongoing follow-up for selected care plans as related to their areas of expertise. Resident # 62 was admitted with Diagnoses including Schizophrenia, Mood Disorder, and Anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of two, which indicated the resident had severely impaired cognition. The Minimum Data Set (MDS) assessment documented Resident #62 had behaviors of hallucinations (an experience that involves a perception of something not present), Delusions (misconceptions or beliefs that are firmly held, contrary to reality), and wandering. Resident #62 was continent of bowel and bladder and was not on any toileting program. A physician's order dated 6/18/2024 documented to administer the following: Latuda (anti-psychotic medication) oral tablet 80 milligrams twice a day; Lorazepam (anti-anxiety medication) oral tablet one milligram twice a day; and Depakote Extended Release (mood stabilizer medication) 500 milligrams one tablet at bedtime. A Comprehensive Care Plan (CCP) dated 5/28/2014 and last reviewed on 6/17/2024 for Behavioral Symptoms- Disruptive or Dangerous to self or others as evidenced by: the resident with a history of entering staff offices and grabbing food from garbage/desk; stuffing items in the toilet; wandering into peers' room which may trigger aggression; and stealing food items off peers' tray, food cart and medication cart. Interventions included but were not limited to escorting Resident #62 to a less stimulating environment; involving Resident #62 in behavior programs; monitoring for antecedents (comes before) or early warning signs of problems behavior; and reviewing intensity, duration, frequency, the pattern of behaviors, their development over time, and their effect on resident and others. All the interventions were initiated in 2014 with no new interventions added since 2014. The care plan was evaluated on 6/19/2023, 7/18/2023, 8/21/2023, 9/25/2023, 10/23/2023, 11/20/2023, 12/18/2023, 1/22/2024, 2/19/2024, 4/15/2024, 5/14/2024, and 6/17/2024. Each time the evaluation note documented: Resident displays being preoccupied internally; Resident has a history of stuffing items in the toilet, disrupting immediate living environment. The resident benefits from the structure of the unit. No behaviors noted during the review period. The Maintenance Logbook from 1/4/2024 to 6/5/2024 documented entries that Resident #62's room needed maintenance due to a clogged toilet. The Behavior Follow-Up Assessment Form from 3/14/2024 to 3/19/2024 did not document Resident #62's behavior of stuffing items in the toilet. Certified Nursing Assistant #1 was interviewed on 7/3/2024 at 10:30 AM and stated that Resident #62 often backs up the toilet by stuffing cups, snacks, and other items in the toilet. Certified Nursing Assistant #1 stated they always report the issue to the Nurse for Maintenance to fix the toilet. Registered Nurse #4 was interviewed on 7/3/2024 at 11:00 AM and stated Resident #62 frequently throws different items in the toilet which causes the toilet to clog. Registered Nurse #4 stated the behavior has been ongoing for a long time. Registered Nurse #4 stated the Certified Nursing Assistant supervised Resident #62's continence needs, but most of the time, Resident #62 goes to the bathroom independently. Registered Nurse #4 stated they usually call the maintenance staff to unclog the toilet. The Maintenance Director was interviewed on 7/3/2024 at 11:30 AM and stated they had fixed Resident #62's toilet numerous times. Once the toilet is clogged, it causes a backflow, causing a leak in another resident's bathroom that is located below Resident #62's bathroom. The Maintenance Director stated they did not know what else to do because of Resident #62's continuing behavior of stuffing items in the toilet. The Behavior Program Director was interviewed on 7/3/2024 at 1:00 PM and stated they primarily worked on the Behavior Unit where Resident #62 resides. The Behavior Program Director stated updating Resident #62 care plan is their responsibility. The Behavior Program Director stated that Resident #62's care plan interventions have not been revised since 2014 because the behavior has been the same for a long time. The Behavior Program Director stated as far as the Behavior Department, Resident #62's behavior of stuffing items in the toilet had stopped. The Behavior Program Director stated that the Maintenance and Nursing department did not tell them that Resident #62 had been stuffing items in the toilet, otherwise the behavior team would have completed a Behavior Follow Up Assessment Form to trigger a new intervention in the care plan. The Behavior Program Director stated they had written the same evaluation on the care plan monthly for the past year because the resident's behaviors were the same and there were no reports from other disciplines that Resident #62 had been stuffing items in the toilet. The Behavior Supervisor was interviewed on 7/5/2024 at 12:09 PM and stated they had written the same evaluation note on the care plan for Resident #62 because there were no new behaviors reported. The Behavior Supervisor stated they did not know that Resident #62 was stuffing items in the toilet and clogging the toilet and if they knew, they would have triggered a behavior follow-up and added new interventions to the care plan. The Director of Nursing Services was interviewed on 7/5/2024 at 12:36 PM and stated the care plan for Resident #62 should have been updated for any changes, especially with new behaviors, but the resident's behaviors were not new. The Director of Nursing Services stated the intervention should have been evaluated for effectiveness and if ineffective, then a new care plan intervention should have been initiated to address the resident's needs. 415.11(c)(2) (i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure that each resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for two (Resident # 107 and Resident #138) of five residents reviewed for Pressure Ulcers. Specifically, Resident #107 and Resident #138 had a physician's order for an alternating pressure relief air mattress. During multiple observations, the adjustable weight setting on the air mattress pump was not accurately set according to each resident's weight. The findings are: The facility's Pressure Ulcers policy and procedure last revised on 5/21/2019 documented that residents who have pressure ulcers receive the necessary treatment to promote healing, prevent infection, and prevent new ulcers from developing. Residents will be assessed for pressure ulcer risk factors upon admission, re-admission, quarterly, and with change in condition. It is the Nurse's responsibility to oversee the Pressure Ulcer program which includes ensuring an appropriate Plan of Care is implemented and carried through, conducting weekly pressure ulcer rounds with the Physician, and completing the pressure ulcer progress assessment form. The Operation Manual for the Alternating Pressure and Low Air Loss Mattress System documented the adjustable patient weight settings allow for optimal immersion, patient comfort, and compliance. The weight capacity was documented to be 350 pounds. 1) Resident #107 was admitted with diagnoses including Spinal Stenosis, Pressure Ulcer of the Sacral Region, and Respiratory Failure. The admission Minimum Data Set assessment dated [DATE] documented no Brief Interview for Mental Status score due to Resident #107's severe cognitive impairment. The Minimum Data Set assessment documented Resident #107 was at risk for developing a pressure ulcer and had one Stage 4 (defined as full-thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer on the sacrum. A Comprehensive Care Plan for Pressure Ulcer dated 4/11/2024 documented interventions included heel and elbow protectors as needed, and the use of an air mattress. A physician's order dated 4/11/2024 documented the use of an alternating pressure relief air mattress. A physician's order dated 6/5/2024 documented to apply Santyl (medication that removes damaged tissue from the area) ointment to the sacral ulcer; lightly pack the wound with Calcium Alginate (medication that absorbs excess moisture and promotes healing); and then cover with silicone border gauze twice a day. A review of the electronic medical record indicated that Resident #107's most recent weight was 156 pounds on 6/13/2024. A Wound Care Progress Note dated 6/21/22024 documented the resident's sacral wound measured 5.5 centimeters in length 3.0 centimeters in width and 0.5 centimeters in depth. The wound bed was noted with 100 percent granulation (new tissues and blood vessels) tissue and the surrounding skin was intact. There was a moderate amount of serous (pale, yellow watery fluid) drainage with no odor. The progress note documented multiple other wounds with measurements and treatment recommendations including a left hip Deep Tissue Injury, a left elbow ulcer, a right lateral ankle wound, and a right inner thigh wound. Resident # 107 was observed lying in bed on 6/27/2024 at 12:15 PM. The alternating air mattress pump was set at 350 pounds. Resident #107 was observed in lying bed on 6/28/2024 at 9:00 AM. The alternating air mattress pump was set at 350 pounds. Resident # 107 was observed in lying bed on 7/1/2024 at 11:55 AM. The alternating air mattress pump was set at 350 pounds. Registered Nurse #4, the Unit Manager, was interviewed on 7/1/2024 at 11:40 AM and stated that Licensed Nurses are responsible for monitoring that the weight setting on the air mattress is set based on the resident's actual weight. Registered Nurse #4 stated there was a physician's order for the use of an alternating air mattress; however, there was no order to monitor the air mattress settings and therefore the monitoring was not being completed and documented every shift. Certified Nursing Assistant # 5 was interviewed on 7/1/2024 at 11:20 AM and stated they were responsible for checking the resident's alternating air mattress was appropriately inflated. Certified Nursing Assistant #5 stated they do not touch the alternating air mattress pump nor change the settings on the air mattress. The Wound Care Manager was interviewed on 7/2/2024 at 9:15 AM and stated the alternating air mattress weight setting should correspond with the resident's weight. All staff are responsible for monitoring the air mattress. The Wound Care Manager stated Resident #107 weighed 156 pounds and they were not sure why the alternating air mattress weight setting was set at 350 pounds. Physician #1, the Wound Care Physician, was interviewed on 7/2/2024 at 1:29 PM and stated it was up to the facility to ensure that the air mattress setting was properly monitored. Physician #1 stated for optimal wound healing the alternating air mattress weight setting should be calibrated to match the resident's actual weight. The Director of Nursing Services was interviewed on 7/2/2024 at 2:12 PM and stated the nursing staff should have monitored the alternating air mattress weight setting every shift. Monitoring the air mattress can be documented every shift by the nurses in the treatment administration record or the medication administration record. 2) Resident #138 was admitted with diagnoses including Alzheimer's Disease, Seizure Disorder, and Aphasia. The 6/24/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 1, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment documented that the resident had one Stage 4 pressure ulcer (full-thickness tissue loss with exposed bone, tendon, or muscle) with an intervention for a pressure-reducing device for the bed. The resident's documented weight was 139 pounds. An actual Pressure Ulcer Comprehensive Care Plan, effective 2/15/2024 and last updated on 6/21/2024, documented the resident had a Stage 4 pressure ulcer to the sacral area. The intervention included the use of an alternating air mattress for Resident #138. A physician's order as of 7/2/2024 documented to cleanse the resident's sacral ulcer with normal saline, apply Calcium Alginate (an absorptive wound dressing) to the wound bed, and cover with silicone-bordered gauze twice a day. A wound assessment completed by Registered Nurse #1, the wound care nurse, dated 6/21/2024 documented the resident had a Stage 4 sacral ulcer measuring 1.7 centimeters in length, 1.2 centimeters in width, and 1.0 centimeters in depth with tunneling/undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface; the clock scale provides the basic location of the undermining) 1.5 centimeters at 5-12 o'clock. The wound care recommendations included providing a special alternating air mattress or offloading devices if indicated. Resident #138 was observed in their room sitting in a Geri chair (a chair used for residents who have difficulty sitting upright in a conventional wheelchair) adjacent to their bed on 6/27/2024 at 2:03 PM. The resident's bed had an alternating air mattress with the weight setting set at 350 pounds. Resident #138 was observed in bed on 6/28/2024 at 8:05 AM. The alternating air mattress weight setting was set at 350 pounds. Registered Nurse #4, who is the supervisor, was interviewed on 6/28/2024 immediately after the observation. Registered Nurse #4 stated the resident did not weigh 350 pounds and the setting on the mattress should be set to the resident's weight of 139 pounds. Registered Nurse #4 adjusted the alternating air mattress setting to 139 pounds. Registered Nurse #1, the wound care nurse, was interviewed on 7/2/2024 at 9:00 AM and stated it is the facility's policy that residents with Stage 3 and 4 sacral pressure ulcers are provided an alternating air mattress. The alternating air mattress weight setting is based on the resident's weight. The nurses are supposed to check the alternating air mattress weight setting; however, there is no documentation to confirm. The certified nursing assistants are supposed to check the alternating air mattress to make sure the mattress is not deflated, but they do not adjust the weight setting. Certified Nursing Assistant #1 was interviewed on 7/2/2024 at 11:32 AM and stated the Certified Nursing Assistants do not adjust the alternating air mattress weight setting; they just check the alternating air mattress to make sure the mattress is not deflated and let the nurse know if there is a problem. Certified Nursing Assistant #1 stated they do not check the weight setting. Resident #138's wound care treatment was observed on 7/2/2024 at 11:36 AM. Registered Nurse #2 performed the wound care treatment and was assisted by Certified Nursing Assistant #7. The alternating air mattress weight setting was set at 150 pounds. Wound Care Physician #1 was interviewed on 7/2/2024 at 1:29 PM and stated they recommended the use of an alternating air mattress for Resident # 138, but it was up to the facility to ensure that the alternating air mattress was monitored properly. Wound Care Physician #1 expected the facility to follow the weight of the resident and calibrate the alternating air mattress accordingly. Wound Care Physician #1 stated proper calibration of the alternating air mattress was important to ensure effective wound healing. The Director of Nursing Services was interviewed on 7/2/2024 at 1:59 PM and stated the facility did not have a plan in place for monitoring the alternating air mattress weight setting. The nurses should monitor the air mattress setting, including the weight setting, every shift. The Certified Nursing Assistants should notify the nurse when they notice that the mattress is overinflated or underinflated. 10 NYCRR 415.12(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews conducted during a Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. This was identified for one (Resident #113) of two residents reviewed for Respiratory Care. Specifically, Resident #113 had a physician's order to receive 3 liters of oxygen per minute every shift. The resident was observed receiving 4.5 liters of oxygen per minute on 6/27/20224 and 6/28/2024 and 5 liters of oxygen per minute on 7/1/2024. The finding is: The facility's policy and procedure titled Oxygen Concentrator last revised in March 2017, documented that while delivering oxygen via an oxygen concentrator, the flow meter knob is to be adjusted to the ordered flow rate. All precautions for traditional oxygen therapy will be adhered to for oxygen administration. The facility's policy and procedure titled General Oxygen Administration last revised in February 2017, documented to administer oxygen as per the physician's order. Assess the resident for signs of adverse reactions to oxygen therapy (hypoventilation and bradypnea-abnormally slow breathing), and therapeutic response to oxygen. Resident #113 was admitted with diagnoses including Heart Failure, Morbid Obesity, and Atrial Fibrillation. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The Minimum Data Set further documented the resident did not receive oxygen therapy. A physician's order dated 5/29/2024 documented to administer oxygen at 3 liters per minute via a nasal cannula every shift. No diagnosis was indicated for the use of oxygen therapy. The Comprehensive Care Plan for Alteration in Respiratory Status dated 5/29/2023 revised on 5/30/2024, documented interventions including administering oxygen at 3 liters per minute. Resident # 113 was observed sitting in their wheelchair near their bed on 6/27/2024 at 11:16 AM. Resident #113 was using a nasal cannula that was attached to an oxygen concentrator. The oxygen concentrator was out of Resident #113's reach. The display window on the oxygen concentrator indicated Resident # 113 was receiving 4.5 liters of oxygen per minute. Resident #113 was observed in bed on 6/28/2024 at 9:20 AM. Resident #113 was using a nasal cannula that was attached to an oxygen concentrator, which was placed at the end of the resident's bed. The oxygen concentrator was out of Resident #113's reach. The display window on the oxygen concentrator indicated Resident # 113 was receiving 4.5 liters of oxygen per minute. Resident #113 declined to be interviewed at this time. Resident #113 was observed sitting in a wheelchair by their bed on 7/1/2024 at 11:52 AM. Resident #113 was using a nasal cannula that was attached to an oxygen concentrator. The display window on the oxygen concentrator indicated the resident was receiving oxygen at 5 liters per minute. The oxygen concentrator was out of Resident #113's reach. Resident #113 stated they were not able to change the setting on the concentrator and the oxygen therapy made no difference to their breathing. The display window on the oxygen concentrator was again observed with Licensed Practical Nurse #1 on 7/1/2024 at 11:58 AM. The display window on the oxygen concentrator indicated the resident was receiving oxygen at 5 liters per minute. Licensed Practical Nurse #1 adjusted the oxygen to 3 liters per minute and stated Resident #113 was not supposed to be receiving oxygen at 5 liters. Licensed Practical Nurse #1 was interviewed immediately after the observation on 7/1/2024 at 11:58 PM and stated any licensed nursing staff could check Resident #113's oxygen at the start of the shift. Licensed Practical Nurse #1 stated they could not recall if they had checked the resident's oxygen concentrator today, 7/1/2024. Licensed Practical Nurse #1 stated that Resident #113 could not reach the oxygen concentrator to change the oxygen setting. Licensed Practical Nurse #1 stated this was not the first time they had observed Resident #113's oxygen set at a higher rate than ordered. Licensed Practical Nurse #1 stated they did not know why the oxygen was set high on those occasions. Licensed Practical Nurse #1 stated the resident should receive oxygen as ordered by the Physician. The Treatment Administration Record from 5/1/2024 to 7/1/2024 was reviewed and indicated Resident #113 was receiving oxygen at 3 liters per minute every shift including on 6/27/2024, 6/28/2024, and 7/1/2024. Licensed Practical Nurse #2, who was Resident #113's regularly assigned medication nurse, was interviewed on 7/3/2024 at 1:30 PM. Licensed Practical Nurse #2 stated licensed nurses are responsible for ensuring that the oxygen is administered as per the physician's orders. Physician #2, the attending Physician for Resident #113, was interviewed on 7/2/2024 at 2:55 PM. Physician #2 stated the resident should receive oxygen at 3 liters per minute as per the written order. The Director of Nursing Services was interviewed on 7/8/2024 at 10:09 AM and stated they expected the licensed nurses to ensure that the residents receive oxygen therapy as per the physician's orders. 10 NYCRR 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews conducted during a Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure the medical care of each resident is supervised by a Physician. This was identified for one (Resident #113) of two residents reviewed for Respiratory Care. Specifically, Resident #113 had a physician's order for supplemental oxygen therapy at 3 liters per minute every shift; there was no rationale documented for the use of supplemental oxygen. Additionally, the resident expressed that the oxygen therapy has not been effective. There was no documented evidence in the resident's medical record that the Physician monitored and evaluated the resident's oxygen therapy needs until after the Surveyor brought the concern to the facility's attention on 7/2/2024. The finding is: The facility's policy and procedure titled Clinical Operations dated April 2019 documented that the Physician will participate in the resident's assessment and plan of care, monitor changes in their clinical condition, provide consultation or treatment, and oversee the plan of care of the resident. The Physician will perform pertinent and timely medical assessments, prescribe an appropriate medical plan of care, and provide adequate information regarding the resident's condition and medical needs. Resident #113 was admitted with diagnoses including Heart Failure, Morbid Obesity, and Atrial Fibrillation. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The Minimum Data Set documented the resident did not receive oxygen therapy. A physician's order dated 5/29/2024 documented to administer oxygen at 3 liters per minute via a nasal cannula every shift. No diagnosis was indicated for the use of oxygen. The Comprehensive Care Plan for Alteration in Respiratory Status dated 5/29/2023 was revised on 5/30/2024 to document an intervention for oxygen at 3 liters per minute. All progress notes were reviewed from 5/1/2024 to 5/29/2024. There was no documented evidence of any report, assessment, or evaluation related to Resident #113's change in respiratory status or reason for starting oxygen treatment on 5/29/2024. A Physician's progress note dated 5/30/2024, written by Physician #2, documented that Resident #113 was comfortable at examination, lung clear to auscultation (Lung sounds are normal), and cardiovascular S1 S2 (normal rate and rhythm of the heart). The progress note did not include an assessment or plan for oxygen therapy. The Monthly Physician Assessment and Plan of Care dated 6/6/2024 and 7/2/2024 written by Physician #2 did not include an assessment of the resident's lung and did not document the use of oxygen therapy. Resident #113 was observed and interviewed on 7/1/2024 at 11:52 AM. The resident was sitting in their wheelchair by their bed and was using a nasal cannula that was attached to an oxygen concentrator. Resident #113 stated that the oxygen therapy made no difference to their breathing, there's got to be something better. Resident #113 stated they had asked but did not receive any feedback from Nurses and doctors on weaning off their oxygen. Licensed Practical Nurse #1, who was the unit manager where Resident #113 resided, was interviewed on 7/1/24 at 11:58 AM. Licensed Practical Nurse #1 stated they believed Resident #113 was using oxygen because the resident had Chronic Heart Failure. Licensed Practical Nurse #1 stated they were not aware of any plan to re-assess and monitor whether Resident #113's continued use of oxygen is necessary. Resident #113's attending physician, Physician #2, was interviewed on 7/2/2024 at 2:55 PM and stated Resident #113 did not experience changes in respiratory status when oxygen therapy was initiated on 5/29/2024. Physician #2 stated that they believed they ordered the oxygen to encourage the resident to comply with care such as taking a shower as the resident was afraid of having a low oxygen level when they used the shower. Physician #2 stated they did not document a rationale for the oxygen therapy and parameters for monitoring the resident's oxygen saturation levels and should have. Physician #2 stated that the current oxygen order for Resident #113 was wrong as written. The order should have been included to check Resident #113's oxygen saturation every shift and provide oxygen therapy as needed if the oxygen saturation level was below 92%. Physician #2 stated that when a resident is on oxygen therapy, their oxygen saturation must be measured to monitor progress and to determine if a higher level of respiratory care is needed. The Medical Director was interviewed on 7/3/2024 at 12:28 PM and stated they expected the attending Physician to monitor the resident's condition regularly and adjust the course of treatment and interventions as appropriate. The Medical Director stated that Physician #2 should have documented their rationale when oxygen therapy was ordered and included the parameters. The Medical Director stated Resident #113 has been on oxygen therapy for five weeks and the resident cannot be on continuous oxygen forever. The Medical Director stated Physician #2 should have monitored the resident's respiratory status and re-evaluated the resident to determine if oxygen remains an appropriate intervention. 10 NYCRR 415.15(b)(1)(i)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified on two (Unit 2 East and Unit 2 West) of three units reviewed during the Medication Storage Task. Specifically, 1) a used vial (bottle) of insulin for Resident #86 was observed in the medication refrigerator, on Unit 2 East on 7/2/2024, with an open date of 5/29/2024; 2) two opened bottles of Latanoprost Ophthalmic Solution for Resident #76 and Resident #109 were observed in the medication cart on Unit 2 [NAME] on 7/2/2024 without a date that indicated when the eye drop bottles were opened; and 3) a used vial of insulin for Resident #55 was observed in the medication refrigerator, on Unit 2 [NAME] on 7/2/2024, with an opened date of 5/27/2024. The findings are: The facility policy titled Medication: Storage and Handling dated 2/23/2017 and revised on 7/5/2024 documented that the unit nurse will ensure that all resident medications are to be properly labeled, restored, and locked securely in the medication room. Medications and other solutions past their noted expiration date are to be removed from usage and returned to the pharmacy to ensure the desired effect when utilized. No discontinued, outdated, or deteriorated drugs or biologicals are to be used for resident care. All eye drops and insulins for resident care will be discarded 28 days from the opening date. 1) Resident #86 was admitted with diagnoses including Type 2 Diabetes Mellitus and End Stage Renal Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident's cognition was intact. The Minimum Data Set assessment documented the resident was receiving insulin injections during the assessment period. A physician's order for Resident #86 dated 3/8/2024 and renewed on 6/28/2024 documented to administer Humalog insulin (fast-acting insulin) Subcutaneous Solution 100 units per milliliter three times daily before meals for Type 2 Diabetes Mellitus according to blood sugar readings as follows: 151 milligrams per deciliter-200 milligram per deciliter=2 units, 201 milligrams per deciliter-250 milligram per deciliter=4 units, 251 milligrams per deciliter-300 milligram per deciliter=6 units, 301 milligrams per deciliter-350 milligrams per deciliter=8 units, 351 milligrams per deciliter-400 milligrams per deciliter=10 units, and notify the Physician for a blood sugar reading below 60 milligram per deciliter or over 400 milligrams per deciliter. An observation of the Medication Storage was conducted with Licensed Practical Nurse #5 on Unit 2 East on 7/2/2024 at 10:55 AM. A used vial of Humalog insulin solution for Resident #86 was observed in the medication refrigerator. The insulin vial had an open date of 5/29/2024 documented on the vial indicating the vial had been opened for more than 28 days. Licensed Practical Nurse #5, the medication nurse for Unit 2 East, was interviewed on 7/2/2023 at 1:49 PM. Licensed Practical Nurse #5 stated they thought the Humalog insulin vial for Resident #86 that was in the medication refrigerator was new and overlooked the date documented on the insulin vial. Licensed Practical Nurse #5 further stated the vial of Humalog insulin solution should have been removed from the medication refrigerator and discarded after 28 days the insulin vial was opened. Licensed Practical Nurse #4, Nurse Manager for Unit 2 East, was interviewed on 7/3/2024 at 9:47 AM and stated that the insulin vial should have been discarded after 28 days from when it was first opened. 2) Resident #76 was admitted with diagnoses including Glaucoma (an eye condition that can cause vision loss) and Type 2 Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 3, indicating the resident had severe cognitive impairment. A Physician's Order for Resident #76 dated 7/12/2023 and renewed on 6/11/2024 documented to administer one drop of Latanoprost Ophthalmic Solution 0.005 percent into the left eye at bedtime for Glaucoma. Resident #109 was admitted with diagnoses including Bilateral (both eyes) Pre-Glaucoma (a condition in which the pressure in the eye is higher than normal) and Hypertension. The Significant Change in Status Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 7, indicating the resident had severe cognitive impairment. A Physician's order for Resident #109 dated 4/26/2024 and renewed on 7/5/2024 documented to administer one drop of Latanoprost Ophthalmic Solution 0.005 percent to both eyes at bedtime for Bilateral Pre-Glaucoma. An observation of the Medication Storage was conducted with Licensed Practical Nurse #3 on Unit 2 [NAME] on 7/2/2024 at 11:31 AM. Two used bottles of Latanoprost Ophthalmic solution 0.005 percent for Resident #76 and Resident #109 were observed in the medication cart. There was no date documented on the bottles to indicate when they were first opened. 3) Resident #55 was admitted with diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy (a type of nerve damage) and Hypertension. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 8, indicating the resident had moderate cognitive impairment. The Minimum Data Set assessment documented the resident was receiving insulin injections during the assessment period. A Physician's Order for Resident #55 dated 6/6/2024 and renewed on 6/21/2024 documented to administer 35 units of Insulin Glargine-yfgn (a long-acting insulin) 100 unit per milliliter subcutaneous Solution daily for Type 2 Diabetes Mellitus with Diabetic Neuropathy. An observation of the Medication Storage was conducted with Licensed Practical Nurse #3 on Unit 2 [NAME] on 7/2/2024 at 11:53 AM. A used vial of Insulin Glargine-fygn solution was observed for Resident #55 in the medication refrigerator. The insulin vial had an open date of 5/27/2024 documented on the vial indicating the vial had been opened for more than 28 days. Licensed Practical Nurse #3, the medication nurse for Unit 2 West, was interviewed on 7/2/2024 at 2:33 PM. Licensed Practical Nurse #3 stated the Ophthalmic Solution bottles should be discarded 30 days from opening. Licensed Practical Nurse #3 stated the bottles of Latanoprost Ophthalmic Solution for Resident # 76 and Resident #109 should have been dated when they were first opened so that the unit nurses could determine when to discard the medication. Licensed Practical Nurse #3 stated the vial of insulin Glargine solution should be discarded 28 days after opening. Licensed Practical Nurse #1, the Nurse Manager for Unit 2 West, was interviewed on 7/3/2024 at 9:43 AM and stated the unit nurses were responsible for proper labeling and storage of medications on the unit. Licensed Practical Nurse #1 stated the bottles of Latanoprost Ophthalmic solution for Resident #76 and Resident #109 should have been dated when first opened by nursing staff. The used vial of insulin Glargine for Resident #55 should have been discarded 28 days after the vial was first opened. The Pharmacist was interviewed on 7/5/2024 at 10:23 AM and stated Humalog insulin and Glargine insulin should be discarded 28 days after opening. The potency of the insulin decreases and the medications may become less effective after 28 days of opening. The Pharmacist stated Latanoprost 0.005 percent Ophthalmic solution should be discarded six weeks after opening because the medication becomes less effective. The Director of Nursing Services was interviewed on 7/5/2024 at 12:35 PM and stated all ophthalmic solutions and insulin solutions should be discarded 28 days after they were opened. All unit nurses should ensure proper labeling and storage of medications. The Director of Nursing Services further stated the bottles of Latanoprost Ophthalmic Solution for Resident #76 and Resident #109 should have been dated when the bottle was first opened. The insulin vials for Resident #86 and Resident #55 should have been discarded 28 days after the vials were first opened. 10 NYCRR 415.18 (d);10 NYCRR 415.18(e)(1-4)

Based on record review and interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, 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 five of the five units reviewed for the Sufficient Nursing Staffing task. Specifically, 1) a review of the Payroll-Based Journal (PBJ) Staffing Data Report Quarter 1, 2024 indicated excessively low weekend staffing and 2) a review of the daily staffing sheets revealed that the facility did not provide sufficient numbers of Certified Nursing Assistants as indicated in the facility assessment. The finding is: The facility's Policy and Procedure on Staffing last reviewed 7/2024, documented the facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined in the resident's comprehensive care plan. The Registered Nurse Supervisor on duty for each shift will update the daily staffing census sheet. Our facility furnishes information from payroll records setting forth the average numbers and types of personnel on each shift to the New York State Department of Health. The Payroll-Based Journal Staffing Data Report for Fiscal Year Quarter One 2024 (October 1-December 31) documented the facility triggered for the metric of excessively low weekend staffing. The Facility Assessment Tool dated 6/26/2024 documented the average daily census was 170-182 residents. The assessment documented the facility required 19 licensed nurses to provide care on a daily basis and 44 Certified Nursing Assistants to provide care on a daily basis. A review of weekend staffing sheets from 1/7/2024 to 3/17/2024 revealed there were less than 44 Certified Nursing Assistants available to care for residents on a daily basis. The Staffing Coordinator was interviewed on 6/28/2024 at 12:13 PM and stated the facility was having problems with staffing on the weekends, mainly on Sundays, because many of the full-time Certified Nursing Assistants have resigned. The Staffing Coordinator stated the 7:00 AM to 3:00 PM shift requires 19 Certified Nursing Assistants in total, the 3:00 PM to 11:00 PM shift requires 13 Certified Nursing Assistants, and the 11:00 PM to 7:00 AM shift requires 10 Certified Nursing Assistants based on the Daily Staffing Schedule sheets that they use to fill all of the Certified Nursing Assistant slots. The Staffing Coordinator was not sure why the Facility Assessment documented that 44 Certified Nursing Assistants were required on a daily basis because the Daily Staffing Schedule indicated a need for 42 Certified Nursing Assistants daily. The Staffing Coordinator reviewed the Daily Staffing Schedule sheets from 1/1/2024 to 3/31/2024 and stated that short staffing for Certified Nurse Assistants is an ongoing issue every other weekend. A review of weekend staffing from 1/1/2024 to 3/31/2024 revealed insufficient staffing. Examples included but were not limited to the following: -On 1/7/2024, during the 7:00 AM to 3:00 PM shift, there were 11 Certified Nursing Assistants on duty. Based on the Staffing Coordinator's Daily Staffing Schedule sheet there should be 19 Certified Nursing Assistants. There were 32 total Certified Nursing Assistants for 1/7/2024 compared to the 44 as indicated in the facility assessment. -On 1/21/2024, during the 7:00 AM to 3:00 PM shift, there were 13 Certified Nursing Assistants on duty. Based on the Staffing Coordinator's Daily Staffing Schedule sheet there should be 19 Certified Nursing Assistants. There were 31 total Certified Nursing Assistants for 1/21/2024 compared to the 44 as indicated in the facility assessment. -On 2/4/2024, during the 7:00 AM to 3:00 PM shift, there were 17 Certified Nursing Assistants on duty. Based on the Staffing Coordinator's Daily Staffing Schedule there should be 19 Certified Nursing Assistants. There were 38 total Certified Nursing Assistants for 2/4/2024 compared to the 44 as indicated in the facility assessment. -On 2/18/2024, during the 7:00 AM to 3:00 PM shift, there were 14 Certified Nursing Assistants on duty. Based on the Staffing Coordinator's Daily Staffing Schedule there should be 19 Certified Nursing Assistants. There were 35 total Certified Nursing Assistants for 2/18/2024 compared to the 44 as indicated in the facility assessment. -On 3/3/2024 and 3/31/2024, during the 7:00 AM to 3:00 PM shift, there were 15 Certified Nursing Assistants. Based on the Staffing Coordinator's Daily Staffing Schedule there should be 19 Certified Nursing Assistants. There were 40 total Certified Nursing Assistants for 3/3/2024 compared to the 44 as indicated in the facility assessment. -On 3/17/2024, during the 7:00 AM to 3:00 PM shift, there were 16 Certified Nursing Assistants. Based on the Staffing Coordinator's Daily Staffing Schedule there should be 19 Certified Nursing Assistants. There were 38 total Certified Nursing Assistants for 3/17/2024 compared to the 44 as indicated in the facility assessment. The Director of Nursing Services and the Staffing Coordinator were interviewed concurrently on 7/3/2024 at 9:35 AM. The Staffing Coordinator stated the facility has been short-staffed with Certified Nursing Assistants on the weekends for a long time because there is no public transportation to the facility on the weekends. The Director of Nursing Services stated there is a high turnover of Certified Nursing Assistants and the facility has difficulty retaining Certified Nursing Assistants. The Director of Nursing Services stated the facility utilizes a staffing agency; however, the agency staff cannot be mandated to work on the weekends. The Director of Nursing Services stated that full-time employees are required to work every other weekend as per their union contract. The Director of Nursing Services stated they know that the insufficient staffing issue on the weekends occurs on alternate weekends; however, they have not attempted to adjust the staffing schedules. The Director of Nursing Services stated they had been unable to come up with a solution to address the facility's insufficient staffing issue. The Administrator was interviewed on 7/8/2024 at 10:58 AM and stated they were aware of the insufficient staffing issue at the facility, especially on the weekends. The Administrator stated public transportation to the facility is limited and the full-time staff wants higher wages. The Administrator stated they have been thinking about doing a job fair but have not done one yet since becoming Administrator 13 months ago. The Administrator stated they assumed the Director of Nursing Services and the Staffing Coordinator were staggering the schedules to fill the weekend staffing needs. 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 abbreviated survey (NY00326327), the facility did not ensure that an incident of a resident-to-resident altercation was reported immediately, but not later than 2 hours if there were serious bodily injuries or not later than 24 hours if there were no serious bodily injuries. This was identified for one (Resident #1) of 3 residents reviewed for Abuse. Specifically, on 10/12/2023 Resident #1 reported to the nursing staff that Resident #2 yelled and hit them multiple times. The facility did not report the resident-to-resident altercation incident to the New York State Department of Health (NYSDOH). The findings are: The undated policy and procedure title Resident to Resident altercation prevention documented the facility will monitor and document peer to peer behavioral events to allow for proper assessments and effective care planning as well as to evaluate the effectiveness of interventions and programing in maintain a safe therapeutic environment. The policy does not include reporting criteria to state/federal or local agencies. The Policy and Procedure titled Abuse, Neglect and Mistreatment dated 10/24/22 documented any case in which abuse neglect mistreatment exploitation or misappropriation of resident's property has been identified via the investigation or a conclusion can not be drawn, will be reported promptly to the state department of Health for further investigation. Resident #1 has a medical diagnosis including Dementia without behavioral disturbance and generalized muscle weakness. The Minimum Data Set (MDS) dated [DATE] documented a Brief interview mental status (BIMS) score of 13 indicating intact cognition. The MDS further documented Resident #1 has no behavior directed towards others and does not reject care. Resident #2 has a medical diagnosis including Dementia without behavioral disturbances, Alzheimer's disease and age-related osteoporosis. The MDS dated [DATE] documented a BIMS score 11. Resident requires supervision with bed mobility, transfer, eating, toilet use, personal hygiene and requires extensive assistance for dressing. The MDS further documented Resident #2 has no behavior directed towards others and does not reject care. The Nursing Progress note dated 10/12/23 documented Resident #1 had a verbal altercation with roommate and the roommate proceeded to hit Resident #1 on her arms. The community police were notified and interviewed the resident and the roommate. There is no documented evidence of a Patient Accident/ Incident Report for Resident #1. There is no documented evidence a comprehensive care plan related to behavior, altercation with peer or abuse was developed. The Resident Altercation occurrence report dated 10/23/23 in the electronic medical record documented on 10/12/23 Resident #1 reported that her roommate yelled and hit them. The Certified Nursing Assistant instructions (CNA) documented no evidence of monitoring, or intervention related to the altercation. On 10/24/23 at 2PM an interview was conducted with Resident #1 who stated some days ago while on the phone during the night Resident #2 came over to the bedside demanding that Resident #1 stops talking and slapped her multiple times on both arms and hands. Resident #1 stated after screaming for help and Resident #2 walked out. Resident #1 further stated the Resident Representative (RR #1) who was on the phone notified the facility and local law enforcement. On 10/24/23 an interview was conducted with Registered Nurse #1 (RN #1) who stated they were notified by Resident Representative #1 (RR#1) via telephone that Resident #1 was hit. RN #1 stated they reported to the unit to observe resident #2 at the nurse's station. RN#1 stated on interview resident #2 denied hitting resident #1 however resident #1 stated that her arm was slapped. The local police department responded and questioned both residents. In response RN#1 stated he relocated the resident 4 doors down on the same unit. RN #1 stated that staff continued to monitor both residents and they did not verbalize feeling afraid or thoughts of retaliation. RN #1 states that facility administration is notified via the supervisor report of incidents and are responsible for reporting to regulatory bodies. RN #1 state he is not aware if the incidents are reported. On 10/24/23 an interview was conducted with the Director of Nursing (DON) who stated they are made aware of incidents via the supervisor report and discussed in morning meeting. The DON further stated they do not report resident to resident altercations because they deal with them in house. The DON stated she is aware of the state reporting manual and the regulatory requirement however the resident did not have any injuries and so it was determined it did not need to be reported. The DON further stated they are responsible to report to Department of Health and did not report this incident. On 10/24/23 an interview was conducted with the Facility Administrator who stated the Director of Nursing is responsible to report incident to regulatory bodies. The administrator stated the facility has frequent resident to resident altercations, so they are managed in house. The Facility Administrator further stated he became aware of the incident today (10/24/23) and was not aware if it was reported. 10 NYCRR 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 10/11/2022 and completed on 10/18/2022, the facility did not ensure that each resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was identified for one (Resident #81) of four residents reviewed for pressure ulcers. Specifically, Resident #81 was identified with a small opening on the sacrum on 7/14/2022; however, the wound was not assessed until 7/19/2022, five days after the wound was first identified. On 7/19/2022 the wound care Nurse Practitioner (NP) assessed the wound as an unstageable pressure ulcer. The finding is: The facility's policy and procedure for Pressure Ulcers, dated 12/13/2021, documented the unit coordinator will notify the Rehabilitation Nurse for any in-house development of pressure ulcers. The skin assessment sheet will be done by the Registered Nurse (RN) Supervisor and submitted to the wound care nurse to assess the resident with the newly identified pressure ulcer. The assessment of the pressure ulcer is to include the location, size, stage, and exudate (drainage). Resident #81 was admitted with diagnoses including Non-Alzheimer's Dementia, Aphasia, and Muscle Weakness. The 5/11/2022 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented the resident had one Stage 4 pressure ulcer and was at risk for developing pressure ulcers. The MDS also documented that the resident was always incontinent of bowel and bladder and required extensive assistance of one staff member for bed mobility. The 5/11/2022 Braden scale assessment (a predictor of pressure ulcer risk) documented a score of 13, which indicated the resident was at moderate risk for pressure ulcer development. Review of the medical record revealed Resident #81 had a history of Stage 4 pressure ulcer to the right ischium that healed on 6/6/2022. A Comprehensive Care Plan (CCP) effective 9/6/2019 and last updated 5/11/2022 (prior to the wound development on 7/14/2022) documented interventions to turn and position every 2 hours, barrier cream to the buttock area after incontinence and when needed, change diaper every 2-4 hours and when needed, monitor to ensure adequate nutritional intake, maintain proper body alignment in and out of bed, and monitor skin integrity every shift. There were no new interventions added on 7/14/2022 when the open area to the sacrum was first identified. A CCP dated 7/19/2022 for Actual Pressure Ulcer documented interventions which included a ROHO cushion (a specialized pressure relieving wheelchair cushion), Air Mattress, and limited out of bedtime to 4 hours daily. A nursing progress note dated 7/14/2022 at 6:36 AM, written by the 11 PM-7 AM Registered Nurse (RN) Supervisor (RN #1), documented that Resident #81 was noted with a small open area to the sacrum. The physician was notified, and an order was obtained to cleanse the area with normal saline, apply Silvadene cream, and apply a dry dressing twice a day for 10 days. A nursing progress note dated 7/14/2022 at 9:11 AM, written by the 7 AM-3 PM RN charge nurse (RN #2), documented (for the same wound) that Resident #81 was noted with a small open area to the sacrum. A new order from the physician was obtained to cleanse the area with normal saline, apply Triad Cream, and apply a dry dressing twice a day for 10 days. Review of the medical record revealed that there was no assessment of the sacral wound until 7/19/2022 when the resident was seen during wound rounds and examined by the wound NP and the wound care Registered Nurse (RN) #3. The 7/19/2022 NP wound assessment documented that the sacral wound was an unstageable pressure ulcer, measuring 3.5 centimeters (cm) long x 1.0 cm wide x 0.8 cm deep with 100% slough (dead cells that accumulate in the wound) with a small amount of exudate. The treatment was changed to collagenase (an enzymatic debriding wound gel). The next documented wound assessment dated [DATE] indicated the sacral wound was now identified as a stage 4 pressure ulcer measuring 4.0 cm long, x 1.5 cm wide x 2.0 cm deep. The wound was noted with 30 % slough and 70 % granulated tissue with moderate amount of exudate. RN #1, the overnight RN supervisor who first identified the sacral wound on 7/14/2022 at 6:36 AM, was interviewed on 10/18/2022 at 9:14 AM. RN #1 stated the sacral wound was just a small opening. RN #1 stated they (RN #1) are supposed to do a full assessment when a wound is identified, including the size and any drainage, but it was just a small opening. RN #1 further stated they should have done a full assessment. RN #2, who was the RN charge nurse who wrote the nursing progress note on 7/14/2022 at 9:11 AM, was interviewed on 10/18/2022 at 9:30 AM. RN #2 stated they (RN #2) did not do an assessment of the identified open area to the sacrum because the sacral wound was just a small opening. RN #2 stated they (RN #2) did notify the wound care RN on 7/14/2022 when they (RN #2) first identified the wound. RN #2 stated the treatment was changed from Silvadene to Triad cream because RN #2 thought Triad would be better for the wound. RN #2 stated they (RN #2) knew the wound NP would be making rounds on 7/19/2022. RN #2 stated that upon identification of the wound on 7/14/2022 the only documentation that was done was the progress note. Review of the medical record revealed no documentation from the wound care RN until 7/19/2022. RN #3, the wound care RN, was interviewed on 10/18/2022 at 9:47 AM. RN #3 stated when any wound is identified, the nurses are supposed to notify them (RN #3) and there is supposed to be a full assessment documented by the third day following the identification of the wound. RN #3 stated it was an oversight that Resident #81's sacral ulcer was not assessed timely; however, the treatment that was initiated on 7/14/2022 was appropriate for Resident #81. RN #3 stated they (RN #3) did not recall if they (RN #3) were notified when the wound was first identified. The sacrum wound was observed on 10/18/2022 at 10:16 AM. RN #2 removed the dressing while the resident was in bed. RN #2 was assisted by the Infection Control RN. The wound was full thickness [damage extends below the epidermis and dermis (all layers of the skin) into the subcutaneous tissue], Stage 4, about the size of a quarter, round, fully granulating, with minimal exudate, no odors, and no signs of infection. The surrounding tissue was intact. The Director of Nursing Services (DNS) was interviewed on 10/18/2022 at 11:10 AM and stated the nurses are supposed to let the wound nurse know on day one whenever any new wound is identified, and a full assessment should be done within three days. The DNS also stated there should be documentation in the nursing notes that the wound nurse is notified when a wound is identified. 415.12(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey initiated on 10/11/2022 and completed on 10/18/2022, the facility did not ensure that pain management was provided for each resident who requires such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified for four (Residents #39, #40, #121 and #79) of four residents reviewed for pain management. Specifically, the facility did not consistently assess residents for pain and did not monitor the effectiveness of pain medication. The findings include but were not limited to: The current facility policy for Pain Assessment and Management, revised on 2/22/18, documented that all residents will be assessed for pain upon admission/re-admission, quarterly, annually, significant change in condition, acute pain or change in pain medication, and 72 hours after medication change. The need for assessment for the medications prescribed on an as needed (PRN) bases is not addressed in the policy. 1). Resident #39 was admitted with diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy, Metabolic Encephalopathy, and Cerebral Infarction. The Minimum Data Set (MDS) assessment, dated 7/26/2022, documented Resident #39 had clear speech, was usually understood, and had severely impaired cognition. The resident was on a scheduled pain medication regimen and received PRN pain medication. The resident vocalized they occasionally experienced pain or hurting over the last five days and rated the intensity of their worst pain over the last five days as a 2 indicating moderate pain. The current Comprehensive Care Plan for Pain and Alteration in Comfort, dated 8/10/2022, documented the resident has a history of bilateral ankle pain related to Diabetic Neuropathy. Interventions included but were not limited to assessing pain for location, severity, and intensity; medicate as ordered and observe for effectiveness. Resident #39 was observed in bed on 10/11/2022 at 12:40 PM, and again on 10/18/2022 at 10:40 PM. Resident #39 complained of pain and stated, My feet hurt all the time and My pain is a 10 out of 10. The resident further stated, The pain medications don't work most of the time. The resident appeared calm; however, was noted with facial grimacing. The current physician's orders dated 9/23/2022 documented to administer Gabapentin 900 milligrams three times a day, Oxycodone 5 milligrams every 12 hours as needed, and Acetaminophen 650 milligrams every six hours as needed for pain. The Medication Administration Records (MARs), dated September 2022 and October 2022, documented Resident #39 received Gabapentin daily, received the PRN Oxycodone on 24 occasions in September 2022 and on 21 occasions through October 18, 2022, and received the as needed Acetaminophen on 52 occasions in September 2022 and on 26 occasions through October 18, 2022. There was no documented evidence that Resident #39's pain was assessed prior to or after administration of the PRN pain medication to monitor effectiveness. The Nurse Practitioner (NP) was interviewed on 10/18/2022 at 10:35 AM and stated that they (NP) saw the resident today for their (Resident #39) monthly evaluation. The NP stated that Resident #39 has bilateral Diabetic Neuropathy with pain. The NP stated the resident reported pain of 10 out of 10 on a pain scale during the evaluation. The NP stated that an increase to the Gabapentin would be considered. The NP stated that they would expect a pre and post assessments of pain for PRN pain medication administration. The Licensed Practical Nurse (LPN) #1 was interviewed on 10/18/2022 at 10:49 AM and stated that Resident #39 does report when they (Resident #39) have pain. LPN #1 stated they (LPN #1) do not conduct pain evaluations each time prior to or after administering PRN pain medications. The only time a pain assessment is conducted is upon admission, readmission, or change of medication. This assessment is done by the nursing supervisor. The Director of Nursing Services (DNS) was interviewed on 10/18/2022 at 11:10 AM and stated an evaluation is not conducted prior to or after administration of pain medication each time. The DNS stated that staff observe residents for facial expressions of pain and nursing staff perform general rounds during the day. The resident is expected to report to the staff if the medication is not working. The DNS stated that it is the responsibility of the nurse to know if the medication is working or not. The DNS stated that the facility's pain policy does not reflect assessment of pain for non-verbal residents. The DNS stated that the facility policy does not include guidance for staff to perform pre and post evaluation for PRN medications. 2). Resident #40 was admitted with diagnoses that include Gout, Chronic Kidney Disease, and Pain. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #40 was cognitively intact. The MDS documented the resident had clear speech and was usually understood. The resident did not receive a scheduled pain medication regimen, or PRN pain medication during the last 5 days of the MDS review period. The resident did not vocalize any pain or hurting over the last five days of the review. The current Comprehensive Care Plan for Pain and Alteration in Comfort, dated 10/13/2022, documented the resident was receiving pain medication secondary to general discomfort. Interventions included but were not limited to assessing pain for location, severity, and intensity; medicate as ordered and observe for effectiveness. Resident #40 was interviewed on 10/18/2022 at 2:57 PM and stated they get Tylenol for back pain with adequate relief. Resident #40 stated, sometimes they follow-up to see if I feel better and sometimes, they don't. The current physician's orders for October 2022 documented to administer Acetaminophen 650 milligrams every eight hours as needed for pain. The Medication Administration Records (MARs), dated September 2022 and October 2022, documented that the resident received Acetaminophen once in September 2022 and three times in October 2022. There was no documented evidence that Resident #40's pain was assessed prior to or after administration of the PRN pain medication to monitor effectiveness. The Director of Nursing Services (DNS) was interviewed on 10/18/2022 at 11:10 AM and stated an evaluation is not conducted prior to or after administration of pain medication each time. The DNS stated that staff observe residents for facial expressions of pain and nursing staff perform general rounds during the day. The resident is expected to report if the medication is not working to the staff. The DNS stated that it is the responsibility of the nurse to know if the medication is working or not. The DNS states that the facility's pain policy does not reflect assessment of pain for non-verbal residents. The DNS stated that the facility policy does not include guidance for staff to perform pre and post evaluation for PRN medications. 3). Resident #121 has diagnoses including Right Hip Pain, Anxiety and Muscle Spasms. The Minimum Data Set (MDS) assessment, dated 9/3/2022, documented that the resident had clear speech, makes self-understood, and had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The resident was not on a scheduled pain medication regimen but did receive as needed (PRN) pain medication during the five-day MDS look back period. The resident vocalized they frequently experienced pain or hurting over the last five days and rated the intensity of their worst pain over the last five days as a 2 which indicated moderate pain. The current Comprehensive Care Plan for Pain and Alteration in Comfort, dated 9/3/2022, documented the resident is receiving pain medication secondary to Multiple Sclerosis and complaints of generalized pain. Interventions included but were not limited to assessing pain for location, severity, and intensity; medicate as ordered and observe for effectiveness. Resident #121 was interviewed on 10/18/2022 at 2:51 PM. The resident stated that they notify the nursing staff when experiencing pain and receive pain medication but did not recall the nursing staff following up on the effectiveness of the medication. The current physician's orders for October 2022 documented to administer Oxycodone-Acetaminophen 5-325 milligrams every 6 hours as needed (PRN) and Acetaminophen 650 milligrams every six hours PRN. The Medication Administration Records (MARs) dated September 2022 documented that the resident received the Oxycodone-Acetaminophen 5-325 milligram on 40 occasions and Acetaminophen 650 milligrams on one occasion. In October 2022 the resident received the Oxycodone-Acetaminophen 5-325 milligram on 23 occasions and Acetaminophen 650 milligrams on zero occasions. There was no documented evidence that Resident #121's pain was assessed prior to or after administration of the PRN pain medication to monitor effectiveness. The Director of Nursing Services (DNS) was interviewed on 10/18/2022 at 11:10 AM and stated an evaluation is not conducted prior to or after administration of pain medication each time. The DNS stated that staff observe residents for facial expressions of pain and nursing staff perform general rounds during the day. The resident is expected to report if the medication is not working to the staff. The DNS stated that it is the responsibility of the nurse to know if the medication is working or not. The DNS states that the facility's pain policy does not reflect assessment of pain for non-verbal residents. The DNS stated that the facility policy does not include guidance for staff to perform pre and post evaluation for PRN medications. 415.12

Based on observation, record review, and interviews during the Recertification Survey the facility did not ensure that care was provided in accordance with each resident's comprehensive care plan for one (Resident #34) of four residents reviewed for medication administration. Specifically, during the medication pass observation on 3/1/20, for Resident #34, the Licensed Practical Nurse (LPN) administered Calcitonin nasal spray (a medication to treat Osteoporosis), two puffs, in each of the resident's nostrils; Although, the Physician's order required that only one puff was to be administered alternating between the left and right nostril every other day. In addition, the administration directions on the pharmacy label on the calcitonin spray were unclear. The finding is: The facility's policy titled Medication Administration using the E-MAR, dated 2/23/17, documented the Nurse is responsible to read the order and compare the order to the blisterpack and report any discrepancies. Resident #34 has diagnoses including Osteoporosis, Schizophrenia, and Dementia. The 12/13/19 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 2, indicating the resident had severe cognitive impairment. A Physician's Order dated 2/7/20 ordered Miacalcin (Calcitonin) Nasal Solution 200 unit, one spray into nostril every two days at 9:00 AM (Left Nostril) for diagnosis of Osteoporosis. A Physician's Order dated 2/7/20 ordered Miacalcin (Calcitonin) Nasal Solution 200 unit, one spray into nostril every two days at 9:00 AM (Right Nostril) for diagnosis of Osteoporosis. A Comprehensive Care Plan (CCP) effective 4/5/14 and last updated 12/13/19 titled Osteoporosis had an intervention to administer medications as ordered and to monitor response. On 3/1/20 at 9:15 AM during the medication administration pass observation, for Resident #34, the LPN Medication Nurse administered two sprays of the Miacalcin Nasal Spray to each of the resident's nostrils. The LPN Medication Nurse was interviewed on 3/1/20 at 12:41 PM. The LPN stated he sprayed the medication into both of Resident #34's nostrils. The LPN reviewed the Medication Administration Record (MAR) and stated he was not sure why the documentation entry alternates from day to day. The LPN reviewed the pharmacy label on the spray. The label documented one spray nasal every two days and one spray nasal every two days dated 2/16/20. The Registered Nurse (RN) Unit Supervisor was interviewed on 3/1/20 at 12:48 PM and stated she reviewed the physician's order and the order clearly stated the spray should be administered to the right nostril and left nostril on alternating days. The RN stated the pharmacy label on the spray needed to be clarified. A Pharmacist from the facility's Pharmacy was interviewed on 3/5/20 at 9:31 AM and stated the label documentation of one spray nasal every two days and one spray nasal every two days was how the order was originally provided on 1/29/2018. The Pharmacist stated that pharmacy does not have a differentiation between the right and left nostril and that the facility had to provide clarification. The Director of Nursing Services (DNS) was interviewed on 3/5/20 at 10:02 AM and stated she would call the Pharmacy to clarify the label because the physician's order was accurate. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the Recertification Survey, the facility did ensure that each resident's total program of care, including medications and treatments was reviewed at each visit. This was identified for two (Resident #61 and Resident #135) of four residents reviewed for Nutrition. Specifically, 1) Resident #61 had a 7.2% significant weight loss over a one week hospitalization and 2) Resident #135 had a 5.4% significant weight loss in a one month time period which was not addressed by the Attending Physician. There was no Physician's evaluation when a change in the resident's nutritional status was identified to address the medical and nutritional issues related to the significant weight loss. The findings are: The Significant Weight Changes and Charting Weight Changes policy, dated 1/4/19, documented that if a resident has had a significant weight change, the chart will be updated and appropriate measures will be taken. The Registered Dietitian will complete a significant weight change form and a copy will be sent to the Director of Nursing Services (DNS), Minimum Data Set (MDS) Coordinator, and Attending (Primary) Physician. 1) Resident #61 has diagnoses which include Parkinson's Disease and Hypertension. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident was rarely/never understood and could sometimes understand. The MDS also documented that the resident had severely impaired cognitive skills for daily decision making with both long and short term memory problems. Review of the resident's Admission/Discharge/Transfer (ADT) in the Electronic Medical Record (EMR) revealed the resident was hospitalized from [DATE] to 12/12/19. Review of the resident's weight history revealed: 11/5/19 weight of 116.7 lbs (pounds) 11/11/19 weight of 117.0 lbs 11/20/19 weight of 117.9 lbs 11/27/19 weight of 118.9 lbs 12/5/19 weight of 118.7 lb 12/13/19 weight of 110.1 lbs (reflecting a significant weight loss of 7.2% over hospitalization) 12/19/19 weight of 110.6 lbs 12/27/19 weight of 110.9 lbs Review of the Physician Progress Notes revealed the resident was seen by the Primary Physician on 12/13/19 (readmission Assessment), 12/20/19, 12/27/19, 1/6/2020 (Monthly), 1/10/2020, 1/13/2020, and 1/24/2020. None of these notes addressed the resident's significant weight loss. The resident's Primary Physician/Medical Director was interviewed on 3/6/2020 at 11:45 AM and stated he usually does not address a resident's weight loss over a hospitalization because he does not know what happened to them while they were in the hospital. The Primary Physician also stated that the Registered Dietitian (RD) usually alerts him of any significant weight losses or gains with a special form that is sent to the Physicians. The Primary Physician stated that when he receives the form, he documents the weight change. The Primary Physician stated that if there was no note written, then he did not receive a form. The RD was interviewed on 3/6/2020 at 12:15 PM and stated that the Significant Weight Change Evaluation Form is a communication tool she uses, a way to alert the Physician of a significant weight change, gain or loss, seen in a resident. The RD stated that she did not fill out a form in December when the resident returned from the hospital with a significant weight loss. The RD stated that she normally would do this, but did not know why she had not. The DNS was interviewed on 3/6/2020 at 12:45 PM and stated the Significant Weight Change Evaluation Form was instituted to make the doctors aware of significant weight changes in the facility so the doctors could address them. 2) Resident #135 has diagnoses which include Hypertension and Glaucoma. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident was sometimes understood and could sometimes understand. The resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severely impaired cognitive skills for daily decision making. Review of the resident's weight history revealed: 10/5/19 weight of 113.4 lbs (pounds) 10/14/19 weight of 113.2 lbs 10/19/19 weight of 113.3 lbs 10/27/19 weight of 109.8 lbs 11/5/19 weight of 107.5 lb 11/11/19 weight of 107.1 lbs (reflecting a significant weight loss of 5.4% over one month) 11/20/19 weight of 106.7 lbs 11/27/19 weight of 107.0 lbs Review of the Physician Progress Notes revealed that the resident was seen by the Primary Physician on 11/1/19, 11/4/19 (Monthly), and 12/2/19 (Monthly). None of these notes addressed the resident's significant weight loss. The Primary Physician/Medical Director was interviewed on 3/6/2020 at 1:15 PM and stated if the Registered Dietitian (RD) documented a significant weight loss, she should automatically fill out a Significant Weight Change Evaluation Form. The RD was interviewed on 3/6/2020 at 1:25 PM and stated that she must have forgotten to fill out the Significant Weight Change Evaluation Form. The Director of Nursing Services (DNS) was interviewed on 3/6/2020 at 1:35 PM and stated she did not know why the RD did not fill out a Significant Weight Change Evaluation Form, but she should have. 415.15(b)(2)(ii)