**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 10/28/2024 and completed on 11/4/2024 the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. This was identified for two (Resident #92 and Resident #87) of four residents reviewed for Dignity. Specifically, on 10/28/2024, Resident #92 and Resident #87, who resided in the same room, were observed in bed with multiple layers of linen, cloth chucks (pads used to protect the bed linen), and plastic liners. Additionally, both residents were wearing multiple briefs that were saturated with urine and the room had a strong urine odor. The findings are: The facility's policy and procedure for Resident Rights reviewed 1/2024 documented the facility to ensure all residents are afforded their right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration, privacy in treatment and care for personal needs, and access to person and services inside and outside the facility. 1) Resident #92 was admitted to the facility with diagnoses that included Cerebrovascular Accident, Morbid Obesity, and Mood Disorder. The Annual Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 15, which indicated the resident had intact cognition. The resident required maximal assistance from staff for toileting, personal hygiene, lower body dressing, and transfers. The resident was always incontinent of bladder and bowel. The Resident Nursing Instructions dated 4/12/2024 documented the resident required extensive assistance for toileting, personal hygiene, and incontinent care was to be performed every two hours and as needed. The Comprehensive Care Plan for Activities of Daily Living dated 4/30/2024 and reviewed on 10/25/2024 documented to provide dressing, toileting, personal hygiene, and grooming as per the Certified Nursing Assistant Accountability Instructions. During an initial tour conducted on 10/28/2024 at 10:40 AM Resident #92 was observed in their room lying in bed. The room had a strong urine odor. The resident stated they had not seen their assigned Certified Nursing Assistant #9 since after breakfast. The resident stated they would like to be changed, dressed, and transferred out of bed. During an observation of care conducted on 10/28/2024 at 12:50 PM, Resident #92 was observed wearing three briefs. The briefs were saturated with urine and there was a strong urine odor in the resident's room. The resident's clothes, bed linen, and draw sheets were saturated with urine. After the completion of care, Resident #92 was transferred into a wheelchair. Certified Nursing Assistant #9 then removed the following items that the resident was lying on, from the resident's bed: two sets of draw sheets with a translucent sheet of plastic under each draw sheet, a blue chuck which was lying on top of two blankets and four additional blue chucks were observed under the blanket on top of the fitted sheet. 2) Resident #87 was admitted with diagnoses that included Dementia, Depression, and Hypertension. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 0, which indicated the resident had severely impaired cognition. The resident required supervision or touch assistance for toileting, and personal hygiene. The resident was always incontinent of bladder and was frequently incontinent of bowel. During an initial tour conducted on 10/2/24 at 10:51 AM, Resident #87 was observed in their room lying in bed. The resident responded appropriately to greetings. Resident #92, the roommate, stated Resident #87 was also waiting for care. During observation of care conducted on 10/28/2024 at 1:55 PM, Resident #87 was observed wearing two briefs. The brief closest to the resident's skin was observed to be yellow and saturated with urine. There was a strong urine odor in the room. The resident's bed was made with two sets of draw sheets and a blue chuck was placed under each draw sheet. A Comprehensive Care Plan for Incontinence dated 4/18/2024 and updated on 10/16/2024 documented to assist the resident with toileting, to keep the resident clean and dry, and to toilet on a regular schedule. The Resident Nursing Instructions dated 4/12/2024 documented the resident required one-person physical assistance for toileting and personal hygiene, and to toilet the resident every two to three hours and as needed. During an interview on 10/28/24 at 12:40 PM, Certified Nursing Assistant #9 stated they were not regularly assigned to Resident #92 and Resident #87; however, today they were assigned to both residents. Certified Nursing Assistant #9 stated they had not yet performed morning care for both residents. Certified Nursing Assistant #9 stated they were busy caring for the other residents on their assignment and Resident #92 and Resident #87 were the last residents on their assignment to receive the morning care. During an interview on 10/30/24 at 11:28 AM, Registered Nurse #1 stated the morning care should be completed by no later than 11:30 AM. Registered Nurse #1 stated they were not aware that the staff was putting multiple briefs on the residents and padding the residents' beds with plastic and multiple layers of linens and chucks. Registered Nurse #1 stated the resident's bed should have a fitted sheet, a single draw sheet, and a chuck. Registered Nurse #1 stated at no time should the residents be wearing multiple diapers. Registered Nurse #1 stated if a resident was a heavy wetter that the staff should change the resident more frequently. During an interview on 10/30/2024 at 1:54 PM, the Director of Nursing Services stated they expect all the residents to receive their morning care by 11:00 AM. The nurses on the unit should be monitoring the Certified Nursing Assistants to ensure their assignments are completed. The Director of Nursing Services stated that the resident's bed should not have multiple layers of linens. The Director of Nursing Services stated there should be only one fitted sheet, a draw sheet, and a chuck on the resident's bed. The Director of Nursing Services stated at no time should the residents be wearing multiple briefs. During an additional interview on 11/4/2024 at 12:25 PM, Certified Nursing Assistant #9 stated they started their shift at 7:00 AM and went to Resident #92 and Resident #87's room to deliver breakfast. They did not check residents' briefs or the bed linen until 12:50 PM. Certified Nursing Assistant #9 stated they were on their way to provide care for Resident #92 and Resident #87 when they were asked by Registered Nurse #1 to monitor the dining room. Certified Nursing Assistant #9 stated they did not place the plastic, multiple linens, and chucks on the bed. Certified Nursing Assistant #9 further stated they did not place multiple briefs on the resident. During an interview on 11/4/2024 at 2:45 PM, the 11:00 PM-7:00 AM Certified Nursing Assistant #10 stated they changed Resident #92's brief at approximately 5:30 AM and before they ended their shift they checked and both residents were clean and dry. Certified Nursing Assistant #10 stated Resident #92 always asks for two briefs and gets upset if the staff does not provide them with two briefs. Certified Nursing Assistant #10 stated that they did put muliple briefs on the residents. 10 NYCRR 415.3(d)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during the Recertification Survey and Abbreviated Survey (NY 00332218) initiated on 10/28/2024 and completed on 11/4/2024, the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality This was identified for one (Resident #14) of two residents reviewed for Choices. Specifically, on 1/16/2024 the Physician ordered Diclofenac 0.1% (nonsteroidal anti-inflammatory) eye drops for 14 days Resident #14. The Diclofenac eye drops were not delivered by the pharmacy and were not available for administration until 1/24/2024; however, the nursing staff documented that the eye drops were administered to Resident #14 on 11 occasions between 1/16/2024 and 1/23/2024. The finding is: The facility's policy for Medication Administration and Documentation, last reviewed in April 2024 documented to ensure medication administration and documentation occurs in an accurate and timely manner. [Licensed nurses] should immediately notify the nursing supervisor if medication is unavailable for administration and ensure medication is delivered on the next delivery or when available. Notify the Physician if necessary and document missed doses. Document all held or refused medications on the Electronic Medication Administration Record and use prudent judgment by informing the Physician in a timely manner when medications are held, refused, or otherwise unavailable for administration. Resident #14 was admitted with diagnoses that included Dry Eye Syndrome, Obesity, and Hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The resident had adequate vision with the use of corrective lenses. The Visual Function Comprehensive Care Plan dated 9/21/2021 last revised 9/20/2024 documented that the resident had Cataracts. Interventions included but were not limited to encouraging daily use of eyeglasses and monitor changes in visual functioning. A medical progress note dated 1/12/2024, written by Physician #2, documented Resident #14 had right eye Cataract surgery on 12/18/2023. On 1/10/2024, the resident was transferred to the emergency room STAT (immediately) for Ophthalmology evaluation after Resident #14 complained of right eye pain. Resident #14 was diagnosed with bacterial conjunctivitis in the Emergency Room. Physician #2 documented Resident #14 was seen status post right eye pain and was observed with mild redness in the right eye. The resident denied loss of vision. Physician #2 recommended a follow-up visit with Resident #14's Ophthalmologist. A Nursing Progress note dated 1/16/2024, written by Registered Nurse #11, documented Resident #14 returned from an ophthalmology visit with a recommendation to start Diclofenac 0.1% eye drop, one drop to the right eye for 14 days. A physician's order dated 1/16/2024 documented to administer Diclofenac 0.1% eye drops, instill one drop by ophthalmic (eye) route in the right eye 4 times per day for 14 days for Visual Discomfort in the Right Eye. A Pharmacy Clarification Request Form dated 1/17/2024 documented clarification is needed for Diclofenac 0.1% eye drop due to Resident #14's prior reaction to Aspirin. If the medication is new to the resident, the facility has to clarify allergies with the Physician and inform the pharmacy whether to discontinue the order or to dispense the medication. A Pharmacy packing delivery slip dated 1/24/2024 documented the Pharmacy delivered Resident #14's Diclofenac 0.1% solution on 1/24/2024 at 4:45 AM. During an interview on 11/01/2024 at 10:35 AM, Licensed Pharmacist #1 stated the pharmacy received an order for Diclofenac 0.1% eye drop for Resident #14 on 1/16/2024. Licensed Pharmacist #1 stated that the pharmacy did not dispense the eye drop until 1/23/2024 because clarification was needed for a possible allergic reaction to the eye drop due to the resident's documented allergy to Aspirin. A Review of Resident #14's Medication Administration Record dated January 2024 documented Diclofenac 0.1% one drop by ophthalmic (eye) route in the right eye 4 times a day for 14 days for visual discomfort in the right eye. The Medication Administration Record documented that on 11 occasions between 1/16/2024 and 1/23/2024, Diclofenac 0.1% eye drops were administered to Resident #14's right eye; and on 16 occasions between 1/16/2024 and 1/23/2024, the Medication Administration Record indicated that the eye drops were not administered to the resident due to unavailability of the medication. During an interview on 11/01/2024 at 2:10 PM, Licensed Practical Nurse #3, who documented administering Resident #14's Diclofenac 0.1% eye drops on 1/16/2024, stated they no longer worked at the facility and did not recall Resident #14. Licensed Practical Nurse #3 stated if a physician ordered medication was missing, they would have notified their supervisor and would not sign for what they did not administer. An interview with Registered Nurse #10, who documented administering Resident #14's Diclofenac eye drops on 1/18/2024, was attempted on 11/01/2024 at 10:01 AM and again at 11:04 AM. Registered Nurse #10 was unavailable for the interview. An interview with Licensed Practical Nurse #9, who documented administering Resident #14's Diclofenac eye drop on 1/19/2024 and 1/21/2024, was attempted on 11/01/2024 at 10:00 AM and again at 10:59 AM. Licensed Practical Nurse #9 was unavailable for an interview. During an interview on 11/01/2024 at 1:52 PM, the Medical Director stated nurses should notify their supervisor or the Physician if they noticed the physician-ordered medication was missing. The Medical Director further stated it was not acceptable to document medication was administered, when in fact the medication was not delivered by the Pharmacy and was not available for administration. During an interview on 11/04/2024 at 1:25 PM, the Director of Nursing Services stated that the medication nurses who had worked when Resident #14's Diclofenac 0.1% eye drop was unavailable should have reported and notified the Physician. The Director of Nursing Services stated that nurses cannot sign for medications that they did not administer. 10 NYCRR 415.11(c)(3)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview during the Recertification Survey initiated on 10/28/2024 and completed on 11/4/2024 the facility did not ensure that residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming and personal hygiene. This was identified for two (Resident #92 and Resident #87) of three residents reviewed for activities of daily living. Specifically, 1) Resident #92 required staff assistance with activities of daily living care. During an observation on 10/28/2024, the resident did not receive their morning care until 12:50 PM. The resident stated they were wet and had not received care since the 11:00 PM-7:00 AM shift. 2) Resident #87 required staff assistance for the activity of daily living care. During an observation on 10/28/2024, the resident did not receive their morning care until 1:55 PM. The resident's brief was saturated with urine and the room had a strong urine odor. The findings are: The facility Activities of Daily Living (ADL) policy and procedure reviewed 2/2024 documented Activities of Daily Living care and support will be provided for residents who are unable to carry out Activities of Daily Living independently, with the consent of the resident ad in accordance with the resident's assessed needs, personal preferences, and individualized plan of care, that includes but not limited to supervision and assistance with hygiene (bathing, dressing, grooming) and elimination (toileting, incontinent care). 1) Resident #92 was admitted to the facility with diagnoses that included Cerebrovascular Accident, Morbid Obesity, and Mood Disorder. The Annual Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 15, which indicated the resident had intact cognition. The resident required maximal assistance from staff for toileting, personal hygiene, lower body dressing, and transfers. The resident was always incontinent of bladder and bowel. The Resident Nursing Instructions dated 4/12/2024 documented the resident required extensive assistance for toileting, personal hygiene, and incontinent care was to be performed every two hours and as needed. The Comprehensive Care Plan for Activities of Daily Living dated 4/30/2024 and reviewed on 10/25/2024 documented to provide dressing, toileting, personal hygiene, and grooming as per the Certified Nursing Assistant Accountability Instructions. During an initial tour conducted on 10/28/2024 at 10:40 AM Resident #92 was observed in their room lying in bed. The room had a strong urine odor. The resident stated they had not seen their assigned Certified Nursing Assistant #9 since after breakfast. The resident stated they would like to be changed, dressed, and transferred out of bed. During an observation of care conducted on 10/28/2024 at 12:50 PM, Resident #92 was observed wearing three briefs. The briefs were saturated with urine and there was a strong urine odor in the resident's room. The resident's clothes, bed linen, and draw sheets were saturated with urine. After the completion of care, Resident #92 was transferred into a wheelchair. Certified Nursing Assistant #9 then removed the following items that the resident was lying on, from the resident's bed: two sets of draw sheets with a translucent sheet of plastic under each draw sheet, a blue chuck which was lying on top of two blankets and four additional blue chucks were observed under the blanket on top of the fitted sheet. 2) Resident #87 was admitted with diagnoses that included Dementia, Depression, and Hypertension. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 0, which indicated the resident had severely impaired cognition. The resident required supervision or touch assistance for toileting, and personal hygiene. The resident was always incontinent of bladder and was frequently incontinent of bowel. During an initial tour conducted on 10/2/24 at 10:51 AM, Resident #87 was observed in their room lying in bed. The resident responded appropriately to greetings. Resident #92, the roommate, stated Resident #87 was also waiting for care. During observation of care conducted on 10/28/2024 at 1:55 PM, Resident #87 was observed wearing two briefs. The brief closest to the resident's skin was observed to be yellow and saturated with urine. There was a strong urine odor in the room. The resident's bed was made with two sets of draw sheets and a blue chuck was placed under each draw sheet. A Comprehensive Care Plan for Incontinence dated 4/18/2024 and updated on 10/16/2024 documented to assist the resident with toileting, to keep the resident clean and dry, and to toilet on a regular schedule. The Resident Nursing Instructions dated 4/12/2024 documented the resident required one-person physical assistance for toileting and personal hygiene, and to toilet the resident every two to three hours and as needed. During an interview on 10/28/24 at 12:40 PM, Certified Nursing Assistant #9 stated they were not regularly assigned to Resident #92 and Resident #87; however, today they were assigned to both residents. Certified Nursing Assistant #9 stated they had not yet performed morning care for both residents. Certified Nursing Assistant #9 stated they were busy caring for the other residents on their assignment and Resident #92 and Resident #87 were the last residents on their assignment to receive the morning care. During an interview on 10/30/24 at 11:28 AM, Registered Nurse #1 stated the morning care should be completed by no later than 11:30 AM. Registered Nurse #1 stated they were not aware that the staff was putting multiple briefs on the residents and padding the residents' beds with plastic and multiple layers of linens and chucks. Registered Nurse #1 stated the resident's bed should have a fitted sheet, a single draw sheet, and a chuck. Registered Nurse #1 stated at no time should the residents be wearing multiple diapers. Registered Nurse #1 stated if a resident was a heavy wetter that the staff should change the resident more frequently. During an interview on 10/30/2024 at 1:54 PM, the Director of Nursing Services stated when a Certified Nursing Assistant floats to a unit, the charge nurse is responsible for updating the Certified Nursing Assistants with any episodic medical concern, however, the specifics regarding the resident's care should be communicated by the Certified Nursing Assistants on the unit. The Director of Nursing Services stated they expect all the residents to receive their morning care by 11:00 AM. The nurses on the unit should be monitoring the Certified Nursing Assistants to ensure their assignments were completed. The Director of Nursing Services stated that the resident's bed should not have multiple layers of linens The Director of Nursing Services stated there should be only one fitted sheet, a draw sheet, and a chuck on the resident's bed. The Director of Nursing Services stated at no time should the residents be wearing multiple briefs and if the resident was a heavy wetter, then the staff should change the resident more frequently. During an additional interview on 11/4/2024 at 12:25 PM, Certified Nursing Assistant #9 stated they started their shift at 7:00 AM and went to Resident #92 and Resident #87's room to deliver breakfast. They did not check residents' briefs or the bed linen until 12:50 PM. Certified Nursing Assistant #9 stated they were on their way to provide care for Resident #92 and Resident #87 when they were asked by Registered Nurse #1 to monitor the dining room. Certified Nursing Assistant #9 stated they did not place the plastic, multiple linens, and chucks on the bed. Certified Nursing Assistant #9 further stated they did not place multiple briefs on the resident. During an interview on 11/4/2024 at 2:45 PM, the 11:00 PM-7:00 AM Certified Nursing Assistant #10 stated they changed Resident #92's brief at approximately 5:30 AM and before they ended their shift they checked and both residents were clean and dry. Certified Nursing Assistant #10 stated Resident #92 always asks for two briefs and gets upset if the staff does not provide them with two briefs. Certified Nursing Assistant #10 stated that they did put multiple briefs on the residents. 10 NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Extended Survey (NY 00331717), initiated on 10/28/2024 and completed on 11/4/2024, the facility did not ensure 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 #156 and Resident #48) of four residents reviewed for Pressure Ulcers. Specifically, 1) Resident #156 entered the facility on 7/10/2024 with unstageable (the depth and stage of the wound cannot be determined until dead tissue is cleared away or removed and the base of the pressure injury is visible) pressure ulcers to their right and left heels; however, there was no documented evidence of treatment administration to the wound sites until 7/23/2024; and 2) wound care treatments for Resident #48's sacrum and buttock pressure ulcers were not administered as ordered by the Physician. The finding is: The facility's policy titled Pressure Ulcer Prevention and Wound Management, dated 12/2024, documented it is the policy of the facility to ensure that residents who have pressure ulcers receive the necessary treatments and services to promote the prevention of pressure ulcer decline, promote the healing of pressure ulcers, and prevent the development of additional pressure ulcers. The admitting licensed nurse will complete a comprehensive assessment of the resident, including total body and skin check on all admissions and readmissions, and record findings in the nursing admission documentation. Residents who are admitted or readmitted with pressure injuries will have appropriate treatment devices and wound orders obtained and implemented. 1) Resident #156 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Peripheral Vascular Disease, and Depression. The 7/14/2024 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented that the resident had one Stage 4 pressure ulcer and two unstageable pressure ulcers. A review of the hospital discharge instructions dated 7/10/2024 documented that the resident had deep tissue injury to the sacrum/buttocks, bilateral lower extremity weeping edema (a condition where swelling becomes so severe that fluid leaks out of the skin), and unstageable pressure ulcers to bilateral heels. A review of the Nursing admission Assessment, completed by Registered Nurse #7, dated 7/10/2024 documented the resident had a pressure ulcer to the lower back area/buttock area and wounds to the bilateral front of the lower leg areas. No wounds or pressure ulcers were identified on the heels. The nursing admission progress note, written by Registered Nurse #7, dated 7/10/2024 documented the resident had wounds to the sacrum, right buttock, and bilateral lower extremities. The admission physician's orders did not include treatment orders for the heel wounds. A review of the July 2024 Treatment Administration Record revealed no documentation of treatment administration to the bilateral heel wounds until 7/23/2024. A nursing progress note dated 7/17/2024, written by Registered Nurse #6 (wound care nurse), documented skin assessment was attempted on 7/13/2024 for readmission assessment. The resident refused the assessment and complained of too many people assessing and repositioning the resident. The writer was able to visualize scattered openings to the lower extremities and swelling on bilateral feet. A review of the resident's medical record revealed no progress note written by Registered Nurse #6 on 7/13/2024. A medical progress note, written by a Podiatrist, dated 7/17/2024 documented the resident had a chronic right heel Stage 3 pressure ulcer measuring 5.0 centimeters in length, 5.0 centimeters in width, and 0.2 centimeters in depth with 80 % slough (dead tissue) and 20% granulation tissue; and chronic left heel Stage 3 pressure ulcer measuring 3.0 centimeters in length, 1.5 centimeters in depth and 0.2 centimeters in depth with 50 % slough and 50% granulation tissue. The treatment recommendations for both heels were to clean the wounds with Dakin's solution (a topical antiseptic that is used to treat and prevent infections in wounds), apply primary dressing, and cover with gauze. The care plan was discussed with the bedside staff, nurse, and wound care team. Physician orders dated 7/23/2024 for the right and left heel wounds, entered by Registered Nurse #6 (wound care nurse), documented cleanse with Dakin's solution and cover with Dakin's gauze followed by dry sterile dressing every day. A review of the July 2024 Treatment Administration Record revealed the treatments to the right and left heels were started on 7/23/2024. Comprehensive Care Plans effective 8/3/2024, titled Stage 3 right heel and Stage 3 left heel wounds, documented Resident #156 was seen by the Podiatrist on 7/17/2024 who recommended washing the wound with Dakin's solution. The Primary care physician agreed with the recommendations. During an interview on 10/31/2024 at 8:34 AM, Registered Nurse #6 (wound care) reviewed the nursing admission assessment and acknowledged the heel wounds for Resident #156 were not identified in the initial admission assessment. Registered Nurse #6 stated wound treatments should be started upon admission or when a wound is identified. Registered Nurse #6 stated they assess each newly admitted or readmitted resident's wounds on the following day after the admission; however they were not working on 7/11/2024 or 7/12/2024, therefore, they first saw Resident #156 on 7/13/2024 and the resident refused the assessment. Registered Nurse #6 did not know why no treatment orders were in place for the heel wounds until 7/23/2024. Multiple phone calls were made to interview Registered Nurse #7, the admission nurse, and messages were left to no avail. During an interview on 10/31/2024 at 11:39 AM, the Director of Nursing Services and Registered Nurse #6 stated that on 7/17/2024 during the Podiatrist's visit, the Podiatrist decided that the wound care would not be started that day because the resident was refusing care. On a subsequent visit by the Podiatrist on 7/21/2024, a decision was made by the podiatrist to start the wound care on 7/23/2024. A review of the Podiatrist and nursing notes dated 7/17/2024 and 7/21/2024 revealed no documentation related to postponing the recommended wound treatments. During an interview on 11/1/2024 at 1:28 PM, Physician #1 (the resident's Primary Care Physician and the Medical Director) stated they are usually notified of consultant recommendations by the nursing staff. Physician #1 stated they would never give orders to postpone a wound treatment. If there was a conversation with the Podiatrist about postponing pressure ulcer treatments, then the conversation should be documented in the resident's medical record and they expected to be notified. During an interview on 11/4/2024 at 1:40 PM, the Director of Nursing Services stated the admission nurse is expected to make sure wound orders are in place when wounds are identified upon admission and until the wound practitioner evaluates the wounds, treatment orders from the hospital should be followed or interim orders should be obtained. 2) Resident #48 was admitted with diagnoses including Paraplegia, Cancer, and Depression. The 9/2/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident had three Stage 4 (involves full-thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcers. Comprehensive Care Plans titled Left Buttock Stage 4, Right Buttock Stage 4, and Sacrum Stage 4 (pressure ulcers), all initiated on 11/27/2023 and last updated on 10/1/2024 documented that the resident had frequent behavior of refusing assessments by the wound Physician; however, there was no documented evidence that the resident refused actual treatment by the nursing staff. A review of the January 2024 Treatment Administration Records (based on the complaint NY 00331717 allegations) revealed the sacral, right buttock, and left buttock pressure ulcer treatments were not performed on 1/12/2024 and 1/14/2024. The treatments were scheduled for the 11:00 PM-7:00 AM shift. The documentation in the Treatment Administration Record documented that on 1/12/2024 the resident was sleeping and therefore the treatments were not performed. There was no documentation as to why the treatment was not done for 1/14/2024 A review of the September 2024 Treatment Administration Records (based on the complaint NY 00331717 allegations) revealed on 9/28/2024 and 9/30/2024 the sacral, right buttock, and left buttock pressure ulcer treatments were not performed. The treatments were scheduled for the 11:00 PM-7:00 AM shift. There was no documentation as to why the treatment was not administered on 9/28/2024. The Treatment Administration Record documented that on 9/30/2024 the resident refused the treatments. During an interview on 10/29/2024 at 11:14 AM, Registered Nurse #4 stated they worked on 1/12/2024 as the night shift supervisor and as the medication and treatment nurse on Resident #48's unit. Registered Nurse #4 stated the treatment was not provided to the resident on 1/12/2024 because the resident was asleep and they should write a progress note and let the next shift know that the treatment was not provided. Registered Nurse #4 stated when covering a unit and also covering the building as a shift Supervisor, sometimes they are called away to deal with emergencies and are not able to administer medications or do the treatments on the unit. A review of the medical record revealed no progress notes written by Registered Nurse #4 on 1/12/2024 related to wound treatment administration. During an interview on 10/29/2024 at 12:04 PM, Registered Nurse #3 (the Assistant Director of Nursing and the Risk Manager) stated they were assigned to Resident #48's unit as a nurse on 9/28/2024 and were responsible for administering medications and treatments because there were no other nurses to cover the unit. Registered Nurse #3 stated they probably forgot to sign for Resident #48's treatment administration and that lack of documentation meant the treatment was not done. During an interview on 10/29/2024 at 12:14 PM, Registered Nurse #5 (overnight supervisor who was also the assigned nurse to Resident #48's unit on 1/14/2024 and did not document on the treatment record that the treatments were completed) stated as a Supervisor, they usually have to cover a unit, it is impossible to be the supervisor and a floor nurse and do the regularly scheduled treatments on the unit. During an interview on 10/29/2024 at 12:29 PM, Registered Nurse #2 stated they were the assigned shift Supervisor on 9/30/2024 and had to cover Resident #48's unit to provide treatments and medication administration. Registered Nurse #2 stated they only worked at the facility for a week and did not recall doing wound care for Resident #48. Registered Nurse #2 stated they were very much behind in their work and did not think they completed their assigned work. During an interview on 10/31/2024 at 11:00 AM, Resident #48 stated they never refuse their wound care. The only thing they refuse is the assessment from the wound Doctor because the wound Doctor takes off the wound dressing that was already done and does not re-apply the dressing, just leaves, and the resident has to wait for a nurse to do the wound care. Resident #48 stated they prefer wound care treatments be completed on the 11:00 PM-7:00 AM shift because they do not want to wait for wound care during the day. During an interview on 11/4/2024 at 11:05 AM, the Administrator stated the Registered Nurse Supervisor is used as a last resort to cover a unit due to last-minute call-outs. The Registered Nurse Supervisor is instructed if there is an emergency, they attend to that and then go back to the regular duties for the unit. 10 NYCRR 415.12(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 10/28/2024 and completed on 11/4/2024, the facility did not ensure that each resident maintained, to the extent possible, acceptable parameters of nutritional, and hydration status. This was identified for one (Resident #102) of one resident reviewed Dialysis. Specifically, Resident #102 had a physician's order for fluid restriction of 1200 milliliters per day. Resident #102's meal tickets and Electronic Medication Administration Record (EMAR) indicated the resident was receiving fluids that were exceeding the physician-ordered daily amount. The finding is: The facility's policy titled, Fluid Restrictions dated 3/2024, documented the facility provides fluid restrictions for residents placed on such restrictions per the discretion of the Physician. The unit dietitian will be responsible for initiating the physician's order for fluid restriction into the facility's computer system and will work with nursing to determine the amount of fluids that will be provided for the medication pass. The Dietitian, Nurse, and Physician will monitor the resident's status and make recommendations for changes in the fluid restriction as appropriate. Resident #102 was admitted with diagnoses including End Stage Renal Failure, Congestive Heart Failure, and Dependence on Renal Dialysis. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #102 had intact cognition. The Quarterly Minimum Data Set (MDS) assessment documented that Resident #102 was on a therapeutic diet (defined as a meal plan that controls the intake of certain food or nutrients) and received Dialysis. A Comprehensive Care Plan (CCP) titled Nutritional Status dated 10/9/2024 documented interventions that included small frequent snacks between meals, restricted fluid intake to 1200 milliliters per day, and provided supplements as ordered only one can per day. A physician's order dated 10/13/2024 and renewed on 10/29/2024 documented Fluid Restrictions of 1200 milliliters per day: fluids with medication administration of 420 milliliters (180 milliliters for the 7:00 AM-3:00 PM shift, 120 milliliters for the 3:00 PM-11:00 PM shift, and 120 milliliters for the 11:00 AM-7:00 PM shift); fluids with the meals 540 milliliters (300 milliliters for breakfast, 120 milliliters for lunch and 120 milliliters for dinner) and Nepro supplement: 240 milliliters daily. A review of the Electronic Medication Administration Record (EMAR) for October 2024 revealed the following; -On 10/18/2024 the resident received 240 milliliters of fluids on the 7:00 AM-3:00 PM shift and 240 milliliters of fluids on the 3:00 PM-11:00 PM shift for medication administration. The 11:00 PM-7:00 AM shift had no fluid amount documented as administered. The total amount of fluids administered on 10/18/2024 was 480 milliliters which was 60 milliliters more than the Physician's Ordered fluid amount during the medication pass. -On 10/24/2024 the resident received 240 milliliters of fluids on the 7:00 AM-3:00 PM shift, 1200 milliliters on the 3:00 PM-11:00 PM shift, and 100 milliliters 11:00 PM-7:00 AM shift for medication administration. The total amount of fluids given for the medication administration on 10/24/2024 was 1540 milliliters which was 1120 milliliters more than the Physician's Ordered fluid amount during the medication pass. Resident #102 was observed on 10/30/2024 at 8:17 AM. Resident #102 was sitting in their wheelchair and eating their breakfast in their room. Resident #102's breakfast tray had two 120 milliliters of cranberry juice boxes and 180 milliliters of hot water in a cup. Resident #102's meal tickets for breakfast were reviewed for 10/30/2024 and 11/1/2024 which included two, 120 milliliters of cranberry juice and one 180 milliliters of hot water in a paper cup. Resident #102's fluid intake for breakfast was 420 milliliters (the resident was supposed to consume 300 millimeters of fluid during breakfast as per the physician's orders). Resident #102's fluid intake exceeded the fluid restrictions by 120 milliliters for breakfast. The Certified Nursing Assistant Accountability Sheet was reviewed on 10/30/2024 and indicated that the resident consumed 100 percent of their fluids during the breakfast meal. The Certified Nursing Assistant Accountability Sheet for fluid intake for breakfast was reviewed on 11/1/2024 and indicated that the resident consumed 100 percent of their fluids during the breakfast meal. Resident #102's meal tickets for lunch were reviewed for 10/30/2024 and 11/1/2024 which included 120 milliliters of cranberry juice and 180 milliliters of hot water in a paper cup. Resident #102's fluid intake for lunch was a total of 300 milliliters (the resident was supposed to consume 120 millimeters of fluid during the lunch meal as per the physician's orders). Resident #102's fluid intake exceeded the fluid restrictions for lunch by 180 milliliters. The Certified Nursing Assistant did not document the fluid intake for Resident #102 on 10/30/2024 and on 11/1/2024 for the lunch meal. Resident #102's meal tickets for dinner were reviewed for 10/30/2024 and 11/1/2024 which included 120 milliliters of cranberry juice. Resident #102's fluid intake for dinner was a total of 120 milliliters. The Certified Nursing Assistant Accountability Sheet for fluid Intake for dinner was reviewed on 10/30/24 and Certified Nursing Assistants documented that Resident #102 consumed 75 percent of their fluids. The Certified Nursing Assistant Accountability Sheet for fluid Intake for dinner was reviewed on 11/1/2024 and Certified Nursing Assistants documented that Resident #102 consumed 50 percent of their fluids. A review of the Electronic Medication Administration Record (EMAR) revealed that on 11/2/2024 on the 7:00 AM-3:00 PM shift the resident received 100 milliliters of fluids; on the 3:00 PM-11:00 PM shift the resident received 240 milliliters of fluids; and on the 11:00 PM-7:00 PM shift the resident received 120 milliliters of fluids. The resident received a total of 460 milliliters of fluids on 11/2/2024 during the medication administration which was 40 milliliters more than ordered by the Physician. During an interview on 10/31/2024 at 10:45 AM, Certified Nursing Assistant #1 stated during breakfast Resident #102 had two boxes of cranberry juice. Certified Nursing Assistant #1 stated they documented the fluid consumption in percentage and not in the milliliter amount. Certified Nursing Assistant #1 stated they knew that the resident was on fluid restriction and the resident drank the fluids offered to them on the meal tray. During an interview on 11/1/2024 at 2:26 PM, the Food Service Director stated the Dietitian was responsible for all the resident's diets. The Food Service Director stated they were aware of the fluid restrictions for Resident #102, but they did not adjust the amount of fluids on the resident's meal tray as per the Physician's orders because the Dietitian was responsible for any changes in Resident #102's fluid restrictions. During an interview on 11/1/2024 at 3:28 PM, the Chief Clinical Dietitian stated they just started working at the facility and were still in the process of evaluating some of the residents. The Chief Clinical Dietitian stated they did not know there was an issue with Resident #102's fluid intake and that the resident was receiving extra fluids. The Chief Clinical Dietitian stated Resident #102 had a Physician Order for fluid restrictions that must be followed and if Resident #102 requested extra fluids or was non-compliant with the fluid restrictions, the Physician should have been notified. During an interview on 11/4/2024 at 1:36 PM, the Director of Nursing Services stated the meal tickets and Electronic Medication Administration Record (EMAR) for Resident #102 indicated that extra fluids were being given to Resident #102. The Director of Nursing Services stated the Physician's Order for fluid restrictions was very specific and should have been followed. The Director of Nursing Services stated the Certified Nursing Assistants documented fluid intake by percentage because that is how the electronic medical record system was set up to monitor the fluid intake during meals. 10 NYCRR 415.12(j)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a Recertification Survey initiated on 10/28/2024 and completed on 11/4/2024, the facility did not ensure the Physician provided orders for the resident's immediate care and needs. This was identified for one (Resident #75) of two residents reviewed for Choices. Specifically, Resident #75 with a diagnosis of Epilepsy was receiving Topiramate (anticonvulsant medication) that should be gradually withdrawn to minimize the potential for seizures or increased seizure frequency as per the manufacturer's warning and precautions. The medication was abruptly stopped from 10/19/2024 to 10/22/2024 and restarted after four days on 10/23/2024. The finding is: The facility's policy and procedure titled Physicians Services last reviewed in March 2024 documented that the resident's medical care will be supervised by the attending Physician or alternate Physician who will assume the principal obligation and responsibility for managing the resident's medical care. On each visit, the Physician must review the resident's total program of care, including medications and treatments; write, sign, and date progress notes, sign and date all orders. The drug label from accessdata.fda.gov documented the warning and precautions: Withdrawal of Antiepileptic Drugs (AEDs) in patients with or without a history of seizures or epilepsy, antiepileptic drugs, including Topramax (Topiramate), should be gradually withdrawn to minimize the potential for seizures or increased seizure frequency. Resident #75 was admitted with diagnoses including Epilepsy and Epileptic Syndromes with Seizures, Migraine, and Major Depressive Disorder. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, which indicated the resident had intact cognition. The Minimum Data Set documented the resident had a diagnosis of seizure disorder. Resident #75's History and Physician admission assessment dated [DATE] documented that Resident #75 had a past medical history of Seizure Disorder and was admitted into the facility following hospitalization on account of a seizure with fracture of the right tibia (lower leg bone). The Physician documented a plan to continue Topiramate for Seizure Disorder. A physician's order dated 9/19/2024 documented to administer Topiramate 100 milligrams tablet (1 tablet) by oral route every 12 hours for 30 days for Epilepsy. There was no documented evidence that the Topiramate order was renewed after 30 days (on 10/19/2024). A Review of Resident #75's Medication Administration Record dated October 2024 indicated Resident #75 did not receive Topiramate 100 milligrams tablet on 10/19/2024, 10/20/2024, 10/21/2024 and 10/22/2024. A review of all progress notes from 10/18/2024 to 10/23/2024 was conducted. There was no documented evidence that a Physician assessed, evaluated, and ordered to discontinue Resident #75's Topiramate. A new physician's order dated 10/23/2024 documented to administer Topiramate 100 milligrams tablet (1 tablet) by oral route every 12 hours for Epilepsy. The Comprehensive Care Plan for Epilepsy dated 10/30/2024 documented the resident had a Seizure Disorder. Interventions included but were not limited to administering anti-seizure medications as per the physician's order and monitoring [resident] for seizure activity. During an interview on 10/28/2024 at 11:58 AM, Resident #75 stated they had Epilepsy and had been taking a steady dose of Topiramate (Topamax) and other antiseizure medication in the community. During an additional interview on 10/30/2024 at 1:26 PM, Resident #75 stated they were not aware of any changes in dosage and frequency of their Epilepsy medications. During an interview on 10/30/2024 at 3:45 PM, Physician #3 stated they worked together with Physician #1 and oversaw Resident #75's medical care. Physician #3 stated the Topiramate order from 9/19/2024 was automatically discontinued after 30 days; however, there was no plan to discontinue the use of Topiramate for Resident #14. Physician #3 stated they were not aware that Resident #75's Topiramate order was not renewed. During an interview on 11/1/2024 at 1:42 PM, Physician #1, who was Resident #75's Primary Care Physician and the Medical Director, stated that Resident #75 continued with the Epilepsy management per discharge instruction from the hospital and there was no plan or discussion to discontinue Topiramate medication. Physician #1 stated that Topiramate should be gradually reduced and should not be discontinued abruptly. Physician #1 stated if the antiseizure medication is abruptly stopped, the resident could experience seizure activity. Physician #1 stated the Physician should have renewed the Topriramate order to ensure the medication was not abruptly stopped and that Resident #75 continued to receive the medication. 10 NYCRR 415.15(b)(1)(i)(ii)

Based on observation and interviews during the Recertification Survey initiated on 10/28/2024 and completed on 11/4/2024 the facility did not ensure that daily nursing staffing was posted in a prominent location and with the numbers of Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides who were working that day. Specifically, the facility lobby, near the front entrance, near the elevator bank, and the elevators were observed on 10/28/2024 at 8:55 AM and then again at 10:05 AM. There was no daily staffing posted that included the total number of licensed and unlicensed nursing staff working per shift. The finding is: During an observation on 10/28/2024 at 8:55 AM and again on 10/28/2024 at 10:05 AM, nursing staff posting was absent in the facility lobby and near the front entrance, near the elevator bank, in the elevators, and on the unit on the 8th floor. During an interview on 10/29/2024 at 1:30 PM, the Director of Nursing Services stated the Staffing Coordinator is expected to fill out and post the nursing staffing each morning and the Registered Nurse Supervisors for the shift would modify the sheet during their shift. The Director of Nursing Services stated they were not aware they had to post the staffing in public, prominent areas like the receptionist desk or elevator bank. The Director of Nursing Services stated the nursing staffing sheet is posted by the staff time clock and the vending machine area outside the Nursing Office. On 10/29/2024 at 1:35 PM the Director of Nursing Services showed the surveyor the nursing staff posting that was on the wall in an alcove outside the nursing office. The staff schedules were also located here. A review of the staff posting dated 10/29/2024 revealed the census for the 7:00 AM-3:00 PM shift and the categories of Registered Nurse, Licensed Practical Nurse, and Certified Nursing Assistant. For each category, the column number of staff documented 7.5. The total hours for each category were included in the adjacent column. The staff posting did not include the actual number of staff working per shift. During an observation on 10/30/2024 at 8:53 AM, the nursing staff posting was absent in the facility lobby, near the front entrance, near the elevator bank, and in the elevators. During an interview with the Administrator and the Director of Nursing Services on 11/4/2024 at 11:05 AM, the Administrator stated that the nursing staff posting used to be posted by the reception desk and a family member complained that there were too many postings at the front desk, so the facility moved the staff posting to the vending area. The Director of Nursing Services stated that the posting lists 7.5 in the number of staff column indicating the hours worked per shift by each staff member, not the actual number of staff members. The Administrator asked the surveyor if the number of staff should be documented rather than the 7.5 hours per staff member. During an interview on 11/4/2024 at 12:38 PM the Staffing Coordinator stated they filled out the staffing posting and gave it to the Director of Nursing Services daily. The Staffing Coordinator stated maybe the staff posting has to be revamped, and acknowledged the posting does not indicate the actual number of staff who worked. 10 NYCRR 415.13

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during the Recertification Survey and Abbreviated Survey (NY 00332218) initiated on 10/28/2024 and completed on 11/4/2024, the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drug and biologicals) were provided to meet the needs of each resident. This was identified for one (Resident #14) of two residents reviewed for Choices. Specifically, Resident #14's Physician ordered Diclofenac 0.1% (nonsteroidal anti-inflammatory) eye drops for 14 days on 1/16/2024. The eye drop medication was not delivered to the facility by the Pharmacy until 1/24/2024. The finding is: The facility's Ordering and Obtaining Medication policy, last reviewed in August 2024, documented to verify with the attending Physician any dose or order that appears inappropriate considering the resident's age, condition, or diagnosis. The policy further documented to order drugs from the Pharmacy supplier after the order is clarified. Resident #14 was admitted with diagnoses that included Dry Eye Syndrome and Hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The resident had adequate vision with the use of corrective lenses. The Visual Function Comprehensive Care Plan dated 9/21/2021 last revised 9/20/2024 documented that the resident had Cataracts. Interventions included but were not limited to encouraging daily use of eyeglasses and monitor changes in visual functioning. The Allergy Comprehensive Care Plan dated 9/21/2021 last revised on 9/20/2024 documented that the resident was allergic to Aspirin (nonsteroidal anti-inflammatory drug) and Penicillamine (used for immunosuppression for Rheumatoid Arthritis). Interventions included but were not limited to notifying the Pharmacy of allergies and monitoring all medications to ensure that the resident did not ingest any related products. A Physician's progress note dated 12/15/2023, written by Physician #2, documented that Resident #14 was seen for medical clearance for Cataract surgery and was in optimal medical condition for the surgery. A medical progress note dated 1/12/2024, written by Physician #2, documented Resident #14 had right eye Cataract surgery on 12/18/2023. On 1/10/2024, the resident was transferred to the emergency room STAT (immediately) for Ophthalmology evaluation after Resident #14 complained of right eye pain. Resident #14 was diagnosed with bacterial conjunctivitis in the Emergency Room. Physician #2 documented Resident #14 was seen status post right eye pain and was observed with mild redness in the right eye. The resident denied loss of vision. Physician #2 recommended a follow-up visit with Resident #14's Ophthalmologist. A Nursing Progress note dated 1/16/2024, written by Registered Nurse #11, documented Resident #14 returned from an ophthalmology visit with a recommendation to start Diclofenac 0.1% eye drop, one drop to the right eye for 14 days. A physician's order dated 1/16/2024 documented to administer Diclofenac 0.1% eye drops, instill one drop by ophthalmic (eye) route in the right eye 4 times per day for 14 days for Visual Discomfort in the Right Eye. A Pharmacy Clarification Request Form dated 1/17/2024 documented clarification is needed for Diclofenac 0.1% eye drop due to Resident #14's prior reaction to Aspirin. If the medication is new to the resident, the facility has to clarify allergies with the Physician and inform the pharmacy whether to discontinue the order or to dispense the medication. A physician progress note dated 1/18/2024, written by Physician #2, documented Resident #14 returned from an ophthalmology visit on 1/16/2024 with a recommendation to start the Diclofenac 0.1% eye drops. There was no documented evidence that the Physician was made aware and addressed the Pharmacy's request to clarify the Diclofenac eye drop order. A review of Resident #14's Medication Administration Record for January 2024 documented that from 1/16/2024 to 1/23/2024, Resident #14 did not receive their Diclofenac 0.1% eye drops on 16 occasions; the medication was not available due to pending delivery from the Pharmacy. During an interview on 10/29/2024 at 11:17 AM, Resident #14 stated they had Cataract surgery on 12/18/2023 and were prescribed several different eye drops before and after their surgery. Sometimes these eye drops were not given to them. Resident #14 could not recall exactly when each eye drop was ordered and which eye drops were not administered. Resident #14 stated they would never refuse their eye drops. During an additional interview on 11/01/2024 at 11:53 AM, Resident #14 stated they were allergic to Aspirin and would experience a breakout reaction if they mistakenly ingested any. Resident #14 stated they reported pain and discomfort in their right eye after the Cataract surgery. Resident #14 did not recall if they received any eye drops for their eye discomfort. During an interview on 11/01/2024 at 10:35 AM, Licensed Pharmacist #1 stated the Pharmacy received an order for Diclofenac 0.1% eye drop for Resident #14 on 1/16/2024. The Pharmacy did not dispense the eye drop until 1/23/2024 because clarification was needed for a possible allergic reaction to the eye drop, as the resident had an Aspirin allergy. Licensed Pharmacist #1 stated that the Pharmacy would repeatedly call, fax, or communicate through inter-facility chat services to notify facilities if there were any issues with any medication orders. A Call was placed to the facility on 1/17/2024 at 11:19 AM with no answer, then a fax was sent to the facility on 1/17/2024 at 11:22 AM. Licensed Pharmacist #1 stated that medication would not be dispensed until medical clearance was obtained. Licensed Pharmacist #1 stated that the eye drop was delivered on 1/24/2024. During an interview on 11/01/2024 at 12:24 PM, Physician #2, who no longer worked at the facility, stated they did not recall being notified of the need to clarify the Diclofenac 0.1% eye drop order. Physician #2 stated they were not aware that the Diclofenac 0.1% eye drop was not available. Physician #2 stated they expected nursing staff to contact them and they (Physician #2) would have deferred to Resident #14's Ophthalmologist for clarification. Physician #2 stated that Diclofenac eye drop was typically prescribed for anti-inflammatory and pain relief purposes. During an interview on 11/01/2024 at 12:53 PM, Registered Nurse Supervisor #11 stated the nurse on the unit who received an inquiry from the Pharmacy regarding a medication order was responsible for contacting their supervisor or the Physician for clarification. Registered Nurse Supervisor #11 stated they did not recall if they received and responded to the Pharmacy's clarification request on 1/17/2024. Registered Nurse Supervisor #11 stated they did not know Diclofenac eye drop medication was unavailable for one week. Registered Nurse Supervisor #11 stated if they knew that the eye drops were missing, they would have notified the Physician and contacted the Pharmacy. During an interview on 11/01/2024 at 1:52 PM, the Medical Director stated they expected nurses to contact the Physician for clarification regarding the Pharmacy's inquiry to reduce delays in treatment. The Medical Director stated they expected any Pharmacy inquiries should be addressed no later than 12 hours so that medications can be delivered at the next possible delivery. The Medical Director stated that nurses should have notified their supervisor or the Physician that Resident #14's eye drops were unavailable. During an interview on 11/04/2024 at 1:25 PM, the Director of Nursing Service stated the nurse who received an inquiry from the Pharmacy for Resident #14's Diclofenac eye drop was responsible for informing the resident's Physician, obtaining the physician's order, and communicating the Physician's decision back to the pharmacy as soon as possible and document the actions taken. The Director of Nursing Services did not know the Pharmacy sent a clarification form to the facility to be completed. 10 NYCRR 415.18(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification and Abbreviated Survey (NY 00331717) initiated on 10/28/2024 and completed on 11/4/2024, the facility did not ensure it had sufficient nursing staff on a 24-hour basis to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified on six of six resident units during the Sufficient Staffing Task. Specifically, 1) the Facility Assessment did not match the number actual number of Certified Nursing Assistants assigned to work on each unit; 2) medications during the 7:00 AM-3:00 PM shift were administered late on the 3rd and 5th floor nursing units due to understaffing issue; and 3) wound care was not performed on the 11:00 PM-7:00 AM shift for Resident #48 on multiple occasions because understaffing issue. Cross References: F 677 Quality of Life F 686 Quality of Care The finding is: The facility's policy titled Staffing Levels, dated 2/2024 documented the facility will attempt to maintain safe staffing levels at all times. Each department will assess staffing needs on a daily, shift-to-shift basis. The nursing department will arrange staff according to acuity and census to ensure the quality of care is maintained. All efforts will be made to ensure all slots are filled. In the event that a replacement cannot be obtained, efforts will be made to shift assignments and triage tasks. The nursing department will ensure each unit is maintained at safe staffing levels. This may require nursing to shift assignments to the unit with the highest acuity and/or highest census. Licensed nurses may be assigned to complete Certified Nursing Assistant responsibilities and administrative nurses may be assigned to administer medications and treatments. 1) The Facility assessment dated [DATE] documented the bed capacity is 240 residents and the average daily census is 225-240 residents. There are six resident units on floors 3 through 8 (Units 3, 4, 5, 6, 7, 8). Each unit has 40 beds. The Facility Assessment documented the facility does not take a census-based approach to staffing but looks at the acuity levels of the residents in order to provide the best staffing possible. The Administration team collaborates and reviews the staffing census daily. The goal of the facility is to ensure that all residents' needs are met in an appropriate and timely fashion. The Facility Assessment documented the following staffing plan: For the 7:00 AM-3:00 PM shift: -One Registered Nurse per unit except for Unit 8 (sub-acute unit), which required two Registered Nurses; -One Licensed Practical Nurse on each unit, with an exception for Unit 7 and Unit 8 (sub-acute units), which required two Licensed Practical Nurses each; - Four Certified Nursing Assistants for Unit 3 and Unit 5; five Certified Nursing Assistants for Unit 4 and Unit 7. -Unit 6 required 44 (an error in the Facility Assessment) Certified Nursing Assistants, -The Facility Assessment did not document the number of Certified Nursing Assistants needed for Unit 8. For the 3:00 PM-11:00 PM shift: -Two house Registered Nurses (Supervisor) for the shift. -There were no Registered Nurses assigned to the units; -One Licensed Practical Nurse for each unit, except for Unit 8, which required two Licensed Practical Nurses; -Four Certified Nursing Assistants for each unit, except for Unit 8, which required five Certified Nursing Assistants; For the 11:00 PM-7:00 AM shift: -One house Registered Nurse (Supervisor) for the shift. -There were no Registered Nurses assigned to the units; -One Licensed Practical Nurse for each unit; -Two Certified Nursing Assistants; A review of staffing sheets for weekends in July and August 2024 revealed the following: During the 7:00 AM to 3:00 PM Shift: -Unit 3 had three Certified Nursing Assistants assigned on 8/4/2024 and 8/25/2024. -Unit 5 had three Certified Nursing Assistants assigned on 7/7/2024, 7/21/2024, 8/3/2024, 8/4/2024, 8/18/2024, 8/24/2024 and 8/25/2024. The Facility Assessment indicated Unit 3 and Unit 5 needed four Certified Nursing Assistants. -Unit 4 had four Certified Nursing Assistants assigned on 7/7/2024, 7/14/2024, 7/20/2024 and 7/21/2024. -Unit 7 had three Certified Nursing Assistants assigned on 7/7/2024, 7/20/2024, and 8/24/2024. -Unit 7 had four Certified Nursing Assistants assigned on 7/6/2024, 7/13/2024 and 7/14/2024. The Facility Assessment indicated Unit 4 and 7 needed five Certified Nursing Assistants. -Unit 6 had three Certified Nursing Assistants assigned on 7/7/2024, 7/20/2024, 8/3/2024, and 8/18/2024. -Unit 6 had four Certified Nursing Assistants assigned on 7/21/2024. The Facility Assessment indicated Unit 6 needed 44 Certified Nursing Assistants. -Unit 8 had three Certified Nursing Assistants assigned on 7/6/2024, 7/7/2024, 8/3/2024, and 8/25/2024. -Unit 8 had four Certified Nursing Assistants assigned on 7/14/2024. The Facility Assessment did not document the number of Certified Nursing Assistants needed for Unit 8. During the 3:00 PM to 11:00 PM Shift: -Unit 3 had three Certified Nursing Assistants assigned on 7/6/2024. -Unit 4 had three Certified Nursing Assistants assigned on 7/6/2024, 7/28/2024, and 8/3/2024. -Unit 5 had three Certified Nursing Assistants assigned on 7/7/2024, 8/10/2024, 8/18/2024, and 8/24/2024. -Unit 7 had three Certified Nursing Assistants assigned on 7/13/2024, 7/21/2024, 7/27/2024 and 8/10/2024. -Unit 8 had three Certified Nursing Assistants assigned on 7/21/2024 and 8/10/2024. -Unit 8 had four Certified Nursing Assistants assigned on 7/6/2024, 7/7/2024, 7/13/2024, 7/14/2024, 7/21/2024, 7/27/2024 and 8/10/2024. The Facility Assessment documented four Certified Nursing Assistants for each unit, except for Unit 8, which required five Certified Nursing Assistants. During an interview on 10/31/2024 at 12:05 PM, Staffing Coordinator #1 stated the Director of Nursing Services and the Administrator make decisions on how many staff are needed daily for each shift. Staffing Coordinator #1 stated they are not familiar with the Facility Assessment. The number of Certified Nursing Assistants assigned to a unit varies day by day. The Staffing Coordinator discusses staffing needs with the Director of Nursing Services and the Administrator a day before the schedule is made. The Registered Nurse Supervisor is assigned to administer medications and treatments if the scheduled nurses call out or the facility cannot get another nurse to cover. The facility needs more Certified Nursing Assistants and nurses because it is a problem trying to cover staffing needs on all the shifts. Sundays are more difficult. During an interview on 11/4/2024 at 11:05 AM, the Administrator stated a few months ago staff had to work extra shifts to cover staffing needs because the facility was short-staffed. It was difficult to find staff, particularly on the weekends. The Administrator and Director of Nursing Services stated they review the acuity of the units and determine the staffing needs. The Administrator stated there are no staffing par levels as the staffing need is determined by the acuity level of the unit and not by census. The Administrator and Director of Nursing Services stated acuity changes based on how many residents may need a mechanical lift transfer, if there are behavioral problems, and how many residents are fall risks, and this can change daily. The Administrator stated there is an average of 4-5 Certified Nursing Assistants assigned to each unit. The Director of Nursing Services stated one medication nurse is sufficient to administer medications for 40 residents. The Administrator stated the Registered Nurse Supervisor working as a medication and treatment nurse on a unit is used as the last resort to cover the last-minute staff callouts. 2) On 10/28/2024 at 10:35 AM, Licensed Practical Nurse #4 was observed administering medications on the 5th floor nursing unit. The 5th floor nursing unit assignment sheet dated 10/28/2024 documented one Licensed Practical Nurse medication nurse, one Registered Nurse Supervisor, and five Certified Nursing Assistants assigned to the unit. During an interview on 10/28/2024 at 10:37 AM, Licensed Practical Nurse #4 stated they still had to provide the 9:00 AM medications to four residents (Resident #498, #499, #173, and #107). Licensed Practical Nurse #4 stated medication administration is late because they have to administer medication to 35-36 residents and address concerns brought up by other staff and residents. -On 10/28/2024 at 10:40 AM, Licensed Practical Nurse #2 was observed administering medications on the 3rd floor nursing unit. The 3rd floor nursing unit assignment sheet dated 10/28/2024 documented one Licensed Practical Nurse medication nurse, one Registered Nurse Supervisor, and five Certified Nursing Assistants assigned to the unit. During an interview on 10/28/2024 at 10:42 AM, Licensed Practical Nurse #2 stated they just started administering the 9:00 AM medications for the residents on the high side of the unit and still had 19 other residents who did not get their 9:00 AM medications. During an interview on 10/28/2024 at 11:13 AM, Registered Nurse #8 (the 3rd-floor unit supervisor) stated this was the first time they saw Licensed Practical Nurse #2 on the unit. The regularly assigned medication nurse was off today who can manage the medication administration times better. Registered Nurse #8 stated if Licensed Practical Nurse #2 had asked them for help with the medication administration they would have helped. During an interview on 10/29/2024 at 9:00 AM, Registered Nurse #9 (the 5th-floor supervisor) stated Licensed Practical Nurse #4 arrived on the unit at 8:30 AM and started the medication pass late on 10/28/2024. The medications that are scheduled for administration at 9:00 AM should be administered between 8:00 AM-10:00 AM. Registered Nurse #9 stated they should have started the medication pass themselves. During an additional interview on 10/30/2024 at 10:00 AM, Licensed Practical Nurse #2 stated they were assigned to the 3rd floor on 10/28/2024 for the first time and were not familiar with the residents on the unit. Licensed Practical Nurse #2 stated they did not ask for help. During an interview on 10/30/2024 at 1:36 PM, the Director of Nursing Services stated medications should be administered no earlier than one hour before and no later than one hour after they are scheduled. 3) Resident #48 was admitted with diagnoses including Paraplegia, Cancer, and Depression. The 9/2/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident had three Stage 4 (involves full-thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcers. Comprehensive Care Plans titled Left Buttock Stage 4, Right Buttock Stage 4, and Sacrum Stage 4 (pressure ulcers), all initiated on 11/27/2023 and last updated on 10/1/2024 documented that the resident had frequent behavior of refusing assessments by the wound Physician; however, there was no documented evidence that the resident refused actual treatment by the nursing staff. A review of the January 2024 Treatment Administration Records (based on the complaint NY 00331717 allegations) revealed the sacral, right buttock, and left buttock pressure ulcer treatments were not performed on 1/12/2024 and 1/14/2024. The treatments were scheduled for the 11:00 PM-7:00 AM shift. Registered Nurse #4 documented in the Treatment Administration Record on 1/12/2024 that the resident was sleeping and therefore the treatments were not performed. There was no documentation as to why the treatment was not done for 1/14/2024. A review of the September 2024 Treatment Administration Records (based on the complaint NY 00331717 allegations) revealed on 9/28/2024 and 9/30/2024 the sacral, right buttock, and left buttock pressure ulcer treatments were not performed. The treatments were scheduled for the 11:00 PM-7:00 AM shift. There was no documentation as to why the treatment was not administered on 9/28/2024. The Treatment Administration Record documented that on 9/30/2024 the resident refused the treatments. During an interview on 10/29/2024 at 11:14 AM, Registered Nurse #4 stated they worked on 1/12/2024 as the night shift supervisor and as the medication and treatment nurse on Resident #48's unit. Registered Nurse #4 documented the treatment was not provided to the resident on 1/12/2024 because the resident was asleep and they should write a progress note and let the next shift know that the treatment was not provided. Registered Nurse #4 stated when covering a unit and also covering the building as a shift Supervisor, sometimes they are called away to deal with emergencies and are not able to administer medications or do the treatments on the unit. A review of the staffing sheet dated 1/12/2024 indicated Registered Nurse #4 was the Nurse Supervisor for the 11:00 PM-7:00 Shift and covered Unit 8. The nurse assigned to Unit 3 did not have a checkmark in front of their name. During an interview on 10/29/2024 at 12:04 PM, Registered Nurse #3 (the Assistant Director of Nursing and the Risk Manager) stated they were assigned to Resident #48's unit as a nurse on 9/28/2024 and were responsible for administering medications and treatments because there were no other nurses to cover the unit. Registered Nurse #3 stated they probably forgot to sign for Resident #48's treatment administration and that lack of documentation meant the treatment was not done. During an interview on 10/29/2024 at 12:14 PM, Registered Nurse #5 (overnight supervisor who was also the assigned nurse to Resident #48's unit on 1/14/2024 and did not document on the treatment record that the treatments were completed) stated as a Supervisor, they usually have to cover a unit, it is impossible to be the supervisor and a floor nurse and do the regularly scheduled treatments on the unit. A review of the staffing sheet dated 1/14/2024 indicated Registered Nurse #5 was the Nurse Supervisor for the 11:00 PM-7:00 Shift and covered Unit 3. The nurse assigned to Unit 3 called out sick. During an interview on 10/29/2024 at 12:29 PM, Registered Nurse #2 stated they were the assigned shift Supervisor on 9/30/2024 and had to cover Resident #48's unit to provide treatments and medication administration. Registered Nurse #2 stated they only worked at the facility for a week and did not recall doing wound care for Resident #48. Registered Nurse #2 stated they were very much behind in their work and did not think they completed their assigned work. A review of the staffing sheet dated 9/30/2024 indicated Registered Nurse #2 was the Nurse Supervisor for the 11:00 PM-7:00 Shift and covered Unit 3 as the medication and treatment nurse. During an interview on 11/4/2024 at 11:05 AM, the Administrator stated the Registered Nurse Supervisor is used as a last resort to cover a unit due to last-minute call-outs. The Registered Nurse Supervisor is instructed if there is an emergency, they attend to that and then go back to the regular duties for the unit. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, interviews, and record review conducted during the Recertification Survey, initiated on 10/28/2024 and completed on 11/4/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during the Kitchen task observation. Specifically, frozen food items (pancakes, sausage patties, beef burger patties) were stored undated and with opened packaging. The finding is: The facility's policy titled Food Receiving and Storage, dated 12/2023, documented that Supervisors will observe all refrigerated and frozen goods for the integrity of the wrapping materials as a primary barrier to cross-contamination. The management team will ensure that all products are labeled and dated by the staff and utilized by their expiration date. Open dates are hand-written dates that will be placed on all opened kitchen stock products. Kitchen observation was conducted with the Food Service Director on 10/28/2024 at 9:31 AM. A walk-in freezer unit was observed with multiple open boxes of food with the inner plastic wrap also open, thereby exposing the food items to air. These items included three boxes of pancakes, one box of precooked sausage patties, and a box of beef patties. The observed open boxes were not dated to indicate when the boxes were first opened. The Food Service Director was interviewed on 11/04/2024 at 9:36 AM and stated that food packages in the freezer must be closed to prevent freezer burn and to reduce the possibility of cross-contamination. The Food Service Director stated that with freezer burn, the food quality diminishes and with cross-contamination, there is a possibility of illness. Additionally, there should be a date documented on the inner packaging to indicate when the boxes were first opened. 10 NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #4 was admitted with diagnoses including Cerebral Infarction, Hemiplegia, and Dementia. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 99, indicating Resident #4 had severely impaired cognition. The Minimum Data Set documented that Resident #4 was dependent (the helper does all the effort) for rolling left and right, sitting to lying, and lying to sitting on the side of the bed Resident #4 had impairment on one side of the lower extremity. The Comprehensive Care Plan titled At Risk for Falls dated 9/17/2024, documented interventions that included keeping the call bell within reach. Resident #4 was observed on 10/28/2024 at 9:30 AM sleeping in a Geri chair. The call bell was observed on the resident's bed and was out of the resident's reach. Resident #4 was again observed on 10/29/2024 at 8:18 AM lying in their bed. The call bell was observed hanging on the left side of the headboard and was out of the resident's reach. During an interview on 10/29/2024 at 9:18 AM, Certified Nursing Assistant #6 stated the call bell should be kept within reach for all residents. Resident #4 has a behavior of pushing their call bell away. All nursing staff are aware of the resident's behavior and frequently monitor the resident. A review of Resident #4's comprehensive care plan revealed no documented evidence that Resident #4 frequently pushed the call bell out of reach. During an interview on 10/30/2024 at 9:14 AM, Licensed Practical Nurse #6 stated Resident #4 has the behavior of pushing things away from themselves; however, did not know if the resident had a care plan for this behavior. Licensed Practical Nurse #6 could not recall if they notified the Nurse Supervisor of the resident's behavior of pushing the call bell away. During an interview on 10/30/2024 at 9:23 AM, Registered Nurse Supervisor #9 stated they were unaware of Resident #4's behavior of pushing the call bell away and this is the first time [they were] hearing this. Registered Nurse Supervisor #9 stated they would have put care plan interventions to address the behavior. Registered Nurse Supervisor #9 stated that the resident should have had their call bell within reach. During an interview on 10/30/2024 at 1:31 PM, the Director of Nursing Services stated the Nurse Supervisor should be made aware of the resident's behavior of pushing the call bell out. The Director of Nursing Services stated the call bell should be within reach of all residents. Based on observations, record review, and interviews during the Recertification Survey initiated on 10/28/2024 and completed on 11/4/2024 the facility did not ensure call systems were accessible to each resident while the residents were in their rooms. This was identified for three (Resident #350, Resident #4, and Resident #87) of three residents reviewed for call systems. Specifically, 1) Resident #350, who was assessed to require assistance with transfer and locomotion, was observed in their room alone sitting in a chair; the call bell was observed on the floor approximately five feet away from the resident; 2) Resident #4, who was assessed to require staff assistance with transfers and locomotion, was observed on 10/28/2024 and 10/29/2024; the call bell was observed out of the resident's reach; and 3) Resident #87 was observed in bed on two occasions and the call bell was observed hanging from the wall onto the floor out of the resident's reach. The findings are: The facility's policy titled Call Bell and Alarm Response, dated 1/2024, documented the Certified Nursing Assistant will place the call bell within easy access for the resident. If a resident is unable to use or access the call bell, the Rehabilitation Department will assess the resident's fine motor skills and adjust/modify the call bell so that the resident may use it to communicate with the staff. These modifications may include a cord extension, a larger call bell, a handbell, or any other modifications that may meet the resident's needs. 1) Resident #350 was admitted with diagnoses including Alzheimer's Disease, Traumatic Subdural Hemorrhage (brain bleed), and a history of Falls. The 10/22/2024 Nursing admission Assessment documented the resident was alert to self but not the place, time, or situation and needed assistance with transfers and locomotion. A Comprehensive Care Plan titled At Risk for Falls, effective 10/22/2024, documented an intervention for call bell within reach, answer promptly. Accident and Incident Reports dated 10/22/2024 and 10/24/2024 documented the resident had falls from bed. Preventive measures included the call bell being within reach. During an observation on 10/28/2024 at 10:16 AM, Resident #350 was in their room alone, sitting in a regular chair. The resident's wheelchair was observed in the room. The resident was awake but appeared confused. The call bell was on the floor about five feet from the resident. Certified Nursing Assistant #2 came into the room, checked on the resident, and left the room without placing the call bell within the resident's reach. During an interview on 10/28/2024 at 12:23 PM, Certified Nursing Assistant #2 stated the call bell should be accessible to the resident and they did not notice the resident's call bell was on the floor when they went in to check on the resident earlier in the morning. Certified Nursing Assistant #2 stated they placed the resident in the regular chair and did not place the call bell near the resident. Certified Nursing Assistant #2 stated it was unsafe for the resident to get up by themselves. During an interview on 10/30/2024 at 11:34 AM, Registered Nurse #8 (unit supervisor) stated the call bell should have been accessible to Resident #350. During an interview on 10/30/2024 at 1:31 PM the Director of Nursing Services stated the call bell should have been accessible to the resident. 3) Resident #87 was admitted to the facility with diagnoses that included Dementia, Depression, and Hypertension. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 0 is the resident severely impaired in cognition (that section was not filled out). The resident had no functional limitation in range of motion to upper and lower extremities and required supervision or touch assistance for bed mobility and transfers. A Comprehensive Care Plan for Risk for Falls dated 10/7/2023 and updated 8/27/2024 documented to place the call bell within reach and answer promptly. During an initial tour conducted on 10/28/2024 at 10:51 AM, Resident #87 was observed awake in bed with their breakfast tray in front of them. The resident's call bell was observed hanging from the wall onto the floor and was out of the resident's reach. A second observation was made on 10/28/2024 at 12:45 PM. The resident was still in bed and the call bell was observed hanging from the wall onto the floor and was out of the resident's reach. During an interview on 10/30/2024 at 11:15 AM, Registered Nurse #1 stated the Certified Nursing Assistants and the nurses were responsible for ensuring the resident's call bell was within the resident's reach. Registered Nurse #1 stated the call bell should be placed within the resident's reach at all times. During an interview on 10/30/2024 at 1:29 PM, the Director of Nursing Services stated the resident's call bell should have not been on the floor. The Director of Nursing Service stated that the resident's call bell should be placed within the resident's reach at all times. 10 NYCRR 415.29

Based on observation, record review, and interviews during the Recertification Survey initiated on 1/19/2023 and completed on 1/26/2023 the facility did not ensure that services are provided for each resident to restore or improve normal bladder function to the extent possible, after the removal of the indwelling catheter. This was identified for one (Resident #115) of three residents reviewed for Urinary Catheter. Specifically, Resident #115 had a Foley catheter and was started on a trial void (a trial of void assesses the ability of the bladder to empty without the use of a urinary catheter) per Physician's order on 11/25/2022. There was no documented evidence that the resident was monitored for voiding after the Foley catheter was discontinued. On 11/26/2022 the resident was identified by Registered Nurse (RN) #4 with abdominal distension and discomfort. The resident was re-catheterized per the Physician's order and 1,500 cubic centimeters (cc) of urine was removed from the resident's bladder. The finding is: The facility's policy dated December 2022 titled, Indwelling Catheter Justification and Removal, documented once the indwelling urinary catheter has been removed, the nurse removing the catheter will document this in the electronic medical record and initiate every 4-hour monitoring for a period of 8 hours. Resident #115 was admitted to the facility with diagnoses including Parkinson's Disease, Obstructive Uropathy, and Major Depressive Disorder. The 10/18/2022 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS documented that the resident had a urinary catheter and an ostomy for bowel. A Physician's order dated 10/18/2022 documented Foley Catheter, size 14 French, 10 cc balloon, for Obstructive Uropathy. A Physician's order dated 11/23/2022 documented to discontinue Foley, start a trial void, one time on 11/25/2022 during the 7 AM-3 PM shift. A Physician's order dated 11/25/2022 at 12:40 PM documented status-post foley discontinued-measure urine output every shift. Instruct resident to urinate in urinal provided. Review of the November 2022 Treatment Administration Record (TAR) revealed that on 11/25/2022 for urine output monitoring following the discontinuation of the Foley catheter, RN #4 initialed for monitoring during the 7 AM-3PM shift (and wrote corresponding progress note); the 3 PM-11 PM shift was initialed by RN #5 (an RN supervisor) (no corresponding progress note or output amount); and the 11 PM- 7 AM shift was not initialed and no corresponding progress note for 11 PM-7 AM shift. Review of the Resident Clinical Monitoring Information from the Electronic Medical Record revealed output of 600 milliliters (ml) Urine on 11/25/2022 at 6:44 AM followed by output of 600 ml of Urine on 11/26/2022 at 10:37 PM. There is no output listed for the period between when the Foley catheter was discontinued on and when it was re-inserted. A nursing progress note dated 11/25/2022 at 3:45 PM, written by RN #4, documented the Foley catheter was discontinued at 12:20 PM and a trail void was started. About 50 ml of urine output was measured immediately after the Foley catheter was removed. Resident was not able to void anymore, denies lower abdominal pain and discomfort and no abdominal distention was noted. Continuous monitoring endorsed to the evening RN supervisor. Resident provided with urinal and instructed to void inside the container so that output can be measured. No acute distress noted. The next nursing progress note was dated 11/26/2022 at 4:33 PM, which was written by RN #4. The note documented the resident was alert and oriented and complained of abdominal distention, discomfort, and inability to urinate. The 7 AM-3 PM RN supervisor (who is no longer employed) was made aware and the physician was informed. The Physician ordered to re-insert the Foley catheter. 1500 cc's of clear yellow urine output was collected. A new physician's order for the Foley catheter was first entered by an RN Supervisor dated 11/26/2022 at 12:34 PM, documenting Foley catheter, size 16 French, 10 cc balloon, for obstructive uropathy. The Foley Catheter Comprehensive Care Plan (CCP) dated 10/13/2022 was updated on 11/26/2022 by the 7 AM-3 PM RN Supervisor documented the Foley Catheter was reinserted and 1500 ml of yellow urine was collected. Resident #115 was observed with a Foley catheter in place on 1/19/2023 at 11:02 AM and was interviewed. The resident stated there was an issue with their urinary catheter in the past. The resident stated the Foley catheter was taken out, and then they (Resident #115) had excruciating pain. RN #4 was interviewed on 1/24/2023 at 8:41 AM and stated they (RN #4) discontinued the resident's Foley catheter on 11/25/2022. RN #4 stated when they (RN #4) came back the next day (11/26/2022) on the 7 AM-3 PM shift, upon beginning the medication pass for the resident, they (RN #4) noticed the resident's belly was distended and the resident was complaining of abdominal discomfort. RN #4 stated they (RN #4) palpated the bladder, and it was distended. RN #4 stated they (RN #4) told the RN supervisor who spoke to the physician and an order was given to re-insert the Foley catheter. RN #4 stated the Foley catheter was re-inserted by RN #4 and the Supervisor. RN #4 stated we are supposed to inform the doctor if the resident is not voiding. RN #4 stated they (RN #4) were surprised to find the bladder distended. The Assistant Director of Nursing Services (ADNS) #2 was interviewed on 1/24/2023 at 9:20 AM. ADNS #2 stated in general when a Foley catheter is discontinued, the resident is monitored for four hours to see if there is any voiding. ADNS #2 stated if there is no voiding the doctor should be called, and a decision is made whether or not a Foley catheter will be re-inserted. Physician #1 was interviewed on 1/24/2023 at 10:02 AM and stated when a Foley catheter is discontinued the protocol is to monitor urine output every 4-8 hours and the urinary output should be documented. Physician #1 stated they (Physician #1) believe Resident #115 refused to have the Foley catheter re-inserted. Resident #115 was re-interviewed on 1/24/2023 at 12:17 PM and stated the resident absolutely did not refuse to have the Foley catheter re-inserted. The resident stated they (Resident #115) were in excruciating pain. RN #5 was interviewed on 1/24/2023 at 1:58 PM and stated they worked on 11/25/2022 during for the 3 PM-11 PM. RN #5 stated that the urinary output should be documented on the TAR. RN #5 stated they (RN #5) did not recall what was going on with Resident #115 on 11/25/2022 and did not recall if they were working as a supervisor or working as the medication nurse that night. Licensed Practical Nurse (LPN) #4 (11 PM-7 AM) was interviewed on 1/24/2023 at 2:21 PM and stated they (LPN #4) were monitoring the urine output all night and asked the Certified Nursing Assistant (CNA #6) to check if the resident was voiding. LPN #4 stated it was not until early morning on 11/26/2022 when LPN #4 noticed that the resident's abdomen was distended. LPN #4 stated they immediately contacted the RN supervisor and obtained an order from the doctor to re-insert the Foley catheter. LPN #4 stated they were unsuccessful in re-inserting the catheter, so we gave report to the incoming 7 AM-3 PM shift. LPN #4 stated they (LPN #4) made a mistake by not documenting the inability to re-insert Foley catheter. LPN #4 stated when a resident is on a voiding trial the nurse is responsible for monitoring and then writing a corresponding note related to the urinary output and the resident's response to the voiding trial. LPN #4 stated they (LPN #4) were not sure which RN supervisor they (LPN #4) notified. RN #4 was re-interviewed on 1/24/2023 at 2:31 PM and stated they (RN #4) discovered the distended abdomen. RN #4 stated nobody gave them (RN #4) report when they (RN #4) came in for the 7 AM-3PM shift on 11/26/2022. The Director of Nursing Services (DNS) was interviewed on 1/24/2023 at 3:02 PM and stated there should have been documentation regarding whether the resident was voiding or not, and the nurses should have documented everything that took place. CNA #6, who worked on the 11 PM-7 AM shift on 11/25/2022 - 11/26/2022, was interviewed on 1/25/2023 at 1:55 PM and stated the CNAs were told about the trial void. CNA #6 stated they (CNA #6) went into Resident #115's room two times during the shift and there was no wet brief. CNA #6 stated they (CNA #6) told LPN (#4) and LPN #4 called the supervisor. RN #6, who was identified by facility as the supervisor on 11 PM-7 AM shift on 11/25/2022-11/26/2022 night, was interviewed on 1/25/2023 at 2:00 PM. RN #6 stated they (RN #6) did not recall the night or the situation with Resident #115's Foley catheter or trial void. 10 NYCRR 415.12 (d)(1)

Based on record review and staff interviews during the Recertification Survey initiated on 1/19/2023 and completed on 1/26/2023 the facility did not ensure that each resident's medical care was supervised by a physician throughout the resident's stay for 1 (Resident #367) of 1 resident reviewed for Dialysis. Specifically, Resident #367, who had a diagnosis of Orthostatic Hypotension (low blood pressure that happens when standing after sitting or lying down position), had an order for Midodrine (a medication used to treat low blood pressure). There was a Physician's order to monitor the blood pressure; however, the order did not provide guidance regarding blood pressure parameters to hold Midodrine medication and when to contact the Physician. Additionally, there was no Physician's order to monitor the resident's blood pressure in a supine (lying down) and sitting position as per the manufacture's recommendation. The finding is: Resident #367 was admitted with diagnoses including End Stage Renal Disease (ESRD), Myocardial Infarction, and Hypertension. The 12/15/2022 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. A Comprehensive Care Plan (CCP) titled Heart Disease, effective 2/7/2021 and last updated on 1/25/2023, documented the resident had an alteration in cardiovascular functioning secondary to diagnoses of Congestive Heart Failure, Coronary Artery Disease with stents, Hypertension, Cardiomyopathy, Angina Pectoris, Pacemaker/AICD, Respiratory Failure, Atrial Fibrillation, and Ventricular Tachycardia. Interventions included to administer medications as per the Physician's orders. A physician's order dated 12/8/2022 and last renewed on 1/18/2023 documented to administer Midodrine 5 milligram (mg), give 2 tablets by oral route 3 times per day for Orthostatic Hypotension. The order specified to monitor blood pressure. The package insert for Midodrine medication documented a warning: Supine Hypertension: The most potentially serious adverse reaction associated with Midodrine hydrochloride therapy is marked elevation of supine arterial blood pressure (supine hypertension). It is essential to monitor supine and sitting blood pressures in patients maintained on Midodrine hydrochloride. Uncontrolled hypertension increases the risk of cardiovascular events, particularly stroke. The package insert also documented that the supine and standing blood pressure should be monitored regularly, and the administration of Midodrine Hydrochloride Tablets, USP should be stopped if supine blood pressure increases excessively. The physician's order for Resident #367 did not include parameters and directions regarding when to hold the Midodrine medication and when to notify the Physician. The Physician's order also did not include to monitor the resident's supine, sitting, and or standing blood pressure. Review of the January 2023 Medication Administration Record (MAR) revealed that Midodrine was held per physician order (although the medical record did not have corresponding physician's orders to hold the medication) on 1/5/2023 (129/72), 1/12/2023 (149/73), 1/19/2023 (132/78), and 1/20/2023 (133/102). The MAR revealed that Midodrine was administered on other dates when Resident #367 had similar blood pressures readings. Registered Nurse (RN) #7 (7 AM-3 PM medication nurse) was interviewed on 1/24/2023 at 10:28 AM. RN #7 stated Physician's orders for Midodrine did not include blood pressure parameters. RN #7 stated that Midodrine should be held for systolic blood pressure above 110 mmHg. Licensed Practical Nurse (LPN) #2 (7 AM-3 PM nurse) was interviewed on 1/24/2023 at 11:43 AM and stated there should be a hold parameter for Midodrine. RN #8 (unit supervisor) was interviewed on 1/25/2023 at 10:07 AM and stated as far as the Midodrine, there usually are blood pressure parameters and RN #8 stated they (RN #8) would talk to the primary doctor because a discussion is needed between the primary doctor and the dialysis doctor regarding the Midodrine. Primary Physician #1 was interviewed on 1/25/2023 at 10:35 AM and stated the resident's blood pressures will be reviewed, parameters will be issued, and the orders will be clarified because the order to monitor blood pressure did not provide direction for the nurses. A new order for Midodrine was entered on 1/25/2023 at 1:35 PM documenting to administer Midodrine 5 mg tablet, give 2 tablets 3 times a day, call physician if blood pressure is above 120/80 mmHg, for diagnosis of Orthostatic Hypotension. The Physician's orders did not include to monitor the resident's blood pressure in supine, sitting, and or standing positions as per the manufacturer's recommendations. The Director of Nursing Services (DNS) was interviewed on 1/26/2203 at 8:18 AM and stated they (DNS) have never seen an order for Midodrine with blood pressure parameters. The DNS stated blood pressure medication orders are resident specific and any special monitoring should be indicated in the order. 10 NYCRR 415.15(b)(1)(i)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 1/19/2023 and completed on 1/26/2023, the facility did not ensure that residents who requested the Pneumococcal Vaccination received the Pneumococcal Vaccinations in a timely manner. This was identified for three (Resident #17, and #23, #60) of five residents reviewed for immunization. Specifically, Resident #17, #23, and #60 signed a consent form to receive the Pneumococcal Vaccine in September 2022, however, all three residents did not receive the vaccine as per their request. The finding is: The Facility's Policy and Procedure for Influenza & Pneumococcal Immunization dated 4/2022 documented that the Pneumococcal vaccine will be offered upon admission. Residents are given the right to accept or refuse the vaccination, given the resident is provided proper education for declination. Immunizations will be recorded on the medication administration record and the immunization record. 1a) Resident #17 was admitted with diagnoses including Septicemia, Multiple Sclerosis and Anxiety Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS documented that the resident was up to date with their Pneumonia and Influenza vaccinations at the time of the MDS assessment. The consent form for Pneumococcal Vaccination was signed by Residents #17 on 9/20/2022. The Comprehensive Care Plan (CCP) for at Risk for Pneumonia dated 1/19/2023 documented that the resident should be administered a Pneumonia Vaccine. 1b) Resident #23 was admitted with diagnoses including Diabetes Mellitus, Malnutrition, and Chronic Obstructive Pulmonary Disease. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS documented that the resident was up to date with their Pneumonia and Influenza vaccinations at the time of the MDS assessment. The consent form for Pneumococcal Vaccination was signed by Residents #23 on 9/22/2022. The Comprehensive Care Plan (CCP) for at Risk for Pneumonia dated 1/19/2023 documented that the resident should be administered a Pneumonia Vaccine. 1c) Resident #60 was admitted with diagnoses including Alzheimer's Dementia, Malnutrition, and Depression. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severely impaired cognition. The MDS documented that the resident was up to date with their pneumonia and influenza vaccinations at the time of the MDS assessment. Resident #60 was first admitted on [DATE]. The consent form for Pneumococcal Vaccination was signed by Residents #60; however, was not dated. The Comprehensive Care Plan (CCP) for at Risk for Pneumonia dated 1/19/2023 documented that the resident should be administered a Pneumonia Vaccine. The admission Nursing Note for Resident #60 dated 10/01/2022 documented the resident's Pneumococcal immunization status was unknown. The current MDS Coordinator was interviewed on 1/23/2023 at 2:43 PM and stated upon admission they (MDS Coordinator) ask the resident or the family if the resident had received the Pneumococcal Vaccination within the last five years. At times the resident's or the family members are not aware of their immunization status. The MDS Coordinator stated they do not follow up to validate if or when the Pneumococcal Vaccination was administered. The MDS Coordinator stated that Pneumococcal Vaccination is supposed to be administered five years after the vaccine was first administered to the resident. If the resident or the family member can provide the vaccination date the facility would approach the resident five years after the date of the vaccination. If the resident has not received the Pneumococcal Vaccination and consents to receive the vaccination the facility would administer the vaccine and then approach the resident again in five years. The current Director of Nursing Services (DNS) was interviewed on 1/24/2023 at 2:45 PM and stated that the Unit Manager reviews immunization records. The Assistant Director of Nursing Services (ADNS)/Infection Control Nurse oversees consent forms. The facility will take the resident or family's word regarding the immunization status and documents what they report. The infection control nurse is responsible to ensure each resident's vaccination status is up to date and if a resident refuses, the resident is informed of risks and benefits. If a resident wants the Pneumococcal vaccination, the resident will sign a consent. The DNS stated there has been trouble getting the Pneumococcal vaccination for residents and the vaccine is on back-order. The DNS was unaware that residents have been waiting for the Pneumococcal Vaccination since September of 2022. The DNS further stated they (DNS) should have been made aware of the issue with obtaining Pneumococcal vaccinations and was made aware only recently. The current ADNS/Infection Control Nurse was interviewed on 1/24/2023 at 3:05 PM and stated the Pneumococcal Vaccine has been out of stock and they (ADNS) spoke to a representative at the pharmacy on 1/12/2023 and the facility would be receiving the Pneumococcal vaccines soon. The facility tries to administer the Pneumococcal Vaccination to the long-term residents first since they will be with the facility for a long-term. The ADNS stated they did not reach out to another pharmacy to obtain the Pneumococcal Vaccination. The ADNS further stated that they made the DNS aware of the Pneumococcal vaccine being out of stock, however, could not recall when. 10 NYCRR 415.19(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review during the Recertification survey the facility did not ensure that each resident had a person-centered Comprehensive Care Plan (CCP) developed and implemented to meet the resident's medical, nursing, psychosocial needs. This was identified for 1 (Resident #209) of 4 residents reviewed for Pressure Ulcer; 1 (Resident #58) of 3 residents reviewed for nutrition; and 1 (Resident # 103) of 4 residents reviewed for Mood and Behavior. Specifically, 1) the facility did not ensure that a Pain CCP was developed with specific goals and individualized interventions for Resident #209, 2) the facility did not develop a CCP to address Resident #58's refusals to take a Liquid Protein Supplement (LPS), and 3) the facility did not implement the safety intervention identified in a interdisciplinary team care plan meeting to not provide Resident # 103 with a knife on the tray to prevent self harm. The findings are: 1) The facility CCP Policy dated 3/2019 documented that the CCP shall be developed and initiated by the interdisciplinary team and define the problem/needs, attainable goals and interventions. Each discipline is responsible for assessing the resident and completing their required documentation in the medical record. Resident # 209 was admitted to the facility with the diagnosis of Alzheimer's Disease, Hemiplegia, and Seizure Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 209 had a Brief Interview for Mental Status (BIMS) Score of 10 indicating moderately impaired cognition. The MDS documented Resident # 209 received scheduled pain medication and had no pain at any time in the last 5 days. The care plan for Pain dated 1/14/20 documented a focus of alteration in comfort secondary to an unspecified diagnosis. The goals and interventions were not completed. The Physician's Order dated 2/4/20 ordered Percocet 5-325 milligrams (mg) as needed and Tylenol 325 mg 2 tablets 30 minutes prior to dressing change. The Medication Administration Record (MAR) documented Tylenol was administered daily in the month of February 2020. Resident # 209 was observed on 2/13/20 at 9:41 AM lying in her bed wearing bilateral heel booties. Resident # 209 requested the heel booties be removed and stated that the booties are too hot and caused feet pain. The Registered Nurse (RN) Supervisor was informed of Resident # 209's complaint of pain and went to see the resident. The RN Supervisor stated that Resident # 209 declined pain medication and just wanted the heel booties removed Resident #209 was attempting to remove them and the RN Supervisor placed the booties back on with adjustments made. The RN Supervisor stated that Resident # 209 required the heel booties for Deep Tissue Injuries on the heels and needs to keep the booties on. The RN Supervisor was interviewed on 2/14/20 at 11:32 AM. The RN Supervisor reviewed the care plan and stated that she initiated the pain care plan but it was never completed. The Assistant Director of Nursing Services (ADNS) was interviewed on 2/14/20 at 12:12 PM. The ADNS stated that the plan of care should have been developed with goals and interventions based on the Resident's condition. 2) Resident # 58 was admitted to the facility with the diagnoses of Stage 4 Sacral and Left Buttock Pressure Ulcers, Pneumonia and Urinary Tract Infection. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS documented the resident required set up help only for eating. The MDS also documented the resident did not present with any behavior of rejection of care. A Physician's order dated 10/10/19 documented Supplement- Liquid protein Supplement (LPS) 30 milliliter (ml) by mouth twice a day (BID). A Physician's order dated 1/31/20 documented to increase the LPS 30 ml from BID to three times a day (TID). A Nurse's Progress Note dated 2/1/20 documented Resident #58 refused LPS and stated that she does not like it. A review of the Medication Administration Records (MARs) from November 1, 2019 to February 17, 2020 revealed that the LPS was not administered to the resident because the resident refused the LPS 20 days in November 2019, 11 days in December 2019, 16 days in January 2020, and 10 days in February 2020. A review of the electronic medical record, including interdisciplinary notes (Medical, Nursing, Dietary and Social Work) from August 2019 to February 2020 revealed no documentation related with the resident refusing the LPS supplement. A review of the Comprehensive Care Plans (CCP) from August 2019 through February 2020 revealed no CCP addressing the resident's frequent refusal to take the LPS. The Social Worker (SW) was interviewed on 2/14/19 at 10:30 AM. The SW stated she did not recall being informed about Resident #58's refusal to take the LPS supplement. The SW stated that if she knew the resident was refusing to take the supplement she would have informed the Physician and met with the resident to find out why she was refusing. The SW stated that she would have educated the resident and her family member who was very involved with the resident's care. The SW reviewed the CCP and stated she did not see a CCP for refusing care. The SW stated that any Department could initiate a CCP and if she had been made aware she would have initiated a CCP. The SW also reviewed the MDS dated [DATE] and stated that she was responsible for completing the behavior section of MDS. The SW further stated that based on resident's refusal to take the supplement on three days (11/17/19, 11/18/19 and 11/19/19) during the assessment review period she should have documented the rejection of care in the behavior section of MDS. The Dietitian was interviewed on 2/14/19 at 11:00 AM. The Dietitian stated that she speaks with the resident daily but she was not aware that the resident was refusing the LPS. The Dietitian stated the Nurses did not inform her of the resident's refusal and she does not have access to the MAR. She further stated she did not recall if rejection of care was discussed at the CCP meeting dated 11/25/19. The 7:00 AM-3:00 PM Licensed Practical Nurse (LPN) who had documented the resident's frequent refusals of LPS was interviewed on 2/18/20 at 9:28 AM. The LPN stated that she had cared for the resident since November 2019. The LPN stated that the resident does not like the LPS and frequently refused it. The LPN stated that she had told the Nurse Practitioner (NP) and the covering Supervisors on multiple occasions about the refusal to take the LPS and that she does not recall the Supervisor's name. The LPN further stated she should have documented that she had informed the NP and the Supervisors. The NP was interviewed on 2/18/20 at 10:39 AM. The NP stated that the resident has a large wound and was being followed by the wound MD. The NP stated that she was informed about the resident refusing the LPS on one occasion and was not made aware that the refusals were an ongoing problem. She further stated that the second time she heard about the resident's refusal to take the LPS was yesterday. The Physician was interviewed on 2/19/20 at 11:19 AM and stated she was made aware of the resident refusing the LPS once or twice but was not told that the resident was refusing the LPS frequently. 3) The facility Comprehensive Care Plan (CCP) policy dated 3/2019 documented that it is the responsibility of each team member to inform other caregivers of any changes in the resident's plan of care. Each department head is responsible to educate/in-service the comprehensive care process to their appropriate staff. Resident # 103 was admitted to the facility with the diagnosis of Quadriplegia, Depression and Anxiety Disorder. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 209 had a Brief Interview for Mental Status (BIMS) Score of 15 indicating intact cognition. The accident/incident report dated 10/9/18 documented that a CNA responded to the call bell in the shower room and observed Resident #103 with self inflicted stab wounds on his abdomen, laceration to his left arm, and a bloody knife in his lap. The Emergency Medical Services (EMS) and Police arrived and resumed care for Resident #103. Resident #103 was transferred to a Hospital. The Behavior Care Plan dated 11/8/12 documented that on 2/7/20, Resident #103 made reference to an episode of suicide attempt that occurred last year. The Behavior Care Plan note dated 12/23/19 documented the team continues to meet regularly and staff continues to hold the resident's adaptive fork. The staff gives the resident the fork at all meals, then when the meal is over the staff takes the fork back. The resident does not have a knife on his tray and the staff cuts his food. The Mood State Care Plan dated 11/8/12 documented that Resident #103 has a diagnosis of Major Depressive Disorder and Anxiety Disorder. Resident #103 had a suicide attempt and was hospitalized and returned to the facility on [DATE]. Interventions included Psychiatry consultation, weekly Social Work visits, all packages will be opened with staff present, Psychology sessions twice per month, and adaptive utensils will be provided to the resident at meals and kept at nursing station in between meals. Resident # 103 was interviewed on 2/13/2020 at 9:20 AM. Resident #103 stated that he made a suicide attempt in the facility about 15 months ago. He stated that he was trying to get permission to go out on pass independently and currently cannot go out unless he is accompanied by a visitor. He further stated that he recently made a remark referencing his previous attempt and the staff overreacted to it. On 2/14/20 at 1:22 PM, Resident #103 was observed eating the lunch meal. A knife was observed on the tray. An observation of Resident # 103's lunch meal ticket dated 2/14/20 did not document any restrictions for utensils. The 7 AM-3 PM Registered Nurse (RN) Supervisor was interviewed on 2/14/20 at 1:23 PM and stated that Resident #103 normally does not have utensils on his tray and that this observation was an oversight of the CNA. The resident was not supposed to have a knife due to a history of self harm. The meal ticket did not have the knife restriction on it but the nurses and CNA know the resident is not allowed to have a knife. CNA #1 was interviewed on 2/14/20 at 1:27 PM. CNA #1 stated that she was the regularly assigned 7 AM-3 PM CNA for Resident #103. CNA #1 stated that she did not realize the utensils were silverware and the resident usually has plastic utensils and an adaptive fork. CNA #1 stated that she cut up the resident's food and forgot to remove the knife. She stated that she did receive direction not to provide Resident #103 with a knife and he must return the adaptive fork to the CNA or Nurse after every meal. The Director of Social Work (SW) was interviewed on 2/14/20 at 1:45 PM. The SW Director reviewed the care plan and stated that Resident #103 had restrictions with utensils put in place because he had a self harm episode a year ago. The SW Director stated that the knife restriction on the meal tray was given to dietary to implement. She stated she would have to check with the dietary department if the intervention was put in place. The Director of Food Service was interviewed on 2/14/20 at 2:08 PM. The Director of Food Service stated that she never received any directives from anyone on the team not to place a knife on the tray. The Director of Food Service stated she was not present for the care plan meeting on 12/23/19. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the Recertification Survey the facility did not ensure that each residents Comprehensive care Plan (CCP) was reviewed and revised to reflect the resident's most current status. This was identified for 1 (Resident #209) of 4 residents reviewed for Pressure Ulcers. Specifically, Resident # 209 did not have the Pressure Ulcer CCP updated to reflect the intervention of using heel booties. The finding is: The facility Comprehensive Care Plan dated 3/2019 documented that the comprehensive care plan shall be reviewed and updated by the interdisciplinary team if the resident's condition warrants it. Each discipline is responsible for assessing the resident and completing their required documentation in the medical record. Resident # 209 was admitted to the facility with diagnoses including Alzheimer's Disease, Hemiplegia, and Seizure Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 209 had a Brief Interview for Mental Status (BIMS) Score of 10 indicating moderately impaired cognition. The MDS documented that Resident # 209 had two Unstageable Deep Tissue Injuries. The CCP for Actual Pressure Injury: Right Heel Unstageable, dated 1/19/20 documented an intervention to off load the resident's heels when in bed with the use of pillows as tolerated and to assess pain as needed. The CCP for Actual Pressure Injury: Left Heel Unstageable dated 1/19/20 documented an intervention to off load the resident's heels when in bed with the use of pillows as tolerated and to assess pain as needed. The Nursing Progress Note dated 2/3/20 documented that Resident # 209 went out for the wound care appointment and returned to the facility. The treatment changed to Santyl with adaptic and dry dressing daily. The nursing staff will continue to turn and position Resident #209 every 2 hours while in bed and will continue the plan of care. The Physician's Order dated 2/4/20 documented to offload bilateral heels while in bed. Resident # 209 was observed on 2/13/20 at 9:41 AM lying in her bed wearing bilateral heel booties. Resident # 209 requested the heel booties be removed and stated that the booties are too hot and cause feet pain. The Registered Nurse (RN) Supervisor was informed of Resident # 209's complaint of pain and went to see the resident. The RN Supervisor stated that Resident # 209 declined pain medication and just wanted the heel booties removed. Resident #209 was attempting to remove the booties and the RN Supervisor placed the booties back on with adjustments made. The RN Supervisor stated that Resident # 209 required the heel booties for Deep Tissue Injuries on the heels and needs to keep the booties on. Resident # 209 was observed on 2/14/20 at 9:50 AM lying in bed wearing bilateral heel booties. Resident # 209 stated that she had pain and wanted her booties off. The RN Supervisor was informed of Resident # 209's complaint and visited the resident to provide assistance. The RN Supervisor stated that she could remove the booties for brief periods and did not on 2/13/20 and today (2/14/20). The RN Supervisor stated that she issued the booties after the outside Wound Care Physician recommended them. The RN Supervisor reviewed the care plan and stated that the use of the booties are not in the care plan. She stated that this new intervention should have been reflected in the plan of care and that she should have updated the care plan. She further stated that because the heel booties cause discomfort she would consult with the Occupational Therapist to find out if there are any alternatives. The Assistant Director of Nursing Services (ADNS) was interviewed on 2/14/20 at 12:12 PM. The ADNS stated that the plan of care should have been reviewed and revised to reflect the new intervention. 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the Recertification Survey, the facility did not provide timely services to prevent the development of a Stage 3 Sacral Pressure Ulcer. This was identified for one (Resident #198) of four residents reviewed for Pressure Ulcers (PU). Specifically, Resident # 198 with moderate risk for developing PU was identified with a skin opening to the left buttock by the Certified Nursing Assistants (CNAs) on 1/20/2020, 1/21/2020 and 1/25/2020. The CNAs reported skin impairment to a Licensed Practical Nurse (LPN). The resident's medical records lacked documented evidence of an assessment by a qualified health professional or a physician's order for a treatment to the left buttock until after 15 days on 2/4/2020 when the left buttock wound was identified as a Stage 3 Pressure Ulcer. Additionally, the physician ordered treatment was not implemented until the next day on 2/5/2020. The finding is: The facility policy and procedure titled Risk Management/Pressure Ulcer Prevention and Wound Management last reviewed 1/20/2020 documented the Certified Nursing Assistant (CNA) will provide daily observation of the skin integrity during care and report any findings to the Unit Charge Nurse; The Registered Nurse (RN) Manager/RN Supervisor will assess the area, document findings in the medical record, and ensure that an appropriate treatment is obtained from the Personal Care Physician/Nurse Practitioner (PCP/NP). Resident #198 was admitted to the facility with diagnoses including Dementia, Diabetes, and Parkinson's Disease. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) Score of 5, indicating severely impaired cognition. The MDS documented the resident required assist of one staff member for bed mobility and two staff members for transfer. The MDS documented that the resident was always incontinent of bowel and bladder. The MDS also documented the resident had no unhealed pressure ulcers and did not address (section M0150) if the resident was at risk for pressure ulcer development The Braden Scale Assessment (which assesses P/U risk) dated 1/3/2020 documented the resident was at moderate risk for pressure ulcers. The Comprehensive Care Plan (CCP) for Pressure Ulcer, effective date 2/22/2018, documented the resident was at risk for pressure ulcer related to: immobility, incontinence, and Parkinson's Disease. Interventions included to provide a cushion in the wheelchair, to encourage the resident to change position in bed, to lubricate the skin and to monitor for redness and skin breakdown at pressure points. Additional interventions included to initiate treatment per physician's order, turn and position every two hours, pressure relief mattress and preventative skin care. The CCP updated evaluations: dated 4/12/2018, 4/24/2018, 7/28/2018, 10/25/2018, 12/17/2018, 5/1/2019 and 7/26/2019, documented that the resident was free of pressure ulcers. The CCP was updated on 2/4/2020 and documented that the resident was noted with a wound on the left buttock measuring 5 centimeters (cm) X 4 (cm). The Facility Accident/Incident (A/I) Investigation Summary was initiated on 2/5/2020 and completed on 2/6/2020. The investigation summary documented the resident was compromised and was at risk for pressure ulcer development secondary to impaired immobility and dependence on staff for all care. The wound was discovered (no date provided) and treatment was applied (no date provided). The summary stated that the Nurse (not identified) did not put a treatment order into the computer. There was no determination made as to when the skin changes were first noted and when the treatment was put in place. The Supervisor/RN #2 received a Disciplinary Notice on 2/6/20 for administering a treatment and failing to get the physician's order. A Nursing Progress Note dated 2/4/2020 documented the resident was noted with a wound to the left buttock. The Nurse Practitioner (NP) was made aware and a Wound Care Consult was ordered. A Physician's Order dated 2/4/2020 documented to administer Santyl 250 unit/gram topical ointment (an enzymatic debriding agent used to help in the healing of skin ulcers by removing dead skin and tissue) daily to the buttock. The indication was for Pressure Ulcer to the left buttock. The medical record lacked documented evidence of skin impairment, assessment related to an open skin impairment to left buttock or a treatment order to the left buttock until February 4, 2020. The Medication Administration Record (MAR) documented that the treatment to the Stage 3 Pressure Ulcer was initiated on 2/5/2020. The Medical Progress Note by the resident's attending Physician dated 2/12/2020 documented the resident was seen by the Wound Doctor for a Pressure Ulcer on the left buttock, Stage 3 measuring 4 cm X 3 cm X 0.3 cm, 5% granulation and 95 % yellow slough. The Physician's plan of care included to continue the treatment. CNA #1 was interviewed on 2/19/2020 at 12:07 PM. CNA #1 stated that she works on the 3:00 PM-11:00 PM shift and that Resident #198 was on her assignment. CNA #1 stated that while administering care to Resident #198 on 1/20/2020, she noted an opening on the resident's left buttock. CNA #1 stated that the opening was small, pink in color and had no drainage. CNA #1 stated that the unit nurse (LPN #1) was notified promptly following the completion of the resident's care needs. CNA #1 stated that the following day (1/21/2020) when CNA #1 rendered care to Resident #198, there were no dressings or creams observed by CNA #1 to the area, the wound appeared worse to CNA #1 and the unit nurse (LPN #1) was notified. CNA #1 stated that the unit nurse (LPN # 1) gave the CNA cream to apply on 1/21/2020. CNA #3 was interviewed on 2/19/2020 at 12:23 PM. CNA #3 stated that when giving a shower to resident #198 on 1/21/2020 an opening was noted. CNA #3 stated that the nurse was notified (LPN # 1). CNA #3 stated that the wound appeared about the size of a fingernail, a small scratch with some drainage. CNA #3 stated that the unit nurse (LPN #1) handed the CNA #3 a tube of A & D Ointment (a skin protectant for moisturizing and sealing the skin) and stated to CNA #3 that she (LPN #1) was aware of the wound. LPN #1 was interviewed on 2/19/2020 at 1:02 PM. LPN #1 stated that when she was notified about the wound by CNA #1, she looked at it. LPN #1 described the wound as red and small, like a little scratch. LPN #1 could not recall the date the skin impairment was reported to her. LPN #1 stated that she reported her findings to the Supervisor/RN #2; and that LPN #1 also spoke to the NP/RN #1. The Supervisor/RN #2 and the NP were interviewed separately on 2/18/2020 and 2/19/2020 respectively, and they both stated that they did not recall being notified of the resident's left buttock wound prior to 2/4/2020. They both described the wound as a stage 3 Pressure Ulcer. CNA #2 was interviewed on 2/19/2020 at 9:47 AM. CNA #2 stated that during the care of Resident #198, on 1/25/2020 on Unit 4, a bedsore was noticed on the resident's buttock. CNA #2 stated that the resident was left in bed and the opening was reported to the unit nurse (LPN # 2). LPN #2 was interviewed on 2/19/2020 at 12:45 PM. LPN #2 stated that the wound had not been reported to her on 1/25/20 and that she had not seen the wound until 2/4/2020. The Assistant Director of Nursing (ADNS #1)/LPN was interviewed on 2/19/2020 at 1:30 PM. The ADNS stated that the RN was applying Santyl to the wound (date not given) but failed to put the treatment order in. The wound was observed on 2/19/20 at 1:30 PM. A Stage 3 Pressure Ulcer was located on the left buttock. There were no signs of infection. The wound appeared visually to measure approximately 3.0 cm X 2.5 cm X 0.3 cm. 415.12(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure that residents were free from significant medication errors. This was identified for one of four residents reviewed for Choices. Specifically, for Resident #162, the facility did not ensure the resident was administered Metoprolol in accordance with the physician's order for 4 days in January 2020 and 15 days in February 2020. The finding is: The policy and procedure for Medication Administration, dated 1/1/20 documented the licensed nurse will assure the 5 rights as follows; compares the medication name, strength, route and dosage schedule on the medication administration record against the prescription label. Always checks three times prior to the administration of the medication. Resident #162 has diagnoses including Atrial Fibrillation, Hypertension, and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for mental Status (BIMS) Score of 15, indicating the resident was cognitively intact. A physician's progress note dated 1/28/20, describing an evaluation conducted on 1/27/20, documented the physician's intention to discontinue an order for Amlodipine and to reduce the Metoprolol dose from twice a day to once a day due to the resident's blood pressure being on the low side. Physician orders for the Months of January 2020 and February 2020 were reviewed and revealed that the resident had orders to receive Metoprolol Tartrate 50 milligrams (mg) 2 times per day for a diagnosis of Essential Hypertension. The order was changed to Metoprolol Tartrate 50 mg 1 time per day on 1/27/20. The Medication Administration Records (MARs) for the Months of January 2020 and February 2020 revealed the resident continued to receive Metoprolol Tartrate 50 mg 2 times per day from 1/28/20 to 2/17/20 with the exception of 2/1/20 and 2/9/20 when the resident received only the morning doses. Licensed Practical Nurse (LPN #1) was interviewed on 2/18/2020 at 3:00 PM and stated that she looks at both the blister pack and the resident orders prior to dispensing medications. She stated that she followed the blister pack instructions which read, Metoprolol Tartrate 50 mg 1 tab by mouth twice a day; however, this conflicted with the order change on 1/27/20. She stated that she was not aware that the blister pack being used reflected the old orders. LPN #2 was interviewed on 2/19/20 at 2:00 PM. LPN #2 stated that she looks at both the blister pack and the resident orders prior to dispensing medications. LPN #2 stated that the old blister packs are returned to the pharmacy and replaced with the new blister packs by the unit nurses. She stated she was unaware that the old blister pack, reflecting a twice a day dose was the one still being used. The Nurse Practitioner (NP #1) was interviewed on 2/18/20 at 3:15 PM. NP #1 stated that the resident's Metoprolol was reduced by the physician because her blood pressure was fine in January. She further stated that the resident should have received the medication as ordered. The Director of Nursing Services (DNS) was interviewed on 2/19/20 at 2:30 PM. The DNS stated that the orders should have been followed as written. The DNS stated the old blister pack should have been returned to the pharmacy by any one of the nurses on duty and replaced with the newly ordered medication blister pack. The DNS acknowledged that this did not occur and that the older blister pack was used resulting in the medication being dispensed inaccurately. 415.12(m)(2)