**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #s NY00302427, NY00303564, NY00312507, and NY00313484), the facility did not ensure the resident has the right to be free from neglect for 1 (Resident #6) of 7 residents reviewed for neglect. Specifically, for Resident #6, the facility did not ensure facility staff followed the resident's [NAME] (care plan) that documented that the resident was to have a lap buddy (a soft tray-like device with slots that fit around the arm rests of a wheelchair to prevent a fall out of a wheelchair) when in their wheelchair. On 10/9/2022, Certified Nurse Aide did not place the lap buddy on the resident's wheelchair and subsequently the resident fell out of their wheelchair, was transferred immediately to the emergency department (ED), and diagnosed with a swollen, bruised left eye and fractured nose. This was evidenced by: The Policy and Procedure (P&P) titled, Abuse Prevention and Reporting dated 10/2019, documented the purpose of the P&P was to ensure that all residents of the facility were free from neglect. Resident #6 Resident #6 was admitted to the facility with diagnoses of dementia, diabetes, and anxiety disorder. The Minimum Data Set (MDS- an assessment tool) dated 8/29/2022 documented the resident had severe cognitive impairment, could be understood, and could sometimes understand others. The Comprehensive Care Plan (CCP) for Behavior dated 8/1/2019, documented the resident had a history of self-transferring. The CCP for Restraint Use-Frequent Falls dated 8/29/2019, documented the resident required restraint use due to risk for injury from frequent falls. The resident was to have a lap buddy applied when in their wheelchair. The CNA [NAME] (undated) documented the resident was to have a lap buddy for lack of safety awareness when in their chair and released every 2 hours for repositioning. The MDS dated [DATE], documented the resident had a trunk restraint that was used daily. A Medical Doctor (MD) order dated 11/26/2019, documented a lap buddy to be used while Resident #6 was in their wheelchair for positioning and lack of safety awareness. Release every 2 hours for 15 minutes. A Nurse's Note dated 10/9/2022 at 10:56 AM, documented Registered Nurse Supervisor #1 (RNS) was called to the unit. Resident #6 was on the floor bleeding from a head laceration on their left temple area, and their nose was bleeding. 911 was called and the on-call MD was notified. A Nurse's Note dated 10/9/2022 at 12:14 PM, documented the nurse at the ED reported Resident #6 was returning to the facility with a fractured nose and a swollen bruised left eye. The MD was notified. The ED Provider Notes dated 10/9/2022 at 11:15 AM, documented the resident had a nondisplaced nasal bone fracture. No further intervention necessary. Will discharge with Tylenol. During an interview on 4/6/2023 at 10:53 AM, the Medical Director stated Resident #6 had a lap buddy in place when in their wheelchair due to poor judgement and they did not have very good trunk support. Unfortunately, the lack of the lap buddy's use contributed to the resident's fall. The Medical Director stated a fracture nose was not a serious injury as long as the resident did not have difficulty breathing or developed a fever (that could indicate a possible infection). It was more a question of managing the pain from the injury. During an interview on 4/6/2023 at 11:18 AM, the Director of Nursing (DON) stated they realized the staff assigned to the resident did not follow the resident's care plan. The resident's lap buddy was found on the floor of their room. The DON stated RNS #1 was witness to the fact the resident did not have the lap buddy in place at time they assessed the resident. The resident had facial injuries as a result of their fall. They stated the resident had bilateral black eyes and a fractured nose. The DON stated the resident would not have fallen if the lap buddy had been in place. It was an intervention that worked very well for them. They stated the resident would slide out of their wheelchair and it was in place to keep them safe from sliding out. The DON stated the CNAs were supposed to be looking at the residents' [NAME] daily. There was a binder at the nurses' stations and in the electronic medical record where the CNAs documented the care provided. A message was sent through electronic messaging if a change in a resident's [NAME] occurred. During an interview on 5/2/2023 at 1:13 PM, RNS #1 stated they were called about 9:56 AM (on 10/9/2022) to Resident #6's unit. They found the resident lying on the floor of the common area with bleeding from their nose, a laceration to the temple of their head and bleeding from their eye socket from a laceration. RNS #1 stated they did not feel comfortable moving Resident #6, so they called 911 and then the medical provider. The RNS stated the resident had been in their wheelchair but did not witness the fall. The resident was supposed to have a lap buddy, and the lap buddy was not in place. RNS #1 stated they searched for it and the lap buddy was found in the resident's room by the side of their dresser. The RNS stated the resident would not have been able to remove it and place it where it was found in their room. Attempts to contact CNA #6 were unsuccessful. 10 NYCRR 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #s NY00302427, NY00303564, NY00312507, and #NY00313484), the facility did not ensure that in response to allegations of abuse, the facility must ensure all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Specifically, the facility did not ensure abuse was reported to the Department of Health (DOH) or reported within 2 hours if the events that cause the allegation involve abuse or result in serious bodily injury, for 5 (Resident #s 1, 2, 3, 4, and 5) of 7 residents reviewed for abuse. For Resident #1, the facility did not report an incident of alleged sexual abuse until 4 hours after the resident reported the incident, for Resident #2, the facility did not report an incident of alleged sexual abuse until 5 hours after the resident reported the incident. For Resident #s 3 and 4, the facility did not report an allegation of sexual abuse made by Resident #4 against Resident #3 to DOH. For Resident #s 4 and 5, the facility did not report an alleged resident-to-resident altercation between the 2 residents to DOH. This was evidenced by: The Policy and Procedure dated 10/2019 titled, Abuse Prevention and Reporting documented by regulation the facility was responsible to report alleged violations of abuse to the Director of Nurses (DON), and the Administrator in accordance with State law, to DOH as soon as possible, but not to exceed 24 hours after the discovery of the alleged abuse. Resident #1 Resident #1 was admitted to the facility with diagnoses of dementia with psychotic disturbance (hallucinations, delusions, confused, and disturbed thoughts), Alzheimer's disease, and schizoaffective disorder, bipolar type. The Minimum Data Set (MDS- an assessment tool) dated 2/28/2023, documented the resident had severe cognitive impairment, could be understood, and could understand others. The undated and untimed Nursing Home Investigative Report submitted to DOH documented the incident occurred on 3/27/2023 at 8:00 AM. An email from Survey Builder at DOH, documented the Nursing Home Incident Report was submitted on 3/27/2023 at 12:11 PM. During an interview on 4/5/2023 at 1:13 PM, the Administrator stated abuse needed to be reported within 2 hours if bodily harm occurred and 24 hours if no injury occurred. During an interview on 4/5/2023 at 1:41 PM, the DON stated abuse needed to be reported within 2 hours if injury occurred and within 24 hours if no injury. The DON stated they would report abuse as soon as they found out about an incident. Resident #4 Resident #4 was admitted to the facility with diagnoses of dementia, psychotic disorder, and diabetes. The MDS dated [DATE], documented the resident had moderate cognitive impairment, could be understood, and could usually understand others. A Nursing Note dated 3/26/2023 at 10:20 AM, documented Resident #4 was in their wheelchair in Resident #5's doorway. Resident #5 asked Resident #4 to move. Resident #4 would not move, and they hit Resident #5 on top of their left thigh 2-3 times with a closed fist. There was no documentation that the incident was reported to DOH. During an interview on 4/5/2023 at 1:13 PM, the Administrator stated they did not know why the incident was not reported to DOH. Abuse needed to be reported within 2 hours if bodily harm occurred and 24 hours if no injury occurred. During an interview on 4/5/2023 at 1:41 PM, the DON stated both Resident #s 4 and 5 had behaviors. The DON stated the incident probably should have been reported. They stated abuse needed to be reported within 2 hours if injury occurred and within 24 hours if no injury. The DON stated they would report abuse as soon as they found out about an incident. Resident #5 Resident #5 was admitted to the facility with diagnoses of diabetes, seizure disorder, and coronary artery disease. The MDS dated [DATE], documented the resident had moderate cognitive impairment, could be understood, and could understand others. A Nursing Note dated 3/26/2023 at 10:24 AM, documented Resident #5 was in their wheelchair in the hallway attempting to enter their room. Resident #4 was in their wheelchair in the doorway of Resident #5's room. Resident #5 asked them to move, and when Resident #4 would not, Resident #5 attempted to move Resident #4's wheelchair with their foot. Resident #4 then hit Resident #5 on the left thigh with a closed fist 2-3 times. There was no documentation that the incident was reported to DOH. During an interview on 4/5/2023 at 1:13 PM, the Administrator stated they did not know why the incident was not reported to DOH. They stated abuse needed to be reported within 2 hours if bodily harm occurred and 24 hours if no injury occurred. During an interview on 4/5/2023 at 1:41 PM, the DON stated both Resident #s 4 and 5 had behaviors. The DON stated the incident probably should have been reported. They stated abuse needed to be reported within 2 hours if injury occurred and within 24 hours if no injury. The DON stated they would report abuse as soon as they found out about an incident. 10 NYCRR 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #s NY00302427, NY00303564, NY00312507, and NY00313484), the facility did not ensure in response to allegations of abuse and neglect the facility must have evidence that all alleged violations are thoroughly investigated for 4 (Resident #s 4, 5, 6, and 7) of 7 residents reviewed for abuse and neglect investigations. Specifically, incidents that involved Resident #s 4, 5, 6, and 7's did not include investigative summaries, or the summaries that were included were not thorough. This was evidenced by: The Policy and Procedure dated 10/2019 titled, Abuse Prevention and Reporting documented the Administrator will ensure that a complete investigation is conducted. The Director of Nursing (DON) or designee shall coordinate all investigations including but not limited to the following tasks: conducting interviews with staff and resident, writing a summary and conclusion, and what corrective steps were taken. Resident #4 Resident #4 was admitted to the facility with diagnoses of dementia, psychotic disorder, and diabetes. The Minimum Data Set (MDS- an assessment tool) dated 1/17/2023, documented the resident had moderate cognitive impairment, could be understood, and could usually understand others. A Nursing Note dated 3/26/2023 at 10:20 AM, documented Resident #4 was in their wheelchair in Resident #5's doorway. Resident #5 asked Resident #4 to move. Resident #4 would not move, and they hit Resident #5 on top of their left thigh 2-3 times with a closed fist. There was no documentation of the facility's investigation summary of the incident. Resident #5: Resident #5 was admitted to the facility with diagnoses of diabetes, seizure disorder, and coronary artery disease. The MDS dated [DATE], documented the resident had moderate cognitive impairment, could be understood, and could understand others. A Nursing Note dated 3/26/2023 at 10:24 AM, documented Resident #5 was in their wheelchair in the hallway attempting to enter their room. Resident #4 was in their wheelchair in the doorway of Resident #5's room. Resident #5 asked them to move, and when Resident #4 would not, Resident #5 attempted to move Resident #4's wheelchair with their foot. Resident #4 then hit Resident #5 on the left thigh with a closed fist 2-3 times. There was no documentation of facility's investigation summary of the incident. During an interview on 4/5/2023 at 1:13 PM, the Administrator stated an investigation would be started immediately upon report of an incident and consisted of interventions to ensure the resident(s) was/were safe, witness statements, resident statement(s), the care plan was updated as necessary, an assessment would be done on the resident, and corrective action(s) implemented to ensure an incident did not recur. During an interview on 4/5/2023 at 1:41 PM, the DON stated an investigation was not completed for the resident-to-resident incident between Resident #s 4 and 5. The DON stated an investigation was not done due to the residents' behavioral issues. They stated both Resident #s 4 and 5 had behaviors. Resident #6 Resident #6 was admitted to the facility with diagnoses of dementia, diabetes, and anxiety disorder. The MDS dated [DATE] documented the resident had severe cognitive impairment, could be understood, and could sometimes understand others. The facility investigation did not include interventions to prevent a recurrence of the care plan violation that involved Resident #6's lap buddy use. The investigation included one staff interview. A Nurse's Note dated 10/9/2022 at 10:56 AM, documented Registered Nurse Supervisor (RNS) #1 was called to the unit. Resident #6 was on the floor bleeding from their left eye socket from a laceration, a head laceration on their left temporal area. The resident's nose was bleeding. 911 called and the on-call MD was notified. During an interview on 4/5/2023 at 1:13 PM, the Administrator stated an investigation would be started immediately upon report of an incident and consisted of interventions to ensure the resident(s) was/were safe, witness statements, resident statement(s), the care plan was updated as necessary, an assessment would be done on the resident, and corrective action(s) implemented to ensure an incident did not recur. During an interview on 4/6/2023 at 9:17 AM, the DON stated an investigation consisted of staff interviews, including staff who were in the area even if they had not witnessed anything. The resident would be interviewed. An investigation summary would include a history about resident, resident records, what was done about the incident (interventions to prevent recurrence.), and a synopsis of the interviews. The DON stated an investigation must be completed within 5 days. The DON stated for this incident, CNA #6 was not interviewed because they were sent home. 10 NYCRR 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility did not ensure that its residents were free of any significant medication error during an abbreviated survey (Case #s NY00302427, NY00303564, NY00312507, NY00313484, and NY00316282) for 3 residents (Resident #s 9, 10, and #11) of 4 residents reviewed for significant medication errors. Specifically, for Resident #9, the facility did not ensure licensed staff did not administer a medication used to treat anxiety (diazepam-a controlled substance) that was on hold from 12/9- 12/13/2022 on 2 occasions (12/10/2023 and 12/12/2023), for Resident #10, the facility did not ensure that facility staff administered the correct doseage of a controlled substance to treat anxiety (clonazepam) after the doseage of clonazepam was reduced by the Medical Doctor (MD) on 4/19/2023 from clonazepam 0.50 mg to clonazapam 0.25 mg and for Resident #11, the facility did not ensure that the physician order for a narcotic pain medication (Percocet) for 5/325 mg, 2 tablets twice a day as needed was followed on 1 occasion, when only 1 tablet was administered. This was evidenced by: The Policy and Procedure titled, Medication Administration Safety Program documented a medication error is any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional. A medication error can also be defined as a mistake with one of the 6 rights that includes right medication, right time, and right dose. Resident #9 Resident #9 was admitted to the facility with diagnoses of Alzheimer's disease, dementia, and anxiety disorder. The Minimum Data Set (MDS- an assessment tool) dated 11/21/2022, documented the resident had severe cognitive impairment, could sometimes be understood, and could sometimes understand others. The Comprehensive Care Plan (CCP) dated 4/28/2022 for Psychotropic Drug Use: Behavior Problems, documented to administer medications as ordered. An MD (medical doctor) order dated 12/9/2022 at 6:58 PM, documented diazepam 5 (mg), 1 tablet once daily; hold from 12/9/2022 at 7:00 PM- 12/13/2022 at 12:00 PM. The 12/14/2022 facility event report, documented Licensed Practical Nurse (LPN) #2 administered Resident #9's diazepam 5 mg in error on 12/14/2022 at 10:30 AM thinking they were administering lorazepam. The error actually occurred on 12/12/2022 during the timeframe diazepam was on hold. LPN #6 also administered Resident #9 diazepam at 8:00 PM on 12/10/2022 while the medication was on hold. There was no facility medication error report regarding the incident. The 12/2022 Medication Administration Record (MAR) documented diazepam 5 mg tablet, 1 tablet once daily at 7:00 PM. It was documented as held from 12/9/2023-12/13/2023. The Controlled Medication Utilization Record dated 12/5/2022 for diazepam 5 mg daily documented LPN #6 administered diazepam 5 mg at 8:00 PM to Resident #9 on 12/10/2022. The Controlled Medication Utilization Record dated 12/5/2022 for diazepam 5 mg daily documented LPN #2 administered Diazepam 5 mg at 10:30 AM to Resident #9 on 12/12/2022. During an interview on 5/16/2023 at 1:35 PM, the Director of Nursing (DON) stated LPN #2 administered Resident #9 diazepam instead of lorazepam. The resident had a number of medication changes when LPN #2 made the medication error on 12/12/2022. Resident #10 Resident #10 was admitted to the facility with diagnoses of seizure disorder, chronic obstructive pulmonary disease (COPD), and anxiety disorder. The MDS dated [DATE], documented the resident was cognitively intact, could be understood, and could understand others. The CCP for Psychotropic Drug Use dated 3/16/2023, documented to administer medication as ordered. An MD order dated 4/19/2023 at 11:19 AM, documented clonazepam 0.25 mg (give ½ of a 0.5 mg tablet) once daily. The April 2023 MAR documented clonazepam 0.5mg tablet give 1/2 tablet (0.25 mg) once daily at 2:30 PM. The 3/30/2023 pharmacy label on the Controlled Medication Utilization Record, documented clonazepam 0.5 mg by mouth 3 times a day; DIRECTIONS CHANGED, REFER TO CHART. It documented on 4/20/2023, unknown LPN #5 (unable to decipher signature) administered 0.50 mg at 3:30 PM. On 4/24/2023, LPN #2 documented they administered 0.5 mg at 2:00 PM. The Controlled Medication Utilization Record dated 4/19/2023 for medication received from pharmacy, did not document clonazepam 0.25 mg was administered at 2:30 PM on 4/20/23 or 4/24/2023. The undated Event Report for the medication error that occurred on 4/24/2023 documented LPN #2 reported at 3:45 PM they had administered Resident #10 the wrong dose of clonazepam at 2:30 PM. They reported they administered 0.50 mg instead of 0.25 mg as ordered. A Nursing Note dated 4/24/2023 at 4:14 PM, documented LPN #2 notified Registered Nurse #4 (RN) that they administered Resident #10 the wrong dose of clonazepam at 2:30 PM. The LPN administered 0.5 mg instead of 0.25 mg as ordered. The resident had a current gradual dose reduction of clonazepam in progress. Resident #10 did not exhibit and signs or symptoms of fatigue or sedation. The Administrator on call, the medical provider, and the resident's representative were notified. During an interview on 5/16/2023 at 1:35 PM, the DON stated LPN #2 administered Resident #10, 0.50 mg of clonazepam on 4/24/2023. The MD had decreased the dose a few days prior to 0.25 mg. During an interview on 5/22/2023 at 1:07 PM, Registered Nurse Manager #1 (RNM) stated Resident #10's Clonazepam 0.50 mg three times a day was discontinued and changed to 0.25 mg once a day at 2:30 PM and 0.5 mg twice a day at 8:30 AM and 8:30 PM. During an interview on 5/22/2023 at 1:17 PM, the Interim DON, stated when there were changes to controlled substance orders, stickers were put on the pharmacy label of the Controlled Medication Utilization Record to alert the nurses there was a change and to look at the resident's chart. They stated they were unable to identify who unknown LPN #5 was. Resident #11 Resident #11 was admitted to the facility with diagnoses of Alzheimer's disease, COPD, and diabetes. The MDS dated [DATE], documented the resident had severe cognitive impairment, could be understood, and could sometimes understand others. The CCP Alteration in Comfort (Pain), documented to administer medications as ordered by the physician or nurse practitioner. The MD order for Percocet 5 mg-325 mg ordered on 6/3/2022, documented to administer 2 tablets by mouth every 3 days for chronic pain at 2:00 PM. A documented titled, Event Report dated 5/8/2023, documented on 5/7/2023 at 2:00 PM, LPN #2 administered Resident #11 one Percocet 5 mg-325 mg tablet. The order was for the resident to receive 2 tablets. The May 2023 MAR documented LPN #2 administered Resident #11's Percocet on 5/7/2023. The Controlled Medication Utilization Record dated 5/2/2023 for Percocet 5-325mg, documented on 5/7/2023, the number of remaining tablets was 18 after LPN #2 administered the Percocet at 2:00 PM. The remaining should have been 17 on the date the resident was supposed to receive 2 tablets due to their fentanyl patch being changed. On 5/8/2023 before a PRN (as needed) dose was administered, and the number of remaining tablets was 17. A Nurse's Note dated 5/8/2023 at 1:11 AM, documented an unnamed LPN notified RN #4 of the medication error that had occurred on the prior shift on 5/7/2023. Resident #11 was to receive 2 tablets of Percocet 5-325 mg on Fentanyl (a narcotic pain medication) patch change days. The resident only received 1 tablet on 5/7/2023. The resident was noted to be resting comfortably in bed at this time. The resident was not showing any signs of pain. During an interview on 5/16/2023 at 9:46 AM, the Registered Nurse Educator (RNE) stated they had been in their position just a little over a year and was unsure how often nursing competencies were conducted. The RNE stated the DON was following up on the incidents. They stated upon hire, the nurses were given a medication exam. During an interview on 5/16/2023 at 11:59 AM, Registered Nurse Manager (RNM) #1 stated they were aware of the medication errors made by LPN #2 but did not know what remediation had taken place. RNM #1 stated that LPN #2 should have been given a written exam and they should have demonstrated medication administration while supervised by licensed staff. During an interview on 5/16/2023 at 1:35 PM, the DON stated Resident #11 was prescribed 2 Percocet tablets for pain and LPN #2 only administered one on 5/7/2023. The resident did not have an increase in their pain level from being underdosed. The DON stated LPN #2 was educated following each incident. 10 NYCRR 415.12(m)(2)

Based on record review and interviews during the recertification survey dated 08/14/22 through 08/18/2022, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination for two (2) of 3 resident's reviewed. Specifically, the facility did not ensure that Residents #470 and #60, who received Medicare Part A services, received timely notification (2-day notification) of the termination of services with the required form Notice of Medicare Non-Coverage, Form CMS 10123-NOMNC. This is evidenced as follows: The document titled Notice of Medicare Non-Coverage, Form CMS 10123-NOMNC (NOMNC) and dated 12/31/2011, documents that resident #470 last received rehabilitative services on 04/27/2022 and was provided the NOMNC to inform the resident of their right to an expedited review of service termination on 04/27/2022 (date signed), the same day as the termination of services. The document titled Notice of Medicare Non-Coverage, Form CMS 10123-NOMNC and dated 12/31/2011, documents that Resident #60 last received rehabilitative services on 08/04/2022, but does not document the date when the NOMNC was provided to the resident. During an interview on 08/17/2022 at 1:48 PM, the Administrator stated that the facility will conduct trainings to ensure residents receiving Medicare Part A will receive a 2-day notification as the end of services approach and that all NOMNCs are signed and dated. 10 NYCRR 415.3 (g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews during the recertification survey dated 08/14/22 through 08/18/22, the facility did not ensure food was prepared in accordance with professional standards for food service safety in the main kitchen, one (1) of 3 Country Kitchens, and 4 of 6 Activities Kitchens (unit kitchens). Food preparation and serving areas and equipment are to be kept clean, product thermometers are to be calibrated, and kitchen equipment is to be kept in good repair. Specifically, in the main kitchen, one food product thermometer was not in calibration; on the second floor County Kitchen, the electronic thermometer display on the [NAME] dishwashing machine was not functioning; and the refrigerators and floors in the 1-East, 1-West, 2-East, and 2-West Activities Kitchens required cleaning. This is evidenced as follows: During observations on 08/14/22 at 12:24 PM, in the main kitchen, one food product thermometer read 20 degrees Fahrenheit (F) when checked for calibration in an ice bath (32 F is the calibrated temperature); on the second floor County Kitchen, while the machine was in use, the electronic thermometer display on the [NAME] dishwashing machine was not functioning; and the refrigerators, drawers, and/or floors in the 1-East, 1-West, 2-East, and 2-West Activities Kitchens were soiled food particles or dirt. During an interview on 08/14/22 at 1:04 PM, Dietary Aide #1 stated that the [NAME] dishwashing machine is utilized to wash tableware, and maintenance has been notified that the display on this dishwashing machine works only intermittently. During an interview on 08/14/22 at 1:34 PM, the Director of Support Services stated that the 2nd floor [NAME] dishwashing machine should have been tagged as being out of service; the activity kitchens are used to stock snacks and food from outside for the residents; the refrigerators, drawers, and floors noted will be cleaned; and the thermometer should have been in calibration. During an interview on 08/17/22 at 1:45 PM, the Administrator stated that the 2nd floor Country Kitchen [NAME] dishwashing machine should have been tagged as being out of service; the activity kitchens are used to stock snacks and food; the refrigerators, drawers, and floors noted will be cleaned; and the thermometer should have been in calibration. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.85, 14-1.110, 14-1.113, 14-1.170

Based on record review and interview during a recertification survey, the facility did not ensure the resident representative was informed when there was a need to alter treatment significantly for 1 (Resident #108) of 1 resident reviewed for notification of change. Specifically, the facility did not ensure the resident representative was notified of medication changes involving psychotropic medications, due to an increase in behaviors. This was evidenced by: The Policy and Procedure (P&P) titled Family Notification, last reviewed 9/2019, documented families who were on the contact list for the resident and who may receive protected health information (PHI) would be made aware of medication changes, involving psychotropic and emergent medications. Resident #108: The resident was admitted to the facility with the diagnoses of dementia, mood disorder, and anxiety. The Minimum Data Set (MDS - an assessment tool) dated 1/2/20, documented the resident had moderately impaired cognition, could sometimes understand others and could sometimes make self understood. During an interview on 1/27/20 at 12:10 PM, the resident representative stated he/she was not notified when the facility changed the resident's psychotropic medications. He/She stated the resident was very sleepy and just out of it. He/She had to ask a nurse if something had been changed and the nurse told him/her the resident's psychotropic medications had been increased. A review of nursing progress notes dated 10/29/19-12/18/19 documented: -10/29/19 at 4:24 PM: Resident became physically aggressive and attempted to punch and grab staff. The physician was notified and gave a verbal order for as needed (PRN) lorazepam (antianxiety) 0.5 milligrams (mgs) for 14 days. -10/29/19 at 4:40 PM: Nurse attempted to administer PRN lorazepam and resident spit the medication out in the nurse's face. The physician was notified and gave verbal order for one dose of IM (intramuscular) lorazepam 0.5mg/0.25ml injection. -10/29/19 at 5:24 PM: Physician gave order to discontinue PRN lorazepam and gave verbal order for 12.5 mg Trazodone (antidepressant) at 12:00 PM daily for 7 days. -10/30/19 at 10:30 AM: Tele-Psych consultation; The physician was updated on the resident's increased verbal and physical aggression. The physician agreed the additional dose of Trazodone at noon might be beneficial at this time and the resident's representative could call with any concerns. -11/2/19 at 7:49 AM: Resident was on behavior monitoring related to gradual dose increase of Trazodone. Resident was previously taking 50mg at bedtime and was now taking an additional Trazodone 12.5mg at noon. -12/4/19 at 1:57 PM: Resident's pulse at 8:00AM was 47. Resident was lethargic but was able to arouse. The resident's pulse was 55 when it was rechecked at 11:30 AM. -12/11/19 at 1:36 PM: Tele-Psych consultation; Resident was lethargic but arousable, then right back to sleep and at points during the appointment resident was snoring. Physician recommended to change risperidone (antipsychotic) to 0.5mg two times a day (BID), decrease Trazodone (PM dose) to 25mg and continue dose of 12.5 mg and follow up at next available appointment and contact resident representative to attend. -12/13/19 at 1:02 PM: Nursing was monitoring resident for gradual increase in risperidone and gradual dose reduction in Trazodone to attempt to lower lethargy and decrease his/her behaviors. -12/13/19 at 1:25 PM: Resident had demonstrated increased lethargy and decreased participation in physical therapy that week. -12/18/19 at 10:39 AM: Nursing was monitoring resident for gradual increase in risperidone and gradual dose reduction in Trazodone to attempt to lower lethargy and decrease his/her behaviors. The medical record dated from 10/29/19-12/18/19 did not include documentation the resident representative was notified of the changes in the resident's psychotropic medications. During an interview on 1/30/20 at 2:42 PM, Registered Nurse Unit Manager (RNUM) #2 stated the resident representative should be notified of any change in psychotropic medication when the resident had cognitive impairment. She stated Resident #108's representative should have been notified changes in psychotropic medications. She stated the staff should be calling or at least make the attempt to notify resident representatives. RNUM #2 reviewed the progress notes in the medical record and stated the representative was not present at the tele-psych appointment on 10/30/19 and progress notes did not document the resident representative had been notified of the changes in medication. During an interview on 1/30/20 at 2:54 PM, the Director of Nursing (DON) stated resident representatives should be notified with any change in a resident's condition, change in medication, change in status, and for medical appointments. She stated if the resident had a change to his/her psychotropic medications the representative should have been notified. 10 NYCRR 415.3 (e)(2)(ii)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey the facility did not ensure that allegations of abuse, neglect, exploitation, or mistreatment had evidence that all alleged violations were thoroughly investigated for one (Resident #25) of 2 residents reviewed for abuse. Specifically, for Resident #25, the facility did not ensure the resident's allegation that a staff member was rough with him/her was throughly investigated. This is evidenced by: A Policy and Procedure (P&P) titled, Abuse Prevention and Reporting last reviewed 10/2019 documented any employee of the facility had a duty to report concerns, incidents including that of alleged abuse, mistreatment or neglect to their supervisor or to the Director of Nursing, Administrator, or Charge Nurse. The P&P documented examples of neglect that includes failure to carry out nursing, treatment, or individual care plans. Resident #25: The resident was admitted to the facility with the diagnoses of multiple sclerosis, chronic pain, and restless leg syndrome. The Minimum Data Set (MDS - an assessment tool) dated 10/17/19, documented the resident was cognitively intact, could understand others and could make self understood. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) last updated, 4/10/19, documented the resident required extensive assistance of two for bed mobility and slide sheets for bed mobility when physical assistance was required. The Certified Nursing Assistant (CNA) [NAME] (caregiving instructions), print date of 1/29/20, documented Bed Mobility: Two+ person physical assist and slide sheets for bed mobility tasks when physical assist. A notification system between staff within the electronic medical record (named) dated 1/12/20 at 12:35 PM, documented Registered Nurse (RN) #6 messaged RNUM (Registered Nurse Unit Manager) #2 that the resident reported CNA #2 was rough with him the other day and when she was moving him/her something popped. The message documented that RN #6 was working on getting statements from staff members and the resident did not wish to do a formal complaint, but wanted it addressed with the staff member. The medical record did not include documentation of an RN assessment or physician examination from 1/12/20 - 1/17/20 after the resident reported CNA #2 was rough with him/her when turning him/her in bed and something popped. An Occupational Therapy (OT) Note dated 1/15/20 at 11:28 AM, documented the resident reported increased pain and numbness in the left shoulder due to CNA pulling on his/her arm during bed mobility. The note documented the resident's arm appeared weaker at this time however some strength was noted. The resident reported his/her current pain level was 3/10 with 10/10 at its worst. The note also documented the nurse manager was made aware of the situation. A nursing note dated 1/15/20 at 12:16 PM, documented the resident was complaining of pain and weakness in left shoulder and stated it made a popping sound during care a few days ago when staff were rolling him/her in bed. OT evaluation completed and OT also noted some weakness. The note documented the information was reviewed with the Nurse Practitioner who gave a new order for an x-ray of the left shoulder. A Nursing Note dated 1/17/20 at 2:31 PM, documented the resident was on a maintanence program for upper extermity strength, range of motion, and function. The note documented the resident had recently complained of increased pain and weakness of the left upper extremity. During an interview on 1/27/20 at 11:43 AM, Resident #25 stated CNA's were rough during care. The resident stated he/she was rolled too hard in bed and re-injured an old shoulder injury because of it. He/she stated it had happened more than once, but most recently this month (January 2020). During a subsequent interview on 1/29/20 at 3:15 PM, Resident #25 stated a couple weeks ago CNA #1 and CNA #2 were putting him/her back to bed. CNA #2 was standing on the right side of the bed and pulled his/her left arm to turn him/her. He/she stated CNA #2 gave it a yank. The resident stated CNA #2 turned him/her too hard and when she pulled his/her left arm his/her left shoulder popped. He/she stated CNA #1 heard the pop and stated, I hope that was a good pop and not a bad pop. The resident stated he/she replied, I don't think it was either. The resident stated he/she had problems with his left shoulder in the past, but this incident re-injured his shoulder. During an interview on 01/29/20 03:41 PM, CNA #1 stated she and CNA #2 were putting the resident into bed a couple weeks ago and the resident stated his shoulder was sore but said it was ok for CNA #2 to pull him/her toward her during bed mobility. She stated CNA #2 pulled the resident toward her using the back of the resident's left shoulder and left hip. CNA #1 stated she was helping turn the resident's leg over at the time. She stated CNA #2 did not pull on the resident's left arm. She stated she heard something pop and I asked if it was a good or bad pop. The resident said good. She stated she and CNA #2 did not report the resident's shoulder had popped when it happened. She stated the resident had complained of pain on the next shift but had not complained of pain to them after they had positioned the resident in bed, so they did not report that his shoulder had popped. CNA #1 stated she was asked to write a statement a day or two after it happened. During an interview on 01/29/20 03:46 PM, RNUM #2 stated a formal investigation was not completed, but statements were obtained from the CNAs involved. She stated education was provided to the CNAs but there was no documentation of the education provided. The RN stated the incident occurred Saturday, 1/11/20 and she was made aware about the incident on Monday, 1/13/20 in a EMR System Message (named) from RN #6. She stated based on the statements of the CNAs, it was determined that the resident's care plan was followed, and it was fine for the CNA to turn the resident using the resident's hip and shoulder, or just below the back of the shoulder on the resident's ribs. She stated the resident had a history of accusations. She stated she was not sure if the resident was care planned for slide sheets for bed mobility, but if the resident was care planned to be turned with slide sheets, then that was what was supposed to be used to turn him/her. During an interview on 1/30/20 at 8:45 AM, Resident #25 stated the staff did not use a slide sheet during bed mobility. The resident stated staff were technically supposed to use slide sheets when moving him/her in bed. The resident stated the slide sheet was in his/her closet and still in the original packaging. The resident stated the staff had never used the slide sheet with him/her for bed mobility. During an interview on 1/30/20 at 9:34 AM, CNA #3 stated staff did not use slide sheets during bed mobility with Resident #25. She stated the resident was a 2-assist caregiver for bed mobility, but slide sheets were not used with the resident. She stated the resident assisted with bed mobility and when he/she needed physical assistance the staff listened to him/her for direction for what him/her wanted done. She stated the resident had a history of making accusations and was 2 assist caregiver because of accusations and because he/she had a hard time rolling during bed mobility. On 1/12/20, CNA #3 wrote a statement the resident reported his/her left arm hurt because CNA #2 on the evening shift pulled his/her arm so hard that it popped, and she reported it to RN #6. CNA #3 stated the resident has had more pain in the left shoulder since it popped on 1/11/20. During a subsequent interview on 1/30/20 at 11:00 AM, RNUM #2 stated the CNA's should have reported the resident's shoulder popping on the day that it happened to a Licensed Practical Nurse (LPN) or RN because hearing a pop during bed mobility was not normal. She stated there were no progress notes on January 11th, or 12th, 13th or 14th regarding the resident's shoulder. She stated there were statements from CNA's obtained, but the statements did not say the staff were using slide sheets during bed mobility which were part of the resident's care plan. She stated it was reported to an RN on the 12th of January but there were no notes from that nurse. She did not know if an RN completed an assessment when it was reported. She stated there absolutely should have been an RN assessment on the 12th. She stated the resident was last seen by a physician in December 2019. During an interview on 1/30/20 at 12:00 PM, Occupational Therapist #10 stated the resident was on a maintenance OT program and the resident reported to him that a CNA had pulled on his/her arm while turning him in bed. The OT stated he took it easy on the resident for that treatment session because the resident was in more pain. The OT stated the resident was experiencing more pain after reporting his/her shoulder popped during bed mobility with CNAs. The OT stated the recommendation from therapy was to use a slide sheet during bed mobility to reduce friction and prevent pulling on arms, as well as being safer for staff to prevent injury. He stated slide sheets were the best and safest way to move the resident in bed. During an interview on 1/30/20 at 2:57 PM, the Director of Nursing (DON) stated the staff should have been positioning the resident in bed with a slide sheet and the CNA should not have pulled on the resident at all. She stated with a slide sheet, the staff did not have to pull on the resident. She stated the CNA was not following the care plan and the CNA's should have reported the resident's shoulder popped immediately to the LPN or directly to an RN. She stated there should have been formal investigation and looking back on the situation things should have been done differently. She stated the resident had a history of accusations but something the facility had been working on was to not normalize behaviors. The DON stated if an RN assessment was not documented then it was not done. During an interview on 1/31/20 at 9:07 AM, RN #6 stated CNAs reported the resident was complaining of his/her shoulder hurting. She stated the resident reported to her that the pain in his/her shoulder was new. She stated she assessed the resident but was surprised she had not documented the assessment. She stated she reported the resident's complaint to the DON and RNUM #2 thru the EMR Message System (named) or an email. She stated an investigation should be started immediately and she spoke with staff and got statements. She stated based on the accounts of the staff members and what the resident reported to her she did not see where any care plan violations had occurred based on the resident's care plan documented in the medical record. During an interview on 1/31/20 at 9:12 AM, the Administrator stated the incident with Resident #25 that occurred on 1/11/20 and reported on 1/12/20 warranted an investigation. She stated the facility had an abuse reporting policy and the CNAs should have reported the incident when it happened to the nurse. The nurse would then report it to the DON or Administrator. She stated there should have been an incident or accident report and an investigation should have been started immediately. She stated the staff should be following the plan of care and if an RN assessment was completed, it should have been documented in the medical record. 10NYCRR 483.12(c)(2)-(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey and an abbreviated survey (Case #NY00245774), the facility did not ensure each resident received adequate supervision to prevent an elopement for 1 (Resident #105) of 1 resident reviewed for accidents and supervision. Specifically, for Resident #105, the facility did not ensure the resident, who was a known risk to wander and wore a wandergard, did not elope from the building undetected until she was seen outside at the employee entrance door asking to come back into the facility because she was cold. This is evidenced by: While wander, door, or building alarms can help to monitor a resident's activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision, and require scheduled maintenance and testing to ensure proper functioning. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Facility policies that clearly define the mechanisms and procedures for assessing or identifying, monitoring and managing residents at risk for elopement can help to minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision. In addition, the resident at risk should have interventions in their comprehensive plan of care to address the potential for elopement Resident #105: The resident was admitted to the facility with diagnoses of dementia with behavioral disturbance, anxiety disorder and chronic pain. The Minimum Data Set (MDS-an assessment tool) dated 9/26/19, documented the resident had severe cognitive impairment, was understood by others and understood others. Per internal investigation, 9/28/19 at 1:00 PM, the resident had been found outside in the parking lot. She was found at the employee entrance on the west side of the building. She is a new resident to the 1 East Unit and had exhibited elopement type behaviors since admission, making her a high risk for elopement. She had a wanderguard in place since admission. It appeared she exited the unit through the back door of the unit and proceeded out the north doors. Unsafe Wandering and Elopement Policy dated 06/2018, documented residents deemed to be at risk for wandering and elopement shall be monitored. Residents deemed at high risk for unsafe wandering/elopement and have demonstrated or voiced a desire to elope shall wear the Roam alert transmitter. Each caregiver shall be oriented and in-serviced to all policies and procedures regarding identification of the wanderer, preventing unsafe wandering and elopement and reporting such occurrences. The Comprehensive Care Plan (CCP) for a resident was an active elopement risk related to lack of safety awareness, confusion, independent mobility and had history of elopement at home, documented on 9/21/19 at 9:00 PM the resident had been found in the stairwell. The roam alert may not have been alarming. It was later found that the resident was not wearing her wanderguard. On 9/28/19 at 1:00 PM the resident was found in the employee parking lot knocking on the employee entrance door stating she was cold and asking if she could be let back in. An Elopement Risk assessment dated [DATE], documented the resident was at risk for elopement as evidenced by diagnosis of dementia, had wandering behavior, history of eloping at home and ability to leave the facility. A Progress Note dated 9/19/19 at 12:22 PM, documented the resident was placed in the nursing home for long term care as she was no longer able to be left home alone due to unsafe wandering, she had been found walking in the roads unsafely and will leave her home without notifying anyone. She has long and short term memory loss. A Progress Note dated 9/28/19 at 1:43 PM, documented the resident was found in the employee parking lot knocking on the employee entrance at approximately 12:50 PM by an employee. The resident stated she was cold and asked if she could come in. She was waiting for her husband. Resident's roam alert was not sounding on the computer when resident was found outside. Doors all triggered when resident came close to them. Back door appeared to be latched tightly when maintenance came to assess. Resident had no apparent injuries. Per Maintenance logs dated 10/01/19, a request was issued to check the back exit on 1 East as it was not alarming when a resident exited the building with a wander guard, other doors worked. Doors were checked as follows: 9/28/19 at 5:00 PM and 8:15 PM - doors were working. 9/29/19 at 1:00 AM and 3:45 AM - doors were working; 0630 AM tested door with no issues, staff also monitoring door; 4:00 PM doors checked, found to be working. 9/30/19 at 12:45 AM doors working; 4:20 AM doors working. Tested doors with wanderguard bracelet, all doors were locked down, operated properly. A window in one of the rooms may have been open creating a draft and holding door ajar. 10/01/19 at 4:30 PM and 9:00 PM - checked doors, operated properly. During an interview on 01/30/20 at 12:34 PM, the Administrator stated the resident was reported to have been found outside knocking on the employee entrance door because she was cold and wanted to come back into the facility. The roam alert system was checked. The door alarm company came into the facility to look at the doors and the magnetic plates were changed. Facility also is in the process of installing cameras. When the resident exited, her wanderguard was alerting. The magnets on the door would sound as if the door was closed but the green light would stay on. Maintenance had always found the door to be working. After the resident was found in the stairwell on 9/21/19, it was found that there was an issue with the door. A work order was submitted and maintenance checked the door. Door alarm company also came in to check the doors. Staff were put at all exterior doors and stair well doors. At the time of the elopement the receptionist at the front desk was at lunch. If there were no staff in the care base, there would not have been anyone near the computers to see that a resident was out of the building. Dietary Aide (DA) #8 had heard the door alarm sounding but did not check to see if a resident was in the vicinity. A meeting was held with all staff on proper response to an alarm. A written statement dated 9/28/19, from Environmental Services Employee #9, documented she saw the resident walking down the hall toward the end of the east side at 12:30. When she got toward the end of the hall she heard the door alarm going off between 1 East and 1 West. She looked outside and in the courtyard and did not see anyone. She also saw DA #8 walking through while the door alarm was sounding. The DA shrugged her shoulders and continued walking without checking or notifying anyone. She reported the door alarm was sounding to RN #6. A written statement dated 9/28/19 from CNA #6, documented she saw the resident in the dining room [ROOM NUMBER] minutes before she was told the resident had been found in the parking lot. During an interview on 01/30/20 at 12:34 PM, the Director of Nursing (DON) stated the door company came in and checked the doors. Roam alert was not noted on the computers and was not heard on the pagers worn by staff between east and west doors. There is no report that the pagers had been checked after the elopement. Since the pagers had not been checked after they failed to alert staff to the resident's elopement on 9/28/19, the Department of Health Sanitarian checked the pager system on 1/30/20 and found it to be operational. He had been informed by staff on Unit 1 that not all staff were equipped with pagers. During an interview on 01/30/20 at 1:31 PM, Facility Director #1 stated the resident was able to enter the stairwell on 9/21/19 because there was an issue with the door. A work order was put in and maintenance arrived to check. The magnetic strip on the door may not have been operating correctly. Staff were put at the stairwell and exit doors until the vendor came in to check all doors. On 9/28/19, the resident went out an alarming double door on the first floor to two unlocked doors leading to the outside. She followed the sidewalk to the employee entrance where there is a window on the door and was seen trying to get back in. All doors were then manned by employees until the vendor came in. The doors had been checked monthly by maintenance. After the elopement the plan was to check the doors every shift until the vendor came onsite. The roam alert system is checked monthly. He stated the wander alert is connected to the pager system. 10NYCRR415.12(h)(1)

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly Medication Regimen Review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, the facility did not ensure that time frames were established for the steps in the MRR process. This is evidenced by: The Policy for Medication Regimen Review with a revised date of 12/2019, documented: 1. The Pharmacist is to report any identified irregularities to the attending physician and Director of Nursing. 2. If any urgent issues arise, a phone call will be made directly to the Director of Nursing from the Pharmacist. 3. The Director of Nursing will contact the Provider for the resident or the Provider on-call to address the concern. 4. Medical staff review recommendations from Pharmacist and document decision and reasoning for accepting or declining, with alternate measures to be initiated as appropriate. During an interview on 1/30/20 at 07:55 AM, the Administrator stated her understanding was that the physician notifies the Administrator and acts on medical concerns. She stated she is not aware time frames needed to be in the MRR Policy. 10NYCRR415.18 (c)(2)

Based on record review and interview the facility did not provide a complete Facility Assessment that documented a facility wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies during the recertification survey. Specifically, the facility did not ensure the facility assessment included an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's needs. This is evidenced by: The Policy and Procedure (P&P) titled Facility Assessment Policy of Skilled Nursing Facility (SNF), last reviewed 10/2019, documented the facility must conduct and document an individualized facility-wide assessment to determine what resources were necessary to care for the residents competently during both day-to-day operations and emergencies. During a review of the facility assessment on 1/31/20 at 8:30 AM, the assessment did not include an evaluation of the staff needed to ensure a sufficient number of qualified staff were available to meet each resident's needs. On 1/31/20 at 8:47 AM, the facility provided an undated typed paper with normal staffing levels for day shift, evening shift, and night shift. It was not part of the Facility Assessment. During an interview on 11/31/20 at 8:37 AM, the Director of Nursing (DON) stated she was not aware the facility assessment did not include information on the level and competency of staff needed to meet the needs of each resident. She stated she was part of the team working on the facility assessment and the team was completing the assessment in steps. The DON reviewed the information under the Facility Staff tab in the Facility Assessment and stated the information was unclear and did not include the necessary information for staff needed to meet the needs of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections determined for 3 (Resident #'s 50, 63 and #223) of 3 residents reviewed on the third floor. Specifically, for Resident #50, the facility did not ensure standard precautions were maintained during a dressing change, for Resident #'s 50 and 63, the facility did not prevent the development of facility acquired pseudomonas infections (type of germ that can cause infections in humans) in their wounds and for Resident #223, standard precautions were not followed during administration of an intravenous medication. Additionally, the facility did not ensure that a basin filled with wound care supplies was not carried from room to room. This was evidenced by: Resident #50: The resident was admitted to the facility with diagnoses of malignant neoplasm of right kidney with metastasis to the nervous system, quadriplegia and an open wound to buttocks. The Minimum Data Set (MDS-an assessment tool) dated 12/3/19, documented the resident was cognitively intact, was able to understand others and was able to be understood by others. Resident resides on the 3rd floor of the nursing home. Pressure Ulcer-Assessment, Prevention, Treatment and Wound care with a revision date of 03/2017, documented the following for dressings; always cleanse the wound before new dressing is applied, use clean technique to apply dressing after cleansing wound, change dressing when soiling is apparent regardless of timeframe and loosely fill all wound cavities with dressing material, and do not pack wound tightly. A Wound Care Tool dated 12/30/19, documented an unstageable wound to the resident's coccyx measuring 11.1 cm x 13.5 cm x 0.1 cm. tunneling at 6:00. Moderate purulent drainage. 70% necrotic (dead tissue), 30% slough (layer of dead tissue seperated from living tissue), 70% eschar (dead tissue) intact, 30% eschar unstable/mushy-boggy. Necrotic tissue is present in wounds as eschar and slough. Eschar presents as dry, thick, leathery tissue that is often tan, brown or black. Slough is characterized as being yellow, tan, green or brown in color and may be moist, loose and stringy in appearance. Wound Care Tool dated 01/20/20, documented a Stage IV wound to resident's coccyx measuring 11.2 cm x 12.2 cm x 3 cm with undermining (a pocket beneath the skin at the wound's edge) 8 cm at 9:00. Wound Care Tool dated 01/30/20, documented stage IV midline coccyx. which was debrided at the Wound Center one week ago. Packing removed from wound (6 4 x 4's) for a large amount of serous drainage. Wound measurements are 11.0 cm x 10.1 cm x 4.2 cm. Resident denied pain during the procedure. Edges of the wound are distinct. Large area of undermining 1.0 cm to the edge between 10:00 to 5:00. Small amount of soft black eschar at the base of the wound (less than 25%). Skin color surrounding wound is dark red/purple and non-blanchable. Pink granulation tissue covers approximately 25% of the wound with no epithelization (wound healing). Faint foul odor from the wound. Finding #1: During an observation of a dressing change to the resident's stage IV wound to the coccyx on 01/30/20 at 9:50 AM: - Registered Nurse (RN) #1 placed a barrier on resident's bedside table without first wiping the table. There were numerous personal items left on the sides of the table. - RN #1 held the package of cotton tipped applicators, opened the package and pulled out an applicator and placed it on the barrier. She did not remove her gloves and wash her hands after touching the outside of the package. - Wearing the same gloves, she packed the wound with 4 x 4 gauzes using the cotton tipped applicator. -Wearing the same gloves, she placed an ABD pad on the wound. During an interview on 01/30/20 at 02:40 PM, RN #1 stated she was not aware she should not have touched the outside of the dressing packages and touch the dressing contents without first removing her gloves, washing her hands and putting on another pair of gloves. There are monthly in services and during orientation she performed dressing changes but did not remember when she should change her gloves. During an interview on 01/30/20 at 03:42 PM, the Registered Nurse Manager (RNM) #2 stated RN #1 did not receive a specific in-service on dressing changes when she was hired. She should know how to do a dressing change since she had recently became an RN and would have learned it in school. During an interview on 01/30/20 at 03:48 PM, the Infection Control Nurse/Staff Education Nurse #2 stated she had not held a dressing change in-service since she was hired approximately one year ago. The nurses have not been in serviced to do dressing changes. During an interview on 01/30/20 at 04:16 PM, the Director of Nursing (DON) stated RN #1 is a new nurse coming recently from school. She should have known not to touch the outside of the dressing packages without first washing her hands. Finding #2: Wound Care Tool dated 01/30/20, documented stage IV midline coccyx. which was debrided at Wound Center one week ago. Packing removed from wound (6 4 x 4's) for a large amount of serous drainage. Wound measurements are 11.0 cm x 10.1 cm x 4.2 cm. Resident denied pain during the procedure. Edges of the wound are distinct. Large area of undermining 1.0 cm to the edge between 10 to 5:00. Small amount of soft black eschar at the base of the wound (less than 25%). Skin color surrounding wound is dark red/purple and non-blanchable. Pink granulation tissue covers approximately 25% of the wound with no epithelization. Faint foul odor from the wound. Progress Notes 12/14/19 at 10:06 PM, dressing change to buttock. Old dressing removed with moderate amount of thick yellow/green drainage and small amount of blood present. Laboratory report dated 12/16/19, culture to buttock wound result dated 12/20/19-pseudomonas aeruginosa. Per physician order, resident started on Levofloxin 250 mg qd. During an interview on 01/30/20 at 03:48 PM, Infection Control Coordinator stated she was aware that this resident and Resident #63 both resided on the Third Floor of the nursing home and both contracted pseudomonas in their wounds that required dressing changes. Wound cultures were sent, and the resident was placed on contact isolation. Education was done on proper hand hygiene, the donning and offing of personal protective equipment and how to properly throw away any linen. The residents are on opposite sides of Unit 3. She is tracking and monitoring the spread of the infection. During an interview on 01/30/20 at 4:16 PM, the DON stated the pseudomonas infection had been discussed many times with the Interdisciplinary Team (IDT). No common denominator could be found to pin the infection to. Resident #63 The resident was admitted with diagnoses of acquired absence of left leg below knee, end stage renal disease and Type 2 diabetes mellitus. The MDS dated [DATE] documented the resident was cognitively intact, was able to understand others and was able to be understood. Resident resides on the 3rd floor of the nursing home. MD admission assessment dated [DATE], documented resident underwent amputation of the left lower leg on 11/15/19. Progress Note dated 1/04/20 at 10:08 AM, documented dressing removed from stump. Wound bed red/pink with moderate amount green drainage. Physician order dated 1/05/20, documented the resident was to receive to open area left stump, irrigate with normal saline, dry and apply melgisorb dressing to wound bed and cover with a cosmopore dressing daily. Laboratory report dated 01/06/20, culture ordered for wound drainage. Result dated 01/07/20 -pseudomonas species. Per physician order, resident started on Cipro 500 mg twice a day for 10 days. Progress Note dated 01/27/20, documented resident developed a scab on her left amputation site and developed an infection on her stump while in the nursing home. She was diagnosed with pseudomonas of the surgical site to her left stump. During an interview on 01/31/20 at 09:25 AM, Infection Control Coordinator #3 stated she was aware of the 2 residents with pseudomonas in their wounds on the third floor. Wound care education is in the works to start very shortly. For wound rounds, the nurses will be educated on how to set up treatment carts appropriately. During an interview on 01/31/20 at 09:25 AM, the Infection Control Coordinator stated she did not have a listing of reportable diseases. She stated she reported to epidemiology if a resident has noro virus. She stated she has heard about the list of reportable diseases list but did not seem to have a copy. Resident #223 Resident #223 was admitted to the facility with diagnoses of sepsis, acute congestive heart failure (CHF), and pulmonary hypertension. The MDS dated [DATE], documented the resident was cognitively intact, was able to understand others and was able to be understood by others. The Facility Policy for Infection Prevention/Control on hand hygiene dated December 2002 and last updated in June 2009, documented the following: Centers for Disease Control (CDC) - How to use hand washing (soap and water): 1. Turn on water and wet hands. 2. Apply 2 squirts of antimicrobial soap: 3. Thoroughly wash all surfaces of hands (palms, backs), fingers (all 4 sides, with special attention to knuckle and fingernails), and wrists for at least 20 seconds. 4. Rinse and dry hands thoroughly with paper towel. A physician order dated 1/25/2020 documented give Rocephin 2 gram/50 Milliliters (ml) in Dextrose intravenously via PICC line every 12 hours for 5 weeks for bacteremia. During an observation of an intravenous (IV) medication on 1/30/2020 at 9:30, RN #1 placed a bag of Rocephin on the residents overbed table. Sanitation of the bedside table was not done, and a barrier was not placed on the surface before placing the antibiotic there. RN #1 washed her hands less than 5 seconds with soap and water, applied gloves, picked up the bag of antibiotic off the overbed table and attached the IV tubing to the antibiotic solution. During the transfer of the IV tubing RN #1 gloved hand touched the spike of the tubing as it was seperated from the used bag. While reinserting the spike into the antibiotic solution, RN #1 was observed to hold the bag against her/his uniform top touching the spike of the IV tubing with the thumb of her right gloved hand. RN #1 then removed the end of the IV tubing from a port on the used IV tubing and without cleansing the tip of the tubing, inserted it into the resident's valve adapter on the PICC line. A sterile cap had not been placed on the tip of the IV extension set after the IV tubing was used last. During an interview on 1/30/2020 at 10:15 AM, RN #1 stated I wasn't aware I touched the IV spike with my glove. I should have changed my gloves and washed my hands after mixing the antibiotic before attaching the tubing. The person that discontinued the antibiotic must have forgotten to put a cap on the end of the IV, but I didn't realize you couldn't put the end in the injection port. I want to learn the right way. During an interview on 1/30/2020 at 11:56 AM, the Nurse Practitioner stated when reusing IV tubing a sterile cap should be placed on the end of the tubing after disconnecting it from the hub of the PICC line. Placing it inside a port hanging from the IV tubing contaminates the tubing and they should not reuse it. Failure to place a sterile cap on the end of a reusable intravenous administration set that has been removed from an IV catheter hub leaves the resident at risk for infection. The tip of the IV set is exposed to potential contaminants if not cleaned properly when connecting and disconnecting from the PICC line. Facility During an observation on 1/29/20 at 10:01 AM, Registered Nurse #5 (RN) entered room [ROOM NUMBER]-101-B to perform wound care on the resident with a basin full of dressings and wound supplies. RN #5 placed the basin on the overbed table without cleaning the table or placing a barrier underneath the basin. When RN #5 was finished performing wound care for the resident, hands were washed with an alcohol-based sanitizer, the bucket with supplies was picked up and carried by RN #5 under the nurses' arm and against the nurses' uniform to room [ROOM NUMBER] A. RN #5 placed the bucket on the bedside table in the second room without cleaning the basin or the bedside table. Hand washing was not performed before placing the basin in the room. A barrier was not placed under the basin. RN #5 was stopped before performing wound care by this writer to address the possibility of cross contamination. During an interview on 1/29/2020 at 10:17 AM, RN 5 stated I should not have brought the basin of dressings and wound supplies into the resident's room. They are taught to use the wound cart, to clean the bedside trays, and to use a barrier on the surface where supplies are placed in the resident's room. RN #5 stated using the basin was easier than dragging the treatment cart around. During an interview on 1/29/2020 at 10:21 AM, the Registered Nurse Unit Manager (RNUM #4), stated the nurses should be using the treatment cart for wound care. It was unacceptable for RN #5 to carry a basin full of supplies into one residents' room and then bring in into another resident's room. Once supplies are brought into a resident's room they should be left in that room. This was an infection control policy and RN #5 did not follow the facility policy. RN #5 would need to be reeducated. During an interview on 1/29/2020 at 10:33 AM, the Infection Control Registered Nurse #3(ICRN) examined the basin RN #5 had brought into the room. The ICRN #3 stated none of the dressings and multiple use ointments in the basin should have been brought from one residents' room to another resident's room. All items in the basin were now contaminated and would need to be discarded. ICRN #3 stated the nurses had not been given in-servicing on wound care practices in over a year, but all should be aware of the proper infection control procedures. The most important way of preventing cross contamination from one resident to another was maintaining infection control procedures and handwashing with care between residents. During an interview on 01/30/20 at 09:52 AM, the Nurse Manager for Quality Assurance #7 and lead Registered Nurse for wound rounds stated on 1/29/2020 she was aware RN #5 should not have been using a basin to transport wound supplies from room to room during the daily wound rounds. It is an infection control issue that I have addressed since I started this job. I knew you had identified this during observation, so I did not stop RN #5 because I though you would and then it would be addressed and corrected. 10NYCRR415.19(a) (1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews during the recertification survey the facility did not ensure that the resident and resident's representative were notified in writing of the reason for the transfer/discharge to the hospital in a language they understand for two (Resident #'s 54 and 87) of two residents reviewed for hospitalizations. Specifically; for Resident #'s 54 and 87, the facility did not ensure the resident or resident's representatives were notified in writing of the reason for the transfer/discharge to the hospital in a language they understand. This is evidenced by: Resident #54 The resident was admitted to the facility on [DATE] with diagnoses of hypertension (HTN), diabetes mellitus (DM), and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS) dated [DATE], documented the resident was cognitively intact; he understands and is understood by others. The resident was transferred to the emergency room on 8/28/18 and admitted to the hospital on [DATE] with a diagnoses of sepsis. The resident was readmitted to the facility on [DATE] with a diagnosis of resolved episode of sepsis secondary to urinary tract infection (UTI) or sacral decubitus ulcer. During an interview on 11/28/18 at 10:12 AM, Social Worker (SW) #2 could not provide a completed copy of the transfer/discharge form for 8/28/18. She reported that after clarification from administration, the notice of transfer/discharge forms are only being completed for planned discharges and are not being completed for unplanned transfers or discharges. She stated the bed hold policy is signed on admission and are reviewed by word of mouth only for unplanned transfers. During an interview on 11/29/18 at 2:24 PM, the Director of Nursing (DON) stated transfer /discharge notices and bed hold policy are expected to be completed with all transfers and discharges. During an interview on 11/29/18 at 2:25 pm, Registered Nurse (RN) #2 MDS Coordinator reported the notice of transfer/discharge/ and bed hold policy should have been completed at the time of transfer and a written copy should have been provided to resident and resident's representative. Resident #87 The resident was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Diabetes and Hypertension. The Minimum Data Set (MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) of 13 and could understand others and make herself understood. The medical record did not include evidence of a transfer discharge notice when the resident was discharged from the facility on 9/8/18 and 9/25/18. During an interview on 11/30/18 at 09:37 AM, SW #2 stated she currently provides verbal notice of resident transfer and is not provided in writing to the resident/family. 10NYCRR415.3(h)[1](iii)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews during recertification survey the facility did not ensure written notice which specifies the duration of the bed hold policy was provided to the resident and resident ' s representative at the time of transfer for two (Resident #'s 54 and 87) of two residents reviewed for hospitalization. Specifically, for Residents #'s 54 and 87, the facility did not ensure that written notice which specifies the duration of the bed hold policy was provided to the residents' and the resident's representative at the time of transfer. This is evidenced by: Resident #54 The resident was admitted to the facility on [DATE] with diagnoses of hypertension (HTN), diabetes mellitus (DM), and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS) dated [DATE] documented the resident cognitively intact he understands and is understood by others. The resident was transferred to the emergency room on 8/28/18 and admitted to the hospital on [DATE] with diagnoses of sepsis. The resident was readmitted to the facility on [DATE] with a diagnosis resolved episode of sepsis secondary to urinary trach infection (UTI) or sacral decubitus ulcer. On 11/30/2018 the facility provided a policy titled Bed Reservation dated 11/2018 which documented; The charge nurse will be responsible of notification of bed hold and notification of discharge or transfer at the time of transfer to the hospital. They will be required to inform resident/resident representative of bed hold as well as notice of discharge transfer. Forms will be completed, and copies will be distributed: A. To the social workers, B. 1 copy in sealed envelope addressed to resident/resident family will go with them to the ER, C. 1 copy will remain in the medical records. During an interview on 11/28/18 at 10:12 AM, Social Worker (SW) #2 was unable to provide a completed copy of the transfer/discharge or the bed hold policy form for 8/28/18. She reported that after clarification from administration, the Notice of Discharge or Transfer forms are only being completed for planned discharges and are not being completed for unplanned transfers or discharges. She stated, the bed hold policy is signed on admission and are reviewed by word of mouth only for unplanned transfers. During an interview on 11/29/18 at 2:24 pm the Director of Nursing (DON) said transfer /discharge notices and bed hold policy are expected to be completed with all transfers and discharges. During an interview on 11/29/18 at 2:25 PM, RN #2 MDS Coordinator reported the notice of transfer/discharge/ and bed hold policy should have been completed at the time of transfer and a written copy should have been provided to resident and resident's representative. Resident #87 The resident was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Diabetes and Hypertension. The Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) of 13 and could understand others and make herself understood. The facility was not able to provide evidence of a written bed hold notice when the resident was discharged from the facility on 9/8/18 and 9/25/18. During an interview on 11/30/18 at 09:37 AM, SW #2 stated she currently provides verbal notice of resident bed hold and is not provided in writing to the resident/family. 10NYCRR415.3(h)[4(i)(a)]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, during the recertification survey, the facility did not ensure that comprehensive person-centered care plans were developed and implemented for each resident consistent with the resident rights set forth that include measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for three (3) (Resident #'s 43, 95 and #107) of twenty-six (26) residents reviewed. Specifically; for Resident #43, the facility did not ensure that the intervention on the Comprehensive Care Plan (CCP) for fifteen-minute checks secondary to risk for elopement was implemented; For Resident #95, the facility did not implement interventions documented on the resident's comprehensive care plan for the diagnosis of dysphagia; and for Resident #107, the facility did not ensure a CCP was developed to address the resident's skin issues. This was evidenced by: Resident #43: The facility did not ensure that the intervention on the CCP for fifteen-minute checks secondary to risk for elopement was implemented. This resident was admitted on [DATE], with diagnoses of Dementia. The Minimum Data Set, dated [DATE], documented the resident had moderately impaired for cognition, and had ability to understand and be understood. During an observation on 11/28/18 from 8:49 AM to 9:51 AM and from 10:58 AM to 11:58 AM, the resident entered her room and closed the door. Staff did not enter or exit the resident's room during the above time period. During an observation on 11/29/18 from 11:50 AM to 12:50 PM, the resident entered her room and closed the door. Staff did not enter or exit the resident's room during the above time period. The CCP for Elopement, last reviewed on 10/31/2018, documented the resident was to be monitored every 15 minutes. During a review of the fifteen minute observations form, for 11/28/18 and 11/29/18 included (Certified Nursing Assistant) CNA #s 4 and 5 initials (indicating care was provided). During an interview on 11/30/18 at 9:05 AM, CNA #4, stated that all staff document on the fifteen-minute observation form that observations were completed, regardless of whether the resident was assigned to them. CNA #4 stated she had not observed the resident on 11/28/18 from 9:00 AM to 9:45 AM or 11/29/18 from 12:00 PM to 12:45 PM. During an interview on 11/30/18 at 9:40 AM, CNA #5, stated she was aware the resident was care planned for fifteen-minute observations. She confirmed her initials were on the fifteen-minute observation sheet on 11/28/18 from 11:00 AM to 11:45 AM, and that she had not observed resident. During an interview on 11/30/18 at 1:37 PM, the Director of Nursing (DON) stated, the expectation was that all staff will physically observe the resident every fifteen minutes. DON stated that she was not aware care was being initialed as provided on the fifteen-minute observations form, and not performed. Resident #95: The facility did not ensure interventions documented on the comprehensive care plan (CCP) for the diagnosis of dysphagia to sit the resident upright ninety degrees while eating and for thirty to forty-five minutes after meals were implemented. This resident was admitted on [DATE], with diagnoses of Alzheimer's, generalized muscle weakness, dysphagia, and abnormalities of gait and mobility. The Minimum Data Set, dated [DATE], documented the resident had severely impaired for cognition, was sometimes able to understand and to be understood. Facility staff were observed feeding the resident in the dining room on 11/29/2018 at 7:57 AM. At 8:06 AM, staff finished feeding the resident. On 11/29/18 at 8:08 AM, the resident was observed lying in bed. The head of the bed was not elevated at ninety degrees. The Comprehensive Care Plan (CCP) for dysphagia, last updated 04/19/2017, documented the resident was to remain upright ninety degrees during oral intake and thirty to forty-five minutes after. A document titled Resident Nursing Instructions (documents care to be provided by the CNAs), did not include the intervention to sit the resident upright ninety degrees after eating. During an interview on 11/30/2018 at 9:11 AM, CNA #4 stated she regularly cared for this resident and was not aware of the need for the resident to remain upright after eating. CNA #4 stated, the resident is usually put to bed immediately after lunch for a nap. During an interview on 11/30/2018 at 10:12 AM, CNA #5 stated she was unaware that resident needed to remain at ninety degrees for 30-45 minutes after meals. During an interview on 11/30/2018 at 11:02 AM, LPN #4 stated she was not aware the resident was to remain upright after meals. The CCP was reviewed with LPN #4, who states she had previously reviewed this. Resident #107: The resident was admitted to the nursing home on [DATE] with diagnoses of Xerosis Cutis (a skin condition), Parkinson's disease and chronic pain. The MDS dated [DATE], documented the resident had moderately impaired cognitive skills for daily decision making. During the Pool Process of the survey, the resident reported he had itchy spots on his skin that bothered him. Physician (MD) Orders dated 10/12/18, documented: Betamethasone dipropionate 0.5% cream one applicator full QD. Ammonium Lactate/menthol/camphor/TCA 12% lotion; apply 1 topically once daily for Xerosis Cutis. The Comprehensive Care Plan (CCP) did not include a care plan to address the resident's skin issues. During an interview on 11/28/18 at 8:10 AM, Licensed Practical Nurse (LPN) #1 stated that the resident gets little red bumps on his skin and they apply cream to them daily. During an interview on 11/28/18 at 2:04 PM, Registered Nurse (RN) #8 stated that she was responsible for developing the care plans; she could not find one but stated there he should have had one to address his skin issues. 10NYCRR 483.21(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey, the facility did not ensure that residents received adequate supervision to prevent accidents for two (Resident (#'s 45 & 284) of five reviewed. Specifically, for Resident #284, the facility did not ensure that all staff were educated on what keep safe meant, that the resident was supervised when exhibiting unsafe behaviors, that resulted in an unwitnessed fall causing a 2 centimeter laceration to the back of her head requiring 8 staple to close and that 1:1 was added to the residents Comprehensive Care Plan (CCP) when exhibiting these behaviors. Additionally, the facility did not ensure that Resident #45 was provided with plastic silverware as care planned for safety reasons. This is evidenced by: Resident #284: The facility did not ensure that all staff were educated on what keep safe meant, that the resident was supervised when exhibiting unsafe behaviors, resulting in an unwitnessed fall causing a 2 centimeter laceration to the back of her head requiring 8 staple to close and that 1:1 was added to the residents Comprehensive Care Plan (CCP) when exhibiting these behaviors. The resident was admitted on [DATE] with diagnoses of osteoarthritis, hypotension, and depression. The Minimum Data Set (MDS) dated [DATE], documented that the resident had modified independence for cognitive skills for daily decision making. A Progress Note dated 11/19/18 at 7:21 AM, documented that at 6:05 AM, the resident was combative and threw a radio. Writer advised LPN to keep staff with her and keep her safe. At 6:20 AM, the writer received a call that the resident had fallen in the dining area. The resident was noted on the floor in front of the windows. She was grimacing, rubbing her right thigh and bleeding from her posterior scalp. The MD was notified and the resident was sent to the emergency room (ER). An ER Physician (MD) Documentation Sheet dated 11/19/18, documented the resident had a 5-centimeter (cm) laceration to the back of her skull after an unwitnessed fall at the nursing home (NH). A Cat Scan (computerized tomography) was negative for a brain bleed and the laceration was closed with 8 staples. The CCP did not include an intervention to provide 1:1 supervision when the resident was exhibiting uncontrolled unsafe behaviors. During an interview on 11/29/18 at 11:20 AM, Registered Nurse (RN) #8 stated that another resident wheeling into the dining room, found the resident on the floor and called for staff. Anyone having uncontrolled behaviors should have a 1:1. Since this incident they have had to utilize 1:1 at times, it should have been added to the CCP but it was not done. During an interview on 11/29/18 at 11:48 AM, Certified Nursing Assistant (CNA) #7 stated that at a little after 6:00 AM, the resident was very confused and tried to throw a radio out the window. The resident apparently got up from her chair and fell. She did recall LPN #6 telling herself, LPN #5, and the Certified Occupational Therapy Aide (COTA) that the resident had to be safe meaning, she should not be left alone. During an interview on 11/29/18 at 11:55 AM, the COTA stated she came on the unit around 6:00 AM and the observed the resident alone in the dining area, that was dark; she was holding a pillow case in her hand and had ripped a silk flower arrangement apart. She told the COTA, she was going to leave. The COTA reported the incident to the LPN. The LPN called the nursing supervisor, who said to keep the resident safe. The COTA went to find a CNA to let them know. She returned to the dining room just in time to see the resident lift a radio over her head and throw it at the full length window. The radio bounced back but did not break the glass. She again said she was getting out of here. The LPN came out as as well as LPN #5 and CNA #7 so left the unit. The COTA thought keep safe was keep away from other res and windows. She thinks she fell around 6:30PM. She came back to the unit around 7:00 AM, and the resident was still on floor with pillow under head. She did not hear nurse to tell anyone to stay with the resident, she heard her say to keep her safe. Usually, when someone is likely to get up alone, they will sit them in the common area where they can be watched. During an interview on 11/29/18 at 12:13 PM, LPN #5 stated he was on the unit and witnessed the resident's behaviors and aggressiveness. The resident was combative and he talked to the resident to try to calm her while LPN #6 was trying to get her temperature. The resident was still with staff and agitated when he left the unit. He was not aware of anyone said to watch her. During an interview on 11/29/18 at 12:23 PM, the Director of Nursing (DON) the resident was agitated trying to throw radio through the window, she was left unattended fell. The LPN called the RN, who said to keep the resident safe, that would mean to stay with her one to one. Staff may not know that keep safe means to do a 1:1, because there is no policy for it. If 1:1 is required for anyone, it should be in their care plan; because it is not in her current care plan, there is still a chance this could happen again. The res would not have fallen if staff did a 1:1 at the time of the behaviors. Resident #45: The facility did not ensure that Resident #45 was provided with silverware when care planned for plasticware for safety reasons. The resident was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Major depressive disorder, (recurrent, mild), Unspecified dementia without behavioral disturbance, and Generalized anxiety disorder. The Minimum Data Set (MDS) dated [DATE] documented the resident had moderately impaired cognition, and could usually understand others and make herself understood. The Comprehensive Care Plan for Behavior Symptoms, last updated on 9/10/2018, documented the resident was to receive plasticware with meals. During an observation on 11/28/18 at 12:07 PM, the resident was sitting in the dining room, re-arranging and lifting the regular silverware at her table setting. A Progress Note dated 9/18/18, documented the Certified Nursing Assistant (CNA) reported that the resident was attempting to poke another resident with a spoon and fork at the dining room table at lunch time. The note stated that the other resident was relocated to another table, Resident #45 was given plasticware, and silverware was removed. During an interview on 11/28/18 at 3:14 PM, the Registered Dietitian (RD) stated since the plasticware was care planned and on the meal ticket, the resident should have received the it. The RD stated there was no policy and procedure on adaptive equipment. During an interview on 11/29/18 at 8:00 AM, Dietary Aide (DA) #1 stated the CNAs and DAs were responsible for setting tables, and the resident did not receive plasticware. During an interview on 11/29/18 at 8:01 AM, CNA #3 stated the CNAs and the Resident Assistants are responsible for setting the tables, and the resident did not receive the plastic ware, but should have. During an interview on 11/29/18 at 8:59 AM, Nurse Manager (NM) #3 stated the CNAs set the tables using information on the [NAME] and meal ticket, and the resident should have received the plasticware. 10NYCRR 415.12(h)(l)

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review that included steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This is evidenced by: The facility policy titled Drug Regimen Review with a release date of 10/2018, did not address steps the pharmacist would take when an identified irregularity requires urgent action to protect the resident. On 11/30/18 at 11:15 AM, the Director of Nursing reported she was not aware the policy lacked the necessary information. 10NYCRR415.18 (c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification survey, the facility did not ensure residents received pain medications with adequate indications of its use or adequate monitoring for 2 (Resident #'s 23 and 284) of 6 residents reviewed for unnecessary drugs. Specifically, for Resident #23 as needed (PRN) Morphine (MS04) pain medications were prescribed and not adequately monitored to determine the effectiveness of the medication and the need for its continued use and for Resident #284, the facility did not ensure that an antibiotic order from the emergency room (ER) was not doubled in dosage and duration by the nursing home, without adequate indications. This is evidenced by: The Policy & Procedure (P&P) titled Pain Control Management dated 4/2018, documented that documentation is a requirement with each pain assessment and also with each PRN (as needed) pain medication administration. It is to include the pain scale pre-medication, non pharmacological measures attempted, and the medication that is used for pain relief, with the time administered, dose and route. A follow-up note will include the post medication pain scale and what determining factors shows if the medication that is used for pain relief, with the time administered, dose and route. Resident #23: The resident was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease (COPD), anxiety disorder, and chronic pain. The Minimum Data Set (MDS) dated [DATE], documented the Resident was cognitively intact and was able to make herself understood and understand others. The Comprehensive Care Plan for pain, last updated 9/6/18, documented an intervention for on-going assessment of the resident's pain and alleviating and aggravating factors. It documented that the resident will verbalize comfort after 60 minutes of implementation of alleviating factors. The Physician's (MD) order dated 7/5/18, documented, Morphine (MS04) (narcotic pain medication) concentrate 20 milligrams (mg) per milliliter (ml) oral solution. Give 10 mg by oral route every 2 hours as needed (prn). The Electronic Medication Administration Record (eMAR) dated October 2018, documented the resident received the MS04 20 mg prn for pain, on 35 occasions. The notes at the end of the EMAR did not document before and after pain scale on six occasions; 10/12/18 at 8:04 PM and 10/14/18 at 10:18 AM, 10/15/18 at 4:25 PM, 10/18/18 at 3:43 PM, 10/19/18 at 6:09 PM, 10/30/18 at 9:13 PM. The post pain scale was not documented on six occasions; 10/2/18 at 2:27 PM, 10/3/18 at 3:23 AM, 10/4/18 at 3:11 AM, 10/20/18 at 4:26 AM, 10/26/18 at 4:07 AM, and on 10/28/18 at 5:56 AM. The EMAR dated November 2018 documented the resident received the MS04 20 mg prn for pain, on 29 occasions. The notes at the end of the EMAR did not document before and after pain scale on two occasions; 11/2/18 at 6:40 AM and 11/12/18 at 3:14 PM. The post pain scale was not documented on eight occasions; 11/3/18 at 6:40 PM, 11/5/18 at 5:20 PM, 11/6/18 at 4:14 AM, 11/7/18 at 4:18 AM, 11/20/18 at 4:02 AM, 11/21/18 at 5:46 AM, 11/26/18 at 5:10 AM, and on 11/28/18 at 9:50 AM. During an interview on 11/29/18 at 02:14 PM, Licensed Practical Nurse (LPN) #2 stated prn pain medication documentation should be the pain scale rating before and after the medication in the EMAR with the nurse initials. There should also be a nursing note following prn medication with a follow-up note on the effectiveness. During an interview on 11/29/18 at 02:25 PM, the Registered Nurse Manager #3 stated that prn pain medication should be documented in the EMAR with the pain scale before the medication and after. The facility developed a template in the nurse notes for the nurses to use that included the non-pharmaceutical interventions used, the pre and post pain scale, and follow-up note. The nurse should document prn pain medications in both places. During an interview on 11/30/18 at 09:58 AM, the Director of Nursing (DON) stated when a resident complained of pain the nurses should try non-pharmacological interventions first, rate the pain and follow-up for effectiveness of the pain medication within an hour. This should be documented in the nurse notes as well as the EMAR. Resident #284: The resident was admitted on [DATE] with diagnoses of osteoarthritis, hypotension, and depression. The MDS dated [DATE], documented that the resident had modified independence for cognitive skills for daily decision making. An emergency room (ER) Physician (MD) Documentation Sheet dated 11/19/18, documented the resident had a 5 centimeter (cm) laceration to the back of her skull after an unwitnessed fall at the nursing home (NH). The laceration was closed with 8 staples, and the resident will return to the NH on a course of Keflex (an antibiotic). An ER MD Order dated 11/19/18, documented Keflex 250 milligrams (mg); give one twice daily for ten doses. An MD order dated 11/19/18, documented Keflex 500 mg; give on twice daily for 10 days. The Medication Administration Record for 11/2018, documented that the resident received 20 doses of Keflex 500 mg from 11/19/18 - 11/29/18. During an interview on 11/29/18 at 2:13 PM, the Nurse Practitioner (NP) stated the facility just initiated an antibiotic stewardship program that was currently only working on antibiotics ordered for urinary tract infections in residents without catheters. When a resident comes back from the ER with antibiotic orders, she would order what they recommended. The NP stated she could not justify what her thought process was ordering 500 mg rather that 250 mg and for 10 days rather than 5, because she did not write a note. During an interview on 11/29/18 at 2:36 PM, the DON stated she would expect to see a note from the provider as to why the antibiotic dose and duration were doubled, and that was not good antibiotic stewardship. 10NYCRR415.12(1)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey, the facility did not ensure residents were free from unnecessary psychoactive medications for one (Resident #81) of 6 residents reviewed for gradual dose reductions (GDR's). Specifically, the facility did not ensure comprehensive gradual dose reductions were completed for Resident #81 over a one-year period. This is evidenced by: Resident #81 Resident #81 was admitted to the facility on [DATE] with diagnoses of Dementia with behavioral disturbance, Unspecified mood disorder and Alzheimer's Disease. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition, could rarely/never understand others and could rarely/never make herself understood. The Policy and Procedure (P&P) titled Drug Regimen Review dated 10/2018, documented review of resident's medication regime includes gradual dose reduction (GDR) attempts for antipsychotics will be considered, and the facility in collaboration with the Pharmacist will identify the parameters for monitoring medication. Additionally, Medical staff review recommendations from the Pharmacist, and document decision and reasoning for accepting or declining, with alternative measures to be initiated as appropriate. The Comprehensive Care Plan for Psychotropic Drug use, last updated on 9/19/2018, documented the resident was to receive GDR. A Progress note dated 1/25/18 at 1:37 PM, written by Social Worker #2, documented the resident continues on Zoloft and Seroquel with no GDR, and the resident has been resistant to care at times. A Progress note dated 5/10/18 at 1:37 PM, written by Social Worker #2, documented the resident continues on Zoloft and Seroquel with no GDR, and the resident has not had behaviors. A Physician/NP evaluation dated 6/18/18, documented Dementia with Depression, on a low dose antipsychotic, sometimes is resistant to care therefore I will not attempt any Gradual Dose Reduction (GDR) for the time being. A Medication Administration Record dated 11/2018, documented the resident is receiving sertraline 100mg once daily for diagnosis of Depressive Disorder (start date 10/6/14) and quetiapine 25mg once daily (start date 10/6/14) for Dementia without behavioral disturbance. During an interview on 11/30/18 at 9:47 AM, Social Worker #2 was unable to provide documentation on interdisciplinary discussions on the reason for contraindication of a GDR. During an interview on 11/30/18 at 9:58 AM, Director of Nursing stated GDR meetings used to be done before the facility hired two nurse practitioners. There is no formal monitoring process for GDRs at this time. During an interview on 11/30/18 at 10:09 AM, Nurse Practitioner #2 stated there is no one place to find GDR documentation in the medical record. The Pharmacist will provide notice to the Nurse Practitioner, and the Nurse Practitioner lets the facility know when a GDR is done. There is no formal process in place at this time. During an interview on 11/30/18 at 10:33 AM, the Pharmacist stated she completes a monthly review of progress notes, takes her own personal notes of when GDRs are due, and provides the paperwork to the Director of Nursing each month. She notifies the physician when GDRs are due. 10NYCRR415.12(1)(2)(II)

Based on record review and interview during the recertification survey, the facility did not ensure their policy regarding foods brought to residents by family and other visitors included information on the safe and sanitary storage, handling and consumption of food. Specifically, the facility does not provide information for family and other visitors on safe food handling practices or safe reheating of food that is brought in to residents. This is evidenced is as follows. Record review of the facility policy for foods brought in by visitors was reviewed on 11/26/2018. This policy does not include a process to ensure family and other visitors are provided information on safe food handling practices. The Director of Support Services and Social Worker #1 both stated in an interview conducted on 11/26/2018 at 1:52 PM that the policy regarding bringing food does not include information on safe food handling, and neither during the admissions process or thereafter is safe food handling discussed with family or visitors that bring food to residents.

Based on observation, manufacturer ' s directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Specifically, the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer, food temperature thermometers were not in calibration, food contact equipment required cleaning, and hand-washing sinks were not labeled. This is evidenced as follows. The kitchen was inspected on 11/26/2018 at 12:55 PM. The concentration of QAC used in the sanitizing rinse sink, the third sink, was found to be between 0 and 150 parts per million (ppm) when measured at 72 degrees Fahrenheit (F). The manufacturer ' s label directions stated the concentration is to be between 150 ppm and 400 ppm when the solution is measured between 65 F and 75 F. The slicer and can opener holder were soiled with food particles. Additionally, the five hand-washing sinks did not have signage labeling them as hand-washing sinks. The Director of Support Services stated in an interview conducted on 11/26/2018 at 12:55 PM that she will contact the chemical sanitizer vendor to have the concentration adjusted, labeled the sinks, and discuss proper cleaning with staff. The resident unit kitchenettes were inspected on 11/27/2018 at 11:30 AM. Three of 5 food temperature thermometers were found not in calibration when tested in a standard ice-bath method as follows: 25 F, 27 F, 28 F. Milk shake machines, refrigerator door gaskets, cabinets and drawers, and floors under equipment and next to walls were soiled with food splashed and particles. The Nutritional Services Supervisor stated in an interview conducted on 11/27/2018 at 11:30 AM that she will ensure all areas found are cleaned and will discuss thermometer calibration with the staff. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.85, 14-1.110, 14-1.112