**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 8/5/2024 and completed on 8/9/2024, the facility did not ensure a person-centered comprehensive care plan was developed and implemented to address each resident's medical needs. This was identified for one (Resident #81) of three residents reviewed for unnecessary medications. Specifically, Resident #81 was receiving anticoagulant medications as per the physician's orders; however, there was no comprehensive care plan developed for the use of an anticoagulant. The finding is: The undated facility's policy and procedure titled Comprehensive Care Plans (CCP) and Resident/Patient Meeting documented within 14 days of the resident's admission, a comprehensive assessment of the resident's needs will be prepared and developed by the interdisciplinary team, as required by the course of treatment specific to the resident. Information obtained from the comprehensive assessment enables the facility staff to plan care that focuses on the resident's ability to achieve the resident's highest practicable mode of functioning that includes but is not limited to the following: medical status measurement (functional physical and mental abilities including, but not limited to, information on the vital signs, laboratory values and/or diagnostic test), and drug therapy. Resident #81 was admitted with diagnoses of multiple fractures and Atrial Fibrillation. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, which indicated the resident had intact cognition. the resident received an anticoagulant medication. A Physician's order dated 7/2/2024 documented to administer Enoxaparin (an anticoagulant medication) 30 milligrams/0.3 milliliter, inject 0.3 milliliters by subcutaneous route every 12 hours for Fracture of one rib, right side. There was no documented evidence that a comprehensive care plan was developed for the use of the anticoagulant medication use. The Registered Nurse Supervisor #1 was interviewed on 8/07/2024 at 2:13 PM and stated any Registered Nurse can develop and initiate a care plan. The Registered Nurse Supervisor #1 stated that the admitting nurse was responsible for admissions assessment and initiating the care plans. The next day, a Registered Nurse should follow and initiate any other care plans that were required and were not initiated by the admission nurse. Registered Nurse Supervisor #1 stated that if a resident is on an anticoagulant, then there should be a care plan for the use of the anticoagulant medications. The Registered Nurse Supervisor #1 reviewed the resident's electronic medical record and stated no care plan was developed for the use of the anticoagulant medication. The Director of Nursing Services was interviewed on 0/07/2024 at 2:22 PM and stated if the resident is getting an anticoagulant medication, such as Enoxaparin, then there should be an anticoagulant care plan developed. The Director of Nursing Services reviewed the electronic medical record to identify a care plan for the anticoagulant medication use and there was no documented evidence that a care plan was developed. 10 NYCRR 415.11 (c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interviews during the Recertification Survey initiated on 11/29/2022 and completed on 12/6/2022, the facility did not implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (Resident #92) of one resident reviewed for Rehabilitation and Restorative Services. Specifically, Resident #92 had a Physician's order to utilize a right-foot Darco shoe (specialized shoe) to offload heel pressure when out of bed. Resident #92 was observed out of bed on two occasions without wearing the right-foot Darco shoe. The finding is: The facility Policy and Procedure titled, Assistive Devices, dated 4/2017 documented when a resident has an assistive device such as a [NAME] (Darco) shoe or a splint/brace/immobilizer applied to an injured extremity, proper care will be given to ensure healing of the injury without complications and the nursing staff is responsible to ensure the wearing schedule is followed. Resident #92 had diagnoses of Peripheral Vascular Disease, status post left Above Knee Amputation (AKA), Pressure Ulcer to the right heel and anterior foot, and Severe Protein Calorie Malnutrition. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderately impaired cognition. The MDS documented Resident #92 required limited assistance of one staff member for transfer and extensive assistance of one staff member for dressing. The resident utilized a wheelchair for mobility. The MDS indicated the resident was at risk for developing pressure ulcers. The MDS also documented the resident had one unstageable pressure ulcer injury that was present upon admission. The Comprehensive Care Plan (CCP) for Activities of Daily Living effective 7/5/2022 documented, under the focus section, the resident uses a right heel offloading Darco shoe when out of bed and to remove the Darco shoe every shift to check skin integrity. The CCP interventions section did not include use of the Darco shoe. The Physician order initiated on 7/7/2022 and last renewed on 11/12/2022 documented to apply Betadine and a dry protective dressing to the right heel unstageable pressure ulcer daily and as needed. The Physician's order initiated on 8/24/2022 and last renewed on 11/12/2022 documented to utilize a right heel offloading Darco boot (shoe) when out of bed and to remove every shift to check for skin integrity. Resident #92 was observed on 11/30/2022 at 9:30 AM in their room sitting in a wheelchair. Resident #92's right foot was resting on the floor, and there was no dressing observed on the right foot. At 11:38 AM the resident was observed with a white gauze wrapped around their foot. The resident was not wearing the right heel offloading Darco shoe on either occasion. The Licensed Practical Nurse Unit Nurse/ Nurse Manager (LPN) #4 came into the resident's room while the surveyor was present and located the Darco shoe in a bag on top of the resident's dresser. LPN #4 was interviewed on 11/30/2022 at 11:39 AM and stated that the resident was supposed to be wearing the Darco shoe when out of bed and the assigned Certified Nursing Assistant (CNA) #9 should have placed the Darco shoe on the resident's foot as soon as the resident was taken out of bed since the resident has vascular ulcers to their right foot. Resident #92 was interviewed on 11/30/2022 at 11:45 AM and stated that they (Resident #92) have been waiting for the Certified Nursing Assistant (CNA) #9 to put the Darco shoe on their foot. Resident #92 stated that CNA #9 told them (Resident #92) that they (CNA #9) would come back to put the Darco shoe on them (Resident #92); however, they (CNA #9) did not come back. Resident #92 stated they have wounds on their foot and wearing the Darco shoe makes them comfortable. CNA #9 was interviewed on 12/5/2022 at 2 PM and stated they (CNA #9) were assigned to care for Resident #92 on 11/30/2022 during the 7 AM to 3 PM nursing shift. CNA #9 stated they took Resident #92 out of bed in the morning before breakfast and did not put the Darco shoe on the resident's right foot. CNA #9 stated they (CNA #9) were aware that they (CNA #9) needed to put the Darco shoe on Resident #92's foot when the resident was out of bed. CNA #9 stated they (CNA #9) were going to go back to Resident #92 to put the Darco shoe on but forgot. The Director of Nursing Services (DNS) was interviewed on 12/06/2022 at 2:35 PM and stated that CNA #9 should have placed the Darco shoe on Resident #92 as the resident has wounds on their right heel. The DNS stated they (DNS) expected staff to follow each residents' plan of care and follow the Physician's orders. 10NYCRR 415.11(c)(1)

Based on record review and staff interviews during the Recertification Survey initiated on 11/29/2022 and completed on 12/6/2022, the facility must designate one or more individual(s) as the Infection Preventionist(s) (IP)(s) who are responsible for the facility's Infection Prevention Control Program (IPCP). The IP must have completed specialized training in infection prevention and control. Specifically, the facility's designated IP did not have documented evidence of specialized training in infection prevention and control. The finding is: The facility's policy, titled Infection Preventionist, effective 10/25/2022, documented the facility will employ an infection prevention nurse with the mission of preventing the spread and managing the many infections/viruses that the facility may encounter; and the Infection Preventionist (IP) nurse will have specialized training in infection prevention and control and will hold a certification. The Director of Nursing Services (DNS) was interviewed on 12/1/2022 at 11:26 AM and stated the facility has hired a Registered Nurse (RN #1) who is training to be the infection preventionist but is not yet certified. The DNS stated RN #1 was hired in September 2022 and started the specialized infection control training in October 2022. The DNS further stated the facility has no interim infection preventionist at this time. RN #1 was interviewed on 12/1/2022 at 12:05 PM and stated they (RN #1) started working at the facility in September 2022 and began the specialized infection control training in October 2022. RN #1 stated they (RN #1) received infection control guidance from either the DNS or someone at corporate level for this facility. RN #1 stated they (RN #1) are working on modules 1-4 of the required infection control trainings, and none are completed. The DNS was re-interviewed n 12/5/2022 at 2:06 PM and stated they (DNS) have no current documentation for certification or training for infection prevention. The DNS stated the only training they (DNS) have is the infection control training that all nurses have to take when renewing their license. 10NYCRR 415.19

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, record review, and interviews during the Recertification Survey, the facility did not report an alleged allegation of abuse immediately or not later than two hours to the State Agency after the allegation was first made. This was identified for one of one resident reviewed for Abuse. Specifically, Resident # 258 had made an allegation of being forced to take medication that the resident was refusing. There was no documented evidence that the facility had reported the alleged abuse within the two hour time frame to the State Agency. The finding is: Resident # 258 has diagnoses which includes Dementia and Depression. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was usually understood, can sometimes understand and had a Brief Interview for Mental Status (BIMS) Score of 6, indicating severely impaired cognition. The resident's Mood Score was 12, indicating moderate Depression. A Nursing Progress Note dated 11/19/19 at 12:36 AM documented that the resident's 11:00 AM-7:00 PM Certified Nursing Assistant (CNA) had reported to that nurse that the resident had been abused at 9:00 PM on 11/18/19 and that the Supervisor was notified. During the initial tour on 11/19/19 at 10:30 AM, the resident appeared to be anxious and reported to the surveyor that the night before (11/18/19) the resident had been held down and forced to take medication. The resident's Social Worker (SW) was notified by the surveyor immediately at 10:45 AM on 11/19/19 and stated that an investigation would be initiated. A Nursing progress note dated 11/19/19 at 2:58 PM documented that the nurse was made aware by the 11:00 AM-7:00 PM shift that the resident had made a statement regarding mistreatment by staff. The SW was made aware, as well as the Director of Nursing Services (DNS), the Physician and the Psychiatrist. The Accident/Incident Summary of the investigation dated 11/20/19 documented that the facility was unable to substantiate the resident's claims of abuse. The DNS was interviewed on 11/22/19 at 11:40 AM. The DNS stated that the alleged abuse incident had not been called into the State Agency because after the investigation the resident's allegation had been unsubstantiated. The Administrator was interviewed on 11/25/19 at 9:58 AM. The Administrator stated that the State Agency had not been called because the Department of Health was in the facility for survey and had brought the resident's concern to the Administrator's attention. 415.4(b)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey, the facility did not develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. Specifically, one (Resident #159) of one resident reviewed for infections, who had a Midline Catheter line, had no care plan interventions developed for care and monitoring the Midline Catheter. The finding is: There was no policy and procedure developed to address care and monitoring of midline catheters. There was a policy and procedure developed for Peripherally Inserted Central Catheter (PICC) lines dated 4/18 and documented to do assessments before and after administration of intermittent intravenous medications. Assessments included to document the absence or presence of erythema, drainage, swelling, induration and label the dressing with date and time. Resident # 159 admitted on [DATE] with diagnoses including Paraplegia and status post Sepsis. No Minimum Data Set (MDS) Assessment was available due to the resident being a new admission. The hospital Patient Review Instrument (PRI) dated 11/13/19 documented a Midline catheter was inserted on 11/12/19 and care per the facility policy. The Physician's orders dated 11/13/19 documented Midline catheter and to change the dressing every 3 days and as needed. On 11/14/19 the physician ordered Intravenous (IV) antibiotic Ceftriaxone 1 gram (GM) in 100 milliliter (ml) Normal Saline (NS), give 2 grams by intravenous route once daily for 10 days and to flush the Midline catheter with 5 ml NS before and after the medication. On 11/20/19, the physician ordered another Midline Insertion because the resident had dislodged the previous midline. The Comprehensive Care Plan (CCP) for IV Antibiotic, last reviewed/revised on 11/14/2019, documented the resident has a need for IV antibiotic therapy. There were no interventions to address how to care for and monitoring of the Midline catheter. A progress note dated 11/19/2019 at 2:37 PM documented the PICC line was dislodged. A replacement was ordered. The progress note referred to the midline catheter as a PICC line. The Registered Nurse (RN) Supervisor was interviewed on 11/21/19 at 11:44 AM and stated the CCP should have listed interventions on how to take care of the Midline catheter. She stated this was an oversight. She further stated the resident has a behavior that may have caused the Midline catheter to dislodge on 11/18/19 and this behavior should be included in the CCP to prevent the Midline catheter from dislodging again. An observation of the Midline catheter site was made on 11/22/19 at 11 AM. There was an undated dressing in place. No redness or signs and symptoms of infection were observed. The Director of Nursing Services (DNS) was interviewed on 11/22/19 at 1:45 PM and stated the CCP should have been resident-centered to address the resident's Midline catheter. The CCP should have included the care to the Midline catheter and how nurses were to monitor the Midline catheter. Additionally, she stated a CCP should have been developed after the first incident when the resident's Midline catheter was dislodged. 415.11(c)(1)