Based on observation, interview and record review during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not ensure that it promoted and facilitated resident self-determination including the resident's right to make choices about aspects of daily life that are significant to the resident for 1 of 3 residents (Resident #4) reviewed. Specifically, there was no documented evidence Resident #4's informed consent was obtained prior to initiating a chair alarm (a device that detects pressure changes to alert staff of resident position changes) and the care plan was not revised to include the use of a chair alarm. Findings include: The facility policy, Resident [NAME] of Rights, effective 6/26/1997, documented residents had the right to refuse treatment after being fully informed of and understanding the consequences of such action. The facility policy, Care Plans-Specific Writing Guidelines, last reviewed 2023, documented care plan approaches should include resident preferences and should be resident specific. The facility policy, Alarm Use, effective 2000, documented all residents were assessed/evaluated by the interdisciplinary team for fall prevention measures including alarms. If alarms were determined an appropriate intervention, an individualized person-centered care plan would be implemented. Residents had the right to decline or refuse alarms. The facility policy, Fall Prevention for High-Risk Residents, revised 7/2024, documented residents at high risk for falls would have a fall prevention care plan; staff would round when the resident was in bed; and the call bell would be kept in reach. Additional measures to be considered on an individual basis would include a bed and/or chair alarm. Resident #4 had diagnoses including repeated falls and generalized muscle weakness. The 11/19/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not exhibit behavioral symptoms, required substantial/maximal assistance with sitting to standing and chair/bed-to-chair transfers, had a fall prior to admission, did not have any falls since admission, and used a bed and chair alarm daily. The Comprehensive Care Plan, initiated 11/12/2024, documented the resident was at risk for falls related to high risk for falls, frequent falls, impaired mobility, and balance deficit. Interventions included bed in the lowest position, evaluate pattern of falls, and anticipate resident needs. There was documented evidence of use of a bed or chair alarm. The 12/30/2024 Physician order documented a bed/chair alarm. The resident care instruction sheet, updated 1/8/2025, documented the resident was alert and oriented and had bed and chair alarms. Nursing progress notes dated 12/30/2024-1/8/2025 did not include the use of a bed or chair alarm or discussions with the resident or resident representative regarding the use of a bed and chair alarm. Resident #4 was observed sitting in their wheelchair with a chair alarm clipped to their back: - on 1/6/2025 at 11:39 AM, Resident #4 stated the chair alarm bothered them and they had never fallen from the chair. - on 1/8/2025 at 9:03 AM. Resident #4 stated they recalled one time the chair alarm activated. They were not sure why it activated as they had not fallen. The alarm was very loud, and it took a long time for someone to respond to turn it off. No one had asked them if they wanted the alarm and if they had been asked, they would have declined. - on 1/10/2025 at 8:44 AM. During an interview on 1/10/2025 at 2:46 PM, Certified Nurse Aide #4 stated resident rounds were performed on all residents minimally every 2 hours to check such things as positioning, need for bathroom use, and to ensure alarms were in place. Alarms were usually used on someone who fell. Resident #4 was rounded on minimally every 2 hours, they used their call bell appropriately, was able to voice their needs, and did not attempt to get up unassisted. They thought the resident's alarms were put in place on admission as a precaution. If a resident had an alarm but did not need one it could be undignified. Alarms were noticeable to others so even reducing from two to one could help with dignity. They stated, residents had the right to fall. During an interview on 1/10/2025 at 2:57 PM, Licensed Practical Nurse #5 stated alarms required a physician order and should be care planned. Residents identified as high risk for falls on admission had alarms initiated. Within two weeks, if there were no attempts to get up unassisted, the alarms would be taken off. If a resident was using their call bell safely, was not self-transferring or falling they would suggest the alarms be removed. Resident #4 was soft spoken, did not like to complain, used their call bell, was able to make their needs known, was able to understand others, did not attempt to self-transfer, had not fallen, and had intact cognition. The resident had both a chair and bed alarm since admission. They stated removing unnecessary alarms was important for dignity reasons and that use of alarms took some independence away from the residents and residents had the right to fall. During an interview on 1/10/2025 at 3:15 PM, Registered Nurse Unit Manager #6 stated bed and chair alarms were used on residents that did not understand the call bell concept, tried to get up alone, had late-stage dementia, and had a history of falls. They determined the need of alarms, and some residents were put on an alarm on admission if they were agitated or had a history of falls. They initiated the alarms on admission and did not ask the residents' permission first. A high fall risk assessment alone should not trigger the need for an alarm. Resident #4 used their call bell, was able to make their needs known, was able to understand others, did not attempt to self-transfer, had not fallen, and was rounded on every hour. The ongoing need for the resident's alarms had not been reevaluated since admission but should have been. Asking permission for alarm use was important so it was not considered against the resident's will. The use of alarms could cause anxiety, dignity issues, impair independence, and make a resident feel less free. Discontinuing an alarm was important because if a resident used the call bell effectively and no longer was a risk for falls alarms could be considered a restraint. During an interview on 1/13/2025 at 2:30 PM, the Director of Nursing stated the use of alarms was determined on admission. They went higher on alarm use initially and would drop back down if indicated. Use of alarms was reassessed during the first care plan meeting, quarterly, and with any significant change. The use of alarms was discussed with the resident during their care plan meetings. Resident #4 scored high on their fall assessment and therefore needed an alarm. The use of the alarm was discussed with the resident at their care plan meeting. The Interdisciplinary Care Plan Meeting sign-in sheet, dated 11/27/2024, did not document the resident was present for the meeting. 10 NYCRR 415.5(b)(3)

Based on observations, record review and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not consult with the physician when there was a significant change in the resident's physical status for 1 of 3 residents (Resident #30) reviewed. Specifically, Resident #30 had a continued, unplanned weight loss and the medical provider was not notified. Findings include: The undated facility policy, Change in Condition-Notification, documented the facility would notify and inform the resident's physician, and if known, their legal representative when there was a significant change in the resident's physical, mental or psycho-social status in either life-threatening conditions or clinical complications. Resident #30 had diagnoses including Parkinson's disease (a progressive neurological disorder), diabetes, and gastro-esophageal reflux disease (stomach acid rises into the esophagus). The 11/10/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required substantial/maximum assistance of 1 for all activities of daily living, did not have weight loss or a swallowing disorder, had no loose or broken teeth, and did not receive a therapeutic diet. The Comprehensive Care Plan initiated 9/22/2023 documented a focus area of nutritional status. Interventions included follow physician diet order, regular diet with mechanical soft/ground consistency, weights per physician order, labs as ordered, dietitian consult as needed, and observe for signs and symptoms of poor nutrition/hydration status like dry mouth, cracked lips, sunken eyes, dark urine, frequent vomiting, diarrhea, or fever. Care plan updates documented the following: - on 9/27/2023, regular diet. - on 3/12/2024- provide whole milk with meals for calorie intake. - on 12/30/2024- Ensure Plus high protein (nutritional supplement) three times a day with meals. Resident #30's monthly weight report documented the following weights: - 10/2/2024-160 pounds. - 10/7/2024 reweight- 157 pounds. - 11/3/2024- 157 pounds. - 12/3/2024- 143 pounds (8.9% weight loss in 1 month) - 1/2025 (no date)- 139 pounds (13.1% weight loss in 3 months) The 11/7/2024 Dietetic Technician #12 quarterly nutritional assessment documented the resident had a recent decline in food and fluid intake and required staff to assist them with eating. The plan was to follow the resident's intake and adjust their meal/fluid patterns and follow the December weight. The 12/11/2024 Acute Visit list (a list of residents that needed to be seen by the provider) documented Resident #30 was to be seen for an acute visit. The list did not include the reason the resident needed to be seen. There was no documented evidence the physician was notified of the resident's significant weight loss. The 12/11/2024 Physician #10 progress note documented the resident had a slow decline cognitively and physically since the last visit. There was no documentation regarding the 8.9% weight loss from 11/3/2024-12/3/2024. The 12/30/2024 at 12:07 PM Dietetic Technician #12 progress note documented the resident's December weight was 141 pounds and was a 16-pound weight loss from 11/2024, following an illness with decline. The resident had variable intakes despite increased feeding assistance. Eight ounces of Ensure Plus Hi Protein three times a day with meal was added. Follow up in 1/2025 when weights become available. The Acute Visit list dated 1/3/2025-1/13/2025 did not include Resident #30. There were no documented physician progress notes regarding Resident #30's significant weight loss. Resident #30 was observed: - on 1/8/2025 at 8:58 AM, sitting at the dining room table with their breakfast tray that consisted of an egg/cheese biscuit, potatoes, cold cereal, 4 ounces of orange juice, 8 ounces of milk and 8 ounces of a nutritional shake. The resident was partially assisted with eating and consumed 25% of their meal and drank half of their shake. - on 1/10/2025 at 9:12 AM, the resident had just finished eating their breakfast and the tray had been removed. The resident intake form documented they had consumed less than 50% of their meal and drank 240 cubic centimeters (8 ounces) of fluids. During an interview on 1/10/2025 at 10:11 AM, Certified Nurse Aide #16 stated the resident required additional assistance with eating, but they were unsure why they needed extra assistance or if the resident had lost weight. During an interview on 1/10/2025 at 2:41 PM, Dietetic Technician #12 stated they completed the quarterly nutritional assessments for the residents and gave the information to Registered Dietitian #11 who completed the nutritional assessment. Resident #30 had a 16 pound weight loss between 11/2024-12/2024 and they did not notify the physician of the loss. Dietetic Technician #12 stated they only conducted the nutritional assessments and entered progress notes. They filled out a weight change sheet that indicated a resident had a weight loss of 5 pounds or more. The weight change sheet was given to Registered Nurse Unit Manager #7 for review, who gave it to the Director of Nursing. They stated the Director of Nursing was responsible for notifying the physician of the weight change. They had always communicated weight changes that way and they trusted it worked. During an interview on 1/13/2025 at 10:30 AM Registered Nurse Unit Manager #7 stated certified nurse aides were responsible for obtaining the resident's weights every month and if there was a 5-pound weight loss or gain, a re-weight should be done. They did not notify the physician of weight changes. The Director of Nursing reviewed the weight change sheets documented if the resident had a significant weight loss. The notified the registered dietitian and the physician. Registered Nurse Unit Manager #7 stated they were aware Resident #30 had a significant weight loss of 16 pounds. They would not have documented the weight loss anywhere but should have written a nursing note in the resident's chart. It was important to document a significant weight loss, so staff were aware, and treatment was not delayed. During an interview on 10/10/2025 at 10:56 AM the Director of Nursing stated resident weights were obtained by certified nurse aides by the 10th of each month. If there were a significant weight change, the Nurse Managers should request a re-weight. If a resident had a significant weight loss, Dietetic Technician #12 would assess the resident and add supplements. They stated they received weight change sheets monthly from the Nurse Managers, reviewed them, and passed them to Minimum Data Set Coordinator #20 to make changes on the resident's assessment. They were aware Resident #30 had a significant weight loss but did not document in a progress note until 1/4/2025. They stated Registered Nurse Unit Manager #7 would know if the physician was notified. During an interview on 10/13/2025 at 12:40 PM, Physician #10 stated they were unsure if they were notified about Resident #30's significant weight loss. Weight changes were communicated by staff verbally when they did medical rounds and should be listed on their Acute Visit list. They documented in a progress note for acute issues. They expected staff to notify them of a significant weight loss. Treatment might consist of either an appetite stimulant or a review of the Resident's Medical Orders for Life-Sustaining Treatment record for a feeding tube. 10 NYCRR 415.3(2)(ii)(a)

Based on observations, interviews, and record review during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not ensure resident rights to privacy and confidentiality of their personal and medical records for 2 of 2 residents (Resident #3 and 13) reviewed. Specifically, Residents #3 and #13 had their dietary status posted outside their rooms and was visible to the public. Findings include: The facility policy, Patient [NAME] of Rights Procedures, dated 6/26/1997, documented the residents of the facility were assured their medical and personal records would be kept in confidence. All staff were educated to respect the dignity and individuality of each patient with attention to privacy during the treatment and care of the resident's personal needs. 1) Resident #3 had diagnoses including cerebral palsy (a disorder affecting movement and muscle tone) and quadriplegia (paralysis of all 4 limbs). The 11/22/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, was dependent for all activities of daily living, and had a feeding tube (gastrostomy, a tube surgically inserted into the stomach) for more than 51% of their daily total calories. The 12/30/2024 physician order documented the resident was NPO (nothing by mouth) and received Jevity 1.5 (tube feeding formula) continuously at 50 cubic centimeters per hour, and the resident's medications could be mixed to administer via the resident's gastrostomy tube. The follow observations were made: - on 1/06/2025 at 11:35 AM, there was a sign documenting NPO next to their name plaque on the outside of their room. - on 01/07/2025 at 9:08 AM, NPO was handwritten on a folded pink piece of paper taped above their name on the door plaque. - on 01/08/2025 at 8:56 AM, there was NPO next to the resident's name on their door. - on 01/10/2025 at 11:31 AM, there was a sign on pink paper documenting NPO above the resident's name on the door plaque. 2) Resident #13 had diagnoses including cerebral palsy and adult hypertrophic pyloric stenosis (obstruction to the flow of food from the stomach to the small intestine). The 12/21/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent for all activities of daily living, and had a feeding tube for more than 51% of their daily total calories. The 12/30/2024 physician order documented the resident was NPO and received Vital 1.5 (tube feeding formula) at 50 cubic centimeters per hour via their jejunostomy tube (feeding tube inserted into the small intestine.) The following observations were made: - on 1/06/2025 at 11:56 AM, the resident's name plaque outside their room had an NPO sign next to it. - on 1/07/2025 at 9:15 AM, the resident had NPO printed on paper next to their name on their name plaque. - on 1/08/2025 at 9:01 AM, the resident had NPO above their name on the door. - on 1/08/2025 at 2:45 PM, there was an NPO sign above the resident's name on their door plaque. - on 1/10/2025 at 11:33 AM, there was a small sign with NPO next to resident's name on the door plaque. During an interview on 1/10/2025 at 11:39 AM, the Social Services Director stated staff was educated on what classified as resident personal information. A resident's diet and liquid texture were classified as resident's personal health information. A resident's personal health information should not be posted where visitors and non-pertinent staff could see it. The nothing by mouth directive outside a resident's door was a violation of the resident's privacy. During an interview on 1/10/2025 at 2:06 PM, Certified Nurse Aide #18 stated the NPO sign outside the resident's door indicated the resident was to have nothing by mouth. The signs were placed there so no one accidentally gave the resident food or anything to drink. A resident's liquid and/or diet texture was classified as personal health information. It was a violation of the resident's privacy to have NPO posted next to the residents' names on their doors. During an interview on 1/10/2025 2:38 PM, Licensed Practical Nurse #19 stated the NPO sign outside Resident #13's door indicated the residents could not have anything by mouth and alerted unit helpers to not bring them snacks or drinks. Resident health information should not be posted where unauthorized persons or staff could view it. They stated they were undecided if posting the information outside the resident's door was a violation of privacy as they did not want a well-meaning visitor or volunteer to give the resident food or fluids they could not have. During an interview on 1/10/2025 at 2:43 PM, Registered Nurse Unit Manager #6 stated liquid and diet texture were classified as personal health information. The NPO signs for Resident #3 and Resident #13 should not have been posted outside their rooms and was a violation of the resident's privacy. During an interview on 1/13/2025 at 12:02 PM, the Director of Nursing stated staff was educated on what classified as resident personal information at least once a year. A resident's diet and liquid texture were classified as personal health information. A resident's diet and/or liquid texture should not be posted in areas visible to other residents and visitors. They stated a resident who had an NPO sign posted outside their room next to their name was not a violation as it was an abbreviation and non-medical personal would not know what it meant. They stated they did not think about visitors or other residents with a medical background being aware of it. It was a violation of the resident's privacy to have their diet order posted outside their room next to their name. 10NYCRR 415.3(d)(1)(ii)

Based on observations, record review, and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not ensure all alleged violations including injuries of unknown origin, were thoroughly investigated to rule out abuse or neglect for 1 of 5 residents (Resident #25) reviewed. Specifically, staff identified a skin tear on Resident #25's left arm and there was not a timely investigation completed to rule out abuse or neglect. Additionally, the resident's skin tear was not assessed by a qualified professional and the medical provider was not notified of the injury. Findings include: The facility Registered Nurse Job Description dated 2019, documented the responsibilities of the registered nurse were to recognize and report changes in resident condition to the physician and follow through with an appropriate assessment, nursing measures, and documentation. The facility policy, Reporting of Alleged Physical or Verbal Abuse, dated 2/2000 documented: - All alleged violations involving mistreatment, neglect, abuse, and misappropriation of property, including injuries of unknown source were reported immediately to the President and Chief Executive Officer of the facility and when required by law to the New York State Department of Health. - The alleged violation would be reported immediately, and the Registered Nurse Manager would be responsible for initiating the accident/incident form. - The Supervisor shall begin an investigation immediately when a report of an alleged violation is received. A thorough investigation should include the date and time of the incident, who discovered the incident, how the incident was discovered, and the log should include staff interviews including dated and timed statements, a resident statement and a physician and family representative should be notified in a timely manner. Resident #25 had diagnoses including dementia with behavioral disturbances, diabetes, and history of falls. The 12/25/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, had functional limitation in range of motion in both arms and legs, had no skin impairments, had no behavioral symptoms, did not reject care, and used a wheelchair. The Comprehensive Care Plan effective 2/28/2023 documented: - the resident required assistance with activities of daily living. Interventions included extensive assistance of 2 for bed mobility, and total assistance for transfers and toileting, and half side rails as enablers for bed mobility. - the resident was at risk for inappropriate behaviors related to dementia with psychosis. Interventions included remove resident from situation and reapproach as needed. - the resident was at risk for falls. Interventions included investigate cause of fall immediately, bed in lowest position, ensure call bell is in reach, and maintain a safe environment. - the resident was at risk for impaired skin integrity related to impaired mobility, friction and shearing, and incontinence. Interventions included certified nurse aide evaluation of skin daily during care and report any skin abnormalities to the nurse. An additional note dated 10/16/2024 documented the resident had multiple skin tears due to fragile skin. The 1/2025 resident care instructions documented Resident #25 required extensive assistance with activities of daily living, required assistance of 2 and a mechanical lift for transfers into a geriatric lounge chair, was alert and oriented with forgetfulness and disorientation, and requested no male caregivers. The 1/2/2025 at 1:59 PM Licensed Practical Nurse #2 progress note documented the resident was hitting, pinching, and slapping staff. Staff noticed an open area on the resident's left upper arm, it looked like a bruise that had opened, and they cleansed and wrapped it with a bandage. There was no documented evidence the skin impairment Licensed Practical Nurse #2 found on 1/2/2025 was assessed by a qualified professional. The 1/2/2025 24-hour report had no documented evidence the resident had a skin tear to their left arm. The untimed Resident Incident Report initiated by Licensed Practical Nurse #2 and prepared by Registered Nurse Unit Manager #7 on 1/2/2024 documented the resident had a bruise/soft tissue contusion/swelling of their left arm that was discovered on 1/2/2025. The incident was unobserved. The area was cleansed, and telfa (a non-adhesive bandage) and kling wrap (an outer bandage) was applied. The physician signed the report on 1/9/2025. There was no documented evidence the injury to the left arm was investigated timely to rule out abuse and neglect. The Resident Incident Investigation Report dated 1/8/2025 and signed by the Director of Nursing documented the resident had been agitated during care. Staff (unidentified) had just completed hygiene care after transferring the resident into bed (no time documented). The analysis of the incident documented the resident had a history of behaviors with care and had fragile skin. There were no symptoms exhibited which may have contributed to the incident. The plan was to use Geri sleeves (protective skin covering) to aid with protection of fragile skin. The Director of Nursing concluded there were no indications of abuse or neglect through the investigation. A 1/8/2025 (6 days after the incident) staff statement from Registered Nurse Unit Manager #7 documented the resident stated they were not harmed by staff. There was no documented evidence a thorough investigation was completed to rule out abuse or neglect related to the injury of unknown origin identified on 1/2/2025. There was no documented evidence the medical provider was notified timely. During an observation and interview on 1/6/2025 at 10:26 AM, Resident #25 was sitting in their room in a geriatric lounge chair. A medium sized bruise was observed on the resident's left forearm and a small bandage near their elbow. The resident was unable to explain the cause of the bruise. During an observation on 1/10/2025 at 10:47 AM with Licensed Practical Nurse #2 the resident had multiple bruises on their left forearm. There was no bandage on their left elbow. There was a half-moon shaped open skin tear with a flap of skin covering it approximately 1-1/2 inches long and ½ inches wide, approximately ½ inch down from the bend of the resident's elbow. During an interview on 10/10/2025 at 10:11 AM Certified Nurse Aide #16 stated the resident had behaviors with care, they would ask the resident questions and try to distract them. The resident required assistance of 2 with a mechanical lift for transfers. They thought the resident had sores on their arms and was unsure why their left arm had a bandage. During an interview on 1/10/2025 at 10:36 AM Licensed Practical Nurse #2 stated Resident #25 scratched and hit staff during care. Staff had reported the resident had an open area on their arm and they wrote a nursing progress note. They were unsure which staff reported it. They stated the resident had a skin tear, it was initially bleeding, and they placed a bandage on it. Treatments required a physician order, and they did not have a treatment order. Licensed Practical Nurse #2 stated they thought they reported the incident on the 24-hour report, did not recall telling anyone, and a registered nurse did not assess the wound. They determined it was not abuse because the staff told them the resident had an open area. During an interview on 1/13/2025 at 9:18 AM Certified Nurse Aide #15 stated the resident was combative with care, they pinched and scratched the staff and required 2 staff to provide care. They stated they knew the resident had a skin tear to their left arm, they obtained it from pinching and scratching the staff and was not sure when it happened. They did not care for the resident often. Certified Nurse Aide #15 stated if the resident was combative, they would stop care and reapproach them and if they noticed a skin tear, they would tell the medication nurse. During a telephone interview on 1/13/2025 at 10:03 AM Certified Nurse Aide #13 stated they worked per diem (as needed) and worked on the C and D Units. They had cared for Resident #25 two weeks ago and noticed a skin tear to their left arm. Certified Nurse Aide #13 stated the resident was combative with care. The certified nurse aide stated they tried to grab the resident's arms to move them away before the resident could hit or grab them. Certified Nurse Aide #13 stated they thought the resident obtained a skin tear during the transfer into bed and stated they could have caused the skin tear due to the resident flailing their arms around during care or during the transfer but was unsure and reported the skin tear to the medication nurse. During an interview on 1/13/2025 at 10:30 AM Registered Nurse Unit Manager #7 stated the skin tear was not reported to them, they did not assess the skin tear, did not obtain staff or witness statements, and did not initiate an investigation. They stated they did not rule out abuse because the resident told them that they were not harmed by staff. During an interview on 1/13/2025 at 10:56 AM the Director of Nursing stated they expected staff to notify them if a resident had an injury. They stated Resident #25 had dementia and was not alert and oriented. The resident had a skin tear to their left arm on the first of the month and they received an incident report on 1/8/2025. They stated they were familiar with the New York State Reporting Manual, did not report the injury of unknown origin and did not obtain staff statements or interviews. The Director of Nursing stated the resident refused to interview with them, but the resident told Registered Nurse Unit Manager #7 no staff had harmed them. They thought they had ruled out abuse because they believed the resident. They did not determine if abuse had occurred. During an interview on 1/13/2025 at 1:40 PM the Medical Director stated they were familiar with Resident #25, they were not alert and oriented, and had behavioral symptoms. They were unaware of any acute issues with the resident. The Medical Director stated they were not aware of a skin tear to the resident's arm, would expect nursing to notify them because injuries of unknown origin required an investigation. 10NYCRR 415.4(b)(3)

Based on observations, record review, and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 2 of 2 residents (Residents #43 and #57) reviewed. Specifically, Resident #43 did not have medication-specific interventions for the use of anticoagulants (blood thinner), and Resident #57 did not have a comprehensive care plan for the use of a chair alarm. Findings include: The facility policy, Care Plans-Specific Writing Guidelines, last revised 11/2017, documented the facility would develop a care plan specifically tailored to each individual based on person-centered care. Care plans would be updated and reviewed quarterly, annually, and after any significant change in condition. The facility policy, Alarm Use, effective in 2000 documented if alarms were determined to be an appropriate intervention an individualized person-centered care plan would be implemented and would be communicated on the certified nurse aide information sheets. The facility policy, Care Plans-General Development, last reviewed in 2023, documented baseline care plans included instructions needed to provide effective person-centered care and standard care and included medications. Each care plan would consist of four parts: focus details/problem/potential problem, goals, interventions/approaches/preferences, and notes/evaluation/reviews. 1) Resident #57 had diagnoses including diabetes and hypertension (high blood pressure). The 1/3/2025 Minimum Data Set assessment documented the resident had intact cognition, required partial/moderate assistance with bed mobility and transfers, had no falls, and did not use a chair alarm. The 8/5/2024 Comprehensive Care Plan documented the resident was at risk for falls related to impaired mobility and balance deficit. Interventions included anticipate resident needs, use appropriate assistive device and level of assistance as recommended, and provide education on wheelchair safety. Interventions did not include the use of a chair alarm. The resident's undated certified nurse aide information sheet did not document the use of a chair alarm. During an observation and interview on 1/6/2025 at 12:57 PM, the resident was sitting in their wheelchair with a chair alarm attached to their shirt. They stated they had never had a fall. They stated staff attached a chair alarm to them when they were in their wheelchair. During an interview on 1/13/2025 at 9:32 AM, Certified Nurse Aide #21 stated they looked at residents certified nurse aide information sheets to know how to care for a resident. It was the nurse's responsibility to keep the information sheet updated with accurate information and if they noticed it was not accurate, they would notify the nurse manager. Residents who forgot to ask for assistance or had a lot of falls would use bed or chair alarms which were listed on the certified nurse aide information sheet and the care plan. They cared for Resident #57 during the day shift on 1/6/2025 and did not recall the resident using a chair alarm. It was not in their care plan or on their certified nurse aide information sheet so the resident should not have one in place. They stated it was important for care plans to be updated with accurate information so Resident #57 received proper care and were safe. During an interview on 1/13/2025 at 9:50 AM, the Director of Education/Infection Control Nurse #22 stated they passed medications on unit F on 1/6/2024 during the day shift. Staff should look at a resident's certified nurse aide information sheet or care plan to know how to care for a resident, and both had the same information. The Registered Nurse Managers were responsible for reviewing and updating resident care plans with accurate information and they were reviewed quarterly and as needed. Chair alarms were used for residents who forgot to ask for assistance or were high fall risks. They did not recall Resident #57 having a chair alarm on 1/6/2025 and they should not have been using one because it was not on their care plan. It was important to keep care plans updated with accurate information so Resident #57 received proper care and was safe. During an interview on 1/13/2025 at 10:15 AM, Registered Nurse Manager #23 stated staff would look at resident's care information sheets or care plans to know how to care for them. They contained their activities of daily living, transfer status, diet, toileting schedule, and safety information like bed and chair alarms. They were responsible for reviewing and updating care plans quarterly and as needed. Chair alarms were used for fall safety and for residents who forgot to ask for assistance and required a physician order. Resident #57's care plan did not include a chair alarm so they would have expected their staff to not initiate one without coming to them first and were not aware Resident #57 had a chair alarm in place on 1/6/2024. It was important to keep care plans updated with accurate information so Resident #57 received proper care. 2) Resident #43 had diagnoses including atrial fibrillation (an abnormal heartbeat), heart failure, and dementia. The 10/29/2024 quarterly Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent on staff for all activities of daily living, did not have any skin conditions, and did not receive an anticoagulant medication. Physician orders reviewed and renewed 11/25/2024 documented Eliquis 2.5 milligrams, 1 tablet two times daily for atrial fibrillation. The Comprehensive Care Plan initiated 1/7/2023 documented Resident #43 had cardio-vascular disorders with diagnoses of hypertension (high blood pressure), atrial fibrillation, congestive heart failure (heart fails due to fluid overload), and cerebrovascular accident (a stroke). Interventions included take medications as prescribed by physician: Eliquis (a blood thinner). There were no interventions for the use of a blood thinning medication. The Comprehensive Care plan initiated 1/24/2023 documented the resident was at risk for falls and was at risk for impaired skin integrity. During an observation on 1/6/2025 at 12:27 PM, Resident #43 was sitting on a mechanical lift pad in their wheelchair in the dining room waiting to be assisted with lunch. During an interview on 1/10/2025 at 8:42 AM, Licensed Practical Nurse #27 stated the Nurse Managers were usually responsible for care plans and some licensed practical nurses also completed them. They did not know what needed to be included. During an interview on 1/10/2025 at 8:50 AM, Registered Nurse Unit Manager #22 stated they were responsible for reviewing the resident care plans and updating them as needed. Care plans were updated when new physician orders were placed, with any changes in the resident's condition, and quarterly. When they added an intervention or medication to the care plan, a library of interventions populated and should have populated for the anticoagulant medication. Resident #43 received an anticoagulant medication, and it should be on their care plan with interventions such as monitor for bleeding. The resident's anticoagulant medication was only listed under cardio-vascular disorders with no interventions. Anticoagulants should be care planned so the resident was monitored for bleeding or bruising. During an interview on 1/13/2025 at 10:56 AM, the Director of Nursing stated Minimum Data Set Coordinator #28 completed the initial comprehensive care plans on admission and established a baseline care plan. Care plans were updated on day 14 of admission with the Interdisciplinary Team and family, when there was a change in a resident's condition, when there were new physician orders, and quarterly. Resident #43 received an anticoagulant medication, and it should be listed under cardiovascular medications. The resident's care plan did not have interventions documented for their anticoagulant medications. It was important to have interventions for anticoagulant medication so the resident could be monitored for bleeding or bruising. 10NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility failed to ensure that pain management was provided to residents who required such services consistent with professional standards of practice for 2 of 3 residents (Residents #30 and #53) reviewed. Specifically, Resident #30 did not have pre and post pain evaluations completed when as needed pain medication was administered; and Resident #53's pain associated with transfers was not addressed. Findings include: The facility policy, Pain Assessment and Management, revised 12/2024, documented pain would be assessed on all residents during admission, quarterly, during any significant changes, and annually prior to the completion of their Minimum Data Set assessment. Pain interviews could be conducted at any time as needed. Numerical pain scaled from 0 to 10 would be used to assess the degree of pain with 0 describing no pain and 10 describing the worst pain. A face scale could be utilized if the resident could not understand the numerical scale with a happy face representing no pain to a face crying would represent worse pain. Residents who complained of moderate pain above 5 who had pain indicators would be asked about pain every shift and as needed while awake. Nursing would document on the medication administration record, the pain flow sheet and in a nursing note and could be done in combination after administration of an analgesic pain medication. The pain flow assessment record would be reviewed after pain medication had been initiated or until the resident achieved optimal pain control. 1) Resident #30 had diagnoses including osteoarthritis and occlusion and stenosis (narrowing) of vertebral (spine) artery. The 11/10/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required substantial/maximum assistance of 1 for all activities of daily living, received a scheduled pain medication regimen, received as needed pain medications, received non-medication interventions for pain, and frequently had pain. The Comprehensive Care Plan initiated 11/5/2023 documented Resident had potential for pain related to vertebral stenosis (a narrowing of the bone spaces in the spinal column). Interventions included administer medications per physician order, routine, or as needed acetaminophen (Tylenol, a medication to relieve pain or fever), Mobic (an anti-inflammatory medication to relieve pain) as ordered, and on-going assessment of the resident's pain with emphasis on the onset, location, description, intensity of pain, and aggravating and alleviating factors. The physician orders reviewed and renewed 12/26/2024 documented: - Tylenol 325 milligrams, 2 tablets (650 milligrams) by mouth twice a day at 2:00 PM and 8:00 PM, - acetaminophen (Tylenol) 325 milligrams, 2 tablets (650 milligrams) by every 4 hours as needed for pain. - meloxicam (Mobic) 7.5 milligrams, 1 tablet by mouth every morning at 8:00 AM for osteoarthritis. The 1/2025 medication administration record documented the following as administered: - acetaminophen 325 milligrams 2 tablets (650 milligrams) by mouth at 2:00 PM and 8:00 PM. - meloxicam (Mobic) 7.5 milligrams, 1 tablet by mouth at 8:00 AM. During an observation and interview on 1/6/2025 at 11:07 AM, Resident #30 was sitting in their recliner in their room holding a call bell cord. The resident displayed facial grimacing, was moaning, and yelling for help. They stated they hurt all over and had pain in their head. The 1/6/2025 at 8:57 PM Licensed Practical Nurse #30 progress note documented the resident was stiff, observed whimpering, and calling for help. Resident #30 stated they hurt all over and routine Tylenol was given. During an observation and interview on 1/10/2024 at 9:35 AM, the resident was sitting in the recliner in their room, had facial grimacing, was moaning and was restlessness. They stated they had Parkinson's Disease with chronic pain. They received pain medication and it helped sometimes and other times it didn't help. The 12/2024 and 1/2025 pain flow sheets (located in the front of Resident #30's medication administration record) included instructions that documented: record the following data when implementing an intervention for pain. Data included date, time, location of pain, type, intensity (non-verbal/verbal), non-medication interventions, medication/dose, initials, intensity of pain after interventions, and side effects. The pain flow sheets were blank and did not include data on the resident's pain. During an interview on 1/10/2025 at 10:11 AM Certified Nurse Aide #16 stated they were unsure if Resident #30 had pain with care but had observed they needed more assistance with their activities of daily living and eating and had to be fed. They were unsure why. They would tell a nurse if a resident had pain. During an interview on 1/10/2025 at 10:36 AM Licensed Practical Nurse #2 stated the purpose of the pain flow sheet in the medication administration record was to document the severity of pain the resident had, what medications were administered, and their post medication pain evaluation to see if the medication was effective. They stated Resident #30 received routine and as needed pain medicine. They sometimes had pain and other times did not and they relied on the resident to tell them if they were in pain. They did not document a numerical pain scale in the medication administration record and did not utilize a facial grimacing pain scale for residents that could not verbalize pain. Licensed Practical Nurse #2 stated Resident #30 was cognitively intact at times and could verbalize pain. They stated they did not document a post pain evaluation and thought the resident would tell them if they still had pain and the medication was not effective. It was important to document pain to know if the medication was effective. 2) Resident #53 had diagnoses including osteoarthritis (a type of arthritis) and muscle weakness. The 12/19/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, received routine pain medication, did not receive as needed pain medication, received non-medication interventions for pain, had pain that occasionally limited participation in rehabilitation therapy sessions and day to day activities. The Comprehensive Care Plan, last reviewed 10/19/2023, documented the resident had potential for pain related to hernia repair. Interventions included on-going assessment of the resident's pain with emphasis on the onset, location, intensity, and alleviating and aggravating factors. The 12/21/2024 physician order documented acetaminophen (Tylenol, a pain reliever) 650 milligrams by mouth once a day at 8:00 AM and every 4 hours as needed for pain. The 11/2024 medication administration record documented Tylenol 325 milligrams, 2 tablets by mouth every 4 hours as needed for pain as administered on 11/5/2024 at 12:15 AM (initials of nurse administering were illegible). There was no documented evidence of pre or post pain evaluations. There was no nursing progress note documenting indications for administering as needed Tylenol. The 1/2025 medication administration record documented Tylenol 325 milligrams, 2 tablets by mouth every 4 hours as needed for pain as administered on 1/4/2025 at 5:30 PM (initials of nurse administering were illegible). There was no documented evidence of pre or post pain evaluations. The 1/4/2025 at 9:38 PM Licensed Practical Nurse #30 progress note documented the resident refused to get out of bed for dinner with complaints of a headache. As needed Tylenol was given at 5:30 PM with some effect. The note did not include pre and post administration pain levels. During an observation on 1/10/2025 at 9:31 AM, Resident #53 was assisted from their wheelchair back to bed with use of the sit to stand lift by Certified Nurse Aides #25 and #26. They applied the lift sling to the resident then directed them to lean forward. The resident said they were unable to do so. When staff attempted to move the resident forward to reach the lift handles the resident stated, that's enough, ouch, I can't and my shoulders. Staff then encouraged the resident to lean forward independently. When the resident tried, they said that's the part that hurts. Certified Nurse Aide #26 retrieved Licensed Practical Nurse #2 who helped get the resident hooked to the machine and their hands on the handles. Once the resident was lifted to a standing position they began to cry and say, my arms. Resident was rolled over to the bed, lowered onto the bed, and placed in supine position. Resident became quiet, closed their eyes, and voiced no further complaints. During an interview on 1/6/2025 at 11:13 AM, Resident #53 stated the lift machine stretched out their arms and caused them pain. They told this to staff, but staff told them it did not hurt. During an interview on 1/10/2025 at 10:23 AM, Certified Nurse Aide #25 stated Resident #53 complained of shoulder pain during basic care delivery and during the transfer process. They complained more when staff assisted than when they did it themself. The resident's verbalizations made during the transfer that morning was common for the resident. Certified Nurse Aide #25 reported those verbalizations recently to one of the nurse team leads but could not recall who. It was important for the resident to be comfortable during transfers, so they felt safe and not violated in any way. If they were uncomfortable, they could become combative or try to jump out of the chair. During an interview on 1/10/2025 at 2:15PM, Licensed Practical Nurse #2 stated if a resident experienced pain during a transfer they should have therapy check into it. Resident #53 had diagnoses of Parkinson's disease and osteoarthritis both of which predisposed them to pain and stiffness. They could tell the resident was stiff, did not like to be touched, and likely had bone pain. Everyone should be comfortable during transfers and unaddressed pain could cause sadness and an overall decline. During an interview on 1/13/2025 at 9:22 AM, Licensed Practical Nurse #8 stated pain assessments were done on admission and then monitored on an as needed basis. Resident #53 did not like to move their arms, complained of pain when they did, and resisted if staff tried to assist. During the transfer process, the resident did not want to move their arms to reach for the lift handles and complained of pain when staff tried to help them. They received routine Tylenol (brand name for acetaminophen) once a day in the morning at 8:00 AM after they were already up. During an interview on 1/13/2025 at 9:55 AM, Registered Head Nurse #7 stated pain assessments were done quarterly. Interventions such as changing position, assessing the source, massage, medications, and therapy consults could be used to address pain. Resident #53 had Parkinson's disease and osteoarthritis, movement caused them pain, and they had complained of pain in the past. Registered Head Nurse #7 stated from what staff had reported, the stand lift caused the resident pain in their shoulders from trying to hold on to the lift and they thought that was the reason therapy recently had them on program. The resident did not complain of pain except during the transfer process. Routine Tylenol was ordered on 10/12/2023 and was given once a day at 8:00 AM and in between as needed. During an interview on 1/13/2025 at 10:49 AM, Physical Therapist #3 stated nursing could put in a therapy screen request if a resident was having pain. The therapy department could provide such things as electrical stimulation, stretching, and strengthening to address pain. Resident #53 had Parkinson's disease, osteoarthritis, and limited mobility. It had not been reported to them the resident was in pain. The use of the lift and the resident's strength, range of motion and ability to lift arms high enough to hold onto the lift should be assessed. Comfort was important during activities of daily living. They wanted residents to transfer in the least restrictive method while not having any pain. During an interview on 1/13/2025 at 10:56 AM, the Director of Nursing stated residents were interviewed upon admission to determine their pain management goals. The Minimum Data Set assessment was utilized, and the physician also reviewed their goals. A numerical pain scale was not utilized for routine pain medication, only for the as needed pain medications. All medication administration records had a pain flow sheet and they expected nursing to document a pre and post pain evaluation. The risk of not documenting would be not knowing if a medication was effective. 10NYCRR 415.12

Based on observations, record review, and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not provide pharmaceutical services to meet the need of each resident for 4 of 4 residents (Residents #1, #88, #208, and #209) reviewed. Specifically, the facility used Resident #88's oxycodone (a narcotic pain reliever) to administer to Residents #1, #208, and #209 when they did not have the medication available. Findings include: The facility policy, Medication Administration, Handling and Storage, revised 12/2024, documented a resident's controlled drug package was to be fully labeled with the name, drug, and directions and put in the double locked drawer of the medication cart during the medication pass. The facility policy, Controlled Substances; Ordering, Storage, and Handling, last reviewed 2019, documented at the beginning of each shift, all controlled substances were physically counted for accuracy of the number remaining according to the controlled drug sheet compared to the actual number in the unit dose container. The individual resident's narcotic record is completed with the count. Administration of controlled substances was performed with appropriate nursing procedure. The facility did not have a documented policy on borrowing medications. The A Unit controlled substance record documented Resident #88 had an order for oxycodone 5 milligram, one tablet by mouth every 4 hours as needed for pain with a maximum daily dose of 6 tablets. Resident #88's oxycodone was documented as borrowed for Resident #1 a total number of 20 times between 12/6/2024-12/26/2024; for Resident #208 on 12/23/2024; and for Resident #209 on 1/6/2025 and 1/7/2025. Resident #1's 11/24/2024 physician order documented oxycodone 5 milligrams, one half tablet by mouth every six hours as needed for chronic pain with a pain scale of 6-10 out of 10 pain. Resident #208's 12/23/2024 physician order documented oxycodone 5 milligrams, one tablet by mouth every four hours as needed for pain with a pain scale of 6-10 out of 10 pain. Resident #209's 1/7/2025 physician order documented oxycodone 5 milligrams, one tablet by mouth every six hours as needed for pain with a pain scale of 7-10 out of 10. During an observation and interview on 1/07/2025 at 12:59 PM, Licensed Practical Nurse #29 stated Resident #209's last name was written next to the count on the controlled medication sheet for Resident #1's oxycodone 5 milligram tablets because Resident #209 was out of their oxycodone, so they borrowed a dose from Resident #1. They stated it was facility policy to borrow medications from another resident if a resident was out and needed the dose. During an interview on 1/13/2025 at 10:08 AM, Registered Nurse Unit Manager #6 stated controlled substances had to be ordered through a physician prescription. They were unaware Resident #209 ran out of their oxycodone. They stated the resident had just been readmitted from the hospital so that was likely why their prescription was not renewed. When residents were readmitted or newly admitted from the hospital without written prescriptions for controlled substances, they borrowed medications until the facility provider could write the prescription and the medication was received. They stated it was in the facility policy to borrow medications. There was an emergency supply of medications in the facility, but they just borrowed medications from other residents. If the resident they were borrowing from started to run low on the medication, they would get a new prescription for that resident. During a follow up interview on 1/13/2025 at 11:04 AM, Registered Nurse Unit Manager #6 stated they were unsure why the nurses had borrowed 20 doses of Resident #88's oxycodone for Resident #1. They had to call the pharmacy to find out as Resident #1's prescription was sent in on 12/5/2024 but was not delivered until 12/26/2024. On 1/13/2025 at 11:08 AM, they called the pharmacy and was informed there were issues with the original prescription not having a quantity on it, so it was returned to the facility. They were unaware of this and was unsure why it took so long for the prescription to be corrected and filled. During an interview on 1/13/2025 at 12:02 PM, the Director of Nursing stated the pharmacy provided the facility with a formulary for the emergency medication supply system, but they did have the opportunity to change the list. All nurses were able to access the emergency medication supply system with a fingerprint or a code. They stated since morphine was the only narcotic pain medication in the emergency medication supply system, if a resident ran out of a different narcotic pain medication the nurses probably borrowed the dose from another resident. The emergency medication supply system was supposed to have other narcotic pain medications added but the process was never completed. They stated the nurses were not supposed to borrow narcotic medications from one resident to give to another. They stated it used to be the facility policy to borrow medications prior to obtaining the emergency medication supply system. They were unaware Resident #88 had over 23 tablets of their 5 milligram oxycodone medication borrowed from 12/5/2024 to 1/13/2025. Medications should not be borrowed. During an interview on 01/13/2025 at 12:16 PM, Pharmacist #42 stated the emergency medication supply system was stocked based on what the facility needed and requested. For controlled substances, the facility sent the order, it was processed, billed, and then sent on the next scheduled run to the facility. If a medication was needed from the emergency medication supply system, the facility called the pharmacy, they confirmed the patient and the order, and an approval code was given to dispense the medication. If a medication was needed that was not in the emergency medication supply system, there was a courier service was that was used that delivered to the facility within two to four hours for a stat run. Nighttime deliveries could take longer and depended on availability. If controlled medications were needed, they should be obtained through the emergency medication supply system or through a stat run. Borrowing controlled substances was not appropriate and could lead to diversion and billing issues. During an interview on 1/13/2025 at 1:25 PM, the Medical Director stated if a resident needed medication and they did not have it, nursing should contact them to send an electronic prescription to the pharmacy for an immediate fill. They stated the facility still utilized paper prescriptions, but they were allowed to send electronic prescriptions if necessary. They stated it was not an acceptable practice to borrow medication from one resident to give to another. They were unaware Resident #88 had 23 doses of their oxycodone borrowed from 12/5/2024 to 1/13/2025 and stated that should not have happened. 10NYCRR 415.18(e)(2)

Based on observation, record review, and interviews during the recertification survey conducted 3/20/23- 3/23/23, the facility failed to ensure all alleged violations including injuries of unknown origin, were thoroughly investigated to rule out abuse or neglect for 1 of 3 residents (Resident #13) reviewed. Specifically, staff identified a bruise on Resident #13 and there was no investigation completed to rule out abuse or neglect. Additionally, an assessment of the injury was not completed, and the medical provider and family representative were not notified. Findings include: The facility policy Incident Reporting Guidelines for Residents revised 2/2019 documented: - A resident incident reporting system would be in place to provide documentation and analysis of an incident, involving, but not limited to a potential for actual mistreatment, neglect, or abuse. - A Resident Incident Report is used to provide an accurate record of an incident and to be completed whenever (but not limited to): a resident is injured; and bruises or injury of unknown etiology if a resident cannot verbalize that staff did not harm him/her. - To complete the Resident Incident and Investigative Report; the registered nurse (RN) must assess and document the injury; all sections must be completed; all forms must go to the Nurse Manager, the physician for review, statement, and signature, the Director of Nursing (DON), the Administrator, and medical records. - Investigations were to commence immediately. Resident #13 was admitted with diagnosis including Alzheimer's Disease, dementia, and bipolar disorder. The 3/19/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, exhibited physical and verbal behavioral symptoms, rejected care, wandered, required limited assistance of 1 for transfers, bed mobility, and walking, and utilized a wheelchair. The 3/2/23 physician progress note documented the resident had 3 falls with no injury in the last month. The 3/16/23 24-Hour Resident Care Report did not contain any documentation related to Resident #13, on any of the 3 shifts (7:00 AM-3:00 PM, 3:00 PM-11:00 PM, 11:00 PM- 7:00 AM). A progress note by licensed practical nurse (LPN) #13 dated 3/17/23 at 3:43 PM documented the resident had a medium sized bruise to their left outer calf. The origin was unknown. The resident could be resistive to care and often kicked out at objects and staff. The 3/17/23 24-Hour Resident Care Report documented: - On the 7:00 AM-3:00 PM shift, Resident #13 had a medium sized bruise noted to their left outer leg, origin unknown, tender to the touch. LPN #13 was noted as the nurse on the shift; - On the 3:00 PM-11:00 PM shift, Resident #13 was noted as pleasant with no further information. - On the 11:00 PM- 7:00 AM shift, noted by registered nurse Supervisor (RNS) #7, bruise was seen by staff 3/17/23 first changes, but RNS not aware. - On the 11:00 PM- 7:00 AM shift, noted by RNS #7, bruise was seen by staff 3/17/23 first changes, but RN not aware. There was no documented evidence an incident report or investigation was completed to address the injury of unknown origin identified on 3/17/23 or that abuse, or neglect was ruled out. There was no documentation the area was assessed, the medical provider was notified, or the resident's representative was notified of the injury. The 3/18/23 24-Hour Resident Care Report did not contain any documentation related to Resident #13, on any of the 3 shifts (7:00 AM-3:00 PM, 3:00 PM-11:00 PM, 11:00 PM- 7:00 AM). Resident #13 was observed with RN Unit Manager #2 on 3/22/23 at 2:15 PM. The RN Unit Manager lifted the resident's left pant leg and the resident said ow. A large purple oval-shaped bruise was observed on the front of the resident's leg, with a darker purple area in the middle. The resident complained of tenderness and stated they did not know what happened. During an interview with RN Manager #2 on 3/22/23 at 2:15 PM, they stated they returned to work on 3/21/23 from being off and saw that LPN #13 noted Resident #13 had a bruise. The RN Manager stated they asked some staff about it, and no one knew anything about the injury. When an injury of unknown origin was identified, it should be reported to the supervisor on duty, the Unit Manager if they were present, or the Director of Nursing (DON). The DON would then determine if an investigation was needed. If the DON was not available, the Assistant Director of Nursing (ADON) should be notified. The RN Manager was not aware if the bruise was assessed at the time it was found, or if it was reported to a supervisor. During an interview with LPN #13 on 3/22/23 at 3:26 PM, they stated Resident #13's bruise was brought to their attention by staff. The LPN documented the bruise, did not call the supervisor, and was not sure who the supervisor on duty was. The LPN spoke to RNS #7 the following day (3/18/23) and RNS #7 stated they were aware of it the night before. LPN #13 stated an assessment was supposed to be done and it was a Friday evening (3/17/23) and the Unit Manager was not working. LPN #13 stated they just documented the bruise on the 24-hour report because they knew it would be reviewed before the morning meeting. They stated there were no morning meetings on the weekends. During a follow up interview with LPN #13 on 3/23/23 at 10:02 AM, they stated they were notified by certified nurse aide (CNA) #16 during morning care on 3/17/23 that Resident #13 had a bruise. LPN #13 stated they went to look at it and did not report to anyone that day during their shift. They entered a progress note about the bruise at the end of their shift and put it on the 24-hour report. The LPN stated they did not think abuse occurred and did not think to notify a supervisor and thought just putting it on the 24-hour report was sufficient. During a follow-up interview with RN Unit Manager #2 on 3/23/23 at 10:26 AM, they stated they felt LPN #13 took appropriate steps by documenting the bruise and entering it on the 24-hour report. Normally, the DON would review the 24-hour report, but they were not available at that time and the RN Unit Manager was also out of the facility. When an LPN was made aware of an injury, they should report the injury to a Unit Manager or supervisor. An assessment should be completed at the time the injury was identified. The medical provider may not have to be notified unless there was a concern such as the resident being on an anticoagulant medication or if a treatment was needed. The purpose of notifying a supervisor was to determine root cause, investigate the incident, and assess for safety and if changes needed to be made to the care plan. Upon learning of the injury when returning to work on 3/21/23, the RN Unit Manager expected to see an RN assessment had been completed. The assessment should include size and characteristics of the bruise. The RN Unit Manager stated there should have been follow-up on 3/17/23 related to the bruise. During a telephone interview with RNS #7 on 3/23/23 at 12:09 PM, they stated they learned of the bruise on Resident #13's leg in the morning of 3/18/23. The RNS found a progress note entered the previous day (3/17/23), and no one reported it to them on their shift. The RN never saw or assessed the bruised area. The RNS stated If the bruise had been brought to their attention during their shift, they would have assessed the injury and initiated an incident report. During an interview with the ADON on 3/23/23 at 1:05 PM, they stated the procedure when injuries of unknown origin were found included completing an incident report to determine the cause. Any nurse could initiate an incident report. An RN was required to complete the assessment and follow through with the incident report. The incident report/investigation should take place immediately following identification of the injury. The incident report included areas to complete for RN assessment, physician notification, and family notification. The injury should have been reported immediately the morning it was brought to LPN #13's attention, as the ADON was present that day. The physician and family should have been notified on 3/17/23. Entering the information in progress notes and on the 24-hour report was not the appropriate means of notification of a new injury. The ADON stated RN Unit Manager #2 was made aware of the bruise on 3/21/23 and reported they assessed the area. The assessment was not documented and should have been. The ADON expected the RN Unit Manager to initiate an investigation upon learning about the bruise and they did not. The incident report/investigation was utilized to rule out abuse or neglect. The ADON stated there was no investigation or a documented RN assessment of Resident #13's injury of unknown origin. 10NYCRR 415.4(b)(3)

Based on record review and interview during the recertification survey conducted 3/20/23 to 3/23/23, the facility failed to ensure each resident who experienced a significant change in status was comprehensively assessed using the Centers for Medicare and Medicaid Services (CMS)-specified Resident Assessment Instrument (RAI) for 1 of 1 resident (Resident #27) reviewed. Specifically, a Significant Change Minimum Data Set (MDS) assessment was not completed for Resident #27 following enrollment in a hospice program. Findings include: Resident #27 was admitted to the facility with diagnoses including colon cancer, lung cancer, and diabetes. The 1/26/23 Quarterly MDS documented the resident had no cognitive impairment, required limited assistance of one for activities of daily living (ADLs), and did not receive comfort care within the last 14 days. The MDS did not document the resident was receiving hospice services. The 2/10/23 physician's order documented comfort care parameters and a hospice referral. The 2/10/23 social worker (SW) #12's progress note documented a referral was sent to hospice per family/resident request. The Medical Orders for Life Sustaining Treatment (MOLST) documented the resident's wishes included Do Not Resuscitate (DNR, allow natural death), Do Not Intubate (DNI, do not use non-invasive or mechanical ventilation), do not send to the hospital, comfort measures only, no feeding tube, determine use or limitations of antibiotics, and do not use dialysis. The MOLST was signed by the resident's health care proxy (HCP, person appointed to make medical decisions) and the resident gave verbal consent on 2/10/23. The 2/16/23 nursing progress note documented registered nurse (RN) Manager #2, SW #12, the Director of Nursing (DON), and Administrator met with the family on 2/13/23 related to the resident's care plan and comfort care process. The 2/21/23 SW #12's progress note documented the resident had been approved for hospice services with a start date of 2/24/23. The Certification of Terminal Illness (CTI) dated 2/24/23 documented Resident #27 had a terminal prognosis with a life expectancy of six months or less should the disease run its normal course and Resident #27 was certified for the hospice benefit effective 2/24/23. The hospice organizations' s Nursing Home [NAME] Information sheet documented Resident #27 was admitted to hospice on 2/24/23. The 2/24/23 physician order documented the resident was now under the care of hospice services. There was no documented evidence in the medical record that a Significant Change MDS assessment was initiated or completed when the resident was placed on hospice care. During an interview with the Assistant DON (ADON) on 3/24/23 at 1:05 PM, they stated they were the MDS Coordinator and was responsible for initiating MDS assessments. The Unit Managers were responsible for completing the MDS after the ADON triggered the MDS for completion. The ADON stated they were then responsible for signing off the MDS. When a resident was placed in hospice services a Significant Change MDS assessment was required. The interdisciplinary team (IDT) decided at morning meetings or care plan meetings if a significant change occurred and anyone going on hospice should be discussed at the meeting. The ADON was responsible for triggering the MDS upon learning of a resident's change in status. The ADON was not able to recall when the IDT discussed the resident's hospice status and stated they were absent from work for a short time in 2/2023. If the ADON was present to trigger the MDS assessment, the DON was to take over that responsibility. The ADON was unaware of the reason the MDS was not triggered and was not able to locate an MDS since the 1/26/23 assessment. The DON was not available for interview during the recertification survey. 415.11(a)(3)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 3/20/23-3/23/23, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 7 residents (Resident #15) reviewed. Specifically, Resident #15's plan of care documented they were to have blue heel boots on both feet at all times to prevent skin breakdown and the resident was observed for 4 days not wearing the boots. Findings include: The facility policy Care Plan- General Development effective 4/29/1998 documented each resident was to be provided with a comprehensive plan of care to assist the resident in attaining or maintaining their optimal, physical, mental, and psychosocial functioning. The IDCP (interdisciplinary care plan) team was responsible for ensuring the care plan was appropriately designed, documented, implemented, evaluated, and revised as necessary. Resident #15 was admitted to the facility with diagnoses including cerebral palsy (a disorder affecting movement) and seizure disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required total assistance with all activities of daily living (ADLs), had functional limitation in range of motion in both arms and legs, used a wheelchair for mobility, and was at risk for developing pressure injuries. The comprehensive care plan (CCP) effective 2/1/21 documented the resident was at high risk for impaired skin integrity related to impaired mobility, incontinence, and friction and shearing. Interventions included bilateral (both sides) blue heel lift boots as ordered. Physician's orders updated on 2/24/23 documented blue heel lift boots on at all times. The 3/2023 treatment administration record (TAR) documented blue heel lift boots to be worn at all times except during dressing and bathing. Resident #15 was observed: - on 3/20/23 at 4:06 PM, sitting in their wheelchair in their room. The resident was kicking repeatedly with their left foot. Their left heel was hitting the metal part of the wheelchair as they kicked. The resident did not have heel boots on and was wearing only socks. The heel boots were on the resident's bed. - on 3/21/23 at 11:53 AM, in the dining room, in their wheelchair with socks on both feet. The resident was consistently moving their right leg in a continuous motion. There were no blue heel boots present on their feet. - on 3/21/23 at 12:46 PM, in their wheelchair with slipper socks on both feet. Their right leg was in constant movement, and no blue heel boots were present on their feet. - on 3/22/23 at 8:09 AM, in the dining room in their wheelchair with slipper socks on both feet. They were not wearing blue heel boots. - on 3/23/2023 at 8:10 AM, in the dining room in their wheelchair with no blue heel boots on their feet. During an interview on 3/22/23 at 10:50 AM certified nursing assistant (CNA) #14 stated every morning they received a resident care plan to follow, and they checked for any changes in the resident's care. Resident #15 was care planned to have blue heel boots on their feet at all times to prevent skin issues and injuries. The blue heel boots had been in place for a long time as the resident kicked and rubbed their feet continuously. They were not aware the blue boots were not applied. During an interview on 3/22/2023 at 11:00 AM, licensed practical nurse (LPN) #13 stated Resident #15 was care planned to have blue heel boots on at all times to protect the resident's feet from skin issues. The resident was constantly moving and rubbing their legs on the wheelchair. The LPN stated the care plan documented the resident was to wear the blue heel boots at all times even in the dining room. They were not aware the resident had been without the blue heel boots. During an interview on 3/23/23 at 08:45 AM registered nurse (RN) Unit Manager #2 stated Resident #15 had been at the facility for many years. The CCP and care instructions documented the resident was to always wear blue heel boots to prevent skin breakdown. The CNAs and the nurses were responsible to ensure the boots were on at all times including at meals. They were not aware the boots were not on during the meals and expected staff to ensure the boots were on at all times. 10 NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews during the recertification survey conducted 3/20/23 to 3/23/23, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 2 residents (Resident #15) reviewed. Specifically, Resident #15 was observed in a wheelchair that was in disrepair. findings include: The facility policy Resident Equipment Maintenance effective 1/1/2021 documented all facility equipment (wheelchairs, walkers, etc.) was maintained and repaired as follows: if an item required maintenance, a request form could be found on each unit; required maintenance was performed and items were returned to the resident; if the item was unsafe or unable to be repaired, a replacement would be issued. All wheelchairs were checked quarterly for each resident as they were screened following the Minimum Data Set (MDS) schedule. Resident #15 was admitted to the facility with diagnoses including cerebral palsy (a disorder affecting movement) and seizure disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required total assistance with all activities of daily living (ADLs), had functional limitation in range of motion in both arms and legs, and used a wheelchair for mobility. The comprehensive care plan (CCP) revised 1/11/23 documented the resident was at risk for impaired skin integrity related to impaired mobility, incontinence, and friction and shearing. Interventions included leg rests and a good buddy (a padded footrest) in the scoot chair at all times to prevent kicking the chair. The 7/11/2022 occupational therapy (OT) #17 progress note documented the resident should sit upright in the scoot chair. To manage skin integrity and decrease risk of injury skilled interventions included a wheelchair (scoot chair) when out of bed and during meals to ensure safety by providing wheelchair modifications such as additional padding, Physician's orders updated 2/24/2023 documented Resident #15 was to have leg rests with a foot buddy at all times while in the scoot chair to prevent kicking the chair. Observations Resident #15's scoot chair included: - On 3/20/23 at 4:06 PM, the foot buddy attached to the base of the chair was very worn, with foam protruding from the padding on each side. The bottom of the chair was also worn. The resident was repeatedly kicking with their left foot and their heel was hitting the metal part of chair. - On 3/21/23 at 11:45 AM, the foot buddy padding was very worn, there was frayed and peeling pink duct tape, parts of the foot buddy were worn away and there was worn tape around the left arm rest. - On 3/21/23 at 11:53 AM, there were multiple areas of a dried white substance on both arm rests and the left arm rest had pink duct tape. The padding on the foot buddy was frayed with the foam filling protruding from under the foot buddy. The resident had continuous leg movements. - On 3/21/23 at 12:46 PM, the frayed and peeling pink tape and the protruding foam stuffing remained. - On 3/21/23 at 2:49 PM, there was a dried substance on the arms of the chair and the foot buddy padding was torn. - On 3/22/23 at 8:09 AM, the pink tape around the left arm rest and the foot area had padding protruding from the footrest. - On 3/22/23 at 9:00 AM, there was pink tape wrapped around the leg rests with protruding padding around the foot buddy. Thee left arm of the chair had frayed pink tape wrapped around it, and the arms of the wheelchair had large white spots. During an interview 0n 3/22/23 at 10:50 AM, certified nursing assistant (CNA) #14 stated the resident's scoot chair looked as if they needed a new one. The resident was in constant motion and the areas of the chair ripped due to the resident's movement. The CNA stated they did not know the reason the pink tape was on the arm of the wheelchair and stated the chair's appearance was a dignity issue. During an interview on 3/22/23 at 11:00 AM licensed practical nurse (LPN) #13 stated Resident #15's scoot chair was in bad shape and physical therapy (PT) had been notified multiple times about the condition of the chair. The pink tape covered the foam substance on the chair that helped provide extra cushioning. During an interview on 3/23/23 at 8:45 AM registered nurse (RN) Unit Manager #2 stated Resident #15 had a scoot chair for lateral supports, and a foot buddy was at the bottom of the chair due to the resident kicking and to protect their legs. PT provided a new chair yesterday and the chair was not adequate. The arm rest needed to be newer and better. The RN Unit Manager stated the last time they examined the chair was a couple of months ago and they noticed the chair was ripped up and in poor shape. They asked PT to look at the chair when they observed it was ripped and in disrepair. The pink tape was used to protect the resident's skin from skin tears during kicking and they thought it was the best chair the therapy department had available. PT was in charge of all equipment and had limitations on getting what they needed. The RN Unit Manager stated the condition of the chair could be a dignity issue as the chair was old and pieced together. During an interview on 3/23/23 at 12:50 PM, the Director of Rehabilitation Services stated Resident #15 had a scoot chair, they last saw the chair in January 2023 when the resident received occupational therapy (OT), and they did not see the chair in that condition. They were aware the wheelchair had pink duct tape on the arm rest but was not aware the tape had frayed. The Director was not notified of the condition of the frayed duct tape or the protruding padded areas on the foot buddy. They expected to be notified at the time the fraying or protruding foam was identified. They did not think the condition of the chair was a good choice. 10 NYCRR 415.5(a)

Based on record review, interview and observation during the recertification survey, the facility did not ensure residents with pressure ulcers received treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 resident (Resident #70) reviewed. Specifically, during a wound dressing treatment for Resident #70, licensed practical nurse (LPN) #2 did not change gloves and placed unclean wound care supplies in a container with clean wound care supplies. Findings include: The facility policy Infection Precautions-Transmission Based effective 9/27/96 documents hand hygiene is instituted before and after resident contact, before donning gloves to start a procedure, after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings after removing gloves, and before donning a new set of gloves. Glove use is instituted if in contact with blood, body fluids or excretion is anticipated or actual. Gloves should be removed after caring for resident or when moving from a contaminated body site to a clean site during care and during dressing changes. Resident #70 was admitted to the facility with diagnoses including venous insufficiency (poor blood flow from limbs to heart), diabetes and a history of Methicillin-resistant staphylococcus aureus (MRSA, a bacterium resistant to many antibiotics). The 4/13/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, was totally dependent for all activities of daily living (ADL's), had 1 unstageable pressure ulcer with suspected deep tissue injury present on admission or reentry, had pressure reducing devices for bed and chair, a turning and repositioning program and application of dressings to feet. A physician order renewed on 3/25/21 documented left heel deep tissue pressure injury, cleanse with normal saline, pat dry, apply Santyl (an ointmint used to remove dead tissue) to necrotic (dead) skin, apply large Biatain (foam dressing), check every shift and as needed. The 4/2021 treatment administration record (TAR) documented left heel deep tissue pressure injury cleanse with normal saline, pat dry, apply Santyl, skin prep to intact skin, apply large Biatain. Check every shift, change every day, and as needed. During an observation of Resident #70's left heel wound dressing on 04/29/21 at 9:33 AM, LPN #2 donned gloves from a boxed container of gloves in the hallway across from the resident's room. LPN #2 gathered the resident's dressing change supplies into a clean plastic tray, entered the resident's room and placed the tray on the foot of the bed. With gloved hands, LPN #2 removed the resident's blue heel boot and pushed the resident's sock down to expose the left heel. LPN #2 removed the old dressing and placed it in the tray with the clean wound supplies (cotton tipped applicator, gauze, Santyl and foam dressing). Without changing gloves the LPN propped the resident's left heel with the left gloved hand. The LPN cleansed the wound with normal saline and patted the area dry with a gauze sponge removed from the tray with the unclean dressing. The heel was reddish/purple and there was a small pinpoint open area in the center. The LPN stated the wound had been necrotic (dead tissue) but was now healing and looked much better. Wearing the same gloves the LPN removed a cotton tip applicator package and tube of Santyl from the tray and applied the Santyl to the wound with the applicator. The LPN then placed a clean foam dressing on the wound. The LPN pushed the resident's sock back over the ankle and placed the blue heel boot back in place. During an interview with LPN #2 on 4/29/21 at 10:24 AM they stated when they did a dressing change they looked at the treatment order and then would write the order on a piece of paper and gather all the needed supplies to take into the resident's room, wash their hands and apply gloves. LPN#2 stated they had washed their hands and put on new gloves before the surveyors arrived to observe the dressing change. LPN #2 stated after the old dressing was removed, they should have changed gloves. They were aware that they had not changed gloves after removing the dressing and did not know why they had not changed them. They used the tray to place the supplies in and they should not have mixed dirty supplies with clean supplies in the tray. Gloves should be changed, and hand hygiene performed between removing the old dressing and applying the new one because the old dressing had germs and could cause infection. On 4/29/21 at 10:33 AM during an interview with registered nurse (RN) Unit Manager #3 they stated the procedure for a dressing change was for the staff to hand sanitize before getting dressing change supplies, hand sanitize in the room, and hand sanitize in between glove and dressing changes. Specifically with Resident # 70's treatment, the staff should hand sanitize, don gloves, remove the old dressing, take off their gloves, hand sanitize, don new gloves, cleanse the wound with normal saline, use the Santyl ointment, cover the wound, and then make sure all the supplies are taken away. The staff should then take off their gloves and hand sanitize again. She stated a barrier sheet should be placed on a table to provide a clean area or the tray could also be used. Unclean supplies should not be mixed with clean supplies. The purpose for changing gloves between removing the old dressing and applying a new dressing is the possibility of wound contamination. On 4/29/21 at 10:23 AM during an interview with Infection Control RN #6, they stated the process of performing wound care was the staff member would gather supplies, wash their hands, put on clean gloves, sanitize the bedside table, and lay a sterile cover on the bedside table. The staff member should place the supplies on the sterile cover, remove the old dressing, and after removing the old dressing, hand sanitize again, put clean gloves on, and perform wound care. After the treatment was performed, the staff member should discard the soiled dressing, perform hand hygiene, apply gloves, and disinfect any areas that were touched, such as the bedside table. The staff member should then remove their gloves and sanitize their hands. The Infection Control Nurse stated this is done to prevent any cross contamination. The staff members had annual competencies on wound care and infection control. 10NYCRR 415.12(c)(1,2)

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00273084) the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #38) reviewed and the resident environment remains as free of accident hazards as is possible for 1 of 5 means of egress (courtyard door in hallway next to conference room) . Specifically, Resident #38 had known exit seeking behaviors and eloped through an unlocked door to an outside courtyard and there was no documented evidence of adequate supervision of the resident. Additionally, doors to a courtyard were not locked or monitored to prohibit unsupervised exit. Findings include: The Missing Resident/Elopement policy revised 8/2005 documents: - It is the policy to provide a safe and secure environment for all residents. - Any resident who has demonstrated history of potential to exit the facility will be evaluated for a Watchmate alarm. - All residents should be assessed initially upon screening and on an ongoing basis to determine if wandering and elopement issues are present. - When a resident is identified as a risk for wandering or elopement and individualized care plan must be developed. - Remote areas such as the basement, loading dock, non-resident areas including corridors and office should be routinely monitored by staff or if appropriate locked to prevent resident access. The Wandering Resident Control policy last reviewed 2020 documents the Watchmate MR Monitor System is for those residents who attempt to exit the facility unsupervised; but are incapable of safely doing so. A Watchmate unit has been installed at the Main Front Door Entrance. Prior to admission all potential residents shall be assessed for wandering during the preadmission assessment process. This assessment shall be ongoing. SUPERVISION Resident #38 had diagnoses including dementia, acute ischemic cerebral vascular accident (CVA), and anxiety. The 3/8/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment including signs of delirium with disorganized thinking, ambulated independently, and wandered daily which placed the resident at significant risk of getting to a potentially dangerous place. The 3/1/21 Elopement Assessment documented the resident was physically able to leave the building on their own; had impaired decision-making; made statements about going home, unrealistic destination requests, or asking for transportation; displayed persistent anger at family, staff, current placement, or other residents; had a current behavior of wandering; had a roam alert/wanderguard in use; had elopement care plan initiated; and exhibited exit seeking behavior. A wanderguard was placed on the resident's right ankle. Physician orders included: - on 3/1/21 wander guard, bed/chair alarm. - on 3/15/21 at 2:00 PM, verbal order for every 15-minute safety checks. - on 3/17/21 at 2:21 PM, verbal order for every 30-minutes safety checks, discontinue every 15 minute checks. The 3/2021 Medication Administration Record (MAR) documented the resident was on 15-minute safety checks starting 3/15/21 during the 7 AM-3 PM shift through 3/18/21 7 AM-3 PM shift. 30-minute safety checks were initiated on 3/18/21 on the 7 AM-3 PM shift through 3/23/21. The comprehensive care plan (CCP) dated 3/10/21 documented the resident was at risk for elopement related to dementia and change in environment. The resident wandered frequently throughout the facility, wanted to go home, was looking for their car and was easily redirected. Interventions included redirect negative behaviors, reorient to daily routines as needed, Watchmate per order, regularly assess and evaluate risks for elopement, resident's picture in chart, alarms on doors, name on wander list, and document in progress notes intensity, duration or frequency of behavior. Nursing progress notes from 3/1/21 through 3/13/21 documented the resident frequently wandered, needed frequent redirection, was anxious, fidgeting, confused and exit seeking. A nursing progress note on 3/14/21 at 2:41 AM by registered nurse supervisor (RNS) #14 documented at 8:45 PM, the resident was discovered in the back hallway, standing next to the maintenance entry. It appeared the resident had entered the building via the courtyard door that led to the back hallway. Housekeeper #13 had reported the resident had snow on their left sleeve and lower extremities. A small abrasion was noted on the right wrist and right forearm. The Resident Incident Report signed by RNS #14, the Director of Nursing (DON) and the Administrator on 3/15/21 documented on 3/14/21 at 8:45 PM, housekeeper #13 heard a loud metal bang while sitting at the maintenance staff desk. They looked up and could see Resident #38 in a mirror that hangs on a main heating duct. Upon further investigation, the resident had entered the building via the courtyard door that leads to the back maintenance hallway. The door was still partly open. The resident had abrasions to the right wrist and right forearm. The resident was not able to report what happened. The Resident Incident Investigation Report signed by the DON and RNS #14 on 3/15/21 documented the resident exited the building via the courtyard door in the resident main dining room. It appeared from the pattern in the snow the resident fell or laid in the snow. The resident was ambulating prior to exiting via the (gazebo) courtyard door. To prevent this in the future the courtyard door in the resident dining room needed to be locked. All staff at the facility were responsible for resident safety. Nursing progress notes from 3/16/21 through 3/17/21 documented the resident continued to wander and was on 15-minute safety checks. From 3/18/21 through 3/23/21 nursing staff documented 30 minute safety checks continued and the resident continued to wander into other rooms and exit seek. A nursing progress note on 3/23/21 at 8:13 pm, documented the resident was wandering in and out of other resident rooms, was highly agitated and attempting to exit the exterior doors on the unit. The resident was hitting, pushing, and kicking at the door to attempt to open them. Nursing progress notes from 3/24/21 through 3/30/21 documented the resident was on safety checks every 30 minutes. Physician orders documented on 3/25/21, the monthly orders for 4/1/21- 4/20/21 for every 30 minute safety checks were renewed through 4/20/21. Nursing progress notes dated 4/2/21 through 4/8/21 included: - On 4/2/21 at 2:48 PM, LPN #11 documented the resident continued looking for exits, goes to every door, and remained on 30 minute safety checks - On 4/3/21 at 6:23 PM, another resident informed staff Resident #38 entered the soiled utility room on Unit A/B and was found to be sitting in a chair in the soiled utility room. The nurse practitioner (NP) progress note dated 4/5/21 documented the resident had a habit of wandering through the unit. The resident had tried to get out of the building and had tried to go down hallways they should not go down. The resident was not easily redirected. Staff reported increased crying and missing family and trying to get out to see them which came out as anxiety Nursing progress note documented on 4/8/21 at 2:05 PM, the resident continued on 30 minutes checks. Nursing progress notes from 4/9/21 through 4/26/21 documented the resident continued to wander onto other units, in other resident rooms, looking for exits and remained on 30 minutes safety checks. A nursing progress note dated 4/26/21 documented at 3:40 AM the writer checked the resident's room and the resident was not in bed. Staff looked for the resident in every room and found the resident sleeping in a recliner in another resident's room. The 4/2021 MAR documented 30 minute checks every shift starting 4/26/21 7 AM-3 PM through 4/29/21. There was no documented evidence 30 minute checks were in place and documented from 4/1/21 through 4/25/21 as ordered. The following observations of Resident #38 were made: - On 4/28/21 at 3:30 PM, the resident was standing near the medication cart with no staff present; at 3:34 PM, the resident started walking in the direction of CD unit. - On 4/29/21 at 10:51 AM the resident was in the dining room visiting with family, got up and left. The family member stated the resident had gone to the rest room. - On 4/29/21 at 3:05 PM the resident entered the conference room where surveyors were meeting. - On 4/29/21 at 3:22 PM the resident was walking independently in unit hallways. During an Interview with RNS #14 on 4/28/21 at 9:40 AM, they stated the resident was capable of walking out of the building. Staff had been watching the resident closely daily since admission. During an interview with housekeeping staff #13 on 04/28/21 at 9:46 AM, they stated they recalled the incident and they were the first staff person to see the resident on the evening of 3/14/21 at approximately 8:45 PM. While they were sitting in the maintenance office, there was a loud bang and they looked up and saw the resident in the hallway. This was a non-resident area. The resident had entered through the backdoor coming in from the outside gazebo courtyard. During an interview with CNA #10 on 4/29/21 at 11:27 AM, they stated the resident wandered everywhere and has always wandered around. They stated the resident was currently on 30-minute safety checks. During an interview with the Director of Education/IC RN on 4/29/21 at 12:48 PM, they stated safety checks were documented in the MAR. Resident #38 was still on routine checks, all levels of staff knew to look for the resident, and they keep an eye out and redirected the resident back to the correct unit. At 2:40 PM, the Director of Education/IC RN stated the resident care card had all information important to care for the resident on a specific unit. They confirmed the resident care card for Resident #38 did not include 30 minute safety checks. During an interview with Director of Nursing on 4/29/21 at 2:44 PM, they stated residents were screened on admission for elopement risk and if a resident was an elopement risk then staff would place a Watchmate on the resident and initiate 30-minute safety checks. The assigned CNA for the resident would complete the 30-minute checks. The LPN for the shift would document on the MAR the safety checks had been completed. The DON stated safety checks were not documented on Resident #38's MAR from 4/1/21 through 4/25/21. The DON did not know why the order was transcribed on Monday 4/26/21 and staff started signing again at that time. During a telephone interview with LPN #11 (day shift nurse) on 4/30/21 at 3:31 PM, they stated they were not sure who put the order for 30 minute checks on the MAR on 4/26/21 but signed for it because they had been doing 30 minute checks already every day. They were not sure why the order was transcribed to the MAR on 4/26/21. During an interview with CNA #19 on 04/29/21 at 03:57 PM, they stated Resident #38 wandered all the time and off the unit. Resident #38 was on 30-minute eyes on checks and CNA staff were not required to document the 30 minutes checks but must have constant communication with the charge nurse and Supervisor. During an interview with LPN #15 on 4/29/21 at 4:02 PM, they stated the resident had tried to go out the door they enter to come in for work (near rooms F 5 and F 6). The resident would hang around in front of the door they enter. They stated Resident #38 would pound on the door. The resident had also been found in other resident rooms. The resident used to be on 15 minute checks, and they were not sure what the current order was. They stated the resident was a constant wanderer. During an interview with RNS #17 on 04/29/21 at 4:07 PM, they were aware of Resident #38 wandering and the resident was on every 30 minute checks. The resident was exit seeking and looked for doors that had cars in view. ENVIRONMENT During an observation on 4/29/21 at 2:57 PM the outdoor courtyard near the admissions office was enclosed by 4 hallways and there were 2 doors. The courtyard had several elevated garden areas that had stone/brick retaining areas. There was no visible lighting. During an interview with the Director of Maintenance on 4/29/21 at 3:20 PM they stated the activities courtyard was visible from therapy, social services, admitting and the business office. They stated during the day these offices could see if someone was in the courtyard and after hours anyone in the halls could see if someone was in the courtyard. During the day there were so many people working they would be able to see. There were no set times the doors to the courtyard were locked because the residents could go outside anytime they wanted to, and the door had never been on any set locking schedule. They stated there were no outdoor lights in the courtyard but since the halls were lighted that allowed enough light to see outside. They stated there were no cameras in the courtyard. During an interview with LPN #4 on 4/29/21 at 3:58 PM they stated the courtyard door was locked and they had to unlock the door for oriented residents who wanted to go out. They stated the supervisor had the key. During interview with the evening Nursing Supervisor #17 on 04/29/21 at 4:07 PM, they stated the courtyard doors are usually locked on the evening shift. They do not have keys to the doors, and they did not check the doors routinely. During an observation on 4/29/21 at 4:07 PM the door to the courtyard near the admissions office has a small alarm at the very top of the door. The alarm did not sound when the door was opened. The blue handicap panel was pushed, and the door opened immediately and no alarms sounded. The door was not locked. The Administrator was interviewed on 4/29/21 at 4:52 PM and stated the courtyard doors were unlocked during the day, even in the winter, with the intent of allowing residents freedom to go outside. There was no lighting in the courtyard but with the surrounding hallways and windows they were able to see outside. The facility purchased screamers (a device that would alarm when the door was opened) for the doors so staff could hear if the door was opened. The Administrator stated maintenance would shut the switch off to lock the door so residents could not go out at night. The screamer was set to go off when it was dark. The supervisor was the designated staff to check to make sure the doors were locked. There were no cameras in the courtyard. 10 NYCRR 415.12(h)(2)