**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 02/24/2025 to 02/28/2025, for 1 (Resident #44) of 15 resident care plans reviewed, the facility did not review and revise the resident's care plan as necessary to meet the resident's current needs. Specifically, Resident #44 had history of skin tears in addition to a current skin tear on their forearm. Their person-centered care plan was not revised to include the resident was at risk for skin tears or that they had a current skin tear or interventions to prevent ongoing skin tears. This is evidenced by the following: Resident #44 had diagnoses including dementia, failure to thrive, and depression. The Minimum Data Set Resident assessment dated [DATE], documented the resident was severely impaired of cognitive function. The Comprehensive Care Plan initiated on 12/27/2024, included Resident #44 had the potential for pressure ulcer development. The Care Plan did not include that the resident was at risk for skin tears related to frail skin or interventions to prevent further skin tears. Review of a nursing progress note documented by the Director of Nursing on 06/24/2024, revealed Resident #44 sustained a skin tear on their left forearm during a transfer using a non-mechanical lift. Review of a nursing progress note documented by Licensed Practical Nurse #4 on 10/09/2024, revealed Resident #44 had a skin tear on the top of their left-hand found during morning care possible being related to bumping their hand on the side rail of their bed. Review of a nursing progress note documented by Licensed Practical Nurse #3 on 02/10/2025 revealed Resident #44 had a half dollar sized skin tear to the right forearm. The current physician orders dated 02/11/2025 documented to cleanse right forearm skin tear with normal saline, pat dry, apply triple antibiotic ointment, and cover with dry dressing daily until healed. In a nursing progress note dated 02/17/2025 Licensed Practical Nurse #4 documented Resident #44 somtimes bumped their arms on the table while attempting to eat and was sometimes non-compliant and attempted to get out of bed unassisted. During observations on 02/24/2025 at 3:19 PM, 02/26/2025 at 9:36 AM and 02/26/2025 at 11:54 AM, Resident #44 had both forearms exposed with no arm protection to prevent skin tears. During an interview on 02/27/2025 at 9:59 AM, Certified Nursing Assistant #1 stated they know what care a resident needed by looking at the resident's care plan, and the care plan should tell them everything about the resident to provide the proper care to them. During an interview on 02/28/2025 at 12:59 PM, the Assistant Director of Nursing, stated they would know when a resident was at a higher risk for impaired skin integrity by reading their care plan including current skin impairment. The Assistant Director of Nursing stated when a resident was at risk, it should be in the resident's care plan. The Assistant Director of Nursing stated that Resident #44 did have a current skin tear, and they believed the nurse managers were updating residents care plans, but the Director of Nursing and the Assistant Director of Nursing could also update them. They stated it was important to include the risk for altered skin integrity in the resident's care plan so everyone can be aware, and that Resident #44 should have a care plan for the actual skin tears and being at risk for them. 10 NYCRR 415.11(c)(2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 02/24/2025 to 02/28/2025, for one (Resident #18) of one resident reviewed, the facility did not provide appropriate treatment and services to prevent potential complications for a resident who was receiving nutrition via a feeding tube (a tube inserted directly into the stomach via the abdomen to administer nutritional supplements). Specifically, Resident #18's tube feeding was not appropriately monitored to ensure the amount infused daily was the amount ordered by the physician. Additionally, the resident had multiple documented entries in the electronic medical record of tube feeding residuals (amount of feeding tube liquid not absorbed/not tolerated creating a potential hazard) that were greater than 400 milliliters and the facility was unable to provide documented evidence that the physician had been notified or that the residuals were held and rechecked after two hours as ordered by the physician to ensure the necessary nutrition and prevent complications. This is evidenced by the following: Review of the facility policy Enteral Nutrition dated July 2012 revealed that enteral (via a feeding tube) feeding orders will be written to ensure consistent volume infusion. The following information will be included to ensure that the full volume will be infused via pump feedings, regardless of any interruption of feeding, product name, type of tube, rate of infusion (number of milliliters per hour), total calories per day, start time, and total daily volume to be infused (number of milliliters per day). Resident #18 had diagnoses including dysphagia (difficulty swallowing), failure to thrive, and chronic obstructive pulmonary disease. The Minimum Data Set Resident assessment dated [DATE], documented the resident was moderately impaired of cognitive function, had no behaviors, received 51 percent or more of their total calories, and 501 milliliters or more of their fluid needs per day through a feeding tube. The current physician orders dated 12/23/2025 included the resident was to have nothing by mouth and had a feeding tube with feedings to include: a. Continuous Fibersource High Nitrogen tube feeding at 75 milliliters per hour for 24 hours for a total volume of 1,800 milliliters, staff to document amount each shift of 600 milliliters. b. Check and record residual amounts every shift, contact the physician if residuals are greater than 400 milliliters. Recheck residuals again after two hours and if below 400 milliliters may restart feeding. Resident 18's Comprehensive Care Plan dated 01/06/2025 documented the resident was a potential risk for sub-optimal nutrition and dehydration due to having a feeding tube. Interventions included the resident was to ingest nothing by mouth, was on aspiration precautions (steps taken by the facility to prevent complications such as inhalation of liquids into the respiratory tract), received tube feedings (liquid nutrition) at 75 milliliters per hour for 24 hours, 100 milliliters of water every six hours and 50 milliliters of water three times per day with medications. Staff are to monitor weights and intakes as available and monitor for signs and symptoms of dehydration. Review of the Medication Administrator Record dated 02/01/2025 through 02/27/2025 revealed the daily amount of Fibersource High Nitrogen administered to the resident ranged from to 1275 milliliters to 3190 milliliters per day (versus the ordered 1800 milliliters). Residual amounts of the tube feedings were documented as 700 milliliters up to 902 milliliters on three occasions. There was no documented evidence that the Physician had been notified of residual tube feeding amounts greater than 400 milliliters or that the tube feeding was held, and residuals rechecked after two hours per the physician's orders. In a nutrition/dietary progress note dated 02/23/2025 the Registered Dietitian documented Resident #18 tolerated the tube feeding formula and rate well, that the resident had a weight loss over the past six months and the tube feeding amount was increased. During observations on 02/24/2025 at 10:22 AM, 02/26/2025 at 9:15 AM and 02/27/2025 at 10:15 AM, Resident #18 was receiving continuous tube feeding via a tube feeding pump set at 75 milliliters per hour. The tube feeding ready to hang formula bag was labeled with resident's name, date, and rate but did not include a start time (when a new tube feeding bag was started). During an interview on 02/27/2025 at 11:49 AM and again at 1:51 PM Licensed Practical Nurse Manager #1 stated the residents tube feeding order stated 600 milliliters each shift and the nurses documented the totals in the medication administration record. They should clear out the total (amount infused) on the machine each shift so it starts for the next shift and the nurse should look (at the amount infused) prior clearing it out. The total documented per 24-hours should be 1800 milliliters. Licensed Practical Nurse Manager #1 stated if the nurse was documenting less than 600 milliliters per shift it was most likely the tube feeding was held (for some reason). Licensed Practical Nurse Manager #1 stated that Resident #18's tube feeding runs for 24 hours, and it was hard to know when a bag was started, emptied and another one hung but the predetermined amount per shift of 600 milliliters should be documented in the medication administration record. Licensed Practical Nurse Manager #1 said they do not monitor the tube feeding intakes because the Registered Dietitian does. During a telephone interview on 02/27/2025 at 12:52 PM the Registered Dietitian stated that Resident #18 should receive 600 milliliters of tube feeding per shift and the nurses should document (the amounts) in the medication administration record. The Registered Dietitian stated they do not double check what the nurses documented but if the resident was losing weight they should then check if the nurses were documenting correctly and if there were any residuals documented. The Registered Dietitian stated they did not know how to review the resident's electronic medication administration record to review the documented tube feedings amount but nursing should. The Registered Dietitian stated the resident had a history of unplugging their tube feeding. During an interview on 02/28/2025 at 11:26 AM, Registered Nurse #1 stated that Resident #18 has been known to play with the tube feeding ports and fiddle with the tube feeding pump and has turned the feeding tube pump off. During an interview on 02/28/2025 at 1:36 PM, the Director of Nursing stated nurses should notify the physician if there were any tube feeding residuals greater than 400 milliliters and then recheck the residuals. The Director of Nursing said the nurse managers, charge nurses and the Registered Dietitian should be monitoring the resident's total tube feeding and fluid intakes (to ensure ordered amounts were being given on a daily basis). The Director of Nursing said they knew Resident #18 had recently lost weight and their tube feeding rate had been increased. During a telephone interview on 02/28/2025 at 2:05 PM, the Medical Director stated they should be notified if Resident #18 had residuals greater than 400 milliliters since there was an order in place. The Medical Director said the Registered Dietitian should be monitoring the residents tube feeding since the providers are changing the orders based on their recommendations and both nursing and the Registered Dietitian should be monitoring the resident's total fluid intakes daily and any residuals. 10 NYCRR 415.12(g)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 02/24/2025 to 02/28/2025, for two (Resident #9 and #12) of seven residents reviewed, the facility did not ensure a medication error rate of five percent or less. There were 2 medication errors for 30 opportunities resulting in a medication error rate of 6.67 percent. Specifically, during observations of medication administration, Resident #9 did not receive the correct dose of one medication and Resident #12 did not receive one medication in the correct form as prescribed by the physician. This is evidenced by the following: The facility policy Administering Medications revised April 2019 documented medications are administered in accordance with prescriber orders and the individual administering the medication should check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. Resident #9 had diagnoses that included constipation, heart failure, and anxiety. The Minimum Data Set Resident assessment dated [DATE] documented Resident #9 was cognitively intact. The active physician orders reviewed on 02/27/2025 included an order for bisacodyl (stool softner) 10 milligrams two times daily for constipation. During an observation on 02/27/2025 at 9:17 AM Licensed Practical Nurse #1 administered 5 milligrams (one tablet) of bisacodyl. In a follow up interview at 10:15 AM, Licensed Practical Nurse #1 stated the physician had ordered a total of 10 milligrams of bisacodyl and Resident #9 should have received two bisacodyl tablets as opposed to one but that they did not realize they needed to give two tablets. 2. Resident #12 had diagnoses that included a stroke, high blood pressure, and depression. The Minimum Data Set Resident Assessments dated 01/10/2025 documented Resident #12 had severe impairment of cognitive function. The active physician orders reviewed on 02/26/2025 included an order for simethicone (relieves bloating and gas) oral tablet 80 milligrams three times daily and as needed every six hours for indigestion. During an observation on 02/26/2025 at 4:15 PM, Licensed Practical Nurse #2 removed one simethicone 80 milligrams chewable tablet from the bottle, placed it in a cup with five other medications and administered the entire cup of medications. Resident #12 swallowed all medications without chewing any of the tablets. During an observation and interview on 02/27/2025 at 3:40 PM Licensed Practical Nurse #2 stated simethicone was a medication stocked by the facility. Review of the stock bottle at this time revealed the simethicone was a chewable tablet. Licensed Practical Nurse #2 stated that if the medication was a chewable (tablet) it should be put it in a separate cup from the swallowable medications and administered separately. Licensed Practical Nurse #2 said they did not realize the simethicone that was administered was a chewable tablet (versus one you can swallow whole). During an interview on 02/28/2025 at 1:18 PM the Assistant Director of Nursing stated medications should always be given per the physician order and if there is an issue or concern with an order the nurses should clarify it with the medical provider. The Assistant Director of Nursing stated if the physician order does not state chewable, and the medication on hand is chewable the order should be clarified with medical prior to administration. 10 NYCRR 415.12(m)(1)

Based on observations and interviews conducted during a Recertification Survey from 02/24/2025 to 02/28/2025, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws for one (North Unit) of two medication storage rooms reviewed. Specifically, multiple bottles of expired medications were found in the North Unit medication storage room. This is evidenced by the following: The facility policy Medication Labeling and Storage dated January 2023, included if the facility had discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy was contacted for instructions regarding returning or destroying those items. During an observation on 02/26/2025 at 2:25 PM, the North Unit medication storage room included the following expired medications: a. One bottle of magnesium oxide 400 milligrams that expired in November 2023. b. One bottle of vitamin D that expired in May 2024. c. One bottle of daily multivitamins with iron that expired in June 2024. d. Three bottles of docusate sodium (stool softner), two expired in May 2024 and one expired in October 2024. During an interview on 02/26/2025 at 2:57 PM with Licensed Practical Nurse Manager #1 and Licensed Practical Nurse #1, Licensed Practical Nurse #1 stated all nurses check for expired medications when they pull them from the medication storage room. Licensed Practical Nurse Manager #1 stated audits of the medication room were completed monthly and expired medications should be thrown away. Review of a facility document Med Room Audit dated 09/26/2024, revealed the last documented North Unit medication storage room audit had no expired medication bottles identified. During an interview on 02/28/2025 at 1:48 PM, the Director of Nursing stated the expired medications had most likely been pushed to the back of the shelf and not found during audits and expired medications should be removed from the medication rooms and discarded. 10 NYCRR 415.18(e)(1-4)

Based on observations and interview conducted during the Recertification Survey from 02/24/2025 to 02/28/2025 for three (North, West, and South) of three resident units, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, exhaust ventilation in required areas was not functional. The findings are: Observations on 02/24/2025 at 10:05 AM included a significant foul odor inside the North Hall soiled utility room and the exhaust ventilation grate in the ceiling was observed to not be drawing air out of the room when a piece of paper was placed against the grate. Observations on 02/24/2025 from 10:11 AM included the exhaust ventilation grate in the ceiling of the shared bathroom for resident rooms W-27 and W-25 was observed to not be drawing air out of the room when a piece of paper was placed against the grate. Observations on 02/24/2025 at 10:15 AM included the exhaust ventilation in the [NAME] Hall soiled utility room was not functional when a wall switch was pressed for a ceiling fan. During an interview at this time, the Director of Environmental Services stated that they think the motor on the roof is bad and that there is only one unit for the exhaust in the entire building. Observations on 02/24/2025 from 10:38 AM included the exhaust ventilation grate in the ceiling of the shared bathrooms for resident rooms S-6, S-7, S-8, and S-9 were observed to not be drawing air out of the rooms when a piece of paper was placed against the grates. 10NYCRR: 415.29, 415.29(h)(1,2), 415.29(j)(1), 10NYCRR: 713-1.9(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #20) of one resident reviewed for hospitalization, the facility did not ensure a written notification, which specifies the duration of the bed-hold policy, was provided to the resident and/or the resident's representative at the time of transfer to the hospital. This is evidenced by the following: Resident #20 was admitted to the facility on [DATE] and had diagnoses that included Parkinson's disease, restless leg syndrome, and stage four kidney disease. Review of the nursing progress notes dated 1/12/22, revealed the staff were alerted that Resident #20 was on the floor and had an open area that was 2.5 cm x 5 with blood on the back of their head. The resident was transferred to the hospital. Further review of the medical record revealed there was no documented evidence that the resident and/or the resident's representative had been notified in writing of the facility's bed-hold policy. Interviews conducted on 1/20/22 included the following: At 10:45 a.m., the Social Worker (SW) stated the [NAME] Office was responsible for notifying the residents and/or resident representative of the bed-hold policy. The SW stated that the residents are also notified upon admission about the bed-hold policy. At 11:12 a.m., the Administrative Assistant (Billing Office) stated the nurses will verbally notify them of a resident that is being discharged . The Administrative Assistant stated if a resident goes to the hospital, they fill out a notice of discharge and the bed-hold policy and mail it to the residents and/ or the resident representative. When asked why this particular did not receive the bed-hold policy the administrative assistant stated it was an oversight. At 1:33 p.m., the Administrator stated it was the responsibility of the [NAME] Office to send out the bed-hold policy notice to the resident and/ or resident representative. The Administrator stated they would expect that the [NAME] Office would send the notification regarding the bed-hold policy out as soon as they know a resident is being discharged . [10 NYCRR 415.3(h)(4)(i)(a)]

Based on observations, interviews, and record review conducted during a Recertification Survey, completed on 1/21/22, it was determined that for one (Resident #41) of six residents reviewed, the facility did not review and revise the resident's care plan (with input from the resident or resident representative, to the extent possible) to reflect the resident's current needs. Specifically, Resident #41's Comprehensive Care Plan (CCP) was not revised following the addition of an antipsychotic medication prescribed for delusions/hallucinations. This was evidenced by the following: Resident # 41 had diagnoses including dementia, delusional disorder, and anxiety. The Minimum Data Set Assessment, dated 12/22/21, revealed the resident was cognitively intact, had delusions during that time, and received an antipsychotic medication. The current physician orders included Risperdal (antipsychotic medication) 1.25 milligrams(mg) twice a day and behavior documentation every shift. A review of the interdisciplinary progress notes, dated 10/25/21 through 1/12/22 revealed the following: a. On 10/22/21 the psychiatrist documented that Resident #41 had met the criteria for delusional parasitosis (psychiatric condition related to delusions of bugs) and recommended to start Risperdal 0.5 mg at bedtime, increase to twice a day and may need 2-3 mg per day. The psychiatrist recommended to avoid confrontation but also to avoid complete validation while acknowledging the resident's helplessness, pain, and frustration. b. On 10/27/21 the Licensed Practical Nurse documented that Resident #41 was sent out to the hospital for evaluation due to seeing bugs everywhere and was very hard to redirect. The note included that the resident returned from the hospital that night but continued to talk about bugs on their hands and food. c. On 11/8/21 the Registered Nurse (RN) #1 documented the physician increased the Risperdal to 0.5 mg in the a.m. and 1 mg at bedtime. d. On 12/1/21 the Physician documented that the Risperdal was increased to 1 mg twice a day for delusional parasitosis/psychosis. e. On 1/12/21 the physician documented that the Risperdal was up to 1.25 mg twice a day The current CCP, dated as revised 12/13/21, included a history of seeing bugs and was a risk for impaired skin that included picking and scratching behaviors. The behavioral intervention plan, dated 12/22/21, included Geri sleeves (protective arm sleeves). The current Resident Profile (care plan used by the Certified Nursing Assistants) included no behavioral plan. During multiple observations from 1/18/22 through 1/20/22 Resident #41 was observed out of bed, dressed in a chair, doing their nails, reading or eating with a visitor. No behaviors were observed. In an interview on 1/19/22 at 1:43 p.m. RN #1 stated Resident #41 was seen by psychiatry who recommended Risperdal. RN#1 stated they were responsible for developing and revising care plans and that the care plan should include a new antipsychotic medication. When interviewed 1/20/22 at 3:15 p.m. the Director of Nursing stated the CCP should be revised when a resident was started on a new antipsychotic medication and had an increase in hallucinations. 10 NYCRR 415.11 (c)(2) (ii-iii)

Based on observations, interviews, and record review conducted during a Recertification Survey, completed on 1/21/22, it was determined that for one (Resident #32) of one resident reviewed for hydration, the facility did not have a system in place to ensure that daily fluid intake was consistent with physician orders. Specifically, Resident #32 had physician orders for a fluid restriction and there was no documented evidence that the resident's 24-hour intake was being consistently monitored or documented to ensure appropriate fluid intake. This was evidenced by the following: The undated facility policy Intake, Measuring and Recording, included the purpose was to accurately determine the amount of liquid a resident consumed in 24 hours. The policy included that fluid intake should be recorded as soon as possible after consuming and to total the amounts of all liquids consumed at the end of each shift. Resident #32 had diagnoses that included diabetes, end stage renal disease requiring hemodialysis and dementia. The Minimum Data Set Assessment, dated 12/2/21, revealed the resident was moderately impaired cognitively and received hemodialysis. Current physician orders included a 1200 milliliters (mls) fluid restriction secondary to hyponatremia (low sodium), ProSource (a high protein supplement) 30 mls three times a day, and Miralax (a powder laxative mixed in juice or water) 17 grams daily. The current Comprehensive Care Plan included a 1200 mls fluid restriction daily, to encourage adequate fluid intake per dietary recommendations and to monitor intakes. Nutritional Assessments, dated 12/2/21 and 1/18/22, completed by the Registered Dietician (RD) included Resident #32 was on a 1200 mls fluid restriction and that fluids were documented by nursing. Review of the January 2022 Medication Administration Report (MAR) included a fluid restriction was in place but did not include the daily amount allowed. The MAR included the ProSource was administered three times a day, but the amounts documented ranged from 60 mls daily to 300 mls daily. The amount of water given in order to administer the Miralax was not documented at all. Review of the vital sign report for 1/1/22-1/18/22 revealed the amount of fluid intake was documented multiple times per day as fluids or supplements but there was no documentation of the total amounts per shift or per 24 hours. Review of dialysis communication reports, dated 12/1/21 through 1/19/22, revealed education was provided to Resident #32 by the dialysis unit regarding their fluid intake on five different occasions. In an observation on 1/18/22 at 10:50 a.m., Resident #32's door indicated a 1200 mls fluid restriction but did not include which resident in the semi-private room it was for. Resident #32 stated at the time that they did not know what their fluid restriction amounts were but that they only got a half of cup of coffee in the morning despite requesting a full cup. In an interview on 1/19/22 at 1:43 p.m., CNA #2 stated they knew if a resident was on a fluid restriction as there would be a sign on the door. The CNA #2 stated that the amount of fluids allotted for meals should be on the meal ticket. In an interview on 1/19/22 at 1:47 p.m., the Licensed Practical Nurse (LPN) stated it should be on the MAR if a resident was on a fluid restriction and that nursing was allotted 120cc for each medication pass. The LPN stated dietary calculated the fluid amounts allotted for meal trays and nursing entered the amount taken in the computer. The LPN stated they did not know who was responsible for totaling the intake at the end of the shift. In an interview on 1/19/22 at 2:52 p.m. the Director of Nursing (DON) stated nursing and dietary determined the number of fluids allotted for each department and the amounts taken are entered in the computer. The DON stated they do not review the fluid intake at the end of each shift and would need to review the policy to see who is responsible for reviewing the 24-hour totals. In an observation on 1/20/22 at the breakfast meal, Resident #32's meal ticket included the resident was on a fluid restriction but did not include the amount of the fluid restriction. The ticket included 12 ounces of fluid, but the total fluid intake line was not completed. The ticket was obtained from a Certified Nursing Assistant (CNA) #1 after the tray had been collected and was already on the meal cart. In an interview on 1/20/22 at 9:20 a.m., the RD stated that nursing monitored the fluids a resident takes in and determines the amount that dietary and nursing are allotted. The RD stated the intake form did not include total fluids at the end of a shift or 24-hour period. In a phone interview on 1/20/22 at 10:40 a.m. the Dialysis RN stated they expected nursing to monitor a resident's 24-hour fluid intake totals when a resident was on a fluid restriction. In a phone interview on 1/20/22 at 11:43 a.m. the physician stated they expected nursing to monitor the resident's fluid intake to ensure adequate fluid and restrictions are maintained per orders. 10 NYCRR 415.12 (l) (1))