Based on observation, record review, and interviews conducted during the Extended survey completed on 10/3/24, the facility did not exercise reasonable care for the protection of the resident's property from loss or theft for one (Resident #51) of three residents reviewed for personal property. Specifically, Resident #51 had no pants available to wear in their closet and their inventory sheets documented the resident had 17 pairs of pants. The finding is: Resident #51 had diagnoses including dementia, age related physical debility, and high blood pressure. The Minimum Data Set (a resident assessment tool) dated 8/11/24 documented the resident had moderately impaired cognition. The comprehensive care plan dated 8/21/24 documented the resident required extensive assistance with dressing, was non ambulatory, and was not able to make their needs known. During a telephone interview on 9/27/24 at 9:54 AM, the resident's family member stated when they came to visit, the resident would be wearing clothes that were too small for them, like they weren't the clothes they had brought in for the resident. The family member stated the resident's clothes were always missing, they get labeled with the resident's name but that didn't mean anything. When asked if the resident owned a red (name of video character) t shirt that they were observed wearing that morning, the family member stated, no that was not something they brought in for the resident. During an observation and interview on 9/30/24 at 1:29 PM, Certified Nurse Aide #1 exited Resident #51's room and stated they needed pants for the resident and the resident didn't have any in their room. Certified Nurse Aide #1 then went into the resident's room. The resident was observed sitting in their chair with an incontinence brief on and no pants. Observation of the resident's closet revealed there were t shirts and long-sleeved shirts on hangers, but there were no pants available. Certified Nurse Aide #1 stated the resident used to have a bunch and that new staff might put them in a wrong bag or maybe laundry didn't bring them up yet. The Unit Secretary brought a pair of maroon-colored pants for the resident, the Certified Nurse Aide #1 stated they were not the resident's pants, they were extra. During an observation and interview on 10/1/24 at 8:56 AM, Registered Nurse Unit Manager #1 went to the laundry area to look for pants for Resident #51. They looked around the laundry area where there were clean clothes on hangers and another pile of clothes that were unlabeled and stated they could have been the resident's pants, but they were not labeled. The Laundry Attendant #1 arrived and stated they brought up a pair of pants for Resident #51 last night and hasn't seen any pants for that resident. Registered Nurse Unit Manager #1 stated that the resident was wearing those pair of pants right now. Observation on 10/1/24 at 9:56 AM, the Laundry Attendant #1 passed out laundry on the unit. At 10:03 AM, observation of Resident #51's closet revealed there were no pants. Review of Resident #51's Resident Inventory Personal Linen/Appliances dated 3/22/23 and 1/11/24 documented the resident had 17 pairs of pants. They were described as joggers, lounge, or sweatpants in assorted colors. During an interview on 10/1/24 at 10:18 AM, Registered Nurse Unit Manager #1 reviewed the inventory lists and stated the resident should have like 30 pairs of pants. The Registered Nurse Unit Manager #1 stated they were not sure where the pants were, they would wait for laundry to get through what they had, but she hopes there weren't 30 pairs of the resident's pants in laundry. The Certified Nurse Aides were supposed to put resident's personal clothing in purple bags that were then taken down to laundry. Maybe more re-education was needed for staff on which bags staff were to use for personal clothing. During an interview on 10/1/24 at 12:41 PM, Social Worker #1 stated they bought four pairs of new pants for Resident #51, and they would let the family member know about them. During an interview on 10/1/24 at 1:06 PM, Social Worker #1 stated they were aware the resident was getting low on pants in the last couple of days. At times there might be more of a lag with laundry. Social Worker #1 stated they didn't know if they would find all the resident's pants but was hopeful for finding at least 6 pairs. When families bring clothing in, they are inventoried and sent down to laundry to be labeled. Social Worker #1 stated they were not exactly sure why so many of this resident's pants were missing, but they use an offsite laundry service for facility linens so maybe the personal items were getting put into the wrong-colored bags. Social Worker #1 stated when items went missing the business office needed receipts for reimbursement, so they asked families to buy replacements and submit the receipts. Social Worker #1 stated the resident's family had been reimbursed for clothing items in May 2023 but don't have any further reimbursements or grievance/customer service forms since then. During an interview on 10/3/24 at 11:06 AM, Registered Nurse Unit Manager #1 stated they tried to ensure resident's personal property was kept safe from loss by using the different color bags to keep personal clothing separate from facility linens. If staff weren't using this process, things could get lost. When asked if this process worked, the Registered Nurse Unit Manager #1 stated yes and no. During an interview on 10/3/24 at 11:29 AM, the Director of Nursing stated the facility ensured resident's personal items were safe from loss by having the items logged when they come in. If clothing goes missing, they have social work fill out a customer service form or sometimes they could be in laundry as the resident can go through a few pairs per day. The Director of Nursing stated staff were supposed to know that personal clothes go into the purple bags, and they had not witnessed any staff placing personal clothing in the wrong bags. During an interview on 10/3/24 at 12:05 PM, the Administrator stated they had no policies about providing a homelike environment or safeguarding of personal belongings. At 1:56 PM, the Administrator stated they didn't have any policies on laundry either and that resident clothing inventory sheets were part of the admission packet that staff completed. NYCRR10 415.5(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an Extended Recertification survey completed on 10/3/24, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of four residents reviewed for infection control processes during care. Specifically, staff did not wear proper personal protective equipment during hands on care and transfer of the resident, who required enhanced barrier precautions. The finding is: The policy and procedure titled Enhanced Barrier Precautions dated 6/18/24 documented personal protective equipment is used to prevent the spread of multi-drug resistant organism transmission. The recommendations include the use of enhanced barrier precautions during high-contact activities for residents with chronic wounds (open wounds that typically require a dressing change such as pressure injuries, venous and vascular ulcers, diabetic ulcers, and open surgical wounds) or indwelling medical devices (any devices that are inserted into the resident and have contact with external environment) regardless of [NAME]-drug resistant organism status. High contact activities include dressing, bathing/showering, providing hygiene, and transferring. The Centers for Medicare and Medicaid Services Quality Safety and Oversight memoranda QSO-24-08-NH dated 3/20/24, documented enhanced barrier precautions were indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug-resistant organism. Examples of chronic wounds include, but are not limited to, pressure ulcers and examples of indwelling medical devices included urinary catheters. The memo documented enhanced barrier precautions are employed for high contact resident care activities. Resident #2 had diagnoses that included multiple sclerosis (an autoimmune disorder that affects the brain, spinal cord, and other nerves), pressure ulcer of sacral region and neuromuscular dysfunction of bladder (a condition where the bladder function is impaired due to a brain, spinal cord or nerve problem). The Minimum Data Set (a resident assessment tool) dated 9/8/24 documented Resident #2 was cognitively intact, understands others, and was understood by others. Resident #2 required substantial assistance for personal hygiene and was dependent on staff for toileting hygiene and transfers. Additionally, they had a urinary catheter (a thin tube inserted into the bladder to drain urine) and a stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. The comprehensive care plan dated 7/12/23 documented that Resident #2 required extensive assist for bathing/showering and was dependent for toilet hygiene/clothing management. They required a full mechanical lift with 2 person assist for transfers. The comprehensive care plan initiated 8/23/23 documented the resident had a neurogenic bladder that required a suprapubic catheter and had a stage 4 pressure ulcer on their sacrum. The comprehensive care plan did not document evidence that Resident #2 was on enhanced barrier precautions. Review of the [NAME] (a guide for resident care) dated 10/2/24 documented that Resident#2 had a urinary catheter. There was no documented evidence that Resident #2 was on enhanced barrier precautions. During an observation on 9/26/24 at 9:43 AM, an orange-colored Enhanced Barrier Precaution sign was observed on Resident #2's room door. During an observation on 10/1/24 at 10:22 AM-11:00 AM, Certified Nurse Aide #3 was observed providing hands on morning care for Resident #2 that included bathing, hygiene, and dressing wearing only gloves. The Certified Nurse Aide #3 was not wearing a gown. Registered Nurse #2 Unit Manager assisted Certified Nurse Aide #3 with positioning Resident #2's transfer sling, adjustment of their clothing and transfer out of bed while wearing gloves and no gown. Registered Nurse #2 Unit Manager and Certified Nurse Aide #3's clothing was observed in direct contact with the resident's bedding during care. During an observation and interview on 10/2/24 at 10:53 AM, Certified Nurse Aide #3 was providing hands on care, wearing only gloves, to Resident #2 while they were in their bed without wearing a gown. Certified Nurse Aide #3 stated they didn't know they had to gown up during hands on care of residents with urinary catheters. They stated they identified what residents were on precautions by the signs posted on their hallway door, or by the resident's care plan. Certified Nurse Aide #3 stated they did not gown up during hands on care with Resident #2 on 10/1/24 or 10/2/24 and they should have because something could have splashed on them, or they could have had contact with the resident's wound. Certified Nurse Aide #3 stated they did not see the enhanced barrier precaution sign posted on Resident #2's door. During an interview on 10/2/24 at 11:11 AM, Licensed Practical Nurse #3 stated they can identify what residents are on enhanced barrier precautions by the signs posted on the residents' doors. They stated the precaution sign told them what personal protective equipment was to be worn with catheter and wound care. During an interview on 10/2/24 at 11:28 AM, Registered Nurse #2 Unit Manager stated enhanced barrier precautions were for residents that had a urinary catheter or were receiving active wound care. They stated that personal protective equipment was required when emptying, providing urinary catheter care and when performing wound care such as dressing changes. Registered Nurse #2 Unit Manager stated a gown was not required during care if care didn't involve managing a urinary catheter or wound. They stated they didn't believe they needed to wear gown prior to assisting with Resident #2's care on 10/1/24 because they weren't managing their catheter or pressure wound at that time. During an interview on 10/2/24 at 3:37 PM, the Director of Nursing stated nursing staff should be wearing gowns when they were performing high contact activities on residents who were on enhanced barrier precautions. The Director of Nursing expected nurses, aides, whoever was performing care to follow the precaution signs posted for the resident's protection and safety. During an interview on 10/3/24 at 10:48 AM, the Registered Nurse #1 Unit Manager/Infection Preventionist stated staff were supposed to wear personal protective equipment that included gowns and gloves while they provided hands on care, bathing and any personal hygiene to residents who were on enhanced barrier precautions. Residents who were on enhanced barrier precautions included anyone with central lines, urinary catheters, or open wounds. It was important for staff to wear the gown and gloves to reduce the risk of spreading multi drug resistant organisms. The Registered Nurse Unit Manager #1/Infection Preventionist stated they would need to work on more education with the staff. 10 NYCRR 415.19(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during a complaint investigation (NY00346092) conducted during an extended standard survey from 9/26/2024 to 10/3/2024, the facility did not to ensure that each resident receives adequate supervision to prevent accidents for three (Residents #12, 14, and 29) of three reviewed. Specifically, the facility did not monitor the wander guard signaling device's (tag/bracelet) battery life/functionality of those that were assigned (#12, 14, 29) and Resident #14 exited the building unsupervised without staff's knowledge. In addition, the facility staff lacked education and training regarding the wander alert system and policy. The findings are: The policy and procedure titled WanderGuard dated 12/2022 documented all batteries of activated bracelet signaling devices are continuously monitored by the wander guard computer system and, if a battery is low, an alarm on the computer will be activated and identify the low battery; and nursing will be responsible to change the bracelet signaling device. The policy and procedure titled Elopement, Missing Person revised 10/27/2022 documented a resident elopement was defined as when a cognitively impaired resident leaves the facility without staff observation or knowledge of the resident's departure. The Quality Assurance functions after an elopement should include random test personal alarm systems. Resident #14 had diagnoses of dementia, depression, and borderline personality disorder (a mental disorder characterized by instability in mood, behavior, and functioning). The Minimum Data Set (a resident assessment tool) dated 4/28/2024 documented Resident #14 was cognitively intact. Resident #14 could wheel their wheelchair up to 150 feet and make turns. The comprehensive care plan dated 12/22/2022 (current) documented Resident #14 was alert and oriented but has fluctuating memory issues due to dementia and was high risk for falls due to confusion. The comprehensive care plan dated 1/5/2023 documented Resident #14 was an elopement risk due to impaired safety awareness, wandered aimlessly, and stated they need to go home. The comprehensive care plan dated 4/23/2023 documented the resident had poor impulse control, ineffective coping skills, and aggression towards others due to dementia. The physician orders dated 3/8/2024 documented Resident #14 was to have a wander guard on the back of their wheelchair, to check the wander guard once a shift, and to notify security if the wander guard was missing or broken. The [NAME] care plan (guide used by staff to provide care) dated 6/1/2024 documented Resident #14 was a risk for elopement, check whereabouts after meals, at change of shift, and may not leave the facility unaccompanied. The undated (the manufacturer of the wander guard system) Skilled Nurse Facility Wandering System instructions documented each resident is assigned a wander guard tag that actively monitors a resident when they are near a door controller. It documented the battery life can be checked by bringing the wander guard tag to a door controller, holding it there for a few seconds then going back to the wander guard monitor to look for the tag in the tag health field that would indicate if the battery was good or if the battery needed to be replaced. Resident #14's progress notes dated 2/1/2024 to 6/30/2024 documented the resident had exit seeking behaviors on the following dates: 2/9/2024, 2/15/2024, 2/29/2024, 3/7/2024, 3/10/2024, 3/24/2024, 4/8/2024, 4/11/2024, 4/18/2024, 4/25/2024, 5/13/2024, and 5/14/2024. On 6/23/2024 at 6:55 AM Resident #14 was found outside of building on the sidewalk and stated they were waiting for a ride. An undated investigation completed by the Director of Nursing documented Resident #14 was on the sidewalk in their wheelchair and found by Registered Nurse Nursing Supervisor #4 on 6/23/2024 at 6:55 AM. Resident #14's wander guard device was intact but did not lock the doors to prevent them from leaving the building. The investigation documented the batteries were changed for Resident #14's wander guard bracelet that didn't work. An observation and interview on 10/2/2024 at 8:11 AM, Resident #14's wander guard was tested at the front doors. The front doors locked, and the alarm sounded at the wander guard monitor. A red icon appeared on the screen with Resident 14's name and the location of the alarm. During this observation of the wander guard monitor, Registered Nurse Unit Manager #2 stated they did not know how to find out the battery life of the wander guard tag through the tag health field. During an interview on 9/30/2024 at 11:52 AM, Registered Nurse Supervisor #4 stated they saw Resident #14 sitting outside of the building on the sidewalk on 6/23/2024 at 6:55 AM. They stated they checked Resident 14's wander guard, and the door did not lock or alarm. During an interview on 10/1/2024 at 9:03 AM, the Plant Operations Manager stated the maintenance department does not do anything with the wander guard system, and the nursing department was responsible for checking the functionality of the wander guards. During an interview and observation on 10/1/2024 at 9:06 AM, Security Officer #1 stated they only check the alarms on the egress doors and if the front doors lock; they do not check the individual wander guard bracelets that were assigned to the residents. Security Officer #1 demonstrated the egress doors alarmed with a wander guard, and the front doors locked when the wander guard bracelet was nearby, and if the front doors were wide open the alarm would sound. They stated if the alarm does not go off or the front doors do not lock, there was something wrong with the wander guard bracelet. During a telephone interview on 10/1/2024 at 9:28 AM, the sales representative of the wander guard system stated the wander guard system will not work if there was a power outage. They stated metal from a wheelchair could interfere with the alarm system if it was placed on the chair where the metal could block the frequency. They stated there was an issue with a firewall which could have caused the wander guard not working. They stated the wander guard system could still work even if the network was offline. During an interview on 10/1/2024 at 10:14 AM with the technical support customer service representative of the manufacturer of the wander guard system, stated the wander guard tags might not work if the Wi-Fi was not working, if the power was out, if the battery of the wander guard tag was dead, and there was a small possibility the wander guard tag would not work if there was a lot of metal surrounding the tag. They stated there is no device to check the battery life of the individual tag. However, the tag batteries life could be found on the tag health on the wander guard monitor. During an interview on 10/1/2024 at 10:50 AM, Licensed Practical Nurse #1 stated they were working on the morning of 6/23/2024 and did not hear an alarm going off from the front door. They stated they do not check the individual resident's wander guard's functionality; they only check for the placement of the wander guard tag on the resident's person or their wheelchair. During an interview on 10/1/2024 at 11:02 PM, Certified Nurse Aide #1 stated they worked on 6/23/2024. They stated they were on their way to do rounds at approximately 6:45 AM that day and saw Resident #14 in the front foyer. They stated they did not hear an alarm sounding. They stated the resident had tried to elope before. During an interview on 10/2/2024 at 11:11 AM, Licensed Practical Nurse #3 stated they were not sure of the lifespan of the battery of the wander guard tag/bracelet or when the batteries needed to be changed. They stated they were not sure if security tests each individual wander guard tag of each resident. During an interview on 10/2/2024 at 11:24 AM, Registered Nurse Unit Manager #1 stated when someone's wander guard was removed, they had to discontinue it from the system. To reactivate it, they'd go to the front door and hold it up, then it would come up on the monitor and staff would put in the resident's name it was assigned to. The Registered Nurse Unit Manager #1 stated if there was a feature in the system to check the battery life, they were not aware of it. During an interview on 10/2/2024 at 11:28 AM, Registered Nurse Unit Manager #2 stated they check for physical placement of the wander guard tag/bracelet but not batteries. During an interview on 10/2/2024 at 1:56 PM, the Director of Nursing stated they never checked the batteries on the individual resident's wander guard tag but should have been. During an interview on 10/2/24 at 3:00 PM, Licensed Practical Nurse #4 stated they never checked the battery life of the wander guard tags. They stated they only checked the placement of the wander guard tag and check it off on the treatment administration record. During an interview on 10/3/2024 at 8:15 AM, the Administrator stated they attempted to find out how the battery life was shown on the wander guard monitor. They stated they found the tag health field to determine the battery life. They stated they were not aware how the tag health function worked prior to 10/2/24. During a telephone interview on 10/3/24 at 8:41 AM, Licensed Practical Nurse #5 stated Resident #14 tried to leave at times, they were on the wanderer list and have a wander alert band. Nurses checked for placement of the wander guard. They were not responsible for checking the functionality and how long the band had been in use. The nursing supervisors checked the functionality. During a telephone interview on 10/3/2024 at 9:04 AM, Registered Nurse Supervisor #3 stated they have never checked individual wander guard tags. They stated they do recall a device to check the wander guard tag's batteries, but they stated, It didn't work that well. During an interview on 10/3/24 at 10:13 AM, the Director of Nursing stated they were using the tags that required batteries. In June when they looked at the tags they had, some were totally sealed and those went in the garbage. The Director of Nursing stated they couldn't confirm which residents had which type of tags on in June, they all just got new ones (that required batteries) at that point. The Director of Nursing stated when staff go to activate or reactivate the tags, if it wasn't working, it won't show up on the monitor, and they would throw the tag out. The Director of Nursing stated they weren't checking the batteries and didn't know about their policy to check the batteries. The Director of Nursing stated maybe checking the batteries was something they should have been in tune with in June. The Director of Nursing stated they worked at the facility for 2.5 years and there wasn't a record of doing any checks when they first got there or since they've worked there. During an interview on 10/3/2024 at 12:00 PM, the Administrator stated that no one knew the wander guard system was down or that there was a malfunction with the wander guard tags. The Administrator stated they would have to read the policy again and update the policy to reflect any changes. 2. Resident #12 had diagnoses of Alzheimer's disease and depression. Review of Resident #12's Minimum Data Set, dated [DATE] documented Resident #12 was cognitively impaired, needed supervision or touching assistance (help provides verbal cues or steadying assistance as resident completes the task) to wheel 150 feet, and rejected care from staff. The comprehensive care plan dated 1/20/2020 (current) documented Resident #12 was an elopement risk and wanderer related to impaired safety awareness and the resident's wandering is not purposeful. It documented staff were to check the resident's wander guard placement every shift, an elopement tool to be completed, and all staff are to be notified of wandering risk. The physician orders dated 7/18/23 documented Resident #12's wander guard tag every shift and to notify the supervisor or security if the wander guard tag is missing or broken. The treatment administration records dated February 2024 to September 2024 documented nursing staff were to check wander guard placement on the back of Resident #12's wheelchair once a shift. The Elopement Risk Scale dated 2/21/24 documented Resident #12 the resident ambulated with their wheelchair, cognitively impaired with poor decision-making skills, and displays body language or behavior that indicates an elopement may be forthcoming. A plan of care progress note dated 2/21/2024 documented Resident #12 was an elopement risk and made comments about leaving the facility. A social work progress note dated 3/20/24 documented the resident was upset and wanted to leave the facility to go home. A plan of care note dated 6/24/2024 documented Resident #12 asked to return to the community and their home. The undated investigation completed by the Director of Nursing documented Resident #12's wander guard tag was not setting off the alarm or locking the front doors as it should have been. During an interview on 10/2/2024 at 11:28 AM, Registered Nurse Unit Manager #2 stated checking the individual wander guard tags for residents, including Resident #12's was not implemented until today 10/2/2024. During an interview on 10/3/24 at 12:00 PM, the Director of Nursing stated they would expect security to notify them the internet system or the wander guard system was down or not working. 3. Resident #29 had diagnoses of anxiety and depression. The Minimum Data Set, dated [DATE] documented Resident was #29 cognitively impaired, would reject hands on care, and required assistance to wheel their wheelchair 150 feet. The comprehensive care plan dated 4/2/2024 documented Resident #29 had a wander guard tag placed on their wheelchair. It was documented the resident repeatedly asks when they can go home. The physician's orders dated 4/2/2024 documented the wander guard tag placement on the back of Resident 29's wheelchair was to be checked every shift by nursing staff. The treatment administration record dated 4/1/2024 to 7/31/2024 documented nursing staff checked Resident 29's wander guard tag for placement every shift. The elopement risk scale dated 4/29/2024 documented Resident #29 was an elopement risk related to the resident statements of leaving, cognitively impaired with poor decision-making skills, and the resident had a history of wandering. A review of the interdisciplinary progress notes dated 4/1/2024 to 7/31/2024 documented the resident had exit seeking behaviors 4/2/24, 4/29/2024, and 5/31/2024. The undated investigation completed by the Director of Nursing documented Resident 29's wander guard tag was intact and working when tested by security. During an interview on 10/2/2024 at 1:56 PM, the Director of Nursing stated they should be following the wander guard policy about checking battery life. NYCRR 10 415.12(h)(1)

Based on interview and record review conducted during an extended survey completed on 10/3/24, the facility's quality assurance and performance improvement program did not perform improvement activities that tracked adverse resident events, analyze their causes, and implement preventative actions and mechanisms that include feedback and learning throughout the facility. Specifically, the facility did not ensure their WanderGuard policy was updated; that staff were educated about the wander guard system, and did not ensure preventive actions were implemented to ensure resident safety. The finding is: Refer to: F 689 - Free from Accident Hazards/Supervision and Devices to Prevent Accidents The 2024 Facility Assessment Review dated 2/6/2024 documented the facility assessment was used to determine gaps in service or expected outcomes, when identified, are reviewed and correction plans are discussed for implementation. The corrective activities are then review during subsequent meetings to assure changes are sustained and there is no recurrence of the issue. The policy and procedure titled LTC (long term care) Quality Assessment and Performance Improvement revised on 9/23/2021 documented the mission of the LTC Quality Assurance Performance Improvement Plan (QAPI) was to promote the delivery of resident care in keeping with the highest standards of outcomes and services valued by our customers, medical staff, employees, and payors; its institutional relationships and the community served. It documented the Facility QAPI (Quality Assessment and Performance Improvement) Plan includes the policies and procedures used to identify and use data to monitor facility performance: establish goals and thresholds for performance measurement using data from published sources; utilize resident, staff and family input through Resident Council minutes, discharge interviews, concerns, and other ad hoc (for this situation) committee forums; identify and prioritize problems and opportunities for improvement; analyze underlying causes of systemic problems and adverse events; and develop corrective action or performance improvement activities. The facility Quality Assessment and Performance Improvement Plan documented data from multiple sources (performance indicators, input from residents and families, audits) are utilized to monitor care and services. It documented the Quality Assessment and Performance Improvement focuses on a systematic approach to identify problems, their causes, and implications of change, and focuses on processes rather than addressing individual behaviors. An undated investigation completed by the Director of Nursing documented Resident #14 was on the sidewalk in their wheelchair and found by Registered Nurse Nursing Supervisor #4 on 6/23/2024 at 6:55 AM. Resident #14's wander guard device was intact but did not lock the doors to prevent them from leaving the building. It documented that the sales representative for the vendor for the security system thought the reason why the wander guard tag did not set off the alarm was due to a possible software update. It documented the batteries were changed for Resident #14 who's wander guard tags didn't work. On 6/28/2024 the sales representative for security system arrived at the facility to test the wander guard tags and they were found to be working. During an interview on 9/30/2024 at 11:52 AM, Registered Nurse Supervisor #4 stated they saw Resident #14 sitting outside of the building on the sidewalk on 6/23/2024 at 6:55 AM. They stated they checked Resident 14's wander guard, and the door did not lock or alarm. During an interview on 9/30/2024 at 3:00 PM, the Administrator stated they discussed the elopement that occurred on 6/23/2024 but did not discuss the any communication issues with their IT or security IT computer network related to the issues of software. During an interview on 10/1/2024 at 9:06 AM, Security Officer #1 stated they do not check the individual wander guard tags on residents or their wheelchairs. They stated they only check the alarms on the egress doors and if the front doors lock. They stated if they alarm does not go off or if the front doors do not lock, there was something wrong with the wander guard tag. During an interview on 10/1/2024 at 4:00 PM, the sales representative of the wander guard system stated they have not done an in-service on how the wander guard monitor works in at least two to three years. The sales representative stated, it sounds like the nurses need education on how the wander guard monitor works and even if it the system is offline; the tags should still work no matter what. During an interview on 10/2/2024 at 11:11 AM, Licensed Practical Nurse #3 stated they were not sure of the life span of the battery of the wander guard tags or when the batteries needed to be changed. They stated they were not sure if security tests each individual wander guard tag of each resident. During an interview on 10/2/2024 at 11:24 AM, Registered Nurse Unit Manager #1 stated if there was a feature in the system to check the battery life, they were not aware of it. During an interview on 10/2/2024 at 11:28 AM, Registered Nurse Unit Manager #2 stated they were not checking the individual wander guard tags of residents prior to 10/2/2024. During an interview on 10/2/2024 at 1:56 PM, the Director of Nursing stated they have never checked the batteries on the individual resident's wander guard tag. They stated they should have been checking the batteries of resident's wander guard tags. During an interview on 10/3/2024 at 8:15 AM, the Administrator stated they were not aware how the tag health function worked on the wander guard system prior to 10/2/24. They stated there was no wander guard tag battery audit log prior to 10/2/24. During an interview on 10/3/24 at 10:13 AM, the Director of Nursing stated they were using the tags that required batteries. In June 2024 when they looked at the tags they had, some were totally sealed and those went in the garbage. The Director of Nursing stated they couldn't confirm which residents had which type of tags on in June, they all just got new ones (that required batteries) at that point. The Director of Nursing stated they weren't checking the batteries and didn't know about their policy to check the batteries. The Director of Nursing stated maybe checking the batteries was something they should have been in tune with in June. During an interview on 10/3/2024 at 12:00 PM with the Director of Nursing and the Administrator, the Administrator stated the Quality Assurance and Performance Improvement committee meets monthly. No one knew the wander guard system was down or that there was a malfunction with the wander guard tags. The Administrator stated they would have to read the policy again and update the policy to reflect any changes. NYCRR 415.27(c)(3)(iv)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Standard Survey completed on 5/14/21, the facility did not ensure that all alleged violations of abuse, neglect or mistreatment including injuries of unknown origin are thoroughly investigated for one (Resident #24) of three residents reviewed for abuse. Specifically, the facility did not complete an investigation of bruising to the resident's left forehead and left periorbital (area around the eye) area. The finding is: The facility Policy and Procedure (P&P) titled Identification and Reporting of Abuse, Neglect or Mistreatment of a Skilled Nursing Facility Resident, as per Public Health Law Section 2803-d with revised date of 12/19 revealed that the facility is to begin an investigation immediately upon discovery of an incident. Specifically, an investigation of injuries of unknown origin must be immediately investigated to rule out abuse. Injuries included in injuries of unknown origin are, but not limited to, bruising of the inner thigh, chest, face and breast, bruises of an unusual size, multiple unexplained bruises, and/or bruises in an area not typically vulnerable trauma. When a verbal report or written incident report is received, the principal manager of the department shall initiate the investigative process and notify the Administrator/designee. The P&P titled Long Term Care Incident Reporting Policy revised 11/11 documented where there is possible injury or harm to a resident, the supervisor or person in charge must initiate an Incident Report and the resident is evaluated by a RN and a determination is made if the resident requires emergency care or care can be provided in the facility. Medical provider is consulted. Incident report is completed immediately or as soon as possible after the incident. The incident report must reflect the category of the incident and any descriptive natures. Resident representative is notified, as appropriate. 1. Resident #24 had diagnoses that included vascular dementia, history of falling, and fracture of neck of the right femur (broken upper leg bone where it meets the hip bone). Review of the Minimum Data Set (MDS, a resident assessment tool) dated 3/14/21 documented the resident sometimes was able to understand and sometimes was able to make self-understood and had severely impaired cognitive skills for daily decision making. The Comprehensive Care Plan initiated 2/10/21 documented Resident #24 had a high risk for falls related to deconditioning, history of fracture and was restless at times, attempted to self-transfer and frequently lowered self onto the floor. Review of Resident #24's Visual/Bedside [NAME] Report (guide used by staff to direct care) dated 5/14/21 revealed that skin was to be monitored and to report PRN (as needed) any changes in skin status. Intermittent observations from 5/10/21 to 5/14/21 between 8:58 AM and 4:44 PM revealed Resident #24 had various shades of yellow, and green to light purple bruising to the left side of their forehead and left inner periorbital area that spread under their left eye. Review of the Accident and Incident Work Sheet (A&I) reports from 4/1/21 through 5/12/21 revealed no investigation or documentation of Resident #24's facial bruising. The Progress Notes dated 4/1/21 to 5/12/21 revealed no documentation of bruising to Resident #24's face. Review of the 24-Hour Nursing Report from 4/1/21 through 5/12/21 revealed no documentation of facial bruising for Resident #24. During an interview on 5/13/21 at 4:23 PM, CNA #7 stated that the first time they noted bruising to Resident #24's forehead was on 5/12/21 and that it was reported to LPN #2. During an interview on 5/13/21 at 4:44 PM, LPN #2 stated he was unaware of any skin issue on Resident #24's face. After observation of Resident #24, LPN #2 stated the area on the forehead and eye appeared to be an old bruise and he had not noticed the area until now. LPN #2 stated they would report any new skin areas to their supervisor and the supervisor would do an assessment and notify the medical doctor on call. During an interview on 5/13/21 at 4:31 PM, RN #6 (3:00 PM-11:00 PM shift supervisor) observed the area to Resident #24's face and stated it appeared the resident had bruising on their eye and forehead. RN #6 stated they did not know how the bruise happened and they did not see the bruise until now. RN #6 stated that if a bruise was noted on a resident or if staff reported a bruise, the process was to start an investigation, do a head to toe assessment of the resident, the supervisor would start an A&I form, and the bruise would get documented on shift report and in the medical record. During an interview on 5/14/21 at 8:12 AM, CNA #6 stated that they could not recall the date they noticed Resident #24's bruise, but at that time the bruise was darker in color and they reported it to LPN #3. During an interview on 5/14/21 at 8:58 AM, RN #7 Unit Manager observed Resident #24's face and stated that the areas to the resident's forehead and eye were fading ecchymosis (bruising). RN #7 stated they did not recall seeing the bruising until today. RN #7 stated that if a resident had a bruise, an investigation should be started. RN #7 also stated if the bruise could be contributed to another A&I it would be added to that A&I report and a nursing note should be written in the medical record. During a telephone interview on 5/14/21 at 10:23 AM, RN #5 (11:00 PM-7:00 AM part-time supervisor) stated the first time they noted bruising to the resident's face was on 5/13/21 when RN #6 wrote an A&I report. RN #5 stated no staff reported the resident had bruises on their face. RN #5 stated the process would be to start an A&I, start an investigation and question the staff. RN #5 also stated that if the bruising appeared old, they would not start an A&I, but write a nursing note and report it to the nurse manager. During a telephone interview on 5/14/21 at 10:30 AM, LPN #3 stated that on 5/8/21 they noticed Resident #24 had yellow bruising to their left eye and forehead and that it was reported to RN #5. LPN #3 stated they did not document the bruise in the nursing notes because they assumed it was from when the resident fell a few days prior, but that they should have documented it. During an interview on 5/14/21 at 10:58 AM, the Director of Nursing (DON) stated that it was brought to her attention on 5/13/21 that Resident #24 had yellowing bruising on their forehead that extended into the periorbital area. The DON stated they expected the supervisor would assess the area of concern, start an A&I, continue to report on it for three days on the report sheet, and document the assessment in the medical record. The DON stated they expected that the bruise would have been investigated even if it was believed to be from a fall. During an interview on 5/14/21 at 11:18 AM, the Administer stated that they expected an investigation would be started by the supervisor or unit manager when bruising was noted on a resident. The investigation would include getting statement from staff members from the previous shifts and that this could lead to writing an A&I if the injury could not be contributed to another cause. The administrator stated that the bruising should be documented in the medical record. 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during an Abbreviated survey (Complaint #NY00253905) completed during the Standard Survey on 5/14/21, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, one (Resident #216) of two residents reviewed for quality of care lacked follow up to have staples removed, from left hip, that were in place greater than three weeks. The finding is: Review of the facility policy and procedure entitled Staple Removal dated 3/19/19 revealed this document outlines the responsibilities of the Registered Nurse (RN) to safely remove incision closures (staples) used to approximate edges of an incision after healing has occurred. Instructions included check the Medical Doctor (MD)/Nurse Practitioner (NP) order to determine the details for the procedure. Document in a progress note the procedure, condition of incision, pertinent observations, and resident tolerance to the procedure in the resident's electronic medical record (EMR). 1. Resident #216 was admitted with diagnoses of fracture of the left femur (thigh bone), diabetes, and dementia. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 2/11/20 documented the resident had severe cognitive impairment, a surgical wound and surgical wound care. Review of the hospital Discharge summary dated [DATE] revealed under Hospital course: Patient admitted with the diagnose of mechanical fall induced left hip fracture. Orthopedic surgeon (doctor who specializes in bones, joints, tendons, and muscles) was asked to see the patient who did intramedullary nailing (surgery to repair a broken bone) of the left intertrochanteric fracture (broken hip). Review of the Skilled Nursing Facility admission Data Sheet dated 2/4/20 under Skin Integrity: documented a left leg/thigh (inner) scar. There was no description of the site. Review of the left hip x-ray Final Report dated and initialed on 2/6/20 revealed under Findings: 3 views of the left hip joint demonstrated ORIF (open reduction internal fixation, a surgical repair of hip fracture) of intertrochanteric fracture left femur with a metallic screw and intramedullary rod. Skin staples seen along the lateral (side) aspect. Completed action list revealed x-ray was ordered by the Nurse Practitioner (NP) on 2/6/20. Review of the Comprehensive Care Plan (CCP) dated 2/6/20 revised on 3/2/20 revealed no documentation of the left hip surgical site, plans for surgical follow up, or staple removal. Review of the physician Order Listing Report dated 2/4/20 through 3/3/20 revealed the following orders: 2/4/20- monitor left hip incision for signs/symptoms of infection cover with gauze pad as needed for left hip fracture. 2/22/20- Bactroban Ointment (antibiotic) to left hip incision daily for incisional erythema (reddening of skin) for 5 days. Keep open to air. 2/22/20 -Doxycycline (broad spectrum antibiotic) 100mg BID for incisional erythema and leukocytosis (increased of white cells in the blood, especially during an infection) for 5 days. Review of the February and March 2020 Medication Administration Record (MAR) & Treatment Administration Record (TAR) revealed there was no documentation of the left hip surgical site, plans for surgical follow up, or staple removal. Review of the 24-Hour Nursing Reports dated 2/4/2020 through 3/3/2020 documented the following: 2/16/20- left hip incision erythema noted. Staples in place. 2/19/20- left hip incision intact, staples in place. 2/22/20- signs& symptoms of infection to incision left hip, redness found. Doxycycline and Bactroban left hip incision x 5 days. 2/23/20- treatment applied to staples, redness continues. 2/24/20- staples intact left hip. 2/28/20- left hip incision erythema continues, staples in place. 2/29/20- left hip staples intact, erythema around incision continues. 3/01/20- hip staples intact, erythema continues. No documented evidence of plans for surgical follow up or staple removal. Review of the Physician History and Physical (Amended) dated 2/4/20 revealed under Physical Exam- Skin left hip surgical site is intact, without signs of dehiscence (splitting or breaking open), rash, new bruising or bleeding noted. No documented evidence of plans for surgical follow up or staple removal. Review of the nursing the Progress Notes dated 2/4/2020 through 3/2/20 revealed the following documentation: 2/4/20 at 8:52 PM admitting dx (diagnosis): S/P (status post) fall and left femur fracture. 2/6/20 at 6:46 PM reident given one time dose of morphine for pain before X-ray. Results from X-ray negative no displaced fragment is seen. 2/21/20 at 11:45 AM interdisciplinary team (IDT) met for a CCP review. Plan of care was reviewed/revised and was deemed appropriate. 2/22/20 at 10:55 AM during shift crusting and erythema noted around patient's incision site on left hip. NP was updated, new orders for doxycycline 100 milligrams (mg) two times per day (BID) for 5 days, and Bactroban ointment to left hip incision for 5 days and keep open to air. 3/2/20 at 10:35 AM left hip incision intact with slight erythema (redness). No further concerns at this time. Continue to monitor. 3/3/20 at 11:55 AM discharge instructions were reviewed with patient including follow up appointments. Patient was educated on importance of following up with primary care physician and orthopedic surgeon. Patient was discharged to home via private vehicle with spouse. No documented evidence of plans for surgical follow up or staple removal. Review of the Nurse Practitioner (NP) Progress Notes revealed the following documentation: -2/14/20, 2/17/20, 2/21/20, and 2/28/20 under Physical Exam- Skin: hip surgical incision unremarkable without signs or symptoms of infection. No documented evidence of plans for surgical follow up or staple removal. -2/24/20 under Chief Complaint/Nature of Presenting Problem included incisional erythema. Additionally, patient started on antibiotic therapy for some incisional erythema. Plan was reported cellulitis ( bacterial infection under the skin) incisional erythema- not noted today. Will finish antibiotic. Site unremarkable. Review of the NP Discharge summary dated [DATE] documented patient fractured left hip, underwent ORIF, and transferred to facility for restorative therapy. Had some incisional erythema and underwent short course of doxycycline. Physical Exam- Skin revealed hip surgical incision unremarkable without signs or symptoms of infection. Follow Up Appointments documented surgeon as scheduled. No documented evidence of staple removal. During an interview on 5/14/21 at 7:31 AM, RN #1 Unit Manager (UM) stated the process for a resident getting staples removed depends on the surgeon. Some will have us remove them, others prefer their patient to follow up in the office. The hospital discharge will usually have instructions for staple removal in 10 to 14 days. If there are no orders, we will attempt to call the surgeon. The expectation would be, if not on the hospital discharge instructions, the admitting nurse would document that resident has no follow up appointment and the surgeon would be called to schedule. The nurse who admitted the resident no longer works here and I don't really remember why it was not scheduled. RN #1 UM reviewed the residents EMR and stated the resident was here for a femur fracture and there should be follow up. Either me or the admitting nurse would call the surgeon for surgical follow up orders. RN #1 UM reviewed the residents CCP and stated there were no follow up instructions. That should have been done within the first couple days of a resident being in the facility because we have to do the 48-hour care plan. During an interview on 5/14/21 at 10:25 AM, the NP stated the expectation for staple removal depends on the type of surgery and direction from the surgeons. It should be on the hospital discharge summary orders. If not nursing should contact the surgeon to see when the staples should come out and that would go in the physician orders. While reviewing the residents EMR the NP stated they could not remember the incision, it was over a year ago. I would expect nursing to put it on report and my list to see the resident. They should ask why this incision is red, and why aren't these staples out and there should be follow up. They should have been removed before the resident was discharged and I cannot say why they weren't. During an interview on 5/14/21 at 11:06 AM, the Director of Nursing stated if a resident is admitted with staples and there are no instructions for removal, I would expect a call to the surgeon by the next day for follow up. Staples are usually only left in for 14 days. A month is a long time for staples to be left in. I would expect that a call would have been placed to the surgeon to see when they should be taken out. During an interview on 5/14/21 at 12:52 PM, the Medical Director stated the expectation for a resident with staples is to check with ortho, we would follow up with them and expect that they were removed. The expectation is to have them removed after 14 days. During a follow up interview on 5/14/21 at 1:13 PM, the NP reviewed the 24-Hour Nursing Report documentation of resident with staples. The NP stated there must have been a reason we did not take the staples out. 415.12

Based on observation, interview, and record review completed during the Standard survey completed on 5/14/21, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #6) of two residents observed for pressure ulcers. Specifically, infection control practices were not maintained during a pressure ulcer treatment application and the treatment was not completed as ordered by the physician. The finding is: Review of facility policy titled Physician Orders- Long Term Care (LTC) dated 7/21/14 documented telephone or other verbal orders shall be accepted only by a license nurse, pharmacist or such other licensed practitioner as permitted by law. Telephone and verbal orders that follow this policy are considered to be valid orders and will be executed as if the authorized prescriber wrote them. Review of the facility policy titled Pressure Ulcers-LTC revised 11/17 documented the resident's Comprehensive Interdisciplinary Care Plan will be reviewed and/or revised by the members of the interdisciplinary team within 72 hours following a change in any pressure ulcer monitoring point. Review of the facility's policy entitled Hand Washing revised 10/14/19 documented hand hygiene is considered the most important measure for reducing the transmission of microorganisms in healthcare facilities. Hand hygiene is a general term that applies to either handwashing, antiseptic hand wash/alcohol-based hand rub (ABHR), or surgical hand hygiene/antisepsis. Hand hygiene is a practice that must be done faithfully by all personnel without exception. Hand hygiene will be performed by personnel that perform procedures on patients, even though gloves are worn. 1. Resident #6 had diagnoses that included multiple sclerosis (disease of the nervous system affecting brain and spinal cord), unstageable pressure ulcer of right hip, and osteomyelitis (bone infection). Review of the Minimum Data Set (MDS - a resident assessment tool) dated 2/7/21 revealed the resident had severe cognitive impairment and had one unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer. Review of the comprehensive care plan revised on 5/9/21 documented Resident #6 had an unstageable chronic ulcer on the right posterior thigh. Interventions included to administer treatments as ordered and monitor effectiveness. Review of a nursing Progress Note dated 4/8/21 at 12:42 AM documented the Nurse Practitioner (NP) saw Resident #6 and new orders were received for a wound culture (test to find and identify a microorganism causing an infection in a wound) of the right thigh area and the treatment was changed. Review of SNF (Skilled Nursing Facility) Physician Telephone Orders dated 4/8/21, signed by the provider, documented the following: -Discontinue current right posterior thigh treatment; irrigate with normal saline (NS-solution used for wound cleansing) and apply Santyl ointment (promotes the removal of necrotic (dead) tissue and advances wound healing) and pack with gauze every day -Also apply Flagyl powder (medication used to treat bacterial infection and reduce odor) Review of the Bacteriology report dated 4/11/21 documented the right thigh wound culture was positive for Proteus Mirabilis and Staphylococcus Aureus (bacteria that indicated infection). Review of the Wound-Weekly Observation Tool dated 5/7/21 documented Resident #6's right posterior thigh pressure ulcer measured 3.6 centimeters (cm) length (L) x 3.4 cm width (W) x 2.4 cm depth (D). During an observation on 5/13/21 at 9:49 AM, Licensed Practical Nurse (LPN) #1 washed their hands, applied clean gloves, and assisted Resident #6 to lay on their left side. LPN #1 removed the moderately soiled dressing from the resident's right posterior thigh wound and removed moderately soiled gauze packing from the ulcer. With the same gloved hands, LPN #1 irrigated the wound with NS then patted the wound dry with gauze. LPN #1 removed their gloves, did not perform hand hygiene, and put on a new pair of clean gloves. LPN #1 picked up the flagyl container, poured the powder onto a 3x3 gauze pad, and patted the powder into the wound. LPN #1 poured more flagyl powder onto the same gauze and packed the gauze into the wound. Wearing the same gloves, LPN #1 then squeezed santyl ointment from the tube onto to their gloved finger and applied it on the skin edges surrounding the wound. The santyl was not applied to the wound bed. Wearing the same gloves, LPN #1 placed dry clean gauze over the packing in the wound. During an interview on 5/13/21 at 10:04 AM, LPN #1 stated they reviewed the physician's order prior to completing the treatment, that they should have put Santyl on the gauze before the flagyl powder, because it should have been placed on the wound, and should have used an applicator to apply the ointment, not their gloved finger. LPN #1 also stated they should have washed their hands after removing the previous soiled treatment and before applying a new treatment, for proper infection control. During an interview on 5/14/21 at 9:12 AM, Registered Nurse (RN) #7 Unit Manager stated they expected staff to apply Santyl and flagyl powder to a wound bed after the wound was irrigated with NS. RN #7 stated they would also expect hand hygiene to be performed after removing the old treatment, prior to completed the new treatment due to infection control purposes and cross contamination. During an interview on 5/14/21 at 11:04 AM, the Director of Nurses (DON) stated they expected the staff to follow the treatment orders and complete treatments as ordered by the physician. The DON stated they expected hand hygiene be performed after removing soiled dressings and gloves, prior to application of a new treatment for infection control purposes. 415.12(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview completed during the Standard survey completed 5/14/21, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and equipment to prevent further decrease in range of motion for one (Resident #7) of two residents observed for range of motion (ROM-normal range of motion of a joint) services. Specifically, Resident #7 did not have rolled washcloths to the right and left hands as recommended by OT (Occupational Therapy), and lacked comprehensive assessments, including measurements of joint mobility. Additionally, there was no documented evidence to support range of motion services were provided as recommended. The finding is: The facility policy and procedure (P&P) entitled Physical / Occupational Therapy- SNF-Range of Motion (Preventative routine) dated 7/23/19 documented ROM programs are implemented by the rehabilitation department to prevent and manage contractures, maintain joint mobility, and for stretching of upper extremities and lower extremities muscles for functional benefits. ROM Programs are completed by ROM CNAs (Certified Nursing Assistants) per therapists' recommendations. The ROM program is documented in the computer system by the therapy department, exercises are provided by ROM CNAs per resident's schedule and documentation is completed in the computer system. The range of motion program is reviewed on quarterly basis and as requested by nursing. 1. Resident #7 had diagnoses that included spasmodic torticollis (an extremely painful chronic neurological movement disorder causing the neck to involuntarily turn to the left, right, upwards, and/or downwards), anxiety disorder and major depressive disorder. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/2/21 revealed the resident was rarely/never understood, and had long term and short-term memory problems. The MDS documented the resident had functional limitations on both sides of upper and lower extremities. Review of the comprehensive care plan initiated on 7/22/16 revealed Resident #7 had limited ROM related to limited mobility with a revised intervention dated 11/17/20 to include PROM (passive range of motion - someone physically moves or stretches a part of the body) to bilateral upper and lower extremities 3 times per week. In addition, the resident had an ADL (activities of daily living) self-care performance deficit related to impaired cognition with revised interventions dated 6/25/19 to include B (bilateral) wash cloth roll during the day as tolerated 3 days per week. Review of the [NAME] Report (a guide used by staff to provide care) dated 5/12/21 revealed interventions included PROM to bilateral upper and lower extremities 3 times per week and B (bilateral) wash cloth rolls during the day as tolerated 3 days per week. Review of the POC Response History report from April 13, 2021 through 5/12/21 revealed the resident was to receive PROM 3 times per week to their bilateral upper extremities (BUE) and bilateral lower extremities (BLE). There was no documented evidence that PROM was provided to the resident as recommended and per the care plan. Review of the Occupational Therapy Plan of Care dated 3/27/19 through 5/11/21 revealed there were no documented measurements of the resident's BUE ROM. In addition, the Occupational Therapy Plan of Care documented PROM 3 times per week to BUE. The Progress Notes dated 5/10/21 at 7:33 AM, written by Occupational Therapist (OT) #3 documented B wash cloth roll during the day as tolerated 3 days per week, BUE PROM 3 times per week with the ROM aide. Intermittent observation from 5/10/21 to 5/12/21 between 8:00 AM to 4:00 PM revealed Resident #7 did not have rolled wash cloths in either hand. The resident's fingers on bilateral hands were curled in toward their palms. During an interview on 5/12/21 at 11:50 AM, the Lead Physical Therapist stated Resident #7's contractures should have been measured at least annually and the last documented measurements available in the medical record were from July 2018. The Lead Physical Therapist stated the resident was on a therapy program in 2019, 2020, and 2021 and there was no documented evidence the upper extremity contractures were measured. During an interview on 5/12/21 at 12:35 PM, CNA #2 stated she was the ROM aide for the facility, but had worked frequently as a CNA, therefore the CNAs were responsible to complete the ROM for their assigned residents. CNA #2 stated the ROM task gets documented in the computer system. During an interview on 5/12/21 at 12:55 PM, CNA #1 stated she performed ROM to the Resident #7's elbows only, and didn't do the resident's wrists and fingers because they were too contracted. CNA #1 stated she didn't look at the [NAME] to know what ROM was recommended for Resident #7 and she was not educated on how to perform ROM. Observation and interview on 5/12/21 at 1:36 PM, revealed OT #1 completed the measurements of Resident #7's BUE including shoulders, elbows, wrists and fingers. OT #1 stated the measurements should have been completed at least annually and the resident was care planned for rolled wash cloths to both hands 3 times per week which were not in the resident's hands at this time. During an interview on 5/12/21 at 3:30 PM, OT #1 stated she compared Resident #7's previously documented measurements from 2018 and stated the resident had decreased ROM in both elbows and shoulders and due to the lack of yearly measurements was unable to determine when the resident had the decline. OT #1 stated the CNAs were to supposed document the completion of ROM in the computer system. Upon review of the POC Response History from April 13, 2021 through 5/12/21, OT #1 stated there was no documented evidence the resident had received ROM as recommended. Intermittent observations on 5/13/21 at 8:31 AM, 9:25 AM, and 10:10 AM revealed Resident #7 had no rolled wash cloths in bilateral hands. During an interview and observation on 5/13/21 at 10:10 AM, CNA #2 stated she completed Resident #7's AM care and that she didn't know the resident had recommendations for rolled washcloths in bilateral hands. CNA #2 reviewed the resident's [NAME], verified the recommendation and placed the rolled washcloths into both of the resident's hands. CNA #2 stated the recommendation was for 3 times a week, there were no set days of the week, and it was not a task that got documented. CNA #2 stated they were uncertain when the washcloths were to be placed into the resident's hands. During an interview on 5/13/21 at 10:42 AM, the Director of Nursing (DON) stated she expected the CNA's to document completion of ROM in the computer system, but there was a glitch in the computer system and not all the CNA's could see the ROM recommendations. The DON stated there was no documented evidence ROM was performed as recommended for Resident #7. In addition; the DON stated she expected the CNA's to apply the wash cloths to the resident's hands as recommended, 3 times per week. The DON stated there was no documented evidence the recommendation was completed, there were no scheduled set days the wash-cloths were to be applied, therefore, she did not know how the staff would know what days of the week to apply the wash cloths to the resident's hands. The DON also stated she expected the therapy department to measure the resident's upper extremity contractures annually and it was the Lead Physical Therapist's responsibility to ensure that contractures were measured annually. During an interview on 5/13/21 at 11:11 AM, the Lead Physical Therapist stated he expected the CNA's to complete the ROM and apply the wash cloths to the residents hands as recommended to prevent further contractures but there was no documentation that these interventions were completed as recommended. During an interview on 5/14/21 at 9:01 AM, the Administrator stated he expected the nursing staff to follow the recommendations from therapy. 415.12 (e)(2)