**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews and during the Recertification Survey initiated on 11/7/2024 and completed on 11/14/2024, the facility did not ensure an assessment was completed to accurately reflect a resident's status. This was identified for one (Resident #55) of one resident reviewed for Physical Restraints. Specifically, Resident #55 had physician orders for the use of a floor mat alarm and a wheelchair alarm. Resident #55's quarterly Minimum Data Set assessments dated 10/29/2024 and 8/3/2024 did not accurately reflect the use of the chair alarm and the floor mat alarm. The finding is: The facility's policy titled Comprehensive Assessment and Comprehensive Care Planning Process effective 1/2000 and last revised in 12/2023 documented the interdisciplinary team is responsible for Resident Assessments and completion. The Minimum Data Set Coordinator is responsible for coordinating the assessment and care planning process in order to ensure the timely and accurate completion of the Minimum Data Set assessment and care plan. Resident #55 was admitted with diagnoses including a history of Falling, Difficulty in Walking, and Dementia. The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 5, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment, section P0200 Alarms, documented the resident did not use a floor mat alarm and a chair alarm. The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 5, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment, section P0200 Alarms, documented the resident did not use a floor mat alarm and a chair alarm. The Comprehensive Care Plan titled At Risk for Falls last revised 4/1/2024 documented interventions including the use of a chair alarm and a floor mat alarm with consent from the resident's family. A Physician's Order dated 3/28/2024 and last renewed on 11/11/2024 documented the application of a chair alarm with consent from the resident's family. A Physician's Order dated 4/1/2024 and last renewed on 11/11/2024 documented the application of a floor mat alarm with consent from the resident's family. During an interview on 11/14/2024 at 10:55 AM, the Minimum Data Set Coordinator stated they were responsible for scheduling, completing, and submitting the Minimum Data Set assessments. The Minimum Data Set Coordinator stated when they completed an assessment, they reviewed the resident's chart, the physician's orders, progress notes, and care plans and saw the resident in person as well. They stated the quarterly Minimum Data Set assessments for Resident #55 dated 8/3/2024 and 10/29/2024 should have reflected the use of a chair alarm and floor mat alarm. The Minimum Data Set Coordinator stated this was an error on their part. During an interview on 11/14/2024 at 11:20 AM, the Director of Nursing Services stated they agreed with the Minimum Data Set Coordinator's answer that this was a human error. The Director of Nursing Services further stated the Minimum Data Set Coordinator should have paid more attention to the interventions for fall prevention as the resident had a history of falls. The Director of Nursing Services stated the floor mat alarm and chair alarm were in use during the assessment periods and the assessment should have accurately reflected the use of both alarms. 10 NYCRR 415.11(b)

Based on record review and interviews during the Recertification Survey initiated on 11/7/2024 and completed on 11/14/2024 the facility did not ensure that each resident who was prescribed psychotropic drugs (drugs that affect the mind, emotions, and behavior by altering the chemical makeup of the brain and nervous system) received gradual dose reductions unless clinically contraindicated. This was identified for one (Resident #25) of five residents reviewed for Unnecessary Medications. Specifically, Resident #25 was receiving Risperidone (also known as Risperdal, an antipsychotic medication) 0.5 milligrams in the morning and 1.25 milligrams at bedtime. On 3/6/2024 the Psychiatrist and on 9/12/2024 a Pharmacist recommended a gradual dose reduction. There was no documented clinical contraindication to attempt Risperdal gradual dose reduction for Resident #25. The facility did not attempt the gradual dose reduction because the resident's representative did not agree with the Psychiatrist's and the Pharmacist's recommendations. The finding is: The facility's policy, titled Psychotropic Medication, reviewed/revised 2/2024, documented under the heading Antipsychotics, Residents must, unless clinically contraindicated, have a gradual dose reduction of the antipsychotic drug. Clinically contraindicated means: For residents who have had a history of recurrence of psychotic symptoms which have been stabilized with a maintenance dose of an antipsychotic drug without incurring significant side effects. The physician will not initiate dose reduction and will document the same, and for residents for whom a gradual dose reduction has been attempted twice in one year and that attempt resulted in the return of symptoms for which the drug was prescribed, the physician will not continue dose reduction attempts and will document same. Resident #25 was admitted with diagnoses including Vascular Dementia, Nontraumatic Intracranial Hemorrhage (brain bleed), and Aphasia (a language disorder that affects a person's ability to understand and express written and spoken language). The 10/24/2024 Annual Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision-making. The Minimum Data Set assessment documented antipsychotic medications were received on a regular basis, there was no gradual dose reduction attempted, and the Physician did not document that a gradual dose reduction was clinically contraindicated. A physician's order dated 2/15/2024 documented Risperdal oral tablet 0.5 milligrams, one tablet by mouth every day (9:00 AM), for a diagnosis of mood changes. A physician's order dated 3/7/2024 documented Risperdal oral tablet 1.0 milligrams, and 0.25 milligrams (a total of 1.25 milligrams) by mouth at bedtime, for a diagnosis of Delirium due to known physiological condition. A Psychiatrist consult dated 3/26/2024 documented the resident was taking Risperdal 0.5 milligram in the morning and 1.25 milligrams at bedtime for diagnosis of Mood Disorder secondary to Cerebrovascular Accident and Vascular Dementia. The Psychiatrist recommended lowering the bedtime dose to 1 milligram at bedtime instead of 1.25 milligrams. A progress note dated 3/26/2024, written by Registered Nurse #1 (the Unit Manager), documented the resident was seen by the Psychiatrist. Risperdal was decreased to 0.5 milligrams in the morning and 1.0 milligrams at bedtime. A review of the March 2024 Medication Administration Record revealed that the resident received 1.0 milligrams of Risperdal for one day on 3/26/2024 at 9:00 PM. A progress note dated 3/27/2024, written by Registered Nurse #1, documented the resident's family member did not want the resident seen by the Psychiatrist anymore and wanted the Risperdal order changed back to 0.5 milligrams in the morning and 1.25 milligrams at bedtime. No further psychiatry consults are to be done. A physician's order dated 3/27/20204 documented adding Risperdal 0.25 milligrams at bedtime (in addition to the 1.0 milligrams Risperdal order already in place). A review of the March 2024-November 2024 Medication Administration Records revealed except for 3/26/2027, Resident #25 consistently received 0.5 milligrams of Risperdal at 9:00 AM and 1.25 milligrams of Risperdal at bedtime for a diagnosis of Mood Disorder. A Pharmacist Medication Regimen Review dated 9/12/2024 documented [Resident #25] is currently receiving Risperidone (Risperdal) for a diagnosis other than an approved chronic psychiatric condition. Please evaluate the continued need and efficacy. Consider tapering Risperdal to 0.5 milligrams in the morning and 1 milligram at bedtime. Physician #1 agreed with the recommendations on 9/18/2024. A review of September 2024 through 11/12/2024 Medication Administration Records indicated that no changes to the Risperdal orders were made. A progress note dated 9/18/2024, written by Registered Nurse #1 (unit manager), documented the resident's family did not want the Risperdal dosage decreased. On 11/7/2024 at 10:54 AM Resident #25 was observed in the day room. The resident was sleeping but arousable. The resident was not interviewable. During an interview on 11/12/2024 at 11:48 AM, Physician #1 (the house/covering Physician who marked Agree on the pharmacy review) stated the Risperdal dosage as recommended by the Pharmacist, was not decreased because the resident's family member did not want the medication dosage changed. Physician #1 stated they do not alter the residents' medications unless the residents' families agree. Physician #1 stated Risperdal is not the drug of choice for Delirium and that the use of the Delirium diagnosis was a mistake. During an interview on 11/12/2024 at 12:02 PM, Registered Nurse #1 stated the resident's (Resident #25) family member does not let us do anything and that is why we could not decrease the Risperdal dosage. On 11/12/2024 at 1:55 PM Resident #25 was observed in the day room sleeping. During an interview on 11/12/2024 at 1:58 PM, Physician #2 (the Primary Attending Physician) stated they were not made aware of the recommendations for Risperdal gradual dose reduction and refusal by the resident's family member. Physician #2 stated there has to be a clinical contraindication for not attempting a gradual dose reduction for psychotropic medications. Physician #2 stated if they knew, they would have had a conference call with the family member, the Psychiatrist, and themselves to find out why the family member did not want the gradual dose reduction. During an interview on 11/12/2024 at 2:19 PM, the Director of Nursing Services stated the primary Physician should have been made aware of the recommendation for Risperdal gradual dose reduction. The Director of Nursing Services stated the gradual dose reduction was attempted for one day (3/26/2024), but the resident's family member got very upset and Risperdal was changed back to the original dosage of 1.25 milligrams at bedtime. The Director of Nursing Services stated they knew there should be a clinical reason for not attempting a gradual dose reduction of psychotropic medication, but the resident's family member insisted on continuing the same Risperdal dosage. The Director of Nursing Services stated they spoke with the resident's family member regarding recommendations for Risperdal gradual dose reduction made by the Psychiatrist but did not document their discussions with the family member in the resident's medical record. 10 NYCRR 415.12(l)(2)(ii)

Based on observation, record review, and interviews during the Recertification Survey initiated on 11/7/2024 and completed on 11/14/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during the Kitchen observation conducted on 11/13/2024. Specifically, the facility did not monitor the temperature of cold food items (sandwiches, tartar sauce), at the time of meal service. The finding is: A facility policy and procedure titled Food Distribution and Service dated August 2024 documented the facility will distribute and serve food items to the residents in a safe manner, thereby maintaining holding temperatures and safe, covered transportation of food to the resident population. Cold food items will be bathed in ice, except for sandwiches which will be refrigerated for the duration of the tray line. Whether hot or cold holding, all foods will be kept out of the danger zone. Cold holding temperatures will be sampled and recorded. An observation of the kitchen on 11/13/2024 at 11:57 AM revealed a tray of plastic cups of tartar sauce on the cooks' table. The tray was not on an ice bath. The individual resident meal trays were arranged on a food cart, some with sandwiches already placed on them. During an interview on 11/13/2024 at 12:12 PM, the [NAME] stated that the tartar sauce should be served cold and should be kept on ice. During an interview on 11/13/2024 at 12:14 PM, the Dietary Manager stated that no cold food temperatures were taken for this meal and they do not have a temperature log for the cold food items. The Dietary Manager took the temperature of the tartar sauce, and it registered 48 degrees Fahrenheit. The temperature of a tuna sandwich was also taken and registered at 46 degrees Fahrenheit. The Dietary Manager stated that the cold food should be at a maximum temperature of 40 degrees Fahrenheit. During an additional interview on 11/13/2024 at 2:15 PM, the Dietary Manager stated that the tartar sauce should have been stored on ice. The Dietary Manager stated that it is important to keep temperatures below 40 degrees Fahrenheit for food safety, to prevent food-borne illness, and the growth of bacteria or spores. 10 NYCCR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00287822) initiated on 3/5/2023 and completed on 3/10/2023, the facility did not notify the resident's Designated Representative (DR) when a new form of treatment was started. This was identified for one (Resident #145) of one resident reviewed for notification of change. Specifically, on 11/15/2021 at 5:41 AM Resident #145 had episodes of vomiting and was assessed to have a low oxygen saturation rate. Resident #145's physician ordered antiemetic (medication to treat vomiting) medication and to administer oxygen at 2 liters per minute (LPM). The facility staff did not notify the resident's family of the changes in the resident's condition. The family became aware of the resident's status when they (family member) visited the resident at 3 PM and found the resident in bed, shivering. The finding is: The facility's policy for Family Notification dated 9/11/2014 documented to promptly notify family/designated representatives when a resident has an incident, accident, or transferred to the hospital. The facility policy did not include guidance to staff on notification to the family members when a resident is identified as having a change in their clinical status and there is a need to discontinue an existing form of treatment due to adverse consequences or there is a need to commence a new form of treatment. Resident #145 was admitted with diagnoses that include Chronic Obstructive Pulmonary Disease (COPD), Pyelonephritis (Kidney infection), and Coronary Heart Disease. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severely impaired cognition. A nursing progress note, written by Licensed Practical Nurse (LPN) #2, dated 11/15/2021 at 5:41 AM documented the resident had emesis (vomiting) x 2 (twice). The Physician was made aware. The resident's vital signs were: Blood Pressure (BP) 94/69 millimeters of mercury (mmHg), Temperature 96.8 degrees Fahrenheit, pulse 87 per minute, and respiration 20 per minute. A nursing progress note, written by Registered Nurse (RN) #9, the 11 PM-7 AM nursing supervisor, dated 11/15/2021 at 6:49 AM documented Resident #145 had two episodes of emesis of undigested food this tour. Upon assessment, the resident was noted with a low oxygen saturation rate of 85% on room air (Normal range is above 92%). The Physician was made aware and ordered to place the resident on oxygen at 2 LPM and administer Zofran (an antiemetic) 4 milligrams (mg) every 8 hours as needed (PRN). The Physician's order dated 11/15/2021 documented Ondansetron HCL oral Tablet 4 mg (Zofran) one tablet by mouth every eight hours as needed and oxygen at two liters per minute via nasal cannula every shift. The medical record did not include that the resident's family was notified of the change in the resident's clinical status. A Nursing Progress Note dated 11/15/2021 at 3:05 PM written by RN #8, documented the resident's family was at the bedside and was worried about the resident shivering. Resident #145 was alert but non-verbal and was not in any distress. Resident #145 was receiving oxygen via nasal cannula. The nurse was unable to obtain oxygen saturation because the resident's hands were very cold. The resident was given another blanket to warm up. The Physician was made aware of the resident's current condition and ordered to obtain blood work and a urine sample for analysis, including a culture and sensitivity. A nursing progress note dated 11/15/2021 at 3:21 PM, written by RN #6, documented the resident was lethargic with a slow response. The family member who was at the bedside was concerned. The Physician was informed and ordered to transfer the resident to the hospital for evaluation. The resident's family was informed and 911 was called to transfer the resident. The nurse was unable to get BP and oxygen saturation rate. A Non-rebreather mask was applied and the resident was transferred to the hospital. At 9:47 PM the resident was admitted to the hospital with a diagnosis of Sepsis. RN #6, who was the 3 PM-11 PM shift nursing supervisor, was interviewed on 3/10/2023 at 11:10 AM. RN #6 stated when they (RN #6) came into the facility to start their shift, Resident #145's family member was in the facility and asked RN #6 to see the resident. RN #6 stated they assessed the resident, and notified the Physician. RN #6 stated they called 911 and the resident was sent to the hospital as per the Physician's orders. The resident was admitted to the hospital with a diagnosis of Sepsis. RN #6 stated that they normally call the family members when any resident is noted with a change in condition, accidents, incident, or when a resident is sent to the hospital. RN #8 was interviewed on 3/10/2023 at 11:20 AM and stated they (RN #8) vaguely recall that they were called to assess Resident #145 and the resident's family was at the bedside on 11/15/2021. RN #8 stated they could not recall the details. RN #8 stated usually when there is an emergency, the nurse attends to the resident's needs, assesses the resident's condition, calls the doctor, and then calls the next of kin or the resident's family. Rn #8 further stated that if there is not an emergency such as any change in the resident's clinical condition or change in any medication, the RN on the floor notifies the family. RN #1, the Unit Nurse Manager, was interviewed on 3/10/2023 at 11:39 AM and stated the resident's family should be notified of any change in the resident's condition. RN #1 stated that there is no timeframe regarding the notification it is when you know it, that there is a change in condition. RN #1 stated Resident #145 had a change in their condition on 11/15/2021 and was placed on oxygen therapy for a low oxygen saturation rate and was also prescribed Zofran by the physician because the resident was vomiting. RN #1 stated the resident's family should have been notified and the notification to the family should be documented in the resident's medical record. LPN #2 and RN #9 were not available for an Interview. The Director of Nursing Services (DNS) was interviewed on 3/10/2023 at 12:00 PM and stated Resident #145 had a change in condition on 11/15/2021. The DNS stated the resident's family should have been notified of the resident's change in condition and the notification should have been documented in the resident's medical record. 10 NYCRR415.3(f)(2)(ii)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #244 was admitted with the diagnoses that include Stroke, Hemiplegia, and Seizure Disorder. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented Resident #244 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had intact cognition. There were no Psychiatric/Mood Disorders or behaviors noted on the MDS. A Behavior care plan dated 10/17/2019 documented Resident #244 made accusatory statements. The intervention dated 12/31/2020 included to provide a two-person attendance with all care. The evaluation notes section dated 4/30/2020 documented Resident #244 was noted to make accusatory statements that staff are stealing personal items from Resident #244's room. There were no evaluation notes related to Resident #244's accusations made on 7/22/2020. The Social Work progress note dated 7/22/2020 documented that Resident #244 verbalized that they (Resident #244) were feeling as if all staff assigned to provide care were talking to each other about Resident #244 and making fun of Resident #244. Resident #244 stated their (Resident #244) feelings were hurt. The Director of Social Work (DSW) informed the Psychologist of Resident #244's statements. Resident #244 was placed on a two-person approach for all care and staff will provide any support as needed. The psychology note dated 7/24/2020 documented that Resident #244 presented with anxiety and depression regarding housing difficulties. Resident #244 is struggling with recent death of a family member as well as adjusting to COVID-19 precautions. The DSW alerted the psychologist that Resident #244 was reporting discomfort related to staff which was reported in a cyclical manner. The psychologist documented techniques were utilized to challenge and reframe Resident #244's misconceptions related to staff. The psychologist gently reflected that Resident #244 feels this from time to time and worked with Resident #244 to identify ways in which Resident #244 can understand the behaviors of others through a different lens. Resident was reticent to do so, calm and less accusatory at session close. The DSW was interviewed on 3/7/2023 at 2:05 PM. The DSW stated that Resident #244 did express that they (Resident #244) felt that the staff members were talking about Resident #244 and making fun of Resident #244 on 7/22/2020. The DSW stated that they (DSW) were not aware if an investigation was completed for this accusation. The DSW stated that they (DSW) informed the Director of Nursing Services of the resident's concerns on the same day, 7/22/2020. The DSW stated that the nursing department handles allegations made by residents. The DSW stated that they referred Resident #244 to the psychologist to address accusatory behavior. The DSW stated Resident #244 was subsequently care planned for a two-person approach for care. The DSW stated that there was no grievance initiated for this accusation. The only grievance filed was an investigation for missing items on 5/19/2020. The Director of Nursing Services (DNS) was interviewed on 3/8/23 at 11:25 AM. The DNS stated Resident #244 was accusatory in the past and was care planned for the behavior. The DNS stated that they (DNS) responded to Resident #244's allegation that staff were making fun of Resident #244 because of Resident #244's weight. When the DNS spoke with Resident #244, Resident #244 denied that they felt that staff were making fun of them. The DNS stated that they did not document the conversation with Resident #244 and or did not initiate an investigation. The DNS stated that they had implemented the two-person approach to address Resident #244's accusatory behavior. The DNS stated that typically, a resident who makes an allegation of verbal or mental abuse would have their nursing assignment changed and the staff who were accused would be questioned. The DNS stated that the facility would not document an investigation of mental abuse allegations. The Administrator was interviewed on 3/8/2023 at 4:12 PM. The Administrator stated that it is expected that resident allegations of mental abuse should be investigated within 2 hours. The Administrator stated that the investigation should include staff interviews to determine if abuse has occurred. 10 NYCRR 415.4(b)(3) Based on record review, and interviews during the Recertification Survey and Abbreviated survey (NY00279474), initiated on 3/5/2023 and completed on 3/10/2023, the facility did not ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated. This was identified for one (Resident #244) of one resident reviewed for Abuse and one (Resident #43) of four residents reviewed for accidents. Specifically, 1) Resident #43 required the assistance of two persons for bed mobility. On 2/25/2023, Certified Nursing Assistant (CNA) #1 provided care to the resident in bed by themselves, resulting in the resident sliding out of bed. The incident investigation did not include statements from all staff who assisted the resident during the incident. 2) On 7/22/2020, Resident #244 alleged that staff members were talking about them (Resident #244) and making fun of them (Resident #244) which hurt their feelings. There was no documented evidence that an investigation was completed. The findings are: The facility's Abuse, Neglect, Mistreatment investigation and reporting policy and procedure dated 4/12/2022 documented that Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal abuse means the use of oral, written, or gestured communication that willfully includes disparaging and derogatory terms to residents within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes but is not limited to humiliation, harassment, threats of punishment, or deprivation. An immediate investigation is warranted when suspicion or reports of abuse occur. The written procedures for investigations include identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation. Focus the investigation on determining if abuse has occurred, its extent, and its cause. Provide complete and thorough documentation of the investigation. 1) Resident #43 was admitted to the facility with diagnoses of Metabolic Encephalopathy and Urinary Tract Infections. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 12 which indicated the resident had moderately impaired cognition. The resident required total assistance of two staff members for bed mobility, transfer, and toilet use. The MDS further documented the resident was always continent of bowel and bladder. The Comprehensive Care Plan (CCP) dated 1/17/2023 for Activities of Daily Living (ADL) documented the resident required total assistance of two staff members for bed mobility. The Physician's order dated 1/18/2023 documented to transfer the resident with a mechanical lift and the assistance of two staff members. The Certified Nursing Assistant instructions for February 2023 documented Resident #145 required total assistance of two staff members for bed mobility. The Accident/Fall investigation form dated 2/25/2023 at 11:45 PM documented that while CNA [#1] was changing the resident, the resident reached the edge of the bed and slid to the floor. No injury was noted, and the resident had no complaints. The Accident/Fall Investigation form (CNA statement) dated 2/25/2023, completed by CNA #1, documented CNA #1 was changing the resident when they (CNA #1) turned the resident and Resident #43 slid to the side of the bed. CNA #1 documented they (CNA #1) helped the resident and lowered the resident to the floor and then immediately informed the nurse. The summary of the investigation documented resident required transfer with the assistance of two staff members with a mechanical lift. On 2/25/2023 at around 11:45 PM, as the CNA [#1] was turning the resident in bed, the resident almost reached the edge of the bed upon turning and was about to fall. CNA responded right away and lowered the resident to the floor. The resident's body check was done, and no apparent injuries were noted. The investigation concluded there is not sufficient evidence of resident abuse, mistreatment, or neglect. The CCP for falls dated 2/27/2023 documented the resident had a fall on 2/25/2023. The interventions included but were not limited to placing the bed in the lowest position and placing the call bell within reach. CNA #1 was interviewed on 3/8/2023 at 11 AM and stated they started their shift on 2/25/2023 at 11 PM and made their rounds. Resident #145's bed was wet. At approximately 11:30 PM they (CNA #1) went back to change the resident and provide care to the resident. CNA #1 stated they were providing care to the resident by themselves and when they turned the resident in bed, the resident ended up at the edge of the bed and was about to slide out of the bed. CNA #1 stated they held the resident from the back by their (resident's) shirt, but the resident continued to slide. CNA #1 stated while they were lowering the resident, they (CNA #1) yelled for assistance. CNA #2 came to help and assisted CNA #1 to place the resident on the floor. CNA #1 stated the resident requires the assistance of only one person with turning from side to side in bed and they (CNA #1) always turn and position the resident by themselves. CNA #1 stated the resident does need the assistance of two staff members for transfers. CNA #2 was interviewed on 3/8/2023 at 11:30 AM and stated they (CNA #2) worked during the 11 PM-7 AM shift on 2/25/2023. CNA #2 stated they were in the hallway when they heard CNA #1 calling for help. CNA #2 stated they rushed into the room and saw Resident #43 in bed hanging at the edge of the bed with their (Resident #43) legs dangling off the bed and the rest of the body was leaning on CNA #1. CNA #2 stated they helped to lower the resident to the floor because there was no way the resident could have been put back to bed as the resident was a heavy person and most of the resident's weight was hanging out of bed. CNA #1 was holding on to the resident with their (CNA #1) body. CNA #2 stated that Resident #145 required two staff members for transfer and bed mobility because the resident was not able to control their (resident's) body weight. CNA #2 stated they were not sure if they wrote a statement regarding the incident with Resident 43. Risk Manager #1 was interviewed on 3/8/2023 at 11:45 AM and stated they completed the investigation related to Resident#43's incident dated 2/25/2023. Risk Manager #1 stated CNA #1 did not follow the plan of care and provided care to Resident #43 alone. The resident had to be lowered to the floor because CNA #1 did not utilize two staff members to turn and position the resident. Risk Manager #1 stated that CNA #2 provided assistance to CNA #1 after CNA #1 yelled out for help. Risk Manager #1 stated they did not obtain a statement from CNA #2, it was an oversight. Risk Manager #1 further stated that CNA #2's statement should have been part of the investigation. The Director of Nursing Services (DNS) was interviewed on 3/10/2023 at 11:55 PM and stated that it was an oversight that a written statement from CNA #2 was not obtained. DNS further stated that statements should be obtained from all staff members who were involved with the incident or accident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) The facility's undated policy titled, Use of Orthotics/Splints documented the purpose is to provide orthotics for those residents who demonstrate a decline or potential for decline in range of motion and to prevent or alleviate deformity and improve function when possible. Nursing will apply as per recommended wearing schedule. Resident #30 was admitted with diagnoses including Non-Alzheimer's Dementia, Cerebrovascular Accident, and Hypertension. The 1/18/2023 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented that the resident required total care for bed mobility and transfers and had functional limitation in range of motion to one upper extremity. The MDS documented that the resident required total dependence for eating. A physician's order dated 2/23/2023 documented to utilize a large kling roll in the left hand at all times, changing the roll daily and to perform a skin check every shift. A Comprehensive Care Plan (CCP) titled Contractures, effective 1/24/2020 and last updated 10/26/2022, documented an intervention to use a large kling roll in the left hand at all times, changing the roll daily and to perform skin checks every shift. Resident #30's Care Profile (instructions provided to the Certified Nursing Assistants (CNA) for resident care needs) documented the resident is at high risk for contractures and the resident is to use a large left hand kling roll at all times. Resident #30 was observed in bed on 3/5/2023 at 10:23 AM. The resident's left hand appeared contracted. There was no kling roll observed in the resident's left hand. Resident #30 was observed in bed on 3/7/2023 at 10:12 AM. There was no kling roll observed in the resident's left hand. Resident #30's assigned CNA (#6) was interviewed on 3/7/2023 at 10:13 AM and stated they (CNA #6) were not sure if the resident needed a hand roll. Registered Nurse (RN) #4, the unit supervisor, was interviewed on 3/7/2023 at 10:16 AM. RN #4 stated the CNA #6 probably took the hand roll out at breakfast because it gets messy. RN #4 stated the hand roll should have been replaced after it was taken away. The Director of the Rehabilitation (Rehab) Department was interviewed on 3/9/2023 at 12:30 PM and stated the left-hand roll should be in place as per the physician's order to prevent the contracture from getting worse. The Director of Nursing Services (DNS) was interviewed on 3/10/2023 at 8:42 AM and stated the hand roll should be in place because the physician's order indicates the left-hand roll is to be in place at all times except when changing the hand roll or performing skin checks. The DNS stated even if it is taken away during AM care, after the hand dries, the hand roll should be replaced. 10 NYCRR 415.11 (c)(1) Based on record review and interviews during the Recertification Survey initiated on 3/5/2023 and completed on 3/10/2023, the facility did not develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for two (Resident #43 and Resident #66) of four residents reviewed for Accidents and one (Resident #30) of one resident reviewed for Position and Mobility. Specifically, 1) Resident #43 required the assistance of two persons for bed mobility as per their Comprehensive Care Plan (CCP). On 2/25/2023, Certified Nursing Assistant (CNA) #1 did not follow the resident's CCP and provided care to the resident in bed by themselves resulting in the resident sliding out of bed. 2) Resident #66 was receiving Eliquis and Plavix (Anticoagulant medications) for diagnosis of Deep Vein Thrombosis (DVT). There was no CCP developed for the Anticoagulant medication use. 3) Resident #30 required the use of a left-hand roll as per the Physician's orders. During multiple observations Resident #30 was observed without the use the hand roll. The findings are: The facility's policy titled Activities of Daily Living (ADL) Care, dated 8/2016 and last reviewed in 10/2022, documented appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance. 1) Resident #43 was admitted to the facility with diagnoses of Metabolic Encephalopathy and Urinary Tract Infections. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 12 which indicated the resident had moderately impaired cognition. The resident required the total assistance of two staff members for bed mobility, transfer, and toilet use. The MDS further documented the resident was always continent of bowel and bladder. The Comprehensive Care Plan (CCP) dated 1/17/2023 for Activities of Daily Living (ADL) documented the resident required total assistance of two staff members for bed mobility. The Certified Nursing Assistants instructions for the month of February 2023 documented Resident #145 required total assistance of two staff members for bed mobility. The Accident/Fall investigation form dated 2/25/2023 at 11:45 PM documented while CNA [#1] was changing the resident, the resident reached the edge of the bed and slid to the floor. No injury was noted, and the resident had no complaints. The Accident/Fall Investigation form (CNA statement) dated 2/25/2023, completed by CNA #1, documented CNA #1 was changing the resident when they (CNA #1) turned the resident and Resident #43 slid to the side of the bed. CNA #1 documented they (CNA #1) helped the resident and lowered the resident to the floor and then immediately informed the nurse. The summary of the investigation dated 2/25/2023 documented that at around 11:45 PM, as the CNA [#1] was turning the resident in bed, the resident almost reached the edge of the bed upon turning and was about to fall. CNA responded right away and lowered the resident to the floor. The resident's body check was done, and no apparent injuries were noted. The investigation concluded there is not sufficient evidence of resident abuse, mistreatment, or neglect. The CCP for falls dated 2/27/2023 documented the resident had a fall on 2/25/2023. The interventions included but were not limited to placing the bed in the lowest position and placing the call bell within reach. CNA #1 was interviewed on 3/8/2023 at 11 AM and stated they started their shift on 2/25/2023 at 11 PM and made their rounds. Resident #145's bed was wet. At approximately 11:30 PM they (CNA #1) went back to change the resident and provide care to the resident. CNA #1 stated they were providing care to the resident by themselves and when they turned the resident in bed, the resident ended at the edge of the bed and was about to slide out of the bed. CNA #1 stated they held the resident from the back by their (resident's) shirt, but the resident continued to slide. CNA #1 stated while they were lowering the resident, they (CNA #1) yelled for assistance. CNA #2 came to help and assisted CNA #1 to place the resident on the floor. CNA #1 stated the resident requires the assistance of only one person with turning from side to side in bed and they (CNA #1) always turn and position the resident by themselves. CNA #1 stated the resident does need the assistance of two staff members for transfers. CNA #2 was interviewed on 3/8/2023 at 11:30 PM and stated they (CNA #2) worked during the 11 PM-7 AM shift on 2/25/2023. CNA #2 stated they were in the hallway when they heard CNA #1 calling for help. CNA #2 stated they rushed into the room and saw Resident #43 in bed hanging at the edge of the bed with their (Resident #43) legs dangling off the bed and the rest of the body was leaning on CNA #1. CNA #2 stated they helped to lower the resident to the floor because there was no way the resident could have been put back to bed as the resident was a heavy person and most of the resident's weight was hanging out of bed. CNA #1 was holding on to the resident with their (CNA #1) body. CNA #2 stated that Resident #145 required two staff members for transfer and bed mobility because the resident was not able to control their (resident's) body weight. Risk Manager #1 was interviewed on 3/8/2023 at 11:45 AM and stated CNA #1 did not follow the plan of care and provided care to Resident #43 alone. The resident had to be lowered to the floor because CNA #1 did not utilize two staff members to turn and position the resident. The Director of Nursing Services (DNS) was interviewed on 3/10/2023 at 11:55 PM and stated that CNA #1 should have waited for another staff member to turn Resident #43 in bed instead of turning the resident by themselves. The DNS stated they expected the staff to follow the resident's plan of care. 2) Resident #66 was admitted with diagnoses that include Peripheral Vascular Disease (PVD), Hypertension, and Cerebrovascular Accident. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 11 which indicated the resident had moderately impaired cognition. The MDS documented the resident received Anticoagulant medications four times in the last seven days of the look back period. The current Physician's orders for Resident #66 documented to administer Eliquis 5 milligram (mg) one tablet by mouth every 12 hours and Clopidogrel Bisulfate Oral Tablet (Plavix) 75 mg by mouth daily for DVT status post stent placement. A review of Resident #66's CCP was conducted on 3/8/2023 with the Director of Nursing Services (DNS) present. There was no CCP developed for the Anticoagulant medication use to monitor the resident for signs and symptoms of bleeding. Registered Nurse (RN) #1, the Nurse Manager, was interviewed on 3/8/2023 at 3:45 PM and stated they were responsible for formulating CCPs for the residents. RN #1 stated that Resident #66 was receiving Anticoagulant medications and there was no CCP developed for the Anticoagulant use to monitor the resident for any signs and symptoms of bleeding, RN #1 stated that there should be a CCP developed, they (RN #1) did not know why they (RN #1) did not complete a CCP for the Anticoagulant usage and will do so today. The Director of Nursing Services (DNS) was interviewed on 3/8/2023 at 4:00 PM and stated there should have been a care plan developed for the use of the Anticoagulant medication use for Resident #66 to monitor the resident for any signs and symptoms of bleeding.

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 3/5/2023 and completed on 3/10/2023 the facility did not ensure the resident environment remained as free of accident hazards as is possible. Specifically, on 3/5/2023 at 8:30 AM when the survey team entered facility through the front entrance, the front door was unlocked and there was no receptionist on duty. Visitors were observed entering the building and proceeding past the automatic sliding glass doors directly on to the nursing unit without checking in or being monitored. The finding is: The facility's policy titled Receptionist/Lobby last reviewed 7/2022 documented the facility utilizes receptionist/security to monitor the lobby area and provide safety to its residents and staff. During off-duty hours, front sliding doors at the entrance will be locked and opened by the nurse supervisor as necessary. The nurse supervisor will monitor the lobby area by sitting near the lobby or monitor the lobby via camera. During situations when the supervisor cannot properly monitor, responsibilities will be passed over to a nurse/aide on duty. On 3/5/2023 at 8:30 AM, when the survey team entered building through the front entrance, the front door was unlocked and there was no receptionist on duty. The reception area in the lobby was dark. There was no staff member at the South unit nursing station, which was visible from the lobby. The sliding glass doors that lead from the lobby to the South unit were observed automatically opening. On 3/5/2023 (Sunday) at 8:35 AM a staff member questioned the survey team by asking who we were and what we needed. The staff member stated they (staff member) would get the nursing supervisor. The nursing supervisor arrived at the lobby after approximately 15-20 minutes. A visitor was observed by the survey team entering the building and walking past the automatic sliding glass door and onto the nursing unit. This visitor did not sign in and was not questioned by any staff upon entering the unit. The receptionist was interviewed on 3/8/2023 at 8:00 AM and stated they work 8 AM-5 PM and then another receptionist comes in for the 5 PM-11 PM shift. The receptionist stated sometimes they work Saturday but was not sure who worked on Sunday. The receptionist stated after 11 PM the front door is locked and there is a bell outside for any visitors or staff arriving after 11 PM. The receptionist stated the nursing supervisor is responsible to answer the bell. The receptionist stated there is a Wanderguard system in place so that residents who wear a Wanderguard cannot leave the building without an alarm sounding. The receptionist stated they (Receptionist) were not sure when the front doors are unlocked in the morning. The receptionist stated when they (Receptionist) arrive in the morning, the front door is already unlocked. The Recreation Director was interviewed on 3/8/2023 at 9:54 AM and stated they were responsible for the receptionist schedules. The Recreation Director stated the schedule for the receptionist on Saturday and Sundays is 9 AM-4 PM and then 4 PM-11 PM. The Recreation Director stated they believe the 11 PM-7 AM nursing supervisor unlocks the front door in the morning. The Recreation Director had no explanation as to what is expected when the front door is unlocked, and the receptionist has not come on duty yet. The Director of Nursing Services (DNS) was interviewed on 3/8/2023 at 10:54 AM and stated the overnight 11 PM-7 AM nursing supervisor unlocks the front door at 7 AM. The DNS stated between 7 AM and 8 AM or 9 AM on the weekends, the nursing supervisor will always be stationed at the South nursing station to monitor the front door. The DNS stated staff and visitors know they must use the kiosk to sign in. The DNS could not explain what happens if the nursing supervisor is called to an emergency. The Overnight Registered Nurse (RN) Supervisor (RN #2), who worked 11 PM-7 AM shift from 3/4/2023-3/5/2023, was interviewed on 3/8/2023 at 12:19 PM. RN #2 stated they (RN #2) unlocked the front door at 7 AM and there was no receptionist on duty yet. RN #2 stated they think the receptionist comes in at 8 AM or 9 AM. RN #2 stated the nursing supervisor is supposed to monitor the front door or the staff at the South nursing station are supposed to monitor the front door. RN #3, the RN Supervisor on 3/5/2023 on the 7 AM-3 PM shift, was interviewed on 3/8/2023 at 1:16 PM. RN #3 stated there is no receptionist until 9 AM on Sunday and the front door is unlocked at 7 AM for the incoming shift. RN #3 stated the nurse on the South unit is available most of the time and that the nurse on the South unit can see who comes in and out. RN #3 stated there is a camera in the nursing office to monitor who comes into the facility. RN #3 stated I am not in the office all the time, so it depends on the nurse on the South unit to monitor the front entrance. The Administrator was interviewed on 3/9/2023 at 1:03 PM and stated the front entrance area is highly trafficked and people at the nursing station are expected to monitor the area. The facility does have cameras and monitors; however, they (Administrator) will look into getting coverage for the reception desk and to cover the gap in coverage from when the front doors are unlocked and when the receptionist comes on duty. The Administrator acknowledged there may not always be staff monitoring a surveillance camera or present at the South nursing station. 10 NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification survey initiated on 3/5/2023 and completed on 3/10/2023, the facility did not ensure that all residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. This was identified for one (Resident #38) of two residents reviewed for Nutrition. Specifically, Resident #38 had a significant weight loss which was not reported to the Dietician and Physician in a timely manner. The finding is: The facility's undated policy for Significant Weight Changes documented that any resident who loses 5% of their weight in 30 days involuntarily, will be evaluated for causes of the loss and interventions will be implemented to promote gain, if indicated. As soon as possible after a weight loss is confirmed, the Dietician will investigate the causes of the loss. All recommendations are made to the Physician, who will determine which interventions need to be ordered. The facility's Weight Change policy dated May 2012 documented that all residents who are new admissions or re-admissions will have their weight monitored weekly for four weeks (one month period) then monthly when deemed stable. Any weight change whether a gain or loss of three pounds in one week or five pounds in one month warrants the resident to be re-weighed on the same day. The weight change is then confirmed with the Dietician if it is a planned or unplanned weight change. The parameters for determining significant weight changes are 5% weight gain or loss in 30 days. Once the weight change is confirmed, the Dietician is notified by the Unit Coordinator of the weight change. The weight changes are reflected in the 24-hour report to alert the interdisciplinary team. If there is an unplanned significant weight loss, the resident will continue to be on the 24-hour report if a calorie count is instituted. Weekly weight monitoring will be commended and scheduled until the interdisciplinary team decides that weekly weight is no longer indicated. The Dietician and Attending physician are responsible for documentation of assessment and plan for weight. Resident #38 was admitted with diagnoses of Malignant Neoplasm of Pancreas, Acute Kidney Failure, and Sepsis. The admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #38 had a Brief Interview for Mental Status (BIMS) Score of 13, indicating intact cognition. The admission MDS documented that Resident #38's weight was 160 pounds and the resident had a loss of 5% or more in the last month. The MDS indicated that Resident #38 was not on physician prescribed weight loss regimen. Review of the electronic medical record system revealed the Resident #38 had a recorded weight of 160.1 pounds on 1/26/2023 and 153.4 pounds on 2/7/2023. Resident #38's recorded weight on 2/20/2023 was 145.8 pounds, indicating a 8.93% loss since their admission. Review of the weight logs maintained at the North Unit nurses station revealed: -For the week of February 5-February 11 2023 the resident weighed 145.4 pounds and the re-weight was recorded as 153.4 pounds -For the week of February 12-February 25 2023 there was no weights obtained for the resident. -For the week of February 26-March 42023 the resident weighed 151.8 pounds which indicated a 5.18% weight loss in last 30 days. Review of the facility 24-hour report notes dated 2/20/2023 revealed no documented reporting of Resident #38's weight loss. Review of nursing progress notes from 2/20/2023 to 3/9/2023 revealed no documented evidence that the Dietician or Physician were notified of Resident #38's weight loss. Review of Dietary Notes for February 2023 revealed no documented evidence that the Dietician addressed the weight changes noted in the electronic medical record or the weight logs. The Physician's progress note dated 3/5/2023 revealed no documented evidence that the Physician addressed the resident's weight changes. The Dietary Note dated 3/9/23 documented that Resident #38's meal intakes have been good. On 2/20/2023 Resident #38's weight was obtained at 145.8 pounds with no re-weigh to confirm this significant weight loss. This week, Resident #38's weight is back up a bit to 150 pounds. Overall weight is down from 160.1 on admission to 150 pounds. Resident #38 does remain within ideal body weight, but this weight loss is undesirable. Steroids were discontinued which can account for some weight loss. The Dietician documented that the plan was to discontinue the 7 PM snacks at Resident #38's request and to change the timing of Ensure Plus supplement. Additionally, Resident #38 will receive weekly weights, calorie count observation, and consider obtaining prealbumin levels on next blood draw. Licensed Practical Nurse (LPN) #4, who documented Resident #38's weights on 2/20/23 in the electronic medical record, was interviewed on 3/9/2023 at 2:49 PM. LPN #4 reviewed the electronic medical record with the surveyor. LPN #4 stated that after reviewing the records, LPN #4 stated they (LPN #4) did not notify the Physician or the Dietician of Resident #38's weight loss in February when the resident weighed 145 pounds and should have. Registered Dietician (RD) #1 was interviewed on 3/9/2023 at 9:28 AM and stated that the Nursing staff documents the weights in a weights log worksheet and then transcribes the weights in the electronic medical record system. The nursing department is expected to verbally inform RD#1 of weight changes. RD #1 stated that they also generate a report from the electronic medical system at least monthly to identify any weight changes. RD#1 stated that they were just notified yesterday, 3/9/2023, of Resident #38's significant weight loss of approximately 9% from 1/26/2023 to 2/20/2023, which is not good. RD#1 stated that any changes of weight four pounds or more should immediately be verbally reported to the Dietician and Physician. Weight changes should also be presented during morning report. RD#1 stated that LPN #4 did not report the weight changes to RD#1 and a re-evaluation of Resident #38 was not initiated until yesterday, 3/9/2023. Physician #2, Resident #38's Primary Care Physician, was interviewed on 3/9/2023 at 11:12 AM. Physician #2 stated that they do not recall being notified of Resident #38's weight loss. Physician #2 stated that they (Physician #2) expect nursing staff to re-weigh the resident to determine if the weight change is accurate. If the re-weigh reveals a significant weight loss, the nursing staff are expected to notify the Physician and the Dietician immediately. Physician #2 stated that they need to be notified so that a medical work up can be initiated to determine the cause of the weight loss. The Director of Nursing Services (DNS) was interviewed on 3/9/2023 at 11:52 AM. The DNS stated that residents are weighed when they are admitted and weighed every week for 4 weeks. If there is a noted discrepancy with the previous weight, the resident has to be re-weighed to verify a change. The nurse is expected to notify the Dietician who investigates the reason for the weight loss. The nurse should also notify the Physician who would then address the weight loss. 10 NYCRR 415.12(i)(1)

Based on observation, record review and interviews during the Recertification Survey initiated on 3/5/2023 and completed on 3/10/2023, the facility did not ensure pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals were provided to meet the needs of each resident. This was identified during the Medication Storage and Labeling Task on one of one medication room observations. Specifically, the narcotic cabinet assigned to unit 1 South was observed unlocked and open, and two blister packs containing a total of 47 tablets of controlled substances were not properly stored in the narcotic cabinet. The finding is: The undated facility's policy titled Controlled Substance documented that all controlled drugs will be subject to special receipt, handling, storage, disposal, and record keeping. All controlled drugs shall be stored in a two door double locked cabinet with two separate keys designed for that purpose, separate from all other drugs. The access key to controlled drugs is not the same key giving access to other drugs. During an observation on 3/6/2023 at 1:35 PM with Licensed Practical Nurse (LPN) #1, the Narcotic cabinet located in the medication room and identified as 1 South Narcotic Cabinet was observed unlocked and opened. The narcotic cabinet was observed with two doors and both the doors had the locking mechanism installed; however, both the doors were not locked and were found open. There were two blister packs in the open narcotic cabinet containing 30 Xanax (antianxiety medication) tablets (10 milligrams (mg) each tablet); and 17 Ambien (sedative) tablets (10 mg each tablet). LPN #1 tried to lock the narcotic cabinet door and was observed having difficulty locking the cabinet doors. There was no staff member present in the medication room when the surveyor and LPN #1 entered the medication room at 1:35 PM. LPN #1 was interviewed immediately after the observation and stated that the narcotic cabinet door was broken since this morning. LPN #1 stated they were calling the maintenance staff and were waiting for the maintenance staff to come to the unit to take a look at the broken locks. LPN #1 stated that the narcotic medications that were found in the unlocked cabinet were left in the cabinet because those medications were not due to be administered during the morning medication pass. Registered Nurse (RN) #1, the Nurse Manager, was interviewed on 3/6/23 at 1:40 PM and stated that the narcotic medications should be secured behind double locks and it is not acceptable that the doors to the narcotic cabinets were not locked. RN #1 stated they (RN #1) were not aware that the locks on the narcotic cabinet doors for Unit 1 south were broken. The Director of Nursing Services (DNS) was interviewed on 3/6/2023 at 3:30 PM and stated that all narcotic medications should be stored in a double-locked cabinet according to the facility's policy. The DNS stated they (DNS) were not made aware that there was a problem with cabinet door locks before the observation was made. 10 NYCRR 415.18(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 3/5/2023 and completed on 3/10/2023, the facility did not ensure that medication irregularities reported by the Consultant Pharmacist were reviewed and acted upon by the Physician for one (Resident #2) of five residents reviewed for unnecessary medications. Specifically, on 1/5/2023 and 2/8/2023, the Consultant Pharmacist recommended changing Levothyroxine (Thyroid Hormone) administration times from 6 AM to 7 AM; on 1/5/2023 the Consultant Pharmacist recommended changing Omeprazole (medication used to treat too much acid in the stomach) to Famotidine (H2 blocker) 40 mg at nighttime; and on 2/8/2023 the Consultant Pharmacist again recommended switching Omeprazole administration from every day to every other day for two weeks and then to discontinue. The Primary Care Physician (PCP) agreed with the Consultant Pharmacist's recommendations; however, the physician's orders were not changed to reflect the recommended changes. The finding is: The facility's undated policy titled Drug Regimen Review- Monthly, documented the prescriber shall act upon the Drug Regimen Review findings/recommendations in a timely manner of 7-14 days or less. The prescriber shall document on the drug regimen review form whether they agree or disagree with the recommendations and provide a brief clinical rationale if no changes are to be made. Resident #2 was admitted with diagnoses that include Hypothyroidism, Gastroesophageal Reflux Disease (GERD), and Depression. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 5 which indicated the resident had severely impaired cognition. The Physician's orders dated 1/3/2023, documented Levothyroxine Sodium Oral Tablet 100 micrograms (Synthroid) one tablet by mouth every morning for Hypothyroidism. Alendronate Sodium Oral Tablet 70 mg (Fosamax- medication use to treat bone loss) one tablet by mouth one time a week at 6:00 AM on Sunday; Prilosec Over the Counter (OTC) delayed-release 20 mg (Omeprazole Magnesium) one tablet every day for GERD. The Medication Regimen Review (MRR) dated 1/5/2023 documented that the resident was admitted on Omeprazole OTC with a diagnosis of GERD. Please consider a switch to Famotidine 40 mg at night and monitor. The Pharmacist's second recommendation documented the resident was currently on Levothyroxine and Alendronate (Fosamax), both being administered at 6 AM, and to please consider specifying the order to administer Levothyroxine at 7 AM to prevent drug interaction and loss of Fosamax absorption. The MRR was signed by the attending physician on 1/7/2023 and indicated the Physician agreed with the recommendations. Review of the Physician's orders revealed no change was made for either recommendation the Physician agreed with on the MRR. The Treatment Administration Record (TAR) dated January and February 2023 documented the Physician ordered Synthroid and Fosamax medications were administered at 6 AM daily and Omeprazole Magnesium was administered daily at 9:00 AM. The MRR dated 2/8/2023 documented the resident is currently receiving Omeprazole with Bisphosphonate (a group of drugs used to treat bone problems called osteoporosis or osteopenia including Fosamax). Proton Pump Inhibitors (PPIs-Omeprazole) have the potential to decrease the anti-fracture efficacy of Bisphosphonate. Evaluate trial switch Omeprazole to 20 mg every other day for 2 weeks then discontinue if appropriate. The Pharmacist's second recommendation documented the resident was currently on Levothyroxine and Alendronate (Fosamax) both being administered at 6 AM. Please consider specifying the order to administer Levothyroxine at 7 AM to prevent drug interaction and loss of Fosamax absorption. The attending physician signed the MRR on 2/20/2023 and agreed with both recommendations. Review of the Physician's orders revealed no change was made for either recommendation the Physician agreed with on the MRR. The Physician's orders as of 1/31/2023 and 2/28/2023 documented Levothyroxine Sodium Oral Tablet 100 micrograms (Synthroid) one tablet by mouth every morning for Hypothyroidism. Alendronate Sodium Oral Tablet 70 mg (Fosamax) one tablet by mouth one time a week at 6:00 AM on Sunday. Prilosec OTC delayed release 20 mg (Omeprazole Magnesium) one tablet every day for GERD. The TAR dated February and March 2023 documented the physician ordered Synthroid and Fosamax medications were administered at 6 AM daily and Omeprazole Magnesium was administered daily at 9:00 AM. The Medical Director was interviewed on 3/8/2023 at 9 AM and stated that the MRR completed by the Consultant Pharmacist provided recommendations for changing administration times for the medication Fosamax and recommendations regarding the use of Omeprazole. The Medical Director stated that the recommendations were not implemented by the Primary Care Physician (PCP) even though the PCP agreed with those recommendations. The Medical Director stated the PCP should have written new orders based on the Consultant Pharmacist's recommendation to prevent drug interaction and loss of Fosamax absorption. The Medical Director reviewed the Consultant Pharmacist's recommendation from January 2023 and February 2023 and stated that the recommendation should have been implemented in January when first brought to the PCP's attention. The PCP was interviewed on 3/9/2023 at 1:30 PM and stated they (PCP) were aware of the recommendation made by the Consultant Pharmacist for Resident #2's MRR and had agreed with those recommendations. The PCP stated that normally when they (PCP) sign the MRR, nursing staff would put the orders in the Electronic Medical Record (EMR), and then the PCP would sign the newly changed orders. The PCP stated they do not recall why the physician's orders regarding the recommendations made by the Consultant Pharmacist were not implemented. The PCP stated that the recommendations should have been implemented. The Director of Nursing Services (DNS) was interviewed on 3/10/2023 at 11:58 AM and stated that the MRR with the Consultant Pharmacist's recommendations is distributed to the Physicians for review by the DNS or nursing supervisor. If any recommendation is agreed upon, the PCP would then write the orders based on the recommendations. The DNS stated the physician orders should have been changed for Resident #2 based on the MRR recommendations. 10 NYCRR 415.18(c)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 3/5/2023 and completed on 3/10/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the initial tour of the main kitchen on 3/05/2023. Specifically, a ground chicken sealed packet was observed thawing in a kitchen sink. The packet of chicken was submerged in hot water; the water was hot to the touch. The finding is: The facility's Policy titled, Department of Food and Nutritional Services- Preparation-F812, dated September 2022 documented all frozen foods will be thawed in a refrigerator that is 41 degrees Fahrenheit or below, and not at room temperature, using drip-proof containers. Quick thawing using a cold water bath that is 70 degrees Fahrenheit or below and running fast enough to agitate and float loose ice particles while continually draining is another method. During an initial tour of the main kitchen on 3/5/2023 at 8:50 AM, a cylinder shape sealed food packet was observed in a sink. The sign on the wall above the sink read Meat. The sink was filled with water that was hot to the touch. Cook #1 was interviewed immediately after the observation on 3/5/2023 at 8:52 AM and stated that the sealed bag submerged in the warm water contained minced chicken that will be used for the lunch menu today (3/5/2023). [NAME] #1 stated the bag felt a bit tight and they (Cook #1) wanted to make sure that the chicken in the packet was completely thawed. During an interview with the Food Service Director (FSD) on 3/5/2023 at 11:05 AM the FSD stated that the frozen food items should not be thawed in the hot water. The FSD stated that frozen food items should always be thawed in the refrigerator in a drip pan to prevent bacterial growth. On 3/5/2023 at 11:10 AM the FSD asked [NAME] #1 what lunch items were cooked with the chicken that was observed on 3/5/2023 at 8:50 AM being thawed in the sink. [NAME] #1 told the FSD that the chicken was used to prepare the puree and chopped diets for the lunch menu. The FSD instructed [NAME] #1 to throw out the cooked puree and chopped chicken meat and to prepare a new puree and the chopped chicken meal. Cook #1 was interviewed on 3/5/2023 at 1:11 PM and stated that the ground chicken in the packet was icy and that is why they (Cook #1) placed the chicken in the hot water as that chicken was to be used to prepare the lunch meal. [NAME] #1 stated that the chicken was placed in the hot water since 8:30 AM. [NAME] #1 stated normally they (Cook #1) put the frozen food in cold water to thaw to prevent bacterial growth. [NAME] #1 stated they (Cook #1) should not have thawed the chicken in the hot water and should not have cooked that same chicken for the lunch meal. Registered Dietician (RD) #1 was interviewed on 3/10/2023 at 10 AM and stated that [NAME] #1 used the wrong procedure to thaw the chicken and the food prepared by that chicken was thrown out. 10NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 3/5/2023 and completed on 3/10/2023, the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented. This was identified for one (Resident #82) of two residents reviewed for Pressure Ulcers. Specifically, Resident #82 was admitted to the facility on [DATE] with care profile instructions (instructions to the Certified Nursing Assistants regarding resident care needs) to turn and position the resident every two hours. The medical record did not include documented evidence that the resident was turned and positioned every two hours as indicated in the care profile instructions. The finding is: The facility's policy dated 2/2/2009, titled, admission of a Resident documented that the admission nurse is responsible for starting the nurse aide [assistant] accountability record. Resident #82 was admitted with diagnoses including Dementia, Malnutrition, and Stage II Pressure Ulcer. The 1/22/2023 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident could not complete the BIMS assessment and had severely impaired cognitive skills for daily decision making. The MDS documented that the resident had one Stage II Pressure Ulcer. Review of the CNA Accountability Record (CNAAR) for March 2023 revealed documentation by the CNAs of a Turning/Repositioning Program implemented every two hours as evidenced by the CNA initials. Review of the CNAAR for January and February 2023 did not include the CNA initials that indicated that the Turning/Repositioning Program was implemented. Registered Nurse (RN) #7, the wound care nurse, was interviewed on 3/9/2023 at 11:50 AM and stated the resident was admitted in January 2023 with a sacral Stage II pressure ulcer and required turning and positioning every two hours as per the resident care profile. RN #7 could not explain why the CNAs documented turning and positioning every two hours starting 3/1/2023 and why there was no documentation prior to 3/1/2023. RN #5, the Inservice Coordinator, was interviewed on 3/9/2023 at 2:36 PM. RN #5 stated the CNAs started documenting turning and positioning every 2 hours on 3/1/2023 when the resident was re-admitted from the hospital. RN #5 stated when the resident was initially admitted on [DATE] the care profile was created, and it included turning and positioning every 2 hours. RN #5 stated with the facility's electronic medical record (EMR) system, even though the turning and positioning appeared on the care profile, it did not flow automatically to the CNA accountability record where the CNAs are responsible to initial for the care they provided to the resident. RN #5 stated with the facility's EMR system, the turning and positioning has to be added manually by the admission nurse to the CNA accountability record. RN #5 stated when the resident was re-admitted from the hospital on 3/1/2023 the turning and positioning task was added manually by the admission nurse and that is why the turning and positioning task was being initialed for as completed as of 3/1/2023. RN #5 was re-interviewed on 3/10/2023 at 10:15 AM. RN #5 stated any RN can add the turning and positioning task manually to the CNAAR. RN #5 stated the care profile provides general instruction and any specific individualized care the CNAs are required to provide must be added manually to the CNAAR such as turning and positioning. RN #5 stated that by adding the intervention of turning and positioning manually to the CNAAR, this allows the CNAs to initial and provide evidence that the task was completed as required. The initial admission nurse may not complete everything that is required for the resident's admission. The facility policy requires that nurses are to review the new admission documentation, care plans, and physician's orders for the next three shifts so that nothing is missed, including completing the CNAAR information. RN #6, the admission Nurse for Resident #82's initial admission on [DATE], was interviewed on 3/10/2023 at 11:08 AM. RN #6 stated they (RN #6) might have been distracted and that is why the turning and positioning task was not added manually. RN #6 stated they (RN#6) know that the turning and positioning task has to be added to the CNAAR manually. RN #6 stated there are nurses who are supposed to follow up to ensure everything is in place. The Director of Nursing Services (DNS) was interviewed on 3/10/2023 at 11:50 AM and stated with the EMR that the facility is utilizing, turning and positioning is not automatically carried over to the CNAAR. The nurses have to manually add the specific interventions, such as turning and positioning, so the CNAs can validate by initialing the turning and positioning task every two hours. 10 NYCRR 415.22 (a)(1-4)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/5/2023 and completed on 3/10/2023, the facility did not ensure each resident's call device was accessible to the resident while in bed. Specifically, Resident #26 and Resident #30 were observed without their call bell device within their reach. The finding is: The facility's undated policy titled, Call Bells, documented call bells will be operable and accessible to all residents. Residents who are unable to utilize the standard call system will have the system modified to meet their needs. The call bell will be left within reach of the resident. 1) Resident #26 was admitted with diagnoses including Non-Alzheimer's Dementia, Chronic Obstructive Pulmonary Disease (COPD), and Difficulty in Walking. The 11/25/2022 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Resident #26 was observed in bed on 3/5/2023 at 10:05 AM. The call bell was not visible within the resident's reach. Resident #26 stated they did not know where their call bell was. Licensed Practical Nurse (LPN) #3 was immediately notified by the surveyor of the call bell not being accessible to Resident #26. LPN #3 found the call bell behind the resident's bed, out of the resident's reach. LPN #3 then placed the call bell within the resident's reach. Resident #26 was observed in bed on 3/7/2023 at 10:29 AM. The resident's call bell was observed hanging on the wall behind the resident's bed. The resident was unable to access the call bell. Resident #26 was re-observed in bed on 3/7/2023 at 10:32 AM. The call bell was on the bed accessible to the resident. The resident stated a member of the maintenance staff just came in and placed the call bell on the bed. The Registered Nurse (RN) #5, Inservice Coordinator, was interviewed on 3/9/2023 at 12:15 PM and stated the call bells should be functional and within reach of the resident, not behind the bed or behind the pillow. RN #5 stated we have clips that should be used to keep the call bell in place. Certified Nursing Assistant (CNA) #5 was interviewed on 3/9/2023 at 2:00 PM. CNA #5 stated Resident #26 is able to use the call bell. The CNA stated whenever a resident is in bed, the call bell should be available to the resident and clipped to the bed. The Director of Nursing Services (DNS) was interviewed on 3/10/2023 at 8:45 AM and stated the call bell must be accessible to residents when they are in bed and if they are sitting in the chair in their room or on the commode. 2) Resident #30 was admitted with diagnoses including Non-Alzheimer's Dementia, Cerebrovascular Accident, and Hypertension. The 1/18/2023 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented that the resident required total care for bed mobility and transfers and had functional limitation in range of motion to one upper extremity. Resident #30 was observed in bed on 3/5/2023 at 10:10 AM. The resident's call bell was not visible and within the resident's reach. Licensed Practical Nurse (LPN) #3 was immediately notified by the surveyor of the call bell not being accessible to Resident #30. LPN #3 found the call behind the resident's pillow and re-situated the call bell on the resident's left-hand side. Resident #30 was observed in bed on 3/7/2023 at 10:16 AM. The resident was observed with a contracture to the left hand. The call bell was observed situated on the left-hand side of the bed. RN #4 was notified and observed the call bell on the left side of the bed. RN #4 stated the call bell should not be placed on the resident's left side because the resident has a left-hand contracture. RN #4 then positioned the call bell in the resident's right hand. Resident #30 demonstrated they were able to use the call bell with their right hand. RN #4 stated the care plan, and the CNA accountability record will be revised to reflect the call bell should be placed in the resident's right hand. The Registered Nurse Inservice Coordinator (RN #5) was interviewed on 3/9/2023 at 12:15 PM and stated the call bells should be functional and within reach of the resident, not behind the bed or behind the pillow. RN #5 stated if the resident is not able to use a call bell because of a contracture, then common sense dictates that the call bell should be placed by the hand that is functional. CNA #4, who provides care to Resident #30, was interviewed on 3/9/2023 at 1:49 PM. CNA #4 stated Resident #30 cannot use the call bell. CNA #4 stated we check on the resident and have the resident in the day room to keep a close eye on the resident. RN #4 and RN #5 were interviewed concurrently on 3/9/2023 at 2:30 PM. They stated that the CNA accountability record was updated to include that the call bell should be positioned in the resident's right hand. The Director of Nursing Services (DNS) was interviewed on 3/10/2023 at 8:45 AM and stated call bells must be accessible to residents when they are in bed. The DNS stated when a resident has a hand contracture the call bell must be placed in an area where the resident can easily access the call bell. 10 NYCRR 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a Focused Infection Control Survey conducted on 12/8/2022 the facility failed to maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and COVID-19 infection. Specifically, Licensed Practical Nurse (LPN) #2 did not perform hand hygiene during a lunch meal observation in the main dining room while assisting Resident #1 with their meal. The finding is: The facility's Hand Washing policy updated 12/2019 documented the facility considers hand hygiene the primary means to prevent the spread of infection and provide a high quality of care to its residents. The policy documented to wash hands with soap (antimicrobial or non-antimicrobial) and water before and after assisting a resident with meals, and after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. The Administrator and Director of Nursing Services (DNS) were concurrently interviewed on 12/8/2022 at approximately 10:30 AM. They both stated there were seven COVID-19 positive residents in the facility and meals are served to these residents in their rooms. The Administrator stated residents without a COVID-19 diagnosis receive their meals in the main dining room and are required to wear a mask when out of their rooms to prevent the transmission and spread of COVID-19 infection. The Administrator further stated the residents are socially distanced when in the dining room and residents who are cognitively impaired are encouraged and reminded to wear their mask. Resident #1 has diagnoses that include Parkinson's Disease and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score was 7 which indicated the resident had severely impaired cognition. During a lunch meal observation conducted on 12/8/2022 at 12:15 PM Resident #1 was observed sitting in a wheelchair on the right side of the dining room with their back towards the wall. A Styrofoam cup with a straw, a folded mask, and a napkin were observed on an overbed table that was positioned in front of the resident. The resident was observed handling the mask multiple times by folding and unfolding the mask then placing the mask on the overbed table. LPN #2 was observed serving a lunch tray to Resident #1. LPN #2 was observed to move the cup, the napkin and Resident #1's mask with their (LPN #2) bare hands to make room for the lunch tray. LPN #2 then opened the lunch items on the resident's meal tray without washing their hands after making contact with Resident #1's cup, napkin, and the used mask. LPN #2 then went to another resident and touched the resident's arm without washing their (LPN #2) hands. A sink and wall-mounted hand sanitizers were available in the dining room. LPN #2 was interviewed on 12/8/2022 at 12:50 PM and stated they (LPN #2) received in-service on handwashing on 11/5/2022. LPN #2 stated that after moving the cup, napkin, and the used mask they (LPN #2) should have sanitized their hands. The Registered Nurse (RN) Infection Control Preventionist (ICP) was interviewed on 12/8/2022 at 12:59 PM. The ICP stated staff should sanitize their hands when they enter the dining room and that all staff received in-service education on hand washing on 11/5/2022 with ongoing reminders due to the recent COVID-19 outbreak. The ICP stated that LPN #2 should have performed hand hygiene after touching the napkin and mask and before opening the items on the resident's tray and also before interacting with another residents. The DNS was interviewed on 12/8/2022 at 2:54 PM. The DNS stated LPN #2 should have sanitized their hands before opening the items on the resident's lunch tray and before interacting with other residents. 10NYCRR 415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview during the recertification survey, the facility did not make a determination that there had been a Significant Change in the resident's physical and mental condition. Specifically, Resident # 26 had a decline in Mood, Behavior, Cognition, and Activities of Daily Living (ADL) with a significant weight loss. There was no documented evidence that the Interdisciplinary Care Team (IDCT) assessed the resident for a determination of a significant change in condition or initiated a Significant Change Assessment with revised goals and interventions to the Comprehensive Care Plan (CCP). The finding is: The Minimum Data Set (MDS)-CMS-RAI/Version 3.0 Manual-p. 2-16 documents policy for 483.20(b)(2)(ii) for a Significant Change Assessment must be completed within fourteen days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. Resident # 26 was admitted to the facility 8/16/19 with diagnoses including Chronic Obstructive Pulmonary Disease, Depression, and Anxiety. The Quarterly MDS assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating that the resident was moderately impaired. The resident's ADLs for Bed Mobility was 3/3 (extensive assist of two staff), Dressing was 3/2 (extensive assist of one staff), Toilet Use 3/2 (extensive assist of one staff member), and Personal Hygiene (PH) 3/2 (extensive assist of one staff member). The MDS documented that the resident was always Continent of bowel and bladder. A Dietary Progress Note (P/N) dated 2/5/2020 documented that the resident was noted with a significant weight loss. The Annual MDS assessment dated [DATE] documented that the resident had a decline in cognition with a BIMS of 3, indicating severely impaired cognition. Additional declines were documented in Bed Mobility, Transfer, and Toilet Use to 4/3 (totally dependant on two staff) and Dressing and Personal Hygiene declined to 4/2 (totally dependant on one staff). The resident was documented to be Always Incontinent of bowel and bladder, a significant decline from Always Continent. The CCP titled ADL dated 8/16/2019 was not updated to reflect the resident's decline in Bed Mobility, Transfer, Toilet Use or Personal Hygiene and did not identify the resident's significant change in condition or address the needs for new interventions. There was no CCP developed to identify the significant change in Bladder Function from Always Continent to Always Incontinent and, there were no new goals or interventions updated on the CCP. The CCP for Cognition dated 8/16/19 was updated on 5/22/2020 and documented the decline without addressing it as part of the general significant change in the resident's overall condition or the initiation of new goals or interventions. The resident was observed on 9/17/2020 at 11:25 AM in bed in his room. He was still in his hospital gown and interacting with the Certified Nursing Assistant who was caring for the roommate. The resident was not able to be interviewed. The MDS Coordinator/ Registered Nurse (RN) was interviewed on 9/22/2020 at 12:30 PM. The RN stated that the Annual MDS was a Comprehensive Assessment and it was the RN's understanding that it did not require a Significant Change Assessment. The RN also stated that all the care plans were reviewed by the interdisciplinary (IDCP) team during the CCP meeting. In a subsequent interview with the MDS/RN on 9/23/2020 at 1:00 PM, the RN stated that the identification of the significant change was the responsibility of the entire IDCP team. The information was brought forth either by the MDS/RN or another member of the team and then the decision would have been made to go forward with a significant change MDS assessment by the entire team. The RN stated that he should have completed a significant change MDS assessment instead of the Annual MDS assessment due to the decline in the resident's general condition. 483.20(b)(2)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey the facility did not ensure the resident environment remained as free of accident hazards as is possible. Specifically, the facility's main entrance door was not secured and/or supervised between 9:00 PM and 11:00 PM. On 8/30/20 Resident#16, who had moderately impaired cognition, called a taxi to leave the facility, exited the unit without staff knowledge and was found in the front lobby between the double sliding glass doors leading out of the building at 9:30 PM when a Licensed Practical Nurse who happened to be coming back from outside spotted the resident attempting to go out of the building. The finding is: The facility's undated policy, titled Residents Elopement from The Facility, documented that when the code alert alarms or when the exit door alarms, staff will check the outside door to make sure that no resident went through the exit door. Resident #16 was admitted to the facility on [DATE] with diagnoses including Cerebrovascular Accident, Heart Failure, and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS documented that the resident was able to move around the unit with limited assistance with a wheelchair. A Psychology Progress Note dated 8/28/20 documented that the resident had Adjustment Disorder with Depressed Mood with difficulty adjusting to a decline in autonomy and continued to harbor unrealistic expectations and viewpoints of his own capabilities and ability to live independently. A Registered Nurse (RN) Supervisor note dated 8/30/20 documented the RN Supervisor was notified by the Charge Nurse at 9:30 PM that the resident was trying to leave the facility and had already called a car service and was able to reach outside the building. In the Accident/Falls Investigative Form, dated 8/30/20, the RN Supervisor documented that the resident stated, I want to go home to my apartment. The Licensed Charge Nurse (LPN #2) documented that the resident was outside the facility sitting in his wheelchair and was trying to leave. The record review indicated Resident #16 was not assessed for elopement risk or unsafe wandering and a comprehensive care plan for elopement and or unsafe wandering with goals and interventions was not developed related to the incident on 8/30/20. The Assistant Director of Nursing Services (ADNS) was interviewed on 9/22/20 at 3:03 PM. She stated there should have been an elopement care plan created for Resident #16 after the incident on 8/30/20. The ADNS stated that she was not sure if an elopement risk assessment was completed. The ADNS stated that usually the social worker would complete the elopement risk assessment. The ADNS also stated that the facility policy on elopement would have to be updated to indicate that the facility's main entrance door is not equipped with an alarm. The Social Worker (SW) was interviewed on 9/22/20 at 11:29 AM and stated she was not responsible to initiate elopement care plans or conduct the elopement risk assessment. The SW stated that the nursing staff was responsible for developing care plans for elopement and conduct an elopement risk assessment. The RN Supervisor who worked the night of 8/30/20 was interviewed on 9/23/20 at 12:14 PM. She stated she did not see the resident go out the front entrance door. The RN supervisor stated that no one (staff) saw the resident leave the unit. The RN Supervisor stated that the facility does not have a receptionist at the main entrance door after 9:00 PM and the outside front entrance door is locked after 11 PM. LPN #2 was interviewed on 9/23/20 at 12:46 PM. She stated she was the Charge Nurse on 8/30/20. She stated Resident #16 was able to propel himself in his wheelchair. At aproximately 9:15-9:30 PM she had gone out to her car, and when returning, she found the resident alone between the front entrance double glass doors that lead to the street waiting for a car service that the resident had called. LPN #2 stated that the receptionist left at 9 PM and the doors leading to the street are locked after 11 PM. She stated she was not sure how the lobby area or the entrance doors were monitored or secured between 9 PM-11 PM. The Director of Nursing Services (DNS) was interviewed on 9/23/20 at 2:33 PM. She stated the 8/30/20 attempted elopement was spur of the moment and the resident was frustrated and realized he was not able to be independent. The DNS stated it was her understanding that the receptionist was at the lobby reception area until 10 PM. The DNS could not say how the entrance doors/lobby were monitored or secured between 10:00 PM to 11:00 PM. The DNS stated that the front entrance should be monitored and secured for resident and staff safety. The Administrator was interviewed on 9/23/20 at 3:18 PM. He stated the facility does not admit residents who have a high risk for elopement. He stated he thought the facility had extended the time of the receptionist. The administrator stated that between 9:00 PM and 11:00 PM the RN Supervisor roams the building and is around after the receptionist leaves. 415.12(h)(1)