**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification and abbreviated survey (Case # NY00316460), the facility did not ensure each resident was free from misappropriation of resident property and exploitation for 1 (Resident #78) of 3 residents reviewed. Specifically, former Activities Director # 1 used Resident #78 ' s checkbook to write checks that were deposited into their personal account and a partner ' s account amounting to over $11,000. This is evidenced by: Resident #78 was admitted with the diagnoses of end stage renal disease, non-traumatic intracranial hemorrhage, and dementia. The Minimum Data Set (an assessment tool) dated 2/22/2023, documented the resident could be understood, usually understand others, and had moderate cognitive impairment. The facility's Abuse Prevention and Investigation Policy effective 8/2020 documented the facility was committed to providing residents an environment that was free from verbal, mental, and physical abuse, mistreatment, neglect, misappropriation of resident property, and Exploitation through the following Seven Components of a Systematic Approach to Abuse Prohibition. Misappropriation of property was defined in the policy as: The use of deliberate means to exploit, misplace, or the wrongful use of a resident ' s belongings or money—whether permanently or temporarily, without the resident ' s consent. The undated facility document titled Job Description, Activity/Recreation Director, documented one of the essential job functions was to assist residents in handling personal funds. The facility's investigative report dated 5/12/2023 documented the Administrator #1 was notified by Plattsburgh Police Department that the facility Activities Director #1 had been cashing personal checks from Resident #78 and depositing them into their account and an account of their partner. The transactions dated back to 2020, with the most recent being February 2023. The amount taken totaled over $11,000. On 5/15/2023 Activities Director #1 was arrested and charged with grand larceny and check fraud and their employment was terminated. The police Incident Report dated 5/15/2023 documented that a request for a welfare check was received from the North [NAME] Credit Union on 5/02/2023 due to suspicious activity and depletion of Resident #78 ' s bank account. A Police Case Supplemental Narrative Report dated 5/16/2023 documented that Activities Director #1 was interviewed at the Police Department on 5/15/2023. They admitted to filling out, signing checks, and keeping some of the money. Activities Director #1 was arrested on charges of forgery and grand larceny. During an interview on 10/24/2024 at 11:15 AM, Administrator #1 stated there had been no incidents of financial exploitation since this case. All residents that had a personal checkbook or credit card were encouraged to keep it in their locked drawer, which is offered to all residents on admission. Administrator #1 further stated that such items could be kept in the Administrator ' s office for safekeeping. When a resident requests for staff to make a withdrawal or purchase, it is done by Administrator #1 with a witness. The facility had no indication of any issues with the accused staff until they were notified by the Police Department, at which time Activity Director #1 was immediately suspended and then terminated. Administrator #1 further stated they were not informed of the final disposition of the legal matter; however, the resident was reimbursed for the money taken. Past Non-compliance -F602 Based on the following corrective action taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: - Facility staff cooperated with the local Police Department to facilitate their investigation and arrest of the perpetrator. - The alleged perpetrator was not permitted entrance to the facility to protect the residents from further misappropriation. - The incident was reported appropriately to the State Survey Agency. - A thorough investigation was completed, and it was determined there were no other victims of misappropriation. - The facility policy titled, Personal Funds-Resident, was updated to include securing personal checkbooks, bank cards, and cash in a locked drawer or in the Administrators office. - Education was provided on 5/26/2024 to all facility staff on abuse, abuse reporting, misappropriation of property, exploitation, and updated facility policy and procedures on resident funds At the time of survey, there were no additional incidents of misappropriated personal property identified. 10 New York Codes, Rules, and Regulations: 415.4(b)

Based on record review and interviews during a recertification and abbreviated survey (Case #NY00347220), the facility did not ensure each resident had an environment that was as free of accident hazards as was possible to prevent accidents for 1 (Resident #20) of 4 residents reviewed for accident hazards. Specifically, when Resident #20 was holding a lit sparkler, the tip fell on their thigh and resulted in a burn. This is evidenced by: Resident #20 was admitted to the facility with diagnoses of dementia, edema, and asthma. The Minimum Data Set (an assessment tool) dated 09/25/2024 documented they could be understood, usually understand others, and was cognitively intact. The Policy and Procedure titled, Accident/Incident- Investigation and Reporting, dated 12/2023 documented guidelines for the completion, investigation, care plan intervention, and timely regulatory reporting of all accidents and incidents with appropriate follow up and monitoring post-incident occurrences. A Progress Note dated 07/04/2024 documented Resident #20 attended an outside festivity for the holiday and received a burn from the sparkler they were holding. Review of the facility incident report dated 07/04/2024, documented Resident #20 was participating in a July 4th holiday activity outside and was holding a sparkler. It documents Activity Director #1 standing right next to the resident. As soon as the sparkler tip fell onto Resident #20 ' s lap, Activity Director #1 contacted the nurse, who then assessed and treated Resident #20. The nurse notified the family, provider, and Director of Nursing #1. Resident #20 was noted to be psychosocially okay following the incident. During an interview on 10/22/2024 at 09:50 AM, Activity Director #1 stated that they offered each resident that could hold a sparkler to hold one and stood by each resident as they handed them a lit sparkler to hold and watch. They further stated that since children were holding sparklers, they thought it okay for residents to, as well. When Activity Director #1 was with Resident #20, the ashes fell on the resident ' s polyester pajama pants and burned a hole in them. This startled both Activity Director #1 and Resident #20, and Activity Director #1 retrieved the nurse. On the scene, the nurse assessed Resident #20 and removed pants, applied cold compress, applied bacitracin, and covered with a non-stick gauze pad During an interview on 10/22/2024 at 10:04 AM, Director of Nursing #1 stated the incident timeline was as Activity Director #1 stated, Resident #20 was outside during a facility activity when asked if they wanted to hold a sparkler and while holding it the tip fell off into their lap. Director of Nursing #1 stated that Resident #20 received. Director of Nursing #1 went through the treatment and healing of the area, reddened and then open on Resident #20 ' s right thigh. Director of Nursing #1 stated they would no longer provide sparklers to residents for them to hold in their hands, as it was a hazard and ' best to avoid. ' At the time of survey, there were no additional incidents of accidents due to sparklers identified. 10 New York Codes, Rules, and Regulations: 415.12(h)(2)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure foods brought to residents by family and other visitors was in accordance with adopted regulations. Specifically, expired food brought to residents was not discarded. This is evidenced by: During observations on 10/21/2024 at 1:05 PM, entrees (rice and rice with tofu) labeled as belonging to Resident #13 were dated 10/07/2024. The document posted on the nourishment kitchen refrigerators titled, Resident Food Only, and dated 03/13/2023 stated that food greater than 3-days old was to be discarded. During an interview on 10/20/2024 at 1:06 PM, Licensed Practical Nurse #1 stated that dietary staff was responsible for discarding food brought in for residents that were more than 3-days old. During an interview on 10/20/2024 at 4:40 PM, Family Member #1 stated that they labeled and dated the food brought to their relative (their personal preference), that the food dated 10/07/2024 was correct, and that they relied on the facility to discard old food. During an interview on 10/21/2024 at 11:49 AM, Administrator #1 stated that either dietary aides or nursing staff were to ensure resident food that was more than 3-days old were to be discarded, and the policy on food brought to residents would be updated to include which staff are responsible for discarding old food. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on interviews and record review during a recertification survey, the facility did not ensure a Registered Nurse was scheduled for at least 8 consecutive hours a day, 7 days a week. Specifically, there was no registered nurse working for 8 consecutive hours on 6/06/2024, 6/23/2024, 7/14/2024, and 9/28/2024. This is evidenced by: Record review of the written working schedules for 6/06/2024, 6/23/2024, 7/14/2024, and 9/28/2024 revealed no registered nurse was scheduled to be in the building that day. The census was 80 at the time of the survey. Record review revealed the facility submitted a letter to the Department on 10/02/2024 with a request to waive this Federal regulatory requirement. The letter read in part: - 'Request for waiver from 8-hour Registered Nurse requirement under 42 Code of Federal Regulations Section 483.35(b). I am writing to formally request a waiver from the 8-hour Registered Nuse requirement, as stipulated under 42 Code of Federal Regulations Section 483.35(b). There is an Registered Nurse on the night shift, however, it does not constitute 8 hours concurrently as the schedule is 10 PM to 6 AM, which splits the hours. Despite our extensive efforts to recruit qualitied nursing personnel, we have been unable to secure the necessary staff to meet [the requirement]. Our recruitment initiatives have included sign on bonuses, as the need arises opportunities with flexibility, outreach to nursing schools, collaboration with nursing agencies.' - 'We have a registered nurse and a practitioner available to respond to phone calls from the facility during periods when the registered nurse is not in the building. This arrangement guarantees that any urgent medical needs can be promptly addressed.' During an interview on 10/23/2024 at 1:35 PM, Director of Nursing #1 stated when they are on call, they live ten minutes away and would physically come into the building to deal with issues such as falls and resident change in condition. During an interview on 10/24/2024 at 11:32 AM, Administrator #1 stated the facility had 'aggressively' advertised for registered nurses, including online postings, physical job fairs, and roadside advertising. They stated there was an on-call schedule for currently employed registered nurses including the Director of Nursing, the Assistant Director of Nursing, and unit managers for registered nurse coverage, but there were several days that the facility was unable to meet the regulation. They stated the building was always covered with an offsite, on call registered nurse that could come in for emergencies but not for a whole shift. At the time of the interview, surveyor requested facility documentation that would support the waiver request. 10 New York Codes, Rules, and Regulations 415.13 42 Code of Federal Regulations Section 483.35(b)

Based on observation and interview during the recertification survey, the facility did not store, prepare, distribute, or serve food in accordance with professional standards for food service safety. Specifically, equipment in the main kitchen and 1 of 2 unit kitchenettes were not clean, equipment was not in good repair, and a test kit for checking the concentration of chemical sanitizing solution was not provided. This is evidenced by: All observations were conducted on 10/20/2024 between 12:11 PM and 1:10 PM. The following equipment was soiled with food particles or a dusty oily buildup: • Microwave oven. • Can opener and holder. • Utensil drawers. • Shelving. • Fire extinguishers. • Floor behind the floor fan in dishwashing machine room. • B-wing nourishment station refrigerator door gasket. The thermometer for the sanitizing rinse on the automatic dishwashing machine was not functioning. The label of the chemical concentrate used to manually sanitize food equipment stated that the efficacy range of the sanitizer was to be between 200 parts per million and 400 parts per million; the facility could not provide a test kit with a graduation above 400 parts per million to show a solution that was too concentrated. During an interview on 10/21/2024 at 12:09 PM, Food Service Director #1 stated that they would contact the maintenance department to repair the dishwashing machine thermometer, contact the vendor for the correct test papers, and clean the areas found. 10 New York Codes, Rules, and Regulations 415.14(h) Chapter 1 State Sanitary Code Subpart 14-1

Based on record reviews and interviews during the recertification survey, the facility did not ensure the residents and resident representatives were notified in writing of the reason for the transfer/discharge to the hospital in a language they understood for 2 (Resident #'s 57 and 60) of 3 residents reviewed for hospitalizations. Specifically, for Resident #'s 57 and 60, the facility did not ensure the residents or residents representatives were notified in writing of the reason for the transfer/discharge to the hospital in a language they understood. This is evidenced by: The facility Policy and Procedure titled Transfer/Discharge Notice dated 2/2019, documented the purpose of the policy was to ensure residents and their representatives were notified of impending transfers and discharges and must include the following in the transfer/discharge notice in a language and format that the resident can understand: the reason for transfer/discharge, the effective date of the transfer/discharge, the location of the transfer/discharge, a statement of the resident's appeal rights with all pertinent contact information and the contact information for the local Office of the State Long-Term Care Ombudsman. Resident #57: Resident #57 was admitted to the facility with the diagnosis of major depression, anxiety, and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS-an assessment tool) dated 8/9/2021, documented the resident was cognitively intact, could understand others and could make self understood. A nursing progress note dated 7/25/2021 at 4:23 PM, documented the resident was extremely diaphoretic (perspiration or sweating) and would be transferred to the emergency room for evaluation. A nursing progress note dated 7/25/2021 at 5:41 PM, documented the emergency room nurse informed the facility the resident was admitted to the hospital due to not being alert and somewhat unresponsive. A record review, did not reveal documentation that the resident and the resident representative were provided with a written transfer/discharge notification upon the resident's transfer to the hospital. Resident #60: Resident #60 was admitted to the facility with diagnoses of severe sepsis (the body's extreme response to an infection), diabetes, and hematuria (blood or blood cells in the urine). The Minimum Data Set (MDS-an assessment tool) dated 8/13/2021, documented the resident had severely impaired cognition, could understand others and could make self understood. A nursing progress note dated 7/14/2021 at 9:39 AM, documented the resident was very lethargic and the resident was sent to the emergency room. A nursing progress note dated 7/24/2021 at 4:26 AM, documented the resident was very difficult to arouse and speech was extremely elongated with each response. The resident was sent to the hospital. A nursing note date dated 9/2/2021 at 3:25 PM, documented the resident was sent to the emergency room due to being lethargic, clammy, and not responding verbally. A record review did not reveal documentation that the resident and the resident representative were provided with written transfer/discharge notifications upon the resident's transfers to the hospital. Interview: During an interview on 9/23/2021 at 12:02 PM, the Administrator stated the Administrator had assumed the responsibility for providing the transfer/discharge notices upon a resident's transfer to the hospital due to the position being vacant. The Administrator stated the Administrator did not provide the transfer/discharge notices to the residents and the resident representatives. The Administrator stated the Administrator verbally communicated with the families and the hospital discharge planners and the Ombudsman's received a daily census so they were aware of the transfers/discharges. 10NYCRR 415.39(H)(1)(III)(a-c)

Based on interviews and record reviews during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the residents and the resident representatives for 2 (Resident #'s 57 and #60) of 3 residents reviewed for hospitalization. Specifically, for Resident #'s 57 and #60, the facility did not ensure there was documented evidence the residents and the resident representatives received written notice of the facility's bed hold policy when the residents were transferred to the hospital. This was evidenced by: The facility Policy and Procedure titled Policy Regarding Bed Reservations for Temporary Absences not dated, documented a copy of the bed hold notice would be sent with the resident at the time of hospitalization or leave of absence and it would be sent to the responsible party within 1 business day. Resident #57: Resident #57 was admitted to the facility with the diagnosis of major depression, anxiety, and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS-an assessment tool) dated 8/9/2021, documented the resident was cognitively intact, could understand others and could make self understood. A nursing progress note dated 7/25/2021 at 4:23 PM, documented the resident was extremely diaphoretic (perspiration or sweating) and would be transferred to the emergency room for evaluation. A nursing progress note dated 7/25/2021 at 5:41 PM, documented the emergency room nurse informed the facility that the resident was admitted to the hospital because the resident was not alert and was somewhat unresponsive. Review of the resident's record did not include documentation that the resident and the resident representative received a written notice of the facility's bed hold policy when the resident was transferred to the hospital. Resident #60: Resident #60 was admitted to the facility with diagnoses of severe sepsis (the body's extreme response to an infection), diabetes, and hematuria (blood or blood cells in the urine). The Minimum Data Set (MDS-an assessment tool) dated 8/13/2021, documented the resident had severely impaired cognition, could understand others and could make self understood. A nursing progress note dated 7/14/2021 at 9:39 AM, documented the resident was very lethargic and was sent to the emergency room. A nursing progress note dated 7/24/2021 at 4:26 AM, documented the resident was very difficult to arouse and speech was extremely elongated with each response. The resident was sent to the hospital. A nursing note date dated 9/2/2021 at 3:25 PM, documented the resident was sent to the emergency room due to being lethargic, clammy, and not responding verbally. Review of the resident's record did not include documentation that the resident and the resident received a written notice of the facility's bed hold policy when the resident was transferred to the hospital. Interview: During an interview on 9/23/2021 at 12:02 PM, the Administrator stated the Administrator had assumed responsibility for providing the bed hold policy to residents and resident representatives upon transfer to the hospital due to the position being vacant at this time. The Administrator stated the Administrator had not provided the bed hold policy in writing to the residents and the resident representatives upon their transfers to the hospital. The Administrator stated the Administrator verbally communicated with the families and the hospital discharge planners. 10NYCRR 415.3(h)(4)(i)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey and an abbreviated survey (Case #NY00277698), the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 (Resident #'s 21 and 322) of 4 residents reviewed for ADL's. Specifically, for Resident #21, who was dependant on staff for ADL Care, the facility did not ensure incontinence care was provided in accordance with the resident's care plan on 9/21/2021, did not ensure the resident's hair was brushed daily and did not ensure the resident's fingernails were cleaned and trimmed, and for Resident #322, the facility did not ensure the resident received assistance with shaving. This is evidenced by: The Policy and Procedure (P&P) titled Activities of Daily Living (ADLs), not dated, documented residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The P&P documented appropriate care and services would be provided for residents who were 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 for: Hygiene (bathing, dressing, grooming, and oral care) and Elimination (toileting). Resident #21: Resident #21 was admitted to the facility with the diagnoses of dementia with behavioral disturbance, hypertension, and atrial fibrillation. The Minimum Data Set (MDS - an assessment tool) dated 6/25/2021, documented the resident had moderately impaired cognition, could usually understand others and could usually make self understood. Finding #1: The facility did not ensure incontinence care was provided in accordance with the resident's care plan on 9/21/2021. The Comprehensive Care Plan (CCP) for Activities of Daily Living dated 12/17/2020, documented Toilet use: the resident required an extensive assist by 1 staff for check and change every 2 hours or as needed. The CCP for Potential for Pressure Ulcer Development dated 9/10/2021, documented the resident was frequently incontinent of bowel and bladder and had a history of moisture-associated skin damage (MASD) to the sacrum. The interventions included to follow facility policies/protocols for the prevention/treatment of skin breakdown. The CCP for Bladder and Bowel Incontinence dated 9/16/2021, documented the resident was incontinent and to check the resident 2 times a shift and as required for incontinence. Change clothing PRN (as needed) after incontinence episodes. During observations on 9/21/2021 at: -9:35 AM: Resident #21 was dressed and sitting in the wheelchair next to the bed in the resident's room. -10:52 AM: A staff member went into Resident #21's room and brought the resident to the visitation room to visit with a visitor. The resident was not changed prior to the visit. -11:00 AM: Resident #21 was observed visiting with a visitor in the visitation room. -11:17 AM: The visit with the visitor ended. Resident #21 was brought back to the bedroom. -11:24 AM: The staff member who brought the resident back to the bedroom put the call light on and left the room. The Administrator entered the room. -11:25 AM: The Administrator left the room, and a CNA and nurse entered the resident's room. The call was turned off. -11:26 AM: The resident's bedroom door was open; the resident did not receive incontinence care by the nurse or CNA. The nurse and CNA left the room within 1 minute of entering. -12:35 PM: A Certified Nursing Assistant (CNA) entered the resident's room and brought the resident in the wheelchair to the dining room for lunch. The resident did not receive incontinence care prior to lunch. -1:27 PM: A CNA brought the resident out of the dining room to the resident's room and a nurse gave the resident medication in the doorway of the resident's room. -1:29 PM: The CNA brought the resident back to the dining room for lunch. -1:51 PM: Resident #21 remained in the dining room. -2:01 PM: Resident #21 was brought back to the resident's room after lunch. The staff member left room and the resident was not provided with incontinence care. The resident remained in the wheelchair. -2:03 PM: The evening shift started coming onto the unit for change of shift at 2:00 PM. Resident #21 was in the resident's room in the wheelchair. -2:10 PM: The observation concluded. The resident was not provided with incontinence care from 9:35 AM to 2:10 PM. The Certified Nurse Assistant (CNA) Accountability for ADL care documented the resident received urinary incontinence care on 9/21/2021 at 8:36 AM, 6:24 PM, and 11:11 PM. A progress note dated 8/10/2021 documented the resident had new superficial MASD area to sacrum. The note documented the resident was turned and positioned while in bed and should be checked frequently for soiled Depends (incontinence briefs). A review of progress notes from 9/1/2021-9/21/2021 did not include documentation the resident declined incontinence care. During a confidential interview on 9/19/2021 at 9:02 AM, the interviewee stated Resident #21 required more frequent changes due to incontinence. The interviewee stated the Director of Nursing (DON) was aware Resident #21 needed to be changed more often, but nothing was ever done about it. The interviewee stated the resident had a red area on the resident's buttock because the resident would go to the bathroom in the resident's pants and did not get changed timely. During an interview on 9/22/2021 at 9:33 AM, Certified Nursing Assistant (CNA) #1 stated for residents who were incontinent, incontinence care was provided every hour if the CNAs were able to, but the facility policy was to provide incontinence care every 2 hours. CNA #1 stated for the residents who could not ring their call bell or ask to go to the bathroom, the CNAs were constantly changing them throughout the shift, so it worked out to be every 2 hours. During an interview on 9/22/2021 at 9:59 AM, CNA #2 stated Resident #21 did not refuse care. CNA #2 stated Resident #21 was a heavy wetter and was incontinent. CNA #2 stated Resident #21 would wet through the resident's clothes if the resident was not changed. CNA #2 stated CNA #2 would change Resident #21 after breakfast so the resident did not leak through the resident's clothing and then would check the resident again before lunch and would change the resident if needed. CNA #2 stated the residents were supposed to be changed every 2-4 hours for incontinence care. During an interview on 9/23/2021 at 8:42 AM, CNA #3 stated Resident #21 received incontinence care once in the morning and before or after lunch so that the resident received incontinence care twice during the shift. CNA #3 stated the CNA was assigned to Resident #21 on 9/21/2021 and stated CNA #3 did not provide incontinence care twice in the shift to Resident #21. The CNA stated the resident was asked if the resident wanted to lay down, but the resident did not want to lay down, so the resident was not changed twice during the day shift. CNA #3 stated Resident #21 could not consistently tell the staff when the resident needed to be changed so the staff would check the resident's pants to see if the resident wet through. CNA #3 stated Resident #21 was always wet though and the staff usually had time to change the resident two times a shift if they changed the resident with morning care and then again before lunch. CNA #3 stated lunch ran into the evening shift so the staff on day shift did not have time to change residents after lunch. During an interview on 9/23/2021 at 9:18 AM, Register Nurse (RN) #2 stated Resident #21 should be changed at least every 2 hours. RN #2 reviewed Resident #21's care plan for Bladder and Bowel Incontinence and stated RN #2 saw where the care plan documented the resident was to be changed 2 times. RN #2 stated the interdisplinary team reviewed the CCPs together and that was where the discrepancy between the ADL and Bladder and Bowel Incontinence care plans should have been picked up. RN #2 stated incontinence care should be every 2 hour and that was the standard for incontinence care. RN #2 stated the nurse on the medication (med) cart directly oversaw the CNAs. RN #2 was often on a med cart and stated the RN thought a nurse would notice if the resident had not been received cared for a length of time. RN #2 stated the RN frequently told staff and encouraged the staff to go check on Resident #21 because the resident urinated often. RN #2 stated all the nurses oversaw the CNAs and the care they provided. During an interview on 9/23/2021 at 10:28 AM, the Director of Nursing (DON) stated the facility policy was to check and change resident every 2 to 4 hours and as needed for incontinence care. The DON stated Resident #21 was checked and changed every 2 to 4 hours and had not heard that the resident had not been being changed. The DON stated none of the unit managers or nurses had come to the DON with concerns that residents were not being changed as they should be according to facility policy. Finding #2: The facility did not ensure Resident #21, who was dependent for ADL care, received daily hair brushing and routine nail care. The P&P titled Maintaining Skin Integrity dated 9/2018, documented residents shall be provided good skin care according to individual need. This included: Keep resident nails clean and trim to prevent self-injury, and infection; Keep skin dry and free of urine and feces; and Keep residents' hair clean and combed. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) dated 12/17/2020, documented personal hygiene: the resident required limited assist by 1 staff with personal hygiene. During an observation on: -9/19/2021 at 12:30 PM, the resident was in the wheelchair and the resident's hair was sticking straight up in the front. The resident's fingernails were long and had a black substance that appeared to be thick hardened dirt underneath them. -9/21/2021 at 9:35 AM, the resident was dressed and out of bed in the wheelchair and the resident's hair was sticking straight up in the front. The resident's fingers were long and had a black substance that appeared to be thick hardened dirt underneath them. At 10:52 AM, a staff member brought the resident to the visitation room to visit with a family member and the resident's hair was still sticking up. At 11:00 AM, the resident's visitor was observed brushing the resident's hair. The resident's hair was no longer sticking up after being brushed. -9/22/2021 at 8:25 AM, the resident was out of bed eating breakfast with the resident's hands. The resident's fingernails were long and had a black substance that appeared to be thick hardened dirt underneath them. The substance under the resident's nails was not fresh food from the resident's breakfast. A review of progress notes from 9/1/2021-9/21/2021 did not include documentation the resident declined to have the resident's hair brushed or fingernails cleaned. During a confidential interview on 9/19/2021 at 9:02 AM, the interviewee stated Resident #21's fingernails were disgusting and the resident ate with the resident's hands. The interviewee stated Resident #21's hair was never brushed or combed. The interviewee stated the resident had always been a very neat and clean individual, and the resident wore the resident's hair short and combed, not sticking up. The resident would not have wanted the resident's hair to look like it did when it stuck up and was not combed. During an interview on 9/22/2021 at 9:33 AM, Certified Nursing Assistant (CNA) #1 stated every resident received a shower once a week and as part of the shower the resident had nail care done. CNA #1 stated if the CNAs could not get to the nail care, Activities would also do the residents' nails. CNA #1 stated CNAs were supposed to clean, cut, and file the residents' fingernails with their weekly shower. CNA #1 stated part of morning care was to brush the residents' hair. During an interview on 9/22/2021 at 9:59 AM, CNA #2 stated every resident received a shower once a week but the residents were washed up every morning. CNA #2 stated Activities cleaned and trimmed the residents' nails unless the residents specifically asked the CNAs to do it. CNA #2 stated the CNAs did not typically do fingernails and stated nails were not done with showers. CNA #2 stated CNAs were supposed to brush the residents' hair every morning. During an interview on 9/23/2021 at 9:18 AM, Registered Nurse (RN) #2 stated RN #2 had noticed a couple residents with dirty nails and with hair not brushed. RN #2 stated hair brushing was provided daily, and nails were done at least weekly and as needed. Staff should document if a resident refused and should let a nurse know. RN #2 stated all the nursing staff oversaw that the residents were receiving the care they should be. During an interview on 9/23/2021 at 10:28 AM, the Director of Nursing (DON) stated fingernails were cleaned and trimmed on the resident shower day, once weekly and hair brushing was done daily and as a needed. The DON stated CNA oversight was done by the medication nurses to make sure resident care was provided, and then the chain of command was followed. The med (medication) nurse would go to the nurse manager, then to the Assistant DON, or DON. The DON stated none of the Unit Managers or nurses had come to the DON with concerns that ADL care was not being done. Resident #322: The resident was admitted on with the diagnoses of malnutrition, major depressive disorder and peripheral vascular disease. The MDS (Minimum Data Sett-an assessment tool) dated 9/1/21 documented the resident was without cognitive impairment, understood and understands. It documented the resident required extensive assistance for personal hygiene and total assistance for bathing. The Visual/Bedside [NAME] Report dated 9/22/2021 for Resident #322 documented the resident required set up for grooming and hygiene with one staff assistance and for bathing the resident required extensive assistance with two staff members assistance. It did not include documentation for shaving the resident. The documentation survey report dated September 21, documented personal hygiene included combing hair, brushing teeth, shaving, and washing and drying face and hands. It documented the resident received limited to extensive assistance by one staff member with personal hygiene two to three times daily from 9/1/2021 through 9/22/2021. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) dated 8/25/2021, documented for grooming/hygiene, the resident required set up for grooming and hygiene by one staff and for bathing the resident required extensive assistance by two staff. During observations on 9/19/2021 at 12:40 PM, 9/21/2021 at 9:05 AM, 9/21/2021 at 3:42 PM, 9/22/2021 at 11:08 AM and 9/23/2021 at 10:43 AM, the resident was unshaven with facial hair on cheeks, chin, upper neck, and upper lip. A review of progress notes from 9/1/2021-9/21/2021 did not include documentation the resident declined to be assisted with shaving. During an interview on 9/19/2021 at 12:45 PM, Resident #322 reported they preferred to be shaved daily. Resident #322 stated they would attempt to shave themselves if the staff would give them a razor. Resident #322 stated prior to the illness, they consistently were clean shaven. During an interview on 9/22/2021 at 11:08 AM, Certified Nurse Assistant (CNA) #5 stated residents were shaved weekly during their shower. CNA #5 stated Resident #322 was not shaved with their shower today or last week and stated the resident did not like to be in the shower for longer than absolutely necessary as the resident complained of being cold with a shower. CNA #5 stated Resident #322 did not refuse to be shaved, and she didn't know what the facility process was when a resident did not get shaved in the shower. During an interview on 9/23/21 at 10:43 AM, Registered Nurse Unit Manager (RNUM) #3 stated when residents received their weekly shower, they would have their hair washed, their nails filed and cleaned, and the resident would be shaven. RNUM #3 stated they were aware residents were not consistently provided assistance with a shower, shaving and nail care. RNUM #3 stated the resident should receive the level assistance with shaving they were care planned for, and if a resident was not shaved during a shower, they would be shaved in their room as requested and tolerated. During an interview on 9/23/21 at 11:36 AM, the DON stated residents should be shaved as part of their personal hygiene. The DON stated the unit manager should ensure staff provided all residents personal hygiene assistance including shaving as the resident allowed. The DON stated the CCP should be updated when a resident with resident specific information regarding shaving and personal hygiene. 10NYCRR415.12(a)(3)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure acceptable parameters of nutrition were maintained for 1 (Resident #32) of 2 residents reviewed for nutrition. Specifically, for Resident #32, the facility did not ensure the resident's weight was documented and monitored in accordance with professional standards of practice and meal intakes were adequately documented and monitored. Additionally, the facility did not ensure a nutritional supplement was provided in accordance with professional standards. This is evidenced by: Resident #32: Resident #32 was admitted to the facility with the diagnoses of cerebral infarction, vascular dementia, and protein-calorie malnutrition. The Minimum Data Set (MDS - an assessment tool) dated 7/27/2021 documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The Comprehensive Care Plan (CCP) for Nutritional Maintenance Problem dated 8/5/2021, documented the resident had severe protein and calorie malnutrition. Interventions included: Provide supplements as ordered: Med Pass 2.0 (a fortified nutritional shake) 120 cubic centimeter (cc) 3 times a day (TID) with the resident's medication pass (added to the CCP on 8/10/2021); and Provide and serve diet as ordered. Monitor intake and record every meal. The CCP did not document the frequency of weights for the resident. Finding 1: The facility did not ensure the resident's weight was documented and monitored in accordance with professional standards of practice. The Policy and Procedure (P&P) titled Weights dated 9/2018, documented each resident's weight would be carefully monitored on a regular basis (monthly or weekly) so that appropriate timely interventions may be initiated. Interventions would be initiated as needed to track unplanned significant weight variances of 5% weight loss/gain in 30 days, 7.5% weight loss/gain in 90 days, or 10% weight loss/gain in 180 days. Each resident was to be weighed upon admission weekly x 4 weeks and monthly thereafter unless otherwise specified. The Dietitian/Designee must notify the nurse managers to verify any weight variance of 5 pounds or more by reweight. A review of physician orders and CCP did not include documentation for the frequency of weights. Resident #32's weights were as documented: -7/28/2021- 110.5 lbs. - admission weight -8/04/2021- 114.0 lbs. -8/11/2021- 108.6 lbs. (weight variance of 5.4 pounds; a re-weight was not obtained per facility policy) -8/18/2021- Blank (weekly weight was not obtained per facility policy) -9/01/2021- 109.8 lbs. -9/08/2021 -105.0 lbs. (-7.9% weight loss over 30 days) A Weight Change Note dated 8/11/2021, written by the Food Services Director, documented Resident #32's weight was 108.6 and was a 4.7% loss in a week. The note documented the current weight was more in line with the resident's admission weight and the resident remained on weekly weights. A review of progress notes from 8/1/2021 to 9/20/2021 did not include documentation the resident refused to be re-weighed following the weight obtained on 8/11/2021 and did not include documentation the resident refused to be weighed on 8/18/2021. During an interview on 9/22/2021 at 9:33 AM, Certified Nursing Assistant (CNA) #1 stated every week the CNAs received a list of weights to do for residents who either needed a weekly weight or monthly weight. CNA #1 stated the CNAs knew which residents needed to be weighed because the Unit Manager assigned the weights to them. The CNAs were responsible for obtaining the weights that were assigned to them. During an interview on 9/22/2021 at 9:59 AM, CNA #2 stated some residents were weighed monthly and some were weighed weekly. CNA #2 stated the CNAs were provided with a list every Monday of residents who needed to be weighed. The CNAs were responsible for obtaining the weights but did not document the weights in the computer. The CNAs documented the weights they obtained on paper and the Food Services Director (FSD) would input the weights into the computer. During an interview on 9/23/2021 at 9:29 AM, Registered Nurse (RN) #2 stated the staff on the unit obtained the resident's monthly weights and weekly weights. The weights were assigned to the CNAs. The process was that the CNAs would obtain the residents' weights, write the weights on paper, and then dietary would put the weights into the computer. RN #2 stated the frequency of weights should be on the care plan because RN #2 stated RN #2 did not know how often Resident #32 was weighed. RN #2 stated the FSD gave a list to the unit of which residents needed to be weighed and the staff went by that list. RN #2 stated the FSD would also give the unit a list of who needed to be re-weighed, but stated the FSD had been out of work for a few weeks. During an interview on 9/23/2021 at 10:00 AM, the Administrator stated Administrator assumed responsibilities of the FSD position while the FSD was on leave. The Administrator stated the Registered Dietitian (RD) consulted with the facility's FSD and did not work full time at the facility. The Administrator stated Resident #32 was on weekly weights, but that the resident refused at times to be weighed. The Administrator reviewed the FSD's weight book and stated the resident was not on weekly weights. The Administrator stated residents were weighed weekly for 4 weeks upon admission, and then monthly after that. The Administrator stated there should have be a reweight obtained after the 5-pound difference on 8/11/2021. The Administrator reviewed the weight book for 8/18/2021 and stated there was not a weight documented for Resident #32. For 8/18/2021, there was not documentation that the resident was or was not weighed or that the resident had refused to be weighed. The Administrator stated the physician should also write a note when a resident had weight loss. The Administrator stated the FSD monitored the residents' weights and the FSD and RD communicated regularly. The Administrator did not know the RD's role regarding the consultations provided to the FSD. On 9/23/2021 at 10:30 AM, Food Services Director (FSD) #4 and Dietitian #8 were not available for interview. Finding 2: The facility did not ensure meal intakes were adequately documented and monitored. The facility Policy and Procedure (P&P) titled Nutrition and Hydration Policy dated 2/2019, documented it was the policy of the facility to monitor those residents who were identified as at risk for dehydration and malnutrition. The P&P documented Nursing/Designee monitored CNA documentation for fluid and food consumption and alerts. Certified Nursing Assistant (CNA) for Nutrition- Meal Intake from 9/15/2021 to 9/21/2021 documented the resident ate: - 26%-100% of breakfast 2 out of 7 days (5 out of 7 days there was no documentation of the percentage of the meal the resident ate). - 26%-100% lunch 3 out of 7 days. (4 out of 7 days there was no documentation of the percentage of the meal the resident ate). - 26%-100% dinner 5 out of 7 days. (2 out of 7 days there was no documentation of the percentage of the meal the resident ate). A Weight Change Note dated 8/11/2021, written by the Food Services Director, documented the resident's weight was 108.6 and was a 4.7% loss in a week. The resident's intake varied with meals from 25% to 100%. A review of progress notes from 9/15/2021 to 9/21/2021, did not include documentation the resident refused to eat a meal. During an interview on 9/22/2021 at 9:33 AM, Certified Nursing Assistant (CNA) #1 stated it was the CNAs' responsibility to document meal intake for the residents. CNA #1 stated the CNAs documented how much the residents ate and drank at each meal. CNA #1 stated the CNAs were to document the percentage eaten at each meal. During an interview on 9/22/2021 at 9:59 AM, CNA #2 stated it was the CNAs' responsibility to document what a resident ate and the CNAs also documented if a resident refused and reported it to the nurse. During an interview on 9/23/2021 at 9:29 AM, RN #2 stated the CNAs were responsible for documenting the percentage eaten by a resident at meals and the CNAs have an option to document if they provided a snack to the resident. RN #2 stated CNA documentation as whole was an issue, not just with meal intake. During an interview on 9/23/2021 at 10:00 AM, the Administrator stated the Administrative staff had identified CNA documentation as an issue. The Administrator stated the CNAs were responsible for meal documentation. The Administrator stated the Assistant Director of Nursing was monitoring CNA documentation, including meal intake documentation. Finding 3: The facility did not ensure a nutritional supplement was provided in accordance with professional standards. The Policy and Procedure (P&P) titled Oral Nutritional Supplements dated 11/1/2017, documented to provide oral supplements to residents who were deemed to be at increased nutritional risk despite provision of adequate nutrients as provided by the physician ordered diet and/or meal modifications made by the clinical nutrition staff. The RD/Designee would identify residents who would potentially benefit from a change in plan of care, including addition or changes in food or beverage, fortified foods or nutritional supplements. The RD/Designee would determine any monitoring criteria and implement as indicated. The RD/Designee would evaluate the effectiveness of changes to the plan of care, including nutritional supplements, with each subsequent nutritional assessment as part of the complete plan of care, at a minimum quarterly. A review of physician orders and the Medication Administration Record (MAR) did not include an order for the nutritional shake, Med Pass 2.0 120cc TID with med pass. A Weight Change Note dated 8/11/2021, written by the Food Services Director, documented the resident's weight was 108.6 and was a 4.7% loss in a week. The note documented Med Pass 2.0 120cc TID added last week per dietician recommendation. A Weight Change Note dated 8/29/2021, written by the Dietitian, documented to follow the resident's acceptance to interventions and success halting further weight loss. During an interview on 9/22/2021 at 9:23 AM, Licensed Practical Nurse (LPN) #1 stated there would be an order for the Med Pass 2.0 in the computer of the resident was to receive it and then the nurses passing medications would sign off on it on the MAR. LPN #1 stated the Dietitian would recommend the supplement, the physician would order it, and then the nurses would administer it and sign on the MAR whether the resident accepted it or not. LPN #1 stated the Dietitian monitored if the residents were accepting the Med Pass 2.0 by looking at the documentation on the MAR. The nurses would also let the Unit Manager know if the resident was not accepting it and the unit manager would communicate with the Dietitian. During an interview on 9/22/21 09:54 AM, Registered Nurse (RN) #1 stated Resident #32 was not one of the residents who received Med Pass 2.0. RN #1 stated the recommendation for Med Pass 2.0 would come from the Dietitian and then a physician order would be entered into the computer. RN #1 stated RN #1 would know to administer the resident Med Pass 2.0 because it would show up on the resident's MAR as a physician order. RN #1 stated the nurse administering the supplement would document how much of the supplement the resident drank and document it on the MAR. During an interview on 9/23/2021 at 9:29 AM, RN #2 stated dietary monitored nutritional supplements. The process was that a dietary slip would be filled out with the recommendation for the supplement, dietary would tell the RN, and the RN would obtain an order from the physician for the Med Pass 2.0. RN #2 reviewed Resident #32's record and stated something must have been missed with the turnover in staff since there was not a physician order for the supplement. During an interview on 9/23/2021 at 10:00 AM, the Administrator stated the Administrator assumed the responsibilities of the FSD position while the FSD was on leave. The Administrator stated the facility did monitor nutritional supplements but, in this case, the recommendation for the Med Pass 2.0 did not get to the physician orders. The Administrator stated the Dietitian would make the recommendation, the nurse would put the order in and then the med nurses would provide and document the supplement on the MAR. The Administrator stated it was the responsibility of the FSD to monitor the nutritional supplements that the residents received. The Administrator did not know the process used to monitor or track the acceptance of nutritional supplements. On 9/23/2021 at 10:30 AM, Food Services Director (FSD) #4 and Dietitian #8 were not available for interview. 10NYCRR415.12(i)(1)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that its medication error rates were not 5 percent or greater. Specifically, for 25 medication administration opportunities there were 19 errors resulting in a medication error rate of 76%. This is evidenced by: The facility Policy and Procedure titled Administration of Medication-General dated 10/2017, documented Administration of medications will occur utilizing the following eight rights: 1. Right Time; a. assist with administration of medications at the indicated time or within sixty (60) minutes before or sixty (60) minutes after the indicated time. b. Ensure that medications labeled to be taken with food are given at mealtime or with a snack. c. Complete a medication error report if medication is not taken within sixty (60) minute timeframe, 2. Right Resident, 3. Right Medication, 4. Right Dose of Medication, 5. Right Route, 6. Right Documentation, 7. Right Reason, and 8. Right Response. Resident #27: Resident #27 was admitted to the facility with diagnosis of chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), and depression. The Minimum Data Set (MDS- an assessment tool) dated 7/5/2021, documented the resident was cognitively impaired, had clear speech, understands, and was understood by others. During an observation on 9/22/2021 at 9:38 AM, Registered Nurse (RN) #1 administered morning medications that were scheduled on the Medication Administration Record (MAR) for 7:30 AM to Resident #27. The medications administered were: gabapentin 300 milligrams (mg) by mouth three times a day for pain, Daliresp 500 micrograms (mcg) by mouth daily for COPD, metoprolol 25 mg by mouth daily for atrial fibrillation, prednisone 4 mg by mouth daily for COPD, amoxicillin 500 mg by mouth daily for cellulitis (9/8/21- 10/11/21), montelukast 10 mg by mouth daily for COPD, omeprazole 20 mg by mouth daily for gastroesophageal reflux disorder (GERD), potassium chloride (KCL) 20 milliequivalents (MEQ) by mouth daily for replacement therapy, Aspirin 81 mg by mouth daily for atrial fibrillation, Pradaxa 150 mg by mouth two times a day for history of deep vein thrombosis (DVT), Zoloft 25 mg by mouth daily for depression, torsemide 40 mg by mouth daily for edema (8/18/21- 9/22/21), Symbicort Aerosol 160/4.5 MCG/ACT inhalation aerosol 2 puffs inhale orally two times a day for COPD, and Spiriva 18 mcg capsule inhale 1 capsule orally daily for COPD. During an interview on 9/22/2021 at 9:52 AM, Registered Nurse (RN) #1 stated the staff do their best to administer the morning medications within the 2-hour timeframe, but sometimes things happen with our residents that need immediate attention, and the nurse is pulled away from the medication cart. RN #1 stated the charge nurse and supervisors are aware that medications are sometimes administered late, this was being monitored and reeducation would be provided when a specific nurse was consistently running late. Resident #42: Resident #42 was admitted to the facility with diagnosis of congestive heart failure (CHF), Multiple Sclerosis (MS), and depression. The Minimum Data Set (MDS- an assessment tool) dated 8/4/2021 documented the resident was cognitively intact, had clear speech, understands, and was understood by others. During an observation on 9/23/2021 at 9:37 AM, Licensed Practical Nurse (LPN) #2 administered morning medication that were scheduled on the Medication Administration Record (MAR) for 7:30 AM to Resident # 42. The medications administered were: Bisacodyl 5 mg by mouth daily for constipation, Cholecalciferol (Vitamin D3) 1000-unit tablets; 2 tablets by mouth daily for supplement, Eliquis 5 mg by mouth two times a day for atrial fibrillation, Citalopram 10 mg by mouth daily for depression, and Diltiazem extended release (ER) capsule 360 mg by mouth daily for hypertension (HTN). During an interview on 9/23/2021 at 9:37 AM, LPN #2 stated this was LPN #2's fourth shift working in this facility and had not developed a routine yet. LPN #2 stated the standard of practice is medications are supposed to be administered within 1 hour of the scheduled time. During an interview on 9/23/2021 at 10:01 AM, Registered Nurse Unit Manager (RNUM) #2 stated staff have not reported that medications were administered late. RNUM #2 stated staff are expected to ask for help when falling behind and administering medications late. RNUM #2 also a medication error report should be completed when medications are administered later than 1 hour of scheduled time. During an interview on 9/23/2021 at 10:26 AM, RN #5 stated staff are expected to notify the supervisor and the physician when medications are administered late, this should be documentation in the resident's record and a medication error report should be completed. RN #5 also this concern was identified on both units and approximately 2 weeks ago medication administration audits were initiated. During an interview on 9/23/2021 at 12:07 PM, the Director of Nursing (DON) stated medications should be administered 1 hour before to 1 hour after the scheduled time. The DON stated that since the waivers have expired in May 2021 observations have been made of medications being administered late, medication audits with staff reeducation have already been started and will continue. 10NYCRR 415.12(m)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during a Recertification survey, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 8 (Resident #'s 12, 16, 32, 70, 74, 272, 322, and 323) of 13 residents reviewed for baseline care plans. Specifically, for Resident #'s 16, 32, 74, and #272, the facility did not ensure a baseline care plan was developed or completed within 48 hours of the resident's admission and for Resident #'s 12, 70, 322 and #323, the facility did not ensure written summaries of the baseline care plans were provided to the resident and/or the resident's representative. This is evidenced by: The facility Policy and Procedure titled Base Line Care Plan Policy dated 10/2017, documented that a baseline care plan must be developed and implemented for each resident/resident representative according to regulatory grouping §483.21 as an update to the most recent CMS Manual and Procedure titled Base Line Care Plan Policy dated 10/2017. It documented that the purpose was to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. The Procedure documented that Within 48 hours of a resident's admission, the facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Resident #272: Resident #272 was admitted to the facility with the diagnoses of encephalopathy, dementia with behavioral disturbance, and osteoarthritis. The admission Minimum Data Set (MDS- an assessment tool) was not due to be completed as the resident was admitted to the facility within the last 14 days. Review of the resident's medical record revealed a baseline care plan was initiated on 9/14/2021 and had not been completed. The baseline care plan did not include the minimum healthcare information necessary to properly care for a resident including, all Physician orders, Dietary orders, Therapy services, Social services, and PASARR recommendation, if applicable. During an interview on 9/23/2021 at 9:29 AM, Registered Nurse (RN) #2 stated each discipline had a section of the baseline care plan that was supposed to completed within 48 hours of a resident's admission. RN #2 stated the baseline care plan for Resident #272 was initiated but had not been completed. There were sections of the baseline care plan that were incomplete. RN #2 stated after the baseline care plan was completed, it was supposed to be printed out and reviewed with the resident if the resident was able and/or the resident representative. Resident #12: Resident #12 was admitted with the diagnoses of heart failure, diabetes, major depressive disorder, and anxiety. The MDS dated [DATE], documented the resident was without cognitive impairment, was understood and could understand. During a review of the resident's medical record, the 48-hour baseline care plan dated 6/14/21, did not include a documented signature or date the baseline care plan was reviewed, and a copy given to the resident or resident representative. Resident #322: Resident #322 was admitted with the diagnoses of malnutrition, major depressive disorder, and peripheral vascular disease. The Minimum Data Set (MDS- an assessment tool) dated 9/1/2021 documented the resident was without cognitive impairment, was understood and could understand others. Review of the resident's medical record, the 48-hour baseline care plan dated 8/27/2021, did not include a documented signature or date the baseline care plan was reviewed, and a copy given to the resident or resident representative. During an interview on 9/22/2021 at 9:51 AM, Registered Nurse Unit Manager (RNUM) #3 stated completed the Baseline Care plans for Resident #'s 12, 70, 322 and #323 were done but a printed copy was not presented to the resident and or the resident's representative but should have been reviewed and signed. During an interview on 9/23/2021 at 11:35 AM, the Director of Nursing (DON) stated the Registered Nurse Manager (RNM) was expected to complete the baseline care plan within forty-eight hours of the resident's admission to the facility. The RNM was expected to provide a written copy of the baseline care plan to the resident and or their representative. 10NYCRR415.11

Based on record review and interview conducted during the Recertification survey and an abbreviated survey (Case #NY00276384), the facility did not ensure the development and implementation of comprehensive person-centered care plans, that included measurable objectives and timeframe's to meet the resident's medical, nursing, and mental and psychosocial needs, for 7 (Residents #'s 12, 31, 57, 70, 73 322, and #323) of 22 residents reviewed for comprehensive care plans (CCP). Specifically, for Resident #12, the facility did not ensure a resident specific CCP for behavior/emotion was developed; for Resident #31, did not ensure a CCP was developed to address the resident's respiratory care related to the resident's diagnoses of chronic obstructive pulmonary disease (COPD), pneumonia, and asthma; for Resident #57, did not ensure a CCP for impaired skin integrity was developed for the resident's persistent back rash; for Resident #70, did not ensure the CCP for pain management contained resident specific non-pharmacological interventions; for Resident #73, did not ensure that a CCP was developed to address discharge planning; for Resident #322, did not ensure the CCP for ADL's included resident specific information for personal hygiene; and for Resident #323, the facility did not ensure the CCP developed for the resident's fungal infection included resident specific interventions. This is evidenced by: A facility policy titled Comprehensive Care Planning dated 10/2013 documented, it is the facilities policy that an individualized or person-centered Comprehensive Care Plan must be initiated by a Registered Nurse (RN) upon admission for all residents. Resident goals for admission and desired outcomes, preference and potential for future discharge, and discharge plans should be included as part of the Comprehensive Care Plan. Resident #12: Resident #12 was admitted to the facility with diagnosis of heart failure, diabetes, major depressive disorder, anxiety, and bipolar disorder. The Minimum Data Set (MDS-an assessment tool)) dated 6/16/2021, documented the resident was without cognitive impairment, was understood and could understand. The MDS documented the resident received antipsychotic and antidepressant medications. The Comprehensive Care Plan (CCP) for depression and bipolar documented interventions to consult psychiatry as indicated and monitor, document and report signs and symptoms of depression as needed. The CCP did not include resident specific interventions to manage Resident #12's diagnoses of depression, anxiety and bipolar disorder. During observations on 9/20/2021 at 9:07 AM, 9/20/201 11:35 AM, 9/21/2021 at 9:58 AM, 9/22/2021 at 8:33 AM, 9/23/2021 at 10:34 AM the resident was observed lying in bed facing the wall with their eyes closed. During an interview on 9/21/21 at 8:58 AM, Resident #12 stated they had a decrease in appetite and declined breakfast secondary to a decreased in appetite. The resident reported they had a doctor appointment today and did not know what the outcome of the appointment would be. The resident was lying in bed with a flat affect facing the wall during the interview and declined further discussion with the surveyor. During an interview on 9/21/2021 at 11:35 AM, Registered Nurse Unit Manager (RNUM) #3 stated Resident #12 had increased anxiety related to an upcoming outpatient appointment that day. During an interview on 9/22/2021 at 11:30 AM, Certified Nurse Assistant (CNA) #5 stated Resident #12 slept a lot and didn't come out of their room. The CNA stated they were unsure what to do when the resident was anxious or depressed. During an interview on 9/23/2021 at 10:34 AM, RNUM #3 stated Resident #12 had anxiety and depression and often isolated themselves. RNUM #3 stated it was their responsibility to develop and update the CCP and they did not know the CCP should contain resident specific information. During an interview on 9/23/2021 at 11:35 AM, the Director of Nursing stated the CCP should contain resident specific intervention to manage the resident's diagnosis and symptoms of depression, anxiety, and bipolar disorder. The DON stated it was the Unit Managers responsibility to ensure the CCP contained resident specific interventions. Resident #31: Resident #31 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (COPD), pneumonia, and asthma. The Minimum Data Set (MDS - an assessment tool) dated 7/23/2021, documented the resident had moderately impaired cognition, could understand others and could make self understood. The Comprehensive Care Plan (CCP) did not include a care plan to address the resident's respiratory care related to the resident's diagnoses of COPD, pneumonia, and asthma. A Physician Order dated 5/1/2019, documented montelukast (anti-inflammatory medication to prevent asthma attacks) 10 milligrams (mg) one time a day for asthma. A Physician Order dated 11/17/2020, documented Oxygen (O2) at 2 liters via nasal cannula as needed (PRN) to maintain O2 greater than 90%. During an interview on 9/23/2021 at 9:15 AM, the Registered Nurse (RN) #2 stated Resident #31 should have had a respiratory care plan in place. The RN stated the RN was responsible for care planning. The RN stated when the RN developed care plans for a resident the RN reviewed the resident's diagnoses, past medical history, and physician orders. The RN stated the resident should have had a care plan for respiratory care based on the resident's diagnoses, medical history, and physician orders. During an interview on 9/23/2021 at 11:15 AM, the Director of Nursing (DON) stated it was identified recently that CCP's were not being completed and implemented. It was up to the Registered Nurse Unit Manager (RNUM) to implement and update the care plans for the residents. Resident #73: Resident #73 was admitted to the facility with diagnosis of cerebral vascular accident (CVA), osteoarthritis, and major depression. The Minimum Data Set (MDS-an assessment tool) dated 2/29/2021 documented the resident was usually understood, could usually understand, and had moderately impaired cognitive skills for daily decision making. Review of the resident's medical record did not include documentation that a Comprehensive Care Plan (CCP) for discharge planning was developed. During an interview on 9/21/2021 at 11:24 AM, the Administrator stated that in February 2021 Resident #73's family and representatives were provided notice of a facility-initiated discharge. The family declined a lateral transfer to another facility and decided to discharge to home with home care services instead. A progress note titled Interdisciplinary Team (IDT) dated 4/29/2021 at 2:44 PM, documented the IDT met with the resident's wife, daughter, and Ombudsman and discussed the residents needs at length with the family to ensure accommodations can be made and patient can be safely discharged home in the care of his family. discharge date set on or before 5/13/2021. Social Worker (SW) will continue to follow and facilitate discharge with family. A facility document titled Discharge Summary Effective Date 5/10/2021 and Signed Date 5/13/2021 documented Resident #73 will be discharged to home with wife and Home Care of (named) and private aide services. Durable Medical Equipment (DME) needed for this discharge is Hoyer, hospital bed, high back wheelchair with elevated leg rests, hand rolls, and trapeze bar. Primary Care Physician (PCP) appointment scheduled for May 21,2021 at 10:45 AM. Social Worker (SW) faxed home care referral to Home Care of (named) for nursing assessment and therapy needs. Home Care (named) Agency will do a home visit and safety assessment on May 14, 2021. Transportation set up with (named) for a pickup time of 2:00 PM. Scripts for DME have been faxed to pharmacy. Patient discharging with facilities high back wheelchair, will return high back wheelchair when their new one is delivered from the pharmacy. A Social Services progress note dated 5/13/2021 at 3:18 PM, documented Social Worker(SW) faxed discharge summary and Medical Director (MD) orders to PCP and to (named) Home Care Agency. During an interview on 9/23/2021 at 10:43 AM, the Director of Social Services (DSS) stated a discharge planning care plan was not developed for Resident #73. The DSS stated the resident was admitted for long term care and would not expect a discharge care plan to have been initiated. The DSS stated, the facility-initiated discharge happened quickly and the DSS did not think to initiate a new care plan for discharge planning. The DSS stated a discharge care plan should have been developed and implemented. During an interview on 9/23/21 at 11:42 AM, Registered Nurse (RN) #4 stated discharge planning starts on admission and discharge care plans should be developed, implemented, reviewed, and revised quarterly and as needed. RN #4 stated a discharge planning care plan was not developed for Resident #73 and the care plan should have been developed upon admission. During an interview on 9/23/2021 at 11:48 AM, the Administrator stated there was not a discharge planning care plan developed for Resident #73, and a discharge planning care plan should have been developed for the facility initiated the discharge. 10NYCRR 483.21(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey and an abbreviated survey (Complaint #NY00213014), the facility did not ensure the resident environment remained as free of accident hazards as possible, and did not ensure each resident received adequate supervision to prevent accidents for 1 (Resident #19) of 1 resident reviewed for accidents and supervision. Specifically, for Resident #19, the facility did not ensure the wander alarm system was audible to facility staff in all locations of the building. Additionally, when the laundry area door and exit door alarm sounded on multiple occasions, the facility did not ensure staff inspected the immediate area around the exit door before resetting the door alarm. This is evidenced by: The undated Elopement Policy documented that any staff hearing a door alarm activated was to respond to the alarm immediately. If there was no reasonable explanation for the door to be alarming, staff were to inspect the immediate area around the exit door. If no residents were seen, staff were to report back to the nurses station, and were not to reset the alarm. All staff were to be alerted that there was a potential missing resident and begin looking for all residents using name sheets. Two staff members were to be assigned to go outside and search for the resident. Once the resident was found, the door alarm could be reset. Resident #19: The resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Alzheimer's disease, psychotic disorder with delusions and schizoaffective disorder. The Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment and was usually understood by others and usually understood others. The Comprehensive Care Plan (CCP) for Potential for Elopement dated 1/26/18, documented the resident lacked capacity with diagnoses of dementia with behaviors, and history of exit seeking behavior. Documented interventions included: the resident was to wear a wanderguard ankle bracelet, staff were to check every shift to ensure the wanderguard was in place, and check the wanderguard functioning daily. A picture of resident was to be in the medication book and at the nursing stations. The resident was to be redirected and staff were to follow the elopement policy and procedure. The Behavioral Problem Care Plan dated 1/26/18, documented the resident became aggressive during redirection by hitting and swearing if she felt anxious or threatened. The resident had a history of exit-seeking. Interventions included: attempt to identify behavioral triggers, allow time for the resident to calm down, then reapproach, offer alternative options/choices as appropriate, and report behaviors as they occur. A Physician Order dated 5/10/19, documented the resident was to have a wanderguard, and placement on her left ankle was to be checked every shift due to elopement risk. A Progress Note dated 12/31/17 at 6:00 PM, documented the resident was observed outside near the laundry room door at 3:10 PM. Staff last observed the resident at the nurses station at 2:58 PM. A registered nurse (RN) immediately ran to the resident and redirected her back inside without incident. There was no injury to the resident, and she had no complaint of pain or discomfort, or of being cold and no skin issues were noted. The resident was on 15 minute checks at the time of the incident. During an interview on 6/05/19 at 12:27 PM, the Administrator stated when the resident eloped, the facility was in the process of changing the doors so they locked. The resident opened the door by laundry and exited the building by the unlocked door in the laundry room corridor which exited into the enclosed courtyard, and both the laundry and exit doors alarmed. Staff in the breakroom saw the resident ambulating with her walker outside in the snow. At the same time, a Certified Nursing Assistant (CNA) #4 was in a resident room by the laundry room doors, and the alarm sounded when the resident went through the double doors. The CNA came out of the resident's room and disabled the alarm on the double doors by the laundry room without looking to see if a resident was in the vicinity. The Administrator also stated many of the doors did not have locks at the time of the incident, including the exit door by the laundry room, but if the door was opened an alarm sounded. The double door near the laundry room sounded often on the day of the incident because it could not be completely closed, so CNA #4 got mad and kicked the door and turned off the alarm without first looking to see why it alarmed. The resident was pushing on the outside door to get back into the facility which kept setting off the alarm. CNA #5 was pushing a hoyer down the hall, walked toward the door and disabled it, then continued down the hall. Both CNAs turned off the alarm without looking to see why it was alarming. CNA #4 told the Administrator he realized he should have looked around before turning off the alarm. The involved CNAs, and a full-house inservice was conducted after the elopement. Key pads were installed on the doors, and must be used to enter and exit. To ensure the safety of all residents who wander, individual alarm audits were performed by nursing. The Elopement policy was reviewed and revised, a Missing Resident Drill Checklist was created and drills were conducted along with education to all staff. During an interview on 6/05/19 at 12:35 pm, the Environmental Services Director stated the alarms were working but were not sounding at the nurses station because the panel had not yet been installed. Because of this, the nurses could not hear the door alarm sounding. He stated at the time of the incident time there were no key pads on the doors. The doors were alarmed but not locked, and there was a green button to push to get back in the building, and going back in would trigger the alarm. The staff thought it was a false alarm as there were many false alarms prior to the elopement because the double doors to laundry area were not closing completely causing the alarm to sound. The exit door had a contact alarm only and no magnetic lock because they could not have two doors with magnetic locks to the egress. The fire door had a magnetic lock, exterior had alarm only. That day the laundry door was not closing properly. After the elopement, the door was fixed. A motion sensor alarm was placed on the exit door until the new system was installed. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: - RN assessments and continued monitoring showed no physical or psychological harm to the resident. The resident was placed on 15 minute checks. - Education was provided first to immediate staff and then to all staff on door alarms and procedures. - Continued evaluation of alarm system by environmental services. - Individual resident alarm audits performed by nursing on all residents at risk for elopement - Full-house audits were done to ensure all residents were in the facility and all wander guards were functional. - The Elopement/Missing person policies and the Disaster Manual were reviewed and revised. - A Missing Resident Drill Checklist was developed. - Missing Resident Drills began with immediate education provided at the time of the drill. - The Environmental Services Director came into the facility and checked alarm system and added a motion sensor alarm as an additional identifier to alert staff. - The door alarm company completed a troubleshooting of the alarm system. - Key pads were installed at all double doors and all exit doors were locked. 10NYCRR415.12(h)(1)

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, the facility did not ensure that time frames were established for the steps in the MRR process. This is evidenced by: The Facility Policy and Procedure titled Medication Regimen Review dated 10/2017, did not address the time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. During an interview on 6/05/19 at 3:21 PM, DON #2 stated the policy was printed and reviewed yesterday and was not updated with a new review date. The Surveyor reviewed the P&P with the DON who was not aware the policy did not document the timeframe's for the steps in the process. 10NYCRR415.18(c)(2)

Based on observation and staff interview during the recertification survey, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, food was brought to the unit in an open cart with several food item uncovered. Staff proceeded to carry the uncovered food through the hall and serve it to residents. Additionally, food being prepared by a food service worker in the main kitchen was placed on residents dishes with gloves that had been contaminated. This is evidenced as follows: Finding 1 During observation on 6/3/19 at 12:30 PM, on Unit B an open metal cart arrived with 10 trays containing uncovered cake with pink frosting, one tray contained an open container of cottage cheese. The trays sat in the hall while staff prepared to serve the residents in their rooms. Houskeeping was observed cleaning floors and placing the cleaning cart in front of the open food cart. During observation on 6/3/19 at 12:41, LPN #1 went behind the nurse's desk, used the phone, went to the food cart and began to pass food trays. No hand washing was observed. During observation on 6/3/19 at 12:54 PM, LPN #1 was observed taking trays from the cart, and carrying them to the opposite end of the hall with the cake uncovered. A lanyard (long cloth key and badge holder) hanging out of her right pocket, swung into the uncovered cake on 4 of the food trays served as she was removing them from the open metal cart. During observation on 6/3/19 at 1:03 PM, the CNA #2 was handing a tray to LPN #1 and the corner of her uniform top brushed against the uncovered cake with pink frosting. During interview on 6/3/19 at 1:44 PM, LPN #1 stated she should not have placed her lanyard in a place that could have fallen into a resident's food. She wasn't aware how often her lanyard hit the resident's food trays. During interview on 6/3/19 at 2:04 PM, The Resident Nurse Manager (RNM) stated food should not be carried uncovered in the hallways. The serving tray should be rolled down to the resident's room and then brought into the room. The staff should be washing their hands between the residents served in their rooms. During interview on 6/6/2019 at 9:51 AM, The Food Service Director (FSW) #4 stated the food brought on trays that are not in the enclosed food cart should be covered with something and not left openly exposed on the tray. Once the food trays are brought to the unit they should not be carried through the unit with food uncovered especially with the ongoing construction. Finding 2 During observation of meal preparation in the main kitchen on 6/3/19 between 1:12 PM and 1:40 PM, food service worker/cook (FSW) #12 was observed touching the handles of a metal cabinet, the edges of the prep table, and metal cart with gloved hands. She then observed handling pasta and bread with the same gloves. Additionally, on several occasions during the residents meal preparation, FSW #12 adjusted the food on the plates with her gloved hands after touching items around her. During interview on 6/6/2019 at 9:51 AM, The Food Service Director (FSW) #4 stated the kitchen servers in the main kitchen should not be handling food without using utensils and if using gloves, hands should be washed, and gloves reapplied between touching other surfaces. During interview on 6/6/19 at 10:57 AM, The Administrator stated during review of the video in the kitchen with the FSD #4, the FSW/cook #12 was observed touching the oven handles behind her with her gloved hands. She stated they had not reviewed the entire video but would reinforce proper food handling procedure with all kitchen staff. 10 NYCRR415.14(h) .

Based on record review and interview conducted during the recertification survey, the facility did not ensure an Infection Prevention and Control Program was maintained. Specifically, the facility did not ensure a line list, used to track infection trends and clusters, was completed for May 2019 and also did not ensure Infection Control Policy and Procedures were reviewed and/or revised on a yearly basis. This is evidenced by: Finding #1: During an interview on 06/06/19 at 10:16 AM, upon reviewing the line lists for April and May, the Infection Control Coordinator (ICC) stated the May line list had not been completed. The Director of Nursing (DON) had temporarily been assigned as Infection Control Coordinator and had reviewed infection trends of upper respiratory infections and pneumonia in April and May but had not filled out the line list for May. She had gotten through April but the May line list had not been started. Antibiotic reports were received from pharmacy for the respiratory issues. The line list itself was not documented but should have been at this time. During an observation on 06/06/19 at 10:25 AM, the line list was filled out for April 2019 but no documentation was observed for May 2019. During an interview on 06/06/19 at 11:00 AM, the DON agreed the line list for May should have been filled out. She stated she had reviewed the infection trends but had not completed a line list for that month. Finding #2: During an observation on 06/06/19 at 9:15 AM, the Infection Control Manual was not reviewed/revised annually as it was documented with a date of 3/22/17. During an interview on 06/06/19 at 10:16 AM, the ICC reviewed the Infection Control manual dated 3/22/17, and stated the manual is reviewed and revised at the corporate level. She also stated the policies contained in the manual should have been looked at annually. 10NYCRR415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during a recertification survey the facility did not ensure Comprehensive Minimum Data Sets (MDSs) were completed subject to the timeframes prescribed by the Center for Medicare and Medicaid Services (CMS). Specifically, for 6 (Resident #'s 4, 7, 14, 28, 29, and 120) of 6 residents reviewed, the facility did not ensure the resident's initial and periodic Comprehensive MDS assessments were completed within the Center for Medicare and Medicaid Services (CMS) specified timeframes. This is evidenced by: Resident #4: The resident was admitted to the facility on [DATE], with the diagnoses of depression, anxiety and hypertension. The Minimum Data Set (MDS) dated [DATE], documented he understands, is understood, and has moderate cognitive impairments. During record review an annual MDS dated of 4/17/19, included a signature indicating the MDS was completed on 6/4/19. Sections C, D, S, Q, and X of the MDS were not completed. Resident #7: The resident was admitted to the facility on [DATE], with diagnoses of diabetes, hypertension, and cerebrovascular disease. The MDS dated [DATE], documented the resident was cognitively intact, could understand others and could make self understood. The Comprehensive admission MDS dated [DATE] was completed on 6/5/19. Resident #28: The resident was admitted to the facility on [DATE], with diagnoses of dementia, diabetes, and osteoporosis. The Minimum Data Set (MDS) dated [DATE], documented the resident had impaired cognition, could understand others and could make self understood. The Comprehensive Annual MDS dated [DATE] was completed on 10/19/18. During an interview on 6/6/19 at 10:21 AM, the MDS Coordinator reported that some of the MDS's were not completed or were submitted late because they were incomplete. It had been a struggle to get all responsible staff to complete their assigned sections of the MDS on time. This has been an ongoing concern and Administration is aware. At this time Administration and Corporate will be working to ensure all staff complete the MDS assessments as scheduled. In addition, the MDS Coordinator was instructed by the Administrator to submit the completed sections of the MDS's that were currently late. The system will not accept an incomplete MDS for submission, so a dash was entered in the incomplete sections and the late MDS's were submitted on 6/4/19. During an interview on 6/05/19 at 9:10 AM, the Administrator stated a new MDS Coordinator was hired in June of 2018 and when the new MDS Coordinator was hired there were a lot of MDS's that needed completion. She stated she was aware that the MDS's were not being completed timely and they had been piecing it together the best that they could to get the MDS completed. During an interview on 06/05/19 at 9:13 AM, the Regional Director of Quality Assurance & Performance Improvement (QAPI) stated a lot of education needed to be done with the MDS Coordinator and the Interdisciplinary Team. She stated when she started a month ago she was not made aware right away that MDS's were not being completed timely. She stated she did not know there were outstanding MDS's from March 2019, but she was aware that the MDS Coordinator was having difficulty getting Departments to do their part of the MDS. 10NYCRR415.11(a)(3)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey, the facility did not ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not ensure that required Minimum Data Sets (MDS), which included admissions, annuals, quarterly, and significant change assessments, were completed and transmitted as scheduled to provide specific services to residents and to develop resident specific care plans for residents in their care. This was evidenced by: Refer to tag F636 During record review on 6/3/19 at 1:00 PM, MDS assessments needed to perform comparative screening for 22 sampled residents were not readably available. During record review on 6/4/19 at 10:00 AM, MDS assessments needed to perform comparative investigations for 17 sampled residents were not readably available. On 6/4/19 at 10:30 AM, the survey team requested a list of the facility's incomplete and outstanding MDSs. During record review on 06/4/19 2:37 PM, the facility's software Visual for MDS entry and submission documented the following: Resident #2: Quarterly assessment dated [DATE], was not ready to submit. The edit status documented Sections C, D, K, Q, Z were not completed. The 5/22/19 annual MDS was not completed as well. Resident #3: Quarterly MDS Review dated 4/17/19, was not ready to submit. The edit status documented Sections C, D, Q, Z were not completed. Resident #4: Annual MDS assessment dated [DATE], was not ready to submit. The edit status documented Sections C, D, Q, V, Z were not completed. Resident #5: Quarterly MDS assessment dated [DATE], was not ready to submit. The edit status documented Sections Q, Z were not completed. Resident #14: Quarterly Dated 4/17/19, was not ready to submit. The edit status documented Sections C, D, Q, Z were not completed. Resident #29: admission MDS assessment dated [DATE], was not ready to submit. The edit status documented Sections B, E, G, H, I, J, L, M, N, O, P, S, Z were not completed. During record review on 6/5/19 at 9:00 AM, MDS assessments needed to perform comparative investigations for 12 sampled residents, were not available as requested. During record review on 6/5/19 at 10:45 AM, 6 (Resident #'s 2, 3, 4, 5, 29, and 59) of 7 residents' MDSs were identified by the Centers for Medicaid and Medicare Services as being over 120 days old, had not been completed and submitted. During an interview on 6/4/19 at 1:45 PM, the MDS Coordinator stated Resident #59's Quarterly MDS for 5/8/19, was not completed for sections C, D, Q. He stated he was late with numerous MDS assessments and late for submission because he was waiting for other disciplines to complete their sections of the MDSs. When all sections of the MDS were completed he reviewed, signed and submitted them. He stated the Administrator was aware that there was a problem with timely submissions of the MDSs in the facility. He stated he kept the Administrator updated on the difficulties with staff not completing sections needed to perform timely completions and how far behind he was in completing and submitting MDSs. When he first started doing the MDSs, other staff helped with completing them, but recently he was not provided any help to ensure timely submissions. This had been ongoing since he began in the position in late 2018. During an interview on 6/5/19 at 8:59 AM, the MDS Coordinator stated he still did not have all the required MDS assessments requested by the surveyors. The MDS coordinator stated the validation report documented overdue MDS assessments as of 6/5/19. He stated the 6/5/19 validation report documented overdue MDSs that were incomplete and not ready to be submitted to CMS. The validation report would have documented more than the documented 53 outstanding MDSs, but he made a submission of overdue MDSs to CMS on 6/4/19, prior to providing the survey team the validation report. During an interview on 6/6/19 at 10:21 AM, the MDS Coordinator stated he was instructed by the Administrator to submit the completed sections of the MDSs that were late. The system would not accept an incomplete MDS for submission, so a dash was entered in the incomplete sections and the late MDSs were submitted on 6/4/19. During an interview on 6/05/19 at 9:10 AM, the Administrator stated a new MDS Coordinator was hired in June 2018. When the new MDS Coordinator was hired there were a lot of MDSs needing completion. She was aware that the MDSs were not being completed timely and they had been piecing it together the best they could to get the MDS completed and submitted. She had an action plan, but it had not addressed the problem and had not been effective. She was aware of the time-frames of MDS scheduled assessments and the importance of the MDS for reimbursement. During an interview on 06/05/19 at 9:13 AM, the Regional Director of Quality Assurance & Performance Improvement (QAPI) stated a lot of education needed to be done with the MDS Coordinator and the Interdisciplinary Team. She stated when she started a month ago she was not made aware right away that MDSs were not being completed timely. She stated she did not know there were outstanding MDSs from March 2019, but she was aware that the MDS Coordinator was having difficulty getting facility departments to complete their part of the MDS. During an interview on 6/6/19 at 10:57 AM, the Administrator stated she had not developed another plan of action to address the timely completion of the MDS assessments after her initial plan of action developed in 2017 did not correct the problems they were having with MDS completion and timely submission. She stated she had not reviewed validation reports regularly provided by CMS, and had not tasked staff to do this. She was aware that the MDSs were late and that the problem arose when her MDS coordinator retired in 2017. She did secure help for a time, but in December of 2018 they realized they were falling behind again. The MDS coordinator was new to the position and had let her know of the difficulties he was having completing MDSs on time. This should have been addressed sooner. A new policy was being developed to address this after the survey had begun. 10NYCRR415.26