Based on record review and interviews during the Recertification Survey initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that comprehensive assessments of residents were conducted within 14 calendar days after admission and not less than once every 12 months. This was identified for two (Resident #67 and Resident #37) of six residents reviewed during the Resident Assessment Task. Specifically, Resident #67 and Resident #37's annual Minimum Data Set Assessment was not completed within 14 days of the Assessment Reference date. The finding is: The facility policy titled MDS Assessments, dated 12/10/2024, documented all Minimum Data Set assessments are to be completed and submitted to Centers for Medicare and Medicaid Services as per the guidelines provided in the Resident Assessment Instrument Manual. The Minimum Data Set Coordinator will assume the leadership role to ensure that all Minimum Data Set Assessments are completed and submitted as per the guidelines. Resident #67's Annual Minimum Data Set assessment with an Assessment Reference Date of 8/30/2024 was completed on 9/20/2024. This was 7 days beyond the required time frame. Resident 37's Annual Minimum Data Set Assessment with an Assessment Reference Date of 8/22/2024 was completed on 9/11/2024. This was 6 days beyond the required time frame. During an interview on 1/10/2025 at 9:19 AM, the Minimum Data Set Director stated the Minimum Data Set should be completed 14 days from the Assessment Reference Date. The Minimum Data Set Director stated they knew that Resident #37's and Resident #67's Annual Minimum Data Set was completed late. They further stated that the Director of Nursing and Administrator were aware. During an interview on 1/10/2025 at 9:51 AM, the Director of Nursing Services stated they were aware the Minimum Data Set assessments were completed late. The Director of Nursing Services stated the late assessment completion was because of staffing turnover. 10 NYCRR 415.11

Based on record review and interviews during the Recertification Survey initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that the Quarterly Minimum Data Set assessments were completed within the prescribed time frames. This was identified for three (Resident #6, Resident#113, Resident #13) of six residents reviewed during the Resident Assessment Task. Specifically, Resident #6, Resident#113, and Resident #13 Quarterly Minimum Data assessment was not completed within 14 days of the Assessment Reference date. The finding is: The facility policy titled MDS Assessments, dated 12/10/2024, documented all Minimum Data Set assessments are to be completed and submitted to Centers for Medicare and Medicaid Services as per the guidelines provided in the Resident Assessment Instrument Manual. The Minimum Data Set Coordinator will assume the leadership role to ensure that all Minimum Data Set Assessments are completed and submitted as per the guidelines. Resident #6's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 8/23/2024, was completed on 9/9/2024. This was three days beyond the required time frame. Resident #113's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 8/2/2024, was completed on 8/21/2024. This was five days beyond the required time frame. Resident #13's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 8/30/2024, was completed on 9/17/2024. This was four days beyond the required time frame. During an interview on 1/10/2025 at 9:19 AM, the Minimum Data Set Director stated the Minimum Data Set should be completed 14 days from the Assessment Reference Date. The Minimum Data Set Director stated they knew that Resident #37's and Resident #67's Annual Minimum Data Sets were completed late. They further stated that the Director of Nursing and Administrator were aware. During an interview on 1/10/2025 at 9:51 AM, the Director of Nursing Services stated they were aware the Minimum Data Set assessments were completed late. The Director of Nursing Services stated the late assessment completion was because of staffing turnover. 10 NYCRR 415.11 (a)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the Recertification survey initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that a comprehensive care plan was developed and implemented for each resident including measurable objectives and timeframe to meet each resident's medical and nursing needs. This was identified for one (Resident#233) of one resident reviewed for Hydration; one (Resident #68) of seven residents reviewed during the Medication Administration Task; and one (Resident #285) of two residents reviewed for Urinary Catheter or Urinary Tract Infection. Specifically, 1) Resident #233 had a physician's order for intravenous hydration therapy; however, there was no comprehensive care plan developed for the insertion, care, and use of the Intravenous Catheter. 2) Resident #68 was administered Calcium 500 milligrams with Vitamin D 3 instead of the Physician ordered Calcium-Vitamin D 600 milligrams-200 milligrams. 3) Resident #285 received antibiotic therapy intravenously; however, there was no comprehensive care plan developed for the insertion, care, and use of the Peripheral Intravenous Catheter. The findings are: A facility's policy titled Care Plans, Comprehensive Person-Centered, documented a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including services that would otherwise be provided. 1) Resident #233 was admitted with diagnoses including Hypertension, Diabetes Mellitus, and Depression. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. A physician's order dated 1/4/2025 documented to intravenously administer Sodium Chloride Solution 0.9 percent at 100 milliliters per hour every shift for Hydration for two days. A nursing progress note dated 1/6/2025 documented the resident was started on Sodium Chloride Solution 0.9 percent at 100 milliliters per hour intravenously, every shift for hydration until 1/7/2025. There was no documented evidence that a comprehensive care plan was developed for the use of intravenous fluids. During an interview on 1/8/2025 at 9:49 AM, Registered Nurse Unit Manager #2 stated Resident #233 received intravenous fluids related to their elevated blood sugar levels starting 1/4/2024 for two days. Registered Nurse Unit Manager #2 further stated that whoever picked up the Physician's order should have started a comprehensive care plan. During an interview on 1/10/2025 at 10:06 AM, the Director of Nursing Services stated there should have been a care plan developed for the use of intravenous fluids. 3) Resident #285 had diagnoses that included Urinary Tract infection, Chronic Kidney Disease, and Obstructive and Reflux Uropathy (a condition that prevents urine from flowing normally through the urinary tract). The Minimum Data Set assessment dated [DATE] documented Resident #285 had a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. A Physician's order dated 1/02/2025 documented the insertion of an Intravenous Midline Catheter. A Physician's order dated 1/02/2025 documented an order for Ceftriaxone Sodium (antibiotic) Solution 1 gram reconstituted intravenously every 12 hours for 7 days for infection. There was no documented evidence of a Comprehensive Care Plan for an Intravenous Midline Catheter use. Additionally, while there was a Comprehensive Care Plan for a Urinary Tract Infection dated 12/28/2024, the care plan did not include interventions related to the placement or care of an Intravenous Midline Catheter. During an observation on 1/5/2025 at 9:35 AM, Resident #285 was observed in bed with an Intravenous Catheter in their right arm. During an observation on 1/7/2025 at 10:51 AM, Resident #285 was in bed with the Intravenous Catheter in their right arm. During an interview on 1/7/2025 at 10:24 AM, Registered Nurse Unit Manager #4 stated a Care Plan should be developed for the Intravenous Midline Catheter when the peripheral intravenous catheter was ordered and placed. During an interview on 1/8/2025 at 12:01 PM, the Director of Nursing Services stated staff is expected to confirm that a physician's order for the placement of an Intravenous Midline Catheter is obtained and a care plan for the Intravenous Midline Catheter is initiated. 10 NYCRR 415.11(c)(1) 2) The facility's policy and procedure titled Medication Administration, last revised on 10/18/2024 documented that medications are administered in accordance with the prescriber's orders, including the required time frame. Resident #68 was admitted with diagnoses including Vitamin D Deficiency, Hemiplegia (paralysis on one side of the body), and Seizures. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #68 had intact cognition. The Minimum Data Set (MDS) assessment documented Resident #68 had no Osteoporosis (bones become weak and brittle) or Arthritis (joint inflammation). A Comprehensive Care Plan (CCP) dated 10/19/2024 documented Resident #68 was at risk for pain related to contractures (when muscles, tendons, joints, or other tissues tighten or shorten causing deformity). The intervention included administering medication as ordered by the Physician. A Physician's order dated 10/12/2023 documented Calcium with Vitamin D tablet 600 milligrams-200 International Unit (unit of measurement for a substance biological effect or activity) one tablet by mouth daily for supplement. Resident #68 was observed in their room on 1/5/2025 at 9:10 AM. Licensed Practical Nurse #2 was observed during the Medication Administration Task administering two tablets of Calcium 250 milligrams with Vitamin D3 (3.1 micrograms) to Resident #68. The resident refused to take the medications. During an interview on 1/5/2025 at 9:12 AM, Licensed Practical Nurse #2 stated they did not have the Calcium with Vitamin D 600 milligrams-200 International Unit available in their medication cart. Licensed Practical Nurse #2 stated the Calcium 250 milligrams with Vitamin D3 (3.1 micrograms) was the closest dose they had in their medication cart. Licensed Practical Nurse #2 stated they would have documented in Resident #68's Electronic Medication Administration Record (EMAR) that a partial medication dose was administered if Resident #68 did not refuse the medications. During an interview on 1/5/2025 at 11:33 AM, Registered Nurse #3, the Unit Manager stated that Licensed Practical Nurse #2 should never have given a different dose of Calcium with Vitamin D to the resident. Registered Nurse #3 stated that Licensed Practical Nurse #2 should have checked with Central Supply for the medication availability. Licensed Practical Nurse #2 should have also called the Physician to get a different order if Calcium with Vitamin D 600 milligrams-200 International Unit was not available. During an interview on 1/8/2025 at 12:34 PM, the Director of Nursing Services stated Resident #68 should not have been given any medication except for what the Physician had ordered. The Director of Nursing Services stated Nursing staff should follow the orders given by the Physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was identified for one (Resident #94) of one resident reviewed for Activities of Daily Living. Specifically, Resident #94 was observed on multiple occasions with long, untrimmed fingernails on both hands. Resident #94 stated they were unable to trim their fingernails on their own and wanted them trimmed. The finding is: The facility's policy titled Activities of Daily Living Care, dated 10/2024, documented the nursing home shall provide Activities of Daily Living care that promote and maintains residents' health, safety, independence, and dignity. Activities of Daily Living care include assistance with tasks such as bathing, dressing, grooming, eating, toileting, mobility, and transferring. Assist with grooming tasks such as shaving, hair care, oral hygiene, and nail care. Resident #94 was admitted with diagnoses including Cancer, Vertebra Fracture, and Muscle Weakness. The 11/26/2024 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident was dependent on facility staff for personal hygiene. A Comprehensive Care titled Resident requires assist with activities of daily living related to bladder cancer with metastasis to spine, initiated 11/20/2024, documented personal hygiene: dependent on one staff member. The [NAME] (Certified Nursing Assistant care instructions), as of 1/5/2025, documented that the resident was dependent on one staff member for personal hygiene. Resident #94 was observed in bed on 1/5/2025 at 9:58 AM. Their fingernails on both hands were long and untrimmed. The resident stated they would like their fingernails trimmed, but they cannot trim the fingernails themselves because their hands are numb. Resident #94 was observed in bed on 1/6/2025 at 8:20 AM and their fingernails had not been trimmed yet. During an interview on 1/6/2025 at 8:25 AM, Certified Nursing Assistant #1 stated they were not the regularly assigned Certified Nursing Assistant and had not worked with Resident #94 before. Certified Nursing Assistant #1 observed Resident #94's fingernails and stated the nails were long and needed to be trimmed. Certified Nursing Assistant #1 stated they were not sure if the Certified Nursing Assistants were allowed to trim fingernails. During an interview on 1/6/2025 at 8:30 AM, Licensed Practical Nurse #1 stated if the resident is diabetic, the Certified Nursing Assistant can file the resident's fingernails and if the resident is not a diabetic, then the Certified Nursing Assistant can cut the fingernails. A nursing progress note dated 1/6/2025 at 12:28 PM, written by Registered Nurse #2, documented fingernails cut/trimmed/filed this morning. During an interview on 1/7/2025 at 10:41 AM, the Registered Nurse Staff Educator stated the Activities of Daily Living care include keeping fingernails clean. The Certified Nursing Assistants are allowed to cut the resident's fingernails. During an interview on 1/8/2025 at 10:40 AM, the Director of Nursing Services stated that Certified Nursing Assistants are expected to trim and clean the resident's fingernails. 10 NYCRR 415.12(a)(3)

Based on observation, record review, and interviews during the Recertification Survey, initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for one (Resident #234) of four residents reviewed for Pressure Ulcers. Specifically, Resident #234 had a physician's order for a positioning triangle wedge for pressure relief due to the resident having a Stage 3 pressure ulcer (full-thickness tissue loss; a deep wound extending through all layers of the skin into the fatty tissue beneath, indicating significant tissue damage) to the sacrum (a large, triangular bone at the base of the spine). On 1/5/2025 while the resident was in bed, the wedge cushion was observed against the bed's side rail and was not being used for providing pressure relief. The direct care staff were unaware of the reasons for the positioning wedge cushion use. The finding is: The facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised 11/13/2024 documented that the nurse shall describe and document/report the following: full assessment of pressure sore, including location, stage, length, width and depth, presence of exudate or necrotic tissue; pain assessment; resident mobility status; current treatments, including support surfaces, and all active diagnoses. The Physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical treatments. 1) Resident #234 was admitted with diagnoses including Cellulitis of the Left Lower Limb, Muscle Weakness, and Difficulty Walking. The 10/22/2024 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 6, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment documented that the resident was dependent on staff for bed mobility and transfers, had no pressure ulcers, was at risk for pressure ulcer development, and required pressure-reducing devices for the bed and chair. The Braden score (a scale for predicting pressure ulcer risk) dated 10/15/2024, documented a score of 16, indicating the resident was at mild risk for developing pressure ulcers. A nursing progress note dated 12/18/2024, written by Registered Nurse Unit Manager #2, documented the assigned Certified Nursing Assistant reported an open area to the resident's right buttocks. Wound Care Registered Nurse #1 determined the area as a Stage 3 pressure ulcer. Treatment was initiated. A physician's order dated 12/31/2024 documented to apply Santyl External Ointment 250 unit/gram (an enzymatic debriding agent), apply to sacral wound topically every day shift for wound healing; cleanse with normal saline, apply Santyl and cover with dry dressing every day. A physician's order dated 1/3/2024 documented Adaptive Device: Positioning triangle wedge to be placed on right/left side of trunk/hips when in bed. Reposition every 2 hours for pressure relief. A progress note dated 1/3/2025, written by Physical Therapist #1, documented the resident was provided with a positioning wedge for pressure relief, to be placed on the right/left side of the trunk/hips while in bed. Reposition the resident every 2 hours. The Certified Nursing Assistant assigned to the resident was informed and educated. A Comprehensive Care Plan titled Open Area to Right Buttock, Retitled to Sacral Stage 3, initiated on 12/18/2024 and last updated on 1/5/2025, documented an intervention to administer treatments/medications as ordered and monitor for effectiveness; the care plan did not include an intervention for the Positioning Triangle Wedge. A review of the Certified Nursing Assistant Accountability Record for January 2025 revealed that Certified Nursing Assistants started using the triangle wedge on 1/6/2025. During an observation on 1/7/2025 at 8:45 AM, Resident #234 was observed in their room with facial grimacing and was complaining in profane language that their buttocks were hurting and they wanted to die. The resident was lying flat on their back. The positioning wedge was observed against the side rail and did not provide pressure relief to the resident. Registered Nurse Unit Manager #2 entered the resident's room and stated the positioning wedge was to prevent the resident from falling out of bed. Registered Nurse Unit Manager #2 stated they had to check with the Rehabilitation Department to see if the positioning wedge was meant to provide pressure relief. During an observation and interview on 1/7/2025 at 9:00 AM, Registered Nurse Unit Manager #2 returned to Resident #234's room and stated they spoke to the Rehabilitation Department and stated the positioning wedge was meant to offload the sacral area and to provide pressure relief. Registered Nurse Unit Manager #2 and Licensed Practical Nurse #1 (who was also in the room to administer medication to the resident) then left the resident's room without repositioning the resident or placing the positioning wedge under the resident. The resident continued with facial grimacing and complaints of pain in the buttock area. During an observation and interview on 1/7/2025 at 9:04 AM, Certified Nursing Assistant #5 (assigned to Resident #234) entered the resident's room after being alerted of the resident's pain complaints. The resident was complaining in profane language of pain in the buttock area. Certified Nursing Assistant #5 repositioned a pillow under the resident and stated the positioning wedge was to keep the resident safe. During an interview on 1/7/2025 at 09:14 AM, the Rehabilitation Department Director stated the triangular positioning wedge was meant for pressure relief for Resident #234 and should be placed under the resident's hip to offload the wound. The positioning wedge is not used to prevent the resident from falling out of bed. During an interview on 1/7/2025 at 1:53 PM, Physical Therapist #1 stated the positioning triangle wedge was meant to be placed on either side of the resident's hips/trunk and switched every 2 hours for pressure relief and was meant to keep the resident off their back. Physical Therapist #1 stated they spoke to the Certified Nursing Assistant assigned to the resident (could not recall the name) and to the Registered Nurse Unit manager #2. During an interview on 1/8/2025 at 9:37 AM, Registered Nurse Unit Manager #2 stated they did not recall Physical Therapist #1 telling them about the positioning wedge. During an interview on 1/8/2025 at 02:27 PM, the Director of Nursing Services stated the nursing staff taking care of Resident #234 should have known what the positioning wedge was for and should have utilized the wedge cushion to offload the would area. 10 NYCRR 415.12(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 01/05/2025 and completed on 01/10/2025, the facility did not ensure that each resident was offered a therapeutic diet when there is a nutritional problem, and the healthcare provider ordered a therapeutic diet. This was identified for one (Resident #54) of six residents reviewed for Nutrition. Specifically, Resident #54 experienced a 10% weight loss over one month, decreasing from 99 pounds on November 5, 2024, to 89 pounds by December 12, 2024. Registered Dietician #1 recommended weekly weights; however, there was no documented evidence the resident's weights were obtained weekly to monitor further weight loss. Subsequently, Resident #54 had an additional 7% weight loss from 12/12/2024 to 1/7/2024. The finding is: The facility's policy titled Management and Prevention of Significant Weight Loss, revised on 11/01/2023 documented that the Clinical Dietitian will place the resident on a weekly weight if a resident's weight [loss/gain] is unplanned or undesirable. The Physician will be notified of any weekly or monthly significant weight changes or as needed. Care plans will be under continuous revisions to meet the resident's needs with the goal of achieving the desired outcome. Communicate with the Physician and Charge Nurse about any nutritional recommendations based on assessment. Monitor resident's progress and document weekly or sooner in the medical record until weight status resolves. Resident #54 was admitted with diagnoses including Alzheimer's Disease, Atrial Fibrillation, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview could not be completed due to Resident #54's severe cognitive impairment. Resident #54 was on a mechanically altered therapeutic diet and required supervision or touching assistance (the helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completes the activity. Assistance may be provided throughout the activity or intermittently) for eating. The resident's height was 60 inches and weight was 99 pounds. The resident did not have a weight gain or weight loss of 5% in one month or 10% in six months of the assessment period. The Comprehensive Care Plan effective 8/05/2024 last reviewed 11/19/2024 documented the resident had a high nutritional risk secondary to chewing difficulty. The interventions included monitoring weights monthly/weekly and monitoring oral intake of food and fluids. A Physician's order dated 8/05/2024 and revised on 10/30/2024 with an end date of 1/7/2025 documented a puree texture, Nectar Thickened Liquids consistency diet, for the Planned Weight Gain Regimen. A Physician's order dated 08/05/2024 and revised on 10/30/2024 with an end date of 1/6/2025 documented Ensure Clear (a high-calorie drink) two times a day by mouth, thickened to nectar thick consistency, Aspiration Precautions, and planned weight gain regimen. A Dietician progress note dated 11/05/2024 documented Quarterly nutritional assessment. The resident was on a no-salt added diet with puree consistency and nectar thick liquids and was on weekly weights. The resident's weights were: on 8/3/2024 the resident weighed 105.2 pounds; on 10/7/2024 the resident's weight was 99.2 pounds; on 10/23/2024 the resident weighed 98 pounds; and on 11/5/2024 the resident weighed 99 pounds. The resident's weight increased by one pound in 2 weeks and was stable in 30 days; however, there was a 6.2 pounds (5.8%) weight loss in 90 days. The weight loss was not desirable. The resident was receiving additional food items for weight stability/weight gain. The recommendation was to monitor weights and oral intake. The Weights and Vitals Sign Summary documented on 11/17/2024 the resident weighed 132 pounds; however, the weight was crossed off and no reweigh was documented for November 2025. On 12/12/2024 the resident weighed 89 pounds which was a 10% weight loss in one month since 11/5/2024. The resident's weight on 1/07/2024 was recorded as 83 pounds which was an additional 7% weight loss since 12/12/2024. A dietary progress note dated 12/16/2024, written by Registered Dietitian #1, documented the resident's weight decreased by 10 pounds in 30 days (10%). Registered Dietitian #1 documented they observed the resident on meal rounds. The resident was consuming only a few bites of lunch and a few sips of nectar thick liquids. The plan was to continue monitoring the weekly weights, oral intake, and tolerance of supplements. The medical record lacked documented evidence of weekly weights in November and December 2024. A physician progress note dated 12/16/2024, written by Primary Physician #1, documented Resident #54 was seen and examined. The resident's weight was 89 pounds on 12/12/2024. The resident was at risk for Malnutrition. A Physician's order dated 12/19/2024 Infuvite Adult Intravenous Injectable (Multiple Vitamin) intravenously one time a day for Vitamin Insufficiency for 3 Days. Administer into a 500-milliliter bag of normal saline daily for 3 days. A physician's progress note dated 1/03/2025, written by Nurse Practitioner #1 documented staff requested to evaluate Resident #54 for poor appetite. A Calorie Count was ordered for 3 days. The resident would continue to receive Ensure supplement. Nurse Practitioner #1 documented they will reevaluate the resident at the end of the calorie count and will discuss the goals of care with the family. The Calorie Count was not initiated until 1/6/2025. The Certified Nursing Assistant Accountability Record for Resident #54's meal intake in December 2024 documented that Resident #54 consumed 0-75% of their meals. For January 2025, Resident #54 consumed 25-75% of their meals. During an observation and interview on 1/08/2025 at 11:52 AM, Resident #54 was observed sitting in a Geri chair. Certified Nursing Assistant #2 was feeding Resident #54 their lunch meal. The resident fell asleep during the meal and ate less than 25% of their lunch. During an interview on 1/07/2025 at 2:59 PM, Registered Dietician #1 stated Resident #54 had a 10% weight loss in one month in December 2024. Registered Dietician #1 stated the resident was diagnosed with COVID-19 infection in December 2024 and they thought the weight loss was related to COVID-19 infection. Registered Dietician #1 stated the resident lost 10 % of weight in one month; however, they did not change the resident's plan of care. They stated they should have changed the Ensure Clear from twice a day to three times a day on 12/12/2024 when they first identified the weight loss. Registered Dietician #1 stated the Dieticians are responsible for monitoring the resident's weight, assessing the resident for weight loss, notifying the Physician, and providing nutritional interventions to prevent further weight loss. During an interview on 1/07/2025 at 3:40 PM, Chief Dietician #1 stated Resident #54 had a significant weight loss in December 2024. Registered Dietician #1 was expected to make changes to the resident's nutritional plan of care and should have provided increased protein and calories. Resident #54's weekly weights should have been obtained as recommended by Registered Dietician #1. During an interview on 1/10/2025 at 9:24 AM, Primary Physician #1 stated they stated, they were made aware of Resident #54's weight loss. Resident #54 had a COVID-19 infection and was treated with intravenous fluids and intravenous antibiotics. Primary Physician #1 stated they follow the the Dietician's recommendations to increases and decreases the diet and supplements. Primary Physician #1 stated stated they did not documented a weight change in their notes; however, they provided orders to administer intravenous fluids to Resident #54 for hydration. 10 NYCRR 415.12(i)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #285 had diagnoses that included Urinary Tract infection, Chronic Kidney Disease, and Obstructive and Reflux Uropathy ((a condition that prevents urine from flowing normally through the urinary tract)). The Minimum Data Set assessment dated [DATE] documented Resident #285 had a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. The Minimum Data Set did not document that Resident #285 was admitted to the facility with an intravenous catheter. A Physician's order dated 1/02/2025 documented Midline Intravenous Catheter insertion. A Physician's order dated 1/02/2025 documented Ceftriaxone Sodium Solution (antibiotic) 1 gram intravenously every 12 hours for 7 days for infection. The Medication Administration Record for January 2025 documented the resident received intravenous antibiotics. There was no documentation regarding the assessment, monitoring, or flushing of the Midline Intravenous Catheter. The Treatment Administration Record for January 2025 did not include documentation related to an assessment monitoring, or flushing of the Midline Intravenous Catheter. During an observation on 1/5/2025 at 9:35 AM, Resident #285 was sleeping in bed with a Midline Intravenous Catheter in their right arm. The site appeared clean and dry. During an observation on 1/7/2025 at 10:51 AM, Resident #285 was sleeping in their bed with the midline intravenous catheter in their right arm. The site appeared clean and dry. During an interview on 1/7/2025 at 10:24 AM, Registered Nurse Unit Manager #4 stated the nurses were expected to assess the Midline Intravenous Catheter site and flush the catheter before and after administering intravenous medication each shift and document their findings in the medical record. Registered Nurse Unit Manager #4 stated there should be physician's orders to assess the site and to flush the intravenous catheter before and after intravenous medication administration. During an interview on 1/08/2025 at 12:01 PM, the Director of Nursing Services stated they expected nursing staff to ensure a physician's order for placement and the assessment of the intravenous catheter was present for residents with intravenous catheters in place. The Director of Nursing Services stated nurses on all shifts must assess the intravenous catheter site including flushing of the intravenous catheter and document in a progress note or the Medication Administration Record or the Treatment Administration Record. 10 NYCRR 415.12(k)(2) Based on observations, record review, and staff interviews during the Recertification Survey initiated on 1/5/2025 and completed on 1/10/2025 the facility did not ensure Intravenous antibiotics were administered consistent with professional standard of practice and in accordance with physician's orders and the comprehensive person-centered care plan. This was identified for two (Resident #336 and Resident #285) of two residents reviewed for Urinary Tract Infection. Specifically, 1) Resident #336 had a Midline Intravenous Catheter (a type of peripheral intravenous access, flexible tube inserted into a vein in the upper arm) on the left arm. There were no physician orders for monitoring and flushing the Midline Intravenous Catheter. 2) Resident #285 was observed with a peripheral intravenous catheter (Midline Intravenous Catheter ) in their right arm. There were no physician orders for monitoring and flushing of the Midline Intravenous Catheter. The findings are: The facility's policy titled Intravenous Infusion, last revised on 12/10/2024 documented that intravenous sites are checked every four hours and as needed for signs and symptoms of infection or inflammation. The Nurse will assess associated risks due to intravenous fluid administration such as infiltration (when fluids leak out into the tissue under the skin) and infection. The intravenous documentation is recorded in the Nurses' notes and/or Medication Administration Records. Flush vascular access device with normal saline. Resident #336 was admitted with diagnoses including Urinary Tract Infection, non-Hodgkin lymphoma (a type of cancer that develops in the lymph nodes), and Fracture of the Right Pubis (front portion of the hip bone). The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severely impaired cognition. The Minimum Data Set (MDS) assessment documented Resident #336 was incontinent of urine. A Physician's order dated 12/31/2024 documented Unasyn Injection Solution (an antibiotic that treats bacterial infection) three grams intravenously every eight hours for Urinary Tract Infection for seven days. There were no documented Physician's Orders to monitor and flush the Midline Intravenous Catheter until 1/8/2025. There was no Physician's Order to insert the Midline Intravenous Catheter and Midline Intravenous Catheter site dressing until 1/13/2025. A review of Resident #336's Electronic Medical Administration Record (EMAR) revealed there was no documentation that Resident #336's Midline Intravenous Catheter site was assessed for infiltration ( when some of the fluid leaks out into the tissues under the skin where the tube has been put into the vein) and flushed with saline before 1/8/2025 per the facility policy. A review of Resident #336's Progress notes from 12/31/2024 to 1/7/2025 revealed that the Medication Nurses were not consistently documenting that Resident #336's left arm Midline Intravenous Catheter site was assessed for any infiltration and signs of infection. A Comprehensive Care Plan (CCP) dated 12/31/2024 and revised on 1/8/2025 documented that Resident #336 had a Midline Intravenous Catheter on the left arm. The intervention included an assessment of the Midline Insertion site for redness, tenderness, and swelling. Resident #336 was observed on 1/5/2025 at 9:45 AM in bed. Resident #336 was receiving medication intravenously via the left arm Midline Intravenous Catheter. There was no redness or swelling around the Midline Intravenous Catheter site. During an interview on 1/8/2025 at 8:48 AM, Registered Nurse #3, Unit Supervisor stated they forgot to obtain an order to assess and flush Resident #336's Midline Intravenous Catheter. Registered Nurse #3 stated there should have been an order for the assessment and saline flush for Resident #336's Midline Intravenous Catheter. During an interview on 1/8/2025 at 12:00 PM, Licensed Practical Nurse #3 stated there should have been an order for the assessment of the intravenous site which included redness, swelling, and inflammation. Licensed Practical Nurse #3 stated they (Licensed Practical Nurse #3) must have forgotten to document the assessment in Resident #336's Progress Notes. During an interview on 1/8/2025 at 12:08 PM, the Director of Nursing Services stated an intravenous catheter site should be assessed for signs of infiltration and signs of infection every shift as per facility policy. The Director of Nursing Services stated they expected the nurses to document the assessment in the resident's Progress Note every shift while the resident was receiving intravenous fluids or intravenous antibiotics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #283 was admitted with diagnoses that included Benign Prostatic Hyperplasia (a noncancerous enlargement of the prostate gland), Obstructive and Reflux Uropathy (a condition that prevents urine from flowing normally through the urinary tract), and Diabetes Mellitus. The Minimum Data Set assessment dated [DATE] documented the Brief Interview for Mental Status score of 10, which indicated the resident had moderate cognitive impairment. The Minimum Data Set documented that Resident #283 was admitted to the facility with an indwelling catheter. A Comprehensive Care Plan was initiated on 12/19/2024 and documented the resident had a Foley catheter related to Benign Prostatic Hyperplasia and Obstructive & Reflux Uropathy. Interventions included changing the catheter monthly and as needed. The interventions did not document the use of a privacy bag for the Foley bag. A Physician's order dated 12/12/2024 documented to maintain Foley catheter 16 French, 20 cubic centimeter balloon, change every month and as needed for infection prevention. During an observation on 1/05/2025 at 9:17 AM Resident #283 was sitting in bed with a Foley bag attached to the side of the bed. The urinary catheter drainage bag was visible from the doorway, not covered, and half filled with urine. During an interview on 1/05/2025 at 9:17 AM, Resident #283 stated the Certified Nursing Assistant placed their Foley bag on the bedside. The resident stated they did not know anything about covering the urinary catheter drainage bag. During an interview on 1/05/2025 at 10:40 AM, Certified Nursing Assistant #8 stated the night shift put Resident #283 back to bed last night and did not cover the urinary drainage bag with a privacy bag. Certified Nursing Assistant #8 stated they would put the urinary catheter drainage bag in a privacy bag when they would get the resident out of bed to the wheelchair. 3) Resident #284 was admitted with diagnoses that included Cerebral Infarction, Obstructive and Reflux Uropathy (a condition that prevents urine from flowing normally through the urinary tract), and Benign Prostatic Hyperplasia (a noncancerous enlargement of the prostate gland). The Minimum Data Set assessment dated [DATE] documented the Brief Interview for Mental Status score of 10, which indicated the resident had moderately impaired cognition. The Minimum Data Set documented the resident was admitted to the facility with an indwelling catheter. A Comprehensive Care Plan was initiated on 12/21/2024 and revised on 1/06/2025, documented interventions that included positioning the urinary catheter bag and tubing below the level of the bladder and away from the entrance room door. Change Foley catheter every month. The interventions did not document the use of a privacy bag for the urinary catheter drainage bag. A Physician's order dated 12/31/2024 documented an order to change the Foley catheter as needed. During an observation on 01/05/2025 at 9:41 AM, Resident #284 was seen in bed sleeping, with a urinary catheter drainage bag hanging from the side of the bed. There was no privacy cover over the urinary catheter drainage bag. The urinary catheter drainage bag. During an interview on 1/05/2025 at 10:30 AM, Certified Nursing Assistant #8 stated the night shift put Resident #284 back to bed last night and did not cover the Foley drainage bag with a privacy bag. Certified Nursing Assistant #8 stated they would put the drainage bag in the privacy bag when they get Resident #284 out of bed to the wheelchair. During an interview on 1/05/2025 at 10:53 AM, Registered Nurse Manager #4 stated all urinary catheter drainage bags should be covered with a privacy cover. They believe they ordered new bag covers for both Resident # 283 and Resident #284 as the previous ones were soiled. A Physician's order dated 1/06/2025 documented an order to maintain the Foley catheter to a straight drain, keep the urinary catheter drainage bag below the level of the bladder, check for placement and function every shift, monitor for any kinks in the tubing, keep the urinary drain bag covered. During an interview on 1/08/2025 at 12:08 PM, the Director of Nursing Services stated all residents with a urinary catheter should have a privacy bag to cover the urinary catheter drainage bag to promote resident privacy. 10 NYCRR 415.5(a) Based on observations, record review, and interviews during the Recertification Survey initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that each resident was treated with respect and dignity and in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for three (Resident #335, Resident#283, and Resident #284) of three residents reviewed for Dignity. Specifically, Resident #335, Resident #283 and Resident #284 were not provided a privacy cover for their urinary catheter bags. Both residents' urinary catheter bags contained urine and were visible from the hallway. The findings are: The facility's policy and procedure titled Foley Catheter Care and Privacy, last revised on 10/19/2024 documented to ensure that the care of residents with Foley Catheters is conducted safely, effectively, and with respect to their privacy and dignity. To promote resident's rights and privacy, the urinary bag must be maintained in a privacy pouch. 1) Resident #335 was admitted with diagnoses including Acute Kidney Failure, Rhabdomylosis (breakdown of muscle tissue that releases a damaging protein into the blood), and Sacral (bottom of the spine) Pressure Ulcer. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #335 had intact cognition. The Minimum Data Set (MDS) assessment documented Resident #335 had an Indwelling Catheter (a thin tube inserted into the bladder to drain urine). A Physician's Order dated 1/3/2025 documented an order for a Foley catheter French 20 with 10 milliliters balloon. Change the catheter every month and as needed. Provide Foley Catheter care every shift and as needed. A Comprehensive Care Plan (CCP) dated 1/5/2025 documented Resident #335 had a Foley catheter related to urinary retention. Interventions included maintaining the Foley Catheter to a straight drain, keeping the urinary catheter bag below the level of the bladder, checking for placement and function every shift, monitoring for any kinks in the tubing, and keeping the urinary catheter drain bag covered. Resident #335 was observed on 1/5/2025 at 10:30 AM sitting in their room in a wheelchair. The resident's urinary catheter bag and the tubing was visible from the hallway. The urinary catheter bag was half-filled with urine. During an interview on 1/5/2025 at 2:34 PM, Certified Nursing Assistant #3 stated they transferred Resident #335 from the bed to the wheelchair. They did not notice a privacy bag was attached to the wheelchair. Certified Nursing Assistant #3 stated they did not place the urinary catheter bag in the privacy bag and should have. During an interview on 1/8/2025 at 8:41 AM, Registered Nurse #3, the Unit Manager stated Certified Nursing Assistant #3 should have placed Resident #335's urinary catheter bag and tubing in the privacy bag to promote the resident's rights and privacy. During an interview on 1/8/2025 at 12:15 PM, the Director of Nursing stated staff should use a privacy bag to cover the urinary catheter drainage bag and the tubing to promote residents' rights, dignity, and privacy at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during an abbreviated survey (Complaint Number: NY00340154) the facility did not ensure each resident receives adequate supervision and assistance to prevent accidents. Specifically, one (Resident #1) of three residents reviewed for accident sustained 10 falls during a short-term stay. Resident #1 sustained a fall 3-day post admission which required hospitalization. During hospitalization, Resident #1 required continuous visual monitoring. Resident #1 was readmitted to the facility and sustained 9 additional unwitnessed falls. The facilities policy and procedure titled Falls and Fall Risk, Managing dated October 20, 2024 documented based on previous evaluations and current data, the staff will identify interventions related to the residents specific risk and causes to try to prevent the resident from falling and to minimize complications from falling. Resident #1 is an [AGE] year-old female admitted to facility 3/19/2024 discharged on 5/22/24 with medical diagnosis including non-traumatic subarachnoid hemorrhage, Urinary tract infection, Hypertension. The Minimum Data Set, dated [DATE] documented Brief Interview Mental Status summary score of 4 indicating impaired cognition. The Minimum data set documented resident did not have any falls in the 6months prior to admission but has fallen with injury since admission. The admission/readmission assessment dated [DATE] identified Resident #1 as a fall risk. The baseline care plan dated 3/19/2024 titled Nursing safety risk documented Resident has a history of falls and is at risk for falls. The Rehabilitation progress note dated 3/19/2024 documented precautions include fall and safety. Resident referred to occupational therapy for impaired balance decrease strength and functional activity tolerance resulting in the need for extensive to total assistance. Out of bed to reclining wheelchair with foam cushion and bilateral leg elevating leg rest. The Comprehensive Care Plan titled fall dated 4/1/2024 identified that the resident was at risk for falls/history of fall related to decreased mobility. The goal is resident will be free of fall with injury through the next review. Interventions include call light and personal items withing reach, low bed and bilateral floor mats, keep environment well lit and free of clutter. The medical records indicated Resident #1 had a total of 10 (ten) falls from March 19, 2024- through May 22,2024. Progress note dated 3/23/2024 documented Resident fell forward from wheelchair to right side of facial area in hallway sustaining a hematoma to upper eyebrow and abrasion to right chest. Resident was transferred to the hospital and admitted . Hospital discharge summary document dated 4/1/2024 documented the primary diagnosis for hospitalization as Non traumatic subdural hemorrhage unspecified. The discharge summary further documented fall/safety precautions; Resident #1 was on continuous visual monitoring via tele sitter during course of hospitalization. The admission/readmission assessment dated [DATE] identified Resident #1 as a fall risk. No new interventions were implemented. The nursing progress note dated 4/5/2024 documented Resident #1 was found on the floor laying on the right side, stated she was getting out of bed and slipped. Resident #1 was instructed to use the call light system. The nursing progress note dated 4/13/24 documented resident was found sitting on the floor at the window. Resident #1 was encouraged to call for help and every 30 min monitoring was implemented. The Nursing progress note dated 4/21/2024 documented Resident #1 was observed in a prone position on the floor, interventions include monitor closely for falls. The nursing progress note date 4/23/2024 documented Resident #1 was observed sitting down on the floor in her room. The nursing progress note dated 4/26/2024 documented Resident #1 was observed on the floor in her room in a seated position. Interventions include continue to monitor closely. The nursing progress note dated 4/30/2024 documented Resident #1 was observed in the lounge area lying on the floor in a right-side position. The Interdisciplinary note documented a meeting was held with the next of kin and the facility staff including the Director of Nursing, Assistant Director of Nursing and social services who made suggestion for the family to consider private companion. The nursing progress note dated 5/1/2024 documented Resident #1 was observed laying on her right side in the common area. The Resident was transferred to the hospital. The nursing progress note dated 5/6/2024 documented Resident #1 was observed sitting on her buttocks with legs stretched in the television area. The note further documented family refused to provide 1:1 private aide. The nursing progress note dated 5/11/2024 documented Resident #1 fell onto buttock and was observed in a seated position in the hallway. The incident report further documents family fails to provide 1:1 from outside and refuses medial suggestions for restlessness. During an interview conducted with the Director of Nursing on 11/5/2025 at 3:45 PM they stated when a resident falls the family and physician are notified and a rehab referral is made. Resident #1 was provided with a low bed and kept in common area. The Director of Nursing stated they told they The Director of Nursing stated there is no defined fall program and falls are discussed during morning report. The Director of Nursing stated with each fall they individually try new things, and the Interdisciplinary team will meet to discuss, there is no timeline or policy. During a second interview the Director of Nursing introduced some stars and stated the facility has a falling star program which is placed on the door and identifies Residents at increased risk for falls. There is no formal policy, and it is not identified on the Certified Nursing Accountability. During an interview conducted with the administrator on 11/5/2024 at 4pm they stated that admission documents are reviewed off site. The Administrator stated for Residents who have frequent fall, the family is recommended visit more frequent to manage behaviors or falls. The Administrator stated the facility would do whatever they needed to do to ensure the residents are safe. 415.4 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility Accidents Incidents Investigating policy dated 5/2023 documented that the following data shall be included on the Report of Incident/Accident form: the names of witnesses and their accounts of the accident or incident and other pertinent data as necessary or required. Resident #76 was admitted to the facility with the diagnoses of non-traumatic chronic Subdural Hemorrhage, Anxiety Disorder and Major Depressive Disorder. The 5-day admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #76 had a Brief Interview for Mental Status (BIMS) score of 9 indicating moderately impaired cognition. Resident #76 required limited assistance of one for bed mobility and transfers. Resident #76 required extensive assistance of two persons for walking in room, corridor, and locomotion on the unit. Resident #76 was not steady but able to stabilize without staff assistance. Resident #76 did not have any wandering behaviors during the assessment period. The physician's orders dated 6/1/2023 documented to check wander guard placement every shift on the right ankle. The care plan dated 6/1/23 entitled At risk for elopement related to Ability to Ambulate/Self-Propel Wheelchair Unassisted, Exit Seeking Behavior documented that Resident #76 had a wander guard on the right ankle. The interventions included to redirect Resident #76 from exit doors when necessary dated 6/1/2023, check wander guard placement every shift and check wander guard function at night by nurse dated 6/9/2023 and 1:1 for close observation dated 6/21/2023. The Elopement report dated 6/21/2023 documented that at approximately 5:50 AM, it was reported by the unit nurse that Resident #76 left the unit. A search was conducted in all areas of the building. While in the lobby, in the process of calling a code green Resident #76 was with a non-staff person at approximately 5:54 AM. The person stated they saw Resident #76 outside and brought Resident #76 back into the facility. The Summary of the Investigation dated 6/21/23 documented that all involved staff were interviewed by the DNS/Administrator and statements were collected. At approximately 5:15 AM, LPN #3 placed Resident #76 in bed and closed Resident #76's room door. LPN #3 last saw Resident #76 approximately 5:45 AM and proceeded to pass morning medications. At approximately 5:50 AM/5:52 AM LPN #3 noticed that the door to Resident #76 room was open. The stairwell exit door alarm was going off LPN #3 went to check the stairs and entered the code incorrectly. LPN #3 notified the supervisor immediately. After calling the supervisor, LPN #3 continued to look for Resident #76 and went down the stairwell. By the time LPN #3 got to the lobby Resident #76 was with the supervisor. RN Supervisor immediately initiated a search throughout different areas of the building, while in the lobby just about to call code Green for elopement, RN Supervisor saw Resident #76 brought back into the building. Review of the employee statements revealed that CNA #5, CNA #6, LPN #3 who all worked on the unit 3 North and RN #12, the house supervisor, was interviewed for Resident #76's 6/21/2023 elopement investigation. RN #12 was interviewed on 6/27/2023 at 1:07 PM. RN #12 stated that they were the regularly assigned overnight (11P-7A) RN Supervisor for the facility. RN #12 stated that at approximately 5:50 AM, RN #12 received a call in the nursing office on the first floor from LPN #3 on Unit 3 North. LPN #3 was asking about how to shut off the alarm of the stairway exit door on the Unit 3 North and to confirm the code. RN #12 told LPN #3 the code and was still on the phone while LPN #3 stepped away to shut off the alarm. LPN #3 told RN #12 that they were not able to turn off the alarm and Resident #76 was missing. RN #12 stated that they (RN #12) immediately left the nursing office to go up to the 3rd floor and took the stairway in front of the elevator near the first-floor lobby. RN #12 did not see Resident #76 in that stairwell on the way upstairs. RN #12 went up to Unit 3 North to assist with looking for Resident #76. RN #12 stated that they heard the 3 North stairwell exit emergency door alarm sounding that was at the end of the Unit 3 North which led to the rear stairwell. RN #12 then went down that stairwell which led to the perimeter fire exit door. The perimeter fire exit door alarm was also sounding. RN #12 stated that they took a glance outside through the glass panel and did not see Resident #76. RN #12 stated they did not open the door and step outside the door to look for Resident #76. RN #12 then went back into the stairwell and went through the entrance to the Rehabilitation gym which led to the lobby area. When RN #12 arrived in the lobby area they saw Resident #76 at the entrance who was brought in by a community neighbor. Resident #76 was wearing a wander guard. RN #12 stated they collected statements from CNA #5, CNA #6, and LPN #3. RN #12 stated they did not collect statements from the I [NAME] Unit staff or the Maintenance Worker (MW) #1 since they were not involved with the incident. MW #1 was interviewed on 6/28/2023 at 7:20 AM. MW #1 stated that they (MW #1) arrived to the facility at 6:00 AM on 6/21/2023 and saw RN#12 sitting in the hallway with Resident #76. RN #12 told MW #1 that Resident #76 took the 3 North Stairwell and went outside. RN #12 told MW #1 that the exit door alarm sounded. MW #1 stated the alarm was shut off when they arrived. On 6/28/2023 at 7:25 AM, Maintenance Worker (MW) #1 demonstrated the fire exit alarm where Resident #76 left the facility. When MW #1 opened the fire exit door, a loud piercing alarm sounded. MW #1 then stated that although the alarm is loud in the stairwell, it cannot be heard past the rehabilitation gym. MW #1 stated that the exit that Resident #76 used to leave the facility was not connected to the mag lock system, which sends an alert to the security desk which is loud enough for someone to hear on the first floor. The Director of Nursing Services (DNS) was interviewed on 6/28/2023 at 9:44 AM. The DNS stated that they did not speak to the first-floor staff to investigate if they heard the alarm from the emergency exit leading to the street because the alarm is not audible past the rehabilitation room. The DNS stated that the Administrator is working on the alarm to be audible past the rehabilitation room. The Director of Nursing Services (DNS) was interviewed on 6/28/23 at 9:44 AM. The DNS stated that statements were obtained from RN #12, CNA #5, CNA #6, and LPN #3. The DNS stated that the emergency exit leading to the street alarm is not audible past the rehabilitation room. The DNS stated that during the investigation, the DNS did not speak to the 1 [NAME] Unit staff to investigate if they heard the alarm or responded to emergency exit alarm leading to the street. The DNS stated they did not interview the MW #1 to determine if they were present or heard the alarm. 10 NYCRR 415.4(b)(3) Based on observation, record review and interviews during the Recertification Survey and Abbreviated survey (NY00318753 and NY00313454), initiated on 6/21/2023 and completed on 6/28/2023, the facility did not ensure that all alleged violations were thoroughly investigated. This was identified for two (Resident #292 and Resident #76) of 6 residents reviewed for Accidents. Specifically, 1) for Resident #292, who was found on the floor, the facility investigation did not include statements from all involved parties to accurately identify the root cause for Resident #292's fall on 10/26/22; and 2) The facility did not obtain statements from the 1st floor 11P-7AM staff and the Maintenance Worker when Resident #76 eloped from the facility on 6/21/2023. The findings are: The facility's policy titled Accidents/Incidents/Investigating, revised 5/2023, documented the following data shall be included on the Report of Incident/Accident form: The name(s) of witnesses and their accounts of the accident or incident; other pertinent data as necessary or required. 1) Resident #292 was admitted to the facility with diagnoses including Cerebrovascular Accident, Non-Alzheimer's Dementia, and Difficulty in Walking. The 11/4/2022 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident had severe cognitive impairment. Review of the Accident/Incident (A/I) report dated 10/26/2022, prepared by Registered Nurse (RN) #4, the former supervisor, documented the following: On 10/26/2022 at 12:15 PM the Resident #292 was found laying on the floor on their right side next to the bed. Resident #292 was noted with a laceration to the right temple. The resident was unable to give a statement due to cognitive issues. 911 was called and the resident was sent to the emergency department. The report documented the fall was witnessed by two staff members; however, the names of the staff witnesses were not included in the column under name. Statements in the report were obtained from Certified Nursing Assistants (CNA) #1, CNA #2 and RN #5 (a former supervisor). CNA #1's statement, dated 10/26/2022, documented CNAs were giving out lunch trays when Resident #292's call bell went off; one of the CNAs (name not documented) answered the call bell and told CNA #1 that the resident was on the floor. CNA #2's statement, dated 10/26/2022, documented at the time of the incident CNA #2 was passing out lunch trays when they saw the resident's call light was on; upon answering the light, CNA #2 saw the resident lying on the floor and CNA #2 informed the nurse in charge. RN #5's statement (undated) documented alerted by nurse manager that the resident was on the floor and to go to room while nurse manager called 911. Resident was observed on the floor on side of bed next to the closet; noted to be bleeding from the head. The Assistant Director of Nursing Services (ADNS) was interviewed on 6/26/2023 at 8:21 AM. The ADNS stated they also work as the risk manager and had reviewed the 10/26/2022 A/I report related to Resident #292's fall. The ADNS stated the A/I report did not clearly identify who had activated the call bell on 10/26/2022 when Resident #292 fell. The ADNS stated maybe the roommate rang the call bell; however, no statements were obtained from the roommate to determine the root cause of the incident. The ADNS stated they (ADNS) identified that the A/I reports were not being thoroughly investigated with all the details and are in the process of re-educating staff who are responsible to complete the A/I reports. RN #4 (former RN supervisor who prepared A/I report) was interviewed on 6/26/2023 at 8:54 AM. RN #4 stated they honestly cannot remember who rang the call bell and or who found the resident. RN #4 stated all the details regarding the incident should be included in the A/I report. RN #4 stated they can guarantee the resident did not call for assistance; the resident was in a puddle of blood. RN #4 stated they should have identified if someone else rang the call bell and obtained their statement to identify the accurate circumstances of the resident's fall. CNA #2 was interviewed on 6/26/2023 at 9:32 AM and stated the roommate said that they (the roommate) pushed the call bell. Review of the A/I report did not include statement from Resident #292's roommate, who had activated the call bell for assistance. RN #5 (former supervisor) was interviewed on 6/26/2023 at 10:28 AM and stated they do not know who rang the call bell. The Director of Nursing Services (DNS) was interviewed on 6/26/2023 at 11:00 AM and stated in the emergent situation the focus is dealing with the emergency, so identifying who was first on the scene and who rang the call bell may have been missed and should be included in the A/I report. The DNS stated that statements from all involved staff and residents should have been obtained to accurately identify the root cause of the incident and rule out abuse, neglect, and mistreatment. The ADNS was re-interviewed on 06/26/2023 at 2:25 PM. The ADNS stated they are in the process of educating the nurses that they have to write more, and they have to include all the details. If they found out that the roommate rang the call bell, then they have to include that information in the A/I report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the Recertification Survey and Abbreviated Survey (NY00313454) initiated on 6/21/2023 and completed on 6/28/2023 the facility did not ensure that each resident's comprehensive person-centered Care Plan (CCP) was reviewed and revised by the Interdisciplinary Team after each assessment. This was identified for one (Resident #292) of five residents reviewed for Accidents, 2) for one (Resident #82) of two residents reviewed for Pressure Ulcers and 3) one (Resident #35) of five residents reviewed for Unnecessary Medications. Specifically, 1) Resident #292 had five falls between 10/25/2022 and 11/29/2022. The resident's Falls care plan was not updated after each fall to reflect new interventions to prevent further falls; 2) Resident #82 with a history of having Pressure Ulcers, developed a new Pressure Ulcer to the sacral area on 9/15/2022. The resident's CCP was not updated to reflect the newly identified PU until 10/14/2022; and 3) Resident #35 had multiple care plans which were not updated to reflect discontinuation of various medications. The findings are: The facility's Policy and Procedure for Comprehensive Care Plan dated 11/30/2022 documented assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1)Resident #292 was admitted to the facility with diagnoses including Cerebrovascular Accident, Non-Alzheimer's Dementia, and Difficulty in Walking. The 11/4/2022 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident had severe cognitive impairment. Review of Accident and Incident (A/I) reports for Resident #292 revealed that the resident had falls on 10/26/2022, 11/7/2022, 11/9/2022, 11/10/2022, and 11/19/2022. The fall on 10/26/2022 resulted in a head laceration and a cervical fracture and the fall on 11/10/2022 resulted in a left shoulder fracture. A Comprehensive Care Plan (CCP) titled At Risk for Falls/History of Falls, was initiated on 10/26/2022 The CCP was updated with additional interventions following the fall on 11/10/2022; however, there the CCP was not updated to reflect falls that occurred on 11/7/2022, 11/9/2022, and 11/19/2022. The Assistant Director of Nursing Services, who was also the Risk Manager, was interviewed on 6/23/2023 at 11:58 AM. The ADNS stated, to be honest with you, I found that when I took over the risk manager position the Registered Nurses that prepared the A/I reports were not putting in interventions to prevent a further occurrence. The ADNS stated the care plan should be updated after each fall. The Director of Nursing Services (DNS) was interviewed on 6/26/2023 at 2:13 PM. The DNS stated that the Fall Risk care plan should be updated with new interventions after each fall. The DNS stated the RN supervisor is responsible to update the care plan. 2) The facility policy titled, Care Plans, Comprehensive Person-Centered dated 11/30/2022 documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Resident #82 was admitted with diagnoses that include Dementia, Severe Protein Calorie Malnutrition, and Hypertension (HTN). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and a Brief Interview for Mental Status (BIMS) could not be completed. The resident required extensive assistance of two persons for bed mobility, transfers, and toilet use. The resident was always incontinent of bowel and bladder. The resident was at risk for developing pressure ulcers and had one unstageable pressure ulcer upon admission to the facility. The resident utilized pressure-reducing devices while in a chair and bed and was on a turning and positioning schedule. A Quarterly MDS assessment dated [DATE] documented the resident had short and long term memory problems and required extensive assistance of two persons for bed mobility, transfers, and toilet use. The resident remained frequently incontinent of bowel and bladder. The MDS documented the resident had one Stage II pressure ulcer that was present on admission. The resident continued to utilize pressure-reducing devices while in a chair and bed and was on a turning and positioning schedule. A Comprehensive Care Plan (CCP) for alteration in skin integrity-actual pressure injury to the left Trochanter (hip) present upon admission dated 7/21/2022 documented interventions that included but were limited to: administer treatments/medications as ordered and monitor for effectiveness; educate the resident/family/caregivers as to causes of skin breakdown; and to notify the physician of significant findings. The CCP was updated on 7/25/2022, 7/29/2022, 8/4/2022, and 8/11/2022 to include changes made to the left Trochanter wound treatments and modalities as well as turning and positioning every two hours. A Physician's order dated 9/15/2022 documented to apply Medihoney External Gel (Wound Dressing) to the Sacrum topically two times a day for Stage II pressure ulcer. Cleanse the area with normal saline, pat dry, apply Medihoney, and cover with a Foam dressing. The Treatment Administration Record (TAR) for September 2022, documented to apply Medihoney External Gel (Wound Dressing) to the Sacrum topically two times a day for Stage II Pressure Ulcer (PU). Cleanse the area with normal saline, pat dry, apply Medihoney, and cover with a Foam dressing. The treatment was initiated on 9/15/2022 and was discontinued on 10/14/2022. The TAR indicated that the treatment was being administered twice daily at 9:00 AM and 9:00 PM as evidenced by the staff signature except on 9/26/2022. A review of the medical record dated 9/15/2022 through 9/28/2022 revealed no documented evidence of an assessment, measurement, or description of the Stage II sacral wound that was identified on 9/15/2022. The Healthcare Provider Wound Care Evaluation and Treatment Progress Note dated 9/29/2022 at 9:43 AM, written by the Wound Care Physician (MD) #1, documented Late Entry, the resident was assessed for the left Trochanter and Sacral unstageable wounds. Wounds were assessed, measured, discussed, and documented with the facility wound care nurse. A Skin and wound care note dated 9/29/2023, written by Registered Nurse (RN) #2 who was the wound care nurse, documented the resident was seen and examined by the wound MD and noted with impairment to the sacral region. The wound care evaluation note dated 9/29/2022 documented resident was evaluated for a new Stage III full-thickness PU measuring 4.2-centimeter (cm) length x 2.7 cm width x 0.4 cm depth. The wound bed was noted with 80% slough (dead tissue), a moderate serosanguinous exudate (drainage), and a faint odor. The wound was debrided using sharp debridement (removing the dead tissues with a scalpel or scissors). A Physician's note dated 10/9/2022 documented Left trochanter, Stage 3, Sacrum, unstageable wound, warm and dry, apply local wound care. The Wound Physician's Progress Note dated 10/13/2022 documented Sacral wound was re-evaluated, and a sharp wound debridement was performed. The devitalized tissue was removed using sharp debridement with scissors, a scalpel, and a curette. The Sacrum wound was re-characterized after debridement as a Stage IV Pressure Ulcer. The CCP for alteration in skin integrity-actual pressure injury to the left Trochanter was not updated or a new CCP was not initiated to reflect the development of the sacral pressure ulcer when the sacral Stage II Pressure Ulcer was first identified on 9/15/2022. A CCP was not developed for this wound until 10/14/2022. A CCP dated 10/14/2022 documented that the resident has a Pressure Ulcer to the left Trochanter and Sacrum. Interventions included but were not limited to educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements, good nutrition, and frequent repositioning; and monitor nutritional status. RN #2, the interim wound care nurse, was interviewed on 6/27/2023 at 2:48 PM and stated that they were notified by a staff member (could not recall the name) on 9/29/2022 regarding Resident #82's sacral Pressure Ulcer. RN #2 stated that a CCP was already in place for Resident #82 for the preventative measures, the resident was utilizing an air mattress and was on turning and positioning every two to four hours. RN #2 was re-interviewed on 6/27/2023 at 4:29 PM and stated that they should have initiated a CCP for the Sacrum Pressure Ulcer at the time that the PU was identified. The Director of Nursing Services (DNS) was interviewed on 6/28/2023 at 2:40 PM and stated that the staff should have assessed the newly identified sacral Stage II Pressure Ulcer when it was first identified on 9/15/2022 and should then be followed weekly by the wound care team. The DNS stated that the staff should have also updated the CCP to reflect the newly developed sacral PU presence and any changes or updates to the interventions. 3) Resident #35 was admitted with diagnoses that include Urinary Tract Infection, Anxiety, and Congestive Heart Failure. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had impaired short term and long-term memory problems and had significantly impaired decision-making capacity. A Physician's order dated 3/17/2023 documented to discontinue Digoxin (heart medication) Tablet 125 micrograms (MCG). A Comprehensive Care Plan (CCP) for Congestive Heart Failure dated 2/21/2022 and last reviewed 5/12/2023 documented the resident has Congestive Heart Failure as evidenced by Digoxin therapy. The CCP was not updated when Digoxin was discontinued on 3/17/2023. A Physician's order dated 8/15/2022 documented to discontinue Ciprofloxacin (Antibiotic) Oral Tablet 500 milligrams (MG). A CCP for Urinary Tract Infection (UTI) dated 2/21/2022 and last reviewed 5/12/2023 documented the resident had Urinary Tract Infection as evidenced by use of CIPRO therapy for a UTI. The CCP was not updated when Ciprofloxacin was discontinued on 8/15/2022. A Physician's order dated 11/22/2022 documented to discontinue Xanax (antianxiety medication) Oral Tablet 0.25 MG. A CCP for Anxiety Disorder and the use of Anti-anxiety medications dated 2/21/2022 and last reviewed 5/12/2023 documented the resident uses anti-anxiety medications as evidenced by Xanax. The CCP was not updated when Xanax was discontinued on 11/22/2022. Registered Nurse (RN #8), the MDS (Minimum Data Set) coordinator, was interviewed on 6/27/2023 at12:22 PM and stated that it is the job of the floor nursing supervisor to update and revise the care plans. Registered Nurse (RN #7), the current registered nurse supervisor for units 2 North and 2 West, was interviewed on 6/27/2023 at 12:57 PM. RN #7 stated that it is the job of the manager to update, review and revise the care plans for accuracy. RN #7 stated that the manager is expected to write a note to show that an update was conducted and to discontinue the care plan when appropriate. RN#7 stated that the manager who covered unit 2 [NAME] (Res #35's unit) at the time of the 5/12/23 care plan review no longer worked at the facility. The Director of Nursing Service (DNS) was interviewed on 6/28/2023 at 2:25 PM and stated that their expectation was that the discipline who initiated the care plan would be the discipline responsible for its discontinuation when appropriate. Since these three care plans involved medications, nursing was responsible for the discontinuation of the care plans. 10 NYCRR 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the Recertification Survey initiated on 6/21/2023 and completed on 6/28/2023, the facility did not ensure that residents were given the appropriate treatment and services to maintain or improve their ability to carry out Activities of Daily Living (ADLs). This was identified for one (Resident #33) of two residents reviewed for the Rehabilitation and Restorative care area. Specifically, Resident #33 was not ambulated according to their Floor Ambulation Program (FAP) as ordered by the Physician. The finding is: The facility's policy titled, Floor Ambulation Program and last reviewed in March 2023 documented that once a resident is deemed suitable for floor ambulation and staff is adequately trained, the ambulation program will be included in the (Physician) Orders, ADL Care Plan, and the Task [Certified Nursing Assistant (CNA) Instructions]. Staff will document each resident's ambulation sessions, including distance, and level of assistance required. Staff will report to Nurse/Supervisor change in distance, level of assistance, and intolerance. Nurse/Supervisor will document in a Progress Note and notify Rehabilitation and Physician of findings. Resident #33 has diagnoses which include Hypertension and Hypothyroidism. The admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated that the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance of one person for bed mobility, transfers, walking in room/corridor, locomotion on/off unit, dressing, toilet use, and personal hygiene. The resident used a cane/crutch and walker as mobility devices. The Task History dated 5/17/2023 and entered into the resident's Electronic Medical Record (EMR) by Physical Therapist (PT) #3 documented: Description - FAP with rolling walker (RW) up to 100 feet with limited assistance of one (person) and wheelchair (WC) follow twice daily. The Physician's Order dated 5/22/2023 documented Floor Ambulation Program: Patient is to ambulate with RW up to 100 feet with limited assist of one (person) and WC follow twice daily. The Documentation Survey Report dated May 2023 documented: FAP with RW up to 100 feet with limited assist of one (person) and WC follow twice daily. Under this task, there were 7 occasions on the 3:00 PM-11:00 PM shift that CNA #9 documented Not Applicable (NA) for the resident. The Documentation Survey Report dated June 2023 documented: FAP with RW up to 100 feet with limited assist of one (person) + WC follow twice daily. Under this task, there were 3 occasions on the 7:00 AM-3:00 PM shift that CNA #8 documented NA for the resident and 10 occasions on the 3:00 PM-11:00 PM shift that CNA #9 documented NA for the resident. CNA #8 was interviewed on 6/23/2023 at 2:20 PM and stated that they (CNA #8) were not a regular CNA on the resident's unit and they (CNA #8) were not aware that the resident was on FAP and had never done FAP with the resident. CNA #8 stated that usually the regular CNAs on the unit would tell them (CNA #8) if a resident was on a FAP, the resident themselves would tell them (CNA #8), or it would be on the resident's Accountability (Task) to do FAP with the resident. CNA #8 stated that they (CNA #8) never noticed that they (CNA #8) were documenting NA for the resident's FAP on the Documentation Survey Report. CNA #9 was interviewed on 6/23/2023 at 3:30 PM and stated that when they (CNA #9) documented NA for the resident's FAP on the Documentation Survey Report they meant that they (CNA #9) did not perform FAP with the resident. CNA #9 stated that if they (CNA #9) saw Rehab already walking with the resident, then they (CNA #9) would not have to do FAP with the resident. CNA #9 also stated that sometimes the resident would also refuse to be walked, but they (CNA #9) did not know why they (CNA #9) had documented the resident's refusal as NA when they could have chosen the option of Resident Refused (RR) in the computer system. The Director of Rehab was interviewed on 6/23/2023 at 3:45 PM and stated that when a Rehab Therapist walks a resident on the unit to work on functional mobility, that does not take the place of a resident's FAP. Resident #33 was interviewed on 6/23/2023 at 3:55 PM and stated that when their CNA does not walk them (Resident #33), it is because the CNAs are too busy taking care of other residents. Resident #33 stated that they (Resident #33) never refuse to walk because they (Resident #33) enjoy walking, enjoy life, and love moving. The Director of Nursing Services (DNS) was interviewed on 6/23/2023 at 4:15 PM and stated that if a resident refuses anything, including FAP, the CNA should make the Nurse aware as soon as possible. The DNS stated that all refusals must be documented and brought forward to a Nursing Supervisor. 10 NYCRR 415.12(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, during a Recertification Survey initiated on 6/21/2023 and completed on 6/28/2023 the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #82) of two residents reviewed for Pressure Ulcers (PU). Specifically, Resident #82 was identified as having a Stage II Pressure Ulcer to the Sacral region on 9/15/2022 as per a Physician's orders dated 9/15/2022. There was no documented evidence in the medical record that the Sacral PU was evaluated or assessed by a qualified clinician until 9/29/2022. The Wound Care Physician (MD #1) assessed the Sacral wound as an unstageable PU and conducted a sharp debridement (removing the dead tissues with a scalpel or scissors) and then reclassified the Sacral PU as a Stage III PU. Additionally, the wound care recommendations provided by MD #1 were not implemented by the facility staff. The finding is: The facility's untitled policy, dated January 2022 and last reviewed January 2023, documented to assess and treat the skin of each resident to prevent and care for pressure ulcers. The nurse/designee will assess and inspect the condition of the resident's skin upon admission, readmission, quarterly and episodically as needed, initiate a risk for pressure ulcer care plan, and update as needed. New interventions will be added as needed to prevent pressure ulcers and to manage treatment. Wound rounds will be conducted weekly on each unit to assess and plan the care of all residents with pressure ulcers. The Registered Nurse (RN) Supervisor/designee shall measure and track wounds weekly. Resident #82 was admitted with diagnoses that included Dementia, Severe Protein Calorie Malnutrition, and Hypertension (HTN). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and a Brief Interview for Mental Status (BIMS) could not be completed. The resident required extensive assistance of two persons for bed mobility, transfers, and toilet use. The resident was always incontinent of bowel and bladder. The resident was at risk for developing pressure ulcers and had one unstageable PU upon admission to the facility. The resident utilized pressure-reducing devices while in a chair and bed and was on a turning and positioning schedule. A Quarterly MDS assessment dated [DATE] documented the resident had short and long term memory problems and required extensive assistance of two persons for bed mobility, transfers, and toilet use. The resident remained frequently incontinent of bowel and bladder. The MDS documented the resident had one Stage II PU that was present on admission. The resident continued to utilize pressure-reducing devices while in a chair and bed and was on a turning and positioning schedule. A Comprehensive Care Plan (CCP) for alteration in skin integrity-actual pressure injury to the left Trochanter (hip) present upon admission dated 7/21/2022 documented interventions that included but were limited to: administer treatments/medications as ordered and monitor for effectiveness; educate the resident/family/caregivers as to causes of skin breakdown; and to notify the physician of significant findings. The CCP was updated on 7/25/2022, 7/29/2022, 8/4/2022, and 8/11/2022 to include changes made to the left Trochanter wound treatments and modalities as well as turning and positioning every two hours. The Braden Scale for Predicting Pressure Sore Risk dated 7/27/2022 documented the resident was at high risk for developing PU. The risk score was updated on 8/17/2022 to indicate the resident now was at moderate risk for developing PU. A Physician's order dated 9/15/2022 documented to apply Medihoney External Gel (Wound Dressing) to the Sacrum topically two times a day for Stage II pressure ulcer. Cleanse the area with normal saline, pat dry, apply Medihoney, and cover with a Foam dressing. A Wound Physician's Progress note dated 9/22/2022, written by MD #1, documented the presence of the left Trochanter PU. The progress note did not include the presence of the Sacral PU. A Review of the Physician's Wound Evaluation dated 9/22/22 lacked documented evidence of the presence of a Sacral PU. The CCP for alteration in skin integrity-actual pressure injury to the left Trochanter was not updated or a new CCP was not initiated to reflect the development of the sacral pressure ulcer when the sacral Stage II Pressure Ulcer was first identified on 9/15/2022. A CCP was not developed for the Sacral Wound until 10/14/2022. A CCP dated 10/14/2022 documented that the resident with a Pressure Ulcer to the left Trochanter and Sacrum. Interventions included but were not limited to: educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements, good nutrition, and frequent repositioning; and monitor nutritional status. The wound care evaluation and treatment progress note dated 9/29/2022, written by MD #1, documented the Sacral Wound site treatment recommendation: sharp wound debridement. The procedure note section documented: the sacrum wound was sharply debrided with good patient tolerance and the daily treatment recommendations were to apply Silver Alginate and use the dry protective dressing for the unstageable Sacral PU. The skin and wound evaluation dated 9/29/2022 documented resident was evaluated for a new Stage III full-thickness PU measuring 4.2-centimeter (cm) length x 2.7 cm width x 0.4 cm depth. The wound bed was noted with 80% slough (dead tissue), a moderate serosanguinous exudate (drainage), and a faint odor. The wound was debrided using sharp debridement. The wound care evaluation and treatment progress note, written by MD #1, dated 10/6/2023 documented Sacral Wound site treatment recommendation: sharp debridement. Assessment: Sacrum Stage IV, recharacterized after debridement. The Treatment Administration Record (TAR) dated 9/25/2022 through 10/14/2022 documented to apply Medihoney External Gel (Wound Dressing) to the Sacrum topically two times a day for Stage II Pressure Ulcer (PU). Cleanse the area with normal saline, pat dry, apply Medihoney, and cover with a Foam dressing. The wound care evaluation and treatment progress note dated 10/7/2022, written by MD #1, documented the Sacral Wound site Stage IV, the sacral wound was sharply debrided with good patient tolerance. MD #1 documented to continue the use of Silver Alginate, followed by a dry protective foam dressing. A Physician's order dated 10/14/2022 documented, Silvadene External Cream 1 % (Silver Sulfadiazine), Apply to Sacrum topically one time a day for Apply to Sacrum topically two times a day for STAGE II. The Medication Administration Record (MAR) dated 10/15/2022 through 10/21/2022 documented to apply Silvadene External Cream 1% to Sacrum topically one time a day. Under the same section, the MAR also documented directions to apply Silvadene External cream 1% to the sacrum twice daily for Stage II Pressure Ulcer; however, the staff signature indicated that the treatment was only administered once a day. The TAR dated 10/22/2022 through 10/27/2022 documented to cleanse the sacral wound with normal saline and apply Silver Alginate (wound dressing) and cover with a foam dressing one time a day for the wound. Registered Nurse (RN) #6, was interviewed on 6/27/2023 at 3:25 PM and stated that in September 2022, they were working as the nurse manager on Resident #82's unit. RN #6 stated that the staff did not inform them of the resident's Sacral PU when the wound was first discovered on 9/15/2022. Licensed Practical Nurse (LPN) #1 was interviewed on 6/28/2023 at 12:30 PM and stated they were the medication nurse on the 2 [NAME] unit where the resident resided on 9/15/2022. Resident #82 was later transferred to the 3 [NAME] unit on 9/21/2022 or 9/22/2022. LPN #1 stated that Resident #82 had a PU on the Sacrum and was getting treatment to the area twice a day. The treatment order was initiated on 9/15/2022. LPN #1 stated that the LPNs do not assess the PU, it is the responsibility of the RNs and the Wound Care Physician. LPN #2 was interviewed on 6/28/2023 at 1:00 PM and stated they are the medication nurse on the 3rd floor where the resident currently resides. LPN #2 stated when the resident moved from the second floor to the third floor in September 2022, they (Resident #82) had two PUs, one on the left hip and the other one on the sacrum. LPN #2 stated that Medihoney was initially used for the wound treatment which was later changed to Silver Alginate. LPN #2 stated that initially, the Sacral PU was approximately nickel size with some depth. The surrounding skin was red, and the wound bed was pink in color, and then the wound care doctor changed the treatment to Alginate. LPN #2 stated they did not know why the resident's Sacral PU was not evaluated by MD #1. LPN #2 stated the resident is on turning and positioning every two hours, utilizes an air mattress, and receives nutritional supplements. Registered Nurse (RN) #2, the interim wound care nurse, was interviewed on 6/28/2023 at 1:30 PM and stated that they were a part-time Nurse Manager in September 2022 on the 3rd floor. RN #2 stated that Resident #82 was admitted with a hip Pressure Ulcer. RN #2 stated on 9/29/2022 a Certified Nursing Assistant (CNA) (name not recalled) notified them about Resident #82's Sacral Pressure Ulcer. MD #1 was in the building and was making wound rounds. Resident #82 was seen by MD #1 on wound rounds and the Sacral Wound was assessed as a Stage III Pressure Ulcer. RN #2 stated that based on the documentation in the chart there was no evaluation or progress notes in the medical record related to the Sacral PU prior to 9/29/2022. RN #2 stated that once the wound was first identified they expected the unit staff to notify the wound care nurse, and the Primary Care Physician. The PU should have been assessed weekly by the wound care Physician to monitor progress. RN #2 stated that on 9/29/2022 MD #1 recommended Calcium Alginate and Antimicrobial instead of the Medihoney; however, the treatment order was not changed as per the recommendations. RN #2 stated that on 10/7/2022 recommendations were again made to change the treatment to Calcium Alginate; however, the treatments were not changed as per the recommendations and the wound was treated with Silvadine cream instead. RN #2 stated that MD #1's recommendations should have been followed as the wound had moderate drainage and the recommended treatment was appropriate based on the wound presentation. MD #1, the Wound Care Physician, was interviewed on 6/28/2023 at 2:00 PM and stated that they assessed Resident #82's Sacral Wound on 9/29/2022 when they were first made aware of the presence of the Sacral PU. MD #1 stated that they were following the resident's hip wound weekly and on 9/22/2022 they evaluated the resident's hip wound but not the Sacral PU. MD #1 stated when making rounds they normally would not turn the resident to see other areas unless they were made aware of any newly developed wounds. MD #1 stated the recommendations for changes in treatment are based on the changes in wound characteristics and the wound's response to the previous treatments. MD #1 stated they expect that the recommendation be followed by the facility staff for optimal wound healing. MD #1 stated Silvadene Cream is normally utilized on the wound periphery to prevent maceration or erythema. MD #1 stated application of Silvadene on the wound bed would not harm the wound but the recommended treatment should be followed for effectively treating the wound. The Director of Nursing Services (DNS) was interviewed on 6/28/2023 at 2:40 PM and stated that the staff should have assessed the newly identified Sacral Stage II PU when the Ulcer was first identified on 9/15/2022. The DNS stated the wound then should be followed weekly by the wound care team. The DNS stated that the staff must follow the wound care MD recommendations for effective wound healing. The staff should have also updated the CCP to reflect the newly developed wound presence. The DNS further stated that they expected staff to report the changes in the resident's wound condition as soon as it is first identified. 10 NYCRR 415.12(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the Recertification Survey and Abbreviated Survey (NY00318753), the facility did not ensure that all residents received adequate supervision to prevent accidents. This was identified for one (Resident #76) of three residents reviewed for Accident Hazards. Specifically, Resident #76 exhibited exit seeking behaviors. On 6/21/2023, Resident #76 left the facility through two alarmed doors undetected by the facility staff and was located outside the facility by a community member. Additionally, during observation the fire exit door alarm that Resident #76 had previously breached was not audible to staff on the 1st floor, including the reception area. The finding is: The facility's Wandering Elopement policy dated 6/8/2023 documented that if an employee observes a resident leaving the premises, they should attempt to prevent the resident from leaving in a courteous manner; get help from other staff members in the immediate vicinity, if necessary; and instruct another staff members to inform the charge nurse or Director of Nursing Services (DNS) that a resident is attempting to leave or has left the premises. The facility emergency procedure for missing resident dated 6/8/2023 documented that staff should initiate a thorough search to locate the resident. If the resident is not located, proceed with the following: instruct staff members to search the entire facility, grounds, and neighboring streets. Resident #76 was admitted with the diagnoses of non-traumatic chronic Subdural Hemorrhage, Anxiety Disorder and Major Depressive Disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #76 had a Brief Interview for Mental Status (BIMS) score of 9 indicating moderately impaired cognition. Resident #76 required limited assistance of one person for bed mobility and transfers. Resident #76 required extensive assistance of two persons for walking in room, corridor, and locomotion on the unit. Resident #76 was not steady but was able to stabilize without staff assistance. Resident #76 did not have any wandering behaviors during the assessment period. Review of nursing progress notes revealed that from 5/22/2023 to 5/31/2023, Resident #76 was identified as requiring one to one supervision due to unsteadiness and constantly getting out of bed and climbing into the roommate's bed while the roommate was in bed, disrobing and throwing clothes/brief on the floor, resistive with care, and wanting to go home to parents. Staff provided constant redirection with little improvements. The nursing progress note dated 6/1/2023 documented that Resident #76 I want to kill myself, I don't want to stay here, my son put me in this prison. Resident #76 was observed attempting to take the elevators and to use the stairs. Resident #76 was redirected and 1:1 observation with nursing staff was put in place, the physician was made aware, an order was obtained for a psychiatric consult. An elopement assessment was generated and a wander guard was placed on the right ankle. Review of the elopement risk assessment dated [DATE] documented Resident #76 was not an elopement risk, and that resident verbalized a strong desire to leave the facility. The physician's orders dated 6/1/2023 documented to check wander guard placement every shift on the right ankle. A Comprehensive Care Plan (CCP) care plan dated 6/1/2023 entitled, At risk for elopement related to Ability to Ambulate/Self-Propel Wheelchair Unassisted, Exit Seeking Behavior documented that Resident #76 had a wander guard on the right ankle. The interventions included to redirect Resident #76 from the exits when necessary. The CCP was updated on 6/9/2023 to check wander guard placement every shift and check wander guard function at night by nurse. The CCP was updated on 6/21/2023 to provide 1:1 for close observation. The elopement risk assessment dated [DATE] documented Resident #76 was identified with a potential elopement risk due to wandering through facility. The Elopement report dated 6/21/2023 documented that at approximately 5:50 AM, it was reported by the unit nurse that Resident #76 left the unit. A search was conducted in all areas of the building. While in the lobby, in the process of calling a code green, the resident was with a non-staff person at approximately 5:54 AM. The person stated they saw Resident #76 outside and brought Resident #76 back to the facility. Resident #76 stated they were looking for their family member. Resident #76 was assessed, and the wander guard was in place to the right ankle and was functioning. Resident #76 was placed on a 1:1 supervision. The Summary of the Investigation report dated 6/21/2023 documented that all involved staff were interviewed by the Director of Nursing Services (DNS)/Administrator and statements were collected. At approximately 5 AM Resident #76 made attempts to open the exit door, the alarm was sounding, and Resident #76 was redirected each time. At approximately 5:15 AM, Licensed Practical Nurse (LPN) #3 placed Resident #76 in bed, medicated Resident #76 as per orders and closed Resident #76's room door. LPN #3 then closed the double doors to dissuade Resident #76 from going toward the exit door. LPN #3 last saw Resident #76 at approximately 5:45 AM. At approximately 5:50 AM-5:52 AM, LPN #3 noticed that the door to Resident #76's room was open and exit door alarm was going off. All staff on the unit checked for Resident #76. LPN #3 notified the supervisor immediately. After calling the supervisor, LPN #3 continued to look for Resident #76 and took the stairs. By the time LPN #3 got to the lobby Resident #76 was with the nursing supervisor. The facility did not provide documented evidence of the hourly monitoring for Resident #76. Resident #76 was observed lying in bed on 6/22/2023 at 10:00 AM. Resident #76 stated that they did not remember what happened on 6/21/2023. RN #6 was interviewed on 6/27/23 at 11:51 AM. RN #6 stated that they were the regularly assigned RN Supervisor on Unit 3 North on the 7A-3P shift. RN #6 stated that they reassessed Resident #76's elopement risk on 6/1/2023 after Resident #76 had verbalized they (Resident #76) did not want to stay at the facility while attempting to leave the unit on the elevator. RN #6 implemented the wander guard and 1:1 supervision. RN #6 stated that the 1:1 supervision was a temporary measure for 3 days to address the suicidal ideation and elopement attempt on 6/1/2023. Resident #76 was subsequently monitored on standard hourly observations. RN #12 was interviewed on 6/27/2023 at 1:07 PM. RN #12 stated that they were the regularly assigned overnight (11P-7A) RN Supervisor for the facility. RN #12 stated that at approximately 5:50 AM, RN #12 received a from LPN #3 on Unit 3 North. LPN #3 was asking about how to shut off the alarm of the stairway exit door on the Unit 3 North and to confirm the code. RN #12 told LPN #3 the code and was still on the phone while LPN #3 stepped away to shut off the alarm. LPN #3 told RN #12 that they were not able to turn off the alarm and Resident #76 was missing. RN #12 stated that they (RN #12) immediately left the nursing office on the first floor to go up to the 3rd floor and took the stairway in front of the elevator near the first-floor lobby. RN #12 did not see Resident #76 in that stairwell on the way upstairs. RN #12 went up to Unit 3 North to assist with looking for Resident #76. RN #12 stated that they heard the 3 North stairwell exit emergency door alarm sounding that was at the end of Unit 3 North which led to the rear stairwell. RN #12 then went down that stairwell which led to the perimeter fire exit door. The perimeter fire exit door alarm was also sounding. RN #12 stated that they took a glance outside through the glass panel and did not see Resident #76. RN #12 stated they did not open the door and step outside the door to look for Resident #76. RN #12 then went back into the stairwell and went through the entrance to the Rehabilitation gym which led to the lobby area. When RN #12 arrived in the lobby area they saw Resident #76 at the entrance, who was brought in by a community neighbor. Resident #76 was wearing a wander guard. CNA #6 was interviewed on 6/27/2023 at 1:51 PM. CNA #6 stated that they were assigned to Resident #76 on 6/20/2023 overnight shift into 6/21/2023. CNA #6 would often have to redirect Resident #76 back to their room. CNA #6 stated that they never saw Resident #76 attempt to leave the facility prior to 6/21/2023. CNA #6 stated that Resident #76 was constantly getting out of the bed throughout the shift, and they (CNA #6) frequently went out in the hallway to redirect Resident #76 back to their room. At around 5 AM, LPN #3 was in the hallway doing medication rounds while CNA #5 and CNA #6 were doing incontinence care to residents on the unit. Resident #76 was walking towards the 3 [NAME] Unit and CNA #6 escorted Resident #76 back to their room. CNA #6 then went to another room to provide care to another resident and heard the alarm to the exit door at the far end of 3 North Unit. CNA #6 went to the hallway and saw LPN #3 with Resident #76. LPN #3 told CNA #6 that Resident #76 was pushing on the exit door. LPN #3 walked with Resident #76 to the nurse's station and LPN #3 closed the fire doors behind them. CNA #6 assumed that LPN #3 was directly supervising Resident #76, so CNA #6 moved on to provide care for another resident at the far end of the unit. CNA #6 heard the alarm still sounding and LPN #3 asked CNA #6 if CNA #6 saw Resident #76. CNA #6 then went to Resident #76's room and checked Resident #76's bathroom. CNA #6 then took the elevator down to the second floor and informed the 2 [NAME] Unit LPN that Resident #76 was missing. By the time CNA #6 made it downstairs on the first floor, CNA #6 saw RN #12 with a stranger and Resident #76. LPN #3 was interviewed on 6/28/2023 at 6:25 AM. LPN #3 stated that they were the regularly assigned LPN for Unit 3 North on the 11P-7A shift. LPN #3 stated that at around 5 AM, Resident #76 kept leaving the room saying help me, help me which was typical behavior for Resident #76. At 5:15AM, LPN #3 administered Resident #76's medications. As LPN #3 was passing medications Resident #76 tripped the alarm at the end of the 3 North hallway at around 5:45 AM. LPN #3 tried to shut off the alarm but could not. LPN #3 then escorted Resident #76 back to their room, placed Resident #76 in bed and closed the room door. LPN #3 then closed the double doors at the middle of the 3 North hallway. LPN #3 called RN #12 to confirm the code to shut off the alarm. LPN #3 could not get the alarm to stop sounding. LPN #3 then went to the nurse's station to check the code at the desk. LPN #3 stated that they did not take Resident #76 with them to the nurse's station because they saw CNA #6 in the hallway and believed that Resident #76 was in their room. When LPN #3 walked towards the double doors at the middle of the 3 North hallways to attempt to shut of the alarm, LPN #3 noticed that Resident #76's door was open and Resident #76 was missing at 5:52 AM. LPN #3 notified RN #12 that Resident #76 was missing. LPN #3 then went down the 3 North stairwells to look for Resident #76. On 6/28/2023 at 7:25 AM, Maintenance Worker (MW) #1 demonstrated the fire exit alarm where Resident #76 left the facility. When MW #1 opened the fire exit, a loud piercing alarm sounded. MW #1 then stated that although the alarm is loud in the stairwell, it cannot be heard past the rehabilitation gym. MW #1 stated that the alarm can only be disengaged with a key and proceeded to use the key to disengage the alarm. MW #1 stated that the exit that Resident #76 used to leave the facility was not connected to the mag lock system, which sends an alert to the security desk which is loud enough for someone to hear on the first floor. MW #1 stated that only the door to the rehabilitation gym which leads to the exit that Resident #76 took is connected to the mag lock system. MW #1 demonstrated the alarm sound to the rehabilitation gym exit which was loud and piercing at the exit door. MW #1 proceeded to exit the rehabilitation gym and the security desk alarm was sounding throughout the hallway leading to the lobby. The Director of Support Services (DSS) was at the lobby area during the observation. The DSS stated that the stairwell where Resident #76 exited does not have any surveillance camera. The DSS stated that after the incident, they spoke with the Administrator about installing a surveillance camera in that area. The DSS stated that they also suggested connecting that exit door to the mag lock system or enhancing the alarm sound so that staff are aware that the exit leading outside was opened. The Director of Nursing Services (DNS) was interviewed on 6/28/2023 at 9:44 AM. The DNS stated that they did not speak to the first-floor staff to investigate if they heard the alarm from the emergency exit leading to the street because the alarm is not audible past the rehabilitation room. The DNS stated that the Administrator is working on the alarm to be audible past the rehabilitation room. The DNS stated that 11P-7A staff should have been aware that Resident #76 had a previous elopement attempt. The Administrator was interviewed on 6/28/2023 at 12:03 PM. The Administrator stated that after 6/21/2023 the exit door that was breached was determined to be functioning. The Administrator was told by the facility vendor that the alarm at the exit door was set to the loudest setting. The Administrator stated that today (6/28/2023) the facility arranged for an electrician to rewire the exit door alarm to be enunciated to the front desk and 1 [NAME] unit. The Administrator stated that they were unable to get this modification done sooner because the electrician was on another job on 6/21/2023 and was not available until 6/28/2023. 10 NYCRR 415.12(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 6/21/2023 and completed on 6/28/2023, the facility did not assure that each resident was provided medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This was identified for one (Resident #42) of one resident reviewed for Advance Directives. Specifically, Resident #42 was admitted to the facility on [DATE]. Social Services conducted initial Social Services Evaluation upon admission on [DATE]; however, there was no documented evidence that the Advance Directives were reviewed with Resident #42 or their designated representative after 3/12/2022 as per the facility's policy. The finding is: The facility's Advance Directives policy dated 3/2023, documented that prior to or upon admission of a resident, the social services director or designee must inquire of the resident and/or resident's designated representative about the existence of any written advance directives. Changes are documented in the care plan and medical record. Information about whether the resident has executed an advance directive is displayed prominently in the medical record in a section retrievable by any staff. Advance Directives will be reviewed annually with the resident to ensure that such directives are still the wishes of the resident. Resident #42 was admitted with diagnoses including Huntington's Disease, Anorexia, and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. The MDS documented the resident had no advance directives. The initial Social Services Evaluation dated 3/12/2022 documented the resident's representative declined to initiate directives at the time of admission and demonstrated good understanding that Resident #42 would be a Full Code. Education was provided to the family on advance directives. The Physician's order dated 6/27/2023 documented that the resident was a Full Code as their advance directives. The care plan entitled Resident has Advance Directives: Full Code was developed and implemented on 6/27/2023 by Social Services. Social Worker (SW) #1 was interviewed on 6/27/2023 at 10:00 AM and stated that they were responsible for evaluating Resident #42 upon admission. Care plans including Advance Directives are reviewed on a quarterly/annual basis. SW #1 stated that they have reached out to the resident's designated representative about receiving a healthcare proxy (HCP) form but have not received one. SW #1 stated there was no further documentation from SW #1 for the resident on their advance directives. The Social Service note dated 6/28/2023 documented the resident's designated representative sent a copy of Resident #42's living will and Healthcare Proxy (HCP). The representative stated that they want Resident #42 to remain as a Full Code. The Director of Social Services (DSS) #1 was interviewed on 6/27/2023 at 11:50 AM and stated that Social Services is primarily responsible for implementing an Advance Directives CCP and the Advance Directives are reviewed on a quarterly, annual, and as needed basis and should be documented in the Electronic Medical Record (EMR). The Administrator #1 was interviewed on 6/28/2023 at 1:10 PM and stated that Social Services is primarily responsible for reviewing Advance Directives. 10 NYCRR 415.5 (g)(1)(i-xv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 6/21/2023 and completed on 6/28/2023, the facility must develop and implement a Comprehensive Person- Centered Care Plan (CCP) for each resident that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #42) of one resident reviewed for Advance Directives; for one (Resident #79) of two residents reviewed for Communication-Sensory care area; and one (Resident #22) of four residents reviewed for Positioning/Mobility care area. Specifically, 1) Resident #42 had no CCP developed for their Advance Directives. 2) Resident #79 whose primary language is Spanish; however, no CCP was developed to address the resident's communication needs. 3) Resident #22 was admitted on [DATE] with a soft cast on their right leg and a left Ankle Foot Orthosis (AFO); there were no CCP developed to address the use of the soft cast care and use of the AFO. The findings are: The facility Policy and Procedure for Comprehensive Care Plan dated 11/2022 documented that comprehensive, person-centered care plans (CCP) are developed within seven days of the completion of the required Minimum Data Set (MDS) assessment, and no more than 21 days after admission. Residents and their representatives have the right to participate in the planning process, request revisions, and participate in all care plan meetings. 1) The facility's Advance Directives policy dated 3/2023, documented that prior to or upon admission of a resident, the social services director or designee must inquire of the resident and/or resident's designated representative about the existence of any written advance directives. Changes are documented in the care plan and medical record. Information about whether the resident has executed an advance directive is displayed prominently in the medical record in a section retrievable by any staff. Advance Directives will be reviewed annually with the resident to ensure that such directives are still the wishes of the resident. Resident #42 was admitted with diagnoses including Huntington's Disease, Anorexia, and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. The MDS documented the resident had no advance directives. The Physician's order dated 6/27/2023 documented that the resident was a Full Code as their advance directives. The care plan entitled, Resident has Advance Directives: Full Code was developed and implemented on 6/27/2023 by Social Services. In the initial Social Services Evaluation dated 3/12/2022 documented the resident's representative declined to initiate directives at the time of admission and demonstrated good understanding that Resident #42 would be a Full Code. Education was provided to the family on advance directives. The Director of Social Services (DSS) #1 was interviewed on 6/27/2023 at 9:50 AM and stated that the resident did not have a care plan for advance directives prior to 6/27/2023. A care plan should have been created and implemented upon admission to the facility on 3/12/2022. Social Services is responsible to create care plans for advance directives and the social worker who initially evaluated the resident upon admission was responsible for initiating the advance directive care plan. In a Social Service note dated 6/28/2023, the resident's designated representative sent a copy of Resident #42's living will and Healthcare Proxy (HCP). The representative stated that they want Resident #42 to remain as a Full Code. Social Worker (SW) #1 was interviewed on 6/27/2023 at 10:00 AM and stated that they were responsible for evaluating Resident #42 upon admission. A Comprehensive Care Plan (CCP) and a physician's order should have been put in place for the resident's advance directives. SW #1 stated that they did not create a CCP. Registered Nursing (RN) #6 was interviewed on 6/27/2023 at 10:20 AM and stated that they were unaware Resident #42 did not have a CCP or medical order for advance directives. RN #6 stated that the resident should have had an order and care plan implemented within 24 hours upon admission. RN #6 stated that a CCP was created, and the medical order initiated on 6/27/2023. The Director of Social Services (DSS) #1 was interviewed on 6/27/2023 at 11:50 AM and stated that Social Services is primarily responsible for implementing an advance directives CCP. The Administrator was interviewed on 6/28/2023 at 1:10 PM and stated that Social Services is primarily responsible for developing advance directives CCPs. 2) The facility Communication with Persons with Limited English Proficiency Policy dated 1/2023 documented that the resident's primary language will be noted in the resident's medical record. Communication boards with basic terms, pictures, and needs noted in the resident's native language with English translation will be provided to the resident if needed. Resident #79 was admitted with diagnoses including Heart Failure, Malnutrition, and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderately impaired cognition. The Physician Note dated 4/24/2023 stated that Resident #79 is Spanish speaking and translation is provided. The Comprehensive Care Plan (CCP) entitled, Spanish is the resident's primary language and potential language barrier may limit the resident's participating during programs was developed and implemented on 6/23/2023. Certified Nursing Assistant (CNA) #3 was interviewed on 6/23/2023 at 11:10 AM and stated that Resident #79 can understand basic English but uses CNA #3, recreation staff, and housekeeping staff who are fluent in Spanish to translate for the resident. CNA #3 stated that Resident #79 once had a communication board but that the board is no longer in the resident's room. Registered Nurse (RN) #6 was interviewed on 6/23/2023 at 11:15 AM and stated that the resident did not have a CCP for Communication and was unsure if the resident required one. An observation was made on 6/23/2023 at 11:25 AM of Resident #79's room and no communication board was present. The Director of Nursing Services (DNS) #1 was interviewed on 6/23/2023 at 11:55 AM and stated that care plans are implemented by specific departments. The Recreation and Social Services Departments are responsible to create and implement CCPs for Communication. Communication CCPs should be put into place, especially when translators are utilized for a resident. Social Worker (SW) #2 was interviewed on 6/23/2023 at 1:15 PM and stated Resident #79 can speak broken English and that Spanish is their primary language. Resident #79 does need a translator but can get some needs across. Social Services and Recreation are responsible for developing and implementing CCPs for Communication. The Director of Recreation #1 was interviewed on 6/23/2023 at 1:35 PM and stated that Recreation implements CCPs for Communication upon admission if the resident does not primarily speak English. A Communication Board is also provided. Resident #79 primarily speaks Spanish, and a care plan should have been developed and revised as needed. 3) The policy titled: Adaptive Assistive Devices, last reviewed in March 2023, documented that: an orthotic is a device that is externally applied to an area of the patient's body to support, position, or immobilize a joint; correct deformities; modify tone; assist weak muscles, and restore function. An orthotic may be prefabricated, custom fabricated or custom modified [e.g., resting hand splint, arm sling, universal cuffs, Ankle Foot Orthoses (AFO)]. Prior to splint/orthotic application, check to ensure that there is a Physician's Order approving use of the splint. The wearing schedule may be established by the Physician or the Therapist. Document training with nursing staff and education regarding ability to don/doff properly and, after wear schedule is determined, document a Physician's Order for the finalized wear schedule, and document a care plan for the wear schedule. Resident #22 has diagnoses which include Oblique Fracture of the Shaft of the Right Tibia and Hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 7 which indicated that the resident had moderately impaired cognitive skills for daily decision making and was totally dependent on one person for locomotion/on off unit. The resident used a wheelchair and orthotics/prosthetics. On 6/21/2023 at 12:10 PM, Resident #22 was observed seated in a wheelchair in their room. The resident had a soft cast wrapped with an ace bandage on their right foot/ankle and an AFO on their left foot/ankle. The resident was unable to express why these devices were on their feet/ankles. The resident's Physician Orders were reviewed on 6/23/2023 at 2:10 PM. There was no documented evidence of a Physician's order for the soft cast to the resident's right foot or for the AFO on the resident's left foot. The resident's entire Comprehensive Care Plan (CCP) was reviewed on 6/23/2023 at 2:15 PM. There was no documented evidence that the resident wore a soft cast to their right foot or that they wore an AFO on their left foot. The Admission/readmission Evaluation dated 5/21/2023 and the Nursing admission Progress Note dated 5/21/2023, completed by Registered Nurse (RN) #2, documented that the resident's Right Lower Extremity (RLE) was ace bandaged Status Post (s/p) closed reduction on the right ankle fracture on 5/17/2023. The Occupational Therapy (OT) Evaluation and Plan of Treatment dated 5/22/2023, completed by Occupational Therapist, Registered (OTR) #1, documented that precautions for the resident included non-weight bearing (NWB) to the RLE, had bilateral (B/L) foot drop, and a left foot AFO. There was no documented evidence in this evaluation that the resident wore a soft cast to their right foot. The Physical Therapy (PT) Evaluation and Plan of Treatment dated 5/22/2023, completed by Physical Therapist (PT) #2, documented that the resident had B/L foot drop due to stenosis with B/L foot AFOs with left AFO present in the resident's room. The Evaluation documented that precautions for the resident included that they (Resident #22) were NWB to the RLE, had B/L foot drop, and a left AFO in their room. The evaluation documented that the resident was NWB to the RLE due to an impaired Ankle Range of Motion (ROM) limited by a cast on the resident's RLE. The RN Unit Manager (RN #7) was interviewed on 6/23/2023 at 3:00 PM and stated Physician Orders for an AFO or a cast would usually come from the Rehabilitation Department. RN #7 stated that there were no Physician Orders for either the resident's left AFO or soft cast and there should have been. RN #7 stated that both the resident's left AFO and soft cast were not documented on a care plan, and they should have been. The Director of Nursing Services (DNS) was interviewed on 6/23/2023 at 4:20 PM and stated that the resident's left AFO should have been documented on a CCP by Rehabilitation staff and the Nurse completing the initial admission Nursing Assessment should have obtained the Physician's Order for the resident's right soft cast. OTR #1 who completed the OT Evaluation and Plan of Treatment dated 5/22/2023 was interviewed on 6/26/2023 at 10:45 AM and stated that after completing the resident's OT Evaluation on 5/22/2023, either they (OTR #1) or PT #2 could have documented on the resident's ADL (Activities of Daily Living) CCP that the resident had a left AFO since they (OTR #1 and PT #2) both assessed the resident together on 5/22/2023. The Director of Rehab was interviewed on 6/26/2023 at 11:05 AM and stated that the resident's left AFO should have been on the ADL CCP by either OTR #1 or PT #2. PT #2 was interviewed on 6/26/2023 at 11:15 AM and stated that they (PT #2) should have documented the resident's left AFO on either the resident's ADL CCP or the Mobility CCP. RN #2 who completed the resident's Admission/readmission Evaluation dated 5/21/2023 and the Nursing admission Progress Note dated 5/21/2023 was interviewed on 6/27/2023 at 3:10 PM. RN #2 stated that they (RN #2) should have documented that the resident had a soft cast on a Skin CCP when they admitted the resident to the facility on 5/21/2023. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey ( Complaint #NY00297167 and NY00313454) initiated on 6/21/2023 and completed on 6/28/2023, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #107) of two residents reviewed for Pressure Ulcers; one (Resident #292) of five residents reviewed for Accidents; and one (Resident #22) of four residents reviewed for Positioning/Mobility. Specifically, 1) Resident #107 was admitted on [DATE] with a Stage II pressure ulcer to the sacrum as per the nursing admission assessment; however, a treatment for the sacrum wound was not started until 2/15/2022; 2) Resident #292 was identified with staples present in the back of their head on 10/27/2022 on the hospital discharge paperwork. The facility staff did not identify presence of the staples until 11/7/2022 when the resident was being assessed after a fall; however, there was no assessment of the wound with the staples, no monitoring of the staples, and no instructions for the care of the staples site when the resident was discharged home on [DATE]; and 3) Resident #22 was admitted to the facility with a soft cast wrapped in an ace bandage on their right leg on 5/21/2023, and no Physician's order was put in place acknowledging this soft cast until 6/23/2023 when it was brought to the facility's attention by the surveyor. The resident was also noted to have a left Ankle Foot Orthosis (AFO) during their Physical Therapy (PT) and Occupational Therapy (OT) evaluation on 5/22/2023, and no Physician's order was put in place to acknowledge this AFO until 6/23/2023 when it was brought to the facility's attention by the surveyor. The findings are: 1) The untiled facility policy dated January 2022, documented it is the policy of the facility to assess and treat the skin of each resident to prevent and care for Pressure Ulcers (PU). The procedure included but was not limited to the nurse and designee will assess and inspect the condition of the resident skin upon admission, readmission, quarterly and episodically as needed. New interventions will be added as needed to prevent pressure ulcers and to manage treatment. The facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 11/30/2022, documented the staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions; the physician will order pertinent wound treatments (dressings and application of topical agents); during resident visits, the physician will evaluate and document the progress of wound healing; the physician will guide the care plan as appropriate. Resident #107 was admitted with diagnoses including Non-Alzheimer's Dementia, Cerebrovascular Accident, and Hypertension. The 2/14/2022 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS documented the resident had one Stage 2 pressure ulcer identified on admission, was frequently incontinent of bowel and bladder, and required extensive assistance of two staff members for bed mobility. The Patient Review Instrument (PRI) from the hospital discharge date d 2/7/2022 documented the resident had moisture associated dermatitis /incontinence associated dermatitis to the Coccyx (tail bone) and that a moisture barrier should be used. The nursing admission assessment dated [DATE] documented that the resident had a Stage 2 pressure ulcer to the sacrum, size 2 centimeter (cm) by 2 cm. A Comprehensive Care Plan (CCP) effective 2/8/2022 created by Registered Nurse (RN) #2 titled Actual Skin Integrity-Actual Skin Breakdown related to decrease in mobility had an intervention to administer treatments/medications as ordered and monitor for effectiveness. The Physician History and Physical (H & P) initiated on 2/9/2022 documented a Stage 1 pressure ulcer to the sacrum. In the medication management section of the H&P, the physician documented Silvadene Cream topically two times a day. The physician signed the H&P on 2/15/2022. Review of the February 2022 Treatment Administration Record (TAR) revealed an order dated 2/15/2022 for Silvadene Cream, apply to sacrum topically two times a day for skin impairment. There was no documentation in the TAR of a treatment being administered to the sacrum from 2/8/2022 until 2/15/2022. Review of the medical record from 2/24/2022 to 5/18/2022 (when the treatment was discontinued) revealed no further nursing progress notes or nursing wound care evaluations and no physician reports documenting the progress of the sacrum skin condition. RN #1, who completed the admission on [DATE], was interviewed on 6/22/2023 at 8:30 AM. RN #1 stated there should have been a treatment in place from the outset if it was a Stage 2 pressure ulcer. RN #1 stated there are three shifts that follow up on admissions to ensure all care aspects are in place and therefore the treatment orders for the Stage 2 PU should have been obtained. RN #1 could not explain why an order was not placed initially upon the admission assessment. RN #2, who assisted with the resident's admission assessment on 2/8/2022 and created the initial skin impairment care plan, was interviewed on 6/23/2023 at 9:05 AM. RN #2 stated if a Stage 1 or Stage 2 pressure ulcer is identified or any other skin impairment, treatment orders should be instituted upon admission. RN #2 stated the resident should be seen within the next day by the wound care team or the Doctor. RN #2 stated the nurse that performs the admission assessment should reach out to the Doctor and obtain treatment orders. RN #2 could not explain why an order was not placed for Resident #107 initially, after the admission assessment was completed. The Assistant Director of Nursing Services (ADNS) was interviewed on 6/22/2023 at 10:40 AM. The ADNS stated a treatment should have been in place upon admission if a wound was identified. The ADNS stated there should have been documentation of the wound evaluation and if the treatment was effective. The Director of Nursing Services (DNS) was interviewed on 6/22/2023 at 11:45 AM. The DNS stated they expected the staff to put a treatment in place as soon as the wound was identified. The DNS stated there should be ongoing assessments of the wound to determine if the treatment is effective. The Primary Care Physician who was assigned to Resident #107 upon their admission on [DATE] is no longer employed by the facility. The Medical Director was interviewed on 6/22/2023 at 1:10 PM and stated there should have been a treatment initiated immediately upon admission for residents who are identified with skin impairments, and there should be ongoing assessments and documentation of the wound status. 2) Resident #292 was admitted to the facility with diagnoses including Cerebrovascular Accident, Non-Alzheimer's Dementia, and Difficulty in Walking. The 11/4/2022 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The MDS documented the resident had a surgical wound. The initial nursing admission assessment dated [DATE] at 3:15 PM documented a right head laceration from a fall on 10/18/2022. There was no documentation of sutures or staples present and no assessment of the head wound. The Registered Nurse (RN) who did this assessment is no longer employed at the facility. Multiple calls were made to this RN to no avail. The Patient Review Instrument (PRI) from the hospital dated 10/24/2022 documented Resident #292 had right posterior head laceration with intermittent percutaneous sutures (IPCS). A wound care nursing progress note dated 10/26/2022 at 1:09 PM, written by the former wound care nurse, documented upon initial assessment the resident has some redness on the right and left buttocks. There is also blanchable redness on the right and left heels. There was no documentation in this progress note about a head laceration or about the presence of staples. A Comprehensive Care Plan (CCP) initiated 10/26/2022 by the former wound care nurse, titled Scalp Laceration, did not include documentation related to sutures or staples. A Physician progress note dated 10/26/2022 at 12:15 PM documented Resident #292 was noted lying on the floor on their right side next to the bed. The note documented that the resident had a large laceration to the right temple. The resident was then sent to the emergency room via 911 call. The hospital Patient Review Instrument (PRI) dated 10/27/2022 documented the resident had a laceration/head temporal region open to air. The hospital discharge instructions dated 10/28/2022 documented call the trauma office to schedule a follow up for suture/staple removal. The resident was readmitted to the facility on [DATE] at 4:15 PM. The 10/28/2022 nursing admission assessment documented multiple facial lacerations open to air (OTA). There was no documentation of sutures or staples. The Registered Nurse who did this assessment is no longer employed at the facility. Multiple calls were made to this RN to no avail. The initial physician history and physical (H&P) dated 10/29/2022 documented status-post right head laceration. There was no documentation about sutures or staples. A wound care progress note written by the former wound care nurse dated 11/2/2022 documented upon initial wound assessment it is noted that the resident returned from the hospital with a left wrist skin tear and a right temporal area laceration with glue to approximate the edges. Treatment and care plan has been updated. Review of the medical record revealed this was the first wound care assessment following the readmission on [DATE]; there was no mention of sutures or staples. A CCP initiated 11/2/2022 by the former wound care nurse titled Right Temporal Area Skin Alteration provided no documentation related to the presence of sutures or staples. The wound care physician evaluation note dated 11/3/2022 documented the right face surgical wound was closed with tissue adhesive. The evaluation did not address any other wounds with sutures or staples. A nursing progress note written by an RN supervisor dated 11/7/2022 at 1:36 AM documented the resident had an unwitnessed fall in the hallway. In the note the RN documented that the resident was observed to have staples to the back of the head from a previous fall. A nurse practitioner note dated 11/11/2022 documented the resident was transferred to the hospital due to a fractured shoulder from a prior fall. The resident was readmitted to the facility on [DATE]. The nursing readmission assessment dated [DATE] documented right head laceration-healing. There was no documentation related to sutures or staples. A nursing progress note written by an RN supervisor dated 11/19/2022 at 4:58 PM documented the resident had an unwitnessed fall in their room. In the note the RN documented that the resident was observed to have staples to the back of the head from a previous fall. Multiple calls were made to this RN who wrote both 11/7/2022 and 11/19/2022 notes with no call back received. The Accident and Incident reports for the 11/7/2022 and 11/19/2022 falls also documented that the resident was observed to have staples to the back of the head from a previous fall. A Social Work progress note dated 11/29/2022 documented the resident was discharged to the community on 11/29/2022. Review of the discharge instructions dated 11/29/2022 revealed no information regarding follow-up for staple removal. RN #3, the former wound care nurse, was interviewed on 6/23/2023 at 1:41 PM. RN #3 stated they (RN #3) thought the resident had both glue and staples for the head wounds; however, RN #3 could not remember. RN #3 stated they (RN #3) gave the family verbal instructions over the phone when the resident was discharged home regarding who to follow up with for the staple removal. RN #3 was not able to explain why there was no documentation or assessment of the staples. The Assistant Director of Nursing Services (ADNS) was interviewed on 6/26/2023 at 8:21 AM. The ADNS stated they would have expected the admission nurse to include a full assessment of the staple wound, including how many staples, and it should have been followed up by the wound care nurse with documentation of when the staples should be removed. RN #4, who discharged Resident #292 on 11/29/2022, was interviewed on 6/26/23 8:54 AM. RN #4 stated they did a full head to toe assessment of the resident upon discharge; RN #4 stated, to be honest with you, I did not go through every strand of the resident's hair. RN #4 stated after the resident was discharged , the family notified the facility that there were staples in the back of the resident's head. The Director of Nursing Services (DNS) was interviewed on 06/26/2023 at 11:00 AM and stated if a resident has sutures or staples the staff should document the number of staples present. The DNS stated this should be part of the assessment and the staple site should be monitored for signs and symptoms of infection. Additionally, the resident's Physician should be notified and treatment orders should be obtained. The wound care physician was interviewed on 06/26/2023 at 12:05 PM. The wound care physician stated their first visit to see the resident was on 11/3/2022 regarding the right facial wound. The wound care physician stated they evaluate wounds when they receive a referral for a wound. The wound care physician stated there were no sutures to the right facial wound and they did not see the wound behind the resident's head that had staples. The primary physician for the resident is no longer employed at the facility. The Medical Director was interviewed on 6/26/2023 at 12:12 PM and stated if the resident had a wound with staples, the doctor should have documented that and what follow up was required. 3) The policy titled: Adaptive Assistive Devices, last reviewed in March 2023, documented that: an orthotic is a device that is externally applied to an area of the patient's body to support, position, or immobilize a joint; correct deformities; modify tone; assist weak muscles, and restore function. An orthotic may be prefabricated, custom fabricated or custom modified [e.g., resting hand splint, arm sling, universal cuffs, Ankle Foot Orthoses (AFO)]. Prior to splint/orthotic application, check to ensure that there is a Physician's Order approving use of the splint. The wearing schedule may be established by the Physician or the Therapist. Document training with nursing staff and education regarding ability to don/doff properly and, after wear schedule is determined, document a Physician's Order for the finalized wear schedule, and document a care plan for the wear schedule. Resident #22 has diagnoses which include Oblique Fracture of the Shaft of the Right Tibia and Hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 7 which indicated that the resident had moderately impaired cognitive skills for daily decision making and was totally dependent on one person for locomotion/on off unit. The resident used a wheelchair and orthotics/prosthetics. On 6/21/2023 at 12:10 PM, Resident #22 was observed seated in a wheelchair in their room. The resident had a soft cast wrapped with an ace bandage on their right foot/ankle and an AFO on their left foot/ankle. The resident was unable to express why these devices were on their feet/ankles. The resident's Physician Orders were reviewed on 6/23/2023 at 2:10 PM. There was no documented evidence of a Physician's order for the soft cast to the resident's right foot or for the AFO on the resident's left foot. The resident's entire Comprehensive Care Plan (CCP) was reviewed on 6/23/2023 at 2:15 PM. There was no documented evidence that the resident wore a soft cast to their right foot or that they wore an AFO on their left foot. The resident's Certified Nursing Assistant (CNA) Accountability forms for May 2023 and June 2023 were reviewed on 6/23/2023 at 2:20 PM. There was no documented evidence that the resident wore a soft cast to their right foot or that they wore an AFO on their left foot. The Admission/readmission Evaluation dated 5/21/2023 and the Nursing admission Progress Note dated 5/21/2023, completed by Registered Nurse (RN) #2, documented that the resident's Right Lower Extremity (RLE) was ace bandaged Status Post (s/p) closed reduction on the right ankle fracture on 5/17/2023. The Occupational Therapy (OT) Evaluation and Plan of Treatment dated 5/22/2023, completed by Occupational Therapist, Registered (OTR) #1, documented that precautions for the resident included non weight bearing (NWB) to the RLE, had bilateral (B/L) foot drop, and a left foot AFO. There was no documented evidence in this evaluation that the resident wore a soft cast to their right foot. The Physical Therapy (PT) Evaluation and Plan of Treatment dated 5/22/2023, completed by Physical Therapist (PT) #2, documented that the resident had B/L foot drop due to stenosis with B/L foot AFOs with left AFO present in the resident's room. The Evaluation documented that precautions for the resident included that they (Resident #22) were NWB to the RLE, had B/L foot drop, and a left AFO in their room. The evaluation documented that the resident was NWB to the RLE due to an impaired Ankle Range of Motion (ROM) limited by a cast on the resident's RLE. The resident's primary 7:00 AM-3:00 PM Certified Nursing Assistant (CNA) #7 who had cared for the resident for the month of June 2023, was interviewed on 6/23/2023 at 2:50 PM. CNA #7 stated that the resident does not have the left AFO on when they (CNA #7) come in at 7:00 AM. CNA #7 stated that either they (CNA #7) or someone from therapy puts the resident's left AFO on in the morning after the resident is taken out of bed. CNA #7 acknowledged that the resident's left AFO was not documented on the resident's CNA Accountability record, but they (CNA #7) put the resident's left AFO on when caring for the resident because the left AFO was in the resident's room. The RN Unit Manager (RN #7) was interviewed on 6/23/2023 at 3:00 PM and stated Physician Orders for an AFO or a cast would usually come from the Rehabilitation (Rehab) Department. RN #7 stated that there were no Physician Orders for either the resident's left AFO or the RLE soft cast and there should have been. The Director of Rehabilitation was interviewed on 6/23/2023 at 3:20 PM and stated that if a resident has a brace of any sort such as an AFO, there should be a Physician's Order for the schedule of when the brace should be worn. The Director of Rehabilitation stated that a Physician's Order for the resident's soft cast should have been obtained by the Nurse who admitted the resident to the facility. The Director of Rehabilitation was re-interviewed on 6/23/23 at 3:45 PM and stated that the resident used the left AFO for ambulation for a foot drop and came into the facility with it. The Director of Rehabilitation stated that the PT and the OTR who evaluated the resident and acknowledged the left AFO in their assessment should have gotten a Physician's Order for the resident's left AFO. The Director of Nursing Services (DNS) was interviewed on 6/23/2023 at 4:20 PM and stated that the Physician's Order for the resident's left AFO should have been obtained by the Rehabilitation staff and that the Nurse completing the initial admission Nursing Assessment should have obtained the Physician's Order for the resident's right soft cast. PT #2 who completed the PT Evaluation and Plan of Treatment dated 5/22/2023 was interviewed on 6/26/2023 at 10:30 AM. PT #2 stated that on the day they (PT #2) completed the resident's PT Evaluation, OTR #1 was also with them (PT #2). PT #2 stated that they (PT #2) forgot to get a Physician's Order for the resident's left AFO because they (PT #2 and OTR #1) were not able to stand the resident and were not able to put the resident's left AFO on. PT #2 stated that the resident also had a right AFO but was not able to wear it because of the soft cast currently on their right leg. PT #2 stated that they would not get a Physician's Order for the resident's soft cast as that is more of a Nursing issue after Nursing does their assessment looking at blood flow and for any swelling. OTR #1 who completed the OT Evaluation and Plan of Treatment dated 5/22/2023 was interviewed on 6/26/2023 at 10:45 AM. OTR #1 stated that it just slipped their minds to get a Physician Order for the resident's left AFO. OTR #1 stated that the Physician's Order should have been obtained to indicate when the resident should wear their left AFO. OTR #1 stated that in their (OTR #1) Evaluation dated 5/22/2023, they (OTR #1) documented that the resident was non weight bearing but did not identify that the resident had a soft cast on their RLE and they (OTR #1) could have done so. PT #2 was re-interviewed on 6/26/2023 at 11:15 AM and stated that they (PT #2) never inserviced any CNAs on how to correctly put on the resident's left AFO. The Director of Rehabilitation was interviewed on 6/26/2023 at 1:15 PM and stated that the resident's immediate caregivers should have been inserviced, meaning the 7:00 AM-3:00 PM CNA who puts the AFO on when the resident is taken out of bed and the 3:00 -11:00 PM CNA should have been inserviced because they take the AFO off before the resident goes to bed. RN #2 who completed the resident's Admission/readmission Evaluation dated 5/21/2023 and the Nursing admission Progress Note dated 5/21/2023 was interviewed on 6/27/2023 at 3:10 PM. RN #2 stated that they (RN #2) should have gotten a Physician's Order for the resident's soft cast when they (RN #2) admitted the resident to the facility on 5/21/2023. RN #2 stated that the Physician's Order should have been obtained to at least check the resident's circulation where the soft cast was. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey completed on 6/11/2021, the facility did not ensure that a baseline care plan was developed within 48 hours 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. This was identified for 1 (Resident # 183) of 3 residents reviewed for Respiratory Care. Specifically, Resident #183 had an admitting diagnosis of Acute Respiratory Failure and was on Oxygen therapy without a baseline Comprehensive Care Plan (CCP) developed. The finding is: Resident # 183 was admitted on [DATE] with diagnoses that include Acute Respiratory Failure with Hypoxia and Hypercapnia. An admission assessment completed by the admission Registered Nurse (RN) dated 6/3/2021 documented the resident had Dyspnea (labored breathing) and Shortness of Breath (SOB), was coughing and was on Oxygen therapy at 4 liters per minute via nasal cannula. A Minimum Data Set (MDS) Assessment was not completed as of 6/11/2021. Resident #183 was observed in bed on 6/7/2021 at 11:00 AM on 4 liters per minute of Oxygen via Nasal Cannula. Resident #183 was observed on 6/9/2021 at 11:30 AM utilizing Oxygen at 2 liters per minute via Nasal Cannula. On both the 6/7/2021 and the 6/9/2021 observations the Oxygen tubing was not dated to indicate when the Oxygen tubing was changed. No baseline Comprehensive Care Plan (CCP) for Oxygen was developed. Review of the physician's orders from 6/3/2021 - 6/09/2021 revealed no documented orders for the use of Oxygen. The Registered Nurse Supervisor (RNS)#2 was interviewed on 6/9/2021 at 11:20 AM and stated they (RNS#2) could not explain why there were no baseline CCP developed for the use Oxygen. The Director of Nursing Services (DNS) was interviewed on 6/10/2021 at 10:30 AM. The DNS stated that a baseline CCP for Oxygen was not found and that a baseline CCP for Oxygen should have been developed on admission. 415.11

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews during the Recertification Survey completed on 6/11/2021, the facility did not provide proper respiratory treatments and care consistent with professional standards of practice. This was identified for one (Resident #183) of three residents reviewed for Respiratory care. Specifically, Resident #183 had an admitting diagnosis of Acute Respiratory Failure and was receiving Oxygen therapy without a Physician's order. The finding is: The undated policy and procedure for Oxygen administration documented to verify there is a physician order for the procedure and to review the resident's care plan to assess for any special needs of the resident. The policy included to monitor and document the rate of oxygen flow, route and rationale and all assessment data before, during, and after the procedure. The policy lacked directions when to change the oxygen tubing. Resident # 183 was admitted on [DATE] with diagnoses that include Acute Respiratory Failure with Hypoxia and Hypercapnia. An admission assessment by the admission Registered Nurse (RN) dated 6/3/2021 documented the resident had Dyspnea (labored breathing) and Shortness of Breath (SOB), was coughing and was on Oxygen therapy at 4 liters per minute via nasal cannula. A Minimum Data Set (MDS) Assessment was not completed as of 6/11/2021. Resident #183 was observed in bed on 6/7/2021 at 11:00 AM on 4 liters per minute of Oxygen via Nasal Cannula. Resident # 183 was observed on 6/9/2021 at 11:30 AM utilizing Oxygen at 2 liters per minute via Nasal Cannula. On both the 6/7/2021 and the 6/9/2021 observations the Oxygen tubing was not dated to indicate when the Oxygen tubing was changed. The Physician History and Physical (H and P) admission assessment dated [DATE] documented the resident was on Oxygen therapy and documented, patient denies shortness of breath (sob) but appears mildly sob. The Physician did not document how much Oxygen to administer or whether to administer Oxygen on an intermittent or continuous basis. Review of the physician's orders from 6/3/2021 - 6/09/2021 revealed no documented orders for the use of Oxygen. Review of the Comprehensive Care Plans (CCP) revealed no documented CCP for the use of Oxygen. Registered Nurse Supervisor (RNS) #2 was interviewed on 6/9/2021 at 11:20 AM and stated they (RNS#2) could not explain why there were no Physician orders for the Oxygen and why the tubing was not labeled. RNS#2 stated the Oxygen line should be labeled when it is changed. RNS #2 stated the Oxygen tube was probably from the admission date and could not determine when the tubing was last changed. RNS#2 further stated a CCP should have been developed within 48 - 72 hours and that the resident's Oxygen rate is determined by Physician's orders and should not vary unless the physician orders direct nurses to change the Oxygen levels. Physician #6 was interviewed on 6/9/2021 at 1:53 PM and stated that the resident should have had an as needed (prn) order for Oxygen on admission, until the resident was assessed by Physician #6 or a Respiratory Therapist. Physician #6 stated the resident was on Oxygen therapy at the time of the assessment and Physician #6 had not documented how much Oxygen the resident should have been prescribed. Physician #6 stated that if there was no written order it was possible Physician #6 verbally told the nurse to put the resident on Oxygen. Physician # 6 further stated, If there was no documentation of an oxygen order, this was an oversight. The Director of Nursing Services (DNS) was interviewed on 6/10/2021 at 10:30 AM. The DNS stated that a baseline CCP for Oxygen should have been developed on admission, there should be Physician's orders for Oxygen for the Nurses to follow, Respiratory assessments should be documented, and Oxygen tubing should be labeled when it is first used. The Policy and Procedure for Oxygen Administration does not document when to change the Oxygen tubing and the Policy and Procedure will be revised to specify how often to change the Oxygen tubing. 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey completed on 6/11/2021, the facility did not ensure that for one (Resident # 183) of 3 residents reviewed for Respiratory care, the physician reviewed the resident's total program of care, including treatments. Specifically, Resident #183 was administered Oxygen without a Physician's evaluation and without Physician's orders for the use of Oxygen. The finding is: The undated policy and procedure for Oxygen administration documented to verify there is a Physician order for the procedure and to review the resident's care plan to assess for any special needs of the resident. Resident #183 was admitted on [DATE] with diagnoses that include Acute Respiratory Failure with Hypoxia and Hypercapnia. An admission assessment by admission Registered Nurse (RN) dated 6/3/2021 documented the resident had Dyspnea (labored breathing) and Shortness of Breath (SOB), was coughing and was on Oxygen therapy at 4 liters per minute via nasal cannula. A Minimum Data Set (MDS) Assessment was not completed as of 6/11/2021. Resident #183 was observed in bed on 6/7/2021 at 11:00 AM on 4 liters per minute of Oxygen via Nasal Cannula. Resident #183 was observed on 6/9/21 at 11:30 AM utilizing Oxygen at 2 liters per minute via Nasal Cannula. On both the 6/7/2021 and the 6/9/2021 observations, the Oxygen tubing was not dated to indicate when the Oxygen tubing was changed. Review of the physician's orders from 6/3/2021 - 6/09/2021 revealed no documented orders for the use of Oxygen. The Physician History and Physical (H and P) admission assessment dated [DATE] documented the resident was on Oxygen therapy and documented, patient denies shortness of breath (sob) but appears mildly sob. The Physician did not document how much Oxygen to administer or whether to administer Oxygen on an intermittent or continuous basis. The Registered Nurse Supervisor (RNS) #2 was interviewed on 6/9/2021 at 11:20 AM and stated they (RNS#2) could not explain why there were no Physician orders for the Oxygen. Physician #6 was interviewed on 6/9/2021 at 1:53 PM and stated that the resident should have had an as needed (prn) order for Oxygen on admission, until the resident was assessed by Physician #6 or a Respiratory Therapist. Physician #6 stated the resident was on Oxygen therapy at the time of the assessment and Physician #6 had not documented how much Oxygen the resident should have been receiving. The physician stated that if there was no written order it was possible Physician #6 verbally told the nurse to put the resident on Oxygen. Physician # 6 further stated, If there was no documentation of an oxygen order, this was an oversight. 415.15(b)(2)(iii)