Based on record review and interviews during the recertification and abbreviated (NY00362429) surveys conducted 1/2/2025-1/8/2025 the facility did not ensure the resident's physician was consulted and the resident's representative was notified when there was a need to alter treatment significantly for 1 of 1 resident (Resident #61) reviewed. Specifically, Resident #61 did not receive 5 doses of their Parkinson's disease (a progressive neurological disorder) medication (pramipexole dihydrochloride) and there was no documented evidence the physician or resident's representative were notified of the omission. Findings include: The facility policy, Notification of Medical Condition Changes, reviewed 6/2022, documented the nurse immediately reported specific changes in a resident's condition or treatment to their attending physician and shared with the resident and/or the resident's representative. The notification was documented in the resident's medical record. The pharmacy policy Provider Pharmacy Requirements, effective 9/2018, documented the provider pharmacy agreed to provide routine and timely pharmacy services, as well as emergency pharmacy service 24 hours per day, seven days per week. New medication orders were available for administration on the next routine delivery, unless otherwise requested by facility staff. Medications would be delivered by the primary pharmacy or back-up pharmacy or were available from the emergency medication kit/back-up medication supply. Resident #61 had diagnoses including Parkinson's disease and dementia. The 12/3/2024 Minimum Data Set assessment (a health status assessment tool) documented the resident had severe cognitive impairment. The 11/29/2024 physician order documented pramipexole dihydrochloride oral tablet 1.5 milligrams three times a day for Parkinson's disease. The 12/2/2024 History and Physical completed by the Medical Director documented the resident's plan was to continue Sinemet 25/100 (Parkinson's medication) two tabs four times a day, benztropine (Parkinson's medication) 0.5 milligrams a day, and pramipexole 1.5 milligrams three times per day for Parkinson's disease. The resident was also on Sinemet extended release 50/200 one tab once a day. The Comprehensive Care Plan initiated 12/19/2024 documented the resident had impaired cognition related to diagnoses of dementia and Parkinson's disease. Interventions included their family was involved in decision making. The 12/30/2024 at 8:48 PM pharmacy alert message documented the pramipexole dihydrochloride refill was rejected and could not be filled because it was too soon and needed to be resubmitted for refill on or after 1/1/2025. The 12/2024 and 1/2025 Medication Administration Record documented the pramipexole dihydrochloride oral tablet 1.5 milligrams, give one tablet by mouth three times a day for Parkinson's with a start date of 11/29/2024. The pramipexole dihydrochloride was signed off as a 9 chart code which indicated other/ see progress notes, at the following times: - On 12/31/2024 at 9:00 AM by Licensed Practical Nurse #6 and at 3:00 PM and 9:00 PM by Licensed Practical Nurse #7. - On 1/1/2025 at 9:00 AM and 3:00 PM by Licensed Practical Nurse #8. The nursing administration progress notes documented the pramipexole dihydrochloride medication: - Was on order on 12/31/2024 at 9:08 AM by Licensed Practical Nurse #6. - Was on order on 12/31/2024 at 3:56 PM and 8:04 PM by Licensed Practical Nurse #7 - On 1/1/2025 at 9:20 AM Licensed Practical Nurse #8 documented Registered Nurse #5 called the pharmacy and the medication would be delivered on the second pharmacy run that day. - On 1/1/2025 at 3:50 PM Licensed Practical Nurse #8 documented they were waiting on pharmacy to deliver the medication. There was no documented evidence in the nursing progress notes the medical provider was notified of missed doses of pramipexole dihydrochloride or that the medication was unavailable, or the resident's representative was notified of the missed medication doses. During an interview on 1/2/2025 at 11:13 AM, Resident #61's family member stated the resident did not receive doses of their Parkinson's medication on 12/31/2024 and 1/1/2025. They were not notified by the facility and was only made aware of this while visiting during a medication administration. When they questioned the nurse why the resident was not given the medication, they were told the facility was waiting on pharmacy for delivery of the medication. They were upset the medication was not given because it was a vital medication. They could have brought the medication from home, so the resident did not go without it. During an interview on 1/7/2025 at 10:57 AM, Licensed Practical Nurse #6 stated they thought they reported to Registered Nurse #4 (charge nurse) the resident's pramipexole dihydrochloride medication was not available on 12/31/2024. They did not notify the provider or the family. Missed doses meant the body's medication levels were not as they should be and therefore was less effective. During a telephone interview on 1/7/2025 at 2:53 PM, Licensed Practical Nurse #7 stated there was often a delay in medications getting to the facility from the pharmacy and it was not uncommon for residents to miss a day or two of their ordered medications. On 12/31/2024 they stated they called the pharmacy, was not sure who they talked to, and was told the medication was on its way. It was not delivered before the end of their shift. They did not report the missed doses, or that the medication was unavailable. The resident got the pramipexole dihydrochloride for their tremors and the tremors could get worse if it was not given as ordered. During an interview on 1/8/2025 at 10:15 AM, the Charge Registered Nurse #4 stated they had not been notified the pramipexole dihydrochloride for Resident #61 was unavailable and doses were missed. They would have called the pharmacy directly and the provider and the family would have been notified. It was important the provider was informed of missed medication doses as it was a delay in treatment that could cause negative effects. During an interview on 1/8/2025 at 11:01 AM, Medical Director/ Physician #3 stated they were supposed to be notified of any medications not given regardless of the reason why. They did not recall being notified of missed doses of the pramipexole dihydrochloride for Resident #61, but they should have been. The resident should have received all ordered doses for their safety and to treat their Parkinson's disease. Either the licensed practical nurse that administered medications, or the registered nurse should have called. If there was a pharmacy issue, they could have changed the treatment plan if they were made aware. During an interview on 1/8/2025 at 11:15 AM, the Director of Nursing stated nurses were responsible for physician notification of missed medications. The nurse that was supposed to administer the medication should have reported to the registered nurse the medication was unavailable. The registered nurse would then notify the resident or the family as well as the provider. They were made aware yesterday of Resident #61's missed pramipexole dihydrochloride doses and the provider should have been notified at that time. The resident and or family should have been made aware the treatment plan was not followed as ordered. 10NYCRR 415.3(2)(ii)(a)

Based on record review and interviews during the recertification survey conducted 1/2/2025-1/8/2025, the facility did not ensure they assessed residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services not less frequently than once every 3 months for 3 of 3 residents (Residents #28, #46, and #53) reviewed. Specifically, Residents #28's, #46's, and #53's Minimum Data Set assessments were completed later than 14 days after the Assessment Reference Date (the final day of the observation period to gathering information about a resident's condition when completing the assessment). Findings include: The facility policy, Interdisciplinary Minimum Data Set 3.0 Completion, revised 1/2023, documented to complete an accurate Minimum Data Set on all residents based on New York State Department of Health and Centers for Medicare and Medicaid Services guidelines. Assessments would be completed based on the Minimum Data Set 3.0 Manual. The Minimum Data Set Coordinator was responsible for setting up timely assessments within the guidelines as defined in the Minimum Data Set 3.0 Manual. The Centers for Medicare and Medicaid Service's, Minimum Data Set Resident Assessment Instrument Version 3.0 Manual documented An Omnibus Budget Reconciliation Act assessment (comprehensive or quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between Omnibus Budget Reconciliation Act assessments. 1) Resident #53 had diagnoses including epilepsy (a seizure disorder), cognitive communication deficit, and adult failure to thrive. The quarterly Minimum Data Set assessment document an Assessment Reference Date of 11/13/2024 and the assessment was completed on 1/4/2025. 2) Resident #28 had diagnoses including hemiplegia and hemiparesis (weakness and paralysis on one side) following cerebral infarction (stroke), and difficulty walking. The quarterly Minimum Data Set assessment documented an Assessment Reference Date of 11/22/2024 and the assessment was completed on 1/4/2025. 3) Resident #46 had diagnoses including Parkinson's disease (a progressive neurological disorder) and dementia. The quarterly Minimum Data Set assessment documented an Assessment Reference Date of 12/14/2024 and the assessment was not completed as of 1/7/2025. During a telephone interview on 1/7/2025 at 12:56 PM, Minimum Data Set Consultant #9 stated they created the schedule to complete the Minimum Data Set assessments. The Minimum Data Set was completed by the various departments, if they were not done on time, they would reach out to the department to have them completed. They had 14 days from the Assessment Reference Date to complete the assessment. It was important to complete the Minimum Data Set assessment for the resident as it was part of their plan of care. It tracked their progress and helped direct their care. Resident #53 should have had their assessment completed by 11/27/2024 and submitted by 12/4/2025. It was not completed until 1/4/2025. Resident #28 should have had their assessment completed by 12/6/2024 and submitted by 12/13/2024. It was not completed until 1/4/2025. Resident #46 should have had their assessment completed by 12/17/2024 and submitted by 1/3/2025. It was not completed and would be completed on 1/7/2025, and they would submit it after completion. They stated they usually only submitted the Minimum Data Set assessments once a week. The Minimum Data Set assessments for Residents #28, #46, and #53 were not completed timely because section GG (Functional Abilities and Goals) was not completed, all other sections were completed. During an interview on 1/8/2025 at 11:01 AM, the Administrator stated it was the responsibility of the Minimum Data Set Consultant to ensure Minimum Data Set assessments were completed, and they did the audits for those assessments. 10NYCRR 415.11(a)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY00307214) surveys conducted 4/11/23-4/14/23, the facility failed to ensure residents were free from abuse for 1 of 1 resident (Resident #38) reviewed. Specifically Resident #15 was witnessed by facility staff making inappropriate sexual contact with Resident #38 on 10/10/22, 11/18/22, and 12/16/22 and the facility did not have a plan in place to protect Resident #38 from Resident #15's advances. Additionally, the incidents on 10/7/22 and 11/18/22 were not reported to the New York State Department of Health (NYS DOH) as required. Findings include: The facility policy Abuse and Adverse Incident Prevention and Reporting reviewed 3/2023 documented the facility did not permit verbal, mental, sexual, or physical abuse. The facility provided initial and ongoing education for all employees which addressed abuse identification and prevention. Prevention included analysis completed on a continued basis of assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict. The 8/2016 NYS DOH Incident Reporting Manual documented that sexual abuse can be resident to resident, staff to resident, family/visitor to resident. At least one of the following elements must be present for an incident to be reportable to the NYS DOH: - Non-consensual sexual intrusion or penetration. - Touching intimate body parts or the clothing covering intimate body parts. - Examination or treatment of the resident for other than [NAME] fide medical purposes. - Observation or photographs of another person's intimate body parts. Resident #38 was admitted to the facility with diagnoses including Alzheimer's disease, generalized anxiety disorder, and depression. The 9/30/22 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required limited to extensive assistance with most activities of daily living (ADLs). Resident #38's comprehensive care plan (CCP) revised 7/15/22 documented the resident had impaired cognition related to dementia with impaired short-term and long-term memory. The resident did not recognize staff or know that they were in a skilled nursing facility. Interventions included encourage to make daily decisions, provide aides to assist with orientation, reorient when able or needed, and include family in care planning. Resident #15 had diagnosis including hemiplegia and hemiparesis (weakness and paralysis on one side) following cerebral infarction (stroke), anxiety, and legal blindness. The 11/1/22 MDS documented the resident had intact cognition, did not exhibit behavioral symptoms directed toward others, did not walk, and required supervision with locomotion on the unit. Resident #15's CCP initiated 5/13/21 documented the resident self-propelled around the unit during the day and approached other residents without regard for personal space or privacy. The resident's intentions were to help other's and the resident needed reminders to respect other's privacy and personal space. Interventions included to remind resident of social distancing, staff were to complete 15 minute checks when out of bed to monitor where the resident was, and nursing was following with the physician on the resident behavior of respecting other resident's personal space. There was no documented evidence of 15 minute checks completed for Resident #15. A Behavior assessment dated [DATE] by licensed practical nurse (LPN) #13 documented that Resident #15 was observed to be hovering around a female resident, poking at the female resident, and holding the female resident's hand. LPN #13 educated Resident #15 that they were not supposed to be having physical contact with any of the female residents as discussed with them in the past. LPN #13 documented that Resident #15 confirmed understanding of the education and stated that it would not happen again. LPN #13 documented the supervisor was immediately notified of the behavior. A behavior progress note dated 10/7/22 by LPN #12 documented Resident #15 was observed by a CNA reaching into the shirt of Resident #38, while Resident #38 licked the arm of Resident #15. The incident happened between rooms [ROOM NUMBERS] in front of the nurse's station. The behavior was immediately stopped upon request by the reporting CNA. The Summary of Investigation dated 10/10/22 and signed by the Director of Nursing (DON) included: - a witness statement by certified nurse aide (CNA) #11 untimed and dated 10/10/22 documented on 10/7/22 (no time documented) they observed Resident #38 licking Resident #15's arm and Resident #15's hand was inside the shirt and on the breast of Resident #38. CNA #11 asked the residents what they were doing, and Resident #38 replied, do you see what [they] are doing to me? CNA #11 told Resident #15 they were not supposed to be close to Resident #38. Resident #15 freaked out and removed their hand from Resident #38's shirt and tried to give excuses. CNA #11 told Resident #15 to get away from Resident #38 and the behavior was unacceptable because Resident #38 did not know what they were doing. The CNA reported the incident to the nurse. - a statement by Resident #15 untimed and dated 10/10/22 documented they went by Resident #38 a few times that day and Resident #38 grabbed their arm. The second time Resident #38 kissed their arm. The third time Resident #38 took Resident #15's hand and placed it on their breast. Resident #15 told Resident #38 no several times and pulled their arm back. The resident documented they knew they were doing nothing wrong and was surprised Resident #38 placed Resident #15's hand on their breast. - a statement by Resident #38 dated 10/10/22 at 1:25 PM documented no one did anything to them and they would have said something. They would have kicked their butt all the way to the door. - the DON documented that it was determined abuse did not occur and the incident was not reportable according to nursing home incident reporting standards. There was no documented evidence why the incident was not investigated until 3 days after the observed interaction between Residents #15 and #38. There was no documented evidence Resident #15's and #38's CCPs were reviewed to determine if interventions remained appropriate The Summary of Investigation dated 11/18/22 and signed by the Assistant Director of Nursing (ADON) included: - a witness statement by CNA #14 untimed with an obscured date documented on 11/17/22 they witnessed Resident #15 sitting very close to Resident #38. CNA #14 sat at the nursing desk and heard Resident #38 swat Resident #15 away while yelling at Resident #15 for touching them. Resident #15 asked Resident #38 to go to their room with them to watch TV. CNA #14 told the nurse and separated the residents. Resident #15 denied the incident. - a statement from Resident #15 dated 10/18/22 documented they did not touch Resident #38 or ask them to watch TV in their room the previous evening. The resident stated sometimes Resident #38 would reach for Resident #15's arm when they went by. - a statement from Resident #38 dated 11/18/23 documented they did not know what happened on 11/17/22, they did not want to answer the questions, and said to leave them alone. - On 11/18/22 the ADON documented after interviewing staff and residents the incident was not deemed reportable according to the Nursing Home Incident Reporting Manual. There was no documented evidence Residents #38's and #15's care plans were reviewed to determine if appropriate interventions were in place to protect Resident #38 from abuse by Resident #15. The Nursing Home Facility Incident Report documented on 12/16/22 at 4:33 PM Resident #38 was in the hallway near the nurse's desk when Resident #15 passed by in their wheelchair and was observed touching Resident #38's breast. - an undated witness statement by CNA #11 documented on 12/16/22 they were approaching the nurse's station and saw Resident #15 close to Resident #38. Resident #15 grabbed Resident #15's breast. Resident #38 tried to move Resident #15's hands away and Resident #15 touched them again. Resident #38 said I'm going to slap your face. Resident #38 tried to touch Resident #15, and CNA #11 told Resident #15 to get away from Resident #38. Resident #15 asked CNA #11 not to tell anyone and they would not do it again. Another nurse heard the conversation and told Resident #15 to move away from Resident #38 and took care of the situation. - a witness statement dated 12/16/22 by LPN #7 documented on 12/16/22 at 4:20 PM they heard CNA #11 telling Resident #15 to stop touching Resident #15 and Resident #15 said they would not do it again and asked the CNA not to tell on them. LPN #7 called the DON immediately who said they would be in as soon as possible. The DON arrived at 5:00 PM. - a statement from Resident #38 dated 12/16/22 at 5:15 PM by the DON documented Resident #38 stated no one had touched them and they felt safe. - a statement from Resident #15 dated 12/16/22 at 5:45 PM by the DON documented Resident #15 stated they were going towards the dining room at 4:15 PM to watch TV. When they stopped, Resident #38 was sitting in the hallway at the nurse's desk. Resident #38 grabbed their arm and started kissing it. Resident #15 pulled back and Resident #38 grabbed their arm again. Resident #15 stated they did place their hand on Resident #38's left breast. Resident #38 told Resident #15 they were going to slap them, and Resident #15 pulled their hand back and was confronted by staff. There was no documented evidence Residents #38's and #15's care plans were reviewed to determine if appropriate interventions were in place to protect Resident #38 from abuse by Resident #15. Resident #38's CCP was updated 1/3/23 to include observe for all male residents around the resident and remind for social distancing at all times. Resident #15's CCP was updated on 2/3/23 to include the resident was to be a minimum of 6 feet away from any female resident when participating in an activity, and the resident was not to stop in the hallways to have conversations with any female residents. During an interview on 4/14/23 at 1:46 PM, CNA #11 stated that on 12/16/22 Resident #15 started touching Resident #38's feet with their feet and Resident #15 reached out to touch the breast of Resident #38. CNA #11 stated that Resident #38 was pushing Resident #15 away but Resident #15 kept reaching and CNA #11 intervened. CNA #11 stated Resident #38 did not remember or know what they were doing but Resident #15 was alert and oriented. CNA #11 stated that they had reported to the nurse two similar behaviors by Resident #15 toward Resident #38 prior to the 12/16/22 incident and had also told Resident #15 not to touch Resident #38. CNA #11 stated that before 12/16/22, the facility had only spoken to Resident #15 about their behavior with the two previous incidents, to give them a chance. CNA #11 stated that the facility did not increase supervision of Resident #15 or tell them not to go near female residents until after 12/16/22 incident. CNA #11 stated that the facility had provided abuse and neglect training to them. During an interview on 4/13/23 at 3:16 PM, CNA #16 stated that Resident #15 has displayed some inappropriate behaviors toward female staff members, but they have not seen it toward female residents. CNA #16 stated that they had been instructed to monitor where Resident #15 was. During an interview on 4/13/23 at 3:16 PM, CNA #14 stated that they were supposed to watch Resident #15 around female residents as Resident #15 had been caught inappropriately touching other residents. CNA #14 stated they should closely monitor Resident #15 and if they paused too long, they should encourage Resident #15 to move along. During an interview on 04/14/23 at 1:57 PM LPN #12 stated they were trained on abuse and neglect and if they witnessed an inappropriate interaction between two residents they should intervene, make sure both residents were safe, and notify a supervisor. They stated that they knew of the incident on 12/16/22 between Resident #15 and Resident #38. LPN #12 did not think anything happened between the two residents prior to 12/16/22. LPN #12 stated staff should monitor the residents for any future incidents and keep them apart. They stated if a cognitively intact resident inappropriately touched a cognitively impaired resident there was a lack of capacity to consent by the cognitively impaired resident. During an interview on 4/14/23 at 2:04 PM registered nurse (RN) #19 stated they were aware of the incident between Resident #38 and Resident #15 on 12/16/22 but was not aware of any incidents prior to that. RN #15 stated that following the 12/16/22 incident Resident #15 was not allowed to be alone anywhere, staff needed to be watching them when they were out of their room and monitor where they were and who they were with. They stated that staff would be aware of Resident #15's interventions as they would be on the [NAME] (care instructions from the CCP). During an interview on 4/14/22 at 2:18 PM, the DON stated that they were responsible for the incident reports submitted to the NYS DOH. The DON stated they utilized the Nursing Home Incident Reporting Manual and if after a thorough investigation, the incident was reportable they would report it. The DON stated that they reported the incident between Resident #15 and Resident #38 in December on the day of the incident (12/16/22). DON stated that they did not report the incident between Residents #15 and #38 in October due to Resident #38 grabbing Resident #15's arm and putting Resident #15's hand on their breast. DON stated that the only thing they felt was wrong about the situation was that Resident #38 had dementia and Resident #15 did not take their hand away until staff intervened. DON stated that they spoke to Resident #15 following that incident about Resident #38's mental status and Resident #38 did not know what they were doing. The DON stated they discussed perception with Resident #15 and that Resident #15 was alert and orientated but others were not, and Resident #15 cannot engage in that behavior. The DON stated that there were no care plan changes following that incident. The DON stated that the incident in November between Residents #15 and #38 was an overreaction by the CNA, so no interventions were put into place following that incident. The DON stated that it was an issue if a cognitively intact resident inappropriately touched a cognitively impaired resident. The DON stated that even if the cognitively impaired resident was the aggressor that resident could not give informed consent so the cognitively intact person should remove themselves from the situation immediately. 10NYCRR 415.4(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 4/11/23-4/14/23, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #16) reviewed. Specifically, Resident #16 developed a Stage 2 pressure ulcer (partial-thickness skin loss), and the ulcer was not monitored, treatments were not completed as ordered, and the resident's plan of care was not followed. Additionally, the resident had a significant weight loss, and their nutritional needs were not reassessed after the development of the pressure ulcer and significant weight loss. Findings include: The facility policy Prevention and Care for Skin Impairment - Pressure Ulcers revised 1/2023 documented: -A resident who had pressure ulcers would receive necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. -Prevention interventions included turning repositioning the resident at a minimum every 2 hours while in bed and every 1 hour while in their chair. -Nursing staff would notify the Food and Nutrition department of any Stage 2 or greater pressure ulcer. - All wounds would be assessed by a registered nurse (RN) and the wound team would assess the wound weekly. - When a pressure ulcer was present the area should be monitored daily by the licensed practical nurse (LPN). The facility policy Significant Weight Loss revised 2/2023 documented: -Weights would be obtained monthly and significant weight changes would be communicated to and addressed by the registered dietitian (RD) and/or diet technician (DT), physician, and interdisciplinary team (IDT). - Re-weights must be obtained within 24 hours if meets the following criteria: 5-pound (lbs.) change in 1 week, 5% or 5 lbs. in 30 days, 7.5% in 90 days, and 10% in 180 days. - Nursing would notify the physician and family regarding significant weight changes. - The RD/ DT would reassess the resident's nutritional needs and intake with the noted weight change. -The resident's weight would be monitored weekly until their weight stabilized or weight returns to goal weight. Resident #16 was admitted to the facility with diagnosis including dementia and dysphagia (difficulty swallowing). The 1/25/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, did not reject care, required extensive assistance of 2 with bed mobility, transfers, dressing, personal hygiene, and toilet use, extensive assistance of 1 with eating, used a wheelchair, had an indwelling urinary catheter, was always incontinent of bowel, weighed 144 pounds, had no significant weight changes, was at risk for developing pressure ulcers, did not have pressure ulcers, had a pressure relieving device for their chair, and was on a turn and positioning program. The 10/27/20 physician order documented the resident's skin was to be checked on their bath day on Wednesdays on the 2:00 PM-10:00 PM shift. A nutritional assessment dated [DATE] (does not indicate who completed the assessment) documented the resident received a regular pureed diet with nectar thick liquids. The resident's intakes averaged 49% at breakfast, 53% at lunch, and 54% at dinner. The resident weighed 144 pounds (lbs.) via a mechanical lift on 1/24/23. The resident had excoriation to the buttocks and sacrum (lower back). The resident required 1540 Kcals (kilocalories) per day, and 66 grams of protein due to high risk for skin breakdown. The resident received 120 milliliters (approximately 4 ounces) of Ensure Compact (an oral nutritional supplement) at breakfast, lunch, and dinner. The resident's appetite was fair and had declined from last quarter. Weight was trending down which was consistent with decreased intake. The resident did not trigger for significant weight loss, however continued loss was undesirable. The resident received supplements at all meals and HS (hour of sleep) to help meet nutritional needs and stabilize weight. The comprehensive care plan (CCP) revised 1/30/23 documented the resident had potential for pressure ulcer development related to immobility and had maceration (skin breakdown related to moisture) to their buttocks. Interventions included to lay the resident down after meals to keep pressure off their bottom; follow facility protocol and procedures for the prevention/ treatment of skin breakdown; a gel overlay for their mattress; monitor, document, and report any skin changes; a gel cushion for their wheelchair; reposition every 2 hours while in bed, and every 1 hour while in their chair; and check skin daily with care and weekly by the nurse. The CCP revised 1/31/23 documented the resident was at nutritional risk due to dementia, their body mass index (BMI, measurement of body fat based on height and weight) was low 20.1, intakes were fair, their weight was trending down, they were at high risk for skin breakdown, and had an excoriated area on their buttocks. Interventions included providing adaptive equipment at meals, pureed solids and mildly thick (nectar) fluids, assistance with meals, 4 fluid ounces of Ensure Compact at all meals, and Magic Cups (frozen nutritional supplement) at lunch and dinner. The undated [NAME] (care instructions) documented the resident used a tilt and space wheelchair (redistributes pressure), a gel cushion for the wheelchair, a gel overlay mattress for their bed, reposition every hour while in their chair and every 2 hours while in bed, their bath day was Wednesday evening, extensive assistance of 2 people with bed mobility, total dependence to assist with feeding, received pureed solids and mildly thick (nectar) liquids, required assistance of 2 for toileting, and was incontinent of bowel. Physician orders documented: - on 1/31/23 the resident was to receive pureed solid, mildly thick fluid (Nectar) consistency with no straws. - on 2/23/23 use wedges to offload pressure for positioning every shift. On 2/27/23 physician #3 documented they saw the resident for a routine visit. The resident was noted to have deep tissue injury (purple/maroon area of intact skin due to damage of underlying tissue) bilaterally over their buttocks. Apparently, it was noted last week. The resident was at high risk for skin breakdown and had a history of stool incontinence. The resident had a couple of open areas over their buttocks bilaterally towards the mid to upper areas approximately the size of a half dollar, they were not measured, and they appeared to be Stage 2 pressure injuries. The plan included to encourage staff to turn and reposition the resident every 2 hours as needed; clean the area with wound cleanser, pat dry, apply wound gel, and cover with foam dressing every 3 days and as needed; and follow up within a week. The 2/28/23 physician orders documented to cleanse and apply wound cleanser to the buttocks topically one time a day every 3 days for skin impairment, pat dry, apply wound gel, let dry, and cover with foam dressing every three days and as needed. Registered nurse (RN) #9 entered the order into the medical record on 2/28/23. There was no further documentation regarding the buttocks wound. The March 2023 Treatment Administration Record (TAR) documented: Apply wound cleanser to the buttocks topically one time a day every 3 days at 9:00 AM for skin impairment, pat dry, apply wound gel, let dry, and cover with foam dressing every three days and as needed. The treatment was marked as not completed by licensed practical nurse (LPN) #7 on 3/18/23 due to the resident being out of the facility. There were no nursing notes on 3/18/23 documenting the resident was out of the facility or the treatment was administered at a different time. The Weights and Vitals Summary documented the resident weights as follows: - on 3/5/23 145 lbs. via mechanical lift. - on 4/2/23 137.5 lbs. via mechanical lift and was re-weighed at 137.5 lbs. via mechanical lift (a 7.5 lbs./5.1% significant weight loss at one month and 12.5 lbs./ 8.3% significant loss at 3 months). - on 4/9/23, the resident weighed 138.1 lbs. via mechanical lift (a 6.9 lbs./ 5.1% loss at one month and 11.9 lbs./ 7.9% loss at 3 months). There was no documentation the resident's significant weight loss or skin impairment was addressed by clinical nutrition staff (RD or DT). The April 2023 TAR documented to apply wound cleanser to the buttocks topically one time a day every 3 days at 9:00 AM for skin impairment, pat dry, apply wound gel, let dry, and cover with foam dressing every three days and as needed. On 4/2/23 and 4/11/23 the treatment was signed as not completed by LPN #7 due to the resident being out of the facility. There was no documented evidence the wound treatment was administered when the resident returned to the facility on 4/2/23 and 4/11/23. There were no nursing notes on 4/2/23 or 4/11/23 documenting the resident was out of the facility. Observations of Resident #16 included: - on 4/11/23 at 11:39 AM sitting in their tilt and space wheelchair with a blanket over their lap in the dining room. At 12:15 PM, the resident was assisted with their pureed solid lunch meal and mildly thick (nectar) liquids. At 2:31 PM, sitting in their tilt and space wheelchair in their room with a blanket over their lap. - on 4/12/23 at 8:18 AM sitting in their tilt and space wheelchair in the main dining room with a blanket over their lap. At 8:19 AM, the resident was brought out to the television lounge area by an unidentified staff member. At 12:58 PM, the resident was seated in their tilt and space wheelchair in the television area near the nurse's station with a blanket over their lap. At 1:58 PM, LPN #8 brought the resident to their room and closed the door. At 2:04 PM, the door to the resident's room opened and there were 2 CNAs in the room. The resident was in their bed with their eyes closed. - on 4/13/23 at 7:19 AM sitting in their tilt and space wheelchair in the dining room with a blanket over their lap. During a continuous observation starting at 8:11 AM, the resident was brought out to the television lounge area from the dining room. At 8:36 AM, LPN #8 brought the resident to the medication cart for their medication and brought them back to the television area at 8:39 AM. The resident remained in the television lounge area until 10:51 AM, when an activity staff brought the resident outside to the patio for an activity. The resident was not repositioned every hour in their chair as planned. At 11:10 AM, an activity staff brought the resident back inside from the patio to the television lounge area. At 11:48 AM, an unidentified staff brought the resident into the dining room. At 12:07 AM, a nursing student was seated with the resident feeding them lunch which included a pureed hamburger, pureed bun, puree pears, mildly thick (nectar) apple juice, a Magic Cup, and 4 ounces of Ensure Compact. During an interview with CNA #10 on 4/13/23 at 12:30 PM, they stated they knew how to care for the residents by reviewing their care plans. Repositioning a resident helped prevent skin breakdown. If a resident needed to be repositioned it was listed on their care plan. They stated Resident #16 only needed to be repositioned in their bed not in their wheelchair. There was nowhere for the CNAs to document they had repositioned a resident. They stated residents who needed a mechanical lift for transfers should be checked and changed prior to getting out of bed, after breakfast, and after lunch. They stated they had Resident #16 on their assignment on this day. The resident required a mechanical lift for transfers, they did not check or change the resident after breakfast or before lunch, the resident had a skin issue on their buttocks, the resident did not wear a brief, and they were unaware the resident needed to be repositioned while in their wheelchair. They stated it would be important to follow the care plan to prevent further skin breakdown. During an interview with RN #9 on 4/13/23 at 3:22 PM, they stated the RN Charge nurse would complete any wound assessments and document their findings in the computer. Residents who had pressure areas and other wounds were followed weekly by the RN and the LPNs did daily skin documentation in the computer as well. They stated they entered the 2/28/23 physician orders into the electronic health record. They did not assess the resident's pressure ulcer after entering the physician orders. They stated they dropped the ball. They should have documented the resident had a pressure ulcer, assessed the resident's skin, and triggered them to followed weekly for their pressure ulcer. They did not do this, and nobody had been assessing the resident's wound because it was not documented. It was important for pressure ulcers to be monitored to ensure the treatment was working and the area was improving. If it was not followed the wound could get worse. They stated the LPNs should document a skin observation on shower days, but there was no documentation that had been done either. They stated the resident's current interventions included a gel cushion for their wheelchair, gel overlay mattress for their bed, and the resident should be laid down after meals. Any RN could update the CCP, and the resident's pressure ulcer should have been added to the care plan when they entered the order into to the computer. If a resident needed to be repositioned that meant they needed to move the resident in their chair or bed to a different position to aid with preventing skin breakdown. Staff should check and change resident's every 2 hours and as needed. They stated if the resident was in the same position for 2 hours that was a long time as they were at risk for further skin breakdown. During an observation on 4/13/23 at 4:06 PM 2 CNAs and RN #9 rolled the resident over to their side. No dressing was observed on the resident's buttocks. There was a reddened area on their bilateral buttock/ sacral area approximately 10 centimeters (cm) x 12 cm, with a small quarter sized superficial open area at approximately 11 o'clock. RN #9 stated the area looked like a Stage 2 pressure ulcer. The RN stated they recalled entering the physician's orders for the wound but did not know when the wound treatment should be completed. They stated the resident should have a dressing in place as ordered and the LPNs should check the placement of the dressing each shift and write a note. They stated the resident's pressure ulcer should have monitored and had not been since it was found. During a follow up interview with CNA #10 on 4/13/23 at 4:37 PM, they stated they the resident did not have a dressing on when they got them up in the morning. They were unaware the resident needed to have a dressing and they told the LPN the resident's skin looked the same. They said the resident had an open area but did not tell LPN #8. It was important for a nurse to observe the resident's skin if they had any skin issues. During an interview with LPN #8 on 4/13/23 at 4:45 PM, they were unaware the resident had any skin issues and needed to have a dressing in place. They stated if the CNA observed any skin issues, they should have let them know so a nurse could look at the resident's skin. During a telephone interview with LPN #7 on 4/14/23 at 8:10 AM, they stated wound treatments were usually done in the morning before the resident got up. They were aware Resident #16 had a scheduled treatment every 3 days on the day shift for a wound on their buttocks. They stated they did not complete the treatment on 4/11/23 because LPN #6 told them they had completed the treatment on the 10:00 PM to 6:00 AM shift. They documented on the TAR that the resident was absent from home without medications as the resident was either at an appointment or at an activity. They thought LPN #6 documented they completed the treatment. They did not tell anyone they did not complete the treatment or were unable to observe the resident's skin. They should have followed up to make sure the treatment was completed as ordered and they were unsure how the resident's skin looked. It was important to follow physician's orders to ensure the treatment was completed and the wounds was improving and did not get worse. During a telephone interview with LPN #6 on 4/14/23 at 8:40 AM, they stated worked the night shift on 4/10/23. If they completed a treatment when it was not scheduled, they would document it was completed in a progress note. They were aware the resident had an open area on their buttocks, but they had not seen the resident's wound. LPN #6 stated they did not change the dressing on 4/10/23 or 4/11/23 as it was not scheduled to be completed on their shift. They stated it was important for the physician orders to be followed as the wound could get worse. They stated the resident was to be turned and positioned every 2 hours while in bed. During an interview with RN Unit Manager on 4/14/23 at 9:08 AM, they stated treatments should be completed per the physician's orders and the staff member who entered the physician orders into the electronic computer system should have triggered a weekly skin assessment so it could be followed. They were unaware Resident #16 had a pressure ulcer and was not being followed weekly. They stated they were unaware the treatment was not being followed per physician orders and they expected one of the RNs to be notified if a treatment could not be completed as ordered. They stated there could have been negative outcomes including the wound getting worse or infected if it was not monitored and the treatment was not completed as ordered. They stated the resident should be repositioned every hour in their chair and every 2 hours while in bed. They stated the RD let the Unit Managers, RN charge nurses, and the Director of Nursing (DON) know who had significant weight changes by a list they sent out on Mondays and Fridays via electronic communication. After reviewing the resident's record, they stated the resident appeared to have lost weight and their intakes were hit or miss, and the resident was assisted at meals by staff. The RN Unit Manager stated the RD probably did not know the resident had a Stage 2 pressure ulcer and should have made aware so nutritional intervention could be put into place. They stated it was the responsibility of either the RN Unit Manager or RN charge nurse to update the care plan if a resident had a pressure ulcer. During an interview with the DON on 4/14/23 at 12:23 PM, they stated if a resident had any changes to their skin an RN should assess the resident. They expected them to complete a skin assessment, update the care plan, ensure orders were in place for treatments, and make sure the weekly pressure ulcer assessment task was initiated so the wound could be monitored. They stated it was important for the treatments to be completed as ordered and the wound to be monitored to ensure the wound was healing and not getting worse. They stated nurses should checking the placement of the dressing each shift and replace or change as needed per the physician order. The DON stated it would be important for the RD to know if the resident had skin breakdown to make sure their nutritional needs were being met. During an interview with RD #22 on 4/14/23 at 11:32 AM, they if a resident had a 5 lbs. weight change from their previous weight a reweight was to be obtained. They considered significant weight changes 5 lbs. or 5% at 30 days, 7.5% at 90 days, and 10% at 180 days. If a resident had a significant weight change, they would discuss the weights with the IDT, document in a progress note, and review the resident's current nutrition plan of care to determine if any interventions should be added or changed. If they were aware a resident had a pressure ulcer and a significant weight loss they would complete a full nutrition assessment, determine their estimated daily nutritional needs, review current nutritional interventions to determine if any changes were needed, and update the care plan. They were unaware Resident #16 had a Stage 2 pressure ulcer. They stated Resident #16 triggered for a significant weight loss 2 weeks ago, they had emailed the team about the weight loss and were told the scales had been serviced. They requested another reweight and that was obtained on 4/9/23. The resident triggered again for a significant weight loss, but they had not addressed it yet and were currently working on their weight notes. They stated they would have completed their notes or assessment earlier and updated the care plan had they known the resident had a pressure ulcer. The RD stated the resident had a stomach bug a couple of weeks ago which may have affected their appetite and intakes. During a telephone interview with physician #3 on 4/14/23 at 1:19 PM, they stated they expected any resident who had a pressure ulcer to be followed by the RN and the nurses should be documenting on the resident's skin. They stated Resident #16 was at high risk for skin breakdown, they saw them in February and had written orders for wound care. They expected staff to ensure the treatment was completed as ordered. He also expected staff to reposition the resident due to their high risk for skin breakdown. 10NYCRR 415.12(c)(2)

Based on observation, record review, and interview during the recertification survey conducted 4/11/23-4/14/23, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, and the comprehensive person-centered care plan for 1 of 3 residents (Resident #14) reviewed. Specifically, Resident #14 was observed receiving oxygen (O2) via a nasal cannula (NC, a tube delivering oxygen through the nose) and did not have a physician order or indications for use, and did not have ongoing assessments of respiratory status, and response to O2 therapy. Findings included: The facility policy Oxygen Therapy last reviewed on 6/2021 documented routine oxygen therapy required a physician order to include device and percentage of liter flow. Resident #14 had diagnoses including chronic obstructive pulmonary disease (COPD, airflow obstruction), iron deficiency anemia, and congestive heart failure. The 1/31/23 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance for most activities of daily living (ADLs), and required oxygen therapy. The comprehensive care plan (CCP) initiated 8/3/22 did not include a plan for the resident to receive oxygen. Physician's orders with a date range of 8/30/22-3/30/23 did not include oxygen administration. A physician #3 progress note dated 2/27/23 documented the resident was seen for a routine visit. The resident was ambulating in their room with their walker and did not appear to be in acute distress. The resident's lungs were clear to auscultation (listening with a stethoscope). There was no documented evidence the resident required oxygen therapy. The 3/30/23 at 10:44 AM, registered nurse (RN) #24's progress note documented the resident was congested and had wheezes. Vitals signs included oxygen saturation on room air (no oxygen) was 99%. A nursing progress note dated 3/30/23 at 2:03 PM by RN #21 documented the resident had a chest X-Ray (CXR) with results including right basilar (right lung base) atelectasis (lung collapse) or pneumonia. New orders were received from the nurse practitioner for antibiotics. There was no documentation of a plan for oxygen therapy. The April 2023 medication administration record (MAR) and treatment administration record (TAR) did not include administration of oxygen or respiratory status evaluation. The 4/4/23 nurse practitioner (NP) #25's progress note documented the resident was seen for a follow up visit for pneumonia. The resident had a chest X-ray that showed the resident had pneumonia and would need to be started on antibiotics for seven days. The resident was feeling better. The resident was on oxygen chronically. The resident was short of breath at rest and had some wheezes. The resident's pulse oximetry (measurement of a person's blood oxygen saturation, O2 saturation) with oxygen on was 98% (did not document the flow rate of oxygen the resident was receiving) and respiratory rate (number of breaths per minute) was 22. The 4/1/23-4/14/23 Vitals Summary documented the resident had oxygen saturations measured daily. The summary documented the saturations were taken while the resident was on oxygen via a NC on 4/1/23-4/13/23. The resident was observed on 4/11/23 at 11:00 AM and 1:19 PM, 4/12/23 at 9:45 AM, and 4/13/23 at 7:28 AM, receiving oxygen at 2 liters per minute via a nasal cannula. During an interview on 4/13/23 at 3:34 PM, licensed practical nurse (LPN) #12 stated residents that required oxygen should have a physician order for the oxygen. The order would than show up on the electronic MAR or TAR and that would include when the oxygen tubing was changed. Nursing was responsible for checking the resident's oxygen tubing and rate of flow. Resident #14 did not have a physician order and used oxygen daily and should have had an order. During an interview on 4/14/23 at 9:40 AM, RN #19 stated if a resident was on oxygen, they should have a physician order. Resident #14 was on oxygen. The RN reviewed the current physician orders and stated there was no physician order for them to receive oxygen. The oxygen order should include the required liters per minute and the nurse would be responsible for checking this routinely. If a resident routinely used oxygen, the CNAs would check their oxygen level when they completed their vital signs, but the nurse was responsible for the tubing and setting the flow rate. During an interview on 4/14/23 at 1:16 PM, physician #3 stated there should be an order for the resident to receive oxygen. Prior to switching to electronic medical record, they had a standard checklist when a resident was admitted and that had oxygen orders on the list as a reminder. The oxygen order did not make it over to the electronic record and should have because Resident #14 required oxygen. They thought the resident should have an as needed (PRN) order, the resident required use of oxygen routinely and staff should also be checking the resident oxygen saturation. They stated they would expect to be notified by nursing staff if a resident required oxygen and did not have an order. During an interview on 4/14/23 at 2:18 PM, the Director of Nursing (DON) stated the resident used oxygen and every resident that required oxygen should have a physician order. The nurses knew that if a resident used oxygen, it was just like a medication and required a physician order. The order should include the frequency of use and the flow rate. 10 NYCRR 415.12(k)(6)

Based on observation, record review, and interview during the recertification survey conducted 4/11/23-4/14/23 the facility failed to ensure that licensed nurses had specific competencies and skill sets to provide nursing services to assure resident safety for 1 of 3 licensed nurses (licensed practical nurse [LPN]) #12 observed during medication administration. Specifically, LPN #12 was observed pre-pouring resident medications before the ordered times and placing them in plastic cups in the medication cart. Findings include: The facility policy titled Medication Administration Overview revised 4/2023 documented prior to medication administration, scan all required medications, and visually confirm that the correct dose, correct medication, and correct resident ID were displayed on the eMAR (electronic medication administration record) screen. The facility policy Pharmacy Services revised 1/2021 documented when administering medication to review the following: Is it the correct resident? Correct medication? Correct dose? Correct time? Correct route? Identify the resident with the picture ID and medical record number, compare the medical record number with the resident's picture, or pharmacy sticker. Pour medication. Re-check labels with the MAR after pouring and initial and date the blister pack. Re-check the resident's identity. Administer medication with adequate fluids. Stay with the resident until the medication was completely taken. Re-check unit dose/blister pack with MAR. Sign the MAR. Re-check all MARs after medication was completed. During a medication administration observation on 4/12/23 at 3:16 PM, LPN #12 was behind the nursing station with the Unit 3 East medication cart. LPN #12 had the electronic MAR screen displayed with Resident #9's 8:00 PM medications and was placing the medications in a plastic medication cup. The LPN completed pouring Resident #9's 8:00 PM medications and covered them with a paper medication cup. The paper medication cup had the resident's name and 8:00 PM written on it. LPN #12 placed the cup in the top drawer of the medication cart. While the drawer was opened, 2 additional medication cups with medications inside were observed. The medication cups contained pills and were labeled for Resident #32 at 8:00 PM and for Resident #9 at 5:00 PM. LPN #12 stated those medications were removed from the original pharmacy packaging (blister packs). The locked narcotic drawer in the medication cart was observed with 4 medication cups containing pills. LPN #12 stated they had removed the pills in the narcotic drawer from the pharmacy packaging and placed them in the cups. The medication cups in the narcotic drawer contained methadone (opioid agonist) 10 milligrams (mgs) for Resident #5 scheduled to be given at 8:00 PM; clonazepam (benzodiazepine, anti-anxiety) 0.5 mgs for Resident #40 scheduled to be given at 7:00 PM; Xanax (anti-anxiety) 0.5 mgs for Resident #10 scheduled to be given at 8:00 PM; and lorazepam (anti-anxiety) 0.5 mgs for Resident # 4 scheduled to be given at 4:00 PM. LPN #12 stated the medications would be signed out on the narcotic reconciliation book at the times they were to be given. The LPN stated their usual routine was to prepare meds early, because it was very busy after dinner. LPN #12 stated they were not sure what the facility policy was for pre-pouring medications, and they felt that organizing the medications for later administration allowed them to help the certified nurse aides (CNAs) if needed. They stated that the required checks (the 5 rights of medication administration, the right medication, dose, time, route, and resident) were performed when the medications were poured. LPN #12 stated they visualized what medications were in the cup before giving them but did not pull medication cards (blister packs) to verify the pill's appearance or accuracy. The LPN stated they did not feel their practice was unsafe. During an interview on 4/12/23 at 3:51 PM, registered nurse supervisor (RNS) # 20 stated pre-pouring medications was not an acceptable practice because the nurse could not identify the medications at the time of administration. The medications could get mixed up, and the wrong medication could go to the wrong person. It was not safe for residents. Narcotics should not be pre-poured and should be signed out at the time of administration. During an interview on 4/13/23 at 9:51 AM RN #21 stated during medication administration medications should not be pre-poured. The medications could get mixed up and possibly given to the wrong person. Medications should be prepared and given at the same time using the 5 rights of medication administration. During an interview on 4/14/23 at 1:39 PM, the Director of Nursing stated medications should never be pre-poured. The nurse may not give the medications to the right resident and an adverse reaction could occur if a resident received the wrong medications. A medication pass should not be interrupted. It was extremely important to resident safety. 10NYCRR 415.26(c)(I)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted [DATE]-[DATE], the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable for 1 of 2 medication carts (Unit 3 East) reviewed. Specifically, the Unit 3 East medication cart contained an insulin pen for Resident # 9 that did not have an opened date. Findings include: The facility policy Insulin Injection Administration reviewed 9/2022 documented insulin pens could be housed outside the refrigerator safely for 28 days. Check for labeled date/time/initialed when opened. Discard vial if opened more than 30 days. During a medication cart observation with licensed practical nurse (LPN) #12 on [DATE] at 3:16 PM, the Unit 3 East medication cart contained an insulin glargine (long acting insulin) pen for Resident #9. The insulin pen was not labeled with an opened date. LPN #12 stated insulin pens should be dated when opened by the nurse opening the pen to ensure the insulin was in date. They stated insulin was good for 30 days after opening, and all medication nurses should be checking the opened date when administering insulin. They stated they had worked the evening shift on [DATE] and had administered the insulin glargine with the pen to Resident #9. They did not remember if they checked for an opened date at the time of administration. During an interview on [DATE] at 3:51 PM registered nurse (RN) Supervisor #20 stated insulin pens should be labeled by a nurse with the date opened. Insulin was good for 30 days after opening, and the medication nurse should be checking for expiration dates when administering the insulin. Expired insulin could be less effective, less potent, and possibly cause an adverse reaction. During an interview on [DATE] at 1:39 PM, the Director of Nursing (DON) stated insulin pens should be checked for expiration dates and refrigerated until opened. Once opened insulin was good for 30 days, the date opened should be documented on the pen by the nurse who opened it. Every medication nurse should check insulin for the date opened. The danger of administering expired insulin included the insulin may not be effective. Expiration dates should always be checked before administration. 10 NYCRR 415.18 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 4/11/23-4/14/23, the facility failed to assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent prior to the installation of bed rails for 10 of 10 residents (Residents #9, 11, 14, 15, 16, 29, 32, 36, 37, and 38) reviewed. Specifically, for Residents #9, 11, 14, 15, 16, 29, 32, 36, 37, and 38 there was no documented evidence bed rail assessments were completed, and consents were obtained prior to bed rail installation; there was no documented evidence the risks and benefits of bed rails were explained to the residents or their representatives prior to bed rail use; and there were no care plans that included the use and monitoring of bed rails. Findings include: The facility policy Bedrail Safety last reviewed 8/2021, documented it was the facility's policy to prevent entrapment and other safety hazards associated with bed rail use. Staff would be educated on bed rail safety at orientation and annually and would include entrapment, risks and benefits pertaining to bed rails, and the need to report actual or potential risk to their immediate supervisor. 1)Resident #16 had diagnoses including unspecified dementia, cervical spinal stenosis (narrowing of the spinal canal in the neck), and osteoarthritis. The 1/25/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, was totally dependent on 2 for bed mobility and transfers and did not use a bed rail restraint. The following observations were made of Resident #16: -on 4/13/23 at 2:04 PM the resident was transferred to bed using a mechanical lift. The bed had bilateral upper 1/2 bed rails in the raised position. -on 4/13/23 at 4:06 PM the resident was in bed with bilateral upper 1/2 bed rails in the raised position. The comprehensive care plan (CCP) last revised 6/8/2020 documented the resident had an activity of daily living (ADL)/mobility self performance deficit due to dementia and limited range of motion due to spine fractures. Interventions included total assistance of 2 for bed mobility and to boost in bed. There was no documentation the resident required the bed rails. The care instructions ([NAME]) active on 4/13/23 did not document the resident had bed rails in place. There was no documented evidence the risks and benefits of bed rails were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of bed rails. 2) Resident #29 had diagnoses including Alzheimer's disease, osteoarthritis, and a history of falls. The 3/3/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance of 2 for bed mobility, and did not use a bed rail restraint. The following observations were made of Resident #29: - on 4/12/23 at 8:48 AM the resident was in bed with their eyes closed. The bed had bilateral 1/2 bed rails in the raised position. - on 4/13/23 at 9:16 AM the resident was in bed with their eyes closed. The bed was in the low position with fall mats on the floor and bilateral 1/2 bed rails in the up position. - on 4/14/23 at 9:35 AM the resident was in bed with their eyes closed. The bed was in the low position with fall mats on the floor and bilateral 1/2 bed rails in the up position. The comprehensive care plan initiated 10/15/2019 and last revised 6/14/22 documented the resident had an ADL self-care deficit and limited mobility due to left upper extremity contracture and peripheral nerve injury. Interventions included extensive assistance of 2 for bed mobility. The resident was combative and resistive at times. The care instructions dated 4/14/23 documented the resident was dependent on 2 for bed mobility and transfers and did not include the use of bed rails. There was no documented evidence the risks and benefits of bed rails were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of bed rails. 3) Resident #11 had diagnoses including Alzheimer's disease, osteoarthritis, and history of falls. The 4/4/23 Minimum Data Set assessment documented the resident had severely impaired cognition, required extensive assistance of 2 for bed mobility, was totally dependent for transfers, and did not use bed rails. The following observations were made of Resident # 11: - on 4/11/23 at 2:15 PM the resident was in bed with their eyes closed. The bed was at knee height and had bilateral 1/2 bed rails in the raised position. - on 4/12/23 at 1:13 PM staff assisted the resident back to bed with a mechanical lift. The bed had bilateral 1/2 bed rails in the raised position. The care instructions dated 4/14/23 resident did not include the use of bed rails. There was no documented evidence the risks and benefits of bed rails were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of bed rails. During an interview on 4/12/23 at 9:00 AM, the Director of Plant Operations stated bed rails were original manufacturer's equipment and could be removed if needed. Bed rail use would be a nursing area. Bed rails or positioning bars were checked on a semiannual basis using the FDA (Food and Drug Administration) device. They were not sure if all residents used them, but all beds had them and all the beds were measured for entrapment. During an interview on 4/12/23 at 9:10 AM, the Director of Nursing (DON) stated all resident beds were equipped with the bed rails that were original equipment. All the beds had them and if a resident needed to use them, they were available. The DON stated if residents did not need them, they could be left in the down position. The facility did not remove the bed rails. All beds were checked for entrapment. During an interview on 4/12/23 at 1:52 PM certified nurse aide (CNA) #10 stated bed rails were present on all the beds, and some of the residents used bed rails for turning and sitting up. The CNA stated they had just assisted Resident #11 to bed using a mechanical lift and the bed rails were raised after putting the resident to bed. The CNA was not aware of any resident that did not have bed rails and was not aware of potential dangers of bed rail use. During an interview on 4/12/23 at 1:56 PM, CNA # 18 stated all residents were able to have their bed rails up. The CNA was not aware of anybody who was not supposed to have bed rails. The CNA stated they raised resident bed rails after care was complete. They were not aware of any risks associated with bed rail use. During a follow-up interview on 4/13/23 at 8:48 AM, the DON stated the facility did not perform bed rail assessments to determine a resident's ability to use them. All resident beds included bed rails. Their policy contained a statement that upper bed rails used for bed mobility and transfers were not considered a restraint. All of the beds in the facility were equipped with original bed rails that came with the beds. The policy did not address other possible bed rail dangers, or reasons bed rails may not be safe to use. The DON stated maintenance performed entrapment assessments every 6 months on all beds. The DON did not feel there was a danger to the residents from bed rail use. They felt staff would notify the charge nurse if any resident was in danger from bed rail use. During an interview 4/14/23 at 1:18 PM, physician #3 stated bed rail use should be individualized and assessed for each resident's safety. 10NYCRR 415.12(h)(1)(2)

Based on observation and interview during the recertification survey, the facility did not store drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts (north hall medication carts #1 and #2) reviewed for medication storage and labeling. Specifically, multiple expired medications were observed stored in two north hall medication carts. Findings include: The facility policy Pharmacy Services for Rural Health Care Facility (RHCF) reviewed 01/2021, documented the facility stores stocked medications locked in medication carts and medication rooms. All outdated, discontinued, changed, or otherwise unusable drugs will be pulled from the medication cart by the medication nurse and placed in the medication room. The 6:00 AM through 2:00 PM medication nurse is responsible for delivering these medications to the pharmacy by the end of their shift, daily. During an observation on 04/13/21 at 10:41 AM, the 2 north hall medication carts were inspected with LPN #2. The following expired, outdated, and/or unused medications were observed: -on the north medication cart #1 a 430 ml (milliliter) bottle of liquid Colace (stool softener) with an expiration date of 02/2020. -on the north medication cart #2 a bottle of vitamin B1 expiration 2/2020; a bottle of calcium antacid 500 mg (milligram) expiration 1/2021; a bottle of vitamin B12 expiration 2/2020; a bottle of vitamin B6 expiration 1/2021; a bottle of meclizine (used for dizziness) 12.5 mg expiration 7/2020, and a bottle of Allegra -24 hour (allergy medication) expiration 3/2021. During the observation LPN #2 stated the nurse assigned to the medication cart should check for medication expiration dates. The expired medications in the carts were stock medications and had not been administered to any residents. When interviewed on 4/14/21 at 11:53 AM, pharmacist #3 stated the pharmacist was responsible for checking the medication room for outdated stock medications and removing them. She stated the nurse was responsible for checking for outdated stock medications or unused medications on the medication carts. When interviewed on 4/14/21 at 11:55 AM, the Director of Nursing (DON) stated it was the responsibility of the nurse assigned to a medication cart to check for expired, outdated, and unused medications. 10NYCRR 415.18(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification and abbreviated surveys (NY00247612 and NY00249167) the facility did not ensure it maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 nursing units (North/South and East) and 1 of 1 laundry room (first floor laundry room) reviewed. Specifically, dirty lunch trays were observed placed on top of multiple clean PPE (personal protective equipment) carts on 2 of 2 nursing units (North/South and East); and two drying tumblers and two front loading washer-extractors were not maintained per manufacturer instructions. Findings include: NURSING UNITS/MEAL TRAYS The facility's infection control policy, under RHCF Policy Updates for COVID-19 Pandemic effective 9/23/2020 documented meal trays from isolation rooms will be handled with gloves and will be placed directly onto the transportation cart for return to the Food and Nutrition Department. If the carts have already been removed from the RHCF (residential health care facility) area, the meal tray will remain in the isolation room. Nursing staff will then call Food and Nutrition and request for a cart to be brought to the unit for removal of the meal tray. From 4/12/21-4/15/21 all residents were on contact and droplet precautions and remained in their rooms due to a recent COVID-19 positive staff member. There were no COVID-19 positive residents. On 4/12/2021 the following observations were made on North/South unit: - At 12:45 PM a dirty lunch tray was sitting on top of the PPE (personal protective equipment) cart, between rooms [ROOM NUMBERS]. The tray was lying directly on 3 boxes of gloves, procedure masks and sanitizing wipes. The dirty lunch tray contained a food lid, plate, cutlery, two empty juice cups, 2 empty coffee mugs and aluminum foil. An unidentified staff lifted the dirty tray and set two meal tickets underneath and proceeded to walk down the hall. At 12:54 PM the unidentified staff removed the dirty tray from the PPE cart and placed it on the food cart. The PPE cart was not wiped down with a sanitizing cloth. On 4/14/2021 the following observations were made on North/South unit: - At 12:17 PM a dirty lunch tray with two food lids, plates, multiple empty coffee mugs, multiple empty juice cups, a soiled napkin, plastic and foil wrappers, two meal tickets and a soiled white towel was placed directly on top of the PPE cart between rooms [ROOM NUMBERS]. - At 12:20 PM two dirty plastic cups were on top of the PPE cart next to room [ROOM NUMBER]. - At 12:25 PM unit helper #5 reached beyond the dirty tray to obtain a hand sanitizing cloth out of the cannister on top of the PPE cart located between rooms [ROOM NUMBERS]. - At 12:34 PM unit helper #5 picked up the two dirty plastic cups on the PPE cart next to room [ROOM NUMBER] and placed them on the food cart. Unit helper #5 was not wearing gloves and did not wipe the top of the PPE cart with a sanitizing cloth. - At 12:35 PM unit helper #5 picked up the dirty tray on the PPE cart next to rooms [ROOM NUMBERS] and placed it on the food cart. Unit helper #5 was not wearing gloves and did not wipe the top of the PPE cart with a sanitizing cloth. When interviewed 4/14/2021 at 12:36PM unit helper #5 stated the dirty food trays should not have been placed on top of the PPE carts where all the clean PPE was sitting. This was an infection control concern. The dirty trays should have been placed back on the food cart. She stated she should have worn gloves and wiped the top of the PPE cart with a sanitizing cloth after the dirty tray was removed. She stated she just set the trays wherever she could find a spot to put them since all the residents were now eating in their rooms. On 4/14/2021 the following observation was made on East unit: - At 12:40 PM a dirty plate, soup bowl and a two-handled sip mug were sitting on top of the PPE cart next to room [ROOM NUMBER]. The dirty items were placed directly on procedure masks, gloves, and sanitizing wipes. An empty food cart was sitting next to the PPE cart. When interviewed on 4/15/21 at 9:03AM, CNA #6 stated meal trays should not be placed on top of the PPE carts due to infection control. Normally she would leave the dirty trays in the resident rooms. She would then take an empty tray to place the dishes on and find another table to set those down on until all the dirty dishes could be placed on the food cart that goes back to the kitchen. She stated staff should be wearing gloves when picking up trays because all the residents were on isolation precautions. When interviewed on 4/15/2021 at 11:02AM the Infection Preventionist (IP) stated all the residents in the facility were on contact and droplet precautions due to a recent COVID-19 positive staff who had been on all the units. She stated when picking up meal trays staff should be wearing gloves and placing the dirty trays on the food cart. The food cart was sent to the elevator where dietary staff waited to take it down to the kitchen. Staff should not be putting trays or anything else on top of the PPE carts. If any items were placed on top of the PPE carts the area should be wiped down with a sanitizing cloth. When interviewed on 4/15/21 at 12:45PM the Director of Nursing (DON) stated used meal trays should be placed directly on the food cart and gloves should be worn. This was especially important for infection control as all the residents were on contact and droplet precautions. The food carts were then taken to the elevator so dietary staff could take them down to the kitchen, where they were cleaned and sanitized. The facility COVID-19 policy for meal trays addressed this procedure. WASHER/DRYER During an observation on 4/13/21, between 12:35 PM and 1:05 PM, there were two washing machines (#1 and #2) and two dryers (#1 and #2) located in the first floor laundry room. The manufacturer instructions for drying tumblers #1 and #2 documented the following requirements: -Quarterly, clean the lint and any other foreign materials from the air vents located on the front and back of the drive motor; check the steam coils and remove any lint buildup in the coil area; exhaust ducts should be periodically inspected to ensure there has been no build-up of lint which could obstruct the air flow; inspect the dryer area to make sure nothing is obstructing the flow of combustion and ventilation air; and remove front panel and remove any lint buildup; and check belt tension and adjust if needed. -Semi-Annually, check the tumbler over thoroughly for loose nuts, bolts, and screws, and for loose gas, steam, and or electrical connections. The facility dryer inspection dated 3/19/21 documented the following maintenance was done by the facility monthly: - remove cap from large dryer manifold and check for excessive lint; and - check lint screens in bottom of dryers for gaps between frame and housing and for holes, replace if necessary. There was no documented evidence maintenance was completed per manufacturer recommendations. The manufacturer instructions for the front load washer-extractors #1, and #2 documented the following requirements: -Monthly, check V-belts for uneven wear and frayed edges; and for groove-pulley drive systems, verify alignment by placing a straight edge across both pulley faces. There was no documentation maintenance for washer-extractors #1 and #2 was completed per manufacturer recommendations. On 4/13/21 at 3:00 PM, the Director of Plant Operations stated that most of the items listed in the quarterly and semi-annual dryer manufacturer maintenance were completed but not documented. On 4/14/21 at 12:20 PM, the Director of Plant Operations stated that he could not locate documentation for the maintenance of the facility washer-extractors. He was not sure what maintenance had been done for washer-extractors #1 and #2. 10NYCRR 415.19(a)(2)(b)(2)