**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey on 2/21/2023 through 3/2/2023, the facility did not ensure development and implementation of comprehensive person-centered care plans for each resident, consistent with the residents rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 5 (Resident #s 55, 73, 86, 96, and #100) of 23 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #55, the facility did not ensure the CCP for Actual Alteration in skin integrity included resident specific goals and interventions and did not address compliance with positioning; for Resident #73, the facility did not ensure a CCP was developed to address the resident's pain; for Resident #86, the facility did not ensure a CCP was developed for the diagnoses of seizures and dementia, and for the resident's noncompliance with care to prevent further decline; for Resident #96, the facility did not ensure a CCP was developed to address the resident's pain; and for Resident #100, the facility did not ensure a CCP was developed to address the needs of a resident requiring oxygen therapy, nebulized medications, and bilevel positive airway pressure (BIPAP). This is evidenced by: The facility policy titled Care Plan, Comprehensive Person-Centered, last revised 1/2023 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. Identifying problem areas, their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. The facility policy titled Care Planning- Interdisciplinary Team, last revised 1/2023 documented; A comprehensive care plan for each resident will be developed within seven days of completion of the resident's assessment (MDS). Resident #73 Resident #73 was admitted to the facility with diagnoses of multiple sclerosis, polyneuropathy, arthritis, and pain. The Minimum Data Set (MDS-an assessment tool) dated 1/15/2023, documented the resident was without cognitive impairment, had received pain medication, and reported almost constant pain in the previous 5 days. Physician's Orders documented the following medication orders that addressed the resident's pain; gabapentin 800 mg three times daily for pain,order date 1/7/2022; Meloxicam (non-steroidal anti-inflammatory drug) 15 mg one time a day for pain, order date 1/3/2022; oxycodone HCL (opioid analgesic) 5mg three times a day for pain, order date 1/6/2023 discontinued 2/28/2023; oxycodone HCL 5mg four times a day for pain, order date 2/28/2023; pain assessment every shift when awake, order date 1/3/2022. A 30-Day Follow-up signed by the physician on 2/7/2023, documented the resident had a significant medical history including multiple sclerosis with generalized pain and body spasms. The Follow-up documented that the physician agreed to increase oxycodone to 5mg four times daily because the resident reported continued pain. A Pain Assessment Interview completed on 1/16/2023, documented the resident reported frequent moderate pain, and was receiving a scheduled pain medication regimen of gabapentin and oxycodone. The resident's medical record did not include a Comprehensive Care Plan to address pain management. During an interview on 02/28/23 at 1:45 PM, Resident #73 stated the nurses will offer to help when they complain of pain, but don't usually bother because only the medication will help. Resident #73 stated that since the doctor increased the dose it has been better. During an interview on 02/28/23 at 1:50 PM, Certified Nurse Aide (CNA) #2 stated Resident #73 complains of pain in their legs occasionally. CNA #2 stated they tell the nurse and offers repositioning and distracting activities for the resident when they complain. During an interview on 02/28/23 at 2:05 PM, Registered Nurse (RN) #2 stated they would have been responsible for ensuring all necessary care plans were done. RN #2 stated this resident has pain related to multiple sclerosis and it should be care planned and was not sure how this got missed. Resident #55 Resident #55 was admitted to the facility with diagnoses of status post fracture hip, anemia, existing pressure sore, and history of respiratory failure. The Minimum Data Set (MDS-an assessment tool) dated 1/23/2023, documented the resident was understood and understands others with intact cognition for decisions of daily living. During an observation on 02/23/23 at 10:23 AM, Resident #55 was lying in bed on their back, enabler bars were in place on both sides of the bed, and an air mattress was in place over the bed mattress. The CCP for actual alteration in skin integrity, implemented on 2/1/2023 did not include documentation of resident specific goals and interventions for the resident's existing pressure sore and did not address the resident's compliance with positioning. A nursing progress note dated 1/20/2023 documented Resident #55 entered the facility with a wound on their back measuring 1 cm by 1 cm. A nursing progress note dated 2/7/2023, documented wound showing improvement. Compliance with positioning a problem. During an interview on 2/28/2023 at 1:07 PM, Registered Nurse Unit Manager (RNUM) #4 for Unit #1 stated the admission CCP had not been finished and not all the goals and interventions had been added. During an interview on 3/2/2023 at 11:27 AM, the Director of Nursing (DON) stated the facility needed to address and work on better care planning for the residents. There had been changes in staff with the Nursing Education role being vacant and RN's that develop the CCP are not always available. This would be addressed moving forward. During an interview on 3/2/2023 at 11:45 AM, the Administrator stated the facility was currently working on following up on documentation with CCP and treatments. These were areas that have been identified as needing review and education to ensure policies and procedures are followed. Resident #100: Resident #100 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (COPD), obesity, and obstructive sleep apnea (intermittent airflow blockage during sleep). The MDS dated [DATE] documented the resident was cognitively intact and was able to make their needs known. During a review of the medication administration record (MAR) dated 2/2023, a physician order dated 11/3/2022 documented; Oxygen 3 liters via nasal canula at all times (AATs) for COPD. During a review of the treatment administration record (TAR) dated 2/2023, a physician order dated 11/3/2022 documented, BIPAP (bilevel positive airway pressure) every HS (hours of sleep) BIPAP Settings O2:3 at bedtime for COPD. During a review of the TAR dated 2/2023, a physician order dated 11/3/2022 documented; Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/ML- 1 vial inhale orally two times a day for COPD. During a review of the TAR dated 2/2023, a physician order dated 11/9/2022 documented; change nebulizer tubing every Wednesday day shift. During a review of the TAR dated 2/2023, a physician order dated 11/9/2022 documented; change oxygen tubing and ear cushions every Wednesday day shift. The comprehensive care plan (CCP) did not address the respiratory care needs of the resident with the diagnosis of chronic obstructive pulmonary disease (COPD) and the use of oxygen therapy, nebulized medications, and bilevel positive airway pressure (BIPAP) at hour of sleep. During an interview on 2/27/2023 at 3:55 PM, the Admissions Registered Nurse (RN) #1 stated the CCP did not document respiratory care needs with goals and interventions for the resident with COPD. During an interview on 2/28/2023 at 1:52 PM, the Registered Nurse Educator RN #2 stated a respiratory care plan should have been developed for the resident who use oxygen, nebulized medications and BIPAP at night. During an interview on 2/28/2023 at 02:21 PM, the Director of Nursing (DON) stated that a care plan with goals and interventions to the manage Resident #100's respiratory care should have been developed. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review during the recertification survey dated 02/21/23 through 03/02/23, the facility did not ensure necessary housekeeping and maintenance services were provided to maintain a clean, sanitary, comfortable, and homelike environment for three (3) of 3 resident units and the Lobby. Specifically, wallpaper was ripped and curling at the seams and/or bubbling off the wall on the [NAME] Unit (Unit B), Courtyard Unit (Unit C), Mountainview Unit (Unit M), Lobby, and the corridor outside the Beauty Salon; walls were soiled with dirt and/or damaged with holes, scrapes or [NAME] marks, or had missing coving base on Unit B, Unit C and Unit M; on Unit C, the ceiling was peeling in the bathing suite and the kickplate on the outside wall of the nurse station was attached with duct tape; in the Unit M bathing suite, the ceiling light covers had dead flies and were yellowed, and the floor fan was dusty; floors were scrapped or soiled with a wax buildup or dirt in corners and next to walls on Unit B, Unit C, and Unit M; sections of floor were worn to the subfloor on the Unit B nurse station, and floor tiles were cracked in the 2nd floor vending area; furniture upholstery was damaged on Unit B and Unit C; and a resident wheelchair was soiled with food particles on Unit B. This is evidenced as follows: During observations on 02/21/23 at 2:46 PM, on 02/24/23 at 2:30 PM, and again on 02/27/23 at 10:29 AM, the following environmental observations were noted: Finding #1 Wallpaper was ripped and curling at the seams and/or bubbling in the following area: the corridors and in the Solarium on the Courtyard Unit, the corridors and by the elevator on the Mountainview Unit, by the housekeeping closet on the [NAME] Unit, in the Lobby, and in the corridor outside the Beauty Salon. Finding #2 Walls were soiled with dirt or scrape marks and/or damaged with [NAME] marks in the following areas: Resident room #s B1, B4, C16, C17, C3, C6, C8, C10, C14, C18, M9, M20, and M23; the Courtyard activity room and nurse station; the [NAME] corridor walls, bathing suite, and nurse station; and the Mountainview nurse station. A two-foot by 4-inch scrape was on the wall behind the bed in resident room #C17. The Coving base was missing in resident room #B4 and in the bathroom in resident room #C16. On the Courtyard Unit, the bathing suite ceiling was peeling, and duct tape was holding the kick plate to the base of the desk in the nurse station. On the Mountainview Unit, a 3-inch hole was found by the dining room bathroom; and in the bathing suite, a 3-inch hole was found by the shower, the walls had scrape marks, the ceiling light covers had dead flies and/or were yellowed from the light bulbs, and the floor fan dusty. Finding #3 The floors were soiled with dirt in corners and next to walls in the following areas: resident room #s B1, B4, B8, B10, C3, C6, C8, C10, C12, C14, C18, M9, M12, M16, M18, M19, M20, and M23; the [NAME] Unit dining room; the nurse station stations on the Courtyard, Mountainview, and [NAME] Units. Floors were soiled with wax build-up in resident room #s B8 and M12. Floors were soiled with dirt where door frames meet the floor on the Courtyard Unit, Mountainview Unit, and [NAME] Unit. In the nurse station on the [NAME] Unit, three 2-foot sections of floor were worn to the subfloor. Floor tiles were cracked on the 2nd floor vending area. Finding #4 Chair upholstery was ripped in resident room #s B4 and B7 and the Courtyard Unit Solarium. The wheelchair in resident room #B4 was soiled with food particles. Interviews: During interviews on 02/27/23 at 3:51 PM, the Administrator and Director of Environmental Services stated that the cleaning and maintenances items identified will be corrected. 483.10(i)(2); 10 NYCRR 415.5(h)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey dated 02/21/23 through 03/02/23, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen and three (3) of 3 unit kitchenettes. Specifically, in the main kitchen, the automatic dishwashing machine final rinse was 171 degrees Fahrenheit (F) at 37 pounds per square inch water pressure (psi); the concentration of Quaternary Ammonium Compound (QAC) used in the sanitizing rinse sink was found to be zero (0) parts per million (ppm); food temperature thermometers were not in calibration; food and non-food contact surfaces were not clean and in good repair; and the bulk food containers were not labeled; in the kitchenettes, the cabinets below the sinks were in disrepair, and refrigerators were not clean. This is evidenced as follows: Finding #1: Main Kitchen During observations on 02/21/23 at 11:28 AM, in the main kitchen, the automatic dishwashing machine final rinse was 171 F at 37 psi. The automatic dishwashing machine information date plate states that the minimal final rinse water temperature is to be 180 F with a water pressure between 20 psi and 25 psi. The concentration of QAC used in the sanitizing rinse sink was found to be zero (0) parts per million (ppm) when measured at 67 degrees Fahrenheit (F). The manufacturer's label directions stated the concentration is to be between 200 ppm and 400 ppm when the solution is measured between 65 F and 75 F. Two of 3 food temperature thermometers were found not in calibration when tested in a standard ice-bath method as follows: zero (0)F and 28F. The table mixer, walk-in freezer door, and fire extinguisher were soiled with food particles or grime and required cleaning. The edges of 3 rubber spatulas were split and not cleanable; the bulk flour, bulk fortified milk, and bulk thickener were not labeled; the bottom plastic panel in the reach-in freezer was missing exposing the fiber backing; and the reach-in refrigerator door gaskets were split. Finding #2: Kitchenettes During observations on 02/21/23 at 12:35 PM, the bottoms of the cabinets below the sinks in the Courtyard kitchenette, Mountainview kitchenette, and [NAME] kitchenette were heavily stained brown and partially warped from water damage. The countertop behind the sink in the Courtyard kitchenette was worn. The refrigerator and drawers in the Mountainview kitchenette were soiled with food particles. And the cabinets in the [NAME] kitchenette was soiled with food particles. Interviews: During interviews on 02/21/23 at 12:46 PM, the Food Service Director and Regional Director of Food Service stated that the vendor will be contacted to adjust the dishwashing machine final rinse temperature and water pressure; maintenance will be contacted to fix the refrigerator door gaskets and reach-in freezer, the vendor will be contacted to adjust the chemical sanitizer concentration, the split rubber spatulas have been discarded, the bulk food containers will be labeled, and staff will be educated on calibrating thermometers and cleaning procedures. Food Service Director and Regional Director of Food Service stated that the areas found in the kitchenettes will be cleaned, and maintenance will be contacted to repair the stained cabinets below the sinks in the kitchenettes. During an interview on 02/21/23 at 3:46 PM, the Administrator stated that the items found in the main kitchen and in the kitchenettes will be addressed with the dietary staff and maintenance 10 NYCRR 415.14(h)

Based on record review and interviews during an abbreviated survey (Case #NY00303840), the facility did not ensure that each resident was treated with respect and dignity for 1 (Resident #1) of 3 residents reviewed. Specifically, on 9/25/2022, the facility did not ensure Resident #1 was treated with respect and dignity, when a facility staff member used their foot to arouse Resident #1 who had lowered themselves to the floor and was not responding to staff's requests to get off the floor. This is evidenced: Resident #1: Resident #1 was admitted to the facility with diagnoses of low back pain, mild cognitive impairment, recurrent major depressive disorder, and syncope (fainting; loss of consciousness) and collapse. The Minimum Data Set (MDS- an assessment tool) dated 9/20/2022, documented the resident had severe cognitive impairment. The facility policy and procedure (P&P) titled Resident Rights revised 1/2022, documented employees would treat all residents with kindness, respect, and dignity. The P&P documented that Federal and State laws guaranteed certain basic rights to all residents of the facility. Residents had the right to a dignified existence and to be treated with respect, kindness, and dignity. The P&P titled Quality of Life - Dignity revised/reviewed 1/2022, documented that each resident would be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. The P&P documented residents would be treated with dignity and respect at all times. Review of the Comprehensive Care Plan (CCP) documented that the resident had difficulty understanding their surroundings related to cognitive impairment. Prior to admission, the family noted continuous cognitive decline including paranoid thoughts, wandering, and overall disorientation. The CCP interventions documented to provide support and ensure the resident was free from abuse. The facility investigation for date of incident 9/25/2022 at 2:15 PM, documented that at approximately 9:00 PM, the Director of Nursing (DON) received a call from the Licensed Practical Nurse (LPN). The LPN stated that Registered Nurse Manager (RNM) #1 was physically inappropriate towards a resident earlier in the shift. The LPN noted that RNM #1 kicked Resident #1, after the resident lowered themselves to the floor. The DON called the Administrator and started an investigation. During an interview on 10/28/2022 at 12:34 PM, RNM #1 stated that Resident #1 had attempted to elope from the facility and was being combative with staff. When the resident came to the unit, they put themselves on the floor and would not get up. RNM #1 stated that the resident was not responding to verbal instruction to get off the floor and after shaking the resident, the resident still did not move. RNM #1 stated that they then used their foot to nudge the resident on their shoulder. RNM #1 stated that it was wrong to use their foot and stated that they had been working a lot of hours and their back was hurting too much to be able to bend down. RNM #1 stated that they had slippers on at the time. RNM #1 stated they cared about the resident and should have asked other staff to intervene. During an interview on 10/28/2022 at 1:11 PM, Certified Nurse Aide (CNA) #1 stated that the resident tried to elope from the building. When the resident returned to the unit, the resident put their hands on the counter and gently lowered themselves to the floor. CNA #1 stated that they and other staff told the resident that they had to get off the floor and the resident did not respond. CNA #1 stated that RNM #1 went over to the resident and nudged the resident on their shoulder with their foot. CNA #1 stated that RNM #1 should not have used their foot to get the resident to respond. During an interview on 10/31/2022 at 11:57 AM, CNA #2 stated that they saw Resident #1 put themselves on the floor. CNA #2 stated that they went over to the resident, asked if they were okay and told the resident they should not be on the floor. CNA #2 stated that they left the resident so they could calm down because the resident had been combative a few minutes prior. CNA #2 stated that another resident started screaming that a resident was on the floor. CNA #2 stated that they and RNM #1 tried to get the resident off the floor by taking the resident's hands, but the resident would not move. CNA #2 stated that RNM #1 then used their foot and tapped the resident on their shoulder to get their attention. CNA #2 stated that RNM #1 should not have used their foot to arouse the resident. During an interview on 10/31/2022 at 3:51 PM, the Administrator (ADMIN) #1 stated that the expectation was for staff to always use their hands when arousing or providing care. ADMIN #1 stated that RNM #1 could have called someone else over to provide that arousal piece. The ADMIN #1 stated that RNM #1 was reeducated. 10 NYCRR 415.5(a)

Based on record review and interviews during an abbreviated survey (Case # NY00303840), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse to the Administrator of the facility and to the State Agency for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure that an allegation of physical abuse observed by the Licensed Practical Nurse (LPN) on 9/25/2022, was reported to the Administrator and the New York State Department of Health (NYSDOH) within 2 hours after the allegation was made. The allegation was reported to the facility Administrator approximately 7 hours after the allegation was made and was not reported to the NYSDOH until approximately 5 weeks later on 11/2/2022. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses of low back pain, mild cognitive impairment, recurrent major depressive disorder, and syncope (fainting; loss of consciousness) and collapse. The Minimum Data Set (MDS- an assessment tool) dated 9/20/2022, documented the resident had severe cognitive impairment. The policy and procedure (P&P) titled Abuse Prevention Program/Abuse and Neglect - Clinical Protocol/Abuse Investigation and Reporting revised 1/2022, documented residents had the right to be free from abuse. Any person who had knowledge or reason to believe that a resident had been the victim of mistreatment, abuse, neglect, or any criminal offense was to report or cause a report to be made of the mistreatment or offense. A person would not knowingly fail to report an incident of mistreatment or other offenses; screen reports or withhold information to reporting agencies. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property would be reported by the facility Administrator, or his/her designee to the named persons/agencies, including the State licensing/certification agency responsible for surveying/licensing the facility. Alleged violations would be reported immediately, but not later than 2 hours if the alleged violation involved abuse or had resulted in serious bodily injury, or within 24 hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury. The facility investigation for date of incident 9/25/2022 at 2:15 PM, documented that at approximately 9:00 PM, the Director of Nursing (DON) received a call from the LPN. The LPN stated that Registered Nurse Manager (RNM) #1 was physically inappropriate towards a resident earlier in the shift. The LPN noted that RNM #1 kicked Resident #1, after the resident lowered themselves to the floor. The DON called the Administrator and started an investigation. The NYSDOH Intake Information form (Case # NY00303840) dated 10/17/2022, documented an addendum dated 11/2/2022, for receipt of a facility reported incident that occurred on 9/25/2022 at 2:20 PM. During an interview on 10/28/2022 at 1:24 PM, LPN #1 stated that a resident yelled out that a resident was on the floor. LPN #1 went to check and saw Resident #1 on the floor, and they were not moving. LPN #1 shook the resident, and the resident still did not move. LPN #1 stated that RNM #1 went over to Resident #1 and kicked the resident. LPN #1 stated that they did not know why RNM #1 kicked the resident and stated that maybe they did that because the resident was not responding. LPN #1 then stated that the resident had shut her eyes tight and stated that they did not think that RNM #1 saw the resident do that before they kicked them. LPN #1 stated that they did not report the incident right away because they had talked to other staff about it and was told that if it was reported, no action would be taken. LPN #1 then stated that it was the weekend, and they did not have the Administrator (ADMIN) #1's phone number. LPN #1 stated that later that day, they went upstairs to another unit and talked to another nurse about it and was told that they needed to report it. During an interview on 10/31/2022 at 9:38 AM, the DON stated that LPN #1 reported an allegation of abuse to them, and it was not reported to the NYSDOH. The DON stated that they investigated the incident and determined there was no abuse, and therefore, determined that it was not reportable because of the outcome of the investigation. The DON stated they did not fully understand the regulation for reporting and stated that they could the see the importance of reporting the allegation right away. The ADMIN #1 was present and stated their understanding was to do the investigation and report as necessary. During an interview on 11/2/2022 at 11:25 AM, the ADMIN #1 stated that they were notified of the incident by the DON on 9/25/2022 at 9:15 PM. 10 NYCRR 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey, the facility did not ensure (i) A resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and (ii) 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 for 1 (Resident #109) of 3 residents reviewed for pressures ulcers. Specifically, for Resident #109, the facility did not ensure professional standards of practice for infection control were followed during a pressure ulcer dressing change; did not ensure the intervention on the Comprehensive Care Plan (CCP) for turning and positioning the resident from side to side every 2 hours while in bed was implemented and monitored; and did not ensure a physician's order for an air mattress was set to 150 pounds was implemented to assist in the prevention and promote the healing of pressure ulcers. This is evidenced by: Resident #109: The resident was admitted to the facility with diagnoses of spinal stenosis, major depressive disorder and neuromuscular dysfunction of the bladder. The Minimum Data Set (MDS) dated [DATE], documented the resident had three stage 3 pressure ulcers (localized areas of tissue necrosis (dead) that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time, involves full-thickness skin loss potentially extending into the subcutaneous tissue layer) and 3 stage 4 pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle) that developed while a resident at the facility. The Minimum Data Set (MDS-an assessment tool) documented the resident had severe cognitive impairment and required extensive assist with the physical support of 2 persons for bed mobility. A document titled RN: Weekly wound assessment dated 7/23/20, documented an unstageable pressure ulcer to the right buttock, an unstageable pressure ulcer to the left buttock, and a suspected deep tissue injury (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the right and left heel were present. A document titled RN: Weekly wound assessment dated 10/15/20, documented the resident had a stage 3 pressure ulcer on the right buttock, an unstageable pressure ulcer (pressure ulcers where the base of the sore is not visible to determine the stage) to the left buttock with undermining and tunnel areas not visible from the opening in the skin, a right heel unstageable pressure ulcer and a left heel unstageable pressure ulcer. Finding #1: The facility did not ensure infection control practices were maintained according to acceptable standards of practice during the observation of a dressing change. The Policy and Procedure (P&P) for wound care date 3/20 documented gloves should be removed and hand hygiene should be performed after removing a soiled dressing, use gauze to catch irrigation solution that is poured directly over the wound, to wear sterile gloves when holding a moist surface over the wound or physically touching the wound. A physician's order dated 9/10/20, documented to cleanse the left upper buttocks with wound cleanser, pat dry, pack wound with Maxsorb AG (a highly absorbent dressing which provides an antibacterial barrier to combat the bacteria absorbed in the wound exudate.), and cover with Optifoam (a wound dressing designed for wounds with heavy drainage) adhesive every day shift for wound care. A physician's order dated 10/16/20, documented to cleanse the right upper buttocks with wound cleanser well, pat dry and pack wound with Maxsorb AG and cover with Optifoam adhesive every day shift for wound care. During an observation on 10/16/20 at 9:27 AM, LPN #4 was observed performing wound care to the resident's right and left buttock. LPN #4 removed the outer layer of a dressing to the left upper buttock and removed the dressing covering the right upper buttock wound. LPN #4 did not change gloves or perform hand hygiene between removal of the dressings from both wounds. LPN #4 removed a dressing saturated in tan colored drainage from the base of the wound to the left upper buttock and a dressing saturated in tan colored drainage from the base of the wound on the right buttock. LPN #4 did not change gloves or perform hand hygiene between the removal of the dressings from the right and left buttock wounds. LPN #4 picked up a bottle of wound cleanser and sprayed the cleanser oonto the left buttock wound and right buttock wound. LPN #4 did not change gloves or perform hand hygiene prior to picking up the wound cleanser. Additionally, the wound cleanser liquid with wound debris from the left buttock wound drained into the right buttock wound. The Assistant Director of Nursing/ Wound Care Certified (ADON/WCC) Nurse was present during the dressing change. The ADON/WCC told LPN #4 to wash her hands. LPN #4 removed gloves, applied hand sanitizer, and put clean gloves on. The left and right buttock wounds were patted dry. LPN #4 then removed her gloves, and applied hand sanitizer and applied clean gloves. Each wound was packed with Maxsorb AG with gloves changed and hand hygiene performed between application of dressings. During an interview on 10/16/20 at 9:45 AM, LPN # 4 stated wound care to the left and right buttock was regularly performed together, despite the wounds being separate wounds and having separate MD orders for wound care. LPN #4 stated she was told by the ADON/WCC this morning that the wound care for each wound on the resident's buttocks were to be performed separately while the Department of Health was observing. LPN #4 stated she thought it was acceptable practice to remove both dressings and irrigate both wounds at the same time. LPN #4 stated she was unsure how to prevent the irrigation debris from the wound on the left upper buttock to not drip into the right upper buttock wound. LPN #4 stated she did forget to remove her gloves and perform hand hygiene on several occasions during the wound care, until she was instructed to do so by the ADON/WCC. During an interview on 10/16/20 at 10:01 AM, the Director of Nursing (DON) stated he would expect the removal of gloves, hand hygiene performed, and new gloves applied after removing a contaminated dressing, after irrigating a wound and before providing care from one wound to another. The DON stated the left and right buttock wound care should have been completed separately, the irrigation solution with debris from the left upper buttock wound should have been prevented from draining into the right upper buttock wound to prevent cross contamination of the wounds. The DON stated the facility recently had a mock survey and wound care was an area identified as needing improvement. The DON stated in mid-September 2020 education was provided to all licensed staff and performance evaluations were completed. Finding #2 The facility did not ensure the intervention on the Comprehensive Care Plan (CCP) for repositioning (turn and position the resident from side to side every 2 hours) while in bed was implemented and monitored. The P&P for repositioning revised 3/19, documented repositioning of the resident is a common, effective intervention for preventing skin breakdown, promoting circulation and providing pressure relief. Additionally, it documented positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. The P&P instructs the use of two people to prevent shearing (occurs when layers of skin rub against each other or when the skin remains stationary & the underlying tissue moves & stretches & angulates or tears the underlying capillaries & blood vessels causing tissue damage) while turning and moving the resident in bed. The P&P for Pressure Ulcer Prevention revised on 3/20, documented the resident would frequently be repositioned when dependent on staff for positioning, and the care plan interventions and strategies would be reviewed for effectiveness on an ongoing basis. An at Risk for Impaired Dkin Integrity CCP, last revised on 8/4/20, documented the resident would be turned and positioned every 2 hours. A document titled Documentation Survey Report dated October 2020, documented an intervention/ task of turn and re-position at least every 2 hours to be documented every shift. On 10/15/20 and 10/16/20 for the 11 PM -7 AM shift, NA was placed in the signature box with a staff member's initials. The system response key noted on this document that NA indicated Not Applicable. Resident #109 was observed lying on his/her back in bed, with a pillow under her lower legs on a pillow on the following dates and times: 10/14/20 at 11:22 AM; 10/15/20 at 9:34 AM; 10/15/20 at 11:53 AM; 10/16/20 at 8:11 AM; 10/16/20 at 9:15 AM; 10/16/20 at 11:46 AM; 10/16/20 at 2:29 PM; 10/19/20 at 9:38 AM; and 10/19/20 at 11:34 AM. During an interview on 10/16/20 at 2:32 PM, CNA #2 stated tried to reposition the resident approximately every 2 hours. CNA #2 stated the resident required two persons and extensive assistance for bed mobility, however she completed the task by herself, as there wasn't enough staff to assist her. CNA #2 stated she did the best she could to reposition the resident. CNA #2 stated she isn't sure why the resident was laying on her back during each observation today. During an interview on 10/16/20 at 4:58 PM, Registered Nurse Unit Manager (RNUM) #4 stated she expected the resident to be repositioned every two hours with two staff assistance as the resident was care planned for. RNUM #4 stated the resident was unable to assist in repositioning him/herself. RNUM #4 stated she would expect a resident have his/her position alternated to side and back with each position change. RNUM #4 stated she was not aware the resident's position was not being changed or that staff were not available to reposition him/her effectively. RNUM #4 stated she would not expect the CNA's to document not applicable (NA) on the treatment record for turning and positioning of this resident. During an interview on 10/20/20 at 12:40 PM, the DON stated he expected the resident's care plan to be followed. He expected the resident to have a position change, alternating side to back to side, and not just laying on his/her back. The DON stated he would expect two staff members to turn and reposition the resident as he/she is care planned for. The DON stated he would not expect a staff member to document NA for the intervention of turn and position every 2 hours. Finding #3: The facility did not ensure a physician's order for an air mattress to be set at 150 pounds, to assist in the prevention and promote the healing of pressure ulcers. A physician's order dated 9/6/20 documented to check the resident's air mattress set at 150 pounds alternating every shift for wound care. An At Risk for Impaired Skin Integrity CCP, last revised on 8/4/20, documented the resident would have an air mattress applied to the bed, and it would be set at 150 pounds. Resident #109 was observed lying on his/her back in bed on an air mattress. The air mattress was set to 100 pounds on the following dates and times: 10/14/20 at 11:22 AM; 10/15/20 at 9:34 AM; 10/16/20 at 11:46 AM; 10/16/20 at 2:29 PM; 10/16/20 at 4:34 PM10/19/20 at 9:38 AM; and 10/19/20 at 11:34 AM. During an observation on 10/20/20 at 11:35 AM, Resident #109 was observed lying on his/her back in bed on an air mattress. The air mattress was set to 100 pounds. During an interview on 10/19/20 at 4:42 PM, LPN #5 stated she documented on the Treatment Assistance Record (TAR), the air mattress was set to 150 pounds today for the 7:00AM-3:00PM shift. LPN #5 stated she did not physically check the setting on the air mattress and just assumed it was accurate. LPN #5 checked the setting of the air mattress during this interview and noted it to be set at 100 pounds. During an interview on 10/19/20 at 4:50 PM, Registered Nurse Unit Manager (RNUM) #4 stated she would expect staff to confirm the air mattress was set per the MD orders to 150 pounds and as noted on the TAR prior to signing off that it was accurate. During an interview on 10/20/20 at 11:37 AM, RNUM #4 reviewed Resident #109's TAR and confirmed it should be set at 150 pounds, per the MD orders. RNUM #4 entered Resident #109's room with this surveyor and observed the resident laying in bed on an air mattress that was set to 100 pounds. RNUM #4 stated this should have been changed yesterday and set the air mattress to 150 pounds. During an interview on 10/20/20 at 12:40 PM, the DON stated he would expect the TAR to accurately reflect the care and services the resident received. The DON stated he would not expect staff to sign the TAR if the task was not performed. He stated he would expect Resident #109's air mattress to be set per the MD orders, and the staff should have corrected this on 10/19/20 when visualized by LPN #5 and brought to the attention of RNUM #5 as inaccurately set to 100 pounds. 10NYCRR415.12(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey the facility did not ensure that it maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for one (Resident #75) of five residents reviewed for nutrition. Specifically for Resident #75, the facility did not identify and address an ongoing weight loss, and the Medical Doctor (MD) was informed of the resident's weight loss. This is evidenced by: Resident #75: The resident was admitted to the nursing home with diagnoses of dementia, left femur fracture and insomnia. The Minimum Data Set (MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented the resident had no difficulty chewing or swallowing and weighed 129 pounds. A Policy and Procedure (P&P) titled Weight Assessment and Intervention, last revised on 03/2020, documented any weight change of 5 % or more since the last weight assessment will be retaken the next day for confirmation; the dietician will respond within 24 hours of receipt of written notification of significant weight change; the threshold for significant unplanned and undesired weight loss will be based on 1 month of a 5% weight loss is significant and greater than a 5% weight loss is severe. The P&P documented assessment information shall be analyzed by the multidisciplinary team and physician to assist in identifying conditions, clinical situation and or medications that may be causing the weight loss. A Patient Review Instrument (PRI), dated 9/7/20, completed at the hospital prior to the resident's admission documented the resident weighed 119 pounds. A Physician's Order, dated 9/9/20, documented to follow the facility's weight protocol. A Nutrition Assessment was completed on 9/15/20 and documented the resident's most recent body weight was 128.8 pounds on 9/9/20. It assessed the resident as not having difficulty chewing or swallowing. The goals assessed were to maintain weight. The resident's reported usual body weight was 130-150 pounds and the resident would be on weekly weights until a baseline weight was established. A Comprehensive Care Plan (CCP), with a revised date of 9/15/20, documented the resident would be adequately nourished and hydrated and the resident would maintain her weight. The CCP included interventions to monitor weights as needed per facility protocol and to report significant weight loss to the Medical Doctor (MD) and Interdisciplinary Team for input. A dietary note dated 9/18/20 documented the resident had a weight loss of 14.8 pounds, her intake was at goal and weights were varied. A dietary note dated 9/25/20 documented the resident had a 10-pound weight loss from last week and the resident's intake had been at goal since admission. It documented weekly weights would be until a true weight can be assessed and the resident had not lost 24 pounds since admission. A dietary note dated 9/29/20, documented the resident's first 2 weeks of weights were most likely incorrect and her PO intake was at goal. Weights were as follows: 09/09/20 = 128.8 lbs. 09/17/20 = 114 lbs. - weight loss of 11.5% since 9/9/20 09/25/20 = 104.2 lbs. - weight loss of 8.6% since 9/17 and weight loss of 19.1 % since 9/9/20 10/05/20 = 106 lbs. - weight loss of 17.7% since 9/9/20 During an interview on 10/20/20 at 1:14 PM, the Director of Nursing (DON) stated he would expect a resident with a weight loss of greater than 5 % to have daily weights implemented and an intake study completed. The DON stated he would expect the weight loss to be further investigated. During an interview on 10/20/20 at 1:18 PM, Registered Dietician (RD) #5 stated the facility policy was that a resident admitted to the facility would be weighed for three consecutive days and then weekly for four weeks. The facility policy is if there was a weight change, the resident would be added to weekly weights for 4 weeks, an intake study would be completed, supplements may be added, to notify the physician as soon as practicable if significant weight changes, and a CCP would be implemented specific to the significant weight change. RD #5 stated she did not follow the facility policy for weight loss and is not sure why. RD #5 stated the resident had a good appetite and intake of food and fluids, and therefore felt the resident could not have lost a significant amount of weight as noted by the weights obtained. RD #5 stated she did not discuss the resident's significant weight loss with the interdisciplinary team, or with the physician. 10NYCRR 415.12(i)(l)

Based on record review, and interviews during a recertification survey the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one (Resident #57) of one resident reviewed for dialysis. Specifically, for Resident #57, the facility did not consistently provide ongoing monitoring for complications before and after dialysis treatments provided at a certified dialysis facility and did not consistently review the resident's dialysis communication book to provide ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. This is evidenced by: Resident #57: The resident was admitted to the facility with the diagnoses of end stage renal disease (ESRD), diabetes, and hyperlipidemia. The Minimum Data Set (MDS - an assessment tool) dated 8/31/2020 documented the resident was cognitively intact, could understand others and could make self understood. The Policy and Procedure titled Dialysis dated 3/2020, documented a Communications Log would be used for each resident who left the building for dialysis in order to communicate the resident's needs and response to the dialysis treatments. The inter-facility communications would be tracked and followed up on. A Comprehensive Care Plan for Dialysis last revised 9/3/2020, documented the resident required dialysis (hemodialysis (HD) off site) related to ESRD every Tuesday, Thursday and Saturday and had a double lumen CVC (Central Venous Catheter) (28 cm) located to the right chest wall. Interventions included; to check HD port dressing daily and document the condition and report any complications to the Medical Doctor (MD) and dialysis center and to use the communication book to relay information to and from dialysis staff regarding plan of care. A Physician Order dated 8/5/2020, documented the resident attended dialysis 3x a week on Tuesday, Thursday, and Saturday with a pickup at 10:30 AM for a chair time of 11:30 AM (4 hours of time spent at dialysis). Dialysis completed via double lumen CVC (28 cm) located to the right chest wall. The Dialysis Communication Book documented: 10/03/20 - did not include documentation of monitoring for complications after dialysis treatment provided at a certified dialysis facility. 10/06/20 - did not include documentation of the resident's pre and post weight and vital signs while at the dialysis facility and did not include documentation of monitoring for complications after the dialysis treatment provided at a certified dialysis facility. 10/08/20 - did not include documentation of the resident's pre and post weight and vital signs while at the dialysis facility and did not include documentation of monitoring for complications after the dialysis treatment provided at a certified dialysis facility. 10/10/20 - did not include documentation of monitoring for complications after dialysis treatment provided at a certified dialysis facility and did not include documentation that the facility reviewed a question documented by the dialysis center asking if the resident was being administered blood pressure medications on HD days and if so, to hold the medications due to the resident's low blood pressure. The dialysis center documented they were unable to pull the required fluid from the resident. 10/13/20 - did not include documentation of monitoring for complications before and after dialysis treatment provided at a certified dialysis facility. 10/15/20 - did not include documentation of monitoring for complications after dialysis treatment provided at a certified dialysis facility and did not include documentation that the dialysis communication book was reviewed when the dialysis facility documented to please watch the resident's fluid consumption before treatments due to large gains. During a medical record review on 10/20/20, there was no documented evidence from 10/3/20 - 10/15/20 of ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. During an interview on 10/19/20 at 10:59 AM, Licensed Practical Nurse (LPN) #1 stated the resident's weight and vital signs were obtained in the facility prior to the resident leaving for dialysis and were documented in the dialysis communication book. She stated weights and vital signs were not obtained when the resident returned from dialysis. She stated the communication book was reviewed prior to the resident leaving for dialysis but was not reviewed upon the resident's return from dialysis. She stated dialysis usually documented the resident's post dialysis information and did not document anything more. The LPN stated the communication book was not used to document how the dialysis treatment went or how the resident was feeling before or after a dialysis treatment. During an interview on 10/19/20 at 3:39 PM, LPN #2 stated when the resident returned from dialysis on the evening shift, she would give the resident's dialysis communication book to the Registered Nurse (RN) to review. She stated LPNs did not review the communication book. LPN #2 stated the resident's weight and vital signs were not taken when the resident returned from dialysis. During an interview on 10/20/20 09:05 AM, RN Unit Manager #1 stated an RN was supposed to review and initial the resident's dialysis communication book when the resident returned to the facility after a dialysis treatment. She stated if the communication book was not initialed, then it was not reviewed by the RN. She stated sometimes the communication book was reviewed but not always. She stated the RN was supposed to review the book and call the on-call provider if the dialysis facility recommended new orders. She stated she was not aware of the 10/10/20 entry in the communication book regarding the resident's blood pressure medication or the 10/15/20 entry regarding the resident's fluid consumption. The RN stated the resident was weighed and had vital signs taken before he/she went to dialysis but not when he/she returned. During an interview on 10/20/20 at 9:48 AM, the Director of Nursing stated the RN should be reviewing the dialysis communication book and then initialing or signing that it was reviewed. The RN should report any changes to the provider. He stated the 10/10/20 entry regarding the resident's blood pressure medication should have been reviewed with the physician to change the medication times to prevent a decrease in blood pressure at dialysis. He stated there should have been a progress note written to document the dialysis communication book was reviewed with physician. The DON stated the communication book should be reviewed every time the resident came back from dialysis but stated the signatures indicating the book was reviewed were scant. He stated there could be closer monitoring being done of the resident who received dialysis care and services. During an interview on 10/20/20 at 12:48 PM, the Registered Dietician stated the resident was weighed monthly at the facility, but got weighed regularly at dialysis. She stated she was not made aware of dialysis communication regarding the resident's fluid consumption on 10/15/20. She stated she did not review the dialysis communication book, but she should have been made aware of that communication book entry from the nursing unit so that she could address it. 10NYCRR415.12

Based on record review and interviews during the recertification survey, the facility did not ensure laboratory services were obtained or provided timely to meet resident needs for 1 (Resident #57) of 2 residents reviewed for laboratory services. Specifically, for Resident #57, laboratory tests ordered by the physician were not completed according to the physician order. This was evidenced by: Resident #57: The resident was admitted to the facility with the diagnoses of end stage renal disease (ESRD), diabetes, and hyperlipidemia. The Minimum Data Set (MDS - an assessment tool) dated 8/31/2020 documented the resident was cognitively intact, could understand others and could make self understood. The Policy and Procedure (P&P) titled Lab and Diagnostic Test Results- Clinical Protocol dated 3/2020, documented the physician would identify and order diagnostic and lab testing based on diagnostic and monitoring needs and the staff would process test requisition and arrange for tests. The Comprehensive Care Plan (CCP) for Fluid/Electrolyte Imbalance related to dialysis and ESRD documented to monitor labs and report abnormal findings to MD. A Physician Order dated 02/03/2020, documented to obtain a hemoglobin A1C (average blood sugar levels over the past 3 months) every 3 months for baseline labs. A Physician Order dated 02/03/2020, documented to obtain a Vitamin D, Lipids (measures cholesterol levels), AST (aspartate aminotransferase- a measure for liver disorders), and ALT (alanine aminotransferase- a measure for liver disorders) every 6 months for baseline labs. A laboratory report dated 2/6/20 documented a hemoglobin A1C was completed. A laboratory report dated 3/20/20 documented a bilirubin level, lipids, AST, and ALT were completed. During a medical record review on 10/20/20, there was no documented evidence that a hemoglobin A1C was completed every 3 months and Vitamin D, Lipids, AST, and ALT labs were completed every 6 months as ordered by the physician on 2/3/2020. During an interview on 10/20/20 at 9:05 AM, Registered Nurse (RN) Unit Manager #1 stated the resident's labs were completed at dialysis and laboratory work was not obtained for the resident in the facility. She stated she was not aware the labs were not completed. She stated the labs were on the care plan to be monitored and were not being monitored or tracked in the facility and should have been. During an interview on 10/20/20 at 12:27 PM, the Director of Nursing (DON) stated the physician orders for the labs were not followed and the labs were not being tracked in the facility. He stated he could only locate the hemoglobin A1C dated 2/6/2020 and could only locate the lab report dated 3/20/20 for the additional labs ordered by the physician. He stated the labs should have been completed and reviewed by the facility according to the physician orders and it was the responsibility of the RN Unit Manager to track the labs to ensure the labs were obtained. The DON stated the labs were physician orders and regardless of whether dialysis was obtaining labs, the facility should have been obtaining and tracking the labs based on the physician orders. He stated dialysis would not typically obtain a hemoglobin A1C and it was important that the facility obtain the lab considering the resident had diabetes and did not have any other method of diabetic monitoring. He stated the physician or facility provider should have also identified the labs were not completed during their bimonthly reviews of the resident and resident's medical record. 10NYCRR 415.20

Based on observations, interviews and record reviews conducted during a recertification survey the facility did not ensure medical records were maintained in accordance with accepted professional standards of practice on one (Mountainside Unit) of three units. Specifically, the facility did not ensure 3 (Resident #'s 29, 43, and #109) of 9 resident records reviewed for accurate documentation were accurately documented; for Resident #29, the facility did not ensure a physician order for Norco Tablet 5-325 mg (Hydrocodone- Acetaminophen-narcotic pain medication) was discontinued when the order for Norco was renewed resulting in 2 orders for Norco listed on the Medication Administration Record (MAR); for Resident #43, the facility did not ensure documentation for the use of a hearing aide was accurately documented on the Treatment Administration Record (TAR) and for Resident #109, the facility did not ensure facility staff initials were included on the TAR daily to indicate that a treatment was provided to a stage 3 and unstageable pressure ulcer and did not ensure the TAR accurately reflected that oxygen tubing was changed weekly. Additionally, the facility did not ensure that facility staff signed their initials for medications at the time the medications were administered. This is evidenced by; Finding #1: The facility did not ensure a physician order for Norco was discontinued when the order for Norco Tablet 5-325 mg (Hydrocodone- Acetaminophen), was renewed resulting in 2 orders for Norco listed on the Medication Administration Record (MAR). Resident #29: The resident was admitted with the diagnoses of anxiety, depression, and cerebral vascular accident (CVA). The Minimum Data Set (MDS- an assessment tool) date 8/1/20, documented the resident was cognitively intact and could make needs known. During record review on 10/20/20 at 12:40 PM, the MAR for Resident #29 included an order for Norco Tablet 5-325 mg (Hydrocodone- Acetaminophen) Give 1 tablet by mouth three times a day related to low back pain with a start date of 9/14/20 at 12:00 and did not include a stop date. During record review on 10/20/20 at 12:40 PM, the MAR for resident #29 included an order for Norco Tablet 5-325 mg (Hydrocodone- Acetaminophen) Give 1 tablet by mouth three times a day related to low back pain with a start date of 10/14/20 at 12:00 and did not include a stop date. On 10/20/20 at 12:41 PM, Registered Nurse (RN) #4, stated the order with the start date of 9/14/20 should have been discontinued when the renewal order was placed on 10/14/20. RN # 4 discontinued the order at the time of the interview. RN #4 also stated the facility does not have a system in place for checking and verifying the accuracy of all new physician orders. On 10/20/20 at 12:45 PM, the Individual Controlled Medication Record documented the resident received Norco Tablet 5-325 mg (Hydrocodone- Acetaminophen) Give 1 tablet by mouth three times a day related to low back pain; three doses per day between 10/14/20 and 10/20/20. On 10/20/20 at 2:00 PM, the Director of Nursing (DON), stated narcotic medications must be reordered every month, this is a potential for error. The nurse who entered the new order should have immediately discontinued the previous order. Finding #2a: Resident #43: The facility did not ensure documentation for the use of a hearing aide was accurately documented on the Treatment Administration Record (TAR). Resident #43 was admitted to the facility with diagnoses of mild cognitive impairment, hearing loss, and major depressive disorder. The Minimum Data Set (MDS-an assessment tool) dated 8/14/20, documented the resident had a minimal hearing impairment and used a hearing aid or other hearing appliance. A Comprehensive Care Plan (CCP), for hearing loss to bilateral ears documented that on 7/12/20 the resident placed his hearing aides in water and the hearing aides were unfixable. The TAR dated October 2020 documented the resident was to have a hearing aide placed in the right ear in the AM and removed when the resident goes to bed. The TAR documented; - Resident #43's hearing aide was applied at 6:00 AM and removed at 2100 on 10/1/20, 10/3/20, 10/4/20, 10/12/20, 10/13/20 and; - Resident #43's hearing aide was removed at 9:00 PM on 10/7/20, 10/8/20, 10/14/20, 10/15/20, 10/17/20, and 10/18/20. During an interview on 10/16/20 at 12:22 PM, Certified Nursing Assistant (CNA) #3, stated the resident did not have a hearing aide. CNA #3 stated the resident hasn't had a hearing aide for several months. During an interview on 10/19/20 at 4:42 PM, Licensed Practical Nurse (LPN) #5 stated she documented the removal of the resident's hearing aide, several times in October 2020 and did not remove Resident #43's hearing aide. LPN #5 stated she was aware the resident no longer had a hearing aide and did not know how to document on the TAR when a task was not completed. During an interview on 10/20/20 at 12:40 PM, the Director of Nursing (DON) stated he would expect the TAR to reflect actual care provided. The DON stated all staff have been educated on how to document on the TAR when care was not provided. Finding #2b: Resident #109: The facility did not ensure facility staff initials were included on the Treatment Administration Record (TAR) daily to indicate that a treatment was provided to a stage 3 and unstageable pressure ulcer and did not ensure the TAR accurately reflected that oxygen tubing was changed weekly The facility did not ensure the medical reflected if treatment was provided to a stage 3 and unstageable pressure ulcer. Additionally, the facility did not ensure oxygen tubing was changed when the medical record reflected it was. Resident #109 was admitted to the facility with diagnoses of spinal stenosis, major depressive disorder and neuromuscular dysfunction of the bladder. The Minimum Data Set (MDS-an assessment tool)) dated 10/5/20 documented the resident had three stage 3 pressure ulcers (localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Stage 3 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer) and 3 stage 4 pressure ulcers (a pressure ulcer in which full thickness tissue loss with exposed bone, tendon or muscle) that developed while a resident at the facility. The MDS documented the resident was receiving oxygen therapy, had severe cognitive impairment and required extensive assist with the physical support of 2 persons for bed mobility. The TAR dated October 2020 documented; - the resident was to have wound care to the right and left heel every three days. The signature boxes dated 10/2/2020 and 10/11/2020 were blank. - the resident was to have wound care completed to the left upper buttocks daily. The signature boxes dated 10/2/20, 10/3/20, 10/6/20, 10/11/20 and 10/13/20 were blank. - the resident was to have wound care completed to the right upper buttocks daily. The signature boxes dated 10/2/20, 10/3/20, 10/11/20 and 10/13/20. The TAR dated October 2020 documented to change oxygen tubing weekly every night shift every Thursday. The TAR documented oxygen tubing was changed on 10/7/20 and 10/15/20. During an observation on 10/14/20 11:22 AM, Resident #109 was receiving oxygen via a nasal canula dated 10/7/20. During an observation on 10/16/20 at 2:29 PM, Resident #109 was receiving oxygen via nasal canula dated 10/7/20. During an interview on 10/16/20 at 2:46 PM, Registered Nurse Unit Manager (RNUM) #4 stated oxygen tubing is changed by the Social Worker (SW) on the day shift and the SW was on the unit changing the oxygen tubing of each resident today. The RNUM stated the nurses on the unit do not change the oxygen tubing and therefore should not be signed off on the TAR by nursing staff. During an interview on 10/19/20 at 4:50 PM, Registered Nurse Unit Manager (RNUM) #4 stated if there was a blank signature box on the TAR she would think the treatment was not done. RNUM #4 stated she does not monitor for completion or accuracy of the TAR. During an interview on 10/19/20 at 4:42 PM, Licensed Practical Nurse (LPN) #5 stated she signed off that she changed the resident's oxygen tubing on 10/15/20 and did not change it. She stated she did not know why she did that. During an interview on 10/20/20 at 12:40 PM, the Director of Nursing (DON) stated he would expect the TAR to reflect actual care provided. The DON stated all staff have been educated on how to document on the TAR when care was not provided. The DON stated the Unit Managers and the DON was responsible for monitoring the accuracy and completeness of the TAR. Finding #3: The facility did not ensure that facility staff signed their initials on the electronic Medication Administration Record (eMAR) for medications at the time the medications were administered A policy titled Administering Medications dated as last revised on 3/2020 documented medications must be administered in accordance with the orders, including any required time frame and medications must be administered within one (1) hour of their prescribed time. A policy titled Administering Medications dated last revised 3/2020 documented that the individual administering the medication must sign the resident's eMAR (electronic Medication Administration Record) as indicated by the software after giving each medication and before administering the next ones. During an observation on 10/16/20 at 11:45 AM, the eMAR screen for the Mountainside Unit displayed the boxes around resident's names shaded in red. During an interview on 10/16/20 at 11:45 AM, LPN #4 stated the boxes shadded in red indicated the medications were late. LPN #4 also stated the computer turns the names red when the medications had not been administered within the one (1) hour of the prescribed time. During an interview on 10/16/20 at 11:50 AM, LPN #4 stated that she gave the medications on time but did not have time to document the answers to the Pop Up questions so she skipped the questions, administered the medications and planned to document later. The computer would not allow her to sign that the medications were administered without answers to the Pop Up monitoring questions so all the resident's names were shaded red. During an interview on 10/16/20 at 2:55 PM, RN #4, stated the Pop Up questions are physician ordered monitoring such as blood pressure and heart rate parameter, blood glucose levels, and pain levels. The nurse administering medications is expected to complete and document the monitoring prior to and after administering the medication, as well as document that the medication was administered. During an interview on 10/20/20 at 2:00 PM, the Director of Nursing (DON) stated the expectation is that nursing will document at the time care is provided. The practice of documenting medication administration and monitoring at the end of the shift is not acceptable. Staff reeducation and monitoring will be provided. 10NYCRR415.22(a)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not esure that resident assessments accurately reflected the resident's status for 8 (Resident #'s 10, 43, 57, 70, 74, 85, 96, and #109) of 23 resident assessments reviewed. Specifically, for Resident #10, the facility did not ensure the Minimum Data Set (MDS) accurately reflected the resident's status related to pain management, for Resident #43, the facility did not ensure the Minimum Data Set (MDS) accurately documented the resident had a severe hearing impairment and did not utilize a hearing aid; for Resident #57, the facility did not ensure the MDS accurately reflected the resident was receiving dialysis care and services; for Resident #70, the facility did not ensure the MDS accurately reflected the resident had a fall with a major injury; for Resident #74, the facility did not ensure the MDS accurately reflected the resident had a vascular wound; for Resident #85, the facility did not ensure the MDS accurately reflected the resident's use of antibiotics for MRSA in his/her urine; for Resident #96, the facility did not ensure that the MDS accurately reflected the resident's status related to a recent fall and did not ensure the MDS accurately documented the resident's use of antidepressant and antianxiety medications; and for Resident #109, the facility did not ensure the resident's pressure ulcers were accurately reflected in the assessment. This is evidenced by: Resident #43: Resident #43 was admitted to the facility with diagnoses of mild cognitive impairment, hearing loss, and major depressive disorder. The Minimum Data Set (MDS-an assessment tool) dated 8/14/20, documented the resident had a minimal hearing impairment and used a hearing aid or other hearing appliance. During an observation on 10/16/20 at 12:10 PM, the resident was unable to hear normal conversation, or very loud speaking. Resident #43 requested to be spoken to loudly directly near his ear, and stated, I can't hear. A Comprehensive Care Plan for hearing loss to bilateral ears, documented that on 7/12/20 the resident placed his hearing aides in water and they were unfixable. During an interview on 10/16/20 at 12:22 PM, Certified Nursing Assistant #3 stated the resident is very hard of hearing and required the use of a white board or pen and paper to communicate with staff. CNA #3 stated the resident has not had a hearing aid in a long time, and he refused to use them when he did have them. During an interview on 10/19/20 at 4:23 PM, MDS Coordinator (MDSC) #2 stated Resident #43 could not understand normal or loud conversation secondary to the inability to hear. MDSC #2 stated she did not know how to code the MDS accurately when a resident previously had a device, and no longer did. MDSC #2 reviewed the MDS manual during this interview and stated she inaccurately coded Resident #43's MDS assessment. Resident #70: Resident #70 was admitted to the facility with the diagnoses of Parkinson's disease, hypertension, and left femoral neck fracture (type of hip fracture). The Minimum Data Set (MDS - an assessment tool) dated 9/4/2020, documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The Comprehensive Care Plan (CCP) for falls, revised on 9/2/20, documented the resident had a history of falls and an actual fall on 7/15/20, when he/she fell in his/her room and complained of left hip pain. The CCP for Alteration in Physical Function, revised on 9/2/20, documented the resident had Parkinson's disease and a left hip fracture. A progress note dated 7/15/20, documented the resident fell in his/her room and landed on his/her left side. The resident's sneakers were not laced or tied and (there was) no head involvement. He/she complained of left hip pain. A subsequent progress note dated 7/15/20, documented the resident complained of pain in his/her left hip and Tylenol was not helping the pain. The Nurse Practitioner was notified, and the provider said to send the resident out for possible fracture versus dislocation. A progress note dated 7/28/20, documented the resident was admitted to the facility with a fracture of the left hip and had a hemiarthroplasty (surgical procedure that involves replacing half of the hip joint) of the left hip. The MDS dated [DATE] did not reflect that the resident had a fall with a major injury. During an interview on 10/20/20 at 9:33 AM, the MDS Coordinator stated Section J in the MDS dated [DATE] should have been coded as a fall with a major injury when the resident returned from the hospital. She stated the resident had fallen in the facility and fractured his/her hip. She stated section J did not reflect that the resident had a fall with a major injury, and it should have. During an interview on 10/20/20 at 9:56 AM, the Director of Nursing stated the resident's MDS should have been coded as a fall with a major injury considering the resident fell and fractured his/her hip. Resident #96: Resident #96 was admitted with the diagnoses of aortic valve stenosis, diabetes, and major depressive disorder. The Minimum Data Set (MDS-an assessment tool) dated 9/28/20, documented the resident had moderately impaired cognition, could sometimes understand others and make self-understood. The MDS documented the resident had no falls since the previous assessment and the resident received an antidepressant and antianxiety medication on 7 out of 7 days during the look back period. The Centers for Medicare & Medicaid Services' RAI 3.0 Instruction Manual documented that the review period for any fall is from the day after the last MDS assessment to the current assessment. All available sources for any fall since the last assessment are to be rereviewed, including nursing home incident reports, fall logs, and the medical record progress notes. The RAI manual documents that certain medication classifications include a seven day look back to record the number of days a resident received a class of medications. The resident's medical record included a nursing progress note dated 9/10/20 that documented the resident was found on the floor in his room and complained of hitting his head. The resident's comprehensive care plan (CCP) for falls documented a fall on 9/10/20. The resident's Medication Administration Record (MAR) and physician's orders during the seven day look back period for medications did not include documentation that the resident received or was prescribed medications classified as antidepressants or antianxiety medications. During an interview on 10/20/20 at 11:38AM, the MDS Coordinator Registered Nurse #2, stated that she obtained the information for the MDS through a review of the resident's clinical records and by visiting the resident on the unit. She stated that she sometimes missed things and had recently been reviewing the previously submitted MDS assessments to make modifications and correct errors. She stated the antidepressant was entered inaccurately and did not believe the antianxiety medication had been coded inaccurately. The information regarding the resident's fall was corrected by the MDS Coordinator on 10/19/20. 10NYCRR415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 9 (Resident #'s 10, 57, 74, 75, 85, 100, 103, 104 and #313) of 23 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #10, the facility did not ensure the CCP included resident specific and non-pharmacological interventions to address the resident's pain; for Resident #'s 100 and 104, did not ensure nutrition CCP's included resident specific information or interventions; for Resident #57, did not ensure the intervention to monitor labs on the CCP for Fluid/Electrolyte Imbalance was implemented; for Resident #313, did not ensure the intervention for off loading boots on the CCP for risk for pressure ulcers was implemented; for Resident #103, did not ensure the development and implementation of a comprehensive person- centered care plan to meet the needs of the resident with the diagnosis of dementia; for Resident #74, did not ensure a care plan for the management of pain was resident specific and included non-pharmacological interventions for pain management; for Resident #75, did not ensure a CCP was developed and implemented for the management of weight loss; for Resident #109, the facility did not ensure a care plan was developed for the care and treatment of pressure ulcers to the resident's heels and buttocks; and for Resident #85 the facility did not ensure there was a CCP to address MRSA (multidrug resistant organism) in the resident's urine and that the resident was on isolation for it. This is evidenced by: The facility policy titled Care Plan, Comprehensive Person-Centered, last revised 3/2020 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 facility policy titled Care Planning- Interdisciplinary Team, last revised 3/2020 documented; A comprehensive care plan for each resident will be developed within seven (7) days of completion of the resident's assessment (MDS). Resident #10: Resident #10 was admitted to the facility with diagnoses of cerebral infarction, diabetes, and neuropathy. The Minimum Data Set (MDS-an assessment tool) dated 7/22/20 documented the resident was without cognitive impairment. Physician's Orders dated 7/16/20, documented the following to address the resident's pain; the resident was to have a pain assessment every shift, administer Gabapentin 600mg two times daily for neuropathic pain, and acetaminophen 325mg two tablets every 4 hours as needed for pain. The Medication Administration Record (MAR) for October 1-19, 2020, documented the resident reported pain levels of 0-10 each shift. The above MAR documented the as needed acetaminophen was administered on the October 14, 15, 18 (x2), and on October 19th, 2020. During an interview on 10/14/20 at 11:26 AM, the resident stated I'm in too much pain to talk. During an interview on 10/14/20 at 11:35 AM, LPN #3 stated she had already administered the resident's pain medication and was not aware of any other interventions that were specific to alleviating this resident's pain. LPN #3 also reported the resident had refused routine medications yesterday (including those to manage pain) which may be the cause of increased pain today. All medications have been accepted today and LPN #3 expects the resident's pain to be relieved soon. The CCP titled Alteration in Comfort related to Diabetic Neuropathy was initiated on 3/27/20 and last updated on 10/20/20. The CCP documented interventions to; administer medications as ordered, assess pain, evaluate effectiveness of pain interventions, monitor for signs of pain and utilize appropriate non-pharmacological (pharm) interventions, and monitor for probable cause of pain. During an interview on 10/20/20 at 01:29 PM, the Director of Nursing (DON) stated he initiated the CCP for neuropathy and did not review it for thoroughness as he should have. It does not have non-pharm interventions as it should and is not person-centered as it should be. Resident #103: The resident was admitted with diagnosis of diabetes mellitus, history of falls, and dementia. The Minimum Data Set (MDS - an assessment tool) dated 9/28/20 documented the resident had moderate cognitive impairment. The medical record did not include a comprehensive person-centered care plan for the resident's dementia diagnosis. On 10/20/20 at 11:00 AM, Registered Nurse (RN) #1 stated all care plans are resolved in the computer when a resident is discharged . Resident #103 was discharged to the hospital on 9/19/20 and readmitted on [DATE]. A new care plan for dementia should have been developed upon readmission. On 10/20/20 at 11:30 AM, the Admissions Registered Nurse #3 stated a dementia care plan should have been developed. On 10/20/20 at 12:10 PM, RN #4 (Unit Manager) stated the Interdisciplinary Team (IDT) reviews and revises the baseline care plans and a person-centered dementia care plan should have been implemented. On 10/20/20 at 2:00 PM, the Director of Nursing (DON) stated that a care plan for the resident's diagnosis of dementia should have been developed and implemented at the time of readmission. Resident #74: Resident #74 was admitted to the facility with diagnoses of cellulitis of the right lower limb, open wound of the left leg, lymphedema and morbid obesity. The Minimum Data Set (MDS-an assessment tool) dated 9/11/20, documented the resident received as needed pain medication for pain, and that the resident's pain was frequent. The resident did not have cognitive impairment. The Comprehensive Care Plan (CC) titled Resident has an Alteration in Comfort related to Wound Status and Morbid Obesity, last revised on 6/23/20, included interventions to administer medications as ordered and give pain medication prior to treatments and therapy sessions. The Medication Administration Record (MAR) dated [DATE], documented the resident received Norco (a narcotic used to treat moderate to severe pain) 5/325 mg twenty-four times between 10/1/20 and 10/19/20, for pain ratings between four and eight. The result of the medication for pain was documented as effective or unknown. During an interview on 10/19/20 at 2:03 PM, Licensed Practical Nurse (LPN) #5 stated the resident did not receive non-pharmacological interventions for pain. LPN #5 stated the care plan did not reflect nonpharmacological interventions for the management of pain. During an interview on 10/20/20 at 12:40 PM, the Director of Nursing (DON) stated a resident receiving narcotic pain medication should have a comprehensive person-centered care plan that included non-pharmacological interventions for the management of pain. The DON stated the resident should have a note in the medical record reflecting if the narcotic pain medication given was effective or not effective. 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, the facility did not ensure the resident was assessed to determine whether physical restraints were indicated to treat a medical symptom prior to implementing the use of hand mitts, for one (Resident #44 ) of two residents reviewed for restraints. Specifically, for Resident #44, the facility did not identify the use of hand mitts as a restraint and subsequently did not implement their process for the use of restraints that included an appropriate assessment, attempts at the use of the least restrictive measures, documentation of the medical symptoms, physicians' order, the development of a care plan and an ongoing re-evaluation. This is evidenced by: Resident #44 The resident was admitted on [DATE], with diagnoses of Alzheimer's, blindness, and unspecified kyphosis. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition and was rarely understood. The MDS documented the resident was without behaviors and was totally dependent for Activities of Daily Living. The Policy and Procedure (P&P) titled, Physical Restraints undated, documented a restraint is defined as equipment attached to the resident's body that the individual cannot remove easily or restricts normal access to one's body. The policy documented the restraint must be ordered by a physician (MD), be documented in the resident's care plan, must be documented in the MD notes why the restraint was needed and evaluated by the careplanning team for reduction or discontinuation. A document titled Restraint Review, documented the device being evaluated to be utilized was hand mitts. The restraint review did not document reduction attempts, alternatives used with results, or that MD orders were received. The document was reviewed and signed by team members on 08/03/2018 and on 11/27/2018. During an observation on 01/07/19 at 12:32 PM, the resident was being fed lunch by staff in the dining room. The resident had hand mitts in place. During an observation on 01/08/19 at 11:11 AM, the resident was sitting by the nurses' station with hand mitts in place. During an observation on 01/09/19 at 03:39 PM, the resident was sleeping in her room with hand mitts in place. An activities note dated 08/14/2018, documented the resident often holds a stuffed animal. MD orders dated 01/10/2019, did not include orders for hand mitts or a restraint. The medical record did not include a care plan for restraint use. During an interview on 01/10/19 at 02:43 PM, Licensed Practical Nurse (LPN) #1 stated the resident's mitts were not removed on a regular basis. LPN #1 stated she was not aware of how to access the resident's care plan and there was no MD order for the use of restraints. LPN #1 stated she was unaware of the facility's P&P on the use of restraints. During an interview on 01/10/19 at 3:12 PM, Certified Nurse Assistance (CNA) #1 stated the resident's mitts were removed when family was present and when the resident was changed. CNA #1 stated the mitts were not removed on a regular basis when family was not present. During an interview on 01/10/19 at 04:09 PM, Registered Nurse Unit Manager (RNUM) #1 stated the resident had mitts in place per the request of the family. RNUM #1 stated there was no MD order, care plan, or ongoing assessment completed for the use of restraints. During an interview on 01/11/19 at 09:22 AM, the Director of Nursing (DON) and Administrator stated the use of hand mitts was not identified as a restraint. The DON and the Administrator stated the resident was total dependence for care, however the resident did have the ability to touch her face, mouth and other areas on her body with her hands. The DON and Administrator stated the resident had mitts in place to prevent the resident biting her hands. During an interview on 01/11/2019 at 11:50 AM, the DON stated the document titled restraint review was incomplete, the resident was not care planned specifically for restraint use, and there was no MD order in place for the use of restraints. 10 NYCRR 415.4(a)(2-7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey the facility did not ensure the resident's representatives were notified of the transfer or discharge in writing for 4 (Resident #'s 63, 68, 69 and #103) of 4 residents reviewed. Specifically, for Resident #'s 63, 68, and #69, the facility did not provide a written notice of transfer or discharge to the resident or the residents' representatives upon the resident's transfer to the hospital. Additionally, for Resident #103, the facility did not ensure the resident or the resident representative was notified in writing of a planned facility initiated discharge. This was evidenced by: Resident #63: The resident was admitted on [DATE], with the diagnoses of pancreatic cancer, acute kidney failure, and anxiety disorder. The Minimum Data Set (MDS) dated [DATE], documented the resident was cognitively intact and was able to make herself understood and understood others. A nursing progress note dated 1/5/19 at 5:47 PM, documented the resident requested to go to the hospital for abdominal pain. The nurse practitioner was notified and the resident was transferred to the hospital for pain at 2:00 PM. A social work progress note dated 1/7/19 at 2:40 PM, documented the resident's son was contacted today to follow up with the resident being sent out to the hospital over the weekend. During an interview on 1/15/19 at 9:36 AM, the Director of Nursing (DON) stated the facility did not provide the resident or resident representative with a written discharge notice or the facility bed hold policy. The written notice of discharge and bedhold policy should have been provided to the residents or the representative. Resident #68: The resident was admitted to the facility on [DATE], with diagnoses of coronary artery disease, peripheral vascular disease, and dementia. The Minimum Data Set, dated [DATE], documented the resident had severely impaired cognition, could sometimes understand others and could sometimes be understood. Nursing Notes dated 10/30/18 documented; Resident not acting himself, confused, twitching lethargic. Sent to hospital, admitted with diagnosis of urosepsis. There was no documentation that written notification was sent to the resident or resident's representative informing them of the bed-hold policy. Resident #103 The resident was admitted on [DATE], with diagnoses of fracture of the right tibia and right humerus. The Minimum Data Set, dated [DATE], documented the resident's cognition was intact. The Policy and Procedure (P&P) titled, Discharge and Transfer, updated 01/2018, documented the nursing home must issue a valid discharge notice to the resident that included date of discharge, reason for discharge, and a statement that the resident has the right to appeal. A Social Service Note dated 10/12/2018, documented the resident was discharged per discharge planning with resident and resident's husband. Durable Medical Equipment and discharge needs were reviewed. A document titled Interdisciplinary Discharge Summary (IDS) dated 10/12/2018, documented the resident was discharged home with spouse, equipment needs, and follow-up appointments. The remainder of the form was not completed and the bottom of the document did not include the resident or resident representative's signature. During an interview on 01/14/19 at 11:33 AM, Social Worker (SW) #4 stated the IDS is initiated by Social Work and the Registered Nurse Unit Manager (RNUM) is responsible to complete the remainder of the form and review the information with the resident and or the resident's representative. During an interview on 01/14/19 at 11:48 AM, RNUM #2 stated the IDS was not completed, and activity restrictions, areas the resident required assistance for functional ability, care treatments needed were not reviewed prior to discharge with the resident or the resident representative. RNUM #2 stated he provided the resident with an updated list of medications prior to discharge, and did not document this in the medical record. RNUM #2 stated he was aware of the facility P&P in regards to discharge and transfer of a resident. During an interview on 01/14/19 at 12:25 PM, the Director of Nursing stated the expectation is that staff would provide in writing, a discharge summary and obtain a signature of the resident or resident's representative prior to discharge. If the staff were unable to complete this, there would be documentation in the nursing notes to reflect this. 10NYCRR415.3(h)(1)(i)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure written notice which specifies the duration of the bed-hold policy, was provided to the resident and the resident representative at the time of transfer for hospitalization for 3 (Residents #'s 63, 68, and 69) of 3 residents reviewed for hospitalization. Specifically, there was no documented evidence the resident and the resident's representative were notified in writing of the bed hold policy when the resident was admitted to the hospital. This is evidenced by the following: Resident #68 The resident was admitted to the facility on [DATE], with diagnoses of coronary artery disease, peripheral vascular disease, and dementia. The Minimum Data Set, dated [DATE], documented the resident had severely impaired cognition, could sometimes understand others and could sometimes be understood. Nursing Notes dated 10/30/18 documented; Resident not acting himself, confused, twitching lethargic. Sent to hospital, admitted with diagnosis of urosepsis. There was no documentation that written notification was sent to the Resident or Resident's Representative informing them of the bed-hold policy. Resident #69 The resident was admitted to the facility on [DATE], with diagnoses of end stage renal disease, acute cholecystitis, and chronic obstructive pulmonary disease. The Minimum Data Set, dated [DATE], documented the resident had intact cognition, could understand others and could be understood. The Supervisor's Report documented the resident was hospitalized from [DATE] to 7/16/18 and from 10/15/18 to 10/26/18. There was no documentation that written notification was sent to the resident or resident's representative informing them of the bed-hold policy. During an interview on 1/11/18 at 9:21 AM, the Director of Nursing (DON) reported, resident's family members receive phone calls when they are sent to the hospital. There have been no written notices sent out. Resident #63 The resident was admitted on [DATE], with the diagnoses of pancreatic cancer, acute kidney failure, and anxiety disorder. The Minimum Data Set (MDS) dated [DATE], documented the resident was cognitively intact and was able to make herself understood and understood others. A nursing progress note dated 1/5/19 at 5:47 PM, documented the resident requested to go to the hospital for abdominal pain. The nurse practitioner was notified and the resident was transferred to the hospital for pain at 2:00 PM. A social work progress note dated 1/7/19 at 2:40 PM, documented the resident's son was contacted today to follow up with the resident being sent out to the hospital over the weekend. During an interview on 1/15/19 at 9:36 AM, the Director of Nursing (DON) stated the facility did not provide the resident or resident representative with a written discharge notice or the facility bed hold policy. The written notice of discharge and bedhold policy should have been provided to the residents or the representative. 10 NYCRR 415.3(h)(4)(i)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interviews during a recertification survey the facility did not ensure that a resident who enters the facility without limited range of motion (ROM) does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #75) of two reviewed for ROM. Specifically, the facility did not ensure that the contracture splint was used and that the foot cradle did not put the resident at risk for contractures. This is evidenced by: Resident #75: The resident was admitted to the nursing home on [DATE], with diagnoses of dementia, schizophrenia, and asthma. The Minimum Data Set (MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident sometimes understood and was sometimes understood by others. During observations on 01/09/19 at 10:38 AM, 11:14 AM, 01/10/19 at 10:37 AM, and 01/11/19 at 11:00 AM, the resident was in the common area in a reclining geri chair. There was a foot board attached to the chair that was closed in at the end, holding the residents legs in a bent position. During observations on 01/09/19 at 10:38 AM, the resident was in the common area in a reclining geri chair with no side bolsters, at 1:14 AM, the resident was leaning to the right in her chair. During observations on 1/10/19 at 3:20 PM, the resident was in bed with no contracture splint on. During an interview on 1/09/19 at 10:39 AM, Certified Nursing Assistant (CNA) #4 stated the resident had the foot board because her legs kept falling off the chair. During an interview on 1/09/19 at 10:41 AM, Licensed Practical Nurse (LPN) #5 stated the resident did have the ability to straighten her legs in bed. During an interview on 1/10/19 at 10:00 AM, Occupational Therapist (OT) stated she issued the closed foot board and staff had not told her it kept the resident from straightening her legs; the way her legs were positioned could put the resident at higher risk for contractures . During an interview on 1/10/19 at 2:59 PM, the OT stated the resident was internally rotating one leg so she added an abduction contracture splint while in bed. When a new appliance is added therapy would train staff as needed. Therapy would fill out a sheet for the nurse so that the nurse could add the equipment to the CNA tasks she must not have sent the sheet. She issued the closed foot board and staff had not told her it kept the resident from straightening her legs; the way her legs were positioned could put the resident at higher risk for contractures. 10NYCRR 415.12(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the environment was not free from accident hazards over which the facility has control. Specifically, resident room windows were in disrepair lending opportunity for unsupervised elopement. Wardrobes were not secured from toppling. This is evidenced as follows. The exterior wall windows on the [NAME] Unit, a second floor above-ground unit with mostly confused residents, were inspected on 01/09/2019 at 11:15 AM. All windows were designed tilt-in for easy cleaning. When the tilt-in feature was tested, the windows in rooms 1, 5, 11, 15, 16, 17, 18, 19, 21, 22 and 24 and in the dining room, shower suite, and nursing office were not attached at the pivot point and fell out of the frame. The wardrobes on the Courtyard Unit were inspected on 01/09/2019 at 11:45 PM. The wardrobes in resident rooms C6 and C23 were free-standing and could topple over when tested with normal body weight. The Administrator stated in an interview on 01/09/2019 at 7:00 PM, that he understands the hazards and as of this hour all windows on [NAME] have been secured from falling out and unintentional elopement, and all wardrobes have been checked and secured to the wall if free-standing. 10 NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey the facility did not ensure that it maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for two (Resident #'s 5 and 54) of eight residents reviewed for nutrition. Specifically: For Resident #'s 5 and 54, the facility did not ensure that weekly weights were consistently obtained, that the Medical Doctor (MD) was kept apprised of the residents' continued weight loss, that nutritional interventions were put in place and revised as needed. This is evidenced by: Resident #54: The resident was admitted to the nursing home on 8/31/18, with diagnoses of aphasia, dementia, and Diabetes Mellitus. The Minimum Data Set (MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident rarely/never understood and was rarely/never understood by others. Speech and Language Pathology Referral documented: 11/4/18 - The resident was having difficulty with liquids and was downgraded to nectar thick liquids after his hospital readmission. 12/18/18 - The resident was seen for holding food in his mouth. Recommend skilled dysphagia treatment 3-5 days/week. Nutritional Assessments documented: 9/5/18 - A weight (wt) of 143.4 pounds (lbs) and that weekly wts would be done times 4 or until stable. 11/15/18 - The resident's wt was 138 lbs., the residents appetite/fluids/snacks= 50-75%. He remained at an increased nutritional risk related to dementia. After returning from the hospital, the resident was noted coughing with liquids and downgraded to nectar; he required assistance to complete his meal. The resident is currently on weekly wts and no supplements are indicated. Weights were as follows: 8/31/18=143.4 lbs. 9/14/18=146 lbs 10/9/18=141.0 lbs October week 2 no date =141.6 lbs October week 3 no date = 139.0 lbs Resident in hospital from [DATE] - 11/2/18 11/2/18=138 lbs missing wt 11/14/18 = 134.8 lbs 11/21/18 =135 lbs 11/27/18 = no wt done 12/4/18 = no wt done 12/10/18 =126.4 lbs December week 2 not dated =123.4 lbs December week 3 not dated = 124.2 lbs 1/1/19 =122.2 lbs 1/3/18 =124.4 lbs During an interview on 1/09/19 at 11:27 AM, Certified Nursing Assistant (CNA) #4 stated they document intakes in their kiosk; weights will pop up on computer when they are due and they do monthly weights on the first of each month. During an interview on 1/09/19 at 11:11 AM, CNA #9 stated the resident had a sore on his bottom but they don't use a cushion because the weight of the cushion deactivates the auto lock brakes on his w/c. He sleeps a lot in his chair. During an interview on 1/10/19 at 2:23 PM, the Registered Dietitian stated all new residents got weekly wts for 4 weeks, and she would indicate with a star next to their name in the book, who is on weekly wts. She would also bring the list to the Nurse Manager's attention on Thursdays if a wt was still not done; there is an issue getting weights done. They get wts on readmission. During an interview on 1/11/19 at 10:08 AM, the RD stated that this resident's weights were in 3 different places; some were in the weight book on his former unit, some in the book on his current unit and some in computer. The MD would have to look at each book and the computer to see what is going on with the resident. She was responsible for putting all the weights from the black books into the computer which would trigger the significant weight loss, which would be looked at in morning meeting. If the weights were not in the computer it will not trigger, and the weight losses would not be brought up in meeting. Additionally, she was responsible to speak to the MD regarding wt loss. She stated that she talked to the providers but did not document it, so she cannot be sure it was done. Additionally, she assumed she assessed the resident for wound healing but she did not document it. Additionally, the RD stated she was responsible for speaking to the MD regarding wt loss. She stated that she talked to the providers but did not document it, so she can not be sure it was done. Additionally, she assumed she assessed the resident for wound healing but she did not document it. During an interview on 1/11/19 at 12:02 PM, the Nurse Practitioner (NP) stated that nursing or dietary was supposed to notify them of wt loss. The NP would document that they spoke to dietary about an issue with nutrition; there is no indication that the MD was made aware of a weight issue and she would have expected supplementation changes prior to 1/9/18. Resident #5: The resident was admitted to the nursing home on 3/9/17, with diagnoses of Alzheimer's, anxiety, and anemia. The Minimum Data Set (MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident rarely/never understood and was rarely/never understood by others. The resident's weights were as follows: 1/3/18 = 103 pounds (lbs) 3/29/18 =100 lbs 6/29/18 = 93 lbs 7/24/18 = 98 lbs 8/18= no wt 9/4/18 = 92 lbs 10/9/18 = 89 lbs 11/1/18 = 86.4 lbs 12/5/18 = 87.8 lbs 1/1/19 = 81.4 lbs 1/9/19 = 83.1 lbs An MD Order dated 8/31/18, documented Ensure clear tid start 9/6/18. An MD note documented: 9/13/18 - the resident was seen for decreased appetite and poor urine output; will try to obtain urine culture. 9/20/18 - The resident was seen acutely on 9/13/18 for decreased appetite and generalized weakness, and a urine was obtained that showed over 100,000 gram negative rods; she was not eating or drinking well but this seems to have improved slightly. 11/16/18 - The resident's condition was stable at this time, there were no concerns or issues brought ot his attention by the facility staff, and the resident had a 2 lb. weight loss over the past month. Nutritional assessments documented: 9/20/18 - Ensure 6x/day remains high risk due to advance dementia 12/21/18 - Remains high risk poor appetite, advanced dementia 3 lb. wt loss over the last 3 months. She is receiving Ensure clear TID between meals. Intake poor due to advanced dementia and need for total staff assist. 1/9/18 - 6 lb. wt loss in 4 wks. Boost added to Ensure. Intake poor due to advanced dementia and need for total staff assist. Hospice services in place and overall goal is comfort. During an interview on 1/11/19 at 10:08 AM, the RD stated that the resident's weights were documented in either the black book on each unit or the computer. She was responsible for putting all the weights from the black books into the computer which would trigger the significant weight loss, which would be looked at in morning meeting. If the weights were not in the computer it will not trigger, and the weight losses would not be brought up in meeting. Additionally, was responsible to speak to MD regarding wt loss. She stated that she talked to the providers but did not document it, so she cannot be sure it was done. During an interview on 1/11/19 at 12:02 PM, the Nurse Practitioner (NP) stated that nursing or dietary was supposed to notify them of wt loss. The NP would document that they spoke to dietary about an issue with nutrition; there is no indication that the her or the Medical Doctor (MD) were made aware of a weight issue and she would have expected supplementation changes on the residents prior to 1/9/18. 10NYCRR 415.12(i)(l)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during a recertification survey the facility did not ensure that they had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e) for one of three units. Specifically: The facility did not ensure that there was enough staff on the behavior unit to ensure that medications were passed within acceptable time frames and residents were not kept in a common area without planned activities. This is evidenced by: Finding #1: During an observation on 1/14/18 at 11:20 AM, the medication nurse was passing medications. During an interview on 1/14/19 11:20 AM, Licenced Practical Nurse (LPN) #6 stated she was still doing her AM medication pass and this was the norm when she is on alone. She stated she is alone on the unit a lot and because it is a behavior unit she is always dealing with issues while giving medications. The Nurse Manager and the Director of Nursing (DON) are aware. She was told to just go as fast as she could. Additionally, she stated, they put the residents in the common area because it is easier to watch them all. During an interview on 1/14/19 at 1:29 PM, the DON stated that the regular nurse had not reported any issues getting medications done but they had not seen the administration reports that tell them exactly what time a medication was administered. LPN #6 has come to them reporting she was having a hard time getting the medication pass done, but they did not have help to give, so they don't give her a hard time. Finding #2: During observations on: 1/10/19 at 10:25 AM, there were 9 residents sitting in the fireplace common area, the lights were out and there was no TV or music. 1/11/19 at 9:25 AM, the call light was going off in room [ROOM NUMBER], there were 10 residents in library side of the common area and 8 residents on the fireplace side of the sitting area. The residents were sitting in chairs around in a circle facing each other. The lights were off and there was no TV, music or activities. One resident was saying she had to go to the bathroom; no staff were in the area. 1/11/18 at 9:09 AM, there were 7 residents in the library common area. the lights were off and there was no TV or music. While a Housekeeper (HK) was walking by, with a floor cleaning machine, one of the residents was leaning way over in her chair. The HK stated out loud, I think it is time for a merry walker (an enclosed walking device on wheels, that can be considered a restraint). 1/11/19 at 11:00 AM, there were 10 residents on the library side of the common area and 8 residents on the fireplace side of the sitting area. The residents were sitting in chairs around in a circle facing each other. The lights were off and there was no TV, music or activities. 1/14/19 at 10:30 AM, there were 3 residents unattended in the activity room; two of the residents were sleeping in their wheelchairs; eight residents were sitting in the fireplace common area. The lights were not, and there was no TV, or music. 1/09/19 09:04 AM, 1/10/19 at 10:39 AM, 11:45 am, and 3:50 PM, 1/11/19 at 9:57 AM, and 1/14/19 10:36 AM, there were 8-9 residents sitting in the fireplace side common area with no lights, television, music, or activity. During an interview on 1/14/19 11:20 AM, LPN #6 stated residents are kept in the common area because it is easier to watch them all. During an interview on 01/14/19 at 11:45 AM, Certified Nursing Assistant (CNA) #4 stated they put all the residents in the common area because they can watch them. They try to do an activity with them during the day but sometimes not. Some of the Registered Nurses will put on music so they can at least listen to music; the lights are always kept off. They could do better with activities. During an interview on 01/14/19 at 1:29 PM, the DON they are kept in the open so they can be seen. Staffing is tight; they try to put extra Resident Assistants on the unit to help. 10 NYCRR 415.13(a)(1)(i-iii)

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the steps that must be taken when the pharmacist identifies an irregularity that requires urgent action to protect the resident. This is evidenced by: The policy titled Drug Regimen Review, established 11/2016 and last reviewed on 12/2018, documented that when the pharmacist discovers an issue that requires immediate attention, he/she will address with the Unit Manager (UM) or Supervisor, so the provider can be contacted, and the issue addressed. There was no time frame specified for when the pharmacist would contact the UM or Supervisor or when the provider would be contacted. During an interview on 1/14/19 at 12:43 PM, the Director of Nursing reported he was not aware the policy did not have all the necessary time frames. 10NYCRR415.18(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey, the facility did not ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 4 (Resident #'s 20, 54, 69 and #254) of 6 residents reviewed for unnecessary medications. Specifically: For Resident #69, the facility did not ensure documentation of the resident's symptoms prior to or following an antipsychotic being administered; for Resident #20, the facility did not ensure that non-pharmacologic interventions, documentation of behaviors, effect of medication, and documentation to justify extending a PRN order beyond 14 days; for Resident #54, that there was justification to use a psychotropic medication, and that staff identified the possible connection between the falls and the psychotropic medication, and that Resident #254 was not administered a psychotropic medication prior to a Registered Nurse (RN) assessment, when the resident was very lethargic. This is evidenced by: Resident #69 The resident was admitted to the facility on [DATE], with diagnoses of end stage renal disease, major depressive disorder, and post-traumatic stress disorder. The Minimum Data Set (MDS) dated [DATE], documented the resident had intact cognitive skills, could understand others and could be understood. The Comprehensive Care Plan for Psychotropic Medications, last updated on 11/26/2018, documented; monitor/document side effects and effectiveness. Physician's Order Forms documented on 7/20/18, Risperdal (an antipsychotic medication) 0.5 milligrams (mg) at bedtime for depression and psychosis and on 7/27/18, increase Risperdal to 1mg two times a day. Nursing Progress Notes dated 7/20/18, at 3:02 AM, documented the resident was seen because the aide reported she was hearing voices. The resident said she was worried about her son. Will call son so she can talk to him in the morning, at 1:18 PM documented doctor in today, new order for Risperdal 0.5 mg at bedtime for depression and psychosis, and at 3:40 PM, documented resident asking for help because she is hearing voices. There were no other progress notes about the resident hearing voices or starting Risperdal until 7/27/18, when it was documented, seen by doctor for hearing voices, increased Risperdal and refer to psychiatry. During an interview on 1/14/19 at 11:34 AM, Registered Nurse Manager (RNM) #1 reported, when a resident is started on psychoactive medication the nurses should document behavior monitoring on the supervisor's report. RNM #1 was unable to provide any additional documentation. During an interview on 1/14/19 at 12:32 PM, the Director of Nursing (DON) reported he would expect documentation of the symptoms prior to and monitoring for days or even weeks following an antipsychotic medication change. The DON was unable to provide any additional documentation. Resident #20: The facility did not ensure that non-pharmacological interventions were used prior to administering Ativan (an antianxiety medication), that there was documention of what behaviors the resident was presenting with before administration of the Ativan and how the medication affected those behaviors after administration, and that there was documentation from the provider to justify extending the Ativan beyond 14 days. The resident was admitted to the nursing home on [DATE] with diagnoses of Alzheimer's, thyroid disorder, and anxiety. The Minimum Data Set (MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident sometimes understood and was understood by others. The Comprehensive Care Plan for behavior symptoms such as wandering behavior dated 10/30/18, documented to distract the resident from wandering by offering pleasant diversions and acvitivites of interest. Document all behaviors and attempt to identify pattern to target interventions. The Comprehensive Care Plan for wandering and becoming anxious in the evening hours dated 11/4/18, documented invite/escort resident to activities, provide resident with diversional activities during periods of increased confusion/agitation (offering folding, visits, sorting, soft music and an area where she can safely roam with low stimulation). It documented to receive 1:1 guidance in a slow calm reassuring approach; ask the resident to help you with something to redirect. Physician (MD) orders dated 10/1/18, documented Ativan 0.5 milligrams (mg); one every four hours as needed (PRN) for anxiety. The medical record did not include documentation every 14 days from the MD justifying the continued PRN use of the Ativan. Medication Administration Records dated from 11/7/18 - 1/12/18, documented the resident received PRN Ativan on 30 occasions. Of those 30 occasions, 30 of them did not include documentation of non-pharmacological interventions used prior to the administration of Ativan, 17 occasions did not include specific behaviors to indicate the resident was anxious, and on 19 occasions there was no follow up documentation of what behaviors were relieved by the medication. During an interview on 1/10/19 at 4:01 PM, the Activity Aide stated that she would sometimes do things with the resident; she likes to fold and in the afternoons she calms down to egg salad and tea and listening to gospel music. She stated anyone could deescalate the resident and she had told staff about what would work for the resident. During an interview on 1/10/19 at 3:55 PM, Licensed Practical Nurse (LPN) #7 stated prior to administering PRN psychotropics they had to see if they could determine a cause for the behavior. If the psychotropic was used, they were to document the behaviors, notify the supervisor and administer the medication; they should follow up to see if the behaviors were improved and document this. During an interview on 1/11/19 at 9:51 AM, Licensed Practical Nurse (LPN) #4 stated make sure there is nothing else going on with the resident before medicating. Staff should write down what the behavior was, what they tried to do for it, and if necessary give the medication and let the Nursing Supervisor know and it is put on report, then document how it changed the behavior. During an interview on 1/14/19 at 1:05 PM, the Director of Nursing (DON) stated that staff should be attempting specific non-pharmacological interventions prior to administering prn psychotropic medications and if used staff need to document the non-pharmacological interventions attempted, the specific behaviors the resident is presenting with and how the medication affected the behaviors; just writing effective, is not enough. Additionally, there should be written justification from the MD if a PRN psychotropic is used over 14 days. The DON stated he was unable to locate written justification for the prolonged use of PRN Ativan (used for anxiety), and they have spoken to the MD in the past about documenting the justification for use. Resident #54: The facility did not ensure that there was justification to use a psychotropic medication, and that staff identified the possible connection between the residents' falls and the psychotropic medication. The resident was originally admitted to the nursing home on 8/31/18, and readmitted after a hospital admission on [DATE] with diagnoses of aphasia, dementia, and Diabetes Mellitus. The Minimum Data Set (MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident rarely/never understood and was rarely/never understood by others. The MDS dated [DATE] documented that the resident required a limited assistance of one person for transfers and ambulated with supervision in the room and in the corridor, and the MDS dated [DATE], documented that the resident required an extensive assistance of 2 people for transfers, an extensive assist of 2 for ambulation in the room, and and walking in the corridor did not occur. The Comprehensive Care Plan CCP for Psychotropic medications dated 11/14/18, did not include what medication the resident was on or why he was on it. It documented that the resident would have minimal side effects related to the psychotropic medication. Under interventions it documented to give the medication as ordered and to monitor/document side effects and effectiveness; there were no other interventions. The MD order dated 11/2/18, documented Risperdal 0.5 mg at bedtime for anxiety. Common side effects of Risperdal include: Anxiety, restless feeling, dizziness and lightheadedness, (which can increase risk of falls). Progress Notes dated 11/2/18 for Comprehensive Care Path, documented that the resident was no longer able to walk. A readmission History and Physical Examination dated 11/6/18, by the MD, documented that the resident's Trazodone was stopped and he was started on Risperdal 0.5 mg at bedtime; adjustments were made to the psychotropic medications with report of improvement in the note described in the hospital discharge records. A Pharmacy Review dated 12/22/18, documented that the Risperidone lacked an allowable diagnoses to support its use, with a list of allowable diagnoses; the MD selected dementing illnesses with associated behavioral symptoms. The resident's medical records did not include any documented behaviors from 11/2/18 - 1/11/19. A review of Incident and Accident reports for the resident between 11/2/18 and 11/20/18, documented that the resident had nine falls. A Progress Note dated 1/4/19, documented that the resident was stable and there were no concerns or issues brought to his attention by facility staff; it was appropriate to continue the resident's psychotropic medication to help address agitation and inappropriate behaviors which were a problem when the resident was admitted but since largely resolved; he did not believe that a gradual dose reduction would be appropriate at this time. During an interview on 1/10/19 at 3:28 PM, CNA #7 stated that the resident did not get ambulated because he needed 2 assist to do so. His inability to ambulate was reported to the nurses and the supervisor. During an interview on 1/14/19 at 1:05 PM, the DON stated that the resident was on Trazadone prior to going to the hospital on [DATE]. While in the hospital the Trazadone was discontinued and the Risperdal was started. He did not see anything that justified the use of Risperdal; they should be seeing why the was put on Risperdal, follow up effects, and adverse reactions. Additionally, he did not make the connection between the Risperdal and the falls but the falls may have had something to do with Risperdal. 10NYCRR415.12(l)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during a recertification survey the facility did not ensure that in accordance with State and Federal laws, the facility must stored all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for one of three units. Specifically: the facility did not ensure that the medication cart and the narcotic box located in the medication cart were locked when unattended. This is evidenced by: During an observation on 1/14/19 from 10:22 AM - 10:29 AM a medication cart on the [NAME] unit was unattended and unlocked. The only nurse on the unit was down the hall administering medications from another cart. There were 18 residents in the vicinity of the cart at the time. The surveyor sent a staff member to get the nurse. When the nurse came to the cart the surveyor asked her to open it. The medication cart was unlocked as well as the narcotic drawer which had several blister packs of narcotics in it. During an interview on 1/14/19 at 10:29 AM, Licensed Practical Nurse (LPN) #6 stated the medication and narcotic box should have been locked; she thought the narcotic drawer was locked. During an interview on 1/14/18 at 5:00 PM, the Director of Nursing stated that the medication carts should be locked at all times unless the nurse is standing right with them. 10 NYCRR 415.18(d)

Based on observation, manufacturer's directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Specifically, food-contact single-use tableware was not stored safely, the automatic dishwashing machine was not operating within the manufacturer's specifications, the concentration of chemical sanitizing rinse (QAC) was less than that required by the manufacturer, food temperature thermometers were not in calibration, and equipment and the floor required cleaning. This is evidenced as follows. The kitchen was inspected on 01/07/2019 at 9:40 AM. In the dry storage area, toxic cleaning chemicals were stored above single-use disposable plastic tableware. When checked, the automatic dishwashing machine final rinse was 177 F at 25 pounds per square inch (psi) water pressure. The automatic dishwashing machine information date plate states that the minimal final rinse water temperature is to be 180 F at 25 psi. The concentration of QAC used in the sanitizing rinse sink was found to be 500 parts per million (ppm) when measured at 72 degrees Fahrenheit (F). The manufacturer's label directions stated the concentration is to be between 150 ppm and 400 ppm when the solution is measured between 65 F and 75 F. Three of 5 food temperature thermometers were found not in calibration when tested in a standard ice-bath method as follows: 29 F, 29 F, and 26 F. The slicer, table mixer, floor fan, janitor closet light switch, ABC extinguisher, black waste receptacle, and floor in corners and under equipment were soiled and required cleaning. The Dietary Director stated in an interview on 01/07/2019 at 11:46 A that the QAC is not at correct concentration from not using correct testing strips, she will reorganize dry storage so chemical are not above plastic-ware, she is not sure why the automatic dishwashing machine final rinse is not reaching temperature, she did not have a chance yet to check thermometer calibration it being Monday morning, and she will revisit cleaning schedule to ensure all items are properly cleaned 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.60(a), 14-1.85, 14-1.110, 14-1.112, 14-1.113

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, 2 of 2 dumpsters had holes and were not pest and rodent-proof. This is evidenced as follows. The dumpsters were inspected on 01/07/2019 at 11:44 AM. The housekeeping dumpster had four 1-inch by 6-inch cracks in the seams between the bottom and sides and the dietary dumpster two 2-inch holes in bottom. The Food Service Director stated in an interview conducted on 07/30/2018 at 1:30 PM, that he first noticed the compactor leaking last Friday, July 27, 2018. The Director of Housekeeping and Laundry stated in an interview conducted on 01/07/2019 at 11:57 AM, that was not aware of the holes in the dumpsters, and will contact the vendor to have the dumpsters replaced. 10 NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review during recertification survey, the facility did not ensure the development and implementation of baseline care plans within 48 hours of admission and did not ensure summaries of the baseline care plans were provided to the resident and the resident's representative for 7 (Resident #'s 20, 35, 54, 77, 85, 252, and #253) of 24 residents reviewed. Specifically, for Resident #'s 20, 35, 54, 77, 85, 252, and #253, baseline care plans were not developed and implemented and written summaries were not provided to the residents and their representatives. This is evidenced by: The policy and procedure titled Baseline Care Plan with a revision date of 9/2018 documented; It is the policy of the facility to develop a baseline care plan within 48 hours of admission. Along with the baseline care plan is a summary of care plan that is provided to the resident and representative in a language that can be understood. Resident #35 The resident was admitted to the facility on [DATE], with diagnoses of hypertension, benign prostate hyperplasia, and Non- Alzheimer's Dementia. The Minimum Data Set (MDS) dated [DATE], documented the resident rarely/never understands or is understood by others and had severe cognitive impairments. Review of the medical record on 1/11/19 at 10:47 AM, did not include documentation of the development and implementation of a baseline care plan or that a summary of the baseline care plan was provided to the resident or their representative. During an interview on 1/10/19 at 3:43 PM, the Registered Nurse Unit Manager (RNUM) #2 reported that his understanding was that the Electronic Medical Record (EMR) dashboard was the baseline care plan, but he does not provide a written summary to the residents or their representative. During an interview on 1/14/19 at 12:45 PM, the admissions nurse RN #4 reported that she completes the initial baseline care plans with the admission assessments, but she does not print them out or review them with the residents and their representatives. Resident #77 The resident was admitted to the facility on 11918 with the diagnoses of femur fracture, malignant neoplasm of prostate and hypertension. The minimum data set (MDS) dated [DATE] documented the resident had moderate cognitive impairment and was able to understand others and make himself understood. A review of the medical record did not include documetation of the development and implementation of a baseline care plan. During an interview on 1/15/19 at 9:36 AM, the Director of Nursing (DON) stated the baseline care plans had not been completed on most of the residents. There were a few residents that had been done, but the completion of them had not been followed through. Resident #77 did not have a baseline care plan completed. Resident #252 The resident was admitted to the facility on [DATE] for rehabilitation with diagnoses of Cerebral vascular accident, diabetes, and chronic kidney disease. The nursing admission assessment dated [DATE] documented the resident understands and is understood with no cognitive impairment. On 1/09/19 8:51 AM, the medical record did not document implementation of a baseline care plan or that a summary of the baseline care plan was provided to the resident or their representative. During an interview on 1/10/19 at 3:43 PM, the RNUM # 2 reported that his understanding was that the EMR dashboard was the baseline care plan, but he does not provide a written summary to the residents or their representative. During an interview on 1/14/19 at 12:45 PM, The admissions nurse RN #4 reported that she completes the initial baseline care plans with the admission assessments, but she does not print them out or review them with the residents and their representatives. During an interview on 1/14/19 at 1:21 PM, the Director of Nursing (DON) stated that they were aware that there was an issue with the baseline care plans. Everyone was under the impression that the computer was generating them automatically. They became aware that in November of this year that the care plans were not being generated. Prior to November they had not attempted to give a copy of the baseline care plans to the residents' family.

Based on observation, record review and interview during the recertification survey, the facility did not ensure an infection prevention and control program (IPCP) was maintained to prevent the development and transmission of infections, and did not ensure the IPCP policies and procedures (P&P) were reviewed annually. Specifically, the facility did not investigate and document surveillance of the signs and symptoms of resident infections. Additionally, the facility did not review and update the infection control P&Ps annually. This was evidenced by: Finding #1: The Policy and Procedure (P&P) titled Infection Prevention & Control Program dated 11/2016, documented the Infection Preventionist will investigate, monitor and report the development and transmission of infections and communicable diseases. The Infection Preventionist documents and performs surveillance reporting of residents and staff with nosocomial or community acquired infections. Monitors and documents this surveillance weekly, and communicates with Nurse Managers and department heads regarding any new infections present with residents and employees. Provide standard criteria for reporting and surveillance of all types of infections (respiratory, GI, post surgical, wound, skin, UTI, septicemia, and those catheter related). Develop a system of reporting, evaluating and maintaining records of infections among residents and personnel, and report to appropriate authorities. The P&P titled Communicable Disease Outbreak Control Plan dated 11/2016, documented it is necessary to have procedures in place to prevent and control outbreaks and provide a safe and healthy environment for our residents and staff well being. During an interview on 01/09/19 at 12:15 PM, the Assistant Director of Nursing (ADON) stated she had recently been assigned the Infection Control Program, although the DON was still in charge of Infection Control. The ADON was not able to state which residents had symptoms of infections or those who were currently being treated, and there was no day to day tracking of infections. She would have to read through the supervisor's report for each unit in order to see which residents had symptoms of and/or infections. The Supervisor's Report was read aloud in morning report by the Nurse Managers. During an interview on 1/9/19 at 12:25 PM, the Director of Nursing (DON) stated he could print out the monthly Quality Assurance (QA) infection control reports from the computer. There were no current, to date infection control surveillance records available to be reviewed. He reviewed the supervisor's report, the pharmacy antibiotic list and laboratory culture report every 2-3 weeks to complete the QA report. There was no process to track all the details of a resident's infectious symptoms and treatment from start to finish. He was unable to quote how many residents had infection symptoms on a given day, he would have to go through the supervisors report from each unit. During an interview on 1/9/19 at 2:00 PM, the DON stated he had been in charge of the Infection Control Program since September 2018. There was no form of communication for the Nurse Managers to alert the DON/ICN or other disciplines of a resident infection or their symptoms. The units did not have tracking sheets of those residents with infections or symptoms. The DON would hold the Registered Nurse Managers responsible for telling him if there was anything unusual with infections on their units. During an interview on 1/10/19 at 9:00 AM, the Administrator stated the ADON is in charge of the infection control program. He was not aware there was no surveillance tracking being done. The new computer system had the capability of running many reports. He understood the importance of a tracking system of infection, and the facility will be working on a new daily tracking system. During an interview on 1/10/19 at 9:00 AM, the Assistant Administrator stated he did understand the need to have a daily tracking system for infections. The facility needed to update all the staff on the use of the new computer system and the many reports they could run. During an interview on 01/10/19 at 10:36 AM, Nurse Practitioner (NP) #3 stated she is not involved in the Infection Control tracking and was not aware of the facility surveillance program. The Medical Director goes to the QA meetings, he would be the one to talk to about infection control tracking and he is on vacation. During an interview on 01/10/19 at 11:28 AM, Registered Nurse (RN) #2 stated the units do not have a system for tracking resident infections. If a resident had an infection the RN Nurse Manager would document the details on the Supervisor's 24 hour Report. If a Nurse Manager noticed a pattern or outbreak they would report to the team. He was not aware of a facility surveillance tool. Finding #2: A review of the IPCP Policy and Procedures (P&P) documented the following P&Ps were dated 11/2016. Infection Prevention & Control Program, Communicable Disease Outbreak Control Plan, Influenza Prevention and Control, admission of Residents with Infectious Diseases, Blood/Body Fluid Spill, Communicable Disease Reporting, H1N1 Policy and Outbreak Protocol, Infection Control Guidelines, and Initiating Isolation Precautions. During an interview on 1/9/19 at 2:00 PM, the DON stated the Infection Control P&Ps were available in the Supervisor's office for all staff. The new ownership is transitioning to their own P&P format and they are giving the P&Ps to the facility when available. He was aware the Infection Control P&Ps have not been updated annually. 10 NYCRR 415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure it developed and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 12 (Resident #'s 19, 44, 53, 57, 60, 62, 69, 74, 75, 77, 85, and #100) of twenty-five residents reviewed. Specifically: The facility did not ensure that a Comprehensive Care Plan (CCP) was developed for Resident #'s 53 & 69's psychotropic medication use; for Resident #74, the facility did not ensure a care plan was developed for hydration; for Resident #57, who was on routine narcotic medications (side effect of constipation) and on two different bowel medications had a CCP for constipation, that Resident #75's contracture splint was added to the Certified Nursing Assistant (CNA) care guide (guide giving CNAs instructions on what care to give) and for Resident #77 and #85 a CCP was not developed for an indwelling catheter; and for Resident #19, who had a history of falls a CCP was not developed for falls. This is evidenced by: The Policy and Procedure titled, Resident Interdisciplinary Care Plans and Team Conferences, updated in 01/2018, documented the care plan should reflect the resident's condition at a given time and needs to be modified with changes in condition, new diagnosis, hospitalizations, etc Resident #53: The resident was admitted to the nursing home on [DATE] with diagnoses of PVD, hemiparesis, and dementia with behavior disturbance. The Minimum Data Set (MDS) dated [DATE] assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident usually understood and was usually understood by others. Physician (MD) Orders dated 12/19/18, documented Trazadone 100 milligram (mg); 1 every evening and Risperidone 0.5 mg; one twice daily. The Comprehensive Care Plan did not include a care plan for the use of psychotropic medications. During an interview on 1/14/19 at 1:21 PM, the Director of Nursing (DON) stated that there should have been a care plan in place to address the psychotropic medication. Resident #69: The resident was admitted to the facility on [DATE], with diagnoses of end stage renal disease, major depressive disorder, and post-traumatic stress disorder. The Minimum Data Set (MDS) dated [DATE], documented the resident had intact cognitive skills, could understand others and could be understood. The Comprehensive Care Plan for Psychotropic Medications, last updated on 11/26/2018, documented; monitor/document side effects and effectiveness. Physician's Order Forms documented on 7/20/18, Risperdal (an antipsychotic medication) 0.5 milligrams (mg) at bedtime for depression and psychosis and on 7/27/18, increase Risperdal to 1 mg two times a day. During an interview on 1/14/19 at 11:34 AM, Registered Nurse Manager (RNM) #1 reported, when a resident is started on psychoactive medication the nurses should document behavior monitoring on the supervisor's report. RNM #1 was unable to provide any additional documentation. During an interview on 1/14/19 at 12:32 PM, the Director of Nursing (DON) reported he would expect documentation of the symptoms prior to and monitoring for days or even weeks following an antipsychotic medication change. The DON was unable to provide any additional documentation. Resident #74: The resident was admitted to the facility on [DATE], with several noted hospitalizations throughout course of stay, most recent readmission on [DATE] with diagnoses of hemiplegia and hemiparesis secondary to cerebrovascular disease, diabetes mellitus, chronic diastolic heart failure, chronic kidney disease stage 4, and dysphagia. The Minimum Data Set, dated [DATE], documented the resident was without cognitive impairment and had the ability to understand and be understood. A Medical Order for Life Sustaining Treatment (MOLST) updated on 12/28/2018, documented the resident had a do not resuscitate order with limited medical interventions, could be sent to the hospital and no feeding tube to be utilized. Intravenous fluids (IVF) were not restricted on the MOLST form. A Physician's (MD) progress note dated 12/26/2018, documented the resident had a significant decline over the last couple of months. The plan was to encourage oral intake, and give him plenty of water. The Comprehensive Care Plan (CCP) for fluid deficit was discontinued on 11/05/2018. A nursing note dated 1/01/2019, documented the resident refused oral intake, and reported that the resident could not swallow. During an observation on 01/07/2019 at 10:28 AM and 2:03 PM, the resident was in bed. The resident's mucous membranes were dry. Mouth swabs and thickened liquid were observed on the bedside table. There was amber colored urine in the Foley catheter tube. During an observation on 01/08/19 at 08:53 AM and 09:08 AM, the resident was in bed without liquids or mouth swabs on bedside table or in resident room. There was amber colored urine in the Foley catheter tube. During an observation on 01/08/2019 at 03:40 PM, and on 01/09/2019 at 09:35 AM, the resident was in bed, the resident's mouth, lips, and eyes were dry, the back of the resident's throat had white patches and dark red dried patches were noted on the top of mouth. There was amber colored urine in the Foley catheter tube. During an interview on 01/09/2019 at 9:35 AM, the resident's spouse reported the resident had not received mouthcare or oral liquids since her arrival at 8:00 AM that morning. There was amber colored urine in the Foley catheter tube. During an interview on 1/10/19 at 12:46 PM, CNA #2 stated the staff was providing mouth care to the resident on a regular basis. CNA #2 stated fluids were provided when the resident requested them. CNA #2 stated mouth care and fluids were not offered when the family was present. CNA # 2 stated the resident's condition had declined over the past week and he had not requested fluids. During an interview on 01/10/19 at 2:30 PM, LPN #1 stated the resident had been declining since an emergency room visit on 12/24/2018. LPN #1 stated Hospice and comfort care were discussed by the interdisciplinary team months prior, but had not been implemented. During an interview on 1/10/2019 at 4:15 PM, RNUM #1 stated the MD was notified when the resident refused oral intake, however this was not documented in the medical record. RNUM #1 stated fluid intake and urinary output were not recorded in the medical record on a regular basis. RNUM #1 stated the resident did not have a care plan in place to monitor for dehydration (when someone loses more fluids than he or she takes in). During an interview on 01/11/2019 at 02:12 PM, the DON stated the expectation was that all residents had fluid intake and urinary output documented on a regular basis, unless otherwise ordered by the MD. The DON stated the expectation was that a care plan would be developed when change in condition occurred. 10 NYCRR 514.11(c)(1)