Based on record review and interviews during the recertification survey from 01/22/2024 to 01/30/2024, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination for one (1) of 3 residents reviewed. Specifically, the facility did not ensure Resident #111 received timely notification (2-day notification) of the termination of Medicare Part A services. This is evidenced by: The document titled, Notice of Medicare Non-Coverage, Form CMS 10123-NOMNC and dated 09/08/2023, documented that Resident #111 last received rehabilitative services on 09/08/2023 and was provided the Notice of Medicare Non-Coverage, Form CMS 10123-NOMNC to inform the resident of their right to an expedited review of service termination on 09/18/2023 (date signed), ten days after the termination of services. During an interview on 01/25/2024 at 10:46 AM, Regional Administrator #1 stated that the person responsible for issuing the Notice of Medicare Non-Coverage for Resident #111 was no longer is employed with the facility, and all persons having received Medicare Part A coverage would be reviewed to ensure they received proper notification. Regional Administrator #1 stated that the facility would educate the current person responsible for issuing the Notice of Medicare Non-Coverage on the two-day requirement to prevent recurrence. 10 New York Codes, Rules and Regualtions 415.3 (g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the recertification survey from 1/22/2024 to 1/30/2024, the facility did not ensure that written notification was sent to a representative of the Office of the State Long-Term Care Ombudsman of a resident's transfer or discharge for two (2) (Resident #17 and #57) of three (3) residents reviewed for hospitalization. Specifically, the written notice of transfers to the Ombudsman was not provided when Resident #17 and #57 transferred to the hospital. This is evidenced by: The Policy and Procedure titled, Facility Initiated Transfer or Discharge, dated 11/2017, stated if the transfer or discharge was facility initiated, the transfer-discharge notice would be faxed to the county Ombudsman program before or as close to the time of transfer/discharge as possible. The facility Policy and Procedure also stated this would be documented in the resident's medical record. Resident #17 Resident #17 was admitted to the facility with the diagnoses of atrial fibrillation (heart condition where the heart's upper chambers beat out of sync with the lower heart chambers), congestive heart failure, and arthritis. The Minimum Data Set (an assessment tool) dated 11/10/2023 documented the resident was understood, could understand others and was cognitively intact. The resident's Census record documented the resident was hospitalized [DATE] to 12/23/2023, and 12/24/2023 to 12/26/2023. The resident's medical record did not include documentation stating the ombudsman's office was notified of the resident's transfers to the hospital. Resident #57 The resident was admitted to the facility with the diagnoses of atrial fibrillation, cellulitis (a bacterial skin infection that may cause redness, swelling, and pain in the infected area of the skin), and chronic pulmonary obstructive disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems). The Minimum Data Set (an assessment tool) dated 8/13/2023 documented the resident was understood, could understand others and was cognitively intact. A Progress Note dated 10/25/2023 documented the resident was sent to the hospital for evaluation. The resident's medical record did not include documentation stating the Ombudsman's office was notified of the resident's transfer to the hospital. Interviews: During an interview on 1/30/2024 at 10:09 AM, Social Worker #1 stated they were not aware they had to inform the Ombudsman in writing of a resident's discharge or transfer. During an interview on 1/30/2024 at 11:00 AM, Administrator #1 stated they were not sure the Ombudsman's office needed to be informed in writing of a resident's transfer or discharge. 10 New York Codes, Rules and Regulations 415.3(h)(1)(iii)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey conducted from1/22/2024 to 1/30/2024, the facility did not ensure that the residents were free of unnecessary medications for 3 (Resident #'s 5, 16, 42) of 5 residents reviewed. Specifically for Residents #5 and #16, multiple medication orders did not include an indication for use; and for Resident #42, one medication did not have an indication for use, and a second medication with an order to administer as needed did not have parameters indicating what symptoms the as needed medication was for. This is evidenced by: Resident #5 Resident #5 was admitted to the facility with the diagnoses of Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), and diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels). The Minimum Data Set (an assessment tool) dated 1/6/2024 documented the resident was usually understood, could usually understand others, and had a moderate cognitive impairment. The Physician's Order report dated 1/29/2024 documented Resident #5 was prescribed the following medications: Acetaminophen 500 milligrams 2 tablets oral every 8 hours as needed Levothyroxine 88 micrograms 1 tablet oral every day Pimavanserin 34 milligrams 1 tab oral every day Senna tablet 8.6 milligrams 2 tablets oral at bedtime Nemanine 10 milligram1 tab oral twice a day Divalproex capsule delayed release sprinkle 125 milligrams amount 1000 milligrams oral at bedtime Donepezil tablet 5 milligrams 1 tablet oral once a day The Physician's Order report did not document the indication for the use of the prescribed medications. Resident #16 Resident #16 was admitted with the diagnoses of Parkinson's disease, diabetes mellitus, and psoriasis vulgaris (skin disease that causes a rash with itchy, scaly patches). The Minimum Data Set, dated [DATE] documented the resident was usually understood, could usually understand others, and had a moderate cognitive impairment. The Physician Order Report dated 1/29/2024 documented Resident #16 was prescribed the following medications: Acetaminophen 500 milligrams 1 tablets oral every eight hours as needed Allopurinol 300 milligrams 1 tab oral once a day at 5:00 AM Cholecalciferol 1250 micrograms 1 cap oral once a day on the 9th of the month Divalproex tablet delayed release 500 milligrams 1 tablet oral twice a day. Lactulose solution 10 grams per 15 milliliters 15 milliliters oral once a day Metformin 1000 milligrams 1 tab oral twice a day Metoprolol succinate tablet extended release 24 hour 100 milligrams 1 tab oral once a day Apixaban 5 milligrams 1 tab oral twice a day Tamsulosin capsule 0.4 milligrams 1 cap oral at bedtime Amantadine hydrochloride tablet 100 milligrams 1 tab oral once a day Fluticasone furoate-vilanterol blister with device 200=25 micrograms per dose 1 puff inhalation once a day Duloxetine capsule delayed release 20 milligrams 1 capsule oral once a day Lisinopril tablet 10 milligrams 1 tablet oral once a day Atorvastatin tablet 20 milligrams 1 tablet oral once a day The Physician's Order report did not document the indication for the use of the prescribed medications. Resident #42 Resident #42 was admitted with diagnoses of unspecified dementia, polyosteoarthritis (Polyarthritis is the medical term for having arthritis - inflammation or swelling of the joints - that affects five or more joints at the same time), and atrial fibrillation (an irregular and often very rapid heart rhythm). The Minimum Data Set, dated [DATE] documented that the resident could sometimes be understood and understand others, but with moderate cognition problems. The physician orders dated 12/28/2023 documented that the resident had Eliquis ordered twice a day without a diagnosis listed in the order. The physician orders dated 1/22/2024 - 2/5/2024 documented that the resident had Klonopin 0.5 milligrams ordered to be given every 12 hours as needed. There was no indication what parameters would require administration of the as-needed medication. The medication administration history dated 1/1/2024-1/29/2024 documented that Klonopin could be given every 12 hours as needed and did not indicate what behaviors required administration of the medication. Additionally, no reasons were documented why the medication was administered and what the results of administration were. Interviews During an interview on 1/29/2024 at 11:25 AM, Director of Nursing #1 stated each medication prescribed should have had a diagnosis attached for indication of use. Director of Nursing #1 did not know why some medications did not have an indication for use. During an interview on 1/29/2024 at 11:31 AM, Corporate Registered Nurse #1 stated when a medication order was entered, an applicable diagnosis should have been entered as well. Corporate Registered Nurse #1 stated there was a pull-down option in the order screen of the electronic medical record that would list the diagnoses of the resident with an option to enter a diagnosis such as a new onset infection. During an interview on 1/29/2024 at 1:00 PM, Pharmacist #1 stated that when doing medication reviews, the pharmacist looked at a particular resident's diagnosis list and attributed the orders written to the diagnosis list, and did not look specifically at the order as the order was written by the provider. 10 New York Codes, Rules and Regulations 415.12(l)(1)

Based on interviews and record review during a recertification survey from 1/22/2024 to 1/30/2024, the facility did not ensure a Registered Nurse was scheduled for at least 8 consecutive hours a day, 7 days a week. Specifically, no registered nurse worked on 1/28/2024. This is evidenced by: Record review of the written working schedule for 1/28/2024 revealed no registered nurse was scheduled to be in the building that day. During an interview on 1/29/2024 at 1:58 PM, Scheduler #1 stated they made sure all the shifts were covered and was aware that a registered nurse needed to be scheduled for eight consecutive hours, seven days a week, per the regulation. The Scheduler could not explain why no registered nurse was scheduled on 1/28/2024, and stated they must have missed that. During an interview on 1/30/2024 at 2:10 PM, Administrator #1 stated they checked the schedule before leaving for the day and didn't notice that no registered nurse was scheduled for 1/28/2024. Administrator #1 stated it did not happen regularly and the facility should have found a registered nurse for that day. Administrator #1 confirmed the facility did not have any staffing waivers. During an interview on 1/29/2024 at 2:18 PM, Director of Nursing #1 stated they had worked 1/27/2024 as a registered nurse then returned home that evening. They stated they were not aware that the facility did not have a registered nurse scheduled for 1/28/2024 but that they were on-call and available by phone. Director of Nursing #1 stated the facility had a very low acuity, that there were no residents in the facility that required intravenous therapy (the administration of substances such as fluids, electrolytes, blood products, nutrition, or medications directly into a resident's vein), enteral feedings (nutrition delivered directly into the stomach or intestine through a tube), sterile dressings or vacuum assisted closure of wounds. Director of Nursing #1 stated the staffing on 1/28/2024 was not ideal but the event was a fluke and not common. 10 New York Codes, Rules, and Regulations 415.13(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey from 01/22/2024 to 01/30/2024, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety in the main kitchen and two (2) of 2 kitchenettes. Specifically, toxic vapor-emitting fly strips were used in food preparation areas, cleaning equipment was not stored properly, and equipment and floors were not clean. This is evidenced by: During observations of the main kitchen on 01/22/2024 at 11:37 AM, two toxic vapor-emitting fly strips were found near the 3-compartment sink; a broom and dust bin were stored next to the stove; and the can opener and holder, cooking line drawers, wall fan in the dishwashing machine area, and floor under and behind cooking equipment were soiled with food particles. During observations on 01/22/2024 at 12:13 PM in the [NAME] Unit kitchenette, the microwave oven and floor in corners were soiled with food particles; and in the [NAME] Unit kitchenette, the microwave oven and the floor in corners, next to walls, and under the refrigerator were soiled with food particles. The label of the fly strips used in the kitchen titled Fruit Fly BarPro was undated and documented in the section labeled Warnings that this product was not to be used in kitchens or any areas where food is prepared. There was no documented evidence that dietary staff received training or were tasked to clean the can opener and holder, cooking line drawers, wall fan in the dishwashing machine area, and floor under and behind cooking equipment. There was no documented evidence that dietary staff received training or are tasked to clean kitchenette microwave ovens or floors. There was no documented evidence that environmental services staff received training to clean kitchenette microwave ovens or floors. The undated environmental services task schedule for cleaning the unit kitchenettes documented that the unit kitchenettes were to be cleaned by the environmental services staff but did not specify the frequency or that the floors and microwave ovens were to be cleaned. During an interview on 01/22/2024 at 1:30 PM, Nutrition Manager #1 stated that the fly strips used to treat drain flies at the 3-compartment sink were discarded. Nutrition Manager #1 stated that the broom and dustpan should had been stored in their designated area, the soiled items found in the kitchen had been cleaned, the staff would be consulted on cleaning, and the cooking equipment would be moved to enable the floor behind the cooking equipment to be thoroughly cleaned. Nutrition Manger #1 stated that housekeeping staff were responsible for cleaning the kitchenette microwave ovens and floors. During an interview on 01/26/2024 at 2:38 PM, Administrator #1 stated that the cleaning items found in the main kitchen and kitchenettes would be addressed with the Food Service Director and the environmental services department, the dietary department would be assigned to clean the kitchenette microwave ovens, and the dietary and maintenance staff would be educated on not using prohibited fly strips in the kitchen. 10 New York Codes, Rules and Regulations 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1

Based on record review and interviews during an abbreviated survey (Case# NY00298857), the facility did not ensure that all alleged violations involving neglect were reported immediately-but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily harm-to the Administrator of the facility and to the State Survey Agency for 1 (Resident #1) of 3 residents reviewed. Specifically, on 7/6/2022 at 2:45 PM, Registered Nurse #1 was made aware that Resident #1 rolled out of bed when staff attempted to dry the resident's back. Upon arrival to the facility, Registered Nurse #1 found the resident lying flat on their back with legs partially extended toward the foot of the bed, an icepack on their forehead, a laceration approximately 2 centimeters long on the right forehead with minimal bleeding and significant swelling. Resident #1 was transferred to emergency room for evaluation. The incident was reported to the New York State Department of Health 5 days later on 7/11/2022 at 4:19 PM. This is evidenced by: The facility Policy and Procedure titled, Abuse & Neglect Policy; Section 1- Abuse Prevention and Reporting, revised 1/11/2023, documented all employees were required to report in accordance with Public Health laws when they had reasonable cause to believe that a person receiving care or services in a residential health care facility had been physically abused, mistreated, or neglected. Circumstances to be reviewed included but was not limited to the presence of a physical condition at variance with the history and course of treatment of the resident. The Director of Nursing/shift supervisor for the evening and night shifts would take these immediate steps once an allegation or abuse or neglect had been filed: promptly notify the Administrator, Medical Director, and Director of Nursing of alleged or confirmed abuse or neglect. It documented in response to an allegation of neglect the facility must ensure that all alleged violations involving neglect were to be reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia, chronic kidney stage disease stage 3, and primary generalized osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time). The Minimum Data Set (an assessment tool), dated 6/15/2022, documented the resident's cognitive skills for daily decision making were severely impaired and that they never/rarely made decisions. The facility incident report dated 7/06/2022 at 2:45 PM by Registered Nurse #1 documented: -Registered Nurse #1 received a call at home from the Supervisor's cell phone where it was reported to them that Resident #1 rolled out of bed when staff attempted to dry their back. Upon arrival to the facility, Registered Nurse #1 found the resident lying flat on their back with legs partially extended toward the foot of the bed. An icepack had been placed on their forehead. A laceration that measured approximately 2 centimeters was noted on the right forehead with minimal bleeding but had significant swelling. The physician and resident's daughter were notified, and both agreed to transfer the resident to the emergency room for evaluation. -Other Information documented the resident had little control in positioning their legs. While they were rolled onto their side for staff to dry their back, their legs slipped off the bed. The staff who was assisting slipped on water at the bedside and lost their balance and the resident fell to the floor from bed, landing on their right side. The New York State Department of Health Intake Information form for Case # NY00298857 documented the facility incident occurred on 7/06/2022 at 2:45 PM, and the facility reported the incident to the New York State Department of Health on 7/11/2022 at 4:19 PM. It documented the incident was a result of a care plan violation and that the facility had completed their investigation. During an interview on 12/21/2023 at 11:46 AM, Licensed Practical Nurse #3 stated they called the provider and sent the resident to Emergency Department. They stated Director of Nursing #2 was on vacation and was reached by phone. During an interview on 12/28/2023 at 1:38 PM, Administrator #2 stated they did not recall why the facility did not report the incident until 7/11/2022 and stated they did not know about the incident until Director of Nursing #2 reported it to them and could not recall the date. During an interview on 12/28/2023 at 4:02 PM, Director of Nursing #2 stated they were on vacation on 7/06/2022, and that Licensed Practical Nurse #3 was in charge during their absence. Director of Nursing #2 stated they were not informed at the time of the incident, were made aware of the incident when they returned to work on 7/11/2022 and completed the investigation that was started by Registered Nurse #1 back on 7/06/2022. They stated they told Administrator #2 on 7/11/2022, and then reported to the New York State Department of Health. Cross-reference F656. 10 New York Codes, Rules and Regulations 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #s NY00298857 and NY00324981), the facility did not ensure it developed and implemented a comprehensive, person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 2 (Resident #s 1 and 3) of 3 residents reviewed. Specifically, (A) Resident #1's comprehensive care plan for Self-Performance Deficit documented the resident had limited mobility and required 2 staff to assist with bed mobility. The facility did not ensure the care plan intervention for 2 staff to assist with bed mobility was implemented when, on 7/06/2022, Certified Nurse Aide #1 did not wait for Certified Nurse Aide #2 to assist with bed mobility and turned the resident on their side towards the edge of the bed to dry them. As of result, the resident's legs slipped off the bed, Certified Nurse Aide #1 was unable to stop the resident from falling to the floor, the resident sustained a hematoma (solid swelling of clotted blood within the tissues) and laceration to their forehead, and was transferred to the emergency room for evaluation. (B) Resident #3 was assessed at moderate risk for dehydration and had an alteration in nutrition related to poor intake. There was no care plan to address their nutrition and hydration needs. This is evidenced by: The undated facility Policy and Procedure titled, Care Plans Comprehensive Person-Centered, documented a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs would be developed and implemented for each resident. The Interdisciplinary Team, which included the nurse aide who had responsibility for the resident, developed and implemented a comprehensive, person-centered care plan for each resident. Care plan interventions were chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Record review of a facility document with the job description for job title, 'Certified Nursing Assistant - Long Term Care,' dated May 2018, documented the Certified Nursing Assistant would provide each of their assigned residents daily nursing care and services in accordance with the resident's assessment and care plan or directed by the nurse. They would perform all assigned tasks in accordance with the facility's established policies and procedures, and as instructed by their supervisors. They would review [NAME] (an electronic medical record system) daily to determine if changes in each resident's daily care routine had been made on the [NAME]. Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia, chronic kidney stage disease stage 3, and primary generalized osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). The Minimum Data Set (an assessment tool) dated 6/15/2022,documented the resident's cognitive skills for daily decision making were severely impaired, and they never/rarely made decisions. The Comprehensive Care Plan for Self-Performance Deficit related to limited mobility, stroke with residual weakness, non-ambulatory, and bowel and bladder incontinence, last revised 10/27/2022, documented Resident #1 required the assistance of 2 staff for bed mobility. The Visual/Bedside [NAME] Report dated 6/26/2022, documented the resident required assistance of 2 staff for bed mobility. The incident report dated 7/06/2022 at 2:45 PM by Registered Nurse #1 documented: --Registered Nurse #1 received a call at home from the Supervisor's cell phone that the resident rolled out of bed when staff attempted to dry their back. Upon arrival to the facility, they found the resident lying flat on their back with legs partially extended toward the foot of the bed. An icepack had been placed on their forehead. A laceration that measured approximately 2 centimeters was noted on the right forehead with minimal bleeding but had significant swelling. The physician and resident's daughter were notified, and both agreed to transfer the resident to the emergency room for evaluation. -Witness statements documented: --On 7/06/2022, Certified Nurse Aide #1 stated they just finished showering the resident and started to turn the resident and dry them while the other aide was there. They stated that after the aide walked out, they slipped on water while they were trying to hold the resident and that was when the resident slipped from their hands and yelled. --On 7/06/2022, Certified Nurse Aide #2 stated they did not witness the fall. They heard someone scream and went right away. The resident was on the floor on their right side. During an interview on 12/20/2023 at 3:49 PM, Certified Nurse Aide #1 stated they worked for an agency and was assigned to Resident #1 on 7/06/2022. They stated they always looked at the resident's care plan that was in the computer and in the resident's closet to see if the resident was a 1 person or 2 person assist. They stated they were familiar with the resident and knew Resident #1 required 2 staff for care. They stated that on 7/06/2022, they gave the Resident #1 a shower and then they and Certified Nurse Aide #2 used the mechanical lift to place the resident in their bed. They stated Certified Nurse Aide #2 then left the bedside and pushed the mechanical lift outside the room. They stated Certified Nurse Aide #2 was only gone for a few seconds and then came back in the room. They stated they were at the head of the bed and Certified Nurse Aide #2 was at the foot of the bed drying the resident when suddenly the guard rail on the bed came down. They stated it was usually locked in place but did not think to check to see that it was secure. The resident then began to slide off the bed and they could not stop the resident from falling because the floor was wet. Certified Nurse Aide #1 stated their feet slipped, the resident landed on the floor their side and hit their head. Certified Nurse Aid #1 stated Resident #1 sustained a big bump on their head from the fall, and that the bed e guard rail was the cause for the resident falling. They stated they did have a second person, Certified Nurse Aide #2, who was in the room with them when the resident fell. They stated they tried to explain to Director of Nursing #2 that the bed guard rail was the problem, but Director of Nursing #2 did not agree with them. During an interview on 12/21/2023 at 9:43 AM, Certified Nurse Aide #2 stated they worked for an agency and was familiar with Resident #1 and their care needs. They stated it was on the resident's care plan that the resident needed 2 staff to assist with bed mobility. They stated the care plan was in the computer and in the resident's closet. They stated that on 7/06/2022, after the resident was showered, they helped Certified Nurse Aide #1 placed the resident back in their bed using a mechanical lift. They stated the resident required 2 staff for bed mobility because the resident could not turn themselves. They stated they told Certified Nurse Aide #1 to wait for them while they removed the mechanical lift from the room and Certified Nurse Aide #1 acknowledged what they said. They left the room with the mechanical lift to put in the storage area located close to the resident's room and then heard a scream. They stated they saw the resident on the floor and Certified Nurse Aide #1 in the room and screamed for the supervisor. They stated there was no one else in the room. They stated the resident had a head injury and was sent to the hospital. They stated that a few days after the incident, Director of Nursing #2 asked Certified Nurse Aide #1 why they turned the resident by themselves, and Certified Nurse Aide #1 said Certified Nurse Aide #2 was with them. Certified Nurse Aide #2 stated Resident #1 fell out of bed because Certified Nurse Aide #1 did not wait for them to help and turned the resident by themselves. They stated they did not hear anything about the guard rail falling before the resident fell out of bed. They stated Certified Nurse Aide #1 could not use the guard rail as a reason for why the resident fell because it was lowered by staff when care was provided, and the resident still needed 2 staff to turn them in bed. They stated Certified Nurse Aide #1 told them their feet slipped because there was water on the floor from the mechanical lift and they could not hold the resident up when the resident started to slide off the bed. They stated Certified Nurse Aide #1 was familiar with the resident and was aware they needed to look at the resident's care plan before providing care. They stated Certified Nurse Aide #1 made a mistake and should have owned up to it. During an interview on 12/21/2023 at 11:46 AM, Licensed Practical Nurse #3 stated when they worked in the facility, they were the admissions coordinator and worked on the units. They stated Resident #1 had a history of femur (thigh bone) fractures and their bones were very brittle. They stated that after the fractures, the resident was care planned to have 2 staff assist with transfers and bed mobility. They stated they did not have the facility's policy in front of them but knew Certified Nurse Aides were to review the resident's care plan prior to providing any care and stated it was a standard of care. They stated the resident had an enabler bar on the bed that would have been recommended by Physical Therapy following assessment and was used by the resident to assist with some care. The enabler bar was about 2.5 to 3 inches wide, attached to the bedframe, and was positioned between the resident's elbow and wrist. They stated the enabler bar was moved down when providing care to the resident and stated the knob had to be pulled to get the bar down. They stated the knob was pulled and twisted when raising it up and there was a locking mechanism to keep it secured. They stated they never experienced a problem with enabler bars and they were not aware of any issues with Resident #1's enabler bar. They stated the care plan for bed mobility was not adhered to when Certified Nurse Aide #2 removed the mechanical lift from the room and Certified Nurse Aide #1 attempted to turn the resident by themselves and the resident fell to the floor. They stated they called the provider and sent the resident to Emergency Department. During an interview on 12/28/2023 at 4:02 PM, the Director of Nursing #2 stated they recalled the incident with Resident #1 on 7/06/2022. They stated they and the nurse manager were on vacation at that time. They stated they talked to Certified Nurse Aide #1 when they returned to work, and Certified Nurse Aide #1 told them they gave the resident a shower and put the resident back to bed. While they were drying the resident, the resident slid off the bed. They stated Certified Nurse Aide #1 did not follow the care plan when they rolled the resident by themselves. They stated Certified Nurse Aide #1's initial training included looking at the [NAME] prior to providing care to any resident. They stated that after the incident, they had a training conversation with Certified Nurse Aide #1 with what the expectation was for providing care to residents. They stated they were not aware of any issue with a guard rail, and that the resident had an enabler bar that the resident would hold onto while being positioned on their side. They stated Certified Nurse Aide #1 moved the enabler bar down to provide care. They stated if Certified Nurse Aide #1 had followed the care plan, there would have been a second Certified Nurse Aide in the room with them to help turn the resident. Director of Nursing #2 stated Certified Nurse Aide #1 did not wait for the second aide to help and the resident fell. They stated the mechanical lift took less than a minute to put outside the resident's door. They stated Certified Nurse Aide #1's employment contract was then terminated. They stated the resident returned to the facility following the emergency room visit and there were no long-term adverse effects from the fall. They stated direct care staff were re-trained following incident on reviewing the electronic medical record system and in using the mechanical lift. Resident #3: Resident #3 was admitted to the facility with diagnoses of muscle wasting (loss of muscle) and atrophy (thinning of muscle), moderate protein calorie malnutrition, and vascular dementia (caused when decreased blood flow damages brain tissue). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. The Comprehensive Care Plan revised 6/27/2023 for Nutritional Problem related to decreased appetite, dementia, and low body mass index was reviewed. Care plan goals documented the resident would consume at least 75% of at least 2 of 3 meals daily and would have no signs and symptoms of malnutrition as evidenced by significant weight loss and muscle wasting. The care plan did not document the resident's hydration needs, risk for dehydration, and interventions to prevent dehydration. The Comprehensive Care Plan initiated on 8/08/2023 and revised 9/06/2023 for Nutritional Status documented an alteration in nutrition related to poor intake at times. Care plan goals documented the resident would be placed on the most appropriate diet for wellbeing, and care plan interventions documented the facility would complete nutritional evaluation, weigh the resident on admission and the day after admission and as ordered by the Medical Provider, obtain physician order for diet, and communicate to Dietary Department. The care plan did not document the resident's nutrition and hydration needs, risk for dehydration, and interventions to prevent dehydration. During an interview on 1/12/2024 at 2:48 PM, Director of Nursing #1 stated the facility transitioned to a new electronic medical record on 8/08/2023. During the interview, they reviewed the care plan for Nutritional Status in the current computer system and stated it was a bare bone care plan. Director of Nursing #1 stated it would have been up to nursing to place a person-centered care plan with interventions to prevent dehydration and weight loss. They stated the resident was still at risk for dehydration at that time. They stated Director of Nursing #3, who left the facility around 9/13/2023, was responsible for developing and implementing the care plan. During an interview on 1/11/2024 at 4:09 PM, Registered Nurse Manager #1 stated they were the acting Assistant Director of Nursing and left the facility at the end of October 2023. They stated they did not receive any training on the new electronic medical record and did not develop or update any care plans during the three weeks they worked at the facility. They stated they were not aware Resident #3 was at moderate risk for dehydration. Cross-reference F609 and F692. 10 New York Codes, Rules and Regulations 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case # NY00324981), the facility did not ensure acceptable parameters of nutrition were maintained for 1 (Resident #3) of 3 residents reviewed. Specifically, for Resident #3, who was admitted to the hospital by a family member on 9/24/2023 with colitis and acute kidney injury, the facility did not recognize, evaluate, and address the nutritional needs of the resident who was at risk for dehydration. The Hospital Discharge Summary Report, dated 9/27/2023, documented a final diagnosis of prerenal acute kidney injury in the setting of colitis and poor oral intake. This is evidenced by: The undated facility Policy and Procedure titled, Hydration and Prevention of Dehydration, documented the facility would strive to provide adequate hydration and to prevent and treat dehydration. The dietician would assess all residents for hydration as part of the comprehensive assessment, at least quarterly, and more often as necessary per resident need. Minimum fluid needs would be calculated and documented on initial, annual, and significant change assessments, using current standards of practice. The dietician and nursing staff would educate the resident and family regarding hydration and preventing dehydration. Nursing would assess for signs and symptoms of dehydration during daily care. Nurse Aides would provide and encourage intake of bedside snack and meal fluids, on a daily and routine basis as part of daily care. Intake would be documented in the medical records and aides would report intake of less than 1000 milliliters per day to nursing staff. If potential inadequate intake and/or signs and symptoms of dehydration were observed, intake and output monitoring would be initiated and incorporated into the care plan and the physician would be notified. The dietician, nursing staff, and the physician would assess factors that may be contributing to inadequate fluid intake. Orders for medications that may exacerbate dehydration (e.g., diuretics) would be reviewed and held if medically appropriate. Laboratory tests may be ordered to assess hydration if intake and symptoms indicate possible significant dehydration. If laboratory tests were consistent with actual dehydration, the physician may initiate intravenous hydration. Hospitalization would be recommended as necessary. Nursing would monitor and document fluid intake and the dietician would be kept informed of the status. The Interdisciplinary Team would update the care plan and document the resident's response to interventions until the team agreed that fluid intake and relating factors were resolved. Resident #3: Resident #3 was admitted to the facility with diagnoses of muscle wasting (loss of muscle) and atrophy (thinning of muscle), moderate protein calorie malnutrition, and vascular dementia (caused when decreased blood flow damages brain tissue). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. The facility document titled, Dehydration Risk Assessment 2, and dated 6/26/2023 by Registered Dietician #2 documented the resident was at moderate risk for dehydration. The facility document titled, Nutritional Assessment I/A, and dated 6/26/2023 documented the resident required a minimum of 1500 milliliter of fluids daily. The Comprehensive Care Plan was revised 6/27/2023 for Nutritional Problem related to decreased appetite, dementia, and low body mass index, with goals that the resident would consume at least 75% of at least 2 of 3 meals daily and would have no signs and symptoms of malnutrition as evidenced by significant weight loss and muscle wasting. The care plan did not document the resident's hydration needs, risk for dehydration, and interventions to prevent dehydration. During an interview on 1/12/2024 at 2:48 PM, Director of Nursing #1 stated the facility transitioned to a new electronic medical record on 8/08/2023, and that on 08/08/2023, the resident was still at risk for dehydration. The Comprehensive Care Plan was revised on 9/6/2023 for Nutritional Status related to alteration in nutrition because of poor intake at times, with a goal that the resident would be placed on the most appropriate diet for wellbeing. The care plan did not document measurable objectives and timeframes to meet the resident's nutritional needs and did not document the resident's hydration needs, risk for dehydration, and interventions to prevent dehydration. The Treatment Administration Record dated 9/01/2023 to 9/30/2023 documented the following order: 8/08/2023 Fluids with Medication Pass, twice a day, from 5:45 AM to 2:15 PM and from 2:15 PM to 10:15 PM: -On 9/18/2023, 240 milliliters and 120 milliliters of fluids were documented by Licensed Practical Nurse #2 and Registered Nurse #4, respectively. -On 9/20/2023, 240 milliliters and 120 milliliters of fluids were documented by Registered Nurse Manager #1. -On 9/21/2023, 240 milliliters and 240 milliliters of fluids were documented by Licensed Practical Nurse #2. -On 9/22/2023, 120 milliliters and 120 milliliters of fluids were documented by Licensed Practical Nurse #2 and Licensed Practical Nurse #6, respectively. -On 9/23/2023, 240 milliliters and 120 milliliters of fluids were documented by Registered Nurse #6 and Registered Nurse #5, respectively. Review of the Vitals Report dated September 2023 for percentage of meals and total fluids consumed from 9/17/2023 to 9/23/2023, documented the following: -On 9/17/2023, breakfast was documented at 9:45 AM as 26-50% and at 1:31 PM as 76-100%. Lunch was also documented at 1:31 PM as 51-75%. The dinner meal was not documented. Supplements were documented as 26-50%. The total fluids documented was 1440 milliliters: 96% of the daily minimum. -On 9/18/2023, 9/19/2023, 9/20/2023, 9/21/2023, 9/22/2023, and 9/23/2023, the total fluids documented in milliliters, and percentage of the daily minimum of 1500 were 360 (24%), 840 (56%), 360 (24%), 480 (32%), 240 (16%), and 120 (8%), respectively. On 9/19/2023 at 1:45 PM, Certified Nurse Aide #9 documented both breakfast and lunch as 76-100%. The dinner meal was not documented and there was no documentation Nursing staff was made aware. -On 9/23/2023 at 12:54 PM, Certified Nurse Aide #10 documented breakfast as 76-100% and at 12:55 PM documented 76-100% of lunch and AM snack 51-75%. The dinner meal was not documented and there was no documentation Nursing staff was made aware. -On 9/18/2023, 9/20/2023, 9/21/2023, 9/22/2023 there was no documentation by the Certified Nurse Aide of the percentage of meals consumed for breakfast, lunch, and dinner. There was no documentation Nursing staff was made aware of the resident's food intake. The Nursing Progress Note dated 9/22/2023 at 9:15 PM by Registered Nurse #2, documented the family member approached them with concerns about the resident. Specifically, loss of appetite, sleeping almost all the time during the past 2 days and vague complaints of back pain. Registered Nurse #2 documented the resident stated they were sleeping because they were tired and there was nothing to do. They documented the resident said the back pain was general, and they blamed it on the bed. It was documented the resident had no other evident symptoms. It documented returned a call to the family member and they requested follow up by the Registered Nurse on 9/23/2023. There was no documentation in Nursing Progress Notes that the resident's nutritional status was evaluated on 9/22/2023, when it was reported the resident had loss of appetite and was sleeping most of the time over the past 2 days. There was no documentation the physician was notified. Review of the facility report titled, 24 Hour Report (Nursing 24 Hour Report), dated 9/22/2023, did not document a report for Resident #3. The Nursing Progress Note dated Saturday, 9/23/2023 at 10:27 PM by Registered Nurse Manager #1, documented the resident was assessed per the family's wishes. They documented the family stated the resident had a urinary tract infection and the resident denied pain or discomfort in the lower abdomen, pelvic area, or lower back and with urination. The resident denied nausea, vomiting, or diarrhea and stated they felt okay. The resident was noted to have a non-productive cough, had a slight wheeze in left side and a chest x-ray was ordered for 9/25/2023. Resident stated they slept a lot because they were bored, with nothing to do and they needed fresh air. They documented the physician was made aware of the concerns, and a new order for breathing treatments was given. There was no documentation in Nursing Progress Notes that the resident's nutritional status (food/fluid intake) was evaluated on 9/23/2023. Review of the facility report titled, 24 Hour Report (Nursing 24 Hour Report), dated 9/23/2023, did not document a report for Resident #3. The Nursing Progress Note dated 9/24/2023 at 2:30 PM by Licensed Practical Nurse #4 documented the resident's family came to pick up the resident for lunch. The resident was gone for approximately 1 hour when they received a call from the Emergency Department stating the family brought the resident to the hospital due to complaint of severe lower abdominal pain that the resident had complained for a week to the family. They documented the resident was assessed on 9/23/2023 by the Registered Nurse and had contacted the physician and was awaiting new orders. The Emergency Department Provider Report dated 9/24/2023, documented: -The resident presented to the Emergency Department on 9/24/2023 with their family member. They reported they visited the resident and found them to be ill, the resident had been anorexic (lack or loss of appetite for food) for 4 days and had not been out of bed in 4 days. They reported the resident had very little to eat or drink that week, had a cough and had been complaining of dizziness, back pain, and abdominal pain. The resident had 8 episodes of diarrhea on 9/24/2023 and had been incontinent of stool. The family member also noted an increase in the resident's dementia this week. The resident had small (blood) vessel dementia because of a (history of) stroke. The neurological examination documented the resident was confused and showed evidence of dementia with their statements, as they talked about their deceased spouse as if the spouse were present. -The Medical Decision Making Progress Note documented the resident had leukocytosis (increase in the number of white blood cells, especially during infection), diagnostic imaging showed some mild colitis (inflammation of the colon), and the resident currently had diarrhea. Laboratory testing showed the resident had acute kidney injury. -The Emergency Department Departure Clinical Impression documented a primary impression of colitis and a secondary impression of acute kidney injury. The Hospital Discharge Summary Report dated 9/27/2023 documented: -Hospital Course documented: For the colitis, the resident was given antibiotics. With antibiotic treatment, abdominal discomfort and diarrhea resolved and the leukocytosis down trended. For the acute kidney injury, the resident was treated with intravenous fluids as presentation was consistent with prerenal (occurring in the circulatory system before the kidney is reached) etiology in the setting of diarrhea and poor oral intake. Renal function improved with intravenous fluid administration. At the time of discharge, laboratory retesting showed improvement to the kidneys. It documented although the levels were still above the resident's baseline, given continued improvement on oral fluids, the resident was felt stable and appropriate for discharge back to the facility with close follow up of renal function. Final Diagnosis documented prerenal acute kidney injury in the setting of colitis and poor oral intake. The Nursing admission Observation Note dated 9/27/2023 at 2:50 PM by Director of Nursing #1 documented the resident was readmitted on [DATE] after a brief hospital stay due to diagnoses that included prerenal acute kidney injury. During an interview on 1/05/2024 at 3:09 PM, Licensed Practical Nurse #4 stated they documented fluids given during a medication pass and there was a specific place in the computer system for the documentation. They stated they generally documented 120 milliliters for the medication pass. They stated Certified Nurse Aides were responsible for documenting all other fluids consumed, such as with meals and documented the amount of the meal they consumed. They stated if there was a change in the amount the resident usually ate or drank, the Certified Nurse Aide was responsible for reporting to the Licensed Practical Nurse, and then the Registered Nurse would assess the resident and notify the physician. They stated they did not know if Dietary was to be notified. They stated that sometimes Resident #3's nursing unit did not have an assigned Certified Nurse Aide. They stated there were several times when they were left without an assigned aide and had to perform the responsibilities of the Certified Nurse Aide in addition to their nursing responsibilities. They stated they would not have been able to monitor and/or document the amount of fluids or food the resident had consumed during their assigned shift. During an interview on 1/08/2024 at 11:04 AM, Licensed Practical Nurse #5 stated they only documented fluids that were given to a resident during a medication pass and stated the assigned Certified Nurse Aide was responsible for documenting fluid intake at meals. They stated they were familiar with Resident #3, and they often needed encouragement to drink. They stated the Certified Nurse Aide was responsible for reporting to the Licensed Practical Nurse when the resident would not comply, and the Registered Nurse would assess the resident and call the physician if necessary. They stated they would not be able to keep track of what residents had consumed and relied on the Certified Nurse Aide. During an interview on 1/08/2024 at 4:10 PM, Certified Nurse Aide #6 stated they were responsible for monitoring and documenting the total fluids the resident consumed in between and at meals, as well as the percentage of the meal eaten. They stated the Certified Nurse Aides were responsible for letting the nurse know about a change in fluid/food consumption because a resident could be sick. They stated they were familiar with Resident #3 and the resident had dementia and needed encouragement to eat and drink. They stated the resident would do better with eating and drinking when they were not left alone in their room and were brought to the dining area for meals. They stated if a Certified Nurse Aide did not have access to the computer system, it was the aide's responsibility to report it to the nurse. During an interview on 1/11/2024 at 12:51 PM, Registered Nurse #2 stated they were working in another unit when Resident #3's family member approached them about Resident #3. They stated the resident's family member asked them to look at the resident because they were concerned about them and did not recall what the concern was. They stated they documented no evident symptoms because the resident did not appear acutely ill. They stated they did not review the resident's food/fluid intake and did not recall being notified by the Certified Nurse Aide about the intake. They stated they called the resident's family member to let them know the findings. During an interview on 1/11/2024 at 3:21 PM, Registered Dietician #4 stated they had not provided services to the facility for the past few months. They stated they provided coverage 2 days a week and would call into morning meeting on those days. They stated they did not recall being called about Resident #3 and if they were called and had communication with the physician, they would have documented a note. They stated they spoke with the Interdisciplinary Team about Resident #3 after they were readmitted to the facility on [DATE]. During an interview on 1/11/2024 at 4:09 PM, Registered Nurse Manager #1, stated they were the acting Assistant Director of Nursing and left the facility at the end of October 2023. They recalled that the resident's family member picked the resident up for lunch and then took them to the Emergency Department instead. They stated that when they assessed the resident on 9/23/2023, the family member said they were not doing anything about their complaint and stated they did not recall what their complaint was. They stated the resident answered their questions during the assessment and there was no indication of any cognitive issues. They recalled calling the physician but could not recall the details. They stated the resident would pick and choose what they wanted to eat, and they did not review their fluid/food intake. Registered Nurse Manager #1 stated they were responsible for monitoring the resident's intake/output and reporting any changes to the physician. They stated they were not informed by the Certified Nurse Aide about Resident #3's food/fluid intake. They stated they did not know why the Certified Nurse Aides did not document the intakes/outputs and stated most of them were travelers. They stated a few of the Certified Nurse Aides that came in did not have logins for days and could not document in the electronic medical record and had to rely on the other aides to document for them. Registered Nurse Manager #1 stated they submitted multiple requests for logins for the Certified Nurse Aides to Administrator #2 and did not receive any response. They stated they did not have a lot of interaction with Resident #3 and stated they spent most of their 3 weeks of employment in the facility on a medication cart. They stated that for the most part, they were the only Registered Nurse in the building for much of the time and if the facility was full, there were 60 residents. During an interview on 1/12/2024 at 11:09 AM, Medical Director #1 stated they were not made aware on 9/22/2023 and 9/23/2023 of Resident #3's poor oral intake. They stated they typically gave intravenous fluids in the facility and Registered Nurse Manager #1 could have administered them. They stated if they were notified of the poor oral intake and the concern from the resident's family member, they would have ordered orthostatic blood pressures, intravenous fluids or hypodermoclysis (fluids that are administered subcutaneously) or would have sent the resident to the Emergency Department if warranted. During an interview on 1/12/2024 at 2:00 PM, Resident #3's Family Member #1 stated that when they visited the resident on 9/22/2023, the Certified Nurse Aide told them the resident had diarrhea. They did not recall who the Certified Nurse Aide was and stated the facility had agency staff for months and they never saw the same Certified Nurse Aide twice. They stated they did not know how severe the diarrhea was or if the nurse was aware. They stated they spoke to Registered Nurse #2 on 9/22/2023 about the diarrhea and that Resident #3 was sleeping most of the time. They stated Registered Nurse #2 was covering both floors that day and they had to go upstairs to find them. They stated the nurse was overwhelmed and said they would assess the resident. They stated they tried to tell the nurse something was wrong with the resident, and the nurse was saying the resident was staying in bed because they were depressed. Family Member #1 stated the resident was usually very active and was involved with staff and activities. They stated they were sick and were unable to visit the resident during that time. They stated when they visited them on 9/24/2023, they stated the Certified Nurse Aides told them the resident had refused all food and had not eaten or drank in 4 days. They did not recall who the aides were. They stated they signed the resident out of the facility and then brought them to the Emergency Department. They stated they were convinced the resident would have died within a few days if they had not taken them to the hospital. They stated the facility had a changeover in staff in one week's time including the kitchen staff. They stated they felt the resident was not eating because the quality of the food being served was not good. During an interview on 1/12/2024 at 2:48 PM, Director of Nursing #1 stated the Certified Nurse Aide's documentation included residents' intake and output. They stated meals, fluids, and snacks were to be documented, and that Certified Nurse Aides also had a reporting role and were to tell the assigned nurse when the resident was not eating or drinking as per usual. They stated the assigned nurse was to document a progress note and monitor the resident. If poor oral intake was consistent, then the nurse would let the Registered Nurse know and the physician would be notified. Once the physician was notified the Registered Dietician would get involved. They stated a nutritional assessment would be done and there would be low-fluid monitoring by Nursing and Dietary and weights ordered. They stated the facility transitioned to a new electronic medical record on 8/08/2023. During the interview, they reviewed the care plan for Nutritional Status in the current computer system and stated it was a bare bones care plan and it would have been up to nursing to put in a person-centered care plan with interventions to prevent dehydration and weight loss. They stated Director of Nursing #3, who left the facility around 9/13/2023, was responsible for developing and implementing the care plan. They stated they were not aware of Resident #3's hospitalization on 9/24/2023, until they spoke to the resident's family member at the time of readmission to the facility. They stated the resident had intermittent confusion, was a light eater and did not refuse to eat or drink. They stated the nurse was able to monitor the resident's fluid intake because the Certified Nurse Aide's documentation of fluids was in the computer during the current shift, and it was available to the nurse. They stated travelling agency Certified Nurse Aides would get access to the electronic medical record when they arrived in the facility. They stated they would often forget their password and then they were issued a new one by them. They stated they needed computer access to document and stated no one else was to document for them. During an interview on 1/19/2024 at 3:34 PM, Certified Nurse Aide #7 stated they were a traveler/agency and was familiar with Resident #3. They stated they worked on the resident's unit during the evening shift on 9/18/2023 and 9/20/2023 with Certified Nurse Aide #8. They stated things were very hectic on the unit because the facility was short-handed with facility staff. They stated they were not able to keep track of what the residents ate or drank and there was no time to document anything. They stated Resident #3 usually ate and drank with no problems. They stated if there was a change in what a resident ate or drank, they were to report it to the nurse. They stated they did not have any interaction with the resident's family member. They stated the nurses were working as aides in addition to their regular duties much of the time because there were no Certified Nurse Aides on the unit or not enough. They stated that often there was only 1 nurse to cover both nursing units. They stated that when the facility transitioned to the current electronic medical record system, it was a difficult system to use and some of the traveler/agency Certified Nurse Aides did not have access to the computer system, the system was not operational, or they were locked out of it and would not be able to document. They stated there was a period when the small portable computers were not charged for days because the charger was missing, and they had to bring their own chargers to charge them. They stated the facility was aware of the issues with the new computer system. They stated there was no formal training and were told to figure it out themselves. Cross-reference F656 and F725. 10 New York Codes, Rules and Regulations 415.12(i)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during an abbreviated survey ( NY00324981, NY00325409, NY00327186, NY00327811, and NY00327951), the facility did not ensure that the Facility Assessment was completed and available to determine what resources were necessary to care for its residents. This is evidenced by: Upon entrance on 11/13/2023 at approximately 2:00 PM, the Administrator was asked for the Facility Assessment (a facility-completed document required to establish staffing levels and competencies based on residents' assessed needs). The Administrator provided a binder with words, 'Facility Assessment' written on the front. Record review of the binder revealed it did not include the Facility Assessment. On 11/13/2023 at 4:00 PM, the Administrator stated they had not looked at the Facility Assessment. On 12/08/2023, the Administrator supplied a copy of a Facility assessment dated [DATE] to the New York State Department of Health. Record review of the Facility assessment dated [DATE] identified the minimum staffing requirement (for both nurses and Certified Nurse Aides) that was needed to provide resident care to a daily average census of 39 residents. Record review of facility daily census from 11/13/2023 to 11/15/2023 revealed the average daily census was 55 residents per day. During a subsequent interview on 11/15/2023 at 8:59 AM, the Administrator stated they did not have a completed Facility Assessment but was working on one. They further stated that they started in their position on 10/30/2023 and residents had brought it to their attention the history of no staff at the facility. The Administrator stated they had been working on recruiting staff and had not looked at the Facility Assessment. 10 New York Codes, Rules and Regulations 483.70(e)(1)-(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during abbreviated survey (NY00324981, NY00325409, NY00327186, NY00327811, and NY00327951), the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental and psychosocial well-being for all residents in the facility. Specifically, the facility did not ensure there were sufficient staff to meet resident needs, including activities of daily living, meals, medications, and treatments. In addition, five of the complaints investigated onsite had an allegation of insufficient staff and during Residents' interviews on 11/13/2023 - 11/15/2023, multiple residents stated there were long waits for call lights, showers were not given, medications were late, and there were not enough staff to provide care. This is evidenced by: The facility's staffing policy revised on 11/2023, documented staffing numbers and skills requirements of direct care staff were determined by the needs of the resident's care plan. Resident #3 was admitted to the facility with diagnoses of muscle wasting (loss of muscle) and atrophy (thinning of muscle), moderate protein calorie malnutrition, and vascular dementia (caused when decreased blood flow damages brain tissue). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. Resident #5 was admitted with diagnoses of chronic pain, unspecified abnormalities of gait and mobility, and obesity. The Minimum Data Set (an assessment tool), dated 8/16/2023, documented the resident could understand and be understood by others. Resident required extensive 2 assist with Activities of Daily Living. The Comprehensive Care Plan for Activities of Daily Living dated 9/25/2023 last edited on 11/03/2023 documented Resident #5 required 2 assist and dependent for bathing, 2 assist dependent for toileting, and 2 assist dependent for transfers with mechanical lift. The Treatment Administration Record dated September 2023 documented weekly shower on evening shift every Thursday. The Treatment Administration Record was blank on 9/07/2023, 9/14/2023, 9/21/2023, and 9/28/2023. Upon entrance to the facility on [DATE], there were 56 residents residing on 2 units. There were 38 residents on [NAME] unit and 18 residents on [NAME] unit. During an observation on 11/13/2023 at 12:14 PM, 2 Certified Nurse Aides were observed on the [NAME] unit. During an observation on 11/14/2023 at 9:00 AM, 2 Certified Nurse Aides were observed providing resident care on the unit. The facility's daily staffing schedule dated 11/1/2023-11/15/2023 documented the following: -11/3/2023 Day shift (6 AM - 2:00 PM) - 1 Licensed Practical Nurse and 2 Certified Nurse Aides on [NAME] Unit for 42 residents. 1 Licensed Practical Nurse and 1 Certified Nurse Aide on [NAME] unit for 18 residents. -11/11/2023 Day shift (6 AM - 2:00 PM) - 1 Licensed Practical Nurse and 2 Certified Nurse Aides on [NAME] Unit for 41 residents. 1 Licensed Practical Nurse and 1 Certified Nurse Aide on [NAME] unit for 18 residents. -11/12/2023 Day shift (6 AM - 2:00 PM) - 1 Licensed Practical Nurse and 2 Certified Nurse Aides on [NAME] Unit for 40 residents. -11/12/2023 Evening shift (2:00 PM - 10:00 PM) - 1 Licensed Practical Nurse and 1 Certified Nurse Aide until 6:00 PM on [NAME] unit for 17 residents. 1 Licensed Practical Nurse and 1 Certified Nurse Aide on [NAME] Unit for 40 residents. -11/12/2023 Night shift (10:00 PM - 6:00 AM) -1 Licensed Practical Nurse and 1 Certified Nurse Aide on [NAME] Unit for 40 residents. -11/13/2023 Day shift (6 AM - 2:00 PM) - 1 Licensed Practical Nurse and 2 Certified Nurse Aides on [NAME] Unit for 41 residents. -11/13/2023 Evening shift (2 :00 PM - 10:00 PM) -1 Licensed Practical Nurse and 1 Certified Nurse Aide on [NAME] unit for 41 residents. 1 Licensed Practical Nurse and no Certified Nurse Aide on [NAME] unit for 18 residents. -11/13/2023 Night shift (10:00 PM - 6:00 AM) - 1 Registered Nurse and 1 Certified Nurse Aide for [NAME] unit for 40 residents. During an interview on 11/13/2023 at 11:20 AM, Resident #8 stated they did not receive their shower for 2 weeks. They stated the facility had no staff to provide care to the residents' and medications were given late. Resident #8 stated their room was not cleaned over the weekend and the full garbage can was from 11/11/2023 and 11/12/2023. During an interview on 11/13/2023 at 11:00 AM, Resident #5 stated when they called to use the toilet, they had to wait for about an hour. They stated they sometimes had to ease themselves into the incontinence brief. Resident #5 stated they did not receive shower two weeks ago and no one explained to them why the shower was not given. They further stated they had not been washed on 11/13/2023. Resident #5 stated they did not get washed unless they begged for it. During an interview on 11/13/2023 at 11:55 AM, Resident #12 stated there were not enough staff to help the residents with care. They stated most of the time they had two Certified Nurse Aides for the whole [NAME] unit. The resident further stated there were no housekeepers on the weekend to clean their rooms. During an interview on 11/13/2023 at 12:27 PM, Resident #16 stated 1 Certified Nurse Aide was taking care of 20 residents. They stated it was not right for 1 Certified Nurse Aide to be doing four people's job. They further stated there were always 2 Certified Nurse Aides on the evening shift. During an interview on 11/13/2023 at 4:01 PM, Director of Nursing #1 stated they had been doing audits on residents' care provided by staff. They stated it was brought to their attention that residents were not getting their showers. They stated Resident #11 brought it to their attention that Resident #11 was not receiving their weekly showers. They further stated since they started in September 2023, staffing had always been an issue. During an interview on 11/14/2023 at 8:45 AM, Certified Nurse Aide #3 stated there were 37 residents on the [NAME] Unit with 2 Certified Nurse Aides assigned. They stated Licensed Practical Nurse did not help with resident care. They stated sometimes they could not toilet residents when the residents' requested to be toileted, residents had to wait for 30 minutes - 1 hour before they could be toileted. They stated there were times that they could not finish morning care until lunch time or could not pass out breakfast trays. They further stated resident showers were not given at times because they were busy and could not give residents their showers. During an interview on 11/14/2023 at 9:05 AM, Certified Nurse Aide #4 stated they had been working on the [NAME] unit with 2 Certified Nurse Aides on day shift for 40 residents which typically should be 4 Certified Nurse Aides. They stated the nurses did not help with residents' care, meals, and or feeding residents. They stated they had 5 residents on the [NAME] unit that required assistance with eating which was difficult with 2 Certified Nurse Aides. During an interview on 11/15/2023 at 8:00 AM, Resident #18 stated when they rang the call bell the night of 11/14/2023, no one showed up. They stated when they had to use the toilet it took forever for staff to come. Resident #18 stated the staff had many residents on their list to care for and staff did not have enough time to provide the care. They further stated they required 2 people to assist them to the toilet. During an interview on 11/15/2023 at 8:05 AM, Resident #19 stated there was not enough staff to respond when they needed assistance to the toilet. They stated they missed showers the previous week and was told by staff the facility did not have enough staff. An interview was conducted with the Administrator on 11/15/2023 at 8:59 AM regarding the status and information of a facility-wide assessment, such as what resources the facility had identified to competently care for its residents during day-to-day operations. During the interview, the Administrator stated they did not have a completed Facility Assessment but was working on one. They further stated that they started in their position on 10/30/2023 and residents had brought it to their attention the history of no staff at the facility. The Administrator stated they had been working on recruiting staff and had not looked at the facility's Assessment. They further stated they knew what the staffing looked like and should be. During an interview on 11/15/2023 at 10:23 AM, Licensed Practical Nurse #2 stated medications were given late because the facility went from 2 Licensed Practical Nurses to 1 Licensed Practical Nurse on the [NAME] unit. They further stated they were the only Licensed Practical Nurse administering medications to 37 residents. During an interview on 11/15/2023 at 9:51 AM, Certified Nurse Aide #5 stated they usually worked with 2 Certified Nurse Aides on the [NAME] unit on the day shift for 40 residents. Theystated they had 20 residents to provide care to and there were days that they could not assist residents with their shower due to short staff. They stated residents' have complained to them that they were not properly cleaned by staff. During an interview on 1/08/2024 at 11:04 AM, Licensed Practical Nurse #5 stated staffing was a major problem in the facility. They stated there were 2 nursing units in the facility, McAauley (upstairs) and [NAME] (downstairs). They stated there was usually 40 residents on the [NAME] unit, and the facility staffed 1 Licensed Practical Nurse on the unit daily and was to routinely staff 4 Certified Nurse Aides, but usually had only 2 or 3. They stated they were a somewhat new nurse, and 40 residents was too much for one nurse to provide care to. They stated there were several residents with behavioral issues and it was difficult to manage the behaviors and to provide care to the other residents. They stated the medication pass was always done late. They stated it was impossible to get the medications passed on time, even with having an hour window before and after the medication was due to be given. They stated the [NAME] unit had 18 residents and was staffed daily with 1 Licensed Practical Nurse and either 1 Certified Nurse Aide or none. They stated when there was no Certified Nurse Aide, they had to do everything. They had to perform their regular nursing duties; medication pass and treatments and the Certified Nurse Aide tasks; toileting and passing meal trays. They stated lately the facility had been staffing 1 Licensed Practical Nurse on the night shift to provide care to residents on both units. During an interview on 1/08/2024 at 4:10 PM, Certified Nurse Aide #6 stated the facility was extremely short staffed. They stated the facility currently had only 1 Licensed Practical Nurse and 1 Certified Nurse Aide to provide care to all the residents during the entire night shift, and there were no Registered Nurses in the building. They stated when facility was full, the [NAME] unit had 22 residents and the [NAME] unit had 42. They stated there were approximately 17 residents in the facility that were full code status and required cardiopulmonary resuscitation if they stopped breathing. They stated there was no way possible night shift staff could handle an emergency while providing care to the other residents. They stated at least half of the residents on the [NAME] unit required assistance of 2 staff. They stated they were generally assigned to either unit as needed. They stated the facility routinely staffed 1 Licensed Practical Nurse and 1 Certified Nurse Aide on the [NAME] unit during the day shift. They stated that sometimes there was no Certified Nurse Aide staffed on the [NAME] unit during the day and evening shifts and the Licensed Practical Nurse would have to do both jobs and would have administrative duties as well. On the [NAME] unit, the facility routinely staffed 1 Licensed Practical Nurse, 2 Certified Nurse Aides and 1 Hospitality Aide, and there were generally 40 residents on the unit. They stated the Hospitality Aides could not perform tasks done by the Certified Nurse Aide and essentially could only answered call lights. They stated that when they worked on the [NAME] unit and they were the only Certified Nurse Aide, it would take them almost one hour to pass out the meal trays and then would spend more time to run to the kitchenette to reheat the meals because they were cold. They stated the nurse assigned to the unit would not help to pass the trays. Occasionally, the Activities person would help. They stated it was dangerous during mealtimes on the upstairs unit because residents were not being supervised and the Licensed Practical Nurse was rarely available. They stated there were tasks that were not being done when they worked alone on the upstairs unit, such as not having enough time to brush resident's teeth, not toileting all residents, and weekly bedsheet changes. They stated they had to pick and choose who was more important to toilet. They stated there were several residents that were lying in the same sheets for several days, and only had time to do a full bed change when a resident soiled the bed. They stated they made sure they documented on every resident, every day and when they worked alone it would take them about one and a half hours to document, depending on which unit they worked. During an interview on 1/09/2024 at 2:14 PM, the Staffing Coordinator stated the [NAME] unit should have 1 Licensed Practical Nurse, 4 Certified Nurse Aide on day shift, 1 Licensed Practical Nurse, 3 Certified Nurse Aides on evening shift, and 1 Licensed Practical Nurse and 2 Certified Nurse Aides on night shift. The [NAME] unit should have 1 Licensed Practical Nurse and 1 Certified Nurse Aide on day shift, 1 Licensed Practical Nurse and 1 Certified Nurse Aide on evening shift, and 1 Licensed Practical Nurse and 1 Certified Nurse Aide on night shift. They further stated 5 out of 7 days they could only staff 3 Certified Nurse Aides on day shift for the [NAME] unit. They stated it was hard to find local people to work. During an interview on 1/15/2024 at 3:09 PM, Licensed Practical Nurse #4 stated that sometimes Resident #3's unit did not have an assigned Certified Nurse Aide. They stated there were several times when they were left without an assigned Certified Nurse Aide and had to perform the responsibilities of the Certified Nurse Aide in addition to their nursing responsibilities. They stated they would not have been able to monitor and/or document the amount the of fluids or food the residents had consumed. During an interview on 1/12/2024 at 11:09 AM, Medical Director #1 stated facility staffing was a challenge since the new company took over in July 2023. They stated the switch over was difficult and a bunch of nurses quit as well as kitchen staff. They stated the facility tried to get everybody they possibly could hired but no one wanted to drive to where the facility was located. They stated staffing was still a challenge in September 2023. They stated the facility more recently transitioned from inexperienced nurses to nurses who were capable, but the facility was understaffed. They stated that right now, the Director of Nursing and the Assistant Director of Nursing were running medication carts. They stated the facility tried to hire staff so they could do the double checks that needed to be done. They stated the facility was in the process of hiring Licensed Practical Nurses that used to work there. During an interview on 1/11/2024 at 4:09 PM, Registered Nurse Manager #1 stated they were the acting Assistant Director of Nursing and left the facility at the end of October 2023. They stated they did not have a lot of interaction with Resident #3 and stated they were on a medication cart the entire time they worked in the facility, which was about 3 weeks. They stated that for the most part, they were the only Registered Nurse in the building for much of the time and if the facility was full, there were 60 residents. During an interview on 1/19/2024 at 3:34 PM, Certified Nurse Aide #7 stated they were a traveler/agency and was familiar with Resident #3. They stated they worked on the resident's unit during the evening shift on 9/18/2023 and 9/20/2023 with Certified Nurse Aide #8. They stated things were very hectic on the unit because the facility was short-handed with facility staff. They stated they were not able to keep track of what the residents ate or drank and there was no time to document anything. They stated the nurses were working as aides in addition to their regular duties much of the time because there were no Certified Nurse Aides on the unit or not enough. They stated that often there was only 1 nurse to cover both nursing units. During an interview on 1/19/2024 at 3:46 PM, Certified Nurse Aide #8 stated they were a traveler and was not sure if they worked on the [NAME] or [NAME] nursing unit on 9/18/2023 and 9/20/2023. They stated they usually worked with Certified Nurse Aide #7. They stated that often it was only the 2 of them working on the [NAME] unit that had 50 residents, several with COVID, and there was only 1 nurse in the building. They stated they would not have been able to monitor how much residents were eating/drinking. 10 New York Codes, Rules and Regulations 415.13(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during an abbreviated survey (Case #s NY00324981 and NY00325409), the facility did not ensure that residents were free from any significant medication errors for 3 (Residents #s 3, 4, and 11) for 4 residents reviewed for not receiving their medications in a timely manner per physician orders. This is evidenced by: The facility Policy and Procedure for Medication Administration dated 12/2018, documented all medications should be administered one hour before or after the prescribed time. Medications should be given per facility's policy for times as well as recommended administration times. Medication Administration Records should be signed after administration. Resident #3: Resident #3 was admitted to the facility with diagnoses of atrial fibrillation, hypertension, and heart disease of native coronary artery. The Minimum Data Set, dated [DATE], documented the resident's Brief Interview for Mental Status score was cognitively intact. The Physician Order Report dated 9/01/2023 to 9/30/2023, documented: - 8/29/2023 Losartan 100 milligrams once a day at 6:30 AM. Special instructions: hold for systolic blood pressure less than 100. - 8/07/2023 Metoprolol Succinate tablet extended release 24 hour; 50 milligrams; amount 0.5; once a day at 6:30 AM. Special instructions: half tablet (25 milligrams) by mouth once daily for hypertension. Hold for systolic blood pressure less than 100 or heart rate less than 60. Review of the Medication Administration Record dated 9/01/2023 to 9/30/2023 documented the following: Losartan tablet 100 milligrams, once a day, hold for systolic blood pressure less than 100 at 6:30 AM. -9/01/2023 documented at 7:49 AM by Licensed Practical Nurse #5, not administered due to condition and documented heart rate 104, blood pressure 125/70. Metoprolol Succinate tablet, extended release 24 hours, 50 milligrams, once a day, half tablet 25 milligrams, for hypertension, hold for systolic blood pressure less than 100 or heart rate less than 60 at 6:30 AM -9/02/2023 documented at 3:54 PM by Licensed Practical Nurse #4, not administered other and documented DAYS. Blood pressure was documented as 128/70 and pulse was not documented. During an interview on 1/05/2024 at 3:09 PM, Licensed Practical Nurse #4 stated they worked 2:00 PM to 10:00 PM on 9/02/2023 and would not have administered the Metoprolol because it was scheduled to be administered at 6:30 AM. They stated they documented days and should have documented it was to be given on the dayshift. They stated they were not sure if it was given by the dayshift nurse and stated they would have contacted the physician through the named electronic messaging application to let the physician know. They stated they did not recall who the dayshift nurse was. During an interview on 1/08/2024 at 11:04 AM, Licensed Practical Nurse #5 stated it was probably an error when they did not give the Losartan on 9/01/2023. They stated they usually held it when the vital signs were outside of the parameters on the order. They stated they did not know why they documented due to condition and stated the facility had converted to a new computer system and they were not trained. They stated they were a new nurse, and 40 residents was too much for one nurse to provide care to. Resident #4: Resident #4 admitted with diagnoses of congestive heart failure (when the heart cannot pump enough oxygen-rich blood to meet the body's need, atrial fibrillation (an abnormal heart rhythm characterized by rapid and irregular beating of the atrial chamber), and diabetes type II. The Minimum Data Set (an assessment tool) dated 5/24/2023, documented the resident could be understood and could understand others. Physician order dated 5/27/2020 documented Xarelto (rivaroxaban) tablet 20 milligrams, one tablet by mouth once daily at 8:00 PM for A-FIB. Physician order dated 8/28/2023 documented the following: -Bumetanide tablet 0.5 milligrams, one tablet by mouth once daily for congestive heart failure at 8:00 AM -Digoxin tablet 250 microgram, one tablet by mouth daily for Atrial fibrillation at 08:00 AM -Entresto (sacubitril-valsartan) tablet 24-26 milligram, one half tablet (12-13 milligrams) by mouth twice daily for heart failure at 08:00 AM and 8:00 PM. -Farxiga (dapagliflozin propanediol) tablet, 10 milligrams, one tablet by mouth once daily for diabetes at 8:00 AM. Review of the Medication Administration Records (MAR) dated 10/2023 documented the following: Digoxin tablet 250 microgram (MCG), one tablet by mouth daily for Atrial fibrillation (A-FIB) at 08:00 AM -10/6/2023 documented administered at 12:36 PM and documented administered late, nurse running behind. -10/8/2023 documented administered at 09:56 AM and documented administered late. -10/18/2023 documented administered at 10:25 AM and documented administered late. -10/25/2023 documented administered at 2:39 PM and documented administered late. -10/29/2023 documented administered at 10:19 AM and documented late administration; assisting with care. Review of the Medication Administration Records dated 11/2023 documented the following: Entresto (sacubitril-valsartan) tablet 24-26 milligrams, one half tablet (12-13 milligrams) by mouth twice daily at 8:00 AM and 8:00 PM for heart failure were documented as administered late for the following dates: -11/04/2023 8:00 AM dose was administered at 10:49 AM and staff documented charted late. -1/04/2023 8:00 PM dose was administered at 10:43 PM and documented administered late. 1/09/2023 8:00 AM dose was administered at 11:22 AM and documented charted late. -11/9/2023 8 :00 PM dose was administered at 09:58 PM and documented administered late. -11/11/2023 8:00 PM dose was administered at 11:23 PM and documented administered late. 11/13/2023 8:00 PM dose was administered at 9:59 PM and documented administered late. Farxiga (dapagliflozin propanediol) tablet, 10 milligrams, one tablet by mouth once daily at 8:00 AM for diabetes. -11/02/2023 documented administered at 10:10 AM -11/06/2023 documented medication unavailable -11/09/2023 documented administered at 11:22 AM and charted late. -11/10/2023 documented administered at 10:32 AM. and charted late. Xarelto (rivaroxaban) tablet 20 milligrams, one tablet by mouth once daily at 8:00 PM. -11/04/2023 administered at 10:43 PM and documented administered late. -11/06/2023 administered at 10:28 PM and documented administered late. -11/09/2023 administered at 9:58 PM and documented administered late. -11/11/2023 administered at 11:50 PM and documented administered late. -11/13/2023 administered at 9:59 PM and documented administered late. Resident #11: Resident #11 was admitted with diagnoses of spinal stenosis (narrowing of the spinal canal), intervertebral disc degeneration, and depression. The Minimum Data Set (an assessment tool) dated 10/26/2023, documented the resident could be understood and could understand others. Physician order dated 8/30/2023 documented atenolol 25 milligrams. One tablet (25 milligrams) by mouth once daily Review of the Medication Administration Record dated 10/01-10/31/2023 documented the following: Atenolol 25 milligrams. One tablet (25 milligrams) by mouth once daily at 9:00 AM. -10/06/2023 administered at 11:11 AM and documented administered late, nurse running behind. -10/08/2023 administered at 10:21 AM and documented administered late. -10/19/2023 administered at 2:55 PM and documented late administration: charted late. -10/25/2023 administered at 2:22 PM and documented administered late. -10/27/2023 administered at 10:22 AM and documented and documented charted late. Physician order dated 8/10/2023 documented belbuca buccal film 150 microgram. 150 microgram in the cheek at bed time for chronic pain. Review of the Medication Administration Record dated 10/01-10/31/2023 documented the following: Belbuca buccal film 150 microgram. 150 microgram in the cheek at bed time for chronic pain at 8:00 PM. -10/04/2023 administered at 10:09 PM and documented administered late, Registered Nurse was assisting declining resident on other unit. -10/06/2023 administered at 9:14 PM and documented charted late. -10/11/2023 administered at 9:06 PM and documented late administration: charted late. -10/14/2023 administered at 9:16 PM and documented late administration: charted late. -10/15/2023 administered at 9:11 PM and documented late administration. Review of Medication Administration Record dated 11/1-11/15/2023 documented the following: Belbuca buccal film 150 microgram. 150 microgram in the cheek at bed time for chronic pain at 8:00 PM. -11/5/2023 administered at 9:55 PM and documented administered late. -11/11/2023 administered at 9:55 PM and documented administered late: arrived from pharmacy just now. -11/12/2023 administered at 9:01 PM and documented late administration. -11/13/2023 documented no administered: drug unavailable. Physician order dated 10/6/2023 documented fluoxetine tablet 10 milligrams; 2 tablets. Give 20 milligrams by mouth once a day for depression. Medication Administration Record dated 10/01-10/31/2023 documented the following: fluoxetine tablet 10 milligrams; 2 tablets oral. Give 20 milligrams by mouth once a day. -10/06/2023 administered at 11:11 AM and documented administered late: nurse running behind. -10/08/2023 administered at 10:21 AM and documented administered late -10/25/2023 administered at 2:22 PM and documented administered late. Review of Resident #11' progress notes dated 10/01-11/15/2023 did not have documented evidence that the physician was notified when medications were given late and also when resident did not receive their belbuca 150 milligrams on 11/13/2023. During an interview on 11/13/2023 at 12:49 PM, Resident #11 stated they did not receive their belbuca for 3 days last week because the pharmacy did not have the medication and was not sure if they were going to receive it on 11/13/2023. The resident stated they have been getting their other medications late. During an interview on 11/14/2023 at 11:00 AM, Resident #4 stated they received their 9:00 PM medications at 10:15 PM most of the nights. During an interview on 11/14/2023 at 3:30 PM, Licensed Practical Nurse #1 stated medications should be given one hour before or one hour after the time it was ordered. They stated resident medications were given late due to no staff and they were the only nurse administering medication to 35 residents. Licensed Practical Nurse #1 stated Administration knew that resident medications were given late. They further stated that they sometimes gave scheduled 9:00 PM medications at 11:00 PM. They stated they did not notify the physician that the medications were given late. During an interview on 11/15/2023 at 10:13 AM, Licensed Practical Nurse #2 stated they were the only nurse administering medications to 37 residents and that was why the medications were given late. They stated the physician should be notified when medications were given late and should be documented. During an interview on 11/15/2023 at 9:30 AM, the Director of Nursing stated the facility went from two Licensed Practical Nurses on day shift to one Licensed Practical Nurse. They stated medications were given late due to heavy medication pass with only one nurse. The Director of Nursing stated the physician should be notified and documentation completed when medications were administered late. They further stated residents brought to their attention when they started in September 2023, that they were not receiving their medications on time. The Director of Nursing further stated it was their responsibility and the Assistant Director of Nursing to ensure that the physician was notified when medications were given late. During a subsequent interview on 11/15/2023 at 10:45 AM, the Director of Nursing stated the physician should be notified when a medication was not given. They stated they could not find the documentation that the physician was notified on 11/13/2023 for Resident #11 belbuca 150 micrograms when the medication was not available. During an interview on 1/12/2024 at 11:09 AM, Medical Director #1 stated they did not recall the facility calling about Resident #11's Belbuca on 11/13/2023. They stated they have been called about the resident's Belbuca multiple times and stated the medication was difficult to obtain. They stated they tried to get the resident to take something else and the resident continued to request the Belbuca because it worked for them. They stated for any medication issue, they expected nurses to call them and tell them what happened so they could decide on a plan for the resident regarding their medication. They stated they did not recall being called about any medication issues with Resident #3. They stated it was a challenge back in September for the facility to hire nurses. They stated the facility had some inexperienced nurses who were also not trained on the new computer system. They stated mistakes were made and the medical record was not documented accordingly. They stated some nurses were holding medications for the wrong parameters and were holding blood pressure medications when the heart rate was high instead of holding it when the blood pressure was low. They stated it happened infrequently, but it was happening. They stated they expected nurses to call them and tell them what happened so they could decide on a plan for the resident regarding their medication. They stated they used a named electronic application for sending images when the fax machine was not working because sending through email was not secure. They stated nurses were not to use the application for medication issues, they had to call them per the regulation. 10 New York Codes, Rules and Regulations 415.12(m)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during a recertification survey and abbreviated survey (Case #NY00285055) on 06/14/2022 through 06/17/2022, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #144) of 5 residents reviewed for accidents. Specifically, for Resident #144, who fell 5 (five) times between 9/29/21 and 10/16/2021, the facility did not ensure the reasons for each of the resident's 5 falls were identified and interventions developed and implemented to prevent further falls. Additionally, the facility did not follow their policy for Accident and Incident reporting that documented that the root cause of the incident must be determined, and immediate interventions put in place to decrease or eliminate risk for recurrence. This was evidenced by: The Policy & Procedure (P&P) titled Accident/Incident Reporting dated 01/03/2013 documented to; identify, control, reduce and eliminate unsafe acts/conditions. An Accident and Incident Report Form is initiated at the time of an incident by the Charge Nurse/Supervisor. The root cause of the incident must be determined, and immediate interventions put in place to decrease or eliminate risk for recurrence. All Accident/Incident Reports require the Registered Nurse to update the care plan and [NAME] at the time of Incident with appropriate interventions. Resident #144: Resident #144 was admitted to the facility with the diagnoses of status post right below the knee amputation, diabetes mellitus, and anxiety. The Minimum Data Set (MDS-an assessment tool) dated 10/01/2021, documented the resident's cognition was intact and the resident understood and could understand others. The CNA (Certified Nursing Assistant) [NAME] dated 10/01/2021, documented the following for safety; resident is able to control height of bed, encourage lowest position before sleep. The [NAME] did not include documentation of other interventions for fall prevention. Resident #144's [NAME] (care instructions for staff) had not been updated to include each fall and interventions to prevent falls. The [NAME] did not include fall mats. The comprehensive care plan (CCP) titled I am at risk of fall related to recent right below knee amputation dated 9/25/2021 documented the following interventions; encourage resident to keep bed in lowest position, keep call light and personal items within reach, appropriate footwear, and activities to promote exercise. Resident #144's comprehensive care plan (CCP) did not include additional interventions to prevent falls and/or injury and had not been updated to include each fall and interventions to prevent falls after 09/25/2021. The facility's Fall Reports/Post Fall Assessments for the 5 falls during the period of 9/29/21 through 10/16/2021 documented the following: The Fall Report dated 09/29/2021 at 5:45 PM documented; arrived in resident's room and resident was crying, face down next to his bed. Resident stated that he got dizzy and was weaving back and forth on the bed and just lost his balance and fell over. -Post Fall assessment dated [DATE] at 5:45 PM documented; unobserved, resident cognitively intact. -Fall prevention items in place at the time of incident documented; no interventions in place. -Steps were taken immediately to prevent recurrence and maintain resident safety documented; Resident's neuros, pain and range of motion assessed, and resident placed back in bed. There was no documented intervention to prevent recurrence. The Fall Report dated 10/03/2021 at 07:30 AM documented; resident was lying face down on mattress next to bed crying. Resident stated that he was trying to pee and just fell forward. Resident put self on floor-resident was exhibiting behaviors. When staff walked out he rolled onto the mattress next to the floor. -Post Fall assessment dated [DATE] at 07:30 AM documented; unobserved, resident cognitively intact. -Fall prevention items in place at time of incident documented; fall mat. For what steps were taken immediately to prevent recurrence and maintain resident safety documented; Residents range of motion, neurovitals and pain assessed, and resident assisted back into bed. There was no added documentation of further interventions to prevent recurrence. The Fall Report dated 10/09/2021 at 8:40 PM documented; resident was lying on the floor underneath his bed face down. -Post Fall assessment dated [DATE] at 8:40 PM documented; unobserved, resident cognitively intact. -Fall prevention items in place at time of incident documented; fall mat. -Steps were taken immediately to prevent recurrence and maintain resident safety documented; range of motion, pain and neurovitals were assessed and resident was placed back in bed. There was no documented intervention to prevent recurrence. The Fall Report dated 10/12/2021 at 7:45 AM documented; writer heard a crash, resident was lying face down on the floor and contents of breakfast tray was spread all over the floor. Resident stated that he was leaning over to put his urinal on the floor and the table tipped and he fell over. -Post Fall assessment dated [DATE] at 7:45 AM documented; unobserved, resident had impaired decision making. -Fall prevention items in place at time of incident documented; no fall interventions in place. -Steps were taken immediately to prevent recurrence and maintain resident safety documented; range of motion, pain and neurovitals were assessed and resident was assisted back in bed. There was no further documented intervention to prevent recurrence. The Fall Report dated 10/16/2021 at 5:50 AM documented; resident was laying half on crash mat with legs on the bare floor. Resident was assessed, vital signs obtained, range of motion evaluated. Resident unable to give description. -Post Fall assessment dated [DATE] at 5:50 AM documented; unobserved, resident had impaired decision making. -Fall prevention items in place at time of incident documented; fall mat. -Steps were taken immediately to prevent recurrence and maintain resident safety documented; resident was assessed, range of motion within normal limits, neuros started, lifted to recliner with 2 assist staff. There was no further documentation of interventions to prevent recurrence. Review of the Accident Incident Reports dated 10/9/2022 and 10/16/2022 documented that fall mats were in place at the time of fall, however there is no documentation in the resident record regarding the date this intervention was put in place and fall mats were not documented in the resident's [NAME]. During an interview on 06/16/2022 at 02:16 PM, the Director of Nursing (DON) stated the incident reports should have documented a plan to prevent recurrence. The Incident Reports needed to have more clear and accurate documentation. The care plan should have been updated with each fall and the fall mat should be in the care plan and the CNA [NAME]. During an interview on 06/17/2022 at 9:50 AM, Registered Nurse Manager #1 stated the incident reports need some work with documentation. The care plans were normally updated immediately after a fall, Resident #144 should have had the care plan updated following the falls. During an interview on 06/17/2022 at 10:15 AM, the Administrator stated, we did re-educate staff on incident reports in August 2021. The nurse who initially discovers the incident can place a new intervention, and there is always someone on call for advice. The Interdisciplinary Team (IDT) does review all the incident reports and if they are not completed, they would be sent back to the staff member responsible for completion. When the care plan was updated, there was a button to push to send the interventions to the CNA [NAME]. The care plan and [NAME] should have been updated for Resident #144. The Policy & Procedure was in place for Incident reports and should have been followed. 10NYCRR 415.12(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident that included measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs for 6 (Resident #'s 27, 44, 46, 49, 50 and #249) of 13 residents reviewed for comprehensive care plans. Specifically, for Resident #27, the facility did not ensure a CCP was developed to address the diagnoses of depression, hypertension, heart failure, diabetes and the use of psychotropic medications; for Resident #44, the facility did not ensure a CCP was developed to address dental care; for Resident #46, the facility did not ensure a CCP was developed to address the use of psychotropic medication; for Resident #49, the facility did not ensure a CCP was developed for discharge planning, for Resident #50, the facility did not ensure a CCP was developed to address the resident's cardiac care needs and for Resident #249, the facility did not ensure a CCP was developed to address the resident's progressive dysphonia (disorder of the voice). This is evidenced by: The Policy and Procedure titled Care Plans: Creation and Maintenance of Baseline and Comprehensive Care Plans dated 11/28/18, documented the CCP would be consistent with the resident's rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Resident #27: The resident was admitted to the facility with diagnoses of diabetes, recurrent depressive disorders and hypertension. The Minimum Data Set (MDS - an assessment tool) dated 9/11/19, documented the resident had severely impaired cognition, could understand others and could make self-understood. The MDS documented the resident had the diagnoses diabetes, heart failure, hypertension, and depression. The comprehensive care plan did not include care plans to address the diagnoses of depression, hypertension, heart failure, diabetes and the use of psychotropic medications. During an interview on 11/21/19 at 8:48 AM, Registered Nurse Unit Manager (RNUM) #1 stated they would expect care plans for depression, psychotropic medication use, hypertension, heart failure and diabetes for the resident. Nursing was responsible for those specific care plans and is unsure why the care plans had not been developed and should have been developed by the previous unit manager. RNUM #1 was new to the Unit Manager role. Resident #44: The resident was admitted to the facility with diagnoses of Multiple Sclerosis, adjustment disorder, and hypotension. The MDS dated [DATE], documented the resident had moderately impaired cognition, could understand others and could make self-understood. It documented the resident had obvious or likely cavities or broken natural teeth. The comprehensive care plan did not include a care plan to address the resident's dental care needs. A dental consult dated 5/25/19, documented the dental exam revealed several teeth were roots only. During an interview on 11/21/19 at 8:43 AM, RNUM #1 stated there should be a care plan in place for the resident's dental care needs and nursing would be responsible for initiating that care plan. Typically, RNUM #1 would initiate a dental care plan for all resident's because it prompted staff to perform and monitor oral care. Resident #49: The resident was admitted to the facility with diagnoses of Parkinson's Disease, hypertension, and benign prostatic hyperplasia. The Minimum Data Set, dated [DATE], documented the resident had moderately impaired cognition, could understand others and could make self-understood. It documented there was an active discharge plan in place for the resident to return to the community. The comprehensive care plan did not include a care plan to address discharge planning. During an interview on 11/21/19 at 8:18 AM, Social Worker (SW) #6 stated the Social Work Department would be responsible for the discharge care plan and the resident should have had a discharge care plan in place. SW #6 was not employed at the facility at the time of the resident's admission and discharge. During an interview on 11/21/19 at 8:51 AM, RNUM #1 stated she had never seen a discharge care plan on any of the residents and now that RNUM #1 thought about it, all short-term rehab residents should have a care plan for discharge planning since discharge planning started upon the resident's admission. 10NYRR415.11(c)(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 each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #36) of 1 resident reviewed for accidents. Specifically, for Resident #36, the facility did not ensure a smoking assessment was performed upon the resident's admission or afterwards to determine whether the resident required supervision to smoke, and store matches and lighters. Additionally, the facility did not ensure an individualized care plan for smoking was developed. This is evidenced by: Resident #36: The resident was admitted to the facility with a diagnosis of chronic obstructive pulmonary disorder (COPD), diabetes and heart failure. The Minimum Data Set (MDS - an assessment tool) dated 10/9/19, documented the resident was cognitively intact, could understand others and could make self-understood. The policy and procedure titled Tobacco-Free Environment Policy - Resident/ Patient Smoking, last reviewed 4/2018, documented to provide a safe environment and protect the health of its employees, patients/residents and visitors. All residents will be assessed by their physician via the Smoking Assessment form. Residents who smoke will have an assessment and plan of care. The Activities Evaluation dated 10/23/19, documented that the resident had independent activity and goes out of the building daily to town, or to the gazebo to smoke. A review of the medical record from admission on 12/2018 to 11/20/19, did not include documentation that a smoking assessment was completed. The Comprehensive Care Plan (CCP) did not include a care plan that addressed smoking. The Certified Nursing Assessment (CNA) [NAME] did not include documentation regarding the resident's smoking. During an interview on 11/18/19 at 12:22 PM, the resident stated that facility staff would let the resident in and out of the building to the designated smoking area. The resident stated that cigarettes and lighter are kept on the side pocket of the residents electric wheelchair. During an interview on 11/20/19 at 10:26 AM, Certified Nursing Assistant (CNA) #1 stated the resident has smoked independently since admission and will find staff for entering/exiting the building for smoking. CNA #1 believes the resident stores smoking supplies in the residents coat pocket. The residents smoking interventions should be on the CNA [NAME] since its another fact on how to care for the resident. During an interview on 11/21/19 at 8:16 AM, Registered Nurse Unit Manager (RNUM) #1 stated at admission residents who smoke are offered smoking cessation, if they decline, the facility will deem the resident safe or unsafe to smoke by providing supervision with staff and a registered nurse has to assess the resident while smoking to make sure they can use the lighter, put the cigarette out and if they drop ashes on themselves. The residents smoking interventions or assistance would be documented on the communication log and care plan. The resident independently smokes in the smoking area at the facility or when downtown. RNUM #1 stated they have many residents who wander the unit and wander into other residents' rooms. The resident keeps cigarettes and lighter/matches on self, in own private room where the door is always closed with a yellow strip across the doorway. Residents have not gotten past this. RNUM #1 was not aware that a smoking assessment needed to be completed per the facility policy. There was a different nurse manager when the resident was admitted . During an interview on 11/21/19 at 9:00 AM, the Director of Nursing (DON) stated that someone should have done a smoking assessment and a smoking care plan for the resident at admission. During observations from 11/18/19 to 11/21/19, the resident had appropriate winter attire and was observed being let in and out of the building to the designated smoking area in the courtyard, or via the front door to go downtown. During observation of the resident while in the smoking gazebo, the residents shadow was only visible due to an opaque barrier surrounding all sides/door of the gazebo. 10NYCRR415.12(h)(1)(2)

**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 acceptable parameters of nutritional status were maintained for 1 (Resident #23) of 2 residents reviewed for nutrition. Specifically, for Resident #23, the facility did not ensure the resident's weight was verified when a severe weight loss occurred and did not ensure the resident was consistently provided with finger foods and extensive assistance with eating as needed in accordance with the care plan. This is evidenced by: Resident #23: The resident was admitted to the facility with diagnoses of dementia with behavioral disturbance, adult failure to thrive, and metabolic encephalopathy. The Minimum Data Set (MDS - an assessment tool) dated 9/25/19, documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The comprehensive care plan (CCP) for Nutrition, last revised 11/14/19, documented the goal was for the resident to maintain the weight of 110 lbs. +/-3% and eat at least 50% of meals through next review. The care plan interventions included: 10/7/19 - the resident's diet was regular, soft/ground, with finger foods; and 11/14/19 - provide verbal prompts and provide more extensive assistance as needed. The resident's [NAME] (caregiving instructions) with a print date of 11/20/19, documented the resident's diet was regular, soft/ground, with finger foods and provide verbal prompts and provide more extensive assistance as needed. A physician order dated 3/24/17, documented the resident received a regular diet with a mechanically altered texture; soft/ground texture and no added salt (NAS). Finding #1: The facility did not ensure the resident's weight was verified when a severe weight loss occurred. The Policy and Procedure titled Weight Monitoring last reviewed 5/10/17, documented the Nurse Manager was responsible for ensuring all weights were completed by the Certified Nursing Assistants (CNAs) and the Registered Dietician (RD) was responsible for notifying the Interdisciplinary Team of significant weight changes weekly. The Dietician/Nurse Manager was responsible for determining which residents needed re-weighs within 72 hours if there was a 5 pound or greater weight loss, then the resident must be re-weighed within 72 hours. The weight record documented the following: 10/09/19 - weight = 101.6 pounds (lbs.) 11/06/19 - weight = 93.1 lbs. (-8.5 lbs. and an 8.37% loss = severe weight loss for one month) 11/12/19 - weight = 91.0 lbs. 11/13/19 - weight = 91.2 lbs. The medical record did not include a re-weigh within 72 hours per facility policy for the weight obtained on 11/6/19. The medical record did not include documentation that the 8.37% weight loss was recognized and evaluated by the Interdisciplinary Team. A dietary note dated 11/14/19, documented the resident's weight was down 10 pounds in the past month and was confirmed with a re-weight. The note documented the resident was on weekly weights. During an interview on 11/21/19 at 8:26 AM, Certified Nursing Assistant (CNA) #1 stated the CNAs were responsible for weighing the residents. CNA #1 stated the CNAs received a weight sheet from the RD notifying them which residents needed to be weighed monthly, weekly, or if a resident needed a re-weigh. CNA #1 stated the CNAs would not know to get re-weigh unless the RD communicated it to them. CNA #1 stated it was the CNAs responsibility to follow the weight sheet and to obtain the necessary weights and re-weights. During an interview on 11/21/19 at 9:10 AM, Registered Nurse Unit Manager (RNUM) #1 stated RNUM #1 was not aware Resident #23 had lost weight. RNUM #1 stated the RD would normally communicate weight loss to the unit manager. RNUM #1 stated re-weights were obtained depending on the amount of weight lost and the RD provided a weight sheet to staff. The RD would write and highlight the resident's name on the weight sheet if the resident needed to be re-weighed. RNUM #1 stated a re-weigh should be obtained preferably within 24 hours, or at least within a couple of days, of when the RD informed the staff. RNUM #1 stated the RD would be responsible for overseeing that re-weights were completed timely. During an interview on 11/21/19 at 10:12 AM, RD #7 stated the weight obtained on 11/6/19 required a re-weight and stated there should have been re-weight. RD #7 was not sure why one was not obtained. RD #7 stated the weight loss was recognized on 11/6/19 and the RD was sure a weight sheet was given to the CNA's on the unit informing them that the resident needed to be re-weighed. RD #7 stated Resident #23 must have gotten lost in the shuffle and it was the RD's responsibility to monitor if a re-weight was obtained with 72 hours per facility policy. RD #7 stated it should have been caught that the re-weigh was not done. There were no interventions put in place upon the identified weight loss on 11/6/19 because RD #7 was waiting for the re-weigh to confirm the weight loss before intervening. RD #7 stated it was not until 11/14/19 that a new intervention was implemented for staff to provide extensive assistance as needed to the resident with eating. Finding #2: The facility did not ensure the resident was consistently provided with finger foods and extensive assistance with eating as needed in accordance with the care plan. The Facility Inservice titled Preparing Texture Modified Foods dated 9/15/2018, documented Finger Foods were foods that could be easily picked up and eaten with hands such as French toast sticks and sandwiches. During an observation on 11/18/19 at 12:30 PM, the resident was sitting at a table in the main dining area and was provided with a mechanically altered (ground) chicken on a bun for lunch and strawberry mousse as dessert. Strawberry mousse was not a finger food. It was observed that the resident did not eat or drink during the lunch meal and staff did not provide extensive assistance as needed with the meal. During an observation on 11/20/19 at 12:27 PM, the resident was sitting at a table in the main dining area and the resident was provided with ground chicken tenders and French fries. The ground chicken tenders were not served as a finger food. It was observed that the resident did not eat or drink during the lunch meal and staff did not provide extensive assistance as needed with the meal. The resident's lunch meal tickets dated 11/18/19 and 11/20/19, documented finger food option. The resident's intake record documented: 11/18/19: 0-25% of the lunch meal was consumed. 11/20/19: Resident refused the lunch meal. An Occupational Therapist (OT) note dated 10/7/2019, documented the resident was seen for feeding task and was able to eat a full breakfast with finger foods. The note documented the resident was prompted to use utensils but became agitated upon request and continued to use hands. OT communicated with Dietary regarding success with finger foods. Therapy will revisit utensils if needed in the future, or upon request from resident or staff. A dietary note dated 10/7/19, documented the resident was seen by occupational therapy (OT) for self-feeding. The OT recommendation was for finger foods to promote intake. The resident will be provided finger foods at meals. A dietary note dated 11/14/19, documented the resident was provided finger foods and most often ate independently, but occasionally required extensive assistance. During an interview on 11/21/19 at 8:26 AM, CNA #1 stated the resident sometimes needed assistance with eating and staff determined how much assistance the resident needed because the resident was able to feed self sometimes. CNA #1 stated the resident was assisted as needed or when staff observed the resident was not feeding herself. CNA #1 stated the resident should probably have had assistance at breakfast that morning because the resident appeared tired and was not eating much. CNA #1 did not believe the resident was on a special diet and was not entirely sure if the resident was supposed to receive finger foods. CNA #1 stated any dietary interventions that the CNA's were responsible for would be communicated during shift to shift report and documented on the resident's [NAME]. CNA #1 stated it was expected the CNAs read the [NAME] daily to keep up with changes. During an interview on 11/21/19 at 9:10 AM, RNUM #1 stated the resident sometimes needed assistance for eating and staff would assist the resident if the resident was having a hard time or staff would get the resident started with the meal. RNUM #1 stated staff should assist if it looked like the resident was not eating or struggling to eat. RNUM #1 stated any changes to the resident's plan of care were communicated through shift to shift report and updated on the resident's [NAME]. RNUM #1 stated the CNAs were responsible for implementing any feeding assistance per the [NAME] and there was no system for overseeing or supervising that interventions were consistently being done. RNUM #1 stated the dietary department was responsible for providing the resident with finger foods when they sent her tray from the kitchen. During an interview on 11/21/19 at 10:12 AM, the RD #7 stated the resident received assistance with meals as needed and was to be provided with cueing and more extensive assistance as needed. RD #7 stated the resident was provided with finger foods but was sometimes dependent for feeding. RD #7 stated the CNAs were aware because, both finger foods and instructions to provide extensive assistance with feeding as needed were documented on the resident's [NAME]. RD #7 stated the RD monitored the dietary interventions for effectiveness during official nutrition assessments and in general when observing on the unit. RD #7 stated any member of the management team on the unit could observe the resident eating to ensure the resident's care plan was being followed. RD #7 stated kitchen staff were responsible for plating the food and providing finger foods. RD #7 stated ground chicken tenders were not considered a finger food and the ground chicken tenders should have been put on a roll so that the resident could pick it up to eat. RD #7 stated the finger food option documented on the resident's meal ticket prompted kitchen staff to turn anything they could into a finger food for the resident. The kitchen staff was in-serviced on 10/7/19 on how to adjust meals to accommodate finger foods for the resident. RD #7 stated it would be considered a kitchen error anytime the resident did not receive a finger food. During an interview on 11/21/19 at 11:05 AM, Kitchen [NAME] (KC) #9 stated the resident was to be provided with finger foods. KC #9 stated the finger food option on the resident's lunch meal ticket on 11/20 should have been ground chicken tenders on bread or a bun. KC #9 stated it missed when the ticket was being called out on the tray line. KC #9 plated the food and stated the kitchen aide who was calling out the meal ticket was responsible for checking that the plate was correct after it was plated. KC #9 stated the process was that the kitchen aide (KA) read the ticket; called it out loud to the cook, then the cook plated the food, but the cooks never saw the meal ticket. KC #9 stated it was missed by the KA because the KA was not the usual person on the tray line and was not necessarily familiar with the facility's tray line system. During an interview on 11/21/19 at 11:10 AM, KA #10 stated the finger food option was listed on the resident meal ticket but was not called out to the cook as a finger food. There was confusion because the resident was on ground meat and KA #10 was not sure how a ground chicken tender would be made into a finger food. KA #10 was responsible for ensuring the plate was correct after the cook plated the food and before it got to the unit. KA #10 stated if the plate did leave the kitchen and was not correct, the staff on the unit should have made the kitchen aware so that it could be fixed. During an interview on 11/21/19 at 11:18 AM, CNA #3 stated when the CNAs received the meal trays from the kitchen, the CNAs were responsible for reading the ticket and making sure what was on the plate matched the ticket. CNA #3 stated if there were any inconsistencies, staff would call the kitchen to correct the plate. CNA #3 stated anyone who passed out a meal tray to a resident was responsible for making sure the ticket and the plate matched. 10NYCRR415.12(i)(1)

Based on record review and interviews during the recertification survey, the facility did not ensure residents who require dialysis receive such services, consistent with professional standards of practice. Specifically, for Resident #19, the facility did not ensure the following for a resident who received dialysis: ongoing communication and collaboration with the dialysis facility regarding dialysis care and services and physician orders for the provision of dialysis. This is evidenced by: Resident #19: The resident was admitted to the facility with diagnoses of end stage renal disease (ESRD) with dependence on dialysis, type 2 diabetes, and urinary tract infection. The Minimum Data Set (MDS - an assessment tool) dated 9/24/19 documented the resident had severely impaired cognition, could understand others and could make self understood. The P&P titled Care of the Long Term Care Resident receiving Renal Dialysis dated 6/28/18, documented communication of the resident's health status would be documented on the Hemodialysis communication form, and nursing staff would sign off on both ends of the dialysis receiving and sending process. The comprehensive care plan (CCP) for Hemodialysis, last updated 10/4/19, documented the resident was to receive transport to dialysis at 7:30 AM and received dialysis x days per week. The physician orders dated 11/20/19, did not include orders for the provision of the dialysis treatments, including the number of treatments per week, length of treatment time, the type of dialyzer, and specific parameters of the dialysis delivery system (e.g., electrolyte composition of the dialysate, blood flow rate, and dialysate flow rate), and the resident's target weight. During an interview on 11/20/19 at 10:22 AM, RN #3 stated the dialysis center staff transported the resident back to the unit on the days he/she received dialysis, and provided a verbal report and the communication sheet. RN #3 stated the communication sheets are kept in the resident's dialysis communication book, and he/she does not review them. During an interview on 11/20/19 at 10:23 AM, Unit Secretary #5 stated he/she was not responsible for filing the communication sheets in the resident's dialysis communication book. Unit secretary #5 stated the communication and any documentation is provided directly to the nurse. During an interview on 11/21/19 at 9:56 AM, the Director of Nursing (DON) stated the nurse should review the dialysis communication book and there is no oversight to ensure the communication sheets are reviewed. The DON stated verbal communication did occur between the dialysis center staff and the nurse. The DON stated he/she did not know if the physician order included the information as indicated in the regulation. 10NYCRR415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and observations during a recertification survey the facility did ensure residents who used psychotropic drugs received gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, the physician approved pharmacy recommendations were acted upon to ensure prescribed antipsychotic medications were administered at the lowest possible dosage. This is evidenced by: The Policy and Procedure (P&P) titled Gradual Dose Reductions (GDR's) in Nursing Homes dated 5/2018 documented the facility would attempt GDR's for psychotropic medications (including antipsychotic and antidepressant drugs) unless clinically contraindicated. Additionally, the P&P documented the GDR may be clinically contraindicated if the residents target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician documented the clinical rationale for why any additional attempted dose reduction to the time would be likely to impair the resident's function or increase distressed behavior. Resident #33 The resident was admitted to the facility with diagnoses of dementia, anxiety disorder, and adult failure to thrive. The Minimum Data Set (MDS - an assessment tool) dated 10/2/19 documented the resident had moderately impaired cognition, could understand others and could make self understood. The CCP for Antipsychotic use, last updated 10/28/19 documented staff were to consult with physician/pharmacist to consider dosage reduction when clinically appropriate. The physician orders documented the following: - the resident received Risperdal 0.5 milligrams (mg) 2/13/17 - 6/13/19 - the resident received Risperdal 0.25mg starting on 6/3/19 - present The medication regimen reviews documented the following: - On 1/24/19, the pharmacy recommendation was to monitor and document appropriateness of GDRs per regulation, and the undated physician follow through documented attempt GDR for Risperdal. - On 2/21/19, the pharmacy recommendation was to monitor and document appropriateness of GDRs per regulation, and the undated physician follow through documented attempt GDR for Risperdal. - On 4/25/19, the pharmacy recommendation was to document an approved diagnosis for use of Risperdal, and the physician response dated 5/30/19 documented to change the diagnosis to delusions, and to attempt GDR. The medical record did not include documentation of the physician requested GDR requests (1/24/19, 2/21/19, and 4/15/19) prior to 6/3/19. Resident #47 The resident was admitted to the facility with diagnoses of dementia, psychosis, and obsessive-compulsive disorder (OCD) behavior. The MDS dated [DATE] documented the resident had severely impaired cognition, could understand others and could make self understood. The CCP for Antipsychotic medications, last updated 10/30/19 documented the resident was to receive medications as ordered, and staff were to consult with physician/pharmacist to consider dose reduction when clinically appropriate. The physician orders documented the following: - the resident received Risperdal 0.25 milligrams (mg) twice daily starting on 8/1/18 to present - the resident received Zoloft 100mg 6/5/18 - 6/6/19 - the resident received Zoloft 50mg 6/6/19 - 6/12/19 - the resident received Zoloft 100mg starting on 6/12/19 - present The medication regimen reviews documented the following: - On 1/24/19, the pharmacy recommendation was to monitor and document appropriateness of GDRs per regulation, and the undated physician follow through documented to decrease Risperdal if appropriate. - On 2/21/19, the pharmacy recommendation was to monitor and document appropriateness of GDRs per regulation, and the undated physician follow through documented to decrease dose of sertraline and monitor for symptoms. - On 4/25/19, the pharmacy recommendation was to monitor and document appropriateness of GDRs per regulation, and the undated physician follow through documented attempt sertraline GDR. The medical record did not include documentation of the physician requested GDR requests (1/24/19, 2/21/19, and 4/25/19) prior to 6/6/19. During an interview on 11/20/19 at 2:03 PM, the Director of Nursing stated she had not had a role in reviewing the pharmacist's recommendation sheets since she started in her role as Director of Nursing and was unsure who was responsible for the pharmacy reviews before. During an interview on 11/20/19 at 2:18 PM, LPN #1 stated he/she started working in the facility on 4/29/19. LPN #1 stated her current job responsibilities include receiving the recommendations via email from the pharmacist, printing them, and handing them to the physician. LPN #1 stated there is not a specific time frame for the physician to address the recommendations that he/she was aware of. During a phone interview on 11/21/19 at 10:31 AM, the Pharmacist stated he/she started consulting at the facility in 2019, which is why the pharmacy recommendations in January had her signature. The Pharmacist stated she sent her monthly recommendations to the facility (Director of Nursing) via email and uses software to track the completion for reviews. The Pharmacist stated she was aware the recommendations were not being completed and made the facility aware in the QA meetings. The Pharmacist stated he/she made recommendations to the facility for GDR compliance in June 2019 and spoke with the Director of Nursing last month about recommendations that were not completed. During an interview on 11/21/19 at 11:00 AM, the Medical Director stated he/she was not aware of a problem with receiving the pharmacy recommendations in a timely manner. The Medical Director stated the nursing staff are helping out, and recommendations may be addressed at the next physician review. The Medical Director stated there needed to be more consistency in the process for addressing pharmacy recommendations, and he takes responsibility for not rushing to complete the dose reductions. 10NYCRR415.12(1)(2)(i)

**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 the Facility Assessment was reviewed and updated, as necessary, and at least annually. Specifically, the facility did not ensure the facility assessment included an updated evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff was available to meet each resident's needs. This is evidenced by: The Facility Assessment Tool, last reviewed 9/3/19, documented under Staffing Plan Section 3.2 to refer to the Facility (named) Nursing Staff Plan Policy and Procedure (P&P) for the nursing and direct care staffing plan. The P&P titled Facility (named) Nursing Staff Plan, last revised in Fall 2017, documented when the facility had a census of 52 or 53 residents, the staffing plan would be 4 licensed staff and 6 Certified Nursing Assistants (CNAs) on the day shift, 4 licensed staff and 6 CNAs on the evening shift and 2 licensed staff and 4 CNAs on the night shift. Upon entrance to the facility on [DATE], the facility census was 52 residents. The facility census on 11/19/19 and 11/20/19 was 53 residents. The daily staffing sheets did not meet the staffing plan documented in the Facility Assessment from 11/18/19 - 11/20/19. The Daily Staffing Sheet dated 11/18/19, documented the facility had 3 licensed staff and 4.5 Certified Nursing Assistants (CNAs) on day shift, 3 licensed staff and 4 CNAs on evening shift and 2 licensed staff and 3 CNAs on night shift. The Daily Staffing Sheet dated 11/19/19, documented the facility had 3 licensed staff and 5 Certified Nursing Assistants (CNAs) on day shift, 3 licensed staff and 4 CNAs (and 2 CNAs worked a half shift) on evening shift and 2 licensed staff and 2.5 CNAs on night shift. The Daily Staffing Sheet dated 11/20/19, documented the facility had 3 licensed staff and 5 Certified Nursing Assistants (CNAs) on day shift, 3 licensed staff and 6 CNAs on evening shift and 2 licensed staff and 3 CNAs on night shift. During an interview on 11/21/19 at 9:33 AM, the Administrator stated the staffing plan may not have been updated and that was the reason the actual staffing numbers did not meet the facility assessment staffing plan. The Administrator stated the staffing plan policy needed to be updated in the Facility Assessment. The Administrator stated the staffing plan should be updated with any staffing changes whether staffing needs to be increased or decreased.

**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 medical records were maintained in accordance with acceptable standards of practice for 3 (Resident #'s 13, 15 and #50) of 13 residents reviewed. Specifically; for Resident #13, the facility did not ensure the resident's medical record included ongoing documentation regardng the status of the resident's stage 2 pressure ulcer, for Resident #15, the facility did not ensure elopement risk assessments were completed quarterly and for Resident #50, the facility did not ensure the medical record included documentation of physician notification when the resident's blood pressure and/or heart rate were below physician ordered parameters. This is evidenced by; Resident #13: The resident was admitted to the facility with a diagnosis of chronic kidney disease, dementia, and anemia. The Minimum Data Set (MDS - an assessment tool) dated 9/5/19, documented the resident had severely impaired cognition, could understand others and could make self-understood. The MDS documented the resident had a Stage 2 (skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) pressure ulcer (PU). The Policy and Procedure (P&P) titled Pressure Ulcers: Staging, Preventions and Interventions dated 5/19/18, documented all pressure areas will be measured weekly and staged accordingly to the accompanying guidelines documented on the resident's skin flow sheet. Wound rounds will be conducted weekly to assess, measure and recommend change if needed by the nurse manager. The comprehensive care plan titled At Risk for PU related to restricted mobility and I currently have a Stage 2 PU coccyx dated 6/4/19, and revised on 9/4/19, documented to monitor pressure areas for color, sensation, temperature. Monitor/document wound size, depth, margins, peri wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene, document progress in wound healing on an ongoing basis. Administer treatments as prescribed and monitor/document effectiveness. A physician's order dated 9/4/19 documented; Stage 2 PU skin treatment to coccyx in the morning every 3 days for stage 2 PU, protocol cleanse two open areas with wound cleaner and apply Hydrogel (a gel used for absorption) to wound bed only and cover with Optifoam (adhesive foam wound dressings). A review of the medical record documented that the resident's last wound evaluation was on 9/27/19. It did not include documentation that the resident's wound had been evaluated from 9/27/19 through 11/20/19. A review of the Treatment Administration Record (TAR) dated 10/1/19 to 11/20/19, documented the Stage 2 PU skin treatment to coccyx every 3 days was performed for 14 of the 17 opportunities during this time frame. A review of the nursing notes from 10/3/19 to 11/20/19 did not include documentation of wound monitoring/assessment, or measurements when the dressing was changed. During an on 11/21/19 at 8:27 AM, Registered Nurse Unit Manger (RNUM) #1 stated skin rounds have not been done this month. The RNUM stated the last one was on 10/2019 because the RNUM was providing care on the units. RNUM stated the residents wound is healed based on the 9/27/19 wound evaluation. RNUM #1 reviewed the resident's medical record and could not find further documentation regarding the resident's wound other than that dressing changes were performed. During an interview on 11/21/19 at 9:04 AM, the Director of Nursing stated the Licensed Practical Nurse checks the skin and would notify the Registered Nurse as needed when dressings are changed. The resident has weekly skin checks during his shower and staff would notify the RN as needed for skin changes. The resident's sacrum wound is a closed, healing stage 2 PU. The medical record does not include documentation of an assessment of the wound since the last wound evaluation on 9/27/19. Weekly wounds rounds are not as regular as they should be. Resident #15: The resident was admitted to the facility with diagnoses of dementia with behavioral disturbance, anxiety disorder, and osteoporosis. The MDS dated [DATE], documented the resident had severe cognitive impairment, could rarely/never understand others and could rarely/never make self understood. The Policy and Procedure titled Elopement Prevention last revised 6/21/18, documented each resident shall be assessed for elopement risk by the Unit Nurse Manager or Registered Nurse (RN) designee within 24 hours of admission to facility and quarterly thereafter and upon indication or incident of elopement utilizing the Elopement Risk Assessment under the assessment tab in the electronic medical record system. The comprehensive care plan for elopement risk, last revised 1/7/19, documented the resident had actual elopement incidents on 8/21/18 and 12/8/18 and has a Roam Alert Bracelet. An elopement risk assessment dated [DATE], documented the resident was at high risk for elopement. The medical record did not include subsequent elopement risk assessments. During an interview on 11/21/19 at 8:53 AM, RNUM #1 stated elopement risk assessments were completed quarterly. RNUM #1 stated the resident should have an assessment completed quarterly. The resident was still at risk for elopement and continued 15-minute checks. RNUM #1 did not know why the elopement risk assessment had not been completed quarterly and that it was probably just missed. Resident #50: The resident was admitted to the facility with diagnoses of hypertension, coronary atherosclerosis, and dementia with behavioral disturbance. The MDS dated [DATE], documented the resident had severely impaired cognition, could understand others and could make self understood. The comprehensive care plan did not include a care plan to address the resident's cardiac care needs. A physician order dated 6/17/19, documented to check blood pressure (BP) and heart rate (HR) 3 times a day for monitoring; obtain manual BP; and to notify the Medical Doctor (MD) if the BP was less than 90/60 and/or HR was less than 50. A review of the August 2019 Medication Administration Record documented: 8/03/19 - BP 80/46 on the evening shift 8/11/19 - BP 86/55 on day shift 8/11/19 - BP 86/56 on evening shift 8/17/19 - BP 86/55 on day shift 8/17/19 - BP 87/56 on evening shift 8/18/19- BP 89/58 on evening shift 8/19/19- BP 70/40 and HR 46 on day shift 8/19/19- BP 86/51 on evening shift 8/21/19- BP 72/38 on evening shift 8/27/19- BP 77/50 on evening shift 8/29/19- BP 83/48 on day shift The medical record did not include corresponding documentation that the MD was notified when the BP was less than 90/60 and/or HR was less than 50. During an interview on 11/21/19 at 9:01 AM, RNUM #1 stated the resident had issues with his blood pressures and that the MD should have been notified when the BP or HR was outside the ordered parameters. RNUM #1 stated the doctor is typically notified using an app on the phone as that was MD's preferred method of being notified. RNUM #1 stated the RN's were good at notifying the MD using the phone app. RNUM #1 believed the doctor was notified when the resident's BP and/or HR was low, but that the nurses were not documenting the MD notification in the medical record and they should be. RNUM #1 stated the staff were following the physician order but that the documentation was the issue. During an interview on 11/21/19 at 11:24 AM, the MD stated the MD was typically notified when there was an order to notify him. The MD was notified using an app on the phone, but the MD would also expect there to be documentation in the medical record that the BP and/or HR was low, and that the MD was notified. 10NYCRR 415.22(a) (1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping services. Specifically, floors were not clean on 2 of 2 resident units. This is evidenced as follows. Observations of the resident units on 11/21/2019 at 9:15 AM, revealed that the floors were not clean in the [NAME] resident unit hallways and in resident rooms #'s 107, 117, 122, 123, 124, 206, 210, and #216. The Environmental Services Manager stated in an interview on 11/21/2019 at 9:45 AM, that the floors should have been kept clean, and will ensure that the floors are cleaned. 483.10(i)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during a recertification survey, the facility did not provide the resident and their representative with a written summary of the baseline care plan for 10 (Resident #'s 6, 13, 19, 27, 36, 44, 46, 50, 51 and #249) of 10 residents reviewed. Specifically, for Resident #'s 6, 13, 19, 27, 36, 44, 46, 50, 51 and #249, the facility did not ensure a written summary of the baseline care was provided to the residents and resident representatives. This is evidenced by; The policy and procedure titled Care Plans: Creation and Maintenance of Baseline and Comprehensive Care Plans dated 11/28/18, documented the facility must provide the resident and their representative with a summary of the baseline care plan. Resident #6: The resident was admitted to the facility with a diagnosis of diabetes, Multiple Sclerosis and hypertension. The Minimum Data Set (MDS - an assessment tool) dated 8/14/19, documented the resident had moderately impaired cognition, could understand others and could make self-understood. The medical record did not include documentation that a written summary of the baseline care was provided to the resident and resident representative. Resident #13: The resident was admitted to the facility with a diagnosis of chronic kidney disease, dementia, and anemia. The Minimum Data Set, dated [DATE], documented the resident had severely impaired cognition, could understand others and could make self-understood. The medical record did not include documentation that a written summary of the baseline care was provided to the resident and resident representative. Resident #27: The resident was admitted to the facility with diagnoses of diabetes, recurrent depressive disorders and hypertension. The Minimum Data Set, dated [DATE], documented the resident had severely impaired cognition, could understand others and could make self-understood. The MDS documented the resident had the diagnoses diabetes, heart failure, hypertension, and depression. The medical record did not include documentation that a written summary of the baseline care was provided to the resident and the resident representative. Interviews: During an interview on 11/19/19 at 3:05 PM, Registered Nurse Unit Manager RNUM #1 stated they had admitted new residents to the facility, initiated the resident's care plan, but had not provided a summary of the baseline care plan to the resident or resident representative within 48 hours. During an interview on 11/19/19 at 3:27 PM, RNUM #1 stated care plans were reviewed during family care plan meetings. RNUM #1 stated that they did not provide a summary to the resident or resident representative at that time. During an interview on 11/20/19 at 9:00 AM, the Director of Nursing stated they develop the baseline care plan when the resident is admitted . The facility cannot provide documentation that summaries of baseline care plans were provided to the resident's and their representatives. 10NYCRR415.11

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 timeframes for the different steps in the process. Specifically, the facility did not ensure there were timeframes established documented in the policy for steps in the MRR process concerning actions the pharmacist and facility needed to take when an irregularity was identified. This is evidenced by: The Policy and Procedure titled Medication Regimen Review dated 6/3/19, documented resident-specific irregularities and/or clinically significant risks resulting from or associated with medications were documented in the resident's active record and reported to the Director of Nursing (DON), Medical Director, and/or prescriber as appropriate. Notification mode was dependent on severity of the irregularity and was determined through consultation between the consultant pharmacist and the DON. During an interview on 11/21/19 at 12:44 PM, the DON stated the pharmacist notified the facility immediately when a irregularity was identified. The DON reviewed the facility's MRR policy. The DON was not aware timeframes needed to be established for the different steps in the MRR process. 10NYCRR415.18(c)(2)

Based on record review and interview, the facility did not ensure menus met the nutritional needs of the residents in accordance with national guidelines and were reviewed by the facility's dietitian for nutritional adequacy. Specifically, the facility did not ensure menus met basic nutritional needs by providing enough fruits and vegetables based established national guidelines, and that menus were reviewed and revised as needed to ensure nutritional adequacy after changes were made to the menu. This is evidenced by: The 2015-2020 Dietary Guidelines for Americans documented the recommended amounts of food on a 2,000 calorie diet: - 2 1/2 cups of vegetables per day - 2 cups of fruit per day - 6 ounces of grains per day - 3 cups of dairy per day - 5 1/2 ounces of protein per day A review of the facility menu documented the following: - 1 1/2 cups of vegetables or less served per day on 4 of 7 days - 1 cup of fruit or less served per day on 7 of 7 days During an interview on 11/20/19 at 12:51 PM, the Registered Dietitian (RD) stated the United States Department of Agriculture (USDA) nutrition guidelines were used to determine the nutritional adequacy of the menu, and the facility did not have a diet manual. The RD stated the facility used the 2,000 calorie USDA meal pattern as a guide for the menus, and the current menu does not include 2 cups of fruit per day, and the residents do not consistently receive 2 1/2 cups of vegetable daily. During a subsequent interview on 11/21/19 at 8:30 AM, the RD stated she had not reviewed the current menu for nutritional adequacy. The RD stated the menu was reviewed a year and a half ago, and since then, the menu changed as items were taken off due to plate waste, and these items were not replaced. The RD stated the menu was not reviewed again after the changes to ensure nutritional adequacy. 10NYRR415.14(c)(1-3)