Based on record review and interview during the abbreviated (NY00329596) survey the facility did not consult with the resident's physician and notify the resident representative when there was a need to alter treatment significantly for 1 of 1 resident (Resident #1) reviewed. Specially, Resident #1 was not administered twenty doses of their physician ordered antipsychotic medication and there was no documented evidence the physician or the resident representative was notified. Findings include: The facility policy, Notifying the Provider, revised 10/2013, documented the resident's physician would be updated with any changes in a resident that may affect significant change status. The facility policy, Unavailable Medications revised 8/2020 documented the facility must make every effort to ensure medications are available to meet the needs of each resident. Nursing staff should notify the attending physician (or on-call if applicable) of the situation, explain the circumstances, expected availability, and alternative therapies available. If the facility nurse was unable to reach the attending physician or the on-call physician, then the nurse should notify the Nursing Supervisor and contact the Facility Medical Director for orders and/or direction. Resident #1 had diagnoses including orthopedic care following open reduction with internal fixation (surgical repair of a fracture) of the right ankle, anxiety, and schizo-affective disorder. The 10/23/2023 Minimum Data Set assessment documented the resident had intact cognition, had no behaviors, and felt socially isolated at times. The Comprehensive Care Plan initiated 10/30/2023 documented the resident was prescribed an anti-psychotic medication for schizoaffective disorder. Interventions included discuss with physician/family/resident the need for continued use of the medication; review behaviors/interventions and alternate therapies attempted and their effectiveness; licensed nurse to administer medication per physician's order; monitor for side effects and adverse reactions to medication and report to medical provider. The 10/17/2023 physician order documented olanzapine (an anti-psychotic medication) 10 milligram tablets, one tablet by oral route once daily between 6:00 PM and 10:00 PM for schizo-affective disorder. The 11/2023 Medication Administration Record documented olanzapine was not given/unavailable from 11/18/2023-11/26/2023, 11/28/2023, and 11/30/2023. The 11/13/2023 pharmacy received manifest documented Resident #1's 30-day supply of olanzapine 10 milligrams tablets was delivered and signed for by Licensed Practical Nurse #7. The 11/17/2023 progress note by Nurse Practitioner #5 documented the resident was seen for a routine visit and their medications were reviewed and updated. The resident's mood was stable per the resident. The plan was to continue their anti-psychotic medications. There was no documentation Nurse Practitioner #5 was aware the resident's anti-psychotic medication was unavailable. The 12/2023 Medication Administration Record documented olanzapine was not given/unavailable from 12/1/2023-12/9/2023. The 12/1/2023 Pharmacy returned medications log documented Resident #1 had a blister pack of 30 olanzapine 10 milligrams tablets returned to the pharmacy. The 12/7/2023 Physician #8 progress note documented Resident #1 was seen for an acute visit for a headache. Physician #8 documented the resident's review of systems included schizoaffective disorder and olanzapine was in their medication list on 10/23/2023. There was no documentation the resident's anti-psychotic medication was unavailable. There were no documented nursing notes referencing Resident #1's missed doses of olanzapine or that the provider and resident representative were notified of the missed doses. There was no documentation why the resident's olanzapine was returned to the pharmacy. During an interview on 10/17/2024 at 10:55 AM, Nurse Practitioner #5 stated Resident #1 was admitted to the facility on olanzapine. They stated they were not notified when the resident's olanzapine became unavailable. They expected the nursing staff to notify them, and they would have seen the resident if they were notified. During an interview on 10/17/2024 at 12:45 PM, the resident's representative stated they were Resident #1's health care proxy and visited the resident almost daily when the resident was at the facility. They stated they were not notified the resident had missed doses of their medicine. They stated the resident had previous episodes of being hospitalized when their olanzapine was missed at home. The only notification they received was the resident complaining to them that they were having trouble sleeping. Approximately a week later, the resident phoned them to tell them they were not receiving their medication and thought that was the reason for their insomnia. During an interview on 10/18/2024 at 9:03 AM the Director of Nursing stated they were not aware of the missing medication; it was unacceptable, and nursing should have notified the nursing supervisor or the provider. During an interview on 10/18/2024 at 11:10 AM, Physician #8 stated Resident #1 had diagnoses of schizophrenia and schizoaffective disorder. They reviewed their medical notes and were not aware Resident #8 had missed their anti-psychotic medications for 20 doses. Physician #8 stated they expected nursing to notify them, and it would have changed their treatment plan if they had been notified. They would have visited the resident and prescribed them an alternate medication if olanzapine was not available. 10 NYCRR 415.3(2)(ii)(a)

Based on record review and interview during the abbreviated survey (NY00329596) the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #1) reviewed. Specially, Resident #1 was not administered twenty doses of their physician ordered anti-psychotic medication. Findings include: The facility policy, Notifying the Provider, revised 10/2013 documented the resident's physician would be updated with any changes in a resident that may affect significant change status. The facility policy, Unavailable Medications, revised 8/2020, documented the facility must make every effort to ensure medications were available to meet the needs of each resident. Nursing staff should notify the attending physician (or on-call if applicable) of the situation, explain the circumstances, expected availability, and alternative therapies available. If the facility nurse was unable to reach the attending physician or the on-call physician, then the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. The facility policy, Returning Medications to the Pharmacy, revised 8/2020, documented medications other than controlled substances may be returned to the pharmacy if the medication was in a sealed package or container; a copy of the medication disposition form was kept with the medications to be returned until pharmacy picked them up; completed disposition forms were kept by the facility for two years or according to applicable law and regulation. Resident #1 had diagnoses including orthopedic care following open reduction with internal fixation (surgical repair of a fracture) of the right ankle, anxiety, and schizo-affective disorder. The 10/23/2023 Minimum Data Set assessment documented the resident had intact cognition, had no behaviors, and felt socially isolated at times. The Comprehensive Care Plan initiated 10/30/2023 documented the resident was prescribed anti-psychotic medication for schizoaffective disorder. Interventions included discuss with physician/family/resident the need for continued use of medication; review behaviors/interventions and alternate therapies attempted and their effectiveness; licensed nurse to administer medication per physician's order; monitor for side effects and adverse reactions to medication and report to medical provider. The 10/17/2023 physician order documented olanzapine (an anti-psychotic medication) 10 milligram tablets, one tablet by oral route once daily between 6:00 PM and 10:00 PM for schizo-affective disorder. The 11/13/2023 pharmacy received manifest documented Resident #1's 30-day supply of olanzapine 10 milligram tablets was delivered and signed for by Licensed Practical Nurse #7. The 11/2023 Medication Administration Record documented olanzapine was not given/unavailable from 11/18/2023-11/26/2023, 11/28/2023, and 11/30/2023. There were no nursing notes documenting Resident #1's missing medication or that a provider was notified. The 11/17/2023 progress note by Nurse Practitioner #5 documented the resident was seen for a routine visit and their medications were reviewed and updated. The resident's mood was stable per the resident and the plan was to continue their anti-psychotic medications. There was no documentation the resident's anti-psychotic medication was unavailable. The 12/1/2023 Pharmacy returned medications log documented Resident #1 had a blister pack of 30 Olanzapine 10 milligram tablets returned to the pharmacy. There were no nursing progress notes documenting why the olanzapine was returned to the pharmacy. The 12/2023 Medication Administration Record documented olanzapine was not given/unavailable from 12/1/2023-12/9/2023. The 12/7/2023 Physician #8 progress note documented Resident #1 was seen for an acute visit for a headache. Physician #8 documented the resident's review of systems included schizoaffective disorder and olanzapine was in their medication list on 10/23/2023. There was no documentation the resident's anti-psychotic medication was unavailable. During an interview on 10/15/2024 at 9:00AM, Licensed Pharmacist #5 stated olanzapine was an anti-psychotic medication administered for residents with schizophrenia, schizoaffective disorders, and depressive disorders and should not be stopped abruptly. They stated the pharmacy received Resident #1's olanzapine 10 milligrams tablets, quantity of 30, as a return and processed it on 12/1/2023. They could not determine who sent the medication back or the reason why it was returned. During an interview on 10/17/2024 at 10:55 AM, Nurse Practitioner #5 stated Resident #1 was admitted to the facility on olanzapine. Their role was to review all the resident's medications upon admission and approve them. They stated they were not notified when the resident's olanzapine became unavailable. They expected the nursing staff to notify them, and they would have visited the resident. During an interview on 10/17/2023 at 11:54 AM, Registered Nurse #4 stated they no longer worked for the facility and could not recall Resident #1 or any missing medications. They stated when they worked at the facility, they passed medications and if a medication was unavailable, they would notify the nursing supervisor and document a note in the resident's electronic medical record. They thought the supervisor was responsible for ordering medications if they were not available in the emergency medication dispensing machine. On 10/17/2024 at 1:05 PM, a phone call was placed to Licensed Practical Nurse #7 and they did not return the call for an interview. During an interview on 10/17/2024 at 1:44 PM Physician #8 stated olanzapine was prescribed for residents with schizophrenia, hallucinations, and psychosis. The purpose of the medication was to suppress the symptoms. If a resident missed doses, those symptoms could return. If a resident received a small dose of 2-2.5 milligrams, the medication could be stopped abruptly but larger doses of 10-20 milligrams should be tapered down over 2-4 days. During an interview on 10/18/2024 at 9:03 AM, the Director of Nursing stated the facility's medication order policy started with the admission nurse and provider. All medications would be reviewed and then ordered from the pharmacy. Most medications were packaged in blister packs with 30 pills except for stock medications that come in bottles. They stated when a resident only had one weeks' worth of medication left, they expected nurses to order it. The Director of Nursing reviewed Resident #1's Medication Administration Record and stated the resident did not receive olanzapine from 11/18/2023-11/26/2023,11/28/2023, 11/20/2023 and 12/1/2023-12/9/2023. They stated they were not aware of the missing medication; it was unacceptable, and nursing should have notified the nursing supervisor or the provider. The Director of Nursing stated the resident's medication was returned to the pharmacy, but the facility had no system to track who sent it back or why. They stated the pharmacy logged return medications in for the facility, but they did not keep records. During a follow-up interview on 10/18/2024 at 11:10 AM, Physician #8 stated Resident #1 had diagnoses of schizophrenia/schizoaffective disorder. They reviewed their medical notes and was not aware Resident #8 had missed their anti-psychotic medications for 20 doses. Physician #8 stated they expected nursing to notify them, and they would have changed their treatment plan if they had been notified. They would have visited the resident and prescribed an alternate medication if olanzapine was not available. Physician #8 stated the resident could have had symptoms of hallucination or psychosis return from not taking the medications. 10 NYCRR 415.12

Based on observation, record review, and interview during the recertification and abbreviated (NY00323929 and NY00339707) surveys conducted 7/22/2024-7/26/2024, the facility did not ensure residents were treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of quality of life for 1 of 1 resident (Resident #71) reviewed. Specifically Resident #71's urinary catheter drainage bag was uncovered and visible to other residents, visitors, and staff. The facility policy, Quality of Life-Dignity, revised 3/2024 documented residents should be cared for in a manner that promoted and enhanced their sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Residents were treated with dignity and respect at all times. Staff was expected to promote dignity and assist residents in keeping urinary catheter bags covered. Resident #71 had diagnoses including chronic kidney disease, dementia, and urinary retention (neurogenic bladder, lack of bladder control due to a nerve problem). The 4/17/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, was dependent for all activities of daily living, and had a urinary catheter. A physician order dated 7/18/2024 documented Foley catheter 16 French (size) with 10 cubic centimeter balloon (used to anchor the catheter in the bladder) for a diagnosis of neurogenic bladder (lack of bladder control). The comprehensive care plan initiated 9/26/2022 and revised 7/12/2024 documented the resident had Enhanced Barrier Precautions deficit related to having a urinary catheter. The following observations were made of Resident #71: - on 7/22/2024 at 10:40 AM in their room. The resident's uncovered urinary drainage bag could be seen from the hallway. The bag was hanging from the lower side of the bed on the door side and contained yellow urine. - 7/23/2024 at 12:45 PM in the day room with the uncovered catheter drainage bag attached to their chair. Other residents were in the area and one resident was being fed by staff. During an interview on 7/23/2024 at 3:32 PM, Certified Nurse Aide #28 stated it was nursing's responsibility to make sure catheter bags were covered. Failure to have it covered was a dignity issue. During an interview on 7/25/2024 at 12:55 PM, Registered Nurse Unit Manager #16 stated they had seen residents in public areas with catheter bags not covered and educated staff. They expected catheter bags to be covered and it was a dignity and an infection control issue if they were not. During an interview on 7/26/2024 at 9:28 AM, the Director of Nursing stated catheter bags should be covered even in the residents' room if the bag was visible from the hallway because it was a dignity issue. 10 NYCRR 415.5(b)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey conducted 7/22/2024-7/26/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 4 of 6 residents (Resident #20, #69, #71, and #83) reviewed. Specifically, Resident #71's and #83's care plan did not include the use of an anticoagulant (blood thinner) or insulin (used to treat diabetes); Resident #20's care plan did not include the use of insulin; and Resident #69's care plan did not include specific resident centered care interventions for behavioral symptoms. Findings include: The facility policy, Care Planning/Care Conference revised 9/2017, documented the facility would ensure that a comprehensive care plan was developed for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. The facility policy, Dementia-Clinical Protocol, revised 3/2022 documented the interdisciplinary team would identify a resident centered care plan to maximize remaining function and quality of life and would adjust interventions and the overall plan depending on the individual's progression of dementia. 1) Resident #83 had diagnoses including pulmonary emboli (a blood clot in the lung) and diabetes. The 7/11/2024 Minimum Data Set documented the resident had moderately impaired cognition and received daily insulin injections and an oral anticoagulant. Physician orders documented the following: - on 6/30/2023 an order for Eliquis (anticoagulant) twice a day for pulmonary embolism. - on 3/8/2024 an order for Basaglar (long-acting insulin) via pen injector once daily for type 2 diabetes mellitus. -on 5/15/2024 an order for Fiasp (fast-acting insulin) according to a sliding scale (the amount of insulin administered was based on results of finger stick blood sugar levels) via pen injector three times a day for type 2 diabetes mellitus. There was no documented evidence of a Comprehensive Care Plan that included the use of an anticoagulant for history of a pulmonary embolism or a diagnosis of diabetes with the need for insulin administration. The 6/9/2024 Registered Nurse #42 progress note documented the resident had coffee ground emesis (a type of vomit that could indicate internal bleeding), had a positive hemoccult (a test that detects blood in stool), and was sent to the emergency room for evaluation. During an interview on 7/26/2024 at 10:54 AM, Certified Nurse Aide #34 stated If someone was diabetic it would be on their care plan for the aides to see. They would monitor the type of food a diabetic resident was given and report if the resident was lethargic. They would not be able to see if a resident was on a blood thinner. They knew Resident #83 was a diabetic and often asked for snacks and usually ate well. During an interview on 7/26/2024 at 11:07 AM, Certified Nurse Aide #39 stated they could see what medical conditions a resident had by looking in the computer. If they knew someone was a diabetic, they would watch sugar intake and make sure appropriate snacks were given. If someone was on a blood thinner, they were told by nursing as they did not cut nails for those residents. During an interview on 7/26/2024 at 11:27 AM, Registered Nurse #15 stated care plans were generated by the Nurse Manager and the admissions nurse. They expected care plans to include whether a resident was a diabetic or on any high-risk medications such as insulin and anticoagulants so staff could be aware of any detrimental effects such as bruising. Resident #83 was a diabetic and received glucose checks before meals. During an interview on 7/26/2024 at 11:49 AM, Licensed Practical Nurse Unit Manager #14 stated care plans were updated with any incidents and as needed. A registered nurse had to enter the care plan problems and goals. Once entered, they could update the care plan and could choose to have interventions populate so the certified nurse aides had access to that information. Residents that were only at risk for a problem would have a care plan with generic interventions but if they had an actual problem there would be specific interventions tailored to that resident. They felt medical conditions such as diabetes and use of certain medications such as anticoagulants should be care planned due to needed monitoring for bleeding and diabetic symptoms. Resident #83 was taking Eliquis and two different insulins and should have related care plans due to the need for monitoring for bleeding and diabetic symptoms. 2) Resident #20 had diagnose including diabetes. The 4/30/2024 Minimum Data Set documented the resident had severely impaired cognition and received daily insulin injections. Physician orders documented the following: - on 3/9/2024 an order for Lispro (fast-acting insulin) according to a sliding scale via pen injector three times a day for type 2 diabetes mellitus. - on 3/27/2024 an order for Levemir (long-acting insulin) via pen injector once daily for type 2 diabetes mellitus. There was no documented evidence of a Comprehensive Care Plan that included a diagnosis of diabetes with the need for insulin administration. During an interview on 7/26/2024 at 11:27 AM, Registered Nurse #15 stated Resident #20 was a diabetic and received insulin. They expected there to be a care plan for insulin to better monitor for detrimental effects. During an interview on 7/26/2024 at 11:07 AM, Certified Nurse Aide #39 stated Resident #20 was a diabetic and ate well. There was a white board in their room that intakes and glucose levels were documented on it for the family to see. During an interview on 7/26/2024 at 11:49 AM, Licensed Practical Nurse Unit Manager #14 stated Resident #20 was a diabetic and received insulin daily. They did not have a diabetes care plan but should have due to the need for monitoring of diabetic symptoms. 3) Resident #69 had diagnoses including dementia, depression, and restlessness and agitation. The 6/30/2024 Minimum Data Set documented the resident had severely impaired cognition, did not exhibit behavioral symptoms, and received antidepressants daily. Physician orders documented the following: -On 1/22/2024 an order for Melatonin (a supplement used to promote sleep) 3 milligrams once daily for insomnia. -On 2/8/2024 an order for Trazodone (an antidepressant) 50 milligrams once daily for insomnia. -On 1/22/2024 an order for Sertraline (an antidepressant) 25 milligrams once daily for depression. -On 5/20/2024 an order for Remeron (an antidepressant) 15 milligrams once daily for depression. -On 6/18/2024 an order for Memantine (a medication used to treat confusion) 5 milligrams once daily for dementia with behavioral disturbance. -On 7/3/2024 an order for Nudexta (a medication used to treat excessive crying) 20-10 milligrams twice daily for dementia with behavioral disturbance. The nursing progress notes from 5/7/2024-7/22/2024 documented frequent behavioral symptoms including yelling, crying, [NAME], screaming, symptoms of anxiousness, and verbalizations of feeling lonely and sad. There were frequent unsuccessful attempts to determine the cause of behaviors or to successfully redirect the resident. The Comprehensive Care Plan documented: - on 1/24/2024 the resident had severe cognitive loss due to dementia. Interventions included allow ample time to absorb and respond to information; assess contributing factors to cognitive loss; consult with family as needed; explain all treatments and procedures; engage in conversation that was meaningful to the resident; monitor for changes in cognition; staff would not rush or show impatience; provide calm therapeutic environment and structured routine; and provide verbal/visual reminders as needed. - on 5/22/2024 the resident was diagnosed with depression and was prescribed medication to assist with symptom management. Interventions included consult with pharmacy and physician to consider dosage reduction when clinically appropriate, nursing staff would administer medications as ordered and monitor for any adverse side effects and report to physician and monitor for signs and symptoms of depression and report to physician and social worker. The resident was observed on 7/22/2024 at 1:00 PM, in bed in their room hollering out indistinct words. There was no staff interaction with the resident. At 3:40 PM, in their room yelling out loudly and crying. No staff were observed interacting or attempting to soothe the resident. There was no documented evidence of person centered specific interventions used when the resident had behavioral symptoms and was crying out. During an interview on 7/26/2024 at 10:54 AM, Certified Nurse Aide #34 stated Resident #69 was overwhelmed a lot and if they were around too many people, they would cry out more than usual. They were unsure if there were specific care plan interventions for the resident. The certified nurse aide looked at the care log section of the electronic medical record system and stated none was listed for behavior interventions. During an interview on 7/26/2024 at 11:07 AM, Certified Nurse Aide #39 stated there were some behavior interventions listed in the care plans. They were unsure where in the new medical record system behaviors were found. Resident #69 could be whiney and felt lonely when left alone in their room. They found encouraging deep breathing, counting to 10, singing, and staying around other people helped to calm the resident. They were not aware of any specific care plan interventions that were in place for the resident. During an interview on 7/26/2024 at 11:27 AM, Registered Nurse #15 stated Resident #69 was anxious, yelled out, and cried a lot. They were not sure if the resident had a dementia care plan problem or if there were any specific interventions in place for the resident's behavioral symptoms. During an interview on 7/26/2024 at 11:49 AM, Licensed Practical Nurse Unit Manager #14 stated Resident #69 had difficulties dealing with their emotions and cried a lot. The resident was discussed many times at the weekly risk management meetings, had psychiatric consults, medical testing, and various medication changes to manage behavioral symptoms. Nudexta was most recently added and seemed to be working as what started as a regular behavior was now only an intermittent behavior. There was little in the care plan related to managing behaviors other than generic interventions. They felt there should be specific interventions tailored to the resident. 10NYCRR 415.11(c)(1)

Based on observations, record review, and interview during the recertification and abbreviated (NY00289910, NY00305753, NY00316721, NY00323929, and NY00339707) surveys conducted 7/22/2024-7/26/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 7 Residents (Residents #88 and #127) reviewed. Specifically, Resident #88 was not assisted with shaving and Resident #127 was not assisted with showering and oral care. Findings include: 1) Resident #88 had diagnoses of age-related osteoporosis (weak/brittle bones), tremors, and depression. The 6/15/2024 Minimum Data Set assessment documented the resident had intact cognition, had no behavioral symptoms, did not reject care, and required supervision/touch assistance with personal hygiene. The Comprehensive Care Plan revised 3/2024 documented the resident had impairment with activities of daily living function/physical mobility related to weakness. Interventions required supervision/touch assistance of 1 for personal hygiene. The 7/2024 resident care instructions documented the resident required supervision/touch assistance of 1 for personal hygiene. The instructions did not include shaving preferences. During observations on 7/22/2024 at 11:14 AM and 7/23/2024 at 8:31 AM, the resident had dark facial hair on their upper lip and their chin. On 7/23/2024 at 12:31 PM, the resident had dark facial hair on their upper lip and their chin. The resident stated they did not like the facial hair and wanted it shaved. They stated they had their shower that day and the certified nurse aide did not have time to shave them. During an interview on 7/24/2024 at 10:21 AM Certified Nurse Aide #29 stated they were responsible for ensuring residents were clean, had their hair washed, had nail care, and were shaved on their shower day. They stated when care was completed, they documented it on the Point of Care activities of daily living sheet. Resident #88 had a shower the previous day and they did not shave the resident. If a resident was not shaved and wanted to be, it could be a dignity issue. The Point of Care History for performance of activities of daily living did not document personal hygiene was completed for the resident from 7/19/2024-7/26/2024. During an interview on 7/25/2024 at 12:55 PM Registered Nurse Unit Manager #16 stated resident care included washing, oral care, nail care, and shaving. The certified nurse aides were responsible for resident care and if the resident wanted to be shaved, they expected the certified nurse aides to shave them. It was a dignity issue if they were not shaved per their preference. During an interview on 9/28/2024 at 9:28 AM, the Director of Nursing stated the resident's personalized care plan should be followed regarding activities of daily living and the Unit Managers were responsible for checking that documentation was completed and rounding on the residents. 2) Resident #127 had diagnoses of cerebral vascular accident (stroke), hemiplegia and hemiparesis (muscle weakness and paralysis affecting one side of the body), and depression. The 5/8/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, required substantial/maximum assistance of 1 for bathing/showering, and partial/moderate assistance of 1 for dressing. The comprehensive care plan initiated 5/22/2024 last reviewed 7/18/2024 documented the resident had impaired activities of daily living performance/physical mobility related to left sided hemiparesis (paralysis) and right sided weakness, decreased muscle strength and coordination, balance deficit and neurological impairment. Interventions included partial/moderate assistance of 1 for bathing/showering, set up assistance for oral hygiene and supervision/touch assistance with personal hygiene. The 7/2024 resident care instructions documented the resident required partial/moderate assistance of 1 for bathing or showering and partial/moderate assistance of 1 staff for oral hygiene. During an observation and interview on 7/23/2024 at 9:02 AM, Resident #127 was sitting in their wheelchair wearing a t-shirt, a flannel shirt, and sweatpants. They stated they had not had a shower in 3 weeks and needed assistance with brushing their teeth. Their teeth were yellow, and their breath had an unpleasant odor. They stated therapy used wipes to wipe them down, but they wanted a real bath or shower. At 1:38 PM, the resident was sitting in their wheelchair in the same clothing. They stated all they wanted was a shower on Sunday and did not want to smell bad when visitors came to see them. During an observation and interview on Wednesday, 7/24/2024 at 8:49 AM, the resident was dressed and sitting in their wheelchair. They stated they had not had their shower and it did not matter anymore. They stated they would get a shower on Sunday. The Point of Care History for activities of daily living did not include documentation of a shower or oral hygiene from 7/22/2024-7/26/2024. During an interview on 7/24/2024 at 12:38 PM, Certified Nurse Aide #40 stated resident care plans were printed and posted in their closets, so the aides knew how to care for them. The shower list was at the nursing station and included who was to be showered. If therapy showered a resident, they told the nurses. All rooms were private so showers could be performed. They stated it was unacceptable for Resident #127 to not have a shower and it was undignified. Agency certified nurse aides had no access to the electronic medical record system so they could not document a shower was given, but they would tell regular staff that one was completed. During an interview on 7/25/2024 at 2:17 PM Registered Nurse Unit Manager #24 stated they were not aware Resident #127 had not showered in 3 weeks. They stated the resident required assistance with oral hygiene and the certified nurse aides should have completed both tasks. If the resident had not received showers or oral hygiene in 3 weeks, it could lead to increased risk of infections, including dental caries (cavities). NY10CRR 415.12

Based on observation and interview during the recertification survey conducted 7/22/2024-7/26/2024, the facility did not post daily at the beginning of each shift, the current resident census and the total number and the hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, and accessible to residents and visitors for 4 of 5 days reviewed. Specifically, the nurse staffing was not consistently posted. Finding included: The facility did not have documented policy and procedures regarding daily posted staffing. The daily nursing staffing information was observed in a glass cabinet in the main lobby: - on 7/22/2024 at 10:10 AM, 11:35 AM, and 2:20 PM, the daily posted staffing document was dated 7/15/2024. - on 7/23/2024 at 9:08 AM, the daily posted staffing document was dated 7/22/2024 and did not have nurse staffing information for the evening and overnight shifts. - on 7/24/2024 at 4:02 PM, the daily posted staffing document was dated 7/24/2024, and did not have nurse staffing information for the evening shift. - on 7/24/2024 at 4:55 PM, there was no daily posted staffing document. - on 7/25/2024 at 8:08 AM, there was no daily posted staffing document. - on 7/25/2024 at 4:53 PM and 5:19 PM, the daily posted staffing document was dated 7/25/2024, and did not have nurse staffing information for the evening shift. During an interview on 7/25/2024 at 9:55 AM, receptionist #7 stated that either the building Supervisor or the Staffing Coordinator were responsible for posting the daily staffing in the cabinet. During an interview on 7/25/2024 at 11:46 AM, Staffing Coordinator #4 stated they made the schedule, and provided the information to the Director of Nursing and the building Supervisor. The Director of Nursing or the assigned building Supervisor posted the staffing. During a follow up interview on 7/25/2024 at 4:54 PM, Staffing Coordinator #4 stated it was important to have the staffing posted and it was required. They had provided the information to the Supervisor before they left for the day and did not know where the staffing document was posted in the lobby. During an interview on 7/26/2024 at 10:13 AM, Registered Nurse Supervisor #5 stated they worked 7:00 AM to 3:00 PM, and they updated the glass cabinet with the day shift staffing when they came in for the day. They stated the staffing document should be completed on the evening and night shifts. They were not able to complete the full document in the morning, as they did not know the staffing past the day shift. During a telephone interview on 7/26/2024 at 10:58 AM, Registered Nurse Supervisor #6 stated they usually worked 11:00 PM to 7:00 PM, and they did not make the schedule and were not responsible for posting it. They stated they did not post the schedule anywhere, they just told staff where to go. During an interview on 7/26/2024 at 9:28 AM, the Director of Nursing stated the Nursing Supervisor on duty was responsible for posting the daily nursing staffing. They stated they or the Assistance Director of Nursing might also post it. 10 NYCRR 415.13

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted [DATE] through [DATE], the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions when applicable for 1 of 4 medication carts (Brookside Garden medication cart), 1 of 1 treatment cart (Brookside Terrace cart), and 1 of 2 medication rooms (Brookside Terrace medication room) reviewed. Specifically, the Brookside Garden medication cart contained 3 insulin pens without opened dates; and the Brookside Terrace medication refrigerator did not have a complete record of refrigerator temperatures, and the treatment cart was unlocked. Findings include: The pharmacy services policy, Storage of Medications, dated 8/2020 documented medications and biologicals were to be stored safely, securely, and properly, and followed manufacturer's recommendations. Refrigerated medication should be stored between 36- and 46-degrees Fahrenheit with a thermometer for temperature monitoring. The facility should maintain a temperature log in the storage area to record temperatures at least once a day or in accordance with facility policy. Certain medications or package types, such as multiple dose injectable vials, required an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency. When the original seal of a manufacturer's container or vial was initially broken, the container or vail was to be dated. The nurse should place a date opened, sticker on the medication and record the date open and the new date of expiration. Manufacturer instructions for insulin aspart and insulin glargine documented to dispose of the insulin after 28 days, even if there was insulin remaining in the pen or vial. Insulin Pens: During an observation on [DATE] at 11:53 AM with Licensed Practical Nurse #13, the Brookside Garden, D cart contained a basaglar (insulin glargine, long-acting insulin) pen for Resident #83 without an opened date documented on the medication or the pharmacy labelled bag. Resident #83 also had a Fiasp (Insulin aspart, rapid-acting insulin) flex pen without an opened date documented on the medication and did not have a pharmacy labelled bag and was placed in the bag with the Basaglar pen. Resident #20 had a levemir (basal insulin, long-acting) flex pen without an opened date on the medication or the pharmacy labelled bag. The levemir pen was in a pharmacy labelled bag for insulin lispro (rapid-acting insulin) with another insulin pen. During an interview on [DATE] at 12:09 PM Licensed Practical Nurse #13 stated that insulin needed to be dated with an opened date because the medication was only good for 24 or 28 days. There was potential to give the resident an expired insulin. During an interview on [DATE] at 11:03 AM, Licensed Practical Nurse Unit Manager #14 stated the responsibly for checking medications in the medication care fell on them. The medication nurses on the carts should also be checking during their medication passes. They did not expect agency nurses to do anything but pass medications. They stated there was no routine schedule for checking the medication carts, but it would be useful. Insulin should be labeled with an opened date. If it did not have an open date, it would have to be discarded. Insulin was only good for 30 days, without a labeled opened dated a resident could be given expired insulin. Medication Refrigerator Temperatures: During an observation on [DATE] at 10:42 AM, the Brookside Terrace Medication Room medication refrigerator log sheet was missing temperatures for [DATE], [DATE], [DATE], and [DATE]. The refrigerator temperature was 46 degrees Fahrenheit. During an interview on [DATE] at 12:29 PM, Registered Nurse Unit Manager #16 stated that the medication refrigerator log sheet was missing temperatures. It was the responsibility of the overnight nurses to check the refrigerator temperatures and complete the log, but anyone who went into the refrigerator could document the temperature. It was important to monitor the temperature to ensure they did not go out of range. If the refrigerators went out of range, it could cause the medications to go bad. The Registered Nurse Manager put up a new reminder paper on the double lock box to help with medication room responsibilities, but they could monitor everything. Treatment Cart: During observations on [DATE] at 10:37 AM, [DATE] at 2:50 PM, and [DATE] at 8:53 AM the treatment cart on Brookside Terrace was unlocked. The treatment cart contained nystatin (anti-fungal) powder, aspercream (pain relief) cream, estrodial (estrogen hormone) cream, Volteran (pain relief) gel, sunscreen, medicated menthol patch, no rinse cleanser, thera gel shampoo (treats psoriasis/dry skin), and a spray cleaner. During an interview on [DATE] at 8:25 AM, Licensed Practical Nurse #17 stated there were creams in the treatment cart. It should be locked for safety reason as residents that wander could get into the cart. During an interview on [DATE] at 8:33 AM, Registered Nurse Unit Manager #16 stated the treatment carts had creams and other medications, such as anti-fungal and antibiotic creams. It should always be locked so residents could not get into it. During an interview on [DATE] at 9:28 AM, the Director of Nursing stated treatment carts should be locked when not in use as they might have prescription medications for wounds. Locking the cart could prevent people from getting into the contents, and there was the potential for the residents to get into the wound care supplies. Insulin pens should be labeled in the medication cart with the bag, pharmacy label, and the date it was opened. The date the insulin was opened was important to monitor the proper expiration date. The night shift licensed practical nurses typically checked the temperature of the medication refrigerator. It was important to monitor the temperature to ensure that it was within an acceptable range. If the medication refrigerator was out of range, there was potential for medications to go bad. 10 NYCRR 415.18(d)

Based on observation, interview, and record review during recertification survey conducted 7/22/2024-7/26/2024, the facility did not provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional needs, taking into consideration the preferences of each resident for 2 of 4 residents (Resident #107 and #148) reviewed. Specifically, Residents #107 and #148 were missing food items on their meal trays. Findings include: The undated facility policy, Meal Tray Accuracy Audit Report Policy, documented the Food Service Director was responsible for completion of the meal tray accurracy form at least three times a week. The meal tray accurracy form was used to improve accuracy of tray service, resident satisfaction, and resident diet. The week 1 Summer/Spring menu was observed hanging in the hallway in front of the Sunrise Garden nursing station on 7/22/2024 at 10:30 AM. The week 1 lunch menu choices for Monday included barbeque chicken, zesty pork chop, roast beef sandwich on wheat bread, or egg salad sandwich on wheat bread, capri vegetable, broccoli, vegetarian baked beans, steamed rice, and rocky road chocolate pudding. 1) Resident #107 had diagnoses including multiple sclerosis (a central nervous system disease), depression, and dysphagia (difficulty swallowing). The 6/27/2024 Minimum Data Set assessment documented the resident was cognitively intact, was independent with eating. and weighed 131 pounds. The comprehensive care plan initiated 3/8/2022 and revised on 4/18/2024 documented the resident was at risk for an alteration in nutritional status related to anxiety, hyponatremia (low sodium levels in the blood), multiple sclerosis, depression, Barrett's esophagus (damage to the esophogus), and gastroesophageal reflux disease (stomach acid backs up into the esophagus). Interventions included a regular diet with yogurt and milk at breakfast and estimated 1640 kilocalories day. A 2/10/2022 Physician #20 order documented a regular diet with no change in consistency. During an interview on 7/22/2024 at 11:39 AM, Resident #107 stated the food was not good and they were often missing items on their tray that were on their meal ticket. They stated one example was soup with crackers, the crackers would be missing even though they were on their meal ticket. During an observation and interview on 7/22/2024 at 1:04 PM during the lunch meal, Resident #107's meal ticket documented BBQ chicken, vegetarian baked beans, steamed rice, and rocky road chocolate pudding. Rocky road chocolate pudding and steamed rice were not included on the meal tray. Resident #107 stated they would have eaten the pudding and rice if it was on their tray. 2) Resident #148 had diagnoses including fractured left femur (thigh bone), diabetes, and hypertension (high blood pressure). The 5/6/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, required setup assistance with eating, and required a therapeutic diet. The 4/30/2024 physician order documented the resident was to receive a carbohydrate controlled diet, regular solids and thin liquids. The comprehensive care plan dated updated on 5/13/2024 documented the resident was at risk for altered nutrition/dehyration related to hypothyroidism (under active thyroid), hypertension, hip fracture, and diabetes. Interventions included regular controlled carbohydrate diet and supplement with Glucerna (nutritional supplement) at lunch and yogurt and milk at breakfast. During an interview on 7/22/2024 at 11:57 AM, Resident #148 stated the kitchen staff would offfer them food items and then the food did not come as they ordered. They stated staff did not follow the menu and at times there was food missing on their meal tray. During an observation on 7/22/2024 at 12:49 PM, Resident #148's lunch meal ticket documented a tuna sandwich on wheat, an egg salad sandwich on wheat, and broccoli. The resident received a tuna sandwich on white bread, no egg salad sandwich, and mixed oriental vegetables in place of broccoli. The resident stated they preferred wheat bread. During an interview on 7/25/2024 at 12:02 PM, the Food Service Director stated they were not out of wheat bread. They may have run short but if a resident had a preference for wheat bread for their sandwich they should be provided with wheat bread. If a resident requested broccoli as their vegetable they should have gotten that. There was a subustitute on Monday of capri mixed vegetables and the residents should have been notified of the substitution. They ran out of diet jello pudding and this should have been substituted with diet jello. The residents' meal trays were checked by several staff members prior to being brought to the unit. All food service staff was responsible to make sure the food items were accurate. 10NYCRR 415.14

Based on observation and interview during the recertification and abbreviated (NY00339707) surveys conducted 7/22/2024-7/26/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (the 7/23/2024 lunch meal and the 7/24/2024 lunch meal). Specifically, food was not palatable or served at palatable and appetizing temperatures during the lunch meals on 7/23/2024 and 7/24/2024. Additionally, Residents #36, #88, #107 and #136 stated the food was not palatable. Findings include: The facility policy, Maintaining Food Temperatures, revised 4/2012 documented food would be prepared, stored, and transported in a manner that would ensure proper serving temperatures. During an interview on 7/22/2024 at 11:11 AM, Resident #88 stated the food was cold and lacked flavor. The chicken and rice casserole was the least flavorful of all dishes. During an interview on 7/22/2024 at 11:39 AM, Resident #107 stated the food lacked flavor and was often cold and had to be heated in the microwave. During an interview on 7/22/2024 at 11:41 AM, Resident #36 stated the food was not palatable. Tea and coffee were always cold. The food was often cold and had to be heated in the microwave. During an interview on 7/22/2024 at 2:35 PM, Resident #136 stated the pork chop was so tough they could not cut it and they had to pick it up and eat it with their fingers. During an observation and interview on 7/24/2024 at 8:31 AM, Resident #136 stated their eggs were cold and the banana was too ripe to eat. The banana peel appeared mostly brown and black. During a lunch meal observation on 7/23/2024 at 12:51 PM on the First floor Unit D, the last meal tray was selected as a test tray and a replacement tray was ordered for the resident. The temperatures were measured as follows: - pork 120 degrees Fahrenheit - stuffing 143 degrees Fahrenheit - carrots 126 degrees Fahrenheit - gelatin dessert 52 degrees Fahrenheit - Ensure (nutritional supplement) 57 degrees Fahrenheit The pork was overcooked and tough and the stuffing tasted bland. During a meal observation on 7/24/2024 at 12:02 PM meal carts for Second floor Unit C temperatures were measured on the service preparation and the fish measured at 125 degrees Fahrenheit. During a lunch meal test tray observation on 7/24/2024 at 12:38 PM on the Second floor Unit C the fish was measured at 96 degrees Fahrenheit, hot water was 118 degrees Fahrenheit, and juice was 40 degrees Fahrenheit. The fish was not hot, and the noodles lacked flavor. The juice was opened and had an ice block in the middle of the container. During an interview on 7/23/2024 at 3:32 PM, Certified Nurse Aide #28 stated residents often told them the food did not taste good, hot food was cold, and cold food was warm. Residents told them numerous times items were missing from their trays. They observed items missing from trays such as Magic Cups (nutritional supplement), fruit, and even silverware. They saw items on trays that were not listed on the resident's meal ticket and diabetics had missing items on their trays, especially Ensure. When they noticed inaccuracies or had complaints from the residents they told the kitchen staff in the kitchenette area. During an interview on 7/24/2024 at 10:21 AM, Certified Nurse Aide #29 stated residents often complained about the hot food being cold and the meal not looking appetizing. They had observed missing items from trays on several occasions like coffee, a sandwich, and thickening powder (used to thicken liquids). They observed sandwiches on white bread when the meal ticket documented wheat bread. If a resident did not eat the food because it was cold or not appetizing the resident could get upset, lose weight, and not receive the proper nutrition. During an interview on 7/24/2024 at 1:17 PM the Food Service Director stated juice came in frozen and was put in the cooler. Test trays were supposed to be completed three times a week and the results were documented. It should take 7-10 minutes to get the trays prepared and delivered to the resident. Trays should look appetizing and be served at the correct temperatures. Hot food should be above 135 degrees Fahrenheit and cold food should be between 33-41 degrees Fahrenheit. They stated 96 degrees Fahrenheit was not an acceptable temperature for fish, and the hot water for tea should be 125 degrees Fahrenheit and not 118 degrees Fahrenheit. Ensure should usually be served cold. 10NYCRR 415.14(d)(1)(2)

Based on observation, record review, and interviews during the recertification survey conducted 7/22/2024-7/26/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 certified nurse aide and 1 registered nurse (Certified Nurse Aide #12 and Registered Nurse #15) observed. Specifically, Certified Nurse Aide #12 did not wear a gown and gloves as required in a room requiring transmission based precautions and did not perform appropriate hand hygiene before exiting the room; Registered Nurse #15 did not perform hand hygiene or change their gloves during wound care. Findings include: The facility policy, Contact Isolation Precautions for Clostridium Difficile, revised 3/2024 documented all employees were to follow isolation precaution signage on the resident's doors; residents diagnosed with Clostridium Difficile (an easily transmitted bacteria that causes diarrhea) were to be immediately placed on isolation precautions with signage on the door and a personal protective equipment cart placed outside of the door containing masks, gowns, gloves, and clear plastic bags. Certified nurse aides were to don (put on) gown and gloves, bring only supplies needed into the room to care for the resident, perform care last if possible, and wash hands upon exiting the room. Alcohol based hand sanitizer was not effective for removing Clostridium Difficile spores from the hands. The facility policy, Skin and Wound Management, revised 4/2020 documented pressure injury treatment program should focus on managing bacterial colonization and infection. The facility policy, Standard Precautions, revised 7/2019 documented clean gloves should be used before touching mucous membrane and non-intact skin and gloves would be changed between tasks and procedures on the same resident and after contact with material that may contain a high concentration of microorganisms such as wound drainage. 1) Resident #53 had diagnoses of enterocolitis (inflammation of the intestines) due to Clostridium difficile, diarrhea and pneumonia. The 7/11/2024 Minimum Data Set assessment documented Resident #53 had intact cognition, was frequently incontinent of bladder and bowel, and required partial/moderate assistance of 1 for toileting hygiene. The comprehensive care plan, initiated 5/2024, documented Resident #53 was on contact precautions due to Clostridium difficile. Interventions included administer antibiotics as ordered, keep call bell within reach, post sign on door, obtain cart with personal protective equipment, explain contact precautions to resident and family, and monitor for loose bowel movements, nausea, abdominal pain, or cramping. The 5/2024 resident care instructions documented the resident was on contact precautions; post sign on door and obtain care with personal protective equipment. The 7/2024 physician order documented the resident was on isolation precautions due to Clostridium difficile. The 7/23/2024 at 7:18 AM nursing progress note by Licensed Practical Nurse #41 documented Resident #53 was the 24-hour nursing report due to contact precautions for Clostridium difficile and was taking antibiotics. During a continuous observation on 7/24/2024 beginning at 8:51 AM: - An unidentified certified nurse aide entered the resident's room without donning the appropriate personal protective equipment, picked up the resident's breakfast tray, exited the room, and did not wash their hands after removing the tray. - At 8:52AM, Certified Nurse Aide #12 entered the resident's room with towels and washcloths and did not don personal protective equipment. - At 9:08 AM, Certified Nurse Aide #12 exited the resident's room without performing appropriate hand hygiene. - At 9:18 AM, Certified Nurse Aide #12 re-entered the resident's room, donned gloves, and assisted the resident in the bathroom. Certified Nurse Aide #12 disposed of the resident's dirty brief in the trash receptacle outside of the bathroom, doffed their gloves, exited the room, and used alcohol-based hand sanitizer to clean their hands. During an interview on 7/24/2024 at 9:57 AM, Registered Nurse #8 stated the resident was on contact precautions and the surveyor would need a gown and gloves to enter the room. The gown and gloves were in the plastic tower of drawers next to the room door. During an interview on 7/24/2024 at 9:57 AM Certified Nurse Aide #12 stated they cared for Resident #53 on another unit when they had Clostridium difficile. Certified Nurse Aide #12 stated contact precautions meant they had to wear a gown and gloves, but they did not use gown and gloves when they entered the resident's room. They did not know what kind of hand hygiene was required with Clostridium difficile. They used the hall hand sanitizers and did not want to transmit disease to their family. During an interview on 7/25/2024 at 9:28 AM, the Director of Nursing stated certified nurse aides received infection control education when they were hired; as needed if there was an outbreak of COVID-19; if they were unsure how to don/doff (put on/take off) personal protective equipment; or if they needed to know what the sign on the door meant. They should ask Registered Nurse #3 or their Unit Managers if they did not know. Staff should not enter a contact precaution room without gowns and gloves to prevent the spread of infection. During an interview on 7/26/2024 at 12:51 PM, Registered Nurse #3 stated a resident should have a physician order if they required contact precautions. Certified nurse aides were educated on infection control during orientation and had handwashing education yearly or with an outbreak. Certified nurse aides should don a gown and gloves when they entered a room with precautions to prevent the spread of infection. There was a competency fair last fall with a video and handwashing for infection control. 2) Resident # 142 was admitted to the facility with diagnoses of dementia, peripheral vascular disease (reduced blood flow in extremities), and morbid obesity. The 5/23/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required moderate assistance with most activities of daily living, and had a Stage 3 pressure ulcer (full thickness tissue loss). The 7/22/2024 physician wound care order documented to cleanse right heel Stage 3 pressure ulcer with wound cleanser, apply a skin protectant to peri wound (skin surrounding the wound) and apply Pluragel (a wound treatment used to create a moist wound environment) to the wound bed, cover with border gauze (protective gauze covering) daily and as needed. During a wound care observation on 7/25/2024 at 9:36 AM, Registered Nurse #15 applied a pair of clean gloves, removed Resident #142's sock from their right foot, removed the soiled dressing from the right heel, opened a clean gauze packet, moistened the gauze with the cleansing agent, cleansed the right heel wound, applied Pluragel using a cotton tipped applicator, and covered the wound with border gauze. Registered Nurse #15 did not change their gloves or perform hand hygiene after removing the soiled dressing and before applying the clean dressing. During an interview on 7/25/2024 at 1:32 PM, Registered Nurse #15 stated they would have changed their gloves if the new dressing they were applying was ordered as a sterile dressing. Resident #142s dressing was not ordered as a sterile dressing. They stated gloves would be dirty if they touched the soiled dressing and if the same gloves touched a clean, new dressing then cross contamination of the clean dressing could occur. This could result in infection. During an interview on 7/25/2024 at 4:31 PM, Licensed Practical Nurse Unit Manager #14 stated after removing an old dressing gloves should be removed, and hands should be washed. New gloves should be put on before applying a new dressing. It was important to change gloves to prevent contamination of the clean dressing that could result in wound infection or worsening of the wound. 10 NYCRR 415.19(a)(b)

Based on observation, record review, and interview during the recertification survey conducted 07/22/2024-7/26/2024, the facility did not ensure call bells were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, toilet, and bathing facilities for 1 of 1 resident (Resident #28) reviewed. Specifically, Resident #28's call bell was not within reach. Findings include: The facility policy, Call Light System Policy, reviewed by the facility 6/2024 documented when finished providing care to residents be sure to position the call light in their reach for ease of resident use. Tell the resident where the call light is and show them how to use the call light. Resident #28 had diagnoses including epilepsy (seizure disorder), cerebral vascular accident (stroke), and aphasia (difficulty speaking). The 8/10/2023 Minimum Data Set assessment documented the resident had severely impaired cognition and was dependent for all activities of daily living. The comprehensive care plan revised 3/2024 documented the resident had difficulty making themselves understood and understanding others related to aphasia following a cerebral vascular accident. The resident had impaired activity of daily living performance/physical mobility related to weakness. The resident was at risk for falls due to inability to maintain their position. Interventions included anticipate resident needs and keep call bell in reach and answer it promptly. The resident was observed: - On 7/22/2024 at 11:55 AM with their call bell behind the bed and out of reach; - On 7/24/2024 at 10:11 AM with their call bell behind the bed and out of reach; - On 7/25/2024 at 10:49 AM and 12:06 PM with their call bell on the floor and out of reach. During an interview on 7/25/2024 at 12:06 PM, Certified Nurse Aide #43 stated Resident #28 did not always have their call bell and was unable to communicate their needs. Call bells should always be kept near the resident so they could communicate their needs to the staff. If the call bell was not accessible, the resident could need emergency help, have a fall, or obtain an injury and staff would not be aware and able to respond. During an interview on 7/25/2024 at 12:34 PM, Registered Nurse #8 stated they noticed residents with call bells out of reach and they would move them within reach. Resident #28 was not able to verbalize their needs and was a high fall risk, so it was important for them to always have their call bell within reach. If the call bell was in reach it could result in falls or other serious events. During an interview on 7/26/2024 at 9:28 AM, the Director of Nursing stated it was not appropriate for a call bell to be out of reach or behind a bed. Staff should check for call bell placement when they did rounds on their residents and when they left the residents' room. 10NYCRR 415.29

Based on observation, record review, and interview during the recertification survey conducted 7/22/2024-7/26/2024, the facility did not ensure the resident environment remained as free of accident hazards as is possible for 3 of 3 residents (Resident #127, #148, and #146) reviewed. Specifically, Residents #127, #148 and #146 had medications left unattended in their rooms. Additionally, there was no documented evidence Residents #127, #148 and #146 were assessed to determine their ability to safely administer medications or had physician orders to self-administer their medications. Findings include: The facility policy, Administration Procedures for All Medications, dated 8/2020 documented medications would be administered in a safe and effective manner. The facility policy, Self- Administering of Medications, dated 5/8/2015 documented each resident's ability to self-administer mediation would be assessed upon admission. The interdisciplinary team would meet and complete an assessment form to decide to trial a resident for self-administration of medications. The charge nurse would meet with the resident to review and sign the assessment form of when to self- administer medications and review the self- administration procedure. The medication administration record would be labeled to identify the resident able to self-medicate. 1)Resident #127 had diagnoses including cerebral vascular accident (stroke), hypertensive urgency (clinical situation in which the blood pressure is very high with minimal or no symptoms) and hemiplegia (muscle weakness or partial paralysis on one side of the body). The 5/28/2024 Minimum Data Set assessment (health assessment screening tool) documented the resident had moderately impaired cognition, required partial to maximal assistance for activities of daily living, and received insulin, antidepressant, and antiplatelet medications daily. The Comprehensive Care Plan initiated on 5/22/2024 documented the resident had moderately impaired cognitive skills for daily decision making. The care plan include documentation the resident was evaluated or capable for self-administration of medications. The 5/22/2024 physician orders included the following medications: - hydralazine 25 milligrams (for hypertension)1 tablet orally three times a day: 6:00 AM-10 AM, 1:00 PM - 3:00 PM, and 6:00 PM - 10:00 PM. - amlodipine 10 milligrams (for hypertension) 1 tablet oral once a day, due between 6:00 AM-10:00 AM. - aspirin 81 milligrams (for cerebral infarction, blood thinner) 1 tablet oral once a day, due between 6:00 AM-10:00 AM. - chlorthalidone tablet 25 milligrams (for hypertensive urgency) 1 tablet oral once a day, at 10:00 AM. - citalopram tablet 20 milligrams (antidepressant) 1 tablet oral once a day at 8:00 AM. - clopidogrel tablet 75 milligrams (blood thinner) 1 tablet oral once a day due between 6:00 AM - 10:00 AM. - ferrous sulfate 325 milligrams (iron supplement) 1 tablet oral once a day, 6:00 AM - 10:00 AM. - lisinopril tablet 20 milligrams (high blood pressure) 1 tablet oral once a day, 6:00 AM-10:00 AM. - pantoprazole 40 milligrams (for acid reflux disease) 1 tablet oral twice a day, due between 6:00 AM - 10:00 AM and 6:00 PM to 10:00 PM. - ascorbic acid 250 milligrams (vitamin C) oral once a day at 8:00 AM. - ezetimibe 10 milligrams (treats high cholesterol) 1 tab oral once a day between 6:00 AM - 10:30 AM. There was no physician order for self- administration of medications. During an observation and interview on 7/23/2024 at 8:59 AM, there were 9 pills in a plastic medication cup on Resident #127's bedside table. Resident #127 stated they did not know what they were, but the nurse put them there at 6:30 AM. They stated they did not take their medicine until they ate breakfast after 9:00 AM and the nurse should not have left them there. They stated they were a nurse, and medications should not be left with patients because someone else could take them or the patient may forget to take them. At 1:37 PM, the resident stated they took all their medications that morning after they ate their breakfast. They were not sure what the medications were for, they just took them. The nurses knew they would not take the medicine until after breakfast, but they still brought the medicine early. During an observation and interview on 7/24/2024 at 8:32 AM, there were several pills in a plastic medication cup on the resident's bedside table that was set up in front of the resident while they were sitting in their wheelchair. The resident stated they would take them after they ate their breakfast. During an interview on 7/24/2024 at 8:36 AM, Licensed Practical Nurse #22 identified the medications that were in the plastic cup in Resident #127's room. They stated they were amlodipine, chlorthalidone, hydralazine, and lisinopril for blood pressure, pantoprazole for reflux disease and vitamin C for anemia, citalopram for depression, clopidogrel, aspirin and ezetimibe for stroke prevention. They stated these medications were due between 6:00 AM- 10:00 AM. The resident did not have an order to self-administer medication. They should not leave the medications at the bedside, but the resident was good at taking them on their own. They stated they brought the medicine to the resident about an hour ago and there was no good reason the medications were left at the bedside. They should go back to the resident after they ate their breakfast and give their pills then. They stated they circled back around to make sure the resident took their medications and was not worried about the resident taking them. They stated leaving the medication in the resident room was a bad habit. During an interview on 7/24/2024 at 1:42 PM, Registered Nurse Unit Manager #24 stated leaving medication at the bedside was not acceptable. The nurse should never leave medication at the bedside unless the resident had a medication self-administration medication order. It was a lengthy process that included an assessment by the nurse, a physician order, a daily evaluation, and an updated care plan. They were not aware the resident had medication at the bedside for the last 3 days. 2) Resident #148 had diagnoses including chronic obstructive pulmonary disease (lung disease), hypertension, and history of nicotine dependence. The 5/6/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, required partial/moderate assistance with activities of daily living, and received anticoagulation, antibiotic, diuretic, and opioid medications. The Comprehensive Care Plan initiated on 4/20/2024 documented the resident had moderately impaired cognitive skills for daily decision making. The care plan did not include documentation the resident was evaluated or capable of self-administration of medications. The 5/1/2024 physician orders documented the following medications: -Nicotine patch 24-hour, 7 milligrams/24 hour, 1 patch (to treat nicotine dependence) transdermal due between 6:00 AM - 10:00 AM. -Stioloto Respimat (inhalation spray for chronic obstructive pulmonary disease) 2.5-2.5 micrograms/actuation; 2 inhalations; inhale once a day between 6:00 AM - 10:00 AM. There was no physician order for self- administration of medications. During an observation and interview on 7/22/2024 at 12:10 PM, there was an unused nicotine patch and a Stioloto Respimat inhaler on the resident's bedside table. Resident #148 stated those medicines were not usually left at the bedside, but over the last four or five days things had changed. There were different nurses doing different things. They stated they used the inhaler for 5 years. At 12:51 PM, the nicotine patch remained on the table when staff brought the resident their lunch tray. The resident said they wanted to wait and put the nicotine patch on but was waiting to take a shower. The 7/22/2024 medication administration record documented Licensed Practical Nurse #26 administered the nicotine patch at 10:00 AM and it placed on the resident's left arm and administered the Stiolto Respimat inhaler between 6:00 AM and 10:00 AM. During an observation and interview on 7/23/2024 at 12:56 PM, there was a nicotine patch on the resident's tray table. The resident stated they never applied the patch on 7/22/2024 but the nurse had put the nicotine patch on them today. During an interview on 7/23/2024 at 1:05 PM, Registered Nurse #15 stated the patch on the resident's bed side table was from the previous day. They applied the nicotine patch at 7:30 AM this morning. The resident did not have a self-administration order for the nicotine patch or any of their medications. Medications should not be left at the bedside. A resident could forget to take the medication, medications could get thrown away accidently, and the resident may not get the effective dose of their medications. During an interview on 7/24/2024 at 9:33 AM, Registered Nurse #27 stated the resident did not have an order to self-administer any of their medications. If they did have an order, it would be listed on the for your information section in the electronic medication record. During an interview on 7/24/2024 at 1:50 PM, Registered Nurse Unit Manager #24 stated the resident did not have orders to self-administer any of their medication. If the resident did not want their patch at that time, they should reapproach the resident later to apply the patch. 3) Resident #146 had diagnoses including chronic obstructive pulmonary disease (lung disease) and paranoid delusions. The 4/18/2024 Minimum Data Set assessment documented the resident had intact cognition, was independent with most activities of daily living, and received an anticoagulant (blood thinner) and diuretic (water pill) daily. The Comprehensive Care Plan updated on 7/4/2024 did not document the resident was able to self- administer medications. The 7/17/2024 physician orders documented: - aspirin 81 milligrams one tablet oral, due between 6:00 AM- 10:00 AM. - bumetanide (diuretic) 1 milligram, one tablet oral every other day, due between 6:00 AM - 10:30 AM - Eliquis 5 milligrams (blood thinner)1 tablet oral, 6 - 10 AM twice a day. - ferrous sulfate 325 milligrams (iron supplement) 1 tablet oral due between 6:00 - 11:00 AM and 6:00 PM - 11:00 PM. - pantoprazole 40 milligrams (anti reflux), 1 tablet by mouth every day 6:00 AM- 11:00 AM. - vitamin C 250 milligrams, by mouth twice a day; due between 6:00 AM- 10:00 AM and 6:00 PM- 11:00 PM - fluticasone (allergy nasal spray) 250-50 microgram/dose; 1 inhalation, twice a day, 6:00 AM-10:00 AM, and 6:00 PM - 10:00 PM - Ventolin HFA (used to treat difficulty breathing) 90 micrograms/2 puffs/inhalation; every 4 hours as needed. There was no physician order for self- administration of medications. During an observation and interview on 7/22/2024 at 1:43 PM, the resident had a medicine cup on their bedside table with 4 pills. There was a round red tablet, 1 oval peach tablet, 1 round white tablet, and 1 round pink tablet. Resident #146 stated the pills had been there since early that morning. The resident sated they get the wrong medications sometimes and did not take all their medications if the nurses did not tell them what the medicine was. A 7/23/2024 at 9:40 PM, Registered Nurse #10 progress note documented the resident was not to have their inhaler in their room and the physician told them they could have it at the bedside due to their chronic obstructive pulmonary disease. During an observation and interview on 7/23/2024 at 1:04 PM, Resident #146 had their albuterol inhaler at the bedside, labeled with directions to inhale two puffs every 4 hours as needed for shortness of breath. The resident stated they did not feel safe without their inhaler at the bedside. They had a stack of empty medicine cups on their bedside table. The resident stated this was what the nurses placed their medications in, and some nurses leave the pills with them because they did not like to take their medication until after they ate. They stated the pills in the cup the day before were Eliquis, and one for digestion, and vitamin C, potassium, and a cholesterol medication. They stated there was iron and a high blood pressure pill, and they did not have high cholesterol or high blood pressure and did not need the iron, so they threw those pills in the trash. During observation and interview on 7/23/2024 at 1:50 PM, Licensed Practical Nurse #9 stated the resident had a rescue inhaler at their besides and it was usually for asthma or chronic obstructive pulmonary disease. They stated they did not give the inhaler to the resident and assumed it was an as needed order and must have been left by another nurse. They reviewed the resident orders and there was no order for inhaler to be left at the bedside. During medication observation on 7/24/2024 at 11:13 AM, Registered Nurse #8 stated the resident has asked them to leave their medications on the table in the past, and they would not leave them as the resident did not have a medication self- administration medication order. The medications the nurse prepared to administer included aspirin 81 milligrams, ferrous sulfate 325 milligrams, Eliquis 5 milligrams, pantoprazole 40 milligrams, Vitamin C, fluticasone inhaler, and acetaminophen. The resident refused their iron pill. During an observation and interview on 7/25/2024 at 10:35 AM, the resident had an albuterol inhaler at their bedside inside a plastic bag- labeled with directions: 2 puffs every 4 hours as needed. The resident stated they the nurses kept trying to take their inhaler away. They told them they needed the inhaler because of their asthma and shortness of breath so the nurse left it at their bedside. During an interview on 7/25/2024 at 10:36 AM, Registered Nurse #8 stated the resident had their inhaler at the bedside, and they were aware they were not supposed to have it at the bedside. The physician was aware and there was a note in the medical record. The resident did not have a medication self- administration order for the albuterol inhaler. The resident refused to give the inhaler back to the staff. They did not notify the physician. They were told there was a note in the resident record about the physician talking with the resident and allowing the resident to keep the inhaler at bedside. During an interview on 7/26/2024 at 9:28 AM, the Director of Nursing stated they were not sure if there were any residents with a medication self- administration order. The facility policy for medications to be left at the bedside would include a registered nurse assessment to deem that the resident was safe for self- administration, then they would take this assessment to the physician who would place an order for self- administration. The care plan would be updated for medication self- administration. Nurses should not leave medication at the bedside if there was not a physician order for self- administration. This was not safe, and staff would not be able to ensure the medications were taken timely or safely. 10NYCRR 415.12(h)(2)

Based on record review and interview during the recertification survey conducted 7/22/2024-7/26/2024, the facility did not ensure licensed nurses had specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 4 licensed nurses (Licensed Practical Nurses #22, #26, #35 and Registered Nurse #27); and did not ensure certified nurse aides were able to demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care for 2 certified nurse aides (Certified Nurse Aides #12 and #36). Specifically: - Licensed Practical Nurse #22 left medications at a resident's bedside who did not have a physician order for medication self-administration. Licensed Practical Nurse #22 did not receive an annual competency evaluation for medication administration. (see F 689) - Certified Nurse Aide #12 was observed entering a resident's room who was on transmission based precautions, without proper personal protective equipment and without performing appropriate hand hygiene. There was no documented evidence Certified Nurse Aide #12 had competencies or education provided by the facility, specifically infection control practices. (See F 880) - Certified Nurse Aide #36 had no documented competencies or education provided by the facility - Licensed Practical Nurses #26, #27, and #35 had no documented competencies or education provided by the facility. Findings include: The 2/2016 facility policy, Nursing Policy, documented Staff Development/Nurse Educator was responsible for supervising the skilled training program for new nursing personnel. The 5/2022 facility policy, Orientation Program for Newly Hired Employee and Volunteers, documented the orientation program was separate from the role-specific training and/or in-service training of new and existing staff. The orientation included an introduction to resident care procedures, administration structure, infection control practices, and call light and intercom system. In addition to the general orientation, each department orients the newly hired employee/volunteer to their department's policies and procedures. Records of orientation were filed in the personnel file upon completion of orientation programs, and completed copies of the employee orientation checklists were filed in the employee's personnel file. The 3/19/2024-7/16/2024 Facility Assessment, documented skill nursing needs that included oxygen, suctioning, tracheostomy, intravenous medications, isolation, feeding tubes, mechanically altered diet, catheterization, ostomy, toileting programs, injections, immunizations, bariatrics, insulin, psychoactive medications, anticoagulants, antibiotics, diuretics. Competencies and training are conducted upon hire as part of general orientation, annually and as needed. There was no documented evidence of a policy and procedure for competency evaluations. The facility used agency nursing staff to provide direct patient care to the residents from 7/22/2024 - 7/24/2024. - on 7/22/2024, the facility used 22 agency staff. - on 7/23/2024, the facility used 27 agency staff. - on 7/24/2024, the facility used 24 agency staff. Nursing personnel records were reviewed, for the following agency staff, all starting at the facility in 2024: - Certified Nurse Aide #12 had no documented competencies or education provided by the facility. - Certified Nurse Aide #36 had no documented competencies or education provided by the facility. - Licensed Practical Nurse #35 had no documented competencies or education provided by the facility. - Licensed Practical Nurse #26 had no documented competencies or education provided by the facility. - Registered Nurse #27 had no documented competencies or education provided by the facility. Licensed Practical Nurse #22's last medication administration competency was documented as 4/28/2022. An electronic communication from the Administrator dated 7/25/2024 at 10:18 AM, documented the agency staff were provided an on-floor orientation with the understanding that the agency was providing nursing competencies and education for common nursing practices prior to assignment. During an interview on 7/25/2024 at 11:03 AM, Licensed Practical Nurse Unit Manager #14 stated the agency did not receive competencies in the facility. They attended on the unit in-service trainings. They did not go to orientation. Agency staff came in and did the job. There were certified nurse aides and licensed practical nurses on their unit that were from an agency. The Director of Nursing might ask a nurse to walk agency staff around the unit, but there was no formal orientation. During an interview on 7/25/2024 at 2:46 PM, Registered Nurse Unit Manager #24 stated they had agency staff on their unit. They had never seen the facility complete a medication administration observation for agency staff and they did not get a formal orientation. They tried to give any new agency staff a walk around of the unit when they were assigned to their floor. During an interview on 7/25/2024 at 4:54 PM, the Staffing Coordinator stated the standard orientation and orientation packet was only for in-house (employed directly by the facility) staff. During an interview on 7/26/2024 at 11:12 AM, Nurse Educator #38 stated they completed the initial medication administration observation with new staff, when the nurse started at the facility, and then annually, usually in December. They did episodic training as needed. Agency staff received education if they did on unit in-service training when the agency staff member was working. Agency staff did not receive general orientation, and they did not complete competencies. The Nurse Educator was unsure how the facility ensured the agency staff were competent to provide direct care to the residents. They stated ensuring competency was important for the safety of the residents, and to ensure the nurses knew what they were doing before they went out and provided care. Licensed Practical Nurse #22's full training file was provided, everything they had completed was in the folder. During an interview on 7/26/2024 at 9:28 AM, the Director of Nursing stated agency staff did not get orientation. They showed up to the unit and got a brief report from the Unit Manager or the Assistant Director of Nursing. 10 NYCRR 415.26(c)(1)(iv)

Based on observation, record review, and interview during the recertification survey conducted 7/22/2024-7/26/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, food was not maintained at proper temperatures and the dishwasher was not maintaining the proper temperature. Findings include: The Food Service Department policy, Maintaining Food Temps, last reviewed 4/2012 documented food would be prepared, stored, and transported in a manner that would ensure proper serving temperatures. Food Temperatures: During an observation in the main kitchen on 7/23/2024 at 11:18 AM, chicken salad was observed in the walk-in cooler. The chicken salad was covered and was in a large plastic hotel sized pan that was 6 inches deep. The chicken salad contained 10 pounds of chicken, 1 gallon of mayonnaise, and additional ingredients. The chicken salad's temperature was measured at 52 degrees Fahrenheit. During an interview on 7/23/2024 at 11:19 AM, Prep Cook/Dietary Aide #55 stated they prepared the chicken salad about 10 minutes ago. The chicken was pre-cooked, and they added mayonnaise and celery and mixed it all together. They stated food could be out of temperature for up to 10 minutes for meal preparation. During an interview on 7/23/2024 at 11:21 AM, the Food Service Director stated the chicken salad was being served for the dinner meal and was served on whole wheat bread. They stated potentially hazardous food could be left out of temperature during necessary preparation for 2 hours. They stated the chicken salad would be completely cooled by the dinner meal. During an interview and observation on 7/23/2024 at 1:05 PM, the chicken salad was measured at 47 degrees Fahrenheit. The Food Service Director stated the chicken salad was moved from the bigger pan to four shallow pans because it was not cooling timely. The chicken salad had only cooled 5 degrees in nearly 2 hours, therefore was placed in the walk-in freezer to cool rapidly. After 20 minutes the temperature was measured again and was at or below 41 degrees Fahrenheit. Dishwasher Temperatures: During an observation on 7/23/2024 at 1:24 PM, the mechanical dishwasher required specifications documented on the side of the machine were as follows: - wash temperature 160 degrees Fahrenheit - final rinse temperature 180 degrees Fahrenheit The dishwasher was observed with a wash temperature of 157 degrees Fahrenheit and a final rinse temperature of 171 degrees Fahrenheit. During an observation and interview on 7/23/2024 at 1:27 PM, Dietary Aide #56 checked the dishwasher and recorded the following in the log, wash temperature 163 degrees Fahrenheit, final rinse temperature 157 degrees Fahrenheit. They stated they got the temperatures from the digital display on the front of the dishwasher. During an interview on 7/23/2024 at 1:40 PM the Food Service Director stated the wash temperature was between 150-160 degrees Fahrenheit and the rinse temperature was between 180-194 degrees Fahrenheit. They stated they observed staff daily to make sure the temperatures were completed and documented in the log. The log documented several days of recorded temperatures that were below the required temperatures. The Food Service Director stated they did not do anything about it as they went by the wash temperatures on the log sheet. During an observation and interview on 7/24/2024 at 1:46 PM the dishwasher wash temperature read 151 degrees Fahrenheit, and the rinse temperature read 181 degrees Fahrenheit. The Food Service Director stated the machine was not serviced because the service people came and stated it was working fine and just took time to reach the temperature. 10NYCRR 415.14(h)

Based on record review and interview during the abbreviated survey (NY00307423), the facility did not immediately inform the resident's representative when there was a need to alter treatment for 1 of 3 residents reviewed (Resident #2). Specifically, Resident #2 was prescribed a medication for dementia and the resident's representative was not notified. Findings include: The 11/2009 revised Notification of Family/Responsible Party Regarding Change in Resident Status Policy documented a resident's family/responsible party would be notified regarding any change in a resident's medical status including new medications. Resident #2 had diagnoses incluidng a prior fall and dementia. The 11/23/2021 Minimum Data Set Assessment documented the resident's cognition was moderately impaired and it was very important to them to have family or a close friend involved in discussions about their care. The Health Care Proxy (health care decision maker) form documented on 9/27/2019, the resident designated a family member to make their medical decisions if they were unable to do so themselves. The 11/19/2021 Medical Orders for Life-Sustaining Treatment form documented the resident lacked decision making capacity for health care decisions and their Health Care Proxy signed as completing the form. The 11/12/2021 through 11/17/2021 hospital Medication Administration Record documented memantine (dementia medication), 5 milligrams twice daily was not given and to see the provider order. There was no documentation of a hospital physician order for this medication. The 11/17/2021 hospital discharge summary documented the resident was hospitalized following a fall at home and sustained multiple injuries. The resident had a history of Alzheimer's disease and took memantine. Hospital discharge medications included memantine 7 milligrams daily. The 11/17/2021 at 2 PM, registered nurse #20's admission progress note documented the resident's orders and medical history were reviewed with the nurse practitioner #21. The 11/17/2021 admission medication orders did not include an order for memantine. The 11/26/2021 physician order's entered by physician #10 and verified by physician #10 documented memantine 7 milligrams daily. There were no corresponding progress notes documenting why memantine was ordered. The 11/26/2021 History and Physical completed by physician #10 documented the resident was a new admission. They reviewed old records from the hospital and labs. There was no documentation that memantine was going to be ordered. There was no documented evidence the resident's Health Care Proxy was notified of the physician's order for memantine. The 11/28/2021 at 2:12 PM registered nurse Manager #7's progress note documented the resident was screaming they were 8 feet in the air, they were going to fall, and the resident refused to let go of a family member's hand. The resident was shaking vigorously, yelling that everything was spinning, and they could not sit up on their own. The 11/29/2021 at 1:43 PM, registered nurse Manager #7's progress note documented they spoke with the resident's family member and they were concerned regarding the resident's confusion. The family member reported a nurse told them they were administering memantine to the resident that morning per physician #10's order given on 11/27/2021. The family member was concerned the resident had a reaction to the medication in the past and did not want the resident to take it. The note documented the medication was discontinued. The 11/2021 Medication Administration Record documented memantine was given for 2 days, on 11/27/2021 and 11/28/2021, and discontinued on 11/29/2021. During an interview on 11/30/2023 at 10:30 AM, the resident's Health Care Proxy stated: - prior to coming the facility, the resident was in the hospital following a fall at home. - Prior to hospitalization, the resident was prescribed memantine and had an acute reaction to the medication. - When the resident was admitted to the hospital, they told the hospital not to administer memantine to the resident as they had a severe acute reaction to it and it was their understanding that memantine was not administered in the hospital. - Upon admission to this facility, they told staff the resident could not take memantine and it was not ordered. - After approximately 10 days in the facility, memantine was ordered. - They were not notified memantine was ordered and they found out about it when another family member visited inquired about medications being given. - If they had been called when the memantine was ordered, they would have told the facility not to administer it as the resident could not take it. During a telephone interview on 12/7/2023 at 9:03 AM, former registered nurse Manager #7 stated when a resident started a new medication, some families wanted to be contacted to obtain consent and usually the medical provider was responsible to call. They believed when physician #10 was doing the resident's History and Physical, they reviewed the hospital discharge summary, saw orders to continue memantine, and ordered the medication. Physician #10 could enter their own orders without a nurse verifying the order. They spoke with physician #10 in the past to notify nursing when they added or changed a medication. If physician #10 ordered memantine then they assumed physician #10 called the family. They stated they were not aware of a facility policy to notify family members when a new medication started. During a telephone interview on 12/7/2023 at 3:25 PM, attending physician #10 stated when they completed a History and Physical, they always reviewed the hospital discharge summary and talked to residents to review their history. Certain types of medications required consent and the prescriber would obtain consent unless it was a telephone order, then nursing obtained consent. On 11/26/2021, they reviewed the resident's hospital records and memantine was documented on the discharge medication list indicating the resident took the medication in the hospital. They believed they added memantine because it was not originally ordered upon admission. They stated they did not think the family needed to be notified because the resident took the medication in the hospital. They did not notify the family when they ordered memantine. 10NYCRR 415.3(e)(2)(ii)(b,c)

Based on observation, record review and interview during the recertification survey conducted 3/28/22-4/4/22, the facility failed to ensure residents were assessed to determine ability to safely self-administer medication when clinically appropriate for 1 of 1 resident (Residents #116) reviewed. Specifically, Resident #116 had an inhaler (hand-held, portable devices that deliver medication to the lungs) at their bedside and there were no physician order for self-medication administration and/or resident assessments to determine ability to safely self-administer medications. Findings include: The facility policy Self- Administering of Medications dated 5/8/2015, documents residents are assessed and evaluated upon admission, and if found capable, may self-administer medications. The interdisciplinary team will meet and complete assessment form to decide to trial a resident for self-administration of medications. The resident medication administration record (MAR) will be labeled to identify the resident as self-medicating. Resident #116 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia (insufficient oxygen), and pneumonia. The 1/10/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance with activities of daily living (ADL), and received oxygen. The comprehensive care plan (CCP) dated 4/23/21 documented the resident received oxygen (02) at 3 liters via nasal cannula (NC), used continuous positive airway pressure (CPAP) at bedtime, was monitored for oxygen saturations, and equipment was to be observed with each encounter. The care plan did not include an inhaler or if the resident could safely administer an inhaler. The physician order dated 2/23/22 documented ProAir HFA (short-acting bronchodilator containing albuterol) was discontinued. The 3/2022 medication administration record (MAR) did not document an order for ProAir HFA or for the resident to self-administer medications. There was no documented evidence that a self-medication assessment was completed for the resident. Observations of the resident with the ProAir inhaler included: - On 3/28/22 at 12:12 PM, the inhaler was in the bed with the resident. The resident stated they used the inhaler as needed. - On 3/29/22 at 11:51 AM, the inhaler was on the bedside table while the resident was awake in bed. - On 3/30/22 at 10:11 AM, the inhaler was on the nightstand while the resident was asleep in bed. - On 3/31/22 at 9:19 AM, in a bucket of personal belongings next to the resident's bed. During an interview on 3/30/22 at 3:55 PM, the resident stated the inhaler on the table was ordered through the facility's pharmacy. They used the inhaler twice a day, in the morning and the evening, and it could be used in between those times if needed. They had been using an inhaler prior to admission to the facility. They stated they did not tell the nurses how often they used the inhaler and that the nurses did not ask them, either. The resident stated they usually knew when the inhaler was getting low and would tell the nurses. During an interview on 3/30/22 at 4:00 PM, licensed practical nurse (LPN) #7 stated the resident currently used Breztri Aerosphere (long-acting inhalation aerosol medication) 160 mcg/9 mcg/4.8 mcg, 2 puffs twice a day, and it was kept in the medication cart. It could also be used as needed (PRN). The resident had previously used ProAir, but it was discontinued on 2/23/22. The LPN stated the resident also received albuterol nebulizer treatments every 4 hours and PRN. During an interview on 4/1/22 at 9:47 AM, LPN #8 stated they did not know what the process was for residents self-administering medications, but the registered nurse (RN) would do an assessment to determine if the resident was competent to self-administer medications. The nurse stated they were uncertain if the resident was allowed to self-administer medications. During an interview on 4/1/22 at 10:19 AM, RN Unit Manager #9 stated there were residents that could self-medicate. There was an observation check list that the RN would observe and complete the assessment, and then contact the physician to get an order for self-administration. The resident currently used inhalers and there was no self-administration assessment documented. There was no physician order to self-administer. If the self-administration of medication form was completed and there was an order from the physician, then the resident would be allowed to keep the inhaler at the bedside. They were not aware how often the resident was using the inhaler. If a resident did not have a self-medication assessment completed, they should not have any medications at the bedside During an interview on 4/1/22 at 10:37 AM, nurse practitioner (NP) #10 stated the resident would have been able to self-administer their own medications, but they had not received a request for an order to self-medicate. The resident could make their own decisions. During an interview on 4/1/22 at 10:53 AM, the Director of Nursing (DON) stated the resident would need an assessment completed to verify that the resident was able to administer the medication safely and correctly. An order was needed from the provider and the resident's care plan would be updated to reflect that. If a resident did not have the self-administration assessment completed, they should not have any medications at the bedside. They would expect the Unit Manager to complete a self-administration assessment and obtain a physician order if the resident wanted to self-medicate. During an interview on 4/1/22 at 11:46 AM, physician #6 stated if a resident was alert and oriented, able to understand their medications and was assessed by the nurse to be safe to administer their own medications, then they would give an order to self-medicate. They did not recall giving an order for the resident to self-administer their inhaler. 10NYCRR 415.3(e)(1)(vi)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and abbreviated (NY00268244) surveys conducted 3/28/22-4/4/22, the facility failed to promote and facilitate resident self-determination through support of resident choice for 6 of 6 residents (Residents #11, 41, 47, 54, 67 and 77) reviewed for choices. Specifically, Residents #11 and 47 were administered a medication during their normal sleeping hours without consideration of their preferences; Residents #41 and 67 were not offered their preferred food or drink; and Residents #54 and 77 were not provided haircuts per their preference. Findings include: The facility policy titled Food Preferences dated 5/2012 documented every resident upon admission will be asked to list their food preferences. The purpose of the policy is to help maintain a caring, home-like atmosphere. Each resident should have the alternate and substitute policy explained. The facility policy titled Dispensing Times dated 3/2021 documented the facility was to ensure medications are passed within the appropriate times ordered and recognizing resident choices and the need to individualize a resident's plan of care. GROOMING/HAIRCUTS Resident #77 was admitted with diagnoses including osteoporosis and heart failure. The 12/28/21 Minimum Data Set (MDS) assessment documented the resident had intact cognition and required supervision with personal hygiene. During an interview on 3/31/22 at 10:41 AM, the resident stated they would like their hair cut and have not had a haircut in over a year. They preferred their hair short. They stated they told several staff they would like their hair cut but could not recall their names. The last they knew the hairdresser had quit and they were unsure if the salon was even open. During the interview the resident was observed to have shoulder length hair that was pulled back with a cloth head band. The resident's personal funds statements documented the resident's last hair cut was 5/17/21. The hairdresser schedule dated between 12/2021-3/2022 documented they were available on the following Tuesdays and Wednesdays: 12/14, 12/15, 12/21, 12/22 and 12/28/21; 1/4 and 1/5/22; 2/15 and 2/16/22; and 3/2, 3/8, 3/15, 3/16, 3/22, and 3/23/22. During an interview on 4/1/22 at 11:03 AM, licensed practical nurse (LPN) Unit Manager #3 stated when a resident wanted a haircut, the resident usually told the certified nurse aide (CNA) and the CNA reported it to the Unit Manager. Once the Unit Manager was made aware they would then tell the Director of Activities who was responsible for the haircut schedules. During an interview on 4/1/22 at 11:23 AM, the Director of Activities stated the beauty salon was open, but only on Tuesdays and Wednesdays. The hairdresser had not been in to work recently. Resident #77 was on their list for an appointment. They kept an informal list of residents with a request to get their hair done, and once they had received their haircut, they made a note with a check mark next to the resident name. They stated it would not be documented in the resident's medical record. They stated Resident #77's last haircut was 5/17/21. During an interview on 4/1/22 at 1:08 PM, LPN Unit Manager #3 stated they were not aware the resident wanted their hair cut. During an interview on 4/4/22 at 2:45 PM, the Administrator stated the beauty shop was closed in late 4/2021 through 5/2021 and then remained closed until 12/2021 due to COVID-19 in the facility. The beauty shop closed in the middle of 1/2022, and was re-opened for one week in 2/2022, and opened again in 3/2022. During the last year the facility had been very focused on COVID-19 protocols. The beauty shop was supposed to be open on Tuesdays and Wednesdays. The beauty shop had been closed during the recertification survey. The hairdresser had notified the facility they would not be able to work their scheduled Tuesday and Wednesday. The residents were allowed to take a leave of absence for haircuts. It was not acceptable for a resident to go without a haircut for almost a year. FOOD PREFERENCES Resident #67 had diagnoses of diabetes, mild protein-calorie malnutrition, and morbid obesity. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition and was independent with most activities of daily living (ADLs). A physician order dated 11/30/21 documented the resident was to receive a regular texture, regular diet, and thin liquids. The resident was observed: - On 3/30/22 at 8:30 AM, eating breakfast in their room, they had concerns of having hot cereal (cream of wheat) and no sugar on their tray. The meal ticket did not list sugar. They stated the housekeeper had gotten sugar for them that morning. - On 3/31/22 at 8:51 AM, eating breakfast in their room. There was hot cereal and no sugar on their tray and sugar was not listed on the meal ticket. The resident did not remember talking to a dietitian to discuss their food preferences since admission. During an interview on 3/31/22 at 1:45 PM with housekeeper #43, they stated the resident complained there was no sugar on their breakfast tray 3/30/22, and they wanted it for their hot cereal. The housekeeper got some sugar from the kitchenette. It was not the first time the resident had requested missing items from them. They did not check with anyone to make sure the resident was allowed to have sugar. During an interview on 3/31/22 at 1:48 PM certified nurse aide (CNA) #12 stated missing items on trays happened occasionally, and sugar was the most common item missing. This happened often with Resident #67, and they probably should talk to dietary. During an interview with Resident #67 on 3/31/22 at 2:03 PM they stated they had not talked to anyone from the dietary department regarding their likes and dislikes or menu choices. They did not understand why they did not get sugar with their hot cereal in the morning. They had to request it every morning and if staff were not available to get the sugar, they did not eat their cereal. During an interview on 3/31/22 at 4:28 PM with registered dietitian (RD) #45, they stated the process regarding dietary assessment on admission was to wait for the diet order, then generate meal tickets in the meal tracker. Within 24 hours they tried to see a resident in person to ask for specific preferences. There was a list with almost all menu items, to be noted with dislikes to not serve residents those foods. The meal tracker program automatically gave main entrees if not listed as a dislike. If the main entree was listed as a dislike, the alternate was provided. Staff would often report changes that a resident had stated they would like. There had been times when there was no RD in the facility, and that may have caused a gap in completing Resident #69's preferences. Preference forms for Resident #69 did not appear to have been completed as there were no dislikes listed, which indicated the preference form was not done. During an interview on 4/1/22 at 12:13 PM with the Director of Nursing (DON), they stated the expectation for food likes and dislikes was to be assessed on admission. If a resident did not receive a food item on their tray it should be reported to nursing. MEDICATION ADMINISTRATION Resident #47 had a diagnosis including hypothyroidism. The 11/20/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required limited assistance for most activities of daily living (ADLs), and the resident participated in the assessment. The 9/30/20 physician orders documented levothyroxine 50 micrograms (mcg) 1 tab orally once a day at 5:00 AM for hypothyroidism. The order was created by registered nurse (RN) #39 verified by licensed practical nurse (LPN) #40, and telephone ordered by nurse practitioner (NP) #10. The 3/8/22 comprehensive care plan (CCP) documented the resident and family determined long term care placement, and the resident planned their own daily routine. The 3/2022 medication administration record (MAR) documented the resident was administered levothyroxine 50 mcg once daily at 5:00 AM. It was signed as given by LPN #32 on 3/28/22 and 3/31/22, and LPN #4 on 3/29/22 and 3/30/22. During a resident group meeting on 3/29/22 at 10:32 AM, the resident stated they were scheduled to get their thyroid medication at 4:00 AM, sometimes staff gave it at night for convenience, and the resident felt the early morning was too early to receive medications. During an interview with LPN #32 on 3/31/22 at 5:58 PM, they stated thyroid medications were typically given in the morning, around 4:00 AM. They were to be given a couple hours prior to breakfast for absorption purposes. They did not know what time breakfast because they did not work during that shift. The resident was usually sleeping when they gave them the medication. They stated the resident did not state anything as it was routine for them to get the medication at that time. During an interview with LPN #40 on 3/31/22 at 6:05 PM, they stated when a medication was being ordered it would depend on the medication and what time the physician wanted it. Thyroid medications were given early, usually first thing in the morning, which would be around 6:30 AM. They stated thyroid medication was to be given on an empty stomach and before breakfast. The resident could speak for themselves. The LPN did not work during the time the resident was scheduled for that medication. The resident did prefer to stay up later at night. They stated they did not have discussions with residents regarding medications, even if they assisted in entering the orders. That discussion was usually with the physician, the nurse practitioner, or the Unit Manager. During an interview with NP #10 on 4/1/22 at 11:59 AM, they stated thyroid medication was usually administered between 5:00 AM and 6:00 AM. They did have some residents where that time did not work for them, and they adjusted them around their schedule. It was automatically ordered for 6:00 AM unless a resident stated they did not want it at that time. It would be the responsibility of the nurse or Unit Manager to have those discussions with the resident. During an interview with physician #6 on 4/4/22 at 3:25 PM, they stated thyroid medication was to be given before a meal on an empty stomach, about a half hour before a meal, so that it would be absorbed. They stated if a thyroid medication was added the provider would discuss it with nursing, and they would set up a time that was practical for the resident. They stated some residents did not like medications in the morning, so they could adjust the time if needed. They stated they were familiar with the resident, did not realize the resident wanted it at another time, and this resident would qualify for having it administered at another time of day. 10NYCRR 415.5(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification and abbreviated surveys (NY00284523) conducted [DATE]-[DATE], the facility failed to ensure conveyance, within 30 days of death, the resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate, in accordance with State law for 1 of 1 resident (Resident #182) reviewed. Specifically, Resident #182 expired in the facility and disbursement or final accounting of the resident's funds was not sent to the resident's representative within 30 days of their death. Findings Include: Resident #182 was admitted to the facility with diagnoses including neoplasm stromal tumor (formation of abnormal cells) and major depression. The [DATE] Minimum Data Set (MDS) discharge assessment documented the resident had expired in the facility on [DATE]. The resident statement for final accounting in the facility billing system documented the resident had expired on [DATE] and there was no disbursement for remaining funds and final accounting sent to the resident representative until [DATE]. When interviewed on [DATE] at 1:10 PM, the billing office assistant #19 stated all reimbursement of funds or final accounting goes through corporate billing. If a family member asked about a resident's final accounting, they would go through the corporate biller first and find out if there were any billing issues. The family member would be sent a check in the event of a resident's passing. They did not know about a final accounting and were not sure if they did anything other than send a check after review by corporate billing. Most residents did not have accounts at the facility unless they signed papers to have things sent here. They were not aware of any final accounting timelines that needed to be followed when a resident leaves or has expired. When interviewed on [DATE] at 1:16 PM, the Business Manager stated with Medicare/Medicaid patients they would check within 24-48 hours after death if there was any funeral application that money would be needed for. After 72 hours anything that is owed per the admission agreement would be paid. Any money left over would be discussed with family or representative. They would be asked where they would like the check for the remaining funds sent. The Business Manager stated they try to have a final accounting done within a week. The facility would do a billing inquiry the same day to make sure there was no money owed elsewhere prior to dispersing left over funds. The Business Manager stated in 9/2021 they took over for the prior group and conducted an audit of the accounting and personal funds and found the errors with the resident's account. A check should have been sent out to the resident's family on [DATE]. On [DATE] there was a credit adjustment that was caught and not done on [DATE] so they sent out the check. On [DATE] a credit adjustment came in from corporate, so they dispersed another check at that time. The Business Manager stated they were not aware of any time parameters for final accounting for resident funds after they discharged or expired. The Business Manager stated they wanted a final resolution within a week regardless of the resident's situation. 10NYCRR 415.26(h)(5)(iv)

Based on record review and interview during the recertification survey conducted 3/28/22-4/4/22, the facility failed to ensure that all allegations of abuse, neglect, exploitation, or mistreatment were reported immediately but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury, to the New York State Department of Health (NYSDOH) for 1 of 1 resident (Resident #54) reviewed. Specifically, Resident #54 was entrapped in a bed rail and sustained a fractured anatomic neck of the left humerus (upper arm bone where it meets the shoulder) and the incident was not reported to the NYSDOH as required. Findings include: The facility policy Resident, Abuse, Neglect, Mistreatment, Prevention & Reporting revised 11/2017 documented once a facility/staff member has reasonable cause to believe a violation of abuse, mistreatment, neglect, injuries of unknown origin or misappropriation of resident property has occurred, it must be immediately reported to the NYS DOH. Immediately is defined as soon as possible, but no later than 24 hours after the discovery of the incident. Resident #54 had diagnoses including vascular dementia, cerebrovascular disease, and convulsions. The 3/3/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of 1 for bed mobility, was not transferred in the 7-day look back period, had functional limitation in range of motion on one side and the resident did not use a bed rail restraint. The comprehensive care plan (CCP) initiated 11/17/16 documented the resident used 2 half enabler bars as an assistive device for bed mobility. The CCP was updated on 8/15/19 and documented the bed rails were to be assessed quarterly and as needed (prn). The Side Rail Safety Interdisciplinary Evaluation Tool, completed 8/12/20 documented the resident used a bed rail for increased independence with bed mobility, the bed rail was care planned for, and viewed as secure and was without safety concerns. The Accident/Incident report documented on 5/18/21 at 7:25 PM, the resident was observed by temporary nurse aide (TNA) #18 to be slowly sliding from their bed and yelling help. TNA #18 attempted to assist the resident but could not reach them in time to prevent the fall. While sliding the resident's left arm became caught on the top half left bed rail due to resident's left sided paresis (muscle weakness). The bed was noted in the lowest position during the fall. TNA #18 called out to staff for assistance. The resident's left arm was removed from the bed rail by nursing staff and registered nurse (RN) #1 completed a full assessment of the resident. The resident was assisted back into bed and positioned to their preference. The 5/18/21 x-ray report documented the resident had an acute fracture of the anatomic neck of the left humerus. There was no documented evidence the incident related to entrapment of the resident's left arm in the bed rail or use of equipment was reported to the NYSDOH as required. The 5/20/21 investigative summary and conclusion of incident, completed by the Director of Nursing (DON), determined the incident was not reportable to the NYSDOH. This was determined related to the resident being cognitively intact, was attempting to self-transfer, and was care planned and evaluated for use of bed rails prior to the incident. It was documented following the incident measures implemented included reviewing and updating the resident's care plan and a bed rail evaluation was to be completed. During an interview with the DON on 4/4/22 at 3:02 PM, they stated the facility interviewed staff after the incident. The resident was cognizant, had left sided weakness, slowly slid from the bed, and staff were unable to reach the resident prior to their arm sliding under the bed rail and not through it. The DON stated it would be a reportable incident if the resident had a bed rail, the arm got entangled, and the resident got injured. The resident's weight and weight of the mattress caused the left arm to slide under the bed rail and not through it. After reviewing the reportable incident manual, the facility felt it was not a reportable incident. 10NYCRR 415.4(b)(2)

Based on observation, record review, and interview during the recertification survey conducted 3/28/22-4/4/22, the facility failed to ensure allegations of abuse, exploitation, or mistreatment were thoroughly investigated for 1 of 5 residents (Resident #140) reviewed. Specifically, Resident #140 had a fall and the resident's care plan was not reviewed to determine if the care plan was followed. Findings include: The facility policy Incident/Accidents Reporting, Investigating and Implementing Corrective Action dated 10/2017, documents it is the policy of the facility to promptly investigate any incident/accident and initiate measures to prevent reoccurrence. Any incident or accident resulting in bodily injury will be reported immediately to the Director of Nursing (DON)/Assistant Director of Nursing (ADON) who, in turn, will report to the Administrator. Resident #140 had diagnoses including history of falls, dementia with behaviors, and restlessness and agitation. The 2/2/22 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment; exhibited physical, verbal, and other behaviors 1-3 days during the assessment period; was totally dependent for bed mobility, transferring, toilet use, and hygiene; was not steady; and received anti-psychotic, anti-depressant, anti-anxiety, and diuretic medications 7 of 7 days of the assessment period. The 11/18/21 Fall Risk assessment, completed by registered nurse (RN) #33, documented the resident was a high risk for falls. The 12/29/21 Fall Risk assessment, completed by RN Unit Manager #22, documented the resident was a high risk for falls. The 2/26/22 updated comprehensive care plan (CCP) documented the resident had behaviors, had dementia, was at risk for wandering, and was at risk for falls. Interventions included music, 1:1 interaction, maintain calm approach and environment, verbal reminders, Wanderguard bracelet, redirect as needed, snacks, arts and crafts, games, medications as ordered, do not leave unattended in dining room, low bed with floor mat, keep call bell in reach, shoes when out of bed, remind frequently to not get up by self, non-slip pad under bottom on wheelchair pad to prevent slipping, and extensive assistance of 1 with transfers and bed mobility. The 3/18/22 at 2:33 PM, graduate practical nurse (GPN) #36's progress note documented the resident was self propelling around the unit yelling vulgar phrases and was not easily redirected by multiple staff. The 3/22/22 at 11:56 AM licensed practical nurse (LPN) Unit Manager #3's progress note documented the resident was self propelling around the unit yelling at others and yelling about things on the floor not seen by others. The resident had been redirected with short term effect. Staff were closely monitoring the resident. The 3/22/22 incident report documented the resident was in a wheelchair in a common area and fell face forward onto the floor at 7:00 PM. The resident sustained an abrasion and bruise. The interventions in place prior to the incident included low bed with mat, keep room free of clutter, call bell in reach, proper footwear, encourage resident to ask for assistance, and do not leave unattended in dining/common area. The resident was unable to give an account of the incident due to cognition level. Licensed practical nurse (LPN) #37 documented they heard something fall on the ground, the resident was seen on the floor with their face against the floor. The LPN documented they thought the resident was trying to self-transfer and fell to the floor. There was no documented evidence the 3/22/22 incident report included review of the resident's CCP to determine if the care plan was followed at the time of the fall. The 3/22/22 at 11:35 PM LPN #37's progress note documented the resident was found on the floor in the unit common area. The resident was lying on their stomach with their face on the floor. The resident's nose was bleeding, and compression and ice were applied. The resident had facial bruising and swelling. The 3/23/22 at 4:33 PM RN #30's progress note documented the resident was found on the floor on their left side. There was a small amount of bleeding from their nose and the resident had sustained a mid-forehead abrasion. On 3/28/22 at 11:55 AM, the resident was observed sitting in a wheelchair in the unit dining room. The resident had an abrasion on the middle forehead area about 1 inch x 2 inches. The resident had purple fading to yellow bruising to the upper cheeks. The resident stated they had a fall. On 3/28/22 at 2:20 PM, the resident was observed on other wing adjacent to their unit. The resident was wheeling themself in a wheelchair, got stuck on a precaution bin in the hallway, shifted and removed themself, and began wheeling back the opposite direction of the room. No staff were present. At 3:30 PM, the resident was by another room on the same side of the unit, getting stuck on the handrail, and calling for assistance. During an interview on 4/1/22 at 9:35 AM, LPN #37 stated the resident had a fall a couple of weeks ago. The LPN stated they were passing medications on the unit when a thud was heard. The LPN looked up and saw the resident on the floor in the unit common area. The Supervisor was called, and the resident was assessed. The LPN did not remember the RN implementing any new interventions post incident, but the LPN gave the unit staff directions to monitor the resident more closely. They did not know if the resident had a non-slip pad in place. There were no other staff present in the common area. During an interview on 4/1/22 at 12:43 PM, the Director of Nursing (DON) stated any interventions in place at the time of the resident's incident should have been checked and included in the investigative report. The DON stated interventions were not documented on the incident report. One of those interventions was to not leave the resident alone in the dining room, and it was not indicated if this was addressed or reviewed. 10NYCRR 415.4(b)(2)(3)

Based on observation, interview, and record review during the recertification survey conducted 3/28/22-4/4/22, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for 1 of 3 residents (Resident #54) reviewed. Specifically, use of a palm guard (used for hand contractures) was not addressed in Resident #54's comprehensive care plan (CCP) and care instructions to ensure staff applied the palm guard. Additionally, when the palm guard was not available, therapy was not notified to provide a replacement. Findings include: The facility policy Activities of Daily Living (ADL) revised 9/2009 documents the certified nurse aides (CNAs) will assist or provide ADLs according to individual resident needs according to specific care procedures. The policy was to help maintain the residents' highest level of functional ability. ADLs were to be performed following resident care plan after completion by Nurse Manager and Rehabilitation Department. Resident #54 had diagnoses including dementia, stroke, and left hemiplegia (paralysis of one side of body). The 11/30/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact; required extensive assistance with personal hygiene, bed mobility; and had functional limitation in ROM to one arm and one leg. A 5/20/21 occupational therapist (OT) #35's progress note documented the resident was evaluated following a fall from bed with their left arm trapped in the bed rail with findings from X-ray to have a left shoulder fracture. The 5/26/21 OT #35 progress note documented the resident would not be able to complete positioning or management of left hand or splint application without staff assistance and was at risk for skin breakdown and further injury without staff education. The resident would benefit from further staff education for left hand management for comfort and optimal access to meals. The 6/2/21 OT #35's progress note documented the resident required maximal assistance for positioning left shoulder and hand due to hemiparesis. The 8/19/21 OT #35's progress note documented the resident was at baseline and had no active muscle movement in the left arm. The plan was to continue to utilize left terry cloth palm guard to prevent skin breakdown. The resident required extensive assistance of 2 for self-care while lying in bed. There were no signs of increased contractures. The comprehensive care plan (CCP), initiated 7/9/15 and reviewed 2/7/22, documented the resident was at risk for pain, needed assistance with ADLs, and was at risk for impaired skin integrity. Interventions included monitor and observe resident's extremities, inspect skin with morning and bedtime care, report abnormal skin conditions, keep skin clean and dry, range of motion during care and report decline to charge nurse. The CCP documented PT/OT consult as needed, total assistance with upper body dressing, extensive assistance with lower body dressing, bathing, and grooming. The CCP did not document adaptive equipment, including a palm guard, or a plan to prevent further decline in contractures. The 1/3/22 (active) care instructions documented the resident required extensive to total assistance with grooming, dressing, and bathing. The care instructions did not document adaptive equipment, including a palm guard, or range of motion during care. During an observation on 3/28/22 at 11:55 AM, the resident was lying in bed. The resident's left hand was contracted with the tips of their fingers touching their palms without a palm guard device in place. During an observation on 4/4/22 at 3:35 PM, the resident's left hand was contracted and there was no palm guard in their hand. The resident was unable to open their fingers to show the palm of their left hand. During an observation of Resident #54's care by temporary nurse aide (TNA) #24 on 3/31/22 at 1:46 PM, the TNA stated they cared for the resident each day they worked, and the resident did not participate in their care. The resident and the TNA both stated staff never placed anything in the resident's left hand. The TNA stated they did not provide or assist with ROM to the resident's hand. The resident then demonstrated the ability to open their hand up but had pain when doing so. When interviewed on 3/31/22 at 1:55 PM, certified nurse aide (CNA) #25 stated the resident did not assist with care and there were no interventions in place for the resident's left contracted hand. When interviewed on 4/1/22 at 11:06 AM, CNA #26 stated staff had inquired about a palm guard as the resident's nails cut into the left hand due to the contractures. The resident used to have one but had not had one for a long time. CNA #26 stated a rolled-up tissue or hand towel did not help, and staff did not perform left hand ROM for the resident's left contracted hand. The CNA stated there was nothing in the resident's care profile about a palm guard. When interviewed on 4/1/22 at 11:44 AM, graduate practical nurse (GPN) #28 stated the resident did not use the left hand and was not able to open it by themselves. The GPN was unaware of a missing palm guard. When interviewed on 4/1/22 at 12:16 PM, Rehabilitation Director #16 stated OT #35 was no longer employed by the facility. The Director stated after review of the therapy notes, the resident was to continue with the terry cloth left palm guard for skin breakdown. The Director stated they checked the electronic record system for therapy screen requests twice a day and had not seen a request for the resident. The Director stated therapy was not responsible to update CCPs. The Director stated the 8/11/21 CCP update, and resident instructions did not document the left palm guard and both should still have the device documented as it was still needed. When interviewed on 4/4/22 at 11:10 AM, licensed practical nurse (LPN) Unit Manager #3 stated they were unaware the resident was to have a left palm guard and that it was no longer available. After reviewing the resident's record, LPN Unit Manager #3 stated the resident was to have a left palm guard, it required a physician order, and therapy would have to request one. 10NYCRR 415.12(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00277226. NY00293036, NY00263802) conducted 3/28/22-4/4/22, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #4) reviewed. Specifically, Resident #4's care plan for falls was not followed and the resident had a fall with injury. Findings include: The facility Fall Risk Assessment dated 4/14 documents general interventions for fall prevention and injury reduction will be implemented for all residents. Staff are to ensure shoes fit properly with non-skid soles, and ensure non-skid slippers are available. Staff are to supervise resident use of devices until safe and appropriate use is demonstrated and review all activity/mobility privileges with resident. The facility policy Resident Abuse, Neglect, Mistreatment, Prevention & Reporting dated 11/17 documents incident investigations are to include an explanation of the evidence reviewed, why documents are reviewed and why they are selected, conclusion reached as a result of the investigation, and any changes implemented to care plans and procedures to prevent recurrence. Resident #4 had diagnoses including dementia, macular degeneration (vision loss), and low back pain. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, did not reject evaluation of care or wander, and required supervision of one with ambulation. The comprehensive care plan (CCP) initiated 11/8/17 documented the resident was at risk/had history of falls related to weakness and required assistance with activities of daily living (ADLs). Falls were documented on 9/8/21, 9/30/21, and 10/20/21. Approaches were updated on 9/30/21 and included Dycem (non-slip grip pad) to recliner, call bell in reach, encourage non-skid socks and update licensed practical nurse (LPN) if refused. Staff were to walk per therapy recommendations, ensure shoes were worn when out of bed, provide physical therapy (PT) and occupational therapy (OT) as ordered, and keep needed items in reach. The CCP was updated on 10/11/21 and documented the resident required limited assistance of 1 with front wheeled walker for ambulation. The care instructions, updated on 2/8/18, documented the resident was to wear non-skid socks when in bed and update licensed practical nurse (LPN) if the resident chooses not to wear. On 4/29/19 the profile was updated to include to keep call bell in reach and redirect resident as needed for safety. The instructions did not include the resident's ambulation status. An 11/1/21 fall risk assessment completed by registered nurse (RN) #46 documented the resident was at high risk to fall as a result of contributing factors including a balance problem. A 3/21/22 at 6:30 PM Accident/Incident report documented LPN #47 was sitting at the nursing station when the resident walked up. The resident showed the LPN an item, turned to walk away, and fell hitting the back of their head. RN Supervisor (RNS) #30 was at the nursing station at the time of the fall. RNS #30's recommendation on the form was to have PT evaluate. The report documented the CCP was reviewed and noted interventions that were in place. The report did not document what level of assistance or supervision was required with walking. The report documented that abuse, neglect and mistreatment did not occur as the resident was alert and oriented to self and ambulating independently. The report did not include the resident did not receive limited assistance of 1 staff for ambulation as planned when the resident was observed walking to the nursing station unassisted. A 3/22/22 at 1:37 AM progress note by LPN #47, documented the resident sustained a witnessed fall on 3/21/22 at 6:30 PM. The resident was observed ambulating independently on the unit with a front wheeled walker. LPN #47 and RNS #30 were sitting at the nursing station and watched the resident turn to walk away, then fall to the floor, hitting their head. Two staff members then assisted the resident to their wheelchair and back to their room. The progress note did not include the resident was care planned for limited assistance of 1 when ambulating with the wheeled walker. A 3/22/22 at 10:55 AM RN Unit Manager #9 progress note documented the resident had a fall the day prior, the resident complained of a headache in the temple area, back of neck and abdomen. A 3/22/22 at 4:53 PM RN #30 progress note documented they witnessed a fall by the resident who had ambulated with a walker to the nursing station. When turning away from the station, the resident fell hitting their head on the floor. An assessment after the fall identified a hematoma (collection of blood) to posterior (back) scalp, with neuro checks initiated, medical and family notification was completed. The progress note did not include the resident was care planned for limited assistance of 1 when ambulating with the wheeled walker and was witnessed ambulating independently. On 3/28/22 at 1:17 PM the resident was observed being assisted to the bathroom by a certified nurse aide (CNA). The resident ambulated with a walker and staff assistance. A 3/31/22 physician #6 acute visit note documented the resident had back pain following a fall and stopped walking. The X-ray identified lumbar (vertebra) fracture that may require surgical intervention. The physician started Norco (a narcotic pain medication). During an interview on 4/1/22 at 10:20 AM with certified nurse aide (CNA) #12, they stated the resident needed supervision with walking, if they were witnessed walking alone the CNA would make sure they had their walker. During an interview on 4/1/22 at 11:02 AM with RN Unit Manager #9, they stated the RN who responded to the fall was responsible for completing an accident/incident form, completing a fall and pain assessment, adding a note to the resident's record, and updating the care plan. The documentation from the 3/22/22 fall noted the resident was walking independently with a walker, which was not in the resident's care plan. Their care plan documented the resident was to walk with assistance of staff. During an interview on 4/1/22 at 11:36 AM with physical therapist (PT) #48 they stated the resident should not have been walking alone, if witnessed walking alone the resident should have been assisted by staff for safety. During an interview on 4/1/22 at 12:22 PM with the Director of Nursing (DON), they stated care plans were updated by the interdisciplinary team. The information crossed over to the care profile where it was available for staff to see the care to be provided. Staff would be expected to assist if the resident was witnessed walking alone. During an interview on 4/1/22 at 1:52 PM with LPN #47, they stated they witnessed the resident fall on 3/21/22. All resident care information was in the care plan including how the resident transferred and walked. If a plan noted limited or extensive assistance with ambulation, that meant staff were to be with the resident when the resident was walking. The LPN remembered the night of the fall but could not recall if someone else was present. They had been seated at the nursing station with the RN Supervisor when the resident walked up and wanted to show them a book. They stated they did not get up to assist the resident and should have. When the resident turned to walk away, they fell, hitting their head on the floor. The nursing supervisor did an assessment and staff assisted the resident back to their room. 10NYCRR 415.12(h)(2)

Based on record review and interview during the recertification survey conducted 3/28/22-4/4/22, the facility failed to develop and implement appropriate plans of action to identify quality deficiencies after an incident involving bed rail entrapment for Resident #54 (see F 700 Bed Rails). Specifically, Resident #54 became entrapped in a bed rail resulting in a fracture and a plan of action was not implemented to include review of residents with bed rails in place to ensure accurate and current assessments were completed. Findings include: The facility policy Quality Assurance and Performance Improvement Plan (QAPI) revised 1/2022, documents: - The QAPI committee will meet monthly but no less than on a quarterly basis. The Standing Agenda includes the Risk Management Report, which includes falls and other incidents, including unknown etiology. - Monthly audits of high-risk clinical areas include falls prevention and abuse prevention. - A daily morning report is conducted Monday through Friday to improve internal communication and care to the residents. Significant medical events occurring in the previous 24-hour period are reviewed and include falls. When interviewed on 4/4/22 at 12:11 PM, registered nurse (RN) Unit Manager #22 stated they had completed an audit on bed rails last month; however, the audit did not determine if bed rails were assessed, only to see who had bed rails on their bed. During an interview with the Administrator on 4/4/22 at 12:35 PM, they stated the facility conducted a bed rail audit in 2/2022. Each unit did an audit checking care plans and beds. The Administrator was unable to find further documentation of a plan to ensure residents with bed rails in place were assessed for safe use. During an interview with the Medical Director on 4/4/22 at 3:25 PM, they stated they attended the QA (Quality Assurance) meetings and did not recall bed rails being discussed at these meetings. During an interview with the Administrator on 4/4/22 at 4:41 PM they stated they started in this position in 5/2021. They stated they discussed accidents every morning in morning report. They did bed checks annually for the types of beds and if they were functioning properly. They did not know if the bed rails were a part of the audit and they would rely on the nursing department for bed rail audits. They had not investigated any incidents with bed rails related to a fall or injury. During the recertification survey on 4/1/22 they determined that residents with bed rails did not have accurate care plans and care cards. From 4/1/22 through 4/4/22 therapy pulled all the care plans and care cards, and all of the residents with bed rails were getting consents from their health care proxies (HCPs). There were some questions on the Side Rail Interdisciplinary Evaluation Tool that stated stop and the interdisciplinary team would have to address before proceeding with bed rails. The Administrator stated before a new resident was admitted to a unit, the bed rails would come off the bed to ensure bed rails were off before a new resident used the bed. 10NYCRR 415.27(a-c)

Based on observations, record review, and interview during the recertification and abbreviated surveys (NY00289678, NY00280940, NY00268244, NY00270091, NY00277226, and NY00277318) conducted 3/28/22-4/4/22, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 8 residents (Residents #54, 90, 115, and 140) reviewed. Specifically, Residents #54, 90 and 140 were observed with unclean and unkept fingernails and Resident #115 did not receive timely assistance with toileting as requested. Findings include: The facility policy Activity of Daily Living dated 9/2009 documented the certified nurse aide will assist or provide ADLs according to the individual resident needs according to specific care procedures. The facility policy Nail Care-Fingernails revised on 6/2002 documented resident fingernail care was to be done at least weekly and as needed by a nursing assistant under the direction of a licensed registered nurse (RN)/licensed practical nurse (LPN). The purpose of nail care was to keep fingernails clean, neat in appearance, and to prevent injuries to patients and staff. 1) Resident #54 had diagnoses including major depressive disorder, dementia, and blindness. The 11/30/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance with personal hygiene, and had functional limitation in range of motion to one side of their upper extremities. The 1/3/22 care instructions (resident profile), active in 3/2022, documented the resident required extensive assistance with grooming. There was no documentation the resident declined participation/acceptance of grooming/hygiene. The comprehensive care plan (CCP), last reviewed 2/7/22, documented the resident needed extensive assistance of 1 for grooming. Interdisciplinary progress notes dated between 3/1-3/30/22, had no documentation the resident declined nail care. The activities of daily living (ADL) record documented that personal hygiene was completed for the resident on 3/28/22 at 12:36 PM by temporary nurse aide (TNA) #24, on 3/29/22 at 10:28 AM by certified nurse aide (CNA) #25; on 3/29/22 at 11:05 PM by CNA #26; on 3/30/22 at 8:44 AM by TNA #24; and on 3/31/22 at 9:46 AM by TNA #24. All five fingernails of the resident's right hand were observed with brown build up on 3/30/22 at 9:44 AM, and 4/4/22 at 3:35 PM. During an interview with TNA #24 on 3/31/22 at 1:46 PM, they stated staff had to provide all care to the resident. The resident did not decline care and was not able to participate in care themselves. The TNA stated they had not provided nail care to the resident. During the interview the TNA and surveyor went to the resident's room and the resident stated they were not able to see if nail care was needed related to their visual impairment. All 5 fingers of the resident's right hand had medium brown thick build up under the nail beds. The CNA stated, the resident's nails should have been cleaned. During an interview with CNA #25 on 3/31/22 at 1:55 PM, they stated the resident was unable to complete their own care and it had to be provided by staff. The resident did not decline care. They stated they had provided nail care to the resident in the past, but they had not provided any nail care this week. During an interview with CNA #26 on 4/1/22 at 11:06 AM, they stated the resident was totally dependent on staff for care. They stated they provided nail care to residents on bath days. They had not provided the resident any nail care to the resident that week. During an interview with licensed practical nurse (LPN) Unit Manager #3 on 4/4/22 at 11:10 AM, they stated resident nails should be looked at daily with care. They stated the resident's nails should have been cleaned if they were observed unclean with buildup under the nails. 2) Resident #90 had diagnoses including dementia, Alzheimer's disease, and hemiplegia (paralysis) unspecified affecting unspecified side. The 1/12/22 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required limited assistance of 1 with personal hygiene and extensive assistance of 1 with bathing. The comprehensive care plan (CCP) initiated 8/5/16 and active in 3/2022 documented the resident's cognitive skills for daily decision making were severely impaired, the resident required assistance with bathing, dressing, grooming, toileting, and ambulation which required assistance of 1 person. The CCP documented the resident may be washed up in the early AM. The care instructions dated 4/1/22 documented the resident required fingernail trimming and filing 2 times a week. The resident's hands needed to be washed before and after meals, before and after toileting, and after touching their face, nose, mouth sneezing or coughing. The resident required one person assistance with bathing, dressing, and grooming. The certified nurse aide (CNA) documentation plan of care response documented the resident received personal hygiene daily 3/28/22- 3/31/22. The resident's nails were observed on 3/28/22 at 10:47 AM. The nails were long, fungal, and 4 nails had buildup of tan material under the nail beds. On 3/30/22 at 10:46 AM, the resident showed the surveyor their nails. Eight of their 10 nails had light brown build up/debris under the nail beds. The resident was unable to verbalize a response. The resident's nails were observed long, approximately 1/2 inch, with brown colored debris underneath them on 3/30/22 at 3:16 PM, 3/31/22 at 9:12 AM, and 4/1/22 at 9:38 AM, During an interview on 3/31/22 at 1:46 PM, CNA #41 stated personal hygiene included washing the resident, brushing their hair, and cleaning teeth and/or dentures. They stated nails were trimmed and cleaned when they were visibly dirty. If the resident refused nail care they would notify the nurse, and document the resident refused nail care. They stated they provided care to the resident that morning and did not provide nail care. They stated nail care was important for preventing infection and the resident from hurting themselves. They stated the resident care card was found in the kiosk and the resident was to have nail care twice a week and as needed. Nails should be trimmed and cleaned, and it was the responsibility of the CNA to provide nail care. During an interview on 4/1/22 at 9:55 AM, CNA #38 stated Resident #90 required extensive assistance of 1 person, and the resident never refused care. They stated nail care was not provided and nail care was important to prevent infection and it looked nice when the nails were clean. Nail care should be completed and was responsibility of the CNA. During an interview on 4/1/22 at 10:06 AM, LPN #42 stated personal hygiene included nail care and should be done daily and as needed to keep the nails clean. They stated nail care was important to prevent sickness. All staff were responsible for nail care. During an interview on 4/1/22 at 11:29 AM, LPN Unit Manager #3 stated personal care included nail care. Nail care was important because nails harvest bacteria, and residents put their hands in their mouth and touch their face. CNAs were primarily responsible for nail care, but nursing could complete nail care as well. If a resident refused nail care, the resident should be re-approached and continue to try. Resident #90 should have had nail care completed daily. 3) Resident #115 had diagnoses including foot drop to right foot, anoxic brain injury (lack of oxygen), and urinary tract infection (UTI). The 3/4/22 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance of 1 with transferring and toileting, and was continent of urine. The 11/23/21 care instructions documented the resident required extensive assistance with toileting and was continent of bladder and bowel during the day. The resident was to be toileted immediately upon waking, to avoid self-transferring to the bathroom. A plan for the resident's preference/abilities to request toileting assistance were not included in the care profile. The 9/13/21 comprehensive care plan (CCP) documented the resident required extensive assistance with toileting, clothing management and toileting hygiene daily. The resident was to be offered to use the bathroom every 2 hours. There was no documentation a plan for the resident's preference/abilities to request toileting assistance were included in the CCP. The activities of daily living (ADL) record had no documentation that toileting was provided during the day shift on 3/28/22. The resident was observed seated in their room on 3/28/22, during a continuous observation: - At 3:36 PM, the surveyor was sitting in the lounge area approximately 45 feet from the resident's door, and in view of the door and hallway. At that time the resident was yelling, I have to go to the bathroom please. There was an unidentified certified nurse aide (CNA) sitting at a desk approximately 3 feet behind surveyor and CNA #27 standing across from the surveyor outside a resident's room talking with another employee. - At 3:50 PM, the resident was yelling for help to use the bathroom. 2 staff walked by the area and headed to the nursing station, without approaching the room. - At 3:56 PM, the resident yelled again, causing a resident in the lounge area outside the resident's room to yell in response. Two staff responded to the other resident in the lounge, and not to the resident in their room. - At 4:11 PM, the resident was yelling from their room, I have to go to the bathroom please. - At 4:16 PM, the resident yelled an elongated, hello from the room. An unidentified staff person went in and was out of the room at 4:17 PM. Between 4:17 PM and 4:21 PM, graduate practical nurse (GPN) #28 went into the resident's room. - At 4:21 PM, GPN #28 came out of the room and went to CNA #27 and informed them they brought the resident to the bathroom and asked the resident to pull the call bell when they were done. CNA #27 replied to the GPN they had forgotten about the resident. The CNA then walked to the resident's room. - At 4:29 PM, the resident was brought out into the common area. During an interview with the resident on 3/30/22 at 10:46 AM, they stated they could not remember the 3/28/22 incident. At the time of the interview, the resident's family member was present. They stated when the resident resided at home, they had requested the resident yell out when they needed to use the bathroom, so this was something they were used to. The resident was continent and would yell, I need to use the bathroom. During an interview with certified nurse aide (CNA) #27 on 4/1/22 at 10:52 AM, they stated the resident would let staff know when they needed to use the bathroom. The resident required limited assistance to use the bathroom. They stated the resident would sometimes yell, I need to use the bathroom. Sometimes staff heard them and sometimes not. The other day when the resident was calling out, the GPN came and notified the CNA the resident was calling out. The CNA stated they had not heard them. They stated they usually assisted the resident out to a common area so when they needed assistance staff could hear them. The resident was usually continent, although there had been occasions recently when the resident was found wet. On 3/28/22, when they went to the resident's room after the GPN notified them, the resident's incontinence brief was wet. During an interview with GPN #28 on 4/1/22 at 11:44 AM, they stated they were sitting at the nursing station on 3/28/22 and the unit secretary informed them they heard the resident asking to use the bathroom a couple times. The GPN said they got up to assist the resident to the bathroom and then notified the aide they had assisted the resident to the bathroom. 10NYCRR 415.12(a)(1)(3)

Based on observation, record review and interview during the recertification survey conducted 3/28/22-4/4/22, the facility failed to assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent for 8 of 11 residents (Residents #34, 41, 47, 54, 115, 128, 140 and 174) reviewed. Specifically, - Resident #54 became entrapped in a bed rail and sustained a fracture as a result. Resident #54's bed rails were not reassessed timely after the incident to determine their continued use and safety. The bed rails were not removed timely after it was determined they were no longer needed. - Resident #34 was physically compromised and was not appropriately assessed for use of bed rails. The resident was totally dependent for bed mobility and was unable to use bed rails independently and the bed rail evaluation tool was not correctly completed. - Resident #41's and 174's comprehensive care plans did not include the use of bed rails. - For Residents #115, 140 and 174 there was no documented evidence bed rail assessments were reviewed and consents were obtained prior to bed rail installation. - For Residents #34, 41, 47, 115, 128, 140 and 174, there was no documented evidence the risks and benefits of bed rails were explained to the residents prior to their use. - For Residents #34, 41, 47, 54, 115, 128, 140 and 174, there were not updated care instructions noting bed rails and directing direct care staff on the use of bed rails individual to each resident. Findings include: The facility policy Side Rail Use dated 4/2014 documents the purpose was to establish a consistent method for evaluation of safety and mobility for side rail use upon admission and routinely thereafter and no less than every 90 days. It is the intent of the policy to ensure each resident is evaluated independently in terms of safety and assuring resident is afforded their highest practicable quality of life while reducing overuse of side rail devices. Any decision regarding bed rail use or removal from use should be made within the framework of an individual resident assessment. Upon admission it will be the responsibility of the admitting nurse to complete the side rail use safety interdisciplinary evaluation tool. Once completed it will be the responsibility of the Manager to adapt to the resident care plan and certified nurse aide (CNA) profile. A supporting progress note will be placed in medical record, indicating completion of assessment and resident/family education. All side rails will be removed from the bed upon discharge of a resident. Maintenance will be notified via e-mail of any discharge. 1) Resident #54 had diagnoses including vascular dementia, cerebrovascular disease, and convulsions. The 3/3/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance for bed mobility, transferring did not occur, and the resident did not use a bed rail restraint. The comprehensive care plan (CCP) initiated 11/17/16 documented the resident used 2 half enabler bars as an assistive device for bed mobility. The CCP was updated on 8/15/19 and documented the bed rails were to be assessed quarterly and as needed (prn). The area noting if intervention/problem area was to be included in care profile was unchecked. The Side Rail Safety Interdisciplinary Evaluation Tool, completed 8/12/20 documented the resident used a bed rail for increased independence with bed mobility, the bed rail was care planned for, and viewed as secure and was without safety concerns. The tool did not indicate what type of bed rail was used. There was no documented evidence the resident was informed of risks and benefits of using bed rails. The care instructions, active in 5/2021, did not document the resident had bed rails in place. A 5/18/21 at 8:30 PM, registered nurse (RN) #1's progress note documented they went to the resident's unit to assess for a fall. It was reported to the RN the resident was witnessed by certified nurse aide (CNA, not identified) sliding out of bed. The CNA attempted to help the resident, but the resident was already on the floor while their left arm was trapped in the bed rail. The CNA and the licensed practical nurse (LPN) helped the resident to reposition their arm away from bed rail, and a Hoyer lift (mechanical lift) was used to transfer the resident back to bed. The resident complained of pain of 8/10 in the left shoulder, foot, and bilateral knee with movement. The resident had a diagnosis history of CVA (cerebrovascular accident, stroke) with left sided hemiparesis (paralysis), range of motion to right side was within normal limits and limited on the left side. The resident sustained a 1-centimeter (cm) abrasion on the mid right shin, and bruise/redness on right lateral leg above malleolus (ankle). The nurse practitioner (NP) was called and there was an order in place for a STAT (as soon as possible) X-ray and lab. The resident declined hospitalization at that time. A 5/19/21 at 3:12 AM LPN #2 progress note documented x-ray results were pending, the resident was able to move extremities per their normal with baseline weakness in the left arm, and they stated their left elbow was sore. A 5/19/21 at 10:30 AM, LPN Unit Manager #3 progress note documented they received the results from the x-ray and the resident had an acute fracture of the anatomic neck of the left humerus (upper arm at shoulder), and probable subacute fracture of the proximal phalanx (bone) of the left great toe. Results were discussed with the physician and the family member. The resident was to be sent to the emergency room for evaluation. The Accident/Incident report for an incident on 5/18/21 at 7:25 PM documented the resident was observed by temporary nurse aide (TNA) #18 to be slowly sliding from their bed and yelling help. TNA #18 attempted to assist the resident but could not reach them in time to prevent the fall. While sliding the resident's left arm became caught on the top half left bed rail due to the resident's left sided paresis. The bed was noted in the lowest position during the fall. TNA #18 called out to staff for assistance. The resident's left arm was removed from the bed rail by nursing staff and RN #1 completed a full assessment of the resident. The resident was assisted back into bed and positioned to their preference. The resident declined to go to the hospital immediately following the incident. An in-house X-ray was completed, and the resident was found with an acute fracture of the anatomic neck of the left humerus. The resident was sent to the emergency room for further evaluation. The investigation included in the report noted the resident was cognitively intact and attempting to get out of bed without assistance. The resident was reminded to ask for assistance, care plan was reviewed and updated, provider and family were updated, laboratory samples were taken, and a bed rail evaluation was to be completed. A 5/24/21 at 1:18 PM, LPN Unit Manager #3 progress note documented they spoke with the resident's family member regarding need for evaluation for bed rails. The family member agreed with removing the left bed rail if needed. They originally wanted both removed, however, this writer explained that the half bed rail [was] used for bed mobility. The family member agreed with this and would be updated once the evaluation was done. There was no documented work order/note notifying maintenance to remove the left bed rail after the discussion on 5/24/21. A 6/2/21 at 11:43 AM, LPN Unit Manager #3 progress note documented the resident's family member was called. They were reassured the resident had a bed in the lowest position with fall mats in place. Therapy was going to evaluate the need for bed rails. A 6/2/21 at 11:56 AM, LPN Unit Manager #3 progress note documented the Director of Therapy was coming to evaluate the resident for bed rails and would discuss with the Manager on 6/3/21. The 6/2/2021 occupational therapy (OT) plan of care by OT #35, documented OT services started 5/20/21. Services were in place following a hospitalization from a fall from bed where the left arm became trapped in bed rail. The resident would benefit from OT services to assess the resident's safety in bed, use of bed rails, positioning in bed, and self-care participation with use of left shoulder sling, including shoulder sling use. The resident was dependent on staff with left upper extremity positioning and care in bed. The resident would benefit from discontinuing therapy care as of 6/2/21 and continuing with nursing. The OT note had no documentation of the resident's bed rail use. On 6/3/21 at 11:52 AM, LPN Unit Manager #3's progress note documented they spoke with the Director of Nursing (DON) and Director of Therapy regarding removing the resident's bed rails. The family member was made aware. A work order report documented the residents bed rails were requested to be removed on 6/4/21. The work order was updated, and the request was completed on 6/8/21 and was documented as medium importance/severity to complete. The resident was observed on 3/28/22 at 3:05 PM, lying in their bed without bed rails. During an interview with the Director of Therapy on 4/1/22 at 12:16 PM, they stated the resident had a fall from bed in 5/2021 and got their arm stuck in a bed rail and went to the hospital. The resident used bed rails for turning during care/bed mobility. They stated that the therapy department would make a recommendation for someone to use bed rails and provide that recommendation to nursing. Nursing would then make their own assessment and determination based on the resident's cognition, and if they determined bed rails were appropriate a maintenance request would be put in to install bed rails. They stated they did not do ongoing assessments, they only re-assessed if there was a change in the resident. The resident had not had any changes. They sustained a fractured to the shoulder of their weakened arm following the fall. They stated that nursing was responsible for updating the care plan for use of bed rails. During an interview on 4/1/22 at 12:40 PM, the Director of Environmental Services stated they did not remember the bed rails being removed from the resident's bed. The work order system did not indicate who completed the work just who reported it which may have been a CNA from 5/2021. During an interview on 4/1/22 at 2:40 PM, unit secretary #23 stated they did not remember an order for bed rails to be removed from the resident's bed. They stated it was most likely a nurse telling them in passing and they entered the work order for them. They stated they were not able to access if a work order was closed or completed in the system. During an interview with LPN #17 on 4/1/22 at 3:08 PM, they stated TNA #18 called out to the LPN on 5/18/21 to come to the resident's room. Prior to the event the resident had been hallucinating and was trying to climb out of bed. When they arrived at the room on 5/18/21, the TNA told them the resident had their feet off the bed and had been trying to use their arm to pull on the bed rail and pull their feet further out. The LPN assisted the resident's legs back straight and they yelled out in pain. The resident's upper body was on the bed and the lower body was off the bed. The resident's left arm was holding the rail and was between the mattress and the top of the bed rail. They stated the rails on the resident's bed were bigger stocky rails. The Nursing Supervisor was called to come to the room and the resident had been complaining of pain. During an interview with LPN Unit Manager #3 on 4/4/22 at 11:10 AM, they stated the incident occurred on 5/18/21 on the evening shift. The resident had left sided paralysis and two half bed rails. They stated they had talked to the family about the use of the bed rail for bed mobility. The family initially did not want the bed rails, until the LPN notified them the resident used at least one for bed mobility, and the family then agreed to one rail. The LPN stated at some point there was another discussion with the team, and they decided to discontinue both bed rails. They did not recall why they had determined that both bed rails should be discontinued. They stated they did not remember why the work order to have the bed rails removed was not placed until 6/4/21. They stated bed rails were supposed to be reviewed quarterly by nursing and was based on the bed rail start schedule. For instance, if a bed rail was implemented on 4/1/22, then they would review that bed rail again on 7/1/22. The LPN Unit Manager stated the resident's bed rails had not been assessed in 2021 prior to the incident. They stated the resident had a bariatric (large size) bed and had U bars as bed rails. During an interview with the Director of Nursing (DON) on 4/4/22 at 11:45 AM, they stated they interviewed the staff to find out what happened on 5/18/21. At some point, they got therapy involved to have the bed rails removed. They did not remember any time frames of the assessment or process for removal of the resident's bed rails. The resident had previously had them for mobility. Bed rails were reviewed quarterly or with a change in condition for a resident. The Unit Manager was responsible for updating the CCP, care profile, and getting medical orders for the bed rails. This resident's bed rails should have been assessed quarterly. They did not review all residents with bed rails immediately after this incident. When they reviewed the resident's investigation, they did not know what kind of bed rails the resident had at the time of the incident. During a follow up interview with the LPN Unit Manager #3 on 4/4/22 at 12:25 PM, they stated consents for bed rails were usually done over the phone with family or an in-person discussion with the resident. There was not a formal document that was used. They stated if there was a discussion it would be in a nursing progress note. During a follow up interview with the DON on 4/4/22 at 3:02 PM, they stated the facility interviewed staff and determined the resident tried to get out of bed by themself and slid from the low bed. The resident's weight and weight of the mattress caused the left arm to slide under the bed rail and not through it. During an interview with RN Supervisor (RNS) #1 on 4/4/22 at 3:15 PM, they stated they did not remember the specifics of the incident. The resident's left arm had weakness and had been in between the bottom of the bed rail and the mattress, and they did not remember where the rest of the resident's body was. They stated they only used one type of bed rail and it was a rectangular metal bed rail. They stated the resident's bed rail should have been removed when they returned from the hospital to reduce further risk to the resident. They stated the Unit Manager was responsible for updating the care plan and care profile. During an interview physician #6 on 4/4/22 at 3:25 PM, they stated the facility should not be using bed rails if avoidable. If a resident was not routinely assessed for bed rail there could be a risk for the resident to become stuck between the bed rail and the bed. During an interview with the resident on 4/4/22 at 3:35 PM, they stated they had an incident where they attempted to get out of bed, and they got their arm caught in their bed rail and sustained a fracture. The resident stated they had left sided weakness from a stroke they had several years ago. During an interview with CNA #18 on 4/4/22 at 4:06 PM, they stated on 5/18/21, they had been working as a TNA (temporary nurse aide) and was doing rounds on the unit when they walked into the resident's room and saw the resident's arm through the bed rail. They stated it was a rectangular bar with a metal piece in the center and the resident's arm was through that piece. The resident had pain in their arm when they found them. They called for the LPN, who came to the room, and then someone called the RNS to come. They were required to check the resident's care plan/profile to know what level of assistance they needed, and this would have included use of bed rails. 2) Resident #34 had diagnoses of multiple sclerosis (a disease of the central nervous system), spastic quadriparesis (loss of motor control), and a sacral pressure ulcer. The 2/8/22 Minimum Data Set (MDS) assessment documented the resident has moderately impaired cognition, was totally dependent on 2 for bed mobility, and did not use a bed rail restraint. The comprehensive care plan initiated 7/14/17 and last reviewed 2/22/22 documented per resident request they used two 1/4 side rails as an assistive device for bed mobility. Approaches included staff would educate the resident about the risks associated with the use of side rails. The care instructions dated 11/10/21 documented the resident was dependent on 2 staff at all times in bed. The care instructions did not include the use of bed rails The Side Rail Safety Interdisciplinary Evaluation Tool completed 4/1/22 documented the resident used bilateral U bars (a type of bed rail) for increased independence with bed mobility, and the resident received prescribed hypnotics/sedatives or diuretics which was a 'STOP response. The evaluation tool directions for a STOP response were to proceed to an interdisciplinary team (IDT) meeting for further review. There were no documented interdisciplinary team reviews or assessments addressing the resident's ability to use bed rails. The following observations were made of Resident #34: - On 3/29/22 at 9:24 AM, in bed with bilateral side rails in the raised position. - On 3/30/22 at 8:30 AM, lying on their left side in bed with bilateral side rails in the raised position. - On 3/31/22 at 8:51 AM, in bed, positioned toward the left side with bilateral padded side rails in the raised position. - On 4/4/22 at 10:04 AM, in bed with bilateral side rails in the raised position. On 4/1/22 at 10:31 AM, during an interview with certified nurse aide (CNA) #12, they stated all resident care information was available in the computer. The resident required total assistance of 2 for repositioning in bed. They had not witnessed the resident using the bed rails. On 4/1/22 at 10:47 AM, during an interview with CNA #13, they stated the information for resident care was in the computer. The resident needed total assistance of 2 for bed mobility. They stated the resident was not able to use the bed rails. On 4/1/22 at 11:13 AM, during an interview with registered nurse (RN) Unit Manager #9, they stated the resident was to be repositioned every 2 hours. The resident had no ability to reposition themself and did not have range of motion to reach the bed rails. The RN stated staff could move the resident's arm for them, but the resident did not have the strength to hold the bed rails. On 4/4/22 at 2:52 PM, during an interview with the Director of Nursing (DON), they stated all residents should have an assessment before the use of side rails. If one of the responses was a stop, it should lead to further evaluation in a therapy note or in a progress note. There could be several things that could happen with bed rail use such as entrapment or possible injury. They stated they had not obtained consent from the resident or resident representative for side rail use. Resident education on potential risks should be done, and there was no documentation of risk education. On 4/4/22 at 3:00 PM, during an interview with the resident, they stated they were unable to use side rails. They did not have the ability to move their arms far enough to grab, or the grip strength to hold on to the bed rails. On 4/4/22 at 3:01 PM, during an interview with temporary nurse aide (TNA) #14, they stated the resident could not use bed rails independently. On 4/4/22 at 3:03 PM, during an interview with CNA #15, they stated the resident did not have the ability to use side rails independently. On 4/4/22 at 3:04 PM, during an interview with licensed practical nurse (LPN) #8 they stated the resident could not use side rails independently. Dangers of bed rails included entrapment or injury, even death if a resident got caught up in them. On 4/4/22 at 4:52 PM, during an interview with the Director of Rehabilitation, they stated therapy would recommend side rails if it would improve bed mobility or positioning independence. An evaluation should be done and discussed if they needed to discontinue bed rails. They stated the resident's bed mobility during the last therapy treatment (10/2021-11/2021) was listed as dependent with limited range of motion. The resident would not be able to use bed rails independently. The resident had U bars, which still carried the risk of entrapment. An assessment should be completed for anyone using bed rails. 3) Resident #174 had diagnoses including a history of falls, right leg fracture with repair, and stroke with right sided weakness. The 2/21/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of 2 for bed mobility and transfers, had impairment of one arm and leg, and did not use bed rails. The 2/16/22 comprehensive care plan (CCP) documented the resident was at risk for falls. Interventions included call bell in reach, remind the resident to not get up independently, walk per therapy recommendations, physical therapy (PT)/occupational therapy (OT) as ordered, wear shoes when out of bed, and keep most items in reach at all times. The CCP did not document bed rail use. The resident care instructions did not document bed rails were in place for the resident. During observations on 3/28/22 at 12:59 PM, 3/29/21 at 8:51 AM, 3/31/22 at 9:20 AM, and 4/1/22 at 2:07 PM, the resident had padded bed rails on both upper sides of their bariatric bed. There were no documented assessments for use of bed rails to ensure safety and ensure least restrictive device for the resident. Additionally, the resident did not have a consent in place to include risks and benefits of bed rail use. During an interview with the resident on 4/4/22 at 11:15 AM, they stated the facility removed their bed rails on 4/2/22. The resident stated the bed rails had been on their bed since admission and they did not know why they were removed. The resident stated no one had discussed the use of the bed rails with them since their arrival to the facility. The resident stated they had difficulties without the bed rails and the RN Unit Manager had told them they would be putting one rail back on the bed. During an interview with certified nurse aide (CNA) #49 on 4/4/22 at 11:32 AM, they stated the resident was cognitively intact and used the bed rails to reposition themself in bed. They stated the bed rails were not on the care plan or care instructions when they had worked with the resident. During an interview with LPN #50 on 4/4/22 at 11:43 AM, they stated the resident used bed rails for positioning and the resident did not like that they were removed. They stated an RN would be responsible for assessing the use of the bed rails and the medical provider was to place an order for the bed rails. When interviewed on 4/4/22 at 12:11 PM, registered nurse (RN) Unit Manager #22 stated the resident had used the bed rails for positioning themselves in the bed. A RN was responsible for ensuring the assessments were completed and the bed rails were added to the resident's care plan and care instructions. The assessments were to be done quarterly, annually, with a significant change and as needed. They stated the resident's bed had bed rails prior to the resident's admission and they remained on the bed when the resident was admitted . They stated the bed rails were not assessed for use by the resident, there was no physician order in place for use of bed rails and was included in the resident's CCP prior to their removal on 4/2/22. When interviewed on 4/4/22 at 3:02 PM, the Director of Nursing (DON) stated it was expected the RN Unit Manager or RN Supervisor would assess bed rail use and add to the CCP if they were needed. The facility did not require consent from the resident or their representative for use of the bed rails. Bed rail assessments were to be completed annually, quarterly, with significant changes and as needed. 10NYCRR 415.12(h)(1)(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 residents were free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 1 resident (Resident #31) reviewed for restraints. Specifically, Resident #31 had a wheelchair brake applied at meal times to prevent the resident from leaving the table and the resident was not able to release it independently. Findings Include: The 8/2004 Physical Restraints facility policy defined a restraint as any physical or mechanical device attached or adjacent to the resident's body that the resident cannot easily remove which restricts freedom of movement. A locked wheelchair was listed in the examples of a restraint. Restraints were only to be used after assessment by the interdisciplinary team (IDT), with a physician order, and never to be used as a substitute for appropriate observation and monitoring. Resident #31 was admitted to the facility on [DATE] with a diagnosis of dementia without behavioral disturbance. The 5/31/19 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, used a wheelchair for mobility, and had no restraints. The following was observed during lunch in the dining room on 8/19/19: - At 12:52 PM, licensed practical nurse (LPN) #4 attempted to assist the resident with her meal as the resident rolled backward in her wheelchair to leave the dining room. The wheelchair was unlocked and the resident self-propelled away from the table. - At 12:59 PM, LPN #5 brought the resident back to her table from the hall outside the dining room and locked the resident's right wheelchair brake. - At 1:02 PM, the resident attempted to push away from the table and was able to maneuver the wheelchair enough to turn away from the table slightly but was not able to move away from the table completely, as the right wheel brake remained locked. - At 1:03 PM, the resident attempted to pull herself along the wall with her hands and was only able to swing herself back toward the table. The right wheelchair brake remained locked - At 1:04 PM, the resident turned away from the table again, continually attempted to move the wheelchair forward by scooting using her legs and body weight. She was only able to turn herself toward the wall with the right wheelchair brake locked. The following was observed during dinner in the dining room on 8/19/19: - At 5:23 PM, the resident was brought into the dining room by staff. - At 5:29 PM, the right wheelchair wheel brake was locked while the resident was sitting at the table eating; - At 5:38 PM, the wheelchair wheel was still locked, and staff were sitting with the resident engaging her in conversation. The resident was observed during breakfast on 8/20/19 at 8:55 AM. The right wheel brake of her wheelchair was locked, and the resident was trying to move away from the table. LPN Assistant Unit Manager #8 released the wheel brake and the resident left the dining room. There was no documented evidence of a restraint assessment for the resident's locked wheelchair. The 5/14/19 Resident Profile (care instructions) did not document the use of any type of restraint. The 7/22/19 through 8/22/19 physician orders did not document the use of any type of restraint. The 8/14/19 Comprehensive Care Plan (CCP) contained no documented evidence of restraint use. During an interview on 8/22/19 at 2:19 PM the acting Physical Therapy Director stated if a wheelchair lock was engaged and the resident was not able to unlock it, it would be considered a restraint. During an interview on 8/22/19 at 2:46 PM, LPN #5 stated that she would regularly lock the resident's wheelchair to prevent the resident from leaving the dining room. She stated she only locked one wheel, so the resident was less likely to fall and for that reason it was not considered a restraint. The resident received her meal tray early, then would leave the dining room, self-propel into other resident rooms and attempt to self-transfer into their beds or use their bathrooms while staff were busy in the dining room. She stated the resident had fallen doing this in the past. During an interview on 8/22/19 at 3:43 PM the LPN Assistant Unit Manager #8 stated locking the wheels to prevent someone from leaving the dining room was a restraint. During an interview on 8/22/19 at 4:21 PM, certified nurse aide (CNA) #9 stated she did not believe the resident could release a wheelchair brake. During an interview on 8/22/19 at 4:24 PM, CNA #10 stated she had never seen the resident attempt to unlock her wheelchair wheel and did not believe she could. 10NYCRR #415.4 (a)(2)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not ensure the assessment accurately reflected the resident's status for 1 of 1 resident (Resident #49) reviewed for hospice and end of life care. Specifically, Resident #49's quarterly Minimum Data Set (MDS) assessment incorrectly identified the resident as receiving hospice services (medical services to help with terminal illness) when she was not. Findings include: The facility policy MDS 3.0 Assessments revised 8/2019 documented the interdisciplinary team was assigned specific sections of the MDS assessment to ensure the most appropriate discipline member documented accurate information regarding the resident's status. Section O was the area to mark for a resident's hospice status, which was to be documented by the nurse manager. Resident #49 was admitted to the facility from the hospital on [DATE] with diagnoses including chronic pain and non-Alzheimer's dementia. The 12/25/18 admission MDS documented the resident was receiving hospice care and her cognition was moderately impaired, the 3/22/19 significant change MDS documented the resident was no longer receiving hospice care, and the 6/12/19 quarterly MDS documented the resident was receiving hospice care. The resident's medical record documented the resident started hospice services on 12/11/18 while she was still in the hospital. Once admitted to the facility, the resident received hospice visits on 12/27/18, 1/10/19, 1/23/19, 2/6/19, 2/20/19 and 3/6/19. The comprehensive care plan (CCP) dated 12/18/18 and revised 07/04/19 documented the resident was receiving comfort care (care provided by facility staff focusing on symptom control and quality of life). There was no documentation the resident had received hospice care services, and no documentation of the resident's significant change in March 2019 when she was discharged from hospice care and changed to comfort care. Physician orders documented the resident was on hospice care 12/18/18 - 7/26/19. Medical progress notes documented: - On 04/03/19, the resident was receiving hospice services; - On 05/25/19, the resident had hospice in 1/2019; and - On 07/10/19, the resident was on comfort care. Nursing progress notes documented: - On 12/18/18, the resident was admitted on hospice care; - On 3/21/19, a significant change assessment was completed due to discharge from hospice care; - On 3/26/19, a significant change care conference was held with the Unit Manager, social worker, dietary and the resident's son; and - On 03/29/19, the resident was on comfort care, with comfort measures only. During an interview with registered nurse (RN) #17 on 8/22/19 at 10:30 AM she stated the resident was not on hospice care services and those services ended in March 2019. During an interview with MDS nurse #18 on 8/22/19 at 10:45 AM, she stated she first reviewed the resident's electronic health record then stated the resident was no longer on hospice services. The resident's hospice services ended in March 2019. She stated the resident was still marked on the current MDS as being on hospice, she should not be, and she would let the MDS coordinator know. She stated she knew when a resident was discharged from hospice by looking at the census. She saw Resident #49 was changed to Medicaid as a payor source on 3/9/19 so she knew the resident was discharged from hospice. During an interview with MDS coordinator #19 on 8/22/19 at 11:57 AM, she stated she only looked at the resident's physician orders when she was completing the June 2019 quarterly MDS assessment and saw the resident was receiving hospice. She did not look anywhere else or speak with a unit nurse to make the assessment. She stated she did not know what her co-worker meant by looking at the census to determine whether a resident was on hospice. 10NYCRR 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review during the recertification survey, the facility did not ensure residents were provided care and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs) including dining/eating for 1 of 5 residents (Resident #87) reviewed for ADLs. Specifically, Resident #87 was care planned for assistance at meals and was not assisted timely. Findings include: 1) Resident #87 was admitted to the facility on [DATE] and had diagnoses including anemia, Vitamin D deficiency, and right eye injury. The 6/28/19 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and did not exhibit any behavioral symptoms or rejection of care. The resident required supervision and physical assistance of one person for eating. The comprehensive care plan (CCP) last reviewed 4/1/19 documented the resident required assistance with ADLs related to decreased mobility and cognition and needed set-up assistance and encouragement for eating. The Vitals Report documented the resident's weight: - On 7/16/19 was 114 pounds (lbs). - On 8/6/18 was 107.2 lbs. - On 8/13/19 was 107 lbs. - On 8/20/19 was 106 lbs (8 lbs or 7.2% loss over one month). Registered dietitian (RD) #7's progress notes documented: - On 7/3/19 at 2:23 PM, the resident had a 5.6 lb weight loss (4.9%) over one month, as of 7/2/19, average meal intake was 44%, and staff were to encourage intakes by telling the resident it's your turn. - On 8/8/19 at 1:30 PM, the resident had a 8.2 lb weight loss (7.2%) over one month. Average recorded meal intake was 10% and there was an increase of meal refusals per intake records. Nursing progress notes documented; - On 8/7/19 at 3:08 PM, the resident's appetite was very poor, and she refused all offers and alternatives. - On 8/13/19 at 9:55 PM, the resident had decreased appetite and decline a snack at bedtime. The nurse practitioner (NP) progress note dated 8/12/19 documented the resident was seen for follow up for weight loss and shingles (painful rash). The NP discussed the possibility of adding an appetite stimulant with the resident's daughter, who declined and requested the resident's feeding status be changed to dependent at meals in order to have someone assist her. The NP documented licensed practical nurse (LPN) Assistant Unit Manager #8 was notified and the LPN would ensure the change was made to the plan of care. The physician's ancillary orders dated 8/15/19 documented the resident required assistance of one person for eating, cues were needed, to offer bites, and may occasionally need to be fed. The nutrition CCP last reviewed 8/21/19 documented the resident was at risk for altered nutrition/hydration related to dementia, an average intake of less than 75% of most meals, and significant weight loss on 8/7/19 of 7.2% over one month and the resident required assistance with eating and drinking at times. Interventions added on 8/8/19 included: preferences of cola, dislikes of supplements and fortified foods, and encourage intakes by telling the resident it's your turn. The Resident Profile (care instructions) reviewed 8/20/19 at 11:15 AM documented the resident required supervision, set up, and cueing as needed for eating. The resident could be encouraged to eat by asking her: What are you going to play next? Why don't you try that? and she will choose the food. The Resident Profile updated 8/22/19 documented the resident required the assistance of one person for feeding, cues were needed, to offer bites of food, and the resident occasionally needed to be fed. The Point of Care History (POC, ADL documentation) for eating documented the resident: - Ate independently and/or with supervision from 8/1-8/12, 8/14-8/16, and 8/18-8/20/19. - Ate independently with limited assistance on 8/13, 8/17, 8/21, and 8/22/19. The POC History for staff support for eating documented staff provided: - Set-up help only from 8/1-8/12, and 8/14-8/20/19. - One-person physical assistance on 8/13, 8/21, and 8/22/19. On 8/19/19 at 5:45 PM, the resident's family member stated during an interview the resident had been ill with shingles over the past month and the resident's ability to eat independently had declined. She stated the resident formerly ate well independently, and currently required more encouragement, assistance, and feeding at times. The family member was concerned the resident was not being assisted at meals because she had lost weight since she stopped feeding herself independently. The family member stated the resident ate well when someone sat with her, offered her bites, handed her a cup or utensil, and prompted her by staying it's your turn. The following observations were made in the dining room on 8/20/19 during the breakfast meal: - At 8:13 AM, the resident was brought into the dining room. - At 8:34 AM, RD #7 set up the resident's meal. - From 8:34 AM to 8:48 AM, the resident made no attempt to eat or drink, no staff were present at the table or approached the table. - At 8:49 AM, the resident took one small bite of toast and the RD walked by her table and asked her if she was going to eat. - From 8:49 AM to 9:04 AM, the resident made no further attempt eat or drink, no staff approached or assisted. - At 9:05 AM, RD #7 approached the resident and asked how her breakfast was, the resident picked up her fork took a bite of her meal. - At 9:08 AM, LPN Assistant Unit Manager #8 sat next to the resident, fed her 3 bites of food and left the table. - At 9:11 AM, the LPN Assistant Unit Manger returned to the table and continued to feed and encourage the resident to eat (37 minutes after she received her meal). The following observations were made in the dining room on 8/20/19 during the lunch meal: - At 12:28 PM, staff set up the resident's meal on the table. - At 12:30 PM, the resident took one small bite of her spaghetti with her fork. - From 12:30 PM to 1:17 PM, the resident had taken only 3 to 4 bites of her food and drank her milk. - At 1:17 PM, LPN Assistant Unit Manger #8 sat and assisted the resident with the rest of her meal (49 minutes after she received her meal). The following observations were made in the dining room on 8/21/19 during the breakfast meal: - At 8:38 AM, the resident received her meal. - From 8:38 AM to 8:54 AM, no staff approached the resident or assisted her to eat, the resident had eaten 2 to 3 very small bits of her scrambled egg from her fork. - From 8:54 AM to 9:08 AM, the resident made no further attempt to eat or drink. - At 9:08 AM, LPN Assistant Unit Manger #8 sat next to the resident and assisted and encouraged her with her meal (30 minutes after receiving her meal). The following observations were made in the dining room on 8/21/19 during the lunch meal: - At 12:28 PM, the resident was placed at a different table as observed for breakfast and on 8/20/19. - At 12:29 PM, a certified nurse aide (CNA) questioned her placement, another CNA stated the resident now required more assistance, and then the resident received her meal. - At 12:31 PM, the resident's meal was set up in front of her, no staff was seated near her, the resident made no attempt to eat. - At 12:39 PM, CNA #20 sat in between the resident and another resident, and briefly encouraged Resident #87 by offering her a food item. - From 12:41 PM to 1:05 PM, CNA #20 assisted the other resident with eating, and occasionally turned to Resident #87 to verbally offer assistance. - At 1:10 PM, an unidentified CNA at the same table asked the resident if she was going to eat. - At 1:11 PM, LPN Assistant Unit Manger #8 sat next to the resident and began feeding her, she was accepting of the meal and drinks. During an interview on 8/22/19 at 10:59 AM, CNA #25 stated the resident required limited assistance of one person with meals and she had recently required even more assistance and feeding since she had shingles. The CNA stated the resident would eat well with prompting and providing her bites of food or handing her cups and utensils. She was moved to a different table as of the lunch meal on 8/21/19, as her former table was not an assistive table. Residents who received more meal assistance were seated at the same table. Residents were to receive assistance as soon as the meal was provided; she was not getting assisted at the other table and she was moved. She stated supervision and cueing meant the resident should be monitored and encouraged to eat if they were not. Limited assistance of one meant staff should sit with the resident, offer/identify the food, place the utensil or cup in their hand, encourage her to eat, engage with her, and offer to feed if the resident is accepting. When interviewed on 8/22/19 at 12:06 PM, LPN Assistant Unit Manger #8 stated the resident's care plan was just updated this morning and should have been updated sooner to reflect the resident's need for more assistance at meals. She stated the resident required more encouragement and responded well to being fed by some people. She stated staff should have observed if the resident was not eating and approached her to assist. LPN Assistant Unit Manager #8 stated she approached the resident to feed her at the end of the breakfast and lunch meals on 8/20 and 8/21/19 because she had observed the resident had not eaten and 30 to 40 minutes was too long for a resident to wait for assistance. She stated the expectation was for the unit LPN to observe the residents in the dining room, monitor who was not eating well, and direct staff to assist. This was an area recently identified as she had noticed there were residents who were not eating and not receiving cues or encouragement. When interviewed on 8/22/19 at 12:11 PM, CNA #20 stated the resident normally sat at another table for residents who did not need assistance. The resident had declined in her eating ability since she developed the rash on her face. The CNA was informed by another staff member on 8/21/19 the resident had refused assistance and preferred to wait until the end of the meal. The CNA stated she had not received any other information on how to interact with the resident and CNAs from the other side of the unit assisted residents they may not know. The CNA stated she would not take the time during lunch to look up the Resident Profile. She would know how to approach the resident if someone who was familiar with the resident told her. 10NYCRR 415.12(a)(2)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and observation during the recertification survey the facility did not provide proper treatment and assistive devices to maintain vision for 1 of 1 resident (Resident #148) reviewed for vision/hearing. Specifically, Resident #148 did not receive new eyeglasses as recommended by her optometrist. Findings include: The facility policy, Consults, revised 11/2010, documented nursing staff would review the consultation report for any recommendations/follow-up and would date and initial the report when it was called to the provider. Resident #148 was admitted to the facility on [DATE] with diagnoses including anxiety disorder and corneal ulcer of the right eye. The Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the resident had moderate cognitive impairment and did not wear corrective lenses. The annual MDS assessment dated [DATE] documented the resident had intact cognition and did not wear corrective lenses. The Resident Profile (care instructions), with a start date of 9/10/15, documented the resident was at risk for falls and her glasses would be clean and in good repair. The same care instructions had conflicting information, documenting sight: normal, with a start date of 5/20/19. The comprehensive care plan (CCP) dated 4/3/19 and revised 8/2/19 documented the resident had right eye pain and required corrective lenses. Interventions included: arrange optometrist consult, implement recommendations, and assure the lenses of her glasses were clean and in good repair. A 5/14/19 optometry consult documented the resident was seen due to retinal vascular (circulation) changes in the right and left eye. It included a new bifocal eyeglass prescription that had changed since her previous prescription. The description of her new frames documented plastic, antique pewter. The optometry consult was initialed by licensed practical nurse (LPN) #22 and dated 5/15/19. During interviews and observations with the resident: - On 8/19/19 at 1:18 PM, she stated there was something wrong with her right eye, nobody would fix it, and she wanted bifocal glasses. A pair of red reading glasses and yellow-framed sunglasses were observed on her overbed table. - On 8/20/19 at 1:51 PM, she stated she had glasses, but they were broken. She searched her nightstand and overbed table and presented a pair of black-framed glasses with the right bow missing. Upon further inspection they were reading glasses, not bifocals, and the lenses were unclean. - On 8/21/19 at 11:00 AM, she stated she remembered picking out eyeglass frames that were pewter-colored. After looking through her nightstand drawer and overbed table she could not find any eyeglasses that matched that description. Her two pair of reading glasses and sunglasses from the previous days were the only glasses she could find. The two reading glasses lenses were unclean. During an interview with certified nurse aide (CNA) #23 on 8/21/19 at 11:07 AM, he stated the resident had three pair of glasses: a red pair of reading glasses, a black pair of reading glasses, and yellow sunglasses. He was not aware of her black reading glasses having a missing bow. He stated he did recall her going to an eye appointment a few months ago but her prescription eyeglasses must not have come in yet. During an interview with licensed practical nurse (LPN) #24 on 8/21/19 at 11:15 AM, she stated she knew the resident had glasses and they could be in the side of her chair cushion or anywhere. LPN #24 called medical records staff #26 to see if the resident ever had new bifocal eyeglasses ordered. LPN #24 then stated medical records staff #26 told her the resident never received new eyeglasses and she would look into it. LPN #24 stated if a new eyeglass prescription was written the doctor usually scanned it to medical records, the eyeglasses were ordered and would be delivered to the unit. During an interview with LPN #22 on 8/21/19 at 11:16 AM, she stated she did not know if Resident #148 wore prescription eyeglasses and she did not remember signing off on the 5/14/19 optometry consult. During an interview with medical records staff #26 on 8/21/19 at 3:15 PM, she stated optometry appointments were held in the facility clinic. After the provider saw a resident, she received the consult and would look for a check in a box (on the electronic form) that would indicate eyeglasses were to be ordered. She stated she called the optician and asked about Resident #148. It was an oversight and eyeglasses should have been ordered. Someone should have noticed from the consult that the resident had a new prescription with the eyeglass style picked out. 10NYCRR 415.12(b)(3)

Based on observation, record review and interview during the recertification survey, the facility did not ensure the provision of food and drink was palatable, attractive, and at a safe and appetizing temperature for 2 of 3 meal trays tested during dining observations. Specifically, food was not served at palatable and safe temperatures. Findings include: The kitchen policy titled Hot Food Policy dated 12/2017, documents dietary will serve all hot foods at 135 degrees Fahrenheit (F). The kitchen policy titled Cold Food Policy undated, documents cold food will be delivered to the resident at 40 F or below. The kitchen form titled Food and Nutrition Services Test Tray Evaluation undated, documented hot beverages temperature range of 140 F or above. The kitchen form titled Dietary Department Service Line Temperatures dated 8/19/2019 for the 2nd floor documented the hall meal tray assembly started at 4:50 PM and was completed at 5:19 PM. The following observations were made: - On 8/19/19 at 5:18 PM, the hall carts arrived on the 2nd floor C unit on an uninsulated rolling rack. At 5:23 PM, staff began to pass the meal trays. At 5:36 PM, the last meal tray was obtained for testing. Measured temperatures were: navy bean soup was 140 F; fried fish patty on a bun was 117 F; hot coffee was 119 F; and coleslaw was 60 F. - On 8/21/19 at 7:55 AM, the hall carts arrived on the 1st floor C unit. At 8:03 AM, staff began to pass the meal trays. At 8:23 AM, the last meal tray was obtained for testing. Measured temperatures were: scrambled eggs were 126.6 F and French toast was 84.6 F. During an interview with the Corporate Registered Dietitian (RD) on 8/19/19 at 5:45 PM, he verified the temperatures and stated the food temperatures were not acceptable. During an interview with the Assistant Food Service Director on 8/22/19 at 11:05 AM, the test tray temperatures were reviewed. He stated the fried fish on a bun, coleslaw, and scrambled eggs were served at unacceptable temperatures and were in the food danger zone temperatures. He stated hot food was expected to be served at 135 F or higher and cold food was expected to be served at 40 F or below for palatability. 10NYCRR 415.14(d)(1)(2)

Based on observation and interview during the recertification survey, the facility did not store food in accordance with professional standards for food service safety in 1 of 1 main kitchen reach-in coolers. Specifically, the cooler had non-potable condensation dripping from the top of the cooler and there was a container of egg salad with a cracked lid exposing the egg salad to open air. Findings include: The facility policy titled Perishable Foods Policy dated 12/2017, documents all food should be securely covered, dated, and labeled. During the follow-up kitchen visit on 8/21/19 at 6:39 AM, 1 reach-in cooler was observed to have non-potable condensation dripping from top of the cooler. The following was observed inside of the cooler: - 1 container of ranch dressing had standing water on the lid; and - 1 container of egg salad was covered with a cracked lid, which left the food exposed to open air. During an interview with the Assistant Food Service Director on 8/21/19 at 7:29 AM stated there was a sheet pan in the cooler to catch the dripping water and the pan should be changed twice daily. A work order had been placed to have the cooler fixed. The egg salad should have been covered securely to avoid contamination and kitchen staff was aware not to use broken or damaged items. The egg salad was observed discarded by the Assistant Food Service Director. 10NYCRR 415.14(h)