**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024 the facility did not ensure that the interdisciplinary team had determined that self-administration of medications was clinically appropriate for each resident. This was identified for one (Resident #79) of six residents reviewed for Accidents. Specifically, Resident #79 was self-administering the Nasal Moisturizing Spray and the facility staff was aware. A review of the resident's medical records indicated no documented assessment to determine if the resident could safely self-administer the medication and there was no physician's order to self-administer the Nasal Moisturizing Spray. The finding is: The facility's policy and procedure titled Self-Administration of Medication, last revised on 6/3/2024 documented to permit each resident to self-administer medications if the interdisciplinary team has determined that the resident can securely store, safely/accurately administer their medications, and maintain a complete and accurate record of such administration. If a resident is deemed capable of self-administering their medication, the physician will write the orders for medication as self-administration. Resident #79 was admitted with Diagnoses including Paraplegia (loss of muscle function in the lower half of the body), Chronic Obstructive Pulmonary Disease (COPD), and Edema. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #79's Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #79 had intact cognition. Resident #79 received respiratory treatment that included oxygen therapy. A Comprehensive Care Plan (CCP) titled Respiratory Disorders: Nasal Congestion, dated 10/5/2018 and last revised on 1/19/2024 documented interventions that included administering medications and assessing for shortness of breath. Oxygen therapy as per physician's order and provide inhalation or nebulizer treatment. A physician's order dated 10/5/2024 documented Nasal Moisturizing 0.65 percent spray. One drop by nasal route twice a day for Nasal Congestion. During an observation and interview on 10/16/2024 at 10:08 AM, Resident #79 was observed with a bottle of Nasal Moisturizing spray on their overbed table. Resident #79 stated the nurse had left the Nasal Moisturizing spray bottle so they (Resident #79) could self-administer the nasal spray. There was no nurse present in Resident #79's room during the observation. The Medical Record lacked documented evidence of a physician's order and assessment for self-administration of medication. A review of the Electronic Medical Administration Record (EMAR) revealed that the nurses had been signing for the Nasal Moisturizing 0.65 spray at 9:00 AM and 5:00 PM every day. During an interview on 10/16/2024 at 10:08 AM, Resident #79 stated they administered the Nasal Moisturizing spray themselves. Resident #79 stated the nurses gave them (Resident #79) the spray bottle to self-administer the medication and they (nurses) took the Nasal Moisturizing spray bottle at the end of the shift to keep it in the medication cart. During an interview on 10/16/2024 at 12:39, Registered Nurse #3, Medication Nurse, stated they had left the nasal spray with Resident #79 to self-administer the medication and then they (Registered Nurse #3) signed the Electronic Medical Administration Record (EMAR). Registered Nurse #3 stated that they typically handed the nasal spray bottle to the resident to self-administer the medication. During an interview on 10/21/2024 at 3:30 PM, Licensed Practical Nurse #6 stated they worked the 3:00 PM-11:00 PM shift, and Resident #79 had always self-administered the nasal saline spray. Licensed Practical Nurse #6 stated they would take the nasal spray from Resident #79 at the end of their shift to store the nasal saline spray in the medication cart. During an interview on 10/22024 at 11:17 AM, the Director of Nursing Services stated the nurses should not have left the saline spray bottle with Resident #79 to self-administer. Resident #79 should have been assessed first for competency in self-administering the medications and the Physician should have been notified to obtain an order to self-administer the nasal saline spray. 10 NYCRR 415.3(f)(1)(vi)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that each resident was provided a safe, clean, comfortable, and homelike environment. This was identified for one (Unit Seacliff 1) of nine units observed during the environmental task. Specifically, Resident #246 's privacy curtain was ripped and had brown stains. The finding is: The facility's policy for Resident Room Cleaning, dated March 2022, documented meaning and sanitizing to improve sanitation and ensure the highest level of cleanliness throughout the facility. To control cross-contamination, and the spread of bacteria and infection to maintain the outward experience of the facility. Complete high and low dusting of all flat surfaces, wall surfaces, corners and edges, windows, drapery, pictures, and ceiling features. The policy did not include when to change or wash the curtains. The Facility's policy for Resident Room-Homelike Environment, dated 6/21/2024 documented the facility is obligated to provide residents with a safe, home-like environment. Resident #246 had diagnoses that included Polyneuropathy (nerve damage), Type 2 Diabetes Mellitus, and Major Depressive disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. During an environmental tour of Unit Seacliff 1 on 10/16/2024 at 10:25 AM PM, Resident #246's privacy curtain was ripped and had brown stains. During an interview on 10/22/2024 at 10:20 AM, Resident #246 stated the privacy curtain had been ripped and was dirty with brown stains and had never been replaced since they were admitted to the facility. They stated it would be wonderful to have a clean and not ripped privacy curtain. Resident #246 stated the facility staff was aware of the ripped privacy curtain. During an environmental tour of Unit Seacliff 1 on 10/22/2024 at 11:00 AM, Resident #246's privacy curtain was ripped and had brown stains. During an interview on 10/22/2024 at 10:23 AM, Certified Nursing Assistant #5 and Certified Nurse's Assistant #6 both stated they were aware the privacy curtain in Resident #246's room was ripped for a while. They had informed the nurse about the ripped curtain; however, could not recall the name of the nurse. They both stated that the Certified Nursing Assistants do not notify the housekeeping staff about the housekeeping issues including the ripped curtains, they only notify the nurses on the unit, verbally. During an interview on 10/22/2024 at 10:30 AM, Registered Nurse #8 stated they were not aware of the ripped and dirty privacy curtain in Resident #246's room. During an interview on 10/22/2024 at 2:21 PM, Housekeeper Supervisor#1 stated the privacy curtains are replaced for each resident room every three to four weeks. Housekeeper Supervisor #1 stated they did not know Resident #246's privacy curtain was ripped and dirty and they were not notified that the curtain needed to be replaced. 10 NYCRR 415.5(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that the Minimum Data Set (MDS) assessment accurately reflects the resident's status. This was identified for one (Resident #262) of 38 sampled residents. Specifically, the Minimum Data Set assessment for Resident #262 did not accurately indicate that the resident was receiving comfort care. The finding is: The facility policy and procedure titled Completion of the RAI Process last reviewed 3/16/2023, documented that assessments will be completed within the guidelines outlined in the Resident Assessment Instrument (RAI) manual, including the care planning processes to lead to the development of a plan of care to address and monitor each resident's needs and function, and to track changes in the resident's status. Staff may utilize information in the medical record to assist with the completion of the Minimum Data Set. Resident #262 was admitted with diagnoses including Alzheimer's disease, Bipolar Disorder, and Diabetes Mellitus. A Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severely impaired cognition. The Minimum Data Set documented comfort care was not provided in the last 14 days. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severely impaired cognition. The Minimum Data Set documented comfort care was not provided in the last 14 days. A physician's order for Comfort Measures Only (CMO), was first ordered on 2/4/2023 and last renewed on 10/19/2024. A comprehensive care plan titled Advance Directives, effective 3/30/2021 and last reviewed on 9/10/2024, documented that Resident #262 received comfort measures only. A comprehensive care plan titled Comfort Care/Palliative Care/Hospice Care Plan, effective 4/8/2022, last reviewed 9/10/2024, documented interventions including comfort care. During an interview on 10/23/2024 at 1:15 PM, the Minimum Data Set Director stated Resident #262 was placed on comfort care since 2/4/2023 as per the physician's orders. The Minimum Data Set was inaccurately coded as not receiving comfort care in the past 14 days. During an interview on 10/23/2024 at 2:37 PM, the Director of Nursing Services stated the Minimum Data Set Coordinators and Minimum Data Set Director were responsible for ensuring the accuracy of the Minimum Data Set assessment. The Director of Nursing Services further stated the provision of comfort care should have been indicated on the Minimum Data Set assessments for Resident #262. 10 NYCRR 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/24/2024, the facility did not ensure that a person-centered Comprehensive Care Plan (CCP) was developed to meet the resident's medical and nursing needs. This was identified for one (Resident #331) of four residents reviewed during the Infection Control Task. Specifically, Resident #331 had a physician's order to place Resident #331 on contact precautions since 5/22/2024. There was no documented evidence that a care plan was developed to reflect Resident #331 was on contact precaution until 10/16/2024. The finding is: The Comprehensive Care Plan Policy dated 2/01/2021 documented that residents of the facility will have a Comprehensive Care Plan completed per Federal and State requirements. An individual Comprehensive Care Plan will be developed for each problem, strength, or need, measurable objectives, and timetables to meet the resident's physical, mental, and psychosocial needs that are identified on the resident's Comprehensive Assessments. The Comprehensive Care Plan is prepared with an interdisciplinary team approach. Resident # 331 had diagnoses including Cerebral Infarction(disrupted blood flow to the brain), Ventilator-dependent, and Tracheostomy Status. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident received Tracheostomy care and Ventilator care. The Minimum Data Set did not indicate the resident had infections in the look-back period. The physician's order dated 5/22/2024 documented Contact Precautions secondary to Pseudomonas {Carbapenem (antibiotic) Resistant} Organisms. A review of the resident's Comprehensive Care Plan from May 2024-10/15/2024 revealed there was no care plan for isolation precautions developed for Resident #331 until 10/16/2024. During an interview on 10/22/2024 at 10:43 AM, Infection Control Nurse#1 stated the resident had been on isolation precautions since May 2024 when they were readmitted to the facility with the drug-resistant Pseudomonas infection. The Infection Control Nurse stated they were responsible for managing the care plans related to infections. The Infection Control Nurse stated they did not develop the care plan for Resident#331's infection and isolation precautions and should have. During an interview on 10/22/2024 at 1:18 PM, the Minimum Data Set Director stated that the unit nurses were responsible for developing and updating the care plans for each resident and it was an oversight that an isolation care plan was not developed for Resident #341. During an interview on 10/22/2024 at 2:34 PM, the Director of Nursing Services stated Resident#331 should have a care plan developed for infection control including contact precautions. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during a recertification survey initiated on 10/16/2024 and completed on 10/24/2024, the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. The was identified on one (Woodcrest 2 unit) of nine units observed for medication storage task. Specifically, Licensed Practical Nurse #9 pre-poured medications in a medication cup and stored the medication cup in the medication cart without appropriate labels. Licensed Practical Nurse #9 then attempted to administer the medications to the wrong resident (Resident #100) without properly identifying the resident. The finding is: The Medication administration policy dated 9/07/2023 documented Medication administration will be conducted according to each resident's individualized care plan and physician's orders. Medication administration times will be strictly adhered to, and medications will be administered at the prescribed intervals. Before administering any medication, nursing staff will verify the resident's identity using two patient identifiers (for example name band and date of birth ) to ensure the right resident receives the right medication. Nursing home staff will carefully review each medication order for accuracy, including the medication name, dosage, route of administration, and administration time. Medications will be prepared in a clean and designated medication preparation area to prevent cross-contamination. Resident #100 had diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus, and Essential Tremor. The Minimum Data Set assessment dated [DATE] documented that Resident #100 had a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. Resident #100 had diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus, and Essential Tremor. The Minimum Data Set assessment dated [DATE] documented that Resident #100 had a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. The physician's order dated 10/5/2024 documented Bupropion (antidepressant) 150 milligrams 24-hour tablet extended release 1 tablet by oral route once daily for nicotine dependence and Depression. Buspirone (anti-anxiety) 5 milligrams 1 tablet by oral route two times per day for anxiety disorder. Furosemide (diuretic) 40 milligrams tablet, give 1 tablet by oral route once daily at 9:00 AM daily, and Miralax (stool softener) polyethylene glycol 3350 17 grams/dose oral powder, give 17 grams mixed with 8 ounces of fluid by oral route once daily. The Woodcrest 2 Unit Medication Cart #1 was observed on 10/17/2024 at 9:24 AM with Licensed Practical Nurse #9. There was a medication cup containing two tablets and three capsules stored in the top drawer of the medication cart. The medication cup had 214 written on the cup. Licensed Practical Nurse #9 stated 214 indicated the resident room number. Licensed Practical Nurse #9 stated the medications in the cup had two capsules of Bacid (probiotic), two tablets of Tylenol (pain medication) 325 milligrams, and one capsule of Neurontin (medication for nerve pain) 100 milligrams. While Licensed Practical Nurse #9 was speaking to the Surveyor, Resident #100 approached Licensed Practical Nurse #9 and requested they get their medication. Licensed Practical Nurse #9 took the souffle cup with the pre-poured Neurontin and Bacid capsules and Tylenol tablets and attempted to administer the medications to Resident #100. Resident #100 stated they already received their morning medications and were only requesting to get the Miralax and that they did not reside in room 214. During an interview on 10/17/2024 at 9:35 AM, Licensed Practical Nurse #9 stated they were a float nurse covering for the medication nurse on the Woodcrest 2 unit. Licensed Practical Nurse #9 stated they offered the wrong medications to the wrong resident and realized that Resident #100 was not the correct resident to receive the medications that were stored in the souffle cup; they thought Resident #100 resided in room [ROOM NUMBER], but later realized that Resident #100 was not from room [ROOM NUMBER]. They should have checked the resident's identification band to make sure the medication was being administered to the right resident. Licensed Practical Nurse #9 stated they usually prepare the medications in front of the resident rooms and then administer the medications soon after they prepare them. Today they pre-poured the medications at the nursing station and identified the medication cups with the residents' room numbers. During an interview on 10/22/2024 at 4:18 PM, the Director of Nursing Services stated Licensed Practical Nurse #9 failed to follow the five rights for medication administration policy which were: the Right resident, the right medication, the right time, the right dose, and the right route. The Director of Nursing Services stated that the medications should never be pre-poured and should never be left in the medication cart without identification labels. 10 NYCRR 415.11(c)(3)(i)

Based on observation, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #176) of three residents reviewed for Pressure Ulcers. Specifically, Resident #176 had a physician's order for an alternating air mattress due to multiple pressure ulcers. The resident's most recent weight was 86 pounds. The air mattress weight setting was set to a firm setting which corresponds to a resident who weighs between 360-400 pounds; however, the air mattress was observed to be deflated and was not functioning as intended. The finding is: The facility's policy titled Management of Pressure Ulcers, revised on 2/18/2022, documented that pressure ulcer care requires an interdisciplinary approach that addresses the following areas to promote healing of tissue: reduce or eliminate causative factors such as pressure due to immobility, friction, shear, moisture, and circulatory impairments. Establish an interdisciplinary treatment plan that promotes wound healing and addresses other conditions that may affect wound healing. The alternating air mattress manual, provided by the facility, documented that the soft/firm pressure adjustment knob should be adjusted for a comfortable pressure level customized according to the resident's weight. An illustration in the manual confirms that the soft adjustment corresponds to a resident's weight of 80 pounds and the firm adjustment corresponds to a resident's weight of 400 pounds. Resident #176 was admitted with diagnoses including Non-Alzheimer's Dementia, Malnutrition, and Hip Fracture. The 9/4/2024 Significant Change Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision-making. The Minimum Data Set assessment documented the resident had seven unstageable (the wound depth is not clear because the wound is covered by a layer of dead tissue) pressure ulcers due to coverage by slough/eschar (dead tissue), and nine unstageable pressure ulcers classified as deep tissue injury (damage to the underlying soft tissues caused by pressure). The resident required substantial/maximal assistance for rolling left to right and was dependent on staff for transfers requiring mechanical lift. The most recent resident weight in the medical record, dated 9/23/2024, was 86.1 pounds. Physician's orders, dated 10/6/2024, documented Comfort Measures Only; Ensure all wound sites are off-loaded every shift; Concave Air Mattress; monitor placement, function, and settings of the concave air mattress every shift. A physician's order dated 10/9/2024 documented treatment orders for the right hip unstageable pressure ulcer and to ensure the site is off-loaded at all times. A physician's order dated 10/22/2024 documented treatment orders for the sacral and left hip wound pressure ulcer and to ensure the site is off-loaded at all times, for diagnosis of pressure ulcer of left hip, unstageable. A wound consult written by Nurse Practitioner #1, dated 10/15/2024 documented to ensure the sacrum and right and left hip wound areas are off-loaded at all times. A review of the October 2024 Medication Administration Record revealed nurses were monitoring the placement, function, and settings of the concave air mattress each shift. A review of the October 2024 Treatment Administration Record revealed nurses documented each shift that all wound sites were off-loaded. On 10/16/2024 at 10:22 AM, Resident #176 was observed in bed. The air mattress weight setting pressure control knob was set to firm at 360 pounds. On 10/22/2024 at 11:10 AM, Resident #176 was observed in bed. The air mattress weight setting pressure control knob was set to firm between the 360-pound and 400-pound settings. The resident was lying on their back. During an interview on 10/22/2024 at 11:27 AM, Licensed Practical Nurse #1 (unit nurse, not assigned to Resident #176 today) stated housekeeping is responsible for adjusting the weight setting on the air mattress pump. Licensed Practical Nurse #1 checked the mattress pump setting and confirmed that the air mattress weight setting was set between 360-400 pounds. Licensed Practical Nurse #1 did not attempt to adjust the setting and stated they were unfamiliar with the air mattress pump and had never touched the setting. A review of the October 2024 Medication Administration Record revealed Licensed Practical Nurse #1 had signed for monitoring, placement, function, and setting of the concave air mattress for Resident #176 during the month on multiple occasions. During an observation and interview on 10/22/2024 at 11:46 AM, Housekeeping Director #1 observed and assessed Resident #176's air mattress with the Surveyor and stated the air mattress was deflated, even though the air mattress weight setting was set at the maximum weight. Housekeeping Director #1 stated the air mattress was malfunctioning and would have to be changed. Housekeeping Director #1 stated the weight setting on the air mattress should be set according to the resident's weight. The nurses on the unit should check the mattress weight setting, as well as the mattress itself, and notify housekeeping if the air mattress is malfunctioning. During an interview on 10/22/2024 at 1:47 PM, Certified Nursing Assistant #1 stated they make sure the air mattress pump light is on and they also check to see if the mattress is firm, but they do not check the weight setting. Certified Nursing Assistant #1 stated the air mattress was firm when they checked right before they went to lunch today. During an interview on 10/22/2024 at 1:52 PM, Licensed Practical Nurse #3 (assigned to Resident #176) stated they do not check the weight setting on the air mattresses. They just check to see if the mattress is firm. Licensed Practical Nurse #3 stated the mattress was fine today when they did the medication pass administration at 9:00 AM. A review of the October 2024 Medication Administration Record revealed Licensed Practical Nurse #3 had documented for monitoring, placement, function, and settings of concave air mattress for Resident #176 during the month on multiple occasions, including for 10/22/2024. During an interview on 10/22/2024 at 2:13 PM, Licensed Practical Nurse #4 (wound care nurse) stated the weight setting on the air mattress should be consistent with the resident's weight, and the nurses on the unit should check the air mattress weight setting during daily care because it is not uncommon for the air mattresses to malfunction. Licensed Practical Nurse #4 stated they did wound rounds today (10/22/2024) with the Nurse Practitioner, but did not check the air mattress setting for Resident #176 today due to an oversight. During an interview on 10/22/2024 at 2:34 PM, Nurse Practitioner #1 stated the weight setting on the air mattress should be consistent with resident weight because that helps with offloading and pressure relief. During an interview on 10/23/2024 at 9:26 AM, the Director of Nursing Services stated the unit nurses are supposed to check that the air mattress is functioning, is inflated properly, and the setting on the pump is appropriate each shift. The unit nurses should immediately report to the unit supervisor or the housekeeping staff if the setting on the pump is not accurate. The unit nurses do not change the setting. 10 NYCRR 415.12(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that each resident's environment remained as free of accident hazards as possible. This was identified for one (Resident #243) of six residents reviewed for Accident Hazards. Specifically, Resident #243's room was observed with an unsecured, free-standing oxygen E-Cylinder tank (the most common and largest portable oxygen tank) next to the resident's bed. The E-Cylinder tank was not secured in a rolling cylinder stand as per the facility's policy. The finding is: The facility policy and procedure titled Oxygen safety, last revised on 5/4/2024 documented that safety is the responsibility of all staff, residents, visitors, and the public. Hazards or other conditions that could develop into a hazard must be reported to a supervisor or Maintenance Director as soon as practical. Anyone may report a hazard or potential hazard. When small-size (A, B, D, or E) cylinders are in use, they shall be attached to a cylinder stand or medical equipment designed to receive and hold compressed gas cylinders. Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty. Protect cylinders from damage by not storing them in locations where heavy objects may strike or fall on them, or where they can be tipped over by foot traffic or door movement. Resident #243 was admitted with Diagnoses of Alzheimer's, Diabetes, and Acute Cough. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #243 had severe cognitive impairment. The Minimum Data Set (MDS) documented that Resident #243 did not receive any Respiratory Therapy. Resident #243's Physician's Order dated 5/1/2024 documented DuoNeb 2.5 milligrams-0.5 milligrams per 3 milliliters solution for nebulization. Inhale 3 milliliters by nebulization route 3 times per day for Acute Cough. The order was discontinued on 9/11/2024. There were no documented Physician's Orders for the Oxygen use for Resident #243. A Comprehensive Care Plan (CCP) dated 6/15/2024 titled, Acute Cough, documented interventions that included nebulization treatment, medication as per Physician's Orders, and evaluation for shortness of breath, chest pain, and discomfort with breathing or coughing. During an observation on 10/16/2024 at 1:29 PM, a free-standing, unsecured E-cylinder oxygen tank was observed next to Resident #243's bed. The gauge needle of the E-cylinder oxygen tank was at 1,000 pounds per square inch (PSI, defined as the unit of measurement used to indicate the amount of oxygen in a tank or cylinder), which indicated that the oxygen tank was half full. A nebulizer mask and tubing were attached to the E-cylinder oxygen tank delivery port. During an interview on 10/16/2024 at 1:14 PM, Licensed Practical Nurse #5 stated Resident #243 used the oxygen tank for nebulization. Licensed Practical Nurse #5 stated they did not notice the E-Cylinder oxygen tank was still in Resident #243's room and was not secured in the rolling cylinder stand. Licensed Practical Nurse #5 stated all oxygen tanks must be secured in a rolling cylinder stand. During an interview on 10/21/2024 at 2:31 PM, Certified Nursing Assistant #2 stated they worked on the evening shift and did not notice the free-standing, unsecured E-Cylinder oxygen tank in Resident #243's room. Certified Nursing Assistant #2 stated they would have reported to the Nurse if they had seen the unsecured tank in Resident #243's room. During an interview on 10/21/2024 at 2:44 PM, Registered Nurse #3 stated that Resident #243 had an order for nebulization, and they had used the E-Cylinder oxygen tank for nebulization because they did not have a nebulizer machine at that time. Registered Nurse #3 stated that the physician's order for nebulization had been discontinued in September 2024. Registered Nurse #3 stated the E-Cylinder oxygen tank should have been taken out of Resident #243's room. Registered Nurse #3 stated they did not know the E-Cylinder oxygen tank remained unsecured in Resident #243's room. During an interview on 10/22/2024 at 8:46 AM, the Director of Plant Operation stated that all E-Cylinder oxygen tanks should be secured in a rolling cylinder stand. The Director of Plant Operation stated there should not be any oxygen tanks freely standing and unsecured. The Director of Plant Operation stated that oxygen tanks are combustible (able to catch fire and burn easily) and should not be dragged nor bounced on the floor due to static that can cause combustion. The Director of Plant Operation stated that an unsecured oxygen tank can fall, rupture, and cause physical damage because the tank is highly pressurized. During an interview on 10/22/2024 at 9:44 AM, the Director of Nursing Services stated there should not be any unsecured oxygen tanks in the unit. The nurses should not have used the E-Cylinder oxygen tank for nebulization because the facility had plenty of nebulizer machines. 10 NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The Medication administration policy dated 9/07/2023 documented that medication administration will be conducted according to each resident's individualized care plan and physician's orders. Before administering any medication, nursing staff will verify the resident's identity using two patient identifiers (e.g., name band and date of birth ) to ensure the right resident receives the right medication. Nursing home staff will carefully review each medication order for accuracy, including the medication name, dosage, route of administration, and administration time. Medications will be prepared in a clean and designated medication preparation area to prevent cross-contamination. Resident #100 had diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus, and Essential Tremor. The Minimum Data Set assessment dated [DATE] documented that Resident #100 had a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. The physician's order dated 10/5/2024 documented Bupropion (antidepressant) 150 milligrams 24-hour tablet extended release 1 tablet by oral route once daily for nicotine dependence and Depression. Buspirone (anti-anxiety) 5 milligrams 1 tablet by oral route two times per day for anxiety disorder. Furosemide (diuretic) 40 milligrams tablet, give 1 tablet by oral route once daily at 9:00 AM daily, and Miralax (stool softener) polyethylene glycol 3350 17 grams/dose oral powder, give 17 grams mixed with 8 ounces of fluid by oral route once daily. The Woodcrest 2 Unit Medication Cart #1 was observed on 10/17/2024 at 9:24 AM with Licensed Practical Nurse #9. There was a medication cup containing two tablets and three capsules stored in the top drawer of the medication cart. The medication cup had 214 written on the cup. Licensed Practical Nurse #9 stated 214 indicated the resident room number. Licensed Practical Nurse #9 stated the medications in the cup had two capsules of Bacid (probiotic), two tablets of Tylenol (pain medication) 325 milligrams, and one capsule of Neurontin (medication for nerve pain) 100 milligrams. While Licensed Practical Nurse #9 was speaking to the Surveyor, Resident #100 approached Licensed Practical Nurse #9 and requested they get their medication. Licensed Practical Nurse #9 took the souffle cup with the pre-poured Neurontin and Bacid capsules and Tylenol tablets and attempted to administer the medications to Resident #100. Resident #100 stated they already received their morning medications and were only requesting to get the Miralax and that they did not reside in room 214. During an interview on 10/17/2024 at 9:35 AM, Licensed Practical Nurse #9 stated they were a float nurse covering for the medication nurse on the Woodcrest 2 Unit. Licensed Practical Nurse #9 stated they offered the wrong medications to the wrong resident and realized that Resident #100 was not the correct resident to receive the medications that were stored in the souffle cup; they thought Resident #100 resided in room [ROOM NUMBER], but later realized that Resident #100 was not from room [ROOM NUMBER]. They should have checked the resident's identification band to make sure the medication was being administered to the right resident. Licensed Practical Nurse #9 stated they usually prepare the medications in front of the resident rooms and then administer the medications soon after they prepare them. Today they pre-poured the medications at the nursing station and identified the medication cups with the residents' room numbers. During an interview on 10/17/2024 at 9:43 AM, Registered Nurse Supervisor #9 stated that Licensed Practical Nurses should administer the medications immediately after preparing the medications in the medication cup. Before administering the medications, they must check the resident's name and the medication blister pack to ensure the right medication is being administered to the right resident. During an interview on 10/22/2024 at 4:18 PM, the Director of Nursing Services stated Licensed Practical Nurse #9 failed to follow the five rights for medication administration policy which were: the Right resident, the right medication, the right time, the right dose, and the right route. The Director of Nursing Services stated that the medications should never be pre-poured and should never be left in the medication cart without proper identification labels. 10 NYCRR 415.18(a) Based on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure a system of records and accounts of all controlled drugs were maintained, and the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. This was identified for three (Resident #207, Resident #301, and Resident #340) of three residents reviewed during the medication storage task and 2) one (Woodcrest 2 Unit) of nine units observed during the medication storage task. Specifically, 1) Resident #207 and Resident #301 Controlled Substance Disposition Record were not accurately reconciled after the medications were administered to the residents. -A Blister Pack containing 12 Marinol 10 milligram capsules (Scheduled III drug) was observed stored in the locked box in the medication refrigerator; however, there was no Controlled Substance Disposition Record maintained for the medication. 2) During an observation on the Woodcrest 2 Unit, pre-poured medications (three capsules and two tablets) were observed in a medication cup stored in the medication cart. Licensed Practical Nurse #9 was observed attempting to administer the pre-poured medications to the wrong resident. The findings are: 1) Resident #207 was admitted with diagnoses that included Multiple Sclerosis and Chronic Obstructive Pulmonary Disease. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 10, which indicated the resident had moderately impaired cognition. The Minimum Data Set documented the resident received Opioids during the last seven days. Resident #207's physician order dated 9/28/2024 documented Oxycontin 10 milligram crush resistance, extended release, give 1 tablet by oral route every 12 hours for chronic pain. Resident #207's Medication Administration Record documented Oxycontin 10 milligrams was administered at the scheduled time of 9:00 AM on 10/22/2024. During a Medication Storage Task observation on 10/22/2024 at 10:55 AM on the [NAME] 2 Nursing Unit, Resident #207's Controlled Substance Disposition Record for Oxycontin (a narcotic medication) 10 milligrams documented that the last tablet was used on 10/21/2024 at 9:00 PM with 21 remaining tablets; however, the blister pack for the Oxycontin 10 milligram revealed there were only 20 tablets available. The Controlled Substance Disposition Record was not updated after the medication was administered to the resident on 10/22/2024 at 9:00 AM. Resident #301 was admitted with diagnoses that included Parkinson's Disease and Polyneuropathy. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, which indicated the resident had moderately impaired cognition. The Minimum Data Set assessment documented the resident received Opioids during the last 7 days. Resident #301's physician order dated 9/27/2024 documented Tramadol extended-release 100 milligrams, give 1 tablet by oral route once daily for pain. Resident #301's Medication Administration Record dated 10/2024 documented Tramadol extended release 100 milligrams, was administered at the scheduled time of 9:00 AM on 10/22/2024. During a Medication Storage Task observation on 10/22/2024 at 10:51 AM on the [NAME] 2 Nursing Unit, Resident #301's Controlled Substance Disposition Record for Tramadol (pain medication-controlled substance) Extended Release 100 milligrams documented that the last tablet was used on 10/21/2024 at 9:15 AM with eight remaining tablets; however, the blister pack for the Tramadol Extended Release 100 milligram only had seven tablets available. The Controlled Substance Disposition Record was not updated after the medication was administered to the resident on 10/22/2024 at 9:00 AM. -Resident #340 was admitted with diagnoses that included Cachexia (muscle loss) and Dysphagia (difficulty swallowing). The Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status was 13, which indicated the resident had intact cognition. The Minimum Data Set documented the resident did not receive scheduled pain medication. Resident #340's physician order dated 6/9/2024 documented to discontinue Dronabinol (Marinol) 10 milligrams by oral route once daily. During a Medication Storage Task observation on 10/22/2024 at 10:58 AM on the [NAME] 2 Nursing Unit, a Blister Pack containing 12 Marinol 10 milligram capsules (Scheduled III drug) was observed stored in the locked box in the medication refrigerator. There was no Controlled Substance Disposition Record to indicate an account of the controlled drug was maintained and periodically reconciled for the past six months. The Controlled Substance Disposition Record provided by the facility documented the last entry on 4/4/2024 indicating 12 capsules were remaining. During an interview on 10/22/2024 at 11:15 AM, Licensed Practical Nurse #8 stated they had administered the Oxycontin and the Tramadol to the residents at 9:00 AM today, but did not sign the Controlled Substance Disposition Record. Licensed Practical Nurse #8 stated they had a bad habit of not signing the Controlled Substance Disposition Record and that it was their mistake that they were rushing. Licensed Practical Nurse #8 stated they should have reconciled and signed the Controlled Substance Disposition Record as soon as they had removed the tablets from the Blister Packs. Licensed Practical Nurse #8 stated they did not count the Marinol because they were not aware the medication was in the locked box stored in the refrigerator. Licensed Practical Nurse #8 stated they did not know the procedure to store the discontinued controlled medication. During an interview on 10/22/2024 at 11:57 AM, Registered Nurse #7 stated that Licensed Practical Nurse #8 should have reconciled the narcotics at the time they removed the tablets from the Blister Packs to ensure the accuracy of the narcotic count. Registered Nurse #7 stated that the nurses were inserviced on the proper process for reconciling controlled drugs. During an interview on 10/22/2024 at 3:47 PM, the Director of Nursing Services stated when the nurses remove the narcotics from the blister pack, they must sign the Controlled Substance Disposition Record immediately, then sign the Medication Administration Record after administration of the medication. The Director of Nursing Services stated that Licensed Practical Nurse #8 should have reconciled and signed the Controlled Substance Disposition Record at the time they removed the Medications (Oxycontin and Tramadol) from the Blister Packs. During a subsequent interview on 10/22/2024 at 4:01 PM, the Director of Nursing Services stated when a narcotic medication is discontinued, the nurses on the unit were responsible for providing the Controlled Substance Disposition Record and the Blister Pack to their Supervisor who would then bring both the Controlled Substance Disposition Record and the Blister Pack to the Director of Nursing Services. The Director of Nursing Services stated they and the Supervisor would reconcile the medication to ensure the accuracy of the medication on the Controlled Substance Disposition Record and the number of medications in the Blister Pack. The Director of Nursing Services stated they were not aware that Marinol was discontinued for Resident #340 as they did not receive the Controlled Substance Disposition Record or the Blister Pack from the unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure all drugs and biologicals used in the facility were maintained and stored under proper temperature control. This was identified during a Medication Storage and Labeling Task on one ([NAME] 2 Unit) of nine Nursing Units observed. Specifically, [NAME] 2 Nursing Unit medication refrigerator temperature was observed to be at 60 degrees Fahrenheit. There were two unused/unopened Insulin injection pens and a box of Trulicity (used for Diabetes) injection pens observed stored in the medication refrigerator. Both unopened medications were supposed to be stored in the refrigerator at a temperature between 36 degrees Fahrenheit to 46 degrees Fahrenheit as per the manufacturer's recommendations. The finding is: The facility's Storage of Medication Requiring Refrigeration policy and procedure revised on 7/24/2024 documented that the facility will ensure all medications and biologicals will be stored at proper temperature controls. The refrigerator used for the storage of medications and biologicals includes an accurate functioning thermometer, temperature should be maintained between 36-46 degrees Fahrenheit and the refrigerator temperature is to be monitored every shift to ensure proper temperature control. During a tour of the [NAME] 2 Unit, with Charge Registered Nurse #6 on 10/22/2024 at 11:25 AM, the unit's medication refrigerator was observed with two Insulin injection pens and a box containing Trulicity injection pens. The medication refrigerator temperature was observed to be at 60 degrees Fahrenheit. During an interview on 10/22/2024 at 11:30 AM, Registered Nurse #6 stated they did not know if the temperature for the medication refrigerator was checked on the morning of 10/22/2024. Registered Nurse #6 stated that the temperature of the medication refrigerator is checked daily by the medication nurse and documented on the log sheet. Registered Nurse #6 stated they could not find the daily temperature log sheet for the medication refrigerator. Registered Nurse #6 stated that they did not know the acceptable temperature range for the medication refrigerator or the temperature range for storage of the Insulin and Trulicity pen. During an interview on 10/22/2024 at 3:47 PM, the Director of Nursing Services stated the temperature of the medication refrigerator should be checked daily on every shift by the nurses on the unit. The Director of Nursing Services stated the nurse who counted the narcotics on 10/22/2024, was responsible for checking the temperature of the medication refrigerator. The Director of Nursing Services stated if there was a problem with the thermometer or the refrigerator, the nurses were responsible for reporting to the Maintenance Department for timely follow-up. 10 NYCRR 415.18(e)(1-4)

Based on record review and staff interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure laboratory services were obtained in a timely fashion to meet the needs of each resident. This was identified for one (Resident #108) of five residents reviewed for Unnecessary Medications. Specifically, a Lipid Profile (a blood test to determine different types of fat in the blood) was ordered for Resident #108 in response to a pharmacist medication regimen review. The blood test was ordered in the electronic medical record on 9/27/2024 and 10/11/2024 but was not communicated to the laboratory and therefore was not done. The finding is: The facility's policy titled Diagnostic Tests and Results, dated 3/22/2022 documented it is the policy of the facility to identify diagnostic tests and results that are needed for the management of resident's care and delineate the timeframe in which the tests and results are expected to be performed or available. Further, the facility will ensure that the results of these tests are communicated to the treating provider in a manner that is timely, accurate, complete, and understood by the recipient. The facility will continuously measure, assess, and, if needed, take action to improve its performance with respect to the above as part of its Quality Assurance and Performance Improvement initiative. Resident #108 was admitted with diagnoses including Non-Alzheimer's Dementia, Diabetes Mellitus, and Depression. The 8/29/2024 Annual Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision making. A physician's order dated 6/26/2024 documented Quetiapine (an antipsychotic medication) 50 milligrams tablet; give 1 tablet by oral route once daily at bedtime for diagnosis of Major Depressive Disorder and Unspecified Psychosis. A Medication Regimen Review dated 9/23/2024 documented the resident is currently receiving Quetiapine (Seroquel). Unable to locate recent hemoglobin A1C (a blood test that measures a person's average blood sugar level over the past 2-3 months) and Lipid Profile in the chart. Recommend three months after the start of medication and then annually thereafter. The Physician/Prescriber responded Agree/Will Do on 9/27/2024. A physician's order dated 10/11/2024 ordered the following blood tests: Complete Blood Count (measures the number of cells in your blood), Comprehensive Metabolic Panel (measures chemical balance and metabolism), hemoglobin A1C, Lipid Profile, and Thyroid Stimulating Hormone (measures level of thyroid-stimulating hormone in your body) to be collected on 10/11/2024. A review of the medical record revealed there were blood test results from blood collected on 10/11/2024 for Complete Blood Count, Comprehensive Metabolic Panel, hemoglobin A1C, and Thyroid Stimulating Hormone. There were no results for the Lipid Profile. During an interview on 10/22/2024 at 8:37 AM, Laboratory Representative #1 stated there were no laboratory work results for a lipid profile and did not even see an order for a lipid profile. During an interview on 10/22/2024 at 8:54 AM, Physician #1 stated they just started working in the facility on 10/10/2024 and could not explain why the Lipid Profile was not done. Physician #1 stated the lipid profile bloodwork should have been done if it was ordered. During an interview on 10/22/2024 at 9:54 AM, Registered Nurse #1 (unit supervisor) stated there is a two-step system when ordering lab work. First, the order has to be entered into the electronic medical record, and then the laboratory has to be notified through a separate ordering system not related to the resident's medical record. Registered Nurse #1 stated usually, if a resident is prescribed an antipsychotic medication, due to the risk of dyslipidemia (abnormal lipid profile), there should be a lipid profile completed within three months from when the medication was started and then annually thereafter. There is no explanation as to why the lipid profile was not done as ordered on 10/11/2024. During an interview on 10/23/2024 at 9:22 AM, the Director of Nursing Services stated the residents' electronic medical record is not interfaced with the laboratory. All of the laboratory work that was ordered on 10/11/2024 should have been done and the facility will have to speak to the laboratory to determine why the lipid profile was not done. During an interview on 10/23/2024 at 11:25 AM, Registered Nurse #4 (overnight supervisor who entered order on 10/11/2024) stated the laboratory work for the lipid profile should have been drawn, but they did not know why the lipid profile was not done. 10 NYCRR 415.20

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during a Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that medical records were maintained for each resident that were complete and accurately documented in accordance with accepted professional standards of practice. This was identified for one (Resident #184) of one resident reviewed for Respiratory Care. Specifically, Resident #184 was observed receiving oxygen therapy via a nasal cannula on 10/16/2024, 10/17/2024, and 10/21/2024 as per their Physician's order; however, there was no documented evidence that the resident was administered oxygen therapy on 10/16/2024, 10/17/2024, and 10/21/2024. The finding is: The facility policy titled Medication and Treatment Administration Record dated 4/2008 and last revised 5/2023 documented unit licensed nurses are provided with a resident medication profile to ensure medications and treatments are given as ordered. The licensed nurses must adhere to policy and procedure for medication/treatment administration and ensure that medication and treatments are signed for immediately after administration. As needed medications and treatments require documentation on the Medication Administration Record or Treatment Administration Record with time and initial and a nurse's note on the Medication Administration Record or Treatment Administration Record indicating reason for administration. Resident #184 was admitted with diagnoses including Sepsis, and Pneumonia. The Significant Change in Status Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 7, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment documented the resident did not receive oxygen therapy during the assessment period. A physician's order dated 9/9/2024 and discontinued on 10/21/2024 documented to administer oxygen therapy via a nasal cannula at 1 to 2 liters per minute as needed for Elevated [NAME] Blood Cell Count. Resident #184 was observed on 10/16/2024 at 11:03 AM lying in bed and receiving oxygen therapy from a wall-mounted oxygen flow meter via a nasal cannula at 1.5 liters per minute. A subsequent observation was completed on 10/17/2024 at 9:55 AM. Resident #184 was observed resting in bed and receiving oxygen therapy from a wall-mounted oxygen flow meter via a nasal cannula at 1.5 liters per minute. During an additional observation on 10/21/2024 at 10:42 AM, Resident #184 was observed in bed receiving oxygen from a wall-mounted oxygen flow meter via a nasal cannula at a rate of 1.5 liters per minute. The Treatment Administration Record for October 2024 lacked documented evidence that the resident was administered oxygen therapy from 10/1/2024 to 10/21/2024. During an interview on 10/21/2024 at 10:47 AM, Licensed Practical Nurse #7, the day shift medication nurse, stated Resident #184 had a physician's order for oxygen therapy. Licensed Practical Nurse #7 stated they were unsure why they did not sign the Treatment Administration Record on 10/21/2024 to indicate oxygen administration. Licensed Practical Nurse #7 stated they should have signed for the administration of oxygen therapy on the Treatment Administration Record on 10/21/2024. During an interview on 10/21/2024 at 10:58 AM, Registered Nurse #6, the charge nurse, stated the medication nurses were responsible for administering oxygen as per the physician's orders. The medication nurses are then expected to document oxygen administration on the Treatment Administration Record. Resident #184's Treatment Administration Record should have documented that they received supplemental oxygen on 10/16/2024, 10/17/2024, and 10/21/2024. During an interview on 10/23/2024 at 12:00 PM, the Director of Nursing Services stated nursing staff should have documented on the Treatment Administration Record whenever supplemental oxygen therapy was administered for Resident #184. 10 NYCRR 415.22(a)(1-4)

Based on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that each resident was treated with respect and dignity and in a manner that promotes maintenance or enhancement of his or her quality of life. This was identified 1) on nine of nine units during the dining task observations and 2) for seven (Resident #169, Resident #341, Resident #285, Resident #5, Resident #267, Resident #337, and Resident #204) of seven residents interviewed during the resident council meeting. Specifically, 1)during the dining task observations, residents on all nine units were served their breakfast and lunch meals on disposable plates with disposable utensils. 2) On 10/16/2024 at 2:30 PM, all seven residents who attended the resident council meeting verbalized dissatisfaction about meals being served on disposable dishes with disposable utensils because of the broken dishwasher. The finding is: 1) During the dining meal observation of the Breakfast and Lunch meals for all nine resident units on 10/16/2024 and 10/17/2024, the meals were served on disposable Styrofoam plates with disposable utensils. During an interview on 10/16/2024 at 12:45 PM, the Dietary Supervisor stated the residents were receiving their meals on disposable Styrofoam food containers because the dishwashing machine was not working. The Dietary Supervisor did not know how long the dishwashing machine had not been in working condition. During an interview on 10/23/2024 at 3:16 PM, the Administrator stated they were aware of the residents' dissatisfaction with the use of disposable dishes and utensils. The Administrator stated that the dishwashing machine had not been functioning since January of this year (2024). The Administrator stated that the issue has not been addressed since January 2024 due to a combination of failed contractor agreement attempts in January of this year (2024) and the facility's reluctance to provide funds because of a potential facility closure or sale plan earlier this year. 2) During the Resident Council meeting on 10/16/2024 at 2:30 PM, seven of seven residents in attendance verbalized dissatisfaction with utilizing disposable plates and utensils since the beginning of the year due to the facility's broken dishwashing machine. Resident #267 was admitted with diagnoses including Metabolic encephalopathy, Generalized abdominal pain, and Gastric ulcers. The 9/10/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact. During an interview on 10/16/2024 at 3:48 PM, Resident #267, the resident council president, stated that all meals are being served on disposable plates with disposable utensils because the dishwashing machine had been broken for several months with no indication of when it would be repaired. Resident #267 stated that the facility is aware of the resident's dissatisfaction with meals served on Styrofoam plates and the use of poor-quality plastic utensils. Resident #267 stated that the resident council members have conveyed their desire for regular plates and utensils to the facility Administrator on multiple occasions. Resident #267 stated that using the Styrofoam disposable plates diminishes the experience of a quality meal. Resident #5 was admitted with diagnoses including Chronic Kidney Disease, Hypertension, and Gastro-Esophageal Reflux Disease. The 9/6/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. During an interview on 10/16/2024 at 3:50 PM, Resident #5, a regular attendee of the resident council meetings, stated that Resident Council members have complained to the administrator that the plastic utensils are of poor quality and make it difficult for the residents to enjoy their meals. 10 NYCRR 415.3(d)(1)(i)

Based on observation, interviews, and record review, during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility failed to ensure that food was served in accordance with professional standards for food service safety. This was identified for one unit (Woodcrest one) of nine units observed during the Dining Facility Task. Specifically, the facility did not monitor the temperature of cold food items served to residents in the Woodcrest One Unit during a lunch meal observation on 10/16/2024. The cold food temperature served during the lunch meal measured between 50-60 degrees Fahrenheit (normal range: below 41 degrees Fahrenheit). The finding is: An undated facility policy and procedure titled Food Temperatures documented that the temperatures of the food items will be taken and properly recorded for each meal. All cold food items must be maintained and served at a temperature of 41 degrees Fahrenheit or below. Temperatures should be taken periodically to ensure cold foods stay below 41 degrees Fahrenheit during the portioning, transporting, and delivery process until received by the individual recipient. Foods should be transported as quickly as possible to maintain temperatures for delivery and service. Food sent to the units for distribution (such as meals) is transported and delivered with maintained temperatures at or below 41 degrees Fahrenheit for cold foods. During a lunch meal observation at the Woodcrest One unit on 10/16/2024 at 12:58 PM, the cold food temperature was not documented on the temperature log. Dietary Aide #1 was observed serving the meal without taking the temperature of the cold food items (such as sandwiches, yogurt, and pudding). Dietary Aide #1 was immediately interviewed and stated they do not take cold food temperatures, they only take the temperature of the hot food items on the steam table. The cold food items were already placed on the individual resident trays in the kitchen prior to the trays being delivered to the unit. On 10/16/2024 at 1:06 PM, Registered Dietitian #1 took the temperature of the following cold food items: the cheese sandwich was measured at 60.7 degrees Fahrenheit, and the chocolate pudding was measured at 50 degrees Fahrenheit. Registered Dietitian #1 stated that these temperatures were not in compliance with food safety standards. During an interview on 10/23/2024 at 10:53 AM, the Food Service Director stated that the food temperatures of hot and cold food items should be measured by the dietary staff prior to meal services. The Food Service Director stated it is important to take the temperatures to ensure that the food is not in the danger zone (The temperature danger zone for food is between 40°F and 140°F, where bacteria can grow rapidly) where there is an increased risk of illness. The Food Service Director stated the cold food should have gone to the unit in bulk on a pan of ice rather than pre-plated on the individual trays. 10 NYCRR 415.14(h)

Based on observation, interviews, and record review during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. This was identified during the Kitchen Task. Specifically, during a kitchen tour with the Food Production Manager on 10/16/2024 the mechanical dishwashing machine was not in working order. Record review and interviews indicated that the dishwashing machine has been out of order since January 2024. The finding is: A facility policy and procedure dated 4/20/2023 titled Dishwashing, documented the Nutritional Services Department shall maintain a file of written procedures for cleaning and maintaining all equipment in the department. The Dietary Aide will report to the Food Production Manager, Supervisor, or Director of Dietary any problems with the dishwashing machine. Upon receipt of the report of problems with the machine, the Plant Operations is called and a routine work request is prepared. The Plant Operations supervisor will determine whether the problem can be handled internally or if an outside company is required. If the machine requires outside service, the Dietary Supervisor, Production Manager, or Director of Dietary will place a service call. An email dated 1/25/2024 from the former Food Service Director to the equipment repair company documented that a quote for the dishwashing machine repair was received in December 2023. The email documented that approval was received from the facility administration. A follow-up email dated 3/25/2024 documented that there was a delay in receiving the necessary parts for repair. During an interview on 10/18/2024 at 9:25 AM, the Food Service Director stated that they started their employment at the facility approximately four months ago. They stated that during that time, they have had various vendors coming to the facility to provide proposals for the new dishwashing equipment. The food service director further stated that they provided the administrator with the proposal. Last week a plumber was in the facility to review the work needed to be done before the purchase and installation of new equipment. A record review revealed a quote for new equipment dated 9/27/2024. During the kitchen tour with the Food Service Director on 10/18/2024 at 9:27 AM, the inoperable dishwashing machine was observed. During a re-interview on 10/23/2024 at 10:53 AM, the Food Service Director stated they are not aware of the details of the previous conversations. They further stated that they had given the administration recommendations for a new dishwashing machine. During an interview on 10/23/2024 at 3:16 PM, the Administrator stated the facility has been looking into repairing or obtaining a new dishwashing machine since January 2024. The Administrator stated that the dishwashing machine has been inoperable since the beginning of the year (January 2024). At that time (January 2024), the facility received a repair quote which was approved; however, there was a delay in receiving the necessary parts. They further stated that sometime in March 2024, the former Food Service Director resigned and the facility's ownership was reluctant to commit the necessary funds to purchase or repair the equipment due to the pending plans for the facility closure or sale earlier in 2024. 10 NYCRR 415.5(e)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that each resident is treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one (Resident #224) of one resident reviewed for resident rights. Specifically, during a lunch meal observation on 8/1/2023 at time 1:05 PM Registered Nurse (RN) #13 was observed standing over Resident #224 while feeding the resident. The finding is: The facility's policy titled Assisting with Feeding dated 10/26/2022 documented to provide assistance with feeding to residents who require it as part of their care plan in the nursing home. This policy aims to ensure that residents receive proper nutrition and hydration, maintain their overall health, and experience a comfortable dining experience. Staff will respect residents' preferences and dignity while assisting with feeding. Resident #224 was admitted with diagnoses that include Dementia and Major Depressive Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) was not performed because the resident was rarely/never understood. The resident required limited assistance of one person for eating. During the Dining Task observation conducted on 8/1/2023 at 1:05 PM Resident #224 was observed in the dining area, seated in a wheelchair at a dining table. RN #13 was observed standing over Resident #224 feeding the resident their lunch meal. Resident #224's head was tilted backwards with their neck extended. The resident's mouth was open and the eyes were gazing up at the ceiling. The Comprehensive Care Plan (CCP) for Nutritional Status initiated on 1/4/2022 and last reviewed on 7/6/2023 documented that the resident was at risk for altered nutritional status related to: Dementia, Depression, and Vitamin D/B12 Deficiency. The interventions included to allow the resident to make food preference(s) known, to assist the resident with feeding/fluids as needed and, to encourage intake of meals and fluids. The CCP for ADL Functional/Rehabilitation Potential initiated on 1/3/2022 and last reviewed on 7/23/2023 documented the resident is to be provided with limited assistance at mealtimes. RN #13 was interviewed on 8/1/2023 at 1:09 PM and stated Resident #224 usually eats by themselves but they (RN #13) wanted to assist the resident before the resident's food got cold. RN #13 stated they knew they should be seated when assisting a resident with eating. The Assistant Director of Nursing Services (ADNS), RN #12, was interviewed on 8/3/2023 at 3:04 PM. ADNS, RN #12 stated when a staff person is assisting a resident with eating the staff person should be seated next to the resident. RN #13 was re-interviewed on 8/10/2023 at 10:18 AM and stated they made a mistake by standing to feed the resident. RN #13 stated the proper way of assisting a resident at mealtime is to be seated next to the resident and allow the resident to do what they can while providing encouragement. Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:34 PM and stated when meal assistance is provided, the resident should be encouraged to feed themselves as much as possible, and provided with encouragement. The staff should be seated next to the resident and not standing while feeding the resident. 10 NYCRR 415.3(d)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00309550) initiated on [DATE] and completed on [DATE], the facility did not ensure that residents and/or their Designated Representatives participated in the development and implementation of his or her person-centered plan of care. This was identified for one (Resident #43) of four residents reviewed for Notification of Change. Specifically, there was no documented evidence in the Electronic Medical Record (EMR) that Resident #43 had a Comprehensive Care Plan (CCP) meeting held since [DATE]. Additionally, there was no documented evidence that the resident's Health Care Proxy (HCP)/Designated Representative was invited to a CCP meeting since [DATE]. The finding is: The facility's policy titled, Care Plan Scheduling and Meeting dated [DATE] documented to provide each resident with an individualized interdisciplinary plan of care. Scheduling of the CCP Review and Meetings will be generated by the Minimum Data Set (MDS) Coordinator (Director). The MDS Coordinator will distribute MDS/CCP schedule monthly; The Social Worker (SW) notifies the resident, family, or Designated Representative of the CCP meetings as scheduled; Types of meetings or conferences are admission, quarterly, significant change in residents' condition and overall status, and specialized/ad-hoc meetings; The attendance will be documented in the resident's EMR under the Care Plan (CP) Meeting section. Resident #43 has diagnoses which include Atrial Fibrillation and Schizophrenia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 5 which indicated that the resident had severely impaired cognitive skills for daily decision making. The resident's current HCP/Designated Representative was interviewed on [DATE] at 5:05 PM and stated that they (the resident's current HCP) had never been invited to a CCP meeting for Resident #43 and did not even know what a CCP meeting was. The resident's current HCP stated that they became the resident's HCP and Designated Representative approximately a year and a half ago when the previous HCP expired. The resident's current HCP stated that the resident's prior HCP had never been invited to a CCP meeting either for the resident. The annual Care Plan Meeting Report dated [DATE], written by SW #5, documented: Interdisciplinary Team (IDT) met on [DATE] to review the resident's Plan of Care (POC). The questions and concerns were addressed and the goals and interventions were reviewed. The participants of the meeting were Social Services, Dietary, and Therapeutic Recreation staff members. The Social Services Progress Note dated [DATE], written by SW #5, documented that an annual review CCP Meeting was held today. There was no documented evidence that the resident's HCP was invited or present at the meeting. The quarterly CCP Meeting Report dated [DATE], written by SW #5, documented: Interdisciplinary Team (IDT) met on [DATE] to review the resident's Plan of Care (POC). The questions and concerns were addressed and the goals and interventions were reviewed. See SW Progress Note. The participants of the meeting were Social Services and Therapeutic Recreation staff members. The Social Services Progress Note dated [DATE], written by SW #5, documented that a quarterly review CCP Meeting was held today. There was no documented evidence that the resident's HCP was invited or present at the meeting. The quarterly CCP Meeting Report dated [DATE], written by SW #5, documented: Interdisciplinary Team (IDT) met on [DATE] to review the resident's Plan of Care (POC). The questions and concerns were addressed and the goals and interventions reviewed. See SW Progress Note. The participants of the meeting were Social Services, Dietary, and Therapeutic Recreation staff members. The Social Services Progress Note dated [DATE], written by SW #5, documented that a quarterly review CCP Meeting was held today. There was no documented evidence that the resident's HCP was invited or present at the meeting. The quarterly CCP Meeting Report dated [DATE], written by SW #5, documented: Interdisciplinary Team (IDT) met on [DATE] to review the resident's Plan of Care (POC). The questions and concerns were addressed and the goals and interventions reviewed. See SW Progress Note. The participants of the meeting were Social Services, Dietary, Registered Nurse (RN) MDS Coordinator, and Therapeutic Recreation staff members. The Social Services Progress Note dated [DATE], written by SW #5, documented that a quarterly review CCP Meeting was held today. There was no documented evidence that the resident's HCP was invited or present at the meeting. The quarterly CCP Meeting Report dated [DATE], written by SW #5, documented: Interdisciplinary Team (IDT) met on [DATE] to review the resident's Plan of Care (POC). The questions and concerns were addressed and the goals and interventions were reviewed. See SW Progress Note. The participants of the meeting were Social Services and Therapeutic Recreation staff members. A review of the resident's EMR revealed no Social Services Progress Note dated [DATE] documenting the quarterly CCP Meeting was held on this date. A review of all Social Services Progress Notes dated [DATE] to [DATE] in the resident's EMR revealed no documented evidence of a Care Plan Meeting held for this resident. The Director of Social Services was interviewed on [DATE] at 5:15 PM and stated that the MDS Office gives the Social Services Department a list of residents who are due to have a CCP Meeting. The Director of Social Services stated that each SW will then schedule a meeting with their residents' family/Designated Representative. The Director of Social Services stated that by looking at the Resident #43's CCP, there was no documented evidence that the resident had a CCP meeting since [DATE] and should have had one at least quarterly. The Director of Social Services stated that they (Director of Social Services) were not sure how that happened and would speak to the resident's SW to find out. SW #5 was interviewed on [DATE] at 5:30 PM and stated that they (SW #5) were not sure why there had not been a Care Plan Meeting held for the resident since [DATE] because all residents should have Care Plan Meetings quarterly. SW #5 stated that they (SW #5) have tried calling the resident's HCP/Designated Representative, but they (resident's HCP/Designated Representative) do not answer the phone. SW #5 stated that it was on error on their (SW #5) part for not documenting in the resident's EMR when they (SW #5) have tried contacting the resident's HCP/Designated Representative and getting no response. The RN MDS Director was interviewed on [DATE] at 5:35 PM and stated that the MDS Department sends out the schedule for the Care Plan Meetings for each unit. The SW then sets up the Care Plan Meeting with the family or Designated Representative based on the schedule. The RN MDS Director stated that they (MDS Director) did not see a documented Care Plan Meeting in either a Progress Note or in the resident's CCP since [DATE]. 10 NYCRR 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00310476 and NY00309550) initiated on [DATE] and completed on [DATE], the facility did not immediately consult with the resident's Physician and/or notify the resident's Designated Representative when there was a significant change in the resident's physical status. This was identified for two (Resident #738 and Resident #43) of four residents reviewed for Notification of Change. Specifically, there was no documented evidence in the Electronic Medical Record (EMR) that 1A) Resident #738's Designated Representative was informed when the resident developed a Stage 3 pressure ulcer to their left shoulder on [DATE], 1B) Resident #738's Physician was not notified when the Licensed Practical Nurse (LPN) #7 identified a significant change in Resident #738's condition from [DATE] to [DATE], and 2) Resident #43's Designated Representative was informed when the resident became positive for COVID-19 infection on [DATE]. The findings are: The facility's policy titled Resident Change in Condition dated [DATE] documented to ensure timely communication with medical providers, families, and appropriate staff to facilitate appropriate care, including licensed nurses, certified nursing assistants (CNAs), and other healthcare professionals. When a significant change in a resident's condition is identified, the following notification procedure will be followed: The Licensed Nurse or staff member directly involved in providing care will immediately inform the Charge Nurse or Nursing Supervisor. The Charge Nurse or Nursing Supervisor will promptly assess the resident and initiate appropriate interventions as per the Nursing Home's (NH's) established protocols. The medical provider responsible for the resident's care will be notified promptly of the change in condition. Following the notification of the medical provider, the NH will promptly inform the resident's authorized representative or family member(s) about the change in the resident's condition, unless the resident has explicitly expressed their wish to not disclose such information. 1) Resident #738 had diagnoses which include Respiratory Failure, Anoxic (lack of oxygen) Brain Injury and was Ventilator dependent. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognitive skills for daily decision making and a Brief Interview for Mental Status (BIMS) could not be completed. The resident was totally dependent on the assistance of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The resident was always incontinent of bowel and bladder. The resident was at risk for developing pressure ulcers and had one stage IV pressure ulcer upon admission to the facility. 1A) The Wound Care Progress Note dated [DATE] written by the former Registered Nurse (RN) Wound Care Nurse (RN #15) documented that the resident was seen by the wound care team on [DATE]. The Stage 4 sacral wound 19 centimeters (cm) x 20 cm x 0.5 cm. A Stage 3 left shoulder pressure ulcer was identified on [DATE] measuring 3.5 cm x 3.5 cm x 0.2 cm with moderate drainage. A review of the EMR did not reveal documented evidence that the resident's Designated Representative was notified of the Stage 3 pressure ulcer to the left shoulder. The Director of Nursing Services was interviewed on [DATE] at 10:45 AM and stated that when the resident's left shoulder wound was first identified on [DATE], the resident's Designated Representative should have been made aware by the RN Wound Care Nurse. 1B) The Nursing Progress Note dated [DATE] at 2:54 PM documented that the resident's vital signs (V/S) were checked and documented as follows: blood pressure (B/P) 110/72 millimeters of Mercury (mmHg) (normal 120/80 mmHg), Temperature (T) 98.1 degrees Fahrenheit (F) (normal 98.6 F), pulse (P) 78 per minute (normal range 72-80), Respiration (R) 16 breaths per minutes (normal range 12-20), oxygen (O2) saturation level 98% (normal 92% and above). The resident was non-verbal, and no acute distress was noted. The comfort measures were maintained. The Nursing Progress Note dated [DATE] at 7:39 AM written by Licensed Practical Nurse (LPN #7) documented that the resident was first observed sweating but resting quietly. The resident's V/S were checked and documented as follows: blood pressure (B/P) 98/60 mmHg, T 100 degrees F, pulse rate 130 per minute, respiration (R) 15 breaths per minutes oxygen saturation level 90%. Tylenol (fever reducer) administered, no response, unchanged. At 1 AM V/S were B/P 94/58 mmHg, T 100.8 F, P 136 per minute, R 15 per minute, O2 saturation 88%. The V/S were checked again at 4 AM. Resident was notably sweating T 100.0 F, P 128 per minute, R 15 per minute, O2 saturation 89%. LPN #7 documented they were called to Resident #738's room by Respiratory services at 6 AM. V/S taken, none at this time. The resident was on Comfort Measures Only (CMO)/Do Not Resuscitate (DNR)/Do Not Intubate (DNI). The Supervisor was made aware. The Medical Director's service was called and a message was left. A note was placed in the Nurse Practitioner's (NP) communication book. LPN #7 was interviewed on [DATE] at 12:10 PM and stated that they (LPN #7) had taken the resident's V/S four times during their (LPN #7) shift which began on [DATE] at 11 PM and ended on [DATE] at 7 AM. LPN #7 stated that they took the resident's V/S once at the start of their (LPN #7) shift on [DATE], but was uncertain of the exact time, and then at 1 AM, 4 AM, and 6 AM on the morning on [DATE]. LPN #7 stated that now, looking at the Nursing Progress Note they (LPN #7) wrote back on [DATE], with the resident's elevated temperature and high pulse rate, they (LPN #7) should have called a Physician to make them aware so that maybe a Physician could have ordered a medication to help slow the resident's pulse rate down. LPN #7 stated that they (LPN #7) only contacted the Medical Director of the facility after the resident had expired. LPN #7 stated that they could have also called a Registered Nurse (RN) to ask them what they (LPN #7) should do for the resident since the resident had an elevated temperature and a high pulse rate. LPN #7 stated that they (LPN #7) had first worked on a long-term care unit in the facility and when they (LPN #7) were moved to the ventilator unit, the critical care unit of the facility, they (LPN #7) did not know how to handle it because the unit was made up of fragile people. The Medical Director was interviewed on [DATE] at 1:00 PM and stated that the resident was on comfort care which the medical team was aware of and not much could have been done differently for the resident except for end-of-life management. The Medical Director stated that the LPN should have alerted their RN Supervisor and documented that in their (LPN #7) Nursing Progress Note. The Medical Director stated that the resident was ventilator dependent who was on comfort care and would only have been treated to manage severe pain, severe anxiety, or shortness of breath. The Director of Nursing Services (DNS) was interviewed on [DATE] at 3:45 PM and stated that the LPN #7 should have made the RN Charge Nurse or the RN Supervisor aware that the resident had an elevated temperature, high pulse rate, and low BP so they could have assessed the resident and then called the Physician. 2) Resident #43 has diagnoses which include Atrial Fibrillation and Schizophrenia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 5 which indicated that the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance of two persons for bed mobility, transfers, and toilet use; and extensive assistance of one person for walking in the corridor, locomotion off the unit, dressing, and bathing. The resident was frequently incontinent of bowel and bladder. The Physician's Order dated [DATE] and last renewed on [DATE] documented Rapid COVID-19 Swab Test as needed (PRN). The Nursing Progress Note dated [DATE] at 4:58 AM written by Registered Nurse (RN) #16 documented that the resident's COVID-19 Rapid Swab test was positive and that the Nurse Practitioner (NP) and the resident's family would be informed in the morning (AM). The Social Service Progress Note dated [DATE] written by Social Worker (SW) #5 documented that they (SW #5) spoke with the resident due to a change in condition secondary to testing positive for COVID-19 infection on [DATE]. SW #5 provided emotional support and an avenue to ventilate feelings for the resident to improve psychological well-being. Contact precautions remained in place. Resident has the opportunity to call loved ones, thereby maximizing ongoing connection with their designated supports. RN #16 was contacted on [DATE] at 2:00 PM and was unavailable for interview. The resident's Primary Physician (Physician #3) was interviewed on [DATE] at 3:00 PM and stated that they (Physician #3) would not notify the resident's Designated Representative if the resident became positive for COVID-19, the NP would do that. NP #2 was interviewed on [DATE] at 9:45 AM and stated that usually the nursing staff alerts the Designated Representative when a resident turns positive for COVID-19 infection. NP #2 stated that they (NP #2) reviewed the Progress Notes in the Electronic Medical Record (EMR) and did not see any documentation that an NP or Physician alerted the resident's Designated Representative that the resident was positive for COVID-19 infection. SW #5 was interviewed on [DATE] at 9:15 AM and stated that normally the nursing staff calls the resident's Designated Representative to inform them of a positive COVID-19 result. SW #5 stated that they did not call the resident's Health Care Proxy (HCP)/Designated Representative. The Director of Nursing Services (DNS) was interviewed on [DATE] at 10:05 AM and stated that RN #16 should have called the resident's Designated Representative and notified the NP at the time they (RN #16) wrote the Nurse's Note because it was a change in the resident's status. The DNS stated that RN #16 could have informed the RN Supervisor or the Nurse relieving them (RN #16) to contact the Designated Representative because it was early in the morning. 10 NYCRR 415.3(f)(2)(ii)(b)

Based on observations, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior on two of three nursing units in the Woodcrest Building. Specifically, on 8/4/2023 on the Woodcrest 1 unit there was an upholstered couch used by residents in the common area that was soiled and stained; and on Woodcrest 3 unit there were two upholstered chairs used by residents in the common area that were soiled and stained. The finding is: The facility's policy titled, Cleaning Furnishings, dated 6/1/2022, documented to create a clean and hygienic environment for residents, staff, and visitors, promoting infection prevention and overall well-being. Nursing home staff will conduct routine cleaning of all furnishings in common areas, resident rooms, and other designated spaces, as per the established cleaning schedule. Routine cleaning will include dusting, vacuuming, and spot-cleaning of stains to maintain the cleanliness and appearance of the furnishings. On 8/4/2023 at 11:35 AM on Woodcrest 1 unit, there was a couch in the common area used by residents that was observed to be soiled and stained. On 8/4/2023 at 11:40 AM on Woodcrest 3 unit, there were two upholstered chairs used by residents in the common area that were observed to be soiled and stained. The Housekeeping Director was interviewed on 8/4/2023 at 11:50 AM and acknowledged the condition of the couch and chairs and stated they will be cleaned. The Housekeeping Director stated it is up to the assigned building housekeeper to make observations and alert the Housekeeping Director about dirty furnishings. The Housekeeping Director further stated the nursing staff can also make observations and put a request for cleaning through the automated maintenance and housekeeping request software system. Housekeeper #1 was interviewed on 8/7/2023 at 8:28 AM and stated they (Housekeeper #1) do the housekeeping services in the common areas of the Woodcrest building. Housekeeper #1 stated they (Housekeeper #1) brought the condition of the couch and upholstered chairs to the attention of the housekeeping supervisor. Housekeeper #1 could not remember the name of the supervisor or when this was brought to a supervisor's attention. Observations on Woodcrest 1 unit and Woodcrest 3 unit were made on 8/7/2023 between 8:35 AM and 8:40 AM respectively. The couch and upholstered chairs were no longer on the units. Registered Nurse (RN) #2, the Woodcrest Nursing Supervisor, was interviewed on 8/7/2023 at 10:59 AM. RN #2 stated if nursing staff notices housekeeping issues, nursing can report the problem to housekeeping through a computer program. RN #2 stated everyone can report housekeeping and maintenance issues, it is a dual effort between the nursing and housekeeping departments. 10 NYCRR415.5(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the Recertification survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that all residents were free from physical restraints imposed for the purposes of discipline or convenience and are not required to treat the resident's medical symptoms. This was identified for one (Resident #455) of one resident reviewed for restraints. Specifically, Resident #455 was observed in their bed with the right side of the bed placed against the wall. On the left side of the bed three pillows were observed folded in half and wedged between the mattress and bed frame which caused the mattress to curve upward and prevented the resident for exiting the bed. There was not a physician's order or an assessment for the use of pillows to prevent the resident from exiting the bed. The finding is: The facility's policy titled Restraints dated 1/25/2008 and last reviewed 4/2015 documented that the facility shall promote and encourage a restraint free environment. Residents have the right to be free from physical or chemical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. A restraint is any physical or chemical means used to control or restrict freedom of movement. Additionally, the policy documented that restraints include practices that meet the definition of a restraint, such as: placing a chair or bed so close to a wall that the wall prevents the resident from rising out of the chair or voluntarily getting out bed. The policy stated a physician's order must be written and the family/legal representative will be informed, and consent will be obtained. The resident will be evaluated quarterly for the continued need for the restraint. Resident #455 was admitted with diagnoses including Crushing Injury of the head, Traumatic Hemorrhage of the Cerebrum (brain), and Hypertension. The quarterly MDS (Minimum Data Set) assessment dated [DATE] documented the resident had severely impaired cognitive skills for daily decision making and long term and short-term memory problems. The resident was totally dependent on two persons for bed mobility, transfer, dressing, eating, and toilet use. The resident was totally dependent on one person for eating and personal hygiene. The resident used a wheelchair as a mobility device. The resident's CCP (Comprehensive Care Plan) for Behavioral Symptoms/Dementia effective 12/31/2022 and last revised on 8/9/2023 documented the resident exhibited behaviors of kicking others, verbally threatening others, hitting and scratching self, disrobing in public, combative during care, pulling at feeding tube and crawling on the floor. Resident #455 was observed sleeping in bed on 8/1/2023 at 10:50 AM. The right side of the bed was placed against the wall and on the left side of the bed three pillows were folded in half and wedged between the mattress and bed frame which caused the mattress to curve upward and prevented the resident from exiting the bed. The CCP (Comprehensive Care Plan) titled, Care Area: Falls, initiated on 12/30/2022 and last revised on 8/8/2023 documented that the resident is at risk for fall/injury/ fracture related to falls in the last month prior to admission, fracture related to a fall in the last six months prior to admission, impaired balance, gait disturbance, limited endurance, antipsychotic medication, antidepressant medication, laxatives, anti-seizure medication, communication deficits, agitation, restlessness, cognitive impairment, hip fracture and incontinence. Interventions included but were not limited to place the bed in the lowest position. The CCP did not include the use of pillows between the mattress and the bed frame as an intervention to prevent the resident from exiting the bed. The CNA (Certified Nursing Assistant) Accountability Record for July 2023 and August 2023 did not include the use of pillows between the mattress and the bed frame as an intervention to prevent the resident from exiting the bed. Resident #455's physician's orders dated 8/7/2023 did not include orders for the use of pillows between the mattress and the bed frame. Resident #455's Physical and Occupational Therapy assessments and notes from 12/31/2022 through 7/31/2023 were reviewed and there was no documentation regarding the use of pillows. CNA (Certified Nursing Assistant) #15, the assigned 7 AM-3 PM CNA, was interviewed on 8/3/23 at 12:31 PM and stated that the pillows were under the mattress because the resident crawled off the mattress and the resident was found by the door. CNA #15 stated the pillows helped prevent the resident from crawling out of bed. CNA #15 stated that the pillows were placed there recently and was not sure when it started. CNA #15 stated they are not sure who placed the pillows beneath the mattress, the pillows appeared under the mattress one morning, and they (CNA #15) continued the practice. CNA #15 stated they knew placing the pillows under the mattress may not be the right thing to do. On 8/3/2023 at 2:30 PM CNA #15 pointed out that they (CNA #15) removed the pillows and as a result the resident's legs were observed dangling over the side of the mattress. CNA #15 stated this is what happened before they started placing the pillows beneath the mattress. CNA #15 stated they could not recall how long the staff have been placing the pillows under the mattress, so the resident does not climb out of bed. RN (Registered Nurse) #11 was interviewed on 8/3/2023 at 2:44 PM and stated that they (RN #11) usually made rounds on each floor of the building, and they never saw pillows placed beneath the resident's mattress. RN #11 stated the pillows should not be there and that staff are not allowed to place pillows beneath the mattress because the resident would not be able to get out of bed. The ADNS (Assistant Director of Nursing Services) RN #10 was interviewed on 8/3/2023 at 3:04 PM and stated they were not aware of the pillows placed beneath the resident's mattress. RN #10 stated that is not something the facility practiced. RN #10 stated that they knew the resident had a history of falls and someone had probably placed the pillows beneath the mattress to prevent the resident from falling out of bed. The Director of Rehabilitation was interviewed on 8/7/2023 at 2:10 PM and stated if they saw a bed against a wall and pillows placed under the opposite side of the mattress, they would think it is a preventive measure for safety, but it is not the most efficient way. They would use a defined perimeter mattress because the goal is to maximize safety. The resident was evaluated and utilized a low bed and floor mats. The Director of Rehabilitation stated that crawling into the hallway is a behavioral issue and there would not be an intervention from Physical Therapy. The Director of Rehabilitation was re-interviewed on 8/10/2023 at 9:14 AM and stated that the resident had not had an assessment for restraints or siderails since being admitted to the facility in December 2022. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:14 PM and stated they never observed the resident's bed against the wall and the pillows between the mattress and bedframe. DNS stated that placing pillows underneath the mattress would prevent the resident's ability to get out of bed. 10 NYCRR 415.4(a)(2-7)

Based on observations, record reviews, and interviews during the Recertification Survey, initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This was identified for one (Resident #91) of one resident reviewed for Dialysis. Specifically, there was no Dialysis or Renal care plan created for Resident #91, who received bedside dialysis in the facility. The finding is: The facility's policy titled Comprehensive Care Plan, dated 2/1/2021, documented residents of the facility will have a Comprehensive Care Plan (CCP) completed in accordance with Federal and State requirements. The CCP will include the resident's problems, strengths, and needs. An individual CCP will be developed for each problem, strength, or need, measurable objectives, and timetables in order to meet the resident's physical, mental and psychosocial needs that are identified from the Resident's Comprehensive Assessments. The development of the CCP is prepared with an interdisciplinary team approach. Resident #91 was admitted with diagnoses including End Stage Renal Disease (ESRD), Cerebrovascular Accident, and Respiratory Failure. The 7/8/2023 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score, as the resident had severely impaired cognitive skills for daily decision making. The MDS documented the resident received dialysis while a resident. A physician's order dated 6/27/2023 and last renewed on 8/4/2023 documented Hemodialysis, four days per week on Monday, Tuesday, Thursday, and Friday between 7:00 AM-3:00 PM through a right chest Permacath (placement of a special intravenous line into the blood vessel in your neck or upper chest just under the collarbone. This type of catheter is used for short-term dialysis treatment). Resident #91 was observed lying in bed receiving bedside dialysis on 8/7/2023 at 1:46 PM. The dialysis nurse, who worked for an outside contractor, was present. Review of Resident #91's medical record revealed no comprehensive care plan for dialysis or End Stage Renal Disease. Registered Nurse (RN) #7 was interviewed on 8/7/2023 at 1:59 PM. RN #7 reviewed Resident #91's medical record and stated there was no Comprehensive Care Plan (CCP) developed for dialysis. RN #7 stated there should be a CCP for Renal Insufficiency or ESRD. RN #7 stated the care plan is usually done by the admission nurse or the MDS nurse or any RN can implement the care plan. RN #7 stated care plans were updated a lot better before. RN #7 stated for about a year registered nurses have been utilized a lot more like medication nurses and staff nurses and the situation is getting worse due to staffing. RN #7 stated dialysis is one of Resident #91's main diagnoses and there should have been a care plan. The Director of Nursing Services (DNS) was interviewed on 8/8/2023 at 8:36 AM and stated there should have been a dialysis CCP. The DNS stated the MDS nurse, the admission nurse, or any RN can create a care plan. The DNS stated the dialysis company nurse has their own care plan, but the dialysis company is a separate contractor. The DNS stated our facility nurses do not have access to the dialysis company's care plan and our staff need their own care plan. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that services were provided or arranged by the facility, as outlined by the comprehensive care plan, to meet professional standards of quality. This was identified for two (Resident #91 and #422) of 27 residents observed during the initial tour on Seacliff 1 unit. Specifically, Resident #91's and #422's tube feeding bottles were not labeled with the resident name, date, or start time. The findings are: 1) Resident #422 was admitted with diagnoses including Multiple Sclerosis, Respiratory Failure, and Epilepsy. The 7/2/2023 annual MDS assessment documented no Brief Interview for Mental Status (BIMS) score, as the resident had moderately impaired cognitive skills for daily decision making. The resident was also non-verbal and ventilator dependent. The Physician's order as of 8/1/2023 documented to administer Jevity 1.5, 65 milliliter (ml) per hour, start time 4 PM, 1500 ml per 24 hours. On 8/1/2023 at 10:08 AM Resident #422 was observed in bed. The resident was ventilator dependent. The resident's tube feeding was running. The bottle was Jevity 1.5 and the pump was set at 65 ml/hour. There was no label on the bottle indicating the resident's name or the start time of the feeding. On 8/1/2023 at 10:10 AM Registered Nurse (RN) #17 observed the tube feeding with the surveyor and stated there should be label on the bottle with the resident's name and start time of the feeding. RN #17 was not sure who started the feeding. 2) Resident #91 was admitted with diagnoses including End Stage Renal Disease (ESRD), Cerebrovascular Accident, and Acute Respiratory Failure. The 7/8/2023 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score, as the resident had severely impaired cognitive skills for daily decision making. The MDS documented that the resident had a feeding tube while a resident of the facility. The Physician's order as of 8/1/2023 documented to administer Nepro 1.8, 60 milliliters (ml)/hour, start time 8:00 PM, 600 ml per 24 hours. On 8/1/2023 at 10:17 AM Resident #91 was observed in bed. The Nepro 1.8 tube feeding bottle was hung; however, the pump was not running indicating the feeding was complete. There was no resident label on the bottle, with the resident's name and start time of the feeding. On 8/1/2023 at 10:18 AM RN #17 observed the tube feeding with the surveyor and stated there should be label on the bottle with the resident's name and start time of the feeding. RN #17 was not sure who started the feeding. RN #18 was interviewed on 8/7/2023 at 4:00 PM and stated they (RN #18) started the tube feedings for Resident #91 and Resident #422 and hung the bottles on the evening of 7/31/2023 and that the feedings continued into 8/1/2023. RN #18 stated they were working on the unit by themselves. RN #18 stated the unit is a ventilator unit with 27 residents, and 24 of the 27 residents require tube feedings. There was no supervisor to help. RN #18 stated they did not have time to label the bottles. The Director of Nursing Services (DNS) was interviewed on 8/8/2023 at 8:34 AM and stated the evening nurse should have labeled the tube feeding bottles with the resident's name, date and start time. 10 NYCRR 415.11 (c)(3)(i)

Based on observation, record reviews, and interviews during the Recertification Survey, initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that each resident who is unable to carry out Activities of Daily Living (ADLs) receives the necessary services to maintain grooming, and personal hygiene for one (Resident#343) of eight residents reviewed for ADLs. Specifically, on 8/1/2023 Resident #343 was observed lying in bed in a hospital gown with a towel over their chest and abdomen. Coffee had spilled onto the towel, the resident's call bell was behind the resident on the head board and the resident's fingernails were observed to be long, untrimmed, and dirty on both hands. The finding is: The facility's policy titled Activities of Daily Living - General, dated 5/1/2021, documented to ensure residents receive all necessary care including activities of daily living. This policy aims to promote resident independence, dignity, and well-being while ensuring their safety and comfort. This policy applies to all residents in the nursing home who require assistance with Activities of Daily Living and to all nursing home staff responsible for providing ADL care services. ADLs are essential self-care tasks that individuals typically perform on a daily basis to maintain their personal hygiene, health, and well-being. These include, but are not limited to: bathing, dressing, toileting, transferring; eating and drinking, and grooming. Resident #343 was admitted with diagnoses including Diabetes Mellitus, Alzheimer's Disease, and Depression. The 7/23/2023 Annual Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. The MDS documented that the resident required extensive assistance of one person for personal hygiene and required supervision and set-up for eating. A Comprehensive Care Plan (CCP) titled ADLs: Dressing, Grooming, Feeding, Bathing, Toileting, Personal Hygiene, effective 9/23/2022 and last updated 5/2/2023, documented the resident will be clean, dry, and groomed daily and to keep nails trimmed and clean. On 8/1/2023 at 11:32 AM Resident #343 was observed lying in bed in a hospital gown with a towel over their chest and abdomen. An overbed table was observed over the resident's bed. Coffee had spilled onto the towel. Another liquid was observed spilled on the overbed table. The resident's call bell was behind the resident looped over the headboard, and the resident's fingernails were observed to be untrimmed, long, and dirty on both hands. The resident stated they (Resident #343) could not reach the call bell and the spill happened about two hours ago. The resident stated they (Resident #343) would like their fingernails trimmed. Resident #343 was observed by unit Registered Nurse (RN #1) on 8/1/2023 at 11:36 AM. RN #1 removed the coffee soiled towel and observed that the sheet under the towel and the hospital gown were also soiled with coffee. RN #1 stated they (RN #1) would send in a Certified Nursing Assistant (CNA) to clean and dress the resident. RN #1 placed the resident's call bell at the resident's right side and left the room. During an observation on 8/1/2023 at 12:35 PM, CNA #2 (the assigned CNA) and the resident's family member were at the resident's bedside. The resident was in bed and was dressed. The resident's nails were still untrimmed and dirty. CNA #2 was interviewed immediately after the observation on 8/1/2023 at 12:35 PM and stated sometimes the resident is combative and the resident's family member has to be present to keep the resident calm in order to trim and clean the nails. The resident's family member was interviewed immediately after CNA #2's interview on 8/1/2023 at approximately at 12:37 PM and stated they visit the resident every day, and the resident's nails should be cut. The family member stated there are times when the resident might refuse care, but no one ever said anything about the resident refusing to get their nails cut. The family member stated the resident could scratch themselves with the long nails. Resident #343 was observed in the day room with the family member present on 8/3/2023 at 11:57 AM. The resident's nails were trimmed and clean. RN #2, the Unit Supervisor, was interviewed on 8/3/2023 at 2:46 PM. RN #2 stated the CNA is supposed to keep the resident's fingernails trim and clean. RN #2 stated if the resident refused to have their nails trimmed and cleaned, the CNA should document on the CNA accountability record and let the nurse know. RN #2 stated the nurse can intervene and talk to the family and that the resident's family is at the facility most days. The Director of Nursing Services (DNS) was interviewed on 8/3/2023 at 3:20 PM and stated nail cutting is done on bath days and as needed. The DNS stated if the resident refused, the CNA should document that on the accountability record and let the nurse know. The nurse can talk to the resident and ask the family to assist. Review of the CNA accountability record for July 2023 revealed that the resident refused showers on 7/8/2023 and 7/15/2023; however, received showers on 7/19/2023, 7/22/2023, 7/26/2023, and 7/29/2023. 10 NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility's policy titled Use of Helmets for Resident Safety and dated 12/29/2022 documented to ensure the resident's protection, comfort, and well-being while adhering to the prescribed safety measures. Residents requiring the use of a helmet will have undergone a medical assessment, are prescribed based on the resident's medical condition, safety needs, and recommendations of the healthcare provider. A care plan will be developed and will include details about the helmet's usage, fit, maintenance, and monitoring. Residents will wear the prescribed helmet as directed by the healthcare provider and outlined in their care plan. Staff will monitor residents to ensure the helmet is worn as required and is properly secured. Staff will document the helmet's usage in the resident's record, including the times when the helmet is worn, removed and repositioned. Resident #455 was admitted with diagnoses including Crushing Injury of the head, Traumatic Hemorrhage of the Cerebrum (brain), and Hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognitive skills for daily decision making and both short and long term memory problems. The resident was totally dependent on two persons for bed mobility, transfer, dressing, eating, and toilet use. The resident was totally dependent on one person for eating and personal hygiene. The Comprehensive Care Plan (CCP) titled, Activity of Daily Living (ADL) Functional/Rehabilitation Potential initiated on 12/30/2022 and updated on 8/8/2023, documented selfcare deficit as evidenced by decreased mobility, ambulation and transfers. The intervention effective 1/6/2023 documented Helmet at all times. Remove every shift for skin check and hygiene. The CCP for Behavioral Symptoms/Dementia effective 12/31/2022 and last revised on 8/9/2023 documented the resident exhibited behaviors of kicking others, verbally threatening others, hitting and scratching self, disrobing in public, combative during care, pulling at feeding tube and crawling on the floor. A Physician's (MD) order dated 1/6/2023 documented Resident #455 was to wear a helmet at all times and to remove every shift for skin check and hygiene. The following observations of Resident #455 were made: -On 8/1/2023 at 10:50 AM Resident #455 was observed dressed in a hospital gown and not wearing a helmet. -On 8/3/2023 at 12:05 PM there was a strong odor of feces in the hallway which was emanating from Resident #455's room. Resident #455's room door was open, and the resident was observed in bed wearing a hospital gown and lying on their side with their buttock's exposed. Resident #455 was not wearing a helmet. A disposable incontinence pad was placed beneath their buttocks. Fecal material was present on the incontinence pad and was smeared on the bed sheet and the hospital gown. -On 8/3/2023 at 12:31 PM there was a strong odor of feces in the hallway which was emanating from Resident #455's room. Resident #455's room door was open, and the resident was observed in bed wearing a hospital gown and lying on their side with their buttock's exposed. Resident #455 was not wearing a helmet. A disposable incontinence pad was placed beneath their buttocks. Fecal material was present on the incontinence pad and was smeared on the bed sheet and the hospital gown. Certified Nursing Assistant (CNA) #15 was interviewed on 8/3/2023 at 12:31 PM and stated they were the assigned CNA for Resident #455. CNA #15 stated they were just about to provide incontinence care to the resident as they knew that the resident was soiled with feces; however, they were waiting to finish passing the lunch trays. On 8/3/2023 at 2:07 PM Resident #455 was dressed in a hospital gown and was not wearing a helmet. On 8/3/2023 at 2:22 PM Resident #455 was observed in bed wearing a hospital gown and was not wearing a helmet. On 8/4/2023 at 2:37 PM Resident #455 was observed in bed not wearing a helmet. The Physical and Occupational Therapy Evaluations and Plans of Treatment both dated 12/31/2022 documented the resident had the following medical precautions/contraindications: falls/safety, helmet. The Certified Nursing Assistant (CNA) Accountability Record from December 30, 2022 through August 6, 2023 were reviewed. The CNA Accountability Record did not include use of the helmet. MD order, written by the Licensed Practical Nurse (LPN) #8, dated 8/3/2023 documented to discontinue the use of helmet. The order was signed by Physician #3 on on 8/7/2023. The medical progress note dated 8/7/2023, written by Nurse Practitioner (NP) #2 documented Although patient is not compliant with helmet, I will continue order to keep helmet in place pending neurosurgery follow up. The MD order dated 8/7/2023 documented to use the helmet at all times and to remove every shift for skin check and hygiene. The order was signed by NP #2. CNA #15, the assigned 7:00 AM - 3:00 PM CNA, was interviewed on 8/4/2023 at 12:37 PM. CNA #15 stated they have worked with Resident #455 since they were admitted in December of 2022. CNA #15 stated the resident wore a helmet when physical therapy transferred them (Resident #455) from the bed to a geriatric recliner and moved them (Resident #455) to the dining area. CNA #15 looked in the resident's room, but no helmet was found. Physician #3, the resident's Primary Care Physician, was interviewed on 8/7/2023 at 10:42 AM and stated that they did not write the order to discontinue the use of the helmet for Resident #455. Physician #3 stated that the helmet discontinuation order was entered by someone else, and they (Physician #3) just signed off on the order. Physician #3 stated they were not too familiar with Resident #455 and the Nurse Practitioner who saw the resident should be contacted for more detailed information. Licensed Practical Nurse (LPN) #8 was interviewed on 8/7/2023 at 11:17 AM and stated they were instructed by Registered Nurse (RN) #7 to review resident charts and to discontinue devices that were no longer being used. LPN #8 stated they discontinued the helmet order on 8/3/2023 and did not write a progress note with an explanation why the helmet was discontinued. LPN #8 stated they did not remember Resident #455 ever wearing a helmet and there was no helmet in their (Resident #455) room. LPN #8 stated they would not have discontinued the helmet order on their own. LPN #8 stated they do not specifically remember who they communicated with to obtain the helmet discontinuation order. LPN #8 stated they may have spoken to either NP #1 or NP #2. LPN #8 stated they wrote a note in the unit's green book, which is a book used by the nurses to communicate with the Doctors and the NPs. A review of the communication book on 8/7/2023 at 2:47 PM confirmed that LPN #8 wrote a note dated 8/3/2023 that documented Resident #455 no longer wears helmet, not getting out of bed, needs one to one in chair. NP #2 was interviewed on 8/7/2023 at 11:24 AM and stated they wrote the order for the helmet when the resident was admitted because it was probably an order from the Neurosurgeon. NP #2 stated they did not discontinue the order for the helmet on 8/3/2023. NP #2 then stated they were not contacted by anyone from the facility regarding Resident #455's helmet order. NP #2 stated that the resident should have been assessed before the helmet was discontinued and a corresponding progress note should have been written. NP #1 was interviewed on 8/7/2023 at 12:45 PM. NP #1 stated they were not contacted by anyone from the facility regarding the helmet order. RN #7 was interviewed on 8/7/2023 at 12:51 PM and stated that they gave a directive to LPN #8 to discontinue devices that were no longer necessary for all residents. RN #7 stated LPN #8 should have reached out to the resident's Physician or the NP to confirm if the helmet could be discontinued. RN #7 stated Resident #455 does not have fractures of the skull or soft spots that require a helmet, but the NP needed to do an evaluation before the helmet was discontinued. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:14 PM and stated for a new admission, the admitting nurse communicates the hospital discharge orders to the admitting doctor and the doctor will either agree or disagree with the orders. The admitting nurse is also responsible for initiating the CNA Accountability. The helmet orders were initiated on 1/6/22 not on the admission day. 10 NYCRR 415.12 Based on observations, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was identified for 1) one (Resident #318) of three residents reviewed for skin conditions and 2) for one (Resident #455) of one resident reviewed for Restraints. Specifically, 1) Resident #318 did not receive the physician ordered wound treatment to the resident's bilateral legs on 8/6/2023. 2) Resident #455 with diagnoses including crushing injury of the head and traumatic hemorrhage of the cerebrum (brain), had a physician's order to utilize a helmet at all times and on six occasions Resident #455 was observed without wearing the helmet. Additionally, the physician's order was discontinued on 8/3/2023 by Licensed Practical Nurse (LPN) #8 without notifying the resident's Physician. The resident was evaluated by the Nurse Practitioner (NP) #2 on 8/7/2023 who reordered the helmet to be worn at all times. The findings include: 1) The facility's policy titled Wound Interventions-Miscellaneous Wound Treatments, revised 2/18/2022, documented it is the policy of the facility to provide wound interventions to assist in the development of a care plan. These interventions will be selected based on the individual needs of the resident. Resident #318 was admitted with diagnoses including Peripheral Vascular Disease, Non-Pressure Chronic Ulcer of the Left and the Right Calf, and Venous Insufficiency. The 7/15/2023 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident had three Venous/Arterial ulcers. Treatments included application of non-surgical dressings and application of ointments and medications. Physician's orders effective 6/26/2023 and last renewed 7/19/2023 documented to apply Gentamycin (antibiotic) 0.1 % topical cream, cleanse left and right lower legs with normal saline and apply Gentamycin cream and Calcium Alginate, cover with abdominal pads and wrap with kling followed by ace wrap daily and as needed every day on 7:00 AM-3:00 PM shift, for diagnoses of Chronic Venous Hypertension with ulcer of lower extremities. Physician's orders effective 6/19/2023 and renewed 7/19/2023 documented for the nurses to monitor dressings for drainage or any signs/symptoms of infection every shift and inform the physician of any changes each shift. A Comprehensive Care Plan (CCP) titled Skin Integrity: Venous Left Lower Leg-Chronic Venous Ulcer, effective 10/5/2021 and last updated 7/31/2023 included a wound care note: Seen by wound care team for weekly follow up 7/31/2023- Left Lateral leg (venous) measures same: 18.0 centimeters (cm) x 12.0 cm x 0.3 cm with 90% yellow, 10% pink, large drainage. A CCP titled Skin Integrity: Right Posterior Lower Leg, effective 1/16/2023 and last updated 7/31/2023 included a wound care note: Seen by wound care team for weekly follow up 7/31/2023- Right posterior leg measures same 25.0 cm x 25.0 cm x 0.2 cm with 90% yellow and 10% pink, large drainage. A CCP titled Skin Integrity: Venous Right leg (Anterior) effective 11/8/2022 and last updated 7/31/2023 included a wound care note: Seen by wound care team for weekly follow up 7/31/2023- Right lower anterior leg measure same 6.0 x 4.5 x 0.2 with 90% yellow 10% Pink with large drainage. Resident #318 was observed in their room on 8/1/2023 at 11:02 AM. The resident had dressings to both lower extremities. Resident #318 stated the dressing changes are supposed to be done every day, but there have been days when the dressing changes were note done, especially on weekends because of staffing. Resident #318 stated the nurses tell them that they (nurses) do not have time to do their treatments. Registered Nurse (RN) #11 was interviewed on 8/10/2023 at 8:17 AM and stated on 8/6/2023 (Sunday) they (RN #11) were assigned as the medication and treatment nurse on Woodcrest 1 unit. RN #11 stated they were alone and did not get any assistance. RN #11 stated they explained to the Resident #318 that they could not do the ulcer treatments because they (RN #11) did not have time. RN #11 stated they thought someone was going to come in at 3:00 PM to help, but that did not happen. RN #11 stated they did not notify the doctor that the treatment was not done; however, they (RN #11) informed RN #10 (supervisor) that the treatments were not completed for Resident #318. Review of the August 2023 Treatment Administration Record (TAR) revealed that the wound treatments for the bilateral lower leg ulcers and the monitoring of the dressings were not signed for on 8/6/2023. Review of the medical record revealed no progress notes addressing the missed treatments on 8/6/2023. Physician #1 was interviewed on 8/10/2023 at 9:40 AM and stated the resident has Chronic Venous Insufficiency. Physician #1 stated many people at home miss treatments. Physician #1 stated they (Physician #1) were not happy about the missed treatment, and they were not aware that the treatments were missed. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 10:44 AM and stated for missed treatments, the doctor has to be informed; the family has to be informed; we have to determine if there were any negative effects; there has to be a missed treatment investigation; and the staff has to be educated regarding the importance of following the physician's orders. Resident #318 was observed on 8/10/2023 at 11:06 AM during the wound treatments to the bilateral lower extremities. The wound care nurse (RN #9) was performing the treatment and was assisted by Licensed Practical Nurse (LPN) #13. RN #9 was informed that there was a missed treatment on 8/6/2023 and RN #9 stated, I need the treatments done as ordered because there is a lot of drainage, and if it is missed on the day shift it should be done on the PM shift or brought to the supervisor's attention and be put on report. RN #10, the Nursing Supervisor, was interviewed on 8/10/2023 at 12:43 PM. RN #10 stated they were covering all of the buildings on Sunday, 8/6/2023. RN #10 stated that RN #11 did not notify them (RN #10) that they (RN #11) could not get to the treatment for Resident #318. RN #10 stated if RN #11 told them, they would have helped or got someone to help.

Based on observation, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure the resident environment remained as free of accident hazards as is possible. This was identified for one (Resident #39) of four residents observed for medication administration. Specifically, during the medication pass observation conducted on 8/2/2023 Resident #39 was observed with a bottle of Tylenol PM (pain medication also used to assist with sleeping), antacid tablets, and a tube of Icy-Hot pain cream at the resident's bedside. There was no Physician's order for the Tylenol PM, antacid tablets, or tube of Icy-Hot pain cream and the resident was not assessed to self-medicate. The finding is: The facility's policy titled, Preventing Accidents, dated 6/24/2022, documented staff will provide appropriate supervision and monitoring of residents, especially those at higher risk of accidents due to cognitive impairment or mobility issues. Staff will closely observe residents during activities and assist as needed to prevent accidents. Resident #39 was admitted with diagnoses including Diabetes Mellitus, Hypertension, and Heart Failure. The 4/30/2023 Annual Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of Resident #39's current physician orders dated 7/29/2023 revealed that there was no order for Tylenol PM, the antacid chewable tablets, or the pain cream. During the medication pass observation on 8/2/2023 at 9:18 AM, performed by Registered Nurse (RN) #3, Resident #39 was observed to have a bottle of Tylenol PM [a medication containing 500 milligrams (mg) of Acetaminophen (a pain and fever reducer) and 25 mg of Diphenhydramine (an antihistamine that can be used as a sleep aid] at their bedside. The resident stated they (Resident #39) self-medicate with Tylenol PM to help sleep and for pain. Resident #39 stated the family brought in the Tylenol PM last month. The resident also had a bottle of antacid tablets and a tube of Icy-Hot cream. RN #3 stated that the medications would have to be taken away and discussed with the physician; however, the resident was very adamant about keeping the medications. RN #4 was interviewed on 8/3/2023 at 2:04 PM. RN #4 stated they were the nursing supervisor on Resident #39's unit on 8/2/2023. RN #4 stated they (RN #4) took the Tylenol PM, antacid tablets, and pain cream away from the resident but did not call or notify the Physician. RN #4 stated they (RN #4) thought RN #3 (the medication nurse from 8/2/2023) called the Physician. Resident #39's physician, who is also the Medical Director, was interviewed on 8/3/2023 at 2:50 PM. The physician stated they were not aware Resident #39 was self-medicating with Tylenol PM and no one had called to inform them (physician). The physician stated the resident would need an order for that kind of medication, but we would not use Tylenol PM, and it should especially not be at bedside. The physician stated in general, we do not use Tylenol PM in the geriatric populations because of potential side-effects, such as dizziness, drowsiness, and confusion. The Director of Nursing Services (DNS) was interviewed on 8/3/2023 at 3:21 PM. The DNS stated the resident should not have their own medications at the bedside, and if they do, the staff should educate the resident that all medications have to be ordered. In addition, the Physician has to be informed if a resident is self-medicating, and the resident should be assessed to determine if the resident can safely administer their medications. 10 NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2). During the Sufficient Staffing Task review the facility provided nursing schedules including a schedule dated 8/6/2023 which documented one Licensed Practical Nurse (LPN) and two Certified Nursing Assistants (CNAs) were scheduled on Sagamore 2 unit during the 7:00 AM to 3:00 PM shift. The nursing schedule did not include the name of a Registered Nurse Supervisor assigned to the unit. The facility Historical Census Summary Report dated 8/6/2023 documented that there was a total of 30 residents on Sagamore 2 unit resulting in an occupancy rate of 86%. The facility Administration Documentation History Detail Report (a report indicating medication administration time) dated 8/6/2023 documented the following late medication administrations on Sagamore 2 unit: -Resident #4 received Humalog Kwikpen Insulin 100 unit/milliliters subcutaneous injection at 1:48 PM. The medication was scheduled to be administered at 12:00 PM. Resident #4's blood glucose level was 201 milligrams/deciliter at 1:48 PM. -Resident #261 received Ademelog SoloStar U-100 Insulin lispro 100 unit/milliliters subcutaneous pen injection at 1:47 PM. The medication was scheduled to be administered at 12:00 PM. Resident #261's blood glucose level was 239 milligrams/deciliter at 1:47 PM. -Resident #379 received Ademelog SoloStar U-100 Insulin lispro 100 unit/milliliters subcutaneous pen injection at 10:00 AM. The medication was scheduled to be administered at 8:00 AM. Resident #379's blood glucose level was 210 milligrams/deciliter at 10:00 AM. -Resident #426 received Ademelog SoloStar U-100 Insulin lispro 100 unit/milliliters subcutaneous pen injection at 9:54 AM. The medication was scheduled for 8:00 AM. The next dose was administered at 1:45 PM when the insulin was scheduled to be administered at 12:00 PM. Resident #426's blood glucose level was 237 milligrams/deciliter at 9:54 AM and 280 milligrams/deciliter at 1:45 PM. -Resident #442 received Sucralfate (drug used in the treatment of gastric ulcers) 100 milligrams/milliliter oral suspension via gastrointestinal tube at 1:38 PM. The medication was scheduled to be administered at 12:00 PM. Licensed Practical Nurse (LPN) #6, the medication nurse, was interviewed on 8/7/2023 at 2:09 PM. LPN #6 stated they (LPN) were the only nurse on Sagamore 2 unit on 8/6/2023 during the 7:00 AM to 3:00 PM shift. LPN #6 stated that there needs to be two nurses on Sagamore 2 unit to care for the 30 residents on the unit. LPN #6 stated that there were just two CNAs on the unit of 30 residents until 1:00PM then from 1:00 PM to 3:00 PM, there was just one CNA working with LPN #6 because the other CNA had a personal emergency and had to leave. LPN #6 stated that it is difficult to work alone on the unit because they are responsible for medication administration, wound care treatments, and documentation. LPN #6 stated that they were late for the medication pass on 8/6/2023 and the 9:00 AM medication administration was done by 11 AM and the 1:00 PM medications were administered by 3:00 PM. LPN #6 stated there were eight wound care treatments to do, all of which have to be pre-medicated one hour before treatment. LPN #6 stated that for one of the eight residents it takes up to 25 minutes for one wound care treatment. LPN #6 stated that some of the wound care treatments are tied with brief changes, which further interrupts medication administration. LPN #6 stated that there 12 residents who require two-person assistance so that they may be pulled to assist the CNA with care. LPN #6 stated that the 7:00 AM to 3:00 PM shift was especially challenging because Resident #361 was actively passing away and required morphine to be administered every 2 hours. LPN #6 stated that they (LPN #6) provided emotional support for Resident #361 and the family throughout the shift on top of their normal duties. LPN #6 stated that the workload snowballs due to interruptions. LPN #6 stated all of the interruptions causes subsequent medication administrations to be late. LPN #6 stated that there is no way to get everything done on time. LPN #6 stated that they informed RN #5, who was their supervisor, when the CNA had to go home early and RN #5 told LPN #6 to prioritize toileting the residents since that is an emergency. RN #5 was interviewed on 8/10/23 at 10:11 AM. RN #5 stated that they (RN #5) were assisting in multiple units between the Sagamore and the Woodcrest buildings on 8/6/2023. RN #5 stated that they cannot recall if LPN #6 told RN #5 about the CNA going home early. RN #5 stated that if LPN #6 told that them there was just one CNA on Sagamore 2 unit, they would tell LPN #6 to prioritize toileting the residents and keeping the residents comfortable. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:39 PM. The DNS stated that if there are not enough staff available on a unit, it is expected that the supervisor for the unit is to assist with care and to pull other staff members from another unit to fill the needs. 3) Resident #205 was admitted with diagnoses including Anxiety Disorder, Depression, and Diabetes Mellitus. The 5/29/2023 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. A physician's order dated 7/26/2023 documented Klonopin (Clonazepam), 1 milligram (mg) tablet, three times a day, at 9:00 AM, 1:00 PM, and 5:00 PM, for Panic Disorder. The medication cart on Woodcrest 3 unit was observed with LPN #4 on 8/8/2023 at 1:16 PM. Review of the narcotic log compared to the blister pack for the Resident #205's Clonazepam revealed the blister pack had 8 tablets left, while the narcotic log listed 10 medications left. LPN #4 just signed off the narcotic log in front of the surveyor for the two tablets of Clonazepam that were administered earlier in the day. LPN #4 stated they (LPN #4) gave the two tablets at 8:30 AM and 12:30 PM, respectively, and did not get a chance to sign for the medications in the narcotic log. LPN #4 stated they (LPN #4) were the only nurse on the unit. RN #2 (unit supervisor) was interviewed on 8/8/2023 at 2:53 PM. RN #2 stated they just heard about the incident within the hour and spoke to LPN #4 regarding the importance of signing the narcotic log. RN #2 stated being short-handed was no excuse and LPN #4 will be in-serviced. The Director of Nursing Services (DNS) was interviewed on 8/9/2023 at 07:30 AM. The DNS stated when the medication was taken out of the blister pack, it should have been logged in the narcotic book (log). 10 NYCRR 415.18(a) Based on observation, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that medications were administered within one hour of the ordered administration time. This was identified for 1) one of three units in the [NAME] building on 8/1/2023; 2) one of three units in the Sagamore building on 8/6/2023; and 3) the facility did not ensure that an account of controlled drugs was maintained on each unit for one of three units in the Woodcrest building. Specifically, 1) on 8/1/2023 on the Woodcrest 3 unit during the 7:00 AM-3:00 PM shift, 13 residents ( Resident #200, #358, #120, #341, #45, #639, #319, #210, #366, #241, #387, #303, #169) did not get there 9 AM medications within one hour of the physician-ordered administration time; 2) Five (Resident #4, #261, #379, #426, and #442) of 30 residents on Sagamore 2 unit received medications beyond one hour of the scheduled administration time on 8/6/2023 during the 7:00 AM-3:00 PM shift due to insufficient staffing; and 3) On Woodcrest 3 unit the narcotic sheets were not reconciled with the amount of narcotic medications present in the blister pack for Resident #205. The findings include but are not limited to: The facility's policy titled Medication Administration, dated 5/14/2020, documented to promote medication safety, prevent medication errors, and to ensure that residents receive their prescribed medications in a timely and appropriate manner. Medication administration times will be strictly adhered to, and medications will be administered at the prescribed intervals. If a medication must be administered exactly at the time specified, the physician's order will reflect as such. Nursing home staff will carefully review each medication order for accuracy, including the medication name, dosage, route of administration, and administration time. 1). An example of one of the thirteen resident's affected on the [NAME] building: Resident #303 was admitted with diagnoses including Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Cancer. The 7/7/2023 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. During an observation on 8/1/2023 at 11:11 AM of the [NAME] 3-unit, Registered Nurse (RN) #12, the unit coordinator was observed passing medications. RN #12 was interviewed on 8/1/2023 immediately after the observation and stated they (RN #12) were administering 9:00 AM medications. RN #12 stated they (RN #12) still had 13 more residents to administer the 9:00 AM medications to (Resident #200, #358, #120, #341, #45, #639, #319, #210, #366, #241, #387, #303, #169). RN #12 stated they (RN #12) were the only nurse on the unit and usually there are at least two medication nurses assigned to the unit for medication pass. RN #12 stated being the unit coordinator they also are responsible to take care of any other issues on the unit. Review of Resident #303's medication orders as of 8/1/2023 revealed the following: -Aspirin (blood thinner) 81 milligrams (mg) delayed release every day at 9:00 AM (prophylactic) Biotin (supplement) 1 mg tablet every day at 9:00 AM (for hair loss). Diazepam 5 mg tablet, three times a day at 9:00 AM, 1:00 PM, and 5:00 PM (for anxiety). Gabapentin 100 mg capsule three times a day at 9:00 AM, 1:00 PM, and 5:00 PM (for neuralgia-nerve pain) Vitamin D3 50 micrograms capsule, every day at 9:00 AM (supplement) Tiotropium 2.5 mcg-Olodaterol 2.5 mcg actuation mist, inhale 2 puffs once daily at 9:00 AM (for Chronic Obstructive Pulmonary Disease). Review of the Administration Documentation History Detail Report (a report indicating medication administration time) for 8/1/2023 for Resident #303 revealed the above 9:00 AM medications were administered at 11:52 AM. In addition, the 1:00 PM doses of Diazepam and Gabapentin were administered at 12:46 PM as per the Administration Documentation History Detail Report (within one hour of the previous dose). RN #12 was re-interviewed on 8/3/2023 at 11:41 AM and stated they (RN #12) were currently giving out 9:00 AM medications. RN #12 stated usually there are two nurses, but RN #12 was alone again today. RN #12 was asked by the surveyor about the 9:00 AM doses of Diazapam and Gabapentin being administered within one hour of the 1 PM doses on 8/1/2023. RN #12 stated it could happen because things get very confusing; RN #12 stated it is hard when you are alone giving medications for the whole unit. Resident #303 was interviewed on 8/3/2023 at 1:04 PM. Resident #303 stated they get Diazepam for Anxiety. Resident #303 stated sometimes the medications are late, like today the medications are late because they only have one nurse. Resident #303 stated they feel increased Anxiety if they do not get the Diazepam on time. Physician #2 was interviewed on 8/4/2023 at 12:30 PM. Physician #2 stated they were not aware that the Diazepam doses were given that close together on 8/1/2023. Basically, the antianxiety medication was given less than an hour apart. Physician #2 stated they will have to change the order for Diazepam to every 8 hours for the resident's safety. Resident #303 has a high tolerance to the medication, there was no real risk of toxicity, and it does not exceed maximum daily dose, but they (Physician #2) did change the scheduled administration time for the resident's safety. The Director of Nursing Services (DNS) was interviewed on 8/9/2023 at 12:53 PM about the medications being administered late. The DNS stated they were aware of the issue with the late medication administration and the diazepam doses being given within an hour of each other. The DNS stated they were not sure what the staffing issues were on the unit. The DNS stated the accepted standard is medications are due one hour before or one hour after the ordered time. The DNS stated the facility will have to do a medication error in-service education for the nurse.

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00299549) initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure each resident was free from any significant medication errors. This was identified for one (Resident #638) of one resident reviewed for significant medication errors. Specifically, on 7/18/2022 Resident #638 received two doses of Ambien (hypnotic for sleep which is a controlled substance), 10 milligrams each, for a total of 20 mg. The physician order documented a maximum daily dosage of one tablet (10 mg). The finding is: The facility's policy, titled Medication Administration, dated 5/14/2020, documented to promote medication safety, prevent medication errors, and to ensure that residents receive their prescribed medications in a timely and appropriate manner. Medication administration will be conducted according to each resident's individualized care plan and physician's orders. Medication administration times will be strictly adhered to, and medications will be administered at the prescribed intervals. Nursing home staff will carefully review each medication order for accuracy, including the medication name, dosage, route of administration, and administration time. Medication Administration Records (MARs) will be accurately completed, signed, and dated by the administering staff member immediately after medication administration. Resident #638 was admitted with diagnoses including Anxiety Disorder, Hypertension, and Urinary Tract Infection. The 7/7/2022 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident received antianxiety, antidepressant, and hypnotic medications. A physician's order effective 6/11/2022 and renewed on 7/9/2022 documented to administer Zolpidem (Ambien), 10 mg, give one tablet 10 mg by oral route once daily, every day at 12:00 AM; maximum daily dose: one tablet. A nursing progress note dated 7/18/2022 at 2:12 AM, written by Registered Nurse (RN) #6, the 11:00 PM-7:00 AM medication nurse, documented the physician (Physician #2) was notified that Resident #638 was administered Ambien 10 mg twice tonight. The physician ordered to transfer the resident to the emergency room for evaluation. Resident #638 was alert with clear speech and appropriate responses; the resident left the unit at 2:00 AM in stable condition via stretcher with two attendants. A message was left for the family to call the unit. Review of the controlled substance disposition record for Resident #638's Zolpidem 10 mg documented that on 7/18/2022 the midnight dose (12:00 AM) was first signed for by Licensed Practical Nurse (LPN) #3, the 3:00 PM-11:00 PM medication nurse indicating that LPN #3 took a tablet from the blister pack, bringing the count down to three tablets. RN #6 also signed the controlled substance disposition record on 7/18/2022 indicating that RN #6 also took a tablet from the blister pack, bringing the count down to two tablets. Review of the July 2022 Medication Administration Record (MAR) revealed that the 7/18/2022 Zolpidem 10 mg was signed for by RN #6, and not LPN #3. The medication error report dated 7/18/2022 concluded that the 3:00 PM-11:00 PM nurse (LPN #3) administered the 10 mg Zolpidem and did not communicate to the 11:00 PM-7:00 AM nurse (RN #6) that the 12 AM medication was administered. The conclusion further documented that RN #6 failed to check the narcotic log, which would have shown that the medication was already given. The recommendations were that the nurses had to follow the rules of medication administration. Physician #2 was interviewed on 8/4/2023 at 12:30 PM and stated it was dangerous to give the double dose (20 mg) of Ambien to a resident that age. Physician #2 stated that is why the resident was sent to hospital. Physician #2 stated there was a risk because 20 mg exceeds the maximum daily dose of 12.5 mg. Physician #2 stated everything was ok with the resident. RN #6 was interviewed on 8/5/2023 at 9:20 AM and stated they (RN #6) were the assigned medication nurse for Resident #638 on 11:00 PM-7:00 AM shift on 7/17/2022-7/18/2022. RN #6 stated they (RN #6) signed for Ambien in the MAR and the narcotic log. RN #6 stated the nurse before them, LPN #3, gave the Ambien during their shift and did not sign for administering the medication in the MAR. RN #6 stated the medication was not due on the 3 PM-11 PM shift. RN #6 stated the medication was to be given and ordered at midnight because the resident wanted it at midnight. RN #6 stated they do not know why LPN #3 gave the medication. RN #6 stated when they gave the medication, they checked the order, took it out of the narcotic box, signed the narcotic log, gave the medication, and then signed the MAR. RN #6 stated LPN #3 signed for the medication in the narcotic log and they saw LPN #3's initials, but did not think twice about it because they just assumed LPN #3's initials were from night before. RN #6 stated after they gave the medication, they were not sure what happened, they questioned LPN #3 and LPN #3 told them that they (LPN #3) gave the Ambien earlier. LPN #3 was interviewed on 8/7/2023 at 10:12 AM and stated they were the 3:00 PM-11:00 PM medication nurse for Resident #638 on 7/17/2022. LPN #3 stated if the medication was due at midnight, they could give the medication at 11:00 PM. LPN #3 stated the resident requested the Ambien because the resident said sometimes, they (resident) have to wait a long time to get the Ambien with incoming staff because they are getting report and it takes a long time. LPN #3 stated they gave the Ambien at 11:00 PM. LPN #3 stated they could not remember if they told the incoming 11:00 PM-7:00 AM nurse. LPN #3 stated they signed the narcotic log but may not have signed the MAR. The Director of Nursing Services (DNS) was interviewed on 8/7/2023 at 10:33 AM and stated the problem was communication. If LPN #3 was still on unit and gave the medication that was technically due on the next shift, LPN #3 should have communicated this to the other nurse. The DNS also stated LPN #3 should have signed for the medication in the MAR when it was given. The DNS stated there was a disciplinary action done for the nurses involved. 10 NYCRR 415.12(m)(2)

Based on observation and staff interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that each controlled-substance storage box was separately locked as per the state and federal guidelines. This was identified for one of two medication carts on Seacliff 1 unit on 8/8/2023. Specifically, on 8/8/2023, a controlled substance box in a medication cart on Seacliff 1 unit did not have a lock. The unlocked box was observed with narcotic controlled substances. The finding is: The facility's policy, titled Medication Storage, dated 5/1/2021, documented all controlled substances, as defined by federal and state regulations, will be stored in a double-locked area within the medication cart or cabinet. The double locking will include both a locked drawer or compartment and a lock securing the medication cart or cabinet itself. On 8/8/2023 at 2:07 PM on Seacliff 1 unit a medication cart was observed with Licensed Practical Nurse (LPN) #1. The narcotic box (controlled substance storage box) within the medication cart did not have a lock. There was a hole in the box and the key lock was missing. LPN #1 stated that the box was like that when they (LPN #1) came onto their shift in the morning, and they (LPN #1) had placed a maintenance request through the automated system. The medication cart on Sea Cliff 1 unit was observed on 8/9/2023 at 12:10 PM with LPN #5. The narcotic box within the medication cart was still missing the key lock. LPN #5 opened the narcotic box and there were multiple narcotic blister packs present in the box. LPN #5 stated that the blister packs contain narcotic medications, and they then removed the narcotics. LPN #5 further stated they (LPN #5) would place a maintenance work order to repair the narcotic storage box in the medication cart. The Director of Plant Operations was interviewed on 8/9/2023 at 1:53 PM and stated they were not aware of the missing lock on the narcotic box. The Director of Plant Operations was re-interviewed on 8/9/2023 at 2:01 PM and stated the work order was just received today and the lock was fixed about an hour ago. The Director of Nursing Services (DNS) was interviewed on 8/9/2023 at 2:27 PM and stated when the nursing staff identifies a maintenance issue, they need to contact maintenance through the software system and let a supervisor know about the problem. The DNS stated narcotic medications should be stored in a double locked box. 10 NYCRR415.18(e)(1-4)

Based on record review and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure outside services were provided to resident timely as per their Physician's orders. This was identified for one (Resident #97) of one resident reviewed for Psychotropic Medication Side Effects. Specifically, Resident #97, with a medical diagnosis of Parkinson's Disease was on a psychotropic medication, Zyprexa, as per their Physician's orders. A Physician's order for a Neurology consult due to increased shakiness was put in place on 5/12/2023. The resident has not been seen by the Neurologist as of 8/10/2023. The finding is: The facility's policy titled, Consults dated 2/21/2021 documented to provide residents with consultation services in accordance with their plan of care and as ordered by a physician. The physician will order the consult. The nurse generates the Consultation Request form. If the facility has the consultant in-house, the consult request will be sent directly to the consultant for review and scheduling. Once completed, the consultant will document their notes, recommendations, and any additional information into the resident's medical chart. Resident #97 was admitted with diagnoses including Parkinson's Disease, Bipolar Disorder and Generalized Anxiety Disorder. The 3/31/2023 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognition. The MDS documented the resident was independent with one-person physical assistance with eating. The 6/28/2023 Quarterly Minimum Data Set (MDS) assessment documented that the resident required extensive assistance with one person physical assist for eating. A Comprehensive Care Plan (CCP) titled Multiple Medication Use: At Risk for Adverse Drug Interaction related to Use of Multiple Medications, effective 5/20/2019 documented Physician (MD) to review and evaluate medications monthly and as needed (PRN), to observe signs and symptoms of adverse drug reactions, and to review the Pharmacy Consultants' recommendations and follow-up. A Comprehensive Care Plan (CCP) titled Neurological Disease: Parkinson's Disease, effective 5/20/2019 documented interventions including but not limited to assist resident in the Activities of Daily Living (ADL) tasks and to encourage rest periods as needed. Therapy evaluation as needed when changes are noted in ADLs and safety. A Comprehensive Care Plan (CCP) titled ADLs Dressing, Grooming, Feeding, Bathing, Toileting, Personal Hygiene, effective 5/8/2019 documented interventions were updated on 6/15/2023 to provide a two-handled cup with a lid at all meals and to provide extensive assistance at mealtimes. A Medical Progress Note written by Nurse Practitioner (NP) #2 on 5/8/2023 documented that Resident # 97 has worsening tremors likely related to psychotropic medications. Zyprexa was increased for outburst of aggressive behavior. NP #2 documented dosing believed to be too high. NP #2 documented discussion with the resident's Health Care Proxy to attempt a slow gradual drug reduction of Zyprexa. A Medical Progress Note dated 5/12/2023 documented the resident was noted with increased tremors. Resident #97 has Parkinson's disease and was on Carbidopa 25mg/ Levodopa 100mg (medications used to treat Parkinson's symptoms) twice a day. The progress note documented to obtain a Neurology consult to follow up. A Physician's order dated 5/12/2023 documented to obtain a Neurology consult for increased shakiness for Parkinson's disease. Resident #97 was observed in bed on 8/3/2023 at 8:43 AM. The resident was observed shaking. Resident #97 was unable to verbalize why they (resident) were shaking. Resident #97 was observed out of bed on 8/8/2023 at 10:24 AM. The resident was observed in their wheelchair in the hallway. Tremors persisted and Resident #97 stated that they did not recall being seen a specialist for their tremors. Certified Nurse Assistant (CNA) #18, who was Resident #97's assigned CNA, was interviewed on 8/9/2023 at 1:27 PM. CNA #18 stated that Resident #97 had Parkinson's Disease but was previously able to participate more actively during care. CNA #18 stated that there was a gradual but notable decrease in function since last year. CNA #18 stated that Resident #97 became more reliant on staff's assistance and began to request help for different ADLs. CNA #18 stated that they were aware of the resident's increased shakiness. CNA #18 stated that they did not know if tremors have affected the resident's ability to feed themselves or if the resident just preferred to be fed. CNA #18 stated that Resident #97 had recently started to use a cup with a lid to drink their beverages during meals. The Medical Services Coordinator was interviewed on 8/4/2023 at 9:58 AM and stated that they had started working in the facility five weeks ago. The Medical Services Coordinator stated that they run reports in the Electronic Medical Record (EMR) system regularly to update new residents with consult orders. The Medical Services Coordinator stated that they communicate with the respective in-house specialists when they visit the facility to ensure that residents who needed to be seen would be seen. The Medical Services Coordinator was re-interviewed on 8/9/2023 at 1:52 PM and stated that they (Medical Services Coordinator) had reviewed Resident #97's order and the medical record. The Medical Services Coordinator confirmed that Resident #97 had an MD order for Neurology consult on 5/12/2023 but was not able to find documented evidence that the resident was on the list to be seen by the Neurologist. The Medical Services Coordinator stated that there was no documented evidence that Resident #97 was seen by the Neurologist as per their MD order. The Medical Services Coordinator stated that they (Medical Services Coordinator) were not aware of how the previous Medical Services Coordinator ensured that Physician's order for internal consults were received by the specialists. The Neurologist was interviewed on 8/9/2023 at 2:19PM and stated that they visited the facility about once a month. The Neurologist stated that the medical office would provide a list of residents that need to be seen and evaluated. The Neurologist would also be contacted by the resident's attending physician if there was an emergency that required immediate Neurology assessment. The Neurologist stated that they very likely did not receive a referral for Resident #97 and did not see the resident because they would have documented their assessment and findings in the resident's progress note after they visited the resident. NP #2 was interviewed on 8/9/2023 at 2:39 PM. NP#2 stated that Resident #97 had diagnoses of Parkinson's Disease and Bipolar Disorder. NP #2 stated that they were aware of Resident #97's increased tremors after a medication dosage change. NP #2 stated that Neurology consult was appropriate in order to address and re-assess Resident #97's Parkinson's Disease progress and treatment and to provide recommendations to determine the best medical management of the resident's overall health. NP #2 stated that they (NP #2) were not aware that Resident #97 was not followed by the Neurologist and stated that the consult should have been done, preferably within a month after the referral was made. NP #2 stated that Resident #97's tremors improved; however, would still expect the resident to be seen by the Neurologist. Resident #97's attending Physician (MD) #3 was interviewed on 8/9/2023 at 3:20 PM and stated that they (MD #3) expected the medical office staff to notify the specialist when a consultation request was made. MD #3 stated that they would expect that the resident would be seen within a couple of weeks after the referral was made. MD #3 stated that they were not aware that Resident #97 was still not seen by since May of 2023 and they still expected the resident to be seen by the Neurologist now. The Director of Nursing Services (DNS) was interviewed on 8/9/2023 at 3:33 PM and stated that they expected the Neurologist to see the resident who had a physician's order for a neurology consult. The DNS stated that they expected a consult to be completed within two months after the physician's order was written. The DNS stated that the medical office personnel was responsible to provide the specialists a list of residents who needed to be seen when the specialists visited the facility. 10 NYCRR 415.26(e)(1)(i-iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #259 was admitted with diagnoses including of Chronic Obstructive Pulmonary Disease, Muscle Weakness, and Congestive Heart Failure. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. The resident required extensive assistance of two persons with bed mobility, transfer, locomotion on and off the unit, dressing, and toilet use. The Comprehensive Care Plan (CCP) for visual function initiated on 6/13/2023 documented Resident #259 had a visual deficit related to blindness in the right eye. Interventions include ophthalmology and optometry consults as appropriate, leave furniture in their room in the same position, encourage to ask for assistance as needed, eyeglasses on when awake, eye drops as ordered, maintain eyeglasses (e.g., label, clean and repair) provide large print reading materials, provide talking books, audio tapes as per resident interests and provide assistive devices as needed. Resident #259 could be heard yelling in their room on 8/1/2023 at 11:43 AM. Resident #259 was observed in bed with their call bell clipped to the upper right side of their pillow. The resident stated they were unable to find their call bell and could not ring for assistance. Resident #259 was informed of the location of their call bell. Resident #259 stated they were blind in their right eye and were unable to see the call bell. The resident stated they needed to go to the bathroom because they had a bowel movement while in bed. There was a noticeable odor of feces present in the room. Resident #259's was heard yelling in their room on 8/3/2023 at 12:18 PM. Resident #259's call bell was observed on the floor next to their bed with a broken clip. Resident #259 stated they needed to use the bathroom. Certified Nursing Assistant (CNA) #27 entered Resident #259's room with the resident's lunch tray on 8/3/2023 at 12:18 PM. CNA #27 stated Resident #259 likes to keep the call bell near them, but the call bell clip was broken. CNA #27 picked up the call bell and placed the call bell in the resident's hand. On 8/4/2023 at 12:05 PM Resident #259's call bell was observed on the floor next to their bed with a broken clip. Licensed Practical Nurse (LPN) #8 was interviewed on 8/4/2023 at 12:07 PM. LPN #8 stated they were not aware that the clip for Resident #259's call bell was broken. LPN #8 stated they were not asked by CNA #27 to complete a maintenance order for the call bell clip. LPN # 8 picked up the call bell and placed the call bell in Resident #259's hand. LPN #8 stated when a CNA reports a maintenance problem, they (LPN #8) are responsible for submitting a maintenance work order. A maintenance work order dated of 8/4/2023 at 12:09 PM was reviewed and documented Resident #259 needed a new clip for their call bell. CNA #27 was re-interviewed on 8/8/2023 at 11:56 AM. CNA #27 stated they knew Resident #259's call bell clip was broken on 8/3/2023 and they (CNA #27) should have reported to the charge nurse right away. CNA #27 stated they forgot to report the broken call bell clip to the charge nurse. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:34 PM. The DNS stated that alert and oriented resident's call bells should be functioning and within reach of the resident at all times. 10 NYCRR 415.29 Based on observation, record review and interviews conducted during the Recertification survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that each resident could 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. This was identified 1) one (Resident #343) of eight residents reviewed for Activities of Daily Living (ADL) and 2) one (Resident #259) of three residents reviewed for the communication-sensory care area. Specifically, 1) On 8/1/2023, Resident #343's call light was wrapped over the head of the bed frame while the resident was in bed. The call bell was not in view or within reach of the resident. 2) Resident #259, with diagnoses of Chronic Obstructive Pulmonary Disease and Muscle weakness was observed on three occasions without access to their call bell. The findings are: The facility's policy, titled Call Light, dated 1/10/2023, documented every resident must have a call light attached from the wall unit to their bed at all times. When a resident is in bed or sitting at the bedside, the call light switch must be within their reach. Always place the call light within the resident's reach. If the call bell is defective, report immediately to maintenance and to the Charge Nurse. Provide resident with an alternate means of calling for assistance. 1). Resident #343 was admitted with diagnoses including Diabetes Mellitus, Alzheimer's Disease, and Depression. The 7/23/2023 Annual Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. The MDS documented that the resident required extensive assistance of one person for personal hygiene and required supervision and set-up for eating. The MDS documented the resident had no limitations in upper extremity range of motion. Resident #343 was observed lying in bed in a hospital gown with a towel over their chest/abdomen on 8/1/2023 at 11:32 AM. The overbed table was observed over the resident's bed. Coffee had spilled onto the towel. Another liquid was observed spilled on the overbed table. The resident's call bell was behind the resident on the headboard. The call bell was not within view of the resident nor within the resident's reach. The resident stated they (Resident #343) could not reach the call bell and the coffee spill happened about two hours ago. Resident #343 was observed by unit Registered Nurse (RN) #1 with the surveyor present on 8/1/2023 at 11:36 AM. RN #1 removed the coffee soiled towel and observed that the sheet under the towel and the hospital gown were also wet with coffee. RN #1 then placed the resident's call bell at the resident's right side and left the room. Resident #343's 7:00 AM-3:00 PM Certified Nursing Assistant (CNA) #2 was interviewed on 8/4/2023 at 2:47 PM and stated they were assigned to Resident #343 on 8/1/2023. CNA #2 stated they (CNA #2) do not think Resident #343 can use the call bell, but they always place it within the resident's reach. Resident #343 was observed in bed on 8/7/2023 at 10:50 AM. The call light was observed near the resident's right hand. The resident was asked by the surveyor if they (resident) were able to activate the call light. The resident stated, sure, and then activated the call light. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:50 PM and stated call bells should be functional and within reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that the facility assessment included what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility assessment did not include the overall number of facility staff needed to ensure sufficient number of qualified staff required to meet each resident's needs. The facility assessment did not consider a review of individual staff assignment and systems for coordination and continuity of care for resident's within and across these staff assignments. Additionally, the facility assessment did not include the need for the respiratory care clinicians on the ventilator unit. The finding is: Review of the Facility assessment dated [DATE], in its entirety, revealed that there was no overall number of facility staff needed included in the assessment to ensure that each resident's needs were being met. The Facility Assessment documented the following staffing plan: The facility does not take a census-based approach to staffing but looks at the acuity levels of the residents to provide the best staffing possible. The facility looks at various factors including the level of assistance needed, the clinical complexity, and treatment provided to each resident when examining appropriate staffing levels. The goal is to ensure all residents' needs are met in an appropriate and timely fashion. Staff assignments are based on the residents being treated. An untitled document dated 6/27/2022 provided by the Director of Payroll and Schedule documented Nurse and Certified Nurse Aide (CNA) par levels on the 7AM-3PM shift, 3PM-11PM shift, and 11PM-7AM shift on all units. The document included, Please use this as a guideline to staffing, adjust pars as the census fluctuates. The Director of Payroll and Schedules was interviewed on 8/7/2023 at 12:30 PM. The Director of Payroll and Schedules stated that they began supervising the staffing coordinators on Monday, 7/31/2023. Prior to 7/31/2023, the Director of Payroll and Schedules provided assistance with staffing for short periods of time when the facility did not have a Scheduling supervisor available. The Director of Payroll and Schedules stated that the Director of Nursing Services (DNS) provided them with the Registered Nurse (RN), Licensed Practical Nurse (LPN) and CNA par levels based on the census and acuity on the units. The Director of Payroll and Schedules stated that staffing numbers are posted in the scheduling office for the staffing coordinators to follow. The Director of Payroll and Schedules stated that they are not involved in creating the Facility Assessment. The DNS and the Administrator was interviewed concurrently on 8/10/2023 at 10:31 AM. The Administrator stated that the facility assessment was last updated on 3/27/2023 and that the resident acuity section was updated on 8/1/2023. The Administrator stated that the facility assessment does not have the overall numbers or nursing par levels as part of the staffing plan. The Administrator stated that the nursing par levels that the Director of Payroll and Schedules provided was developed by the previous DNS. The Administrator was not involved with developing par levels for nurse staffing. The facility assessment was not updated to include par levels because the Administrator did not know that was something that needed to be included. The Administrator stated that they (Administrator) met with the DNS sometime in June 2023 (could not recall the exact date) to develop par levels based on current census, Minimum Data Set assessments and Electronic Medical Record data. The Administrator stated there were no meeting notes available to confirm that the administrator met with the DNS regarding the facility assessment. The Administrator stated that the new par levels have not been developed as of today (8/10/2023). 10 NYCRR 415.13(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews during the Recertification and Abbreviated surveys (NY00304799 and NY00320391) initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure nursing services are provided by sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. Additionally, the facility did not provide services by sufficient number of licensed nurses and nurse aides (assistants) on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. Specifically, 1) 10 of 10 Residents in the Resident Council meeting held on 8/2/2023 reported chronic understaffing on weekends and some weekdays, 2) Review of weekend staffing and staffing during the recertification survey revealed numerous occasions of insufficient nursing staff to provide timely resident care, 3) On 8/6/2023 during the 7:00 AM-3:00 PM shift on Sagamore 2 unit, there was only one Certified Nursing Assistant (CNA) and one Licensed Practical Nurse (LPN) available to provide care for 30 residents, 4) on 7/30/2023, Resident #22 was not taken out of bed during the 7:00 AM-3:00 PM shift because there was only one LPN and 2 CNAs for 38 Residents on the Seacliff 2 unit. Cross References: F658 - Services Provided Meet Professional Standards F684 - Quality of Care F697 - Pain Management F755 - Pharmacy Services The findings include but were not limited to: 1) A Resident Council meeting was held on 8/2/2023 at 10:45 AM. All 10 residents in attendance reported that the facility is understaffed on weekends and some weekdays. The residents reported that the CNAs are often pulled to other floors to help staff on other units, the call bell response time varies from a half an hour to one hour, and they only receive one shower a week due to understaffing. The residents also reported that medications are not administered timely, and they were not taken out of bed timely because not enough staff are available to assist with the mechanical (Hoyer) lifts to transfer the residents out of bed. The Resident Council president was interviewed on 8/4/2023 at 2:36 PM and stated that they have been the president of the council since the fall of 2022. The Resident Council president stated that the council meets every month and at each meeting there are complaints related to short staffing. The Resident Council president stated they do not get a copy of the meeting minutes and do not get an opportunity to review the contents of the meeting minutes to validate the accuracy. The Resident Council president stated that even the residents who do not attend the meetings complain about staffing issues regularly when they (Resident Council president) meet with them prior to the scheduled Resident Council meetings. Review of the Resident Council meeting minutes dated February 2023 documented residents reported that the [NAME] 3 unit is understaffed on weekends. The Resident Council meeting minutes for May 23, 2023, June 18 2023, and July 14, 2023, were reviewed and lacked documented evidence of staffing issues. The meetings minutes were not signed by the Resident Council president, Administration nor the Director of Therapeutic Recreation. The Director of Therapeutic Recreation was interviewed on 8/8/2023 at 3:04 PM. The Director of Therapeutic Recreation stated that in February 2023 the Resident Council reported that understaffing on weekends was a problem. The Director of Therapeutic Recreation stated that the Resident Council Meeting minutes were not given to the Resident Council president for review for accuracy because the Director of Therapeutic Recreation was not aware that they were required to provide the meeting minutes to the Resident Council president. The Administrator was interviewed on 8/10/2023 at 10:31 AM. The Administrator stated that the Resident Council brought concerns about staffing up during the Resident Council meeting in February 2023. The Administrator stated that there was one weekend that the residents complained about. The Administrator stated that they were not sure of the details because the previous Director of Nursing Services (DNS) addressed the concerns with the Resident Council. The Administrator was not involved with addressing the Resident Council concerns since the DNS was responsible for staffing. 2) Review of the Facility assessment dated [DATE] in its entirety revealed that there was no overall number of facility staff needed included in the assessment to ensure the resident's needs were being met. The Facility Assessment documented the following staffing plan: The facility does not take a census-based approach to staffing but looks at the acuity levels of the residents to provide the best staffing possible. The facility looks at various factors including the level of assistance needed, the clinical complexity, and treatment provided to each resident when examining appropriate staffing levels. The goal is to ensure all residents' needs are met in an appropriate and timely fashion. Staff assignments are based on the residents being treated. An untitled document dated 6/27/2022 documented the following Nurse and Certified Nurse Aide/Assistant (CNA) par levels on the 7:00 AM-3:00 PM shift, 3:00 PM-11:00 PM shift, and 11:00 PM-7:00 AM shift on all units. This document was not included as part of the Facility Assessment. 7:00 AM - 3:00 PM Shift: Brookville 1 unit (Bed Capacity of 30): 1 LPN, 4 CNA Brookville 2 unit (Bed Capacity of 30): 1 Registered Nurse (RN), 4 CNA Brookville 3 unit (Bed Capacity of 30): 1 LPN, 4 CNA [NAME] 1 unit (Bed Capacity of 43): 1 RN, 2 LPN, 5 CNA [NAME] 2 unit (Bed Capacity of 43): 1 RN, 2 LPN, 5 CNA [NAME] 3 unit (Bed Capacity of 43): 1 RN, 2 LPN, 5 CNA Seacliff 1 unit (Bed Capacity of 39): 1 RN, 2 LPN, 6 CNA Seacliff 2 unit (Bed Capacity of 50): 1 RN, 2 LPN, 6 CNA Seacliff 3 unit (Bed Capacity of 54): 1 RN, 1 LPN, 6 CNA Sagamore 2 unit (Bed Capacity of 35): 1 RN, 1 LPN, 3 CNA Sagamore 3 unit (Bed Capacity of 31): 1 LPN, 4 CNA Woodcrest 1 unit (Bed Capacity of 43): 2 LPN, 4 CNA Woodcrest 2 unit (Bed Capacity of 43): 1 RN, 1 LPN, 5 CNA Woodcrest 3 unit (Bed Capacity of 43): 2 LPN, 4 CNA 3:00 PM -11:00 PM Shift: Brookville 1 unit (Bed Capacity of 30): 1 LPN, 4 CNA Brookville 2 unit (Bed Capacity of 30): 1 LPN, 4 CNA Brookville 3 unit (Bed Capacity of 30): 1 LPN, 4 CNA [NAME] 1 unit (Bed Capacity of 43): 1 RN, 1 LPN, 4 CNA [NAME] 2 unit (Bed Capacity of 43): 1 RN, 1 LPN, 4 CNA [NAME] 3 unit (Bed Capacity of 43): 1 RN, 1 LPN, 4 CNA Seacliff 1 unit (Bed Capacity of 39): 1 RN, 1 LPN, 5 CNA Seacliff 2 unit (Bed Capacity of 50): 1 RN, 1 LPN, 5 CNA Seacliff 3 unit (Bed Capacity of 54): 2 LPN, 5 CNA Sagamore 2 unit (Bed Capacity of 35): 1 RN, 3 CNA Sagamore 3 unit (Bed Capacity of 31): 1 LPN, 4 CNA Woodcrest 1 unit (Bed Capacity of 43): 1 LPN, 4 CNA Woodcrest 2 unit (Bed Capacity of 43): 1 LPN, 4 CNA Woodcrest 3 unit (Bed Capacity of 43): 1 LPN, 4 CNA 11: PM- 7:00 AM Shift: Brookville 1 unit (Bed Capacity of 30): 1 LPN, 3 CNA Brookville 2 unit (Bed Capacity of 30): 1 LPN, 3 CNA Brookville 3 unit (Bed Capacity of 30): 1 LPN, 3 CNA [NAME] 1 unit (Bed Capacity of 43): 1 RN, 3 CNA [NAME] 2 unit (Bed Capacity of 43): 1 RN, 3 CNA [NAME] 3 unit (Bed Capacity of 43): 1 RN, 3 CNA Seacliff 1 unit (Bed Capacity of 39): 1 RN, 1 LPN, 4 CNA Seacliff 2 unit (Bed Capacity of 50): 1 RN, 1 LPN, 4 CNA Seacliff 3 unit (Bed Capacity of 54): 1 LPN, 3 CNA Sagamore 2 unit (Bed Capacity of 35): 1 RN, 2 CNA Sagamore 3 unit (Bed Capacity of 31): 1 LPN, 3 CNA Woodcrest 1 unit (Bed Capacity of 43): 2 LPN, 4 CNA Woodcrest 2 unit (Bed Capacity of 43): 1 RN, 1 LPN, 5 CNA Woodcrest 3 unit (Bed Capacity of 43): 2 LPN, 4 CNA The Facility Census Detail Reports were reviewed and documented the following: Brookville 1 unit (Bed Capacity of 30) maintained a census of 29 from 5/13/23 to 8/6/23 Brookville 2 unit (Bed Capacity of 30) maintained a census of 29 to 30 from 5/13/23 to 8/6/23 Brookville 3 unit (Bed Capacity of 30) maintained a census of 30 from 5/13/23 to 8/6/23 [NAME] 1 unit (Bed Capacity of 43) maintained a census of 38 to 41 from 5/13/23 to 8/6/23 [NAME] 2 unit (Bed Capacity of 43) maintained a census of 31 to 39 from 5/13/23 to 8/6/23 [NAME] 3 unit (Bed Capacity of 43) maintained a census of 39 to 42 from 5/13/23 to 8/6/23 Seacliff 1 unit (Bed Capacity of 39) maintained a census of 24 to 29 from 5/13/23 to 8/6/23 Seacliff 2 unit (Bed Capacity of 50) maintained a census of 37 to 40 from 5/13/23 to 8/6/23 Seacliff 3 unit (Bed Capacity of 54) maintained a census of 42 to 43 from 5/13/23 to 8/6/23 Sagamore 2 unit (Bed Capacity of 35) maintained a census of 28 to 30 from 5/13/23 to 8/6/23 Sagamore 3 unit (Bed Capacity of 31) maintained a census of 27 to 31 from 5/13/23 to 8/6/23 Woodcrest 1 unit (Bed Capacity of 43) maintained a census of 42 to 43 from 5/13/23 to 8/6/23 Woodcrest 2 unit (Bed Capacity of 43) maintained a census of 43 from 5/13/23 to 8/6/23 Woodcrest 3 unit (Bed Capacity of 43) maintained a census of 41 to 42 from 5/13/23 to 8/6/23 (Sagamore 1 unit was closed from 5/13/23 to 8/6/23) The Facility Staffing Sheets for weekends from 5/13/23 to 8/6/23 were reviewed. Additionally, staffing sheets throughout the survey, 8/1/2023 to 8/10/2023, were reviewed. The staffing sheets revealed that the facility was understaffed on the following days: Brookville 1 unit, 7:00 AM-3:00 PM Shift, had a par level of 4 CNAs. The unit was understaffed by 2 CNAs on 5/14/23, 7/16/23, 8/6/23. Additionally, the unit was understaffed by 1 CNA on 6/18/23, 7/2/23, 7/15/23, and 8/7/23. Brookville 1 unit, 3:00 PM-11:00 PM Shift had a par level of 4 CNAs. The unit was understaffed by 1 CNA on 7/15/23, 7/16/23, and 8/6/23. Brookville 2 unit, 7:00 AM-3:00 PM Shift had a par level of 4 CNAs. The unit was understaffed by 1 CNA on 6/18/23, 7/2/23, 7/15/23, 8/3/23, 8/5/23, and 8/6/23. Additionally, the unit was understaffed by 2 CNAs on 7/16/23. Brookville 2 unit, 3:00 PM-11:00 PM Shift had a par level of 4 CNAs. The unit was understaffed by 1 CNA on 7/15/23, 7/16/23, and 8/6/23. Brookville 3 unit, 7:00 AM-3:00 PM Shift had a par level of 4 CNAs. The unit was understaffed by 2 CNAs on 5/14/23 and 8/6/23. Additionally, the unit was understaffed by 1 CNA on 6/18/23, 7/2/23, 7/15/23, 7/16/23, 8/1/23, 8/3/23, 8/5/23, 8/7/23, and 8/8/23. Brookville 3 unit, 3:00 PM-11:00 PM Shift had a par level of 4 CNAs. The unit was understaffed by 1 CNA on 7/15/23, 8/5/23, and 8/6/23. Sagamore 2 unit, 7:00 AM-3:00 PM Shift had a par level of 1 RN, 1 LPN and 3 CNAs. The unit was understaffed by 1 CNA on 5/14/23 and understaffed by 1 RN and 1 CNA on 5/28/23, 6/4/23, 6/18/23, 7/2/23 and 8/6/23. Additionally, the unit was understaffed by 1 LPN and 1 CNA on 7/16/23, and 7/30/23. Sagamore 2 unit, 3:00 PM-11:00 PM Shift had a par level of 3 CNAs. The unit was understaffed by 1 CNA on 7/16/23. Sagamore 3 unit, 7:00 AM-3:00 PM Shift had a par level of 4 CNAs. The unit was understaffed by 2 CNAs on 6/4/23, 7/16/23, 7/30/23, 8/5/23, and 8/6/23. [NAME] 1 unit, 7:00 AM-3:00 PM Shift had a par level of 1 RN, 2 LPNs, and 5 CNAs. The unit was understaffed by 1 LPN and 2 CNAs on 5/14/23 as well as1 RN and 2 CNAs on 7/2/23. Additionally, the unit was understaffed by 2 LPNs and 1 CNA on 8/6/23. Furthermore, the unit was understaffed by 1 LPN and 1 CNA on 8/7/23. [NAME] 1 unit, 3:00 PM-11:00 PM Shift had a par level of 1 LPN and 4 CNAs. The unit was understaffed by 1 LPN and 1 CNA on 7/15/23 as well as 1 LPN on 8/6/23. [NAME] 2 unit, 7:00 AM -3:00 PM Shift had a par level of 1 RN, 2 LPNs, and 5 CNAs. The unit was understaffed by 2 LPN on 7/2/23. Additionally, the unit was understaffed by 1 RN, 1 LPN, and 2 CNAs on 7/16/23 and 8/6/23. [NAME] 3 unit, 7:00 AM-3:00 PM shift had a par level of 1 RN, 2 LPNs, and 5 CNAs. The unit was understaffed by 1 RN and 2 CNAs on 7/2/23 and 7/16/23 and 1 RN, 1 LPN and 2 CNAs on 8/6/23. [NAME] 3 unit, 3:00 PM-11:00 PM Shift had a par level of 1 RN, 1 LPN, and 4 CNAs. The unit was understaffed by 1 RN and 1 CNA on 7/15/23 as well as 1 LPN on 8/6/23. Woodcrest 1 unit, 7:00 AM-3:00 PM Shift had a par level of 2 LPNs, and 4 CNAs. The unit was understaffed by 1 LPN and 1 CNA on 5/14/23, 6/18/23, and 7/16/23. Additionally, the unit was understaffed by 1 CNA on 6/4/23 and 2 LPNs on 8/5/23. Furthermore, the unit was understaffed by 1 LPN and 2 CNAs on 7/30/23 and 8/6/23. Woodcrest 1 unit, 3:00 PM-11:00 PM Shift had a par level of 1 LPN, and 4 CNAs. The unit was understaffed by 1 LPN and 1 CNA on 5/14/23 and 1 CNA on 7/15/23. Woodcrest 2 unit, 7:00 AM-3:00 PM Shift had a par level of 1 RN, 1 LPN, and 5 CNAs. The unit was understaffed by 1 RN and 2 CNAs on 5/14/23 and 7/30/23. The unit was understaffed by 2 CNAs on 6/18/23 and 7/2/23, 3 CNAs on 7/16/23, as well as RN and 3 CNAs on 8/6/23. Woodcrest 2 unit, 3:00 PM-11:00 PM Shift had a par level of 1 LPN, and 4 CNAs. The unit was understaffed by 1 RN and 2 CNAs on 5/14/23, 7/2/23, and 7/15/23. The unit was understaffed by 1 CNA on 6/4/23. Additionally, the unit was understaffed by 1 RN and 1 CNA on 6/18/23. Woodcrest 3 unit, 7:00 AM-3:00 PM Shift had a par level of 2 LPNs, and 4 CNAs. The unit was understaffed by 1 LPN and 1 CNA on 5/14/23 and 7/2/23. The unit was understaffed by 1 LPN and 2 CNA on 7/16/23, 7/30/23 and 8/6/23. Additionally, the unit was understaffed by 2 LPNs and 1 CNA on 8/5/23. Woodcrest 3 unit, 3:00 PM-11:00 PM Shift had a par level of 1 LPN, and 4 CNAs. The unit was understaffed by 1 LPN and 1 CNA on 5/14/23 and 7/15/23. Seacliff 1 unit, 7:00 AM-3:00 PM Shift had a par level of 1 RN, 2 LPNs, and 6 CNAs. The unit was understaffed by 1 LPN and 3 CNAs on 7/16/23 as well as 2 LPNs and 2 CNAs on 8/6/23. Seacliff 1 unit, 3:00 PM-11:00 PM Shift had a par level of 1 RN, 1 LPN, and 5 CNAs. The unit was understaffed by 1 CNA on 8/5/23. Seacliff 2 unit, 7:00 AM-3:00 PM Shift had a par level of 1 RN, 2 LPNs, and 6 CNAs. The unit was understaffed by 1 RN and 2 CNAs on 7/2/23, 7/16/23, and 8/7/23. Additionally, the unit was understaffed by 1 RN, 1 LPN and 3 CNAs on 7/30/23 as well as 1 RN, 1 LPN and 2 CNAs on 8/6/23. Seacliff 2 unit, 3:00 PM-11:00 PM Shift had a par level of 1 RN, 1 LPN, and 5 CNAs. The unit was understaffed by 1 RN and 1 CNA on 8/5/23. Seacliff 3 unit, 7:00 AM-3:00 PM Shift had a par level of 1 RN, 1 LPN, and 6 CNAs. The unit was understaffed by 3 CNAs on 6/18/23 and 7/30/23. The unit was understaffed by 1 RN and 2 CNAs on 8/5/23 as well as 1 RN and 3 CNAs on 8/6/23. The Director of Payroll and Schedules was interviewed on 8/7/2023 at 12:30 PM. The Director of Payroll and Schedules stated that they began supervising the staffing coordinators on Monday, 7/31/2023. Prior to 7/31/2023, the Director of Payroll and Schedules provided assistance with staffing for short periods of time when the facility did not have a Scheduling supervisor available. The Director of Payroll and Schedules stated that the Director of Nursing Services (DNS) provided them with the Registered Nurse (RN), Licensed Practical Nurse (LPN) and CNA par levels based on the census and acuity on the units. The Director of Payroll and Schedules stated that staffing numbers are posted in the scheduling office for the staffing coordinators to follow. The Director of Payroll and Schedules stated that the facility has a lot of staff out for various reasons including leave of absence, Family Medical Leave Act (FMLA), and sick leave. The Director of Payroll and Schedules stated that staffing agencies are unable to provide new licensed nurses. When staff call out for their shift, the staffing coordinators approach all staff currently working in the facility for coverage. The Director of Payroll and Schedules stated that the part time staff are working full time hours and that the facility has contract limitations and cannot hire per diem staff. The DNS and the Administrator was interviewed concurrently on 8/10/2023 at 10:31 AM. The Administrator stated that the facility assessment does not have the overall numbers or nursing par levels as part of the staffing plan. The Administrator stated that the nursing par levels that the Director of Payroll and Schedules provided was developed by the previous DNS. The Administrator was not involved with developing par levels for nurse staffing. The facility assessment was not updated to include par levels because the Administrator did not know that was something that needed to be included. The Administrator stated that they (Administrator) met with the DNS sometime in June 2023 (could not recall the exact date) to develop par levels based on current census, Minimum Data Set assessments and Electronic Medical Record data. The Administrator stated there were no meeting notes available to confirm that the Administrator met with the DNS regarding the facility assessment. The Administrator stated that the new par levels have not been developed as of today (8/10/2023). The Administrator was re-interviewed on 8/10/2023 at 3:30 PM. The Administrator stated that the staffing coordinators use the par levels dated 6/27/2022 as a guide and adjust the staffing numbers based on daily conversations with the DNS regarding changes in census. The Administrator stated that some days the facility does have sufficient staff and some days they can do better. The Administrator stated that the staffing levels fluctuate with the number of staff who are out for various reasons. The DNS was re-interviewed on 8/10/2023 at 3:39 PM. The DNS stated that they staff the units according to the availability of staff and the needs of the residents. If there are not enough staff available on a unit, they will pull staff from another unit. The DNS stated that most days the facility does have sufficient staff but some days they do not because of call outs, leave of absence, etc. 3) Review of the final staffing sheet dated 8/6/2023 revealed that there was one Licensed Practical Nurse (LPN) #6 and two Certified Nursing Assistant (CNAs) CNA #8 and CNA #9 on the Sagamore 2 unit during the 7:00 AM-3:00 PM Shift. The facility Historical Census Summary Report dated 8/6/23 documented that there were 30 occupied beds on Sagamore 2 unit with an occupancy rate of 86%. An untitled document dated 6/27/2022 documented the following par level for Sagamore 2 unit during the 7:00 AM-3:00 PM shift based on a full census of 35 Residents: 1 RN, 1 LPN and 3 CNAs. Licensed Practical Nurse (LPN) #6, the medication nurse, was interviewed on 8/7/2023 at 2:09 PM. LPN #6 stated they (LPN#6) were the only nurse on Sagamore 2 unit on 8/6/2023 during the 7:00 AM to 3:00 PM shift. LPN #6 stated that there needs to be two nurses on Sagamore 2 unit to care for the 30 residents on the unit. LPN #6 stated that there was just two CNAs on the unit of 30 residents until 1:00 PM. LPN #6 stated that from 1:00 PM to 3:00 PM, there was just one CNA working with LPN #6 because the other CNA had a personal emergency and had to leave. LPN #6 stated that it is difficult to work alone on the unit. LPN #6 stated that they are responsible for medication administration, wound care treatments, and documentation. LPN #6 stated that they were running late with the medication pass on 8/6/2023 and the 9:00 AM medication administration was done by 11:00 AM. The 1:00 PM medications were administered by 3:00 PM. LPN #6 stated that if there were two nurses, it would take an hour and a half to complete the medication pass. LPN #6 stated there were eight wound care treatments to do, all of which have to be pre-medicated one hour before the treatment. LPN #6 stated that for one of the eight residents it takes up to 25 minutes for one wound care treatment. LPN #6 stated that some of the wound care treatments are tied with brief changes, which further interrupts medication administration. LPN #6 stated that there 12 residents who require two-person assistance so that they (LPN #6) may be pulled to assist the CNA with care. Also, LPN #6 stated lunch was served at 12:00 PM that they had to collect the lunch trays at 2:35 PM because the one CNA was so busy. LPN #6 stated that the 7:00 AM to 3:00 PM shift was especially challenging because Resident #361 was actively passing away and required Morphine (pain medication) to be administered every 2 hours. LPN #6 stated that they (LPN #6) provided emotional support for Resident #361 and the family throughout the shift on top of their normal duties. LPN #6 stated that the workload snowballs due to interruptions. LPN #6 stated all of the interruptions cause subsequent medication administrations to be late. LPN #6 stated that there was no way to get everything done on time. LPN #6 stated that they informed Registered Nurse (RN) #5, who was their supervisor, when the CNA had to go home early. LPN #6 stated that RN #5 told LPN #6 to prioritize toileting the residents since it was an emergency. CNA #8 was interviewed on 8/9/2023 at 11:07 AM. CNA #8 stated that on 8/6/2023 at 1:00 PM, CNA #9 had a personal emergency and had to leave. CNA #8 was the only CNA on the unit from 1:00 PM to 3:00 PM. CNA #8 stated that they requested for another CNA to come to the unit to assist but no one came. CNA #8 stated that LPN #6 had to interrupt medication pass to provide assistance with two-person care and picking up meal trays. CNA #8 stated that a lot of residents were using the call bell for assistance and they (LPN #6 and CNA #8) could not be everywhere at once. CNA #8 stated that residents had to wait for care and that it could take up to 20 minutes to provide care for just one resident. CNA #8 further stated that even 2 CNAs for the unit was not enough because when they went on break, that leaves just one CNA for the whole unit. CNA #9 was interviewed on 8/9/2023 at 11:41 AM. CNA #9 stated that they had to leave at 1:00 PM on 8/6/2023. CNA #9 stated that they (CNA #9) started the shift at 7:00 AM with just 2 CNAs. CNA #9 stated that they normally have 3 CNAs, but 4 CNAs is needed. CNA #9 stated that every resident has care needs that require 30-45 minutes of the staff's time. CNA #9 stated that when there are just two CNAs for 30 residents, it is impossible to get to every resident. CNA #9 stated that several call bells were sounding on 8/6/2023 and that it is stressful and overwhelming to work with just two CNAs. CNA #9 stated that they cannot provide care to two-person assist residents timely because the other CNA is usually busy or no one else is available to assist and the residents have wait for care until the other CNA or the LPN is available. CNA #9 stated that when the CNAs go on break there is just one CNA on the unit because there is no one else to cover. RN #5 was interviewed on 8/10/2023 at 10:11 AM. RN #5 stated that they (RN #5) were assisting on multiple units between the Sagamore and Woodcrest buildings on 8/6/2023. RN #5 stated that they cannot recall if LPN #6 told them about CNA #9 leaving early. RN #5 stated that if LPN #6 told that them there was just one CNA on Sagamore 2 unit, they would instruct LPN #6 to prioritize toileting the residents and keeping the residents comfortable. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:39 PM. The DNS stated that if there are not enough staff available on a unit, it is expected that the supervisor for the unit is to assist with care and to pull other staff members from another unit. The DNS stated that they were not sure if two CNAs were sufficient for 30 residents on Sagamore 2 unit on 8/6/2023 during the 7:00 AM-3:00 PM shift. The DNS stated that they were not sure if one licensed nurse was sufficient on Sagamore 2 unit. The DNS stated that if the LPN needed assistance the RN Supervisor should have assisted the LPN. 4) Resident #22 was admitted with the diagnoses of Chronic Obstructive Pulmonary Disease, Heart Failure, and Muscle weakness. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #22 had a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident had moderately impaired cognition. Resident #22 required limited assistance of one-person for bed mobility and transfer. Resident #22 was not steady and only able to stabilize with staff assistance during surface-to-surface transfers and moving from a seated to a standing position. Resident #22 utilized a wheelchair as a mobility device. The At Risk for Falls Care plan dated 4/6/2023 documented that Resident #22 was at risk for falls/injury related to use of cardiovascular and diuretics medications. The care plan documented the intervention of transfers with supervision. The facility's final Staffing Schedule dated 7/30/2023 on the 7:00 AM- 3:00 PM shift documented one Registered Nurse (RN) and two Certified Nursing Assistants (CNAs) worked on Seacliff 2 unit. The facility's Census Detail Report dated 7/30/2023 documented 38 residents were residing on the Seacliff 2 unit. Resident #22 was interviewed on 8/1/2023 at 10:33 AM. Resident #22 stated that on Sunday, 7/30/2023, they were not transferred out of bed until 4:00 PM. Resident #22 stated that they (Resident #22) prefer to get out of bed after breakfast, between 8:00 AM and 9:00 AM. Resident #22 stated their legs hurt and feel wobbly and therefore they require assistance to get out of bed. Resident #22 stated they knew they did not get out of bed until 4:00 PM on Sunday, 7/30/2023 because they looked at the clock on the wall in their room. The CNA assigned to Resident #22 on 7/30/2023 during the 7:00 AM-3:00 PM shift was unavailable for interview during the recertification survey. Licensed Practical Nurse (LPN) #8 was interviewed on 8/10/2023 at 4:27 PM. LPN #8 stated that they recalled working on 7/30/2023 on the Seacliff 2 unit during the 7:00 AM-3:00 PM shift. LPN #8 stated that the unit was understaffed with just 2 CNAs on the unit during the 7:00 AM- 3:00 PM shift. LPN #8 stated that they knew that Resident #22 was not assisted to get out of bed because there were not enough CNAs available. Resident #22 was taken out of bed during the 3:00 PM-11:00 PM shift after 4:00 PM because there were three CNAs and two licensed nurses working on the 3:00 PM -11:00 PM shift. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 4:37 PM. The DNS stated that if a resident asked to get out of bed, the CNAs could have alerted a Supervisor to assist with the request. The DNS stated that they were not sure if two CNAs were sufficient to provide care for 38 residents. The DNS stated that if they had more staff available from other units, they should have been directed to the Seacliff 2 unit. 10 NYCRR 415.13(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility was not effectively administered to ensure sufficient staffing was provided to promote the highest practicable physical mental and psychosocial well-being of each resident. The Facility Assessment did not include the overall number of facility staff needed to ensure that each resident's needs were being met. Additionally, the Administrator did not monitor and enhance the quality of care and services by repeating the same deficiencies including: F656 Develop/Implement Comprehensive Care Plan, F658 Services Provided meet Professional Standards, F689 Free of Accident Hazards/Supervision/Devices and F840 Use of Outside Resources. Cross Reference: F697 Pain Management F725 Sufficient Nursing Staff F755 Pharmacy Services F838 Facility Assessment The finding is: Review of the Facility assessment dated [DATE], in its entirety, revealed that there was no overall number of facility staff needed included in the assessment to ensure that each resident's needs were being met. The Facility Assessment documented the following staffing plan: The facility does not take a census-based approach to staffing but looks at the acuity levels of the residents to provide the best staffing possible. The facility looks at various factors including the level of assistance needed, the clinical complexity, and treatment provided to each resident when examining appropriate staffing levels. The goal is to ensure all residents' needs are met in an appropriate and timely fashion. Staff assignments are based on the residents being treated. The Director of Nursing Services (DNS) and the Administrator were interviewed concurrently on 8/10/2023 at 10:31 AM. The Administrator stated that the Facility Assessment was last updated on 3/27/2023 and that the resident acuity section was updated on 8/1/2023. The Administrator stated that the facility assessment does not have the overall numbers or nursing par levels as part of the staffing plan. The Administrator stated that the nursing par levels that the Director of Payroll and Schedules provided were developed by the previous DNS. The Administrator was not involved with developing par levels for nurse staffing. The Facility Assessment was not updated to include par levels because the Administrator did not know that was something that needed to be included. The Administrator stated that they (Administrator) met with the DNS sometime in June 2023 (could not recall the exact date) to develop par levels based on current census, Minimum Data Set assessments, and Electronic Medical Record data. The Administrator stated there were no meeting notes available to confirm that the Administrator met with the DNS regarding the facility assessment. The Administrator stated that the new par levels have not been developed as of today (8/10/2023). The Administrator stated that Resident Council brought concerns about staffing in February 2023. The Administrator stated that there was one particular weekend that the residents complained about but was not sure of the details because the previous DNS addressed it with the Resident Council. The Administrator was not involved with addressing the Resident Council Concerns since the Director of Nursing was responsible for staffing. The Administrator was re-interviewed on 8/10/23 at 3:30 PM. The Administrator stated that they (Administrator) were not sure if there was sufficient staffing on 8/6/2023 on Sagamore 2 unit or in the other example dates provided regarding staffing shortages during the sufficient staffing task review. The Administrator stated that they (Administrator) would have to finalize the par levels in order to determine that. Currently, the Administrator and DNS speak with the Director of Payroll and Schedules on a daily basis to adjust staffing according to changes in census and needs. The 6/27/2022 par levels are used as a guide. The Administrator stated that some days the facility does have sufficient staff and some days they can do better. The Administrator stated that it fluctuates with the number of staff who are out for various reasons. The Administrator stated there have been issues that are brought to the Quality Assurance Performance Improvement (QAPI) meetings continually, like nosocomial wounds, weights, safety, and grievances. We address staffing at the quarterly QAPI meeting because staffing problems have come up. We discuss job fairs, how can we attract people, i.e. new hires, bonuses, and incentives. The Administrator stated there has been some progress. 10 NYCRR 415.26

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey completed on 5/24/2021, the facility did not ensure that a thorough investigation was conducted for one of three residents reviewed for accidents. Specifically, Resident #471 had two Accidents/Incident (A/I) reports with injuries without an investigation to determine whether the call bell was functioning, was within the resident's reach, and if the call bell was activated prior to the incident. The finding is: The Facility Policy titled Abuse Prevention Program Policy and Procedure dated 12/2017 documented it is the policy of the facility that all reports or allegations of abuse, mistreatment, neglect and/or misappropriation of resident belongings be promptly and thoroughly investigated. Resident # 471 was admitted with diagnosis that include Schizophrenia. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment. The resident had no short-term or long-term memory problems. The resident required extensive assistance of 2 staff members for bed mobility, transfers, and toilet use. The resident was non ambulatory, frequently incontinent of bowel and bladder, and had one fall with injury since admission. The Comprehensive Care Plan (CCP) for Falls last updated 5/16/2021 documented that the resident was at risk for falls/injury/fracture related to Physical limitations, Impaired balance, Gait disturbance, use of antipsychotic and the use of anti-anxiety medications. Interventions included to place the call bell within easy reach at all times. On 5/16/2021 at 9:14 PM, the CCP was updated as follows: A/I, fell and bumped head while going to the bathroom. The CCP was revised, a helmet was provided for safety. The A/I report dated 4/15/2021 documented the resident was noted with injury to the forehead, root cause analysis documented likely self-transfer, fell, and did not alert staff due to impaired mental status, poor decision making, and impaired judgement. The corrective action plan included to provide frequent reminders to the resident to call for assistance with transfers. Place call bell within easy reach at all times. A nurse's note dated 4/16/2021 at 2:01 AM, documented that at approximately 7:30 PM a Certified Nursing Assistant (CNA) reported to the nurse that the resident had redness to the forehead. The resident was questioned about what happened to his forehead and responded that nothing happened, then, stated, I hit myself then stated, I fell last night. The Nursing supervisor was made aware and then came to the unit to see the resident. The RN documented the discoloration to the forehead was darker in color after a few hours and notified the Physician. The resident was transferred to Hospital for Computerized Tomography (CT) scan of head. The A/I dated 5/16/2021 documented the resident had an unwitnessed fall and was noted with a bump to the forehead. The A/I did not indicate if the use of the call bell and the proximity of the call bell to the resident was included as part of the investigation. A nurse's note dated on 5/16/2021 at 10:57 PM documented the resident was alert, verbally responsive, and was noted with a 1.5-centimeter (cm) x 1.5 cm raised area on the forehead. On assessment the resident stated that he fell today in the room. Risk Manager #1 was interviewed on 5/20/2021 at 4:05 PM and stated that the A/I report should include whether the resident' s call bell was in reach, functioning and whether the call bell was pressed by the resident prior to the incident. Registered Nurse (RN) Supervisor #2 was interviewed on 5/20/2021 at 4:15 PM and stated they were the supervisor on 5/16/2021. RN Supervisor #2 stated the resident could use the call bell, however, they (RN Supervisor #2) did not document the call bell placement or functioning on the A/I. The Director of Nursing Services (DNS) was interviewed on 5/24/2021 at 4:30 PM and stated the A/I reports should include an investigation on the use of the call bell and whether the call bell was properly functioning at the time of the incidents. 415.4(b)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #279 was admitted with diagnoses including Urinary Tract Infection, Hypertension and Congestive Heart Failure. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) Score of 15 which indicated the resident had intact cognition. The MDS indicated the resident was always incontinent of Bowel and Bladder and required extensive assistance of two staff members. A Resolved CCP for UTI dated 9/28/2020 documented the last dose of antibiotic was administered on 10/7/2020 and the CCP was resolved on 1/2/2021. The medical record lacked documented evidence of an active CCP related to use of the CCP. A Physician's order dated 4/16/2021 documented Minocycline (Antibiotic) 100 milligram (gm) capsule, give 1 capsule (100 mg) by oral route once daily for History of UTI. A Nursing progress note dated 5/13/2021 documented a Urinalysis and Culture and Sensitivity (UA/CS) (urine specimen) collected via straight catheter secondary to UTI, tolerated well. A Nursing progress note dated 5/14/21 documented the urine results were pending and the resident denies dysuria (pain upon urination) at present. A urine Laboratory test result dated 5/14/2021 documented a large amount of Leukocyte Esterase (white blood cells) and was positive for Nitrite (Abnormal). A Nursing progress note dated 5/15/2021 documented the resident was alert and oriented x 3. Urinalysis result indicated positive nitrite and large Leukocytes, and the Culture and Sensitivity results were still pending. A Nursing note dated 5/16/2021 documented the resident's Physician was aware of the urine results and came to evaluate the resident. Macrobid (Antibiotic to treat and prevent UTI) 100 mg twice daily for seven days was ordered for UTI. The Registered Nurse (RN) Supervisor was interviewed on 5/21/2021 at 1:55 PM and stated the RN believed the resident was on Antibiotic for prophylactic purposes. The RN stated that there was a CCP for active UTI that was resolved in the beginning of 2021 for the resident. The RN stated that a CCP was not initiated for the use of Macrobid for the UTI and that any RN in charge could have initiated a CCP. The Director of Nursing Services (DNS) was interviewed on 5/24/21 AT 3: 47 PM and stated if there was a Physician's order for Antibiotic use for prophylactic treatment of UTI for the resident, there should have been a CCP initiated. 415.11(c)(1) Based on record review and staff interviews during the Recertification Survey completed on 5/24/2021 the facility did not ensure that each resident had a Comprehensive Care Plan (CCP) developed to meet each resident's individualized care needs. This was identified for one (Resident #12) of two residents reviewed for Behavior and for one (Resident #279) of one resident reviewed for Urinary Tract Infections (UTI). Specifically, 1) Resident #12, who had a history of accusatory behavior, did not have a CCP developed addressing the need for a two person approach during care 2) Resident # 279 did not have a CCP developed for the use of an Antibiotic to treat a UTI. The findings are: 1) Resident #12 has diagnoses which include Cerebral Infarction and Hypothyroidism. The resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was understood and was able to understand. The resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of the resident's medical record on 5/18/2021 at 10:00 AM revealed a Protected Health Information (PH I) Restriction Alert. The Alert documented a two- person approach was needed for accusatory behavior. This Alert was entered into the medical record on 11/14/2020. Review of the Nursing Behavior Progress Note dated 11/14/2020 revealed that the writer (Registered Nurse #4) received a call from a [NAME] County 911 Operator indicating the resident had called 911 to complain that they did not have their call bell. Registered Nurse (RN) #4 promptly contacted a Nurse (unidentified) on the resident's unit who immediately checked the resident's room. The unidentified Nurse reported to the Nursing Supervisor (RN #4) that the resident had their call bell and that they had recently left the resident's room and at no time was the resident's call bell used for assistance. The resident was re-educated on how to use the call bell with a return demonstration received. The resident was placed on a two-person approach due to accusatory behavior. Review of the resident's entire CCP on 5/24/2021 at 10:30 AM revealed no documented evidence that the resident should be a two-person approach due to accusatory behavior. Review of the Certified Nursing Assistant (CNA) Care Profile (instructions provided to the CNA for specific resident care needs) revealed that a Note was added on 1/30/2021 by RN #4 which indicated that the resident was a two-person approach. Certified Nursing Assistant (CNA) #2 was interviewed on 5/18/2021 at 11:55 AM and stated that CNA #2 cared for the resident a few times in the past two weeks on the 7:00 AM - 3:00 PM shift when the resident's regular CNA was scheduled off. CNA #2 stated that they (CNA#2) have cared for the resident alone and was not aware that the resident should be a two-person approach. CNA #3 was interviewed on 5/19/2021 at 10:40 AM and stated that CNA #3 has regularly cared for the resident on the 7:00 AM - 3:00 PM shift for approximately two months. CNA #3 stated that they (CNA #3) have cared for the resident alone, without a second CNA, and was not aware that the resident should be a two-person approach. RN #4 was interviewed on 5/24/2021 at 4:00 PM and stated they (RN #4) created the PHI Restriction Alert on 11/14/2020 indicating the resident should be a two-person approach due to accusatory behavior because the resident called 911 to claim that they did not have their call bell despite having the call bell next to them. RN #4 stated that they (RN #4) told the unidentified Nurse to inform the staff that the resident was now a two-person approach. RN #4 stated that she did not know why the nurse did not add the instructions to the CNA Care Profile or the CCP immediately. The Director of Nursing Services (DNS) was interviewed on 5/24/2021 at 4:30 PM and stated that need for a two-person approach for the resident due to accusatory behavior should have been written in a CCP for the continuity of care for the resident. The DNS further stated that person-centered care is not always the same for everyone and if a resident is accusatory, the accusatory behavior should be documented on a care plan for the protection of both the resident and the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during a Recertification Survey completed on 5/24/2021 the facility did not ensure that for one (Resident #360) of four residents reviewed for medication administration, the Licensed Practical Nurse (LPN) #3 followed the Physician's order as written. Specifically, the LPN crushed the medication Clozaril (Antipsychotic) 100 milligrams (mg) two tablets and placed the crushed medication in Resident #360's food without a Physician's order to crush the medication. The finding is: Resident #360 was admitted to the facility with a diagnoses that include Schizophrenia and Anxiety Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS also documented that the resident had delusions. The resident received Antipsychotic and Antianxiety medication 7 of 7 days during the look-back period. The Physician's order dated 5/3/2021 included to administer Clozaril 100 mg tablet, two tablets by oral route two times per day with meals. The Physician's order did not include crushing the medication. During a medication administration pass observation on 5/18/2021 at 8:03 AM LPN #3, medication nurse, was observed crushing Clozaril and then placing the crushed medication in the resident's oatmeal. LPN #3 was interviewed immediately after the medication administration and stated that the resident's family wants the medication hidden in cereal, or the resident will not take the medication, which would cause an exacerbation of Schizophrenia. LPN #3 was re-interviewed on 5/21/2021 at 2:44 PM and stated that the LPN was aware that there needs to be an order to crush medications. The LPN further stated that they (LPN) thought the resident had an order to crush the medication. The Psychiatric Nurse Practioner (NP) was interviewed on 5/21/2021 at 3:21 PM and stated that there should have been a Physician's order to crush the Clozaril for the resident. The Assistant Director of Nursing Services (ADNS) was interviewed on 5/21/2021 at 3:40 PM and stated there should be an order to crush medication. 415.11(c)(3)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey completed on 5/24/2021 the facility did not ensure the resident environment remains free of accident hazards. This was identified for 2 of 3 residents reviewed for accidents. Specifically, 1) Resident # 249, who was identified as an elopement risk and wore a wander guard, entered an elevator and was able to reach the facility lobby on 1/23/2021. The elevator door did not function as intended with the use of the wander guard. The Registered Nurse Supervisor (RNS) did not report the elevator door malfunction. Subsequently, on 3/1/2021 Resident #249 entered the elevator and was able to reach the facility lobby again. 2) Resident #36 was using a wheelchair with a broken removable right arm rest which was identified on 5/21/2020 and was not addressed by the facility staff until 5/24/2021. The findings are: 1) The facility policy entitled Wandering Residents Security system dated 12/2004 documented that an elevator alarm system designated to prevent residents considered to be elopement risks from leaving the unit on the elevator will be utilized in designated buildings. When a resident has been found wandering beyond the limits deemed safe by the comprehensive care plan team, an Occurrence Report will be initiated. The facility will arrange for necessary repairs of the wander guard system. Resident #249 was admitted to the facility with the diagnoses of Traumatic Brain Injury, Anoxic Brain Injury and Alzheimer's Disease. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #249 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS documented that Resident #249 used a wander/elopement alarm daily. Resident #249 was also documented to have wandering behavior 4 to 6 days, but less than daily in the 7 day look back period. The MDS further documented that the wandering placed the resident at significant risk of getting to a potentially dangerous place and the wandering significantly intrude on the privacy or activities of others. The Elopement Care Plan dated 7/5/2017 documented that Resident #249 had a history of wandering on the unit with frequent attempts to leave the unit via exit doors or the elevator. Resident #249 remained at risk for elopement and the wander guard remained in place since 7/5/2017. The care plan monitoring note dated 1/23/2021 documented that Resident #249 wandered into the elevator and the staff followed the resident off the unit and to the lobby. A Certified Nursing Assistant (CNA) assisted Resident #249 back to the unit. The wander guard was verified twice and sounded. The physician was made aware, 1:1 supervision was implemented for the night and the team was updated. The facility did not have documented evidence of an A/I report related to 1/23/2021 elopement attempt made by Resident #249. The facility Accident and Incident (A/I) report dated 3/4/2021 documented that on 3/1/21 at 8:15 PM, Resident # 249 got on the elevator and went to the lobby area. The staff quickly went to the lobby and escorted Resident #249 back to the unit. Resident # 249 did have a wander guard on the ankle which was checked for function by staff. The wander guard did function. The wander guard was placed on the resident's wrist to increase detection sensitivity. Plant operations was informed to check the elevator system as a precaution. The root cause analysis indicated that there was a malfunctioned elevator sensor. The facility maintenance work order dated 3/1/2021 documented that the Brookville 2 Elevator needed to be checked and was not compatible with the wander guard. On 5/18/21 at 2:55 PM, Resident # 249 was observed pacing down the hallway in unit 2 of the Brookville Building. Resident #249 wore the wander guard on the left wrist. The Maintenance Supervisor was interviewed on 5/21/2021 at 2:37 PM. The Maintenance Supervisor stated that the wander guard system in the elevator is supposed to sound an alarm if a resident wander onto the elevator. The elevator should lock until a staff member escorts the resident off the elevator. If the resident must leave for an appointment, the staff members must punch in a code to release the lock. The Maintenance Director was interviewed on 5/21/21 at 2:50 PM. The Maintenance Director stated that the wander guard can have some interference if the resident places it under a sock or in a shoe. In that case, the alarm may sound but the signal may not be strong enough to lock the elevator. The Maintenance Director stated that the Maintenance Director was not made aware of the 1/23/2021 incident and was only made aware of the 3/1/2021 incident when the wander guard system allowed the resident to go off the unit. The Maintenance Director stated the maintenance worker on duty on the 3/1/21 evening shift checked the functionality and the elevator seemed to be functioning correctly. The Maintenance Director stated he would review the work orders to see if there was one placed on 1/23/21. The Maintenance Director was re-interviewed on 5/21/21 at 3:36 PM and stated that there was no work order for 1/23/2021 and that the Maintenance Director was not made aware of a wander guard malfunction on 1/23/2021. The RN Supervisor was interviewed on 5/21/21 at 4:06 PM. The RN Supervisor stated that Resident # 249 got onto the elevator and the elevator proceeded to go down to the lobby on 1/23/21. Resident #249 stood in the back of the elevator and that the elevator had a glitch, where the sensor was weak if you stand towards the back of the elevator. The elevator will go down or up if you stand where the signal is weak. The RN Supervisor did not initiate, and A/I report, did not inform the Maintenance Department of the glitch, and did not replace the wander guard because it worked when they rechecked for functionality on 1/23/21. The Director of Nursing Services (DNS) was interviewed on 5/24/21 at 3:57 PM and stated that the DNS was not aware of the wander guard malfunction. The DNS stated that the RN Supervisor should have notified the DNS and the maintenance department of the malfunction on 1/23/2021. The DNS stated that the wander guard system should have been checked the first time due to the possibility it could be defective. The DNS was not sure of the facility wander guard policy and procedure because she is new to the facility. 2) Resident #36 was admitted to the facility with diagnosis including Monoplegia of upper limb affecting the right dominant side and a history of falls. The 2/21/2021 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident was cognitively intact. The resident required extensive assistance of two persons for bed mobility and transfers. The resident was interviewed on 5/24/2021 at 1:00 PM and stated that the wheelchair armrest was broken. The resident stated that the arm rest broke on Friday 5/21/2021. The Occupational Therapy (OT) department was made aware of the issue by the resident during an OT session on 5/21/21. The Occupational Therapist Registered (OTR) informed the resident that the maintenance department would be notified of the issue. Observation on 5/24/2021 at 1:00 PM revealed the right arm rest was missing a mechanism to secure and hold the arm rest in place. The Registered Nurse (RN) Unit Coordinator was interviewed on 5/24/2021 at 1:05 PM and stated the RN was unaware of any issue with the resident's wheelchair. Upon examination of the wheelchair, the nurse was unable to identify any issues with the wheelchair. OTR #1, was interviewed on 5/24/21 at 1:10 PM and stated they provided OT to the resident on 5/21/21. OTR #1 stated an email was sent to the maintenance department regarding the broken wheelchair on 5/21/2021. OTR #1 did not notify the nurse. The Director of Maintenance was interviewed on 5/24/2 at 1:25 PM and stated that they (Director of Maintenance) was not aware of the issue. The Director of Maintenance reapproached the surveyor on 5/24/2021 at 3:20 PM and stated that an email regarding the resident's wheelchair was sent to the Maintenance Department on Friday, 5/21/21. The email documented Right lateral arm rest is broken. Kindly fix if possible. The Director of Maintenance stated that emails are reviewed Monday through Friday and the Director of Maintenance was unaware of this email until today (Monday, 5/24/21). A weekend supervisor is generally available however was not available this past weekend. The 7:00 AM-3:00 PM shift Certified Nursing Assistant (CNA) was interviewed on 5/24/2021 at 2:15 PM and stated that they were not aware of any issues with the resident's wheelchair, however the resident mentioned a pending repair to the wheelchair. The Maintenance Supervisor was interviewed on 5/24/2021 at 3:00 PM and stated that they (Maintenance Supervisor) examined the wheelchair today with a mechanic. They identified that the armrest could not be repaired and would have to be replaced. 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the Recertification Survey completed on 5/24/2021, the facility did not ensure that each resident is free from unnecessary medications. This was identified for one (Resident #60) of five residents reviewed for unnecessary medications. Specifically, Resident #60 was prescribed Haldol (an antipsychotic medication), which was increased from 10 milligrams (mg) twice daily to 20 mg twice daily without documented evidence of the justification for the increase of the Haldol. The finding is: Resident #60 has diagnoses that include Dementia superimposed on Schizoaffective Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The resident had no verbal or physical behavior problems identified on the MDS. On 05/17/2021 at 3:50 PM the resident was observed sleeping in bed. The physician's order dated 2/14/2021 documented to discontinue Haldol (Haloperidol lactate 2 mg/mL dose)10 mg twice daily and to start Haldol (Haloperidol lactate 2 mg/mL dose) 20 mg twice daily by oral route. The current physician orders (5/6/2021) documented to administer Haldol 20 mg twice daily. The Comprehensive Care Plan (CCP) for Psychotropic Drug Use dated 3/21/2021 documented Resident #60 was on Haldol Deaconates Intramuscular (IM) monthly, Haldol by mouth (po), and Depakote intended for behavioral problem of Paranoid Schizophrenia. The documented Goals included that the resident will demonstrate decreased need for psychoactive medication by 06/21/2021. Interventions included to Assess behavior pattern daily; Assess effectiveness of medication; Assess need for psychotherapeutic medication; Establish appropriate diagnosis for medication use and obtain a psychiatry consult. A CCP for Behavioral Symptoms dated 9/29/2017 documented Resident #60 exhibited physical behavioral symptoms directed toward others: Hitting, Pushing, Scratching, Grabbing and sits on the floor and then and gets up unassisted; Agitation with behavioral disturbances and throwing self on the floor; and Unpredictable Behaviors. The CCP evaluation dated 3/1/2021 documented the resident was followed by Psychiatry and was last seen by the Psychiatrist in February 2021. The resident displayed less agitation/disruptive behaviors since the last review. The resident has not required any STAT (immediate) dose of medication. The resident however continues to have intermittent episodes of agitation with limited response to verbal/behavioral interventions at times. The resident had episodes of talking/yelling to self but has not been combative. The resident remains on psychotropic medications. A Psychiatric evaluation dated 3/8/2021 documented the reason for the visit was to monitor the resident's Medication and Side Effects and to monitor the resident's Behavior and Mood/Anxiety Symptoms. The Psychiatrist documented that the resident has been stable since last seen 3 months prior. There have been no mood swings, acute Depression or Psychosis. The resident was confused but was generally cooperative with care. No recent report of impulsive or disruptive behaviors. The Psychiatrist documented the resident was on Haldol 20 mg 2 times per day, Haldol Deaconates 250 mg IM every month and Depakote 1500 mg 2 times per day. The Psychiatrist's recommendations were to continue the current medication regimen for Schizoaffective Disorder. A dose increase (risk/benefit) rationale was not documented by the Psychiatrist. A review of the progress notes from January 2021 through March 2021 revealed no behaviors were documented to warrant an increase in the Psychiatric Medication Haldol from 10 mg to 20 mg by oral route 2 times per day. The Psychiatrist was interviewed on 5/24/2021 at 7:19 PM and stated there was no rationale for the increase in the Haldol. The Psychiatrist further stated if they (the Psychiatrist) compared the resident's medication to the previous review, he would have noticed there was an increase in the dose and would have questioned why the dose was increased. The Psychiatrist further stated if there was an increase in the Psychiatric medications, there should be a rationale for the increase and that no behaviors were reported to the Psychiatrist by the facility staff. The Nurse Practitioner (NP) was interviewed on 5/24/2021 at 7:31 PM and stated there should have been a rationale documented why Haldol medication was increased. Certified Nurse Assistant (CNA) #5 that cares for the resident was interviewed on 5/24/21 at 7:40 PM and stated CNA #5 has been caring for the resident for more than one year and that the resident has been good and no behaviors were reported or observed. 415.12(l)(2)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey completed on 5/24/2021, the facility did not ensure that outside professional services were furnished in a timely manner for one (Resident #472) of 5 residents reviewed for unnecessary medications. Specifically, Resident #472 had a Physician's order for a Psychiatry consult dated 4/25/2021 and the Psychiatry consult was not completed as of 5/24/2021. The findings is: Resident #472 was admitted on [DATE] and readmitted on [DATE] with diagnosis including Dementia with Behavioral Disturbances. A Progress Notes dated 4/25/2021 at 2:38 PM , written by the Nurse Practitioner (NP) documented the NP was asked to see resident for behavior, and that the resident placed themselves on the ground and was laying on ground refusing to get up. A Nursing Note (NN) dated 04/25/2021 at 5:19 PM documented the resident attempted to kick/punch staff and was removing the suprapubic (hollow flexible tube inserted directly to the bladder to drain the urine) bag. A Physician's order dated 4/25/2021 ordered a Psychiatric consult. On admission, there were no Psychotropic medications prescribed for the residents. A NN dated 4/26/2021 at 07:54 PM documented the resident was aggressive. The resident refused to let the nurse take vital signs. The resident pulled out the suprapubic bag and at 6:40 PM Police Officers took the resident to the hospital. The NN dated 4/26/2021 documented the resident was transferred to the hospital for an Acute Kidney Injury. The resident returned to the facility on 5/8/2021. The Physician re-admission order dated 5/8/2021 Risperidone (Psychotropic) 1 Milligram (mg) tablet, give 1 tablet (1 mg) by oral route 3 times per day for Unspecified Dementia without behavioral disturbance. The NN dated 5/10/2021 documented the resident developed an episode of severe agitation and broke the window and was a danger to self and others. The resident was transferred to the Emergency Department for management of severe agitation and Psychosis. The resident returned to the facility on 5/14/2021. A NN dated 5/15/21 at 9:09 PM documented the resident was barricading themselves in the bedroom, moved the bed, armoire and dresser out of their place, then tried to break the bedroom window using a garbage can. The resident was redirected unsuccessfully, the NP on call made was made aware, the supervisor was notified, and the Nurse stayed by the resident's room monitoring the resident for safety. The resident was seen by NP on call, Haldol 2 mg Intramuscular (IM) was ordered (one-time dose) and administered. The Physician orders dated 5/15/2021 included Risperidone 1 mg tablet, by oral route 3 times per day for Unspecified dementia without behavioral disturbance and a Psychiatrist Consult. The Comprehensive Care Plan (CCP) for Behavioral Symptoms dated 5/15/2021, documented the resident exhibited physical behavioral symptoms directed toward others including hitting and kicking. The resident also exhibited verbal behavioral symptoms directed toward others including threatening, cursing, and screaming. The resident exhibited barricading behaviors in the bedroom with furniture. The Behavioral Symptoms were noted to put the resident at significant risk for physical illness or injury, significantly intrude on the privacy of activity of others, and significantly disrupts care or the living environment. Interventions included to order a Psychiatry consult. The Physician order dated 5/16/2021 documented the addition of Mirtazapine (Antidepressant) 15 mg, give 1 tablet by oral route once daily at bedtime for agitation. A NN dated 5/19/2021 at 6:29 AM documented the resident pulled out the suprapubic tube. The Physician order dated 5/20/2021 documented the addition of Depakote (Antiseizure medication also used for Bipolar disorder) 250 mg tablet, delayed release, give 1 tablet (250 mg) by oral route every 12 hours for restlessness and agitation. The Assistant Director of Nursing Services (ADNS) was interviewed on 5/20/2021 at 2:55 PM and stated that the psychiatry consult should have been completed. The ADNS further stated that due to the resident being transferred to hospital many times since admission, the psychiatry consult was not completed. The Nurse Practitioner (NP) # 1 was interviewed on 5/20/21 at 3 PM and stated she would expect the resident to have been seen by the Psychiatrist. The resident was sent to the hospital multiple times because of behaviors. The Psychiatrist visits the facility once a week and the resident should have been a priority to be seen by the Psychiatrist. 415.26(e)(i-iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey completed on 5/24/2021 the facility did not ensure that each resident was offered Influenza and Pneumococcal vaccination and that each resident's medical record documented whether or not the resident received the immunization. This was identified for 1 (Resident # 13) of 5 residents reviewed for Influenza and Pneumococcal immunizations. Specifically, Resident #13's medical record lacked documented evidence of whether the resident received or declined the Influenza and Pneumococcal vaccines. The finding is: The facility's undated policy titled Conducting the Vaccination Program documented within 5 days of Admission/readmission the admitting nurse will complete the admission vaccine assessment, noting the resident's Influenza/Pneumococcal vaccine status. Resident #13 was admitted to the facility with diagnoses including Diabetes Mellitus, Non-Alzheimer's Dementia, and Chronic Kidney Disease. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident had severe cognitive impairment. The MDS documented that the resident did not receive the Influenza vaccine in the facility and there was no reason documented; and the MDS documented that the resident's Pneumococcal vaccine was not up to date and the vaccine was not offered. The resident's Immunization Form, created on 3/18/2021, documented that the resident did not previously receive the Pneumococcal vaccine and that the Pneumococcal vaccine was up to date (inconsistent with the MDS documentation as noted above). There was no information documented regarding the Influenza vaccine. The Assistant Director of Nursing Service (ADNS)/Infection Preventionist (IP) was interviewed on 05/19/2021 at 12:40 PM. The ADNS/IP stated that hospital records were checked on 5/19/2021 and there were no records that the resident received either vaccines. The ADNS/IP further stated that there were no consent or declination forms located in the resident's medical record. The ADNS/IP was re-interviewed on 05/20/21 at 10:34 AM. The ADNS/IP stated a declination was just received on 5/19/2021 from the resident's family member for the Influenza vaccine. The ADNS/IP stated that Resident #13 received the Influenza vaccine in the community in the fall of 2020. The ADNS/IP was re-interviewed on 5/21/2021 at 8:11 AM. The ADNS/IP stated Resident #13 received the Pneumococcal vaccine in the community as per a discussion the ADNS/IP had with the resident's family member on 5/20/2021. The ADNS/IP stated that the process of documentation for the influenza and pneumococcal vaccines has been historically very disorganized. The Director of Nursing Services (DNS) was interviewed on 5/21/2021 at 2:00 PM. The DNS stated that the process of influenza and pneumococcal vaccine documentation must be reworked and reorganized. 415.19(a)(1)