Every finding on record at Laconia Nursing Home

Based on observation, record review, and interview, the facility did not ensure that residents had the right to send and promptly receive mail. This was evident for 11 residents (Residents #47, #13, #80, #99, #102, #136, #172, #212, #108, #113, and #122) reviewed during the Resident Council Meeting Task. Specifically, the facility did not have a procedure in place for residents to send and receive mail on Saturdays.The findings include:The facility's policy titled, Residents' Mail Distribution, dated 01/2026, documented that the Recreation Department staff will sort out mail and deliver it unopened within 24 hours. On weekends or if Recreation Staff are not available, residents can go to the Business Office to check if there is any mail for them. On 06/24/2026 at 10:30 AM, during the Resident Council Meeting, Residents #47, #13, #80, #99, #102, #136, #172, #212, #108, #113 and #122 stated that the facility does not deliver mail to residents on Saturday. They stated this was because the Business Office is closed on weekends.On 06/29/2026 at 10:35 AM, the Security Officer was interviewed and stated that mail is given to the security office, and they will notify staff in the Business Office to come and retrieve the mail. On 06/29/2026 at 10:45 AM, the Human Resource Director was interviewed and stated that mail is first given to the security staff. The security staff will notify the business office about incoming mail and will also inquire about any outgoing mail at the same time. The business office sorts the incoming mail, separating facility mail from resident mail. The business office will notify the activities department that mail is available for them to pick up and distribute to residents. The Human Resources Director stated that resident packages are handled and delivered by the social services department. Additionally, the Human Resources Director stated that although the business office is closed on the weekends, the Marketing Liaison comes in on Saturdays to perform activities associated with the admissions process. The Human Resources Director further stated that if mail is delivered on Saturday, the residents may get their mail on Saturday or will receive their mail on the following business day.On 06/29/2026 at 11:03 AM, the Social Worker was interviewed and stated that they work from 8:30 AM to 5:00 PM from Monday through Friday. They are responsible for the delivery of residents' packages during the business days. The Social worker further stated that if a package is delivered past 5:00 PM during the week, then the residents will receive their package the following business day. Many times, some of the residents track their packages and will inform the Social Services office about their expected package. On 06/29/2026 at 11:14 AM, the Marketing Liaison was interviewed and stated that they work on Saturdays in the Social Services office from 9:00 AM to 5:00 PM. They stated their responsibilities included being the hospital liaison, making admission referrals, and other tasks. The Marketing Liaison further stated that they have a key to the business office and can leave any incoming mail in the business office. They also included that when they go to the units to speak to residents, they will check if a resident has mail and deliver it, if the resident requests it. The Marketing Liaison stated they do not sort out any mail, but that they will take mail, if any, from the security office to the business office and leave it on the desk of the Human Resource Director. They further stated that some residents will inquire about expected mail on Saturdays, but all others will receive their mail on the following Monday.On 06/29/2026 at 11:53 AM, the Director of Recreation was interviewed and stated that they work from Monday to Friday. They stated that recreation staff do not deliver mail on Saturday because the business office is closed. They further stated that the activities department does not sort out mail. During the week incoming resident mail is retrieved from the business office for delivery to residents. If any mail is delivered on Saturday, the resident will receive it the following business day. On 06/29/2026 at 12:01 PM, the Administrator was interviewed and stated that mail is delivered and sorted by business office, who then notifies the activities department to pick up and deliver resident mail. Residents can come down and ask if their mail has been received by the facility. The activities staff will go to the units and provide residents with their mail if any has been received. The Administrator stated that the residents seemed happy with the current arrangement of having mail delivered on all business days and having access to mail on the weekend by asking the Marketing Liaison if their mail was received.10 New York Codes, Rules and Regulations 415.3 (e) (2) (i)

Based on interview and record review, the facility failed to ensure that irregularities reported in drug regimen reviews were acted upon. This was evident for one (Resident #19) of five residents reviewed for Unnecessary Medications out of a total of 39 sampled residents. Specifically, the physician failed to document the clinical rationale for which a gradual dose reduction was not initiated. The findings include: The facility's policy, Gradual Dose Reduction of Psychotropic Medications, last revised 01/2026, documented that a gradual dose reduction shall be based on the resident's diagnosis, target symptoms, response to treatment, behavioral monitoring, past medical history and overall clinical condition. Resident #19 was admitted to the facility with diagnoses including schizophrenia, vascular dementia with behavioral disturbance, major depressive disorder, and diabetes mellitus. The medication order, initiated on 07/26/2022, documented Risperidone (an antipsychotic medication) 2 milligram tablet with instructions to take one tablet by mouth once a day for Schizophrenia. The drug regimen review dated 01/31/2026 documented that Resident #19 was receiving risperidone which could increase the risk of falls. The recommendation also documented that the clinical record was indicative of recent falls. The Consultant Pharmacist's recommendation included to evaluate and consider tapering the dose or implementing alternative treatment, if appropriate. The provider's acknowledgement and response to the drug regimen review was completed by Primary Physician #1 on 02/05/2026. Primary Physician #1 selected Disagree but provided psych as the rationale. A Psychiatry Consult, dated 02/09/2026 at 12:47 PM, documented that the Psychiatric Nurse Practitioner also reviewed the drug regimen review and they documented that they agreed with the recommended gradual dose reduction. The Psychiatric Nurse Practitioner also documented that the risperidone dosage may be reduced from 2 milligrams daily to 1 milligram daily. A Physician's Monthly Progress Note, dated 02/23/2026 at 7:21 PM and completed by Primary Physician #1, documented that the Resident #19 was currently stable with no changes in the past 30 days. The Primary Physician #1also noted during that encounter that Resident #19 had no new complaints and there were no significant weight fluctuations. Primary Physician #1 concluded that there was no need to change Resident #19's current plan of care. The drug regimen review, dated 02/28/2026, documented that the most recent psychiatric consultation recommended a gradual dose reduction of risperidone and for a follow-up. The Consultant Pharmacist noted that the gradual dose reduction was not located in the resident's chart and recommended that the physician consider ordering the new dosage as well as the follow-up with the psychiatrist. The provider's acknowledgement and response to the drug regimen review was completed by the Primary Physician #1 on 03/03/2026. Primary Physician #1 selected Disagree but provided follow-up with psychiatrist as the rationale. On 06/29/2026 at 10:45 AM, Primary Physician #1 was interviewed and stated that because the pharmacist does not know Resident #19, they would not understand the complexity of the resident's condition. Primary Physician #1 also stated that the pharmacist recommended a reduction in risperidone because they were concerned about a fall. Primary Physician #1 asserted that despite the fall, the resident still required the medication. They further stated that they had reviewed the risks and benefits of a reduction in risperidone and that given Resident #19's persistent and chronic condition, they did not reduce the medication. Primary Physician #1 stated the Medical Director instructs the doctors to review the drug regimen reviews monthly. Primary Physician #1 could not recall if they wrote a note in Resident #19's record addressing the pharmacy recommendation. On 06/29/2026 at 1:12 PM, the Medical Director was interviewed and stated that they are made aware of all pharmacy recommendations and has asked the doctors to review the drug regimen reviews monthly. The Medical Director stated that the physicians are to document all medication changes and document if the gradual dose reduction is or is not appropriate for the residents. The Medical Director stated they do not know why Primary Physician #1 did not document an appropriate rationale for their disagreement with the recommendation provided in the drug regimen review. 10 New York Code Rules and Regulations 415.18(c)(2)

Based on observation, interview, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure nurse staffing data was posted. This was evident for the Main Lobby and 2nd, 3rd, 4th, 5th, 6th, and 7th Floors. Specifically, the nursing staffing data was posted above a staff time clock in an area not accessible to residents and visitors. The findings are: On 01/18/2024 at 2:10 PM and 01/19/2024 at 3:11 PM, nurse staffing data was not observed posted in the Main Lobby or 2nd, 3rd, 4th, 5th, 6th, and 7th Floors. The nurse staffing data was observed posted above the staff time clock, down a hallway that was not accessible to residents or visitors. On 1/19/2024 at 3:11 PM, Security Guard #1 was interviewed and stated that they were unaware of where nurse staffing data was usually posted. On 01/23/2024 at 11:30 AM, the Administrator was interviewed and stated they assumed if staffing was accessible to residents, it did not matter where it was posted. The Administrator stated visitors were not directed to the time clock but might notice the staffing because the time clock is near the elevator. 10 NYCRR 415.13(1)

Based on observation, interview, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure the results of the most recent survey of the facility were posted in a place readily accessible to residents and family members. This was evident during observation of the Main Floor and 2nd, 3rd, 4th, 5th, 6th, and 7th Floor resident units. Specifically, the facility's most recent survey results were not posted anywhere in the facility. The findings are: The facility policy titled Making Available Copy of Previous Recertification Survey dated 01/2024 documented states that a copy of the most recent recertification survey will be made available for residents, staff, and visitors at the front desk. On 01/18/2024 at 10:57 AM, Resident Council Meeting was held with Resident #82, #179, #217, #96, #184, #112, #34, #1, #227, and #55. All residents in attendance stated they did not know where the most recent state survey results were posted in the facility. On 01/18/2024 at 2:10 PM, the 2nd Floor was observed with an index card posted near the elevator documenting the most recent survey results were available at the security desk. There were no postings on the Main Floor, or 3rd, 4th, 5th, 6th, and 7th floors regarding the location of the survey results. On 01/19/2024 at 3:11 PM, the facility's most recent survey results were not observed at the security desk. Security Guard #1 was interviewed and stated they did not know where the stat survey results were kept. Security Guard #1 stated nobody asked to see the survey results since the last year, so they were taken away and no longer kept in the binder behind the security desk. On 01/23/2024 at 11:47 AM, Nursing Supervisor #1 was interviewed and stated the facility's most recent survey results were kept in the back of the recreation room. Nursing Supervisor #1 was aware there was an index card on the 2nd Floor documenting the results were kept at the security desk, but they were not kept in that location. On 01/23/2024 at 10:29 AM, the Director of Nursing was interviewed and stated the facility's moist recent survey results were kept at the security desk. 10 NYCRR 415.3(d(1)(v)

Based on observation, interview, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure e facility did not ensure a list of names, addresses, and telephone numbers of the State Survey Agency and the Long-term Care Ombudsman was posted. This was evident during observation of the Main Floor and 3rd, 4th, 5th, 6th, and 7th Floor resident units. Specifically, there was no evidence the New York State Department of Health and Ombudsman's Office information was posted in an accessible manner for residents throughout the facility. The findings are: The facility policy titled Posting Contact Information for Department of Health and Ombudsman dated 01/2024 documented the facility will post in a public area the contact information for the local Department of Health and Ombudsman. On 01/18/2024 at 10:57 AM, Resident Council Meeting was held with Resident #82, #179, #217, #96, #184, #112, #34, #1, #227, and #55. All residents in attendance reported they did not know where the New York State Department of Health and Ombudsman information was posted. On 01/18/2024 at 2:10 PM, the Main Floor was observed with a poster containing the New York State Department of Health and Ombudsman information. The poster was above the employee timeclock and in an area not accessible to residents. The 3rd, 4th, 5th, 6th, and 7th Floor resident units were observed without the New York State Department of Health and Ombudsman information posted. On 01/23/2024 at 10:29 AM, the Director of Nursing was interviewed and stated the Ombudsman's information was previously posted on all resident units near the elevators but was moved during recent construction. On 01/23/2024 at 11:30 AM, the Administrator was interviewed and stated bulletin boards on the resident units were removed when construction work was done in the facility and the posters with the New York State Department of Health and Ombudsman information were thrown away. The Ombudsman's office was contacted in 12/2023 and a request for new posters was made. One poster was accessible to all residents on the Main Floor. 10 NYCRR 415.3(d(1)(vi)

Based on observation, record review, and interviews conducted during the Recertification survey from 01/16/2024 to 01/23/2024, the facility did not ensure residents remained free from physical restraints. This was evident for 4 (Resident #97, #64, #195, and #99) of 5 residents reviewed for physical restraints out of 35 total sampled residents. Specifically, 1) Resident #97 had a lap tray in place without assessment and medical justification, 2) Resident #64 had bilateral upper half siderails raised while in bed without assessment, 3) Resident #195 had bilateral upper half siderails raised while in bed without assessment, and 4) Resident #99 had bilateral upper half siderails raised while in bed without assessment. The findings include but are not limited to: The facility policy titled Physical Restraints dated 11/2023 documented the facility will conduct a comprehensive assessment of residents who are considered to present potential risk within a restraint free environment, discuss with family members the need of restraint, and implement a plan of care consistent with the use of restraints. 1) Resident #97 had diagnoses of dementia and schizophrenia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #97 was severely cognitively impaired, required extensive assistance of 1 person for transfers, and used a trunk restraint. On 01/16/2024 at 10:18 AM, Resident #97 was observed alone in their room in a recliner with a lap tray in place. Resident #97 was unable to follow simple instructions, was not able to be interviewed, and was unable to release the lap tray. No recreational activities were observed. The Physician's Order dated 08/15/2023 documented Resident #97 was ordered a lap tray when out of bed to their recliner as needed for recreational activities. There was no documented evidence an assessment for lap tray use was done for Resident #97, of ongoing monitoring of lap tray use, and a comprehensive care plan for lap tray use was developed. On 01/18/2024 at 11:18 AM, Certified Nursing Assistant #2 was interviewed and stated they assisted Resident #97 with getting dressed and out of bed but did not apply of release the lap tray while the resident is in the recliner. On 01/18/2024 at 11:31 AM, Licensed Practical Nurse #1 was interviewed and stated Resident #97 used the lap tray during recreational activities in the dayroom, had unsteady gait, and was at risk for falls. Licensed Practical Nurse #1 stated they did not apply the lap tray to Resident #97. Recreation staff applied and removed the lap tray. On 01/18/2024 at 11:40 AM, Licensed Practical Nurse #2 was interviewed and stated Resident #97 was unable to release themselves from the lap tray. There was no documentation regarding application, release, and monitoring of lap tray use with Resident #97. On 01/18/2024 at 11:55 AM, Registered Nurse #1 was interviewed and stated Resident #97 used a lap tray for recreation. Nursing and Recreation staff remove the lap tray after recreational activities were finished because Resident #97 was unable to remove the lap tray. Resident #97 attempts to get up and walk around, did like to sit still, and was at risk for falls. The lap tray was used with Resident #97 when they were in the dayroom. On 01/19/2024 at 12:36 PM, the Recreation Director was interviewed and stated Nursing staff applied and removed the lap tray for Resident #97. Recreation staff were not responsible for applying or removing the lap tray. Resident #97 was provided with the lap tray to keep them calm and prevent them from getting up. On 01/18/2024 at 1:30 PM and 01/23/2024 at 02:44 PM, the Director of Nursing was interviewed and stated the lap tray was not considered a restraint for Resident #97 and was inaccurately coded on the Minimum Data Set 3.0 assessment. There was no assessment or comprehensive care plan for Resident #97's lap tray use because it was not a restraint. The lap tray was used during recreational activities and was applied and removed by the Nursing staff. 44472 2) Resident #64 had diagnoses of seizure disorder and major depressive disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #64 had mild cognitive impairment, required substantial assistance from 1 person for transfers, and used siderails as a restraint. On 01/17/2024 at 12:02 PM, Resident #64 was observed in bed with bilateral upper half siderails raised. Certified Nursing Assistant #4 was present during the observation. Resident #64 was unable to grasp the siderails to assist with turning or positioning and was unable to independently lower the siderails. The Physician's Order dated 11/10/2023 documented Resident #64 had 2 half siderails raised while in bed for turning and positioning. There was no documented evidence Resident #64 was assessed for siderail use, monitored for siderail use, and had a comprehensive care plan developed to address siderail use. 3) Resident #195 had diagnoses of dementia and a history of falling. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #195 was severely cognitively impaired and required extensive assistance of 1 person for bed mobility. On 01/17/2024 at 11:41 AM, Resident #195 was observed in bed with bilateral upper half siderails raised. Certified Nursing Assistant #4 was present during the observation. Resident #195 was unable to follow simple instructions, unable to hold onto the siderails, and was unable to independently lower the siderails. The Physician's Order dated 12/27/2023 documented 2 half siderails were raised for turning and positioning while Resident #195 was in bed. There was no documented evidence Resident #195 was assessed for siderail use, monitored for siderail use, and had a comprehensive care plan developed to address siderail use. On 01/23/2024 at 10:44 AM, Certified Nursing Assistant #4 was interviewed and stated Residents #64 and #195 were confused, unable to follow direction, always had siderails raised while they were in bed, and were unable to independently lower their siderails. On 01/23/2024 at 11:05 AM, Licensed Practical Nurse #1 was interviewed and stated Residents #64, #195, and #99 had dementia, were unable to follow simple instructions, always had bilateral half siderails raised, and were unable to independently lower their siderails. On 01/23/2024 at 11:15 AM, Registered Nurse #1 was interviewed and stated Residents #64, #195, and #99 were not assessed for siderail use because they used the siderails as enablers during turning and positioning. On 01/22/2024 at 12:05 PM, the Director of Nursing was interviewed and stated restraints were devices that restrict resident movement. Some residents did not have safety awareness and used siderails for positioning. 10 NYCRR 415.4(a)(2-7)

Based on observation, interviews, and record review conducted during the recertification and abbreviated (NY00310176) survey from 1/16/2024 to 1/23/2024, the facility did not ensure an alleged violation of abuse was reported immediately, but not later than 2 hours, to the New York State Department of Health. This was evident for 2 (Resident #106 and #167) of 4 residents reviewed for abuse out of 35 total sampled residents. Specifically, Residents #106 and #167 were involved in a physical altercation that was not reported to the New York State Department of Health within 2 hours of occurrence. The findings are: The facility policy titled Resident Abuse, Neglect, and Exploitation dated 10/2023 documented all employees and contractors must report any allegation of abuse to the Administrator and Director of Nursing immediately, but not later than two hours after being informed of the allegation. Resident #106 had diagnoses of schizoaffective disorder and mood disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #106 had intact cognition. Resident #167 had diagnoses of major depressive disorder and dementia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #167 had mild cognitive impairment. Nursing Note dated 02/02/2023 at 5:37 PM documented Residents #106 and #167 had an altercation. Resident #106 had a bump on their forehead and scratches to their chin and cheek. Resident #167 was transferred to the hospital for a psychiatric evaluation. The Aspen Complaint Tracking System intake dated 2/6/2023 at 12:39 PM documented the facility reported the resident-to-resident altercation between Residents #106 and #167, more than 2 hours after the occurrence. There was no documented evidence the facility reported the altercation between Resident #106 and #167 to the New York State Department of Health within 2 hours of occurrence. On 01/23/2024 at 02:44 PM, an interview was conducted with the Director of Nursing who stated the facility only reported resident-to-resident altercations to the New York State Department of Health when it resulted in a resident being seriously injured. Residents #106 and #167 had psychiatric histories and the facility did not look at their incidents as possible abuse. 10 NYCRR 415.4(b)(2)

Based on observation, interview, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure food was stored according to professional standards for food safety. This was evident for 1 (3rd Floor) of 6 resident units observed during review of the kitchen. Specifically, the 3rd Floor pantry refrigerator had an internal temperature of more than 41 degrees Fahrenheit and contained unlabeled, undated food. The findings are: The facility policy titled Food Refrigerator dated 7/2023 documented the refrigerator was set at 40 degrees Fahrenheit or below. The facility policy titled Residents Food Storage dated 7/2023 documented food containers were labeled with the resident's name, room number, and dated. Perishables must be stored in the pantry refrigerator for only 72 hours. On 1/18/2024 at 9:40 AM, the 3rd Floor pantry refrigerator was observed with an internal temperature of 48 degrees Fahrenheit. An unlabeled, undated food container was observed in the refrigerator. On 1/18/2024 at 9:42 AM, Registered Nurse #3 was interviewed and stated the thermometer for the refrigerator might not be working properly and they would request for the Maintenance Department to check the refrigerator. The charge nurse was responsible for checking the refrigerators for undated, unlabeled food items. Food left in the refrigerator was discarded after 3 days according to facility policy. Registered Nurse #3 was unable to provide a reason undated, unlabeled food was in the pantry refrigerator. On 1/22/2024 at 4:51 PM, the Director of Nursing was interviewed and stated food had to be labeled and dated before being placed in the pantry refrigerator. The nurse on the unit was responsible for checking the temperatures of the pantry refrigerators and reporting problems to the Maintenance Department. 10 NYCRR 415.14(h)

Based on record review and interviews conducted during the Recertification Survey from 01/16/2024 to 01/23/2024, the facility did not ensure that a copy of the notice of transfer or discharge was sent to the Office of the State Long-Term Care Ombudsman. This was evident for 1 (Resident #78) of 2 residents out of 35 total sampled residents. Specifically, the facility did not notify the Ombudsman's Office of Resident #78's discharge to the hospital on 10/11/2022. The findings are: The facility policy titled Facility-Initiated discharge date d 1/2024 documented upon issuing a notice of involuntary discharge to a resident, the facility will send a copy of the notice to the local Ombudsman's Office. Resident #78 had diagnoses of hypertension and diabetes mellitus. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #78 was discharged with an anticipated return to the facility. Nursing Note dated 10/11/2022 documented Resident #78 was transferred to the hospital. The Notice of Transfer/discharge date d 10/11/2022 documented Resident #78's next of kin was informed of their transfer to the hospital. There was no documented evidence Ombudsman's Office was provided with a copy of Resident #78's Notice of Transfer/discharge date d 10/11/2022. During an interview on 1/23/2024 at 11:33AM, the Ombudsman stated the Ombudsman's Office required notification from the facility when a resident was hospitalized to ensure the resident knew of their discharge appeal rights. During an interview on 01/22/2024 at 12:39 PM, the Director of Social Services stated they were unable to locate notices of transfer and discharge sent to the Ombudsman's Office prior to 11/2023. On 01/22/2024 at 5:01 PM, the Administrator was interviewed and stated notices of transfer and discharge were sent to the Ombudsman's Office when a resident was voluntarily discharged . The Administrator stated the Ombudsman's Office told them not to send notices of involuntary transfer and discharge for hospitalized residents. 10 NYCRR 415.3(h)(1)(iii)(a-c)

Based on observation, record review, and interviews conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure an account of all controlled drugs was maintained and periodically reconciled. This was evident for 1 (2nd Floor) of 6 resident units. Specifically, Licensed Practical Nurse #5 did not reconcile the count of Fentanyl narcotics patches for Resident #148. The findings are: The facility policy titled Controlled Drug Record dated 5/2/2023 documented immediately after a dose is administered, the licensed nurse enters the following information: date and time of administration, dose administered, and signature of the nurse administering the dose. The facility policy titled Medication Administration dated 10/2023 documented the nurse signs the Medication Administration Record immediately after administering medication to a resident. Resident #148 had diagnoses of quadriplegia and major depressive disorder. On 1/19/2024 at 3:22 PM, the 2nd Floor medication cart was observed with Licensed Practical Nurse #5 present. The narcotics box contained 2 boxes of Fentanyl Transdermal Patches 25 MCG/HR for Resident #148 with a total count of 9 patches remaining. The Controlled Drug Record dated 1/19/2024 at 8:00 AM documented 10 Fentanyl patches for Resident #148 were remaining. A Physician Order dated 9/30/2021 documented Resident #148 was prescribed 1 Fentanyl Transdermal Patch 25 MCG/HR every 72 hours for pain management. The Medication Administration Record dated 1/16/2024 documented a Fentanyl patch was applied to Resident #148 at 9:05 AM. There was no documented evidence a Fentanyl patch was removed from, and a new Fentanyl patch was applied to Resident #148 on 1/19/2024. On 1/19/2024 at 3:38 PM, Licensed Practical Nurse #5 was interviewed and stated they applied a Fentanyl patch to Resident #148 at 9:05 AM on 1/19/2024 and did not document the administration of the patch in the Medication Administration Record or the Controlled Drug Record because they were too busy. On 1/19/2024 at 3:56 PM, Registered Nurse #4 was interviewed and stated Licensed Practical Nurse #5 should have signed the Medication Administration Record and Controlled Drug Record immediately after applying the Fentanyl patch to Resident #148. On 1/22/2024 at 4:48 PM, the Director of Nursing was interviewed and stated Licensed Practical Nurse #5 was newly hired and received Inservice on filling out and signing the Medication Administration Record and Controlled Drug Record. 10 NYCRR 415.18(b)(1)(2)(3)

Based on observation, interview, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure drugs and biologicals were labeled in accordance with professional standards of practice. This was evident for the 2 (4th and 6th Floor) out of 6 resident units. Specifically, 1) an opened and undated vial of insulin was in the 4th Floor medication cart, and 2) Certified Nursing Assistant #5 transported medications from the 6th Floor to the Nursing Office on the Main Floor without supervision from a licensed nurse. The findings are: The facility policy titled Storage of Drugs dated 10/2023 documented all medications for residents who expire or are discharged shall be removed from the medication area and brought down to the Nursing Office by the Licensed Practical Nurse or Registered Nurse Supervisor only. 1) On 01/19/2024 at 12:48 PM, the 4th Floor medication cart was observed with Licensed Practical Nurse #3 and contained an opened and undated vial of Admelog insulin 100 units/milliliter in the top drawer. During an interview on 01/19/2024 at 12:53 PM, Licensed Practical Nurse # 3 stated the insulin belonged to a resident that was hospitalized . The insulin vial should have been dated with the date it was opened and the date it should be discarded. During an interview on 01/19/2024 at 2:37 PM, he Registered Nurse #1 stated they checked the medication carts daily for expired medications but did not check the 4th Floor medication cart this morning. The Licensed Practical Nurse on duty should also check the medication carts. Open insulin vials were dated with the date it was opened and expiration date. Insulin expiration dates were determined according to manufacturer recommendations. Medications should be removed from the medication cart for residents transferred to the hospital. Licensed Practical Nurse #3 was not the regular nurse for the 4th Floor and forgot to remove the medication from the cart. 2) 01/19/2024 at 3:02 PM, Certified Nursing Assistant #5 was observed on the elevator carrying a brown paper bag filled with blister packs of medication. Certified Nursing Assistant #5 exited the elevator on the Main Floor, entered the Nursing Office, and left the bag of medication with Registered Nurse #1. The following medications were observed in the brown paper bag: 1 tablet of Doxazosin 4 mg, 4 tablets of Benztropine 1 mg, 90 tablets of Protonix 40 mg, 60 tablets of Metformin 500 mg, 19 capsules of Gabapentin 400 mg, 9 tablets of Januvia 50 mg, and 26 tablets of Nifedipine 60 mg. During an interview on 01/19/2024 at 3:05 PM, Certified Nursing Assistant #5 stated Licensed Practical Nurse #4 on the 6th Floor told them to bring the paper bag with medication blister packs to the Nursing Office downstairs. On 01/23/2024 at 12:18 PM, Licensed Practical Nurse #4 was interviewed and stated they asked Certified Nursing Assistant #5 to bring the bag of medication blister packs to the Nursing Office. Certified Nursing Assistant #5 was only supposed to take down empty blister packs. Licensed Practical Nurse #4 stated they made a mistake by handing Certified Nursing Assistant #5 a bag of blister packs containing medications to be returned to the pharmacy. Licensed Practical Nurse #4 stated they usually bring the medications to the Nursing Office, but Certified Nursing Assistant #5 was available. During an interview on 01/22/2024 at 05:24 PM, Registered Nurse #1 stated medication blister packs brought to the Nursing Office were cosigned by the Nursing Supervisor and the Director of Nursing and then returned to the pharmacy. Only a Licensed Practical Nurse or Registered Nurse should bring the discontinued medications or discharged resident medications to the Nursing Office. On 01/23/2024 at 12:04 PM, the Director of Nursing was interviewed and stated that only a Registered Nurse or Licensed Practical Nurse should transport medication from the units to the Nursing Office. Medications were not transported by any other staff. The Certified Nursing Assistant can pick up empty blister packs that need to be shredded. Licensed Practical Nurse #4 recently asked Certified Nursing Assistant #5 to bring blister packs to the Nursing Office. Licensed Practical Nurse #4 was instructed to look in the bag of blister packs to ensure they do not hand the Certified Nursing Assistant blister packs that still contained medication. 10 NYCRR 415.18(e)(1-4)

Based on interviews and record review conducted during the Recertification and Complaint survey (NY00329940) from 1/16/2024 to 1/23/2024, the facility did not ensure a resident's right to privacy and confidentiality. The was evident for 1 (Resident #222) of 35 total sampled residents. Specifically, the Director of Social Services had a conversation with Resident #222 while the door to the Social Work Office was open for public and staff to overhear. The findings are: The facility policy titled Resident [NAME] of Rights dated 08/2023 documented all residents were afforded their right privacy. Resident #222 had diagnoses of arthritis and hypertension. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #222 had intact cognition. On 1/16/2024 at 2:59 PM, Resident #222 was interviewed and stated the Director of Social Services violated their privacy by talking about them being on probation out loud in the Social Work Office with the door open and other staff present. The Social Work Office was in the main lobby by the Security Desk. On 1/18/2024 at 12:00 PM, Registered Nurse #4 was interviewed and stated they were present in the lobby when the Director of Social Service was at their office doorway having a discussion with Resident #222. The Director of Social Service was overheard telling Resident #222 they had to contact the resident's Parole Officer. The Social Work Office was in the main lobby where staff and visitors entered the facility. On 1/22/2024 at 4:11 PM, the Director of Social Service was interviewed and stated they were sitting in their office when Resident #222 came and requested to go out on pass. The Director of Social Service informed Resident #222 they had to call and inform the resident's Parole Officer and attorney. The Director of Social Service stated they did not close their door while having the conversation with Resident #222. On 1/22/2024 at 5:05 PM, the Director of Nursing was interviewed and stated the Director of Social Service should have closed their office door and spoke privately with Resident #222. 10 NYCRR 415.3(e)(1)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY 50), the facility failed to ensure that the resident environment remains as free from accident hazards as is possible, and each resident receives adequate supervision to prevent elopement. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, on 5/23/22 at 9:03 AM, the facility's surveillance camera showed that Resident #1 climbed over a nine feet high fence, that surround the facility's patio, landed on the feet, and disappeared from the camera view. Resident #1 was missing for approximately nine hours before the facility staff began searching (at approximately 6:00 PM). The Facility's Physician orders dated 3/17/22 and 3/22/22 documented that Resident #1 to be monitored every 30 minutes for elopement risk. The monitoring sheet dated 5/23/22, documented by the Certified Nursing Assistant #1, (CNA#1), that from 9:00 AM to 2:30 PM: Resident #1 was on the unit. At 3:00 PM, CNA #1 documented that Resident #1 was off the unit and went to the Main Dining Room (MDR). Vital Sign and Pain Level assessments that was due at 4:00 PM were not documented. On 5/25/22, Resident #1 went to a friend's house and was taken to the local police precinct. The Police informed the facility that Resident #1 was transferred to the hospital emergency room for an evaluation. The findings are: A facility's policy entitled, The facility Policy and Procedure to Prevent Elopement from the Facility, last revised date: 7/2021, documented that to prevent a resident from eloping, all the facility's exit doors are alarmed. Residents identified as high risk for wandering are given a Sigmagard bracelet and a Certified Nursing Assistant (CNA) must check the resident at scheduled intervals. The Policy did not document which steps the staff should take if a resident refuse to wear the Sigmagard bracelet. A review of the facility's Accident/Incident Report and Investigation dated 5/26/2022, documented that on 5/23/2022 at around 6:00 PM, Licensed Practical Nurse #1 (LPN #1), reported that Resident #1 was not in their room or in the dining room. Resident #1 usually goes to MDR to buy snacks from the vending machines. Code Green was called. The Staff responded, and a search was completed throughout the entire building. The Director of Nursing #1 (DNS #1) and the Administrator were informed. At 10:45 PM, the police were called and arrived at the facility. Resident #1 had no family listed. On 5/25/2022, Resident #1 was taken to the local police precinct by a family friend who reported that Resident #1 came to their house after leaving the facility. It was determined that Resident #1 left the facility by climbing over the fence in the patio area. The timeline of the incident are: At 5/23/2022 at 5:45 PM Resident #1 was missing. At 6:00 PM, A Code Green was called. At 6:15 PM, The DNS #1 was notified. At 6:30 PM, 911 was called, the camera surveillance check was initiated by the Administrator #1. On 5/25/22 at 1:23 PM, the police department informed the facility that Resident #1 was brought in by a family/friend and will be transferred to the hospital. On 5/25/22 at 10:20 PM, Resident #1 was readmitted to the facility from the hospital. Resident #1 was admitted to the facility with diagnoses that included [CONDITION(S)] disorder, [CONDITION(S)], and Dementia. The Minimum Data Set (MDS, a resident assessment tool), dated 5/13/2022, documented that Resident #1 had a short-term memory problem. Section C1000: Cognitive Skills for daily decision making, documented that, Resident #1 had moderately impaired decisions making skills and required supervision. Resident #1 required supervision with bed mobility, transfer, walking, and locomotion on the unit. A review of the Comprehensive Care Plan (CCP) Unsafe/Wandering/Potential for Elopement initiated on 9/20/2019, documented that Resident #1 was at risk for elopement. Resident #1 removed and refused to wear the Sigmaguard (wander guard), despite being encouraged to wear the bracelet for safety. The interventions included placing a green charm on the Resident#1's chart, room door, and armband. A photo of Resident #1 was place as per facility's policy. Any attempt of elopement/unsafe wandering must be reported to the CCP team. The CCP must be updated, and the administration and the DNS #1 notified. A review of the Wandering /Elopement Risk assessment dated [DATE], documented that Resident #1 remains at risk for elopement due to unpredictable behavior of standing in the hallway and going to MDR. A review of the facility's surveillance video with the Administrator #1, dated 5/23/2022, revealed that at 9:03 AM, Resident #1 was observed standing on the patio, dressed in white sneakers, and a black and navy-blue jacket. Resident #1 approached the corner of the patio, climbed over the fence, and jumped on the other side. Resident #1 landed on his/her feet in the grass on the neighboring parking lot and disappeared from the camera view. A review of the Monitoring Sheet dated 5/23/2022, documented that Resident #1 was on every 30 minutes monitoring. Multiple staff documented that Resident #1 was in the bed from 7:30 AM to 12:00 PM. At 12:30 PM, sitting in the day room. At 1:00 PM eating lunch. From 1:30 PM to 2:30 PM, Resident #1 was in the bedroom. At 3:00 PM, Resident #1 was off the unit to MDR. After 3:00 PM, there were no record of the Resident's #1 whereabouts. A review of the Medication Administration Record (MAR) dated 5/23/2022, there were no documentation that vital signs, (pulse, blood pressure, respiration, and temperature), and pain level that was due at 4:00 PM was done. A review of the Nursing Note written by LPN # 1, dated 5/23/2022 at 6:00 PM, documented that Resident #1 was not in his/her room at supper time. The Nursing Supervisor #1 (RNS #1) was notified and completed rounds on all units. Code Green was called, and all Staff responded. A review of the Nursing Note, written by LPN #3, dated 5/25/2022 at 10:29 PM, documented that Resident #1 returned to the facility. Resident #1 refused to wear the wander guard, refused body assessment, and to have vital signs taken. Resident #1 was placed on every 15 minutes visual monitoring. A review of a Physician Order written by Medical Doctor#1(M.D #1), dated on 3/17/2021, documented that Resident #1 was an Elopement Risk. A review of a Physician Order dated 3/22/2022, documented an order to Monitor Resident #1, every 30 Minutes for Elopement Risk. A review of a Physician Note dated 5/26/2022, by Medical Doctor#1(M.D. #1), documented that Resident #1 was readmitted from the hospital after elopement from the facility. No visible injuries were observed. During an interview on 6/2/2022 at 12:19 PM, Security #2, who worked on 5/23/2022 at 9 AM-7 PM shift, stated that their responsibility was to monitor residents through the camera on the patio and to entertain residents in MDR. They usually go to the patio every 10 minutes to check on residents. Security #2 stated that he/she did not see Resident #1 on 5/23/2022 in the MDR. Security #2 arrived at the facility at 9:20 AM and went to MDR, Resident #1 was not there. During an interview on 6/2/2022 at 1:15 PM, CNA #3 who worked on the 5/23/2022, 7-3 shift stated that he/she was not assigned to Resident #1. Resident #1 was on every 30 minutes monitoring for elopement. CNA #1 visually observed Resident #1 at 7:30 AM, 8:00 AM, and 8:30 AM. Resident #1 asked for soap for the shower. CNA #3 stated that he/she signed every 30 minutes monitoring sheet because he/she was helping the assigned CNA. CNA #3 stated that they assumed that Resident #1 was in the bedroom from 1:30 PM to 2:30 PM and signed the monitoring sheet. At 3:00 PM, CNA #3 went to Resident #1's room and he/she was not there. CNA assumed that Resident #1 went downstairs to the MDR. CNA #3 stated that they did not go to MDR to check on Resident #1 but signed the monitoring sheet. During an interview on 6/2/2022 at 2:00 PM, CNA #4, stated that he/she was not assigned to Resident #1. CNA #4 stated that they knew that they must physically check the resident. CNA #4 stated that they assumed that Resident #1 was on the unit and signed the monitoring sheet from 9:00 AM to 11:00 AM. During an interview on 6/2/2022 at 2:27 PM, assigned CNA #5 stated that he/she worked 3-11 shift on 5/23/2022 and came to work at 3:30 PM. CNA #5 did a round and Resident #1 was not in his/her room. CNA #5 got distracted by another resident and forgot to go and look for Resident #1. Resident #1 was allowed to go downstairs unescorted. Resident #1 was on every 30 min monitoring for elopement. Resident #1 never made any attempts to leave the facility in the past. At around 5:00 PM, CNA #5 went to check on Resident #1 (it was dinner time) and Resident #1 was not in their room. CNA #5 went to the main dining room, and Resident #1 was not there. CNA #5 reported to the LPN #1. The Nursing Supervisor #1 (RNS #1)was notified, and code Green was called which includes headcount, searching facility, and police notification. Staff was not able to find Resident #1 and the police took over. During a telephone interview on 6/27/2022 at 11:20 AM, assigned CNA #6, stated that he/she was assigned to Resident #1 on 5/23/2022 7-3 shift. CNA #6 saw Resident #1 after breakfast when he/she took a shower. Resident #1 was ambulatory, an elopement risk, and should be checked every 30 minutes. CNA #6 stated that the assigned CNAs were responsible for visually checking resident's whereabouts and signing the monitoring sheet. If the CNA is busy with other residents or on the break, the covering CNA should check on Resident #1 and sign the paper. At the lunch time, Resident #1 usually sits at the same spot to eats. When CNA #6 came to the day room to pick up the trays, he/she did not look at the ticket and assumed that the Resident #1 had already eaten the lunch and went downstairs. CNA #6 brought a snack to Resident #1's room at around 2:15 PM and the Resident #1 was not there. CNA #6 left a snack in the room thinking that Resident #1 was in MDR. CNA #6 did not complete end of shift rounds to make sure that Resident #1 was present and assuming that other CNA did. During an interview on 6/2/2022 at 2:44 PM, the LPN #1/ Charge Nurse, stated that he/she was working on 5/23/2022 4-12 shift. Resident #1 had not attempted to leave the facility before. LPN #1 stated that he/she made rounds at 4:00 PM and did not see Resident #1 on the unit. Resident #1 was on every 30 minutes monitoring and CNA should physically see the resident before signing the monitoring sheet. LPN #1 also stated that the morning shift did not report anything about Resident #1. CNA #5 reported at around 5:30 -6:00 PM that Resident #1 was not on the unit. CNA #5 went downstairs to MDR to check, and the Resident #1 was not there. LPN #1 also came downstairs and could not find Resident #1. LPN #1 notified the RNS #1. Code Green was called, and staff start looking everywhere but could not find Resident #1. The police were called and arrived at the facility. During a telephone interview on 6/27/2022 at 2:27 PM, LPN #2, who worked on 5/23/22 during the 8 AM - 4 PM shift stated that they saw Resident #1 after 8:20 AM. Resident #1 refused morning medication went to his/her room. That was the last interaction with Resident #1. During an interview on 6/2/2022 at 4:34 PM, the DNS #1, stated that if residents were at risk for elopement and refused to wear a wander guard, the staff should monitor the resident every 30 minutes. The staff should visually check resident's whereabouts. The staff cannot assume that the resident was on the unit without physically conforming. On 5/23/2022, the day of the elopement, the staff were signing the monitoring sheet without checking Resident #1's whereabouts. Resident #1 was noted missing during dinner time, at around 6:00 PM. During a telephone interview on 6/24/2022 at 12:25 PM, the DNS #1, stated that they do not have Monitoring Policy. The monitoring policy was incorporated into the Elopement Policy. The incident was investigated, and all staff were in-serviced on monitoring residents and not assuming without visually checking. The assigned CNA #6 received written counseling due to signing the accountability record when Resident #1 was not present on the unit. During an interview on 6/2/2022 at 2:55 PM, the Administrator #1, stated after being informed that Resident #1 was missing, multiple cameras were reviewed to determine how Resident #1 eloped. The facility ordered a fence screen to cover the fence, but it was delayed in shipping due to COVID-19. The screen will be made it impossible for someone to climb the fence. The administrator stated that Resident #1 told his/her family how he/she exited the facility and that he/she climbed a nine feet high patio fence in the backyard. The camera review showed that Resident #1 climbed the fence at 9:03 AM. When staff became aware that Resident #1 was missing it was 6:00 PM. Code Green was initiated, and the police were called immediately. The Police notified the Administrator #1 that the Resident #1 went to a friend's house and the friend brought him/her to the police. 10 NYCRR: 415.12(h)(2)

Based on record review and interview during the re-certification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, a discharge assessment was not submitted and transmitted within 14 calendar days from the MDS Completion Date. This is evident for 1 of 1 resident reviewed for the Resident Assessment facility task (Resident #1). The finding is: The facility Policy and Procedure titled, MDS 3.0 with a review date of 01/2021 documented: The MDS Coordinator will generate an MDS book upon admission, quarterly, annually, significant change in status, significant corrections to prior comprehensive assessments, significant corrections to prior quarterly assessments, not OBRA required assessments and PPS assessment. The MDS Assessor /designee will be responsible for transmission to Federal Data Base and will check validation report against the MDS schedule to ensure that all scheduled MDS 3.0 assessments are transmitted and accepted. Resident #1 was discharged to the community on 06/08/2021. The discharge Minimum Data Set 3.0 (MDS) assessment dated [DATE] was not transmitted within 14 days. The CMS Submission Report documented the 6/8/21 MDS was transmitted on 11/03/2021. On 11/03/2021 at 12:30 PM, the Director of MDS was interviewed and stated the MDS Assessors first complete the MDS book and check what needs to be submitted through the electronic medical record (EMR). The completed document is submitted to the Registered Nurse (RN) responsible for transmitting MDS documents in a timely manner. On 11/03/2021 at 2:57 PM, the Registered Nurse (RN #3) was interviewed and stated, Once the MDS are completed I transmit them. I have a record and a calendar of all the completed MDS that needs to be transmitted, and I do this weekly. She further stated The discharge MDS of Resident #1 was transmitted today, 11/03/2021, I don't understand how it happened.

Based on observation, record review, and interview, during the Recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, Residents with lap tray, left hand splint, and anticoagulant use were not captured on the Minimum Data Sets (MDS) assessments. This was evident for 1 of 3 residents reviewed for position, mobility (Resident #149) and for 1 of 2 residents reviewed for PASARR (Resident #71) out of total sample of 35 residents. The findings are: The Facility policy and procedure for Minimum Data Set 3.0 (MDS 3.0), dated 10/2010 and reviewed 1/2021, documented: assessment of the resident during the MDS process consists of observation, written documentation in the medical record and staff, resident, and/or family member interview (of which must be documented in the medical record at the time or immediately after the interview). Each interdisciplinary team (IDT) team member must complete their assessments of each resident by these methods of data collection. 1) Resident #149 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/02/21 at 2:46 PM, Resident #149 was observed in day room sitting in high back wheelchair with left arm resting on left arm trough. On 11/04/21 at 11:08AM, Resident #149 was observed in day room sitting in high back wheelchair with left arm resting on left arm trough. Resident was listening to a recreation staff member during an activity program. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE], documented the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had upper extremity range of motion (ROM) impairment on both sides. The MDS documented there was no splint device used and anticoagulant medication not received. The Comprehensive Care Plan (CCP) for Rehabilitation Potential, created on 4/8/21 and updated 10/28/21, documented: left hand splint in bed to be released during hygiene care and skin checks as an intervention. The CCP for Anticoagulant Therapy, created 4/9/21 and updated 10/15/21, documented problem as: On [MEDICATION(S)] and goal as Have no untoward effects from anticoagulant therapy for (90) days. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/03/21 at 3:14 PM, the MDS Coordinator (MDSC) was interviewed. The MDSC stated the MDS assessments are completed by the MDSC. The splint is supposed to be captured in section O of the MDS, which is completed by Rehab. The MDSC did not notice the [MEDICATION(S)] and therefore did not include it on this MDS. The MDSC did not understand why the splint and anticoagulant were not captured. On 11/03/21 at 3:58 PM, the Physical Therapist (PT) was interviewed. The PT stated, it is not rehab's responsibility to code splint on the MDS. Rehab does not complete section O for splint on MDS because it is not part of our restorative nursing program. The MDSC is responsible for capturing the splint. I do not see splint captured on this MDS. On 11/04/21 at 12:36 PM, the Director of Nursing Services (DNS) was interviewed. The DNS stated if the resident is on restorative therapy for splint, then it should trigger in that MDS section. Resident # 149 is not on restorative therapy for splint, so it is not captured on this MDS. The MDSC is responsible for accuracy of the sections completed by the MDSC. The MDSC also ensures all departments have completed their section for submission and transmission. The MDSC should have captured anticoagulant on this MDS. 2) Resident # 71 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/02/21 at 3:35 PM, Resident # 71 was observed sitting in wheelchair in 2nd floor hallway with lap tray on, secured with straps. Resident appeared clean and well groomed. On 11/03/21 at 11:24 AM, resident # 71 was observed sitting in wheelchair in 2nd floor hallway with lap tray on, secured with straps. Resident appeared clean and well groomed. On 11/04/21 at 12:04 PM, resident # 71 was observed sitting in wheelchair in 2nd floor hallway with lap tray on, secured with straps. Resident observed mumbling to self and appeared calm. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE], documented the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident had short and long term memory problem and moderately impaired cognitive skills for daily decision-making. The resident had Range of Motion impairment of upper and lower extremities and required total care for activities of daily living. The MDS documented no restraints were used. The Comprehensive Care Plan (CCP) for Physical Restraints/Enabler/Devices, created on 11/9/18 and updated 8/12/21, documented the resident required a restraint due to Status Epilepticus/[CONDITION(S)]. The Goal documented: have the least restrictive form of restraint to treat medical symptoms/condition in the next 90 days. Interventions documented: therapeutic device laptray when out of bed to wheelchair, remove every 2 hours x (for) 10 minutes. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/03/21 at 2:59 PM, the MDS Coordinator (MDSC) was interviewed. The MDSC the MDS assessments are completed by MDS coordinator. The laptray is supposed to be captured in section P of MDS. The MDSC stated, I forgot to capture laptray on MDS. I was the one that signed for it. The MDSC does observe if resident can remove lap tray on own when completing MDS assessment. On 11/04/21 at 12:36 PM, the Director of Nursing Services (DNS) was interviewed. The DNS stated the laptray is considered a restraint and should be documented in section P of MDS. The MDSC is responsible for accuracy of sections completed. The MDSC also ensures all departments have completed their section for submission and transmission. The MDSC should have captured laptray as a restraint on this MDS. 415.11(b)

Based on record review and interviews conducted during the recertification survey, the facility did not ensure appropriate liability and appeal notices to Medicare beneficiaries were provided. Specifically, the facility did not provide residents with the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN- form CMS- ) at the termination of their Medicare Part A benefits. The residents remained in the facility. This was evident for 2 of 3 residents reviewed for Beneficiary Protection Notification Rights (Resident #15 and #371). The findings are: The facility policy and procedures for Skilled Nursing Facility Advance Beneficiary Notices, dated 4/30/18 documented the following: After the determination by Utilization Review Committee or by the MDS Coordinator (whichever decides first), that the resident does not qualify or no longer qualify for a skilled level of care, the social service department will issue the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN- form CMS- ) letter, informing the resident/responsible party that they do not qualify or no longer qualify for Medicare payment. Resident #15 was admitted to the facility on [DATE]. The resident was started on Medicare Part A Skilled Services on 01/11/19. The last covered day by Medicare Part A was 2/28/19, and the resident remained in the facility. There was no documented evidence that a SNF ABN-form CMS- was given to the resident or legal representative, informing them of their potential liability for payment. Resident #371 was admitted to the facility on [DATE]. The resident was started on Medicare Part A Skilled Services on 10/27/19. The last covered day by Medicare Part A was 11/30/19, and the resident remained in the facility. There was no documented evidence that a SNF ABN- form CMS- was given to the resident or legal representative, informing them of their potential liability for payment. On 04/24/19 at 11:18 AM, an interview conducted with the Director of Social Services (SW). She stated that she is responsible to offer beneficiary notices to residents after the interdisciplinary team makes their decision. She also stated that team meets once per week to discuss the Medicare residents. They discuss when the resident started, when skilled services are ending, and how many days the resident has left. She further stated that rehab will give her the list of residents who need to receive notices, and then she follows-up as directed. The SW acknowledged she did not offer these two residents the SNF ABN-form CMS- . On 04/24/19 at 11:49 AM, an interview conducted with the Rehab Director. He stated that he has been working in the facility since (MONTH) (YEAR) . He stated that the end of therapy and the last Medicare-covered day are discussed with the resident and family at least 3 days prior to discharge. He stated that Rehab communicates with the Social Services Department at the Medicare meeting and sends an e-mail listing each Medicare resident and how many Medicare-covered days they have remaining out of their 100 days. He stated that the only time they give the SNF-ABN to residents is when they reach 100 days, exhausting their Medicare benefit. Her further stated the Notice of Medicare Non Coverage is provided to residents who have Medicare days remaining. 415.3(g)(2)(i)

Based on observations, record review, and staff interviews during the re-certification survey, the facility did not ensure a resident with limited Range of Motion (ROM) and mobility received appropriate treatment and services to improve or prevent further decrease in range of motion. Specifically, gauze hand rolls were not provided to a resident as per physician order. This was evident for 1 resident reviewed for Range of Motion out of a total investigation sample of 35 residents (Resident #100). The finding is: The facility policy and procedure titled Prevention of Complication of Immobility/Contractures dated 5/6/2012 documented the following: If any device is indicated the Rehab Director will take an MD T/O (telephone order), the therapist will issue the device and rehab nursing will get a wearing schedule, which will be communicated, to the nurses. Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] after being hospitalized from [DATE] to 3/30/19, and the resident was put on Hospice Care on 4/2/2019. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident was non-verbal and had moderately impaired cognition with short and long-term memory problems. The MDS further documented that the resident did not have a behavior of rejecting care, and the resident required total assistance for all Activities of Daily Living (ADLs). The resident had Range of Motion (ROM) impairments on both sides in the upper and lower extremities. On 04/16/19 at 12:07 PM, the resident was observed with a hand roll in the left hand only. The right hand was closed with no device in place. On 04/22/19 at 09:11 AM, 04/22/19 at 11:59 AM, and 04/23/19 at 10:29 AM, the resident was observed with both hands contracted with no rolls in place. There were no gauze rolls observed in the room. On 04/24/19 at 09:38 AM, the resident was observed resting in bed with both hands contracted and no gauze rolls in either hand. The Comprehensive Care Plan (CCP) for Rehabilitation Potential (mobility) initially dated 5/25/2018 documented the treatment intervention of gauze rolls in both hands to be changed daily by nursing. The Physicians Order dated 3/30/19 documented orders for: gauze roll in right and left hands. Change daily and remove during hygiene care and skin checks by nursing. Start 3/30/19 End date 5:27/2019. An Occupational Therapy (OT) Evaluation Note added to the CCP for Rehabilitation Potential on 4/1/19 documented that the resident was seen for an annual evaluation and a decline in ROM. The note further documented no physical therapy was needed at the time, and the resident would benefit from OT to reach maximum potential for functioning. An OT Evaluation Note added to the CCP on 4/3/19 documented that the resident was discharged from OT due to comfort care being put in place. The note documented the devices that were ordered should be continued. The OT discharge summary dated 4/3/2019 documented that the left and right gauze rolls were ordered. The summary further documented the gauze rolls should be worn at all times. The Physician's Monthly Progress notes dated 4/2/19 and 4/24/19 documented that the resident has contractures on all four of her extremities. The Certified Nursing Assistant (CNA) Accountability records from (MONTH) 2019 to (MONTH) 2019 document under special instructions that gauze rolls are to be worn in right and left hands at all times, except during skin checks and hand hygiene by nursing. On 04/24/19 at 09:53 AM, an interview with the Certified Nursing Assistant (CNA #1) was held. CNA #1 stated that she performs total care and transfers the resident out of bed and into the geri chair. CNA #1 stated the resident has rolls that go in her hands, and it is the CNA's responsibility to put the gauze rolls in the resident's hands. CNA #1 stated that the resident's hands are semi-constricted, and the aids have been trained on how to open the resident's hands to place the gauze rolls inside them. CNA #1 stated that she has been assigned to the resident all week. When asked about not seeing the gauze rolls in the resident's hands this week, she stated that maybe she didn't put them in yet. On 04/23/19 at 10:40 AM, an interview with Licensed Practical Nurse (LPN #1) was held. The LPN stated that in the morning or when the resident comes out of bed, the gauze rolls get put in the resident's hands. LPN #1 stated that this morning (4/23/19) she did not think the resident had the gauze rolls in her hands. When asked if the resident refuses the gauze rolls, the LPN stated that the resident does not refuse to wear the gauze rolls. When asked about the gauze rolls not being in the resident's hands, the LPN stated that the resident does not have the gauze rolls in yet today. On 04/23/19 at 10:55 AM, an interview with Registered Nurse (RN #1) was held. RN #1 stated when a resident has a device ordered, PT/OT will come to the unit and show nursing and the CNA staff how to use the device. The RN stated that when a new device is ordered the RN supervisor will get a sheet of paper with the order on it. The RN supervisor will then put the device on the CNA accountability forms for the resident. This is how the CNA assigned to the resident knows how to complete the task. RN #1 stated that she will go around and check to see if the residents with devices and restraints are in place. RN #1 stated that the resident does not have the behavior of dropping or losing the gauze rolls. When asked about multiple observations of the resident without the gauze rolls in place, RN #1 stated that the resident should have the gauze rolls in her hands. RN #1 stated that the CNA assigned to the resident today is not the regular CNA. RN #1 stated that if a CNA is new, they shadow a regular CNA. RN #1 stated that all CNAs get report in the morning if there is any special device or equipment for the resident, they find out at that time. On 04/24/19 at 10:19 AM, an interview with the Registered Occupational Therapist (OT) was held. The OT stated that when the treating therapist discharges the resident they will tell her the progress of the resident and the discharge plan. The OT stated that she will type up the discharge note then resident then goes on nursing rehab and range of motion exercises. The OT stated that nursing is in-serviced on what to do for the resident when the resident is discharged from OT- when the devices are supposed to be put on and taken off. The OT stated for this resident the gauze rolls should always be worn except for skin checks and hygiene. The OT stated that the resident uses gauze rolls for her hands because hand rolls could not fit in her hand due to contractures. The OT stated that the resident was discharged with the gauze rolls on 4/3/2019, and the order was still active. The purpose of the gauze rolls is to maintain or improve and not worsen the resident's contractures. The OT stated that if the resident does not wear the gauze rolls, her contractures will worsen. The OT stated that if a resident is put on hospice it is to make them comfortable and the devices are to maintain what they have. The OT stated that even if a resident is on hospice, the goal is to continue with the devices to promote quality of life. 415.12 (e) (1)

Based on record review and interviews conducted during the recertification survey, the facility did not ensure the assessment accurately reflected the resident's status. Specifically, a resident's Minimum Data Set (MDS) assessment did not include the active [DIAGNOSES REDACTED].#209). The findings are: Resident # 209 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Annual MDS dated [DATE] did not document Paranoid [MEDICAL CONDITION] as an active [DIAGNOSES REDACTED]. A Psychiatry note dated 2/25/19 documented the resident has a [DIAGNOSES REDACTED]. The medical record during the lookback period, from 3/15/19 to 3/21/19, was reviewed. The resident had an active [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. On 04/23/19 at 09:54 AM, an interview was held with the MDS Coordinator (MDS-C). The MDS-C stated that she is responsible for completing the nursing sections of the MDS- sections A, B, H, I, J, L, M, N, part of O, P, part of S, and V. The MDS-C stated she reviews the paper and EMR portions of the medical record, and she obtains information from the nursing and social service staff. The MDS-C stated the resident's [DIAGNOSES REDACTED]. The MDS-C stated this was an isolated case. 415.11 (b)

Based on staff interviews and record reviews conducted during an abbreviated survey (NY 432), the facility did not have evidence that all alleged violations involving resident abuse by facility staff reported to New York State Department of Health (NYS DOH) and local law enforcement. This was evidenced in 1 out of 4 sampled incidents (Resident #1). Specifically, Resident #1 reported that a facility staff raped her. The facility did not report this allegation to NYS DOH or local law enforcement. Th findings include: The facility Policy and Procedure on Abuse/Neglect with a revised date of 11/26/2016 states, report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take corrective actions depending on the results of the investigation. Resident #1 is a [AGE] year-old resident who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, an assessment tool) dated 12/01/2017, Resident #1 had a BIMS (Brief Interview for Mental Status used to determine attention, orientation and ability to recall information) score of 15 out of 15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment & 12-15 cognitively intact). Resident #1's care plan on Abuse Prevention dated 09/01/2017, documented the resident at risk for victimization with interventions that included psychological therapy, psychiatric consults and monitoring of behavior and provide early intervention on any changes. The facility Accident/Incident form dated 02/14/2018 documented that Resident #1 reported to the Social Worker (SW) on 02/14/2018 that she was raped by a staff member. The facility investigation included review of video evidence and staff statements. The investigation summary documented that Resident #1's testimony was inconsistent. The investigation concluded that sexual abuse did not happen. The Accident/Incident Report revealed no documented evidence that the facility reported the allegation to NYS DOH and local law enforcement. The Acting Director of Nursing was interviewed on 02/21/2018 at 12:00 PM. The Acting Director of Nursing stated that the allegation of sexual abuse made by Resident #1 was investigated but not reported to the NYS DOH and law enforcement authorities because Resident #1's testimony was inconsistent. During a follow-up interview with the Acting Director of Nursing on 04/10/2018 at 11:29 AM, she stated that the Director of Social Service (DSS) told her only the Administrator, DON and DSS report incidents to NYS DOH. The Acting Director of Nursing responded to a questing regarding her responsibilities. She stated that she has never reported anything to the DOH and that she thought the DSS would have reported the allegation of sexual abuse as it was first reported to her. The Registered Nurse Supervisor (RNS) was interviewed on 02/21/2018 at 3:00 PM and stated that she initiated the investigation into the sexual abuse allegation made by Resident #1, but that the Director of Nursing Service (DNS) was responsible for reporting to the appropriate agencies. The Assistant Administrator was interviewed on 02/21/2018 at 2:15 PM and stated that he was aware that the incident should have been reported, but that he had no answers as to why the allegation of sexual abuse made by Resident #1 was not reported. The Director of Nursing Services (DNS) was interviewed by phone on 02/27/2018 at 10:03 AM and stated that she stated that she was on vacation at the time of the alleged incident. During a follow-up interview with the DNS on 04/10/2018 at 11:02 AM, she stated that while she was on vacation, the Registered Nurse Supervisor/MDS Coordinator was Acting Director of Nursing and that she was aware of the reporting protocol to NYS DOH. The DNS responded to a question regarding the Acting Director of Nursing knowledge of reporting to local law enforcement authorities. She stated No, I don't believe she was aware of reporting to law enforcement authorities. 415.4(b)(I)(i)

Based on observation, record review and interview, the facility did not ensure that professional standards were met. Specifically, the nurse entered the readmission orders [REDACTED]. In addition, the medication nurse did not clarify the duplicate medication orders and signed for the administration of both doses of the medication when she only gave one. This was evident for 1 of 5 residents reviewed for Unnecessary Medication (Resident #85) The findings are: Resident is a [AGE] year-old, readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented resident's cognitive status was severely impaired (BIMS score of 7). The MDS further documented that no mood or behavioral concerns were exhibited in the past few weeks. The Nursing Admission Note dated 05/16/16 documented the resident returned from the Hospital after abdominal surgery with staples in place. The hospital discharge record dated 05/16/16 documented the resident was discharged on [MEDICATION NAME] 45 mg (milligrams) PO (by mouth) QHS (every night). The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. On 5/18/16 at approximately 12 noon, the License Practical Nurse (LPN) was interviewed and stated she administered 30 mg of [MEDICATION NAME] on 5/16/16 and 5/17/16. The LPN further stated that she saw the two orders, but she knew the resident was on [MEDICATION NAME] 30 mg for a while prior to the hospitalization . She also stated that she never administered [MEDICATION NAME] 45 mg, and the medication was not available at the time. The LPN stated that she should have reported the duplicate orders and unavailable mediction to the Registered Nurse Supervisor, but since she knew the resident was on [MEDICATION NAME] 30 mg before she decided to administer 30 mg. The LPN stated that she was not aware that she signed the MAR for both doses of the [MEDICATION NAME], and she stated that she did so in error. On 5/18/16 at 12: 33pm, the 3-11 shift Registered Nurse Supervisor (RNS) was interviewed and stated she readmitted the resident to the facility on [DATE]. She further stated that she reviewed the hospital discharge summary and reconciled the medications with the Physician (MD). She also stated that the MD agreed to order [MEDICATION NAME] 45 mg (the dosage given in the hospital), and the MD requested to have the resident seen by a Psychiatrist as soon as possible. The RNS stated that she was not aware that [MEDICATION NAME] 30mg was also ordered, and she admitted it was an error. On 5/18/16 at around 12:45pm, the day shift RNS was interviewed and stated she never noticed the duplicate order for [MEDICATION NAME], but she would have contacted the doctor if she noticed it. She showed the surveyor the [MEDICATION NAME] 45 mg blister packs which were intact to show that the resident never received the medication. On 5/19/16 at 1:26pm, an interview conducted with the Physician who stated that he thought he ordered 30mg of [MEDICATION NAME] instead of 45mg. He further stated that he could not recall his conversation with the Nurse. He also stated that he changed the order to [MEDICATION NAME] 30mg, and requested the resident be seen by the psychiatrist. The facility policy for Medication Reconciliation dated 3/1/16 documented the following: The Registered Nurse is responsible for taking telephone orders for newly admitted or readmitted residents. The telephone orders must be read back to the physician after entry in the Electronic Medical Record (EMR). The policy further documented that the LPN must also read the individual order transcribed in the EMR prior to signing it. If order is not clear, the LPN must clarify it with RN supervisor who will call the attending physician for clarification. The facility policy on Medication Unavailable dated 1/2014 documented that (a) the nursing supervisor must inform the prescriber or the medical director if medication is unavailable (b) the Nurse must also inform the pharmacy or back up pharmacy for and obtain medication if necessary . 415.11(c)(3)(i)