Every finding on record at Mayfair Care Center

Based on interviews and record review, the facility failed to ensure each resident received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This was identified for one (Resident #76) of two residents reviewed for Mood and Behavior. Specifically, Resident #76 had a Level II Preadmission Screening and Resident Review (PASRR) Conditions due to serious mental illness including schizoaffective disorder, bipolar type and obsessive-compulsive disorder. The resident had worsening behaviors and psychiatry consultations were ordered on 04/13/2026, 06/22/2026, 06/25/2026, 06/28/2026, and 07/10/2026 for evaluation and medication review. The psychiatry consults were not completed. Subsequently, the resident was transferred to the hospital for psychiatric evaluation as per the resident's family member request.Complaint #3107485The findings include:The facility policy titled Consults, dated 01/2026, documented the facility uses outside resources to furnish specific services provided by the facility. Written, signed, and dated agreements are maintained for each consultant. Consultants provide the facility with written, dated, and signed reports of each consultation visit. Such reports contain the consultant's recommendations, plans for implementation of their recommendations, findings, and plans for continued assessments.Resident #76 was admitted with diagnoses including Parkinson's disease, anxiety, and depression. The 05/16/2026 significant change Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact, and that the resident had a Level II Preadmission Screening and Resident Review (PASRR) Conditions due to serious mental illness.A notice of Preadmission Screening and Resident Review Level II Outcome dated 09/23/2021, documented diagnoses of schizoaffective disorder, bipolar type; attention deficit/hyperactivity disorder; obsessive compulsive disorder; and tardive dyskinesia (a movement disorder). According to the Preadmission Screening and Resident Review the resident needs supportive mental health treatment, hospitalizations, and medications; and the resident's life has been impacted by their mental health. The resident may choose nursing facility care. The resident would need a person-centered psychiatric plan of care; ongoing psychiatric consultations and medication management by a psychiatrist or a licensed prescriber is recommended. The resident needs to meet with a psychiatrist or prescriber monthly to see if their medications are working well.A psychiatry consult dated 03/14/2026 documented the resident had a history of chronic mental illness and polysubstance abuse with multiple psychiatric hospitalizations. The resident denied any psychosis including visual or auditory hallucinations. The resident was experiencing increasing cognitive symptoms due to the progression of Parkinson's disease. Follow-Up as needed for the management of this resident and updating the treatment plan to maintain stability.A physician's order dated 04/13/2026 (written by the attending physician) documented psychiatry consult for medication review.A pharmacy drug regimen review dated 06/19/2026 documented psychiatry consult was ordered on 04/14/2026 (04/13/2026); however, the consult report was not located. The pharmacist recommended to follow up and obtain a duplicate copy or consider reordering psychiatry consult.A review of the electronic medical record from 06/25/2026 to 06/29/2026 documented resident was exhibiting worsening behaviors including trouble sleeping, delusions including the police coming to get them and that their friend wanted to get them arrested. The resident was repeatedly washing hands and hair in the sink and engaging the lock and unlock mechanism on the rollator brakes.A review of the physician's order dated 04/13/2026, 06/22/2026, 06/25/2026, 06/28/2026, documented psychiatry consults for evaluation and medication review.A nursing progress note dated 06/29/2026 documented the resident was noted with increased agitation and hallucinations. The physician recommended transferring the resident to the hospital for psychiatric evaluation.The resident left the facility at 3:25 PM on 06/29/2026 and returned at 8:45 PM on 06/29/2026.A review of the 06/29/2026 hospital discharge instruction revealed information was provided to the resident regarding community mental health services.A follow-up medical note dated 06/30/2026 documented the resident returned to the facility. There were no medication changes, and work-up was unremarkable.The primary physician's follow-up progress note dated 06/30/2026 documented post-hospital follow-up after emergency department evaluation for worsening hallucinations, paranoid behavior, agitation, and altered mental status. The hospital records were reviewed. The resident was started on Lorazepam 0.5 milligram (a medication to treat anxiety) by mouth twice daily for anxiety.A review of the July 2026 medication administration record revealed the resident was prescribed the following psychotropic medications:Remeron oral tablet 30 milligrams at bedtime for depression;Lurasidone 60 milligram tablet in the evening for schizoaffective disorder, bipolar type;Donepezil oral tablet 10 milligrams at bedtime for dementia;Memantine oral tablet 10 milligram one tablet by mouth two times a day for dementia;Trazodone 50 milligrams, give 0.5 tablet by mouth at bedtime for major depression.A physician's order dated 07/10/2026 (written by the medical director) documented psychiatry consult.A follow-up note dated 07/15/2026, written by covering physician (Physician #1) documented the resident was evaluated today after the nursing staff notified the medical provider of the resident's increased anxiety. The resident appeared anxious and restless but was cooperative with the examination. No acute hallucinations, aggressive behavior, suicidal ideation, chest pain, shortness of breath, or other acute medical complaints were noted at the time. Given the acute anxiety symptoms and psychiatric history, Lorazepam (a medication to treat anxiety) 0.5 milligram by mouth twice daily for 14 days was re-ordered for symptom management.A review of the electronic medical record from 07/10/2026 to 07/21/2026 documented the resident continued exhibiting behaviors including another resident coming for them; wandering on the unit with a walker stating, someone is trying to kill me; and that people were out to get them and poison their food.A covering physician (Physician #1) progress note dated 07/24/2026 documented several days ago, the resident experienced an acute episode of hallucinations. Following this event an extensive medical workup was completed at the facility to evaluate for reversible causes of delirium or worsening psychosis; all of which were unremarkable and did not identify acute infectious, metabolic, or other medical causes for delirium or exacerbation of psychosis. The resident remained under close observation, and psychiatry has been involved in ongoing medication management. Despite the negative medical workup, the resident's family requested the resident be transferred to the hospital for a comprehensive psychiatric evaluation.A review of the medical record revealed no psychiatry consultation after 03/14/2026.During an interview on 08/06/2026 at 9:35 AM, Physician #1 (who covered for the attending in July 2026) stated they were not Resident #76's primary physician. Physician #1 stated they saw the resident on 07/10/2026 but did not write a note and did not document any recommendations, which was an oversight. Physician #1 stated they saw the resident again on 07/15/2026 and checked the resident's record. The resident was prescribed Lorazepam earlier in the month, so they reordered the same medication on 07/15/2026. Physician #1 stated they would have expected the psychiatrist to visit, if there were psychiatry consults ordered.During an interview on 08/06/2026 at 9:38 AM, Registered Nurse #2 (unit manager) stated the psychiatry consults were not completed as ordered. The process for ordering a psychiatry consult is to place an order in the electronic medical record and the Assistant Director of Nursing (who was no longer employed at the facility) was following up on the consults.A call was placed with the psychiatry consulting company, that the facility utilizes services from, on 08/06/2026 at 12:48 PM. There was no return phone call.During a phone interview on 08/06/2026 at 1:13 PM, the former Assistant Director of Nursing Services stated psychiatry consult orders were not correctly placed in system. If the order was not correctly entered, the vendor psychiatry services will not add the residents to their list for consultation. The Psychiatrist comes to the facility every Thursday with a list of residents to be seen. The nurses on the unit should alert the psychiatrist when a resident needs to be evaluated by the psychiatrist, even if the resident is not on their list.During an interview on 08/06/2026 at 1:50 PM, the Medical Director stated residents are seen by the psychiatrist based on urgency. If a resident is exhibiting extreme behaviors, the resident is sent to the hospital. The timeline from ordering the consult to when the resident is seen is based on urgency. If the psychiatrist is coming in every Thursday and there are repeated psychiatry consults being ordered, you would think the nurse on the unit would alert the psychiatrist. The Medical Director stated Resident #76 should have been seen by the psychiatrist sooner and that there was a delay in receiving psychiatry services. During an interview on 08/07/2026 at 7:40 AM, the Director of Nursing Services stated that due to worsening behaviors, the resident had multiple orders for the psychiatry consult after they were last seen in March 2026. There was a delay in psychiatry services for Resident #76 as the physician orders were not entered accurately in the electronic medical record.During an interview on 08/07/2026 at 8:08 AM, the Administrator stated the new psychiatry vendor (who started in May 2026) has a specific preference for how psychiatry consult orders are placed in the electronic medical record, but the facility was never told that if the consult order was not entered a certain way in the electronic medical record, they would not make the visit. The Administrator stated they have to follow up with the psychiatry vendor for clarification and inservice education for the staff entering the consult orders would have to be done. 10 New York Code Rules and Regulations 415.12(f)

Based on record review and staff interviews, the facility failed to ensure that each resident's medical records were complete, accurately documented, and were in accordance with accepted professional standards and practices. This was identified for one (Resident #19) of two residents reviewed for Activities of Daily Living. Specifically, Resident# 19 had scheduled shower days every Monday and Thursday; however, the Certified Nursing Assistant Accountability Sheet for 01/2026 and 03/2026 did not document that the scheduled showers were provided to Resident #19. Additionally, Resident#19 had a turning and positioning schedule every two hours. There was no documented evidence for 01/2026, 02/2026 and 03/2026, on multiple shifts, that turning and positioning was completed by the staff.Complaint # 2796395The findings include:The facility policy titled, Charting and Documentation last revised on 01/2026 documented that all services provided to the resident's progress towards the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. Documentation in the medical record will be objective (not opiniated or speculative), complete, and accurate. Documentation of procedures and treatments will include care specific details, including date and time the procedure/treatment was provided; name and title of individual who provided the care; whether the resident refused the procedure/treatment and notification of family, physician or other staff, if indicated.Resident # 19 was admitted with diagnoses including type two diabetes (high blood sugar), anemia (lack of healthy red blood cells to carry adequate oxygen to the body tissue), and paraplegia (loss of feeling and movement in the lower half of the body). A Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated that Resident #19 had intact cognition. A Quarterly Minimum Data Set assessment documented that Resident #19 had impairment to the lower extremities. A Quarterly Minimum Data Set assessment documented that Resident #19 was dependent on staff for toileting, showering, lower body dressing, and transfers. The Minimum Data Set documented that Resident #19 had unhealed pressure ulcers upon admission.A Physician's Order dated 06/17/2026 documented turn and position every two hours and as needed for offloading (reducing or redistributing weight), every shift.A Comprehensive Care Plan dated 01/08/2025 and revised on 07/20/2026 documented that Resident #19 rested on their back for long periods of time and refused to be turned and repositioned. Interventions included two-person approach for activities of daily living, turning and repositioning every two hours and as needed, and redirecting the resident when agitated.A Comprehensive Care Plan dated 03/30/2025 revised on 03/05/2026 documented that Resident #19 was at risk for functional decline in mobility and self-care related to type two diabetes. Interventions included bathing and showering during the 7:00-3:00 shift every Monday and Thursday, and assistance with bladder and bowel incontinence.The Braden Scale (predicting pressure sore risk) dated 03/26/2026 documented a score of 12, which indicated that Resident #19 was at a high risk for developing pressure ulcers.A review of Certified Nursing Assistant Accountability record from January 2026 through March 2026 indicated that the resident did not receive a shower on 01/05/2026, 01/08/2026,01/12/2026, 01/22/2026, 03/09/2026, 03/12/2026, 03/19/2026, 03/23/2026. A review of Certified Nursing Assistant Accountability record from January 2026 through March 2026 indicated that that turning and positioning was not performed every two hours for Resident #19 on 01/24/2026, 1/25/2026, 01/26/2026, 01/28/2026, 02/01/2026, 02/02/2026, 02/03/2026, 03/25/2026, 03/26/2026, 03/27/2026, 03/28/2026, 03/29/2026, 03/30/2026, 03/31/2026.During an interview on 08/05/2026 at 10:38 AM, Certified Nursing Assistant #1 stated that they worked during the 7:00 AM-3:00 PM shift and had provided showers to Resident #19; however, they could not recall why they did not sign for the showers provided. Certified Nursing Assistant #1 stated that Resident #19 will demand showers and was aware of their shower days.During an interview on 08/05/2026 at 10:54 AM, Certified Nursing Assistant #2 stated that they worked during the 7:00 AM-3:00 PM shift and had always provided showers to Resident #19. Certified Nursing Assistant #2 stated that there were times that the computer availability was limited, especially at the end of their shift and they must have missed signing for the showers provided.During an interview on 08/05/2026 at 11:15 AM, Certified Nursing Assistant #3 stated that they worked during the 7:00 AM-3:00 PM shift and had taken care of Resident #19. Certified Nursing Assistant #3 stated that Resident #19 would not refuse their showers. Certified Nursing Assistant #3 stated that they must have missed signing for the shower provided. Certified Nursing Assistant #3 stated that there were times when Resident #19 refused their turning and positioning. Certified Nursing Assistant #3 stated that they should have reported any refusal to the Nurse.During an interview on 08/05/2026 at 1:31 PM, Certified Nursing Assistant #4 stated that they worked during the 3:00 PM-11:00 PM shift. Certified Nursing Assistant #4 stated that they could not recall why they did not sign for Resident #19's turning and positioning sheets. Certified Nursing Assistant #4 stated there were times that Resident #19 refused to be turned and positioned and they (Certified Nursing Assistant #4) should have reported to the Nurse and recorded the refusal. During an interview on 08/05/2026 at 2:00 PM, Certified Nursing Assistant #5 stated that they worked during the 3:00 PM-11:00 PM shift. Certified Nursing Assistant #5 stated that Resident #19 was on every two hours turning and positioning schedule and refused to be turned and positioned at times. Certified Nursing Assistant #5 stated they could not recall if they recorded the refusal or notified the Nurse. During an interview on 08/06/2026 at 8:30AM, Registered Nurse #1, Unit Manager, stated that they could not recall if Resident #19 had refused their showers. Registered Nurse #1 stated that the Certified Nursing Assistants should have recorded and reported any refusal of care.During an interview on 08/06/2026 at 10:31 AM, the Director of Nursing Services stated that they had identified the issue of missing documentation , particularly with the Certified Nursing Assistant's recording of care when they first started working at the facility approximately 10 weeks ago and they are working with the vendor company to modify the system for Certified Nursing Assistant documentation. The Director of Nursing services stated that the staff must document as soon as care is provided to the residents. The Director of Nursing Services stated that Nursing staff should not end their shift with missing documentation on the resident's electronic medical record.10 New York Code Rules and Regulations 415.22(a) (1-4)

Based on observations, record review, and interviews during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024, the facility did not ensure that each resident received adequate supervision to prevent accidents and the resident environment remained as free of accident hazards as is possible. This was identified for two (Resident #51 and Resident #165) of ten residents reviewed for Accidents. Specifically, 1) Resident #51 had a history of falls and wandering behavior and the Comprehensive Care Plan directed staff to place the resident in a supervised area when awake. Resident #51 was left unsupervised in the hallway on 7/24/2024 at 1:10 AM and was found on the floor with injuries to the right side of their forehead and mouth. Subsequently, the resident was transferred to the hospital and was diagnosed with Traumatic Subdural Hemorrhage (brain bleed) and a Cervical Fracture (spine). 2) Resident #165, with a history of Suicidal Ideation was observed with an unattended disposable shaving razor in their room. This resulted in actual harm to Resident #51 that is not Immediate Jeopardy. The findings are: 1) The Falls Prevention Policy and Procedure last updated in January 2024 documented that as part of the initial assessment, the interdisciplinary team will help identify the individuals with a history of falls and risk factors for subsequent falling. The staff, with the support of the attending Physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. The staff and attending Physician will collaborate to identify fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. Resident #51 had diagnoses that included Dementia, Insomnia, and Hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severely impaired cognitive skills for daily decision-making. The Minimum Data Set documented that the resident needed partial/moderate assistance of one person to walk 10 feet. The Minimum Data Set documented that the resident had a history of falling and had no behaviors. The Fall Risk Evaluation dated 2/11/2024 documented a score of 21 indicating the resident was a high risk for falls. The Comprehensive Care Plan for Falls initiated on 1/22/2023, updated 1/24/2024, documented interventions to place the resident in a supervised area when awake and monitor the resident every 15 minutes for frequent falls Updated 1/22/2024, documented provide redirection and encourage the resident to utilize one-person assistance for ambulation with a rolling walker for safe ambulation and for fall prevention. The Comprehensive Care Plan for Behaviors dated 2/2/2023 documented the resident had potential risks for exhibiting behavior symptoms such as verbally aggressive/abusive, physically aggressive/abusive, and wandering behavior related to cognitive impairment secondary to Dementia. The interventions included administering medications, distracting the resident from wandering and modifying the environment to reduce episodes of negative behavior and risk for falls or injury. There was no documented evidence the current Certified Nursing Assistant Kardex (care instructions for Certified Nursing Assistants) did not include interventions indicated in the Comprehensive Care Plan to place the resident in a supervised area when out of bed. The Nursing Progress Note dated 7/24/2024 at 6:53 AM, by the Registered Nurse Supervisor #6, documented that the resident was observed sitting on the floor hallway around 1:10 AM. The resident had a bump on the right side of their forehead and a swollen upper lip with blood inside their mouth. The resident denied pain and the range of motion (ROM) was within normal limits. The resident stated, I am going home. The resident's Physician was called and ordered to transfer the resident to the emergency room for a head Computed Tomography (CT) scan. The Occurrence Report/Investigation dated 7/31/2024 documented Certified Nursing Assistant #3, who was assigned to the resident, reported that while they attended to another resident, Resident #51 got up (from their wheelchair) and fell to their right side in the hallway. The investigation concluded that the resident was confused, had a history of Dementia, Depression, poor sleeping patterns, and needed constant reminders. The resident was non-compliant with the use of their call bell and ambulated without assistance at times despite redirection. The resident was to remain on close monitoring, and for the staff to not leave the resident unattended and maintain safety visual checks. During an interview on 9/20/2024 at 11:35 AM, Certified Nursing Assistant #3 stated when they came on duty for their 11:00 PM-7:00 AM shift on 7/24/2024 (their shift started on 7/23/2024), Resident #51 was already seated in the hallway in their wheelchair. Certified Nursing Assistant #3 stated Resident #51 was agitated and wanted to go home. Resident #51 had packed a bag using a pillowcase in which the resident had put their belongings. Certified Nursing Assistant #3 stated that Resident #51 had a history of getting up from their wheelchair and going to the bathroom without assistance if they were left alone. Certified Nursing Assistant #3 stated they sat with the resident in the hallway because someone had to be there to watch the resident. Certified Nursing Assistant #3 stated they had to leave Resident #51 in the hallway to help Certified Nursing Assistant #9 with another resident in a room. Certified Nursing Assistant #3 stated they did not expect Resident #51 to get up from their wheelchair by the time they got back from helping Certified Nursing Assistant #9 in a room with another resident. During an additional interview on 9/23/2024 at 12:00 PM, Certified Nursing Assistant #3 stated they left Resident #51 in the hallway to help another Certified Nursing Assistant #9 break up a fight between two residents in their room. Certified Nursing Assistant #3 stated Licensed Practical Nurse #10 also got up from the Nurse's Station and went into the same room, leaving Resident #51 alone in the hallway. Certified Nursing Assistant #3 stated they heard a noise in the hallway, ran out of the room, and saw Resident #51 lying on the floor. Licensed Practical Nurse #10 was unavailable for an interview. During an interview on 9/24/2024 at 12:55 PM, the Assistant Director of Nursing Services/Risk Manager stated the resident always has to stay in someone's line of vision because you could not tell when the resident would get up so you would have to be able to see the resident. The Assistant Director of Nursing Services/Risk Manager stated Resident #51 fell on [DATE] at 1:10 AM during the night when Certified Nursing Assistant #3 left Resident #51 in the hallway to assist another Certified Nursing Assistant #9. The Assistant Director of Nursing Services/Risk Manager stated that Certified Nursing Assistant #3 should have called for help so they could have stayed with Resident #51 while someone else went to help the other Certified Nursing Assistant #9. The Assistant Director of Nursing Services/Risk Manager stated the resident's care plan was not followed and Certified Nursing Assistant #3 should have stayed with Resident #51. During an interview on 9/24/2024 at 1:23 PM, the Director of Nursing Services stated there was a break in the resident's plan of care. Certified Nursing Assistant #3 or Licensed Practical Nurse #10 should not have left Resident #51 alone in the hallway. During an interview on 9/24/2024 at 1:50 PM, the Medical Director stated that someone should have at least been there, some responsible party, to stay with the resident. Both the Certified Nursing Assistant and Licensed Practical Nurse should not have left the resident alone. A responsible party should have relieved the individual watching the resident, unless it was an emergency or urgent situation, such as a resident having a cardiac arrest. 48827 2) The facility's Hazardous Area, Devices, and Equipment policy last reviewed on 1/2024 documented a hazard is defined as anything in the environment that has the potential to cause injury or illness. The policy identified hazards including sharp objects that are accessible to vulnerable residents. The policy further documented that any element of the resident environment that has the potential to cause injury and is accessible to a vulnerable resident is considered hazardous. Resident #165 was admitted with diagnoses including Bipolar Disorder, Schizophrenia, and Major Depressive Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. The Minimum Data Set documented the resident had potential indicators for Hallucinations (a false perception of objects or events involving your senses: sight, sound, smell, touch, and taste). The Minimum Data Set documented the resident used a manual wheelchair and walker for mobility and could walk 150 feet with supervision. A Comprehensive Care Plan titled Behavior Symptoms initiated on 1/06/2024 and revised on 9/23/2024, documented interventions that included 15-minute monitoring for suicidal ideation initiated on 1/06/2024 and modifying the environment to reduce episodes of negative behavior and risk for falls or injury. A nursing progress note, written by Registered Nurse Unit Supervisor #2, dated 6/04/2024 documented Resident #165 was exhibiting behavioral symptoms such as repeated movements and wandering. The resident complained of hearing voices to hurt themselves but had no plan. The physician's order dated 6/04/2024 documented to monitor Resident #165 every 15 minutes for Suicidal Ideation. The Psychiatry Consult note dated 6/05/2024 documented Resident #165 had a history of Depression and Schizophrenia. Resident #165 reported auditory Hallucinations (hearing voices that were not there). The nursing progress note, written by Registered Nurse Unit Supervisor #2, dated 6/07/2024 documented Resident #165 complained of hearing voices and could not control the voices in their head anymore. The resident reported they have a plan to kill themselves. The resident was transferred to the hospital. The medical progress note, written by Physician's Assistant #1, dated 6/07/2024 documented Resident #165 was seen for a weekly follow-up and for continued monitoring of chronic and acute conditions including Suicidal Ideation. The resident was sent to the hospital for Suicidal Ideation. The hospital discharge summary dated 6/07/2024 documented Resident #165 was seen in the emergency room for Psychiatric evaluation for Suicidal Ideation. A review of the medical record from 6/07/2024 to 9/19/2024 indicated no behaviors of Suicidal ideation or a plan for self-harm. A review of the 15-minute monitoring sheets from 8/22/2024 to 09/23/2024 documented that staff monitored the resident every 15 minutes. Resident #165 was observed sleeping in their bed on 9/17/2024 at 10:28 AM. A disposable shaving razor was observed at the sink in the resident's room. During an interview on 9/19/2024 at 9:34 AM, Resident #165 was in their room lying in bed and stated they just had breakfast, enjoyed the breakfast, and had no concerns with the facility. During an observation on 9/23/2024 at 10:47 AM, Resident #165 was observed sleeping in their bed. A disposable shaving razor was observed at the sink in the resident's room. During an interview on 9/23/2024 at 10:48 AM, Certified Nursing Assistant #4 stated they were the assigned Certified Nursing Assistant for Resident #165, and the razor that was observed in Resident #165's room belonged to the resident's roommate. Certified Nursing Assistant #4 stated the disposable shaving razor should not be left in the resident's room. Certified Nursing Assistant #4 then removed the disposable shaving razor from the resident's room. During an interview on 9/23/2024 at 10:49 AM, Registered Nurse Supervisor #2 stated Resident #165 was on every 15-minute monitoring for suicidal ideation and should not have access to the disposable shaving razor. During an interview on 9/23/2024 at 11:36 AM, Psychiatrist #1 stated Resident #165 should not have access to a razor because in the past Resident #165 had expressed thoughts of self-harm. During an additional interview on 9/24/2024 at 10:29 AM, Registered Nurse Supervisor #2 stated Resident #165 has not been verbalizing thoughts of suicidal ideation since their return from the hospital in June 2024. Resident #165 is monitored every 15 minutes for a history of auditory hallucinations. During an additional interview on 9/24/2024 at 10:58 AM, Certified Nursing Assistant #4 stated the resident has been much more pleasant since they returned from the hospital and has not expressed thoughts of hurting self. During an interview on 9/24/2024 at 1:25 PM, the Director of Nursing Services stated that no razors should have been kept in any resident's room. Resident #165 had the potential to self-harm. 10 NYCRR 415.12(h)(1)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for 1) six (Resident #52, Resident #194, Resident #29, Resident # 32, Resident #1, Resident #50) of six residents reviewed for the Medication Storage and Labeling Task and 2) one (Resident #53) of three residents observed for infection Control Task. Specifically, Licensed Practical Nurse #6 did not use an Environmental Protection Agency approved cleaning agent to sanitize the glucometer (a handheld device used to measure the concentration of sugar in the blood) machine after using the glucometer machine for each resident. 2) Resident #53 was on contact precautions for a Vancomycin Resistant Enterococcus (a multi-drug resident organism) infection to the right lower extremity wound. During the initial tour of the second floor, the Case Manager was observed not wearing appropriate Personal Protective Equipment while in Resident #53's room. The finding is: The facility's policy and procedure titled, Cleaning and Disinfection of Glucometer, last revised on 1/2024 documented that glucometer cleaning should take place prior to and immediately after each use to prevent the spread of pathogens from blood or body fluids. In cases where the manufacturer has no cleaning recommendations, using an Environmental Protection Agency (EPA) registered high-level disinfectant is standard. Resident-care equipment including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standards. Blood Glucose Monitoring System Manual documented the use of an Environmental Protection Agency (EPA) registered disinfecting wipe for disinfecting the Blood Glucose Monitoring System. The disinfection process reduces the risk of transmitting infectious diseases. -Resident #52 was admitted with diagnoses including Type 2 Diabetes Mellitus, Bipolar Disorder, and Chronic Obstructive Pulmonary Disease (COPD). A Comprehensive Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #52 had intact cognition. Resident #52's physician order dated 2/12/2024 documented Novolog Flex Pen Subcutaneous Solution Pen-injector 100 units per milliliter, inject per sliding scale before meals and at bedtime and notify the Physician of the blood sugar levels of below 60 milligrams/deciliter and above 400 milligrams/deciliter. -Resident #194 was admitted with diagnoses including Type 2 Diabetes Mellitus, Benign Prostatic Hyperplasia, and Alcohol Dependence. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #194 had moderately impaired cognition. Resident #194's physician order dated 2/13/2024 documented Humalog Kwikpen Subcutaneous Solution Pen-injector 100 units per milliliter, inject per sliding scale before meals and at bedtime and notify the Physician of the blood sugar levels of below 60 milligrams/deciliter or above 400 milligrams/deciliter. -Resident #29 was admitted with diagnoses including Type 2 Diabetes Mellitus, Anemia, and Schizophrenia. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented no Brief Interview for Mental Status (BIMS) score as Resident #29 had severely impaired cognitive skills for daily decision-making. Resident #29's physician order dated 5/1/2024 documented Humalog Kwikpen Subcutaneous Solution pen injector 100 units per milliliter, inject per sliding scale before meals and at bedtime and notify the Physician of the blood sugar levels of below 60 milligrams/deciliter and above 400 milligrams/deciliter. -Resident #32 was admitted with diagnoses including Type 2 Diabetes Mellitus, Anemia, and Hypertension. A Comprehensive Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, which indicated Resident #32 had moderately impaired cognition. Resident #32's physician order dated 2/4/2024 documented Novolog Injection Solution 100 units per milliliter, inject per sliding scale before meals and at bedtime and notify the Physician of the blood sugar levels of below 60 milligrams/deciliter and above 400 milligrams/deciliter. -Resident #1 was admitted with diagnoses including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), and Congestive Heart Failure. A Comprehensive Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #1 had intact cognition. Resident #1's physician order dated 8/31/2024 documented Insulin Lispro 100 units per milliliter, inject insulin as per the sliding scale before meals and at bedtime, and notify the Physician of the blood sugar levels of below 60 milligrams/deciliter and above 400 milligrams/deciliter. -Resident #50 was admitted with diagnoses including Type 2 Diabetes Mellitus, Anemia, and Chronic Kidney Disease. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, which indicated Resident #50 had moderately impaired cognition. Resident #50's physician order dated 9/11/2024 documented Insulin Lispro Injection 100 units per milliliter, inject insulin as per the sliding scale before meals and at bedtime, and notify the Physician of the blood sugar levels of less than 70 milligrams/deciliter or greater than 400 milligrams/deciliter. During the Medication Storage Task observation, a medication cart was observed with Licensed Practical Nurse #6 on 9/20/2024 at 10:15 AM. A glucometer machine was observed in the medication cart. Licensed Practical Nurse #6 stated they always used the 70% isopropyl alcohol prep pads to wipe the glucometer machine between each resident because the Environmental Protection Agency approved cleaning wipes were not available, Registered Nurse #4, the Unit Supervisor, was interviewed on 9/20/2024 at 10:30 AM with Licensed Practical Nurse #6 and stated the facility only uses the Environmental Protection Agency-approved disinfecting germicidal wipes for glucometer cleaning and disinfecting. Registered Nurse #4 stated that Licensed Practical Nurse #6 should not have used the alcohol prep pad to disinfect the glucometer because the alcohol pads would not disinfect any blood-borne pathogens on the glucometer. The Nurse Educator was interviewed on 9/20/2024 at 2:26 PM and stated all Nurses had a competency in-service regarding the use of the glucometer machine within the year which included cleaning and disinfection. The Nurse Educator stated it is not the facility's protocol to use alcohol pads to clean the glucometer machine because the alcohol does not effectively clean the bloodborne pathogens. The Infection Preventionist was interviewed on 9/20/2024 at 2:47 PM and stated the facility uses Environmental Protection Agency approved germicidal wipes to clean the glucometer machines and the facility has plenty of supply. Licensed Practical Nurse #6 should have requested the germicidal wipes for cleaning and disinfecting the glucometer machine. The Infection Preventionist stated that germicidal wipes are effective against bloodborne pathogens (Hepatitis B, Human Immunodeficiency Virus, and Hepatitis C). The Director of Nursing Service was interviewed on 9/24/2024 at 8:46 AM and stated it is unacceptable to use any cleaning wipes except for the approved germicidal wipes to clean and disinfect the glucometer machine. 28173 2) The facility's policy titled Isolation-Categories of Transmission-Based Precautions, last reviewed 1/2024, documented contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Staff and visitors will wear gloves and a disposable gown upon entering the room, remove the gloves and gown before leaving the room, and avoid touching potentially contaminated surfaces with clothing after the gown is removed. Resident #53 was admitted with diagnoses including a Right Lower Leg Wound and Skin Infection. The 7/12/2024 Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. The Physician's order dated 7/18/2024 documented to place the resident on contact precautions for positive Vancomycin-Resistant Enterococcus infection of the right lower extremity. Current Physician's orders as of 9/5/2024 documented to administer Piperacillin Sod-Tazobactam Solution (antibiotic medication) 3.375 gram intravenously every 6 hours for Infected Wound with positive wound culture for 14 days and Bactrim DS (antibiotic medication) Tablet 800-160 milligrams, give one tablet by mouth every 12 hours for infected wound with positive wound culture for 14 days. During an initial tour of the second floor on 9/17/2024 at 11:11 AM, Resident #53's door was observed with a contact precautions sign. The contact precautions sign documented: everyone must put on gloves before room entry and discard gloves before room exit; put on a gown before room entry and discard the gown before room exit; clean hands before entering and when leaving the room. Case Manager #1 was observed inside the resident's room, standing in very close proximity to the resident. Case Manager #1 was not wearing Personal Protective Equipment including a gown or gloves. During an interview on 9/17/2024 at 11:17 AM, Case Manager #1 stated that they did not see the signage outside the resident's room and were not aware that Resident #53 was on contact precautions. Case Manager #1 stated they now know that they should have put on a disposable gown and gloves while in the room with the resident. During an interview on 9/19/2023 at 8:34 AM, the Infection Preventionist stated Case Manager #1 should have put on a gown and gloves when they entered the resident's room in accordance with the facility's infection control policies. During an interview on 9/25/2024 at 1:46 PM, the Director of Nursing Services stated Case Manager #1 should have put on appropriate Personal Protective Equipment as per the facility's infection control program and the signage that was posted outside the resident's room before entering. 10 NYCRR 415.19(a)(1-3)

Based on observations, interviews, and record review during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024, the facility did not ensure that each resident received food that accommodated resident allergies, intolerances, and preferences. This was identified for one (Resident #39) of eighteen residents reviewed during the dining task. Specifically, Resident #39 had a physician's order for a gluten-free diet (gluten is a protein found in grains like wheat, rye, and barley). During observations on 9/17/2024 and 9/19/2024, the resident was served white bread with their meal for lunch. The finding is: Resident #39 was admitted with diagnoses including Hypertension and Chronic Obstructive Pulmonary Disease. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. The Minimum Date Set assessment documented the resident was on a therapeutic diet. The Comprehensive Care Plan titled Resident has or is at Risk for Impaired Gastrointestinal Function dated 3/22/2023 revised on 2/12/2024, documented the resident had a non-celiac gluten sensitivity. Interventions included referring the resident to dietary for a modification to the resident's diet. The Comprehensive Care Plan titled The Resident has Actual or Potential for Fluid Deficit dated 4/18/2023 revised on 2/12/2024, documented the resident had a food limitation with wheat and gluten. A physician's order dated 2/4/2023 documented to provide the resident with no wheat (gluten-free) products. Resident #39 was observed eating lunch in their room on 9/17/2024 at 12:49 PM. The items on the resident's meal tray included a turkey sandwich with white bread, cooked string beans, coffee, and two containers of apple juice. The meal ticket, included with the resident's meal tray, indicated highlighted words gluten-free. The resident was observed eating the turkey from the sandwich and leaving the white bread aside. A subsequent observation was completed on 9/19/2024 at 1:08 PM. Resident #39 was observed in their room during the lunch meal service. The resident's meal tray included a pastrami sandwich with white bread and assorted cooked vegetables. The resident stated they usually leave the white bread on the side and knew not to consume the bread. The meal ticket included with the meal tray documented gluten-free which was observed to be highlighted on the meal ticket. The Director of Food Services was interviewed on 9/19/2024 at 1:08 PM and stated Resident #39 should not have had white bread included with their meal. The Director of Food Services stated it was an oversight. The Director of Food Services stated they highlight any pertinent information on a resident's meal ticket such as allergies, intolerances, and preferences. The Director of Food Services stated they were responsible for ensuring each resident's meal followed the resident's diet, preferences, allergies, and intolerances. The resident should have received gluten-free meals and substitutes. Dietary Supervisor #1 was interviewed on 9/19/2024 at 1:54 PM and stated they were responsible for ensuring each resident's meal followed the specified diet, allergies, intolerances, and preferences. Dietary Supervisor #1 stated Resident #39 should not have had a pastrami sandwich with white bread included with their lunch because white bread is not gluten-free. Dietary Supervisor #1 stated the facility did not have gluten-free bread and the resident should have had pastrami with gluten-free options such as rice or mashed potatoes. Dietary Supervisor #1 stated that this was an oversight. An interview was conducted with Dietary Supervisor #2 on 9/24/2024 at 1:56 PM and stated Resident #39 should not have had any bread included with their meal and this was an oversight. The Director of Nursing Services was interviewed on 9/25/2024 at 11:31 AM and stated Resident #39 should not have had bread included with their meal. The resident's meal ticket should only include gluten-free foods. The Director of Nursing Services further stated the nurses on the unit were also responsible for checking each resident's meal tray and meal ticket to ensure the accuracy of the meal. 10 NYCRR 415.14(d)(4)

Based on record review and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that a qualified Dietician is licensed or certified as a nutrition professional by the state in which the services are performed. This was identified for one (Registered Dietitian #1) of five employees reviewed for the Criminal History Record Check task. Specifically, part-time Registered Dietitian #1 did not have an active license or certification issued by the New York State as a Dietitian or nutrition professional since [DATE]. Registered Dietician #1 was hired by the facility on [DATE] and continued to work directly with the residents without documented evidence of being supervised by a qualified professional. The finding is: A review of Registered Dietitian #1's personnel file revealed that they were hired by the facility on [DATE] and their Dietetics-Nutrition license from New York State had expired on [DATE]. There was no documented evidence that Registered Dietician #1 was supervised by a qualified professional from [DATE] until [DATE]. The Director of Human Resources was interviewed on [DATE] at 12:30 PM and stated that registered Dietician #1 was hired by the facility on [DATE] and they (the Director of Human Resources) overlooked the fact that Registered Dietitian #1's professional license for Dietetics-Nutrition was expired as of [DATE]. The Administrator was interviewed on [DATE] at 2:20 PM and stated the Director of Human Resources should have ensured that part-time Registered Dietitian #1's Dietetics-Nutrition license was current. 415.14(a)(1)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024 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 #75) of ten residents reviewed for Accidents. Specifically, Resident #75 was applying the Biofreeze Professional Pain-Relieving Gel to their knees and the facility staff was aware. A review of the resident's medical records revealed there was no assessment to determine if the resident could safely self-administer the medication. Additionally, Resident #75 did not have a Physician's Order to apply the Biofreeze Professional Pain-Relieving Gel. The finding is: The facility's policy and procedure titled Self-Administration of Medications, last revised on 1/2024 documented that as part of a resident's overall evaluation, the staff and the practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. The staff and the practitioner will ask residents who are identified as being able to self-administer medications whether they wish to do so. Self-administered medications must be stored in a safe place, which is not accessible by other residents. Staff shall identify and give the Charge Nurse any medicines found at the bedside that are not authorized for self-administration. Resident #75 was admitted to the facility with diagnoses including a Periprosthetic (close to an implant or artificial joint) Fracture Around the Internal Prosthetic Right Knee Joint, Atrial Fibrillation, and Malignant Neoplasm. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #75 had intact cognition. Resident #75 received Pain Management and scheduled pain medications as needed. A Comprehensive Care Plan (CCP) dated 2/13/2023 and revised on 9/19/2024 documented that Resident #75 had an altered comfort related to immobility and gout. Resident #75 received pain medications. Interventions included administering medications as ordered. Assess for breakthrough pain and the need for supplemental doses. Assess the nature, intensity, location, duration, and frequency of pain. Notify the Physician if interventions are unsuccessful or if the current complaint is a significant change from the resident's experience of pain. A Comprehensive Care Plan (CCP) dated 6/8/2024 documented that Resident #75 was at risk for contractures and functional impairment. Interventions included assessing joints for limitations, swelling, redness, or pain. Resident #75 will participate in ambulation exercises as prescribed. During an observation on 9/17/2024 at 10:45 AM, Resident #75 was observed with a tube of Biofreeze Professional Pain-Relieving Gel on their overbed table. Resident #75 stated they had the Biofreeze tube for a while and used the medication on both knees. The medical record lacked documented evidence of a Physician's Order and assessment for self-administration of the Biofreeze medication. Certified Nursing Assistant #8 was interviewed on 9/17/2024 at 10:45 AM and stated they had seen the Biofreeze Professional Pain-Relieving Gel on top of the resident's overbed table and in the drawer a few times. Certified Nursing Assistant #8 stated they could not recall if they informed the Nurse about the Biofreeze medication. Licensed Practical Nurse #6 was interviewed on 9/17/2024 at 10:59 AM and stated they had never seen Resident #75 with Biofreeze Professional Pain-Relieving Gel. Licensed Practical Nurse #6 stated that Resident #75 should not have any medications stored in their room because Resident #75 did not have any order for self-administration of medications. Resident #75 was interviewed on 9/23/2024 at 9:38 AM and stated they had purchased the Biofreeze Professional Pain-Relieving Gel online. Resident #75 stated the Physical Therapist used to apply the Biofreeze Professional Pain-Relieving Gel on their knee during therapy, but the Physical Therapist is not always available when they (Resident #75) need the medication. Resident #75 stated they had the Biofreeze Professional Pain-Relieving Gel for a while and kept it on their overbed table. Resident #75 stated the staff was aware that they had the Biofreeze Professional Pain-Relieving Gel tube. Physical Therapist #1 was interviewed on 9/23/2024 at 9:49 AM and stated they used Biofreeze Professional Pain-Relieving Gel for Resident #75 to relieve pain during therapy. Physical Therapist #1 stated they did not need a Physician's order to apply the Biofreeze medication because it is part of Physical Therapy. The Biofreeze is applied after the exercises and they only keep the medication in the therapy gym. The Director of Nursing Services was interviewed on 9/24/2024 at 8:34 AM and stated that Certified Nursing Assistant #8 should have reported the Biofreeze Professional Pain-Relieving Gel was at Resident #75's overbed table. The Director of Nursing Services stated nurses should perform a self-administration of medication competency assessment and get a Physician's Order if a resident is deemed capable of self-administering the medications. 10 NYCRR 415.3(f)(1)(vi)

Based on record review and interviews during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024, the facility did not ensure an assessment was completed to accurately reflect the resident's status. This was identified for one (Resident #167) of one resident reviewed for Hospice and End of Life. Specifically, the Quarterly Minimum Data Set assessment dated [DATE] did not reflect that Resident #167 received Hospice care. The finding is: The facility's policy titled MDS Assessment Coordinator, last reviewed on 1/2024 documented a Registered Nurse should be designated the responsibility of conducting and coordinating each resident's Minimum Date Set assessment. Each individual who completes a portion of the assessment must certify the accuracy of that portion of the assessment by dating and signing the assessment and identifying each section completed. Resident #167 was admitted with diagnoses including Palliative Care, Cerebrovascular Disease, and Dementia. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status was not conducted because the resident had severely impaired skills for daily decision-making. The Minimum Data Set did not include that Resident #54 received Hospice Services while a resident at the facility. A Comprehensive Care Plan titled Resident is at End of Life/Diagnosis of Terminal Illness, dated 9/1/2024 and last revised on 9/17/2024 documented that the resident received Hospice care. The care plan interventions included providing comfort measures, honoring preferences when possible, and referring the resident to the Hospice program per the physician's orders. A Physician's Order dated 5/1/2024 documented Hospice care. During an interview on 9/23/2024 at 12:07 PM, Registered Nurse #3, the Minimum Data Set assessment nurse, stated they were responsible for completing the Minimum Data Set assessment Section O (Special Treatments). Registered Nurse #3 stated when they completed the assessment dated [DATE], the resident was receiving Hospice care. Registered Nurse #3 further stated they made an error and did not document the resident received Hospice care under the Special Treatments section of the Minimum Data Set assessment. During an interview on 9/23/2024 at 12:38 PM, the Minimum Data Set Assessment Coordinator stated the Quarterly Minimum Date Set assessment for Resident #167 should have documented that the resident received Hospice care. The Minimum Data Set Assessment Coordinator stated this was an error and an oversight. During an interview on 9/25/2024 at 11:40 AM, the Director of Nursing Services stated Resident #167 received Hospice care and the Quarterly Minimum Data Set assessment dated [DATE] should have documented Hospice care. 10 NYCRR 415.11(b)

Based on interviews and record review during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024 the facility did not ensure that comprehensive assessments of residents were conducted within 14 calendar days after admission and not less than once every 12 months. This was identified for three (Residents #126, Resident#168, and Resident #181) of 11 residents reviewed for the Resident Assessment Task. Specifically, Resident #168's Significant Change Minimum Data Set, Resident #126's Annual Minimum Data Set, and Resident # 181's Discharge Minimum Data Set Assessments were not completed within 14 days of the assessment reference date. The findings are: The facility's policy and procedure for Minimum Data Set, last revised on 8/2023 documented a Registered Nurse shall be designated for conducting and coordinating each resident's assessment. The Assessment Coordinator must date and sign each assessment to certify that the assessment has been completed. Each individual who completes a portion of the assessment must certify the accuracy of that portion of the assessment by dating and signing the assessment and identifying that each section was completed. The policy did not include the timeframe for the completion of the assessment. Resident #168's Significant Change Minimum Data Set with an assessment reference date of 7/12/2024 documented a completion date of 8/27/2024, 32 days past the due date of 7/26/2024. Resident #126's Annual Minimum Data Set with an assessment reference date of 8/16/2024 documented a completion date of 9/17/2024, 18 days past the due date of 8/30/2024. Resident #181's Discharge Minimum Data Set with an assessment reference date of 5/21/2024 documented a completion date of 6/18/2024, 14 days past the due date of 6/4/2024. During an interview on 9/25/2024 at 1:20 PM with the Minimum Data Set Coordinator they stated they are responsible for ensuring the timely completion of the Minimum Data Set assessments. The Minimum Data Set Coordinator stated they are aware of the late completion of the Minimum Data Set assessments. The Minimum Data Set Coordinator stated the Dietary Department was not completing their respective sections timely which resulted in a delay in the completion of the Minimum Data Sets. During an interview on 9/25/2024 at 1:49 PM the Administrator stated they are aware of the late completion of the Minimum Data Set assessments. The lateness was related to a dietary contractor who failed to complete their assessments on time, which delayed the completion of the assessments. 10 NYCRR 415.11(a)(3)(i)

Based on interviews and record review during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024 the facility did not ensure residents were assessed using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services not less frequently than once every three months. This was identified for eight (Resident #92, Resident #161, Resident #170, Resident #120, Resident #135, Resident #194, Resident #153, and Resident #155) of 11 residents reviewed for the Resident Assessment Task. Specifically, the Quarterly Minimum Data Set assessments for Resident #92, Resident #161, Resident #170, Resident #120, Resident #135, Resident #194, Resident #153, and Resident #155 were not completed within 14 days of the assessment reference date. The findings are: The facility policy titled Minimum Data Set Completion and Submission Timeframes dated 1/2024 documented that the timeframes for completion and submission of the assessments are based on the current requirements published in the Resident Assessment Instrument Manual. Resident #92's Quarterly Minimum Data Set with an assessment reference date of 8/16/2024 documented a completion date of 9/17/2024, 18 days past the due date of 8/30/2024. Resident #161's Quarterly Minimum Data Set with an assessment reference date of 7/13/2024 documented a completion date of 8/28/2024, 32 days past the due date of 7/27/2024. Resident #170's Quarterly Minimum Data Set with an assessment reference date of 8/16/2024 documented a completion date of 9/17/2024, 18 days past the due date of 8/30/2024. Resident #120's Quarterly Minimum Data Set with an assessment reference date of 8/9/2024 documented a completion date of 9/16/2024, 24 days past the due date of 8/23/2024. Resident #135's Quarterly Minimum Data Set with an assessment reference date of 8/16/2024 documented a completion date of 9/17/2024, 18 days past the due date of 8/30/2024. Resident #194's Quarterly Minimum Data Set with an assessment reference date of 8/2/2024 documented a completion date of 9/14/2024, 29 days past the due date of 8/16/2024. Resident #153's Quarterly Minimum Data Set with an assessment reference date of 7/26/2024 documented a completion date of 9/12/2024, 34 days past the due date of 8/9/2024. Resident #155's Quarterly Minimum Data Set with an assessment reference date of 8/16/2024 documented a completion date of 9/17/2024, 18 days past the due date of 8/30/2024. During an interview on 9/25/2024 at 1:20 PM with the Minimum Data Set Coordinator they stated they are responsible for ensuring the timely completion of the Minimum Data Set assessments. The Minimum Data Set Coordinator stated they are aware of the late completion of the Minimum Data Set assessments. The Minimum Data Set Coordinator stated the Dietary Department was not completing their respective sections timely which resulted in a delay in the completion of the Minimum Data Sets. During an interview on 9/25/2024 at 1:49 PM the Administrator stated they are aware of the late completion of the Minimum Data Set assessments. The lateness was related to a dietary contractor who failed to complete their assessments on time, which delayed the completion of the assessments. 10 NYCRR 415.11(a)(4)

Based on observation, record review and interviews during the Recertification Survey and Abbreviated Survey (NY00305185) initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure each resident was free from abuse, neglect, misappropriation of resident property, and exploitation. This was identified for one (Resident #140) of two residents reviewed for Resident-to-Resident Abuse. Specifically, on 11/8/2022, Resident #326, with intact cognition, verbalized that they are going to hit Resident #140 if the resident went to their room again. Soon after the verbal threat, Resident #326 went to Resident #140's room and was observed hitting Resident #140 in the head. Subsequently, Resident #140 was transferred to the hospital and was diagnosed with a left orbital (eye) skull fracture and bruising to the head. This resulted in actual harm to Resident #140 that is not Immediate Jeopardy. The finding is: The facility's policy titled, Abuse Prevention Program/Abuse and Neglect-Clinical Protocol/Abuse Investigation and Reporting, last reviewed 1/2023, documented that residents have a right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility defined Physical abuse as the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse includes but is not limited to such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, slapping, kicking, pinching, and burning. Resident #326 (aggressor) was admitted with diagnoses including Bipolar Disorder, Panic Disorder, and Difficulty in Walking. The 8/19/2022 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS documented that the resident had verbal behavioral symptoms directed toward others and required extensive assistance for bed mobility and transfers. Walking did not occur, and the resident utilized a wheelchair for mobility. The Comprehensive Care Plan (CCP) for Resident #326 titled, Behavior Problems effective 8/12/2022 documented that the resident had behaviors of increased agitation, yelling and was verbally abusive to staff and others, physically abusive toward staff, and was socially inappropriate. A 9/6/2022 entry documented that the resident was overheard talking to a friend on the phone about an incident in another facility and what they would do at the other facility with a gun. Interventions were put in place including close supervision. A Psychiatry consult for Resident #326 dated 9/6/2022 documented diagnoses of Bipolar Disorder, Panic Disorder, and Alcohol Use. The resident was noted with a worsening condition and with mood instability. Recommendations included Quetiapine (an antipsychotic medication) 50 milligrams (mg) twice a day. A review of Resident #326's progress notes from August 2022 to October 2022 revealed on 8/11/2022 Resident #326 made a threat to hit staff. Other documented behaviors in progress notes included agitation, yelling, verbally abusive, harmful to self and others, erratic, voicing suicidal and homicidal ideation, physically aggressive, cursing, disruptive to the whole unit, and slamming the nursing station desk for narcotics (controlled substance). A nursing progress note for Resident #326, written by Licensed Practical Nurse (LPN) #4 (charge nurse), dated 11/8/2022 documented LPN #4 was informed by Certified Nursing Assistant (CNA) #1 that the resident stated, If [Resident #140] goes into my room again, I am going to punch [Resident #140] out. Resident #326 repeated the same statement to LPN #4. LPN #4 notified the nursing supervisor. The nursing progress note documented that CNA #1 yelled out for assistance because Resident #326 was going into Resident #140's room. LPN #4 ran down the hall and saw Resident #326 standing over and punching Resident #140 with a closed fist. LPN #4 jumped in between the two residents and screamed, and then Resident #326 stopped punching Resident #140. Staff responded and a physician was notified. Resident #326 left the unit with the ambulette attendants and three police officers. Resident #326 returned to the facility on [DATE]. A Social Work note for Resident #326 dated 11/9/2022 documented a 30-day transfer-discharge notice issued to Resident #326 due to the resident being a danger to other residents. A review of admission transfer and discharge (ADT) data revealed that Residents #140 and #326 resided across the hallway from each other. Resident #140 (victim) was admitted with diagnoses including Alzheimer's Disease, Hypertension, and Altered Mental Status. The 10/2/2022 Significant Change MDS assessment documented a BIMS score of 4, indicating the resident had severely impaired cognition. The MDS documented that the resident sometimes understands and is sometimes understood. The MDS documented no mood or behavioral issues. The MDS documented that the resident required limited assistance for transfers and walking. A CCP titled Abuse Prevention for Resident #140 dated 10/26/2022 documented that the resident was at risk for victimization related to the diagnosis of Alzheimer's Disease. Interventions included to remove the resident from the area of the aggressor and counsel the resident to avoid contact with the aggressor. A nursing progress note for Resident #140 dated 11/4/2022 documented the resident was observed going into other resident rooms and eating from their food trays. Resident #140 was redirected whenever this behavior was observed. A nursing progress note, written by Registered Nurse (RN) #6, for Resident #140 dated 11/8/2022 documented that at 5:30 PM Resident #140 was assaulted by another resident (Resident #326). Resident #326 left their room and went into Resident #140's room and started punching Resident #140 in the head several times for no reason. Resident #140 was assessed for injury; some swelling was noted. Due to Resident #140's scalp deformity, RN #6 was unable to assess the injury. Physician #4 was made aware of the incident and ordered to transfer Resident #140 to the hospital for head injury evaluation. A nursing progress note dated 11/9/2022 documented that RN #4 spoke to the emergency room physician, resident had a Computerized Tomography (CT-a diagnostic imaging exam) scan of the head which indicated a non-displaced left orbital (eye) wall fracture. Due to Resident #140's anatomy of the skull, the resident needed to follow up in a few weeks with an orthopedic surgeon to determine if surgical intervention was needed. Resident #140 was admitted to the hospital. A review of Resident #140's medical record revealed no documented evidence that a follow-up with an Orthopedic Surgeon was completed to determine if surgical intervention is needed. Resident #140 was readmitted back to the facility on [DATE] and relocated to a different unit. A physician's order dated 11/11/2022 documented to place Resident #140 on every 15-minute monitoring due to Resident #140's wandering behavior into other resident rooms. A CCP for Resident #140 titled Resident-to-Resident Altercation, effective 6/27/2022, documented the resident is a potential victim related to the inability to protect self and inability to walk away from an abuser. A review of the Accident and Incident (A/I) report dated 11/8/2022 at 5:30 PM documented that when Resident #140 was lying in their bed, Resident #326 entered the room and began punching Resident #140 on their head. Resident #326 said they did not want Resident #140 coming into their room and taking their food. The A/I investigation dated 11/8/2022 documented there was no reasonable cause to believe any resident abuse, neglect, or mistreatment occurred. On 3/22/2023 at 1:40 PM Resident #140 was observed lying in bed. The resident was awake; however, spoke minimally. The resident appeared calm and comfortable. The resident's skull appeared deformed and enlarged. During an interview with LPN #4 on 3/24/2023 at 11:47 AM, they stated after they went to speak to Resident #326, LPN #4 went back to the nursing station to call the nursing supervisor and that was when CNA #1 alerted them that Resident #326 was observed wheeling themselves into Resident #140's room. LPN #4 stated they ran down the hallway to intervene and witnessed Resident #326 punching Resident #140 in the head. LPN #4 stated Resident #140 had behaviors of wandering into other resident rooms. LPN #4 stated they were not aware of any incidents between the two residents prior to 11/8/2022. During an interview with CNA #1 on 3/24/2023 at 11:56 AM, they stated they were the assigned CNA for Resident #140 on 11/8/2022. CNA #1 stated Resident #140 always wandered and was on every 15-minute check. CNA #1 stated on 11/8/2022 they were completing room checks and saw Resident #140 sleeping in bed. CNA #1 then went into Resident #326's room, who was lying in bed, and told the CNA that they were going to hit Resident #140 because Resident #140 comes into their room and takes stuff. CNA #1 stated at that point CNA #1 left the room and informed LPN #4. CNA #1 stated they were in the hallway when they saw Resident #326 wheeling into Resident #140's room, CNA #1 yelled for help, and LPN #4 responded. There was no documented evidence provided by the facility that every 15-minute monitoring was being completed for Resident #140 on or prior to 11/8/2022. During an interview with Physician #4 on 3/28/2023 at 9:55 AM, they stated the resident has a hypertrophic (enlargement or overgrowth) skull due to Paget's Disease (bone disease). The physician did not recall if Resident #140 went out for a follow-up appointment regarding the fracture of the left lateral orbit wall. Physician #4 stated Resident #326 was a very aggressive individual, staff provided a lot of redirection to the residents but the redirection cannot be performed 100% of the time. During an interview with the Director of Nursing Services (DNS) on 3/28/2023 at 12:02 PM, they stated Resident #326 went to seek Resident #140; the altercation was not in response to Resident #140 going into Resident #326's room again. The DNS stated that after 11/4/2022 when there was documentation that Resident #140 was wandering and seeking food, the resident was given snacks and monitored when in the hallway. The DNS stated they were not able to provide documented evidence of the hallway monitoring. The DNS stated that every-15-minute monitoring requires a physician's order. Resident #140 was placed on every 15-minute monitoring on 11/11/2022 after the incident on 11/8/2022. The DNS further stated that the 15-minute monitoring would not be documented without a physician's order. The Medical Director was interviewed on 3/29/2023 at 11:55 AM. The Medical Director stated Resident #140 sustained a mild fracture because of the incident. The Medical Director stated that the fracture would heal on its own and that a referral to the Orthopedic Surgeon was not warranted. 10 NYCRR 415.4(b)(1)(i)

Based on record review and staff interviews during the Recertification Survey initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure that high protein supplements were provided as ordered by a Physician. This was identified for one (Resident #128) of four residents reviewed for Nutrition. Specifically, Resident #128 was assessed by the Registered Dietician (RD) on 10/13/2022 with recommendations to provide LPS (liquid protein supplement) and then again on 12/17/2022 with recommendation to provide LPS and Juven (a powdered protein supplement) to aid in wound healing. A Physician's order first documented on 12/17/2022 indicated to administer both LPS and Juven as per the RD's recommendations. There was no documented evidence in the Medication Administration Record (MAR) that the resident received the LPS until 1/22/2023 and the Juven until 2/2/2023. The finding is: The facility's policy titled, Enteral (tube) Nutrition last reviewed on 1/2022 documented that the Dietitian will monitor residents who are receiving enteral feedings and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. The facility's policy titled, Nutrition and Hydration to Maintain Skin Integrity last reviewed on 1/2023 documented that the healing of acute (e.g., postoperative) and chronic (e.g., pressure ulcers) wounds requires enough protein and calories so that the body will not use lean body mass for energy and wound repair. The policy also documented that the recommended protein levels for a resident with wounds or at risk of developing wounds is approximately 1.2 - 1.5 grams (gm) of protein per kilogram (kg) of body weight. Resident #128 has diagnoses which include Cerebral Infarction and Dysphagia and was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderately impaired cognitive skills for daily decision making. The resident was totally dependent on one person for eating. The resident's height was 68 inches and the resident weighed 140 pounds (lbs). The resident received 51% or more of their total calories through tube feeding. The Dietary Progress Note dated 10/13/2022, written by RD #2, documented that the resident's Current Body Weight (CBW) was 145.8 lbs on 10/11/2022 and that the resident had a Stage 4 sacral pressure ulcer. The Plan recommended a change in the tube feeding amount and flow rate and also suggested liquid protein supplement (LPS) 30 milliliter (ml) via Percutaneous Endoscopic Gastrostomy (PEG) tube twice daily (BID) which would provide the resident with an additional 200 kilo calories (kcal) and 30 gms protein per day to help meet the resident's increased protein needs related to wound healing. The Physician's Order dated 10/13/2022 documented for the resident to receive Jevity 1.5 tube feeding formula, 1000 cubic centimeter (cc) at 50 cc/hour via PEG tube for a total of 20 hours starting at 4:00 PM until completion which provided a total of 1500 calories per day. There was no documented evidence in the resident's Electronic Medical Record (EMR) that the LPS was ordered as suggested by RD #2. The Nutrition Wound Note dated 12/17/2022, written by RD #1, documented that the resident had a Stage 4 sacral pressure ulcer, current size measuring 5.5 centimeters (cm) x 5.5 cm x 2 cm. The note documented that protein supplementation of LPS by mouth (po) BID was recommended to provide the resident with an extra 200 kcal and 30 gms of protein per day and Juven (a high protein powder) was recommended to provide the resident with an extra 180 kcal and 33 gms of protein per day. The Physician's Order dated 12/17/2022 documented for the resident to receive LPS Sugar Free 30 ml by mouth twice daily and Juven 1 packet by mouth twice daily. Review of the resident's December 2022 Monthly Medication Administration Record (MAR) revealed no documented evidence that the resident received the LPS Sugar Free or the Juven as ordered by the Physician. Review of the resident's January 2023 Monthly MAR revealed that the resident started to receive the LPS Sugar Free 30 ml by mouth twice daily on 1/22/2023, 36 days after the physician's order was first placed on 12/17/2022. Review of the resident's February 2023 Monthly MAR revealed that the resident started to receive the Juven 1 packet by mouth twice daily on 2/2/2023, 47 days after the physician's order was first placed on 12/17/2022. RD #2 was interviewed on 3/28/2023 at 11:35 AM and stated that when they (RD #2) assessed the resident on 10/13/2022, they (RD #2) adjusted the resident's tube feeding and recommended that the resident receive the LPS twice daily due to the resident's increased protein needs related to wound healing. RD #2 was re-interviewed on 3/29/2023 at 10:10 AM and stated that when they (RD #2) stated that they (RD #2) had no idea why the order for the LPS was not obtained in October 2022 when they (RD #2) had first recommended LPS because the resident had increased protein needs due to a Stage 4 sacral pressure ulcer. RD #2 stated that the LPS order was not obtained until 12/17/2022. RD #2 further stated they (RD #2) could not explain why the resident did not receive the LPS until 1/22/2023 after the Physician's Order was obtained on 12/17/2022. RD #1 was interviewed on 3/29/2023 at 11:10 AM and stated that when completing the Nutrition Wound Note on 12/17/2022, they (RD #1) made a request for the resident to receive the two high protein supplements because the tube feeding was not providing enough protein to promote wound healing. RD #1 stated that they (RD #1) put both orders into the computer on 12/17/2022 for the LPS and the Juven. RD #1 further stated they (RD #1) had no idea why the resident did not receive the LPS for the first time until 1/22/2023 and the Juven for the first time on 2/2/2023. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 2:40 PM and stated that the RDs are responsible to place the dietary supplement orders into the computer and then Nursing confirms the order. The DNS stated that Nurses are responsible to notify the Physician of the RD's recommendation. The DNS stated that if there were no signatures on the MAR, there was no evidence that LPS or Juven were administered to Resident #128 in the month of December 2022. The DNS stated LPS was first administered on 1/22/2023 as evidenced by the staff signature on the MAR. The DNS stated that the first time the Juven was administered was on 2/2/2023 as evidenced by the staff signature on the MAR. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews during the Recertification Survey initiated on 3/22/2023 and completed on 3/30/2023 the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified for one (Resident #24) of one resident reviewed for Hydration. Specifically, Resident #24 was observed with Intravenous (IV) hydration fluid infusing via an IV port. The IV bag was not labeled with the resident's name nor the date and time the IV fluid was hung. The finding is: The facility Intravenous Administration of Fluid and Electrolytes policy and procedure reviewed 1/2023 documented for continuous therapy, mark solution container with label that states when the bag was started and approximate time of completion. The policy documented to always use a label or tape (never write directly on the bag with ink or marker). Resident #24 had diagnoses that include Volume Depletion, Localized Edema, and Hypertension. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 8 which indicated the resident had moderately impaired cognition. A Physician's order dated 3/22/2023 documented to administer Dextrose-Normal Saline (NS) at 50 milliliters (ml) per hour every hour for Volume Depletion for two days. A Comprehensive Care Plan (CCP) for Hydration dated 2/19/2023 documented the resident was at risk for fluid and electrolyte imbalance related to the use of Diuretics. Interventions included to encourage the resident to drink if not contraindicated, to monitor laboratory results and report abnormal findings to the Physician, and to monitor vital signs as needed to identify signs and symptoms of electrolyte imbalance/ Hypovolemia (such as weak pulse, tachycardia, temperature elevation and Orthostatic Hypotension) and report to the Physician. The CCP was not updated to include interventions related to IV use. During a tour conducted on 3/23/2023 at 10:38 AM on the 2 North nursing unit Resident #24 was observed out of bed in a reclining chair in the hallway. IV Dextrose Normal Saline was observed infusing via a right-hand IV port and there was no label observed on the IV fluid bag. Licensed Practical Nurse (LPN) #2, the medication nurse, was interviewed on 3/23/2023 at 10:38 AM and stated that the Registered Nurse (RN) Supervisor that started the IV line should have labeled the IV bag with the resident's name, date, and time the fluid was hung. RN #6, the 7:00 AM - 3:00 PM Nursing Supervisor, was interviewed on 3/30/2023 at 10:31 AM. RN #6 stated there should have been a label on the IV fluid bag. The RN who hung the IV fluid bag should have labeled the IV bag. RN #6 stated the receiving shift RN Supervisor, or the LPN medication nurse could have labeled the IV bag with the resident's name, date, and time the fluid was hung. An interview was conducted on 3/30/2023 at 1:30 PM with the Director of Nursing Services (DNS). The DNS stated that the IV bag should have been labeled with the date and time. 10NYCRR 415.18(d)

Based on observation, record review, and interviews during the Recertification Survey initiated on 3/22/2023 and completed on 3/30/2023 the facility did not ensure that all residents were free of any significant medication errors. This was identified for two (Resident #8, and Resident #114) of two residents reviewed for choices. Specifically, both residents did not receive their medications as ordered by the Physician. On 3/22/2023 Resident #8 complained that they received all their 9:00 AM medications at 11:00 AM, and Resident #114 did not receive the 9:00 AM Buprenorphine HCl-Naloxone (treatment of Opioid Dependency) medication until 12:00 PM. The finding is: 1). Resident #8 was admitted with diagnoses that included Pain, Deep Vein Thrombosis, Bipolar Disorder, Panic Disorder and Muscle Spasticity. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognition. The resident had no behavior problems and received Antidepressant, Antianxiety, Anticoagulant, and Opioid medication during the assessment period. Resident #8 was interviewed on 3/23/2023 at 12:58 PM. The resident stated that on 3/22/2023 they received all their 9:00 AM medications late. A Physician's order dated 2/1/2023 documented to administer: -Oxycodone HCl oral tablet 5 milligrams (mg). Give 1 tablet by mouth every 12 hours related to Pain; -Eliquis (Anticoagulant) oral tablet 5 mg. Give 1 tablet by mouth two times a day related to Acute Embolism and Deep Vein Thrombosis of lower extremity. -Baclofen oral tablet 20 mg. Give 1 tablet by mouth three times a day for Muscle Spasticity. -Zanaflex oral tablet 4 mg. Give 1 tablet by mouth three times a day for Muscle Spasticity. -Clonazepam oral tablet 1 mg. Give 1 tablet by mouth two times a day related to Bipolar Disorder, Current Episode of Depression, Panic Disorder, and Anxiety. A Review of the Medication Administration Audit Report (timed stamp) dated 3/27/2023 documented Resident #8 received all 9:00 AM medications at 10:57 AM -11:00 AM on 3/22/2023. LPN #6 was re-interviewed on 3/29/2023 at 10:46 AM. LPN #6 stated that they came into work at 9 AM on 3/22/2023 and that as soon as they arrived in the facility, they (LPN #6) immediately went to their assigned unit. LPN #6 stated that it was a busy morning, and all the residents were waiting and asking for their medications at the same time; the medication pass had not started, the finger sticks were not completed and that was why they were running late with the medication pass. Physician #3 was interviewed on 3/30/2023 at 6:45 PM. The Physician #3 stated that the resident should not have receive their medications late. Physician #3 stated that currently the resident's main concern is pain and that it was important to administer the pain medication on time and the goal is for the resident to be comfortable. Physician #3 stated that the expectation would be that all residents receive their medication timely. 2) Resident #114 was admitted with diagnoses that included Hypertension, Diabetes Mellitus, History of Opioid Dependence. An admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 11 which indicated moderate cognitive impairment. The resident had no behavior problems. A Physician's order dated 3/18/2023 documented Suboxone Sublingual Film 2-0.5 mg, Give 2 film sublingually every 12 hours. Continue to use this medication until the tablet form is added to the medication record. A Physician's order dated 3/20/2023 documented Buprenorphine HCl-Naloxone HCl (Suboxone) Sublingual Tablet Sublingual 2-0.5 mg. Give 2 tablet sublingually every 12 hours for medication for Opioid Dependency. Resident #114 was observed on 3/22/2023 at 11:30 AM speaking loudly and was visibly upset. The resident stated that they did not receive their special medication that they should have received at 9:00 AM. The resident stated that they were told the medication was not on the unit and the Registered Nurse (RN) Supervisor was following up. A review of the Medication Administration Audit Report (timed stamp) dated 3/27/2023 documented Resident #114 received their 9:00 AM Buprenorphine HCl-Naloxone films Sublingual 2-0.5 mg at 12:02 PM on 3/22/2023. Licensed Practical Nurse (LPN) #6, the 7:00 AM - 3:00 PM medication nurse, was interviewed on 3/22/2023 at 11:33 AM. LPN #6 stated the resident did not receive their Buprenorphine HCl-Naloxone HCl medication because they (LPN #6) were unable to find the resident's medication. LPN #6 stated that the RN Supervisor was made aware and was currently following up. RN #6, who was the 7:00 AM - 3:00 PM RN Supervisor, was interviewed on 3/28/2023 at 5:02 PM. RN #6 stated that on 3/22/2023 they checked the narcotic cabinet and found the resident's medication. LPN #6 was re-interviewed on 3/29/2023 at 10:46 AM. LPN #6 stated that they came into work at 9 AM on 3/22/2023 and that as soon as they arrived in the facility, they (LPN #6) immediately went to their assigned unit. LPN #6 stated that it was a busy morning, and all the residents were waiting and asking for their medications at the same time; the medication pass had not started, the finger sticks were not completed and that was why they were running late with the medication pass. LPN #6 stated the initial order for Resident #114's Buprenorphine HCl-Naloxone HCl medication was a Sublingual Film and they (LPN #6) had looked for the medication in the narcotic cabinet and could not find the medication. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 3:30 PM and stated the shift RN Supervisor should have covered the unit until a medication nurse arrived. The DNS stated that they were not made aware that the residents received their medications late. The DNS further stated the expectation is for the residents to receive their medications timely. The window for medication administration is one hour before to one hour after the physician prescribed time. 10 NYCRR 415.12(m)(2)

Based on record review and interviews during the Recertification Survey initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure that Physician Responses (actions) documented on Monthly Medication Regimen Reviews (MRR) were carried out to address irregularities identified by the Pharmacist. This was identified for two (Resident #7 and Resident #109) of five residents reviewed for Unnecessary Medications. Specifically, 1) a Psychiatric Consult was requested for Resident #7 by the Physician in February 2023, in response to the MRR dated 2/11/2023; however, no Physician's Order was documented in the resident's Electronic Medical Record (EMR). A Psychiatric Consult was not completed until 3/27/2023 after a subsequent MRR was completed on 3/7/2023 and the physician again recommended a Psychiatry Consult. 2) Resident #109 was seen by the Pharmacy Consultant on 2/21/2023 who recommended a Gradual Dose Reduction (GDR) for Risperidone (an antipsychotic medication) from 0.5 milligrams (mg) daily to 0.25 mg daily on the Medication Regimen Review (MRR). The physician agreed with the recommendation; however, the GDR was not initiated until the resident was seen by the Psychiatry Services on 3/27/2023. The finding is: The facility's undated policy titled, Drug Regimen Review-Monthly documented that the Consultant Pharmacist shall review the medical record of each resident and perform a Drug Regimen review at least once each calendar month. The Consultant Pharmacist shall identify, document and report possible medication irregularities for review and action by the Attending Physician, where appropriate. The attending Physician or licensed designee shall respond to the Drug Regimen Review within 7-14 days or more promptly, whenever possible. 1) Resident #7 has diagnoses which include Type 2 Diabetes Mellitus and Hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 10 which indicated that the resident had moderately impaired cognitive skills for daily decision making. The MDS also documented that the resident received antipsychotic and antidepressant medications during the last 7 days. The original Physician's Order dated 5/14/2020 and last renewed on 1/31/2023 documented to administer Risperdal (an antipsychotic medication) oral tablet (tab) 2 milligrams (mg) - give 1 tab by mouth (po) at hour of sleep (HS) for Schizophrenia. The original Physician's Order dated 9/1/2022 and last renewed on 1/31/2023 documented to administer Risperdal M-tab dispersible 1 mg, give 1 tab po once daily related for Schizophrenia. The MRR dated 2/11/2023 documented the resident was currently receiving Risperidone (Risperdal). The Consultant Pharmacist documented they were unable to locate recent documentation of current need/effect, absence or presence of side effects, and ability or lack of ability to taper current dose in the chart. Under the Physician/Prescriber Response the resident's Physician checked the box indicating,Agree; Will do. On the MRR the Physician wrote to obtain a Psychiatry Consult and signed the MRR, however, did not date the MRR. There was no Physician's Order for a Psychiatry Consult in response to the MRR in February 2023. The MRR dated 3/7/2023 documented the resident was currently receiving Risperidone (Risperdal) with a diagnosis of Schizophrenia, however, there appeared to be no supporting evidence of a history of Schizophrenia located in the medical record or consult reports. Please evaluate current use, consider either adding a progress note to support the diagnosis, changing the diagnosis, or gradual dose reductions and discontinuing Risperidone, if appropriate. Under the Physician/Prescriber Response, obtained by the Registered Nurse (RN #6) Supervisor dated 3/21/2023, the resident's physician agreed with the recommendations and gave a verbal order for a Psychiatric Consult. Review of the resident's EMR revealed that the Physician's Order for a Psychiatric Consult was not entered into the EMR until 3/27/2023. The Nursing Progress Note dated 3/27/2023, written by RN #6, documented that a verbal order from Physician #1 was obtained for a psychiatric referral for review of medications for the purpose of a possible gradual dose reduction (GDR). RN #6 was interviewed on 3/28/2023 at 4:55 PM and stated that when they (RN #6) got the verbal telephone order from Physician #1 on 3/21/2023, they (RN #6) did not put the Physician's Order into the computer until 3/27/2023 because they (RN #6) knew that the Psychiatric Nurse Practitioner (NP) was on vacation and not was returning until 3/27/2023 when the Psychiatry Consult was completed. Physician #1 was interviewed on 3/28/2023 at 5:00 PM and stated they expected the Psychiatry Consult order to be documented in the EMR after they (Physician #1) gave the verbal order on 2/11/2023. Physician #1 stated that a Psychiatry Consult should have been obtained when the Pharmacy Consultant first made the recommendations on 2/11/2023. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 3:10 PM and stated that there may not have been a rush to put the Physician's Order into the computer to have the resident seen by the Psychiatrist in February of 2023 because the facility did not have a Psychiatrist back then. The DNS further stated that the Physician's Order should have been put into the resident's EMR on the day the telephone order was obtained on 3/21/2023, but it would not have changed the outcome because the Psychiatric NP was not coming back from vacation until 3/27/2023. 10 NYCRR 415.18(c)(2) 46058 2) Resident #109 was admitted with diagnoses including Heart Failure, Dementia, and Psychosis. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severely impaired cognition. A Physician's order dated 1/28/2023 documented to administer Risperidone 0.5 mg daily. The MRR dated 2/21/2023 documented a recommendation for a GDR of Risperidone 0.5 mg to Risperidone 0.25 mg. The physician agreed and recommended a Psychiatric Consultation. The psychiatric evaluation dated 3/27/2023 documented to attempt a trial GDR of Risperidone Oral tablet 0.5 mg to Risperidone Oral Tablet 0.25 mg daily. The Nursing Progress Note dated 3/28/2023 documented that Resident #109 was seen by the Psychiatrist and a physician's order was obtained to decrease Risperidone from 0.5 mg daily to 0.25 mg daily. Registered Nurse (RN) Supervisor #1 was interviewed on 3/28/2023 at 3:11 PM and stated the Psychiatrist was on vacation and the Medical Director had to cover for the Psychiatrist. The RN Supervisor is unsure why the recommendation for a Psychiatric consultation was conducted on 3/27/2023, over a month after the order was recommended by the physician. The RN Supervisor was unable to find the consultation order in the medical record. RN Supervisor stated they were responsible to place the order for the Psychiatry consult in the EMR and must have forgotten to do so. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 2:50 PM and stated that when a consultation of any kind is recommended, the Physician's order is placed immediately in the EMR. The Psychiatrist was on vacation until 3/27/2023 and no one was assuming the responsibilities of the Psychiatrist while they were away. The DNS stated that if the physician determined the Psychiatric consultation was needed, there should have been an order in place on 2/21/2023. 10 NYCRR 415.18(c)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure it provided pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. This was identified for two (Resident #47 and #98) of four residents observed during medication pass. Specifically, on [DATE], 1) Resident #47 did not receive the scheduled Furosemide (a medication for Hypertension) dose; and 2) Resident #98 did not receive the scheduled Divalproex (Depakote-prescribed for Schizophrenia) dose during the medication pass observation. The medications were not available for administration because the medications were not re-ordered in a timely manner from the pharmacy. The finding is: The facility's undated policy titled, Prescribing and Ordering of Medications documented the facility will communicate any medication reorders, changes, or discontinuation to the pharmacy in accordance with pharmacy guidelines and state/federal regulations, thus ensuring a standardized process of communication. Communication may be transmitted through verbal, written, or electronic orders. All orders must clearly be communicated to the pharmacy by the facility. 1) Resident #47 was admitted with diagnoses including Hypertension, Diabetes Mellitus, and Depression. The [DATE] Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 6, indicating the resident had severe cognitive impairment. A physician's order effective [DATE] and active as of [DATE] documented Furosemide oral tablet 20 milligram (mg), give 1 tablet by mouth one time a day for Hypertension. A medication pass observation on [DATE] at 8:58 AM for Resident #47 was conducted. The medications were being administered by Registered Nurse (RN) #1, who was the RN Supervisor. RN #1 stated they (RN #1) were conducting the medication pass because the scheduled medication nurse called out. RN #1 stated Resident #47 was due to receive Furosemide 20 mg tablet at 9 AM and they (RN #1) were unable to find the blister-pack for the Furosemide 20 mg tablet. RN #1 was re-interviewed on [DATE] at 11:19 AM and stated they (RN #1) had searched everywhere for the Furosemide 20 mg tablet blister-pack but were unable to find the medication. RN #1 stated they (RN #1) will call the pharmacy to re-order the medication. Review of the [DATE] Medication Administration Record (MAR) revealed that Furosemide 20 mg was not signed as administered for Resident #47 on [DATE]. Pharmacist #1 was interviewed on [DATE] at 8:31 AM and stated the last refill request for Resident #47's Furosemide prior to [DATE] was on [DATE]. Pharmacist #1 stated the new refill request for Furosemide came in from RN #1 on [DATE] at 3:19 PM. Pharmacist #1 stated the facility must request re-orders through the Electronic Medication Record (EMR) or through a phone call, the pharmacy do not just refill the medications. RN #1 was re-interviewed on [DATE] at 9:43 AM and stated the Furosemide was delivered very late on [DATE]. RN #1 stated the Furosemide 20 mg is in the emergency box (E-Box), but they (RN #1) did not use it. RN #1 stated they did not notify the doctor regarding the missing Furosemide until today ([DATE]). The Director of Nursing Services (DNS) was interviewed on [DATE] at 9:05 AM and stated if the medication supply is getting low, the nurses should call the pharmacy to re-order the medication at least ,d+[DATE] days before the medication runs out. 2) Resident #98 was admitted with diagnoses including Diabetes Mellitus, Hypertension, and Schizophrenia. The [DATE] Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. The MDS documented the resident was receiving psychotropic medications. A Physician's order effective [DATE] and active on [DATE] documented Depakote oral tablet, 500 milligrams (mg), by mouth two times a day for Schizophrenia. A medication pass observation on [DATE] at 9:09 AM for Resident #98 was conducted. The medications were being administered by Licensed Practical Nurse (LPN) #2. A blister-pack for Depakote contained Depakote tablets. The blister-pack had a label indicate Depakote was delivered on [DATE]. LPN #2 did not administer Depakote for Resident #98 and stated that the blister-pack was expired because the blister-pack was only good for one month. LPN #2 stated they (LPN #2) had re-ordered the medication two days ago on [DATE] and the medication has not yet arrived from the pharmacy. Review of the [DATE] Medication Administration Record (MAR) revealed that Resident #98 did not receive either the 9 AM and 9 PM doses of Depakote on [DATE]. Pharmacist #1 was interviewed on [DATE] at 8:31 AM and stated the Pharmacy had a re-order request for Resident #98's Depakote on [DATE], which was delivered on [DATE]. Pharmacist #1 stated the March re-order request for Resident #98's Depakote was made by LPN #2 on [DATE] at 9:30 AM. The Director of Nursing Services (DNS) was interviewed on [DATE] at 9:05 AM and stated if the medication supply is getting low, the nurses should call the Pharmacy to re-order the medication at least ,d+[DATE] days before the medication runs out. 10 NYCRR 415.18(a)

Based on record review and interviews during the Recertification initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure that the medical care of each resident was supervised by the Physician including monitoring changes in the resident's medical status. This was identified for one (Resident #7) of four residents reviewed for Nutrition. Specifically, Resident #7 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. The resident's Physician did not monitor the resident's blood work timely to evaluate the progression of the disease and need for treatment. The finding is: The facility's policy titled Diabetes - Clinical Protocol last reviewed on 2/2023 documented that the Physician will follow up on any acute episodes associated with a significant change in blood sugars or deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. Resident #7 with diagnoses including Type 2 Diabetes Mellitus and Hypertension was admitted to the facility on [DATE]. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated that the resident had moderately impaired cognitive skills for daily decision making. One of the resident's Active Diagnoses was Diabetes Mellitus (DM). Review of the resident's Electronic Medical Record (EMR) revealed the following Comprehensive Metabolic Panel (CMP) Glucose results: -1/24/2022 Glucose high 250 milligram/deciliter (mg/dl) (reference range 65-99 mg/dl)mg/dl -9/12/2022 Glucose high 385 mg/dl Review of the medical record revealed that Resident #7 was not receiving medication to manage the diagnosis of DM. The Medical Doctor (MD) Monthly Progress Note dated 10/1/2022, written by Physician #1, documented under Diagnostic Tests - Glucose 385 non fasting. Review of the resident's EMR revealed the following CMP glucose result: 11/16/2022 Glucose high 345 mg/dl. The Nursing Progress Note dated 11/17/2022 documented that the blood test results were available, and the Glucose level was 350 mg/dl. Physician #1 was made aware and ordered to repeat the Glucose level tomorrow. Review of the resident's EMR revealed the following CMP Glucose result: 11/18/2022 Glucose high 319 mg/dl. The 11/18/2022 Medical Progress Note, written by Physician #1, documented that the resident's laboratory reports were reviewed, and a random Glucose level was 345 mg/dl. The Physician documented to start Metformin (oral medication to treat DM) and to check the resident's hemoglobin A1c (HgbA1c- blood test to determine the blood glucose levels over 2-3month period). The Physician's Order dated 11/19/2022 documented for the resident to start Metformin HCl (an oral diabetes medicine used to treat high blood sugar levels caused by Type 2 diabetes) oral tablet 500 mg (milligrams) - 1 tablet po (by mouth) once a day for Type 2 diabetes mellitus without complications. The laboratory report dated 11/21/2022 documented a Glucose level of 297 mg/dl (high) and HgbA1c 13.5%, high (reference range 4.8-5.6%). The 11/26/2022 MD Monthly Progress Note dated 11/26/2022, written by Physician #1, documented that the resident was found to have DM. and was started on Metformin. The Note also documented that the resident's blood Glucose level was 297 mg/dl and their HgbA1c was 13.6%. The resident's Physician (Physician #1) was interviewed on 3/30/2023 at 11:30 AM and stated that when the resident first had a very high glucose level in September 2022, they (Physician #1) were not concerned because the blood glucose level was not a fasting blood glucose test. Physician #1 stated that the resident's DM was controlled by diet for a long time, but that they (Physician #1) should have ordered a HgbA1c for the resident a few times a year to monitor their DM. Physician #1 stated that they (Physician #1) were not sure why they (Physician #1) had not ordered a HgbA1c after the CMP glucose result on 11/16/2022 when the resident's Glucose was 345 mg/dl and they (Physician #1) should have. Physician #1 stated that the resident's diabetes was not well controlled and that they (Physician #1) take responsibility for that and will now have the resident's HgbA1c checked twice a year. Physician #1 also stated that they (Physician #1) did not know why the resident's Glucose level was not checked for almost a year between January 2022 and September 2022 and that it should have been checked more often since the resident's Glucose was on the high side in January 2022. The Medical Director (Physician #2) was interviewed on 3/30/2023 at 6:10 PM and stated that the resident's HgbA1c should have been checked yearly or every other year as a standard of practice for someone having a diagnosis of DM. 10 NYCRR 415.15(b)(1)(i)(ii)

Based on record review and interviews during the Recertification Survey initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure that the resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (Resident #128) of four residents reviewed for Nutrition. Specifically, Resident #128 was not provided the adequate amount of protein via tube feeding that was needed for wound healing, as assessed and recommended by the Registered Dietician (RD). The finding is: The facility's policy titled, Enteral (tube) Nutrition last reviewed on 1/2022 documented that the Dietitian will monitor residents who are receiving enteral feedings and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. The facility's policy titled, Nutrition and Hydration to Maintain Skin Integrity last reviewed on 1/2023 documented that the healing of acute (e.g., postoperative) and chronic (e.g., pressure ulcers) wounds requires enough protein and calories so that the body will not use lean body mass for energy and wound repair. The policy also documented that the recommended protein levels for a resident with wounds or at risk of developing wounds is approximately 1.2 - 1.5 grams (gm) of protein per kilogram (kg) of body weight. Resident #128 has diagnoses which include Cerebral Infarction and Dysphagia and was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderately impaired cognitive skills for daily decision making. The resident was totally dependent on one person for eating. The resident's height was 68 inches and the resident weighed 140 pounds. The resident received 51% or more of their total calories through tube feeding. The Physician's Order dated 8/30/2022 documented for the resident to receive Jevity 1.5 (1.5 Calories/milliliter) tube feeding formula, 600 cubic centimeter (cc) per day at 50 cc per hour via a percutaneous endoscopic gastrostomy (PEG) tube starting at 4:00 PM until completion and for the resident to receive nothing by mouth (NPO). The Initial Wound Round Evaluation Progress Note dated 9/1/2022 documented that the resident had a Stage 4 sacral pressure wound measuring 9.5 centimeter (cm) x 14.2 cm x 2.3 cm; 40% granulation (newly formed healthy tissue); 60% necrotic (dead tissue), no exudate (drainage). The resident's weight dated 9/8/2022 documented the resident's weight as 130.6 pounds (lbs). The Nutrition Assessment completed on 9/9/2022, by Registered Dietitian (RD) #3, documented that the resident's weight was 130.6 lbs. The resident's daily caloric needs were documented as 1475-1770 kilo calories (kcal) based on 25-30 kcal/kg of the resident's current body weight (CBW) and that their daily protein needs were 60 gms of protein based on 1 gm/kg of the resident's current body weight. The resident's tube feeding order was documented as Jevity 1.5 600 cc/day and that the resident had a Stage 4 sacral pressure ulcer. There was no documented evidence that RD #3 had calculated that the resident's current tube feeding was only providing 900 kcals and 38.4 gms of protein per day; rather than the 1475-1770 kcal and 60 gms of protein calculated in the nutritional assessment. The Physician's Order dated 9/11/2022 documented for the resident to receive Jevity 1.5 tube feeding formula, 1040 cc/day at 65 cc/hr via PEG tube for a total of 16 hours starting at 4:00 PM until completion which provided a total of 1560 calories per day. The Dietary Progress Note dated 10/13/2022, written by RD #2, documented that the resident's CBW was 145.8 lbs on 10/11/2022 and that the resident had a Stage 4 sacral pressure ulcer. The resident's estimated nutrient needs based on ideal body weight (IBW) of 63.6 kg (140 lbs) was 1590-1908 kcal (25-30 kcal/kg) and 76-95 gms of protein (1.2-1.5 gms protein/kg). The note also documented that the resident's current tube feeding order was Jevity 1.5 1040 milliliter (ml-which is the equivalent to cc) at 65 ml/hour x 16 hours which provided the resident with 1560 kcal and 66 gms protein daily. The Plan documented in this progress note to suggest Jevity 1.5 1000 ml at 50 ml/hour x 20 hours which would provide the resident with 1500 kcal and 63.8 gms of protein daily. The Plan also suggested liquid protein supplement (LPS) 30 ml via PEG twice daily (BID) which would provide the resident with an additional 200 kcal and 30 gms protein per day to help meet the resident's increased protein needs related to wound healing. The Physician's Order dated 10/13/2022 documented for the resident to receive Jevity 1.5 tube feeding formula, 1000 cc at 50 cc/hour via PEG tube for a total of 20 hours starting at 4:00 PM until completion which provided a total of 1500 calories per day. There was no documented evidence in the resident's EMR that the LPS was ordered as suggested by RD #2. The Physician's Order dated 12/1/2022 documented for the resident to receive a No Added Salt (NAS) diet, with a Puree diet consistency, and thin liquids. The Nutrition Wound Note dated 12/17/2022, written by RD #1, documented that the resident had a Stage 4 sacral pressure ulcer, current size measuring 5.5 cm x 5.5 cm x 2 cm. The note documented that protein supplementation of LPS by mouth (po) BID was recommended to provide the resident with an extra 200 kcal and 30 gms of protein per day and Juven (a high protein powder) was recommended to provide the resident with an extra 180 kcal and 33 gms of protein per day. The Physician's Order dated 12/17/2022 documented for the resident to receive LPS Sugar Free 30 ml by mouth twice daily and Juven 1 packet by mouth twice daily. Review of the resident's December 2022 Monthly Medication Administration Record (MAR) revealed no documented evidence that the resident received the LPS Sugar Free or the Juven as ordered by the Physician. Review of the resident's January 2023 Monthly MAR revealed that the resident started to receive the LPS Sugar Free 30 ml by mouth twice daily on 1/22/2023, 36 days after the physician's order was first placed on 12/17/2022. Review of the resident's February 2023 Monthly MAR revealed that the resident started to receive the Juven 1 packet by mouth twice daily on 2/2/2023, 47 days after the physician's order was first placed on 12/17/2022. RD #3 was not available for interview. RD #2 was interviewed on 3/28/2023 at 11:35 AM and stated that when they (RD #2) assessed the resident on 10/13/2022, they (RD #2) adjusted the resident's tube feeding and recommended that the resident receive the LPS twice daily due to the resident's increased protein needs related to wound healing. RD #2 was re-interviewed on 3/29/2023 at 10:10 AM and stated that when they (RD #2) make a recommendation, they enter the order themselves into the EMR and then there is a pending sign off notification that nursing and the physician has to also sign. RD #2 believed that they (RD #2) had entered the request into the computer on 10/13/2022 after making the recommendation for the resident to receive LPS twice daily. RD #2 stated that they (RD #2) had no idea why the order for the LPS was not obtained in October 2022 when they (RD #2) had first recommended LPS because the resident had increased protein needs due to a Stage 4 sacral pressure ulcer. RD #2 stated that the LPS order was not obtained until 12/17/2022. RD #2 further stated they (RD #2) could not explain why the resident did not receive the LPS until 1/22/2023 after the Physician's Order was obtained on 12/17/2022. RD #1 was interviewed on 3/29/2023 at 11:10 AM and stated that when completing the Nutrition Wound Note on 12/17/2022, they (RD #1) made a request for the resident to receive the two high protein supplements because the tube feeding was not providing enough protein to promote wound healing. RD #1 stated that they (RD #1) put both orders into the computer on 12/17/2022 for the LPS and the Juven. RD #1 further stated they (RD #1) had no idea why the resident did not receive the LPS for the first time until 1/22/2023 and the Juven for the first time on 2/2/2023. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 2:40 PM and stated that the RDs are responsible to place the dietary supplement orders into the computer and then Nursing confirms the order. The DNS stated that Nurses are responsible to notify the Physician of the RD's recommendation. The DNS stated that if there were no signatures on the MAR, there was no evidence that LPS or Juven were administered to Resident #128 in the month of December 2022. The DNS stated LPS was first administered on 1/22/2023 as evidenced by the staff signature on the MAR. The DNS stated that the first time the Juven was administered was on 2/2/2023 as evidenced by the staff signature on the MAR. 10 NYCRR 415.12(i)(1)

Based on record review and interviews during the Recertification Survey and the Abbreviated Survey (NY00311955) initiated on 3/22/2023 and completed on 3/30/2023 the facility did not ensure that a Baseline Care Plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care was developed within 48 hours of admission. This was identified for one (Resident #276) of four residents reviewed for Pressure Ulcer (PU). Specifically, Resident #276 was admitted with a Sacral PU on 12/16/2022. A Baseline care plan for the Sacral Pressure Ulcer was not completed within 48 hours as required. The finding is: The facility's Baseline Care Plan policy reviewed 1/2023 documented to assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. Resident #276 was admitted on [DATE] with diagnoses that included Stage III Sacral Pressure Ulcer, Malnutrition, and Diabetes Mellitus. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a short-term memory problem and was moderately impaired for daily decision making. The resident required total assistance of two staff members for bed mobility and was frequently incontinent of bowel. The resident had an indwelling Foley catheter. The MDS further documented the resident was at risk for developing PU and had one unhealed Stage III PU that was present on admission. The Baseline Care Plan dated 12/16/2022 was blank under the Skin Concern section. A Nursing Admission assessment dated [DATE] documented the resident had redness to both heels and had a Stage IV PU to the Sacrum that measured 5 centimeters (cm) x 4.5 cm. A wound care initial evaluation completed on 12/22/2022 reassessed to wound as a Stage III PU. A Comprehensive Care Plan (CCP) dated 12/26/2022 documented the resident had a Stage III Sacral PU. Interventions included but were not limited to apply skin treatment as per the Physician's order, monitor effectiveness of treatment, and to monitor skin during daily care for signs and symptoms of infection. Registered Nurse (RN) #7, who completed the admission assessment, was interviewed on 3/28/2023 at 1:24 PM. RN #7 stated when a resident is admitted or readmitted to the facility, a head-to-toe body check is completed during the assessment. RN #7 stated after completing the assessment an admission note should be documented and a care plan should be initiated. RN #7 stated they should have completed the Baseline Care Plan; however, the care plan can be completed within twenty-four hours after admission and that any RN on the unit can review and complete the care plan. RN #1, who was the 7:00 AM - 3:00 PM RN Supervisor at the time the resident was readmitted , was interviewed on 3/30/2023 at 9:55 AM. RN #1 stated on admission or readmission, the RN that completes the admission assessment also initiates the Baseline Care Plan. RN #1 stated if the admission RN was unable to complete the care plan, they (RN #1) should follow up and complete the care plan the next day. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 6:32 PM. The DNS stated that the admission RN should have completed the Baseline Care Plan; however, if the admission RN was unable to complete the Baseline Care Plan, then the RN Supervisor should have completed the Baseline Care Plan the following day. 10 NYCRR 415.11

Based on record review and staff interviews during the Recertification Survey and the Abbreviated Survey (NY 00311955) initiated on 3/22/2023 and completed on 3/30/2023 the facility did not ensure that each resident representative was notified timely when there was a change in the resident's condition and a need to commence a new form of treatment was identified. This was identified for one (Resident #276) of two residents reviewed for notification of change. Specifically, Resident #276 was identified with significant weight loss of twenty-nine pounds in last six months and received intravenous fluids due to poor oral intake. The facility staff did not notify the resident's family in a timely manner of the resident's poor oral intake, significant weight loss, and administration of the Intravenous (IV) fluids in response to the poor oral intake. The finding is: The facility's policy and procedure titled; Acute Condition Changes Clinical Protocol last reviewed 1/2023 did not address notification to the resident's representative when there is a significant change in the resident's condition. Resident #276 was admitted with diagnoses that include Stage III Sacral Pressure Ulcer, Malnutrition, and Diabetes Mellitus. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a short-term memory problem and was moderately impaired for daily decision making. The MDS documented the resident was at risk for developing Pressure Ulcer (PU) and had one unhealed Stage III PU that was present on admission. A Dietitian assessment dated [DATE] documented the resident consumed 50% - 75% of meals with supervision. The note documented the resident had a significant weight loss of twenty-nine pounds(lbs.) / 10.5 percent (%) over the past six months. The etiology was likely due to a combination of acute Gastrointestinal (GI) issues, diagnosis of COVID-19 infection, as well as reduced appetite and oral (po) intake. A Nursing progress note dated 11/20/2022 documented the resident was alert and responsive to all stimuli. The resident's appetite was poor this tour and the resident consumed 25% of supper and 100% of fluids. IV fluid continues to the left arm with no signs and symptoms of infiltration. The note did not document that the resident's family was notified of the initiation of the IV fluids. A Nurses note dated 11/22/2022 documented the resident completed the second round of IV fluids on 11/20/2022 and the Physician ordered IV D5.33% (Dextrose) NS for 3 days and to hold Lasix (Diuretics) for 3 days. The note did not document that the resident's family was notified of the initiation of the IV fluids. A Nutrition Significant Change assessment dated [DATE] documented the resident was status post intravenous (IV) hydration earlier this month 11/21/22 for 3 days secondary to lethargy and decrease po intake. Currently the resident was started on IV hydration for 3 days, and calorie count was requested by the Physician. A Nurses note dated 11/30/22 documented the resident was alert and responsive to all stimuli. IV fluids D5.1/2% NS on going at 70 cc an hour. The resident was on a 3-day calorie count due to poor appetite. The note did not document that the resident's family was notified of the initiation of the IV fluids or decreased oral intake. A review of the progress notes from 11/2022 to 12/2022 lacked documented evidence that the resident's representative was notified regarding the resident's poor po intake, weight loss, and need for IV hydration. Dietitian #2 was interviewed on 3/28/2022 at 11:22 AM. Dietitian #2 stated when there is an acute change in weight that they (Dietitian #2) would notify nursing, the Physician, and the resident's family. Dietitian #2 stated Resident #276 had a significant unplanned weight loss over a six-month period due to multiple comorbidities including poor oral intake. Dietitian #2 stated that they did not notify the family of the weight changes. RN #1 was interviewed on 3/30/2023 at 9:27 AM and stated that when Resident #276's condition changed and warranted a change in the plan of care such as initiation of intravenous fluids, the resident's family should have been notified. RN #1 stated after they had reviewed the progress notes, that there was no documented evidence that the family was notified of the changes in the resident's condition. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 1:20 PM. The DNS stated that the nursing staff should have notified Resident #276's family when the IV hydration was initiated as an intervention in response to the resident's poor oral intake. The dietician should have updated the resident's family regarding the resident's significant weight changes and deterioration in the oral intake status. The DNS stated they expected the facility staff to document in the resident's medical record that the resident's family was notified of the changes in the resident's clinical status. Physician #3 was interviewed on 3/30/2023 at 3:45 PM. Physician #3 stated that any significant alteration in the resident's treatments, including starting a new form of treatment such as administration of Intravenous fluids, the resident's family must be informed. 10 NYCRR 415.3(f)(2)(ii)(c)

Based on interview and record review during an abbreviated survey (Complaint # NY 920) the facility did not ensure the residents rights to be free from physical abuse for one of four residents reviewed for resident to resident altercations (Resident #1). Specifically, Resident #2, with a history of wandering in to other residents' rooms, wandered into Resident #1's room. Resident #1, with history of physically abusive behavior, pushed Resident #2 to the floor resulting in a [MEDICAL CONDITION] for the resident (#2). The findings were: The facility Policy and Procedure titled Resident to Resident Altercations, revised 5/2017, defined resident to resident altercations as an unacceptable behavior of one or more residents toward one or more residents. These behaviors can be physical, verbal or threatening behavior directed towards a specific resident or group of residents. The facility Policy and Procedure titled Resident Abuse, Neglect and Mistreatment, Involuntary Seclusion, Exploitation and Misappropriation of Property, undated, documented physical abuse was defined as the inappropriate contact with a resident which harm, or is likely to harm. This includes, but is not limited to: hitting, slapping, pinching, kicking, shoving and bumping. 1). Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment tool) dated 3/15/2018, documented the resident's cognitive skills for daily decision making as severely impaired. He had no mood or behavior symptoms. He required extensive assistance with transfer and used a wheelchair for mobility. The Comprehensive Care Plan (CCP) titled behavior dated 4/4/17 documented the resident had an actual aberrant behavior evidenced by hitting staff and cursing. Interventions included to administer medications as ordered, keep MD (physician) informed of the resident's status, psychiatric and psychological consultations, monitor relationship with other residents, anticipate needs and positive reinforcement. The Nursing Progress Notes (NPN) dated 11/17/2017 documented that Resident #1 attacked another resident and hit him on his back while the resident was passing by him (Resident #1). The staff separated both residents and told Resident #1 to stop. The CCP titled Resident to Resident Altercation (Abuser) dated 11/18/2017 documented Resident#1 was an actual abuser and hit another resident. Interventions included to remove the resident from situation utilizing calm approach immediately, provide 1:1 supervision until calm, engage in diversional activities and place the resident near nurse's station as needed. The resident had a history of [REDACTED]. Resident was moved to another unit and he was referred to psychiatrist. No specific staff assigned to monitor, frequency or method of monitoring to prevent altercations with other residents were designated. The Resident Care Profile (RCP) dated 11/27/17 documented behavior problems: aggressive during care and attempted to go to bed by himself. The RCP lacked documented evidence of history of resident to resident altercation and the monitoring needs. The NPN dated 2/26/18 documented the resident was combative during care and hit a staff member in her left eye. The CCP was updated on 2/26/18 to note that the resident hit staff on the face and staff was reinstructed to approach the resident in a calm manner. The NPN dated 3/19/2018, documented Resident#1 was sitting in his wheelchair in his room while another resident (Resident #2) was found by staff on the floor in his room. Resident #1 stated he pushed Resident #2. 2). Resident #2 (Victim) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment tool) dated 1/25/2018, documented the resident's cognitive skills for daily decision making as moderately impaired. He had no documented mood and behaviors. He required supervision and set up help for transfer, walking and locomotion and he did not use any mobility device. The Comprehensive Care Plan (CCP) titled Resident to Resident Altercation (RTR) (Victim), dated 12/31/2015, documented that Resident #2 was a potential victim related to inability to protect self. Interventions included remove from situation, remain with the resident until calm and encourage verbalization of feelings, Psychiatry consult, engage in diversional activities like snack and music and redirect as needed. No specific staff assigned to monitor behaviors as per the CCP, frequency or method of monitoring to protect the resident from altercations and potential victimization were designated. The CCP dated 11/11/16 titled potential/actual Elopement/Wandering documented the resident wandered in and out of other residents' rooms related to confusion/poor memory. Interventions included to monitor behaviors; identify patterns; monitor signs and symptoms of injuries; falls; abrasions and cuts. Quarterly evaluations dated 6/6/2017, 9/18/2017, 12/21/2017 and 1/31/2018 documented the resident continues to wander around the unit and other residents' rooms and easily redirected. The Resident Care Profile/Nursing Assistant Accountability Record and Assignment, revised 12/14/2017, documented that Resident #2 was physically aggressive with staff and had a history of [REDACTED]. The resident paces on the unit, redirect the resident. Monitoring of behaviors, per the CCP, or interventions to protect the resident from altercations and potential victimization were not designated. The undated Investigative Summary documented that on 3/19/2018 at around 9:30 AM, the Certified Nurse's Aide (CNA #1) went to get juice for another resident and she observed Resident #2 lying on the floor near the door. When she looked inside the room, she saw Resident #1 was inside the room sitting in his wheelchair by the foot of the bed watching TV. The CNA immediately called the LPN (Licensed Practical Nurse) and the RNS (Registered Nurse Supervisor) was notified and responded. Resident #2 was assessed by the nursing supervisor. He was noted to have limited movement of his right leg, pain rating of 6/10; X rays were ordered. The resident was medicated with Tylenol. Upon reassessment, the resident was noted with facial grimacing. The resident was transferred to the hospital and admitted with [DIAGNOSES REDACTED].#1 was interviewed by the charge nurse and he stated that he pushed Resident #2 because he came to his room. The facility concluded that the incident was isolated, both residents involved were confused. Abuse/neglect/mistreatment was ruled out. The 7:00AM-3:00PM LPN was interviewed on 4/3/2018 1:58 PM and stated the Resident #1 was easily agitated and was not on specific monitoring. The LPN stated that on 3/19/2018 CNA #1 notified him that Resident #2 was on the floor by Resident #1's room door. The LPN asked the Resident #1 what had happened. He stated that he pushed Resident #2 and there was no reason for Resident #2 to be in his room. The LPN stated that he did not observe Resident #2 going to the other resident's room since he was giving out medications at that time. The LPN stated that Resident #2 was not supposed to be on specific monitoring because he was not a danger to other residents. During a subsequent interview with the LPN on 7/6/18 at 11:00 AM, he stated that the Resident #1 was transferred from another unit to his unit due to altercation with another resident. He had very short temper and at times got real upset and started screaming and shouting at other residents. The LPN stated that Resident #2 had wandering behaviors. He would go into other residents' rooms and sometimes would go on another unit on the same floor. The staff from another unit would redirect him back to his unit. Resident #2 was not on any specific monitoring. At times when Resident #2 attempted to go into other residents' rooms, they would shout and scream at him and staff would then redirect him. The 7:00AM-3:00PM CNA #2 was interviewed on 4/3/2018 at 2:50 PM and stated Resident #1 was moved from another unit to the 3rd floor due to physical altercations with other residents. Resident #1 got physically aggressive and tried to hit other residents when they came in front of his wheelchair while he was pushing it. Resident #2 always walked the hallways on his unit and to another unit on the same floor. He at times would go to other residents' beds. At times other residents got upset with Resident #2 and shouted and screamed at him. CNA #2 stated that there was no history of any altercation between the Resident #1 and Resident #2. The staff would look for Resident #2, if they did not see him walking in the hallways. Resident #2 was not on any specific monitoring. CNA #2 stated that she saw Resident #2 walking in the hallway at approximately 8:45 AM-9:00 AM prior to the incident but she did not see him go inside the aggressor's room. CNA #2 stated that the Resident #1 was sitting in his chair and he told her that he pushed him (Resident #2) because he was in his room. The 7:00AM-3:00PM CNA #1 was interviewed on 4/3/2018 at 3:01 PM and stated she worked on 3/19/2018 and was feeding a resident in another room. CNA #1 passed by the aggressor's room, when she went to get some juice, and saw Resident #2 sitting on the floor in the doorway. CNA #1 stated that the Resident #1 was sitting in a wheelchair and watching TV. Resident #2 was trying to get up from the floor. The Resident #1 said he pushed Resident #2 because he did not belong in his room. CNA #1 stated that before the incident neither residents were on specific monitoring. The Director of Nursing (DON) was interviewed on 4/16/18 at 2:02 PM and stated she was aware of the aggressor's history of unpredictable resident to resident altercations in the past. Upon investigation the resident stated that Resident #2 came in to his room; he did not want anyone in his room and that was why he pushed him (Resident #2). Resident #2 wandered in the hallways and the staff would redirect him. Resident #2 also had a history of [REDACTED]. Resident #2 was not on specific monitoring because he was not acting out. There was no history of altercation between the two residents. During a subsequent interview with the DON on 6/14/18 at 3:56 PM, she stated that the facility concluded that there was no abuse. The Resident #1 was sorry when he was told that Resident #2 sustained a fracture. The DON stated that the staff knew Resident #1's past history of resident to resident altercations and Resident #2's wandering behaviors. The DON stated that both residents were not on any specific monitoring. 415.4(b)