Every finding on record at Oasis Rehabilitation And Nursing, Llc

Based on observations, record review, and interviews, the facility did not ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (1) (Resident #75) of one (1) resident reviewed for Care Plans, and for one (1) (Resident #7) of one (1) resident reviewed for Dementia. Specifically, Resident #75 and Resident #7 had physician's orders for the use of ace wraps (compression bandages) to their lower extremities; however, both residents' comprehensive care plans were not revised to reflect the use of the ace wraps. The finding is:The undated facility policy titled Comprehensive Care Plans, documented comprehensive care plans will be revised, or new care plans will be developed quarterly, annually and as needed. -Resident #75 was admitted with diagnoses including congestive heart failure (the heart cannot pump enough blood to meet the body's needs, causing fluid buildup in the lungs and the body), chronic obstructive pulmonary disease (lung disease causing breathing issues due to airway damage and inflammation), and hypertension (high blood pressure). The Minimum Data Set assessment, dated 01/12/2026 documented a Brief Interview for Mental Status score of 15, indicating Resident #75 was cognitively intact.A physician's order dated 01/17/2026 documented a treatment of ace wraps bilaterally (both legs) to the lower extremities each morning and remove each night at 9:00 PM for edema (swelling in parts of the body because of trapped fluid, usually in legs, feet or ankles).The Treatment Administration Record for January 2026 indicated that every day the ace wraps were applied to the bilateral lower extremities at 06:00 AM and removed at 09:00 PM.The comprehensive care plan titled cardiovascular dated 01/06/2026 documented goals that included Resident #75 will be free from signs and symptoms of cardiovascular dysfunction i.e. dyspnea (difficulty breathing), pain, edema, mental status changes, headache, fatigue, weakness, palpitations, and bradycardia. The care plan did not include the use of the ace wraps and monitoring the lower extremities when applying and using the ace wraps.The comprehensive care plan titled skin integrity, potential for impairment dated 01/06/2026 documented skin impairment evidenced by edema with goals that included resident will remain free of skin breakdown and interventions that included float heels off mattress with pillows as tolerated. The care plan did not include the use of the ace wraps and monitoring the lower extremities when applying and using the ace wraps.During an observation and interview on 01/27/2026 at 11:47 AM, Resident #75 was observed with the ace wraps to both lower extremities. Resident #75 stated they have cuts on their legs, so the staff applies the ace wraps to their legs every day.During an interview on 01/29/2026 at 10:25 AM, Registered Nurse Unit Manager #1 stated they were responsible for updating the care plans annually, quarterly, and as needed. Registered Nurse Unit Manager #1 stated the use of the ace wraps should have been included in Resident #75's comprehensive care plan. -Resident #7 was admitted with diagnoses including congestive heart failure (where the heart cannot pump enough blood to meet the body's needs, causing fluid buildup in the lungs and the body), bacteriuria (presence of bacteria in the urine), and dementia (progressive decline in mental ability). The Minimum Data Set assessment dated [DATE] documented that a Brief Interview for Mental Status score could not be completed because Resident #7 was rarely/never understood.A physician's order dated 01/08/2026 documented to apply ace wraps bilaterally to the lower extremities each morning and remove them at bedtime for prophylactic measures.The Treatment Administration Record for January 2026 indicated that every day the ace wraps were applied to the resident's bilateral lower extremities at 06:00 AM and removed at 09:00 PM.The comprehensive care plan titled cardiovascular last revised 12/23/2025 documented goals that included Resident #7 will be free from signs and symptoms of cardiovascular dysfunction i.e. dyspnea, pain, edema, mental status changes, headache, fatigue, weakness, palpitations, and bradycardia. The care plan did not include the use of the ace wraps and monitoring the lower extremities when applying and using the ace wraps.The comprehensive care plan titled skin integrity, potential for impairment last revised 12/03/2024 documented skin impairment evidenced by edema with goals that included the resident will remain free of skin breakdown and interventions that included float heels off mattress with pillows. The care plan did not include the use of the ace wraps and monitoring the lower extremities when applying and using the ace wraps.During an observation on 01/30/2026 at 08:20 AM, Resident #7 was observed in bed with both lower legs wrapped with the ace wraps.During an interview on 01/30/2026 at 8:22 AM, Registered Nurse Unit Coordinator #1 stated Resident #7 had a physician's order for the ace wraps to be applied to both lower extremities in the morning and removed at night daily for the lower leg edema. Registered Nurse Unit Coordinator #1 stated the resident's comprehensive care plan should have been updated to include the use of ace wraps.During an interview on 01/30/2026 at 8:55 AM the Director of Nursing Services stated the Resident #75 and #7's care plan should have been updated to include the use of the ace wraps, when the order for ace wraps to lower extremities was first received. 10 NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during the Recertification Survey initiated on 12/15/2024 and completed on 12/19/2024, the facility did not ensure it established and maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Port unit) of two nursing units. Specifically, 1) Resident #79 was identified with a COVID-19 infection and was observed with a Transmission Based Precautions signage outside their room. On 12/16/2024, Housekeeper #1 was cleaning Resident #79's room wearing Personal Protective Equipment including gloves. Housekeeper #1 handed a surgical mask to Resident #20, who was passing by the room in their wheelchair, from the housekeeping cart while wearing the same gloves used to clean Resident #79's room and 2) Appropriate Transmission-Based Precautions signage was not posted when Resident #36 tested positive for COVID-19 infection on 12/15/2024. Additionally, a visitor was observed not wearing appropriate Personal Protective Equipment while visiting Resident #36 on 12/15/2024. The finding is: The facility's policy titled Transmission-Based Precautions (Isolation Precautions), dated August 2024, documented the facility will use Transmission-Based Precautions to manage specific, highly transmissible, or epidemiologically important pathogens based on the mode of transmission: contact, droplet, and airborne. The facility will implement Transmission-Based Precautions when the resident is known or suspected to be infected based on the route of transmission of the infectious agent. Residents on Transmission-Based Precaution will have isolation signage posted outside the resident's room. Residents who tested positive for Coronavirus disease (COVID-19) will have blue droplet/contact precaution signage posted. Residents who were exposed to positive Coronavirus disease (COVID-19) residents or whose swab test results were pending will have an orange droplet/contact precaution signage posted. The Infection Preventionist will follow up with the Housekeeping Director to ensure housekeeping readiness to work in isolation conditions, compliance with different requirements of Transmission-Based Precautions, and disposal of cleaning products and supplies to reduce the risk of room-to-room transmission. Housekeepers will put on appropriate Personal Protective Equipment when entering the resident's room and remove all Personal Protective Equipment before exiting the resident's room. Nursing staff will post appropriate isolation signage outside the resident's room. 1) During an interview on 12/15/2024 at 9:59 AM, the Administrator and Director of Nursing Services stated the facility was experiencing a COVID-19 infection outbreak among residents and there were currently eight positive COVID-19 residents who were placed in rooms in the COVID-19 designated area of the Starboard unit. A Social Work progress note dated 12/16/2024 at 8:11 AM documented Resident #79 was moving (to the COVID-19 isolation area on the Starboard unit) as the resident was positive for COVID-19 infection. During an observation on 12/16/2024 at 11:55 AM, Resident #79 was observed sitting in a wheelchair in their room on the Port unit awaiting transfer to the Starboard unit isolation area. Resident #79 was wearing a surgical mask. There was contact/droplet isolation signage at the room doorway. The signage documented N95 mask; providers and staff must put on gloves before room entry; discard gloves before room exit; put on a gown before room entry; discard the gown before room exit; make sure eyes, nose, and mouth are fully covered before room entry with an N95 mask covered with a blue surgical mask and a face shield; remove the blue surgical mask face protection before room exit. Housekeeper #1 was observed in the room coming in contact with the resident environment and was observed mopping the floor. Housekeeper #1 was wearing a gown, gloves, an N95 mask, and goggles; however, the housekeeper did not have a surgical mask over the N95 mask or a face shield. On 12/16/2024 at 12:05 PM, Resident #79 was transferred out of their room to their new room on the Starboard unit by a staff member. Housekeeper #1 was still in the room cleaning. The Housekeeping Supervisor was standing outside of the room in the hallway. On 12/16/2024 at 12:10 PM Housekeeper #1 was still in the same room cleaning when Resident #20 was observed self-propelling their wheelchair passing the room that was being cleaned by Housekeeper #1. Housekeeper #1 was observed reaching for a surgical mask from their housekeeping cart that was outside the room. Housekeeper #1 was wearing the same gloves that were used for cleaning the room, to retrieve the mask, and then handed the surgical mask to Resident #20. Resident #20 took the surgical mask. The surveyor immediately informed Licensed Practical Nurse #1 and Registered Nurse #2 (unit manager) of the observation. Licensed Practical Nurse #1 immediately took Resident #20 into the bathroom to wash the resident's hands. Registered Nurse #2 stated Housekeeper #1 should have been wearing a surgical mask over the N95 mask and will have to be re-educated about infection control. During an interview on 12/16/2024 at 1:58 PM, Housekeeper #1 stated they were cleaning the room and placing all of the dirty linens in a bag because residents in the room were being moved. Housekeeper #1 stated they made a mistake when they gave Resident #20 the surgical mask with the same gloves that were used for cleaning. Housekeeper #1 stated they knew what the signage at the doorway instructed and they should have had a covering over the N95 mask. During an interview on 12/17/2024 at 1:47 PM, the Housekeeping Director stated the housekeepers are expected to follow directions on the isolation signage. The Housekeeping Director stated it was an infection control breach when Housekeeper #1 handed the surgical mask to Resident #20 while wearing gloves that were used to clean Resident #79's room. During an interview on 12/18/2024 at 8:39 AM, the Infection Preventionist stated the facility had a COVID-19 outbreak. Resident #79 tested positive for COVID-19 infection on the morning of 12/16/2024. The Infection Preventionist stated Housekeeper #1 should have been wearing a surgical mask to protect the N95 mask. The Infection Preventionist stated Housekeeper #1 breached infection control protocols when they handed the surgical mask to Resident #20 with the same gloves that were used to clean a COVID-19 room. During an interview on 12/18/2024 at 1:00 PM, the Director of Nursing Services stated Housekeeper #1 was nervous and thought they were doing the right thing by handing a surgical mask to Resident #20, but that was a breach of infection control protocol. Additionally, Housekeeper #1 was expected to follow the isolation signage at the doorway and cover the N95 mask with a surgical mask. 44963 Resident #36 was admitted with diagnoses of Cough, Chronic Obstruction Pulmonary Disease, and Asthma. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 5, which indicated Resident #36 had severely impaired cognition. A physician's order dated 12/15/2024 at 11:33 AM documented to implement Droplet/Contact Precautions. A review of the nursing progress note dated 12/15/2024 at 11:39 AM documented that Resident #36 had an elevated body temperature of 100.3 degrees Fahrenheit, sore throat/hoarseness, cough, congestion, and complaint of overall not feeling well. Resident #36 was provided a rapid Coronavirus (COVID-19) swab test and the result was positive. The Physician Assistant was notified and had a new order to begin the Coronavirus disease (COVID-19) protocol. Droplet/Contact precautions were in place. The Comprehensive Care Plan titled Contact/Droplet/Isolation Precaution, dated 12/15/2024 documented Resident #36 was positive for Coronavirus disease (COVID-19) infection. Interventions included but were not limited to maintaining Transmission-Based Precautions per the physician's orders and maintaining strict single-room isolation for positive Coronavirus Disease (COVID-19) residents. Resident #41 was admitted with diagnoses of Anemia, Stage 4 Chronic Kidney Disease, and Chronic Atrial Fibrillation. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated Resident #41 had intact cognition. A physician's order dated 12/7/2024 documented Contact Precautions for Extended Spectrum Beta-Lactamase in urine (people with ESBL could be resistant to some antibiotic treatment). The Comprehensive Care Plan titled Contact/Droplet/Isolation Precaution dated 12/7/2024 documented the resident had Extended Spectrum Beta-Lactamase in urine and Coronavirus (COVID-19) infection Exposure. Interventions included but were not limited to maintaining precautions per the physician's order and wearing proper Personal Protective Equipment. The Comprehensive Care Plan titled Coronavirus (COVID-19), effective 11/14/2024 and last revised 12/16/2024, documented the resident was exposed to Coronavirus (COVID-19) on 12/15/2024. Contact/Droplet precautions were in place per the physician's orders. A physician's order dated 12/15/2024 documented Contact/Droplet Precautions for [COVID-19 infection] Exposure. During an observation on 12/15/2024 at 10:02 AM, a Contact Precaution signage was observed posted at the doorway where Resident #36 and Resident #41 resided. During an interview on 12/15/2024 at 10:02 AM, Licensed Practical Nurse #1 stated that the Contact Precaution signage observed at the doorway was for Resident # 41 who had bacteria in their urine. During an observation on 12/15/2024 at 12:45 PM, a Contact Precaution signage was observed posted at the doorway where Resident #36 and Resident #41 resided. Both residents were observed in the room. Resident #41 was out of bed with no mask. Resident #36's behind the privacy curtains that were drawn. A visitor was observed at Resident #36's bedside and was wearing a surgical mask. The visitor was not wearing a gown, gloves, or eye protection while interacting with Resident #36. During an interview on 12/15/2024 at 12:46 PM, Resident #36's visitor, who was wearing a blue surgical mask stated that Resident #36 just tested positive for Coronavirus (COVID-19) infection this morning and the resident was waiting to be moved to another room. Resident #36's visitor stated that Resident #36 has been symptomatic since Friday (12/13/2024), but tested negative for Coronavirus (COVID-19) on Friday (12/13/2024). During an observation on 12/15/2024 at 12:54 PM, a Contact Precaution signage was observed posted at the doorway where Resident #36 and Resident #41 resided. Both residents were observed in the room. Resident #41 was out of bed by their bedside and wore a blue surgical mask. Resident #36 was observed in their bed and did not wear a mask. Resident #36's visitor remained in the room and was wearing a blue surgical mask and no other Personal Protective Equipment. During an interview on 12/15/2024 at 12:55 PM, Licensed Practical Nurse #1 stated this morning they were aware that Resident #36 was being moved out of their room due to a newly positive test result for Coronavirus (COVID-19) infection. Licensed Practical Nurse #1 stated that Resident #41, who is Resident #36's roommate, is now considered exposed and would either be placed with other exposed residents or remain in the room by themselves. During an interview on 12/15/2024 at 1:00 PM, the Infection Preventionist stated both Resident #36 and Resident #41 were tested for Coronavirus (COVID-19) infection today (12/15/2024) and Resident #36's test results came back positive. The Infection Preventionist stated both residents should be placed on Droplet Precautions because Resident #36 tested positive for Coronavirus (COVID-19) Infection and should be placed on Droplet Precautions as per the facility policy. The Infection Preventionist stated that Resident #36 will be moved to another room for isolation. The Infection Preventionist stated that the correct Transmission-Based Precaution signage was not yet posted but staff and family members were notified about the resident's positive COVID-19 infection results. During an additional interview on 12/15/2024 at 1:53 PM, the Infection Preventionist stated they were responsible for keeping track of all residents who required to be placed on Isolation Precautions. The Infection Preventionist stated Resident #36 should have a blue Droplet and Contact precaution signage at the doorway to indicate positive Coronavirus (COVID-19) infection status and Resident #41 should have an orange Droplet/Contact precaution signage to indicate their exposure to a positive Coronavirus (COVID-19) infection resident. The Infection Preventionist stated they expected the appropriate signage to be posted once the residents completed their move to their designated rooms. The Infection Preventionist stated that the signage was not posted at the door of the room where both residents stayed while waiting for a room change to eliminate confusion. During an interview on 12/16/2024 at 2:21 PM, Registered Nurse #2, the unit manager, stated that primarily the Infection Preventionist was responsible for posting isolation precaution signage. Registered Nurse #2 stated they were aware Resident #36 tested positive for Coronavirus (COVID-19) infection and that Resident #41 was exposed to Resident #36. Registered Nurse #2 did not post the updated Transmission-Based Precautions signage after Resident #36 tested positive for COVID-19 infection. During an interview on 12/18/2024 at 12:57 PM, the Director of Nursing Services stated there should be a blue Droplet and Contact precaution signage for residents who tested positive for Coronavirus (COVID-19) infection and an orange Droplet and Contact precautions signage for residents who were exposed to a positive resident Coronavirus (COVID-19) infection. 10 NYCRR 415.19(a) (1-3)

Based on observations, record review, and interviews during the Recertification Survey initiated on 12/15/2024 and completed on 12/19/2024, the facility did not ensure that each resident was provided with a safe, clean, comfortable, and homelike environment. This was identified on one (Starboard Unit) of two units observed during the Environmental Task. Specifically, Resident #292 was using a ripped, inverted (turned inside out) fitted bed sheet on three separate observations. The finding is: The facility's policy titled; Homelike Environment last revised on 7/1/2017 documented that the facility will ensure that residents live in an environment that is clean and neat, with appropriate furnishings in a state of good repair. The housekeeping and nursing staff would observe the environment for needed repairs including but not limited to ripped/torn soiled curtains, damaged furniture, etc. Resident #292 was admitted with diagnoses including Atrial Fibrillation, Congestive Heart Failure, and Type 2 Diabetes Mellitus. Resident #292's Minimum Data Set (MDS) assessment had not been completed because they were recently admitted to the facility. A Nursing Admission assessment dated [DATE] documented that Resident #292 was alert, friendly, and cooperative. Resident #292 was oriented to time, place, and person. Resident #292 was observed on 12/15/2024 at 10:15 AM, lying in bed with an inverted (inside out) and ripped fitted bed sheet that was covering the resident's mattress. Resident #292 was observed on 12/16/2024 at 10:33 AM, sitting in a wheelchair. An inverted and ripped fitted bed sheet was covering the resident's mattress. Resident #292 was observed on 12/17/2024 at 8:30 AM lying in bed with an inverted fitted bed sheet that was ripped. During an interview on 12/17/2024 at 8:30 AM, Registered Nurse #1 (Unit Manager) stated that Resident #292 was recently admitted to the facility, and the room was set up by the Housekeeping Department. Registered Nurse #1 stated Certified Nursing Assistant (CNA) assigned to Resident #292 did not report any issues with the bed sheet. During an interview on 12/17/2024 at 8:43 AM, Certified Nursing Assistant #1 stated they were focused on Resident #292's care and did not notice the fitted sheet on the mattress. Certified Nursing Assistant #1 stated if they had seen the ripped bed sheet, they would have changed the sheet with a new one. During an interview on 12/17/2024 at 11:00 AM, the Housekeeping Director stated they did not know who cleaned the room before Resident #292's admission. The Housekeeping Director stated they expected the housekeeping staff to use linens that are in good condition. During an interview on 12/19/2024 at 12:31 PM, the Director of Nursing Services stated the resident's bed sheets are changed during the resident's shower days, and when visibly soiled. The Director of Nursing Services stated that Certified Assistant #1 should have changed the torn bed sheet. 10 NYCRR 415.5(h)(3)

Based on record review and interviews during the Recertification Survey initiated on 12/15/2024 and completed on 12/19/2024, the facility did not ensure its Facility Assessment considered specific staffing needs for each resident unit. This was identified for two (Starboard Unit and Port Unit) of two units reviewed during the Sufficient Staffing Task. Specifically, the Facility Assessment, last updated in October 2024, did not include a breakdown of the staffing needs for each resident unit. Additionally, the Facility Assessment did not indicate the use of staffing agencies to meet the staffing needs of the facility. The finding is: The facility's policy, titled Facility Assessment reviewed and revised 7/09/2024, documented the facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The Facility Assessment, last updated in October 2024 did not include a breakdown of staffing needs for each of the facility's two units. The Facility Assessment documented that the facility required 11-12 Certified Nursing Assistants for the day shift; 7-9 Certified Nursing Assistants for the evening shift; 3-5 Certified Nursing Assistants for the night shift; 3-4 Licensed Nurses on the day and evening shift; 1-2 Licensed Nurses on the night shift. The Facility Assessment did not include the use of staffing agencies to meet its staffing needs. During an interview on 12/19/2024 at 12:23 PM, the Administrator and the Director of Nursing Services both stated they had updated the Facility Assessment in October 2024. The Director of Nursing Services stated the facility uses a staffing agency for Licensed Practical Nurses approximately four to five times a month. The Director of Nursing Services stated the resident acuity is not the same in each unit. The Starboard unit has 54 beds and the Port unit has 46 beds, and the staffing needs are different on both units. The Administrator stated the Facility Assessment did not include a breakdown of staffing needs for each unit. The Administrator stated the Facility Assessment does not include the use of the staffing agency for its staffing needs. 10 NYCRR 415.26

Based on observation, record review and staff interviews during the abbreviated survey (NY 00311733) dated 4/7/23, the facility did not ensure that Resident #1's environment was free of accident hazard. Specifically, Resident #1 was given food they were allergic to (fish, seafood). The findings are: The Policy and Procedure for food allergies dated 12/2018 documented it is the policy of the facility to ensure that all resident food served accommodates for resident allergies and/or intolerances.Procedure: The Admitting RN will evaluate admissions documentation for food allergies. Allergy/intolerance can also be updated as identified. Information regarding food allergies will be documented in the Dietary section of the medical record and will be entered into the computer system in the Dietary office. Food allergy information will be printed on each meal slip for the individual in the note section of meal tickets for identification. The Food Service Director/Food Service Supervisor and/or the Dietitian will make alterations to the menu system for individual residents identified with food allergies/intolerances to ensure those items are not reflected on the meal ticket to be provided to the resident. All known food allergens will be avoided when meals and snacks are provided to the resident. Resident # 1 was admitted on [DATE] with diagnoses that include Depression, anxiety disorder, Malignant neoplasm of bronchus or lung. The Minimum Data Set (MDS-an assessment tool) MDS dated [DATE] documented Resident#1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS documented the resident had no behaviors. The MDS documented that Resident #1 was independent in eating and may require one staff member as support. The Physician Orders (PO) dated February 2023 documented Resident#1 had allergies including fish and shellfish. EpiPen 0.3 mg/0.3 mL injection, auto-injector, inject 0.3 milliliter (0.3 mg) by intramuscular route once as needed for anaphylaxis (a severe, potentially threatening allergic reaction). Resident#1's face sheet documented the resident had allergies that included fish and shellfish. The Comprehensive Care plan (CCP) titled Therapeutic diet dated 9/1/21 and updated on 3/23/2023 included interventions as follows: food allergy: shellfish, all fish- dietary to omit from meal pattern. The CCP dated 11/5/22 titled Resident is allergic to fish and shellfish. The CCP documented goals: Resident will not be given drugs/food containing allergens as listed. Interventions documented: Do not give resident drug/food to which resident is allergic to. A review of the lunch meal ticket dated 2/26/23 documented the Resident#1's allergies in red (Fish/shellfish). The meal ticket documented for the supervisor to check all meals. The meal ticket also documented that the resident was to be served puree hamburger on that date. A nursing progress note (NPN) dated 2/26/23 at 10:57 PM documented by Licensed Practical Nurse#1 (LPN #1) that at approximately 1:05 pm went to evaluate, Resident#1 who was complaining that the lunch tray was not a hamburger as requested. The NPN documented that while waiting, the resident tasted the food served and notified staff that they believed it was crab. Resident was allergic to shellfish; and stated they only ate half a teaspoon before noticing. The Physician Assistant (PA) was notified immediately, and 1 dose of Benadryl given for prophylactic measures. The NPN documented that the resident had no shortness of breath, respiratory distress, swelling, or wheezing observed. Oxygen was applied for comfort. On 4/7/23 at 10:30 AM, the kitchen was observed along with the crabby cake ingredients that was served to the resident on 2/26/23. The Crabby cakes box by miss Friday's ingredients included imitation crab meat, Alaska [NAME], Pacific [NAME], and snow crab. An investigation by the facility found on Sunday 2/26/23, during the lunch meal service, Resident#1 was served lunch tray. After being served puree lunch tray, Resident#1 notified the staff, passing in the hallway, that they believed pureed meal was not hamburger as they requested, and tasted like crab. The staff member notified the Registered Nurse Supervisor#1 (RNS#1) who responded to the Resident along with the unit LPN. Upon arrival, Resident stated to RNS#1 that there was fish in their meal that they ate, and alerted staff of her shellfish/fish allergy. The meal/puree food that was served was light in color and RNS#1 noted that resident consumed approximately a half of a teaspoon of the puree meal. The meal ticket did reflect shellfish/fish allergy. Upon RNS#1's assessment, the resident appeared in no apparent distress, and was able to speak and respond at her baseline. The PA#1 was made aware, and orders obtained to administer one time dose of Benadryl as prophylaxis. Upon investigation, it was determined that the dietary staff did not follow protocol regarding ensuring meal tray accuracy check was maintained and this was an isolated incident. The Food service supervisor #1 was interviewed on 4/7/23 at 10:30 AM and stated Crabby Cakes by Miss Fridays have ingredients that should not be served to someone who has allergies to shellfish and fish. Dietician #1 was interviewed on 4/7/23 at 1:15 PM and stated Resident#1 has food allergies and this was documented in the notes in their assessment. Dietician #1 stated that food allergies are also documented on meal tickets. Kitchen staff should have identified food allergy and should not have served imitation crab cakes to the resident. Dietician #1 also stated that the resident shouldn't have been served this because of fish ingredients. Food service Director #1 (FSD#1) was interviewed on 4/7/23 at 2:08 pm stated that a crab cake was given to Resident#1. The FSD#1 stated that allergies are highlighted in red on the food ticket and apparently that day the crab cakes were accidentally given. The crabcakes contain fish and the resident has an allergy to fish and shellfish. Resident#1 should not have been given the crabcakes. The Certified Nurse Assistant (CNA) #1 was interviewed on 4/7/23 at 2:45 PM and stated that on 2/26/23 they just gave the resident the tray, the tray was missing a soda and the meal was pureed. CNA#1 stated the Resident had no concerns at the time when the tray was served. LPN#1 was interviewed on 4/7/23 at 3:00 pm and stated the trays were given out without any concerns identified. After CNA#1 gave the tray, and after concern was brought to staff attention, resident was assessed, PA#1 was made aware, and Benadryl was given for allergy. The Director of Nursing Services (DNS) was interviewed on 6/15/23 at 2:15 PM and stated CNA#1 gave the resident a puree tray and it was hard to distinguish by looking at the food whether the resident was served food that the resident had an allergy to. The DNS stated that CNA#1 was not made aware by the resident of any concerns regarding the food when the tray was served to the resident. The resident was a self-feed and when the resident knew the meal contained crab, CNA#1 intervened and notified the nurse. 415.12(h)(1)

Based on observation, record review and staff interviews conducted during the Recertification survey initiated on 4/13/2023 and completed on 4/19/2023, the facility did not ensure that services provided by the facility as outlined in the comprehensive care plan (CCP) must meet professional standards of quality. This was identified for one (Resident # 21) of six residents reviewed for unnecessary medications. Specifically, nursing staff were not rotating the Subcutaneous (sq) injection sites, when Lovenox (an Anticoagulant) was administered. The finding is: The Policy and Procedure for Injection Site Rotation dated [DATE] documents that rotation of the injection site helps reduce irritation and bruising and improves absorption. Resident # 21 was admitted with diagnosis that included Thrombocytopenia. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident's cognition was intact. The MDS documented Resident # 21 received 7 days of anticoagulants and 7 days of injections during the MDS assessment look-back period. The Physician's order dated 2/27/2023 documented to administer Lovenox Enoxaparin 40 milligrams (mg)/0.4 milliLiter (mL) subcutaneous syringe- inject 0.4 milliliter (40 mg) by subcutaneous route once daily by injection for prophylactic measures. A review of the Medication Administration Record (MAR) for March 2023 documented the Lovenox injection was administered to the left abdomen on 11 consecutive days at 9 PM, (March 19- March 29). The MAR for April 2023 documented Resident # 21 was administered Lovenox to the left abdomen on 7 consecutive days (April 1- April 7). On 4/17/23 at 1:54 PM, Resident #21's abdomen was observed with ecchymosis (bruising) to left lower abdomen. Resident # 21 was interviewed on 4/17/23 at 1:54 PM and stated they (Resident #21) were unaware of where the last injection of Lovenox was given and they do not monitor where they get their injections. Licensed Practical Nurse (LPN) # 3, the 3 PM - 11 PM nursing shift medication nurse, was interviewed on 4/18/2023 at 3:45 PM and stated that Lovenox is given subcutaneously and the injection site should be rotated; however, because of technical reasons, the Electronic Medical Record (EMR) drop down box does not allow the nurse to record any other site on the MAR except the left abdomen. LPN #3 further stated the medication nurse cannot verify the actual site of the previous injection because the MAR only allows the left abdomen site to be selected. The Director of Nursing Services (DNS) was interviewed on 4/18/2023 at 11:52 AM and stated that the site of Lovenox administration should be documented and the injection site should be rotated. The medication should not be given to the same site on consecutive days because it can cause tissue damage and discomfort for the resident. The Physician was interviewed on 4/19/2023 at 3:12 PM and stated bleeding, pain, and tissue damage can occur if the injection of Lovenox is not rotated. 10NYCRR 415.11(c)(3)(i)

Based on observation, record review and interviews during the Recertification Survey initiated on 4/13/2023 and completed on 4/19/2023, the facility did not ensure that residents are free of significant medication error. This was identified for one (Resident #64) of five residents reviewed for unnecessary medication. Specifically, Resident #64 was administered Lasix (diuretic) outside the specified duration date. The finding is: The facility Medication Administration policy dated 2/2019 documented the nurse will review physician's orders and compare against medication administration record and to compare the medication name, strength, and dosage schedule on the medication administration record against the prescription label. The policy documented to always check three (3) times prior to administration of medication. Resident #64 was admitted with diagnoses that included Morbid Obesity, Atrial Fibrillation, Peripheral Vascular Disease, and Hypertension. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had intact cognition. The resident received a Diuretic for seven of seven days during the assessment look-back period. A Medical Progress note dated 11/22/2022 documented the resident was seen for follow up and laboratory report review. The resident was noted with increased lower extremity Edema (swelling). Start Lasix 40 milligram (mg) daily (QD) for 10 days and increase Potassium (KCL) to 20 milliequivalent (meq) twice (BID) daily for 10 days then resume QD dosing. A Nursing progress note dated 11/22/2022 documented the Physician Assistant (PA) was in on rounds and ordered to start Lasix 40 mg and an additional 20 meq of Potassium for 10 days. A Physician's order dated 11/22/2022 documented to administer Furosemide (Lasix) 40 mg, give 1 tablet (40 mg) by oral route once daily in the evening for 10 days for Edema. A Medical note dated 11/25/2022 documented the patient was seen for follow up and laboratory report review. Improving lower extremity edema with Lasix in progress. Laboratory results on 11/22/2022 revealed the Blood Urea Nitrogen (BUN) level was 18 milligrams/deciliter (mg/dl) and the Creatinine level was 0.51 mg/dl. According to the laboratory report, the normal reference range for BUN is 8-23 mg/dl and Creatinine is 0.50-0.90 mg/dl. A Review of the Medication Administration Record (MAR) dated 11/2022 documented Lasix 40 mg give 1 tablet by oral route once daily in the evening for 10 days. The start date was 11/22/2022 for diagnosis of Edema. The MAR documented the resident received the Lasix from 11/22/22 to 11/30/22. A Basic Metabolic Panel (BMP) laboratory report dated 12/1/2022 documented a low Potassium level of 2.7 millimoles per liter (mmol/L). The normal Potassium range per the laboratory report was 3.4-5.1 mmol/L. A Nursing note dated 12/1/2022 documented the PA reviewed the laboratory report for 12/1/2022. The Potassium (K+) was 2.7. The PA ordered Potassium Chloride (KCL) 40meq for 1 dose then 40 meq BID for 3 days, then after change to KCL 40 meq daily. A Physician's order dated 12/1/2022 and with a start date of 11/22/2022 documented to administer Furosemide 40 mg, give 1 tablet (40 mg) by oral route once daily in the evening for 10 days for Edema. A Review of the MAR dated 12/2022 documented Lasix 40 mg give 1 tablet by oral route daily in the evening at 5pm for 10 days. The start date was 11/22/2022 for diagnosis of Edema. The MAR documented the resident received Lasix 40 mg from 12/1/2022 to 12/31/2022, outside the duration date of 12/2/2022 without a Physician's order. A Physician's order dated 1/1/2023 and with a start date of 11/22/2022 documented to administer Furosemide 40 mg tablet, give 1 tablet (40 mg) by oral route once daily in the evening for 10 days for Edema. A Review of the MAR dated 1/2023 documented Lasix 40 mg give 1 tablet by oral route daily in the evening at 5pm x 10 days. Start date (11/22/2022) for diagnosis of Edema. The MAR documented the resident received Lasix from 1/1/2023 to 1/3/2023 and from 1/9/2023 to 1/19/2023 outside the completion date without a Physician's order. Lasix was held from 1/4/2023 to 1/8/2023 due to elevated BUN level of 44 mg/deciliter (dl) and Creatinine level of 1.49 mg/dl. A Pharmacy review dated 1/12/2023 documented the resident has an order of Lasix with a stop date of 10 days that was started 11/22/2022 with an end date of 12/2/2022. The recommendation was to consider discontinuing and or starting a new Lasix order with or without a stop date. The Pharmacist documented the reason for the recommendation was if Lasix was administered outside the date parameter it could lead to a medication error. A BMP laboratory report dated 1/4/2023 documented a Blood Urea Nitrogen (BUN) level of 44 (8-23 mg/dl), and Creatinine Serum level of 1.49 H (0.50-0.90 mg/dl). The laboratory report was reviewed by the Physician Assistant (PA), and they (PA) recommended to hold Lasix for 5 days and repeat the BMP on 1/10/2023. A Nursing note dated 1/4/2023 at 8:18 PM documented as per the PA hold Lasix for 5 days and repeat a BMP on 1/10/2023. A Nursing note dated 1/8/2023 at 1:51 PM documented Lasix hold maintained at this time 5 of 5 days. No signs and symptoms of adverse reactions noted at this time. A BMP laboratory report dated 1/10/2023 documented a BUN level of 35 mg/dl and Creatinine level of 1.12 mg/dl. Licensed Practical Nurse (LPN) #2 was interviewed on 4/18/2023 at 3:40 PM. LPN #2 stated when the Physician orders a medication for ten days the nurse that enters the order in the electronic medical record (EMR) also includes the end date. LPN #2 stated that the nurse that entered Lasix in the system should have entered Lasix with a stop date. LPN #2 stated when an order is active, the medication appears on the resident's current MAR and discontinued medications would appear under the discontinued tab. LPN #2 stated if the nurse that entered the order in the system did not set a stop date, then the medication will still show up on the resident's MAR. LPN #2 stated that they did not check the Physician's order prior to administering Lasix 40 mg on 12/2/2022. LPN #2 stated that they (LPN #2) should have verified the resident's order to ensure that the Physician's order for Lasix was current prior to administering the medication. LPN #4 was interviewed on 4/19/2023 at 11:23 AM. LPN #4 stated they were the LPN that entered the original order in the resident's EMR. LPN #4 stated if Lasix was ordered for 10 days, that when they (LPN #4) entered the order they had the option to enter the medication for the duration of (10) days as ordered. LPN #4 stated when they entered the order, they should have entered the Lasix for 10 days as ordered to prevent an error. LPN #4 stated after 12/11/2022 they should have notified the Supervisor and the Physician for clarification on if the Lasix should have been continued. Registered Nurse (RN) #2 was interviewed on 4/19/2023 at 11:58 AM. RN #2 stated when the Physician orders a medication with a duration date, when the order is entered in the system, a duration date should be set up in the system. RN #2 stated that the system would X out the medication when the duration date is reached unless the medication is extended by the PA or the Physician. RN #2 stated that if the Physician wishes to continue the medication after the duration date the Physician would give a new order for an additional 10 days. RN #2 stated after 12/11/2022 the medication should have been entered in the system as a new order with a new end date. RN #2 stated if a medication is sent to the Pharmacy with a 10-day duration, the medication would be dispensed for only 10 days and if the Physician or the PA gave a new order for the medication to continue, the Pharmacy would dispense medication for another 10 days. RN #2 stated that they did not know where the nurses obtained the medication to be administered to the resident after 12/11/2022. RN #2 stated that there was an Emergency medication box; however, only 1 to 2 Lasix tablet is kept in the box. The Assistant Director of Nursing Services (ADNS) was interviewed on 4/19/2023 at 12:49 PM. The ADNS stated that they (ADNS) were responsible for reviewing the monthly Pharmacy reviews. The ADNS stated when the medication was entered into the EMR the medication was entered incorrectly because the medication was entered without a duration date. The ADNS stated the Physician's order was for Lasix to be administered for ten days; however, when the nurse entered the medication, it was not scheduled for 10 days in the EMR and should have been. PA #1 was interviewed on 4/19/2023 at 1:53 PM. PA #1 stated they had written the initial order for Lasix 40 mg on 11/22/2022 for Edema of bilateral lower extremities. PA #1 stated they were in the facility every day and saw improvement in the resident's lower extremities and continued the order for Lasix 40 mg. PA #1 stated that they did not enter the order but after assessing the resident that they should have written a note and given a verbal order to the nurses on the unit. PA #1 stated that the 12/1/2022 order should have been a standing order for Lasix without the 10-day duration date. PA #1 further stated that the Lasix could have contributed to the resident's abnormal renal function and Dehydration. The Pharmacist Director was interviewed on 4/19/2023 at 2:02 PM. The Pharmacist Director stated that when a medication is ordered for 10 days, they dispense a 10-day supply and that each time the medication is renewed they would dispense an additional 10-day supply. The Pharmacist Director stated that they received a Physician order for Lasix on 11/22/2022 and a renewal signed by the Physician on 12/1/2022. The Pharmacist Director stated on 11/30/2022, 12/22/2022, 12/30/2022 and 1/16/2023, they received an electronic request for Lasix 40 mg and that they (Pharmacist Director) dispensed Lasix 40 mg by linking the request to the most recent order which was the 12/1/2022 renewal order. The Pharmacist stated in the EMR the 12/1/2022 order was not discontinued, however, stated the process was they should have obtained a new Physician's order with each request for renewal of the Lasix, and that each request should have been linked to a new Physician's order. The Pharmacist stated that if Lasix was administered past the duration date that the medication can contribute to Dehydration and Renal Function problems. The Director of Nursing Service (DNS) was interviewed on 4/19/2023 at 2:53 PM. The DNS stated that when the order is uploaded in the EMR, there is a function that allows the staff to enter the 10-day duration. The DNS stated when the staff enters the 10 days duration on the 11th day the system would automatically discontinue the medication. The DNS stated if the Physician would like the medication to continue the Physician or the PA would give a new telephone order to the nurse who would then enter the new order in the electronic record. The DNS stated that the Lasix order should have been discontinued and a new order obtained from the Physician or PA for a standing order without a stop date. The DNS stated after 12/11/2022 the nurses should not have administered the medication, and that the nurses should have verified the order with the PA or the Physician before administering the Lasix. 10NYCRR 415.12(m)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the initial and subsequent tour of the kitchen on [DATE] and [DATE]. Specifically, the facility did not ensure that emergency dry food and food products delivered with no expiration dates were tracked and that safety of consumption and discard dates of these food products were determined as per the manufacturer's recommendations. The finding is: The facility's policy titled Food Receiving/Storage Procurement- General dated ,d+[DATE] documented that when food, food products or beverages are delivered to our facility, staff will inspect these items for safe transport and quality upon receipt and ensure their proper storage, covering, labeling, and dating all Potentially Hazardous Food/Time/Temperature Control for Safety (PHF/TCS) foods stored in the refrigerator or freezer as indicated. Perishable and non-perishable food items will be stored/discarded as per the manufacturer's recommendations. Food items that display a best by date will be used for consumption as indicated by the manufacturer recommendations. Foods with a use by or expire date will be consumed or discarded by that date. During an initial tour of the kitchen on [DATE] at 10:43 AM, an inspection of the emergency dry storage room was conducted. Several boxed food items including ravioli in tomato sauce, aged cheddar cheese sauce and light tuna chunk in water were observed with facility-applied sticker labels indicating expiration dates of [DATE], [DATE] and February 2023 respectively. The food products were uncovered from the boxes and the ravioli in tomato sauce was noted to have a best by date by [DATE], the cheese sauce was noted to have a best by date by [DATE] and the light tuna chunk was noted to have a best by date by February 2023. The Food Services Director (FSD) was interviewed immediately and stated that the items should be discarded. Dietary Aide (DA) #1 was interviewed on [DATE] at 12:53 PM and stated they (DA#1) were responsible for receiving and stocking the food delivery. DA #1 stated that they checked for products' expiration dates at the time of delivery and would not accept any expired items. DA#1 stated that they considered best by date the same as expiration date. DA#1 stated that when they noticed the cheese sauce that was delivered on [DATE] with a best by date of [DATE], they would have seen it as expired and should have notified the Director of Food Services. DA#1 stated that when they noticed the chunk light tuna that was delivered on [DATE] with a best by date in February 2023, they would have seen it as expired and should have notified the Director of Food Services. DA#1 stated that they did not notify the Director of Food Services (FSD) about the cheese sauce. DA#1 did not recall if they notified the FSD about the ravioli and the light tuna. A subsequent tour of the emergency dry storage room was conducted on [DATE] at 1:17 PM. Canned green beans and canned sliced carrots were inspected and noted without expiration dates on the boxes. The delivery date of the canned green beans was noted to be [DATE], the expiration date on the body of the cans were incomprehensible. The delivery date of the canned sliced carrots was noted to be [DATE], the expiration date on the body of the cans were incomprehensible. A facility-applied sticker was observed on the packaging of the sliced carrots indicating an expiration date of [DATE]. The Food Services Director (FSD) was interviewed immediately and stated that canned vegetables were normally good for one year past best by date and should be discarded by [DATE]. The FSD stated that they did not know how an expiration date of [DATE] was determined for the canned sliced carrots. The FSD stated that the facility's purchasing staff had reached out to the vendor to obtain the manufacturer's recommendations for foods with best by date to determine how long those foods will be safe to consume beyond best by date and whether or not those foods are safe to consume. The FSD stated that they will now request the vendor to provide expiration dates for the canned vegetables with incomprehensible expiration dates. The FSD was re-interviewed on [DATE] at 1:35 PM and stated that all dietary staff were expected to reach out to them (FSD) whenever there were uncertainty related to food's safety of consumption and or the food's discard dates. The FSD stated that all dietary staff will receive an in-service about reading the dates on the food packaging. The FSD stated that they (FSD) were still waiting for the manufacturer's reference for the ravioli in tomato sauce, aged cheddar cheese sauce and light tuna chunk in water at this time. The Food Service Supervisor (FSS) was interviewed on [DATE] at 1:33 PM and stated that they (FSS) were also the cook. The FSS stated they only received food delivery on rare occasions when both the primary stock person and the Food Service Director were absent. The FSS stated that when they received an order, they would reconcile the order and the marked date of delivery on the packages. The FSS stated that they do not inspect the expiration dates and that the stock person responsible would check, determine, and label the expiration dates when they (stock person) sorted and stocked the foods. The FSS stated that they were in-serviced on food safety and on how to determine discard dates for food that did not have an expiration date in the past. The FSS stated that all food's discard dates should be three months beyond best by date. The FSS stated that food with best by date of February 2023 should be discarded by [DATE]. The FSD was re-interviewed on [DATE] at 1:52 PM and stated that they (FSD) were still waiting for the manufacturer's reference for the ravioli in tomato sauce, aged cheddar cheese sauce and light tuna chunk in water at this time. They (FSD) were also still waiting for the manufacturer's clarification of the canned green beans and canned sliced carrot which had incomprehensible expiration dates. The FSD stated that they (FSD) had referenced the United State Department of Agriculture (USDA) government website when determining the safe consumption dates and discard dates for foods with best by dates. The FSD stated that they should reference the manufacturer's recommendations to accurately determine actual expiration/discard dates of foods in their inventory that did not have expiration dates. The USDA reference titled Food Product Dating dated [DATE] was provided and reviewed. The reference documented that a Best if used by/Before date indicates when a product will be of best flavor or quality. It is not a purchase or safety date. The Administrator was interviewed on [DATE] at 10:30 AM and stated that they (Administrator) expected that the food safety and discard dates would be determined by following the manufacturer's recommendations, especially with foods that had best by date. The Administrator stated that the facility currently did not have the manufacturer reference available to determine the exact expiration/discard date for food items that did not have expiration dates on them. The Administrator stated that there was no way to be certain how long each food item with a best by date can be kept beyond its best by date. The Administrator stated that the facility had reached out to obtain the manufacturer reference and was still waiting for the manufacturer's reference for the food items at this time. 10NYCRR 415.14(h)

Based on observation, record review and interviews during the Recertification Survey initiated on 4/13/2023 and completed on 4/19/2023, the facility did not ensure that procedures that assure the accurate acquiring dispensing and administering of all drugs and biologicals meet the needs of each resident. This was identified for one (Resident #64) of five residents reviewed for unnecessary medication. Specifically, Resident #64 had a Physician's order dated 11/22/2022 for Lasix (diuretic) 40 mg for 10 days. The Medication was renewed on 12/1/2022 and 1/1/2023 for an additional 10 days. Review of the Medication Administration Record (MAR) revealed the medication was dispensed by the Pharmacy after the duration date and administered to the resident without a current Physician's order. The finding is: Resident #64 was admitted with diagnoses that included Morbid Obesity, Atrial Fibrillation, Peripheral Vascular Disease, and Hypertension. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had intact cognition. The resident was non-ambulatory and received a Diuretic for seven of seven days during the assessment look-back period. A Physician's order dated 11/22/2022 documented to administer Furosemide 40 milligram (mg), give 1 tablet (40 mg) by oral route once daily in the evening for 10 days for Edema. A Pharmacy Electronic Shipping Manifest (medication invoice) dated 11/30/2022, 12/22/2022, 12/30/2022 and 1/17/2023 documented Furosemide 40 mg was requested and accepted. A Physician's order dated 12/1/2022 and with a start date of 11/22/2022 documented Furosemide 40 mg, give 1 tablet (40 mg) by oral route once daily in the evening for 10 days for Edema. A Review of the MAR dated 12/2022 documented Lasix 40 mg give 1 tablet by oral route daily in the evening at (5pm) for 10 days. The start date was (11/22/2022) for diagnosis of Edema. The MAR documented the resident received Lasix 40 mg from 12/1/2022 to 12/31/2022 outside the duration date of 12/2/2022 without a Physician's order. A Physician's order dated 1/1/2023 and with a start date of 11/22/2022 documented to administer Furosemide 40 mg tablet, give 1 tablet (40 mg) by oral route once daily in the evening for 10 days for Edema. A Review of the MAR dated 1/2023 documented Lasix 40 mg give 1 tablet by oral route daily in the evening at (5pm) x 10 days. Start date (11/22/2022) for diagnosis of Edema. The MAR documented the resident received Lasix from 1/1/2023 to 1/3/2023 and from 1/9/2023 to 1/19/2023 outside the completion date without a Physician's order. Lasix was held from 1/4/2023 to 1/8/2023 due to elevate a Blood Urea Nitrogen (BUN) level of 44 mg/deciliter (dl) and Creatinine level of 1.49 mg/dl. The laboratory report indicated the normal reference range for BUN was 8-23 mg/dl and Creatinine level was 0.50-0.90 mg/dl. A Pharmacy review dated 1/12/2023 documented the resident has an order of Lasix Furosemide with a stop dated of 10 days that was started on 11/22/2022 with an end date of 12/2/2022. The recommendation was to consider discontinuing and or starting a new Lasix order with or without a stop date. The Pharmacist documented the reason for the recommendation was if Lasix was administered outside the date parameter it could lead to a medication error. Physician Assistant (PA) #1 was interviewed on 4/19/2023 at 1:53 PM. PA #1 stated they had written the initial order for Lasix 40 mg on 11/22/2022 for Edema of bilateral lower extremities. PA #1 stated they were in the facility every day and saw improvement in the resident's lower extremities and continued the order for Lasix 40 mg. PA #1 stated they did not enter the order but after assessing the resident that they should have written a note and given a verbal order to the nurses on the unit. PA #1 stated that the 12/1/2022 order should have been a standing order for Lasix without the 10-day duration date. PA #1 further stated that the Lasix could have contributed to the resident's abnormal renal function and Dehydration. The Pharmacist Director was interviewed on 4/19/2023 at 2:02 PM. The Pharmacist Director stated that when a medication is ordered for 10 days that they dispense a 10-day supply and that each time the medication is renewed they would dispense an additional 10-day supply. The Pharmacist Director stated that they received a Physician order for Lasix on 11/22/2022 and a renewal signed by the Physician on 12/1/2022. The Pharmacist Director stated on 11/30/2022, 12/22/2022, 12/30/2022 and 1/16/2023, they received an electronic request for the for Lasix 40 mg and that they (Pharmacist Director) dispensed Lasix 40 mg by linking the request to the most recent order which was the 12/1/2022 renewal order. The Pharmacist stated in the EMR the previous order was not discontinue;, however, stated the process was to obtain a new Physician's order with each request and they should have linked each request to a new Physician's order. The Pharmacist stated that if Lasix was administered past the duration date the medication can contribute to Dehydration and Renal Function problems. The Director of Nursing Service (DNS) was interviewed on 4/19/2023 at 2:53 PM. The DNS stated that when the order is uploaded in the EMR, there is a function that allows the staff to enter the 10-day duration. The DNS stated when staff enters the 10 days duration on the 11th day the system would automatically discontinue the medication. The DNS stated if the Physician would like the medication to continue the Physician or the PA would give a new telephone order to the nurse who would then enter the new order in the EMR. The DNS stated the Lasix order should have been discontinued and a new order obtained from the Physician or PA for a standing order without a stop date. The DNS stated after 12/11/2022 the nurses should not have administered the medication, and the nurses should have verified the order with the PA or the Physician before administering the Lasix. 10NYCRR 415.18(a)

Based on observation, record review and staff interviews conducted during a recertification survey, the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. Specifically, 1) nursing staff were not documenting the Subcutaneous (sq) injection sites when [MEDICATION NAME] was administered for 1 (Resident # 19) of 5 residents reviewed for medication review. 2a) Resident #238 was prescribed Keflex for 10 days. The Medication Administration Record (MAR) revealed that Keflex was documented for a 9-day period, with 7 of 18 doses refused. The Nurse Practitioner (NP) was not made aware of the refusal; and 2b) Resident #238 was administered [MEDICATION NAME] injection reconstituted with [MEDICATION NAME] without specific injection route and without specific [MEDICATION NAME] strength solution to be used. The Licensed Staff administered the [MEDICATION NAME] and [MEDICATION NAME] reconstituted without verification with the NP or Attending Physician regarding the route of injection and the strength of the [MEDICATION NAME] solution. 3) Resident #1 was administered Milk of Magnesia (MOM) without a Physician's Order. The subsequent bowel protocol order was not followed. The findings are: 1) The Policy and Procedure for Injection Site Rotation dated (MONTH) (YEAR) documents Rotation of the injection site helps reduce irritation and bruising and improves absorption. Resident # 19 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident received 7 days of anticoagulants and 7 days of injections during the MDS assessment period. The 1/10/19 physician order documented to administer 5000 units of [MEDICATION NAME] by injection for an unspecified diagnoses. A review of the Medication Administration Record (MAR) from 1/10/19 to 1/3019, except on 1/14/19, did not document the [MEDICATION NAME] injection sites after every [MEDICATION NAME] sq Injection. An interview with the 7 AM to 3 PM Medication Nurse Licensed Practical Nurse (LPN) was held on 1/31/19 at 11:45 AM. The LPN stated that the [MEDICATION NAME] is given subcutaneously. The LPN further stated that she would not know where the [MEDICATION NAME] medication was last given because it was not documented on the MAR. The Registered Nurse (RN) supervisor was interviewed on 1/31/19 at 11:52 AM and stated that the site of [MEDICATION NAME] Administration should be documented and if there was no documentation, it would be difficult to determine where the previous nurse administered the medication. 2a) Resident #238 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating the resident was cognitively intact. The MDS documented active [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP) developed for Skin Infection dated 1/10/19 documented Left Chest Wall Infection. The Physician's Order dated 1/9/19 documented to administer Keflex 500 milligram (mg) capsule by oral route (PO) every 12 hours for 10 days for Bacterial Infection. The Medication Administration Record (MAR) for (MONTH) 2019 documented Keflex was administered from 1/9/19 through 1/18/19 for a total 18 doses (9 days) instead of 20 total doses (10 days). The record also documented 7 doses were refused by the resident. There was documented evidence that the Physician or Nurse Practioner (NP) were made aware of the resident's Keflex refusals and that Keflex was only administered for 9 days. An interview with the NP was conducted on 1/30/19 at 9:30 AM. The NP stated that he was not made aware that the Keflex was only administered for 9 days. The NP also stated the he was not made aware that the resident refused 7 doses of Keflex. The NP stated that If he had been made aware, he could have reassessed the resident and he could have made another option of treatment. An interview with the Licensed Practical Nurse (LPN), who documented the Keflex dose was refused, was conducted on 2/1/19 at 10:00 AM. The LPN stated that she presumed that the NP or doctor was already made aware that the resident had been refusing Keflex so she did not call the NP or doctor. 2b) Resident # 238 had a Physician's Order dated 1/19/19 which documented to administer [MEDICATION NAME] 1 gram solution for injection once daily, reconstitute with 2.1 ml [MEDICATION NAME] for 4 days for a UTI. The Physician's Order dated 1/19/19 did not document the strength of the [MEDICATION NAME] solution to be used. The MAR for (MONTH) 2019 documented that the [MEDICATION NAME] ([MEDICATION NAME]) was administered with [MEDICATION NAME] reconstitution from 1/19/19 through 1/23/19. The NP was interviewed on 1/31/19 at 11:01 AM. The NP stated that the nurses should have confirmed with the Physician or the NP the route of injection and the strength of [MEDICATION NAME] to be reconstituted to [MEDICATION NAME]. An interview was held on 2/4/19 at 10:00 AM with a Licensed Practical Nurse (LPN) who administered the [MEDICATION NAME] via injection. The LPN stated she used the [MEDICATION NAME] that was in stock. The Director of Nursing Services (DNS) was interviewed on 2/5/19 at 1:00 PM. The DNS stated that the the facility has the [MEDICATION NAME] in stock from the pharmacy, which was used. It brought to her attention that the there was no Physician's Order indicating the [MEDICATION NAME] strength and no injection route was specified. 3) Resident #1 has [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE]. The Admission Minimum Data set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 13 indicating the resident was cognitively intact. The Physician's Order dated 1/10/19 documented MOM 400 mg/5 milliliter (ml) oral suspension to give 30 ml by mouth as one dose PRN if no bowel movement after 48 hours. The Medication Administration Record (MAR) for (MONTH) 2019 revealed that MOM was administered on the admitted [DATE], then on 1/11/19 and 11/12/19. The resident was interviewed on 2/5/19 at 12:00 PM. The resident stated that he had requested MOM on the admitted . There was no documentation for a one time MOM dose in the Physician's Order. An interview with the Nurse Practitioner was conducted on 2/5/19 at 12:01 PM. The NP stated the Licensed staff should have requested a one time dose of MOM on 1/10/19 to cover the resident's request. 415.11(c)(3)(i)

Based on record review and interviews during the recertification survey, the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments. Specifically, the physician did not ensure that the physician orders [REDACTED]. Specifically,1) Resident # 19 was receiving [MEDICATION NAME] Injection without specification of an injectable route; 2) Resident #238 had a physician's orders [REDACTED]. The findings are: 1) Resident # 19 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident received 7 days of anticoagulants and 7 days of injections during the MDS assessment period. The 1/10/19 physician order [REDACTED]. The order was signed by the physician on 1/11/19. A review of the Medication Administration Record [REDACTED]. An interview with the 7 AM to 3 PM Medication Nurse Licensed Practical Nurse (LPN) was held on 1/31/19 at 11:45 AM. The LPN stated that the [MEDICATION NAME] is given subcutaneously. The Registered Nurse (RN) Supervisor was interviewed on 1/31/19 at 11:52 AM and stated that the physician's orders [REDACTED]. She stated it was never questioned and she did not contact the physician to clarify the order. The Nurse Practioner was interviewed on 2/1/19 at 11 AM and stated the injectable route should be specified on the monthly physician's orders [REDACTED].> 2) Resident #238 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. An interview with the Nurse Practitioner (NP) was conducted on 1/31/19 at 11:01 AM. The NP stated the [MEDICATION NAME] order needed to have a specific injection route. The NP stated that the order should document injection by intramuscular (IM) route for [MEDICATION NAME]. The Licensed Practical Nurse (LPN), who administered the 5 [MEDICATION NAME] injections, was interviewed on 2/4/19 at 10:00 AM. The LPN stated that she presumed the [MEDICATION NAME] would be administered intramuscularly. 415.15(b)(2)(iii)

Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that residents are free of any significant medication errors that are not in accordance with the prescriber's order, manufacturing specifications and accepted professional standards and principles. Specifically, Resident #1 was administered [MEDICATION NAME] (an antibiotic) orally with [MEDICATION NAME] tablet at the same time. The order was to have a 2 hour interval between the two medications. The finding is: The facility's policy and procedure dated 10/2016 titled Medication Administration - General documented .4) The nurse will review physician's orders [REDACTED]. Resident #1 has [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE]. The Admission Minimum Data set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 13 indicating the resident was cognitively intact. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Protocol: Not within 2 hours of Iron, Zinc, Milk,or Magnesium/Calcium for [MEDICAL CONDITIONS]. The Medication Administration Record [REDACTED]. An interview with the Nurse Practitioner (NP) was conducted on 1/31/19 at 11:01 AM. The NP stated the [MEDICATION NAME] and Iron tablet order was to be administered with at least a 2-hour interval to prevent interaction between the two and that iron would affect the absorption of [MEDICATION NAME]. The NP stated that this was not brought to his attention by the nurses administering the medications. An interview with the Licensed Practical Nurse, who administered both medications at the same time, was conducted on 2/1/19 at 10:00 AM. The LPN stated that the timing on the computerized MAR indicated [REDACTED]. An interview with the Registered Nurse (RN) Unit Charge Nurse was conducted on 2/4/19 at 10:00 AM. The RN stated that [MEDICATION NAME] should be administered at least 2 hours apart from Iron as ordered. 415.12(m)(2)

Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections was maintained. This was evident for 1 (Resident #69) of 2 residents reviewed for falls. Specifically, Resident #69 was observed in bed with his call bell on the floor. The Social Worker (SW) picked up the call bell from the floor and placed the call bell on top of the resident's blanket. The SW did not clean the call bell before placing it on top of the resident's blanket. The finding is: Resident #69 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 4 indicating the resident was severely impaired in cognition. The resident had no functional limitations of both upper and lower extremities. On 2/4/19 at 11:50 AM, Resident #69 was observed in bed. The resident's call bell was found on the floor. On 2/4/19 at 11:52 AM, the Certified Nursing Assistant assigned to the resident was observed entering the resident's room followed by the Social Worker. At 11:53 AM, a Licensed Practical Nurse (LPN) entered the resident's room and then exited the room. The LPN was interviewed on 2/4/19 at 11:54 AM. The LPN stated she was just straightening the resident's bedsheet. On 2/4/19 at 11:55 AM, the surveyor entered the resident's room, in the presence of the CNA and SW, and observed the resident's call bell was still on the floor. The SW was made aware that the resident's call bell was on the floor. The SW immediately removed the call bell from the floor and placed the call bell on top of the resident's blanket without first cleaning the call bell. The SW was immediately interviewed on 2/4/19 at 11:55 AM. The SW stated that she should have cleaned the call bell first. The Registered Nurse (RN) Infection Control Nurse was interviewed on 2/4/19 at 11:57 AM. The RN stated that the call bell should have been cleansed before placing it on top of the resident's blanket for infection control purposes. 415.19(a)(1-3)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that medical records are maintained in accordance with accepted professional standards and practices that are complete and accurately documented. This was identified for 1 (Resident #63 ) of 1 resident reviewed for accidents and for 1 (Resident #238) of 2 residents reviewed for pain and skin infection. 1) Specifically, for Resident # 63, the Accident/Incident (A/I) report dated 11/6/18 was not signed by the Medical Director to complete the investigation report; and 2) For Resident # 238, there was no assessment of pain prior to the administration of an as need (PRN) pain medication ([MEDICATION NAME]). Additionally, the Comprehensive Care Plan (CCP) developed for Infections and Skin Impairment was updated on 1/30/19. The CCP indicated the resident had [MEDICAL CONDITION] of the right chest wall rather than the left chest wall. The findings are: 1) Resident #63 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Accident/Incident (A/I) Report dated 11/6/18 at 6:45 PM documented the resident was found on the floor sitting next to his bed and that the resident's bed alarm sounded. The resident stated that she was returning from the bathroom to her bed. The A/I report also documented the resident was self-toileting and the resident did not call for assistance to go to the bathroom. Review of the A/I report dated 11/6/18 revealed no signature of the Medical Director to complete the investigation. An interview with the Administrator was conducted on 2/1/19 at 1:00 PM. The Administrator stated that the A/I Report should have been signed by the Medical Director. 2) Resident #238 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating the resident was cognitively intact. The MDS documented active [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP) developed for Pain dated 1/5/19 documented the resident had actual and potential pain status [REDACTED]. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. There was no pre and post assessment of pain when [MEDICATION NAME] PRN was administered. The resident's Pain Monitor Assessment Record revealed 0 pain description from 1/5/19 - 1/7/19. The Nurses' Notes reviewed from 1/5/19 through 1/7/19 documented no pre-assessment of the resident's pain level before the [MEDICATION NAME] PRN was administered. The [MEDICATION NAME] PRN order was discontinued on 1/7/19, and on 1/7/19 the Physician ordered [MEDICATION NAME] 5 mg tablet to give 1 tablet 5 mg PO q 6 hours for Acute Pain due to Trauma. An interview with the Nurse Practitioner (NP) was conducted on 1/31/19 at 11:01 AM. The NP stated that when giving a PRN pain medication such as [MEDICATION NAME], he expects the licensed staff to document the pre and post pain assessments. The Licensed Practical Nurse (LPN), who administered the PRN [MEDICATION NAME], was interviewed on 2/1/19 at 10:00 AM. The LPN stated that she must have forgotten to document the pain level. b) The Physician's Progress Note dated 1/9/19 documented left upper chest wall with abraded superficial section, with moist wound bed, with 80% light yellowish tissue; no necrotic tissue and tenderness on palpation. The plan was to administer Keflex. The CCP developed for Infections and Skin Impairment dated 1/10/19 documented [MEDICAL CONDITION] on the left chest wall. The CCP was reviewed on 1/30/19 documenting resolving right chest wall abrasions instead of left chest wall location. An interview with the Director of Nursing Services (DNS) was conducted on 2/5/19 at 11:00 AM. The DNS stated that the documentation of the right chest wall abrasion was an error, the CCP should have documented a left chest wall abrasion. 415.22 (a)(1-4)

Based on record review and staff interviews during the recertifcation survey, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. This was evident for two of five Stage 2 residents reviewed for unnecessary drugs in a total Stage 2 sample of 26. Specifically, 1) Resident #10 was prescribed an increase in a dosage of [MEDICATION NAME] (an antipsychotic) for high risk behaviors and [MEDICAL CONDITION] and there was no supporting documented evidence in the medical record of behaviors or [MEDICAL CONDITION] and 2) Resident #30 was administered [MEDICATION NAME] which has a black box warning (there is a higher risk for death) and not FDA approved for elderly residents with a [DIAGNOSES REDACTED]. This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. This is a repeat deficiency. The findings are: 1) Resident #10 has [DIAGNOSES REDACTED]. A Significant Change Minimum Data Sets Assessment ((MDS) dated [DATE] documented that the resident had short and long term memory problems, and was severely impaired in cognitive skills for daily decision making. The MDS documented no potential indicators of [MEDICAL CONDITION] or behaviors. A physician's orders [REDACTED]. A Psychiatric Consultation dated 4/29/15 documented that the resident was seen for increased signs and symptoms of depression, and the psychiatrist recommended to increase the [MEDICATION NAME] to 0.25 mg at 9:00 AM and keep [MEDICATION NAME] 0.5 mg one tablet by mouth before bedtime for high risk behaviors and paranoid [MEDICAL CONDITION]. The consult documented that non drug measures were not always helpful. A physician's orders [REDACTED]. for agitation/aggression. A review of the Nurses Progress notes dated 2/23/15 to 4/24/15 documented that on 2/23/15, the resident was restless and calling out multiple times despite needs met. There was no further documentation in the notes of behaviors from 2/24/14 to 4/24/15 and no notes documented from 4/25/15 to 5/7/15. A review of the Medication Administration Sheets (MAR) dated 3/31/15 to 5/11/15 documented no behaviors. physician progress notes [REDACTED]. There was no documentation of any behaviors exhibited by Resident #10. The 7:00 AM to 3:00 PM Certified Nursing Assistant (CNA) responsible for Resident #10 was interviewed on 6/29/15 at 11:00 AM and stated that he has been the resident's CNA for about 2 years, and that he is resistive to care most of the time, he swings and grabs, but he calms down when you talk to him, and his behavior has improved over the last few months, as it seems he has calmed down. The CNA stated that he is unpredictable, and if he has behavior like kicking, he would tell the nurse. The CNA stated that the psychiatrist has never spoken to him concerning the resident. The registered nurse (RN) manager responsible for Resident #10 was interviewed on 6/29/15 at 12:15 PM. The RN stated behaviors should be documented in the Nursing Progress Notes or on the MAR, and that the behaviors described in the Psychiatric Consultation should have been documented. The Psychiatrist responsible for Resident #10 was interviewed on 6/30/15 at 12:30 PM and stated that he speaks to the Nurse Manager, medication nurses and CNAs, and reads the progress notes when consulting for residents. The Psychiatrist stated that the resident was seen on 4/29/15 for high risk behaviors but he could not recall if there was documentation in the record, and although [MEDICAL CONDITION] have limited use in a resident who is [AGE] years old, he must have had a great deal of discussion with the multipdiciplinary team and that the benefit outweighs the risk in this case. The Director of Nursing Services was interviewed on 6/29/15 at 2:00 PM and stated that the Nursing Progress Notes should document if Resident #10 has any behaviors. 2) Resident #30 is a [AGE] year old resident who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Patient Instrument Review (PRI) dated 4/20/15 under the title Behaviors documented that the resident had no verbal or physical disruption, no hallucinations and no socially inappropriate behavior. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had long and short term memory loss and was severely impaired with decision making. The MDS had no documented evidence that the resident had any episodes of [MEDICAL CONDITION], mood, or behavior concerns. The MDS dated [DATE] documented that the resident had long and short term memory loss and was severely impaired with decision making. The MDS also had no documentation that the resident had episodes of [MEDICAL CONDITION], mood or behavior concerns. A physician's orders [REDACTED]. A POF dated 6/12/15 documented [MEDICATION NAME] 1.25 mg at bedtime for a [DIAGNOSES REDACTED]. MARs dated 4/20/15 to 6/7/15 documented that the resident was administered [MEDICATION NAME] 2 mg at bedtime for a [DIAGNOSES REDACTED]. An MAR dated 6/25/15 to 6/28/15 documented [MEDICATION NAME] 1 mg for a [DIAGNOSES REDACTED]. A Nursing Progress Note (NPN) dated 5/30/15 documented that the resident was found on the floor at 8:00 AM in front of the wheelchair. The NPN also documented that the resident complained that her head hurt and that the Physician was notified and ordered to send the resident to the hospital. A NPN dated 6/2/15 documented that the resident returned from the hospital with [DIAGNOSES REDACTED]. The NPN also documented that the resident had bruises around the left eye and left forehead. A Pharmacy Consultant Review (PCR) dated 5/29/15 documented that the resident is on [MEDICATION NAME] for a [DIAGNOSES REDACTED]. There is no documented evidence in the medical record that the resident was assessed for a medical justification/indication for the continued use of [MEDICATION NAME]. An observation on 6/30/15 at 10:15 AM revealed that the resident was in her room sleeping in the wheelchair was not easily aroused. An observation on 7/1/15 at 12:05 PM revealed that the resident was sitting in her room in the wheelchair and was awake. The resident was not able to answer questions appropriately. An interview was held with Resident #30's Certified Nursing Assistant (CNA) on 6/29/15 at 1:15 PM. The CNA stated that he gets the resident out of bed around 8:00 AM and that the resident sometimes states she is tired and wants to be left alone. The CNA stated that the resident is pleasant during the day but that she is confused. An interview was held with the Registered Nurse (RN) Nurse Manager on 6/29/15 at 1:30 PM. The RN reviewed the medical record and stated that there was no documented medical justification/indication on the POF or MAR and could not explain why. The RN also sated that the resident sometimes resists care. An interview was held with the Psychiatrist on 6/30/15 at 12:30 PM. The Psychiatrist stated that the resident was administered [MEDICATION NAME] for delusions and [MEDICAL CONDITION]. The Psychiatrist also stated that he could not explain why there was no documentation in the medical record that the resident had episodes of [MEDICAL CONDITION] or delusions but that the resident had it in the hospital. An interview was held with the Pharmacist on 7/1/15 at 10:30 AM. The Pharmacist stated that he informed the Physician on 5/29/15 that the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. 415.12(l)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that a comprehensive care plan (CCP) was periodically reviewed and revised by a team of qualified persons. This was evident for one of five Stage 2 residents reviewed for unnecessary drugs in a total Stage 2 sample of 26. Specifically, Resident #10 was prescribed an increase in a dosage of [MEDICATION NAME] (an antipsychotic) for high risk behaviors and [MEDICAL CONDITION] and there was no documented evidence in the CCP to address the increased behaviors or [MEDICAL CONDITION] and no documented evidence of revised interventions specific to the resident at the time of the dosage increase. This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. This is a repeat deficiency. The finding is: Resident #10 has [DIAGNOSES REDACTED]. A Significant Change Minimum Data Sets Assessment ((MDS) dated [DATE] documented that the resident had short and long term memory problems, and was severely impaired in cognitive skills for daily decision making. The MDS documented no potential indicators of [MEDICAL CONDITION] or behaviors. A physician's orders [REDACTED]. A Psychiatric Consultation dated 4/29/15 documented that the resident was seen for increased signs and symptoms of depression, and the psychiatrist recommended to increase the [MEDICATION NAME] to 0.25 mg at 9:00 AM and keep [MEDICATION NAME] 0.5 mg one tablet by mouth before bedtime for high risk behaviors and paranoid [MEDICAL CONDITION]. The consult documented that non drug measures were not always helpful. A physician's orders [REDACTED]. for agitation/aggression. A CCP titled Alteration in Mood and Behavior dated 4/1/14 and updated 4/1/15 documented that the resident had behaviors by history and was non-compliant with transfer and mobility status. The CCP documented interventions including to monitor for any changes in mood and behavior, approach resident calmly and use friendly tone of voice and to remove resident from environmental stimulants at the signs of inappropriate behavior. The CCP documented on 3/12/15 that the resident was stable and continue the plan of care. The CCP documented on 4/1/15 that there was a significant change and to continue the plan of care. There was no documented evidence that the Mood and Behavior CCP was updated to reflect the increase in behavior documented on the Psychiatric Consultations, and there was no documented evidence that the CCP was updated with resident specific interventions to address the increased behaviors or specific [MEDICAL CONDITION] for Resident #10. A CCP titled [MEDICAL CONDITION] Medication Use dated 6/11/14 and updated on 4/1/15 documented to monitor the effectiveness and potential side effects of the medication, to monitor Mood/Behavior/Affect and to document any behavioral incidents. There is no documented evidence that any behaviors were addressed on the CCP, and there was no documented evidence that the CCP was updated to reflect the increase in the [MEDICAL CONDITION] medication and there was no documented evidence of any resident specific, revised interventions to address the increase in behaviors or [MEDICAL CONDITION] and [MEDICAL CONDITION] medication for Resident #10. The registered nurse (RN) manager responsible for Resident #10 was interviewed on 6/29/15 at 12:15 PM. The RN stated that the CCP should have been updated to reflect the increased behaviors and the increased [MEDICAL CONDITION] medication. 415.11(c)(2)(i-iii)

Based on observation, resident and staff interview and record review the facility did not ensure that each resident and if known, a family member or legal representative of the resident were notified of the resident's discharge and reasons for the move in writing and in a language and manner they understand. Specifically, three of three residents (Resident #1,#2,#3) reviewed for transfer and discharge lacked documented evidence that the residents and their legal representatives were provided a written notice including the reasons, effective date of discharge and the location to which the residents are to be transferred or discharge or a statement that the resident has the right to appeal the actions to the state and the name, address and telephone number of the state long term care ombudsman as soon as practical. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Complaint Identification # NY 1251 The findings are: Resident#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #1 was cognitively intact. The Comprehensive Care Plan (CCP) for short term rehabilitation dated 10/30/13 documented the social worker will discuss discharge planning with the resident. The Social Worker Progress Notes (SWPN) dated 1/15/14, documented that the resident was made aware his last covered date of stay would be 1/17/14 and he would be discharged on [DATE] and the resident stated he would be going to a men's shelter. The notice of Medicare Provider Non-Coverage Form dated 1/15/14 documented the last date of coverage as 1/17/14 for non-coverage. The resident's medical record lacked documented evidence that a discharge notice was issued to the resident that included date of discharge, reason and location to which the resident was being discharged , a statement that the resident has the right to appeal the actions to the state and the name, address and telephone number of the state long term care ombudsman. As per the facility investigation (not dated) by Social Service Director #13 documented paper work was submitted to Brookhaven town for housing dated 12/31/13 but the resident was declined. On 1/15/14 the resident was notified that he reached his potential and would no longer be covered by Medicare dated 1/18/14 and was ready for discharge. He was notified of his rights to appeal and signed the denial letter. Resident #1 stated he wanted to go to Pax Cristi (men's shelter) and submitted a telephone number to SW#13. On 1/15/14 the shelter was contacted with no opening at that time. On 1/16/14, Resident #1 advised SW#13 he would go to his sister's home. SW #13 unsuccessfully called the sister and the resident requested discharge date d 1/17/14. On 1/17/14 the SW spoke with resident #1 who refused discharge to his sister's home and stated he would be going to a boarding house. The Nursing Progress Notes (NPN) dated 1/17/14 documented the resident was discharged with scripts at 9:15AM. Resident#2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented the residents' cognition was intact. The Comprehensive Care Plan (CCP) for discharge potential dated 9/27/13 documented social work will follow up on discharge and arrange for discharge. The Medicare Denial Letter SNF Determination on Continued Stay dated 1/9/14 documented coverage would end dated 1/12/14. The resident's medical record lacked documented evidence that a discharge notice was issued to the resident that included date of discharge, reason and location to which the resident was being discharged , a statement that the resident has the right to appeal the actions to the state and the name, address and telephone number of the state long term care ombudsman. The SW PN dated 1/16/14 documented the resident requested to be discharged to a hotel. The resident is alert and oriented and able to make her own decisions. All prescriptions were ordered through the resident's mail order drug plan dated 1/9/14 and the resident agreed the medications would be mailed to her mothers' house. The PN dated 1/16/14 at 6:00PM documented the resident was discharged . Resident#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented the resident's cognition was severely impaired. The Comprehensive Care Plan (CCP) for discharge potential dated 10/3/13 documented social work will follow up on discharge and arrange for discharge. The SWPN dated 12/31/13 documented the resident and the daughter made a request for discharge home on 1/6/13. The Notice of Medicare Provider Non-Coverage dated 1/3/14 documented coverage would end dated 1/5/14. Resident#3's medical record lacked documented evidence that a discharge notice was issued to the resident that included date of discharge, reason and location to which the resident was being discharged , a statement that the resident has the right to appeal the actions to the state and the name, address and telephone number of the state long term care ombudsman. The PN dated 1/6/24 documented the resident was discharged home at no time noted. The policy for discharge planning documented notice and documentation and appeal rights documented the resident and or designated representative will be served with notification of discharge and right to appeal, 30 days prior to discharge or as soon as practical. During an interview with the Director of Nursing (DON), and Administrator on 8/7/14 at 9:30AM, the Director of Nursing (DON) stated Social Service Director#13 no longer works at the facility. The DON stated a written 30 day notice of discharge should be given to the resident or the next of kin for routine discharge and 15 day notice in writing for emergency discharge and this done by the SW. The DON stated when Resident#1 changed his mind about where he was going on discharge, the SW could have kept him at the facility and contacted the boarding house. The Notice of Medicare Provider Non-Coverage form is the only notice submitted to the resident/next of kin for pending discharge. The Administrator stated the SW is responsible to give each resident/responsible party 30 days written notice of discharge for routine discharges. The Administrator stated the SW should have given 30 days ' written notice to Residents #1,#2 and #3 but the prior SW did not. During an interview with Social Worker#14 on 8/7/14 at 10:30AM, the SW stated the notice of Medicare provider non-coverage is the form that is used to notify residents that they are being discharged . During an telephone interview with the West unit, RN (Registered Nurse) Supervisor #15 who was on duty on 1/17/14 at 1:07 PM and the RN stated when resident#1 was going to be discharged the plan was that he would go to the home of his sister. Prior to the resident leaving the facility in a cab, the Resident stated to her that he had an argument with his sister and would go to a shelter on discharge. The RN stated she reported this to the former administrator and SW#13. The RN did not recall the details of discharge for Residents #2 and #3. 415.3 (h) (1) (iv) (a)

Based on observations, resident and staff interviews, and record review during a recertification survey, the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and that each resident receives adequate supervision and assistive devices to prevent accidents. This was noted for one resident (#28) out of 30 Stage two sampled residents. Specifically for Resident # 28, the facility did not provide adequate supervision to prevent accidents during visits to the facility courtyard. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident # 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Comprehensive Care Plan (CCP) dated 4/17/14, updated on 5/13/14, documented that the resident had intact short and long term memory, modified independence in decision making, was understood and understands others. A CCP dated 4/17/14, updated on 5/13/14, documented that the resident is at risk for falls/injury due to impaired balance, Parkinson's disease, Dementia and mild memory impairment. A CCP dated 4/14/14, updated 5/22/14, for Activities of Daily Living (ADL's) documented that the resident required extensive assist of one person for transfers. The CCP also documented that the resident required a wheel chair and extensive assist of one person for locomotion off the unit. A CCP dated 4/17/14, updated on 5/13/14 and 6/11/14, for Psycho Social wellbeing documented that the resident preferred to sit outside in courtyard alone but is supervised by staff at a distance. Resident #28 was interviewed on 6/26/14 at 9:25 AM. The resident stated that she likes to get away from the sounds of people and telephones and likes spending quiet time in the courtyard. She stated that she is escorted to the courtyard by staff. She stated the problem is she is unable to come back in without assistance and there is no way to alert the staff that she is ready to return. She stated that sometimes she tries to call out and wave her arms for someone to notice her so that she can be brought back in. She stated that there was a call bell attached to a post in the courtyard which had been removed approximately 3 months ago. She stated that about 2-3 months ago she asked the Maintenance Director and Maintenance Assistant to replace the bell but the bell has not been replaced. The courtyard was observed to be an enclosed area surrounded by resident rooms. The entrance door from the hallway into the courtyard had glass panes which allowed a view of the courtyard from the hallway. The Registered Nurse (RN) Charge Nurse was interviewed on 6/26/14 at 9:30 AM. She stated that, "I am always aware if a resident is in the courtyard, I always check on them every 15 minutes. There used to be a call bell for the residents to call if they wanted to come back in. It was removed sometime last year and never put back in place." In an interview with the Rehabilitation Director on 6/26/14 at 11:45 AM, she stated that the resident's primary means of mobility was the wheel chair (w/c) and the resident is independently able to propel the w/c on the nursing unit. She stated that the resident requires assistance of one person off the unit, for long distances and an uneven surfaces. She also stated that the resident would need assistance opening the doors to and from the courtyard and navigating through the doors. The RN Supervisor was interviewed on 6/26/14 at 10:00 AM. She stated that," the resident likes going to the courtyard. She is alert and likes her space, so we try to give her privacy. I watch her from the door so that she does not feel we are baby sitting her. She does not stay out long, if I cannot stand I ask some one to keep an eye on them. Some one has to be supervising them or sit with them. No one should be left outside unsupervised. Never had any instance where she was left alone unsupervised from distance." The Maintenance Director and Maintenance Assistant were interviewed on 6/26/14 at 10:30 AM. They stated that the call bell was removed from the courtyard area sometime last year probably due to it being broken. They did not state the reason why it had not been replaced. 415.12 (h)(1)(2)

Based on record review and staff interviews during the recertification survey, the facility did not provide accurate comprehensive assessments that accurately identified the residents' complete health status. This was evident for two of thirty residents' Minimum Data Set (MDS) Assessments reviewed during Stage two of the Quality Indicator Survey (QIS). Specifically, 1) the Admission MDS Assessment for Resident #171 did not accurately reflect the stages of two Pressure Ulcers (P/U) and; 2) the MDS Assessment for Resident # 24 did not document a P/U identified within the assessment period. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: 1) Resident # 171 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission Progress Note (P/N) dated 6/12/14 at 10:00 PM documented that the resident had a left foot gangrenous wound and an open area to the inner buttock. The Comprehensive Care Plan (CCP) for Alteration in Skin Integrity dated 6/13/14 documented Stasis Ulcers including the Sacrum and Left Heel. There was no documented plan of care specifically addressing the opening to the sacrum and the gangrenous left heel as identified on the Nursing Admission P/N. The MDS assessment dated [DATE] (assessment dates 6/12/14-6/19/14) documented a Stage III P/U and an Unstageable P/U, both present on admission. The Wound Care Assessment flow sheet dated 6/20/14 documented that the Sacral P/U was classified as Unstageable and the Left heel was classified as a Deep Tissue Injury. The MDS Coordinator/ Registered Nurse (RN) was interviewed on 7/1/14 at 11:30 AM. The RN stated that she determined the stage of the wounds by the written descriptions in the Nursing P/N. The RN stated that she was in disagreement with the Physicians Wound Care Assessment regarding the staging of the P/U. 2) Resident # 24 has [DIAGNOSES REDACTED]. A Comprehensive Care Plan (CCP) for Impaired Skin Integrity dated 3/20/14 documented that the resident was at risk for P/U. There were no P/U documented on the CCP. The Nursing P/N dated 4/7/14 3-11 shift documented that the resident was noted to have a blanchable errythema to both lower buttocks and an open area on the right gluteal fold. The MDS assessment dated [DATE] (assessment dates 4/7/14-4/14/14) did not document the P/U. The CCP developed on 4/8/14 for actual P/U documented a Deep Tissue Injury to the Coccyx/ Sacrum and Left Heel. They were not documented on the MDS Assessment. During the Interview with the MDS Coordinator/RN on 7/1/14 at 11:30 AM the RN stated that a corrected MDS would be submitted documenting the P/Us. 415.11 (a) (2)

Based on record review and staff interviews during a recertification survey the facility did not review and revise a Pressure Ulcer (P/U) Comprehensive Care Plan (CCP) addressing the resident's P/U that developed in the facility. This was noted for one resident (Resident #156), out of 3 reviewed for pressure ulcers in a total of 30 Stage two sampled residents. Specifically, for Resident #156 there was no documented evidence in the resident's plan of care that CCP for the P/U was revised to reflect an accurate assessment of the resident's condition. This resulted in no actual harm with the potential for more than minimal harm which was not immediate jeopardy. The finding is: Resident #156 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility Comfort Care form dated 3/27/14 documented that the resident was to have no outside consults, blood transfusion, [MEDICAL TREATMENT], hospitalization or weights taken. A Nurse's note dated 5/5/14 documented a newly acquired pressure ulcer measuring 2 centimeter (cm) x 1 cm to the left buttock. A physician's orders [REDACTED]. A Wound Assessment Flow Sheet, completed by a Nurse Practitioner, dated 5/9/14 documented a nosocomial Stage II pressure ulcer on the left buttock measuring 0.7 x 0.5 cm, with scant serosanguineous drainage, a pink wound base and intact peri-wound. . The Physician order [REDACTED]. There was no documented revisions to the CCP for P/U updating the facility acquired P/U. A Nurse's progress note documented that the resident was discharged to the hospital on [DATE]. In an interview with the Assistant Director of Nursing on 6/30/14 at 10:45 AM, she stated that the resident was on comfort care and was very compromised. The RN stated that a wound assessment would have caused discomfort to the resident. 415.11(c)(2) (i-iii)