Every finding on record at White Oaks Rehabilitation and Nursing Center

Based on observation, interviews and record review during an abbreviated survey conducted on 10/28/2025 for case number 2616775, the facility failed to ensure one (1) (Resident #1) of three (3) residents was free from accidents. Specifically, Certified Nursing Assistant #1 failed to follow the care plan for Resident #1 requiring a two-person assist. On 09/11/2025, Certified Nursing Assistant #1 transferred Resident #1 from their wheelchair to their bed alone resulting in a fractured left humerus (upper arm bone). This resulted in actual harm to Resident #1 that is not Immediate Jeopardy.Resident #1 was admitted on [DATE] with diagnosis that include vascular dementia (a decline in thinking skills caused by conditions that damage blood vessels and reduce or block blood flow to the brain,) cerebral vascular accident (stroke,) and osteoarthritis. On 08/21/2025, a Minimum Data Set (a resident assessment tool) Brief Interview of Mental Status was completed for Resident #1 and documented a score of 99 indicating severe cognitive impairment. Facility Safe Patient Transfer Policy dated 11/02/2024 and revised 09/12/2025, documented before any transfer, staff must: Review patient's mobility level, weight-bearing status, cognitive ability, and cooperation, review care plan and physician orders for mobility or transfer restrictions. Identify risk factors (e.g., weakness, pain, wounds, lines/tubes), determine appropriate number of staff and equipment needed. Medical Doctor Orders for Resident #1 dated 08/29/2025 at 3:04 PM documented transfer: out of bed to reclining back wheelchair with assist x 2 daily, (Two-Person Lift). Nursing Progress Notes dated 09/12/2025 at 6:56 AM documented Certified Nursing Assistant #2 reported a bruise was observed while providing care. Upper arm was noted with a bruise, swollen and painful when Resident #1 tries to move the arm. The Medical Doctor was made aware of bruise to left upper arm and ordered an X-ray to left arm. Nursing Progress Notes dated 09/12/2025 at 7:37 AM documented Resident #1's Family Member #1 was notified of left arm ecchymosis (bruising) and plan for x-ray. Orders placed for physical therapy/occupational therapy evaluation as left arm is painful.Nursing Progress Note dated 09/12/2025 at 11:50 PM documented Resident #1 alert, X-ray results reviewed with Medical Doctor, Acute fracture proximal humerus is noted, Tylenol given, place left arm on a pillow, place in sling and needs orthopedic follow up as per Medical Doctor order.Facility Accident/Incident Report finalized on 09/15/2025 documented, on further investigation via telephone conference call with Director of Nursing and Licensed Practical Nurse Risk Manager while interviewing evening Certified Nursing Assistant #1, it was stated by them that they had placed Resident #1 to bed around 7:00 PM on 09/11/2025 and transferred them out of their wheelchair to the bed by themself and explained how they wrapped their arms around Resident #1's body while the resident's arms were at rest at the side of their body and lifted them out of the wheelchair to bed. When Licensed Practical Nurse Risk Manager asked them to further explain and elaborate on that transfer technique, Certified Nursing Assistant #1 replied with stating again that they wrapped their arms around Resident #1 and lifted them up like a bear hug and placed them into the bed. Certified Nursing Assistant #1 stated that they then provided PM care and left the resident in bed without seeing any bruising or injury or any signs or symptoms of discomfort during care. As Licensed Practical Nurse Risk Manager and Director of Nursing reviewed Resident #1's transfer plan of care it was discovered that this was a violation to the care plan, as Resident #1 had orders for a two (2) person assist with transfers. The Director of Nursing instructed Certified Nursing Assistant #1 be removed from the facility and sent home pending further investigation. Facility Accident/ Incident Report further documented Certified Nursing Assistant #1's transfer against Medical Doctor's order contributed to Resident #1's humerus fracture and harm. The incident report further documented medical orders were received for sling application, pain management with Tylenol, and therapy evaluation, and anticoagulation therapy was held due to the fracture. The resident's family was notified, and pain management was subsequently adjusted with additional medication. An orthopedic follow-up was arranged, and the resident has remained stable with immobilization in place and ongoing therapy support. During a telephone interview conducted by the State Agency with Certified Nursing Assistant #1 on 11/04/2025 at 9:39 AM, they stated they transferred Resident #1 from the chair to the bed alone. The nurse told Certified Nursing Assistant #1 to put Resident #1 in bed. Certified Nursing Assistant #1 stated they transferred Resident #1 by seat of pants to bed. Resident #1 had always been a one-person assist. Suddenly, they changed Resident #1 to a two-person assist. They work part time. They didn't have Resident #1 all the time because they float units. They don't know what happened to cause injury to Resident #1. Resident #1 had fallen one or two weeks ago. Certified Nursing Assistant #1 further stated the transfer was uneventful and it went okay. They stated they would have reported any changes. The facility called them a few days later and asked what happened. They stated they did not use a bear hug to lift Resident #1. The Certified Nursing Assistant stated the two-person assist appears in kiosk of Certified Nursing Assistant Accountability and Resident #1 always had been one (1) assist and the Nurse should have told them prior to assigning transfer. During an interview with Licensed Practical Nurse Risk Manager on 10/28/2025 at 11:27 AM, they stated during their investigation of the fracture identified on 09/12/2025 they went back the prior 72 hours to identify the source of injury. The investigation identified Certified Nursing Assistant #1 stated they picked Resident #1 up from their wheelchair using a bear hug. They sent Certified Nursing Assistant #1 home. Licensed Practical Nurse Risk Manager concluded Resident #1 is very frail, bruises very easily, and the bear hug transfer contributed to the injury. There should have been two (2) persons for the transfer. During an interview with the Director of Nursing on 10/28/2025 at 11:56 AM, they stated they learned of the injury late at night on 09/12/2025. An X-ray was ordered and resulted in a fracture. Initially it was identified as an unknown injury. During the investigation, staff were interviewed by the Risk Manager both in-person and telephonically. When asked about positioning in wheelchair and transfer, Certified Nursing Assistant #1 told them they lifted Resident #1 without assistance. They did a bear hug from the front, lifted and pivoted the resident into bed. The Director of Nursing checked Resident #1's orders and discovered Resident #1 was a two-person lift. Certified Nursing Assistant #1 came in the following Monday and demonstrated on the Director of Nursing. They determined this was the cause of the injury along with comorbidities. Certified Nursing Assistant #1 received education and training and returned to work. The expectation is for Certified Nursing Assistant #1 to read the Certified Nursing Assistant accountability record and find assistance to do a two-person transfer. During an interview with Medical Doctor #1 on 11/10/2025 at 4:07 PM, they stated they ordered an x-ray for Resident #1 of the left arm. X-ray documented a fractured left humerus (upper arm bone). Medical Doctor #1 stated they assessed the arm on 09/15/2025, and the fracture was caused by something other than osteopenia or osteoporosis (a condition caused by bones losing minerals causing them to be frail). They stated staff should follow the plan of care for all residents to ensure resident safety. 10 NYCRR 415.4 (b)(1)(i)

Based on observation, record review, and interviews during the recertification initiated on 09/02/2025 and completed on 09/08/2025, 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 Kitchen task observation on 09/02/2025 and during the Dining Task on 09/02/2025 at the lunch meal. Specifically, frozen food items (tiramisu, broccoli florets, pizza slices, a tray of diet pudding, regular pudding and peaches, roast beef, Brussel Sprouts) in the walk-in freezer were stored undated and or with opened packaging. Specifically, the facility did not monitor the temperature of cold food items (sandwiches, yogurt, milk) at the time of meal service. Upon request, temperatures were taken and found to be above the standard range (cold food temperatures should be 40 degrees Fahrenheit or below) for food service safety (United States Department of Agriculture). The finding is:A facility policy and procedure titled Food Storage, dated 08/2024, documented all perishable foods will be stored at proper temperatures, refrigerated at 35 degrees to 41 degrees Fahrenheit, and frozen at zero (0) to minus ten (10) degrees Fahrenheit. All food will be dated upon stocking when removed from its original packaging. If not in the original packaging, all food items must be dated and labeled with the name of the contained food.A facility policy and procedure titled Meal Temperature, dated 08/2024, documented to ensure the safety and quality of the food items. It is the policy to obtain and record the temperature of food items prior to serving to residents. The Kitchen observation was conducted with the Clinical Dietitian on 09/09/2025 at 9:46 AM. A walk-in freezer unit was observed with an open clear bag of an unidentified and undated food item (The Registered Dietitian was unable to identify the food item); 1 individual container of tiramisu (as identified by the Registered Dietitian) unlabeled and undated; an open package of broccoli florets wrapped in plastic wrap unlabeled and undated; 1 bag of Brussel sprouts out of its original packaging, undated; individual slices of pizza in plastic wrap undated; an unopened package of slices of pizza undated; three (3) packages of roast beef out of its original packaging, undated; one (1) tray each of diet pudding, regular pudding and peaches undated; and package unlabeled and undated (the Registered Dietitian was unable to identify the food item.)During an interview on 09/02/2025 at 9:52 AM, Dietary Aide #1 stated that they perform the job of a storeroom person (put away deliveries); however, the Cooks are responsible for putting food away properly once they are done using the item. During an interview on 09/03/2025 at 1:33 PM, the Food Service Director stated that everything must be labeled and dated, including if something is taken out of its original packaging, it must have the item name and date of delivery, and an open package also needs to have a label and date on the wrapping. This is to maintain the quality of the food item. Dining observation was conducted during the lunch service on Unit Two (2) South on 09/02/2025 at 12:00 PM. Dietary Aide #2 was observed placing cold food items (milk, juice, yogurt, dessert, sandwiches) on the individual resident trays. These cold food items were observed in a container with ice, except for the sandwiches, which were on a tray without ice or other cooling mechanism. On 09/02/2025 at 12:20 PM, Dietary Aide #3 was observed taking the temperature of the hot food items. Dietary Aide #2 and Dietary Aide #3 were not observed taking the cold food temperatures. Dietary Aide #3 was immediately interviewed and stated that they do not take the temperature of the cold food items except when it is the main entree. They further stated that the cold food is delivered on ice; therefore, it is at the appropriate temperature. The lunch meal service began on 09/02/2025 at 12:27 PM. Dietary Aide #2 was immediately interviewed and stated they started to set up the trays with the cold food items (milk, yogurt, etc.) at approximately 12:15 PM. Dietary Aide #2 stated that they prepare all the trays prior to the start of meal service. They further stated that they do not take the temperature of the cold food items as they are on ice. Dietary Aide #3, at the request of the State Agency, took the temperature of the cold food items on 09/02/2025 at 12:30 PM, with the findings of 60 degrees Fahrenheit for a tuna sandwich, 59 degrees Fahrenheit for a cheese sandwich, 42.1 degrees Fahrenheit for a four (4) ounce container of milk and at 12:50 PM, 50.2 degrees Fahrenheit for a yogurt container. During an interview on 09/03/2025 at 1:33 PM, the Food Service Director stated approximately one-half hour prior to lunch service, the cold food items, such as desserts, milk, and sandwiches, are transported in a container with ice to the unit for the Dietary Aides to place on the individual resident meal trays. Resident Unit 2-South lunch meal service time is 12:30 PM, so the items go up at 12:00 PM. The Food Service Director stated that a second Dietary Aide will bring the hot food to the unit and is responsible for obtaining and recording the food temperatures. They further stated that cold food items are not checked for temperature on the units because they are always refrigerated and iced. During an interview on 09/04/2025 at 9:56 AM, the Administrator stated that they would expect items in the kitchen to be properly wrapped, labeled, and dated. The Administrator stated that they were aware that food temperatures are to be monitored; however, they were not aware that the cold food temperatures were not being monitored. 10 NYCRR 415.14(h)

Based on observation, interviews, and record review during the Recertification Survey initiated on 09/02/2025 and completed on 09/08/2025, the facility did not ensure each resident had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical symptoms. This was identified for one (1) (Resident #36) of one (1) resident reviewed for Physical Restraints. Specifically, on 09/02/2025, Resident #36 was observed sleeping in a bed with the bed positioned between another empty bed on the right side and a Geri chair on the left side, thereby blocking the resident from getting out of the bed. During an interview on 09/05/2025, the resident's assigned Certified Nursing Assistant #5 acknowledged they intentionally placed the resident's bed between another bed and the Geri chair to prevent the resident from getting out of bed.The finding is:The facility policy titled Policy and Procedure for Restraint Use last reviewed on 09/2022, documented the facility was to maintain and establish a restraint-free environment for all residents. It may be necessary to use some measures of restraint to protect a resident from self-injury or from inflicting injury upon another resident. Restraints will only be applied when all other interventions have proven to be unsuccessful. The residents shall have the expectation that while residing at the facility, their right to freedom and dignity as individuals shall be acknowledged and promoted. The facility will provide the least restrictive environment appropriate to the resident's individual needs. This philosophy is expressed to the residents and their family members.Resident #36 was admitted with diagnoses including Muscle Wasting and Atrophy, Repeated Falls, and Generalized Anxiety Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status Score of 99, indicating the resident had severe cognitive impairment. The Minimum Data Set documented the resident required partial or moderate assistance when rolling left and right in bed, sitting to lying in bed, lying to sitting on the side of the bed, and during transfers. The resident did not have physical restraints or alarms during the assessment period. The resident did not have any falls during the assessment period.A Comprehensive Care Plan titled Falls/Safety last revised 08/10/2025 documented interventions including placing floor mats on each side of the resident's bed, keeping the bed in the lowest position, and referring to rehabilitation services for evaluation as needed.A nurse's progress note dated 09/01/2025 documented that Resident #36 was found on their knees on the floor mat by the bed with the resident's body and head in bed. The bed was in the lowest position. There was no injury noted.A Physical Therapy Interim note dated 09/02/2025 documented that the resident was screened by Physical Therapy after having fallen out of bed on 09/01/2025. There were no changes to the resident's range of motion. The resident's functional mobility remained the same. The resident had floormats in place. Physical Therapy services will continue to monitor the resident.During an observation on 09/02/2025 at 11:10 AM, Resident #36 was observed resting in their bed. The bed was in the lowest position. An empty bed was observed along the right side of the resident's bed, and a Geri-chair was placed on the floor mat along the left side of the resident's bed, thereby blocking both sides of the resident's bed. During an observation and interview on 09/05/2025 at 08:35 AM, the resident was observed in their room sitting in a Geri-chair. Certified Nursing Assistant #5 was also present in the room. A floor mat was observed on each side of the resident's bed. Certified Nursing Assistant #5 stated they were assigned to Resident #36 on 09/02/2025. They put the empty bed and the Geri-chair alongside the resident's bed to stop the resident from getting out of bed. Certified Nursing Assistant #5 stated the resident already had a fall on 09/01/2025, and they wanted to prevent the resident from getting out of bed and falling again.During an interview on 09/05/2025 at 10:09 AM, Registered Nurse #4, the Charge Nurse, stated they did not know that Certified Nursing Assistant #5 positioned the resident's bed between an empty and a Geri-chair to stop the resident from getting out of bed. Certified Nursing Assistant #5 should have kept the floor mats on both sides of the bed while the bed was at the lowest position. Registered Nurse #4 stated the resident had a history of falls, and last fell on [DATE].During an interview on 09/05/2025 at 12:45 PM, Physical Therapist #1 stated they were familiar with Resident #36 and the resident had a history of Dementia and falls. The resident required one person's assistance for bed mobility and transfers. Physical Therapist #1 stated that floor mats were in place when the resident was in bed as an intervention for fall prevention. Physical Therapist #1 stated the resident had a fall from bed on 09/01/2025, and they recommended having the bed in the lowest position with a floor mat on both sides of the bed. Physical Therapist #1 stated that nursing staff should implement the recommended interventions and should not position the resident's bed in a manner that would restrict the resident's movement.During an interview on 09/08/2025 at 10:05 AM, the Director of Nursing Services stated the facility was a restraint-free facility. The Director of Nursing Services stated Certified Nursing Assistant #5 should have utilized the floor mats on both sides of the bed and should not have placed an empty bed on one side of the resident's bed and a Geri-chair on the other side of the resident's bed, as this would be a restriction to the resident's movements while in bed.10 NYCRR 415.4(a)(2-7)

Based on observation, record review, and interviews during the Recertification Survey initiated on 09/02/2025 and completed on 09/08/2025, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #12) of five residents reviewed for Accidents. Specifically, Resident #12 was at risk for elopement and had a physician's order for a Wanderguard (a wearable bracelet for residents at risk for wandering, which causes an alarm when the resident approaches a restricted area). On 08/01/2025, the resident removed the Wanderguard; however, no new interventions were put in place to ensure the resident was appropriately supervised and did not remove the Wanderguard. During an observation on 09/05/2025, Resident #12 was not wearing their Wanderguard, and the assigned staff were not aware that the resident did not have their Wanderguard in place.The finding is:The facility policy titled Code Alert System/Code Alert Bracelet, last reviewed 01/2022, documented Code Alert System is designed to trigger when a resident passes the area where parameters have been set. The system is triggered by a bracelet transmitter placed on or in the vicinity of the resident in question. Once the decision has been made that the resident exhibits unsafe wandering or is at risk for elopement, the bracelet transmitter is placed on the arm, leg, wheelchair, walker, or pocketbook of those residents who wander or are at risk. The nursing supervisor will monitor that the nursing staff check the location of the bracelet on the resident, assistive device, or wheelchair every day.Resident #12 was admitted with diagnoses including Multiple Sclerosis, Malnutrition, and Chronic Pain. The 07/03/2025 Quarterly Minimum Data Set assessment documented a Brief Interview of Mental Status score of 3, indicating the resident had severe cognitive impairment; the resident required supervision or touching assistance for ambulation and transfers; and no wandering behaviors were exhibited.A Nursing-Elopement Risk Evaluation dated 04/01/2025 documented the resident was at risk for elopement.A Comprehensive Care Plan, titled Elopement/Wandering, effective 04/02/2025, last updated on 08/01/2025, documented resident exhibited wandering behavior. Interventions included ensuring proper placement of the ankle alert and checking for any malfunction. The Code alert (Wanderguard) was applied to the right ankle. The Comprehensive Care Plan update on 05/27/2025 documented the resident was noticed with wandering behaviors, such as leaving the unit and walking toward the front door unattended. The resident was redirected, and an order was obtained for Code alert and applied. The Comprehensive Care Plan update on 08/01/2025 documented the resident removed the Wanderguard from the right lower extremity by cutting the strap; the room was searched, and no sharp objects were found to have cut the strap. The strap was replaced, and the Wanderguard was reapplied to the right lower extremity. Will continue to monitor. There were no new interventions added to the care plan.A physician's order dated 05/16/2025 documented Wanderguard to the right lower extremity each shift.A review of August/September 2025 Treatment Administration Records revealed Resident #12's Wanderguard was present on the right lower extremity each shift as evidenced by the nurses' signature.During an observation and interview on 09/05/2025 at 10:55 AM, Resident #12 was sitting in the day room. The surveyor observed the resident ambulate independently with a cane from their room to the day room. The surveyor asked Resident #12 to show the Wanderguard bracelet on the resident's right lower extremity. The resident did not understand the question.During an observation and interview on 09/05/2025 at 11:00 AM, the surveyor requested Certified Nursing Assistant #4, who was in the day room, to check Resident #12's lower extremities for a Wandergurad bracelet. Certified Nursing Assistant #4 stated Resident #12 was not assigned to them. Certified Nursing Assistant #4 checked the resident's lower extremities and stated the resident did not have a Wanderguard on. During an interview on 09/05/2025 at 11:10 AM, Registered Nurse Charge Nurse #1 stated they found the Wanderguard on the resident's bedside table without the strap. Registered Nurse Charge Nurse #1 stated they have to get a new strap and reapply the Wanderguard to the resident's right lower extremity.During an interview on 09/05/2025 at 1:20 PM, Licensed Practical Nurse #2 (the medication nurse) stated they provided medications to Resident #12 this morning and did not check if the resident was wearing the Wanderguard. The Wanderguard placement was supposed to be checked each shift, and they (Licensed Practical Nurse #2 ) have not yet completed that task. Licensed Practical Nurse #2 stated, I guess I could have checked the at the same time that I administered the medications. Licensed Practical Nurse #2 could not recall seeing the Wandergurad on the resident's bedside table when they administered the medications. During an interview on 09/05/2025 at 2:15 PM, Licensed Practical Nurse Risk Manager #1 stated that after the resident removed the Wanderguard on 08/01/2025, the care plan should have definitely been updated with new interventions, like increased monitoring or placing the Wanderguard bracelet in a different location, and another elopement risk assessment should have been completed.During an interview on 09/05/2025 at 3:01 PM, Registered Nurse Charge Nurse #1 stated the resident had previously removed the Wanderguard on 08/01/2025, and since it was the first time the resident removed the Wanderguard, 30-minute monitoring was not necessary. We just had to reapply the Wanderguard.A progress note, written by Registered Nurse Charge Nurse #1, dated 09/05/2025 at 4:16 PM, documented resident's Code alert (Wanderguard) was noted to be missing today. Supervisor was notified. A function check was completed on the Code alert device by the Assistant Director of Nursing, and the device was found to be working properly. The Code alert was reapplied and placed on the resident's right lower extremity. The resident was noncompliant with keeping the Code alert on the right lower extremity, and as a result, the resident has been placed on 30-minute safety checks. The care plan has been updated accordingly. The resident was also educated on the importance of keeping the Code alert on.During an interview on 09/08/2025 at 8:56 AM, the Director of Nursing Services stated appropriate actions were taken on 08/01/2025 when the resident removed the Wanderguard. The device was placed back on the resident's right lower extremity. 30-minute monitoring was added as a new intervention after the Wanderguard was found to be missing on 09/05/2025. The Director of Nursing Services could not state if an elopement risk assessment should have been completed on 08/01/2025 or if increased monitoring should have been added as an intervention.10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews during the Recertification Survey, initiated on 9/2/2025 and completed on 9/8/2025, the facility did not ensure that each resident who required respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified for one (1) (Resident #129) of three (3) residents reviewed for Respiratory Care. Specifically, Resident #129 did not receive pulse oximetry (oxygen saturation) monitoring (measures the oxygen saturation in blood) as recommended by the Physician in a progress note dated 09/01/2025; however, the Physician did not write an order for their recommendation. The finding is:Resident #129 was admitted to the facility with diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Schizophrenia. The 08/11/2025 quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 12, indicating the resident had moderate cognitive impairment; received oxygen therapy while a resident; and received non-invasive mechanical ventilator (BiPAP-Bilevel Positive Airway Pressure, a non-invasive ventilation technique that uses a machine to deliver pressurized air to the lungs during sleep) while a resident.Resident #129 had the following current physician orders as of 09/02/2025: -Oxygen at 3 liters per minute continuously for Chronic Obstructive Pulmonary Disease. -Head of bed elevated to avoid shortness of breath while lying flat for Chronic Obstructive Pulmonary Disease.-Ipratropium 0.5 milligram-albuterol 3 milligram/3 milliliter nebulization solution, inhale every 6 hours for Chronic Obstructive Pulmonary Disease.-Advair Diskus 250 microgram-50 microgram dose powder for inhalation, 1 puff every 12 hours for Chronic Obstructive Pulmonary Disease.-Nurse to ensure the heart monitor is on and working at all times for atherosclerotic heart disease.-BiPAP (noninvasive ventilation that helps you breathe) at the hour of sleep for sleep apnea (a sleep disorder characterized by repeated episodes of pauses in breathing during sleep).A physician's order dated 06/20/2025 documented Vital Signs every shift for seven days, then every day-monitor blood pressure, oxygen saturation, pulse, respirations, temperature. This order was discontinued on 09/01/2025.A Physician #1 progress note dated 09/01/2025 documented follow-up for Chronic Obstructive Pulmonary Disease, vital signs stable, decreased breath sounds bilaterally (noises made when breathing and assessed with stethoscope), slight rales at bases of lungs (abnormal lung sounds that resemble rattling caused by fluid in the lungs or airways), maintain oxygen saturation above 88%; BiPap nightly and as needed for hypoxia (inadequate oxygen supply to body tissues).A review of the resident's oxygen saturation monitoring screen in the electronic medical record revealed that the nursing staff stopped monitoring the resident's oxygen saturation levels on 09/01/2025. There was no associated progress note with an explanation. The oxygen saturation monitoring was done every day since the resident was admitted in February 2025 until 09/01/2025.During an observation and interview on 09/02/2025 at 11:15 AM, Resident #129 was in bed. The oxygen cannula had been removed by the resident. The resident stated they did not need the oxygen at present and had their oxygen cannula. During an interview on 09/05/2025 at 11:15 AM, Registered Nurse Charge Nurse #1 stated the resident's oxygen saturation levels had been stable, so the doctor said the oxygen saturation (pulse oximetry) levels did not have to be checked any further, and that is why oxygen saturation has not been monitored since 09/01/2025.During an interview on 09/05/2025 at 11:55 AM, Physician #1 stated they did not order or give directions to stop monitoring oxygen saturation. Physician #1 stated the resident was on oxygen and required their oxygen saturation to be monitored daily.A progress note written by Registered Nurse Charge Nurse #1, dated 09/05/2025 at 12:52 PM, documented that oxygen saturation monitoring is no longer required at this time, as the resident maintains oxygen saturation levels stable with supplemental oxygen in place and shows no signs of respiratory distress. General monitoring of the resident's respiratory status will continue.During a re-interview on 09/05/2025 at 1:00 PM, Physician #1 stated they did not give direction to discontinue monitoring Resident #129's oxygen saturation, which should be checked daily to make sure the resident was not desaturating (decreasing level of oxygen in the blood); in which case, a pulmonary follow-up may be needed. Physician #1 stated they do not write an order for monitoring oxygen saturation--nursing should be checking oxygen saturation as general practice for a resident on oxygen therapy.A nursing progress note dated 09/06/2025 at 2:11 PM, written by Registered Nurse Charge Nurse #1, documented resident was seen today by the Physician (Physician #1). A new order was received to monitor oxygen saturation daily. A physician's order dated 09/06/2025 documented Pulse Oximetry every day on the 7:00 AM-3:00 PM shift.During an interview on 09/08/2025 at 9:00 AM, the Director of Nursing Services stated the order for vital signs included monitoring for oxygen saturation, and the Physician may not have realized that when the order to discontinue monitoring vital signs was given on 09/01/2025. The Director of Nursing Services stated the nurses do not read the doctor's progress notes. If the Physician wanted nurses to maintain oxygen saturation above 88%, they should have written an order. The conversation between the doctor and the nurse (Licensed Practical Nurse #3) on 09/01/2025, regarding the need for oxygen saturation monitoring, was not documented, and there may have been miscommunication. During an interview on 09/08/2025 at 9:40 AM, Licensed Practical Nurse #3 stated they had a conversation with Physician #1 on 09/01/2025; the Physician stated the vital signs were stable and that the vital sign order could discontinued; the vital sign order included oxygen saturation and the doctor did not say to continue oxygen saturation monitoring; Licensed Practical Nurse #3 stated they do not read the doctor's progress notes; the doctor may not have realized that the oxygen saturation monitoring was part of the vital sign order and therefore the oxygen saturation monitoring was being discontinued also. During an interview on 09/08/2025 at 11:00 AM, the Medical Director #1 stated Physician #1 should have written for monitoring the resident's oxygen saturation to ensure the oxygen saturation remained above 88%. 10 NYCRR 415.12(k)(6)

Based on observations, record review, and interviews during the Recertification Survey initiated on 09/02/2025 and completed on 09/08/2025 the facility did not ensure that it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections for 1) one (Resident #16) of one resident reviewed for Pressure Ulcers and for one (1) (Resident #111) of three (3) residents reviewed for Transmission-Based Precautions. Specifically, 1) during the wound care observation for Resident #16 (bilateral heel wounds) on 09/04/2025, Licensed Practical Nurse #1 did not perform hand hygiene during the various steps of the wound care treatment process, allowed the cleansed heel wounds to come in contact with a dirty surface, and did not re-cleanse the heel wounds. 2) Resident # 111 was placed on Contact Isolation for Klebsiella Pneumoniae (a bacterial infection often spread through person-to-person contact or contaminated surfaces and equipment) in the wound as per the physician's order. Certified Nursing Assistant #2 was observed entering Resident #111's room without wearing appropriate Personal Protective Equipment (PPE), including a gown and gloves, to deliver Resident #111's lunch tray. Certified Nursing Assistant #2 did not perform hand hygiene before entering or exiting from Resident #111's room. The findings are: The facility policy titled Wound Care, effective 10/16/2024, documented: arrange the wound care supplies so they can easily be reached; wash and dry hands thoroughly; place on gloves; a disposable cloth may be placed under the wound to serve as a barrier to protect the bed linen and other body sites; remove old dressing and discard in receptacle and wash hands thoroughly; put on clean gloves and clean the wound bed with normal saline; discard gloves and wash hands thoroughly; put on clean gloves and apply the wound medication to the wound; cover the wound with a dressings and wash and dry hands thoroughly. The facility's policy titled Contact Isolation last revised on 08/2024, documented that Contact Isolation/precautions are intended to prevent the transmission of infectious agents, which are spread by direct or indirect contact with the resident or the resident's environment. Direct contact transmission involves direct body-to-body contact and the transfer of microorganisms from a susceptible host to an infected or colonized resident, such as when staff perform resident care activities that require direct personal contact. Indirect contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, such as contaminated instruments or dressings, or contaminated gloves that are not changed between residents. Fundamentals of Contact Isolation includes hand hygiene, the single most important measure for preventing the spread of infection; and Personal Protective Equipment (PPE), including masks, gowns, and gloves, is worn alone or in combination to provide barrier protection. 1) Resident #16 was admitted with diagnoses including Cerebrovascular Accident, Non-Alzheimer's Dementia, and Pressure Injuries to the Right and Left Heels. The 08/08/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of four (4), indicating the resident had severe cognitive impairment, and had one Stage three (3) pressure ulcer (full-thickness skin loss where fat is visible in the wound bed) and one unstageable pressure ulcer (a full-thickness skin and tissue loss that is fully or partially covered by slough-dead tissue). A Comprehensive Care Plan titled, Pressure Ulcer-Right Heel Stage three (3), effective 08/06/2025, documented an update on 09/04/2025 by Wound Care Registered Nurse #1 indicating the wound consultant and wound nurse saw the resident this week for weekly rounds, right heel Stage 3, 2.6 centimeters x 2.6 centimeters x 0.2 centimeters, 80% granulation tissue (healing tissue), 20% slough/fibrin tissue (dead tissue/protein that forms a clot), 30 % dermal tissue (skin), small amount serous drainage (clear fluid). A Comprehensive Care Plan titled, Pressure Ulcer-Left Heel, effective 08/06/2025, documented an update on 09/04/2025 by Wound Care Registered Nurse #1, indicating the wound consultant and wound nurse saw the resident this week for left heel deep tissue pressure injury 4.4 centimeters x 3.4 centimeters x 0 centimeters, 100% epithelial tissue (protective barrier to wound). A Physician's order dated 08/07/2025 documented cleanse the right heel with normal saline, apply Hydrogel (wound treatment), and apply a clean dry dressing every day; cleanse the left heel with normal saline, apply skin prep, and cover with an Allevyn (foam) dressing every day. During an observation on 09/04/2025 at 10:20 AM, Licensed Practical Nurse #1 performed Resident #16's wound treatment for both heels. The nurse worked alone without assistance from other staff. The resident was in bed with their heels resting on a pillow. The nurse wore a gown because the resident was on Enhanced Barrier Precautions. The nurse set up all the wound care supplies on a clean field on the overbed table. The nurse washed their hands prior to beginning the wound care treatment and then put on multiple pairs of gloves. The nurse performed the wound care treatment on the left heel first; they removed the old dressing, removed one pair of gloves, cleansed the heel wound with normal saline, then allowed the cleansed heel to come in contact with the dirty pillow (there was no protective barrier), applied the wound treatment and applied a dressing; and removed another pair of gloves. The nurse then proceeded to do the wound care on the right heel without performing hand hygiene; they removed the old dressing, removed one pair of gloves, cleansed the heel wound with normal saline, and allowed the cleansed heel to come in contact with the dirty pillow. There was no protective barrier placed on the pillow. The nurse applied the wound treatment and dressing and then removed another pair of gloves. During an interview on 09/04/2025 at 10:20 AM, Licensed Practical Nurse #1 stated they were supposed to get assistance to elevate the resident's heels from another staff member, but both the Charge Nurse and the Certified Nursing Assistant were busy. Licensed Practical Nurse #1 stated they should have recleaned the wounds and applied a clean barrier. Licensed Practical Nurse #1 stated they normally used the hand sanitizer during wound care to sanitize their hands during the various wound treatment steps, but they forgot. During an interview on 09/04/2025 at 12:20 PM, Registered Nurse Wound Care Nurse #1 stated that Licensed Practical Nurse #1 should have waited for someone to help elevate the resident's legs. Registered Nurse Wound Care Nurse #1 also stated that the nurse was not supposed to use multiple gloves. They should have used one pair of gloves for each step of the dressing change and sanitized their hands. During an interview on 09/05/2025 at 9:37 AM, Licensed Practical Nurse Infection Preventionist #1 stated that hand hygiene must be performed during wound care rather than using multiple gloves. The nurse should have re-cleansed the wound areas after the resident's heels came in contact with the dirty surface. During an interview on 09/05/2025 at 10:28 AM, the Director of Nursing Services stated Licensed Practical Nurse #1 should have performed hand hygiene during the wound care rather than wearing multiple gloves and then removing each pair at a time when hand hygiene should have been performed. The Director of Nursing Services stated that Licensed Practical Nurse #1 should have had someone help elevate the resident's legs or used a clean field to rest the cleansed heels. 2) Resident #111 was admitted with diagnoses of malignant Neoplasm (Cancer) of the Bone, Dementia, and Klebsiella. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated Resident #111 had moderate cognitive impairment. The admission Minimum Data Set (MDS) assessment documented that Resident #111 had an Active diagnosis, including a Multi-Drug-Resistant Organism (bacteria that have developed resistance to multiple classes of antimicrobial drugs, making infections difficult or impossible to treat with standard antibiotics) and Wound Infection. A Comprehensive Care Plan (CCP) titled, Contact Isolation Precaution: Right Hip Wound Klebsiella Pneumoniae dated 08/23/2025, documented interventions including maintaining strict infection control protocols in handling the contact isolation waste, monitoring signs and symptoms of the causative organisms, reporting to the Physician for any changes, and applying isolation equipment upon entry to the room. A Physician's Order dated 08/23/2025 documented Augmentin (an antibiotic) 875 milligrams-125 milligrams tablet every twelve (12) hours for five (5) days for changes in skin texture. A Physician's Order dated 08/25/2025 documented Contact Isolation every shift. During an observation on 09/02/2025 at 10:24 AM, Resident #111 was wheeled by their family member from Rehabilitation therapy. A precaution sign was posted outside Resident #111's room indicating Contact Isolation Precautions: everyone must clean their hands before entering and when leaving Resident #111's room. The sign also instructed to use Personal Protective Equipment (PPE), including wearing a gown and gloves before entering Resident #111's room and discarding the gown and gloves before exiting the room. The Personal Protective Equipment (PPE) was stored inside the resident's room. Resident #111's room. The family member was not wearing any Personal Protective Equipment. During an observation on 09/02/2025 at 12:20 PM, Certified Nursing Assistant #2 was observed entering Resident #111's room with a lunch tray without using a gown and gloves. Certified Nursing Assistant #2 did not perform hand hygiene before entering Resident #111's room and when exiting the room. During an interview on 09/02/2025 at 12:38 PM, Certified Nursing Assistant #2 stated that they read the sign outside Resident #111's room and knew that they were supposed to wear Personal Protective Equipment prior to entering the room. Certified Nursing Assistant #2 stated they did not perform hand hygiene and did not put on a gown and gloves because there were none outside Resident #111's room. Certified Nursing Assistant #2 stated the Personal Protective Equipment (PPE) was inside the room by the wall near the door. Certified Nursing Assistant #2 stated they did not use any of the gloves or gown because they were just handing the tray to Resident #111's family member. Certified Nursing Assistant #2 stated they should have used a hand sanitizer before entering the room and when exiting Resident #111's room, but they forgot. During an interview on 09/04/2025 at 10:17 AM, Registered Nurse #1, Unit Manager, stated the Personal Protective Equipment (PPE) and hand sanitizer were available inside Resident #111's room. Registered Nurse #1 stated that Resident #111 had completed their antibiotics, and the bacteria were in Resident #111's wound on the right hip. Registered Nurse #1 stated that Resident #111's wound was covered. The possibility of contact with the bacteria when Certified Nursing Assistant #2 handed the tray was minimal. Registered Nurse #1 stated that they do the full donning of gown and gloves during high contact care, including wound care, toileting, and personal hygiene care. Registered Nurse #1 stated that Certified Nursing Assistant #2 should have performed hand hygiene before entering Resident #111's room and when exiting the room. During an interview on 09/05/2025 at 9:37 AM, the Infection Preventionist stated that they expect the staff to follow the facility's policy for infection control. The sign outside the resident's door only applied if the staff was performing high-contact care, not for delivering trays or giving medication. The Infection Preventionist stated that high contact care includes providing care during wound care, toileting, and personal hygiene care. The Infection Preventionist stated that the Certified Nursing Assistant #2 should have performed hand hygiene before entering the room and when exiting the room as instructed on the sign outside the door. The Infection Preventionist stated that the Personal Protective Equipment (PPE) was inside the room by the door, as they expect staff to wear proper Personal Protective Equipment once inside the room. During an interview on 09/05/2025 at 10:28 AM, the Director of Nursing Services stated that when a resident is on Contact Isolation, it is the resident who has an infection that is on contact isolation and not the environment. The Director of Nursing Services stated that they expected the staff to perform hand hygiene before entering and exiting the resident's room. The Director of Nursing Services stated that Personal Protective Equipment (PPE) is available inside the resident's room for the staff to use. The Director of Nursing Services stated they expect the staff to wear the Personal Protective Equipment during high-contact care for Resident #111. 10 NYCRR 415.19(a) (1-3)(b) (4)

Based on observations, interviews, and record review during the Recertification Survey initiated on 09/02/2025 and completed on 09/08/2025, the facility did not ensure nursing staffing was posted daily and included the actual number of licensed and unlicensed staff working hours per shift. Specifically, the facility's entrance lobby was observed on 09/02/2025 at 09:28 AM with the nursing staffing sheet posted for 08/29/2025. Additionally, the nursing staffing sheets dated 09/02/2025 to 09/03/2025 did not include the actual hours worked by the licensed and unlicensed nursing staff per shift.The finding is:The facility's policy titled Staffing, last revised 11/01/2023, documented the facility will provide sufficient numbers of licensed and non-licensed personnel (Registered Nurse, Licensed Practical Nurse, and Certified Nursing Assistant) on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. The policy did not include guidance related to nursing staffing posting.The facility did not provide a policy related to the staffing posting requirement. During an observation on 09/02/2025 at 9:28 AM, a nursing staffing sheet was posted at the facility entrance by the receptionist area. The nursing staffing sheet was dated 08/29/2025 and did not include the actual hours worked for licensed and unlicensed nursing staff for each shift (7:00 AM-3:00 PM; 3:00 PM-11:00 PM; 11:00 PM-7:00 AM).During an observation on 09/02/2025 at 3:15 PM, a nursing staffing sheet was posted at the facility entrance by the receptionist area. The nursing staffing sheet was dated 09/02/2025 and included projected nursing staffing for the night (11:00 PM-7:00 AM) shift. The nursing staffing sheet did not include the actual hours worked by the licensed and unlicensed nursing staff for each shift (7:00 AM-3:00 PM; 3:00 PM-11:00 PM; 11:00 PM-7:00 AM).During an observation on 09/03/2025 at 9:00 AM, a nursing staffing sheet was posted at the facility entrance by the receptionist area. The nursing staffing sheet was dated 09/03/2025 and included projected nursing staffing for the evening (3:00 PM-11:00 PM) and night (11:00 PM-7:00 AM) shift. The nursing staffing sheet did not contain the actual hours worked by the licensed and unlicensed nursing staff for each shift (7:00 AM-3:00 PM; 3:00 PM-11:00 PM; 11:00 PM-7:00 AM).During an interview on 09/03/2025 at 10:29 AM, the Staffing Coordinator stated they were responsible for completing the nursing staffing sheet. The Staffing Coordinator stated they prepared the nursing staffing sheet the day prior, during weekdays, and on Fridays for the weekends. The Staffing Coordinator stated they used the projected nursing schedule and the actual resident census at the time they prepared the nursing staffing sheet. The Staffing Coordinator stated the nursing staffing sheet is sent to the receptionist, who is responsible for posting the nursing staffing sheet in the morning. The Staff Coordinator stated that the information on the nursing staffing sheet may not reflect actual nursing staffing, and they do not revise the sheet for any changes in nursing staffing numbers or resident census. The Staffing Coordinator stated there was no one assigned to revise the nursing staffing sheet posted in the receptionist area. The Staffing Coordinator further stated they were not aware that the facility's nursing staffing sheet must include actual hours worked by licensed and unlicensed nursing staff each shift.During an interview on 09/03/2025 at 11:20 AM, the Director of Nursing Services stated the receptionist is responsible for posting the nursing staffing sheet daily, and the nursing supervisor on shift is responsible for revising information on the sheet as necessary to reflect actual nursing staffing and resident census. The Director of Nursing Services stated that they were not aware that the facility's nursing staffing sheet must include actual licensed and unlicensed nursing staff working hours for each shift.During an interview on 09/03/2025 at 1:22 PM, the Administrator stated the nursing staffing sheet must be posted daily, and the Registered Nurse supervisor on shift is responsible for revising and updating the information on the sheet as necessary to reflect actual nursing staffing and resident census. The Administrator stated that they were not aware that the facility's nursing staffing sheet must include actual licensed and unlicensed nursing staff working hours for each shift.During an interview on 09/04/2025 at 8:25 AM, Receptionist #1 stated they were responsible for posting the nursing staffing sheet daily; however, they do not make changes to the nursing staffing sheet. Receptionist #1 stated they had posted the nursing staffing sheet on Monday (09/01/2025). Receptionist #1 stated they were not sure why Friday's (08/29/2025) staffing sheet was still displayed on Tuesday (09/02/2025). Receptionist #1 stated they should have checked and ensured the daily nursing staffing sheet was posted.10 NYCRR 415.13

Based on record review and interviews during the Recertification Survey initiated on 09/02/2025 and completed on 09/08/2025, the facility did not ensure the Facility Assessment determined and indicated specific nursing staffing necessary to care for residents during both day-to-day operation (including night and weekends) and emergencies. This was identified during the Sufficient Nursing Staffing Task. Specifically, the facility stated that nursing staffing, specifically the number of Registered Nurses required for the facility's daily operations, was not accurately documented in the Facility Assessment.The finding is:The facility's policy titled Facility Assessment, last revised 5/8/2025, documented the facility will complete and maintain a facility-wide assessment, which will be reviewed and updated quarterly, annually, or whenever there is any change that would require a substantial modification to any part of the assessment. The assessment will address a range of facility staffing to provide competent support and care for the resident population every day, including weekends and emergencies. A review of the Facility assessment dated [DATE] revealed that the Facility Assessment documented nursing staffing needed to provide competent support and care for the resident population every day, including weekends and emergencies. Specifically, the facility determined each resident unit (1 North, 1 South, 2 North, and 2 South) required zero (0) to one (1) Registered Nurse during the day shift (7:00 AM-3:00 PM). During the evening shift (3:00 PM-11:00 PM) and overnight shift (11:00 PM-7:00 AM), unit 1 North required zero (0) to one (1) Registered Nurse, whereas unit 1 South, 2 North, and 2 South did not require a Registered Nurse. During an interview on 09/03/2025 10:29 AM, the Staffing Coordinator stated that they always scheduled one (1) Registered Nurse on each resident unit (1 North, 1South, 2 North, 2 South) during the day shift (7:00 AM-3:00 PM), and there is always at least one (1) Registered Nurse scheduled during the evening shift (3:00 PM-11:00 PM) and overnight shift (11:00 PM-7:00 AM). The Staffing Coordinator stated that the schedule remained the same during weekends and holidays. During an interview on 09/08/2025 at 10:54 AM, the Director of Nursing Services stated that the facility always has at least one (1) Registered Nurse on any given shift, including the evening shift (3:00 PM-11:00 PM) on a normal operation day. During an interview on 09/08/2025 at 12:46 PM, the Administrator stated the facility always strives to schedule at least one (1) Registered Nurse on any given shift on a day-to-day operation. The Administrator stated that the nursing staffing section in the Facility Assessment represented staffing needs, such as for Registered Nurses, in emergency situations, such as widespread and catastrophic events that could severely impact staffing availability. The Administrator stated that the lower range of the licensed and unlicensed nursing staff number represented the bare minimum the facility required to provide necessary care to all residents during emergency circumstances only. The Administrator stated that they do not expect the lowest number documented in the Facility Assessment, of any nursing staff category (Registered Nurse, Licensed Practical Nurse, and Certified Nursing Assistant), to be considered when scheduling staff on a normal day-to-day operation. The Administrator stated that such a range was documented to provide some wriggle room for the facility to staff under an emergency.10 NYCRR 415.26

Based on observations, record review and interviews conducted during a Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, were reported to the New York State Department of Health. This was identified for one (Resident #119) of eight residents reviewed for Accidents. Specifically, Resident #119, with a diagnosis of Dementia and impaired cognition, sustained the following unwitnessed injuries of unknown origin 1a) a laceration to the right arm which required transfer to the hospital and treatment of 16 staples on 12/6/2023, 1b) ecchymotic (bruise) area to the left buttock on 2/27/2024 and 1c) ecchymotic area to left upper inner forearm and right outer arm on 2/29/2024. The facility did not report Resident #119's injuries of unknown origin to the New York State Department of Health. The findings are: The facility's policy titled, Abuse Prevention and Reporting last revised in January 2020 defined Injuries of Unknown Origin as when the source of the injury was not observed by any person or the resident could not explain the source of the injury and the injury is suspicious because of the extent of the injury or the location of the injury. Under the section Reporting, all alleged cases of abuse, neglect, or mistreatment will be reported to the Department of Health or any other agency as appropriate by the Administrator and the Director of Nursing Services. All alleged violations must be called in immediately, but no later than two hours if the alleged violation involves abuse or results in serious bodily injury, or 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury. Resident #119 was admitted with diagnoses including Dementia, Anxiety, and Lack of Coordination. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. The Minimum Data Set documented that Resident #119 was sometimes able to understand and be understood and did not exhibit behaviors of rejection of care or wandering. A Comprehensive Care Plan for Aggressor/Victim dated 6/9/2021 and last reviewed on 2/4/2024 documented the resident has a potential of being an aggressor or victim as evidenced by being easily agitated, continuing to ambulate ad lib (as much and as often as desired) on the unit, and wandering in peers' rooms at times. Interventions included but were not limited to monitoring behaviors, and redirecting away from situations that cause frustrations when resident raise fists. On 7/10/2023 interventions were updated to include 30-minute visual checks, and on 10/3/2023 the interventions were updated to include one to one supervision. A Comprehensive Care Plan for Falls dated 6/9/2021 and last reviewed on 2/27/2024 documented the resident was at risk for falls/injuries secondary to a history of falls, psychotropic drug use, impaired vision, and Dementia. Interventions included to investigate the cause of the fall immediately and to ensure the use of proper footwear. The care plan interventions were updated on 12/18/2023 to include one to one monitoring at all times. 1a) An Accident and Incident Report dated 12/6/2023 at 9:30 PM documented Resident #119 was noted with a laceration to the right arm. The resident was unable to explain what happened. The location of the incident was unknown. A Certified Nursing Aide observed the resident with their (Resident #119) right arm bleeding. The Accident and Incident report was not signed by the nurse who initiated the report and also did not identify the Certified Nurse Aide who had initially reported the resident's injury. A statement written by Certified Nursing Aide #2 dated 12/6/2023 documented that Certified Nursing Aide #2 was assigned to Resident #119 and saw Resident #119 at approximately 5:30 PM in the hallway. Certified Nursing Aide #2 documented that the resident was seen eating dinner in the dining room around 5:50 PM. Certified Nursing Aide #2 documented they did not witness the incident or any environmental issue that may have contributed to the incident. The written statement did not indicate that Certified Nursing Aide #2 had observed Resident #119's right arm injury on 12/6/2023. A nursing progress note dated 12/7/2023 by Licensed Practical Nurse #3 documented that Licensed Practical Nurse #3 was called to the resident's room around 9:30 PM on 12/6/2023. Upon arrival, the resident was observed with a laceration of unknown origin to the right forearm. The resident was transferred to the hospital for possible sutures. The resident's physician was notified. A nursing progress note dated 12/7/2023 documented that the resident returned from the hospital with 16 staples on the right forearm intact with a small amount of blood noted. Staples removal on 12/14/2023. Doxycycline antibiotic therapy for wound infection as ordered. The summary of the investigation dated 12/7/2023 documented that at 9:30 PM on Thursday 12/6/2023 (12/6/2023 was a Wednesday) Certified Nursing Aide #2 found Resident #119 in another resident's room with a large laceration on their (Resident #119) right forearm. Certified Nursing Aide #2 called for a nurse. Licensed Practical Nurse #3 came and applied pressure on the wound. A Physician was notified and the resident was transferred to the hospital. The investigation summary documented that when Resident #119 was found with the right-arm laceration, they (Resident #119) were standing with a piece of wood from the dresser in their hand and it was determined the resident scraped their arm with the piece of wood that resulted in a laceration. The investigation concluded that there was no cause to believe abuse, mistreatment, or neglect had occurred. The facility investigation did not include statements from the resident or the staff member who initially found the resident with the laceration. Furthermore, there were no statements from the staff members who allegedly saw the resident holding a piece of wood that may have caused the laceration to the resident's right arm. Certified Nursing Aide #2 was interviewed on 3/8/2024 at 4:14 PM and stated that they were assigned to Resident #119 on 12/6/2023 during the evening shift. Certified Nursing Aide #2 stated they helped the resident during dinner time and last saw the resident around 6:00 PM. Certified Nursing Aide #2 stated they had dressed the resident before dinner and the resident did not have any injuries to their right arm. Certified Nursing Aide #2 stated they did not witness the resident sustaining the injury and were not the one who found the resident with the laceration. Certified Nursing Aide #2 stated they did not know how the resident got hurt. 1b) An Accident and Incident Report dated 2/27/2024 documented Resident #119 was observed with an ecchymotic area to their left buttock. The resident was unable to state what happened secondary to impaired mental status. The location of the incident was unknown. The Registered Nurse assessment documented the resident was alert and responsive with confusion with no signs and symptoms of pain or discomfort. A statement written by Certified Nursing Aide #4 dated 2/27/2024 documented that Certified Nursing Aide #4 was assigned to Resident #119 and observed a purple bruise around Resident #119's left buttock during care. Certified Nursing Aide #4 documented they immediately notified the nurse. Certified Nursing Aide #4 documented that the incident was not witnessed by any personnel or visitor. The summary of the investigation dated 2/28/2024 documented that on Tuesday 2/27/2024 around 11:00 AM Certified Nursing Aide #4 was changing Resident #119's brief and noticed a bruise on the resident's left buttock. Resident #119 was on 1:1 supervision and had no falls or incidents of late. Upon investigation, the interdisciplinary team determined that the ecchymotic area on the resident's left buttock could be from their buttock hitting against the arm of a stationary chair and/or the bench in the unit dining room as the resident was attempting to sit. The resident is up and down in chairs in their room and the unit dining room all day with a 1:1 staff member by their side. At times the resident needed assistance and redirection with sitting and standing. The investigation concluded that there was no cause to believe abuse, mistreatment, or neglect had occurred. The Accident and Incident report or the Investigation Summary did not include statements from the staff from the previous shift to determine the root cause of the injury of unknown origin. 1c) An Accident and Incident Report dated 2/29/2024 documented on 2/29/2024 at 3:00 PM, Resident #119 was observed with an ecchymotic area to their right outer arm near the armpit and to their left upper inner forearm. The resident was unable to explain the cause of the injuries due to cognitive impairment. The location of the incident was documented as unknown. The Registered Nurse assessment documented a visible ecchymotic area on both left and right arms, there was no swelling observed. The Accident and Incident report was not signed by the staff member who completed the report. A verbal statement obtained by the facility from Certified Nursing Aide #5 dated 2/29/2024 documented that Certified Nursing Aide #5 was assigned to Resident #119 and observed bruises while changing the resident. The resident did not fall while they were with Certified Nursing Aide #5. The summary of the investigation dated 3/1/2024 documented that on Thursday 2/29/2024 Certified Nursing Aide (not identified in the summary) was providing care and noticed slightly reddened/ecchymotic areas on the resident's left and right upper arms. The resident had no falls or incidents and remained on 1:1 supervision for safety. The summary concluded that if the resident pulled away quickly while a staff member was redirecting or guiding the resident by gently holding the resident, the resident could possibly injure their fragile skin which caused purpura or ecchymosis. The investigation concluded that there was no cause to believe abuse, mistreatment, or neglect had occurred. The Accident and Incident report or the Investigation Summary did not include statements from the staff from the previous shift to determine the root cause of the injuries of unknown origin. Certified Nursing Aide #5 was interviewed on 3/8/2024 at 2:29 PM and stated that they were the assigned 1:1 staff for Resident #119 on 2/29/2024. Certified Nursing Aide #5 stated that they did not receive reports about any injuries from the overnight shift for Resident #119. Certified Nursing Aide #5 stated on 2/29/2024 at around 9:30 AM, they observed the bruises on the resident's arms while changing the resident's clothing. Certified Nursing Assistant #5 stated they always handled the resident gently and there was no incident before the bruising was identified. Certified Nursing Aide #5 stated they notified the unit nurse immediately. Certified Nursing Aide #5 stated they did not provide a written statement to the facility because no one asked them to. Certified Nursing Aide #5 stated they had reported the incident to Registered Nurse #5 and did not know why the incident report reflected that the incident happened at 3:00 PM. Resident #119 was observed on 3/4/2024 at 9:02 AM. Resident #119 was alert but not interviewable, a staff was next to the resident and was observed assisting the resident while they (Resident #119) ambulated on the unit. A dark purple area of discoloration on the right arm, approximately half the size of the palm of a hand was observed. The Risk Manager, who was also the facility's Infection Preventionist, was interviewed on 3/9/2024 at 1:00 PM. The Risk Manager stated they (Risk Manager) were responsible for reviewing the entire Accident and Incident report to determine if further investigation is required. The Risk Manager stated they were responsible for obtaining additional statements as needed to complete a thorough investigation. The Risk Manager stated that they would summarize the investigation once they reviewed all documentation and the report would then be submitted to the Administrator and the Director of Nursing Services for review. The Risk Manager stated the Administrator and the Director of Nursing Services will decide whether the accident/incident should be reported to the New York State Department of Health. The Administrator and the Director of Nursing Services were interviewed concurrently on 3/9/2024 at 3:41 PM and stated they both reviewed all the Accident and Incident reports after the investigation was completed to determine if the incidents should be reported to the New York State Department of Health. The Administrator and the Director of Nursing Services stated that all incidents of injuries of unknown origin must be reported to the New York State Department of Health. The Director of Nursing Services stated that all three incidents for Resident #119 were unwitnessed and the resident was unable to give an account of the causes of the injuries due to poor cognition. The Director of Nursing Services stated they believed there were known causes that explained how the resident could have sustained those injuries and therefore, the facility was not required to report the incidents to the New York State Department of Health. 10 NYCRR 415.4 (b)(2)

Based on observations, record review and interviews conducted during a Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that all alleged violations were thoroughly investigated in response to allegations of abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown source. This was identified for one (Resident #119) of eight residents reviewed for Accidents. Specifically, Resident #119 with a diagnosis of Dementia and impaired cognition sustained the following unwitnessed injuries of unknown origin 1a) a laceration to the right arm which required transfer to the hospital and treatment of 16 staples on 12/6/2023, 1b) ecchymotic (bruise) area to the left buttock on 2/27/2024 and 1c) ecchymotic area to the left upper inner forearm and the right outer arm on 2/29/2024. Resident #119 was observed with injuries of unknown origin on three occasions. The facility did not thoroughly investigate the incidents to identify the root cause of the injuries and to rule out Abuse, Neglect, or Mistreatment. The findings are: The facility's policy titled, Abuse Prevention and Reporting last revised in January 2020 defined Injuries of Unknown Origin as when the source of the injury was not observed by any person, or the resident could not explain the source of the injury and the injury is suspicious because of the extent of the injury or the location of the injury. Under the section Investigation, the policy documented the nursing supervisor is to begin an investigation upon the identification of an incident or occurrence, to obtain all statements necessary to complete the investigation; and to report all allegations including injuries of unknown origin to the Administrator. Resident #119 was admitted with diagnoses including Dementia, Anxiety, and Lack of Coordination. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. The Minimum Data Set documented that Resident #119 was sometimes able to understand and be understood and did not exhibit behaviors of rejection of care or wandering. A Comprehensive Care Plan for Falls dated 6/9/2021 and last reviewed on 2/27/2024 documented the resident was at risk for falls/injuries secondary to a history of falls, psychotropic drug use, impaired vision, and Dementia. Interventions included to investigate the cause of the fall immediately and to ensure the use of proper footwear. The care plan interventions were updated on 12/18/2023 to include one to one monitoring at all times. 1a) An Accident and Incident Report dated 12/6/2023 at 9:30 PM documented Resident #119 was noted with a laceration to the right arm. The resident was unable to explain what happened. The location of the incident was unknown. A Certified Nursing Aide observed the resident with their (Resident #119) right arm bleeding. The Accident and Incident report was not signed by the nurse who initiated the incident report and also did not identify the Certified Nurse Aide who had initially reported the injury. A statement written by Certified Nursing Aide #2 dated 12/6/2023 documented that Certified Nursing Aide #2 was assigned to Resident #119 and saw Resident #119 around 5:30 PM in the hallway. Certified Nursing Aide #2 documented that the resident was seen eating dinner in the dining room around 5:50 PM. Certified Nursing Aide #2 documented they did not witness the incident or any environmental issue that may have contributed to the incident. The written statement did not indicate that Certified Nursing Aide #2 had observed Resident #119's right arm injury on 12/6/2023. A nursing progress note dated 12/7/2023 by Licensed Practical Nurse #3 documented that Licensed Practical Nurse #3 was called to the resident's room around 9:30 PM on 12/6/2023. Upon arrival, the resident was observed with a laceration of unknown origin to the right forearm. The resident was transferred to the hospital for possible sutures. The resident's physician was notified. The summary of the investigation dated 12/7/2023 documented that at 9:30 PM on Thursday 12/6/2023 (12/6/2023 was a Wednesday) Certified Nursing Aide #2 found Resident #119 in another resident's room with a large laceration on their (Resident #119) right forearm. Certified Nursing Aide #2 called for a nurse. Licensed Practical Nurse #3 came and applied pressure on the wound. A Physician was notified and the resident was transferred to the hospital. The investigation summary documented that when Resident #119 was found with the right-arm laceration, they (Resident #119) were standing with a piece of wood from the dresser in their hand and it was determined the resident scraped their arm with the piece of wood that resulted in a laceration. The investigation concluded that there was no cause to believe abuse, mistreatment, or neglect had occurred. The facility investigation did not include statements from the resident or the staff member who initially found the resident with the laceration. Furthermore, there were no statements from the resident or staff members who allegedly saw the resident holding a piece of wood that may have caused the laceration to the resident's right arm. Certified Nursing Aide #2 was interviewed on 3/8/2024 at 4:14 PM and stated that they were assigned to Resident #119 on 12/6/2023 during the evening shift. Certified Nursing Aide #2 stated they helped the resident during dinner time and last saw the resident around 6:00 PM. Certified Nursing Aide #2 stated they had dressed the resident before dinner and the resident did not have any injuries to their right arm. Certified Nursing Aide #2 stated they did not witness the resident sustaining the injury and were not the one who found the resident with the laceration. Certified Nursing Aide #2 stated they did not know how the resident got hurt. Certified Nursing Aide #3, who worked on the resident's unit on 12/6/2023 during the evening shift(3:00 PM-11:00 PM), was interviewed on 3/8/2024 at 5:23 PM and stated that they were not assigned to Resident #119 on 12/6/2023 and did not witness how Resident #119 sustained the injury to their arm and therefore did not report the incident regarding Resident #119. Certified Nursing Aide #3 did not recall if they were interviewed or asked to write a statement by the facility. Certified Nursing Aide #6, who worked on the resident's unit on 12/6/2023 during the evening shift (3:00 PM-11:00 PM), was interviewed on 3/8/2024 at 5:34 PM and stated that they were not assigned to Resident #119 on 12/6/2023 and did not witness how Resident #119 sustained the injury to their arm and therefore did not report the incident regarding Resident #119. Certified Nursing Aide #6 did not recall if they were interviewed or asked to write a statement by the facility. Certified Nursing Aide #7, who worked on the resident's unit on 12/6/2023 during the evening shift (3:00 PM-11:00 PM), was interviewed on 3/9/2024 at 12:10 PM and stated that they were not assigned to the resident on 12/6/2023 and did not witness how Resident #119 sustained the injury to their arm and therefore did not report the incident regarding Resident #119. Certified Nursing Aide #7 stated they were not interviewed or asked to write a statement by the facility. Licensed Practical Nurse #3 was interviewed on 3/9/2024 at 11:17 AM and stated that they responded to a call from Resident #119's unit on 12/6/2023 during the evening shift. Licensed Practical Nurse #3 stated when they arrived on the unit, they (Licensed Practical Nurse #3) saw Resident #119 with their long sleeve shirt removed by staff which revealed a deep laceration to the resident's arm and the resident was bleeding. Licensed Practical Nurse #3 stated they did not witness what happened and did not recall seeing any object in the resident's hand or surroundings. Licensed Practical Nurse #3 stated after they (Licensed Practical Nurse #3) arranged to send the resident to the hospital, they (Licensed Practical Nurse#3) and other unit staff conducted a room and unit search to look for any sharp objects such as knives that could potentially cause the injury. Licensed Practical Nurse #3 stated no sharp objects were found and they (Licensed Practical Nurse#3) observed no broken or damaged pieces of furniture. Licensed Practical Nurse #3 did not recall being asked to write a statement. The Risk Manager, who was also the facility's Infection Preventionist, was interviewed on 3/9/2024 at 1:00 PM. The Risk Manager stated they were responsible for reviewing all the Accident and Incident reports and determining if further investigation is required. The Risk Manager stated they were responsible for obtaining additional statements as needed to complete a thorough investigation. The Risk Manager stated that they would summarize the investigation once they reviewed all documentation; the report would then be submitted to the Administrator and the Director of Nursing Services for review. The Risk Manager stated there should be a statement from the staff who saw and reported the injury. The Risk Manager stated they (Risk Manager) also had information as to how they (Risk Manager) were able to conclude the resident was injured by a piece of broken drawer. The Risk Manager stated all documentation and statements obtained for this incident should have been filed away together and did not know why those statements were not attached to the Accident and Incident report. The Risk Manager stated they would look for the missing documents again in their office. The Risk Manager returned on 3/9/2024 at 2:46 PM with the statement of occurrence signed by Licensed Practical Nurse #3. The date of occurrence on the statement was documented as 12/6/2024 and was signed by Licensed Practical Nurse #3 on 12/7/2024. The statement documented that on 2/6/2024, Licensed Practical Nurse#3 was called to Resident #119's unit by a Certified Nursing Aide to find Resident #119 holding a piece of wood and Resident #119's right arm bleeding. The Risk Manager was immediately interviewed on 3/9/2024 about the inaccurate dates and stated they reviewed the statement at the time and did not notice the inaccurate dates (year 2024) on the statement. The Risk Manager stated they should have caught the error; however, they were just typographical errors. The Risk Manager stated they did not know why Licensed Practical Nurse #3 provided inconsistent information regarding the incident in their (Licensed Practical Nurse #3) nursing progress note, in the incident statement, and during the interview with the surveyor. Licensed Practical Nurse #3 was re-interviewed on 3/9/2024 at 3:09 PM and stated that someone wrote the statement and they (Licensed Practical Nurse #3) signed after reviewing what was written on December 7th. Licensed Practical Nurse #3 stated they were not aware that the date of occurrence was incorrect, and they were not aware that they (Licensed Practical Nurse #3) signed and also dated the document incorrectly. Licensed Practical Nurse #3 stated when they responded and went to the unit on 12/6/2023, the resident was already bleeding. Licensed Practical Nurse #3 stated they did not see that the resident was cut by a piece of wood. Licensed Practical Nurse #3 did not recall which Certified Nursing Aide saw the resident holding a piece of wood. 1b) An Accident and Incident Report dated 2/27/2024 documented Resident #119 was observed with an ecchymotic area to their left buttock. The resident was unable to state what happened secondary to impaired mental status. The location of the incident was unknown. The Registered Nurse assessment documented the resident was alert and responsive with confusion with no signs and symptoms of pain or discomfort. A statement written by Certified Nursing Aide #4 dated 2/27/2024 documented that Certified Nursing Aide #4 was assigned to Resident #119 and observed a purple bruise around Resident #119's left buttock during care. Certified Nursing Aide #4 documented they notified the nurse upon discovery. Certified Nursing Aide #4 documented that the incident was not witnessed by any personnel or visitor. The summary of the investigation dated 2/28/2024 documented that on Tuesday 2/27/2024 around 11:00 AM Certified Nursing Aide #4 was changing Resident #119's brief and noticed a bruise on the resident's left buttock. Resident #119 was on 1:1 supervision and had no falls or incidents of late. Upon investigation, the interdisciplinary team determined that the ecchymotic area on the resident's left buttock could be from their buttock hitting against the arm of a stationary chair and/or the bench in the unit dining room as the resident was attempting to sit. The resident is up and down in chairs in their room and the unit dining room all day with a 1:1 staff member by their side. At times the resident needed assistance and redirection with sitting and standing. The investigation concluded that there was no cause to believe abuse, mistreatment, or neglect had occurred. The Accident and Incident report or the Investigation Summary did not include statements from the staff from the previous shifts to determine the root cause of the injury of unknown origin. Certified Nursing Aide #8, who was assigned to Resident #119 during the day shift (7:00 AM-3:00 PM) on 2/27/2024, was interviewed on 3/8/2024 at 1:52 PM. Certified Nursing Aide #8 stated was Certified Nursing Aide #4 was assigned to Resident #119 for one to one monitoring and was also providing care to the resident on 2/27/2024. Certified Nursing Aide #8 stated they (Certified Nursing Aide #8) did not provide any care to the resident or notice anything prior to the discovery of the discoloration to the resident's buttock area. Certified Nursing Aide #8 stated they were not interviewed by the facility after the incident was reported. The Risk Manager, who was also the facility's Infection Preventionist, was interviewed on 3/9/2024 at 1:00 PM. The Risk Manager stated Resident #119 was not able to explain the bruise and the incident was unwitnessed. The Risk Manager stated there were no falls or incidents reported prior to the discovery of the bruising to the buttock area. The Risk Manager stated that Resident #119 was likely sitting too hard onto the chairs which caused the bruising. The Risk Manager stated there could be pending statements in their office for this incident because the incident was recent. The Risk Manager returned at 3:24 PM and stated there were no additional statements found because there was no need for additional statements. 1c) An Accident and Incident Report dated 2/29/2024 documented on 2/29/2024 at 3:00 PM, Resident #119 was observed with an ecchymotic area to their right outer arm near the armpit and to their left upper inner forearm. The resident was unable to explain the cause of the injuries due to cognitive impairment. The location of the incident was documented as unknown. The Registered Nurse assessment documented a visible ecchymotic area on both left and right arms, there was no swelling observed. The Accident and Incident report was not signed by the staff member who completed the report. A verbal statement obtained by the facility from Certified Nursing Aide #5 dated 2/29/2024 documented that Certified Nursing Aide #5 was assigned to Resident #119 and observed bruises while changing the resident. The resident did not fall while they were with Certified Nursing Aide #5. The summary of the investigation dated 3/1/2024 documented that on Thursday 2/29/2024 Certified Nursing Aide (not identified in the summary) was providing care and noticed slightly reddened/ecchymotic areas on the resident's left and right upper arms. The resident had no falls or incidents and remained on 1:1 supervision for safety. The summary concluded that if the resident pulled away quickly while a staff member was redirecting or guiding the resident by gently holding the resident, the resident could possibly injure their fragile skin which caused purpura or ecchymosis. The investigation concluded that there was no cause to believe abuse, mistreatment, or neglect had occurred. The Accident and Incident report or the Investigation Summary did not include statements from the staff from the previous shifts to determine the root cause of the injuries of unknown origin. Certified Nursing Aide #5 was interviewed on 3/8/2024 at 2:29 PM and stated that they were the assigned 1:1 staff for Resident #119 on 2/29/2024. Certified Nursing Aide #5 stated that they did not receive reports about any injuries from the overnight shift for Resident #119. Certified Nursing Aide #5 stated on 2/29/2024 at around 9:30 AM, they observed the bruises on the resident's arms while changing the resident's clothing. Certified Nursing Assistant #5 stated they always handled the resident gently and there was no incident before the bruising was identified. Certified Nursing Aide #5 stated they notified the unit nurse immediately. Certified Nursing Aide #5 stated they did not provide a written statement to the facility because no one asked them to. Certified Nursing Aide #5 stated they had reported the incident to Registered Nurse #5 and did not know why the incident report reflected that the incident happened at 3:00 PM. Registered Nurse #5, who was the unit charge nurse, was interviewed on 3/8/2024 at 3:27 PM and stated there was no report from the previous night (2/28/2024) shift regarding Resident #119. Registered Nurse #5 stated around 9:30 AM on 2/29/2024, Certified Nursing Aide #5 notified them (Registered Nurse #5) about the bruises on the resident's arm. Registered Nurse #5 stated they assessed the resident and notified the resident's Physician and family. Registered Nurse #5 stated they initiated an incident report and acknowledged the time of notification was documented incorrectly. Registered Nurse #5 stated they had likely documented the time they were writing the report and not the actual time the calls were made. Registered Nurse #5 stated they were not asked to write a statement as their nursing assessment on the report is considered part of their statement. Registered Nurse #5 stated they documented their findings in the progress note. A nursing progress note written by Registered Nurse #5 on 2/29/2024 at 3:43 PM documented an ecchymotic area to the right outer arm near the armpit and to the left upper inner forearm. There was no swelling. The progress note was not included or attached to the Accident and Incident report. The Risk Manager was interviewed on 3/9/2024 at 1:00 PM and stated Resident #119 was not able to explain how they sustained the bruising. The Risk Manager stated that the resident's bruises were unwitnessed and therefore the origin of the bruising was not known. The Risk Manager stated there could be pending statements in their office for this incident because the incident was recent. The Risk Manager returned at 3:24 PM and stated there were no additional statements found because there was no need for additional statements. Resident #119 was observed on 3/4/2024 at 9:02 AM. Resident #119 was alert but not interviewable, a staff member was next to the resident and was observed assisting the resident while they (Resident #119) ambulated on the unit. A dark purple area of discoloration on the right arm, approximately half the size of the palm, of a hand was observed. The Administrator and the Director of Nursing Services were interviewed concurrently on 3/9/2024 at 3:41 PM and both stated the Risk Manager should ensure all Accident and Incident reports are reviewed and investigated thoroughly. The Director of Nursing Services stated that the Risk Manager should ensure all data and information in the reports were completed accurately and correctly. The Administrator stated that there is room to improve regarding how the investigations are conducted. 10 NYCRR 415.4 (b)(3)

Based on record review and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024 the facility did not ensure that a Baseline Care Plan for each resident was developed that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of admission. This was identified for one (Resident #78) of four residents reviewed for skin conditions. Specifically, Resident #78 was admitted with impaired skin integrity, and a baseline care plan was not developed within 48 hours of the resident's admission. The finding is: The facility's policy titled, Care Planning last revised 1/2022 documented that upon admission the baseline care plan will be initiated and completed within 48 hours as per the Centers for Medicare & Medicaid Services guidelines. Resident #78 was admitted with diagnoses that included Alzheimer's Disease, Parkinson's Disease, and a Stage 1 Sacral Pressure Ulcer. The Admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 99 indicating the resident was unable to complete the interview. The Minimum Data Set assessment documented Resident #78 was at risk for developing Pressure Ulcers and had one unhealed, Stage 2 Pressure Ulcer on admission. The Minimum Data Set assessment documented Resident #78 was dependent on staff for bed mobility and transfer. The Minimum Data Set assessment documented Resident #78 was always incontinent of bladder and frequently incontinent of bowel. Resident #78's Admission Nursing Evaluation completed on 1/5/2024 documented Resident #78 had a Stage 1 Sacral Pressure Ulcer which measured 3 centimeters long x 3 centimeters wide x 0 centimeters deep and a Braden scale (an assessment tool for predicting the risk of pressure ulcer development) score of 17 which indicated a mild risk for pressure ulcer development. Resident #78's Baseline Care Plan created on 1/4/2024 did not document Resident #78 had a Pressure Ulcer. The intervention section for skin breakdown was not completed. A wound care initial evaluation completed on 1/8/2024 documented the sacral wound as a Stage 2 Pressure Ulcer which measured 1.5 centimeters long x 1.5 centimeters wide x 0.1 centimeters deep. A Comprehensive Care Plan for Skin Integrity dated 1/8/2024 documented Resident #78 had a Stage 2 Sacral Pressure Ulcer. Interventions included but were not limited to the provision of wound care consults, treatments as ordered, skin assessment on every shift, and incontinence care every shift and as needed. Registered Nurse #7, the unit Charge Nurse, was interviewed on 3/7/2024 at 3:56 PM and stated the Baseline Care Plan was completed by the admission nurse. A Baseline Care Plan for Skin Integrity is completed for every resident at admission and should have been completed for Resident #78 due to the presence of a Pressure Ulcer upon admission. The Director of Nursing Services was interviewed on 3/9/2024 at 12:16 PM. The Director of Nursing Services stated a Baseline Care Plan for Skin Integrity should have been put in place for Resident #78 due to the presence of a Pressure Ulcer at the time of admission. 10 NYCRR 415.11

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024 the facility did not ensure each resident's Comprehensive Care Plan was reviewed and revised to reflect the current needs of each resident. This was identified for one (Resident #78) of three residents reviewed for pressure ulcers and one (Resident #171) of two residents reviewed for edema. Specifically, 1) Resident #78's Comprehensive Care Plan was not updated to reflect the resident's use of the heel off-loading medical surgical shoe or offloading the heels; and 2) Resident #171's Comprehensive Care Plan was not updated to reflect the use of lower leg compression wraps to treat bilateral lower leg edema (swelling caused by too much fluid trapped in the body's tissues). The findings are: The facility's policy, titled Care Planning, last reviewed in January 2022, documented care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan, and development of goals for the resident that are reasonable and measurable. The plan of care shall be individualized, based on diagnosis, resident assessment, and the personal goals of the resident and their family. Care planning is based on data collected from resident assessments with the integration of those assessment findings into the care planning process. 1) Resident #78 was admitted with diagnoses that included Alzheimer's Disease, Parkinson's Disease, and a Stage 1 Sacral Pressure Ulcer. The Admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 99 indicating the resident was unable to complete the interview. The Minimum Data Set assessment documented Resident #78 was at risk for developing Pressure Ulcers and had one unhealed Stage 2 Pressure Ulcer on admission. A Nursing Progress Note, written by Licensed Practical Nurse #5, dated 2/3/2024 documented Resident #78 was noted with an intact blister on their right heel. The treatment to cleanse the area with normal saline solution and application of a conventional daily dressing once a day was in place. The doctor and resident representative were made aware and the wound care team was to follow up on 2/5/2024. The progress note documented to use of the heel off-loading medical surgical shoe that was provided by the Physical Therapy department. A wound care assessment dated [DATE] documented a Deep Tissue Injury to Resident #78's sacrum which measured 1.5 centimeters long x 1.5 centimeters wide x 0 centimeters deep; a fluid-filled blister to the right heel which measured 6 centimeters long x 6 centimeters wide x 0 centimeters deep; and blanching erythema (first clinical sign of a pressure ulcer) to the left heel. Recommendations were made to offload heels with pillows and to utilize an air mattress. A Skin Integrity Care Plan for Right Heel Stage 3 effective 2/12/2024 documented an intervention of heel booties in bed that was not added until 3/6/2024. A Skin Integrity Care Plan for a Left Heel Deep Tissue Injury was initiated on 2/27/2024. The Care Plan did not include any intervention to offload heels. Resident #78 was observed on 3/6/2024 at 11:28 AM in the dining area. Resident #78 was observed in their wheelchair with heel booties on both feet. Registered Nurse #7 was interviewed on 3/7/2024 at 3:56 PM. Registered Nurse #7 stated there should be an order for heel off-loading medical surgical shoes. Physical Therapy Assistant #1 was interviewed on 3/8/2024 at 3:08 PM. Physical Therapy Assistant #1 stated they provided the heel off-loading medical surgical shoe for Resident #78 to Licensed Practical Nurse #5 on 2/3/2024. Physical Therapy Assistant #1 stated they spoke to the Wound Care Nurse and the Wound Care Nurse recommended the heel off-loading medical surgical shoe, but they (Physical Therapy Assistant #1) did not document the conversation. Certified Nursing Assistant #12 was interviewed on 3/8/2024 at 3:37 PM. Certified Nursing Assistant #12 stated they informed the nurse ( could not recall which nurse or exact date) that Resident #78 had a blister on their right heel. Certified Nursing Assistant #12 stated they do not document anything regarding heel off-loading medical surgical shoes on the Certified Nursing Assistant Accountability. Certified Nursing Assistant #12 stated they saw Resident #78 with the off-loading medical surgical shoe on and just continued to put them on so that their (Resident #78's) pressure ulcer did not get worse. Licensed Practical Nurse #5 was interviewed on 3/9/2024 at 9:11 AM. Licensed Practical Nurse #5 stated they wrote the Nursing Progress Note on 2/3/2024 regarding the blister on Resident #78's right heel. Licensed Practical Nurse #5 stated Physician #2 told them (Licensed Practical Nurse #5) to get a heel off-loading medical surgical shoe for Resident #78. Licensed Practical Nurse #5 stated the wound care team was to follow up on 2/5/2024 and they did not know why the blister on the right heel was not assessed by the wound care team until 2/12/2024. Licensed Practical Nurse #5 stated they should have entered a consultation order for wound care on 2/5/2024 into the electronic medical record but they must have forgotten to do so. Licensed Practical Nurse #5 stated there is a binder at the unit's nurse's station where consultations for wound care are placed. Licensed Practical Nurse #5 stated they recalled placing Resident #78's face sheet and a note regarding the blister on the right heel in the binder and did not know why the resident was not seen by the wound care team on 2/5/2024. Licensed Practical Nurse #5 stated they should have updated the Skin Integrity Comprehensive Care Plan to include the heel off-loading medical surgical shoe. Registered Nurse #2 was interviewed on 3/9/2024 at 11:04 AM. Registered Nurse #2 stated Licensed Practical Nurse #5 should have updated the Comprehensive Care Plan once they received the telephone order for the heel offloading medical surgical shoe from the doctor. If Licensed Practical Nurse #5 was not able to update the Comprehensive Care Plan they should have notified the Charge Nurse. Registered Nurse #2 stated a physician's order for the heel offloading medical surgical shoe also should have been placed in the electronic medical record. The Director of Nursing Services was interviewed on 3/9/2024 at 12:16 PM. The Director of Nursing Services stated the heel off-loading medical surgical shoe should have an order from the wound care doctor. The Director of Nursing Services stated Licensed Practical Nurse #5 should have placed an order in the electronic medical record for Resident #78 to be seen by the wound care team The Wound Care Nurse was interviewed on 3/9/2024 at 12:42 PM. The Wound Care Nurse stated they do not recall talking to Physical Therapy Assistant #1 regarding Resident #78. The Wound Care Nurse stated they would not direct a heel off-loading medical surgical shoe to be put in place. The Wound Care Nurse stated a recommendation would come from the Wound Care Nurse Practitioner and the Medical Doctor would make the final decision. The Wound Care Nurse stated they did not receive a referral to see Resident #78 on 2/5/2024. The Wound Care Nurse Practitioner was interviewed on 3/9/2024 at 4:07 PM. The Wound Care Nurse Practitioner stated they completed wound care rounds with the Wound Care Nurse on 2/5/2024 and the Wound Care Nurse set up who they (the Wound Care Nurse Practitioner) had to see. The Wound Care Nurse Practitioner stated they did not see Resident #78 on 2/5/2024. 2) Resident #171 was admitted with diagnoses that included Multiple Rib Fractures, Vascular Dementia, and Hypertension. Resident #171's Admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 7 which indicated the resident had severe cognitive impairment. Resident #171 was on a therapeutic, no added sodium diet. A physician's order dated 2/1/2024 documented to apply compression wraps on every morning and off every evening. The order did not indicate where to apply the compression wraps. Resident #171 was observed on 3/4/2024 at 9:28 AM. Resident #171's both lower legs appeared swollen and no compression wraps were observed on Resident #171's lower legs. Resident #171 was interviewed on 3/4/2024 at 9:28 AM and stated they do not feel like their legs are any less swollen than they were in January of 2024. Resident #171 was observed on 3/5/2024 at 12:22 PM. Compression wraps were present on both lower legs. A Cardiovascular Care Plan initiated on 1/11/2024 documented the resident was at risk for cardiovascular dysfunction secondary to Congestive Heart Failure, Hypertension, and High Cholesterol. Interventions included but were not limited to, monitor for edema and administer medications as prescribed by the medical doctor. The care plan was updated on 1/31/2024 and documented the resident had bilateral lower extremity edema. The comprehensive care plan was not updated to include the physician-ordered compression wraps for the lower extremities. Registered Nurse #8 was interviewed on 3/8/2024 at 4:03 PM and stated care plans are initiated by any Registered Nurse on the unit or the Registered Nurse Supervisor. Any Licensed Practical Nurse can also update a care plan. Registered Nurse #2, a Registered Nurse Supervisor, was interviewed on 3/9/2024 at 11:20 AM. Registered Nurse #2 stated the care plans for Resident #171 should have been updated when the compression wraps were ordered. The Director of Nursing Services was interviewed on 3/9/2024 at 12:28 PM and stated the care plans for Resident #171 should have been updated when the compression wraps were ordered. Physician Assistant #1 was interviewed on 3/9/2024 at 2:19 PM. Physician Assistant #1 stated they asked Licensed Practical Nurse #5 to order bilateral compression wraps for Resident #171 on 2/1/2024 after they (Physician Assistant #1) examined Resident #171. An attempt was made to interview Licensed Practical Nurse #5 on 3/9/2024 at 2:17 PM but they were not available. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review and staff interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that services provided or arranged by the facility outlined by the comprehensive plan of care meet professional standards of care. This was identified for one (Resident #169) of eight residents reviewed for medication administration. Specifically, during a medication pass observation on 3/6/2024 at 6:25 AM for Resident #169, Registered Nurse #4 removed a Levothyroxine (medication used to treat underactive thyroid gland) 50 micrograms tablet from a blister pack that had Resident #49's identification label and then administered the medication to Resident #169. The finding is: The facility Medication Administration policy and procedure updated 11/2023 documented medications are administered to residents in a timely and accurate manner by a Licensed nurse who compares the medication name, strength, and dosage schedule on the medication administration record against the prescription label. Resident #169 was admitted with Hypothyroidism and Hypertension. A Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 14 which indicated the resident had intact cognition. A Physician's order dated 1/26/2024 and renewed on 2/23/2024 documented to administer Levothyroxine 50 micrograms one tablet via oral route once daily at 6:00 AM. A medication pass observation was conducted on 3/6/2024 at 6:25 AM for Resident #169. Registered Nurse #4 was unable to locate a Levothyroxine 50 microgram tablet for Resident #169 and was observed to remove a Levothyroxine 50 microgram tablet from another blister pack that had Resident # 49's identification label and then administered the Levothyroxine 50 microgram to Resident #169. Registered Nurse #4 was interviewed on 3/6/2024 at 6:30 AM and stated that they ran out of the Levothyroxine medication and needed to reorder the medication from the pharmacy for a refill for Resident #169. Registered Nurse #4 stated that they were not the regularly assigned nurse for Resident #169. Registered Nurse #4 stated that the medication should have been reordered when there were 3 to 4 pills left in the blister pack. Registered Nurse #4 stated when they run out of medication, they either borrow medication from another resident, from the blister pack of a resident who was discharged , or from another unit. Registered Nurse #4 stated they were aware they should not borrow the medications from one resident to administer to another resident. Registered Nurse #4 stated that they borrowed the Levothyroxine tablet because it was an important medication and that they did not want Resident #169 to miss their medication. Registered Nurse #6, who was the Nursing Supervisor on the 11:00-7:00 AM shift, was interviewed on 3/6/2024 at 6:45 AM. Registered Nurse #6 stated if a nurse ran out of a critical medication like Eliquis (blood thinner), they were allowed to borrow the medication from another resident. Registered Nurse #6 stated Levothyroxine was not a critical medication and that the nurse should not have borrowed the medication to administer it to Resident #169. The Director of Nursing Services was interviewed on 3/6/2024 at 7:45 AM and stated that the nurses should absolutely not be borrowing medication from one resident to administer to another resident. The Director of Nursing Services stated that there should not be any occasion where the resident medication should run out. The Director of Nursing Services stated that there is no policy for borrowing medication. 10 NYCRR 415.11(c)(3)(i)

Based on observation, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene. This was identified for one (Resident #56) of three residents reviewed for activities of daily living. Specifically, on 3/4/2024 and 3/7/2024 Resident #56 was observed with long fingernails to both hands. The resident's right-hand fingernails were resting on the resident's palm and a brown substance was observed under the nails of the left hand. The finding is: The facility's undated policy and procedure for Fingernails and Toenails Care documented nail care includes daily cleaning and regular trimming, and to trim and smooth the resident's nails to prevent the resident from accidentally scratching their skin. Resident#56 was admitted with diagnoses that included Right-hand contracture and Generalized Osteoarthritis. The Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 11 which indicated the resident had moderate cognitive impairment. The resident had functional limitations in bilateral upper and lower extremities and required moderate assistance for personal hygiene. Resident #56 was observed lying in bed on 3/4/2024 at 11:30 AM. The resident's left-hand fingernails were long with a brown substance under the nails. The resident's right hand was observed with long fingernails which were resting on the resident's palm. Resident #56 was observed sitting in a wheelchair in their room on 3/7/24 at 12:10 PM. The resident's fingernails were long on both hands and there was a brown substance under the left hand fingernails. The right-hand fingernails were resting on the resident's palm. The Comprehensive Care Plan for Activities of Daily Living dated 4/19/2017 and last updated on 12/19/2023 documented that the resident required assistance with all activities of daily living. The Comprehensive Care Plan documented the resident required extensive assistance for Personal Hygiene. A Comprehensive Care Plan for Skin Integrity dated 4/19/2017 and last updated 12/19/2023 documented to keep the resident's fingernails trimmed. A Physician's order dated 12/19/2023 and updated 2/24/2024 documented to keep the resident's fingernails trimmed. Certified Nursing Assistant #10 was interviewed on 3/7/2024 at 2:50 PM. Certified Nursing Assistant #10 stated they were not the regularly assigned Certified Nursing Assistant for Resident #56. An observation of the resident's nails was made by Certified Nursing Assistant #10 during the interview, and they stated that the resident's nails needed to be trimmed and cleaned. Certified Nursing Assistant #10 stated the resident's nails are usually trimmed on shower days and as needed by the Certified Nursing Assistant who showers the resident. Certified Nursing Assistant #10 stated that they were also responsible for trimming and cleaning the resident's nails as needed during care of the resident. In a subsequent interview with Certified Nursing Assistant #10 on 3/9/2024 at 1:57 PM they stated they were supposed to clean the resident's nails during daily care. Certified Nursing Assistant #10 stated that they cleaned between the resident's fingers but did not pay attention to the resident nails. Certified Nursing Assistant #10 stated that they should have ensured that the resident's nails were clean. Registered Nurse #3, who was the unit Manager, was interviewed on 3/7/24 at 3:20 PM and stated the Certified Nursing Assistants were responsible for clipping the resident's nails on shower days and as needed. Registered Nurse #3 stated that nail clippers were available for the Certified Nursing Assistants to trim and clean the resident's fingernails. Registered Nurse #3 stated the regularly assigned Certified Nursing Assistant was on vacation and that the Certified Nursing Assistants who were caring for the resident were responsible for clipping and cleaning the resident's nails. Registered Nurse #3 further stated there was no excuse for the resident's nails not to be cleaned and trimmed. The Director of Nursing Services was interviewed on 3/8/2024 at 3:29 PM and stated that the Certified Nursing Assistant who cares for the resident was responsible for the clipping and cleaning of the resident's nails on shower days. The Director of Nursing Services stated that if the resident's nails were not clipped on shower days the Certified Nursing Assistant that performed daily care for the resident should have completed that task. The Director of Nursing Services stated the expectation is for the resident's nails to be trimmed and cleaned by their caregivers irrespective of shower days or not. 10 NYCRR415.12(a)(3)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to prevent further decrease in range of motion. This was identified for two (Resident #56 and Resident #36) of three residents reviewed for position/mobility. Specifically, Resident #56 and Resident #36 had a Physician's order for a hand roll to be worn at all times. On multiple occasions, Resident #56 and Resident #36 were observed not wearing the physician-ordered hand rolls. The findings are: The facility policy and procedure titled Physician Visits and Medical Orders dated 6/16/2021 documented that members of the interdisciplinary team shall provide care, services, and treatment according to the most recent medical orders. The facility policy and procedure titled, Quality of Care dated 12/2021, documented nursing services based on the comprehensive assessment of each resident will ensure that any resident who enters the facility with limited Range of Motion receives necessary treatment and services to promote an increase in Range of Motion and/or to prevent further decrease in Range of Motion, except as an unavoidable consequence of the resident's clinical condition. 1) Resident #56 was admitted with diagnoses that included right-hand contracture and Generalized Osteoarthritis. The Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 11 which indicated the resident had moderate cognitive impairment. The resident had functional limitations to bilateral upper and lower extremities and was receiving both Physical and Occupational Therapy services 5 days a week for 300 minutes. A Comprehensive Care Plan dated 4/19/2017 and last updated 12/19/2023 documented the resident was at risk for impaired skin integrity. Interventions included to apply a hand roll to the palm to offload pressure from the resident's fingernails and to assess the resident's skin every shift. A Physician's order dated 12/19/2023 and updated 2/24/2024 documented to apply a gauze roll to the right hand; to be worn at all times and removed for nursing care, hygiene, and skin checks. Resident #56 was observed lying in bed on 3/4/2024 at 11:30 AM. The resident's right hand was observed to be in a closed-fisted position and the resident was not able to open their hand on command. There was no gauze hand roll observed in the resident's right hand. Resident #56 was observed on 3/05/2024 at 12:18 PM sitting in the unit dining room. The resident was not wearing their right-hand gauze hand roll. Resident #56 was observed in their room sitting in a wheelchair on 3/7/2024 at 12:10 PM. The resident was not wearing their right-hand gauze hand roll. Certified Nursing Assistant #10 was interviewed on 3/7/2024 at 2:50 PM. Certified Nursing Assistant #10 stated that they were not aware that the resident was supposed to have a hand roll as they do not always care for the resident. Certified Nursing Assistant #10 stated that the care of the resident is documented in the Certified Nursing Assistant Accountability Task which is to be reviewed every shift. The Certified Nursing Assistant Accountability Task was reviewed with Certified Nursing Assistant #10 and revealed that the accountability record documented the use of the right-hand roll to be applied at all times. Licensed Practical Nurse #4, who was the medication nurse on 3/4/2024 and 3/5/2024, was interviewed on 3/7/2024 at 3:06 PM. Licensed Practical Nurse #4 stated that they were responsible for applying the hand roll to the resident's right hand and that generally, they do apply the hand roll but they were busy and forgot. Licensed Practical Nurse #4 stated that the hand roll should have been applied to the resident's right hand as ordered by the Physician. Registered Nurse #3, who was the Unit Manager, was interviewed on 3/7/2024 at 3:15 PM. Registered Nurse #3 stated that the medication nurses were responsible for applying the hand roll to the resident's hand. Registered Nurse #3 stated that if there was a Physician's order in place for a device the expectation was for staff to apply the device as ordered by the Physician. Physician #2, who was the resident's assigned Physician, was interviewed on 3/9/2024 at 10:44 AM. The Physician stated that the hand roll should be in place as ordered. The Physician stated that failure to apply the hand roll can lead to skin breakdown, especially if the resident's nails were not trimmed. Physical Therapist #1 was interviewed on 3/9/2024 at 11:37 AM. Physical Therapist #1 stated that the Occupational Therapist was responsible for recommending the hand gauze roll for Resident #56 due to the contracture(s) of the right hand. Physical Therapist #1 stated that it was important for the resident to wear the hand roll, as failure to wear the device can cause skin breakdown. 2) Resident #36 was admitted with diagnoses that included Vascular Dementia and right-hand contracture. A Significant Change Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 2 which indicated the resident had severely impaired cognition. The resident was dependent on staff for all areas of Activities of Daily Living. A Physician's order dated 1/23/2024 documented to apply a right-hand gauze roll, to be worn at all times. Remove for nursing care, hygiene, and skin checks. Resident #36 was observed on 3/5/2024 at 12:30 PM in the unit dining room during a lunch meal observation. The resident's right hand was tightly closed. There was no hand roll observed. Resident #36 was observed on 3/7/2024 at 2:57 PM in the unit dining room. The resident was not wearing a hand roll to the right hand. A Comprehensive Care Plan for Functional Abilities Self Care Mobility dated 1/5/2024 and last updated 3/6/2024 documented to apply a right-hand gauze roll, to be worn at all times. Remove for nursing care, skin check/hygiene, and report any changes to the Physician. Certified Nursing Assistant #11 was interviewed on 3/7/2024 at 3:00 PM. Certified Nursing Assistant #11 stated they were made aware that the resident should have a hand roll to the right hand; however, when they attempted to put the hand roll in place, the resident began to cry. Certified Nursing Assistant #11 stated they have reported difficulty getting the hand roll in place to the charge nurse. Licensed Practical Nurse #2, who was the medication nurse, was interviewed on 3/7/2024 at 3:10 PM. Licensed Practical Nurse #2 stated that at the start of their 7:00 AM-3:00 PM shift, they had applied the resident's hand roll; however, it might have fallen out during care. Licensed Practical Nurse #2 stated the Certified Nursing Assistant should have reported to them if the hand roll was not in place because the hand roll should be in place as ordered by the Physician. Registered Nurse #3, who was the Unit Manager, was interviewed on 3/7/2024 at 3:15 PM. Registered Nurse #3 stated that the nurses were responsible for applying the hand roll; however, the task can be delegated to the Certified Nursing Assistants. Registered Nurse #3 stated the resident's hand roll should have been in place as ordered by the Physician. The Director of Nursing Services was interviewed on 3/8/2024 at 3:11 PM. The Director of Nursing Services stated that the medication nurse and or the charge nurse were responsible for applying the hand roll to the resident's hand. The Director of Nursing Services stated that the hand roll should have been applied as ordered by the Physician. Physician #2, who was the resident's assigned Physician, was interviewed on 3/9/2024 at 10:44 AM. The Physician stated that the hand roll should be in place as ordered. The Physician stated that failure to apply the hand roll can lead to skin break down especially if the resident's nail was not trimmed. Physical Therapist #1 was interviewed on 3/9/2024 at 11:37 AM. Physical Therapist #1 stated that the Occupational Therapist was responsible for recommending the hand gauze roll for Resident #36 due to contracture(s) of the right hand. Physical Therapist #1 stated that it was important for the resident to wear the hand roll, as failure to wear the device can cause skin breakdown. 10 NYCRR 415.12(e)(2)

Based on observations, record review and interviews conducted during the Recertification Survey initiated on 3/04/2024 and completed on 3/09/2024, the facility did not ensure that each resident's environment remains as free of accident hazards as possible. This was identified for one (Resident # 167) of three residents reviewed for Accidents. Specifically, Resident #167 was not assessed to safely self-administer medications. During multiple observations on 3/04/2024 at 8:48 AM, 3/04/2024 at 11:13 AM, and again on 3/05/2024 at 8:38 AM. Resident #167 was observed with Physician-ordered medication in their room with no staff member in the vicinity. The finding is: The facility policy titled, Medication Administration dated 11/2023 documented that the Nurse ensures medications are not left unattended and to keep medications secured in a locked area or are visible at all times. The facility policy titled, Self Administration of Medications dated 11/2022 documented that residents who desire to self-administer their medications will be permitted to do so after appropriate counseling/teaching and with the specific order from the resident's Physician. Resident #167 was admitted with diagnoses including Chronic Kidney Failure, Cirrhosis of the Liver, and Hypokalemia (low potassium level). A Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 14 which indicated the resident had intact cognition. The Comprehensive Care Plan dated 1/13/2024 and last reviewed on 2/28/2024 titled Functional Abilities: Self Care and Mobility, documented the resident required maximum assistance from a staff member for putting on and taking off footwear (the helper does more than half the effort). A Physician's order dated 1/27/2024 and renewed on 3/04/2024 documented to apply Ammonium Lactate 12% lotion (used to treat dry itchy skin) two times a day by topical route bilaterally to feet. Resident #167 was observed on 3/04/2024 at 8:48 AM, 3/04/2024 at 11:13 AM, and again on 3/05/2024 at 8:38 AM with Ammonium Lactate 12% lotion on the over-bed table. There was no staff member in the vicinity during each observation. Resident #167 was interviewed on 3/04/2024 at 11:13 AM and stated they have scabs on their feet and lower legs and they need the lotion. Resident #167 stated they usually apply the lotion to their feet and sometimes the nurse helps them. Resident #167 stated they cannot always reach their feet. Resident #167 was re-interviewed on 3/07/2024 at 8:53 AM and stated they put the Ammonium Lactate 12% lotion on their arms when they felt it was needed. Licensed Practical Nurse #1 was interviewed on 3/07/2024 at 8:59 AM and stated Resident #167 did not have a physician's order to self-administer their medications including Ammonium Lactate 12% lotion. This resident can not reach their own feet and need the nurse to apply the lotion. Licensed Practical Nurse #1 stated that the resident did not have a physician's order to apply Ammonium Lactate lotion to their arms or legs; the order was to apply the medication just to their feet bilaterally twice a day. Licensed Practical Nurse #1 stated that the resident should have been evaluated by their Physician for self-administration of medications including applying the Ammonium Lactate lotion. Register Nurse Supervisor #1 was interviewed on 3/07/2024 at 9:09 AM and stated there was no order for Resident #167 to self-apply Ammonium Lactate 12% lotion or any other medication. The Ammonium Lactate 12% lotion is ordered for the resident's feet bilaterally twice a day. Register Nurse Supervisor #1 stated that Resident #167 was not evaluated to self-administer their medications. Register Nurse Supervisor #1 stated that Ammonium Lactate 12% lotion should be stored in the treatment cart and not in the resident's room. For the resident to self-administer a medication they would need to be evaluated and be able to give a return demonstration to ensure safety. The Director of Nursing Services was interviewed on 03/07/2024 at 2:36 PM and stated the Ammonium Lactate 12% lotion should not have been left at the bedside of this resident. The Ammonium Lactate 12% lotion should be kept in the treatment cart. If a resident wants to self-administer, we will reach out to the Physician to see if the resident can administer the medication. The resident would need to be evaluated by an Occupational Therapist and then obtain a Physician's order to self-apply. Pharmacist #1 was interviewed on 3/08/2024 at 11:42 AM and stated Ammonium Lactate 12% lotion can irritate the skin if used in excess. Physician #1 was interviewed on 3/09/2024 at 9:30 AM and stated the nurses are expected to follow the written orders and have a thin layer of the Ammonium Lactate 12% lotion applied to the resident's feet bilaterally to prevent ulcers and dry skin. Physician #1 stated if Ammonium Lactate 12% lotion is not applied correctly it can cause irritation, dry skin, and further complications. Physician #1 stated that Ammonium Lactate 12% lotion should not be applied to open wounds as it can irritate the open skin. 10 NYCRR 415.12(h)(1)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that all nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs. This was identified for one (Resident #20) of two residents reviewed for skin conditions (non-pressure). Specifically, Resident #20 was observed with a bruise on the back of the left hand. Certified Nursing Assistant #10 was aware of the bruise on 3/4/2024; however, did not report the change in skin condition to Registered Nurse #3 until the Surveyor identified the bruise on the resident's left hand. The finding is: The facility's policy for Pressure Ulcer-Prevention and Care dated 2019 documented that during all care, all nursing staff are required to report any change in residents/patients' skin condition. In the event of skin integrity issues, a skin assessment will be conducted and interventions are placed to prevent pressure ulcers and to manage treatment. Resident #20 was admitted with diagnoses that included Diabetes Mellitus and Hypertension. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The Minimum Data Set documented no behavioral symptoms. The resident had no pressure ulcers. During an initial tour on 3/4/2024 at 10:58 AM on the 2 North nursing unit, Resident #20 was observed sitting in a wheelchair in their room. A large bruise was observed on the dorsal (back) aspect of the resident's left hand. The resident stated while propelling their wheelchair into the room, the wheelchair was too close to the door frame and their hand hit against the door frame. A Physician's order dated 8/28/2023 and updated 2/19/2024 documented Eliquis (blood thinner) 2.5 milligrams; give 1 tablet by oral route every 12 hours. The Comprehensive Care Plan for Skin Integrity dated 11/28/2018 and last updated on 9/5/2023 documented the resident was at risk for impaired skin integrity. The interventions included to assess skin every shift. A Comprehensive Care Plan for Anticoagulant Therapy dated 11/29/2018 and updated on 2/7/2024 documented the resident was on anticoagulant therapy. Interventions included to administer anticoagulant therapy as per the Physician's order, assess for signs of abnormal bleeding, avoid bumping and handle the resident gently when providing hands-on care. The Skin Check/Care section of the Resident Certified Nursing Assistant (CNA) Documentation Record dated 3/2024 was reviewed and was signed for all shifts to indicate skin checks were completed. The nursing progress note dated 3/7/2024 at 8:52 PM documented the resident was noted with a bruise to the dorsal aspect of the left hand. The resident was alert and oriented. As per the resident, they hit their hand on the door frame when leaving their room. The resident was able to self-propel their wheelchair. Licensed Practical Nurse #4, who was the medication nurse on duty on 3/4/2024 on the 7:00 AM - 3:00 PM shift, was interviewed on 3/7/2024 at 3:30 PM. Licensed Practical Nurse #4 stated they were not aware of the bruise on the resident's left hand. Licensed Practical Nurse #4 stated that they cared for the resident on 3/4/2024, 3/6/2024, and 3/7/2024; however, they did not notice the bruise. Licensed Practical Nurse #4 stated that it was not reported to them that the resident had a bruise on the left hand. Certified Nursing Assistant #9 was interviewed on 3/7/2024 at 3:15 PM and stated that they were assigned to Resident #20 on 3/7/2024 during the 7:00 AM-3:00 PM shift. Certified Nursing Assistant #9 stated they assisted the resident with morning care and also toileted the resident but did not observe the discoloration on the resident's left hand. Certified Nursing Assistant #10, who was assigned to Resident #20 on 3/4/2024, was interviewed on 3/8/2024 at 2:37 PM. Certified Nursing Assistant #10 stated that on 3/4/2024 they rendered care to Resident #20. Certified Nursing Assistant #10 stated they were responsible for checking the resident's skin while providing care. Certified Nursing Assistant #10 stated on 3/4/2024 they observed that the resident had a bruise on their left hand and the resident told them (Certified Nursing Assistant #10) that they banged their hand on the door frame. Certified Nursing Assistant #10 stated they did not report the bruise because they thought the nurse already knew about the bruise since the incident did not happen on their shift. Certified Nursing Assistant #10 stated they were going to report the bruise but forgot to do so. The Director of Nursing Services was interviewed on 3/8/2024 at 2:58 PM and stated that skin checks are supposed to be conducted by Certified Nursing Assistants during care. The Director of Nursing Services stated they expected the Certified Nursing Assistants to report any skin impairments to the nurse. The Director of Nursing Services stated that the Certified Nursing Assistant who identified the bruise on the resident's left hand should have reported the change in the resident skin to the nurse. 10 NYCRR 415.26(c)(1)(iv)

Based on observation, record review and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that the procedure that assure the accurate acquiring, receiving, dispensing and administration of all drugs and biologicals to meet the needs of each resident and the facility did not ensure that drug records are in order and that an account of all controlled drugs are maintained and periodically reconciled. This was identified for one (Resident #169) of eight residents reviewed for medication administration and for one (Unit 2 North) of four units reviewed for the Medication Storage task. Specifically, 1) Resident #169 had a Physician's order for Levothyroxine (Synthroid-thyroid medication) 50 microgram to be administered daily at 6:00 AM. During the medication pass observation on 3/6/2024 at 6:25 AM, the Levothyroxine 50 microgram was not available to be administered to the resident. Registered Nurse #4 borrowed the medication from another resident; 2) The Controlled Substance Administration Record was not reconciled for Resident #12 to reflect the accurate amount of Clonazepam 0.5 milligram that was observed in the blister pack. The findings are: 1) The facility Renewal of Medication and Reordering Policy dated 11/1/2023 documented Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than seven (7) days prior to the last dosage being administered to ensure that refills are readily available. Resident #169 was admitted with Hypothyroidism and Hypertension. A Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 14 which indicated the resident had intact cognition. A Physician's order dated 1/26/2024 and renewed on 2/23/2024 documented to administer Levothyroxine 50 micrograms one tablet via oral route once daily at 6:00 AM. A medication pass observation was conducted on 3/6/2024 at 6:25 AM for Resident #169. Registered Nurse #4 was unable to locate a Levothyroxine 50 microgram tablet for Resident #169 and was observed to remove a Levothyroxine 50 microgram tablet from another blister pack that had Resident # 49's identification label and then administered the Levothyroxine 50 microgram to Resident #169. Registered Nurse #4 was interviewed on 3/6/2024 at 6:30 AM and stated that they ran out of the Levothyroxine medication and needed to reorder the medication from the pharmacy for a refill for Resident #169. Registered Nurse #4 stated that they were not the regularly assigned nurse for Resident #169. Registered Nurse #4 stated that the medication should have been reordered when there were 3 to 4 pills left in the blister pack. Registered Nurse #4 stated when they run out of medication, they either borrow medication from another resident, from the blister pack of a resident who was discharged , or from another unit. Registered Nurse #4 stated they were aware they should not borrow the medications from one resident to administer to another resident. Registered Nurse #4 stated that they borrowed the Levothyroxine tablet because it was an important medication and that they did not want Resident #169 to miss their medication. Registered Nurse #6, who was the Nursing Supervisor on the 11:00-7:00 AM shift, was interviewed on 3/6/2024 at 6:45 AM. Registered Nurse #6 stated if a nurse ran out of a critical medication like Eliquis (blood thinner), they were allowed to borrow the medication from another resident. Registered Nurse #6 stated Levothyroxine was not a critical medication and that the nurse should not have borrowed the medication to administer it to Resident #169. The Director of Nursing Services was interviewed on 3/6/2024 at 7:45 AM and stated that the nurses should absolutely not be borrowing medication from one resident to administer to another resident. The Director of Nursing Services stated that there should not be any occasion where the resident's medication should run out. The Director of Nursing Services stated that there is no policy for borrowing medications. 48827 2) Resident #12 was admitted with diagnoses that included Dementia, Anxiety, and Hypertension. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 14 which indicated the resident had intact cognition. The Minimum Data Set assessment documented the resident received anti-anxiety medication for seven days during the assessment look-back period. During a Medication Storage observation on 3/09/2024 at 10:04 AM on nursing unit 2 North, the medication cart was observed, including the Narcotic medications in the cart. Resident #12's Controlled Substance Administration Record for Clonazepam was reviewed. The Controlled Substance Administration Record documented that the last Clonazepam tablet was administered on 3/08/2024 at 8:00 AM. The amount of the Clonazepam medication remaining on the Controlled Substance Administration Record was documented to be 12 tablets; however, the Clonazepam medication blister pack contained only 11 tablets. The physician's order dated 2/23/2024 documented to administer Clonazepam 0.5 milligram tablet, give one tablet by oral route once daily in the morning at 8:00 AM for Anxiety disorder. The Medication Administration Record for March 2024 was reviewed and revealed the Clonazepam was signed as administered on 3/09/2024 at 8:00 AM. Licensed Practical Nurse #2 was interviewed on 3/09/2024 at 10:04 AM and stated they administered Clonazepam 0.5 milligrams at 8:00 AM for Resident #12 today (3/9/2024) but got called away and did not sign and update the Controlled Substance Administration Record. Licensed Practical Nurse #2 further stated they should have signed the Controlled Substance Administration Record at the time the tablet was removed from the blister pack. Registered Nurse Supervisor #2 was interviewed on 3/09/2024 at 11:23 AM and stated the nurses should sign the Controlled Substance Administration Record when they remove the tablet from the blister pack. The Director of Nursing Services was interviewed on 3/09/2024 at 12:30 PM and stated in order to reconcile narcotic medications they expected the nurses to sign off on the Controlled Substance Administration Record and Medication Administration Record when the narcotic medication is administered to a resident. 10 NYCRR 415.18(b)(1)(2)(3)

Based on observation, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024 the facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition services. This was identified for one (Unit 1 North) of four Units observed during the initial tour. Specifically, Resident #107 and Resident #171 were observed eating their breakfast meal served on disposable plates, cups, and bowls. During the Resident Council Meeting held on 3/5/2024 eight of eight residents stated they often received disposable plates, cups, bowls, and utensils for meals on the weekend because of short staffing in the kitchen. The finding is: An undated facility policy titled Disposable Dinnerware documented the facility will use single-service items only in extenuating circumstances, such as dish-machine failure, individual resident needs, or other documented reasons. 1a) Resident #107 was admitted with diagnoses that included Alzheimer's Disease, Bipolar Disorder, and Chronic Obstructive Pulmonary Disease. Resident #107's Admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 3 which indicated the resident had severe cognitive impairment. During a tour of the 1 North Unit on 3/4/2024 at 9:01 AM Resident #107 was observed with a breakfast tray on their overbed table. A disposable plate and bowl were on Resident #107's meal tray. Resident #107 did not respond to questions. 1b) Resident #171 was admitted with diagnoses that included Multiple rib Fractures, Vascular Dementia, and Hypertension. Resident #171's Admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 7 which indicated the resident had severely impaired cognition. During a tour of the 1 North Unit on 3/4/2024 at 9:28 AM Resident #171 was observed with a breakfast tray on their overbed table. A disposable plate and bowl were on Resident #171's meal tray. Resident #171 stated they sometimes receive their meals on disposable dishes. Resident #171 stated they could not recall how often they received disposable products and they do not like to eat meals using disposable dishes. A Resident Council Meeting was conducted on 3/5/2024 from 10:19 AM to 11:30 AM. There were eight residents in attendance. All eight residents stated on the weekends they are often served meals on disposable plates. They stated they could not recall the specific dates they received their meals on disposable plates, but they did ask a staff person why they used the disposable items, and the staff person told them that the kitchen was short-staffed. The residents in attendance at the resident council meeting could not recall the name of the staff person. The Food Service Director was interviewed on 3/9/2024 at 7:59 AM. The Food Service Director stated the facility policy is to use disposable dinnerware only if a resident is on isolation precautions or if there is a safety concern with a resident. The Food Service Director stated sometimes when they are extremely short-staffed on the weekends and when they do not have kitchen staff available to run the dishwasher, they use the disposable dinnerware. Dietary Aide #1 was interviewed on 3/9/2024 at 9:35 AM. Dietary Aide #1 stated they worked on 3/4/2024 and served the breakfast meal on the 1 North Unit. Dietary Aide #1 stated the kitchen was short-staffed on the morning of 3/4/2024 and they were the only dishwasher. Dietary Aide #1 stated their shift begins at 6:00 AM and breakfast is served between 7:10-7:15 AM. Dietary Aide #1 stated they chose to use the disposable dinnerware on the unit because they would not have time to wash all the dishes before lunchtime. The Food Service Director was re-interviewed on 3/9/2024 at 9:42 AM and stated they created the schedule for the kitchen and on 3/4/2024 they were fully staffed for breakfast; however, one of the scheduled dietary aides was not able to come in. The Food Service Director stated the overnight nursing supervisor received a call from the dietary aide at 5:00 AM and then the overnight nursing supervisor informed the cook. The Food Service Director stated the cook attempted to call a replacement staff member; however, was not successful. Cook #1 was interviewed on 3/9/2024 at 9:49 AM and stated they worked the morning of 3/4/2024. At 6:20 AM they were informed by the overnight nursing supervisor that one Dietary Aide would not be coming in for the 6:00 AM to 2:00 PM shift. Cook #1 stated they were not able to find another person to cover the shift. Cook #1 stated disposable dinnerware should only be used when a resident is on isolation or for resident safety. Cook #1 stated they will sometimes use disposable dinnerware for breakfast and lunch when they are short-staffed because a delay with the breakfast meal would cause the lunch meal to be late and a delay with the lunch meal would cause the dinner meal to be late. The Food Service Director was re-interviewed on 3/9/2024 at 10:43 AM and stated there are ongoing recruitment efforts, but dietary staff are hard to find. The Food Service Director stated they offered overtime as an incentive, monitored staff attendance, and if there was an attendance concern they provided education and discipline if needed. The Administrator was interviewed on 3/9/2024 at 3:34 PM and stated they were aware that disposable dinnerware is used from time to time. The Administrator was aware of staffing concerns in the kitchen and stated they offered overtime as an incentive for staff to come in. The Administrator stated they expect to have sufficient staff for the kitchen but while attempts were made to staff the kitchen the facility had to improvise and serve meals on disposable dinnerware. 10 NYCRR 415.14(b)(1)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/6/2022 and completed on 4/13/2022 the facility did not ensure that the interdisciplinary team had determined that self-administration of medications was clinically appropriate for each resident. This was identified for 1 (Resident # 113) of 8 residents reviewed for Accidents. Specifically, Resident #113 incorrectly self-administered a Physician's prescribed nasal spray medication [MEDICATION(S)] ([MEDICATION(S)]) during a medication pass observation. The medication was being stored by the resident at their bedside. There was no documented assessment by the interdisciplinary team to determine if the resident could safely self-administer the medication. The finding is: The facility's policy, titled Self-Administration of Medications, revised in November 2020, documented those residents deemed capable, and who desire to self administer their medications, will be permitted to do so, after appropriate counseling/teaching and with the specific order of the resident's physician; and the resident will be evaluated to determine if criteria for self-administration is met. Resident #113 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/7/2022 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. A Physician's order dated 4/2/2022 documented [MEDICATION(S)] 50 microgram (mcg)/actuation nasal spray, suspension, spray 1 spray (50 mcg) in each nostril by intranasal route 2 times per day for allergic Rhinitis due to pollen. On 4/6/2022 at 2:05 PM Resident #113 was observed in their (Resident #113) room. Licensed Practical Nurse (LPN) #2 was present. The [MEDICATION(S)] spray bottle was observed on the resident's bedside table. LPN #2 stated the resident had a physician's order to keep the spray at their (Resident #113) bedside. A review of the Physician's order revealed Resident #113 had no physician's order to keep the Physician prescribed medication in their room. On 4/6/2022 at 2:13 PM a new order was placed for [MEDICATION(S)] 50 mcg/actuation nasal spray, suspension, spray 1 spray (50 mcg) in each nostril by intranasal route 2 times per day, OK to keep at the bedside, for allergic Rhinitis due to pollen. During the medication pass observation on 4/7/2022 at 8:08 AM for Resident #113, the [MEDICATION(S)] spray bottle was observed on the resident's bedside table. Registered Nurse (RN) #confirmed with Resident #113 that the resident had the nasal spray at their bedside. Resident #113 was then observed to self-administer 4 sprays of the medication [MEDICATION(S)] to each nostril while RN #1 was present. A review of the Physician's order revealed there was no physician's order for Resident #113 to self-administer the Physician prescribed medication. RN #1 and LPN #2 (charge nurse) were interviewed concurrently on 4/7/2022 at 10:16 AM. RN #1 and LPN #2 stated Resident #113 was non-compliant with the [MEDICATION(S)] spray and a behavior care plan will be created for the non-compliance with the [MEDICATION(S)] spray. RN #1 and LPN #2 stated they spoke with the doctor and the resident can keep the nasal spray medication at their (Resident #113) bedside with the understanding of side effects and to take one spray per nostril. LPN #2 stated they (LPN #2) were not sure if an assessment to self-administer medications was completed and where it would be documented. A Comprehensive Care Plan (CCP) effective 4/7/2022, titled Behavior Problem, documented the resident has a history of behaviors including resisting care and being non-compliant with the medication regime. The resident is using [MEDICATION(S)] ([MEDICATION(S)]) at the bedside, educated on proper usage; the resident is insisting on using more than 1 spray in each nostril. A nursing progress note dated 4/7/2022 at 11:44 AM written by LPN #2 documented after speaking with the physician it is acceptable for the resident to take two sprays twice a day. On 4/7/2022 at 11:47 AM a new order was placed for [MEDICATION(S)] 50 mcg/actuation nasal spray, suspension, spray 2 sprays (100 mcg) by intranasal route 2 times per day, OK to keep at the bedside. The physician was interviewed on 4/8/2022 at 8:50 AM and stated it was acceptable for Resident #113 to take two sprays of [MEDICATION(S)] in each nostril twice a day, but the physician stated they (the physician) were not so sure about 4 sprays in each nostril. The physician stated they (Physician) will be in on the weekend to re-evaluate and educate the resident. A CCP titled Self Medication, effective 4/8/2022, documented resident prefers to self administer medication [MEDICATION(S)] as per the Physician's order, with an intervention to assess the ability to self administer medications safely quarterly and with a significant change in medical condition. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #113 has [MEDICATION(S)] nasal spray at their bedside. When using the inhaler the resident has been doing 4 sprays at a time. The resident was taught to use 1 spray to each nare twice a day only. The resident was counseled on the need not to overuse the medication as the medication can cause epistaxis (nose bleed) and prostate irritation. The resident verbalized directions back to the practitioner. The Physician wrote that they explained to the resident that if the resident does not take the prescription at the right dosing, the nursing staff will have to administer the medication and the medication cannot be left at the resident's bedside. The Director of Nursing Services (DNS) was interviewed on 4/11/2022 at 3:15 PM and stated if a resident wants to self-administer medications, there must be a documented assessment and a care plan initiated before the resident could self-administer medications to ensure the resident's safety. 415.3(e)(1)(vi)