Based on observation, record review, and interviews during a recertification survey, the facility did not ensure residents received services in the facility with reasonable accommodation for 1(Resident #86) of 30 residents reviewed. Specifically, the facility did not ensure Resident #86 had a call device they were able to use and was accessible to the resident. This is evidenced by: Resident #86 was admitted to the facility with diagnoses of end stage renal disease, generalized muscle weakness, and need for assistance with personal care. The Minimum Data Set (an assessment tool) dated 9/16/2024, documented the resident was cognitively intact, could be understood, and understand others. The resident had upper extremity impairment on both sides. The Care Plan for Comfort Care/End of Life, updated 11/15/2024, documented the resident was admitted to Hospice on 11/14/2024 for end-of-life care related to end stage renal disease. Goals documented resident would have their wishes for supportive end of life care honored and the resident would be supported emotionally, physically, and palliatively through end-of-life care. During an observation on 12/03/2024 at 9:08 AM, Resident #86 was lying in bed on their back. A push button call bell was noted to be clipped to the resident's bedding in an area that was not accessible to the resident. Resident #86 stated they were unable to use the call bell due to their condition and said they would ask their roommate (Resident #2) to put their call light on when they needed help. Resident #86 stated the facility was supposed to be getting them a touch call bell to use. During an observation on 12/04/2024 at 9:15 AM, Resident #86 was lying in bed on their back. The resident stated they had not given them a different call bell. A push button call bell was clipped to the resident's bedding and was not accessible. During an observation on 12/09/2024 at 3:30 PM, Resident #86 was noted to have a tap call bell that was located to the side of the resident and was accessible. During an observation on 12/10/2024, at 9:15 AM. Resident #86's tap call bell was under the resident's blanket and was not accessible to the resident. The Hospice nurse stated they just came to check the resident and found the call bell out of reach when they arrived. The Hospice nurse adjusted the call bell and placed it on the inside of the resident's bedding, below the resident's chin. During an interview on 12/04/2024 at 5:36 PM, Resident #2 stated their roommate (Resident #86) had them use their call bell to get help for them. When asked how often, Resident #2 stated it usually occurred at least 5 or 6 times during the day and night hours. During an interview on 12/10/2024 at 9:31 AM, Registered Nurse #1 stated Resident #86 was on Hospice and was weak. They provided the resident with a tap call button. They stated the call bell should be placed where the resident could reach it. Registered Nurse #1stated they would reeducate staff if that was not being done. The expectation was for the resident to be able to call for assistance when needed. They stated the bell should not be obstructed and under blankets because that would defeat the purpose of the soft tap button. They stated they were not sure when the soft touch button was made available to the resident. 10 New York Code of Rules and Regulations 415.5(e)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey, the facility did not ensure that Comprehensive Care Plans were reviewed and revised to meet the needs of each resident for 2 (Residents #16 and #79) of 30 residents reviewed. Specifically, Resident #16 and Resident #79 had multiple falls and the patient centered Comprehensive Care Plans were not updated to reflect number of falls with corresponding interventions and goals to prevent falls. This is evidenced by: The facility's Policy and Procedure titled Care Planning, Minimum Data Set (is a standardized assessment tool that measures health status in nursing home residents) Assessments and Minimum Data Set Interviews effective 4/2015 and last revised 2/2024, documented PHILOSOPHY: It is the policy of the facility to provide each resident with current care plans reflecting their needs to maintain optimal ability as able and to keep current with Professional Standards. PURPOSE: To evaluate and assess each resident's status and plan of care in order to prevent deterioration/decline unless a clinical condition makes the decline unavoidable. PRINCIPLES: Care Plans to be developed based on resident's Care Area Assessment (CAA), needs, desires, problems with appropriate interventions and realistic goals. Utilize care planning guide to ensure all potential areas were addressed. Further Care Plans to be initiated when problems arise and were to be updated with each routine Minimum Data Set as set forth in the Minimum Data Set Process Protocol. Resident #16: Resident #16 was admitted to the facility with a diagnoses of dementia unspecified (loss of memory, language, problem-solving and other thinking abilities), anxiety (a type of mental health condition), and aged-related osteoporosis (bones to become weak and brittle). The Minimum Data Set (an assessment tool) dated 9/07/2024, documented the resident could be understood and understand others and was moderately cognitively impaired. Nurse progress notes documented falls on 6/19/2024, 10/10/2024, and 10/19/2024. The Comprehensive Care Plans for falls was updated 10/11/2024. Resident #16 had a subsequent fall on 10/16/2024, no updates to care plan were made. During an interview on 12/06/2024 at 9:56 AM, Assistant Director of Nursing #1 stated Care Plans were not updated after every fall if an intervention was already in place. Failure to follow a care plan was referred to the Director of Nursing. Director of Nursing #1 also stated staff should be updating care plan after each fall. Resident 79: Resident #79 was admitted to the facility with diagnoses of unspecified dementia (loss of memory, language, problem-solving and other thinking abilities), acquired absence of right leg above knee, legally blind, and anxiety disorder (involves persistent anxiety or dread, which can interfere with daily life). The Minimum Data Set, dated [DATE], documented Resident #79 was severely cognitively impaired, could be understood and understand others. Nursing Progress notes dated 10/07/2024 and 11/16/2024 documented Resident #79 had witnessed falls with no injuries. The Comprehensive Care Plan for falls dated 8/08/2024 documented the resident was at risk for falls with the following interventions: Wear proper footwear/non-skid, observe for decline in strength, mobility, and transfer ability, and ensure proper lighting. Educate resident and family on mobility and transfer. Physical Therapy or Occupational Therapy evaluation and participation to build strength + endurance as needed lab tests as appropriate. Remind resident to call for assistance before attempting to get out of bed, keep bed in low position. Encourage resident to sit near nurse's station when in wheelchair 8/27/2024. There were no updates to the fall care plan after 8/27/2024. During an interview on 12/06/2024 at 10:33 AM, Director of Nursing #1 stated the care plans should be updated after each fall noting the fall and interventions. The previous Director of Nursing had not made the appropriate updates to care plans. Going forward Nurse Managers and the Director of Nursing will update care plan after each fall. 10 New York Codes, Rules, and Regulations 415.11(c)(2)(ii-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey, the facility did not ensure a dependent resident was provided with appropriate treatment and services to maintain or improve their language and communication for 1 (Resident #367) of 1 reviewed for Activities of Daily Living. Specifically, nursing staff did not provide Resident #367 with adequate, consistent interpreter services in accordance with professional standards of care. This was evidenced by: The facility's Policy and Procedure titled Communication effective 6/19/2029 and reviewed 3/2024, documented its Purpose: To provide our residents who communicate with non-oral communication devices, sign language, or who speak a language other than the dominate language of the facility (English) the highest practicable level of quality of life and the resources to achieve just that. Social Services kept an up-to-date list of all of our residents who communicate with non-oral communication devices, sign language, or who speak a language other than the dominate language of the facility (English), English Second Language (ESL) residents. For our English Second Language residents interpreter services could be utilized: Provide translator [PHONE NUMBER] code:527633. The New York State Department of Health Code, Rules and Regulation, Volume C (Title 10) Section 415.3 Effective 2/24/2022, documented each resident shall have the right to: (i) adequate and appropriate medical care, and to be fully informed by a physician in a language or in a form that the resident can understand, using an interpreter when necessary, of his or her total health status including but not limited to, his or her medical condition including diagnosis, prognosis, and treatment plan. Residents shall have the right to ask questions and have them answered. Resident # 367 was admitted to the facility with a diagnoses of Alzheimer's Disease unspecified (a brain disorder that slowly destroys memory and thinking skills), dementia unspecified (loss of memory, language, problem-solving and other thinking abilities), and anxiety. The minimum Data Set (an assessment tool) dated 11/25/2024 documented resident could be understood and understand others in Spanish. Resident was unable to complete Brief Interview for Mental Status. Resident's primary language is Spanish, and resident observed speaking Spanish only. Resident #367 Comprehensive Care Plan dated 11/25/2024, documented preferred language is Spanish. During an observation on 12/02/2024 at 10:45 AM, Resident #367 was observed pacing up and down halls on 400 unit. Resident appeared distressed and was speaking in Spanish. Staff did not respond to resident. During a dining observation on 12/02/2024 at 11:54 AM, Resident #367 observed pacing in and out of dining room. Resident required much re-direction to sit at dining room table for lunch. Staff observed making gestures to resident and speaking to resident in English. During an observation on 12/02/2024 at 12:35 PM, Resident #367 approached surveyor speaking in Spanish. Surveyor asked resident their name. Resident responded inappropriately in Spanish. Survey asked how are you in Spanish ([NAME] estas?) resident responded bien [NAME] with a smile. During an observation on 12/03/2024 at 10:30 AM, resident had a male visitor (husband). Resident observed having a fluent conversation with visitor in Spanish. Resident appeared very happy to have the visitor present. Visitor brought Latin music and resident was moving to the music happily. During an interview on 12/02/2024 at 12:12 PM, Social Worker #1 stated they keep translation line for English Second Language Residents in their office along with the code. If staff needed to use the interpreter line, they would contact the social worker. When Social Worker is not available, they have bilingual staff to translate. During an interview on 12/02/2024 at 12:15 PM, Certified Nurse Aide #3 stated they use google translator to communicate with Resident #367. They stated there was a point object sheet in the manager's office but had not used it. During an interview on 12/02/2024 at 12:17 PM, Certified Nurse Aide #4 stated they communicated with Resident #367 using hand movements, guide with hands, and had never used google translator. During an interview on 12/02/2024 at 12:33 PM, Licensed Practical Nurse #15 stated they used communication phone line if needed, but was not sure where to locate the number, and was not aware there was a code. During an interview on 12/03/2024 at 11:15 AM, Administrator #1 stated they had a language line for English Second Language residents, but there was no specific training on language line. Administrator #1 stated they staffed facility each shift with Spanish speaking staff that can be used as an interpreter. 10 New York Codes, Rules, and Regulations 415.12(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 (Resident #49, and #367) of 4 residents reviewed. Specifically, Residents #49, and #367 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by: The Facility's Policy and Procedure titled Activity Assessment and Programming, undated, documented, The purpose of this policy was to establish a framework for meaningful, individualized activities that promote physical, cognitive, emotional, and social well-being of each resident. The goal was to offer activities that enhanced residents' quality of life by fostering independence, engagement, and a sense of purpose, while respecting each individual's preferences and abilities. Guiding Principles: 1. Person-Centered Care: Activities will be personalized to each resident's interests, cultural background, and life history. The focus will be on offering choice and autonomy, allowing residents to engage in activities that resonate with them. Resident #49 Resident # 49 was admitted to the facility with a diagnoses of dementia unspecified (loss of memory, language, problem-solving and other thinking abilities), anxiety, and hard of hearing. The Minimum Data Set (an assessment tool) dated 11/25/2024, documented resident was severely cognitively impaired, could be understood, and understand others. During an observation and interview on 12/02/2024 at 11:19 AM, Resident #49 was in bed awake, wearing hospital gown. Resident responded to writer in Spanish when asked how are you? Resident #49 was observed in bed on subsequent days of 12/03/2024 at 10:00AM, 12/04/2024 at 11:40 AM, and 12/05/2024 at 9:50 AM. On all days the room lights were off, and roommate had television on. During an observation and interview on 12/05/2024 at 9:47 AM, several residents on the 4th floor unit were engaged in a music activity with staff. Resident #49 was noted not in attendance but was found in bed dressed in shorts and a shirt and was asleep. Activities Aide #1 stated they worked 1:1 with Resident #49. They stated on 12/03/2024 they talked with Resident #49 at the bedside about how the day was going. Activities Aide #1 stated they did not speak Spanish but had a conversation with resident with the limited knowledge of Spanish that they had. Director of Nursing #1 stated Resident #49 generally got up in the afternoon and sat in the corridor. During an observation on 12/05/2024 at 3:21 PM, Resident #49 was in bed asleep, difficult to arouse. Resident #49's Activity Log documented resident refused the following: 11/27/2024 sensory; 11/28/2024; educational; 11/27/2024; games; 11/28/2024; floor carts; 12/01/2024 floor carts. Resident #367 Resident # 367 was admitted to the facility with a diagnoses of Alzheimer's Disease unspecified (a brain disorder that slowly destroys memory and thinking skills), dementia unspecified (loss of memory, language, problem-solving and other thinking abilities), and anxiety. Resident's primary language is Spanish, and resident observed speaking Spanish only. The documentation indicated resident could understand and be understood by others in Spanish. The Minimum Data Set, dated [DATE], documented a Brief Interview for Mental Status score of 99 suggesting resident was unable to complete the interview. Resident #367 Comprehensive Care Plan dated 11/25/2024, documented preferred language is Spanish. During an observation on 12/02/2024 at 01:07 PM, Resident #367 paced up and down 4th floor unit. Resident was anxious and required much encouragement and direction. Activities calendar for the day consisted of BINGO, resident with dementia and unable to actively participate; cooking club at 1:30 PM; and Wheel of Fortune at 3:00 PM. English is resident's Second Language. Activities Director #1 stated activities were not in Spanish. During an observation on 12/03/2024 at 10:30 AM, resident had a male visitor (husband). Resident observed having a fluent conversation with visitor in Spanish. Resident appeared very happy to have the visitor present. Visitor brought Latin music and resident was moving to the music happily. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey, the facility did not ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 (Resident #s 114 and 172) of 2 residents reviewed. Specifically, for Resident #s 114 and 172, the facility did not ensure (a.) multiuse feeding sets (syringe/bottle) were labeled with the date opened and disposed of within 24 hours; (b) opened multiuse bottles of formula were labeled with the date/time opened and discarded within 48 hours. This is evidenced by: The Policy and Procedure titled, Tube Feeding and Tube Care, reviewed 6/2024, documented the policy was written to provide guidance and general guidelines for administration of enteral feedings by the licensed nurse. Administration of feeding documented label the outside of the container (formula) with the date, time, and initials if appropriate (i.e. multiuse bottles). Prevention of bacterial contamination documented the enteral tube feeding set and tubing along with syringe was to be changed every 24 hours and discard any unused feeding after 48 hours of being open. Resident #114 Resident #114 was admitted to the facility with diagnoses of gastrostomy status (a surgical opening in the stomach used for feeding), dysphagia (difficulty swallowing), generalized muscle weakness. The Minimum Data Set (an assessment tool) dated 11/11/2024, documented the resident was cognitively intact. The resident was able to make themselves understood and understood others. The resident had a feeding tube while a resident in the facility. The Care Plan for Tube Feeding, revised 11/26/2024, documented the resident received bolus tube feeds (administration of a limited volume of enteral formula over extended periods of time). Interventions documented: 5 bolus tube feeds of 237 milliliters of Jevity (enteral formula) per day and change the feeding tubing and bag every day per policy and procedure. The Nutrition Progress Note dated 12/02/2024, documented the resident was receiving 100% of estimated needs from bolus tube feeds and well as an oral diet. The Nurse's Note dated 12/02/2024 by the Registered Nurse #3, documented Jevity was given via bolus as ordered. During an observation on 12/02/2024 at 12:25 PM, Resident #114 was noted to have two opened multiuse bottles of Jevity in their room. One bottle was dated 11/29/2024 and one was dated 12/01/2024. The time opened was not indicated. Two multiuse feeding sets were in the room that were dated 11/29/2024 and 12/01/2024. During an observation on 12/05/2024 at 12:10 PM, Resident #114 was noted to have a multiuse feeding set labeled 12/03/2024 8:20 AM. There was an opened multiuse bottle of Jevity dated 12/01/2024 with a line through the date and a date of 12/03/2024 written above it. The time opened was not indicated. Resident #172 Resident #172 was admitted to the facility with diagnoses of gastrostomy status (surgical opening in the stomach used for feeding), dysphagia (difficulty swallowing), and prediabetes. The Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment. The resident sometimes made themselves understood and usually understood others. The resident had feeding tube while a resident in the facility. The Care Plan for Nutrition, updated 11/26/2024, documented the resident received bolus feeds. Interventions documented: 3 bolus feeds per day of 237 ml of Jevity 1.2. During an observation on 12/2/2024 at 12:48 PM, Resident #172 had an opened multiuse bottle of Jevity dated 11/29/2024 with no time indicated. A multiuse feeding set was in the room and was not dated. The Nutrition Progress Note dated 12/4/2024, documented to continue with 3 bolus feeds per day of 237 ml of Jevity 1.2. During an observation on 12/05/2024 at 12:12 PM, Resident #172 had a multiuse feeding set in their room that was not dated and was filled about one-half inch with water and a multiuse feeding set that was labeled 12/3/2024 9:00 AM. During an interview on 12/10/204 at 10:43 AM, Registered Nurse #1, stated everything should be labeled. The Jevity bottle should be labeled with date/time when it was opened and should be discarded after 24 hours. Stated the feeding syringe and bottle should be dated/time and discarded after 24 hours. Stated Resident #s 114 and 172 both received bolus tube feeds daily by gravity. During an interview on 12/10/2024 at 11:00 AM, Director of Nursing #1 stated the Jevity multiuse bottle should be discarded after 24 hours. Stated the Jevity bottle should be dated and timed so that you know exactly when the 24 hours was. Stated the syringe/bottle was changed daily on the night shift and documented on the treatment administration record. 10 New York Code of Rules and Regulations 415.12(g)(2)

Based on observations, record review, and interviews during a recertification survey, the facility did not ensure that each resident received respiratory care consistent with professional standards of practice for 1 (Resident #86) of 3 residents reviewed. Specifically, Resident #86's oxygen tubing was not changed on 12/01/2024 as ordered by the physician. This is evidenced by: The Policy and Procedure titled, Oxygen Therapy - Mask and Nasal Cannula, revised 5/2024, documented all oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. Oxygen administration would be monitored by the licensed nurse and documented on the Treatment Administration Record and in the electronic medical record. Resident #86 was admitted to the facility with diagnoses of chronic respiratory failure with hypoxia (decreased perfusion of oxygen to the tissues), end stage renal disease, and generalized muscle weakness. The Minimum Data Set (an assessment tool) dated 9/16/2024, documented the resident was cognitively intact. The resident was able to make themselves understood and understand others. The resident received continuous oxygen therapy. The Care Plan for Risk for Compromised Respiratory Status, updated 9/11/2024, documented chronic respiratory failure with hypoxia. Interventions documented oxygen per physician order. The Physician Order dated 10/29/2024 for oxygen therapy, documented change oxygen nasal cannula/tubing weekly on Sunday during the night shift. During an observation on 12/03/2024 at 9:08 AM, Resident #86 was receiving supplemental oxygen. There was no date on the oxygen tubing. The Treatment Administration Record as of 12/04/2024 at 11:04 AM, documented the oxygen tubing was last changed on 11/24/2024 at 5:00 AM. There was no documentation on the Treatment Administration Record that the oxygen tubing was changed on 12/01/2024. During an interview on 12/10/2024 at 11:00 AM, Director of Nursing #1 stated oxygen tubing was changed weekly on the night shift and documented in the medical record on the Treatment Administration Record. They stated the facility did not have oxygen tubing labels. They said that although they were not sure about the facility's policy, the documentation on the Treatment Administration Record was done at the time the oxygen was changed and that was how they knew when it was last changed. 10 New York Code of Rules and Regulations 415.12(k)(6)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice, for 2 of 2 medication rooms reviewed (200 unit and 300 unit), and 3 of 3 medication carts reviewed (200, 300, and 400 units). Specifically, (a.) opened medications had no open and/or expiration dates; (b.) opened stock eye drops were not labeled with resident's name; (c.) medication refrigerator temperature was outside of therapeutic range; (d.) non-medication items were stored in narcotic cabinet; (e) a narcotic box was not secured with double lock; and (d) open cups of food were stored in medication cart. This is evidenced by: The facility's Policy and Procedure tilted Medication Storage Date Revised: 3/2023 documented, Medications would be stored in an orderly, organized manner in a clean area. Expired, discontinued and/or contaminated medications would be removed from the medication storage areas and disposed of in accordance with facility policy. Medication would be stored at the appropriate temperature in accordance with the pharmacy and/or manufacturer labeling. Medications requiring refrigeration would be stored in a refrigerator that is maintained between 2 to 8 degrees Celsius (36 to 46 degrees Fahrenheit). The facility's Policy and Procedure tilted Medication Administration date revised: 6/2024, documented its purpose was to administer medications in a way that ensures resident's safety and satisfied medical and legal concerns. PROCEDURE: #3: Avoid distractions when administering medications. Ensure medication is not outdated. All medications were to be properly labeled. All labels were to be clean and clear. NYS Title: Part 80 - Rules And Regulations On Controlled Substances 80.50 (1) Schedule I, II, III and IV controlled substances shall be kept in stationary, locked double cabinets. Both cabinets, inner and outer, shall have key-locked doors with separate keys; spring locks or combination dial locks are not acceptable. For new construction, cabinets shall be made of steel or other approved metal. During an observation and interview on 12/04/2024 at 10:05 AM, on 200-unit, Medication Cart #1 contained two Humalog Kwik pens, 1 pen was inside plastic bag labeled open date 11/20/2024 and expiration date 12/06/2024. The 2nd pen was located in the back of the medication cart top drawer. Licensed Practical Nurse #1 placed the 2nd pen inside the plastic bag along with the other insulin pen. The 2nd pen did not have an open and or expiration date. Licensed Practical Nurse #1 stated the pen was opened on that morning. 1 albuterol inhaler had an open date of 10/01/2024. Licensed Practical Nurse #1 was unable to determined what the expiration date would or should be. During an observation and interview on 12/04/2024 at 10:15 AM, on 200-unit, Medication Room, Narcotic box #1 contained a wallet and a medic alert of an expired resident. Licensed Practical Nurse #1 stated they were waiting for family to pick up the wallet. During an observation and interview on 12/04/2024 at 10:15 AM, on #200-unit, Medication Room, Narcotic Box #2 outer lock was left open. Licensed Practical Nurse #5 stated it was an oversight and the lock was left open. During an observation interview on 12/04/2024 at 10:40 AM on 300 -unit, Medication Cart #2 contained 3 open bottles of artificial tears stock eye drops. Licensed Practical Nurse #14 stated each resident received their own bottle of eye drops. The eye drops were not labeled with resident name, instead illegible initials were on each of the 3 bottles. In addition, 2 unopened bottles of refresh eye drops were dated 11/07/2024. During an observation and interview on 12/04/2024 at 10:55 AM, the 300 Unit Medication Room refrigerator temperature was 50 degrees Fahrenheit. Licensed Practical Nurse #14 stated they would notify maintenance. During an observation interview on 12/04/2024 at 11:00 AM, the 400-Unit Medication Room Narcotic Box side 1 contained a wedding band. Licensed Practical Nurse #15 stated it was unknown who the wedding band belonged to. The jewelry was placed there for safe keeping. During an observation interview on 12/04/2024 at 11:20 AM, 400-Unit, Medication Cart #2 contained 3 open cups of applesauce and 1 unopened cup of vanilla pudding labeled refrigeration required. Licensed Practical Nurse #15 discarded the items. During an interview on 12/04/2024 at 11:30 AM, Assistant Director of Nursing #1 stated all resident valuables were stored in the business office. During an interview on 12/10/2024 at 11:00 AM, Director of Nursing #1 stated all resident valuables were kept in the business office. When the business office is closed, valuables could be stored in locked medication room, but not in narcotic box. All nursing staff received medication administration education upon hire and throughout year as needed. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on record review and interviews during a recertification and abbreviated survey (Case# NY00349706), the facility did not ensure it promptly notified the ordering physician of laboratory results that fell outside of clinical reference ranges per the ordering physician's orders for 1 (Resident #269) of 1 resident reviewed. Specifically, the ordering physician was not notified when Resident #269's blood sugar results were outside of the clinical reference range on 7/11/2024, 7/12/2024, 7/18/2024 and 7/19/2024. This is evidenced by: Resident #269 was admitted to the facility with diagnoses of type 1 diabetes without complications, urinary tract infection, and muscle weakness. The Minimum Data Set (an assessment tool) dated 10/10/2024, documented the resident was cognitively intact. The resident was able to make themselves understood and understood others. The Policy and Procedure titled, Medication Administration Time Guidelines, revised 2/2024, documented fingersticks as ordered by the physician. The Policy and Procedure titled, Resident Status Change/Physician/Family Notification, revised 10/2021 and reviewed 5/2024, documented the resident's physician would be notified of a significant change in the resident's condition whether physical, mental, or emotional. The Care Plan for Diabetes, updated 8/26/2024, documented the resident's blood sugar would be maintained in the therapeutic range. Interventions documented administer medications as per orders, fingerstick blood sugars as ordered, and insulin coverage. Review of Physician Orders documented: - 7/06/2024 Fingerstick/Insulin Coverage Orders: every day before meals and at bedtime. Insulin Aspart Solution (fast-acting) Pen-injector 100 units/ml. Insulin scale: range 151-200, 2 units; range 201-250, 4 units; range 251-300, 6 units; range 301-350, 8 units; range 351-400, 10 units; result 400, 12 units. Result 400 - contact physician. Review of the Medication Administration Record documented: - 7/11/2024 at 7:30 AM Registered Nurse #1 - blood sugar result was 456 and 12 units of Insulin Aspart Solution was given. There was no documentation in Nurse's Notes that the physician was notified. - 7/12/2024 at 7:30 AM Registered Nurse #1 - blood sugar result was 428 and 12 units of Insulin Aspart Solution was given. There was no documentation in Nurse's Notes that the physician was notified. - 7/12/2024 at 11:30 AM Licensed Practical Nurse #15 - blood sugar result was 558 and 12 units of Insulin Aspart Solution was given. There was no documentation in Nurse's Notes that the physician was notified. - 7/12/2024 at 5:30 PM Licensed Practical Nurse #16 - blood sugar result was 446 and 12 units of Insulin Aspart Solution was given. There was no documentation in Nurse's Notes that the physician was notified. - 7/18/2024 at 5:30 PM Licensed Practical Nurse #17 - blood sugar result was 400 and 12 units of Insulin Aspart Solution was given. There was no documentation in Nurse's Notes that the physician was notified. - 7/19/2024 at 11:30 AM Registered Nurse #4 - blood sugar result was 600 and 12 units of Insulin Aspart Solution was given. There was no documentation in Nurse's Notes that the physician was notified. - 7/19/2024 at 5:30 PM Licensed Practical Nurse #16 - blood sugar result was 600 and 12 units of Insulin Aspart Solution was given. There was no documentation in Nurse's Notes that the physician was notified. - 7/19/2024 at 9:00 PM Licensed Practical Nurse #16 - blood sugar result was 503 and 12 units of Insulin Aspart Solution was given. There was no documentation in Nurse's Notes that the physician was notified. During an interview on 12/10/2024 at 1:30 PM, Registered Nurse #4 stated the resident frequently had high blood sugars above 600. They stated they probably communicated to the Registered Nurse on the unit after they gave the 12 units of insulin. Stated for a blood sugar greater than 400, they usually cover the 400 (give the insulin) and called the physician, who usually orders an extra dose of insulin. During an interview on 12/10/2024 1:55 PM, Registered Nurse #1 stated they did not recall the resident. Stated they would call the physician and let them know what the order and the blood sugar result was, and the physician would usually order additional insulin. 10 New York Code of Rules and Regulations 415.20

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #44: Resident #44 was admitted to the facility with a diagnosis of dementia unspecified (loss of memory, language, problem-solving and other thinking abilities), anxiety (a type of mental health condition) and hard of hearing. The Minimum Data Set, dated [DATE], documented the resident was severely cognitively impaired, could sometimes be understood and could sometimes understand others. During an observation on 12/05/2024 at 10:15 AM, Certified Nurse Aide #8 was overheard yelling relax and sit back in chair to Resident #44. Resident #44 was overhead yelling back, stating no, I don't want to. Certified Nurse Aide #4 stated Resident #44 did not like to be dressed, they were upset because they just had a shower and gotten dressed. During an interview on 12/05/2024 at 10:15 AM, Registered Nurse #7 stated nursing staff received Oasis (a certified program) training on care of residents with dementia, as well as annual training on abuse and neglect. Registered Nurse #7 stated that abuse could be verbal, and that Resident #44 was hard of hearing. They were in the process of finding more comfortable clothing to accommodate Resident #44. Certified Nurse Assistant #8 was removed from Resident #44's care and coached on tone of voice when speaking with residents that were hearing impaired. During an observation on 12/09/2024 at 10:46 AM, Registered Nurse #7 was shouting anxiously at Resident #44. Registered Nurse #7 was aware that their shouting was observed and stated Resident #44 was very hard of hearing. When asked if they had hearing aids, Resident #44 stated I need hearing aids. Registered Nurse #7 stated Resident #44 had bilateral cochlear implants, but they were not aware of hearing aids for the resident. During an interview on 12/10/2024 at 10:31 AM, Director of Nursing #1 stated Resident #44 was hard of hearing, had hearing aids but refused to wear them. Resident #44 went out to have an audiology evaluation but did not cooperate with the exam. Additionally, all staff undergo Oasis (a certified program) for care of patients with dementia. Surveyor: [NAME], [NAME] Resident #97: Resident #97 was admitted with the diagnoses of unspecified dementia with behavioral disturbances (a degenerative neurological disease affecting memory and mood), Parkinson's disease (a progressive neurological disease causing uncontrollable muscle movement), and peripheral vascular disease (dysfunction of blood flow all extremities). The Minimum Data Set, dated [DATE] documented the resident could usually understand others, could usually be understood, was severely cognitively impaired and required moderate assistance with activities of daily living. During general floor observations on 12/03/2024 at 9:18 AM, Resident #97 was getting cleaned up with the assistance of Certified Nurse Aide #1. Resident #97 could be heard yelling at Certified Nurse Aide #1 indicating they were displeased with what Certified Nurse Aide #1 was doing in their room. Resident #97 stated they were cold multiple times. Certified Nurse Aide #1 was heard explaining what they were trying to accomplish. At 9:35 AM, Resident #97 shouted I'm leaving!, Certified Nurse Aide #1 shouted back Good! Resident #97 left the room while Certified Nurse Aide #1 continued to finish their job of changing the resident's bed linens. During an interview on 12/05/2024 at 10:46 AM, Certified Nurse Aide #1 stated that when they were having a difficult time with a resident while trying to provide care, they walked away and came back after the resident had calmed down. Certified Nurse Aide #1 stated that they did not believe that staff struggled to work with the residents on the floor. They knew that when residents were upset that the best approach was to back away and reapproach later. Agitated residents were given the option of a sensory room to relax as well. When asked if the Certified Nurse Aide gave a shift-to-shift report to provide the opportunity to share if certain residents had a bad day or to give heads up to oncoming staff, Certified Nurse Aide #1 stated that they were and that was what kind of information was shared. During an interview on 12/06/2024 at 11:21 AM, Certified Nurse Aide #2 stated that if a resident spoke inappropriately with them or refused to comply with their request, they would approach at a later time when the resident had calmed down. During an interview on 12/06/2024 at 12:15 PM, Social Worker #1 stated that they worked with staff to prevent burnout and off-the-cuff responses when staff members felt frustrated. When a resident had significant behavior issues, the behavior committee, which met every two weeks, would discuss different strategies to help staff manage the resident. It was not expected that staff would response sharply to residents and if they were to have seen it, they would pull the staff member aside and tell them to take a break or report them if it was appropriate. During an interview on 12/10/2024 at 12:00 PM, Dietitian #1 stated the facility did use plasticware as part of their adaptive equipment for resident's who had muscle weakness, recommendations from therapy or just request to use plasticware. They stated that the plasticware was care planned for each resident under adaptive equipment in the resident's care plan. Dietitian #1 also stated that when the dishwasher was broken, plasticware was used facility wide until the dishwasher was repaired. Dietician #1 stated that they have seen more plasticware than expected on the units recently but could not attest to whether the resident's receiving the plasticware were care planned for it. Dietitian stated they did not believe plasticware should be used regularly for all residents. During an interview on 12/10/2024 at 12:15 PM, Dietary Director #1 stated that the residents normally received silverware unless they were care planned for plasticware. They stated they have residents who were care planned for plasticware with every meal based on the Unit Managers discretion and recommendation. They stated sometimes plasticware was recommended by speech therapy or occupational therapy and the resident would be care planned through those departments to receive plasticware. The plasticware was put on the care plan under adaptive equipment. Dietary Director #1 stated they could not print a list of residents receiving plasticware because it did not come up on the list of adaptive equipment. The resident would have plasticware identified on their meal ticket and dietary staff place the items when they prepare the tray. Dietary Director #1 stated that the plasticware would only be used facility wide if the dishwasher was not operational. Dietary Director #1 confirmed that the dishwasher was operating adequately, and they did not believe that any resident received plasticware who was not care planned to receive it. Dietary Director #1 stated that they had multiple sets of silverware and that it was used daily. Dietary Director #1 stated they were aware plasticware should not be used regularly for all residents. 10 New York Code Rules and Regulations 415.3(c)(1)(i) Based on observation, record review and interviews during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life for 6 (Resident #'s 2, 12, 28, 44, 97, and 114) of 35 residents reviewed. Specifically, (a.) Resident #'s 2, 12, 28, and 114 were provided plastic flatware with their meals instead of silver flatware. (b.) Residents #44 and #97 were not talked to in a dignified manner by staff providing care. This is evidenced by: A facility policy Dignity and Quality of Life Policy, not dated, documented that each resident shall be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Under the policy section procedure/implementation it was documented that: Residents should be treated with dignity and respect at all times. Staff should promote and ensure each resident had a dignified dining experience through: - Consider resident wishes when using clothing protectors - Ensuring the residents receive plastic utensils/dishware when care planned or in the event of a temporary kitchen need. - Sit next to residents while assisting them to eat. - All residents at a table were served at a time - Wait for residents at a table to finish before clearing the table. - Talk with residents for whom they were providing assistance rather than conducting social conversations with other staff. - Allow residents adequate time to complete their meal. - Speak with residents politely, respectfully, and communicate personal information in a way that maintains confidentiality. - Respond to residents' requests in a timely manner Staff shall treat cognitively impaired residents with dignity and sensitivity: for example: a. Addressing the underlying motives or root causes for behavior; and b. Not challenging or contradicting the resident's beliefs or statements. A facility policy Resident Rights, not dated, documented that the facility would abide by all state and federal regulations pertaining to resident rights. Under the policy section procedure, it was documented that: - Upon admission each resident will be provided with a Your Rights As A Nursing Home Resident booklet, see attached. This booklet could be provided again to any resident at any time during their stay. - Resident Rights were discussed monthly at Resident Council Meetings. - Ombudsman name and contact information is displayed throughout the facility. Resident #2: Resident #2 was admitted to the facility with diabetes, chronic obstructive pulmonary disease, and depression. The Minimum Data Set (an assessment tool) dated 10/09/2024, documented the resident was cognitively intact. The resident was able to make themselves understood and understand others. During an interview on 12/02/2024 at 1:58 PM, Resident #2 stated they received plasticware with their meals 90% of the time. They stated they did not receive an explanation from the facility. Resident #12: Resident #12 was admitted to the facility with diagnoses of diabetes, hypertension, and depression. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and understand others. During an interview on 12/06/2024 at 10:44 AM, Resident #12 stated that sometime last week they received plasticware with their meals. They received plasticware a few times prior to that. They stated it was not as easy to use plasticware as silverware. They did not know the reason for the plasticware. Resident #28: Resident #28 was admitted to the facility with diagnoses of heart failure, generalized muscle weakness, and difficulty walking. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and understood others. During an observation on 12/06/2024 at 10:50 AM, Resident #28 had 4 plastic knives on the bedside table. Resident stated they received plasticware regularly. The stated they did not get metal utensils that often. Stated they were given a metal knife this morning and usually received silverware at breakfast and for lunch and dinner it varied between metal and plastic. Resident #114: Resident #114 was admitted to the facility with diagnoses of dysphagia (difficulty swallowing), generalized muscle weakness, and anemia. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and understand others. During an observation on 12/06/2024 at 10:47 AM, Resident #114 stated they were given plasticware today. A plastic spoon was noted inside of a cup of coffee. Resident #114 stated they occasionally received plasticware and stated, It's not the best. They stated they did not know why they received plasticware. They stated normally they received silverware wrapped in a napkin and when they received plasticware it was a loose spoon or fork. During an interview on 12/10/2024 at 10:43 AM, Registered Nurse #1 stated they were not aware Resident #s 2, 12, 28, and 114 were receiving plasticware. Stated there were couple residents who were care planned for plasticware, but these residents were not. Stated they would have to talk to someone in the kitchen. During an interview on 12/10/2024 at 11:00 AM, Director of Nursing #1, stated there were a couple of residents who received plasticware due to mental health issues. Stated they were not aware of any problems in the kitchen and would not necessarily be made aware of the plasticware being given to residents.

Based on observation and interviews conducted during the recertification survey, the facility did not provide effective housekeeping and maintenance services on 1 of 3 resident units and the building exterior. Specifically, the exterior of the building and walls were not clean. This is evidenced by: During observation on 12/03/2024 at 11:17 AM, the walls beneath the hand sanitizer dispensers attached to the walls outside room #s 366, 374, 337, 387, and by the elevator on unit 3 had multiple streak stains around the dispenser that descended to the baseboard. During observations on 12/04/2024 at 5:29 PM, the walls beneath the hand sanitizer dispensers attached to the walls outside room #s 237, 266, 274, 279, and 287 had multiple streak stains that descended to the baseboard. During observation on 12/09/2024 at 11:35 AM, the walls beneath the hand sanitizer dispensers attached to the walls outside room #s 366, 374, 337, and 387 had multiple streak stains around the dispenser that descended to the baseboard. During observations on 12/09/2024 at 8:15 AM and again on 12/10/2024 at 12:15 PM, the front of the building was soiled and stained with a black build-up and a green mold-like substance around the windows and along the bottom 10-feet of the façade. During an interview on 12/10/2024 at 10:26 AM, Certified Nurse Aide #5 stated the hand sanitizer don't work right, the containers were either empty or the tubing inside got clogged and the gel squirts outside ways and more runs down the wall than ends up in your hand. Housekeepers or staff can fill them if they were empty, but housekeeping should be cleaning the walls. During an interview on 12/10/2024 at 11:13 PM, Housekeeper #2 stated they clean the walls periodically, but they were not done every day. The gel squirts out of the hand sanitizers dispensers and gets on the walls. Housekeeper #2 was ot sure what the plan was to correct that. During an interview on 12/10/2024 at 1:49 PM, Director of Plant Operations #1 stated that the front of the building and walls the coving base would be repaired. 10 New York Codes, Rules, and Regulations 415.5(h)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey, the facility did not ensure pain management was provided to each resident in accordance with professional standards of care for 3 (Resident #'s 22, 25, and 317) of 4 residents reviewed for pain management. Specifically over a two-month period, the facility did not evaluate their existing pain and the cause(s), and managing or preventing pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. This resulted in residents' pain symptoms not being relieved to the extent possible. This is evidenced by: The Policy and Procedure titled, Pain Management, dated 3/17/2018 and last updated 8/2024, documented the resident's pain level was to be checked every shift, and documented in the resident's Medication Administration Record. Pain levels should have been determined using a scale appropriate to the resident's cognitive level and pain medication given as ordered in addition to non-medication interventions. Additionally, the facility policy documented it was the philosophy of this facility that pain management would be available to all residents. Residents who experience pain would be assessed and a treatment plan will be established to allow the resident the ability to function at their highest practicable level. Resident #22 Resident #22 was admitted to the facility with diagnoses which included hypertensive heart and chronic kidney disease with heart failure (a disease of the heart and kidneys causing increased blood pressure and damage to the heart muscle), lymphedema (chronic swelling of the legs caused by excess fluid) and chronic pain syndrome (constant pain). The Minimum Data Set assessment dated [DATE], documented the resident had moderately impaired cognition, could be understood, and understand others. The Comprehensive Care Plan for Pain, last updated on 11/15/2024, documented the resident was to have a pain assessment on admission and every 3 months. The staff were to provide medical management of underlying causes of pain, evaluate effectiveness of the pain medication, encourage family to bring in comforting objects, utilize alternative methods of pain relief such as repositioning, rehabilitation evaluation as needed including physical therapy and monitor for side effects of analgesics, administer pain medications as per orders, observe for pain including nonverbal cues of discomfort, and observe effectiveness of pain control measure if needed. During observations on 12/02/2024 at 10:34 AM and on 12/04/2024 at 5:50PM, Resident #22 was observed seated in their wheelchair, holding the left side of their face and moaning. During an observation on 12/04/2024 at 5:50PM, Resident #22 was observed sitting in their wheelchair in the dining room area of Unit Two (2). Resident #22 was noted to have bilateral leg lymphedema with edematous skin (swelling of the lower extremity)?f ?Resident #22 was observed bending over and rubbing their legs. Resident #22 was observed bending over and rubbing their legs. During an interview on 12/05/2024 at 5:50 PM, Resident #22 stated that they hurt, and referred to their legs. They further stated that their mouth was very painful and could not remember when they had last been given pain medication. A Physician order dated 9/26/2024 documented administer Oxycodone 5 milligrams by mouth three times per day and Oxycodone 5 milligrams by mouth once a day as needed for moderate to severe pain, with maximum daily dose of 4 pills per day. A narcotic administration record dated10/03/2024 at 12:17 PM documented Licensed Practical Nurse #6 removed oxycodone, 5 milligrams from the narcotic pre-filled dispensing card. Record review of narcotic administration records for the following dates and times revealed that in each instance, a nurse removed oxycodone 5 milligrams, and the signature was illegible for: - 10/03/2024 at 8:00 PM. - 11/14/2024 at 8:00 AM. - 11/15/2024 at 8:30 PM. - There was another oxycodone removed on 11/15/2024; in this instance, the time listed as removed was also illegible. - 11/16/2024 at 8:30 AM. - 11/16/2024 at 11:20 AM. - 11/16/2024 at 1:00 PM. - 11/16/2024 at 8:00 PM. - 11/17/2024 at 11:30 AM. - 11/17/2024 at 1:30 PM. - 11/17/2024 at 8:00 PM. - There was an oxycodone removed on 11/17/2024; in this instance, the time listed as removed was also illegible. - 11/21/2024 at 6:30 AM. - 11/21/2024 at 10:50 AM. - 11/21/2024 at 1:30 PM. - 11/21/2024 at 8:00 PM. - 11/26/2024 at 6:00 AM, 10:40 AM, 2:00 PM, and 8:00 PM. - 12/01/2024 at 1:00 PM and 8:00 PM. There was no documented evidence provided by the facility that indicated which nurse names were attributed to the illegible signatures. A narcotic administration record dated 10/08/2024 at 8:30 PM documented oxycodone, 5 milligrams, was removed by Registered Nurse #3. There were no other documented removals of oxycodone from the narcotic pre-filled dispensing card for Resident #22 for 10/08/2024. There was no documented evidence of the narcotic removal accountability sheet for Resident #22 from 10/22/2024 through 10/30/2024. During an interview on 12/06/2024 at 1:00PM, Director of Nursing #1 stated they reported narcotic administration records for the dates of 10/22/2024 through 10/30/2024 missing. Record review of medication administration record entries for the following dates and times revealed that in each instance, Resident #22 received a dose of oxycodone, 5 milligrams; entry did not document the resident's pain level before or after administration: - 10/03/2024 at 8:30 AM, 1:30 PM and 8:30 PM. - 10/08/2024 at 8:30 AM, 1:30 PM and 8:30 PM. - 11/15/2024 documented that Resident #22 received oxycodone at 8:30 PM only. - 11/16/2024 at 8:30 AM, 1:30 PM, and 8:30 PM. - 11/17/2024 at 8:30 AM, 1:30 PM, and 8:30 PM. - 11/21/2024 at 8:30 AM, 1:30 PM, and 8:30 PM. - 11/26/2024 at 8:30 AM, 1:30 PM, and 8:30 PM. The medication administration record dated 11/14/2024 documented that there were no medications administered to Resident #22. The medical provider notes dated 11/25/2024 documented Resident #22's chronic pain and the order for oxycodone 3 times a day for pain control. Record review of nursing progress notes for Resident #22 on 10/03/2024, 11/14/2024, 11/15/2024, 11/21/2024, 11/26/2024, revealed there was no documented evidence that the resident's pain was assessed prior to or after administration of the pain medication to monitor effectiveness. There were no nursing notes between 11/28/2024 and 12/02/2024 indicating pain medication use. Resident #25 Resident #25 was admitted to the facility with diagnoses which included Unspecified nondisplaced fracture of a cervical vertebra (neck fracture), other chronic pain, and congestive heart failure (a condition where the heart does not pump blood as well as it should). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, could be understood, and be understood by others. The Comprehensive Care Plan for Pain, last updated on 11/25/2024, documented the resident goals for pain, were pain assessment on admission and every month, evaluate effectiveness of pain medication, encourage their family /significant other to bring in comforting objects, repositioning as needed, rehab evaluation as needed, and provide pain medications as ordered and evaluate for effectiveness. Physician's order dated 11/22/2024 documented oxycodone 10 milligrams should be administered every 6 hours as needed for moderate/severe pain. Record review of narcotic administration records for the following dates and times revealed that in each instance, a nurse removed oxycodone 10 milligrams, and the signature was illegible for: - 11/01/2024 at an illegible time in the morning, 9:30 AM, 3:30 PM, and 9:45 PM. - 11/02/2024 at 5:00 AM, an illegible time in the morning, 11:30 AM, an illegible time in the evening, and 9:40 PM. - 1/26/2024 at 6:40 AM, 1:30 PM, and 8:00 PM. - 11/28/2024 at 7:00 AM, 1:00 PM, and 5:19 PM. - 11/29/2024 at 8:00 AM, 7:25 PM, and 9:30 PM. - 11/30/2024 at 2:00 AM, 6:48 AM, 11:12 AM, 1:40 PM, and 6:00 PM. - 12/01/2024 at 7:00 AM, 12:00 PM, and 8:00 PM. - 12/03/2024 at 8:52 AM, 3:00 PM, and 8:30 PM. - 12/04/2024 at 8:00 AM, 3:00 PM, and 8:30 PM. The narcotic administration records dated 11/03/2024 to 11/25/2024 for Resident #25 were not available to review. Record review of medication administration record entries for the following dates and times revealed that in each instance, Resident #25 received a dose of oxycodone, 5 milligrams; entry did not document the resident's pain level before or after administration: - 11/01/2024 at 9:32 AM, 3:27 PM, and 9:35 PM. - 11/29/2024 at 7:57 AM, and 7:22 PM. Additionally, the following medication administration record entries did not document the resident's pain level after administration: - 11/02/2024 at 5:23 AM. - 11/26/2024 at 1:12 PM, and 7:32 PM. - 11/28/2024 at 7:30 AM, and 5:14 PM. - 11/30/2024 at 4:05 PM. - 12/01/2024 at 1:28 PM. - 12/03/2024 at 8:46 AM, and 8:15 PM. - 12/04/2024 at 7:00 AM, and 8:24 PM. The nursing note dated 11/26/2024 documented that the resident did not have pain. The nursing note dated 12/04/2024 did not document pain. Resident #317 Resident #317 was admitted to the facility with diagnoses of bilateral primary osteoarthritis of the hip (pain caused by arthritis and bone deterioration in both hip joints), Type II diabetes, and Alzheimer's Disease (a type of dementia that affects memory, thinking, and behavior). The Minimum Data Set, dated [DATE] documented the resident was moderately cognitively impaired, could be usually understood, and understand others. The Comprehensive Care Plan titled Pain dated 11/29/2024 documented Resident #317 had pain related to arthritis, bilateral osteoarthritis of the hips and other vertebral disc degeneration of the lumbar region. Interventions listed included participate in activities of daily living, continue to participate in therapy activities, maintain comfort, encourage family/significant other to bring in comforting objects, utilize alternative methods of pain relief, provide pain medications as ordered and evaluate effectiveness, and provide comfort measures as needed. During an observation on 12/06/2024 at 11:20AM, Resident #317 was observed seated in a wheelchair loudly moaning. Licensed Practical Nurse #2 asked Resident #317 whether they were in pain and Resident #317 stated they were having pain. A record review of medication administration record dated 12/06/2024 documented Resident #22 did not receive their pain medication until 12:59 PM. A physician order dated 11/29/2024 documented to do a pain evaluation every shift using appropriate pain scale, and as needed. A physician order dated 12/07/2024 documented an order for Tramadol 50 milligrams, 1 tablet, by mouth, as needed for pain every 6 hours for bilateral osteoarthritis of the hip. During an interview on 12/02/2024 at 10:43 AM, Resident #25 stated their biggest concern was that the nurses were not consistently giving them pain medications. During an interview on 12/06/2024 at 11:00AM, Licensed Practical Nurse #1 stated the process to administer narcotic medications was first to look at the order in the resident's medication administration record. Licensed Practical Nurse #1 stated they were 'old school' and always checked the resident's pain level before administering medication. During an interview on 12/10/2024 at 9:32AM, Licensed Practical Nurse #3 stated when they administered as-needed narcotics or other types of pain medication, they would look at the last documented administration date and time. Licensed Practical Nurse #3 stated they checked the effectiveness of the last dose of pain medication and then confirmed that the resident was within the right time frame to receive another dose. Licensed Practical Nurse #3 stated they would ask the resident their current level of pain or they would use the facial recognition pain scale to determine the pre-medication pain level. They stated they determined the type of medication to offer resident based on their level of pain. If Tylenol was ordered for the resident, they would offer that first for any pain level under five. Licensed Practical Nurse #3 stated most residents would request the narcotic pain medication be given, even if offered Tylenol first. Licensed Practical Nurse #3 stated they would administer the medication per the resident's orders and then would go back an hour later to recheck effect. They stated the electronic medical record system would send a reminder one hour after administration to document the pain level after medication. Licensed Practical Nurse #3 stated when a medication was missed or a pain level was not checked, the electronic medical record system would turn the medication order to the color red from the color green. They stated it served as a reminder to the nurse that they still needed to document the administration. During an interview on 12/10/2024 at 9:48 AM, Registered Nurse #1 stated when residents experienced pain, they should have been assessed with a pain scale and administered the ordered pain medication within 20-30 minutes of their first request. Registered Nurse #1 stated they were not aware that residents were not receiving medication in a timely manner from the Licensed Practical Nurses. During an interview on 12/10/2024 at 12:10 PM, Registered Nurse #4 stated that they usually asked all the residents that they cared for if they needed anything for pain. They stated they asked Resident #25 if they needed something for pain and gave them a pain medication. They stated not every resident was screened for pain, but staff screened them if they were given pain medications. They stated on a daily basis not everyone who received pain medication was screened for pain, but pain assessments were done quarterly for the Minimum Data Set assessment. 10 New York Codes of Rules and Regulations 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during an abbreviated survey (NY00353512), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's staffing minimum staffing levels were not met each day from 12/02/2024 through 12/10/2024 per facility assessment. This is evidenced by: Upon entrance to the facility on [DATE] there were 118 residents residing on 3 units. The Facility assessment dated 2024 and based on a resident population profile from 7/23/2023 to 7/23/2024 documented, the facility's staffing plan for direct residential care. The assessment documented that the facility strived to have at a maximum for staff the following: Each floor was provided with 2 Licensed Practical Nurses and 5 Certified Nurse Assistants on days (6:00 AM to 2:00 PM), 2 Licensed Practical Nurses and 4 Certified Nurse Assistants on evenings (2:00 PM to 10:00 PM), and 1 Licensed Practical Nurse and 2 Certified Nurse Aides on nights (10:00 M to 6:00 AM) per floor and a Registered Nurse supervisor daily on evening and night shift. On weekends the facility strives to have a Registered Nurse supervisor on days, evenings, and nights. The facility's minimum staff requirements were the following: 1 Licensed Practical Nurse and 2 Certified Nurse Aides on days, 1 Licensed Practical Nurse and 2 Certified Nurse Assistants on evenings, and 1 Licensed Practical Nurse and 1 Certified Nurse Aide on nights per floor and Registered Nurse coverage 8 consecutive hours per day. A review of staffing sheets provided by the facility from 12/03/2024 through 12/10/2024 documented the following: On 12/03/2024 the 3rd floor unit were short 1 Licensed Practical Nurse and 1 Certified Nurse Assistant for the day shift, short 1 Licensed Practical Nurse on evenings, and had no Licensed Practical Nurses scheduled for night shift. The 4th floor was short 1 Licensed Practical Nurse on the day and evening shifts. On 12/04/2024 the 2nd floor unit was short 1 Licensed Practical Nurse on the evening shift. The 3rd floor was short 1 Licensed Practical Nurse on both day and evening shifts and short 1 Certified Nurse Assistant on day shift. The 4th floor was short 1 Licensed Practical Nurse on day and evening shift. On 12/05/2024 the 2nd floor unit was short 1 Licensed Practical Nurse and 1 Certified Nurse Aide on day shift, and 1 Certified Nurse Aide on evening shift. The 3rd floor was short 1 Licensed Practical Nurse and 1 Certified Nurse Aide on the day shift, short 1 Licensed Practical Nurse and 1 Certified Nurse Aides on evening shift and short 1 Licensed Practical Nurse on night shift. The 4th floor was short 1 Licensed Practical Nurse and 1 Certified Nurse Aide on day shift, and 1 Licensed Practical Nurse on evening shift. On 12/06/2024 the 2nd floor unit was short 1 Licensed Practical Nurse and 1 Certified Nurse Aide for day shift, short 2 Licensed Practical Nurses, and 1 Certified Nurse Aide on evening shift and had no Licensed Practical Nurses scheduled for the night shift. The 3rd floor was short 2 Licensed Practical Nurses and 2 Certified Nurse Aides on day shift, short 1 Licensed Practical Nurse, and 1 Certified Nurse Aide on evening and night shift. The 4th floor was short 2 Licensed Practical Nurses and 1 Certified Nurse Aide for day shift, short 2 Licensed Practical Nurses and 1 Certified Nurse Aide on evening shift, and short 1 Licensed Practical Nurse on night shift. On 12/07/2024 the 2nd floor was short 1 Certified Nurse Aide on day, evening, and night shifts. The 3rd floor was short 1 Licensed Practical Nurse, 2 Certified Nurse Aides on day shift, short 1 Licensed Practical Nurse and 1 Certified Nurse Aide on evening shift, and short 1 Licensed Practical Nurse and 1 Certified Nurse Aide on night shift. The 4th floor was short 1 Licensed Practical Nurse and 1 Certified Nurse Aide on day and evening shifts, and short 1 Certified Nurse Aide on night shift. On 12/08/2024 the 2nd floor was short 2 Certified Nurse Aides on the day and evening shifts. The 3rd floor was short 2 Certified Nurse Aides on the day shift, short 1 Licensed Practical Nurse and 2 Certified Nurse Aide on the evening shift and short 1 Certified Nurse Aide on the night shift. The 4th floor was short 1 Licensed Practical Nurse and 1 Certified Nurse Aide on day shift, and short 1 Licensed Practical Nurse and 2 Certified Nurse Aides on the evening shift. On 12/09/2024 the 2nd floor was short 1 Certified Nurse Aide on the day and evening shifts. The 3rd floor was short 2 Certified Nurse Aide on day shift, short 1 Licensed Practical Nurse and 1 Certified Nurse Aide on the evening shift, and short 1 Licensed Practical Nurse and 1 Certified Nurse Aide on the night shift. The 4th floor was short 1 Licensed Practical Nurse on the day shift, short 1 Licensed Practical Nurse, and short 1 Certified Nurse Aide on the evening shift. On 12/10/2024 the 2nd floor was short 1 Certified Nurse Aide on day shift, and short 1 Licensed Practical Nurse on evening shift. The 3rd floor was short 1 Licensed Practical Nurse and 1 Certified Nurse Aide on the day shift, short 1 Licensed Practical Nurse on the evening shift, and short 1 Licensed Practical Nurse on the night shift. The 4th floor was short 1 Licensed Practical Nurse on the day shift, and short 2 Licensed Practical Nurses on the evening shift. During an interview on 12/02/2024 at 11:18 AM, Resident #103 stated that they have had to wait for staff for 10-20 minutes when they were short staffed, but since the resident did a lot on their own, they did not feel it affected them as much as other residents. During an interview on 12/02/2024 at 12:48 PM, Resident #60 stated they did not get up because they had to wait too long. During an interview on 12/02/2024 at 12:59 PM, a resident's family member who wished to remain anonymous stated that staff were very nice, there just were not enough of them. During an interview on 12/06/2024 at 11:00 AM, Nurse Scheduler #1 stated they knew staffing was an issue but thought it was getting better for nurses. The facility had recently hired a couple of nurses. The goal was to have 2 Licensed Practical Nurses per unit on days and evening and 1 Licensed Practical Nurse on nights with 2 Certified Nurse Aides. Certified Nurse Aide numbers had gotten better. Thursday and Friday were rough days because everyone worked every other weekend, so they took the Thursday or Friday off before their weekends off which made bigger holes in staffing. Call ins have always been a problem. They stated 2nd and 4th floor were where they focused their attention because those tended to be the units with the heavier workload. During an interview on 12/10/24 at 9:58 AM, Nurse Scheduler #2 stated that it was the first day that they had a significant problem with staffing. Usually, every Monday the staffing sheets went to the Director of Nursing and the Administrator. The same people were also given staffing sheets whenever there was a change in the staffing. The facility did not want to put Registered Nurses on medication carts but would if the staffing holes required it. Nurse Scheduler #1 stated Director of Nursing #1 had never taken an assignment since they had been there. The unit managers have had to take an assignment when there have been staffing shortages the scheduler could not fix. There were no incentives offered to incentivize the staff to come to work. Shift swaps were done to try and make deals to get the nurses to come in. At the time of the interview, the Nurse Scheduler #1 was calling the next staff to try and get someone to come in and cover the holes for the day but had not yet heard anything. Nurse Scheduler #1 stated that they would turn to agency staff if nothing else was working. During an interview on 12/10/2024 at 12:11 PM, Administrator #1 stated that Unit managers were being educated that they were mini-Directors of Nursing and needed to be responsible for the staff on their units. To increase staff, retain staff already in house and entice new staff to work at the facility, there were frequent raffles. If staffed picked up extra shifts, they got extra [NAME] tickets. There were monetary bonuses for nurses that picked up extra shifts. Swapping of shifts was offered to try and fill staffing needed. Agency staff were also used to complete staffing patterns. The facility also did a lot of employee appreciation events like lunches and pies and turkeys for thanksgiving. The facility had upcoming parties for the holidays along with gifts. Additionally, the facility offered assistance with transportation for the staff for example transportation gift cards were given out. Administrator #1 stated that they try to foster a family environment within the facility and all upper leadership staff knew the floor staff and there were open door policies throughout the building. Administrator #1 stated the facility did not share staff between sister facilities and that roughly 70% of the staff had left and came back because they liked it better at their facility. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

Based on observations, record reviews, and interviews during the recertification survey, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, the facility nursing staff did not document unit narcotics were counted by two licensed staff members and signed as appropriately done on the facility provided narcotic record sheets. This is evidenced by: The Facility assessment dated 2024 and based on a resident population profile from 7/23/2023 to 7/23/2024 documented, Staff Training/competency/skill sets that were necessary to provide the level and types of care needed for the resident population: The facility had a full time Nurse Educator who maintained a list of position- based competencies for nursing staff which was position dependent. An annual education calendar was utilized and included within the supporting documentation section of this facility assessment. See job descriptions for skill sets needed under supporting documentation. See staff training policy in supporting documents. A facility policy titled Facility Training Policy and Procedure, not dated, documented that all new staff received a comprehensive orientation and initial training that covered the facility's policies, procedures, and resident care requirements. Nursing specific education included but was not limited to documentation and medication administration. A facility policy titled Medication Storage dated 3/2023, documented that all medications would be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and is in accordance with Department of Health Guidelines. A facility policy titled Medication Administration dated 6/2024 documented the following: That if a resident refused a medication, re-approach twice more as appropriate. If the resident still refuses the medication/s properly dispose of the medication. Documentation should include refusal, notification of MD at the time of refusal. Notification of Unit Manager/Supervisor and place on the 24-hour report. Additionally, the policy documented the if the medication was dropped or integrity compromised, dispose of medication. Do not to administer medication prepared by someone else Do not prepare medication for another person to administer. Document all medication and treatment administration in the electronic medical record. Narcotic medications were to be signed for in the control drug book at the time they are administered and document administration in the electric Medication Administration Record. Discarded Narcotics required 2 signatures of Licensed Practical Nurse or Registered Nurse staff. Medications were to be administered no more than one-hour before or one hour after the ordered time. If you believe you would be outside the expected time frame notify Registered Nurse Manager/Supervisor, Registered Nurse Manager/Supervisor to notify Medical Doctor of late administration and obtain any new owners if applicable. The medication cart was not to be left unattended and unlocked. Both the controlled substance drawer lock and outer lock are to be locked if cart is unattended. A facility policy titled Facility Training Policy and Procedure, not dated, documented the following: All new staff received a comprehensive orientation and initial training that covers the facility's policies, procedures, and resident care requirements. Nursing specific education included but was not limited to medication administration and documentation. During an observation of the 2nd floor unit on 12/06/2024 at 1:15 PM, the narcotic record book was observed to be on top of the medication cart in the hallway unattended and accessible to anyone in the hallway. Narcotic count sheets required to be signed by two licensed nurses at change of shift were found in the unattended book. Sheets dated throughout October, and November 2024 documented two licensed staff (one from on-coming shift and one from off-going shift) were supposed to be counting narcotic at change of shift but that was not occurring. The second narcotic book on unit 2 was in the medication room locked behind the door. It contained narcotic sheets inconsistently signed from multiple months and shifts in September and November 2024. During an interview on 12/06/2024 at 1:28 PM, Nurse Educator #1 stated that they were unable to explain why the shift-to-shift narcotic count sheets were unsigned or signed incorrectly. It was expected that the licensed staff would do the count together and sign the sheets together. During an interview on 12/06/2024 at 3:42 PM, Administrator #1 stated that they did not know the policy and would need to refer to the policy or ask the Director of Nursing regarding the requirement for counting narcotics at change of shift. Administrator #1 stated that they knew that two nurses needed to do the count, that two nurses need to sign the sheets, knew there were 2 sheets - 1 sheet for the floor count and 1 sheet for individual resident's narcotics. Administrator #1 stated that they knew 2 nurses were needed to waste medications. During an interview on 12/06/2024 at 3:50 PM, Director of Nursing #1 stated that the narcotic count needed to be done at change of shift before keys were handed off. 2 licensed staff members needed to do the count and sign the shift-to-shift narcotic sheet. 1 on coming staff member and 1 outgoing staff member was the expectation of the nurses that count and sign the sheets together. When wasting medication, it was expected that two nurses would sign for the wasted medication. Additionally, it was the expectation that both nurses would observe the wasting of the medication, not just sign the sheets, and let the one licensed staff member dispose of or count any narcotics on the units by themselves. When asked if the rules surrounding narcotics were taught or reviewed with new staff, or if the licensed staff were expected to know because it was part of nursing licensure, Director of Nursing #1 stated that it was reviewed when staff was newly hired and reviewed annually. During an interview on 12/10/2024 at 9:58 AM, Nurse Scheduler #1 stated that the staffing agency that was used to find staff for the facility had a star rating which helped the facility determine if the potential staff member had the competencies and skill required to work there. The star rating of potential staff fluctuated based on the ratings received from previous facilities. Not calling or showing up for a shift would lower a star rating as well as a bad review from previous facilities. The lower the star the less likely the facility would be to employ them through the agency. During an interview on 12/10/2024 at 10:42 AM, Nurse Educator #1 stated that Licensed Practical Nurses and Registered Nurses r received 3 days of orientation training. Medication competencies were part of orientation and were done annually. It was recently reviewed in April 2024. Nurse Managers did annual performance reviews of the licensed staff on the floors. Nurse Educator #1 stated they would not get the performance reviews unless they asked for them. Nurse Educator #1 stated that they went to the floor and watched the staff to make sure things were done according to policy. During an interview on 12/10/2024 at 12:11 PM, Administrator #1 stated that due to the extent of the issues surrounding the narcotic counts and administrations, there was someone checking the licensed staff's narcotic count sheets every shift change to make sure that the counts and sheets were done correctly. Shift supervisors were the first people to check the sheets. After that the sheets would be given to the Assistant Director of Nursing #1 to check. Then Director of Nursing #1 would check all the work to make sure it was correct. Administrator #1 stated that they had not come up with the long-term plan to ensure that staff were doing their job correctly but that the Director of Nursing was going to be very involved. The Unit Managers were being educated that they were essentially mini-Directors of Nursing and needed to be responsible for the staff on their units. Additionally, Administrator #1 stated that the corporate office was going to provide the facility a person that would travel between their facility and one other and be overseeing operations to help get them on track. 10 New York Codes, Rules, and Regulations 415.26(c)(1)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey, the facility did not ensure residents were free of any significant medication errors for 4 (Resident #s 3, 12, 22, and 25) of 30 residents reviewed. Specifically, for Resident #'s 3, 12, 22 and 25, the facility did not ensure accurate medication administration and documentation of Oxycodone (narcotic pain medication). This is evidenced by: The Policy and Procedure titled, Medication Administration, revised 6/2024, documented medications would be administered by a licensed and/or registered nurse. All medications and treatments would be administered and documented using the electronic medical record. Narcotic medications were to be signed for in the control drug book (Control Substance Record) at the time they were administered, and the administration was to be documented in the electronic Medical Administration Record. Discarded Narcotics required two (2) signatures of Licensed Practical Nurse or Registered Nurse staff and Rreview of the electronic Medication Administration Record to ensure all medications were given at the end of the assigned shift. Resident #3 Resident #3 was admitted to the facility with diagnoses of calcific tendonitis (calcium deposits form on the tendons and can cause inflammation and pain) left ankle and foot, pain in right wrist, and chronic pain syndrome. The Minimum Data Set (an assessment tool) dated 10/14/2024, documented the resident was cognitively intact. The resident was able to make themselves understood and understood others. The Care Plan for Pain, updated 10/10/2024, documented calcific tendonitis left ankle and foot, pain in right wrist, and chronic pain syndrome. Interventions documented provide medical management of underlying cause of pain. Physician Order renewed on 11/26/2024 for Oxycodone HCl 10 mg, 1 tablet by mouth PRN (as needed) for left leg pain. PRN (as needed) limit every 6 hours. Review of the a) Control Substance Records and b) electronic Medication Administration Records dated November and December 2024 documented: Control Substance Record for Oxycodone 10 mg tablet, 1 tablet by mouth every 8 hours as needed for pain. Maximum daily dose: 3 tablets. 110/2/2024 a) Oxycodone 10 mg was administered at 8:30 PM. 11/02/2024 b) Medication Administration Record did not document the administration. The Control Substance Records dated 11/03/2024 to 11/16/2024 were not available for review. 11/17/2024 a) Oxycodone 10 mg was administered at 2:30 PM and 9:00 PM. 11/17/2024 b) Medication Administration Record did not document the administrations. 11/18/2024 a) Oxycodone 10 mg was administered at 7:30 AM. 11/18/2024 b) Medication Administration Record did not document the administration. 11/19/2024 a) Oxycodone 10 mg was administered at 2:30 PM and 9:30 PM. 11/19/2024 b) Medication Administration Record did not document the administrations. 11/22/2024 a) Oxycodone 10 mg was administered at 8:00 PM. 11/22/2024 b) Medication Administration Record did not document the administration. 11/23/2024 a) Oxycodone 10 mg was administered at 7:10 AM, an illegible PM time, and 8:00 PM. 11/23/2024 b) Medication Administration Record did not document the administrations. 11/24/2024 a) Oxycodone 10 mg was administered at 6:30 AM. 11/24/2024 b) Medication Administration Record did not document the administration. 11/25/2024 a) Oxycodone 10 mg was administered at 8:30 PM. 11/25/2024 b) Medication Administration Record did not document the administration. 11/28/2024 a) Oxycodone 10 mg was administered at 6:45 AM and 12:30 PM. 11/28/2024 b) Medication Administration Record did not document the administrations. 12/1/2024 a) Oxycodone 10 mg was administered at 8:00 AM. 12/1/2024 b) Medication Administration Record did not document the administration. 12/2/2024 a) Oxycodone 10 mg was administered at 3:30 PM. 12/2/2024 b) Medication Administration Record did not document the administration. 12/3/2024 a) Oxycodone 10 mg was administered at 8:00 PM. 12/3/2024 b) Medication Administration Record did not document the administration. 12/4/2024 a) Oxycodone 10 mg was administered at 7:00 AM and 1:00 PM. 12/4/2024 b) Medication Administration Record did not document the administrations. 12/5/2024 a) Oxycodone 10 mg was administered at 7:00 AM. 12/5/2024 b) Medication Administration Record did not document the administration. 12/6/2024 a) Oxycodone 10 mg was administered at 7:00 AM. 12/6/2024 b) Medication Administration Record did not document the administration. 12/7/2024 a) Oxycodone 10 mg was administered at 7:26 AM. 12/7/2024 b) Medication Administration Record did not document the administration. 12/8/2024 a) Oxycodone 10 mg was administered at 2:00 PM, then at 6:34 AM, and then at 12:40 PM. 12/8/2024 b) Medication Administration Record documented one administration at 11:32 AM. Resident #12 Resident #12 was admitted to the facility with diagnoses of diabetes, arthropathies (joint disease) right shoulder, and weakness. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and understood others. The Care Plan for Pain updated 10/4/2024, documented pain in bilateral shoulders and neck. Interventions documented provide medical management of underlying cause of pain and monitor for side effects of analgesics. Physician Order dated 10/9/2024 for Oxycodone HCl 5 mg, 1 tablet by mouth as needed for shoulder and back pain. PRN (as needed) limit 3 times/day. Review of the a) Control Substance Records and b) electronic Medication Administration Records dated November and December 2024 documented: Control Substance Record for Oxycodone IR (immediate release) 5 mg, 1 tablet by mouth 3 times daily as needed for shoulder/back pain. Maximum daily dose: 3 tablets. 11/5/2024 a) Oxycodone 5 mg was administered at 12:30 AM. 11/5/2024 b) Medication Administration Record did not document the administration. 11/7/2024 a) Oxycodone 5 mg was administered 7:00 AM, 1:00 PM, and 8:00 PM. 11/7/2024 b) Medication Administration Record, documented Oxycodone 5 mg was administered at 7:00 AM and again at 7:00 AM. The 1:00 PM administration was not documented. The 8:00 PM administration was documented at 8:47 PM. 11/9/2024 a) Oxycodone 5 mg was administered at 5:00 AM, 12:30 PM, 6:00 PM, 10:00 PM (4 times) 11/9/2024 b) Medication Administration Record did not document the administrations. 11/14/2024 a) Oxycodone 5 mg was administered at 12:00 PM. 11/14/2024 b) Medication Administration Record did not document the administration. 11/16/2024 a) Oxycodone 5 mg was administered at 7:00 AM, 1:00 PM, and 8:00 PM 11/16/2024 b) Medication Administration Record did not document the administrations. 11/18/2024 a) Oxycodone 5 mg was administered at 12:00 PM. 11/18/2024 b) Medication Administration Record did not document the administration. 11/20/2024 a) Oxycodone 5 mg was administered at 12:00 PM and 7:30 PM. 11/20/2024 b) Medication Administration Record did not document the administrations. 11/21/2024 a) Oxycodone 5 mg was administered at 1:00 PM and 8:00 PM. The 8:00 PM administration had a line through it and error was written next to the amount remaining that had changed from 30 and was 29. There was no documentation to indicate the medication was discarded. 11/21/2024 b) Medication Administration Record did not document the 1:00 PM administration. 11/22/2024 a) Oxycodone 5 mg was administered at 12:00 PM and 8:00 PM. 11/22/2024 b) Medication Administration Record did not document the administrations. 11/23/2024 a) Oxycodone 5 mg was administered at 12:00 PM. 11/23/2024 b) Medication Administration Record did not document the administration. 11/25/2024 a) Oxycodone 5 mg was administered at 12:30 PM and 2:00 PM. 11/25/2024 b) Medication Administration Record did not document the administrations. 11/26/2024 a) Oxycodone 5 mg was administered at 12:00 PM. 11/26/2024 b) Medication Administration Record did not document the administration. 11/27/2024 a) Oxycodone 5 mg was administered at 1:00 PM. 11/27/2024 b) Medication Administration Record did not document the administration. 11/28/2024 a) Oxycodone 5 mg was administered at 12:00 PM. 11/28/2024 b) Medication Administration Record did not document the administration. 11/29/2024 a) Oxycodone 5 mg was administered at 7:30 PM. 11/29/2024 b) Medication Administration Record documented the medication was administered at 4:44 PM. 11/30/2024 a) Oxycodone 5 mg was administered at 5:00 AM, 12:00 PM, and 7:30 PM. 11/30/2024 b) Medication Administration Record did not document the administrations. 12/1/2024 a) Oxycodone 5 mg was administered at 12:00 PM and 8:00 PM. 12/1/2024 b) Medication Administration Record did not document the administrations. 12/2/2024 a) Oxycodone 5 mg was administered at 7:00 AM and 12:00 PM. 12/2/2024 b) Medication Administration Record did not document the administrations. Resident #22 Resident #22 was admitted to the facility with diagnoses of chronic pain syndrome, lymphedema (chronic swelling of the legs caused by excess lymphatic fluid), and dorsalgia (pain in the back or spine) The Minimum Data Set, dated [DATE], documented the resident had moderately impaired cognition, could understand others and be understood. The Care Plan for Pain updated 11/15/2024, documented dorsalgia (back) and chronic pain syndrome. Interventions documented administer pain medications as per orders. Physician order dated 11/15/2024 documented Oxycodone 5 milligrams by mouth three (3) times per day and one (1) as needed dose for pain. Review of the a) Control Substance Records and b) electronic Medication Administration Records dated November and December 2024 documented: Control Substance Record for Oxycodone IR (immediate release) 5 mg, 1 tablet by mouth 3 times daily and 1 tablet as needed. Maximum daily dose: 4 tablets. 11/14/2024 a) Oxycodone 5 mg was administered at 8:00 AM 11/14/2024 b) Medication Administration Record did not document the administration. 11/15/2024 a) Oxycodone 5 mg was administered at 8:30 PM and was documented on the Medication Administration Record at 8:30 PM. - After the 8:30 PM administration, there was another administration dated 11/15/2024 with an illegible AM time. - b) Medication Administration Record did not document the administration. 11/16/2024 a) Oxycodone 5 mg was administered at 11:20 AM. 11/16/2024 b) Medication Administration Record did not document the administration. 11/17/2024 a) Oxycodone 5 mg was administered at 11:30 AM. 11/17/2024 b) Medication Administration Record did not document the administration. 11/21/2024 a) Oxycodone 5 mg was administered at 10:50 AM. 11/21/2024 b) Medication Administration Record did not document the administration. 11/26/2024 a) Oxycodone 5 mg was administered at 10:40 AM. 11/26/2024 b) Medication Administration Record did not document the administration. 12/1/2024 a) Oxycodone 5 mg was administered at 1:00 PM and 8:00 PM. 12/1/2024 b) Medication Administration Record did not document the administrations. Resident #25 Resident #25 was admitted to the facility with diagnoses of unspecified nondisplaced fracture of the fourth cervical vertebra (neck fracture), other chronic pain, and congestive heart failure (a condition where the heart does not pump blood as well as it should). The Minimum Data Set assessment dated [DATE], documented the resident was cognitively intact, could understand others and be understood. The Care Plan for Pain updated 11/27/2024. Interventions documented provide pain medications as ordered and evaluate effectiveness. Physician's order dated 11/22/2024 documented oxycodone 10 mg should be administered every 6 hours as needed for moderate/severe pain. Review of the a) Control Substance Records and b) electronic Medication Administration Records dated November and December 2024 documented: Control Substance Record for Oxycodone IR 10 mg tablet, 1 tablet by mouth every 6 hours as needed for pain. Maximum daily dose: 4 tablets. 11/1/2024 a) Oxycodone 10 mg was administered at 5:00 AM. 11/1/2024 b) Medication Administration Record did not document the administration. 11/2/2024 a) Oxycodone 10 mg was administered 5 times: 5:00 AM, an illegible AM time, 11:30 AM, 4:30 PM, and 9:40 PM. 11/2/2024 b) Medication Administration Record documented one administration at 5:23 AM. The Control Substance Records dated 11/03/2024 to 11/25/2024 were not available to review. 11/26/2024 a) Oxycodone 10 mg was administered at 6:40 AM. 11/26/2024 b) Medication Administration Record did not document the administration. 11/28/2024 a) Oxycodone 10 mg was administered at 7:00 AM and 1:00 PM. 11/28/2024 b) Medication Administration Record documented two administrations, both at 7:30 AM. The record did not document the 1:00 PM administration. 11/29/2024 a) Oxycodone 10 mg was administered at 9:30 PM. 11/29/2024 b) Medication Administration Record did not document the administration. 11/30/2024 a) Oxycodone 10 mg was administered 5 times: 2:00 AM, 6:48 AM, 11:12 AM, 1:40 PM, and 6:00 PM. 11/30/2024 b) Medication Administration Record documented one administration at 4:05 PM. 12/1/2024 a) Oxycodone 10 mg was administered at 7:00 AM, 12:00 PM, and 8:00 PM. 12/1/2024 b) Medication Administration Record documented one administration at 1:28 PM. 12/3/2024 a) Oxycodone 10 mg was administered at 3:00 PM. 12/3/2024 b) Medication Administration Record did not document the administration. 12/4/2024 a) Oxycodone 10 mg was administered at 3:00 PM. 12/4/2024 b) Medication Administration Record did not document the administration. During an interview on 12/06/2024 at 11:00 AM, Licensed Practical Nurse #1 stated the process to administer narcotic medications was first to look at the order in the resident's medication administration record. Licensed Practical Nurse #1 stated they determined whether the medication was as needed or a regular dose. If the medication was a scheduled dose, it would appear in green on the medication administration record as a scheduled medication for that shift. Licensed Practical Nurse #1 stated they were old school and always checked the resident's pain level before administering medication. They stated they would compare the medication administration record order of the resident to the narcotic administration record sheet in the narcotic book on their cart. They would unlock the narcotic box and remove the correct medication. They would pop the pill out of the pill pack and write down the full count of the remaining pills on the narcotic administration record. Licensed Practical Nurse #1 stated they would administer the medication to the resident and then sign the medication administration record. During an interview on 12/09/2024 at 9:17 AM, Registered Nurses #1 and #4 stated they were not aware of a nurse signature sheet. Registered Nurse #1 suggested asking Director of Nursing #1. During an interview on 12/09/24 at 9:19 AM, Director of Nursing #1 stated they did not have a nurse signature sheet. They stated the facility was currently doing signature audits so they could have an updated list. They stated PRN (as needed) Oxycodone was supposed to be documented on the Medication Administration Record. The routine medications would show up on the screen as ready to be given, whereas the PRN (as needed) would still appear on the screen as a medication that was available to be given. They stated they were not aware of any problems with documenting PRNs (as needed) on the Medication Administration Record. During an interview on 12/09/2024 at 12:35 PM, Licensed Practical Nurse #3 stated they never gave Resident #22 Oxycodone on their shift. They stated they worked with Licensed Practical Nurse #7 around 11/15/2024. Licensed Practical Nurse #3 stated it was not their signature on the Control Substance Record dated 11/15/2024, with a time that was illegible. During an interview on 12/09/2024 at 3:16 PM, Licensed Practical Nurse #7 stated it was not their signature on Resident #22's Control Substance Record dated 11/15/2024, with a time that was illegible. They stated they recognized the signature, and it was Registered Nurse #1's. they stated the time looked like 11:20 AM. They stated their process for narcotic pain medication was to do the count first and then get the keys. They check the physician order and then does the 5 checks, several times. They give the medication at the scheduled time. They stated for PRN (as needed) pain medications, they would look to see when the medication was given last and when it was documented. Stated they document on the Medication Administration Record right after they document on the Control Substance Record. Surveyor asked how any other nurse could get the keys to the narcotic box and they stated they would have to get the keys from the medication nurse. During an interview on 12/09/2024 at 4:14 PM, Registered Nurse #1 stated it was not their signature on the Control Substance Record dated 11/15/2024, with a time that was illegible. They stated it looked like Licensed Practical Nurse #3's signature and the time looked like 6:00 AM. During an interview on 12/9/2024 at 4:33 PM, Director of Nursing #1 stated Licensed Practical Nurse #20 worked on 11/15/2024. They stated Resident #22 came back from the hospital late on 11/15/2024. They stated the time on the Control Substance Record for 11/15/2024 was 11:20 PM and was written incorrectly under AM. Review of timecard punches for 11/15/2024, did not document any time punches for Licensed Practical Nurse #20. During an interview on 12/10/2024 at 9:32AM, Licensed Practical Nurse #3 stated when they administer as needed narcotic or other types of pain medication, they always waited for the resident to request the medication. Licensed Practical Nurse #3 stated their process was to look at the last documented administration date and time. Licensed Practical Nurse #3 stated they checked the effectiveness of the last dose of pain medication and then would confirm that the resident was within the right time frame to receive another dose. Licensed Practical Nurse #3 stated they would check the medication order on the Narcotic Administration record (Control Substance Record) located in the narcotic book and the medication order in the electronic medical record system. They would then check the dose and strength against the medication order on the pill pack from pharmacy. Licensed Practical Nurse #3 stated they would ask the resident their current level of pain or they would use the facial recognition pain scale to determine the pre-medication pain level. Licensed Practical Nurse #3 stated they determined the type of medication to offer resident based on their level of pain. If Tylenol was ordered for the resident, they would offer that first for any pain level under five (5). Licensed Practical Nurse #3 stated most residents would request the narcotic pain medication be given, even if offered Tylenol first. Licensed Practical Nurse #3 stated they would administer the medication per the residents' orders and then would go back an hour later to recheck effect. The electronic medical record system would send a reminder in one hour to document the pain level after medication. Licensed Practical Nurse #3 stated when a medication was missed or a pain level was not checked, the electronic medical record system would turn the medication order to red from the color green. They stated this indicated to the nurse they needed to document the administration. The system also allowed the nurse to review the past month of medication administrations to review whether they had any outstanding documentation. They stated the electronic medical record system allowed the nurse to complete a late entry for missed documentation. They stated if the medication administration was missed, they would go to Registered Nurse #1 and notify them of the missed dose. Resident Nurse #1 would call the physician to notify them of the missed dose and then would complete a new order based on the physician's recommendation. Licensed Practical Nurse #3 stated they had only given Resident #22 an extra as needed dose of their Oxycodone 5 milligram pain medication one time on the 11-7 shift. They stated Resident #22 normally does not request more than their scheduled three (3) times per day dose. During an interview on 12/10/2024 at 9:48 AM, Registered Nurse #1 stated they did not know they were responsible for checking the medication administration record for narcotics. They stated they had learned that day there were reports that could be run for when medications were administered and the responsible nurse administering the medication. Registered Nurse #1 stated they had depended on the nurses working each shift to review their medication documentation and complete a narcotic count at the end and beginning of each shift. Registered Nurse #1 stated they were aware there were medications that had not been documented by Licensed Practical Nurses administering medications. They stated these medication administrations should have been documented, and they acknowledged they were responsible to review the medication records and request corrections. They stated the residents had made formal complaints to the previous Director of Nursing they were not receiving their pain medication. Registered Nurse #1 stated they are aware they need to report any suspicious or missed narcotic administrations to the facility administration, or they would call the State Department of Health if the situation ever occurred again. During an interview on 12/10/2024 at 1:32 PM, Licensed Practical Nurse #3 was shown the timecard punches for 11/15/2024, the Controlled Drugs and Narcotics Change of Shift record for 11/15/2024, and the Control Substance Record dated 11/15/2024 for Resident #22. They stated it was not their signature on the records. They said they never gave the resident an oxycodone and stated they would go under oath and swear to it. Surveyor asked how another nurse would get the keys to the narcotic box during their shift and they stated it could have been done on a shift after theirs. They said they took their job seriously and always documented on the Medication Administration Record and on the narcotic sheets when they administered a narcotic. 10 New York Code of Rules and Regulations 415.12(m)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a recertification and complaints survey (NY00349706, NY00352500, NY00353512, and NY00359446), the facility did not ensure it was administered in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 9 (Resident #'s 18, 22, 25, 96, 101, 103, 108, 317, and 319) of 9 residents reviewed. Specifically, for Resident #'s 18, 22, 25, 96, 101, 103, 108, 317, and 319, the facility was unable to provide documented proof of electronic medication administration that could identify the actual time the medication was administered to each resident that would support medication was given as ordered. This was evidenced by: Document requests were given to the facility from 12/5/2024 through 12/10/2024 until time of exit on 12/10/2024 at 4:45 PM for checked marked electronic medications administration records that were time stamped demonstrating the time medication were given throughout the day. No documents with time stamping medication administration was provided to surveyors throughout the survey. A facility document titled Consulting Services dated 11/2016 and last reviewed on 4/2024 documents the following: 1. The Facility Consultant Pharmacists Coordinate Pharmacy policies and procedures within the facility and provide staff development regarding Pharmacy related topics. 2. The Facility Consultant Pharmacist shall review the resident's medication regimen and make appropriate recommendations to improve the overall care within the facility. The Consultant Pharmacist's medication regimen review shall include monitoring for appropriate medication use, clinically significant interactions, and side effects, OBRA compliance (Omnibus Budget Reconciliation Act (law that established federal standards for long term care facilities to improve quality of care for residents), and laboratory review. 3. All recommendations based on irregularities shall be made in writing 4. The facility was responsible to assure that these recommendations were addressed by the appropriate personnel, and that the reports were filed in a retrievable fashion to support compliance with state guidelines regarding Pharmacy Services. 5. The pharmacists will also act as a liaison to facilitate communication between the facility's nursing personnel and dispensing Pharmacy. A facility document titled Medication Administration dated 7/2016 last revised 6/2024 documents the following: 1. Policy: Medications would be administered by a Licensed Professional Nurse or Registered Nurse. All medication would be administered and documented using the electronic medical record. 2. Purpose: to administer medications in a way that ensured the resident's safety and satisfies medical and legal concerns. 3. Procedure: check all residents orders carefully, and administer according to basic rules, (right drug, right dose, right resident, right time, right route). 4. Medications were to be administered no more than 1 hour before and 1 hour after the ordered time. If they believed they would be outside the expected time frame notify the Registered Nurse Supervisor and the Registered Nurse Supervisor will notify the physician. A facility document titled Medication Administration Time Guidelines dated 04/97 last revised 02/2024 documented the following: 1. Times were to be used as a guideline, Consult Registered Nurse as appropriated to change medication administration times. Medical Doctor medication orders may override the times indicated below. a. Every day 0700 to 1200 b. Two times a day 0700 to 1200 and 1600 to 2100 c. 2 times a day diuretics would be administered at 8 am and 4 pm d. Three times a day 0700, 1200, 1900 e. Four times a day 0500, 1000, 1500, 2000 f. Every 4 hours scheduled 0000, 0800, 1200, 1600, and 2000 g. Every 6 hours scheduled 0200, 1000, 1800 h. Every night hours of sleep 1900 to 2300 i. Insulin scheduled as ordered Resident #18 was admitted with diagnoses of Downs Syndrome, paraplegia (paralysis that affect all or part of the trunk, legs, and pelvic organ), and seizure disorders. The Minimum Data Set (an assessment tool) dated 11/20/2024 documented the resident was sometimes understood and could sometimes understands others with severely impaired cognition for daily decision making. Resident #22 was admitted with diagnoses of anemia, heart failure, and peripheral vascular disease. The Minimum Data Set date 11/26/2024 documented the resident was usually understood and could usually understand others with severely impaired cognition for daily decision making. Resident #25 was admitted to the facility with diagnoses of heart failure, chronic obstructive pulmonary disorder and anxiety. The Minimum Data Set, dated [DATE], documented the resident was understood and could understand others with intact cognition for daily decision making. Resident #96 was admitted to the facility with diagnoses which included non-Alzheimer's dementia, atrial fibrillation, and Anxiety. The Minimum Data Set, dated [DATE], documented the resident was understood, and could sometimes understand others with severely impaired cognition for daily decision making. Resident #101 was admitted to the facility with diagnoses which included Non-Alzheimer's Dementia, Coronary Artery Disease, and Anxiety. The Minimum Data Set, dated [DATE], documented the resident was understood, and could usually understand others with severely impaired cognition for daily decision making. Resident #103 was admitted to the facility with diagnoses of chronic venous insufficiency (poor blood flow to extremities), difficulty walking, need for assistance with personal care, and Type 2 diabetes with hyperglycemia (endocrine dysfunction causing high blood sugar and poor insulin production). The Minimum Data Set (an assessment tool) dated 10/03/2024, documented the resident was cognitively intact, able to understand others and be understood. Resident #108 was admitted to the facility with diagnoses which included Non-Alzheimer's Dementia, end-stage renal disease, and anxiety. The Minimum Data Set (an assessment tool) dated 07/18/2024, documented the resident was sometimes understood and could sometimes understand others with severely impaired cognition for daily decision making. Resident #317 was admitted to the facility with diagnoses of bilateral primary osteoarthritis of the hip (pain caused by arthritis and bone deterioration in both hip joints), Type II Diabetes without complications, and Alzheimer's Disease (a type of dementia that affects memory, thinking, and behavior). The Minimum Data Set, dated [DATE] documented the resident had moderately impaired cognition, could be usually understood and understood others. Resident # 319 was admitted to the facility with the diagnoses of cerebral infarction (a blood clot on the brain causing neurological damage), muscle weakness, need for assistance with personal care, and type 2 diabetes (endocrine dysfunction causing high blood sugar and poor insulin production). The Minimum Data Set, dated [DATE], documented the resident's admission information only as the resident was admitted [DATE] and had not been in the facility long enough to have a full Minimum Data Set Assessment completed. During an observation on 12/09/2024 at 9:29 AM, Licensed Practical Nurse #5 was observed administering medications on the 2nd floor Unit and had documented in the record that all morning medication for Resident #22 had been given. The resident was not in the building and had gone out for an appointment. During an interview on 12/09/2024 at 9:45 AM, Licensed Practical Nurse #5 stated they could not allow this surveyor to look at their electronic medication administration computer because they had been told by the Director of Nursing and Administrator that the surveyors had access to all records they would need, and that staff was not allowed to let us review any of the documentation on their computers. Medications that were to be given 2 times a day fell under the administration times of 7:00 AM to 12:00 PM and then 4:00 PM to 9:00 PM. Licensed Practical Nurse #5 stated they did not know what was going on in the building, but they did their job, and they had nothing to with anything other than doing their job. They stated medications were not time stamped, they just get checked off on the electronic record. During an interview on 12/09/2024 at 10:31 AM, the Registered Nurse Unit Manager #1 stated they did not do medication pass. They have a window of time on each shift to pass medications to prevent medication administration from being late. They were not sure how a nurse would know what time a pill had been given or if it was late. That might cause a problem for the next shift if a pill that was twice a day was given late, and the evening nurse gave it early. Administration for most medications, including twice a day, fall into the range of 07:00 AM to 12:00 PM and 4:00 PM to 9:00 PM. If medication was given late in the day the nurse on the next shift should adjust their times, but that could not happen if they were not aware that the medication was given early. They were unaware of any auditing that could be done because the way medications were documented in the record was in a note that did not time stamp the time the medication was given. Nurses should communicate that information to the oncoming nurse. Even with liberal medication administration all nurses should be using nursing judgement. If a medication was 2 times a day, it should be given as directed, knowledge of the medication was required to make sure medication was not given too close together. During an interview on 12/09/2024 at 11:45 AM, Administrator #1 and Director of Nursing #1 stated they were unable to print the electronic medication administration record in a format that would demonstrate the time that the actual medication was given or timestamped. The actual printed form that showed the medications being checked off, that were provided to this surveyor on a document titled Medication /Treatment Variation Report, was Quality Assurance protected. Administrator #1 further stated that if those documents were provided, they needed to be placed in a brown manilla envelope that were clearly marked Quality Assurance protected. During an interview on 12/10/2025 at 10:35 AM, Director of Nursing #1 stated they did not have the records requested for Resident #s 18, 22, and 25 because they had no knowledge of how to print the electronic administration medication records in the format seen by the nurses when administering medications to the resident. The system records the medication as being given in a progress note and does not record the exact time the medication was given. The policy for the liberal administration of medication to residents had been in place when they became Director of Nursing in October of 2024. They were not aware of how an audit could be completed to ensure the medication that required 2 times a day administration was not given to close together because times of administration were not time stamped. During an interview on 12/10/2024 at 10:35 AM, Administrator stated they were unable to provide the electronic medication administration record in any form other than the form that was documented on the formal electronic medical record (computer program for nursing documentation currently used by the facility). They were not knowledgeable on how to print it. The printed medication form documenting medication administration in the monthly and daily check marked format was done by the previous Director of Nursing. They were unable to reach anyone that could access that format. They stated the surveyors had access to all documents that were needed on the program to review all documents. This included review of the medications given to residents. The program did not time stamp any medications given to residents other than PRN (as needed) medications and if the user double clicks on the medication after it has been given it showed the documented time that it was administered. The rest of the medication that was given to a resident, with the liberal times ordered, does not document the exact time the medication was given. Administrator #1 stated the facility could audit whether the medication had been given but not the exact time. 10 New York Code Rules and Regulations 415.26

Based on record review and interviews during an abbreviated survey (Case # NY00295962 and NY00319632), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but not later than two (2) hours after the allegation was made to the State Survey Agency for 2 of 2 qualifying reportable incident and accident investigations. Specifically, when Resident #2 and Resident #3 were observed with injuries of an unknown origin, the facility conducted investigations into the incidents, however, never reported them to the New York State Department of Health. The findings include: The Policy and Procedure titled Abuse, last revised February April 2023, read in pertinent part, that each resident had the right to be free from abuse, corporal punishment, and involuntary seclusion as well as mistreatment, neglect and misappropriation of property. Residents must not be subjected to abuse by anyone including but not limited to facility staff, other residents, consultant, volunteers, staff or other agencies serving the resident, family member or legal guardians, friends or others such as visitors. All employees, volunteers and consultants had an obligation to report resident abuse, mistreatment, or neglect (including misappropriation of property) when they had reasonable cause to believe that such incident had occurred. Allegations of abuse, mistreatment, and neglect from other sources such as family member or other visitors also required further inquiry. Staff were reminded in the policy that they were mandated reporters of abuse, neglect, mistreatment, and misappropriation of property to the New York State Department of Health hotline of any potential concerns. The facility policy informed all employees and volunteers that it was their legal obligation to report actual or suspected instances of resident abuse, mistreatment, or neglect, including injuries of unknown etiology/origin and misappropriation of property. The facility also informed all other personnel providing care in the facility of their obligation to report actual or suspected instances of resident abuse, mistreatment, or neglect, including injuries of unknown cause. Resident #2 Resident #2 was admitted to the facility with diagnoses of unspecified dementia with behavioral disturbance, muscle weakness and age-related osteoporosis with current pathological fracture (fracture caused by weakness of the bone structure that leads to decrease mechanical resistance). The Minimum Data Set (an assessment tool) dated 5/05/2022, documented the resident had severe cognitive impairment, could sometimes be understood and could sometimes understand others. A Nursing Progress Note dated 5/10/2022 documented that Director of Nursing was called to the resident's room by Certified Nurse Aide and Licensed Practical Nurse after it noted by other nursing staff that the resident had bruising to their chest/ shoulder area. The resident was documented to otherwise appeared to be themself. The Nurse Practitioner was to assess the resident and contact the resident's family to discuss the bruising/treatment. Review of the facility's investigation revealed Certified Nurse Aide #2 was interviewed on 5/13/2022 (three days after the injuries were observed). Review of the facility's investigation revealed Certified Nurse Aide #3 was interviewed on 5/19/2022 (nine days after the injuries were observed). The Facility Investigation, initiated 5/10/2022, concluded that the resident did not have any falls that would have contributed to the bruising that was found. Staff statements and notes indicated that the resident's baseline was to be combative when care was being performed. It was also documented, that at times the resident's breasts could get caught in the gait belt due to being care planned not to wear a bra. Progress notes just prior to the observed bruising had also documented that the resident was observed pushing their tray table into themself. The facility determined that bruising was the result of behaviors. The facility investigation documented that the investigation showed no signs/symptoms of abuse, neglect or injury of unknown origin and the timeline of the resident's behaviors being in direct correlation of when the bruises had presented; the interdisciplinary team determined to not report the incident to the New York State Department of Health. Resident #3 Resident #3 was admitted to the facility with diagnoses of unspecified dementia with behavioral disturbance, difficulty walking and retention of urine (when the bladder does not empty completely or at all). The Minimum Data Set (an assessment tool) dated 12/21/2022, documented the resident had severe cognitive impairment, could usually be understood and could sometimes understand others. A Nursing Progress Note, dated 12/24/2022, documented that the resident was observed to have discoloration around their left eye which was of unknown origin. The resident's son was documented to be in visiting in the resident and wanted answers about the injury. A Nursing Progress Note dated 12/24/2022 documented that the resident's son insisted that an X-ray be performed on the resident's eye. The Facility Investigation, undated, documented on 12/24/2024 Resident #3's son had insisted on sending the resident out to the hospital for an X-ray, after the resident was identified to have discoloration around their left eye. The resident was sent out via ambulance as requested and the results indicated no abnormal findings. The investigation documented the resident was observed during an activity in the dining room on 12/22/2022 with the behavior of repeatedly picking up their head and dropping it down onto the table they were seated at. The investigation concluded that after review, it was indicated that less than forty-eight (48) hours prior to the identification of the discoloration around the resident's left eye, that the resident was noted with behaviors that could have caused the injury. The resident was also noted to be prescribed a blood thinning medication (Eliquis). Due to the investigation showing no indications of abuse having occurred, the interdisciplinary team determined to not report the incident to the New York State Department of Health. During an interview on 3/14/2024 at 11:05 AM, Registered Nurse #4 stated that if a resident was found to have an injury of an unknown origin; they would assess the resident and alert the physician, supervisors, and facility administration. They stated the facility would initiate an investigation to determine the cause of injury and rule out possible abuse. They stated that they would assist and participate in conducting interviews of staff on various shifts to determine when and how the injury may have occurred. They stated injuries of unknown origin should be reported to the New York State Department of Health within two hours from the time they were observed. During an interview on 3/14/2024 at 12:20 PM, Registered Nurse #5 stated if a resident was observed with an injury of unknown origin, an investigation would be initiated and interviews of all staff on various shifts who interacted with the resident would be conducted. They stated the resident would be assessed and their physician, emergency contact and facility administration would be notified right away. They stated the incident should be reported right away but no later than two (2) hours from the time the injury was observed to New York State Department of Health or within twenty-four (24) hours if there was no serious injury occurred. They stated facility administration would make the report to the New York State Department of Health. During an interview on 3/14/2024 at 12:26 PM, Director of Nursing #1 stated that if a resident was observed with an injury of unknown origin, an investigation would be initiated immediately to rule out abuse and try to determine how the resident was injured to treat and prevent recurrence. They stated they would complete the investigation and then determine if the facility needed to report the incident to the New York State Department of Health. They stated since they had become the Director of Nursing at the facility, there had not been any incidents of injuries of unknown origin that were determined to be reportable incidents. During an interview on 3/14/2024 at 1:36 PM, Nursing Home Administrator #1 stated if a resident was observed to have an injury of unknown origin; first the resident would be assessed, and staff would ensure the resident was safe and then a statement would be taken from the person reported the injury. They stated they would notify the police if any harm had been caused. They stated they would conduct an investigation to rule out potential abuse. They stated that if their investigation ruled out abuse within two hours, then they would not report the incident to the New York State Department of Health. They stated their belief that injuries of unknown origin could be investigated and then a determination be made on whether to report. The Nursing Home Administrator was unaware of the requirement to report all incidents of injuries of unknown origin. 10 New York Codes, Rules, and Regulations 415.4(4)

Based on record review and interviews during an abbreviated survey (Case #NY00302737), the facility did not ensure that a resident was permitted to return to an available bed in the location in which they previously resided. Specifically, Resident #10 was sent to the hospital on 9/09/2022 for evaluation, and not permitted to return after medically cleared to return back to facility. This is evidenced by: Resident #10 was admitted with diagnoses of unspecified dementia with behavioral disturbance, post-traumatic stress disorder, and Alzheimer's Disease. The Minimum Data Set (an assessment tool) dated 9/01/2022, documented the resident had significant cognitive impairment, could be understood and could sometimes understand others. A facility Policy and Procedure titled Transfer and Discharge Right Policy and Procedure, last revised 6/02/2022, read in pertinent part, that when a resident was transferred or discharged because the resident's needs could not be met at the facility, the resident's physician must document the specific needs the facility could not meet, the facility's attempts to meet the resident's needs, and the services available at the receiving facility to meet the resident's needs. A resident and/or resident representative had the right to appeal their transfer or discharge. If the appeal was required prior to the actual discharge, the facility may not discharge the resident while the appeal was pending unless the discharge was based on imminent danger of the resident or other residents of the facility. The facility must document the danger that failure to transfer or discharge the resident would pose. If a resident, or was applicable, their representative, appealed their discharge while in the hospital, the facility must allow the resident to return pending their appeal, unless there was evident that the facility could not meet the needs to the resident or the resident's return would pose a danger to the health or safety of the resident or others in the facility. A Discharge Summary from a hospital dated 8/29/2022 at 12:30 PM, documented that Resident #10 was brought to the emergency room by the resident's family for aggressive behavior. The summary documented that the resident had been hospitalized since 8/21/2022 and had no violent outbursts while hospitalized , was up and ambulatory in no distress. The resident was documented to be stable and expected to discharge back to their nursing home on 8/29/2022. The facility's discharge notice dated September 9, 2022 with the discharge date of September 9, 2022. The reason cited for discharge was that the safety of others in the facility would be endangered. A nursing note dated 9/01/2022 documented that the resident had a history of violent behaviors toward family and other residents at previous facilities. A nursing note dated 9/09/2022 documented that Resident #10 was self-ambulatory in the hall when they attempted to aggressively go toward another resident in an attempt to strike them. Staff were able to intervene and prevent the resident from reaching the other resident; however, the resident did strike staff and continued to make threats against both staff and residents. The note further documents the facility was not able to provide care for the resident as they were violent, aggressive, and unstable. Medical provider and family made aware that the resident was sent to the hospital. During an interview on 3/12/2024 at 11:45 AM, Nursing Home Administrator #1 stated Resident #10 resided at the facility for 7 days. The resident arrived the Thursday before Labor Day weekend. Administrator #1 stated they were unaware of the resident's violent history when they accepted the resident. The facility did try to medicate Resident #10, however they refused to take medications. They stated the resident was not at the facility long enough to have in the house psychiatrist see them. They stated that under normal situations, the facility would not take someone back from the hospital if the resident could not be managed medically. When asked for the process regarding transferring a resident to another facility, the Administrator stated that social work assisted in the planning for discharge, helped set up services, or helped with a lateral transfer. The facility would never just release a resident without setting them up first. In this case, the facility was unaware of the resident's history and Director of Nursing #1 and staff had reported Resident #10 was too dangerous to be at the facility. During a subsequent interview on 3/14/2024 at 1:37 PM, Nursing Home Administrator #1 stated they were not made aware of Resident #10's behaviors prior to admission to the facility. They stated there was a break-down in the system and they should have made aware of the resident's history of behaviors. They stated the admissions paperwork that was sent documented the resident's history of aggression on the last page submitted. They stated the nurse who approved the resident's admission no longer worked at the facility. They stated Resident #10 went after staff and other residents physically. They stated Resident #10 attempted to strike another resident in the face and staff were able to intervene. They stated the resident said they liked to punch and hit. They stated the facility could not have a staff member with the resident 24 hours per day and did not feel they could continue to intervene and protect other residents. They stated the resident was moved to a private room. They received an order from the physician to administer haldol (an antipsychotic medication) but were unable to administer. They stated the resident continued with physically aggressive behaviors and was sent to hospital. They stated that they would not accept the resident back at the facility because they did not feel it was safe for others if they were to be readmitted . 10 New York Codes, Rules, and Regulations 415.3(h)(4)(iii)

Based on record review and interviews during an abbreviated survey (Case #NY00302737), the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not ensure that a resident was permitted to return to an available bed in the location in which they previously resided. Specifically, Resident #10 was sent to the hospital on 9/09/2022 for evaluation, and not permitted to return after medically cleared to return back to facility. The facility stated they could not provide 1:1 care to the resident upon a readmission from the hospital until such time a safe discharge could be secured. This is evidenced by: Resident #10 was admitted with diagnoses of unspecified dementia with behavioral disturbance, post-traumatic stress disorder, and Alzheimer's Disease. The Minimum Data Set (an assessment tool) dated 9/01/2022, documented the resident had significant cognitive impairment, could be understood and could sometimes understand others. A facility Policy and Procedure titled Transfer and Discharge Right Policy and Procedure, last revised 6/02/2022, read in pertinent part, that when a resident was transferred or discharged because the resident's needs could not be met at the facility, the resident's physician must document the specific needs the facility could not meet, the facility's attempts to meet the resident's needs, and the services available at the receiving facility to meet the resident's needs. A resident and/or resident representative had the right to appeal their transfer or discharge. If the appeal was required prior to the actual discharge, the facility may not discharge the resident while the appeal was pending unless the discharge was based on imminent danger of the resident or other residents of the facility. The facility must document the danger that failure to transfer or discharge the resident would pose. If a resident, or was applicable, their representative, appealed their discharge while in the hospital, the facility must allow the resident to return pending their appeal, unless there was evident that the facility could not meet the needs to the resident or the resident's return would pose a danger to the health or safety of the resident or others in the facility. A Discharge Summary from a hospital dated 8/29/2022 at 12:30 PM, documented that Resident #10 was brought to the emergency room by the resident's family for aggressive behavior. The summary documented that the resident had been hospitalized since 8/21/2022 and had no violent outbursts while hospitalized , was up and ambulatory in no distress. The resident was documented to be stable and expected to discharge back to their nursing home on 8/29/2022. The facility's discharge notice dated September 9, 2022 with the discharge date of September 9, 2022. The reason cited for discharge was that the safety of others in the facility would be endangered. A nursing note dated 9/01/2022 documented that the resident had a history of violent behaviors toward family and other residents at previous facilities. A nursing note dated 9/09/2022 documented that Resident #10 was self-ambulatory in the hall when they attempted to aggressively go toward another resident in an attempt to strike them. Staff were able to intervene and prevent the resident from reaching the other resident; however, the resident did strike staff and continued to make threats against both staff and residents. The note further documents the facility was not able to provide care for the resident as they were violent, aggressive, and unstable. Medical provider and family made aware that the resident was sent to the hospital. During an interview on 3/12/2024 at 11:45 AM, Nursing Home Administrator #1 stated Resident #10 resided at the facility for 7 days. The resident arrived the Thursday before Labor Day weekend. Administrator #1 stated they were unaware of the resident's violent history when they accepted the resident. The facility did try to medicate Resident #10, however they refused to take medications. They stated the resident was not at the facility long enough to have in the house psychiatrist see them. They stated that under normal situations, the facility would not take someone back from the hospital if the resident could not be managed medically. When asked for the process regarding transferring a resident to another facility, the Administrator stated that social work assisted in the planning for discharge, helped set up services, or helped with a lateral transfer. The facility would never just release a resident without setting them up first. In this case, the facility was unaware of the resident's history and Director of Nursing #1 and staff had reported Resident #10 was too dangerous to be at the facility. During a subsequent interview on 3/14/2024 at 1:37 PM, Nursing Home Administrator #1 stated they were not made aware of Resident #10's behaviors prior to admission to the facility. They stated there was a break-down in the system and they should have made aware of the resident's history of behaviors. They stated the admissions paperwork that was sent documented the resident's history of aggression on the last page submitted. They stated the nurse who approved the resident's admission no longer worked at the facility. They stated Resident #10 went after staff and other residents physically. They stated Resident #10 attempted to strike another resident in the face and staff were able to intervene. They stated the resident said they liked to punch and hit. They stated the facility could not have a staff member with the resident 24 hours per day and did not feel they could continue to intervene and protect other residents. They stated the resident was moved to a private room. They received an order from the physician to administer haldol (an antipsychotic medication) but were unable to administer. They stated the resident continued with physically aggressive behaviors and was sent to hospital. They stated that they would not accept the resident back at the facility because they did not feel it was safe for others if they were to be readmitted . 10 New York Codes, Rules, and Regulations 415.3(h)(4)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case # NY00294993), the facility did not provide needed care and services that were resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 1 (Resident #1) of 7 residents reviewed. Specifically, Resident #1 order for urinalysis with culture and sensitivity on 5/02/2022 was not obtained in a timely manner with urine culture obtained on 05/10/2022, and the provider was not notified when staff's attempt to obtain a urine sample was unsuccessful. This is evidenced by: The Policy and Procedure titled, Lab Services Protocol, last revised May 2023, documented Licensed Practical Nurses/ Registered Nurses were to ensure collection of ordered specimens. Any outstanding specimens needed, such as urine or stool, should be reported to the oncoming nurse. If an ordered specimen was not obtained in 2 days, the physician would to be notified for further orders. If nursing was unsuccessful at attempting to obtain specimens that were date specific, notify physician on the date the specimen was to be obtained. Monitor resident for any changes in mental status, change in vital signs such as fever, or hypotension, and acute functional decline while awaiting specimen collection or results and notify physician of any changes. Once a specimen was obtained, the Licensed Nurse were to assure that the results were obtained from the lab within a reasonable amount of time; example given: 3 days for culture results. For all results not received, a follow up call was to be placed to the lab with documentation in the resident's record of the phone conversation and any subsequent follow up with the physician. Nurse managers were to follow up to ensure that the results of all laboratory orders have been followed up on. Resident #1 Resident #1 was admitted to the facility with diagnoses which included spinal stenosis, weakness and need for assistance with personal care. The Minimum Data Set (an assessment tool) dated 3/24/2022 documented the resident could be understood and could understand others, with intact cognition for decisions of daily living. A Medical Services Progress Note dated 4/27/2022 from the Doctorate Nurse Practitioner documented that the resident was seen by the provider and discussion with resident revealed no competent capacity for medical decision making based on cognitive impairment with possible diagnosis of early dementia. A medical decision form was signed. A Nursing Progress Note 4/27/2022 documented the resident had been seen by the Doctorate Nurse Practitioner and was evaluated to lack cognitive capacity. A Nursing Progress Note dated 4/29/2022 documented the resident had a change in ability to communicate and memory. A Medical Services Progress Note, dated 5/02/2022, written by the Doctorate Nurse Practitioner, documented Resident #1 was seen and had presented with new complaint/findings of dysuria (pain with urination) and a cough for 2 to 3 days with associated symptoms of worsening weakness and debility. A urinalysis with culture and sensitivity was ordered to rule out urinary tract infection. A Nursing Progress Note dated 5/04/2022 documented Resident #1 fell on the floor from the commode while staff assisted them. The resident was documented to have complained of burning with urination. A Nursing Progress Note dated 5/06/2022 documented repeated attempts at collecting a urine specimen via straight catheter (insertion into the bladder to obtain urine sample) were unsuccessful due to the resident being incontinent. There was no documentation in the resident record of attempts prior to 05/06/2022 to obtain the urine sample. A Nursing Progress Note dated 5/09/2022 documented the resident had tolerated a straight catheterization for urinalysis with culture and sensitivity. laboratory results dated [DATE] documented the urine culture was obtained on 5/10/2022 and was positive for a urinary tract infection. A Nursing Progress Note dated 5/14/2022 documented the Medical Doctor was notified of the urinalysis with culture and sensitivity results and the resident was started on Bactrim DS twice daily for 3 days. A Physician Order, discontinued on 5/17/2022, ordered Bactrim DS oral tablet 800-160 milligram tablet by mouth from 5/14/2022 to 5/17/2022, twice daily for dysuria (pain with urination). During an interview on 1/29/2024 at 12:55 PM, Director of Nursing #1 stated the following: Resident #1 was observed to have a change in condition on 5/02/2022, their provider was notified. Resident #1 was seen by the Doctorate Nurse Practitioner on 5/02/2022 and a uranalysis with culture and sensitivity was ordered. Per the medical record, nursing staff were unable to obtain a urine sample until 5/09/2022 when a nursing progress note documented that a straight catheterization to obtain a urine sample was well tolerated. Urine sample should typically obtained within 1 to 2 days. The Doctorate Nurse Practitioner saw the resident again on 5/04/2022 and a urine sample had still not been obtained at that time. The first progress note indicating that staff had attempted to collect a urine sample was on 5/06/2022 which documented multiple attempts were unsuccessful, however, did not document when nursing staff had previously attempted to obtain the culture prior to 5/06/2022. Director of Nursing #1 further stated it was their expectation that nursing staff attempt to obtain an ordered urine sample during each shift if previously unsuccessful and document each time they attempted to collect the sample and the outcome. The progress note did not indicate that the Doctorate Nurse Practitioner or attending physician (Medical Doctor) were notified that the nursing staff had been unable to obtain the urine sample. They stated, generally, it should not take that long for a urine sample to be obtained. When a resident had signs or symptoms of a urinary tract infection, nursing staff should notify physician and get an order for a urinalysis. Nursing staff should be documenting each attempt to collect a urine sample and should notify the provider/physician within two days, at the most, if the sample was not able to be obtained. The physician should decide if the resident seemed like they were doing okay based on monitoring of the resident's condition by nursing staff, whether they would have staff continue to try to obtain the urine sample or if a different treatment or course of action was needed. If the resident was becoming increasingly confused; the physician would typically order an antibiotic to prevent the resident from becoming septic (infection of the blood). After the results of the urinalysis determined that the resident had an infection, an antibiotic treatment was ordered. During an interview on 1/30/2024 at 9:50 AM, Doctorate Nurse Practitioner #1 stated the following: they saw Resident #1 on 5/02/2022 and the resident reported pain with urination and presented with a cough. They stated that they ordered a urinalysis with culture and sensitivity be completed to determine if the resident had a urinary tract infection. They stated they saw the resident again on 5/04/2022 and documented the results of the uranalysis were still pending, however, they were unaware that the urine sample had not yet been obtained by nursing staff. They stated that after they wrote an order, the facility would often then follow up with the attending physician instead since they were only in the facility two days per week. They stated they saw the resident again on 5/09/2022 and the resident was still complaining of pain with urination at that time. They stated, upon review of the resident record, a urine specimen was not collected until 5/10/2022. They said the result was received by the attending physician on 5/12/2022 and an antibiotic was ordered to treat a urinary tract infection. They stated they received the results on 5/18/2022 which confirmed that the resident had a urinary tract infection, however, they saw at that time that a treatment had already been ordered for the resident. They stated that the physician should be notified if nursing staff had been unable to obtain a urine specimen. Doctorate Nurse Practitioner stated there were several potential options to treat the resident empirically if there was a delay in obtaining the sample, but it would be dependent on how the resident was presenting which was why a physician should have been consulted. They stated the facility should have monitored the resident and followed up with the attending physician if an ordered urine specimen could not be collected. They stated they could not say or defend why there was no communication/ follow-up when the urine sample was delayed and unable to be collected by nursing staff. They stated they would be concerned for risk of sepsis if an infection was not treated timely; and that facility nurses did not communicate to them that the sample had been delayed when they were in the facility and saw the resident again on 5/09/2022. During an interview on 2/01/2024 at 1:20 PM, Medical Doctor #1 (attending facility physician) stated, upon reviewing the resident's medical record, that they were notified of the positive urine analysis on 5/14/2022 and ordered antibiotic treatment. They stated they did not see documentation that they were informed of any delay in obtaining the urine culture from the resident. They stated it would depend on the resident's symptoms whether a treatment would be ordered prior to a urine analysis result had been obtained. They stated the Doctorate Nurse Practitioner #1 saw the resident on 5/02/2022, 5/04/2022 and 5/09/2022, and if the resident was still complaining of pain and a urine sample had not been obtained, there should have been follow-up. They stated they ordered treatment accordingly when the cultured urinalysis sample test came back positive for a urinary tract infection. They further stated the risk to a resident when a urine sample was delayed would depend on the symptoms the resident was exhibiting during the time. 10 New York Codes, Rules, and Regulations 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey the facility did not ensure treatment with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #55) of 2 residents reviewed for dignity. Specifically, for Resident #55, the facility did not ensure facility staff responded to the residents call light from the time it was turned on at 10:35 AM until 11:20 AM (forty five minutes). Nine staff members were observed walking past the resident's call light during this time period. This was evidenced by: The Policy & Procedure titled Call Lights and dated 06/2021, documented, the purpose of call bells was to respond to residents request for assistance in a timely manner and meet their immediate needs. All nursing personnel must be aware of call lights at all times. All nursing staff is expected to answer all call lights and address the resident's issues even if they are not the resident's primary care giver. Non-nursing staff may also acknowledge that a call light is ringing by entering the room and asking how the resident needs help and then letting nursing staff know of the need. Resident #55: Resident #55 was admitted to the facility with the diagnoses of dementia, depression, and diabetes mellitus. The Minimum Data Set (MDS - an assessment tool) dated 11/19/2021 documented the resident had moderate cognitive impairment, could understand others, and could make self understood. The MDS further documented the resident required extensive assistance with the activities of daily living. During an observation in room [ROOM NUMBER] on 01/13/2022 at 10:53 AM, Resident #55 pushed her call bell button while sitting in their bed talking with the DOH Surveyor. At 11:04 AM, the Surveyor exited the resident room, proceeded to the nursing station across the hall from room [ROOM NUMBER], and observed room [ROOM NUMBER]'s call light above the door illuminated. During the observation the following was observed: - 11:06 AM, the Graduate Nurse Manager (GNM) walked with a visitor, past room [ROOM NUMBER] toward the unit. - 11:07 AM, a dietary staff member walked past room [ROOM NUMBER] carrying a meal tray with empty containers. A Certified Nursing Assistant (CNA) walked past room [ROOM NUMBER] walking toward the exit, entered the next room, took their coat, and left the unit. - 11:08 AM, the Graduate Nurse Manager (GNM) walked past room [ROOM NUMBER] walking toward the unit. An unidentified staff member walked past room [ROOM NUMBER] walking toward the unit. - 11:10 AM, a Licensed Practical Nurse (LPN) walked past room [ROOM NUMBER] toward the exit and stopped at the nursing station. - 11:12 AM, an LPN walked past room [ROOM NUMBER] walking toward the unit. - 11:18 AM, 2 staff members wearing scrub tops walked past room [ROOM NUMBER] toward the unit. - 11:20 AM, an LPN Medication Nurse entered room. During an interview on 01/18/2022 at 11:04 AM, the GNM stated Resident #55 usually calls out and does not push the call bell. There are only two residents on the unit that have the cognition to put the call light on when they need something. The staff will need to get used to Resident #55 and pay more attention to their call light. The GNM was not aware of the call light protocol for the facility. During an interview on 01/18/2022 at 11:24 AM, CNA #2 stated all nursing staff and activity staff should answer call bells. CNA #2 stated It is not OK for a staff member to walk by a call light and not answer it. During an interview on 01/20/2022 at 11:07 AM, Registered Nurse #4 stated all nursing staff are responsible to always answer call lights and acknowledge the residents' needs. If the staff member is not assigned to the resident, they still must answer the call light. Non-nursing staff members should also answer call lights and report the resident's needs to the nursing staff. During an interview on 01/20/2022 at 11:07 AM, the Director of Nursing stated they would expect nursing staff to answer resident call lights. 10NYCRR483.10(a)

Based on observations, interviews and record reviews conducted during the recertification survey, the facility did not ensure prompt efforts were made to resolve a grievance for 1 (Resident #84) of 3 residents reviewed for dental services. Specifically, for Resident #84, the facility did not ensure the facility's process for missing property was followed when the resident's representative reported the facility lost the resident's dentures and that the resident could not eat without them. Additionally, the resident representative was not appropriately apprised of the progress toward a resolution and as of 1/20/2022, Resident #84 had not been seen by the dentist to initiate the process of getting new dentures. This is evidenced by: Resident #84: Resident #84 was admitted to the facility with the diagnoses of cerebral infarction, dementia with behavioral disturbance, and major depressive disorder. The Minimum Data Set (MDS - an assessment tool) dated 12/13/2021, documented the resident was cognitively intact, could understand others and could make self understood. The facility Policy and Procedure (P&P) titled Missing Property (Resident), last revised 6/2021, documented the term missing property is defined as items a resident family member or visitor have reported as being lost or misplaced. Missing property should be immediately reported to the charge person in any department. The staff member receiving the report must initiate a Resident Missing Property Tracking Form or notify someone to do so. The Supervisor/Nurse Manager would be notified and begin the search. The Missing Item Report would be taken to the next interdisciplinary team meeting to determine who would contact the resident and resident representative to report the missing item and the result of the search to determine the expectations and potential replacement. During an interview on 1/13/2022 at 9:51 AM, Resident #84 stated they were missing their full set of dentures and could eat ok most of the time. Resident #84 stated when they were moved from the 2nd floor to the 3rd floor, their dentures did not move with them and the facility was aware their dentures were missing. A Dental Progress Note dated 6/2/2021, documented the resident had dentures and had a full upper and full lower. The Comprehensive Care Plan (CCP) for Dental Care, last revised 11/5/2021, documented the resident was edentulous (lacking teeth) and to provide oral hygiene every shift, monitor evidence of oral pain and/or chewing problems, and to have a dental evaluation yearly and as needed (PRN). The CCP did not include documentation related to dentures. A Nursing Progress Note dated 11/27/2021, by Registered Nurse (RN) #2 documented the family member stated the facility lost the resident's dentures and that was why the resident could not eat. According to the family member, the dentures had been lost for approximately 2 months. The RN documented they spoke with dietary, and the dietary aide would communicate this to their manager. During an interview on 1/20/2022 at 9:43 AM, the Food Service Director (FSD) stated they did not recall getting notified that Resident #84's dentures were missing. The FSD stated when the Dietary Department was made aware dentures were missing, nothing formal was done. The dietary staff would look for the dentures when they were reported missing and if they found the dentures, they would put the dentures on the FSD's desk. During an interview on 1/20/2022 at 9:46 AM, the Director of Social Work (DSW) stated there were no missing property reports for the last 6 months. The DSW stated any staff could fill out a grievance or complaint form or the staff could report it to the Supervisor, and the Supervisor would report it to Social Work or the Unit Manager. The DSW stated even if the resident was not noted to have dentures upon admission, it would still be investigated if dentures were reported missing to determine when the resident had them and if anyone saw that the resident had them. The DSW stated the process of investigating would take place because the dentures could have been brought in on an off shift or could have been brought into the facility without staff being notified. The DSW stated there was not a separate missing property form and a report of missing property would be documented on a grievance form. During an interview on 1/20/2022 at 10:21 AM, RN #1, the Nurse Manager of the 3rd floor, stated they recalled the situation when the resident representative called RN #2 and told RN #2 the resident's dentures were missing. RN #1 stated they should have followed up on it but did not. The RN stated they took it for granted that the resident representative had it taken care of it since they had not recently heard about the missing dentures. RN #1 stated the resident had not said anything about their missing dentures but stated this was bound to come up again since the resident was eating more now. The resident used to be a tube feed and did not eat by mouth, but now the resident eats by mouth. RN #1 stated they would now find out how to get the resident new dentures. During an interview on 1/20/2022 at 10:35 AM, RN #2 stated they were working as the Evening Supervisor when the resident's representative called stating the facility lost the resident's dentures 2 months ago. RN #2 stated they called dietary and then they passed it on to RN #1, the Nurse Manager. RN #2 wrote a note and spoke with the staff on the unit. The staff reported to RN #2, the resident had a habit of putting things in the sheets, so the dentures probably want to laundry. The RN did not notify laundry because laundry was not in the building at the time. The RN stated they did not fill out any form when the dentures were reported missing. The RN stated they did not know a form existed to fill out for missing property and passed on it on the Unit Manager and then left it at that. During an interview on 1/20/2022 at 12:07 PM, the Director of Nursing (DON) stated when missing property was reported an investigation was started. The DON stated a report may or may not have been filled out at the time because the Supervisor probably thought they covered their bases. The DON stated when an investigation was started, the person initiating the investigation should check with all the departments, do a room and unit search, and once it was determined they could not find the missing item, the facility would work to rectify the problem and replace it. In this case, the facility would work to get the resident new dentures which would mean getting the dentist involved. The DON stated missing property forms were used in the facility and stated they would look for a missing property report regarding the resident's missing dentures. On 1/20/2022 at 2:26 PM, the DON provided an investigation summary dated 11/29/2021, and stated the Administrator had completed an investigation on the missing dentures. The summary documented it was reported by RN #2 that they had a conversation with Resident #84's representative regarding missing dentures. The summary documented dietary, housekeeping, and unit sweeps were done, which did not result in locating the missing dentures. The summary also documented it was best to refer the resident to the dentist to initiate the process of getting the resident new dentures. The summary did not document the resident or resident representative were notified of the investigation or provided with a response to their report of missing dentures. As of 1/20/2022, the resident had not been seen by the dentist to start the process for getting new dentures. During a subsequent interview on 1/20/2022 at 3:13 PM, RN #2 stated they were not involved in the investigation and had not reported the missing dentures to the DON or the Administrator. They only reported the missing dentures to the Unit Manager. When shown the investigative summary for the missing dentures that was provided by the DON and completed by the Administrator, RN #2 stated they had never seen that investigation before. RN #2 stated they did not fill out a missing property report because they did not know the forms existed. During an interview on 1/20/2022 at 3:29 PM, the Administrator stated RN #2 had not reported the missing dentures to them. The Administrator stated they saw the progress note RN #2 had documented and started their own investigation. The Administrator did not involve RN #1 or RN #2 in the investigation. The Administrator did not complete a missing item report and stated they probably should have. The Administrator stated the facility still used missing property reports but did not provide the survey team with any missing reports over the last 6 months because the facility did not have any to provide. The Administrator stated they did not get back to the resident representative with a response to the investigation regarding the missing dentures. The Administrator stated the resident's nursing assessment did not document the resident came in with dentures, but the report of the missing dentures would still be investigated. During a subsequent interview on 1/21/2022 at 9:05 AM, the Administrator stated the facility was having issues with the dentist. The Administrator stated ideally, the resident should have been seen by the dentist. The dentist was coming today, because the Administrator realized yesterday that everyone on the dental list had not been seen, including Resident #84. 10NYCRR 415.3(c)(1)(ii)

Based on observation, record review and interview during the recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #84) of 3 residents reviewed for ADLs. Specifically, for Resident #84, who was dependent on staff for ADL care, the facility did not ensure the resident's fingernails were cleaned and trimmed in accordance with the resident's preference and comprehensive care plan. This is evidenced by: Resident #84: Resident #84 was admitted to the facility with the diagnoses of cerebral infarction, dementia with behavioral disturbance, and major depressive disorder. The Minimum Data Set (MDS - an assessment tool) dated 12/13/2021, documented the resident was cognitively intact, could understand others and could make self understood. The Policy and Procedure titled Resident Nail Care dated 5/2021, documented resident nail care was to be done weekly with their scheduled shower, may be done sooner if indicated. The Certified Nursing Assistant completing the resident's shower was to check the resident's nails and provide nail care as needed and tolerated by the resident. Nails that were dirty, long, jagged and/or sharp etc. were to have nail care. Nail care was to be documented in the electronic medical record (EMR) under personal hygiene. The Comprehensive Care Plan (CCP) for ADL Function, last reviewed 11/5/2021, documented to monitor the cleaning and condition of nails according to neighbor's (resident's) ability. A review of CNA documentation for Nail Care from 1/1/2022 to 1/19/2022 documented the resident received nail care 2 times; once on 1/11/2022 and once on 1/13/2022. The facility provided an undated statement to note that residents were offered nail care during activities sessions where manicures were scheduled, and this was documented within the activity log; however, the facility did not provide an activity log for Resident #84. During an observation and interview on 1/13/2022 at 9:46 AM, Resident #84 stated the staff did not clean or cut their fingernails. The resident's fingernails on their right hand were long and had a dark substance under the fingernails. Resident #84 stated they normally kept their fingernail short as that was their preference. The resident stated they were able to maintain their fingernails on their left hand using their right hand, but they were unable to move their left side so they could not use their left hand to maintain to their fingernails on their right hand. The resident's fingernails on the left hand were short and clean. The resident stated they used their right hand to pick the long fingernails off his left hand and stated they would rather have them clipped but the staff did not do it. The resident stated they had asked staff to cut their fingernails, but staff tell him They don't do that. During an observation on 1/14/2022 at 9:04 AM, Resident #84's right hand fingernails were long and had a dark substance underneath them. During an observation and interview on 1/18/22 at 12:13 PM, Resident #84's right hand fingernails were long and had a dark substance underneath them. The resident stated he wanted the fingernails cut and cleaned, but none of the staff had done it. The resident stated they sometimes ate with their fingers and preferred to have clean nails when eating. During observation and interview on 01/19/2022 at 08:20 AM, Registered Nurse (RN) #1 looked at Resident #84's fingernails with the Surveyor in the resident's room, and stated they saw that the resident's fingernails on the right hand were long and not clean and had a dark substance underneath them. RN #1 stated Activities typically did the resident's finger nails. The RN asked Resident #84 if the resident had asked the CNAs to cut their fingers nails and the resident stated, yes, they had but the CNAs responded, they don't do that. The RN stated Resident #84 was not diabetic so the CNAs could cut their nails. RN #1 stated the CNAs should provide nail care, clean and trim, in addition to the Activities staff. Resident #84 stated to the RN and Surveyor that they did not care who did their nails as long as they were done. During an interview on 1/19/2022 at 9:26 AM, Licensed Practical Nurse (LPN) #1 stated if the resident was not diabetic, it was the responsibility of the CNAs to clean and trim the residents' fingernails. The LPN stated resident fingernails should be cared for daily if they were soiled and cut/trimmed weekly. LPN #1 stated there was not a process to keep an eye on nail care. The LPN stated if the LPNs noticed something while passing medications, then they would say something to the staff, but other than that, there was not a process for monitoring nail care. During an interview on 1/19/2022 at 9:35 AM, Temporary Nurse Aide (TNA) #2 stated they did daily nail care, but residents who were diabetic had their nails done by the nurse. The TNA stated they trimmed and cleaned resident nails daily and documented in the medical record yes or no under Nail Care if nail care was provided. During an interview on 1/19/2022 at 11:10 AM, TNA #1 stated resident nail care was provided weekly with bed baths or showers. The TNA stated that the CNA's trimmed the residents' nails and TNAs cleaned the nails weekly. The TNA stated nail care was documented in the medical record under Nail Care and the staff had to document yes or no for whether nail care was provided. The TNA stated if resident nails were dirty, they would clean them daily or as needed when they noticed they were dirty, but they had not had to do that nail care yet. During an interview on 1/19/2022 at 2:13 PM, the Director of Nursing (DON) stated resident nails were trimmed and cleaned every week or every other week, typically on shower day and Activities also did manicures. The DON stated nail care may or may not be documented in the medical record. It may be documented under personal hygiene/care and may not necessarily be documented under Nail Care. The DON stated they had Care Observation Audits that included nail care, and the Unit Managers did the audits monthly. The DON stated the CNAs documented nail care and the monthly observation audits were how they monitored personal care and nail care. The DON stated Resident #84 was able to trim their own nails on their left hand. The DON stated the resident ate with their hand sometimes, so food could get in the fingernails right after they were cleaned and stated the nails could be cleaned one day and then the next day, they would be dirty again. When discussing observations made regarding Resident #84's fingernails on the right hand for 4 days with the DON, the DON stated, nail care was signed for around 1/13/2022. During a subsequent interview on 1/20/2022 at 10:45 AM, RN #1, the Unit Manager on the 3rd Floor, stated they cut and cleaned Resident #84's fingernails and stated stuff was at the tips. Resident #84 ate with their hand, so it did not surprise the RN that the resident's nails had stuff under them because they were so long. The RN stated the staff should wash the residents hands as part of morning hygiene and when they noticed a resident's nails were dirty. Resident nails are cut weekly with showers. The RN stated they had heard talk about environmental observation rounds, but as the Unit Manager, they did not do the audits themself on the residents. RN #1 stated the CNAs should have noticed Resident #84's nails were dirty during morning care or when providing the resident with a meal. The RN stated nails got overlooked but should not be. 10NYCRR415.12(a)(3)

Based on record review and interviews during the recertification survey, the facility did not ensure residents diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 1 (Resident #19) of 2 residents reviewed for dementia care. Specifically, the facility did not ensure that person-centered care plans with individualized interventions that included and supported the residents' dementia care needs were developed. This is evidenced by: Resident #19: Resident #19 was admitted to the facility with the diagnoses of Parkinson's disease, dementia, and hypertension. The Minimum Data Set (MDS-an assessment tool) dated 10/15/2021, documented the resident had severe cognitive impairment and was sometimes able to make self understood and understand others. The Policy & Procedure titled Dementia & Memory Care-Clinical Protocol last reviewed 6/2021, documented for the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. The comprehensive care plan (CCP) titled Cognitive loss/Dementia dated 12/7/2021 documented, severely impaired never/rarely made decisions. Approaches included, assess resident's level of involvement, social work intervention as needed, provide support/reassurance, medical/nursing intervention as appropriate, anticipate needs, counseling as needed, and address in slow quiet manner. The care plan did not include interventions specific to the resident and did not address customary routines, preferences, or choices to enhance the resident's well-being related to their cognitive status. Review of the CCPs on 01/14/2022 did not include a care plan that addressed dementia associated behaviors and interventions. The CCP titled Activities dated 4/3/2021 documented; limited activity participation, new admission, cognitive deficits, and sensory deficit. The resident loved listening to Opera music, cats, going outside weather permitting and found strength in their Christian beliefs. Approaches included place calendar in resident's room, explore resident's past for activity suggestions, provide activity tools/materials for independent activity, respect right to refuse. The care plan did not specify what activity tools would be provided or include interventions specific to the resident preferences or choices with activities to enhance the resident's well-being related to their cognitive status. During an interview on 01/14/2022 at 02:19 PM, the Director of Social Work (DSW) stated the facility has a Dementia Cafe Program where they do lots of activities. The DSW was not sure what they do during the program, they thought music was p[layed for the group. Each discipline do their own care plans, then they are reviewed and revised with the Interdisciplinary Team (IDT) and the family if they are present during the care conference meeting. Dementia education included Oasis (person-centered dementia care training) when new staff start at the facility. Human Resources does the education. The Social Work (SW) role in dementia care was, if a resident was having a hard time and needed redirection SW would intervene. SW would sometimes call families for help. During an interview on 01/18/2022 at 10:38 AM, the Graduate Nurse Manager (GNM) stated Resident #19 needs a minute to comprehend what is said to them, if this is not done the resident will stiffen up. The GNM stated that when speaking with the resident staff need to use a lower tone, or the resident will try to hit from sensory overload. These interventions should be in the care plan. During an interview on 01/20/2022 at 11:16 AM, the Director of Nursing stated the facility provided OASIS education on hire and yearly. The education covers person centered resident care. Resident #19's care plan is lacking, the care plan for dementia and psychosocial need to be more individualized. 10NYCRR415.12

Based on record review and interview during a recertification survey, the facility did not ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days, unless the attending physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, they should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #71) of 6 residents reviewed for unnecessary medications. Specifically, for Resident #71, the facility did not ensure a PRN lorazepam (Ativan- antianxiety medication) was not ordered for more than 14 days without a documented rationale and duration from the attending physician or prescribing practitioner. This is evidenced by: Resident #71: Resident #71 was admitted to the facility with the diagnoses of dysphagia, anxiety disorder and dementia with behavioral disturbance. The Minimum Data Set (MDS - an assessment tool) dated 12/7/2021 documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The Policy and Procedure titled Psychoactive Medication Protocol dated 10/2021, documented PRN orders for psychotropic medications, excluding antipsychotics must be time limited to 14 days. Orders may be extended beyond 14 days if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days. Such rationale must be documented in the medical record and indicate the duration for PRN order. The Comprehensive Care Plan (CCP) for the Use of Psychotropic Drugs, last revised 1/18/2022, documented the resident was at risk for drug related effects: Cognitive impairment and behavioral impairment. Interventions included to approach calmly, maintain calm environment, report any exacerbation of behaviors to the MD/NP and to monitor for side effects and adverse reactions and report to MD/NP. A Physician Order dated 10/15/2021, documented lorazepam (Ativan) injection 2 MG (milligrams)/ML (milliliters), 0.5 ml(s)/cc(s) (cubic centimeter), IM (intramuscular injection), PRN (as needed): aggression, PRN limit every 6 hours related to unspecified dementia with behavioral disturbance. The order was discontinued on 11/18/2021 (34-day duration). A Physician Order dated 11/29/2021, documented lorazepam injection 2 MG/ML, 0.5 ml(s)/cc(s), IM, PRN: aggression, PRN limit once per day related to unspecified dementia with behavioral disturbance. The order was discontinued on 1/13/2022 (45-day duration). The facility provider notes dated: -11/14/2021, documented the resident had anxiety and to continue current medications. -11/18/2021, documented the resident had been having more behaviors including combative and agitated toward staff and other residents. Most recently on 11/15/2021, the resident required Ativan 1 mg at time of agitation. In the past, the resident had required up to 4mg IM Ativan to control behavior. Ativan increased to 2 mg TID (three times a day) on 11/15/2021 and nursing reports that the resident had been calm on that dose and not behavioral. -11/19/2021, documented the resident had been having more behaviors including combative and agitated toward staff and other residents. Most recently on 11/15/2021, the resident required Ativan 1 mg at time of agitation. In the past, the resident had required up to 4mg IM Ativan to control behavior. Ativan increased to 2 mg TID (three times a day) on 11/15/2021 and nursing reports that the resident had been calm on that dose and not behavioral. Will re-assess dose and need to continue tomorrow. -11/30/2021, documented the resident was seen on 11/29/2021 due to reports of increased behaviors on that day. Stat dose of Ativan ordered which it does not appear the resident received. The resident reported received a pneumococcal vaccine prior to behaviors starting. Behaviors might have been triggered by receiving vaccine. The resident was back to their baseline today. -12/12/2021, documented the resident had dementia with behavioral problems and anxiety and to continue lorazepam. -12/23/2021, documented the resident had persistent behaviors and was unable to complete recent cancer treatment due to agitation. Nursing reported the resident had agitation today. The medical record did not include documentation of a clinical justification and duration by the attending physician or prescribing practitioner for continuing the PRN lorazepam orders for more than 14 days. During an interview on 1/19/2022 at 10:54 AM, Graduate Nurse (GN) #1 they were now aware of the regulation for the limit of 14 days for PRN psychotropic medications. The GN stated at the 14-day limit, they would have to go to the provider to re-evaluate the resident for the need of the PRN. The GN stated the Nurse Practitioner (NP) was the provider who typically reviewed and re-evaluated for the need to continue the 14-day PRNs. The GN stated now limit the PRN orders to 14 days. The GN the PRN order would have been continuous if you did not make it limited to 14-days in the computer system with a stop date. The physician orders dated 10/15/2021 and 11/29/2021 for the PRN lorazepam were reviewed with the GN. The GN stated the resident was on scheduled lorazepam and those orders were for the PRN. The GN stated they must have put the orders in and not picked a stop date for the PRN. During an interview on 1/19/2022 at 1:56 PM, Director of Nursing (DON) stated PRN psychotropics should have automatically had a 14 day stop. The unit managers communicated with the provider whether to extend the PRN past the 14 days. The NP was very involved with Resident #71's treatment plan. The DON stated they understood the psychotropic PRN medications were to have a rationale to extend past 14 days and a duration indicated if it were to extend past 14 days. The DON stated it seemed like the computer system did not prompt the 14 days stop for the order, but stated the NP was very involved and saw the resident. DON stated they would look for the rationale and the duration in the provider documentation. During a subsequent interview on 01/20/2022 at 12:04 PM, the DON stated scoured the provider notes and the notes do not indicate a duration for the continued use of the PRN Ativan. The DON stated other than the NP knowing they were using it, there was no duration for the extended use. During an interview on 1/21/2022 at 9:01 AM, the Administrator stated they were not aware of that specific PRN order for Resident #71. The Administrator stated the pharmacist consultant sent the facility a review and then they reviewed what the consultant pharmacist sent Gradual Dose Reduction (GDR) meeting where the Medical Director was present. The Administrator stated they were aware PRN psychotropic medications were limited to 14-days and should not be longer than 14-days without rationale and duration. 10NYCRR 415.12(1)(2)(ii)

Based on observation and interview during a recertification survey, the facility did not maintain an infection prevention and control program (IPCP) to prevent the development and transmission of disease and infection for 1 (3rd floor) of 3 units observed for dining. Specifically, the facility did not ensure staff assisted residents on the 3rd floor with hand hygiene before meals. This is evidenced by: The facility Policy and Procedure titled Infection Control Program Manual dated 9/2021, documented standard precautions for infection control were used for the care of all residents regardless of their diagnoses or presumed infection status. Hands were washed after touching blood, body fluids, secretions, excretions, and contaminated items. During an observation on 1/14/2022 at 9:04 AM, breakfast trays were being passed to residents on the 3rd floor. The staff were not observed assisting residents with hand hygiene. During an observation and interview on 1/18/2022 from 12:00 PM to 12:13 PM, meal trays were being passed to residents in the back hallway on the 3rd floor. Staff did not offer to wash the residents' hands prior to the resident's eating lunch. Resident #84 was provided thier lunch tray by staff at 12:06 PM. At 12:13 PM, the resident's fingernails on the right hand were observed to be long and dirty. Resident #84 stated staff did not wash their hands before eating and their fingers nails on right hand were long and dirty. The resident stated they sometimes ate with their fingers depending on the food they received. Resident #84 had not yet used their hands to eat during this observation. During an observation on 1/19/2022 at 11:47 AM, the meal cart arrived to the 3rd floor. The staff were not observed assisting residents with hand hygiene prior to the residents receiving their lunch trays. During an interview on 1/19/2022 at 11:57 AM, Resident #62 stated staff did not wash their hands before meals. Resident #62 stated they had difficulty walking to the bathroom to wash their hands, so they wished staff would assist them with washing their hands. During an interview on 1/20/2022 at 10:11 AM, Certified Nursing Assistant (CNA) #1 stated the residents should have their hands washed before meals. CNA #1 stated they sometimes used hand sanitizer or used a soapy washcloth to wash the residents' hands. CNA #1 stated staff tried to wash the hands of resident's who need help washing their hands. During an interview on 1/20/2022 at 10:12 AM, Temporary Nurse Aide (TNA) #2 stated performing hand hygiene on residents before meals was not perfect and a lot of residents had hand sanitizer in their room that they were able to use themselves. The TNA stated the staff encouraged the residents to hand sanitize before eating. The TNA stated hand hygiene did not always happen, but the staff tried to help those resident who could not do it themselves. During an interview on 1/20/2022 at 10:51 AM, Registered Nurse (RN) #1 stated the staff were supposed to offer and provide hand hygiene before each meal to the residents who could not wash their own hands. RN #1 stated they did not complete audits for resident hand washing. During the interview, the RN got up from their desk and located hand wipes in their office. RN #1 stated the staff could use those hand wipes to wash the resident hands before meals. RN #1 stated Resident #83 ate with their right hand and their hand should be cleaned before the meals, and after if they were dirty. During an interview on 1/20/2022 at 12:17 PM, the Director of Nursing (DON) stated the staff should be doing hand hygiene on residents who could not do it themselves. The DON stated the staff should offer Resident #84 hand hygiene and provide it if the resident accepted. The DON stated the facility had tubs and packages of hand wipes for the staff to use. The CNAs should be using the wipes to wash the residents' hands. 10NYCRR415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, the facility did not ensure that on 3 of 3 resident units' walls and floors were clean and/or in good repair. This is evidenced as follows: During observations on 01/14/22 at 10:30AM, the bathroom in resident room [ROOM NUMBER], the right foot-peddle to the bed pan washer was laying on the floor under the sink, and the floor was heavily soiled with dirt and a brown build-up. During observations on 01/14/22 at 12:45 PM and on 01/19/22 at 9:15 AM, walls were scraped or had unpainted spackling in resident room #'s 258, 366, 379, 443, 437, 456, 474, 483, and #489 and the 3rd floor common area. The floors were soiled with dirt or food debris in resident room #'s 437, 456, and #489. During an interview on 01/14/22 at 10:50AM and again on 01/18/2022 at 3:30 PM, the Director of Plant Operations stated maintenance was not aware of and did not have a work order regarding the broken foot-peddle in resident room [ROOM NUMBER]. During an interview 01/21/2022 at 10:43 AM, the Administrator stated that the facility is aware of all scrapes and areas requiring patching and painting and will have the resident rooms noted cleaned. The process of in-house repairs and in hiring a contractor to do the repair work has been slowed due to the COVID outbreak. 483.10(i)(3) 10 NYCRR 415.5(h)(4)

Based on observation, manufacturer's directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the automatic dishwashing machine final rinse was not sanitizing, the concentration of quaternary ammonium compound (QAC) utilized to manually sanitize food contact equipment was less than that required by the manufacturer, and 3 of 3 kitchenettes required cleaning and repairs. This is evidenced as follows: The main kitchen and resident unit kitchenettes were inspected on 01/13/22 at 09:30 AM. The concentration of sanitizing chemical in the final rinse of the automatic dishwashing machine final rinse was zero (0) parts per million (ppm) of available chlorine. The label directions on the sanitizing chemical concentrate state the concentration in the final rinse is to be between 50 ppm and 100 ppm of available chlorine. The concentration of QAC used to sanitize food contact equipment in the 3-compartment sink was found to be zero (0) ppm when measured at 67 degrees Fahrenheit (F). The manufacturer's label directions stated the concentration is to be between 200 ppm and 400 ppm when the solution is measured between 65F and 75F. On the resident unit kitchenettes, the microwave ovens and cabinetry were soiled with food particles or dried drip marks, and cabinetry doors were loose and would not close and seat. The sink on the second-floor kitchenette was soiled with black mold around the drain. During an interview on 01/13/22 at 10:14 AM, the Food Service Manager stated the booster heater for the dishwashing machine was not on and that having a chemical sanitizer for the dishwashing machine is a backup, the cleaning and maintenance items in the kitchenettes will be addressed, and the QAC pre-mix at the sink faucet should have been perfect as it serviced last week. During an interview on 01/13/22 at 02:44 PM, the Administrator stated that dietary should be cleaning the kitchenettes, maintenance will be contacted about the repairing the cabinetry, and staff should be checking the concentration of chemical sanitizer in the dishwashing machine and 3-compartment sink. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110, 14-1.112

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure an ongoing program to support residents in their choice of activities for 3 (Resident #'s 25, 77, and #87) of 3 residents reviewed for activities. Specifically, the facility did not ensure residents were provided, an ongoing program to support them in their choice of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, based on the comprehensive assessment, care plan and preferences of the resident. The findings are: Resident #25: The resident was admitted to the facility on [DATE], with diagnoses of dementia, depression, and anxiety disorder. The Minimum Data Set (MDS - an assessment tool) dated 7/25/19, documented the resident had severe cognitive impairment. The Comprehensive Care Plan (CCP) for Activities, last updated on 10/4/19, documented the resident was to be encouraged to attend group activities 4 times per month, respond positively to 1:1 visits 4 times per week, and socialize with staff during 1:1 visits 4 times per week. Activity Progress Notes documented; 10/04/19 - Resident accepts 1:1 visits, staff encouraged to ask if resident will join activities on unit. 07/12/19 - No changes in leisure preferences since last note on 4/3/19. 04/03/19 - Continues to show anxiety but gets distracted when she does activities. She likes to do crafts such as paint and color, enjoys music programs, parties, and getting her nails done every week or every other week. Staff will continue to encourage participation in on and off unit activities. The Resident's Activity Log in the Electronic Medical Record (EMR) for June 30 through October 18, 2019 documented the resident attended the following activities; 06/30/19 - 1:1 time. 08/01/19 - Bingo. 09/26/19 - Music entertainment, walking, storytelling, bible study, social activity, and Bingo (all documented before noon). During an interview on 10/22/19 at 9:59 AM, the Social Worker, temporarily in charge of activities, stated she would review the activity log to determine if a resident was meeting their activity goals. Upon review of this resident's activity log she stated, it appears this resident is not attending much, and she could not explain why there were 6 activities documented to have been attended by the resident in the morning of 9/26/19, stating that it must be a mistake. She further stated she has been trying to add more activities on the dementia unit, but it has been challenging. Resident #77: The resident was admitted to the facility on [DATE], with diagnoses of dementia, anxiety disorder, and major depressive disorder. The MDS dated [DATE], documented the resident had severe cognitive impairment. She could usually be understood and could usually understand others. During observations made on 10/16/19, 10/17/18, 10/18/19, 10/21/19, and 10/22/19, 10-15 residents were always sitting in the common area, unengaged by staff and sleeping, or just sitting. The television was on, but the residents did not show interest in it. The TV lounge had 3-4 residents watching TV when observed on those dates. Resident #77 was not observed participating in any activities during any of these observations. The CCP for Activities updated on 8/14/19, documented the resident would attend art therapy twice a week, accept 1 to 1 activity visits twice a week, and socialize with staff during 1 to 1 visits twice a week. The resident's Activity Log dated August 2019, documented the resident received a 1 to 1 visit on 8/13/19. The Log did not include documentation that the resident received staff 1 to 1 visits or art therapy. The resident's Activity Log dated September 2019, did not include documentation that the resident received 1 to 1 visits from activities, participated in staff 1 to 1 visits, or art therapy. The resident's Activity Log dated October 2019, documented the resident participated in crafts on 10/22/19 at 9:45 AM. There was no other documented activity for the month of October in the electronic medical record. The Recreation Progress Note dated 8/29/19 at 11:31 AM, written by an Activities Aide, documented the resident responded well to 1 to 1 visits. The Recreation Progress Note dated 10/4/19 at 2:19 PM, written by an Activities Aide, documented the resident enjoyed 1 to 1 visits. During an interview on 10/22/19 at 8:49 AM, the Activities Aide stated if a resident refused an activity, it would be documented in the computer on the Activity Log. During an interview on 10/22/19 at 9:10 AM, Certified Nursing Assistant (CNA) #1 stated there had not been many activities in the building lately. She was not sure why; maybe they were short of help. During an interview on 10/22/19 at 9:17 AM, CNA #2 stated the residents did not go to many activities. Sometimes the Activities Department would take one or two residents downstairs to an activity. The activity aides did not come to the unit very often. The residents mainly sat in the common area all day and went back to bed after lunch. She stated she did not like the fact the residents just sat there. It would be good for them to get off the unit for a music program- a change of scenery for them. Resident #87: The resident was admitted to the facility on [DATE], with diagnoses of dementia, depression, and anxiety disorder. The Minimum Data Set (MDS - an assessment tool) dated 8/30/19, documented the resident had severe cognitive impairment. The Comprehensive Care Plan for Activities, last updated on 10/4/19, documented the resident loves to join activities such as bingo, musical events, and arts and crafts, with a goal of attending group programs on and off unit 3 times per month and will accept 1:1 visits 2 times per week. The Resident's Activity Log in the Electronic Medical Record (EMR) documented on 9/22/19 at 10:00 AM, that the resident attended bible study and cooking club, and at 2:00 PM attended cooking club. The facility Activities Calendar documented at 10:00 AM - Devotions and at 3:00 PM - pumpkin pie bars. The Resident's Activity Log in the EMR documented on 9/21/19 at 10:00 AM, that the resident attended cooking club. The facility Activities Calendar did not include documentation of cooking activities scheduled for 9/21/19. The Resident's Activity Log in the EMR documented on 9/13/19 at 11:00 AM, that the resident attended music entertainment and at 10:00 AM - cooking club. The facility Activities Calendar documented that a senior picnic was the only activity offered for the day. During an interview on 10/22/19 at 9:59 AM, the Social Worker, temporarily in charge of Activities stated, it appears some of the activities were documented in error and she would have to review with the staff how and when they should be documenting. 10NYCRR 415.5(f)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview during the recertification survey, the facility did not ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 (Resident # 90) of 1 resident reviewed for dialysis. Specifically, the facility did not ensure there was resident-specific communication between the dialysis center and the facility. This was evidenced by: Resident #90: The resident was admitted to the facility on [DATE], with a diagnosis of end stage renal disease, dependence on renal dialysis and diabetes. The Minimum Data Set (MDS - an assessment tool) documented the resident was cognitively intact and is able to make self-understood and can understand others. A review of the policy titled Dialysis Care and Management of Residents on Dialysis dated 7/2019, documented to maintain communication with dialysis. A licensed nurse is to review the communication book upon the residents return to the facility and dialysis is to be called by the nurse for any missing communication such as, pre and post dialysis weights, vital signs, medications or antibiotics given, dressing change information and any notes or recommendations. A Doctors Order dated 9/4/19, documented dialysis on Monday, Wednesday and Friday. A review of the resident's dialysis communication book containing the forms titled Dialysis Communication Tool did not document the residents post dialysis communication for 7 out of 19 dialysis treatments from 9/6/19, to 10/18/19. Review of the nursing progress notes did not include documentation that nursing staff called for the post dialysis communication for the above 7 days. During an interview on 10/21/19 at 11:03 AM, Registered Nurse Manager #1 stated she is aware of the dialysis policy. When a resident comes back from dialysis with missing information the nursing staff should have called dialysis to gather the residents missing information. There is no way to know if the nurse looked at the dialysis book when the resident returned from dialysis. Review of the medical record did not include documentation of any calls to dialysis for missing communication. During an interview on 10/22/19 at 11:00 AM, the Director Of Nursing stated the Dialysis Center does not always fill out the communication sheet and she was not aware the Dialysis Policy documented that nursing call dialysis for missing communication. Sometimes the transportation driver or the resident will give the nurse a report. 10NYCRR415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during a recertification survey, the facility did not develop and implement, or provide the resident and their representative with a summary of the baseline care plan for 8 (Resident #'s 3, 37, 40, 55, 65, 67, 90 and #219) of 12 residents reviewed. Specifically: for Resident #'s 3 and 55, the facility did not ensure summaries of the baseline care plans were provided to the resident and the resident's representative; and for Resident #65, the facility did not ensure development and implementation of a baseline care plan. This is evidenced by: The Policy and Procedure (P&P) titled Care Planning, MDS (Minimum Data Set) assessment and MDS Interviews dated 7/2019, stated a baseline care plan is initiated upon 48 hours of admission and a summary of the resident's baseline care plan will be provided to the resident and their representative. Resident #3: The resident was admitted to the facility on [DATE], with diagnoses of dementia, hypertension, and chronic obstructive pulmonary disease. The Minimum Data Set (MDS - an assessment tool) dated 7/1/19, documented the resident had severely impaired cognition, could usually understand others and could usually make herself understood. During an interview on 10/18/19 at 08:02 AM, Registered Nurse Manager (RNM) #1 stated the 48-hour baseline care plans are completed by the Admissions/Discharge Registered Nurse (ADRN) at admission. During an interview on 10/18/19 at 1:30 PM, ADRN #2 stated the baseline care plan was developed/implemented for Resident #3 at admission, and a written summary of the baseline care plan was not documented or provided to the resident and/or their representative. ADRN #2 stated she has never given a summary of the baseline care plan to residents and/or the residents representatives. During an interview on 10/18/19 at 1:45 PM, the Director of Nursing (DON) stated a summary of the baseline care plan is supposed to be given. Resident #55: The resident was admitted to the facility on [DATE], with diagnoses of dementia, depression and congestive heart failure. The Minimum Data Set (MDS - an assessment tool) dated 8/7/19, documented the resident had severe cognitive impairment. The Baseline Care Plan Summary scanned into the Electronic Medical Record was signed by a Registered Nurse on 2/3/19. The signature lines for the resident and resident representative were blank. During an interview on 10/18/19 at 1:30 PM, ADRN #2 stated she has never given a summary of the baseline care plan to residents and/or the residents representatives. Resident #65: The resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of hemiplegia (muscle weakness or partial paralysis on one side of the body) that affected the right side, pressure ulcer stage 4 (a deep wound that may expose muscle, tendons and bones), and dementia. The MDS dated [DATE], documented the resident had severe cognitive impairment, could sometimes be understood and could sometimes understand others. The admission Nurse's Note dated 7/23/19 at 6:18 PM, written by the ADRN, did not contain documentation that the base line care plan was completed or given to the resident and/or representative. The Quarterly Care Plan meeting notes dated 7/24/19 at 2:45 PM, did not include documentation that the resident and/or representative were provided with the base line care plan summary. During an interview on 10/18/19 at 1:32 PM, the ADRN stated she did the baseline care plans when she admitted residents. After she interviewed the resident and/or their representative about the resident's goals, diet, activity preferences, and medications, she wrote the baseline care plan. Following the interview, she completed the baseline care plan form with the information gathered. The resident's and representative names were on the form and the admitting nurse signed it. In her initial nursing note, she documented that the plan of care was reviewed with family. She stated residents or their representatives had not been given a paper summary of the baseline care plans and that a baseline care plan was not completed for Resident #65. The baseline care plan was supposed to be scanned into the electronic medical record after completion. During an interview on 10/18/19 at 1:49 PM, the DON stated the baseline care plan procedure was that the ADRN start the care plan with the resident and/or their representative at the time of admission. The resident/representative is supposed to be given a copy of the baseline care plan. 10NYCRR 415.11