Based on record review and staff interview conducted during the Recertification survey from 01/14/2025 to 01/22/2025, the facility did not ensure that residents' personal funds in excess of $50, for residents whose care was funded by Medicaid, and in general resident funds in excess of $100 were placed in an interest-bearing account. This was evident for 2 (Resident #59 and Resident #56) of 2 resident reviewed for Personal Funds out of 39 sampled residents. Specifically, the Resident Funds Ledgers for Resident #59 and Resident #56 did not reflect that interest was earned and deposited into the accounts. The finding includes but is not limited to: The facility policy and procedure titled Policy and Procedure Residents Funds with revision date of 06/10/2024 states that interest will be posted monthly to all residents receiving it. 1. The Resident Funds Ledgers dated 01/01/2024 to 09/30/2024 for Resident #59 documented an opening balance of $376.19 and closing balance of $539.12. The statements did not reflect interest earned or deposited. 2. The Resident Funds Ledgers dated 01/01/2024 to 06/12/2024 for Resident #56 documented an opening balance of $1105.70 and closing balance of $105.84. The statements did not reflect interest earned or deposited. On 01/22/2025 at 03:49 PM, an interview was conducted with the Chief Financial Officer who stated that their accounts were closed by the previous institution that the facility banked with in 2023. The Chief Financial Officer also stated that the current institution the facility is banking with does not provide interest bearing accounts, so the resident's funds have not accrued interest since that time. On 01/22/2025 at 03:51 PM, the Administrator was interviewed and stated that they were not aware that resident funds were not being maintained in an interest-bearing account as that issue would be handled by the finance office. 10 NYCRR 415.26(h)(5)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey from 01/14/2025 to 1/22/2025, the facility did not ensure an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident. This was evident for 1 (Resident #42) of 1 resident reviewed for Activities out of 37 total sampled residents. Specifically, Resident #42 who had severely impaired cognition, was observed for extended periods of time without meaningful activities, and there was no activity plan to provide activities to the resident while in the dining room. The findings are: The facility policy and procedure titled Therapeutic Recreation Dementia Program reviewed 10/2024 stated it is the policy of the Recreation department to provide group and individual programs that will meet the psychosocial needs of residents with dementia and allow residents to achieve standard quality of life. The policy also stated that the Recreation department will modify the content of programs to allow for successful participation, regardless of the level of cognition/functional improvement. Resident #42 had diagnoses which included Dementia and Major Depressive Disorder. The Annual Minimum Data Set assessment dated [DATE] documented Resident #42 had severely impaired cognition. The assessment also documented in Section F Preferences for Customary Routine and Activities that the family indicated that for Resident #42 it was very important to listen to music you like, be around pets, do favorite activities, and participate in religious services or practices, and it was somewhat important to keep up with the news, do things with groups of people, and go outside for fresh air. The Comprehensive Care Plan titled Activities-Language Barrier effective 2/9/2021 and reviewed 1/2/2025 documented a goal of Resident #42 will show signs of pleasure or enjoyment as they attend day room group programs 2-3 times a week by recreation. Provide non-verbal cueing and gestures to comprehend the programs directions secondary to English being their second language. Provide books, music, movies/television show in language of preference. The Recreation Quarterly note dated 1/2/2025 documented Resident #42 engages in facilitated small group activities and enjoys listening to Spanish music and looking through magazines. On 01/14/2025 from 10:00 AM to 12:30 PM, Resident #42 was observed sitting in their wheelchair in the corner of the dining room nodding off to sleep and not engaged in any activities. There was no 1:1 or group activity being provided for Resident #42, and there were no magazines, puzzles, books, or Spanish music provided. Resident #42 was sitting with their back turned away from the television that was showing an English language local news program. On 01/15/2025 from 10:00 AM to 12:45 PM, and on 01/22/2025 from 10:00 AM to 12:30 PM Resident #42 was observed sitting in their wheelchair, in the same area in the corner of the dining room nodding off to sleep and not engaged in any activities. Resident #42 was sitting with their back turned away from the television that was playing an English language talk show. Resident #42 was not provided with any books or magazines. The Facility Recreation Calendar dated 1/1/2025 to 1/31/2025 did not include any activity program scheduled to occur on the 6th floor. The calendar documented the following: 1/14/2024: Tuesday: Catholic Service 1st Floor. 2:00 PM Sip & Paint, 1st Floor. 1/15/2025: Wednesday: Strolling Music 1st Floor. 2:30 [NAME] King Jr. Celebration 1st Floor. 1/22/2025: Wednesday: Strolling Music 1st Floor. 2:30 Happy Hour 1st Floor. There was no documented evidence that 1:1 room or unit visits were provided to Resident #42 as indicated in the Comprehensive Care Plan. There was no documented evidence that Resident #42 was provided with an activity program that supported their physical, mental, and psychosocial wellbeing or met their preference for Spanish music, or being provided books and magazines. On 01/22/2025 at 12:18 PM, the Director of Recreation was interviewed and stated that Resident #42 is provided with magazines, books, and 1:1 visits are provided for residents who prefer not to attend a group setting and that are unable to participate in group settings. Activities are provided in smaller group setting 1-3 times a week during the morning from 9:30 AM to 12 PM and in the afternoon from 1:15 PM to 4:45 PM. The Director of Recreation also stated that leaders create the care plan, and the Director of Recreation follows up to make sure that the care plan is being followed. The Director of Recreation further stated that Resident #42 declines to be in a group setting programing as is documented on the Statsheet for Recreational Programs which is used to decide which residents will receive 1:1 visits. The Director of Recreation stated that they go into the resident's rooms and make sure that they have enough books and magazines. The Director of Recreation also stated that the facility does not provide any electronics such as iPads and if a resident needs any activity materials such as a radio or speakers, the resident can get the items if they have money in their account. If the resident cannot buy activity materials, then the family is contacted. The Director of Recreation further stated that if the resident has no money and no family, the facility will provide a radio and speaker for a brief period, and this is done on a case-by-case basis if the resident is able to operate the devices. 10 NYCRR 415.5(f)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview conducted during the Recertification survey, from 01/14/2025 to 01/22/2025, the facility did not ensure that a resident that needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. This was evident for 1 (Resident #138) of 3 residents reviewed for Respiratory Care out of a sample of 37 residents. Specifically, Resident #138 did not receive continuous oxygen as per physician orders. The finding is: The facility Policy and procedure titled Oxygen Therapy dated 06/17/24 stated that all residents shall receive oxygen therapy when necessary and in accordance with physician's orders. The policy also stated that nursing staff will set up check and supervise all treatments. Resident #138 was initially admitted to the facility with diagnoses that included Chronic Respiratory Failure, Tracheostomy Status and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #138 was moderately cognitively impaired and was receiving Oxygen Therapy. The Physician orders dated 12/04/2024 documented Oxygen device-Trach Collar-HME (Heat Moisture Exchange) at 30 percent, Rate: 5-6 Liters per minute-Continuous. The Comprehensive Care Plan for Respiratory/Tracheostomy dated 04/20/24 documented administer humidified oxygen as ordered. On 01/14/2025 at 11:22 AM, Resident #138 was observed in bed receiving humidified oxygen at 8 liters via tracheostomy collar to oxygen concentrator. On 01/14/2025 at 01:04 PM, 01/15/25 at 08:22 AM, and 01/15/2025 at 12:13 PM Resident #138 was observed awake in bed, receiving humidified oxygen at 8 liters via tracheostomy collar to oxygen concentrator. On 01/15/2025 at 12:13 PM, Licensed Practical Nurse #1 was interviewed and stated that they increased the oxygen rate to 8 liters because it had been on 4 liters and that this was an incorrect rate. Licensed Practical Nurse #1 also stated that when Resident #138 is suctioned their oxygen saturation percentage is in the low 90's and that the oxygen rate will be increased a liter more. Licensed Practical Nurse #1 reviewed the physicians orders and stated that they believed that the rate had been changed from 4 liters to 8 liters. Licensed Practical Nurse #1 further stated that they should always check the medical orders to ensure oxygen rate is correctly administered On 01/17/2025 at 11:00 AM, the Director of Nursing was interviewed and stated that the expectation of nurses is that they follow the medical orders before providing treatments and or medications to ensure correct dosages or oxygen liters are administered correctly. On 01/22/2025 at 09:26 AM, Attending Physician #1 stated that the order for administering oxygen at 5- 6 liters is a standard range, especially if the resident is being suctioned and their oxygen saturation goes down. Attending Physician #1 also stated that a resident can receive either 5 or 6 liters depending on the vital signs and nurse discretion at the time. Attending Physician #1 further stated if there is a change in respiratory status they would be notified by the nurse and the resident would be assessed. 10 NYCRR 415.12(k)(6) Based on observations, record review and interview conducted during the recertification survey, it was determined that for one (# 138) of three residents reviewed for Respiratory Care, the facility did not provide care consistent with professional standards of practice. Specifically, Specifically, the resident did not receive continuous oxygen as per physician orders. Facility Policy and procedure titled, Oxygen Therapy, dated 06/17/24 documented, All residents shall receive oxygen therapy when necessary and in accordance with physician's orders, . nursing staff will set up check and supervise all treatments. The finding is: Resident #138 was initially admitted to the facility on [DATE], with a most recent re-entry date on 12/04/2024 from acute hospital. The Minimum Data Set assessment dated [DATE] documented a brief interview of mental status score of 10. Diagnoses included but not limited to Chronic Respiratory Failure, Tracheostomy Status and Chronic Obstructive Pulmonary Disease. Respiratory treatments included Oxygen Therapy. Physician orders dated 12/04/2024, documented, Oxygen device-Trache Collar-HME (Heat Moisture Exchange) at 30 percent, Rate: 5 - 6 Liters per minute-Continuous. The Comprehensive Care Plan for Respiratory / Tracheostomy dated 04/20/24 documented, administer humidified oxygen as ordered. Observation on 01/14/25 at 11:22 AM found the resident in bed eyes receiving humidified oxygen at 8 liters via tracheostomy collar to oxygen concentrator. Observation on 01/14/25 at 01:04 PM found the resident awake in bed, receiving humidified oxygen at 8 liters via tracheostomy collar to oxygen concentrator. Observations on 01/15/25 at 08:22 AM found the resident awake in bed, receiving humidified oxygen at 8 liters via tracheostomy collar to oxygen concentrator. On 01/15/25 at 12:13 PM found the resident awake in bed, receiving humidified oxygen at 8 liters via tracheostomy collar to oxygen concentrator On 01/15/25 at 12:13 PM, the Licensed Practical Nurse # 1 was interviewed and stated that they increased the oxygen rate to 8 liters because it had been on 4 liters and that this was an incorrect rate. Further stating that when the resident is suctioned their oxygen saturation percentage is in the low 90's and that the oxygen rate will be increased a liter more. The State Agency together with Licensed Practical Nurse # 1 checked the physicians orders. Licensed Practical Nurse # 1 stated that they believe that the rate had changed fro 4 liters to 8 liters, but no evidence was provided. Licensed Practical Nurse # 1 stated that they should always check the medical orders to ensure oxygen rate is correctly administered. By checking orders prior to care and treatments ensures safe resident care. On 01/17/25 at 11:00 AM the Director of Nursing stated that the expectation of my nurses is that they follow Medical Orders before providing treatments and or medications to ensure correct dosages or oxygen liters are administered correctly. On 01/22/25 at 09:26 AM the Medical Doctor # 1 stated that his order for administering oxygen at 5 - 6 liters is a standard range, especially if the resident is being suctioned and their oxygen saturation goes down. The resident can receive either 5 or 6 liters depending on the vitals signs and nurse discretion at the time. If there is a change in respiratory status the nurse will notify me and I will assess the resident. 10 NYCRR 415.12(k)(6)]

Based on observations and interviews conducted during the Recertification survey from 01/14/2025 to 01/22/2025, the facility did not ensure that garbage and refuse were disposed of properly. Specifically, the garbage was not properly contained outside of the facility and various types of garbage were observed overflowing around the dumpster. The finding is: The facility policy and procedure titled Waste and Garbage Removal dated 12//05/2024 documented that all garbage is placed in a 35-yard compactor, door closed, and power button pressed. The policy also documented that all cardboard is broken down flat and placed in 7.5 yards dumpster. On 01/16/2025 at 11:50 AM, Dietary Aide #1 was observed taking garbage from the kitchen to the garbage disposal area. The compactor was observed with the door open and two clear garbage bags blocking the opening of the compactor. In addition, there were 14 to 16 large garbage bags on the ground in front of the dumpster. There was litter strewn behind the dumpster including discarded gloves, cardboard and cans behind the dumpster. There was another dumpster that contained flattened cardboard, and there were 6 large clear plastic bags containing flattened cardboard on the ground in front of that dumpster. Dietary Aide #1 added the large bag garbage from the kitchen to the compactor, removed gloves, returned the garbage can to the kitchen and performed hand hygiene. Dietary Aide #1 did not close the compactor door after discarding garbage. On 01/17/2025 at 9:45 AM and 2:45 PM, the compactor door was observed opened. On 01/21/2025 at 08:40 AM, the compactor door was observed opened. Several large black bags were observed in a large, uncovered blue laundry bin in front of the compactor. On 01/21/2025 at 09:34 AM, Dietary Aide #3 was observed removing garbage from the kitchen to the garbage disposal area. Dietary Aide #3 placed the garbage bag in the compactor, activated the compactor button and returned to the kitchen. Several large black bags were still observed in a large, uncovered blue laundry bin in front of the compactor. Dietary Aide #3 did not close the compactor door before returning to the kitchen. Dietary Aide #3 was interviewed immediately and stated that they are supposed to close the door to the compactor, but they forgot to do it today. On 01/21/2025 at 09:51 AM, an interview was conducted with the Director of Nutrition who stated that when they observed the compactor overflowing on 01/16/2025 they immediately brought it to the attention of the Administrator and a pickup was scheduled for the next the next day. The Director of Nutrition also stated that they did not know the schedule for compactor pick-up as that is handled by maintenance. The Director of Nutrition further stated that the compactor is supposed to be closed as soon as the garbage is put into it and the persons using the compactor are responsible for keeping it closed to prevent the animals from getting to it. On 01/21/2025 at 09:56 AM, the Director of Maintenance was interviewed and stated that the facility has 35-yard compactor for garbage, a 4-yard individual compactor, and a 15-yard compactor for recycling and the compactor has never been filled to capacity. The Director of Maintenance also stated that the compactor is picked up 3 times a month, and that they were not informed that the compactor was overflowing last week. The Director of Maintenance further stated that from experience the compactor is not full, but it is just that staff does not activate the compactor button to compress the garbage probably due to it being cold outside and them rushing to get back inside. The Director of Maintenance stated that proper disposal of garbage is the responsibility of the kitchen and housekeeping staff, and they did not know why the laundry bin was stored with garbage in-front of the compactor, but it may have been left there by night shift staff and should have been discarded properly. On 01/22/2025 at 09:27 AM, the compactor door was observed opened once again. 10 NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Recertification Survey from 01/14/2025 to 01/22/2025, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for 1 (Residents #169) of 2 residents reviewed for Tube Feeding out of 37 sampled residents. Specifically, appropriate handwashing was not practiced and Enhanced Barrier Precautions were not maintained during tube feeding administration. The findings are: The Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memorandum titled Enhanced Barrier Precautions in Nursing Homes, Ref: QSO-24-08-NH dated 03/20/2024 documented that effective 04/01/2024, Centers for Medicare and Medicaid Services is issuing a new guidance for long term care facilities on the use of enhanced barrier precautions to align with nationally accepted standards. Enhanced Barrier Precautions recommendations now include use of enhanced barrier precautions for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. The new guidance related to enhanced barrier precautions is being incorporated into F880 Infection prevention and Control. The facility policy and procedure titled Enhanced Barrier Precautions effective 12/10/2024 documented all personnel which have direct contact with a resident with indwelling medical devices, regardless of multidrug-resistant organism colonization or infection status, the facility will implement Enhanced Barrier Precautions. Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities which provide opportunities for transfer of multidrug-resistant organism to staff hands and clothing. The facility policy titled Hand Hygiene Policy effective 10/28/2024 stated that apply antimicrobial soap or hand hygiene agent and thoroughly distribute over hands and wrist. Use a rotary motion and vigorously rub hands together for 20-40 seconds generating friction on all surfaces of hands and fingers. Resident #169 was admitted with Diagnoses that included Non-Alzheimer's Dementia, Cancer, and Malnutrition. The Significant Change in Status Minimum Data Set assessment dated [DATE] documented that Resident #169 was severely cognitively impaired and had a feeding tube. The physician's order dated 12/04/2024 documented tube feeding- continuous using pump kit, IV pole, and pump due to failure to thrive. Formula: Fibersource HN Total Formula Volume: 1800 ml/day Strength Full (90 ml/hr. rate of flow) A Physician's Order dated 01/08/2025, documented enhanced barrier precautions due to presence of wounds/peg tube/foley. A sign on the door stated Stop-Enhanced Barrier Precautions: Everyone Must: clean their hands, including before entering and when leaving the room. The notice also stated that providers and staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities, Device care or use: central line, urinary catheter, feeding tube, tracheostomy. On 01/16/2025 from 04:01 PM to 04:15 PM, Licensed Practical Nurse #4 was observed performing the administration of enteral feeding to Resident #169 via gastrostomy tube. Licensed Practical Nurse #4 was observed taking a gown into Resident #169's room which they placed on the resident's nightstand. Licensed Practical Nurse #4 then turned on the tap at the sink, adjusted the water, applied soap to their hands and lathered hands and rinsed their hands for approximately ten seconds. Licensed Practical Nurse #4 applied gloves, cleansed Resident #169's peg tube site with gauze moistened with water, flushed the tube, and set the pump. Licensed Practical Nurse #4 left the resident's room and went to the medication cart where they retrieved several gauze pads and normal saline from the cart. Licensed Practical Nurse #4 re-entered the resident's room, and did not perform hand hygiene or don a gown. Licensed Practical Nurse #4 then donned gloves, cleaned the site with gauze moistened with normal saline, wiped site dry, applied dry dressing and hung feeding. Licensed Practical Nurse #4 discarded the unworn gown and used supplies, removed gloves, and washed hands again for approximately 10 seconds before leaving the resident's room. On 01/16/2025 at 04:35 PM, Licensed Practical Nurse #4 was interviewed and stated that when washing hands they go to the sink, turn water on, put the soap on and rub with friction for 10 seconds. Licensed Practical Nurse #4 also stated that the whole handwashing process should last for 20 seconds but they do not think that they did if for this long today. Licensed Practical Nurse #4 stated that they were aware there is a sign on the door for precautions and they think it is for contact precautions which means they should wear gloves and a mask. Licensed Practical Nurse #4 then reviewed the sign on the door and stated that the sign was for Enhanced Barrier Precautions so they should wear you wear gloves and mask. Licensed Practical Nurse #4 then stated that they thought that they were supposed to wear a gown. Licensed Practical Nurse #4 also stated that they were inserviced some time ago, but could not recall when, but remembered that they were told to wear gowns for residents who come in from the hospital with some kind of infection, and that Enhanced Barrier Precautions were to be used for residents who had a bacterial infection or something. On 01/16/2025 at 04:44 PM, the Assistant Director of Nursing, who is also the Infection Control Preventionist, was interviewed and stated that they informed staff about hand washing, personal protective equipment before they start working their shift and staff were also told during the in-service. The Assistant Director of Nursing also stated that when washing hands, staff should rub hands for 20- 30 seconds. The Assistant Director of Nursing further stated that residents on Enhanced Barrier Precautions have signs on their door to let staff know that they need to wear Personal Protective Equipment which includes gowns and gloves. The Assistant Director of Nursing stated that the Director of Nursing and themselves do education on hand washing and precautions. 10 NYCRR 415.19(b)(4)

Based on record review and staff interviews during the Recertification survey from 01/14/2025 to 01/22/2025, the facility did not ensure that a surety bond or similar protection with the amount equal to at least the current total amount of resident's funds. Specifically, the surety bond held by the facility did not cover the total amount of resident personal funds deposited with the facility. This was evident for 185 resident accounts maintained at the facility. The findings are: The facility policy and procedure titled Resident Funds approved 6/10/2024 did not contain any reference to the requirement that the facility purchase a surety bond. The facility document titled Resident Funds Trial Balance 12/01/2024-12/31/2024 documented a Closing Balance of $518,157.31. On 01/22/2025 at 10:02 AM, the Administrator provided 2 surety bonds in the amount of $250,000, one was effective on 02/01/2024 and terminated on midnight 02/01/2025, and the second would be effective on 02/01/2025 and would terminate on midnight 02/01/2026. The facility did not ensure that the value of the surety bond covered funds currently held in all residents' accounts. On 01/22/2025 at 01:17 PM, an interview was conducted with the Administrator who stated that resident's personal fund must be separated from that of the facility and must be protected in a trust and the surety bond protect the residents' money. The Administrator also stated that the current surety bond for the facility was $250,000 and the balance in residents accounts as listed was $518,0000 and the bond is supposed to cover the total of resident's funds. The Administrator further stated the resident finances are handled by the Corporate office who should be able to provide clarification on this issue. On 01/22/2025 at 1:34 PM, an interview was conducted with the Chief Financial Officer who stated that the surety bond is obtained once a year and is supposed to be enough to cover the total of all resident's funds. The Chief Financial Officer also stated that they were not aware that current bond was insufficient to cover the total balance in the residents accounts. The Chief Financial Officer attempted to contact the assigned staff at the Corporate office but was informed that person was on vacation and could not be reached for interview. 10 NYCRR 415.26(h)(5)(v)

Based on interview and record review during a Recertification and Extended survey from 01/14/2025 through 01/22/2025, the facility did not ensure an effective training program for all new and existing staff was developed, implemented, and maintained based on the facility assessment. Specifically, for 6 of 6 employee files reviewed, the facility did not include effective communications as a mandatory training for direct care staff. The findings are: The facility policy titled Staff training/Development dated 11/16/2024 stated that the facility's staff development process would be directed towards personal and professional growth of its personnel. The policy also stated that Certified Nursing Assistants will receive at least twelve (12) hours of education on an annual basis. Training will include dementia management, effective communications, and abuse prevention training. On 01/22/25 at 02:45 PM, training plans were reviewed for 6 randomly selected Certified Nurse Assistants as follows: 1.The Orientation In-service Exam and Attestation Booklet for Certified Nurse Assistant #1 dated 09/20/24 did not include training on Effective Communication Techniques as a mandatory training for staff. 2. The Orientation In-service Exam and Attestation Booklet for Certified Nurse Assistant #2 dated 09/03/24 did not include training on Effective Communication Techniques as a mandatory training for staff. 3. The Orientation In-service Exam and Attestation Booklet for Certified Nurse Assistant #3 dated 09/03/24 did not include training on Effective Communication Techniques as a mandatory training for staff. 4. The Orientation In-service Exam and Attestation Booklet for Certified Nurse Assistant #4 dated 09/03/24 did not include training on Effective Communication Techniques as a mandatory training for staff. 5. The Orientation In-service Exam and Attestation Booklet for Certified Nurse Assistant #5 dated 09/03/24 did not include training on Effective Communication Techniques as a mandatory training for staff. 6. The Orientation In-service Exam and Attestation Booklet for Certified Nurse Assistant #6 dated 10/12/24 did not include training on Effective Communication Techniques as a mandatory training for staff. During an interview on 01/22/25 at 02:35 PM, the Director of Nursing was interviewed and stated they do the in-service training, but they did not provide training on Effective Communication Techniques. The Director of Nursing also stated that they would inquire whether the Administrator had provided this training to staff, however the Director of Nursing did not provide any further updates on this issue. 10 NYCRR 415.26

Based on interview and record review during a Recertification and Extended survey from 01/14/2025 through 01/22/2025, the facility did not ensure an effective training program for all new and existing staff was developed, implemented, and maintained based on the facility assessment. Specifically, for 6 of 6 employee files reviewed, the facility did not provide mandatory training that outlines and informs staff of the elements and goals of the facility's Quality Assurance Performance Improvement program as part of its Quality Assurance Performance Improvement program. The findings are: The facility policy titled Staff training/Development dated 11/16/2024 stated that the facility's staff development process would be directed towards personal and professional growth of its personnel. The policy also stated that Certified Nursing Assistants will receive at least twelve (12) hours of education on an annual basis. Training will include dementia management, effective communications, and abuse prevention training. The policy did not state that training on the Quality Assurance Performance Improvement program would be provided to staff. On 01/22/25 at 02:45 PM, training plans were reviewed for 6 randomly selected Certified Nurse Assistants as follows: 1.The Orientation In-service Exam and Attestation Booklet for Certified Nurse Assistant #1 dated 09/20/24 did not include training on the Quality Assurance Performance Improvement program. 2. The Orientation In-service Exam and Attestation Booklet for Certified Nurse Assistant #2 dated 09/03/24 did not include training on the Quality Assurance Performance Improvement program. 3. The Orientation In-service Exam and Attestation Booklet for Certified Nurse Assistant #3 dated 09/03/24 did not include training on the Quality Assurance Performance Improvement program. 4. The Orientation In-service Exam and Attestation Booklet for Certified Nurse Assistant #4 dated 09/03/24 did not include training on the Quality Assurance Performance Improvement program. 5. The Orientation In-service Exam and Attestation Booklet for Certified Nurse Assistant #5 dated 09/03/24 did not include training on the Quality Assurance Performance Improvement program. 6. The Orientation In-service Exam and Attestation Booklet for Certified Nurse Assistant #6 dated 10/12/24 did not include training on the Quality Assurance Performance Improvement program. During an interview on 01/22/25 at 02:35 PM, the Director of Nursing was interviewed and stated they do the in-service training, but they did not provide training the Quality Assurance Performance Improvement program. The Director of Nursing also stated that they would inquire whether the Administrator had provided this training to staff, however the Director of Nursing did not provide any further updates on this issue. 10 NYCRR 415.26

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On Unit 2 the following was observed: 1. Rooms: a. Stale odors upon unit entry. a. Ceiling tiles along the corridor had brownish and black stains and were cracked and broken. b. The corridor border wall molding had an accumulation of dirt and dust. c. The corridor walls had broken plaster near the nurse's station, stained with black streaks. d. The blood pressure stand and IV pole were embedded with dust, dirt, and brownish stains. e. In room [ROOM NUMBER], there was a torn window screen, the window shades were stained and dirty, the privacy curtains were stained, windowsills had an accumulation of dust and broken plaster, and the outside cover of the hand soap dispenser was layered with dust. f. In room [ROOM NUMBER], the window shades and valance were stained, dusty, discolored and torn, and the windowsill had an accumulation of dust and broken plaster. g. In room [ROOM NUMBER], there was an accumulation of dust and cracked plaster on the windowsills, and there were loose borders below window area. 2. Dining Room on Unit 2 a. The tables were in disrepair, and there were broken sharp edges underneath the half-moon shaped tables. b. The windows shades and curtains were dusty, dirty, and discolored. c. The suction machine table had rusty legs, and a dusty and dirty counter top. d. The microwave was heavily stained and dirty, and there was a stained and dirty sink. 3. In the resident bathroom/shower room across from Rooms 202/203: a. The floor corners were embedded with dirt and debris. b. The shower stall had a loose grab bar, rusty pipe covers, and a hole in ceiling around the sprinkler. c. There was broken ceiling plaster in the shower stall. d. There were dirty wall end coverings and missing cover ends. e. The area behind the toilet tank was layered with accumulated dirt and dust. f. A yellow mop bucket was embedded with black ground-in dirt. g. The floor corners were embedded with a black ground-in substance. h. There were stained and dirty mirrors above the sink area. i. The tub room floors had an accumulation of dirt and dust. j. The edges of the wall were missing bottom molding. On Unit 5, the following was observed: 1. In room [ROOM NUMBER] there was a wheelchair with encrusted food particles and an accumulation of dirt and debris. 2. In room [ROOM NUMBER], there was a dusty, soiled wheelchair with a cracked and torn arm rest. 3. In room [ROOM NUMBER], there was a heavily soiled wheelchair with a dusty, stained seat cushion and torn armrest. Crusty food particles were observed on the metal parts of the chair, and the spokes of the wheelchair were dusty and dirty. On 01/22/2025 at 10:35 AM, Housekeeper #3, who worked the 7:00 AM to 3:00 PM shift and was assigned to the 2nd Floor unit, was interviewed and stated that their routine housekeeping duties included, but were not limited to, routine cleaning and upkeep of the entire 2nd floor unit. Housekeeper #3 also stated that this included dust mopping and mopping the floors of the entire corridor, dining room area, resident rooms, and bathroom floors, and wiping and dusting resident rooms and resident furniture, including room and bathroom mirrors when dirty. On 01/22/2025 at 11:26 AM, the Director of Maintenance, currently the Acting Director of Housekeeping Services was interviewed and stated that their primary role is maintaining the major systems in the facility. The Director of Maintenance also stated that the facility has a challenging population, and they are confronted with leaks due to overflow of toilets, which caused havoc on the 2nd and 6th floors, walls and ceilings. Wheelchairs are cleaned manually by the night shift housekeeper, as they currently have no power washing equipment. Every three months and as needed, the privacy and window curtains are washed. The Director of Maintenance further stated that there is a maintenance logbook located on each unit for any staff to submit areas of concern. The logbook is checked daily to ensure issues are addressed. Each floor has a housekeeper tasked with a specific role to ensure the cleanliness of their assigned unit. The Director of Maintenance stated that about a year and a half ago, all the dining room tables, and a large percentage of the chairs were replaced on the 4th floor. The Director of Maintenance also stated that they make random rounds and spot checks to ensure that the units and resident rooms are being cleaned as assigned, and they have noticed that the molding where the floor meets the wall could be cleaned. The Director of Maintenance further stated that this is a [AGE] year-old building and given the population, they consistently find themselves patching up problem areas. The Director of Maintenance stated that there is no formulated plan for renovations of the units, but it is in discussion. On 01/22/2025 at 1:06 PM, the Administrator was interviewed and stated that the facility is an old building with a difficult population. The Administrator also stated that they try to maintain a clean and safe environment, which is why there is a housekeeper assigned to each unit. The Administrator further stated that they make daily rounds to ensure the cleanliness and safety requirements are met, and they have gone over their concerns with the staff when issues have been identified. The Administrator stated that a proposal that was initiated in 2022 to renovate the first-floor lobby area and the Rehabilitation area, but the proposed work has not yet been started. 10 NYCRR 415.5(h)(2) Based on observations and interviews conducted during the Recertification and Extended survey from 01/14/2025 to 01/22/2025, the facility did not ensure that a safe, clean, comfortable homelike environment was provided. This was evident on all resident units (Unit 6, 4, 3, 2 and 5). Specifically, rooms were not cleaned, walls were discolored and in disrepair, bathrooms were not cleaned, wheelchairs were soiled, window treatments were soiled, window ledges were damaged, and resident's dining areas were in disrepair. This resulted in a finding of Substandard Quality of Care and an Extended Survey was conducted. The findings include but are not limited to: The facility policy titled Environmental Services dated 03/2024 stated that Housekeeping staff are responsible to keep the environment safe, sanitary, and comfortable, and attractive for our residents, staff, and visitors. The policy also stated that the entire facility, inside and outside of its buildings, as well as surrounding premises including, but not limited to the floors, walls, windows, doors, ceilings, fixtures, equipment, furnishings, walkways, and driveways, shall be maintained in good repair, clean and free of insects, rodents, and trash. In addition, the policy stated that effective environmental sanitation is required to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Frequent cleaning of the building's interior will aid in physically removing some of the micro-organisms which might cause these hazards. On 01/15/2025 at 10:52 AM, room [ROOM NUMBER] was observed with brown-colored stains on the floor, an old, yellow-colored stain was on the floor by the bedside. The surrounding corners of the room were also observed with old, dark, greasy, dirty stains. On 01/16/2025 at 11:00 AM, an interview was conducted with Housekeeper #2 who stated that they have been assigned to the 6th floor for several years. Housekeeper #2 also stated they would not usually go into a room to clean unless the resident is taken out. Housekeeper #2 further stated they could not recall the last time they cleaned room [ROOM NUMBER]. On 01/16/2025 at 11:15 AM, an interview was conducted with Registered Nurse # 2, who was also present at the time of the observation and acknowledged that Room # 618 was dirty. Registered Nurse #2 could not explain why the room was dirty, however stated that sometimes residents throw things around, as there are a lot of residents with behavioral problems at the facility. On 01/21/2025 at 2:21 PM, an interview was conducted with Certified Nursing Assistant #7 who was regularly assigned to the resident in room [ROOM NUMBER]. Certified Nursing Assistant #7 stated they did not notice that the room was dirty, and if they had noticed the room was dirty they would have informed the house keeping staff. On Unit 4 on 01/14/2025 at 10:25 AM, on 01/15/2025 at 12:26 PM and on 01/21/2025 at 2:27 PM the following was observed: 1. In room [ROOM NUMBER], the window base had cracks in the molding around the window. 2. In room [ROOM NUMBER], the entrance wall base was peeling and the corner of the floor under the sink was very dirty. 3. In room [ROOM NUMBER], the radiator had brown, rust colored areas and the wall by the entrance door had peeling paint. 4. In room [ROOM NUMBER], the wall base at the entrance of the room had peeling paint and the side of the air conditioner was damaged. 5. In room [ROOM NUMBER], the window base had cracks, the molding around the window was dirty, and there was an accumulation of dirt under the sink. 6. In room [ROOM NUMBER], there were multiple, black-colored spots on the floor. 7. In room [ROOM NUMBER], there was peeling paint on the right entrance wall. On 1/21/2025 at 2:30 PM, an interview was conducted with the Director of Maintenance who stated that there has not been a Director of Housekeeping in the building since Thanksgiving. The Director of Maintenance also stated that because of this absence, a lot of things are not being done. The Director of Maintenance further stated that Administration and Maintenance are aware of the housekeeping problem. The following was observed on Unit 6: 1. In room [ROOM NUMBER], there was dark red splatter on the wall by the resident's bed, and yellow peeling paint on the wall around the air/heating unit. 2. In room [ROOM NUMBER], there were yellow walls with brownish discoloration located behind bed A, and there was a chipped and peeling brown dresser. 3. In room [ROOM NUMBER], there were yellow walls with black and brown spots, yellow paint peeling off the wall, black paneling was peeling off the wall, a hole in ceiling located above closets, rusted radiator, a yellow peeling substance around the surface of the window and air conditioner, and an unclean toilet full of feces. 4. In room [ROOM NUMBER], the base floor paneling was peeling off and discolored. 5. In the 6th floor corridor, a resident's wheelchair was not clean and there was a whitish substance stuck on it. 6. The dining room had yellow-stained walls, peeling yellow paint, and a silver-colored metal rolling tray had caked-on dust and dirt. 7. The shared resident shower/bathroom had a dirty shower curtain, a toilet with multiple grey scratches surrounding the toilet bowel brim, a brownish substance was noted on the tiles in the shower stalls and surrounding the sink, and on the two bedside tables, and there were deflated silver balloons on the floor. On 01/21/2025 at 1:40 PM, an interview was conducted with Housekeeper #2 who stated their job was to make sure the unit was cleaned and wiped down. As far as repairs, that was the job of the maintenance department. Housekeeper #2 also stated if the unit needed repairs, it is documented in the maintenance logbook, and maintenance would check the log to see what needed to be done. Housekeeper #2 further stated that they had not seen anyone doing walk-throughs to follow up on repairs needed. During multiple observations on Unit 3 that occurred at different times from 01/14/2025 to 01/22/2025 the following was observed: 1. In room [ROOM NUMBER], the floor was stained with a brownish colored substance, the ceiling above the window had peeling plaster, and there were brownish colored water stains on the window valance. 2. In room [ROOM NUMBER], the walls near the sink and in front of the beds were discolored with brown colored splashes and there was peeling paint on the ceiling. 3. In room [ROOM NUMBER], there was peeling plaster on the ceiling, water stains on the window valance, the window ledge was cracked and broken, there was debris on the ledge and on top of the air conditioning unit, and the toilet bowl base was discolored. 4. In room [ROOM NUMBER], there was rust around the air conditioner, the window screen was torn, and there was peeling paint on the wall. 5. In room [ROOM NUMBER], there were water marks on the ceiling and on the window valance. 6. In room [ROOM NUMBER], there were water marks on the ceiling, and the toilet did not flush properly. 7. In room [ROOM NUMBER], there were splatters of a black-colored substance on the wall above the light fixture behind the resident bed. 8. The hallway toilet opposite room [ROOM NUMBER] had a dusty vent, the toilet seat was chipped, the floor was littered with tissues and toilet paper, there was no door, and the doorway was covered with a cloth curtain that was missing hooks and was not hung properly. 9. Multiple rooms on the unit had missing numbers on the door plate, and on some doors the missing numbers were written in with different types of markers and print. 10. In the bathroom, there were water stains on the ceiling, rusty garbage bin stands, and used gloves on the floor. 11. In the Dayroom, the ceiling had mismatched painted areas and cracked plaster on the wall near the window. The wall under the table and blue wall protectors in the dayroom were dusty and discolored, and the upholstery on the rolling stools was torn. 12. Blue wall protectors in the hallway were dusty and discolored. Review of the Maintenance logbook dated 11/27/2024 to 1/09/2025 did not have any of the above observations listed. On 01/22/2025 at 11:11 AM, an interview was conducted with the resident in room [ROOM NUMBER], who stated they informed staff that the toilet does not flush properly, and it has been like that for the past two weeks. On 01/22/2025 at 11:37 AM, an interview was conducted with Housekeeper #1, who stated that they do a thorough cleaning in the room when a resident is discharged . Housekeeper #1 also stated that they had spoken to the supervisor about the bathroom curtain, as they do not have the correct hooks. Housekeeper #1 further stated that the vents do need to be cleaned, and their supervisor is aware that the toilet in room [ROOM NUMBER] needs to be replaced. Housekeeper #1 stated that any ceiling or window treatment issues are handled by maintenance. Housekeeper #1 also stated that they clean the wall guards every other week and they definitely need cleaning now. Housekeeper #2 further stated that there used to be two housekeeping staff on the floor and now there has just been one person for the past year. This makes it difficult to get to everything in one day, and it is now too much for one person to handle.

Based on observation, record review, and interviews conducted during the Recertification and Abbreviated Survey (Complaint #NY00363144) conducted from 01/14/2025 to 01/22/2025, the facility did not ensure that the sufficient nursing staff was consistently provided to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. Specifically, 1). review of the actual staffing schedules dated from 10/01/2024 to 12/31/2024 revealed that staffing assignments were consistently less than the projected staffing needs specified in the Facility Assessment for Certified Nursing Assistants, 2). the facility Payroll Based Journal (Quarter 1 2024 (October 1 - December 31) also revealed an excessively low weekend staffing, 3). residents, family and staff reported that the facility was short staffed with Certified Nursing Assistants, especially on weekends both days and nights, which resulted in a lack of timely staff response to call bells and delays in performing Activities of Daily Living and personal care. The findings include but are not limited to: 1.The Facility Assessment Tool dated 10/28/2024 documented the facility had a bed capacity of 200 residents with an average daily census of 190. The facility assessment documented that based on their acuity levels, most residents have reduced physical function and had behavioral health needs. The facility had no independent residents, some residents were dependent, and most residents required the assistance of 1-2 staff for activities of daily living. The Facility Assessment further documented that based on the resident population and their needs for care and support, the total number of required staff needed to appropriately meet the needs of the residents at any given time were 30 licensed nurses providing direct care and 50 Certified Nursing Assistants. The facility's general staffing plans documented the facility would provide 4 Certified Nursing Assistants for 7:00 AM shift, 3 Certified Nursing Assistants for 3:00 to 11 PM shift and 2 Certified Nursing Assistants for 11 PM to 7 AM shift in units 2, 3, 4, 5 and 6. A review of the actual staffing schedules from 10/01/2024 to 12/31/2024 revealed consistently low staffing of Certified Nursing Assistants especially on weekends. This includes but not limited to: On 10/06/2024, Sunday, 7AM to 3PM shift, there were 4 Certified Nursing Assistants scheduled for each unit (Units 2, 3, 4, 5, and 6) which had census ranges from 35 to 40 residents. The daily staffing documentation revealed 3 Certified Nursing Assistants worked on each unit. On 10/13/2024, Sunday, 7AM to 3PM shift, there were 4 Certified Nursing Assistants scheduled for each unit (Units 2, 3, 4 and 5) which had census ranges from 37 to 39 residents. The daily staffing documentation revealed 3 Certified Nursing Assistants worked on each unit. On 11/23/2024, Saturday, 7AM to 3PM shift, there were 4 Certified Nursing Assistants scheduled for each unit (Units 2, 3, 4, 5, and 6) which had census ranges from 35 to 38 residents. The daily staffing documentation revealed 3 Certified Nursing Assistants worked on each unit. On 11/24/2024, Sunday, 7AM to 3PM shift, there were 4 Certified Nursing Assistants scheduled for each unit (Units 2, 3, 4, 5, and 6) which had census ranges from 35 to 38 residents. The daily staffing documentation revealed 3 Certified Nursing Assistants worked on each unit. On 11/30/2024, Saturday, 3 PM to 11 PM shift, there were 3 Certified Nursing Assistants scheduled for each unit (Units 5 and 6) which had census of 35 and 37 residents. The daily staffing documentation revealed 2 Certified Nursing Assistants worked on each unit. On 11/30/2024, Saturday, 11 PM to 7 AM shift, there were 2 Certified Nursing Assistants scheduled for each unit (Units 5 and 6) which had census of 35 and 37 residents. The daily staffing documentation revealed 1 Certified Nursing Assistants worked on each unit. On 12/01/2024, Sunday, 7AM to 3PM shift, there were 4 Certified Nursing Assistants scheduled for each unit (Units 2, 3, 4, 5, and 6) which had census ranges from 35 to 38 residents. The daily staffing documentation revealed 3 Certified Nursing Assistants worked on each unit. On 12/01/2024, Saturday, 11 PM to 7 AM shift, there were 2 Certified Nursing Assistants scheduled for each unit (Units 5 and 6) which had census of 35 and 37 residents. The daily staffing documentation revealed 1 Certified Nursing Assistants worked on each unit. On the weekends of 12/08/2024, 12/14/2024, 12/15/2024, 12/21/2024, 12/22/2024, 12/28/2024 and 12/29/2024 on 7 AM to 3 PM shift, there were 4 Certified Nursing Assistants scheduled for each unit (Units 2, 3, 4, 5, and 6) which had census ranges from 36 to 40 residents. The daily staffing documentation revealed 3 Certified Nursing Assistants worked on each unit on those days. On 12/28/2024, Saturday, 3 PM to 11 PM shift, there were 3 Certified Nursing Assistants scheduled for each unit (Units 5 and 6) which had census of 39 and 40 residents. The daily staffing documentation revealed 2 Certified Nursing Assistants worked on each unit. 2. The facility Payroll Based Journal for Quarter 1 2024 (October 1 - December 31) revealed that the facility triggered for excessively low weekend staffing. 3. On 12/04/2024, a hotline call (#NY00363144) was received from an anonymous caller to the New York State Department of Health. The caller complained that since Thanksgiving staffing had been cut on weekends and overnight shifts for multiple units to the extent there is only one Certified Nursing Assistant providing care for approximately forty residents on each floor. The caller also stated that this creates an unsafe environment for the residents because the existing staff frequently get called to other floors and it is impossible to provide timely care, answer call lights in a timely manner, and the risk of resident falls/accidents is greatly increased, especially if they attempt to toilet themselves because there are no staff to assist them. On 01/14/2025 at 12:52 PM, an interview was conducted with Resident #56 who was dependent in grooming and toileting. Resident #56 stated that they are totally dependent with care, but the facility is short staffed especially on weekends and at nights. Resident #56 also stated that it takes a longer time for staff to get in touch after they ring the call bell, and this happens all the time. Resident #56 further stated that they fell from bed about a month ago, and they also fell in toilet when trying to use the toilet on their own after waiting a long time for staff to assist. On 01/14/2025 at 03:19 PM, an interview was conducted with Resident #127 who was also dependent in grooming and toileting. Resident #127 stated that they are totally dependent with care, but the facility is short staffed especially on weekends and at nights. Resident #127 also stated that they needed help, but it takes hours for the Certified Nursing Assistant to come to assist them with grooming. Resident #127 further stated that it always takes forever for staff to change and bathe them. On 01/15/2025 at 12:20 PM, an interview was conducted with Certified Nursing Assistant #6 who stated they work in the morning shifts. Certified Nursing Assistant #6 also stated the staffing had been worse and the aides sometimes reduced from 4 to only 2 aides per shift in the units. Certified Nursing Assistant #6 further stated it was hard to answer call bells and try to give showers to residents because of this. On 01/17/2025 at 10:28 AM, an interview was conducted with Certified Nursing Assistant #8 who stated there were times when there were only 2 to 3 Certified Nursing Assistants working in Unit 5 during the daytime. Certified Nursing Assistant #8 stated they try to manage but there will be a delay in caring for residents when there are not enough aides. On 01/17/2025 at 11:45 AM, an interview was conducted with Licensed Practical Nurse #2 who stated they work 5 to 6 days a week and the units are supposed to be staffed with 4 Certified Nursing Assistants during the 7 AM to 3 PM shift. Licensed Practical Nurse #2 also stated they often have only 3 Certified Nursing Assistants working on the unit, and they sometimes have to stop what they are doing to help the Certified Nursing Assistants. On 01/16/2025 at 10:06 AM, an interview was conducted with Registered Nurse #3 who stated the residents had not been complaining to them about low staffing. Registered Nurse #3 also stated that there are times when they have less staff than scheduled and they have to help them out. Registered Nurse #3 further stated the staff, who are mostly from the agency, call out and are not being replaced. On 01/21/2025 at 01:20 PM, an interview was conducted with the Human Resources Director who stated that they are covering for the Staffing Coordinator as the facility did not currently have anyone in this position. The Human Resources Director also stated that they were not surprised that the Payroll Based Journal was triggered for low staffing on weekends and was accurate as they are the person who extracts the time record data, using a software program to track staff attendance. The Human Resources Director further stated that the challenges they had was when the Certified Nursing Assistants are scheduled off every other weekend and the other agency staff that would be used might have other commitments and are unable to cover. The Human Resources Director stated that staff is supposed to call out at least 2 hours prior to the start of shift and if a staff then comes in excessively late, this would not be reflected on the Payroll Based Journal as credit. The Human Resources Director also stated that they have at least four staffing agencies that they use, and staffing has got better recently. On 01/21/2025 at 01:38 PM, the Administrator was interviewed and stated that staffing is based on the census and if the census drops it may affect the number of staff they have. The Administrator also stated that staffing is a challenge, and the facility has contracts with several agencies that provide staffing. The Administrator further stated that they post vacancies online and they also offer bonuses, higher salaries and provide uniforms as an incentive. The Administrator stated that the facility has been offering overtime pay for extra shifts and they ensure that there are additional staff to call in cases where there are callouts during the weekends. 10 NYCRR 415.13(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Recertification survey from 01/14/2025 to 01/22/2025, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, several perishable food items were stored on a food rack in the refrigerator and were not dated, a tray of seasoned chicken with no date was placed on top of thawing chicken, freezer temperatures were outside of acceptable range and food was not stored appropriately, standing water was observed on the floor of the dry storage room, broken floor tiles observed in different areas, and staff were observed not wearing hair restraints while assembling food trays. This was observed during the Kitchen task. The findings are: The facility policy titled Food and Nutrition Services dated 01/08/2025 documented that the facility shall follow proper sanitation and food handling practices to prevent outbreak of foodborne illness, safe food handling to prevent foodborne illnesses beginning from when food is received from the vendor and continues throughout the facility's food storage, and handling processes. During the Kitchen tour with the Director Of Nutrition on 01/14/2025 from 9:28 AM to 9:50 AM, the following was observed: 1. The walk-in refrigerator had approximately 12 trays of perishable food items undated on a preparation tray rack. An unlabeled red substance resembling a sauce was left in a tray. A undated tray of seasoned chicken was observed resting on top of two trays of thawing chicken. 2. The outer freezer thermometer read 24 F. There was no thermometer inside of the freezer. Several boxes of food were also stored less than 18 inches from the ceiling, and some were positioned right under the sprinkler head. 3. The floor of the dry storage area was observed a large area of standing water under racks on the left side of the room. 4. The kitchen ceiling had water stains on various places, and broken floor tiles were observed. 5. Food Service Aide #1 was observed with their hair was not fully covered with hair net exposing some of their hair while cracking hard-boiled eggs. Food Service Aide #1 stated that they were preparing egg salad. The Director of Nutrition was interviewed immediately and stated that seasoned food should not be stored on top of thawing meat, all food items should be labeled. The Director of Nutrition also stated that they could not locate an internal thermometer for the freezer and was aware that the temperature on the external thermometer was out of range and they would place a thermometer inside of the freezer. The Director of Nutrition further stated that the standing water in the dry storage room was an ongoing issue which was due high tide in their area. On 01/16/2025 between 11:09 AM and 11:17 AM, the trayline was observed. Dietary Aide #4 was observed adding food items to trays being prepared while not wearing a head covering. Dietary Aide #2 was also observed adding food items to trays while wearing a [NAME] hat folded down to their ears. Hair was visible below the top of the ears that was not covered, and Dietary Aide #2 was not wearing a hair restraint. On 01/16/2025 at 11:17 AM, Dietary Aide #4 was interviewed and stated that must have forgotten to put a hairnet on and would do so now. On 01/16/2025 at 11:19 AM, the Director of Nutrition was interviewed and stated that Dietary Aide #4 was not wearing a hair restraint as they were bald. On 01/22/2025 at 12:19 PM during an observation of tray line assembly Food Service Aide #2 was observed placing food items on the tray with a hair restraint that covered the top of their head and did not restrain their ponytail. In addition, Dietary Aide #2 was observed placing food items on trays and was wearing a [NAME] hat that was folded down at the top of their ears which left the hair from the top of ears to nape of neck exposed and not restrained. On 01/22/2025 at 12:21 PM, Dietary Aide #2 was interviewed and stated they were wearing a hat and not a hairnet because they were told that their hair only needed to be covered. Dietary Aide #2 further stated that they worked in other food service industries and only ever had to wear a hat and not a hairnet, so they did the same thing here. Dietary Aide #2 further stated that the hat covered all of their hair even though it was folded over above their ears and they had hair to the back of their head and nape. On 01/22/2025at 12:24 PM, Food Service Aide #2 was interviewed and stated that they were wearing hairnet earlier and it must have slipped off without them realizing. On 01/22/2025 at 12:27 PM, temperature readings from the two internal thermometers in the freezer read 16 F and 20 F respectively, the external thermometer read 24 F, and several boxes were observed stacked less than 18 inches from the ceiling. On 01/22/2025 at 12:31 PM, an interview was conducted with the Director of Nutrition who stated that once staff enter the kitchen their head must be covered at all times and was not aware that Dietary Aide was not wearing a hairnet under their hat. The Director of Nutrition also stated that staff are always instructed to cover their head while in the kitchen. The Director of Nutrition acknowledged that food items were not stored at the correct height in the freezer and stated that the freezer is small, and they may need more racks. The Director of Nutrition further stated that the freezer is maintained at 0 F degrees as demonstrated by the 0 F degree temperature recorded by the cook on a daily basis. 10 NYCRR 415.14(h)

Based on observations, interviews and record reviews conducted during the Recertification, Complaint and Extended survey from 01/14/2025 to 01/22/2025 and Extended Survey on 01/22/2025, the facility did not ensure effective and efficient administration of its resources to attain or maintain highest practicable well-being of each resident. Specifically, the facility administration 1) did not provide a safe, clean, comfortable, and homelike environment to the residents; 2) did not sufficiently staff the facility; 3) did not have activities that met the interest or needs for each resident; 4) did not monitor and enhance the quality of care and service by repeating the same deficiencies including F695 Respiratory/Tracheostomy Care, F725 Sufficient Nursing Staff, and F880 Infection Prevention & Control. The environmental concerns in F584 were widespread, indicating Substandard Quality of Care. The findings are: 1) The facility did not ensure a clean, comfortable, and homelike environment was maintained. It was observed but not limited to all 5 resident units that multiple rooms were not properly cleaned and maintained and had soiled walls, and peeling paint and plaster on ceilings, multiple rooms had soiled window treatments, window sills were chipped, dusty and dirty, window screens were torn, wheelchairs were soiled, and floor corners were embedded with dirt and debris. Refer to citation text at F584 for further information. 2) The facility daily nursing actual staffing schedules from 10/01/2024 to 12/31/2024 revealed consistently low staffing of Certified Nursing Assistants especially on weekends. This includes but not limited to: On 10/06/2024, Sunday, 7 AM to 3 PM shift, there were 4 Certified Nursing Assistants scheduled for each unit (Units 2, 3, 4, 5, and 6) which had census ranges from 35 to 40 residents. The daily staffing documentation revealed 3 Certified Nursing Assistants worked on each unit. Refer to citation text at F725 for further information 3) The facility did not ensure that safe, sanitary conditions were maintained in the kitchen. Food items were not labeled and dated, freezer temperatures were not observed to be out of acceptable range, and standing water was observed in the dry food storage areas. Refer to citation text at F812 for further information. 4) The facility did not ensure that there were sufficient emergency provisions for residents, staff and family or volunteers. Refer to citation text at E0015 for further information. 5) The facility did not ensure effective Quality Assurance and improvement programs to monitor and enhance the quality of care and service and compliance with all federal, state, and local regulations governing nursing home operation by repeating citations from the last survey conducted from 12/22/2022 to 01/05/2023. Refer to citation text at F695, F725 and F880 for further information. On 01/22/2025 at 03:41 PM, the Administrator was interviewed and stated that they are aware that the facility needs repairs and that the Director of Building services is responsible to ensure that the repairs are done. The Administrator also stated that they had begun to conduct repairs on the facility, then COVID-19 came and put a hold on the plans to renovate the building. There was a proposal initiated in 2022 to renovate the first-floor lobby area and the Rehabilitation area, but the proposed work has not begun yet. The Administrator further stated that they walk through the facility every day to ensure the cleanliness and safety requirements are met and the facility is an old building with a difficult population. The Administrator stated that they try to maintain a clean environment and a safe environment which is why there is a housekeeper assigned to each unit. The Administrator also stated that the facility has not been able to meet the 3.5 staff hours, and it is difficult to get people to work after the COVID-19 pandemic. The Administrator further stated that staffing is adequate based on 200 bed capacity and the case mixed index, and resident acuity and the facility has signed a contract with 1199 to attract and hire more staff. The Administrator stated that they were not aware of many of the issues that were identified during the survey and therefore the issues could not be addressed by the Quality Assurance committee. 10 NYCRR 415.26

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the Recertification and Extended Survey from 01/14/2025 to 01/22/2025, the facility did not ensure that it provided a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was evidenced by multiple observations of the outside front entrance, staff bathrooms, elevators and nursing stations. The findings are: The facility policy titled Environmental Services dated 03/2024 stated that Housekeeping staff are responsible to keep the environment safe, sanitary, and comfortable, and attractive for our residents, staff, and visitors. The policy also stated that the entire facility, inside and outside of its buildings, as well as surrounding premises including, but not limited to the floors, walls, windows, doors, ceilings, fixtures, equipment, furnishings, walkways, and driveways, shall be maintained in good repair, clean and free of insects, rodents, and trash. On multiple occasions from 01/14/2025 to 01/22/2025 the following was observed: 1. Front Entrance Pavement: a. The outside pavement leading to the front door entrance was widely cracked and broken. 2. Lobby Area: Main Dining: a. Dining room tables were unsteady and in disrepair, exposing inner corking along the edges. 3. Elevators: a. 2 of 2 elevators had an accumulation of dirt and debris within the tracks. b. the inside elevator doors and walls had streaks and stains. c. the floors along the edges were embedded with black-colored substance, dirt, and debris. 4. 2nd floor staff bathroom: a. there were unidentified odors b. there were broken wall tiles c. there was a stained and dirty mirror e. the paper towel dispenser was dusty f. there was embedded dirt and debris along floor edges and corners. g. walls were stained and dirty 5. 2nd floor Nurse Station: a. the counter top edges were broken and chipped. b. the wall below the fan area heavily streaked and stained. c. 2 black swivel chairs and seat cushion were layered with dust and stains. The back of the chairs was with layered dust and dirt. 6. Housekeeping equipment: a. the outer aspect of the yellow mop bucket used by housekeepers was embedded with black dirt. 7. The 6th floor nurses station a. the arm rest padding on one of the chairs was torn and had a dark colored discoloration. 8. The 3rd Floor a. upholstery on the chairs in nursing station was discolored and appeared soiled. b. the hand sanitizers in the hallway were dusty. On 01/22/2025 at 10:35 AM, Housekeeper #3 who worked the 7 AM to 3 PM shift and was assigned to the 2nd Floor unit was interviewed and stated that their routine housekeeping duties include but are not limited to routine cleaning and upkeep of the entire 2nd floor unit. Housekeeper #3 also stated that this included dust mopping and mopping the floors of the entire corridor, dining room area, resident rooms, and bathroom floors, wiping and dusting resident rooms and resident furniture including room and bathroom mirrors when dirty. On 01/22/2025 at 11:26 AM, the Director of Maintenance and currently the Acting Director of Housekeeping Services was interviewed and stated that their primary role is maintaining the major systems in the facility. The Director of Maintenance also stated that the facility has a challenging population, and they are confronted with leaks due to overflow of toilets which cause havoc on the floors, walls and ceilings. The Director of Maintenance further stated that this is a [AGE] year-old building and given the population, they consistently find themselves patching up problem areas. The Director of Maintenance stated that there is no formulated plan as yet for renovations of the units, but it is in discussion. On 01/22/2025 at 01:06 PM, the Administrator was interviewed and stated that the facility is an old building with a difficult population. The Administrator also stated that they try to maintain a clean and safe environment which is why there is a housekeeper assigned to each unit. The Administrator further stated that they make daily rounds to ensure the cleanliness and safety requirements are met, and they have gone over their concerns with the staff when issues have been identified. The Administrator stated that is a proposal that was initiated in 2022 to renovate the first-floor lobby area and the Rehabilitation area, but the proposed work has not yet been started. 10 NYCRR 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey from 12/11/22/ to 12/16/22, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments accurately reflected a resident's status. This was evident for 1 (Resident #16) of 39 total sampled residents. Specifically, the MDS for Resident #16 Preadmission Screening and Resident Review (PASRR) was coded incorrectly. The findings are: The facility's policy titled Minimum Data Set (MDS 3.0) last reviewed 04/01/22, documented that it is the policy of [NAME] Nursing Care Center to follow the (MDS 3.0), which is a Federal mandated specific instrument to be used for conducting a comprehensive assessment of all nursing home residents, initially and periodically. Resident #16 had diagnoses of Schizophrenia unspecified, Extrapyramidal Syndrome. The Annual MDS dated [DATE] documented that the resident was cognitively intact, section A1500, (PASRR): the resident currently was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition There was no documentation of Level II in the MDS. Annual MDS dated [DATE] documented the resident was cognitively intact, section A1500, (PASRR): the resident currently was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. There was no documentation of Level II in the MDS. A PASRR Screen Dated completed 11/06/2019 with recommendations in section b1. No Dementia diagnosis. Level I Review for Possible Mental Illness. This person does not have a serious mental Illness. The Level II PASRR dated 3/13/2019 documented Resident #16 met the PASRR inclusion criteria for a serious mental illness due to the diagnosis of Schizophrenia. The evaluation documented Resident #16 was appropriate for nursing home placement. A Social Service progress notes dated 8/19/2022 documented Psych Note: Resident was seen on 8/19/2022 Psychiatric follow up: Schizophrenia chronic. EPS. Diagnosis: Schizophrenia unspecified Psychiatric Medications: Risperdal 2 mg orally twice daily and Benztropine 1 mg orally twice daily. A Psychiatry note dated 12/16/2022 documented Schizophrenia chronic, EPS- Drooling saliva, primary history of EPS, and Schizophrenia. Diagnosis: Schizophrenia unspecified, EPS Recommendations: Increase Benztropine 2 mg orally twice daily. Continue other psych meds. Gradual Dose Reduction is contraindicated due to chronic severe mental illness. On 01/05/23 at 01:33 PM Senior MDS Coordinator, was interviewed and stated that their role is to schedule the MDS booklets that are created and setup a date for them to start. Upon completion, they review the books, and each discipline are responsible for accuracy for their own sections and based on their sections, the Senior MDS Coordinator would oversee for the completion of the booklet before submission. The Social Worker (SW) is responsible for Section A where the SW will do the screen and complete that section. Senior MDS Coordinator said that they will clarify to check and look the booklet before submission, verify and have it corrected. 415.11

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification and Abbreviated survey (ACTS # NY00297460) from 12/22/22 to 01/05/23, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #120) of 39 total sampled residents. Specifically, wound care treatments were not performed on Resident #120 in accordance with Medical Doctor Order (MDO). The findings are: The facility policy titled Comprehensive Skin Care and Pressure Injury Prevention Policy dated 9/23/2021 documented comprehensive skin care must be implemented and maintained, and the nurse is responsible for following the treatment plan. Resident #120 had diagnoses of chronic non-pressure right lower leg ulcer with necrosis and chronic pain. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #120 was cognitively intact, did not reject care, and had surgical wounds. On 12/30/22 at 10:19 AM, wound care observation of Resident #120 was conducted, and the right ankle and right lateral lower leg wounds had large amounts of white and brown exudate. On 12/30/2022 at 10:25 AM, Resident #120 was interviewed and stated at times, they wait several hours for the nurse to provide wound care treatments, but no one comes to do it. Prior to this morning, wound treatment and dressing change was not done for Resident #120 since last week. The Comprehensive Care Plan (CCP) initiated 8/20/2022 and last updated 12/3/2022 documented Resident # 120 skin breakdown on right lower leg and ankle. Interventions included applying local treatments as ordered by the Medical Doctor (MD). MD Note dated 11/21/22 documented Resident #120 was undergoing evaluation for leg pain. The Treatment Administration Record (TAR) for November 2022 documented Resident #120 was started on calcium alginate with silver dressing for wounds to the right lateral ankle and below the right lateral ankle as of 10/12/22. The TAR documented treatment was not administered on 11/8/22 and 11/9/22. On 11/9/22, the treatment order was changed to Dakins cleanse, iodosorb cream, and calcium alginate to surgical wound on right lateral ankle and below the right lateral ankle. The TAR documented treatment was not administered on 11/26/22, 11/27/22, and 11/30/22. Nurse Practitioner note dated 11/29/22 documented Resident #120 complained of bilateral ankle pain. X-rays and labs were ordered. MD Orders dated 12/19/22 documented the treatment plan for Resident #120 was to cleanse right lower leg with normal saline, apply calcium alginate dressing, and cover with a gauze roll once daily. The treatment plan for Resident #120's right lateral ankle was to cleanse with Daken's solution, apply iodosorb cream, cover with plain calcium alginate, and wrap dressing daily. The MD note dated 12/20/22 documented Resident #120's right ankle wound continues to ooze yellow discharge and antibiotics were ordered to treat MRSA in the wound. Wound Care MD note dated 12/21/22 documented Resident #120 had non-healing right lateral leg and ankle surgical wounds that have deteriorated again. Increased pain, large amounts of exudate, and purulent drainage noted. A repeat course of Bactrim DS was needed. The Wound Care Consult dated 12/21/2022 documented Resident #120's wounds have deteriorated and were draining purulent discharge. The resident will need an antibiotic course of Bactrim DS. On 1/3/2023 at 1: 28 PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated prior to providing wound care treatment, LPN #2 refers to the TAR to ensure the treatment is being provided according to MD Order. LPN #2 reviewed the TAR for Resident #120 and stated they were so busy; they fell behind on providing wound care. The missed wound care on the TAR was unacceptable. On 1/5/2023 at 12:21 PM, the Director of Nursing (DON) was interviewed and stated Registered Nurse (RN) Supervisors are responsible for reviewing the TAR to ensure completion. If there is no nursing signature on the TAR, then the service was not performed. Resident #120 refuses wound treatment sometimes. Nurses from other units are assigned to perform wound care for Resident #120's unit when the facility is short of staff. The DON does not know whether assigned nurses complete the wound treatment for Resident #120 or their unit. The Administrator was interviewed on 1/5/2023 at 12:41 PM and stated it is unacceptable that wound care treatment was not provided in accordance with the MD order. 415.12(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey from 12/22/22 to 01/05/22, the facility did not ensure a resident with respiratory care, including tracheotomy care and tracheal suctioning, was provided such care consistent with professional standards of practice. This was evident for 1 (Resident #168) of 1 resident(s) reviewed for respiratory care out of 39 total sampled residents. Specifically, Licensed Practical Nurse (LPN) #7 provided tracheostomy care (TC) to Resident #168 without changing the Velcro straps according to Medical Doctor (MD) order, suctioning the resident, or performing hand hygiene. The findings are: The facility policy titled Tracheotomy Care last reviewed 09/2022 documented position resident for comfort and accessibility to the site and suction tracheostomy tube. Then remove the tracheostomy dressing, doff gloves, perform hand hygiene, and open disposable inner cannula package. Resident #168 had diagnoses of tracheostomy status and dysphagia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #168 had mild cognitive impairment and received suctioning and TC. On 12/29/22 at 10:06 AM, Resident #168 was observed lying in bed with a suctioning machine on their bedside table. LPN #7 was present in the room and stated they were trained not to use the suction machine with residents who can cough on their own. LPN #7 then initiated TC for Resident #168 by washing their hands, placing a gauze package and normal saline bottles on the resident's bed, and donning 2 pairs of gloves. LPN #7 picked up a washcloth, wet the washcloth with tap water, and used the washcloth to wipe around Resident #168's stoma. The tracheostomy Velcro straps were untied, LPN #7 removed the disposable inner cannula, and the cannula was thrown in the garbage. Hand hygiene and glove change was not performed and LPN #7 soaked gauze pads with normal saline, placed the gauze pads on Resident #168's stoma, and instructed the resident to cough. As the resident coughed, LPN#7 collected sputum on the gauze and threw it in the garbage. Resident #168 was asked to cough again, and LPN #7 collected sputum onto the gauze a 2nd time. LPN #7 removed 1 pair of gloves from their hands, picked up gauze, wet the gauze with normal saline, and used the gauze to wipe Resident #168's tracheostomy site. Hand hygiene was not performed, and the Velcro straps were not changed. LPN #7 inserted the new disposable inner trach cannula into the stoma, connected Resident #168's tracheostomy to the oxygen concentrator at bedside and removed their gloves. MD Order initiated 08/29/2022 and last renewed 12/21/22 documented provide TC every shift and as needed, suction tracheostomy secretions every shift and as needed, and change tracheostomy Velcro strap daily and as needed. On 01/04/23 at 12:33 PM, LPN #7 was interviewed and stated they received inservice from an outside consultant who changed Resident #168's tracheostomy. The outside consultant told LPN #7 the suction machine does not have to be used since Resident #168 has the strength to cough. Resident #168 does also receive suctioning with the suction machine. LPN #7 is aware that placing the items on the Resident #168's bed prior to TC is a breach of Infection Control. On 01/04/23 at 04:06 PM, the Assistant Director of Nursing (ADNS)/Infection Preventionist was interviewed and stated a Respiratory Therapist came to inservice the staff about TC, but the ADNS cannot recall the date of the inservice. The last inservice on TC given by the facility was in 2019. The ADNS could not recall whether the facility provided an inservice to nursing staff regarding infection control and TC. TC inservice should be done annually. On 12 /29/22 at 1:00PM, the Director of Nursing (DNS) was interviewed and stated they have not conducted any TC competency evaluations on licensed nursing staff in the 1 ½ years they have been working for the facility. 415.12(k)(6)

Based on observation, interviews, and record review conducted during the Recertification and Complaint survey from 12/22/2022 to 01/05/2023, the facility did not ensure the Director of Nursing (DNS) served as a charge nurse, only when the facility has an average daily occupancy of 60 or fewer residents. Specifically, there was documented evidence the DNS worked as a charge nurse and administered medication to residents when the facility was short of nursing staff. The findings are: The facility policy titled Administration dated 5/21/21 documented the DNS develops a master staffing plan and delegates responsibilities. Actual Daily Staffing Schedules documented insufficient Licensed Practical Nurses (LPN) with the DNS assigned as LPN on various shifts on the following dates: 10/2/22, 10/3/22, 10/5/22, 10/6/22 , 10/7/22, 10/10/22, 10/11/22, 10/12/22, 10/15/22, 10/25/22, 10/26/22, 10/27/22, 10/29/22, 10/31/22, 11/1/22, 11/10/22, 12/1/22, and 12/30/22. On 12/28/22 at 04:39 PM, the DNS was interviewed and stated staffing is a big challenge. The DNS acts as Nursing Supervisor on various shifts when the nurses are short staffed. The DNS comes to work on the weekends when there is no medication nurse, and the gives out medications to the residents. On 01/03/23 at 10:58 AM and 01/05/23 at 12:15 PM, the Administrator was interviewed and stated they were aware the DNS gives out medications when the facility is short of nursing staff. 415.13(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during a Recertification Survey from 12/22/22 to 1/5/23, the facility did not ensure that a resident who is diagnosed with Dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #145) of 1 resident(s) reviewed for Dementia Care of 39 total sampled residents. Specifically, the facility did not develop and implement a person-centered comprehensive care plan (CCP) that included and supported the dementia care needs of Resident #145. The findings are: The facility policy titled Care of Residents with Dementia last reviewed 11/2022, documented the facility provides interdisciplinary, person centered care for residents with dementia that assists the resident with dementia to reduce potentially distressing or harmful behaviors. Resident #145 had diagnoses of dementia and psychotic disorder. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #145 was severely cognitively impaired, did not exhibit behaviors, required assistance of 1 person for transfers, and supervision with ambulation. Between 12/22/22 at 11:59 AM and 12/28/22 at 12:54 PM, there were several observations of Resident #145 in their unit restless, crying, yelling, and walking up and down the hallway. The CCP related to dementia and cognition initiated 03/24/2022 documented Resident #145 will make their needs known with interventions that include staff anticipating resident needs, assessing level of resident involvement, assisting with decision making, counseling, maintaining a calm environment, monitoring for changes, providing reality orientation, providing support/reassurance, and redirection and recall. The CCP did not document review or revision since being initiated on 3/24/22. The CCP related to behavior symptoms initiated 4/18/22 documented Resident #145 exhibits wandering and socially inappropriate behavior. Interventions to address Resident #145's behavior included encouraging resident participation in activities of daily living (ADLs), escorting resident to a private area if needed, notifying the Medical Doctor (MD) for resident to be assessed medically, orienting the resident to daily routines, and redirecting resident's negative behaviors. The CCP did not document review or revision since being initiated on 4/18/22. Social Work Note dated 4/17/22 documented Resident #145 wandered into another resident's room. Counselling was ineffective and Resident #145 presented with impaired cognition. SW notes dated 5/11/22, 7/31/22 and 12/28/22 documented Resident #145 requires reminders and redirection to refrain from inappropriate behaviors. Resident #145 has a history of wandering. Psychiatry consult dated 10/7/22 documented Resident #145 was confused with physical agitation, restless, and wandering. Psychiatric medications include Quetiapine 25 mg by mouth (po) twice a day (BID) Mirtazapine 30 mg po at night, Aricept 10 mg po at night, and Depakote sprinkles 125 mg po three times a day (TID). Nursing Note dated 11/09/22 documented Resident #145 was pacing around the unit, entering other residents' room, opening different doors, talking to self. Resident#145 does not follow directions, screams, hits, and yells at staff members. Psychiatry consult dated 12/01/22 documented Resident #145 was confused, agitated, delusional, and recommended to increase Quetiapine to 50 mg po bid. Nursing Note dated 12/11/22 documented Resident #145 was observed with increased agitation, yelling, cursing at staff and other residents. When redirected, Resident #145 became very aggressive and attempted to hit other residents and staff. There was no documented evidence Resident #145's CCP related to dementia and related behaviors was reviewed and revised to address cognitive loss and wandering. On 12/29/22 at 11:56 AM an interview conducted with Certified Nursing Assistant (CNA) #3 who stated Resident #145 is confused and has a behavior of screaming and wandering but never attempts to leave the unit. CNA#3 redirects Resident #145's behavior and informs the nurse but does not document Resident #145's behaviors in the medical record. CNA #3 cannot recall receiving dementia inservice. On 12/29/22 at 03:00 PM, an interview was conducted with License Practical Nurse (LPN) #4, who stated Resident #145 is confused, has continuous agitation, and wanders the unit. It is very difficult to redirect Resident #145. LPN #4 cannot recall receiving dementia inservice recently. On 12/29/22 at 03:26 PM, the Director of Social Services (DSS) was interviewed and stated the SW Department is responsible for reviewing resident CCPs related to cognition and behavior. The CCPS are supposed to be reviewed quarterly, annually, upon significant change, and as needed. Resident #145 did not have a change in status and new interventions were not added to their CCPs. On 12/29/2 at 03:50 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated the Registered Nurse (RN) on duty is responsible for overseeing CCPs. Each department has issues with updating medical records and the ADNS was unsure if this was related to care planning. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews conducted during the Recertification survey from 12/22/22 to 01/05/22, the facility did not ensure infection control practices were maintained. This was evident for 1 (Resident #168) of 1 resident(s) reviewed for respiratory care out of 39 total sampled residents. Specifically, Licensed Practical Nurse (LPN) #7 placed sterile gauze and saline solution on the resident's bed and did not perform hand hygiene during Resident #168's tracheostomy care (TC). The findings are: The facility policy titled Tracheotomy Care last reviewed 09/2022 documented position resident for comfort and accessibility to the site and suction tracheostomy tube. Then remove the tracheostomy dressing, doff gloves, perform hand hygiene, and open disposable inner cannula package. Resident #168 had diagnoses of tracheostomy status and dysphagia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #168 had mild cognitive impairment and received suctioning and TC. On 12/29/22 at 10:06 AM, Resident #168 was observed lying in bed with LPN #7 present in the room. LPN #7 initiated TC for Resident #168 by washing their hands, placing a gauze package and normal saline bottles on the resident's bed, and donning 2 pairs of gloves. LPN #7 picked up a washcloth, wet the washcloth with tap water, and used the washcloth to wipe around Resident #168's stoma. The tracheostomy Velcro straps were untied, LPN #7 removed the disposable inner cannula, and the cannula was thrown in the garbage. Hand hygiene and glove change was not performed and LPN #7 soaked gauze pads with normal saline, placed the gauze pads on Resident #168's stoma, and instructed the resident to cough. As the resident coughed, LPN#7 collected sputum on the gauze and threw it in the garbage. Resident #168 was asked to cough again, and LPN #7 collected sputum onto the gauze a 2nd time. LPN #7 removed 1 pair of gloves from their hands, picked up gauze, wet the gauze with normal saline, and used the gauze to wipe Resident #168's tracheostomy site. Hand hygiene was not performed, and the Velcro straps were not changed. LPN #7 inserted the new disposable inner trach cannula into the stoma, connected Resident #168's tracheostomy to the oxygen concentrator at bedside and removed their gloves. MD Order initiated 08/29/2022 and last renewed 12/21/22 documented provide TC every shift and as needed, suction tracheostomy secretions every shift and as needed, and change tracheostomy Velcro strap daily and as needed. On 01/04/23 at 12:33 PM, LPN #7 was interviewed and stated they are aware that placing items on the Resident #168's bed was an infection control breach. On 01/04/23 at 04:06 PM, the Assistant Director of Nursing (ADNS)/Infection Preventionist was interviewed and stated a Respiratory Therapist came to the facility to provide an TC inservice to nursing staff. The ADNS could not recall the date of the TC inservice and did not know when infection control competencies were done for nursing staff providing TC care. The Director of Nursing (DNS) and ADNS work together to provide infection control inservices with the ADNS concentrating mostly on the evening and night shifts. On 12 /29/22 at 1:00PM, the DNS was interviewed and stated TC competency evaluations have not been performed with nursing staff in the 1 ½ years the DNS has worked for the facility. The DNS has only concentrated on the core competency evaluations because the facility was behind. 415.19 (a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the Recertification survey from 12/22/22 to 1/5/23 the facility did not ensure resident Comprehensive Care Plans (CCP) were reviewed and revised with each assessment and as needed with interventions to reflect the resident's changing needs. This was evident for 2 (Resident #98 and #62) of 39 total sampled residents. Specifically, 1.) multiple CCPs for Resident #98 that were not reviewed and revised upon quarterly Minimum Data Set 3.0 (MDS), and 2.) the CCP related to nutrition and activities of daily living (ADL) were not reviewed and revised for Resident #62. The findings are: The facility policy titled Care Planning dated 12/14/2021 documented CCPs for each resident are individualized and based on assessments done at the time of admission, quarterly, annually, and when there is a change in condition. 1.) Resident #98 had diagnoses of dementia and schizophrenia. The MDS dated [DATE] documented Resident #98 was moderately cognitively impaired and required assistance with ADLs. The CCP related to psychotropic drug was initiated 9/9/20, last updated 9/15/22, documented Resident #98 received medication for schizophrenia and depression, and documented resident be monitored for changes in mood and behavior. The CCP related to advance directives was initiated 10/19/20, last updated 8/21/22, and documented Resident #98's guardian will be reeducated re: advance directives. The CCP related to mental illness and IPRO Level II was initiated 10/19/20 and documented Resident #98 had a diagnosis of schizophrenia and will be monitored for significant mood and behavior changes. There was no documented evidence multiple CCPs for Resident #98 were reviewed and revised upon quarterly MDS assessment dated [DATE]. 2) Resident #62 had diagnoses of dementia and cirrhosis. The significant change MDS dated [DATE] documented Resident #62 was severely cognitively impaired, required extensive assistance of 1 person for eating, and had a significant weight loss within the past 6 months. The CCP related to risk for altered nutrition status was initiated 1/19/22, last updated 3/16/22, and documented Resident #62 would be assisted with feeding and have weights monitored to address significant weight loss. The CCP related to ADLs was initiated 10/18/21, last updated 7/31/22, and documented Resident #62 will have function level assessed and required extensive assistance with eating. The CCPs related to nutrition status and ADLs were not reviewed and revised upon Resident #62's significant change MDS dated [DATE]. An interview was conducted on 12/28/22 at 12:04 PM with the Registered Nurse Supervisor (RNS) #1 the residents' CCPs are reviewed every 3 months and if there is a change in resident care. Each department is responsible for updating their own CCPs. On 12/28/22 at 12:30 PM, Social Worker #2 was interviewed and stated CCPs are not reviewed unless there is a change. If there is a change in the resident's condition, the Social Worker will update the CCP. CCPs are updated annually. On 1/3/23 at 11:39 AM, the Registered Dietitian (RD) was interviewed and stated they reviewed Resident #62's CCP related to nutrition in December of 2022 and there were no new interventions. On 12/29/22 at 10:44 AM, the MDS Coordinator was interviewed and stated each department is responsible for completing their own CCPs quarterly, annually, and upon significant change. The CCPs should be updated during a resident's CCP meeting. The MDS Coordinator will randomly spot check CCPs to ensure completion. On 12/28/22 at 12:53 PM, the Director of Nursing (DNS) was interviewed and stated the MDS department is responsible for updating the nursing CCPs if there is a change in condition and according to the MDS schedule. 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification and Complaint (NY00293868 and NY00297460) survey from 12/22/22 to 01/05/23, the facility did not ensure there was sufficient nursing staff available to meet the residents' needs considering the number, acuity and diagnoses of the facility's resident population as determined by the Facility Assessment (FA). This was evident during review of Sufficient Staffing. Specifically, 1.) Resident #120's wound care was not administered daily according to Medical Doctor Order (MDO), 2.) during the Resident Council Meeting, Resident #82, #100, and #165 reported there are times when there is no nurse on the unit , and 3.) the actual staffing for Licensed Practical Nurses (LPN) was less than the necessary LPNs as determined by the FA. The findings are: 1) Resident #120 had diagnoses of chronic non-pressure right lower leg ulcer with necrosis and chronic pain. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #120 was cognitively intact, did not reject care, and had surgical wounds. On 12/30/22 at 10:19 AM, wound care observation of Resident #120 was conducted, and the right ankle and right lateral lower leg wounds had large amounts of white and brown exudate. On 12/30/2022 at 10:25 AM, Resident #120 was interviewed and stated at times, they wait several hours for the nurse to provide wound care treatments, but no one comes to do it. Prior to this morning, wound treatment and dressing change was not done for Resident #120 since last week. The Treatment Administration Record (TAR) for November 2022 documented Resident #120 was started on calcium alginate with silver dressing for wounds to the right lateral ankle and below the right lateral ankle as of 10/12/22. The TAR documented treatment was not administered on 11/8/22 and 11/9/22. On 11/9/22, the treatment order was changed to Dakins cleanse, iodosorb cream, and calcium alginate to surgical wound on right lateral ankle and below the right lateral ankle. The TAR documented treatment was not administered on 11/26/22, 11/27/22, and 11/30/22. On 1/3/2023 at 1: 28 PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated prior to providing wound care treatment, LPN #2 refers to the TAR to ensure the treatment is being provided according to MD Order. LPN #2 reviewed the TAR for Resident #120 and stated they were so busy; they fell behind on providing wound care. The wound care not done, per the TAR documentation, was unacceptable. 2.) Resident #82 had diagnoses of anxiety disorder and bipolar disorder. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #82 had moderate cognitive impairments and required staff assistance with Activities of Daily Living (ADL). Resident #100 had diagnoses of schizoaffective disorder and hypertension. The MDS dated [DATE] documented Resident #100 had mild cognitive impairment and required supervision and staff assistance to perform ADLs. Resident #165 had diagnoses if paraplegia and schizophrenia. The MDS dated [DATE] documented Resident #165 was cognitively intact and required supervision and staff assistance to perform ADLs. During a Resident Council Meeting held on 12/28/2022 at 3:00 PM, Resident #82 stated sometimes there is no nurse on the floor and medications are not given all the time. Resident #100 stated sometimes there is no nurse on the unit, and it is a big problem. Resident #165 stated sometimes they don't see a nurse on the unit. 3.) On 12/27/22 at 09:34 AM, the Minimum Data Set 3.0 (MDS) Coordinator was interviewed and stated the Director of Nursing (DNS) is currently acting as Nursing Supervisor because Registered Nurse (RN) #1, the regularly scheduled Nursing Supervisor, must give out medications and cover the charge nurse position on the 6th floor. On 12/30/22 at 10:39 AM, the 3rd floor was observed with a census of 33 residents and a charge nurse was not stationed on the unit yet. FA last reviewed 2/22/2022 documented the facility required 5 LPNs per shift (7AM-3PM, 3PM-11PM, 11PM-7AM) to adequately care for the resident population. Actual Daily Staffing Schedules documented insufficient LPNs with the DNS assigned as LPN on various shifts on the following dates: 10/2/22, 10/3/22, 10/5/22 ,10/6/22 , 10/7/22, 10/10/22, 10/11/22, 10/12/22, 10/15/22, 10/25/22, 10/26/22, 10/27/22, 10/29/22, 10/31/22, 11/1/22, 11/10/22, 12/1/22, and 12/30/22. Daily Posting of Nursing Staff documented the following actual working staff: 12/27/2022 Census 183 7-3 RN 5 LPN 4 CNA 17 12/28/2022 Census 181 7-3 RN 5 LPN 4 CNA 17 12/29/2022 Census 181 11-7 RN 1 LPN 4 CNA 10 12/30/2022 census 184 7-3 RN 5 LPN 3 CNA 18 01/03/2023 Census 181 7-3 RN 3 LPN 4 CNA 18 01/04/2023 Census 177 7-3 RN 4 LPN 3 CNA 21 On 12/30/2022 at 1:00 PM, Certified Nursing Assistant #1 stated there are days the unit has no nurse, and the Nursing Supervisor is called so the CNA can give out meal trays. On 01/05/23 at 11:59 AM, LPN #1 was interviewed stated they cannot complete medications on time because sometimes they are pulled into another unit to give medications because there is no nurse in that unit. LPN #1 further state sometimes they worked without break and need to stay after their shift to complete their work. On 01/04/23 at 03:11 PM, night Nursing Supervisor, RN#3, was interviewed and stated if they are unable to cover someone calling out sick, RN #3 will cover the floor and give out medications. There are a lot of sick calls, and the nurses are difficult to replace. On 1/0/5/23 at 12:17 PM, the MDS Director was interviewed and stated they were asked to give out medications on the 4th floor on morning of 1/3/23 because there was no nurse. The nurse scheduled to work on the evening shift came in before 3 PM and relieved the MDS Director. On 12/28/22 at 04:39 PM, the DNS was interviewed and stated staffing is a big challenge. The DNS acts as Nursing Supervisor on various shifts when the nurses are short staffed. The DNS comes to work on the weekends when there is no medication nurse, and the gives out medications to the residents. The pay rate of the facility is not competitive, and their staffing agencies are unable to give an adequate number of licensed nursing staff. On 12/30/22 01:03 PM, the DNS was interviewed and stated there is currently no LPN working on the 3rd floor and they were unaware whether residents receive their medications. LPNs from other units have been assigned to cover the 3rd floor charge nurse responsibilities. There are nursing staff that work 2 jobs. The night nurse had to go to another facility to work this morning and had to hand over the nursing department keys to the Assistant Director of Nursing to leave. Between 12/30/22 at 10:34 AM and 01/05/23 at 12:15 PM, the Administrator was interviewed various times and stated staffing is a part of the facility's quality assurance and monthly staff meetings. The facility is doing its best to recruit nursing staff by looking at different nursing staffing agencies, hiring nurses directly, giving bonuses upon hire and for staff working extra shifts. On 12/30/22, no nurse showed up to the 3rd floor and the DNS, ADNS, and one other nurse had to divide charge nurse responsibilities for the unit. The DNS gives out medications when there is no LPN as charge nurse on the units. 415.13 (a)(1) (i-iii)

**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 ensure that each resident remained free from physical restraints not required to treat the resident's medical symptoms for 2 of 2 residents (Resident #157 and Resident #7) reviewed for Physical Restraints. Specifically, 1) Resident #157, with severely impaired cognition, had a physician's order to use a wheelchair for mobility. The resident was issued a reclining Geri-chair without an evaluation by a qualified health care professional and a physician's order. 2) Resident #7 continued to utilize two half side rails without evaluation and assessment by a qualified healthcare professional to determine the need for the side rails. The findings are: 1) The facility Restraints policy dated 1/2008 documented, any device that restricts freedom of movement, including any chair that prevents rising, is considered a restraint. The undated facility policy on Orthotics and Positioning Devices documented that all residents are assessed for positioning devices as appropriate on admission, readmission, quarterly and as needed. Resident #157 was admitted with diagnoses of Non-Alzheimer's Dementia, Seizure Disorder, and Bipolar Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #157 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition. The MDS documented that Resident #157 required limited assistance of one person for locomotion on the unit and extensive assistance of one person for locomotion off the unit. Resident #157 had a Wheelchair as a mobility device. The physician (MD) orders from 9/16/19 to 12/11/19 documented out of bed to wheelchair with one person assistance. The Mobility Comprehensive Care Plan (CCP) dated 5/8/19 documented that Resident #157 was chair-fast in a wheelchair. The Activities of Daily Living CCP dated 8/12/19 documented Resident #157 required supervision and set up help only for locomotion on and off the unit. The mobility care plan evaluation note dated 10/17/19 documented Resident #157 might benefit from Occupational Therapy (OT) for wheelchair positioning. The nurse's note dated 10/20/19 at 9:15 PM documented that Resident #157 was on the floor mat sleeping. The supervisor was notified and Resident #157 was placed in a reclining chair (Geri-chair). The medical record lacked documented evidence of an assessment by a qualified professional for the use of a Geri-chair for Resident #157. The medical record lacked documented evidence of a physician's order for the use of Geri-chair for Resident #157. The mobility CCP evaluation note dated 10/23/19 documented that Resident #157 fell and received a Physical Therapy (PT) screen. There was no significant change in bed mobility or transfer. The note documented that Resident #157 might benefit from OT for wheelchair positioning. The mobility care plan evaluation note dated 10/24/19 documented that Resident #157 fell and was seen at the bedside. Resident #157 had no significant change in functional mobility during bed mobility and transfer. The medical record lacked documented evidence of an OT screen from 10/2019-11/2019. The Certified Nursing Assistant (CNA) Accountability Record (CNAAR) for November 2019 and December 2019 documented locomotion via wheelchair with limited assistance of one person. The locomotion instruction for November 2019 and December 2019 documented out of bed to a wheelchair with assistance of one person. The tasks section documented wheelchair use in the room, hallway, and for locomotion on and off the unit. The OT evaluation dated 12/2/19 documented that Resident #157 was referred to OT due to a decrease in functional mobility, strength, transfers, and balance. Resident 157's previous level of functioning for wheelchair mobility required supervised assistance and his current level was total dependence without attempts to self-initiate wheelchair propulsion. The long-term goals of OT include increasing Resident #157's ability to safely propel self in a wheelchair, 100 feet with supervised assistance and to return to the prior level of function. The Physical Therapy (PT) evaluation dated 12/2/19 documented that Resident #157's level of assistance changed from contact guard to maximal assistance of two persons for transfers. Resident #157 was observed on 11/27/19 at 9:57 AM. Resident #157 was transported in a reclined Geri-chair from the dayroom to his room by a CNA. The 7:00 AM - 3:00 PM shift CNA #1 was interviewed on 12/2/19 at 2:08 PM. CNA #1 stated that she was the assigned CNA for Resident #157 since 10/18/19. CNA #1 stated that Resident #157 used to be in a wheelchair, however, the Licensed Practical Nurse (LPN) Charge Nurse ordered a Geri-chair because Resident #157 had some falls due to sliding out of the wheelchair. The 7:00 AM - 3:00 PM shift LPN Charge Nurse was interviewed on 12/02/19 at 2:19 PM. The LPN Charge Nurse stated that she did not order a Geri-chair for Resident #157 and did not know how Resident #157 received the Geri-chair. The LPN Charge Nurse stated that usually the rehabilitation department evaluates residents to determine if a change in a chair is necessary. The 7:00 AM- 3:00 PM shift Nursing Coordinator was interviewed on 12/2/19 at 2:23 PM. The Nursing Coordinator stated that she did not know how Resident #157 received a Geri-chair and there is supposed to be a doctor's order for the use of a Geri-chair. The Nursing Coordinator stated that currently there is no physician's order for the use of the Geri-chair for Resident # 157. The Occupational Therapist (OT) #1 was interviewed on 12/2/19 at 2:53 PM. OT #1 stated that there was no assessment for Resident #157's use of a Geri-chair. OT #1 stated that unless there was an emergency, a Geri-chair should not be issued to any resident without an assessment by the rehabilitation department for its appropriateness. The 7:00 AM - 3:00 PM shift CNA #2 was interviewed on 12/3/19 at 11:41 AM. CNA #2 stated that she was the assigned CNA for Resident #157's prior to 10/18/19. Resident #157 was using a wheelchair and was able to self-propel throughout the unit. CNA #2 stated the resident required close supervision because he used to lean forward while sitting in the wheelchair. CNA #2 did not know who issued the Geri-chair to Resident #157. The Director of Rehabilitation was interviewed on 12/03/19 at 12:06 PM. He stated that Resident #157 required one person assistance for transfer and used a regular wheelchair. Resident #157 was able to move on and off the unit with the wheelchair. The Director of Rehabilitation stated that on 10/17/19, 10/23/19 and 10/24/19, he assessed Resident #157 related to a fall. Resident #157 had no change in the level of functioning. The Director of Rehabilitation stated that he made a referral for OT to evaluate Resident #157 for wheelchair positioning. The Director of Rehabilitation stated that there was no documentation indicating an OT evaluation was ever completed. The Director of Rehabilitation stated that he or the OT did not issue a Geri-chair to Resident #157. On 12/2/19 the Rehabilitation Department conducted an evaluation for Resident #157 after the Geri-chair use was questioned. Resident #157 had a significant decline in mobility since 9/13/19 when Resident #157 was discharged from the Rehabilitation services. Resident #157 will now receive Restorative services from Physical and Occupational Therapy. The Director of Nursing Services (DNS) was interviewed on 12/3/19 at 2:55 PM. The DNS did not know when and who issued the Geri-chair to Resident #157. The DNS stated that normally the Nursing staff would send a referral to the Rehabilitation department. After an assessment, the rehabilitation staff would recommend equipment/assistive devices needed for the residents such as a wheelchair or the Geri-chair. A physician's order would be placed for the use of the suggested assistive devices. The Nursing Department would subsequently update the Resident Care Profile and Care Plan to include the use of new equipment/assistive. The Administrator and the DNS were concurrently interviewed on 12/3/19 at 4:59 PM. The Administrator and the DNS stated that Resident #157 should have been assessed for the use of the Geri-chair to determine if the reclining Geri-chair would limit Resident #157's mobility. Resident #157 was previously able to self-propel a wheelchair on and off the unit however, the resident was not able to self-propel after he was placed in the Geri-chair. 2) The facility Restraint policy dated 1/08 documented that any device that the resident cannot easily remove and restricts freedom of movement, including bed rails, is considered a restraint. The purpose of restraints is to enable the resident to attain or maintain his highest practical level of functioning and to help the resident sit upright and prevent falls from a bed to a wheelchair. Resident #7 was admitted to the facility with the diagnoses of Non-Alzheimer's Dementia, Schizophrenia, and Anxiety Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #7 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severely impaired cognition. The MDS documented that Resident #7 required extensive assistance of two persons for bed mobility. The physician (MD) orders dated 7/27/18 to 12/15/19 documented Resident #7 may use two half side rails for unawareness of bed boundaries. The Certified Nursing Assistant (CNA) Accountability Record (CNAAR) dated November 2019 and December 2019 documented Resident #7 required extensive assistance of two persons for bed mobility. Resident #7 had impaired cognition, was a high risk for falls and used two 1/2 side rails when in bed. The Physical Therapy Discharge summary dated [DATE] documented that Resident #7 required moderate assistance with bed mobility. The discharge recommendations included environmental modifications, low bed, floor mats, and an air mattress. The ADL Comprehensive Care Plan (CCP) dated 11/22/19 documented that Resident #7 required total dependence of one person for bed mobility and total dependence of two persons for transfers. There were no Care Plans addressing bed rail use in the medical record as of 12/3/19. Resident #7 was observed lying in bed on 11/27/19 at 10:11 AM. Resident #7's bed had bilateral ½ side rails up. Resident #7 stated she did not know why the rails were up. The 7 AM-3 PM CNA was interviewed on 12/03/19 at 11:30 AM. The CNA stated that she has worked regularly with Resident #7 for months. The CNA stated that Resident #7 is not able to move in the bed and needs total assistance of two persons for positioning in the bed. The CNA stated for as long as she has worked with Resident #7, Resident #7 never could use the side rails to move in the bed. The Rehabilitation Director was interviewed on 12/03/19 at 12:38 PM. The Rehabilitation Director stated that Resident #7 was discharged from Physical Therapy (PT) on 7/20/18 and required moderate assistance of one person for bed mobility and has not been re-evaluated for rehabilitative services since the discharge from PT. The Rehabilitation Director stated that he never received a referral for Physical Therapy to address changes in bed mobility. The Rehabilitation Director stated that the use of side rails is solely for getting in and out of bed and as an enabler for bed mobility. If Resident #7 has no use of the bed rails and is totally dependent on staff for bed mobility, the bed rails should no longer be in use and would be considered a restraint. The Registered Nurse (RN) Supervisor was interviewed on 12/3/19 at 1:43 PM. The RN Supervisor stated that there were no side rail assessments for Resident #7. She stated the use of the side rails was not addressed in any of the care plans in the medical record. The RN Supervisor stated that there should be an ongoing care plan for the use of side rails. The RN Supervisor stated that Resident #7 is totally dependent on staff for repositioning and cannot get out of the bed without assistance. The Administrator and the DNS were concurrently interviewed on 12/3/19 at 4:59 PM. The Administrator and the DNS stated that Resident #7 should have been assessed for the use of the side rails. The Administrator stated that the bed rails are also used as a fall prevention measure. The Administrator stated that she was not very clear how the use of side rails is considered a restraint for an individual who is cognitively impaired and has no use for side rails. 415.4(a)(2-7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey, the facility did not ensure that care was implemented according to each residents' person-centered plan of care for one (Resident #6) of one resident reviewed for Rehabilitation and one (Resident #143) of one resident reviewed for Dialysis. Specifically, 1) Resident #6 had a Physician's order for a floor ambulation program (FAP) with a quad cane. The FAP was not done on [DATE] and [DATE] because the quad cane was not available, and 2) Resident #143 had a Physician's order for the Arterio-Venous (AV) shunt to be monitored every shift for bruit and thrill; however, there was no documented evidence that the bruit and thrill were checked every shift. The findings are: 1) The facility's undated policy titled Nursing Restorative documented that nursing restorative services recommended by therapy staff include floor ambulation plan. Nursing restorative services are performed by Certified Nursing Assistants (CNA) as ordered. Documentation of nursing services are indicated by daily accountability of performance by the CNAs. Resident #6 has diagnoses including Cerebrovascular Accident, Hemiplegia, and Depression. The [DATE] Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident required extensive assistance of one person for transfers, and that walking in the room or corridors had not occurred. The [DATE] Physical Therapy (PT) discharge summary documented a recommendation for FAP, 100 feet, with Hemi-walker with a contact guarding twice a day. A Physician's order dated [DATE] documented Floor Ambulation Program (FAP), 100 feet using a quad cane with the limited assistance of one person twice daily. A Comprehensive Care Plan (CCP) titled, Mobility, dated [DATE] updated [DATE], documented the resident was discharged from Restorative Physical Therapy (PT) and has reached maximum level of Rehabilitation (Rehab) potential. An update added on [DATE] documented the resident was to start nursing rehab: FAP times (x) 100 feet using a quad cane with limited assistance of one person twice daily. Resident #6 was interviewed on [DATE] at 12:06 PM. The resident stated that he was receiving rehab and now rehab has ended. The Rehab Director was interviewed on [DATE] at 11:41 AM. He stated that the resident achieved maximum plateau for rehab and was discharged from rehab on [DATE]. He stated the resident was now on a floor ambulation program of 100 feet twice daily with supervision using a quad cane. Resident #6's Certified Nursing Assistant (CNA) was interviewed on [DATE] at 11:47 AM. She stated she had worked over the past weekend ([DATE] and [DATE]) and the FAP was not done over the weekend because the quad cane was locked in the rehab department. She stated she tried to get the Maintenance Department to open the rehab department door, but there was no Maintenance personnel available. Review of the CNA Accountability Record (CNAAR) for [DATE] and [DATE] revealed the FAP was not signed as being performed on [DATE] and [DATE]. The Licensed Practical Nurse (LPN) Charge nurse, Rehab Director, and CNA were interviewed concurrently on [DATE] at 12:09 PM. The Rehab Director stated he was not aware why the quad cane was in the rehab department over the weekend. The CNA stated the quad cane cannot be left in the resident's room because the resident may try to use it himself, so the quad cane is put in the bathroom. The LPN stated someone took the quad cane out of the bathroom and put the quad cane in the rehab department, but she did not know who. The Rehab Director stated that the rehab department is only open Monday-Friday and closed on the weekend and the rehab doors were locked over the weekend. The Director of Nursing Services (DNS) was interviewed on [DATE] at 10:22 AM. She stated the facility staff will need to find a different location for the quad cane. The Maintenance Director was interviewed on [DATE] at 11:22 AM. He stated the nursing supervisor had the key to the rehab room. He stated if the staff reached out to the nursing supervisor, that would have remedied the situation. 2) The facility's policy and procedure titled Dialysis, dated 9/2009, documented that shunts are to be monitored for infection or problems and the dialysis center to be notified of any problems. Resident #143 has diagnoses including End-Stage Renal Disease, Hypertension, and Coronary Artery Disease. The [DATE] Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS documented that the resident was receiving Dialysis services. A Physician's order, effective [DATE] and renewed on [DATE], ordered to Check Left Arm Arterio-Venous (AV) Graft Site every shift for bruit and thrill. A Physician's order, effective [DATE] and renewed on [DATE], ordered Hemodialysis Tuesday, Thursday, Saturday; Check Vital Signs, Weight, and Hemodialysis access site before going to Hemodialysis. A Comprehensive Care Plan (CCP) titled, Endocrine, effective [DATE] and last updated [DATE], documented that the resident received dialysis, had an intervention to check bruit and thrill, and to monitor the dialysis AV graft. Review of nursing progress notes from [DATE]-[DATE] revealed documentation of bruit and thrill monitoring as follows: [DATE] at 6 am, [DATE] at 3 pm, [DATE] at 3 pm, [DATE] at 10 pm, [DATE] at 6 am, [DATE] at 3 pm, [DATE] at 10 pm, [DATE] at 6 am. Resident #143 was observed lying in bed on [DATE] at 9:03 AM. The resident stated there was a dialysis graft to his left upper arm. The resident was wearing a long sleeve sweater, therefore, the site was not able to be observed. The Licensed Practical Nurse (LPN) medication/treatment nurse was interviewed on [DATE] at 10:23 AM. She stated she did not check bruit and thrill on non-dialysis days. She stated she only checks bruit and thrill before the resident goes to dialysis and documents in the nursing progress notes because the resident did not have a Treatment Administration Record (TAR). She stated she worked on the 7 AM - 3 PM shift on [DATE] (non-dialysis day) and did not check for bruit and thrill that day. The LPN who worked the 3 PM - 11 PM shift on [DATE] was interviewed on [DATE] at 12:50 PM. She stated she assesses for bruit and thrill and documents in the progress notes on dialysis days. She stated she would document on a non-dialysis day only if there was an abnormality. The Registered Nurse (RN) unit supervisor was interviewed on [DATE] at 10:47 AM. She stated the bruit and thrill monitoring should have been documented in the nursing progress notes every shift. The Director of Nursing Services (DNS) was interviewed on [DATE] at 10:23 AM. The DNS stated that instruction for checking the bruit and thrill was under a general order and did not appear on the TAR. The order should have been under the treatment orders so the order would appear on the TAR and the nurses would have been prompted to monitor the bruit and thrill every shift. 415.11(c)(1)