Based on observations, record review, and interviews conducted during an abbreviated survey (NY00360005), the facility did not ensure a resident's designated representative was notified of changes in condition. This was evident in one out of three residents (Resident #2) sampled. Specifically, a Health Status Note dated 11/05/2024 documented Resident #2 complained of left eye pain. An assessment was done and revealed mild swelling to the left eye. The Medical Doctor was informed and an ordered for Diclofenac eye drops. There is no documented evidence that Resident #2's designated representative was notified of the changes in condition. The findings are: The facility policy titled: Family Notification revised 01/2025 documented it is the facility's policy to notify the resident, the representative/designee or guardian whenever there is a transfer, room change and change in the resident's condition. Resident #2 was admitted to the facility with diagnoses including Hypertension and Cerebrovascular Accident (a medical term for a stroke). The Minimum Data Set (an assessment tool), dated 09/26/2024, documented Resident #2 had moderate cognitive impairment. A Health Status note dated 11/05/2024 documented Resident #2 complained of left eye pain, an assessment revealed no eye redness or discharge. Pain at the edge of the left upper eyelid when touched and mild swelling observed. The Medical Doctor was informed and ordered Diclofenac eye drops to the left eye three times daily for seven days. An Attending Physician/Provider note dated 11/06/2024 documented Resident #2 was assessed and observed with mild swelling around their left eye. No evidence of acute infection. Plan was to start eye drops to reduce inflammation and any discomfort. If no improvement in the next twenty-hour to thirty -six hours, oral antibiotics will be started. A Physician's Order dated 11/05/2024 documented instill one drop pf Diclofenac Sodium Ophthalmic Solution 0.1 % in the left eye three times a day for left eye pain for seven days. There was no documented evidence that Resident #2's representative was notified. A Social Service note dated 11/07/2024 documented Resident #2's representative visited and observed that Resident #2's left eye was slightly puffy. The representative stated they were not informed of the resident's condition. During an interview on 03/05/25 at 9:49 AM, Social Worker #2 stated that on 11/07/2024 at 4:43 PM Resident #2's representative approached them into their office and reported that they were not informed about Resident #2's left eye. Social Worker #2 stated the policy is to call the resident's family if there is a change in condition or if the resident is being discharged to the hospital. The Social Worker stated that the policy states that nurse is supposed to call the family if there is a change in condition. During an interview on 03/05/2025 at 3:38 PM, Registered Nurse Supervisor #2 stated they assessed Resident #2 on 11/05/2024 and Resident #2 complained of pain while pointing to their left lower eye. The Medical Doctor was notified and assessed Resident #2. The Registered Nurse Supervisor #2 stated that the Medical Doctor ordered eye drops. Registered Nurse Supervisor #2 stated they do not recall notifying Resident #2's representative, however, Resident #2 was alert and oriented and able to understand their plan of care. Registered Nurse Supervisor #2 stated that the Medical Doctor discussed the plan of care with Resident #2. During a telephone interview on 03/11/2025 at 1:00 PM, the Director of Nursing stated the protocol is to always inform the family of any change in the resident condition, incident, physician's orders, and anything pertaining the resident. The Director of Nursing stated Resident #2 was alert, oriented and the Medical Doctor discussed with them about ordering eye drops to treat the discomfort and swelling and Resident #2 agreed with the Medical Doctor's plan of care. During a telephone interview on 03/11/2025 at 2:38 PM, that Administrator stated it is the facility's protocol to notify the family of resident's change in condition, fall, incident, hospital transfer, etc. the Administrator stated that Resident #2's representative should have been notified of Resident #2's eye condition. 10 NYCRR 415.3(f)(2)(ii)(c)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00372860), the facility did not ensure that a resident was free from abuse. This was evident for one (1) out of nine (9) residents (Resident #1) sampled. Specifically, the facility's dining room surveillance video recording dated 02/22/2025 showed at 9:05 AM Certified Nursing Assistant #1 hit Resident #1 on their left upper shoulder (once) with the back of their left hand, then walked out of the dining room, after Resident #1 threw liquid on Certified Nursing Assistant #1 who was standing behind them. Housekeeper #1, who was in the dining room, then walked over to Resident #1 and wheeled the Resident out of the dining room at 9:08 AM. Resident #1 was assessed by Registered Nurse Supervisor #1 with no visible injury, pain, or discomfort. The findings are: The facility's Policy and Procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property was revised on 08/2024. The policy states that each resident will be free from Abuse and will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Resident #1 was admitted to the facility with diagnoses including Hypertension (high blood pressure) and Schizophrenia (a chronic mental illness characterized by disruptions in thought processes, perceptions, emotions, and social interactions). The Minimum Data Set (an assessment tool) dated 01/09/2025 documented Resident #1 had severe cognitive impairment. The Comprehensive Care Plan titled: At Risk for Victimization dated 02/01/2024 documented Resident #1 was at risk for victimization due to observed verbal aggression and socially inappropriate behavior. The interventions documented to encourage verbalization of feelings and to observe for changes in mood, behavior, and affect. The dining room surveillance video (#1) recording dated 02/22/2025 showed at 9:05AM Certified Nursing Assistant #1 picked up Resident #1's meal tray and exited the dining room. Certified Nursing Assistant #1 returned to the dining room and went up behind Resident #1, used their right hand to tap the right side of Resident #1's wheelchair three times. Resident #1 in turn, picked up a cup and without looking tossed the content (liquid) of the cup behind them. The liquid spilled onto Certified Nursing Assistant #1 and onto the floor. Certified Nursing Assistant #1 hit Resident #1 on their left shoulder (once) with the back of their left hand and walked out of the dining room. Housekeeper #1 who was in the dining room rearranging the dining tables, turned around and saw Resident #1 throw the liquid and Certified Nursing Assistant #1 hit Resident #1 on their left shoulder with the back of their hand. Housekeeper #1 then walked over to Resident #1 and was talking to Resident #1 before escorting the resident out of the dining room. Camera view of the dining room ended. The unit hallway surveillance video (#2) recording dated 02/22/2025 showed at 9:08 AM on 02/22/2025, Housekeeper #1 escorted Resident #1 from the dining room to the nursing station and was observed having a conversation with Licensed Practical #1 (Housekeeper #1 was reporting the incident). Resident #1 was observed at the nursing station and a staff providing supervision. Licensed Practical Nurse #1 observed preparing/administering medication. Licensed Practical Nurse #1 observed having a conversation with Certified Nursing Assistant #1 (Licensed Practical Nurse stated they told Certified Nursing Assistant #1 to stop caring for residents). Certified Nursing Assistant #1 walked away from Licensed Practical Nurse #1 and could be seen on camera carrying linens into a resident room, then went into another resident's room (resident alert and oriented times three) with linens after Licensed Practical Nurse #1 spoke with them. Registered Nurse Supervisor #1 arrived on the unit at 10:14 AM. Certified Nursing Assistant #1 left the unit at 10:25 AM. An Incident Note dated 02/22/2025 by Registered Nurse Supervisor #1 documented at approximately 9:35 AM, Housekeeper #1 reported they witnessed Resident #1 tossed apple juice at Certified Nursing Assistant #1, and Certified Nursing Assistant #1 hit Resident #1 on their left should with the back of their hand. Resident #1 was assessed for any physical or emotional trauma. There were no physical injury or pain reported. The dining room camera was reviewed and showed at approximately 9:05 AM Certified Nursing Assistant #1 hit Resident #1. The facility's investigation dated 02/22/2025 documented at approximately 9:35 AM, Housekeeper #1 reported to Registered Nurse Supervisor #1 that they witnessed Resident #1 tossed back liquid at Certified Nursing Assistant #1. Certified Nursing Assistant #1 then hit Resident #1 on their left shoulder with the back of their hand. Resident #1 was assessed and there was no injury or complaints of pain. The facility concluded that abuse had occurred. Certified Nursing Assistant #1 was suspended and subsequently terminated. Staff were re-in serviced on abuse, neglect, mistreatment, and reporting. During a telephone interview on 03/03/2025 at 11:01 AM, Certified Nursing Assistant #1 stated on 02/22/2025 between 10:15 AM and 10:30 AM (not sure of the time), Resident #1 had completed their breakfast in the dining room. Certified Nursing Assistant #1 stated they were attempting to remove Resident #1's meal tray and the resident became excited and threw water at them. Certified Nursing Assistant #1 stated they did not hit Resident #1, but they rubbed Resident #1 on their back and told the resident not to throw anything at them. Certified Nursing Assistant #1 stated Housekeeper #1 was in the dining room and thought they had hit Resident #1. Certified Nursing Assistant #1 stated they did not react to Resident #1's behavior and walked away to care for another resident. Certified Nursing Assistant #1 stated while they were providing incontinent care to a resident (identified as alert and oriented times three) Licensed Practical Nurse #1 approached them and they showed Licensed Practical Nurse #1 their uniform and explained what Resident #1 had done. During an interview on 03/03/2025 at 9:22 AM Housekeeper #1 stated that on 02/22/2025 between 9:00 AM and 9:15 AM (not sure of the time) they observed Certified Nursing Assistant #1 walked up behind Resident #1 and Resident #1 threw juice at Certified Nursing Assistant #1. Certified Nursing Assistant #1 punched Resident #1 on their back with a closed fist. Housekeeper #1 stated they were standing at approximately 10-15 feet away from Resident #1 and Certified Nursing Assistant #1 when they heard a popping sound. Housekeeper #1 stated Resident #1 reported to them that Certified Nursing Assistant #1 punched them in their back. Housekeeper #1 stated they wheeled Resident #1 to the nurse and informed Licensed Practical Nurse #1. Housekeeper #1 stated they are aware that they should not have wheeled Resident #1 out of the dining room and that they could have used the phone in the dining room to call the nurse. Housekeeper #1 stated they were in-serviced on calling the nurse immediately and provide supervision to protect the resident. During a telephone interview on 03/06/2025 at 12:51 PM, Licensed Practical Nurse #1 stated at approximately 9:15 AM Housekeeper #1 informed them that they witnessed Certified Nursing Assistant #1 hit Resident #1 on their back. Licensed Practical Nurse #1 stated they did not report the incident immediately to Registered Nurse Supervisor #1 because they were in the middle of distributing medication. However, Registered Nurse Supervisor #1 arrived on the unit and was asking for Certified Nursing Assistant #1, as they were getting ready to inform Registered Nurse Supervisor #1 of the incident. Licensed Practical Nurse #1 stated Resident #1 was unable to explain what happened. Licensed Practical Nurse #1 stated they had instructed Certified Nursing Assistant #1 to stop working. Licensed Practical Nurse #1 they received in-service to report any incident t their supervisor immediately, stop the perpetrator from completing their assignment and monitor the resident or victim. During an interview on 03/03/2025 at 4:09 PM Registered Nurse Supervisor #1 stated at 9:30 AM Housekeeper #1 approached them with the Administrator on Duty and reported that they witnessed Certified Nursing Assistant #1 punch Resident #1. Registered Nurse Supervisor #1 stated they joined the Administrator on Duty between 9:45 AM and 9:50 AM and reviewed the surveillance video recording before going to the unit at approximately 10:10 AM because they did not receive a call from Licensed Practical Nurse #1. Registered Nurse Supervisor #1 stated the surveillance video recording showed Certified Nursing Assistant #1 hit Resident #1 on their left upper shoulder with an open hand (palm hitting the shoulder). Registered Nurse Supervisor #1 stated they assessed Resident #1 and there were no injuries and Resident #1 denied pain. Registered Nurse Supervisor #1 stated at approximately 10:20 AM they were on the unit looking for Certified Nursing Assistant #1 and saw them in a room and told them to stop what they were doing and report to the nurse's office. Registered Nurse Supervisor #1 stated they should have gone to the unit before watching the video. During an interview on 03/04/2025 at 8:54 AM Acting Administrator stated on 02/22/2025 at 10:25 AM Registered Nurse Supervisor #1 informed them that they removed Certified Nursing Assistant #1 from the unit. Acting Administrator stated after reviewing the surveillance video recording it was determined that abuse had occurred. Acting Administrator stated the surveillance video recording showed Certified Nursing Assistant #1 hit Resident #1 on the left upper shoulder with the back of their hand. Acting Administrator stated Resident #1 was assessed by Registered Nurse Supervisor #1 and Resident #1 did not complain of discomfort and there were no injuries. Acting Administrator stated that the Social Workers were called into the facility to conduct interviews with all residents on the unit. Acting Administrator stated that the Administrator was notified of the incident at 10:30 AM on 02/22/2025 and an ad hoc meeting was held via phone conference. Acting Administrator stated the Abuse policy was reviewed, and no changes were made. Acting Administrator stated that Certified Nursing Assistant #1 was suspended and later terminated. Acting Administrator stated all staff were reeducated on abuse and reporting and they also had discussions with the staff on how to protect residents from further abuse. During an interview on 03/04/2025 at 11:00 AM, Administrator stated Director of Nursing informed them on 02/22/2025 at 10:30 AM that Certified Nursing Assistant #1 hit Resident #1. Administrator stated they instructed Director of Nursing to remove Certified Nursing Assistant #1 off the unit and start an investigation. Administrator stated a conference was held on 02/22/2025 and in attendance was the Medical Director, Director of Nursing, Acting Administrator and the Administrator on Duty. Administrator stated they discussed the incident, reviewed the Abuse policy and instructed the Social Workers to go to the facility to interview all the residents on the unit. Administrator stated to prevent reoccurrence, all staff were reeducated on abuse and an audit tool was initiated to reinforce reporting. During a telephone interview on 03/11/2025 at 12:47 PM, the Director of Nursing stated they were informed of the incident by Registered Nurse Supervisor #1 on 02/22/2025 at approximately 10:19 AM. The Director of Nursing stated they notified the Administrator, and a meeting was held with the administrative team to discuss the incident. The Director of Nursing stated they instructed Registered Nurse Supervisor #1 to remove Certified Nursing Assistant #1 off the unit. The Director of Nursing stated they watched the surveillance video recording and had concluded that abuse did occur. The Director of Nursing stated they conducted in-services on abuse and reporting to all staff. The Director of Nursing stated that the staff were instructed to report any incident timely and not wait. The Director of Nursing stated to prevent reoccurrence, Certified Nursing Assistant #1 was suspended, abuse police was reviewed, and all staff were re in serviced on abuse and reporting. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the non-compliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey. A Plan of Correction is not required for this citation. The facility took immediate corrective actions and was found to incompliance on 02/24/2025, prior to Surveyors' onsite visit on 03/03/2025. On 02/22/2025, Policy and Procedure on Abuse was reviewed. No revisions were done. On 02/22/2025, facility re-in-serviced all staff members (nursing staff, housekeeping, administrative staff, Occupational/Physical Therapy staff, Security, Activity staff, Dietary staff etc.) on the following: Verbal Abuse, Sexual Abuse, Mental Abuse, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Property, Screening, Training, Prevention, Identification, Investigation, Reporting/Response, and Protection. The facility took immediate corrective actions. On 02/22/2025 at 10:25 AM Certified Nursing Assistant #1 was removed from the schedule immediately and subsequently terminated. On 02/22/2025 Resident #1 was assessed with no visible injuries or complaints of pain. On 02/22/2025 - Psychiatrist conducted a virtual evaluation of Resident #1. On 02/22/2025 - Abuse policy reviewed with no changes made. On 02/22/2025 a Quality Assurance and Performance Improvement meeting was held on. Topic: Resident #1 being hit on the back of their left shoulder by Certified Nursing Assistant #1. Attendance sheet with names of attendees obtained. On 02/22/2025 - assessment done on all cognitively impaired residents on the unit. On 02/22/2025 an audit done to identified residents with potential for abuse. On 02/22/2025 - all residents on the unit were interviewed to determine if they had experienced any abuse. 02/22/2025 all residents on CNA #1's assignment was interviewed to ascertain if abuse had occurred. On 02/22/2025 an in-service on Abuse, Mistreatment, Neglect and Misappropriation of Property, Protecting, and Reporting was completed. Target audience: All staff. Certified Nursing Assistants 33/33 in-serviced =100% Licensed Practical Nurses 15/15 in-serviced =100% Registered Nurses 15/15 in-serviced = 100% Dietary, Housekeeping, Rehab, Security, and Administrative staff 100% in-serviced. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews conducted during an Abbreviated Survey (NY00372860), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident in one out of nine (9) residents (Resident #1) reviewed. Specifically, the facility's dining room surveillance video recording dated 02/22/2025 showed at 9:05AM Certified Nursing Assistant #1 hit Resident #1 on their left shoulder after Resident #1 picked up a cup and without looking tossed the content (liquid) of the cup behind them (wetting Certified Nursing Assistant #1.) Housekeeper #1 who was in the dining room at the time stated that they heard a popping sound after Certified Nursing Assistant #1 hit Resident #1 on their shoulder. The facility did not report the allegation of abuse within 2 hours to law enforcement. The facility notified law enforcement at 12:08 PM. The findings are: The facility's Policy and Procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property was revised on 08/2024. The policy states the facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. Resident #1 was admitted to the facility with diagnoses including Hypertension (high blood pressure) and Schizophrenia (a chronic mental illness characterized by disruptions in thought processes, perceptions, emotions, and social interactions). The Minimum Data Set (an assessment tool) dated 01/09/2025 documented Resident #1 had severe cognitive impairment. The dining room surveillance video (#1) recording dated 02/22/2025 showed at 9:05AM Certified Nursing Assistant #1 picked up Resident #1's meal tray and exited the dining room. Certified Nursing Assistant #1 returned to the dining room and went up behind Resident #1, used their right hand to tap the right side of Resident #1's wheelchair three times. Resident #1 in turn, picked up a cup and without looking tossed the content (liquid) of the cup behind them. The liquid spilled onto Certified Nursing Assistant #1 and onto the floor. Certified Nursing Assistant #1 hit Resident #1 on their left shoulder (once) with the back of their left hand and walked out of the dining room. Housekeeper #1 who was in the dining room rearranging the dining tables, turned around and saw Resident #1 throw the liquid and Certified Nursing Assistant #1 hit Resident #1 on their left shoulder with the back of their hand. Housekeeper #1 then walked over to Resident #1 and was talking to Resident #1 before escorting the resident out of the dining room. Camera view of the dining room ended. The facility's investigation dated 02/22/2025 documented at approximately 9:35 AM, Housekeeper #1 reported to Registered Nurse Supervisor #1 that they witnessed Resident #1 tossed back liquid at Certified Nursing Assistant #1. Certified Nursing Assistant #1 then hit Resident #1 on their left shoulder with the back of their hand. Resident #1 was assessed and there was no injury or complaints of pain. The facility concluded that abuse had occurred. Certified Nursing Assistant #1 was suspended and subsequently terminated. During a telephone interview on 03/14/2025 at 9:40 AM the Director of Nursing stated it is the policy of the facility to report abuse within two hours to the law enforcement. The Director of Nursing stated they notified the Department of Health, then the Attorney General, and then law enforcement. The Director of Nursing stated that the report to law enforcement was late. During a telephone interview on 03/14/2025 at 10:48 AM the Administrator stated that the policy states law enforcement should be notified within two hours of being aware of an incident. The Administrator stated that law enforcement was notified at around 12:00 PM because they were gathering information. 10 NYCRR 415.4 (b)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interviews conducted during the Recertification survey from 01/02/2025 to 01/10/2025, the facility did not ensure infection control 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 (Resident #76) of 1 resident reviewed for Pressure Ulcer out of a sample of 27 residents. Specifically, Licensed Practical Nurse #2 failed to practice appropriate infection control and placing the barrier on a visibly soiled overbed table and did practice appropriate hand hygiene and glove changes during wound care. The findings are: The facility policy titled Wound Care effective date 07/2024 and last reviewed 08/08/2024 stated that the purpose is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors as well as to provide guidelines for the care of wounds to promote healing. The policy also stated under the heading Steps in the Procedure: 1. Use disposable cloth (paper cloth is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange supplies so they can be easily reached. Resident #76 was admitted with diagnoses that included Pressure Ulcer Left Hip, unstageable and Pressure Ulcer Sacral Region, Stage 4. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #76 had short and long-term memory problems, severely impaired cognitive skills for decision-making. The Annual Minimum Data Set assessment also documented that Resident #76 required dependent assistance for transfers, was always incontinent of bowel and bladder, and had two stage 4 pressure ulcers that were present upon admission. The Physician Orders dated 12/20/2024 documented cleanse Left Hip wound with Dakin's solution (1/4 strength) to left hip topically and pat dry. Apply Calcium Alginate, cover with Opti foam dressing two times a day for Stage 4 pressure ulcer of left hip, and cleanse sacral wound with Dakin's (1/4/ strength) solution and pat dry. Apply calcium alginate and cover with Opti foam dressing two times a day for Stage 4 pressure ulcer of sacral area. The Advantage Surgical and Wound Care Progress Note dated 12/30/2024 documented Stage 4 measuring 7cm x 7cm x1cm with undermining at 6:00 ends at 9:00 distance 1.5cm Moderate sero-sanguineous drainage, no odor, 90% granulation 10% slough. Periwound skin does not exhibit signs of infection. The progress note also documented a Left Hip Stage 4 wound measuring 3.5 x 2 x 1 with undermining noted at 9:00 and ends at 12:00 maximum distance. On 01/07/25 at 10:36 AM, a wound care observation for Resident #76 was conducted with Licensed Practical Nurse #2 who was assisted by Certified Nurse Assistant #2. Licensed Practical Nurse #2 washed hands, donned a gown, mask, and gloves, then placed a sterile drape on a visibly soiled overbed table. Licensed Practical Nurse #2 did not clean the overbed table before placing a sterile drape on the visibly soiled overbed table. A white Styrofoam tray was then placed on top of the barrier, solutions were placed at side of barrier, an unwrapped scissor was used to open the Opti foam and Calcium alginate packaging and then used to cut the Calcium alginate film which was then placed on the tray along with a bulk pack of gauze pads. Licensed Practical Nurse #2 washed their hands, donned gloves and removed the soiled dressing from Resident #76's left hip. Licensed Practical Nurse #2 removed the soiled gloves and donned a clean pair of gloves without performing hand hygiene and then placed several gauze pads onto the Styrofoam tray and proceeded to moisten gauze with Dakins solution. Licensed Practical Nurse #2 then used a dabbing motion to clean wound before cleaning in a circular motion. Licensed Practical Nurse #2 patted the wound dry with gauze picked up from the tray, changed gloves without performing hand hygiene, applied the Calcium Alginate and bordered gauze, and then removed a pen from their pocket which they used to date the dressing, returned the pen to their pocket, removed gloves and washed hands. Licensed Practical Nurse #2 performed the exact same procedure when cleaning the wound to the sacrum, with the same breaches in infection control and hand hygiene observed. On 01/08/25 at 11:13 AM, an interview was conducted with Licensed Practical Nurse #2 who stated they were a little bit under the weather and not as organized as they usually are. Licensed Practical Nurse #2 then described the procedure of wound care as follows: wash my hands, gather supplies, cover table with a clean towel drape, then place supplies on a clean surface, then wash hands. Put on Personal Protective Equipment, remove old dressing, wash my hands, then put on clean gloves, clean area with Dakin's, cover with Calcium alginate, then apply bordered gauze. Licensed Practical Nurse #2 further stated that they perform hand hygiene before they start the procedure, after removing the old dressing and after they have applied the new dressing. Licensed Practical Nurse #2 stated that when gloves are removed, hands should be washed then and also when the wound is cleaned and before the dressing is put on, but they did not always do this today while doing the wound care. Licensed Practical Nurse #2 also stated that they had instructed the Home Health Aide to clean the overbed table before the dressing change and assumed it had been done. Licensed Practical Nurse #2 stated that they were informed that the tray was provided for them to do wound care today, but usually they just use the drape sheet and place supplies directly on to it. Licensed Practical Nurse #2 stated they received training on wound care some time ago and that a refresher training from time to time would be good. On 01/10/25 at 11:12 AM, an interview with Registered Nurse Supervisor #1 who stated that if nurses observe complications or a change in the wound, they assess the wound and notify the doctor. Registered Nurse Supervisor #1 also stated that they do not do the actual wound care and does not make observations of what the Licensed nurses are doing during wound care as they are the only supervisor in the building. On 01/10/25 at 11:30 AM, an interview was conducted with the Assistant Director of Nursing, who is also the Infection Preventionist, stated that they are the wound care nurse and assess residents on admission who are at risk for developing wounds. The Infection Preventionist described the process for wound care as follows: set up side table which should be cleaned first, place sterile drape, then supplies and treatments are placed on drape. Gauze is separated for normal saline and for treatments, scissors are taken from the treatment cart in a sealed package, wash hands, don gloves and remove dressing have bag close for garbage, wash hands put new gloves on and do treatment, cleanse wound with normal saline from cleanest to dirty, apply treatment and cover. The Infection Preventionist also stated that hand hygiene is done before contact, and when gloves come in contact with contaminated areas. The Infection Preventionist further stated that periodically observations of wound care are done, but it is not something that is done routinely or documented. The Infection Preventionist stated that they do competencies on wound care. The Infection Preventionist stated that use of Styrofoam trays during wound care is not encouraged, and hand hygiene is to be performed whenever gloves are removed. On 01/10/25 at 11:49 AM, an interview was conducted with the Director of Nursing Services who stated that the Infection Preventionist is in charge of wound care and wound care competencies are done by the Assistant Director of Nursing or themselves or a Registered Nurse will do observations in between. The Director of Nursing Services also stated they were not if the observations were documented anywhere. 10 NYCRR 415.19(b)(4)

Based on record review and interviews conducted during a Recertification Survey from 01/02/2025 to 01/10/2025, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 3 (Residents #47, #51, and #99) of 3 residents reviewed for Beneficiary Notification. Specifically, the facility did not provide appropriate notification at least two calendar days before Medicare covered services ended as required and did not provide the designated form for notification in the nursing home setting. The findings are: The facility policy titled Advanced Beneficiary Notice of Non-Coverage revised 07/2024, documented that it is the facility policy to provide advance notice to Medicare beneficiaries of expected non coverage of services(denial) under Medicare Part B. Effective January 1,2012. CMS form R-131 will be utilized to provide timely advance notification to residents/ designated representatives. 1. Resident #47 was discharged from Medicare Part A services on 11/01/2024 with 1 day remaining and remained in the facility. The Notice of Medicare Non-coverage Form (CMS Form 10123) was signed by Resident #47 and dated 11/01/2024, the same date of discharge from skilled services. In addition, Resident #47 was provided with the Advance Beneficiary Notice of Non-coverage (CMS-R-131) instead of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 which was also signed and dated 11/01/2024. 2. Resident #51 was discharged from Medicare Part A services on 06/21/2024 with 1 day remaining and remained in the facility. The Notice of Medicare Non-coverage Form (CMS Form 10123) was signed by Resident #51 and dated 06/21/2024, the same date of discharge from skilled services. In addition, Resident #47 was provided with the Advance Beneficiary Notice of Non-coverage (CMS-R-131) instead of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 which was also signed and dated 06/21/2024. 3. Resident #99 was discharged from Medicare Part A services on 07/12/2024 with 4 days remaining and remained in the facility. The Notice of Medicare Non-coverage Form (CMS Form 10123) was signed by the spouse of Resident #99 and dated 07/12/2024, the same date of discharge from skilled services. In addition, Resident #47 was provided with the Advance Beneficiary Notice of Non-coverage (CMS-R-131) instead of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 which was also signed by the spouse of Resident #99 and dated 07/12/2024. Additional information on the Notice of Medicare Non-coverage Form (CMS Form 10123) documented that notification was provided to Resident #99's spouse but did not document when the notification was made. On 01/08/25 at 03:21 PM, an interview was conducted with the Director of Social Services who stated that they had been providing notices for the past year and the Rehabilitation department provides a schedule of who is coming off therapy and their last day of services. The Director of Social Services also stated that notices are reviewed with resident who will sign it, and if the resident is not able to sign it then it is mailed to the family with a request that they return signed copies. The Director of Social Services further stated that notices are given as soon they receive the information from the Rehabilitation department. The Director of Social Services stated that they were not sure of and could not remember the timeframe in which the notices should be given, whether the notices needed to be given three days or 1 week in advance and could not explain why the notices were not given within this timeframe if they thought this to be the correct timeframe. The Director of Social Services also stated that for Resident #99 the spouse was notified on 07/11/2024 and came in to sign the form on 07/12/2024. The Director of Social Services also stated that the Finance department provided them with the form, and they were not aware that an incorrect form was being used. On 01/08/25 at 04:40 PM, an interview was conducted with the Administrator who stated that they did not have much involvement with the Beneficiary notice process, The Administrator also stated that the process of providing notification involves several departments so the facility tries to give themselves extra time so they thought that their policy references that notices should be provided three days before discharge from skilled services and not two as required. The Administrator further stated they were not aware that notices were not being provided in a timely manner and the incorrect form was being used. 10 NYCRR 415.3(g)(2)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews during the Recertification survey from 01/02/2025 to 01/10/2025, the facility did not ensure that the residents' environment was maintained in a safe, sanitary, and comfortable manner. Specifically multiple observations were made of ceiling tiles and resident equipment and found to be unsanitary and in disrepair. This was evident for 1 of 3 resident units (Unit 3). The findings are: The facility policy titled Homelike Environment dated 10/02/24 state that residents are provided with a safe clean and comfortable and homelike environment. During multiple observations on the 3rd floor unit from 01/02/2025 to 01/10/2025 the following was observed: 1. ceiling tiles along the unit corridors were noted in disrepair, not firmly affixed to the ceiling, cracked and stained. 2. Corridor borders were noted to not be firmly attached and layered with dirt and dust. 3. room [ROOM NUMBER] B had brownish water-stained ceiling tiles. 4. room [ROOM NUMBER] B had a broken wall bumper behind the head of the bed, the wall tile behind the room sink was layered with dirt and stains, and the sink was chipped. 5. room [ROOM NUMBER] A had a high back wheelchair which was heavily stained with dried encrusted food particles. 6. room [ROOM NUMBER] had a wheelchair with a dusty seat cushion and torn left arm rest. 7. room [ROOM NUMBER] had a high back wheel chair which was layered and encrusted with dirt and dried food particles. 8. In the Dining Room there was a dusty worn piano, stains on the walls, and bent, dusty window blinds. On 01/10/25 at 09:08 AM, Housekeeper #2 was interviewed and stated that they start their shift by first cleaning the dining room area before breakfast. Cleaning includes but not limited to dining room tables, chairs, floors and walls if needed. Housekeeper #2 also stated that rooms are also cleaned and disinfected, and they wipe down the walls if they are dirty. Housekeeper #2 further stated that heavy duty cleaning of rooms is also done which consists of cleaning the walls, bed frame, mattress, floors, from top to bottom. On 01/10/25 at 10:08 AM, the Director of Environmental Services was interviewed and stated that their role is to ensure the safety and wellness of all residents, staff and visitors by maintaining a clean and safe and homelike environment. The Director of Environmental Services also stated that they oversee the performance of their staff and make spot checks to ensure the work is carried out, and when they come across an issue they address the issue at that moment with the staff. The Director of Environmental Services further stated that the wheelchairs are challenging to get washed, however they notify the Director of Nursing of the wheelchairs that are to be power washed, and the night shift nurse will remove the wheelchair and place it outside the room door. Sometimes residents will refuse to have their wheelchairs removed from their room. The Director of Environmental Services stated that they do have an issue with the roof which does leak when it rains, which is way the ceiling tiles are stained, and they do try to replace them. On 01/10/25 at 11:06 AM, the Administrator was interviewed and stated that the cleanliness of the environment is important for the prevention of infection control issues and for the overall well-being of the resident and staff morale. The Administrator also stated that they expect to receive a large grant that is going to enable them to replace all the room furniture, the windows, the roof which leaks when it rains, the air conditioners, ceiling tiles and more. The Administrator further stated that they ordered furniture, but the wrong items were sent and they are in the process of correcting this with the company. 10 NYCRR 415.5(h)(2)

Based on observations and interviews conducted during the Recertification survey from 01/02/2025 to 01/10/2025 the facility did not ensure a safe functional environment for residents, staff, and public. This was evident for the staff bathroom and nursing station on 1 (Unit 3) of 3 Units. The finding is: The facility policy titled Homelike Environment dated 10/02/24 stated that residents are provided with a safe, sanitary and orderly environment. During multiple observations on the 3rd floor unit from 01/02/2025 to 01/10/2025 the following was observed: 1. The Staff bathroom adjacent to the Tub Room had a loose and wobbly toilet seat. 2. in the Nurse's Station: a. the Plexi glass was covered with dust, dirt and streaks. b. two swivel chairs were layered with dirt and dust. c. the call bell console was layered with dust and dirt d. there was an accumulation of dirt and dust on the floors underneath the desk e. the computer screen monitors and phones were layered with dust. On 01/10/25 at 09:40 AM, Housekeeper #2 was interviewed and stated that only the floors in the Nurse's station are cleaned and not the station itself. Housekeeper #2 also stated that they do not want to move anything and that the nurse is usually sitting at the nurse station, and they believe that they wipe down their own equipment. Housekeeper #2 further stated that they mostly wipe down the outer counter top of the nurse station. On 01/10/25 at 10:08 AM, the Director of Environmental Services stated that they make rounds to ensure that staff are performing their duties. The Director of Environmental Services also stated that housekeeping staff is supposed to clean the nurse's station, and they can speak with the unit nurse about the areas that they could clean. The Director of Environmental Services further stated that the nurses also wipe their station to keep it free from dust. 10 NYCRR 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure a resident's right to formulate an advance directive (AD). This was evident for 1 (Resident #371) of 33 total sampled residents. Specifically, Resident #371's AD status was not determined with their Legal Guardian (LG) upon readmission to the facility. The findings are: The facility's policy titled AD dated 4/21/2023 documented in the event residents cannot make their own decisions the Medical Orders for Life-Sustaining Treatment (MOLST) process will be followed. Resident #371 was readmitted to the facility on [DATE] with diagnoses of schizophrenia and diabetes mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #371 was severely cognitively impaired. The Comprehensive Care Plan (CCP) related to AD and initiated 5/26/2022 documented Resident documented maintain communication with Resident #371's LG regarding all needs and concerns for resident's advance directive. The CCP was last revised 7/20/2023 and did not document an update to Resident #371's AD status upon readmission from the hospital on 8/31/2023. The Hospital Discharge summary dated [DATE] documented Resident #371 had a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders initiated in the hospital on 8/15/2023. The MOLST form included in the Hospital Discharge Summary and dated 8/15/2023 documented verbal consent was provided by Resident #371's LG for the DNR and DNI orders. The MOLST form also documented Resident #371 receive limited medical interventions, no feeding tube, and limitation of antibiotic use. The Physician's Orders dated 8/31/2023 documented Resident #371's AD status was full code and did not document DNR and DNI orders. The Baseline Care Plan (BCP) dated 8/31/2023 documented Resident #371's AD status was full code and Registered Nurse (RN) #2 was unable to contact the resident's LG. The BCP documented the nurse would follow up with the LG the next morning. The Nursing Note dated 8/31/2023 documented Resident #371 was seen by Medical Doctor (MD) #1, had an AD status of full code, and the resident's LG and brother could not be contacted; therefore, the nurse in the morning would follow up with the resident's LG. The Care Plan Meeting Attendance dated 9/7/2023 documented Resident #371's LG attended via telephone conference and requested the interdisciplinary team (IDT) update them regarding Resident #371's status the next week. There was no documented evidence Resident #371's LG was contacted to discuss and verify the resident's AD status upon readmission from the hospital on 8/31/2023. On 9/13/2023 at 2:57 PM, RN #1 was interviewed and stated a readmitted resident's AD status is determined from the Hospital Discharge Summary and interview with the LG. within 24 hours of the resident's admission to the facility. On 9/13/2023 at 3:25 PM, RN #2 was interviewed, and stated Resident #371 was readmitted from the hospital on 8/31/2023 and RN #2 completed the resident's readmission assessment. Resident #371 had full code AD status prior to being transferred to the hospital and the resident's status remained full code upon readmission and after RN #2's review of the Hospital Discharge Summary. RN #2 was unable to contact Resident #371's LG and brother to confirm. The Social Worker (SW) is responsible for contacting the LG the following day. RN #2 stated they do not know if the SW contacted Resident #371's LG or family since their readmission. After reviewing the Hospital Discharge summary dated [DATE], RN #2 stated they missed the MOLST form with Resident #371's DNR and DNI AD status and did not see it. RN #2 stated if they had seen the MOLST from the hospital, RN #2 would have continued Resident #371's DNR and DNI orders to reflect the resident's updated AD status. On 9/13/2023 at 4:54 PM, the Director of Social Work (DSW) was interviewed and stated they did not know Resident #371 had an AD change in the hospital to include DNR and DNI orders. The DSW contacted Resident #371's LG to invite them to the Care Plan Meeting held on 9/7/2023 and did not discuss the resident's AD status. On 9/13/2023 at 3:37 PM, MD #1 was interviewed and stated Resident #371's AD status was full code prior to their hospitalization, and they do not recall seeing the MOLST or DNR and DNI orders in the Hospital Discharge Summary paperwork. MD #1 stated if they had seen Resident #371's MOLST from the hospital, the DNR and DNI orders would have would have been continued upon the resident's readmission to the facility for 96 hours or until it confirmed with the LG. 415.3(e)(2)(iii)

Based on record review and staff interviews conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were completed in a timely manner. This was evident for 2 (Resident #103, #105) of 2 residents reviewed for Resident Assessment. Specifically, 1) Resident #103's Discharge MDS was not completed within 14 calendar days from the Assessment Reference Date (ARD), and 2) Resident #105's Discharge MDS was not completed within 14 calendar days from the Assessment Reference Date (ARD). The findings are: 1. Resident #103 was admitted to the facility with diagnoses including Dementia, Hypertension, and Obstructive Uropathy. The physician note dated 5/5/23 documented resident noted AMS/hypotension/hypoxia, possible severe sepsis vs shock. Oxygen started and 911 was activated. Resident was discharged to the hospital on 5/5/23. There was no documented evidence a Discharge MDS was completed upon Resident #103's discharge to the hospital on 5/5/2023. 2. Resident #105 was admitted to the facility with diagnoses including Diabetes Mellitus, Hypertension, and Hyperlipidemia. The nursing note dated 4/27/23 documented resident complained of having pain and recommended to transfer to hospital. Awaiting transportation. Resident was transferred to hospital on 4/27/23. There was no documented evidence that a Discharge MDS assessments was completed for Resident #105. On 9/18/23 at 2:41 PM, the MDS Coordinator was interviewed and stated Discharge MDS assessments are due within 14 days of the ARD. MDS Coordinator acknowledged that Resident #103 and Resident #105's assessments were missed after they were discharged to the hospital and therefore, they did not complete the assessments. 415.11(a)(3)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification and complaint (NY00318527) from 9/10/2023 to 9/18/2023, the facility did not ensure services met professional standards of practice. This was evidenced for 1 (Resident #79) of 27 total sampled residents. Specifically, Resident #79 was found on the floor in their room and was placed back in bed by the Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) prior to receiving an assessment by a Registered Nurse (RN). The findings are: Resident #79 had diagnoses of bipolar disorder and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #79 was severely cognitively impaired and had a fall since their prior assessment that did not result in injury. Resident #79 required extensive assistance of 2 people for walking in their room and for transfers. On 09/14/2023 at 12:30 PM, an interview was conducted with the complainant who stated they came to visit Resident #79 on 6/19/2023 after the facility staff reported to them that Resident #79 was found on the floor early that morning. The complainant observed large deep red scratches on the resident's left arm. The undated Accident Incident (AI) Report documented Resident #79 was found on their floor mat at bedside at 6:45 AM on 6/18/2023. A Registered Nurse (RN) assessment was done, and Resident #79 had blanchable redness and sheering to the left upper arm. Left shoulder and humerus X-ray were done and were negative for fracture. An undated Investigation documented Resident #79 had an incident on 6/19/2023 that caused left upper arm redness and sheering. On 6/20/2023, staff reported to the Assistant Director of Nursing (ADON) that the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) used a Hoyer lifter to transfer Resident #79 back to bed from the floor mat next to their bedside. Resident #79's left upper arm may have rubbed against the Hoyer lift straps or against a metal part of the bed. Room was changed closer to the nursing station and Resident #79 was provided with a floor bed. The Investigation was unsigned, and the Director of Nursing's name was typed at the bottom. The RN Permittee statement dated 6/18/2023 documented Resident #79 was in bed when the RN Permittee and RN #2 arrived in their room to assess the resident post-fall. There was no documented evidence Resident #79 was assessed by the RN prior to being moved back into bed from the floor where they were found on 6/19/2023. On 09/18/23 at 09:49 AM, CNA #7 was interviewed and stated when Resident #79 fell on 6/19/2023, the LPN assigned to the unit instructed CNA #7 to pick the resident up using a Hoyer lifter and transfer them back to bed without having an RN assessment first. CNA #7 stated they knew this was not the normal protocol and protested but the LPN insisted, and CNA #7 did assist in placing the Resident #79 back to bed. The RN Permittee and RN 32 then came to Resident #79's room to assess the resident after they had already been moved. On 09/15/23 at 12:38 PM, LPN #7 was interviewed and stated they did not work the shift when Resident #79 fell on 6/19/2023. Residents are never moved until an RN conducts the assessment. The LPN takes the resident's vitals when they are found on the floor and waits for the RN to come to the unit to assess prior to moving the resident. On 09/18/23 at 11:06 AM, the RN Permittee was interviewed and stated they were the RN Supervisor on the shift when Resident #79 was found on the floor in their room on 6/19/2023. Resident #79 had already been moved back to their bed by the LPN and CNA #7 before the RN Permittee and RN #2 arrived in the resident's room to assess them. When Resident #79 was assessed, they expressed pain in their left arm. On 09/14/23 at 05:07 PM, RN #2 was interviewed, and stated Resident #79 was already in bed when they came to their room to assess them on 6/19/2023. The LPN and CNA #7 reported Resident #79 was found on their floor mat and was placed back into bed using a Hoyer lifter. RN #2 stated residents are not moved after a fall or incident until the RN assesses because the LPN cannot perform an assessment of the resident and moving the resident could cause further injury. On 09/18/23 at 12:55 PM, the Director of Nursing (DNS) was interviewed, and stated Resident #79 was moved back to bed prior to RN assessment, and this is not a standard of practice or facility protocol. The LPN and CNA #7 was inserviced and the LPN no longer works at the facility. 415.11(c)(3)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure a resident received quality care. This was evident for 1 (Resident #24) of 27 total sampled residents. Specifically, Resident #24 was observed on multiple occasions without compression stockings in place as ordered to address left lower extremity (LLE) edema. The findings are: The untitled facility policy related to anti-embolic stocking use dated 1/2023 documented report and document application of compression stockings, any skin issues, or other changes noted with the resident. Resident #24 had diagnoses of schizophrenia and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #24 was severely cognitively impaired and required the extensive assistance of 1 person for dressing. On 09/10/23 at 09:59 AM, Resident #24 was observed wheeling themselves in wheelchair in the hallway towards their room. Resident #24 had LLE swelling and a tight white cotton sock was on their LLE. The sock was pulled up to Resident #24's shin and was squeezing the LLE in a manner that left indentations and impression on the lower half of their leg. At 01:09 PM and 03:32 PM, Resident #24 was observed lying in bed with the same tight white cotton sock on their left leg. Compression stockings were not observed on the resident's legs. On 09/11/23 at 01:27 PM, Resident #24 was observed with ankle socks on bilateral feet. LLE swelling observed with no compression stockings in place. Medical Doctor (MD) Note dated 7/26/23 documented Resident #24 had LLE and was walking less. Nursing Note (NN) dated 7/27/23 documented Resident #24 had LLE edema and decline in ambulation ability. NN dated 7/29/23 documented Resident #24 was ordered compression stockings. MD Order dated 7/31/23 documented Resident #24 wear compression stockings every day shift to bilateral lower extremities. The Treatment Administration Record (TAR) documented compression stockings were applied to Resident #24's bilateral lower extremities daily from 9/1/2023 to 9/14/2023. There was no documented evidence Resident #24 refused to wear compression stockings or removed the compression stockings once applied to their bilaterally lower extremities. On 09/15/23 at 12:31 PM, Certified Nursing Assistant (CNA) #9 was interviewed and stated Resident #24 was ordered to have compression stockings for lower extremity swelling. CNA #9 attempted to put the compression stockings on Resident #24 this morning and Resident #24 took them off right away. CNA #9 then placed regular socks on Resident #24. CNA #9 stated they should have informed the nurse but did not do so. This gets documented on the CNA Accountability as a refusal. On 09/15/23 at 11:52 AM, Licensed Practical Nurse (LPN) #2 was interviewed and stated Resident #24 has edema in their lower extremities and the LLE is bigger than the other. The resident is ordered to receive compression stockings in the morning and have them removed at night. Resident #24 takes off the compression stockings once they are applied and they are kept in the nursing supply room. LPN #2 stated Resident #24 was able to take off their compression stockings and by the time they are wheeled to the dayroom in the morning, the resident has already removed them. Staff attempt to counsel Resident #24 regarding complying with the compression stockings but Resident #24 becomes aggressive. The staff try to elevate the legs to address the edema when Resident #24 is in the wheelchair. Resident's removal of the compression stockings is not considered a refusal and is not documented as such. The TAR documents that the compression stockings have been applied to the resident. LPN #2 stated they are unable to determine whether the order for compression stockings has been effective because the resident removes them. The nursing staff keep applying them even though the resident refuses. On 09/18/23 at 12:48 PM, The Director of Nursing (DNS) was interviewed, and stated application of compression stockings is documented on the TAR and signed for by the nurse. If the resident refuses, the Social Worker, and MD must be informed so that different measures can be used to address their edema. Resident #24 does not follow commands, and this is a resident's behavior. The LPN signs for the application of the compression stockings on the TAR immediately after they are applied to the resident. There should be a behavior note documented if he resident refuses to wear the compression stockings. It should be documented so the LPN is aware the resident has removed the compression stockings. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey from 9/10/23 to 9/18/23, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for Resident #371 reviewed for Position/Mobility out of 27 total sampled residents. Specifically, Resident #371 had bilateral upper and lower extremity contractures and was observed without an abduction/contraction cushion (ACC) as per Medical Doctor Order (MDO). The findings are: The facility policy titled Assistive/Adaptive and Positioning Devices dated 4/2023 documented the assigned Certified Nursing Assistant (CNA) will be responsible for the application of devices according to the Plan of Care and signs the CNA Accountability record every shift daily. Resident #371 had diagnoses of diabetes mellitus and schizophrenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #371 was severely cognitively impaired. On 9/11/23 at 12:24 PM and 09/12/23 at 11:57 AM, Resident #371 was observed lying in bed without an ACC in place. The ACC was observed on top of Resident #371 ' s dresser in their room. The MDO dated 8/31/2023 documented ACC at all times. On 09/12/23 at 11:57 AM, CNA #1 assigned to Resident #371 was interviewed and stated they were repositioning the resident in bed. CNA #1 stated they apply the ACC and any other positioning devices to Resident #371 every 2 hours. 415.12(e)(1)

Based on observation, record review, and staff interview conducted during the Recertification and abbreviated survey, the facility did not ensure policies and procedures to prevent loss of controlled drugs were implemented. This was evident on 1 of 3 units reviewed for Medication Storage (Unit 3). Specifically, a bag containing a pair of glasses and dentures (top and bottom) were stored in the Unit 3 narcotic cabinet. The findings are: The policy and procedure titled Medication Storage last reviewed on 4/20/2023 documented that the facility stores all drugs and biologicals in a safe, secure and orderly manner. Only person authorized (Licensed Nurses) to prepare and administer medications have access to locked medications. On 9/12/2023 at 3:35 PM, an observation of the medication storage room on the 3rd floor was conducted with the Licensed Practical Nurse (LPN #4). A small plastic bag containing a pair of glasses and full dentures (top and bottom) was observed in the narcotic cabinet. On 9/18/2023 at 12:34 PM, the Licensed Practical Nurse on the unit (LPN#4) was interviewed and stated the policy is that the narcotic box should be double locked and only narcotics should be stored in the narcotic box. On 9/18/2023 at 10:29 AM, the Director of Nursing (DON) was interviewed and stated that as per the facility policy, narcotics must be double locked at all time. Nothing other than narcotics should be kept in the narcotic box. She further stated that staff will receive verbal counseling and will be in-serviced. 415.18 (b)(1)(2)(3)

Based on observation, interview, and record review conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure drugs and biologicals were stored in accordance with professional standards of practice. This was evident for 2 (2nd Floor and 4th Floor) of 3 units. Specifically, 1) medications were not kept in locked compartment and were on the 2nd Floor Nursing Station, and 2) the 4th Floor medication cart contained unopened eye drops labeled with directions to refrigerate until opened. The findings are: The policy titled Medication Storage dated 4/20/2023 documented the facility stores all drugs and biologicals in a safe, secure and orderly manner. Only Licensed Nurses are authorized to prepare and administer medications and have access to locked medications. 1) On 09/10/23 at 12:07 PM, medication blister packs containing 3 pills of Seroquel 50mg, 3 pills of Finasteride 5mg, 3 pills of Lexapro 20mg, and 3 pills of Eliquis 5mg were observed on the 2nd Floor Nursing Station desk, open to the public and accessible to anyone walking in the hallway. There were no licensed nurses or staff observed in the area until Licensed Practical Nurse (LPN) #2 arrived at the Nursing Station at 12:31 PM. LPN #2 then took the medication blister packs to the medication cart. On 09/10/23 at 01:01 PM, an interview was conducted with LPN #2 who stated they wanted to reorder the medication that was in the blister packs because there were 3 pills left in each. LPN #2 does not leave the medication blister packs in the cart when they need to be reordered and reorders them after they are done administering medications in the morning. LPN #2 stated they left the blister packs unattended at the nursing station because the SA was sitting there and medications are not supposed to be left on the desk. 2) On 09/12/23 at 11:43 AM, observation of the 4th floor medication cart took place with Licensed Practical Nurse (LPN) Permittee #7. The top drawer of the cart contained an unopened bottle of Latanoprost .005% (order date 9/8/2023, Rx #: 43882178) prescribed to Resident #104 with no date of delivery documented. The prescription label documented refrigerate until opened. At the time of the observation, LPN Permittee #7 was interviewed and stated they did not notice the bottle of Latanoprost before today. They will put the bottle in the refrigerator immediately. The Latanoprost should have been refrigerated until used for Resident #104 on the evening shift at 7 PM as ordered. LPN Permittee #7 stated they did not take the medication out of the refrigerator and put it in the medication cart. The medication cart is checked daily and LPN Permittee #7 checked the medication cart today but left the Latanoprost in the cart because they know Resident #104 gets the medication at night. On 09/18/23 at 01:42 PM, the Director of Nursing (DNS) was interviewed and stated blister packs of medications should not be left at the nursing station and should be locked in the medication cart or medication room at all times. Medications that are supposed to be refrigerated should be kept in the refrigerator until opened as per instruction. The pharmacist and the Nursing administration makes rounds and conducts audits to ensure medications are not left out. 415.18(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure adequate dental services were provided for a resident with tooth pain. This was evident for 1 (Resident #66) of 2 reviewed for Dental out of 27 sampled residents. Specifically, Resident #66 had tooth pain that was not evaluated by the dentist in a timely manner. The findings are: The facility policy and procedure titled Dental Services - Hygiene Program, reviewed 4/20/23, documented the program will meet residents' specific oral hygiene and dental care needs. Resident #66 was admitted to the facility with diagnoses of Dementia, Glaucoma and Depression. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented resident #66 had severely impaired cognition for decision making and daily life tasks. During an interview on 9/10/23 at 11:43 AM, Resident #66's family member stated that the resident's toothache was reported to the nurse about three months ago, but the family member did not know if resident ever had their exam and what was the outcome of the exam. A Physician's note dated 6/12/23 documented Resident #66's family reported the resident had a toothache. The physician examined the resident. Resident #66 denied pain, and the examination was limited due to Resident #66 refusing to open their mouth. No gross lesions or [NAME] of the cheeks were noted. The phsycian ordered Tylenol for pain and a dental consult. A Physician's order dated 6/12/23 documented Resident #66 should get a dental consultation for toothache. Dental consult dated 6/22/23 documented Resident #66 was seen for toothache, but the resident refused the assessment. A Physician's order dated 6/30/23 (discontinued 9/6/23) documented an order for Resident #66 to receive a dental consultation at the hospital dental clinic. The review of the medical record dated from 6/22/23 to 8/30/23 revealed there was no documented evidence an appointment was made for Resident #66 to be seen at the hospital dental clinic. A dental consult dated 8/30/23 documented Resident #66 was seen for an examination, but the consultant was unable to wake the resident to complete the exam. A dental consult dated 9/7/23 documented Resident #66 had a limited exam; Resident #66 was noted with some natural teeth lost, but there was no broken/loose teeth or inflamed gums. The dentist recommended no treatment for Resident #66. The resident was never seen at the hospital dental clinic for a full examination. On 9/15/23 at 10:58 AM RN Supervisor (RN #3) stated that Resident #66 was seen by the dentist for toothache but refused the examination on 6/22/23 as per resident's medical record. There was an order dated 6/30/23 for resident to go to the hospital dental clinic for a dental consultation following the refused examination on 6/22/23 but this order was discontinued. RN #3 stated Resident #66 was seen by the dentist again on 8/30/23 and 9/6/23. On 9/15/23 at 12:08 PM Assistant Director of Nursing (ADON) stated that a dental consultation was ordered for Resident 366 after family reported tooth pain, but the resident refused the initial dental examination on 6/22/23 as per the medical record. The ADON stated that there was an order for Resident #66 to go to the hospital dental clinic initiated 6/30/23 and discontinued 9/6/23. The order was never completed. The ADON stated they do not know if Resident #66 had a follow-up after refusing the initial dental examination. The ADON stated Resident #66 saw the dentist two months later as per resident's medical record. 415.11(c)(1)

Based on observation, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure the residents had a right to organize and participate in resident groups in the facility. This was evident during Resident Council wit Resident #64, #95, #39, #118, #53, #56, and #16. Specifically, the facility did not take reasonable steps to organize and assist residents with meeting regularly as a Resident Council. The findings are: The facility policy titled Resident Council Rights in Nursing Homes dated 3/2/2023 documented the facility must provide a resident council with private space for meetings and make residents aware of upcoming meetings. On 09/11/2023 at 11:48 AM, a Resident Council meeting was held with Resident #64, the President of Resident Council, and Resident #64, and Resident #95, #39, #118, #53, #56, and #16. All residents in attendance stated the facility does not assist with scheduling and organizing Resident Council meetings that residents could regularly attend without staff present. The Resident Council has not gathered since the COVID-19 pandemic and Resident #64 stated they were elected to their position as President by the staff and not the residents. The Patient Roster - Moving Resident Council meeting minutes dated 7/3/2023, 8/25/2023, and 9/1/2023 documented residents were met with individually according to room number, were informed of positive COVID-19 cases, and were encouraged to attend activities according to preference and activity calendar. On 09/10/2023 at 03:45 PM, the Director of Social Work (DSW) was interviewed and stated the facility had Resident Council meetings prior to the COVID-19 pandemic. The facility now uses a Moving Resident Council where the DSW will meet individually with residents in their room to discuss COVID-19 cases. Residents are referred to the activities calendar and encouraged to engage in activities they enjoy and to wear masks. Residents are encouraged to go outside and to minimize the risk of spreading infection. There is an area for residents to gather for activities. The DSW meets with residents whenever there is a new COVID-19 case. If there are no COVID-19 cases to report to residents, the Moving Resident Council takes place monthly. On 09/18/2023 at 02:19 PM, the Administrator was interviewed and stated the DSW is responsible for organizing the Resident Council. The Administrator stated they were aware the DSW was using a Moving Resident Council stemmed from the COVID-19 pandemic and is used to provide banking information and COVID-19 case information to residents. The residents have an opportunity to communicate their concerns. The purpose of Resident Council is for residents to communicate their life in the facility and meet as a group without staff present. Residents currently have group activities but are kept separate as much as possible to prevent the spread of infection. The DSW tried to keep the residents safely distanced. The Administrator stated they did not discuss keeping residents at a safe distance for Resident Council with the DSW. 415.5(c)(1-5)

Based on observation, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure residents were provided with the contact information for the State Long Term Care Ombudsman (SLTCO). This was evident in the lobby and 1 (3rd Floor) of 3 units. Specifically, the posted telephone number for the SLTCO was incorrect in the lobby and on the 3rd Floor. The findings are: On 09/11/2023 at 11:48 AM, a Resident Council meeting was held with Resident #64, the President of Resident Council, and Resident #95, #39, #118, #53, #56, and #16. Resident #53 and #39 stated the SLTCO contact information posted throughout the facility was incorrect and they attempted to contact the SLTCO but were unable to do so. On 9/11/2023 at 1:55 PM, the SLTCO poster including the contact telephone number was observed in the main lobby and 3rd Floor bulletin boards. A phone call was attempted using the telephone number listed and no contact was made with the SLTCO office. The phone number listed was not the currently published contact number for the local SLTCO office. On 09/18/2023 at 02:35 PM, the Director of Social Work (DSW) was interviewed and stated they were responsible for posting the SLTCO information throughout the facility. The DSW did not recall the last time they checked the telephone contact information and were unaware the SLTCO phone number was incorrect. The SLTCO contact number is posted because residents have a right to call the SLTCO if they have concerns regarding their stay at the facility. 415.3(1)(c)(1)(vi)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification and complaint (NY00310185), the facility did not ensure the residents' right to a safe, clean, comfortable environment. This was evident for the outdoor patio and 3 of 3 resident floors (2nd, 3rd, and 4th). Specifically, 1) the outdoor patio was observed with paper cups, gloves, and cigarette butts on the ground and overgrown shrubs, trees, and grass; 2) the 2nd floor was observed with sticky dirty furniture, sticky floors stained black at the baseboards, broken dressers, peeling paint, sagging unhooked privacy curtains, a bed frame in disrepair, missing mirror, urine odor, and a stained faucet with a loose handle in resident rooms and dirty air conditioning (AC) units in the dayroom; 3) the 3rd floor was observed with a broken AC unit, dirty windowsills, broken floor and wall tiles, a leaking rust colored sink, urine odor, and a hole in the wall of resident rooms; and 4) the 4th floor was observed with mismatched peeling paint and cracked plaster in a sink of resident rooms. The findings are: 1) On 9/10/2023 at 9:30 AM and 9/11/2023 at 11:00 AM, the outside patio and resident smoking area were observed with overgrown bushes and shrubs protruding through the perimeter fence and onto the patio by several feet. There were weeds protruding through the fence and cracks in the patio. Garbage and debris including paper drinking cups, snack bags, and plastic gloves, were strewn throughout the patio. Several cigarette butts were on the floor next to the ashtrays. 4) On 09/15/2023 at 01:54 PM, Resident #22 from room [ROOM NUMBER] was interviewed and stated the AC unit in their room is very dirty and has cracks in the plaster where the AC unit connects to the wall. Resident #22 stated that looking at the condition of the AC unit makes them sick. The dirt flies all over the room. They told the Housekeeper (HK), but the HK only cleans the floor. They informed the Maintenance Worker (MW), but the MW never returned to fix it. On 09/14/2023 at 12:16 PM, the following observations were made on the 4th Floor: - room [ROOM NUMBER] had white spackled paint on walls and numerous [NAME] on the shared sink - room [ROOM NUMBER] had an AC unit covered in dirt and debris with cracks in the plaster connecting the unit to the wall - room [ROOM NUMBER] had dirt and debris on the AC unit and peeling paint on the walls - top of radiator with dried up cracked compound cement all over top of radiator, dirty - room [ROOM NUMBER] had plaster covering the wall tiles near the shared sink - room [ROOM NUMBER] had plaster covering the wall tiles near the shared sink - room [ROOM NUMBER] had white spackle on the walls and debris on the AC unit - room [ROOM NUMBER] had white spackle on the walls and debris on the AC unit - The floor dayroom had a dirty, dusty floor, peeling paint, and dirt and debris accumulated on the AC units. There was no documented evidence in the 4th Floor Maintenance Logbook that any of the above-mentioned environmental concerns were reported from 2/8/2023 to 9/10/2023. On 09/14/2023 at 03:19 PM and 09/15/2023 at 11:15 AM, Director of Housekeeping and Maintenance (DHM was interviewed stated there is a Maintenance Logbook on each unit that the Maintenance Worker (MW) is responsible for checking. The DHM acknowledged some walls have spackle because they have not finished repainting areas of the facility. Some AC units do have dust, debris, and cracks in the plaster surrounding them. The Housekeeper (HK) is responsible for cleaning the windows and the windowsills. There are 3 rooms a day on each unit that have the floors buffed and completely cleaned. The DHM checks the 3 buffed and cleaned rooms after the HK is done. There is flooding in the 2nd Floor shower room because of a resident that washes their clothes in there. The outside area of the facility gets cleaned every other day. There is garbage that gets built up from the streets because there are people that dump garbage from the neighboring buildings onto the facility property. As soon as the facility cleans outside, the neighbors dump more garbage. A lawn service comes monthly and as needed to take care of the shrubs and grass that need to be cut. The DHM makes rounds on each of the units and makes note of broken furniture. The HK also informs the DHM of any broken furniture they observe on the unit and the DHM checks the Maintenance Logbook daily. The DHM stated they did not notice the resident in 214A was missing the footboard to their bed when they last made their rounds. That is something that staff should have recorded in the Logbook. The mirror in 214A was cracked and had to be removed last week. The DHM plans to replace the mirror and had to order it. The hallways get buffed every other day and as needed. The DHM stated they buff one day but because of the residents, the floors will be dirty the next day. HK staff also try to scrape the edges of the floors by the baseboards when they buff the floors. On 9/18/2023 at 11:00 AM, the Administrator was interviewed and stated they are aware of the areas in the facility that need cleaning and repair. They will try to repair all those findings and will have an audit of what else needs to be done . 415.5(h)(2) 2) From 09/10/2023 at 09:34 AM to 09/12/2023 at 11:11 AM, observations of the following were made on the 2nd Floor: - 204B had peeling paint on the wall above their bed - 210 had a sticky floor and 2 dressers with broken drawers - 210B had a privacy curtain hanging around the bed that was missing several hooks and sagged - 207 had an overbed table that was stained with a sticky substance - 221 had a strong urine smell emanating from the room into the hallway, sticky floors, a privacy curtain for the shared bathroom that was missing several hooks and sagged, and a water stain on the ceiling over the sink - 221B had a dresser with a broken top drawer - 212 had water pitchers in a wash basin on the floor of the shared bathroom, the floor was sticky, paper towels were shoved in between the bathroom light and the ceiling, and a shared rusty stained sink with a loose hot water handle separated and hanging down from the ceramic - 217A had sticky floors stained with a black grime near all baseboards and behind the room door - 214 had a missing mirror over the shared sink with metal prongs protruding from the wall where the mirror previously hung - 214A had a bed frame missing the wooden footboard and a dresser with a missing top drawer - 2 air conditioning (AC) units in the floor dayroom were dusty and had grime and debris around the knobs and grates on top of the unit and all windows had a film buildup on the glass portion and a layer of dirt and dust on the sills - 1 dresser in a hallway alcove stained with a sticky substance and with a broken top drawer that was missing the front panel - 1 shower room near the floor dayroom that was wet, slippery, had underwear hanging from the grab bar next to the toilet, and had a puddle of water on the floor surrounding the toilet There was no documented evidence the above-mentioned observations were listed in the Maintenance Logbook from 7/17/2023 to 9/11/2023. On 09/15/2023 at 10:46 AM, Housekeeper #2 (HK) was interviewed and stated they are currently assigned to the 2nd Floor and their daily cleaning routine for the unit involves mopping with bleach, cleaning the floor and tables in the dayroom, and emptying the garbage. HK #2 cleans anything dirty they see. They also wipe down the windowsills but never cleaned the glass panes of the windows. A resident in 201 uses the shower room near the dayroom as their own personal bathroom and is there several times throughout the day and wets the floor and washes their clothes in the sink leaving puddles of water on the shower room floor. There is always a urine smell in the shower room and HK #2 cleans it with bleach. HK #2 stated they clean that shower room approximately 4 times a day. HK #2 mopped the unit this morning but the black grime along the baseboards does not come off with mopping. The floors need to be buffed to take off the black grime. HK #2 last buffed the unit this past Saturday. 3) On 9/12/2023 at 12:20 PM, 9/13/2023 at 12:05 PM, and 9/15/2023 at 11:28 AM, the following was observed on the 3rd Floor: - room [ROOM NUMBER] had a heavy urine smell - room [ROOM NUMBER] had a heavy urine smell, the AC unit rusty and stained brown, and there were broken tiles under the shared sink - room [ROOM NUMBER] had a windowsill rusted and stained brown - room [ROOM NUMBER] had dirty, dusty, brown, rusty windowsills and wall tiles by the shared sink that were coming off the wall - room [ROOM NUMBER] had a heavy urine smell, broken floor tiles by the shared sink, and a large hole in the wall between the window and the bed -room [ROOM NUMBER] had tiles coming off the wall by the shared sink, a constantly running sink faucet that could not be turned off by hand, and a sink that was stained brown with rust -The floor dayroom windowsill on the right side of the room was broken dislodged from the track On 9/15/2023 at 11:34 AM, the Maintenance Worker (MW) was interviewed and stated they check the Maintenance Logbook on every unit every morning. Staff also call the MW directly if there are concerns. Sometimes, the MW stated they might miss something. The MWs do rounds every day but there are only 3 MWs assigned for the whole building. On 9/15/23, at 12:01 PM, Housekeeper #1 was interviewed and stated they are assigned to the 3rd Floor and the floor dayroom, pantry, garbage, all resident rooms, and hallways are cleaned daily. The urine smell comes from residents' dirty clothes. They will speak to their supervisor regarding how to address the urine smell. On 9/18/23 at 12:10 PM, Licensed Practical Nurse (LPN) #4 was interviewed and stated they report issues on the 3rd Floor to Housekeeping and Maintenance. The MW comes to look at the Logbook but do not do anything.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the recertification and abbreviated survey (NY00302016 and NY00318527) from 9/10/2023 to 9/18/2023, the facility did not ensure all alleged violations involving abuse were reported within 2 hours, or events not involving abuse were reported within 24 hours to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident #92) of 3 residents reviewed for abuse and 1 (Resident #79) of 2 residents reviewed for accidents out of 27 total sampled residents. Specifically, 1) Resident #92 reported a Certified Nursing Assistant (CNA) pushed them in the chin and the facility did not report the allegation to the NYSDOH within 2 hours, and 2) the facility did not report Resident #79 was found on the floor in their room with left arm redness and sheering within 24 hours. The findings are: The facility's policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 4/20/23 documented the resident will be free from Abuse that include verbal, mental, sexual, or physical abuse, corporal punishments, or involuntary seclusion. 1) Resident #92 was admitted to the facility with diagnosis of Schizophrenia and Scoliosis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #92 had intact cognition. The facility's investigative report initiated 9/9/22 at 2:30 PM documented Resident #92 reported to the Director of Nursing (DNS) that the Certified Nursing Assistant (CNA) from the night shift pushed Resident #92 in the chin during provision of care. The Aspen Complaint Tracking System documented the facility reported the incident involving Resident #92 to NYSDOH on 9/10/22 at 2:00 PM, more than 2 hours after the occurrence. On 9/18/23 at 1:30 PM, the DNS stated the investigation of this incident involving Resident #92 was initiated immediately on 9/9/22 when it was reported to the DNS and was completed on the following day. The DNS acknowledged that alleged incident was not reported to NYSDOH within 2 hours and was submitted on 9/10/22 at 2:00 PM. 2) Resident #79 had diagnoses of bipolar disorder and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #79 was cognitively impaired. On 09/14/2023 at 12:30 PM, the complainant was interviewed via telephone and stated they received a call on 6/19/2023 from the facility to inform them Resident #79 was found on the floor and had fallen out of bed. Resident #79 was in pain and had left arm swelling and scratches. The undated Accident Incident (AI) Report documented Resident #79 was found on their floor mat at bedside at 6:45 AM on 6/18/2023. A Registered Nurse (RN) assessment was done and Resident #79 had blanchable redness and sheering to the left upper arm. Left shoulder and humerus X-ray were done and were negative for fracture. An undated Investigation documented Resident #79 had an incident on 6/19/2023 that caused left upper arm redness and sheering. On 6/20/2023, staff reported to the Assistant Director of Nursing (ADON) that the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) used a hoyer lifter to transfer Resident #79 back to bed from the floor mat next to their bedside. Resident #79's left upper arm may have rubbed against the Hoyer lift straps or against a metal part of the bed. Room was changed closer to the nursing station and Resident #79 was provided with a floor bed. The Investigation was unsigned and the Director of Nursing's name was typed at the bottom. Medical Doctor Note dated 6/20/2023 documented Resident #79 had an unavoidable mechanical fall. The facility reported the incident on 6/21/2023 to the NYSDOH, more than 24 hours after occurrence. On 09/18/2023 at 12:55 PM, the Director of Nursing (DNS) was interviewed and stated Resident #79's incident happened over the weekend on the night shift. The ADON received the call about the incident and the DNS was not notified until Monday, 6/19/2023. The incident was not reported to the NYSDOH within the regulatory guidelines because the facility did not determine abuse occurred. The DNS decided to report the incident when the Resident #79's wife became very upset and the DNS wanted to report the incident to the NYSDOH before the wife reported it. 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #79 had diagnoses of bipolar disorder and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #79 was cognitively impaired. On 09/14/2023 at 12:30 PM, an interview was conducted with the complainant who stated they came to visit Resident #79 on 6/19/2023 after the facility staff reported to them that Resident #79 was found on the floor early that morning. The complainant observed large deep red scratches on the resident's left arm. The scratches appeared to have already started healing but were draining pus and the complainant reported to the Director of Nursing (DNS) that the scratches appeared to have come from a incident when Residnt #79 was found on the floor the previous week, 6/11/2023. Resident #79 was in a lot of pain. The complainant requested the DNS address Resident #79's injuries and incidents and stated the DNS replied they did not want to take bread out of any staff member's mouth. The complainant responded to the DNS that if someone did this to Resident #79, they need to be held accountable. Nursing Note (NN) dated 6/11/2023 documented Resident #79 was found on the floor next to their bed and unable to verbalize what occurred. Resident #79 was assessed and had a skin tear to their left knee. NN dated 6/12/2023 documented Resident #79 was found on the floor, Medical Doctor (MD) made aware, and first aid treatment provided for skin tear to the left knee. The incident was unavoidable and there is no cause to believe neglect, mistreatment, or abuse occurred. The plan included rehab evaluation, neuro check, hourly monitoring, and fall precautions. The AI Investigation Form dated 6/11/2023 documented the Licensed Practical Nurse (LPN) observed Resident #79 lying on the floor with a skin tear to their left knee. The Nursing Supervisor was made aware. The CNA Statement dated 6/11/2023 documented CNA #7 was making rounds at 6 AM when they observed Resident #79 on the floor next to their bed. Nursing Staffing Sheets dated 6/11/2023 documented CNA #7 and CNA #8 worked on Resident #79's floor on the 11 PM to 7 AM shift. There is no documented evidence a thorough investigation to rule out abuse was conducted and statements were gathered by all staff members present on the unit when Resident #79 was found on the floor on 6/11/2023. On 09/18/2023 at 12:55 PM, the Director of Nursing (DNS) was interviewed and stated Resident #79 has behaviors of and episodes of falling. The AI investigations are used to rule out abuse. The DNS gathers staff interviews as part of the investigation. The DNS stated Resient #79 was found on the floor so they must have fallen because Resident #79 was alone in the room. Resident #79's first fall occurred on 6/11/2023 and, the DNS stated only 1 CNA statement was included in the AI report so only 1 CNA must have been working contact shift. The DNS stated they did not check the staffing sheet. After review of the Staffing Sheets for 6/11/2023, the DNS stated CNA #8 was working when Resident #79 fell on 6/11/2023 and their statement was not gathered as part of the investigation. The DNS stated this is not an adequate investigation. 415.4(b)(2) Based on record reviews, and staff interviews during the recertification and abbreviated (NY00318546 and NY00318527) survey from 9/10/2023 to 9/18/2023, the facility did not ensure all alleged violations of abuse were thoroughly investigated. This was evident for 2 (Resident #171 and #79) of 27 total sampled residents. Specifically, 1) Resident #171 was observed with a bump and redness to their forehead that was not thoroughly investigated, and 2) staff statements were not obtained to rule out abuse when Resident #79 was found on the floor. The findings are: The facility policy titled Accident/Incident (AI) Report dated 3/9/2023 documented promptly submit completed statements from all Certified Nursing Assistants (CNA) related to the AI to the Nursing Supervisor within the tour of duty. 1) Resident #171 had diagnoses of Psychotic Disturbance, Mood Disturbance and Anxiety. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #171 had severely impaired cognition. On 9/14/2023 at 5:28 PM, the complainant was interviewed and stated they received a phone call from the facility on 6/17/23 and were asked whether Resident #171 had a history of falling. The complainant stated they reported to the facility that Resident #171 did not have a history of falling. The facility reported to the complainant during the phone call that Resident #171 had redness and swelling to their forehead. The Nursing Note (NN) dated 6/17/23 documented that the facility called the complainant to report swelling and redness to Resident #171's forehead. The NN documented the complainant reported receiving a call from the clinic Resident #171 visited 3 days prior and during this call, the clinic reported to the complainant that Resident #171 fell during their visit. The NN dated 6/17/23 documented Resident #171 had swelling between the forehead and was unable to verbalize how the injury occurred. NN dated 6/20/2023 documented upon investigation, Resident #171 noted with redness and a bump. The medical Doctor was made aware and complainant called. Resident #171 was confused and wanders and could not relate what transpired. There is no cause to believe abuse occurred. There is no documented evidence staff statements were obtained and thorough investigation was conducted to rule out abuse for Resident #171. On 9/15/2023 at 11:09 AM, the Home Health Aide (HHA) who accompanied Resident #171 to their clinic appointment was interviewed and stated Resident #171 did not have any falls or incidents while at their clinic appointment. Resident #171 did not return to the facility with a bump or redness to their forehead. On 9/12/2023 at 2:25 PM, the Licensed Practical Nurse (LPN) #4 was interviewed and stated Resident #171 was observed with a bump and redness on their forehead. LPN #4 made the Nursing Supervisor, Registered Nurse (RN) #4, aware. On 9/15/23 at 10:35 AM, RN #4 was interviewed and stated the CNA reported to them Resident #171 had a bump and redness to their forehead. RN #4 assessed Resident #171 and informed the Assistant Director of Nursing (ADON) and the complainant. RN #4 stated the complainant reported being informed by the clinic that Resident #171 fell during their visit. The complainant also reported to RN #4 that the clinic did not inform them of any redness or swelling to the resident's forehead and that something must have happened at the facility. On 9/14/2023 at 6:13 PM, the (ADON) was interviewed and stated RN #4 informed them that the complainant called 911 and had Resident #171 transferred to the hospital due to forehead bump and redness. The ADON attempted to speak with the complainant but they refused. The ADON started their investigation by calling RN #4 and concluded Resident #171 fell while at the clinic. Resident #171 wanders but the ADON did not determine that their injury was of unknown origin because the complainant reported a fall in the clinic. Staff noted the bump and did not witness any fall. The ADON immediately reported the incident to administration. On 9/18/2023 at 10:29 AM, the Director of Nursing (DNS) was interviewed and stated they attempted to call the clinic to find out whether Resident #171 fell during their appointment but no one was there. The DNS did not follow up with the clinic to investigate the origin of Resident #171's forehead bump.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed and implemented. This was evident for 5 of 27 sampled residents (Resident #s 60, 109, 110, 66, and 27). Specifically, Resident #60 had no CCP for Glaucoma. Resident #66 and #109 had no CCP developed to address dental issues. Resident #110 had no CCP developed to address the care needs of Latent Syphilis. Resident #27 had no CCP to address pain. The findings include but are not limited to: The facility policy and procedure title Comprehensive Care Plan last updated on 4/20/23 stated that an individualized comprehensive care plan will be developed and implemented for each resident. The policy further stated that the care plan will be maintained within the medical record of each resident in the facility. The care plan will be developed by an interdisciplinary team of health care professional as appropriate to the need of each resident. 1) Resident #60 was admitted to the facility on [DATE] with the diagnoses of Cerebral Infarction, Glaucoma, and Hypertension. The Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #60 has severely impaired cognition. The MDS further documented that the Resident required limited assist of one person for bed mobility and toilet use. Extensive assist of one for transfer and personal hygiene. Supervision and one assist for dressing and supervision and set up for eating. The Physician's Orders renewed on 9/13/23 documented that Resident #60 received Latanoprost solution 0.005% one drop to both eyes at bedtime for Glaucoma. The order has been active since 2/28/2022 There was no documented evidence that a comprehensive care plan related to vision care was developed for the Resident. 2) Resident #109 was admitted to the facility on [DATE] with the diagnoses of Systolic Congestive Heart Failure, type II Diabetes Mellitus, and Hypertension. The admission Minimum Data Set (MDS) dated [DATE] documented that Resident #109 has moderately impaired cognition. The MDS further documented that the resident is extensive and one assist for bed mobility, transfer, Dressing, toilet use and personal hygiene. Supervision with one assist for eating. On observation, Resident was noted with missing teeth from upper and lower parts of the mouth. The dental consultation dated 3/15/23 stated that the Resident lost some natural teeth and broken teeth are noted. Broken teeth are asymptomatic, no work at this time. There was no documented evidence that a comprehensive care plan related to dental care was developed for the Resident. 3) Resident #110 was admitted to the facility on [DATE] with a diagnosis of Latent Syphilis The admission Minimum Data Set (MDS) dated [DATE] documented that Resident #110 has severely impaired cognition. The MDS further documented that the Resident is supervision with one assist for bed mobility, Extensive of 2 assists for transfer, dressing, toilet use and personal hygiene. Limited and 1 assist for eating. During an interview with the psychiatrist on 9/15/2023 at 3:53 PM, he stated that Latent Syphilis triggers if not treated goes to the secondary stage which affects the skin. Then psychosis in the tertiary stage which affects the brain. The Resident can become very aggressive and can also develop depression There was no evidence that a comprehensive care plan related to Latent Syphilis was developed for the Resident. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure resident's Comprehensive Care Plan (CCP) were reviewed, revised, and implemented after each assessment. This was evident for 1 of 2 residents reviewed for Pain Management (Resident #87) and 1 (Resident #79) of 2 residents reviewed for Accidents out of 27 total sampled residents. Specifically, 1) CCPs related to Pain Management/Therapy were not reviewed and revised quarterly to reflect current pain management regimen for Resident #87, and 2) the CCP related to Resident #79's risk for falls was not reviewed and revised to reflect updated interventions after the resident had an incident on 6/19/2023. The findings are: The facility policy titled CCP dated 4/20/2023 documented CCPs are reviewed and revised quarterly and as needed. 1) Resident #87 was admitted to the facility with diagnosis of Schizophrenia, Osteoarthritis and Diabetes Mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented resident is cognitively intact, receiving schedule pain medication regimen. On 9/10/23 at 1:20 PM, Resident #87 stated they have arthritic pain to their left hip and have been getting Gabapentin and Tramadol for pain medication. Resident #87 complained of ongoing pain to staff, but resident was told that medication can't be changed to stronger medication/dosage. Resident #87 stated they are not asking for stronger medication but something to relieve their ongoing pain. The physician order initiated 2/28/22 documented Resident #87 to receive Gabapentin 100 mg capsule TID for pain in left hip. The physician order initiated 2/28/22 documented Resident #87 to receive Tramadol 50 mg tablet every 8 hours for chronic pain for osteoarthritis. The CCP titled Communication problem related to pain revised 5/29/23 documented to monitor/document for physical/nonverbal indicators of discomfort, distress and follow up as needed. The CCP titled Pain medication therapy Tramadol revised 5/29/23 documented to review efficacy of the pain medication and to assess whether pain intensity acceptable to resident. There was no documented evidence that the pain management/therapy was discussed with Resident #87 or that CCP related to pain management/therapy were revised quarterly after the MDS assessment on 8/10/23. On 9/15/23 at 12:25 PM, the Assistant Director of Nursing (ADON) stated CCP is initiated upon admission, then updated quarterly and as needed. ADON stated Resident #87's care plans related to pain management/therapy were last revised on 5/29/23 and should have been revised quarterly on 8/30/23. ADON does not know why the CCP were not updated for Resident #87. On 9/15/23 at 1:33 PM, Director of Nursing (DON) stated Resident #87 was admitted to the facility on pain medication and was on pain management therapy. DON stated they were not aware that Resident #87 had any pain related issues. DON stated they were invited to the recent care plan meeting, but resident refused to attend the meeting as per attendance record on 8/31/23. DON stated they were not aware that care plans related to pain management/therapy were last revised 5/29/23. 2) Resident #79 had diagnoses of bipolar disorder and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #79 was severely cognitively impaired and had a fall since their prior assessment that did not result in injury. Resident #79 required extensive assistance of 2 people for walking in their room and for transfers. The Comprehensive Care Plan (CCP) related to Resident #79's high risk for falls initiated 3/20/2022 documented the resident had gait problems, confusion, and psychoactive drug use. Interventions documented maintain a safe environment with the bed in a low position, ensure proper footwear, and physical therapy evaluation and treatment as needed. The CCP was revised goal was revised on 6/12/2023 and documented Resident #79 will be free of falls. The interventions were not revised since 3/20/2022. The AI Investigation dated 10/19/2022 documented Resident #79 had an unwitnessed fall in the dayroom after they got up from their chair suddenly and fell before a Certified Nursing Assistant could get to them. There was a bump on the resident's forehead, no predisposing factors, no physiological factors, no situational factors, and no witnesses. Resident #79 sustained a right elbow abrasion. The plan included staff to monitor, frequent visual checks, and standard fall and safety precautions. The Licensed Practical Nurse (LPN) documented in their statement that the therapist reported to them that they saw Resident #79 on the floor in the dayroom. The Fall Risk assessment dated [DATE] documented Resident #79 scored a 15 with 10 being a score that indicates the resident is at high risk for falls. The Medical Doctor Order (MDO) dated 6/7/2023 documented monitor Resident #79 hourly for safety. The CCP related to risk for fall post-fall initiated 6/11/2023 documented Resident #79 receive assistance with transfers, maintain a safe environment, education of resident re: use of mobility devices, ensure bed is in the lowest position, ensure call light is available,alert provide in the event of a fall, and evaluate resident's environment to identify factors known to increase falls. Nursing Note (NN) dated 6/11/2023 documented Resident #79 was found on the floor next to their bed and unable to verbalize what occurred. Resident #79 was assessed and had a skin tear to their left knee. The AI Investigation Form dated 6/11/2023 documented the Licensed Practical Nurse (LPN) observed Resident #79 lying on the floor with a skin tear to their left knee. The Nursing Supervisor was made aware. The CNA Statement dated 6/11/2023 documented CNA #7 was making rounds at 6 AM when they observed Resident #79 on the floor next to their bed. Nursing Staffing Sheets dated 6/11/2023 documented CNA #7 and CNA #8 worked on Resident #79's floor on the 11 PM to 7 AM shift. NN dated 6/12/2023 documented Resident #79 was found on the floor, Medical Doctor (MD) made aware, and first aid treatment provided for skin tear to the left knee. The incident was unavoidable and there is no cause to believe neglect, mistreatment, or abuse occurred. The plan included rehab evaluation, neuro check, hourly monitoring, and fall precautions. An undated Investigation documented Resident #79 had an incident on 6/19/2023 that caused left upper arm redness and sheering. On 6/20/2023, staff reported to the Assistant Director of Nursing (ADON) that the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) used a hoyer lifter to transfer Resident #79 back to bed from the floor mat next to their bedside. Resident #79's left upper arm may have rubbed against the Hoyer lift straps or against a metal part of the bed. Room was changed closer to the nursing station and Resident #79 was provided with a floor bed. The Investigation was unsigned and the Director of Nursing's name was typed at the bottom. On 09/14/23 at 05:07 PM, Registered Nurse (RN) #2 was interviewed and stated they are responsible for updating Resident #79's CCPs related to falls and thought they were updated after each fall. Resident's room was changed closer to the nursing station and they went from a low bed to a very low bed. 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification and complaint (NY00318527) survey from 9/10/2023 to 9/18/2023, the facility did not ensure residents remained free of accidents and hazards. This was evident for 1 (Resident #79) of 2 residents reviewed for Accidents and the 1 (2nd Floor) of 3 resident units. Specifically, 1) Resident #79 was not adequately assessed for fall risk following each fall, did not have a CCP related to fall risk with adequate interventions that was reviewed upon each fall, and did not receive supervision to prevent further falls; and 2) there were observations of a 2nd floor window in the floor dayroom that can fully open, an eyewash station without an eyewash device in place, a dental office with an x-ray machine and drill that remained unlocked, and a wet shower room floor without a wet floor sign. The findings are: 1) Resident #79 had diagnoses of bipolar disorder and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #79 was severely cognitively impaired and had a fall since their prior assessment that did not result in injury. Resident #79 required extensive assistance of 2 people for walking in their room and for transfers. On 09/14/2023 at 12:30 PM, an interview was conducted with the complainant who stated they came to visit Resident #79 on 6/19/2023 after the facility staff reported to them that Resident #79 was found on the floor early that morning. The complainant observed large deep red scratches on the resident's left arm. The scratches appeared to have already started healing but were draining pus and the complainant reported to the Director of Nursing (DNS) that the scratches appeared to have come from an incident when Resident #79 was found on the floor the previous week, 6/11/2023. The Comprehensive Care Plan (CCP) related to Resident #79's high risk for falls initiated 3/20/2022 documented the resident had gait problems, confusion, and psychoactive drug use. Interventions documented maintain a safe environment with the bed in a low position, ensure proper footwear, and physical therapy evaluation and treatment as needed. The CCP was revised goal was revised on 6/12/2023 and documented Resident #79 will be free of falls. The interventions were not revised since 3/20/2022. The AI Investigation dated 10/19/2022 documented Resident #79 had an unwitnessed fall in the dayroom after they got up from their chair suddenly and fell before a Certified Nursing Assistant could get to them. There was a bump on the resident's forehead, no predisposing factors, no physiological factors, no situational factors, and no witnesses. Resident #79 sustained a right elbow abrasion. The plan included staff to monitor, frequent visual checks, and standard fall and safety precautions. The Licensed Practical Nurse (LPN) documented in their statement that the therapist reported to them that they saw Resident #79 on the floor in the dayroom. The Fall Risk assessment dated [DATE] documented Resident #79 scored a 15 with 10 being a score that indicates the resident is at high risk for falls. The Medical Doctor Order (MDO) dated 6/7/2023 documented monitor Resident #79 hourly for safety. The CCP related to risk for fall post-fall initiated 6/11/2023 documented Resident #79 receive assistance with transfers, maintain a safe environment, education of resident re: use of mobility devices, ensure bed is in the lowest position, ensure call light is available, alert provide in the event of a fall, and evaluate resident's environment to identify factors known to increase falls. Nursing Note (NN) dated 6/11/2023 documented Resident #79 was found on the floor next to their bed and unable to verbalize what occurred. Resident #79 was assessed and had a skin tear to their left knee. The AI Investigation Form dated 6/11/2023 documented the Licensed Practical Nurse (LPN) observed Resident #79 lying on the floor with a skin tear to their left knee. The Nursing Supervisor was made aware. The CNA Statement dated 6/11/2023 documented CNA #7 was making rounds at 6 AM when they observed Resident #79 on the floor next to their bed. Nursing Staffing Sheets dated 6/11/2023 documented CNA #7 and CNA #8 worked on Resident #79's floor on the 11 PM to 7 AM shift. NN dated 6/12/2023 documented Resident #79 was found on the floor, Medical Doctor (MD) made aware, and first aid treatment provided for skin tear to the left knee. The incident was unavoidable and there is no cause to believe neglect, mistreatment, or abuse occurred. The plan included rehab evaluation, neuro check, hourly monitoring, and fall precautions. An undated Investigation documented Resident #79 had an incident on 6/19/2023 that caused left upper arm redness and sheering. On 6/20/2023, staff reported to the Assistant Director of Nursing (ADON) that the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) used a Hoyer lifter to transfer Resident #79 back to bed from the floor mat next to their bedside. Resident #79's left upper arm may have rubbed against the Hoyer lift straps or against a metal part of the bed. Room was changed closer to the nursing station and Resident #79 was provided with a floor bed. The Investigation was unsigned, and the Director of Nursing's name was typed at the bottom. Medical Doctor Note dated 6/20/2023 documented Resident #79 had an unavoidable mechanical fall. The CNA Accountability for June 2023 documented 142 of 432 opportunities to observe Resident #79 for hourly monitoring for safety and fall precautions were left blank and were not documented. The Fall Risk assessment dated [DATE] documented Resident #79 scored a 23 and was at a higher risk for falls than the previous assessment dated [DATE]. There was no documented evidence Resident #79 was assessed for the risks and benefits of fall mats prior to use when deemed a fall risk. There was no documented evidence Resident #79 received hourly supervision in accordance with MDO to prevent falls on 6/12/2023 and 6/19/2023. There was no documented evidence Resident #79's CCPs related to falls were reviewed and revised to include interventions to address multiple falls on 10/19/22, 6/12/23, and 6/19/23. On 09/18/23 at 09:49 AM, CNA #7 was interviewed and stated they were assigned to Resident #79 on 6/12/2023 and 6/19/2023 when the resident was found on the floor in their room. The unit works short staffed often on the weekends and CNA #7 does the best they can to address resident needs but there are times you cannot get to all residents to provide activity of daily living care. Some residents wander and must be monitored. CNA #7 makes rounds and checks in on confused residents to ensure they are safe and in bed and not on the floor. CNA #7 stated the CNA Accountability informs them of resident care needs. Resident #79 had 2 incidents of being found on the floor in their room. Resident #79 was not considered a fall risk prior to the 2 incidents in 6/2023. After reporting the first fall to the LPN, the CNA was told Resident #79 needed a low bed. After the 2nd fall, Resident #79's bed was changed to a floor bed and the floor mats were changed from worn mats to brand new floor mats. Resident #79 was found on the floor mat on the 2nd fall. Resident #79 was confused and wandered on the unit after getting dressed in the morning and would normally sit in the floor dayroom. Resident #79 was still able to ambulate after the first fall on 6/12/23. Fall and safety precautions were in place, and this means the CNA ensures there is no clutter on the floor for the resident to trip over and that Resident #79 is monitored for a change in balance. If the resident is unsteady, they need to be placed in a wheelchair. Sometimes Resident #79 attempted to get up from the wheelchair on their unassisted. Resident #79 was placed on hourly checks. CNA #7 normally performed the hourly checks. Resident #79 was on the list of residents to get out of bed and dressed early in the morning. Sometimes, CNA #7 required the assistance of a 2nd CNA because the resident had a behavior of screaming. On 6/19/2023, CNA #7 last saw Resident #79 in bed at 5:45 AM, alert and shaking. When CNA #7 came back to give Resident #79 care, the resident was on the floor mat. CNA #7 informed the LPN assigned to the unit and the LPN directed CNA #7 to get a Hoyer lifter to transfer Resident #79 back to bed before the RN came to the unit to assess the resident. On 09/15/23 at 12:38 PM, LPN #6 was interviewed, and stated Resident #79 had a low bed in place due to their high risk for falls. Resident #79 was not receiving any special supervision and had floor mats in place. LPN #6 was not present for either of Resident #79's falls in 6/2023. Resident #79's room was changed to be closer to the nursing station after the fall on 6/12/2023. Hourly supervision is documented separately. On 09/18/23 at 11:06 AM, the RN Permittee was interviewed, and stated Resident #79 was known as a fall risk that frequently placed themselves on the floor. This was not documented in Resident #79's medical record, but the CNAs informed the RN Permittee of the resident's behavior. Resident #79 was on fall and safety precautions prior to their fall on 6/19/2023. The bed was already in the lowest position and floor mats were already in place. The appropriateness of floor mats is determined by the Director of Nursing (DNS). Rehab assesses the resident also. It is not one person's decision to place floor mats in a resident's room. The CNA is responsible for monitoring residents hourly to ensure they are still in bed. There is a supervision logbook that is checked by the LPNs. On 09/14/23 at 05:07 PM, RN #2 was interviewed and stated Resident #79's low bed was changed to a very low bed after their first fall on 6/12/2023. On 09/18/23 at 12:55 PM, the DNS was interviewed and stated Resident #79's incidents of being found on the floor were investigated. Resident had floor mats on the floor after the first fall on 6/12/2023 and they were still in place when the resident fell on 6/19/2023. Nursing uses their judgment to determine the appropriateness of floor mats for a resident at risk for falls. Floor mats are not appropriate for a resident who can walk. Resident #79 was unable to walk so floor mats were used as an intervention. It should be listed on under the nursing task list. The AI investigation on 6/12/2023 was not adequate as it did not contain all the statements from staff that were working that shift. could be an error. 2) On 09/10/23 at 11:52 AM, the shower room close to the floor dayroom on the east side of the unit was slippery without visible spills and did not have a wet floor sign. AN Eyewash Station sign was posted on the door and no eyewash station was observed in the shower room. A Supervisor's Office door was unlocked, and the room contained a drill attached to a desk and an x-ray machine. East Wing High side of 2nd floor unit. Shower room with slippery floor. No visible spills. At 3:13 PM, the shower room was still slippery, and a large puddle of water had accumulated under the toilet and no wet floor sign was in place. The Supervisor's Office was still unlocked. At 3:24 PM, the floor dayroom was observed with a window on the left side of the room that opened all the way and had a large enough opening for a person to fit through. On 09/12/23 at 11:11 AM, the shower room on the east side by the floor dayroom had a large puddle of water under the toilet and no wet floor sign. On 09/12/23 at 11:31 AM, the Maintenance Worker (MW) was interviewed and, after observing the window that can open all the way in the dayroom, stated each floor is equipped with a window that can open all the way in case of an emergency for the fire department to access the facility. Nursing should know if there are any residents to monitor that might attempt to open the window and could fall out. The Supervisors Office is a dentist office and the x-ray machine contained inside is functional. Nursing is responsible for ensuring the room is locked. On 09/15/23 at 10:46 AM, Housekeeper (HK) #2 was interviewed and stated they must clean the shower room [ROOM NUMBER] times a day because there is a resident on the unit that uses it like their personal bathroom and splashes water on the floor. HK #2 was unaware that the shower room was also an eyewash station and did not observe an eyewash station in the room. On 09/15/23 at 11:15 AM, the Director of Housekeeping and Maintenance (DHM) was interviewed and stated the 2nd floor window in the dayroom should not open all the way and was fixed after pointed out to the MW to ensure there is a stopper in place. Each floor does not have a window that can open all the way. The DHM stated the Maintenance Department does check the windows to ensure they cannot open but not often. A resident on the 2nd floor causes floods in the shower room because they wash their clothing in the sink. Staff redirect the resident, but the resident's behavior continues. The eyewash station piece is in the Maintenance office downstairs because the resident removed the eyewash station when they use the sink. The DHM is looking into ordering individual bottles of eyewash to equip each floor with. At 11:46 AM, the DHM observed the open unlocked Supervisors Office and stated the Dentist, the DHM, and the owner have a key to this door. It is supposed to remain locked unless in use by the dentist. It may have been opened by staff to clean it but then should be locked again after. 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews conducted during the recertification and complaints (NY00307070, NY00318546, survey from 9/10/23 through 9/18/23, the facility did not ensure there was sufficient staff available to meet residents' needs considering the number, acuity and diagnose of the facility's resident population as determined by the Facility Assessment. Specifically, 1) the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal (PBJ) Staffing Data Report, 2) Resident #171 was discovered with an injury of unknown origin on a day when the unit was short of Certified Nursing Assistants (CNA), and 3) Resident #121 reported not receiving care on a day when the facility was short of CNAs on their unit. The findings include but are not limited to: The Facility Staffing policy reviewed 4/20/23 documented that each nursing unit will have adequate staff to safely and effectively complete resident care on a daily basis. The Facility Assessment tool revised 1/24/23 documented facility is licensed to care for 120 residents with 3 nursing units and with average daily census ranges from 117. Staffing Plan is to ensure sufficient staff to meet the needs of the residents at any given time. 1. PBJ Staffing Data Report and Daily Staffing Sheet The PBJ Staffing Data Report dated Fiscal Year (FY) Quarter 2 2023 (January 1- March 31) documented the facility triggered for the metric of excessively low weekend staffing. A review of Daily Staffing sheets from 8/6/23 to 9/10/23 revealed following weekend dates did not meet the minimum number required on following weekend dates: 8/06/23 Day shift - 9 CNAs (3 short) 8/12/23 Night shift -5 CNAs (1 short) Day shift - 10 CNAs (2 short) Evening shift - 7 CNAs (2 short) 8/13/23 Night shift -5 CNAs (1 short) Day shift - 9 CNAs (3 short) Evening shift - 8 CNAs (1 short) 8/19/23 Night shift -5 CNAs (1 short) Day shift - 10 CNAs (2 short) 8/20/23 Night shift -4 CNAs (2 short) Day shift - 11 CNAs (1 short) 8/26/23 Night shift -5 CNAs (1 short) Day shift - 10 CNAs (2 short) Evening shift - 7 CNAs (2 short) 8/27/23 Night shift -3 CNAs (3 short) Day shift - 8 CNAs (4 short) Evening shift - 7 CNAs (2 short) 9/02/23 Night shift -4 CNAs (2 short) Day shift - 10 CNAs (2 short) Evening shift - 8 CNAs (1 short) 9/03/23 Night shift - 5 CNAs (1 short) Day shift - 10 CNAs (2 short) 9/09/23 Night shift -5 CNAs (1 short) Day shift - 9 CNAs (3 short) 9/10/23 Night shift -5 CNAs (1 short) Day shift - 9 CNAs (3 short) The number of CNAs needed for Night shift, were not met for 10 out of the 11 weekend days, Day shift were not met for 11 out of the 11 weekend days and Evening shift, were not met for 5 out of the 11 weekend days. The facility utilized Home Health Aides(HHAs) to assist on the units. 3) Resident #121 has a diagnosis of End Stage Renal failure, Morbid obesity. Minimum Data Set (MDS) dated [DATE] documents resident #121 needs extensive to total assistance of staff to complete Activities of daily Living (ADL) Resident # 121 stated the unit have only one CNA on 12/5/2022 and 4/20/2023 and bells were unanswered. The unit have 39 residents. Staffing schedule was reviewed and revealed that for both dates Resident #121 reported, it was documented that on the night shift only one CNA was assigned to unit for 39 residents. Facility Assessment documents that 2 CNAS must be scheduled to work for 39 residents for the night shift. On 09/14/23 at 04:41 PM CNA # 5 was interviewed and stated on 12/5/22 on 11-7 shift only one CNA worked to care for 39 residents, understaffing happened mostly on weekends on all shift, staff leaves the facility because there is no incentives. On 09/18/23 at 09:49 AM, CNA #7 was interviewed and stated they have worked in the facility for 9 years, always works the night shift and usually works the weekends. Since the COVID pandemic, the facility often works short staffed of CNAs. The 4th Floor has a census of 40 residents and there are 2 CNAs scheduled to provide activity of daily living care to residents, monitor wanderers, and get residents for dialysis in the morning. There are many times, CNA #7 must work alone as the only CNA on the unit to provide care for all 40 residents. CNA #7 does the best they can to cover all resident needs but there are times they cannot get to all residents. It is a lot of responsibility even when staffed with 2 CNAs. In month, the unit will work short-staffed of CNAs an average of 3 times. If the other CNA scheduled to work is on vacation or calls out, the facility does not replace them. CNA #7 stated it gets frustrating and is an ongoing problem even though staff have communicated their concerns with staffing to the Administration and Human Resources. CNA #7 stated they feel burnt out and overworked. CNA #7 requested a personal day several a week in advance for a funeral and was told by the Director of Nursing that they will not grant the day off because they will not be able to find a replacement. Human Resources tells the staff they are putting more work on the other CNAs if they take vacation or call out. CNA #7 had to call out on the personal day they requested because they could not miss the funeral for their family member. CNA #7 was informed when they returned to work that the other CNA scheduled to work on the day CNA #7 took as a personal day ended up having to work alone. If a resident requires 2 people to assist with care or transfers, the LPNs try to help if they have time, otherwise the residents must wait until the day shift comes to work or the CNA will try to request for a CNA from another unit to help. The facility employs Home Health Aides (HHA) to work on the unit instead of more CNAs. HHAs cannot provide direct care to residents so they cannot assist with activities of daily living and do not have access to the medical record so they cannot assist with completing necessary documentation. Administration does give overtime easily so when CNA #7 is asked to cover other CNAs shifts, it is a fight to get paid for the extra time. When care cannot be provided to the residents, the residents start to break down. On 09/15/23 at 10:50 AM LPN # 4 was interviewed stated the unit is almost full capacity every day and gives medications to about 37 to 39 residents and also do the treatment also. The RN supervisor is only one for the whole building. The unit have sometimes 3 CNAS for 37 or 4 CNAS sometimes. If the unit have 3 CNAs in the day shift it is difficult because we have a lot of total care residents. On 09/18/23 at 11:06 AM, the RN Permittee was interviewed and stated they have worked in the facility per diem as an LPN. The unit they manage has worked short of staff approximately 5 times on the night shift. The facility tries to get coverage, but they cannot usually get anyone to cover. On 09/15/23 at 09:45 AM RN# 4 was interviewed stated worked full time in the facility and most of the residents complaint of short staffing, they get upset if the call bell are not answered timely. They tried to reason out to residents that they will attend to them as soon as they're done with whatever they're doing with one resident. On 9/14/23 at 12:31 PM and On 9/15/23 at 1:45 PM, an was conducted with the Staffing Coordinator who stated weekend staffing is very hard to fill in if somebody calls in sick. CNA is harder to replace than an LPN. If they failed to get a replacement, they notify the RN supervisor, and the supervisor continues to look for a replacement. If still the RN supervisor cannot replace a CNA, then that CNA must work by themselves with the help of the nurse on the unit. They make the Director of Nursing (DON) aware that they cannot get a replacement for sick calls and the RN is trying also to get a replacement. The Staffing Coordinator stated that staffing has been challenging for the last year and a half, especially the weekends. They have been continuously reaching out to 9 different staffing agencies, posting on Indeed to recruit more CNAs. Currently they are hiring 1 part time and 2 full time CNA positions for Night shift, 2 part time and 1 full time CNA positions for Day shift, and 1 part time CNA position for Evening shift. It's difficult to find staff to cover the call outs on the weekend. On 9/14/2023 at 6:13 PM, The Assistant Director of Nursing (ADON) was interviewed and stated that Resident wanders around days and night. For the staffing in the facility, it is supposed to be 2 CNAs at night on each floor, 3 CNAs in the evening and 4 CNAs during the day. There are days they worked short during the week and the weekend. Mostly, there is a pattern for staff to call out over the weekend. Specially in the weekend, it is hard to find replacement. If they are working short, depend on the shift, the night shift can end up with 1 CNA, evening shift with 2 CNAs and day shift with 3 CNAs. Staffing is a big problem in the facility. On 09/18/23 at 2PM the Director of Nursing was interviewed and stated they are aware of short staffing and are actively hiring staff, however new hires do not stay long enough, they leave for reason they do not know. On 9/18/23 at 12:12 PM, Administrator stated they are assigning staff sufficiently on a daily basis, but it is a problem finding coverage for all the call outs. There are not enough staff to cover all the call outs. They have been posting in indeed and through word of mouth. Administrator stated that only one resident came to him to complain about staffing issues. He stated staffing issue started during COVID because staff got sick, never came back, and have retired. The positions were never fully replaced. It has been about last 6 months that the call outs gotten worse especially weekend staff. 415.13(a)(1) (i-iii) 2) Resident #171 was admitted to the facility on [DATE] with diagnoses which included Psychotic Disturbance, Mood Disturbance and Anxiety. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #171 had severely impaired cognition. The MDS further stated that the Resident is extensive and one assist for bed mobility and dressing. Extensive and 2 assists for transfer and toilet use. On 9/14/2023 at 5:28 PM, the complainant was interviewed and stated that they don't get enough staff at night to watch the Residents. On 9/12/2023, CNA #6 was interviewed and stated that on that day, 6/18/23 , the unit was working short, The 3rd floor had 2 CNAs with the regular charge nurse. CNA #6 further stated that when entered the Resident's room, the Resident was observed with a bump on the forehead and the nurse in charge was immediately notified. On 9/12/23 at 2;25 PM, the LPN #4 was interviewed and stated that a bump with redness was observed on the Resident's forehead and staff did not know how it happened and Resident was unable to express themselves.

Based on observation, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident during 7 of 7 Licensed Practical Nurse (LPN) Permittees and 1 of 1 Registered Nurse (RN) Permittees employed by the facility. Specifically, the facility employed 7 LPN Permittees and 1 RN Permittee to work in the capacity as a licensed nurse without the required application approval and documented RN supervision. The findings are: The facility policy titled Limited Permit dated 5/12/2023 documented the facility employs nurses who do not hold a New York State (NYS) license by accepting a permit from the NYS Education Department (NYSED). Permits to practice a RN or LPN are issued by the NYSED after filing an application. No Permittee will be allowed to begin employment without form N5 of the NYSED. Upon employment, the Permittee will practice nursing only under the supervision of a nurse currently registered in this state and with the endorsement of the facility. The policy was signed by the Administrator. A facility list titled Limited Permit LPNs provided on 9/14/2023 documented LPN Permittee #1 was hired 9/19/2022, LPN Permittee #2 was hire 3/6/2022, LPN Permittee #3 was hired 6/27/2023, LPN Permittee #4 was hired 7/5/2023, LPN Permittee #5 was hired 7/27/2023, LPN Permittee #6 was hired 8/14/2023, and LPN Permittee #7 was hired 4/19/2022. Nurse Form 5 from the Office of Professions (N5) documented a limited permit authorizes practice as a nurse under the immediate and personal supervision of a New York State licensed, currently registered, registered professional nurse. The supervising nurses listed in this section must be Registered Professional Nurses who will work directly with the Permittee on the same unit so that consistent supervision is ensured. The applicant may not begin practice until the limited permit is issued. The N5 forms documented attestations from the Director of Nursing (DNS) and the Assistant Director of Nursing (ADON) that direct supervision would be provided to the LPN Permittees on the following dates: LPN Permittee #1 - 8/24/2023 LPN Permittee #2 - 3/1/2023 LPN Permittee #3 - 8/24/2023 LPN Permittee #4 - 8/24/2023 LPN Permittee #5 - 8/11/2023 LPN Permittee #6 - 9/11/2023 LPN Permittee #7 - 4/29/2022 The Office of Professions Validation Report documented Limited Permit RN status was approved for LPN Permittee #1 from 9/8/2023 to 9/7/2024. Limited Permit LPN status was approved for LPN Permittee #7 from 4/13/2023 to 4/12/2024. The employee file for the RN Permittee documented they were hired on 5/3/2023 and the N5 was signed by the RN Permittee on 6/21/2023. The N5 attestation form was undated and signed by the DNS and ADON. Staffing Sheets from 5/21/2023 to 9/9/2023 documented the LPN Permittees #1, #2, #3, #4, #5, #6, and #7 worked on facility units as LPNs without the authorized direct supervision of the DNS, ADON, or RN Supervisor. The RN Permittee worked with no RN Supervisor in the building on 6/5/2023 and 6/19/2023. The RN Permittee worked with LPN Permittee #4 on the 4th Floor on 6/5/2023. There was no documented evidence LPN Permittee #2, #3, #4, #5, #6 and RN Permittee were approved for Limited Permit status by the Office of Professions. There was no documented evidence direct supervision was provided to the LPN Permittees #1, #2, #3, #4, #5, #6, #7 and RN Permittee since their dates of hire with the facility. On 09/18/23 at 09:49 AM, Certified Nursing Assistant (CNA) #7 was interviewed and stated when Resident #79 fell on 6/19/2023, the RN Permittee was the RN Supervisor for the entire building and there was no other RN working in the building. CNA #7 has worked in the facility for 9 years and has not previously worked without an RN Supervisor in the building. The RN Permittee was working their first night as an RN Supervisor when Resident #79 was found on the floor, assessed Resident #79 after they had already been placed back to bed, and applied bacitracin to the resident's left arm. On 09/14/23 at 05:07 PM, RN #2 was interviewed and stated they are the supervisor for the day shift and recall the incident involving Resident #79 being found on the floor on 6/19/2023 before 7 AM on the night shift. The RN Permittee was the RN Supervisor for the building that night. When RN #2 arrived at work, Resident #79 had already been placed back into bed and RN #2 performed an assessment of the resident's condition. RN #2 stated in their experience, residents are not moved prior to RN assessment to prevent further injury. On 09/18/23 at 11:06 AM, a telephone interview was conducted with the RN Permittee they received approval for their limited permit this year and will need to check with their staffing agency re: updating their employee file with the facility. The RN Permittee stated they are familiar with the requirements to be approved for a limited permit. The RN Permittee only needs to be eligible to take a nursing licensing exam for New York. The RN Permittee does not have an LPN license or permit in NY. Their application was submitted but not approved yet. The RN Permittee requires supervision from the DNS and ADON who directly supervise the RN Permittee when they work in the facility. Their job duties entailed medication administration as an LPN unit manager, and they worked one evening in the capacity of RN. The RN Supervisor was not always with them on the unit when they performed their job duties. The DNS and ADON were not always in the building, but the RN Permittee stated they could call the DNS and ADON if there were any concerns or incidents. On 09/15/23 at 01:38 PM, Human Resources (HR) was interviewed and stated prospective RNs and LPNs meet with the DNS and Administrator. LPNs and RNs with international degrees and licensures are fingerprinted and their licensure and degrees are not verified by the facility prior to being hired. RNs and LPNs with international licensures must have a N5 application completed. The staffing agency initiates the N5 and the DNS and ADON complete the attestation portion of the N5. The N5 is then sent back to the agency, and it is mailed to the Office of Professions for approval. The staffing agency has reported long wait times for N5 approvals. While the N5 is being processed, the DNS is responsible for ensuring the Permittees are acting appropriately. Nursing is responsible for any supervision of the Permittees. The N5 should already be completed by the time the Permittee begins their orientation to work in the facility and is not normally dated 6 weeks after the date of hire as is the case with the RN Permittee. HR was unsure of the number of Permittees the facility had on staff. Nursing determines their staff's job responsibilities. HR does call to follow up on the N5 application status but how often this occurs varies. The Administrator meets with the Permittees. HR cannot tell the Administrator or DNS not to hire someone. On 09/18/23 at 12:55 PM, the DNS was interviewed and stated the RN Permittee was scheduled and acting in the capacity as RN Supervisor on 6/19/2023 when Resident #79 was found on the floor. The facility could not staff an RN Supervisor for that shift and decided to assign the RN Permittee to that position. Some of the facility LPNs are RN Permittees. They are not licensed here but they are licensed somewhere. HR takes care of the N5, and the DNS signs the attestation of the N5. The RN Supervisor on the unit is supposed to provide supervision to the Permittees by checking on the Permittees on their unit. An RN Supervisor is not on the unit at all times with the Permittees. The DNS does not keep documentation off supervision of the Permittee staff because they were not asked to keep records. The Administrator gave permission for the use of Permittees and did not inform the DNS of the process to adequately provide supervision. The DNS stated they only know that they sign the N5, and it is submitted to the Office of Professions. On 09/18/23 at 02:02 PM, the Administrator was interviewed and stated they are of the use of Permittees in the Nursing department and the prospective Permittees are sent to the facility via their staffing agency. The facility screens the Permittees if they have an international license, the DNS interviews them, and the agency sends the Permittees paperwork to the facility. The Criminal History Record Check (CHRC) is done and the N5 is completed by the DNS and ADON for Permittees. The Administrator was not familiar with the details of requirements listed on the N5 application for Permittees to work in the capacity of LPN or RN. The Administrator stated the agency informed them if the agency sends a prospective employee with an N5 application, the Permittee can work in the capacity of LPN or RN. Supervision was not discussed with the staffing agency. The Administrator did see that Permittees need to be supervised by an RN and was unfamiliar with the requirement for the RN Supervisor to be on the unit with the Permittee. The Administrator stated they believed Permittees could work as LPNs or RNs as soon as the N5 application is submitted because there is a backlog of N5s awaiting approval. If the DNS does not have supervision documented, then the facility does not have documentation that supervision of the Permittees occurred. HR informs the Administrator of prospective employees and informs the Administrator if there are any concerns with the hiring process. The Administrator was aware the RN Permittee was assigned in the capacity of night RN Supervisor without an RN working in the building. The Administrator approved of this decision. 415.26

Based on observation, record review, and interviews conducted during the recertification survey from 9/10/2023 to 9/18/2023,the facility did not ensure a quality assurance and performance improvement (QAPI) program that use evidence to define and measure indicators of quality and facility goals, include resident choice, and address all systems of care and management practices. This was evidenced Specifically, the facility's QAPI topics were not reflective of previous State Survey Inspection results and the method of gathering measurable data was not accurate or adequate to identify quality improvement. The findings are: The facility policy titled QAPI Plan dated 1/23/23 documented Governing Body is responsible for: 1) Identifying and prioritizing problems based on performance indicator data. 2) Incorporating resident and staff input that reflects organizational process, functions and services provided to residents. 3) Ensuring that corrective actions address gaps in the system and are evaluated for effectiveness. 4) Setting clear expectations for safety, quality, rights, choice and respect The Quality Assurance (QA) Committee report to the governing body and is responsible for developing and implementing appropriate plans of action to correct identified quality deficiencies. The State Survey Inspection results from recertification survey with exit date 1/25/2022 resulted in a Statement of Deficiencies including: F584 F609 F656 F657 F689 Please refer to repeat deficiencies for F584, F609, F656, F657, and F689. The facility QA Meeting Minutes dated 7/20/2023 documented quarterly reports on high risk and problem areas were presented including infection prevention, antipsychotic use, implementation of the new electronic medical record, missing clothing, weight loss, activity of daily living changes, meal tickets, pressure injuries, corporate compliance, open survey issues of fireproofing, discharge plans, falls, and human resources. The QA Audit Tool dated 3/18/22, 4/18/22, 5/17/22, 6/17/22, 7/17/22, 8/17/22, 9/17/22, and 11/17/22 documented F609 Reporting, F657 care Plans, and F656 Care Plan audits resulting in 100% compliance with no concerns identified. Methodology and Target were not documented. There was no documented evidence QA audits related to F584 were conducted since 1/25/2022. On 09/18/23 at 04:53 PM and 05:32 PM, the Director of Nursing (DNS) was interviewed and stated the QA Committee identifies performance improvement projects through complaints from families and residents. The Committee meets quarterly and whenever a problem occurs. Previous survey results are also used to determine QAPI topics. There is a plan of correction that the QA Committee work off of. Audits were done for the previous deficiencies from last recertification survey. For care planning for example, 114 charts were audited to ensure a psychotropic care plan was in place. If the auditor saw that a care plan was missing from the resident's chart, the care plan was immediately placed in the resident's chart. As a result, the audits show 100% compliance because the issues found were fixed right away. Then the data is presented to the QA Committee that care planning was in 100% compliance. On 9/18/23 at 4:10 PM, the Administrator was interviewed and stated when there is a problem, all the department heads meet together to talk about the situation. If the problem involves the nursing department, an interdisciplinary meeting is held to find a solution but the head of the nursing department is in charge of the meeting. If the problem involves dietary, the team meets to find a solution and the Dietitian or Food Service Director is in charge of addressing problem. The QAPI meeting is done quarterly with all department heads and as needed. The QA Committee has been meeting monthly and as needed to resolve issues. Audits are conducted. The QA Committee is aware of there have been several concerns identified on survey. The resident and their representative are involved in the process when the QA Committee identifies there is an issue that directly effects that resident. 10NYCRR 415.27 (a-c)

Based on observation, interviews, and record review conducted during the recertification and complaint (NY00310185) from 9/10/2023 to 9/18/2023, the facility did not ensure a safe, functional, and comfortable environment for residents, staff, and the public. This was evident for the outside area of the facility and 1 (2nd floor) of 3 Units. Specifically, the outside surrounding area of the nursing home had overgrown grass and shrubs and garbage on the sidewalks and in the parking lot, and insects hovering around standing water in a cart near the entrance to the facility; and, the 2nd Floor had a nursing station that had chipped and missing veneer and broken filing cabinets. The findings are: The facility policy titled Terminal/Environmental Room Cleaning dated 4/20/2023 documented the facility will maintain a clean environment for resident care that meets professional standards. 1) On 9/10/2023 at 8:30 AM, 9/11/2023 at 9:00 AM and 10:00 AM, and 9/12/2023 at 11:36 AM, the grass and shrubs surrounding the facility in the parking lot and along the perimeter fence and sidewalk were overgrown. The grass was approximately 12 inches in height and the shrubs protruded onto the concrete portion of the parking lot and sidewalks. Garbage consisting of a used condom, crumpled fast food bags, water bottles, food wrappers, snack bags, surgical masks, and empty soda cans were strewn about the grass, sidewalk, under the facility sign at the perimeter of the facility, and parking lot. There were 3 large filled black garbage bags in the grass embankment at the rear of the parking lot. A gray cart next to the entrance of the facility had accumulated standing rain water mixed with dirt. A half-used bag of garden soil was stored on the bottom level of the cart. Bees and flies were hovering over the standing water. 2) On 09/10/2023 at 12:19 PM, the 2nd Floor Nursing Station desk was observed with chipped and missing strips of veneer on the top and edges. A black 3-drawer filing cabinet under the desk and to the left of the nursing station had surgical tape wrapped around the sides of the top 2 drawers to keep them closed. The bottom drawer jutted out and did not close all the way. A 2nd black 3-drawer filing cabinet had 3 broken drawers that would not close all the way, were open, and jutted out, One of the office chairs behind the Nursing Station had cracked broken leather arms that were peeling off. There was no documented evidence the Nursing Station broken filing cabinets, peeling leather chair, and chipped and missing veneer were communicated to the Maintenance Department in the 2nd Floor Maintenance Log Book. On 09/10/2023 at 01:01 PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated the filing cabinets at the Nursing Station had been broken for a couple of months. Sometimes, the Maintenance Department fixes the filing cabinets to they continue to get broken. On 09/15/2023 at 11:15 AM, the Director of Housekeeping and Maintenance (DHM) was interviewed and stated they make note of broken furniture on the units during regular rounds. The housekeeper assigned to the unit also communicates to them when there is broken furniture. There is a Maintenance Log Book on each unit that is checked by the DHM daily. The DHM sent their Maintenance staff to address the repair concerns with the 2nd Floor Nursing Station and they fix what they can. NYCRR 415.29

Based on observations and staff interviews conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure the daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors. This was evident for the total census of 113 residents. Specifically, the daily staffing information was observed posted on the wall near the staff time clock, not in a prominent place readily accessible to residents and visitors. The findings are: The facility policy and procedure titled Posting Direct Care Daily Staffing Numbers reviewed 4/20/23 documented the facility will post daily for each shift, the number of nursing personnel responsible for providing direct care to residents. On 9/10/23 at 9:51 AM, observation of the facility's daily staffing was made on the main floor and revealed that daily staffing dated 8/23/23 was posted on the wall near the staff time clock, not visible to residents and visitors. On 9/10/23 at 11:52 AM, the observation of unit 3 revealed there was no daily staffing observed posted on the unit. On 9/11/23 at 10:03 AM, observations of unit 2 and unit 4 revealed there were no daily staffing posted on unit 2 and unit 4. During an interview on 9/10/23 at 2:30 PM, the Director of Nursing Services (DNS) stated that the staff responsible for the daily staff posting was currently off for the day but will follow up to ensure that the information is updated when they return to work. However, the DNS acknowledged that the daily staffing information was not up to date and should have been updated to reflect daily staffing information. During an interview on 9/14/23 at 12:17 PM, the Nursing Office Manager (NOM) stated that daily staffing is updated/posted on the wall next to the staff time clock and are not posted on the residents' units. The NOM stated that they were not aware that the daily staffing needed to be readily accessible for residents/visitors. The NOM further stated the daily staffing information may not be up to date especially during the weekends and when the NOM is off. 415.13

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the Recertification survey, the facility did not ensure that a safe, clean, comfortable, and homelike environment was maintained. Specifically, a resident's room was observed on multiple occasions to be cluttered with food items, plastic utensils and clothing strewn on the window sills, overbed table, closet, and floor. This was observed during environmental observations on 1 of 3 units. (Unit 2) The findings are: The facility policy and procedure Maintenance of Facility corridors and other floor areas dated 4/22/15 and revised on 8/3/21 documented that the policy is to maintain the corridors and all other floor areas clean, orderly, neat, and free of obstructions. The purpose is to maintain good infection control practices. Resident's rooms are cleaned daily on the 7-3 shift by the housekeeper on the assigned floor. The housekeeper on each unit will clean 3 rooms thoroughly. During observations of the environment conducted on Unit 2 on 1/18/2022 at 11:37 AM, 1/19/2022 at 12:30 PM and on 1/20/2022 at 1:52 PM, room [ROOM NUMBER] B was observed with multiple bottles of juice covering the windowsill, multiple sleeves of unused plastic utensils and newspapers and other papers covering the overbed table, clothes were in disarray in the closet with some items hanging on the outside of the closet, and multiple plastic bags with various items including clothing, boxes and shoes were on the floor. On 1/20/22 at 11:58 AM, an interview was conducted with Licensed Practical Nurse (LPN) # 4. She stated that the resident always has a lot of stuff in the room and becomes verbally abusive to staff when spoken to about the condition of the room. On 1/20/22 at 12:30 PM, an interview was conducted with Certified Nursing Aide (CNA) #2. CNA #2 stated that the resident is very demanding and any simple remark regarding the room needing to be cleaned will cause the resident to become verbally abusive. CNA #2 also stated that resident purchases a lot of items which they store in their room. On 1/20/22 at 2:14 PM, the Director of Social Service (DSS) was interviewed and stated that resident likes to order from Amazon. The DSS also stated that when the resident is told about the condition of the room the resident responds with verbal threats and gets easily upset and agitated if things do not go their way. The DSS further stated that the resident is spoken to repeatedly about the condition of the room but the resident does not listen to anyone. On 1/21/22 at 2:54 PM, an interview was conducted with the Director of Housekeeping (DOH). The DOH stated that they talked to the resident about the condition of the room but the resident refuses to have anything done with the room. The DOH also stated that on occasion resident will agree to have room cleaned but before this can be done the resident would change their mind and tell the staff not to enter the room. On 1/25/2022 at 11:06 AM, Housekeeper # 1 was interviewed and stated that they are not allowed by the resident to clean a certain area in the room, particularly the shoes. HSK #1 stated that the resident has Amazon boxes which he will not allow housekeeping to touch, and the shoes have to stay the way they are. HSK # 1 stated that they reported the issue to their supervisor. 415.5(h)(1)

Based on interviews and record review conducted during a Recertification survey and Complaint investigation (NY 00264258) the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency. Specifically, the facility did not report the self-inflicted injury of a resident to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for 1 of 4 residents reviewed for Accidents out of a sample of 24 residents. (Resident #323). The findings are: The facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident's property, effective 11/28/16 and reviewed on 11/01/21, documented that the facility will ensure that that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. The facility's occurrence report dated 09/16/20, documented that on 9/15/20 at about 8:40 PM, the porter asked 4th floor staff and Registered Nurse Supervisor (RNS) to come to the backyard to assess the resident. Resident #323 was observed sitting in a wheelchair with injury to their wrists, abdomen, and inner thigh. Staff attempted to assess the resident, but the resident resisted. A body search revealed a small stick, and a pair of small scissors. The report also documented that the RNS applied a pressure bandage, and a neuro check was done. 911 was called, and the resident was transferred to the hospital and was admitted . The Health Electronic Response Data System (HERDS) Data Entry report documented that the incident occurred on 9/15/20 at 8:40 PM and submitted on 9/16/20 at 1:15 PM, via the Health Commerce System (HCS), which was more than 2 hours after the allegation was made. On 01/24/22 at 04:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the accident should have been reported within the 2-hour timeframe, and they did not know exactly what transpired. The DON also stated that they were on vacation at the time, and the Assistant Director of Nursing who reported the incident in the Health Commerce System no longer works at the facility. On 01/25/22 at 01:21 PM, an interview was conducted with the Administrator. The Administrator stated that they were made aware when the incident occurred and that there was time lapse in reporting. The Administrator also stated that maybe there was more of a concern in taking care of the resident at that time so this contributed to the delay in reporting. 415.4(b)2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification and abbreviated survey, the facility did not ensure that a person centered comprehensive care plan was developed and implemented to address the resident's medical needs. Specifically, there was no care plan developed to address the use of psychotropic medications. This was evident for 1 of 5 residents reviewed for Unnecessary Medication out of a sample of 24 residents. (Resident #40) The finding is: The facility policy and procedure Comprehensive Care Plan revised on 9/21/21 documented that a written comprehensive care plan will be developed and implemented for each resident in conjunction with the resident and the resident's representative. An individual comprehensive care plan will be maintained within the medical record of each resident at the facility. The physical, mental, and psychosocial condition of the resident will determine the composition of the interdisciplinary team. The care plan will be developed as appropriate to the need of each resident. Resident #40 was admitted to the facility on [DATE] with diagnoses that included Anxiety Disorder, Hypertension, and Shortness of Breath. The admission Minimum Data Set (MDS) dated [DATE] and the Quarterly assessment MDS dated [DATE] documented that the resident was cognitively intact and required supervision of staff to complete Activities of the Daily Living (ADL's). Both MDS assessments further documented that the resident had a diagnosis of Anxiety Disorder and received anti-anxiety medication on 7 of 7 days. Physician orders dated 04/14/2021 documented an order for Clonazepam 1 mg tablet by mouth every 12 hours for Anxiety Disorder. There was no documented evidence that a care plan for psychotropic medication had been initiated prior to the beginning of the Recertification survey. A care plan was created on 1-20-22 after it was requested by the survey team. On 1/25/2022 at 1:08 PM, the Director of Nursing (DON) was interviewed. The DON stated that on admission, within 48 hours, a care plan is developed for the resident and then there is a care plan meeting on the 21st day. The DON also stated that a comprehensive care plan is developed for each resident and should include any issues or concerns for the resident. 415.11 (c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during a Recertification survey and Complaint investigation (NY00264258) the facility did not ensure that a resident received adequate supervision to prevent accidents. Specifically, a resident was observed sitting in their wheelchair in the back courtyard of the facility, unsupervised at night, with injury to wrists, abdomen, and inner thigh. This was evident for 1 out of 4 residents reviewed for Accidents out of a sample of 24. (Resident #323) The findings are: The facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident's property, effective 11/28/16 and reviewed on 11/01/21, documented that it is the policy of BUMCH ([NAME] United Methodist Church Home) that each resident will be free from Abuse. The policy also documented that resident will be protected from abuse, neglect, and harm while they are residing at the facility. Resident #323 was admitted to the facility with diagnoses that included Depression and Psychotic Disorder. The Annual MDS dated 05/22 20 documented that the resident's cognition was severely impaired, and resident exhibited rejection of care occurring 1 to 3 days; no wandering behavior was exhibited. The MDS also documented the resident experienced symptoms of feeling or appearing down, depressed, or hopeless, on 2-6 days, and received anti-depressants on 7 of 7 days. The Quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident's cognition was moderately impaired, and resident exhibited rejection of care occurring 1 to 3 days; no wandering behavior was exhibited. The MDS also documented the resident experienced symptoms of feeling or appearing down, depressed, or hopeless, on 2-6 days, and received anti-depressants on 7 of 7 days. The facility's occurrence report dated 09/16/20, documented that on 9/15/20 at about 8:40 PM, the porter asked 4th floor staff and Registered Nurse Supervisor (RNS) to come to the backyard to assess the resident. Resident #323 was observed sitting in a wheelchair with injury to their wrists, abdomen, and inner thigh. Staff attempted to assess the resident, but the resident resisted. A body search revealed a small stick, and a pair of small scissors. The report also documented that the RNS applied a pressure bandage, and a neuro check was done. 911 was called, and the resident was transferred to the hospital and was admitted . On 01/24/22 at 03:37 PM, an interview was conducted with Licensed Practical Nurse (LPN) # 1 who stated that they were the 3-11 nurse when the incident occurred. LPN #1 stated that when they made rounds, they recalled that the resident was on the unit. Most of the times they would be in their room, but the resident is able to take the elevator and go off the unit. LPN #1 also stated that they went with the Supervisor and observed the resident in the back courtyard, in the wheelchair (w/c), and their hands were on their abdomen and blood was on their shirt and on their thigh. LPN #1 further stated that resident was saying that they just wanted to be left alone, but they eventually got the resident back up to their unit and cleaned off the blood. LPN #1 said that the resident had a little stick, like a dry branch and they thought that there were also a small pair of scissors. The resident did not say what transpired. On 01/24/22 at 03:50 PM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1 who worked the 3-11 shift. RNS # 1 stated that the resident was in the smoking area, and someone called the RNS. The RNS #1 stated that there was blood on the shirt and in the pants, and that the resident did not want to be touched when they took them back upstairs to the unit. RNS #1 also stated that the resident was holding a small stick and while being cleaned and staff found a small pair of scissors. The resident's wrists had lacerations, but none was noted to the abdomen after being cleaned. 911 was called and took the resident to the hospital. RNS #1 further stated that the resident never exhibited that behavior before, because usually they would want to stay alone and did not usually go outside so late. RNS #1 stated that usually the aides know of the resident's whereabouts and there was no formal documentation of the resident's location. On 01/24/22 at 04:02 PM, an interview was conducted with Security Guard (SG) #1. SG #1 stated that it was after 8 PM when the [NAME] reported there was a problem. SG #1 also stated that when they saw the resident, the resident was covered in blood, and had a stick in their hand. At the time, there was no one else in the back courtyard with the resident. SG #1 further stated that sometimes Resident # 323 would go out in the back courtyard however, there was no smoking scheduled at that time. SG #1 stated that the porter who does the last smoking break, checks to see if there is anyone else there after smoking. SG #1 also stated that it was not the first time that the resident came down to the courtyard but although the resident did not smoke, it was uncommon for that Resident #323 to be outside at that time. On 01/24/22 at 04:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that Resident # 323 would spend a lot of time outside gardening and was an alert and oriented resident. The DON also stated that usually the smokers would have been out at that time and the security guard would have been supervising the area. The DON further stated that the resident did not display any suicidal ideations prior to resident hurting themselves. The DON stated that it was customary that the resident would be outside without supervision, and they would go outside to the patio. On 01/25/22 at 10:09 AM, an interview was conducted with the Certified Nursing Assistant (CNA) #1. CNA #1 stated that when they went to the back courtyard to assist the nurse, they saw blood on the resident's stomach and wrists. CNA#1 stated that they had never had any prior concerns with the resident. On 01/25/22 at 10:14 AM, an interview was conducted with the [NAME] (#1). [NAME] #1 stated they oversaw the smoke break that night which was to start at 9:00 PM. [NAME] #1 also stated they looked over in the back courtyard and saw the resident sitting in the wheelchair, gesturing with their hand. They then noticed blood and a stick, which Resident #323 was jabbing themself with. As [NAME] #1 attempted to take the stick, Resident #323 then grabbed the stick and held onto to it saying that they wanted to die. [NAME] #1 stated that they then ran back inside quickly and called for security. [NAME] #1 also stated that the resident was more of a loner and did not visit downstairs frequently. [NAME] #1 further stated that during nonsmoking periods, there is no one outside to supervise during those times, but the security has cameras which they can review. On 01/25/22 at 01:21 PM, an interview was conducted with the Administrator. The Administrator stated that during nonsmoking times, there is no one to monitor and supervise the residents in the back courtyard, since the residents go in and out the back courtyard. The Administrator also stated that the resident spent some time outside and that they were a loner and would not usually be out at that time. The Administrator further stated that after the last smoke session, which is at 9:30 PM, that area would be usually closed off. 415.12 (h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and staff interviews conducted during the Recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, 1) oxygen tubing was observed touching the floor on multiple occasions, and 2) residents were observed on the unit sitting in less than 6 feet apart from each other and were not wearing face masks. This was evident on 1 out of 3 units observed for infection control. (Unit 4) The findings are: 1. Resident # 99 was admitted to the facility with diagnoses that included Viral Hepatitis and Legionnaire disease. The Quarterly Minimum Data Set, dated [DATE] documented the resident cognitive level is severely impaired and required dependent assistance for most Activities of Daily Living. The MDS also documented that the resident is receiving oxygen therapy, trach care and suctioning. On 01/18/22 at 10:46 AM, 01/18/22 at 12:22 PM, 01/19/22 at 10:29 AM and on 01/20/22 at 12:30 PM, Resident #99 was observed seating in geriatric chair and the oxygen tubing was observed touching the floor. Physician original order dated 05/04/21 documented oxygen via tracheostomy mask at 5 liters per minute with continuous humidifier every shift 3 times a day. On 01/21/22 at 12:22 PM, Licensed Practical Nurse (LPN) #2 was interviewed. LPN #2 stated that as the medication nurse they go in to see the residents a few times during the shift. LPN # 2 also stated that they check on the resident to ensure that the resident is medically stable and the oxygen is running. If tubing is found on the floor, it has to be changed. The oxygen tubing is changed on a weekly basis. LPN #2 further stated that all of the staff were trained on keeping all tubings off the floor. On 01/24/22 at 03:01 PM, an interview was conducted with LPN #3. LPN #3 stated that they check on the resident at least three times each shift to ensure that the resident is medically stable. LPN #3 also stated they are checking for proper positioning ensuring the oxygen is running. LPN #3 further stated that oxygen tubing is supposed to be changed if it is found on the floor and the oxygen tubing is not supposed to be on the floor. On 01/25/22 at 12:30 PM, the Infection Control Nurse (ICN) was interviewed. The ICN stated that infection control trainings are done frequently. The ICN also stated that if there is an outbreak, we would do even more frequent trainings. All staff are trained to keep all tubings off the floor. The ICN further stated that they identified tubings on the floor as a concern and we teach all staff constantly to ensure all tubings are off the floor. The ICN stated that rounds are done constantly to ensure tubings are off the floor. On 01/25/22 02:10 PM, the Director of Nursing (DON) was interviewed. The DON stated that all tubings must be off the floor. If oxygen tubing is found on the floor, it is supposed to be discarded. The DON also stated that they in-service the staff about infection control procedures on a weekly basis and review all infection procedures when in-services are done with the staff. The DON further stated all staff were told to keep all tubings off the floor. 2. The Centers for Disease Control and Prevention (CDC) guidance titled COVID-19 Interim Infection Prevention and Control Recommendations to prevent SARS-CoV-2 spread in Nursing Homes updated 9/10/21, documented that source control and physical distancing should be followed for residents during an outbreak response. Facility records documented that on 1/17/22, 111 residents were tested and 22 residents tested positive for COVID-19. Unit 4 was designated as the facility's COVID-19 unit. Resident #57 was admitted to the facility with diagnoses that included Seizure Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident was moderately cognitively impaired and required extensive assistance of two persons for most activities of daily living. Resident # 104 was admitted to the facility with diagnoses that included Hypertension and Seizure disorder. The Quarterly MDS dated [DATE] documented the resident moderately cognitively impaired and required extensive assistance of two persons assist for most activities of daily living. On 01/18/22 at 10:57 AM, 01/19/22 at 11:43 AM, 01/20/22 at 10:45 AM and on 01/25/22 at 12:10 PM, Resident # 57 and Resident # 104 were observed sitting on Unit 4 less than six feet apart and were not wearing face masks. There was no documented evidence that Residents # 57 and #104 had been educated about wearing face masks prior to the recertification survey. Facility records documented that on 1/17/22, 111 residents were tested and 22 residents tested positive for COVID-19. Unit 4 was designated as the facility's COVID-19 unit. On 01/24/22 at 03:01 PM, LPN #3 stated that the residents are told to keep on masks on. LPN #3 also stated that the residents are educated constantly about keeping masks on when they are out of their rooms. LPN #3 further stated that some residents refused to keep masks on. On 01/25/222 at 12:30 PM, the ICN was interviewed and stated that infection control trainings are done frequently. The ICN also stated that if there is an outbreak, even more trainings are done. The ICN further stated that they have educated all residents on wearing masks when they are out of their rooms, however some of the residents do not keep their masks on when they are outside of their rooms. If a resident is refusing to wear mask, the nurse should document in the medical record that the resident is refusing to wear mask despite education. On 01/25/22 at 02:03 PM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that infection control trainings are done periodically and as needed. All residents were educated on keeping masks on when they are out of their rooms. The ADON also stated that residents on the 4th floor are independent and they are the most noncompliant. The ADON further stated that Resident # 57 and Resident# 104 constantly refuse to wear masks when they are out of their rooms and care plan was updated to reflect this on 1/24/22. 415.19 (a)(1)(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that each Resident or resident representative was offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, residents were not invited to quarterly care plan meetings. This was evident for 1 of 2 residents reviewed for Care Plan and 1 of 1 resident reviewed for Dental out of a sample of 24 residents. (Resident #42 & Resident #1) The findings are: 1. The facility's policy titled Comprehensive Care Plan last reviewed 09/21/21, documented that the resident and his or her legal representative, are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. The policy also documented that care plans be reviewed at least quarterly by the Interdisciplinary team (IDT) and revised as necessary. Resident #42 was admitted on [DATE] with diagnoses that include Anxiety Disorder, Depression, Bipolar Disorder, and Cerebrovascular Accident. The Quarterly Minimum Data Set (MDS) dated [DATE] documented that resident is cognitively intact. On 01/18/22 at 12:50 PM, an interview was conducted with Resident #42 who stated that they did not remember when the last time was that they were invited to a care plan meeting, and that they are not always invited to attend the meetings. An Advance care planning note dated 08/25/21 documented that discharge care plan meeting with the Interdisciplinary team (IDT) team, Social Worker (SW), Rehab, Certified Nursing Assistant (CNA,) Dietician- and resident participated in assessment., discussed current medication and treatment and concerns regarding discharge. Social Services note dated 10/26/21 documented that resident asked for a meeting to discuss their going out on pass by themselves. Social Worker met with resident and discussed their behavior choices. Resident was reminded they can go out with family, which they have, and continue to do. There was no documented evidence that the resident #42 was invited to participate in the quarterly review and revision of their plan of care. On 01/25/22 at 12:18 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who stated that the Social Worker (SW) does the invitation for all the meetings as well inviting the family. The ADON also stated that the ADON is responsible for documentation regarding the actual care plan meeting and who participated. The ADON further stated that care plan meetings are held only for Significant changes, Annuals and for interim meetings, as in the discharge care plan meeting. The ADON stated that the Quarterly MDS is done, but no interdisciplinary meeting is held. On 01/25/22 at 12:29 PM, an interview was conducted with the Director of Resident Services (DRS). The DRS stated that an MDS calendar is prepared and a sheet with the date is given to the alert residents and a copy of the sheet is retained as evidence that the residents were invited. The DRS also stated that meetings are not held for Quarterly meetings, and the team only meets for Annual MDS and for a Significant Change MDS at which time the nurses who attend would enter a note in the record that the meeting was held. 2. The policy and procedure Comprehensive Care Plan revised on 9/21/21 documented an individual comprehensive care plan will be maintained within the medical record of each resident at the facility. The care plan will be reviewed at least quarterly by the interdisciplinary team and revised as necessary. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Iron Deficiency Anemia, Vitamin B12 Deficiency, Adjustment Disorder. The Annual Minimum Data Set (MDS) dated [DATE] documented resident had moderately impaired cognitive status and required extensive assistance of 1 staff person for bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS further documented that the resident has obvious or likely cavity or broken natural teeth. The Nursing Progress Notes dated 9/14/2021 documented that the resident returned from dental clinic accompanied by Certified Nursing Aide (CNA) in stable condition with findings several questionable maxillary and mandibular teeth and that the resident requires a comprehensive exam with a general dentist for treatment planning with diagnoses of caries and periodontal disease. The Physician order dated 9/16/21 documented dental consultation for comprehensive exam with general Dentist. Dental Consultation dated 9/23/2021 documented please send patient to the hospital for a comprehensive exam with a general dentist. Patient needs work that is beyond the scope of what can be done at the facility. Speech Therapy notes dated 11/16/2021 documented that resident is safely tolerating current diet of chopped with thin liquid without any overt s/s of aspiration. Dental Care Plan created 5/1/2020 documented some/all natural teeth lost/no denture or partial plate and included a goal of resident will have optimal oral hygiene daily with an intervention of encourage fluids intake as tolerated. There was no documented evidence that the dental care plan had been revised to reflect the resident's current dental status. On 1/25/2021 at 1:08 PM, the Director of Nursing (DON) was interviewed. The DON stated that for quarterly reviews there is a meeting and the care plan is reviewed. The DON also stated that if there is no change, the care plan is not updated, but if there are new concerns, we put it in the care plan with the date that the concern is being added. 415.11(c)(2)(i-iii)