**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews during a recertification survey, the facility did not ensure a safe, comfortable home-like environment, and effective housekeeping and maintenance services were not maintained for four (4) of four (4) resident units. Specifically, lighting fixtures on all units were unclean and had deceased bugs within covers, and windows on units were unclean and had dirt and debris. During an observations on [DATE] at 9:45 AM, multiple lighting fixtures on the 2nd and 3rd East and [NAME] units, main corridor, and near the nursing supervisor's office had dirt, debris, and deceased bugs within the lighting covers. The windows on either end of the hallways on each unit had dirt, debris, and cobwebs on the window sills and corners of the windows.During an interview on [DATE] at 11:46 AM, Housekeeper #1 stated that the windows were supposed to be cleaned every week. They stated that the night shift sometimes leaves the windows open at night, and the bugs came into the building. They stated that the rooms were cleaned every day with sweeping, mopping, and dusting. They stated that one room a day was scheduled for a deep cleaning as per the supervisor. Housekeeper #1 stated that they had never been asked to clean the lighting fixtures, and they were unsure whether or not they were supposed to.During an interview on [DATE] at 12:15 PM, Director of Maintenance #1 stated that the cleaning of the lighting fixtures was the responsibility of housekeeping. They stated that they did have a contract with a local pest company to come in and fumigate the facility for bugs. They stated that the last time they were at the facility was on [DATE] and were due to come in for service soon.During an interview on [DATE] at 12:30 PM, Director of Housekeeping #1 stated it was the responsibility of all housekeeping aides to perform routine tasks to ensure the cleanliness of assigned areas of the facility. They stated that housekeeping aides' primary responsibility included, but were not limited to, dusting halls, offices, resident rooms, recreation rooms, lounges, washing walls, windows, window frames, tiles, door frames, and other high areas. They stated that it was the responsibility of the maintenance department to ensure that the lighting fixtures were cleaned and free of dirt and debris. During an interview on [DATE] at 12:45 PM, Director of Maintenance #1 stated they would take on the responsibility to ensure that the lighting fixtures were cleaned regularly. Director of Maintenance #1 was shown the lighting fixtures in the main hallway and the ones near the nursing supervisor's office, and they agreed that they should have been cleaned. 10 New York Codes of Rules and Regulations 415.5(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification and abbreviated survey (Case # NY00344590), the facility did not ensure each resident was free from misappropriation of resident property and exploitation for one (1) (Resident #136) of three (3) residents reviewed. Specifically, a former Certified Nurse Aide took property from Resident #136 after they had died without permission.This is evidenced by: Resident #136 was admitted with the diagnoses of respiratory failure with hypoxia (occurs when the lungs cannot adequately oxygenate the blood, leading to low blood oxygen levels), chronic congestive heart failure (a long-term condition where the heart struggles to pump enough blood to meet the body's needs, leading to fluid buildup and congestion in various parts of the body), and chronic kidney disease (a condition where the kidneys are damaged and lose the ability to filter blood effectively, leading to a buildup of waste and excess fluid in the body). The Minimum Data Set (an assessment tool) dated [DATE], documented that the resident had intact cognition, could be understood, and understand others.The Facility's Abuse Policy and Procedure, revised 12/2023, documented that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Misappropriation of property was defined in the policy as: the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy further documented that staff would refrain from all actions that could be considered abuse, mistreatment, and/or neglect.The Facility's Investigative Report dated [DATE] documented that Administrator #2 was notified by Director of Housekeeping #1 on [DATE] that they had concerns that Certified Nurse Aide # 3 wanted to retrieve items, a watch and bracelet, from Resident #136's personal belongings before they packed the room up for the resident's family. Administrator #2 and Director of Housekeeping #1 searched the packed belongings on [DATE], and the mentioned items were not present in the box. Administrator #2 met with Certified Nursing Aide #3 and inquired about the items. Certified Nurse Aide #3 stated that they purchased the items for Resident #136 and retrieved them without permission. They stated that they felt they could take them back as they purchased the items for Resident #136but could not provide proof that the purchase was made. Administrator #2 instructed Certified Nurse Aide #3 to return the items immediately, which they did on the evening of [DATE], and were terminated at that point.An attempted interview on [DATE] at 1:15 PM with Administrator #2 was unsuccessful, and no return phone call was made.An attempted interview on [DATE] at 1:20 PM with Certified Nurse Aide #3 was unsuccessful, and no return phone call was made.Past Non-compliance -F602 Based on the following corrective action taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement at the time of this survey: A thorough investigation was completed, and it was determined there were no other victims of misappropriation. The misappropriated property was returned and given to the resident's family. The family expressed no other concerns at that time. The alleged perpetrator was terminated and not permitted entrance to the facility to protect the residents from further misappropriation. The incident was reported appropriately to the State Survey Agency. Education was provided on [DATE] to all facility staff on abuse, abuse reporting, misappropriation of property, exploitation, and updated facility policy and procedures. At the time of the survey, there were no additional incidents of misappropriated personal property identified. 10 New York Codes, Rules, and Regulations: 415.4(b)

Based on record review and interview conducted during a recertification and abbreviated survey (Case # NY00344590), the facility did not ensure they reported the results of all investigations to the administrator or their designated representative, and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for one (1) (Resident #136) of three (3) residents reviewed. Specifically, a 5-day investigation report was not submitted to the state agency. This is evidenced by: Resident #136 was admitted with the diagnoses of respiratory failure with hypoxia (occurs when the lungs cannot adequately oxygenate the blood, leading to low blood oxygen levels), chronic congestive heart failure (a long-term condition where the heart struggles to pump enough blood to meet the body's needs, leading to fluid buildup and congestion in various parts of the body), and chronic kidney disease (a condition where the kidneys are damaged and lose the ability to filter blood effectively, leading to a buildup of waste and excess fluid in the body). The Minimum Data Set (an assessment tool) dated 3/06/2024, documented that the resident had intact cognition could be understood, and understand others.The facility's Abuse Policy and Procedure, revised 12/2023, documented that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Misappropriation of property was defined in the policy as: the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy further documents that staff will refrain from all actions that could be considered abuse, mistreatment, and/or neglect.The facility's investigative report dated 6/07/2024 documented that the Administrator #2 was notified by Director of Housekeeping #1 on 6/06/2024 that they had concerns that Certified Nursing Aide # 3 wanted to retrieve items (a watch and bracelet) from Resident #136's personal belongings before they packed the room up for the resident's family. Administrator #2 and Director of Housekeeping #1 searched the packed belongings on 6/07/2024, and the mentioned items were not present in the box. Administrator #2 met with Certified Nursing Aide #3 and inquired about the items. Certified Nurse Aide #3 stated that they purchased the items for Resident #136 and retrieved them without permission. They stated that they could take them back as they purchased the items for Resident #136 but could not provide proof that the purchase was made. Administrator #2 instructed Certified Nurse Aide #3 to return the items immediately, which they did on the evening of 6/07/2024, and were terminated at that point.A review of the facilities investigation documents showed that the facility did report the incident on 6/07/2024 at 12:47 PM through the electronic Nursing Home Facility Incident Report program.A review of the facilities investigation documents showed that a thorough investigation and education were completed. The outcome of the investigation was not submitted to New York State through the electronic Nursing Home Facility Incident Report program within 5 days as required.During an interview on 7/02/2025 at 1:00 PM, Administrator #1 stated that if the investigation findings were sent, the report would have been in their investigation file. They stated that they would expect that if it were done, then it would have been in the file. They stated that if the report of submission was not in the folder, then it must not have been done. Administrator #1 stated that the only person who would have known that it was completed was Administrator #2.An attempted interview on 7/02/2025 at 1:15 PM with Administrator #2 was unsuccessful, and no return phone call was made. 10 New York Codes of Rules and Regulations 483.12 (C)(4)

Based on record review and interviews conducted during a recertification survey, the facility did not ensure it developed and implemented a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of a resident's admission for one (1) resident (Resident #248) of 28 residents reviewed for baseline care plans. Specifically, Resident #248's baseline care plan did not address resident's dialysis.This is evidenced by:The policy and procedure titled, Baseline/Comprehensive Person -Centered Care Plan, revised 3/2023, documented the baseline care plan must include the minimum of healthcare information necessary to provide the proper care for the resident, establish goals (include the resident's goals and preferences), and orders from the Healthcare Provider, dietary, therapy, social services, and Preadmission Screening and Resident Review (PASARR) (if applicable). Resident #248 was admitted to the facility with the diagnoses of acquired absence of right leg above the knee (surgical removal), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids).The Baseline Care Plan dated 6/18/2025 did not have documented evidence of care plan for dialysis.During an interview on 7/3/2025 at 11:16 AM, Director of Nursing #1 stated the resident's baseline care plan should have included dialysis.10 New York Codes, Rules and Regulations 415.11

Based on observations, record review, interviews conducted during the recertification survey, the facility did not ensure dependent residents were provided with appropriate treatment and services to maintain or improve their language and communication for one (1) (Resident #7) of two (2) residents reviewed. Specifically, (a.) for Resident #7, nursing staff did not ensure there was consistent access to their communication dry/erase board so resident could use it to write down what they wanted to express as Resident #7 had difficulty speaking secondary to cerebral palsy (group of neurological conditions that affect movement and posture). This is evidenced by:The Facility's Policy and Procedure titled Quality of Life - Accommodation of Needs, issued 9/2024, documented, the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed as needed throughout the residents stay in the facility. Staff shall interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity.Resident #7 was admitted to the facility with diagnosis of Parkinson's Disease (a progressive neurological disorder that primarily affects movement, but also involves non-motor symptoms like cognitive and emotional changes); Cerebral Palsy (group of neurological conditions that affect movement and posture); and profound mental retardation (the presence of significantly sub average general intellectual functioning). The Minimum Data Set (an assessment tool) dated 3/05/2025 documented the resident's cognition was unable to be assessed, but they usually were able to be understood and understand others. The Comprehensive Care Plan titled, Communication, dated 4/24/2025, documented Resident #7 has a communication problem. Goal: Resident #7 will maintain current level of communication function by making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, writing messages. Problem: Resident has Cerebral Palsy. Goal: The resident will be able to function at the fullest potential possible as outlined by the treatment team.During an observation on 6/26/2025 at 12:20 PM, Resident #7 was observed in their room eating lunch independently with adaptive utensils. Resident with food in lap, clothing and face. Resident did not respond when writer said hello.During an observation on 6/27/2025 at 11:14 AM, resident observed sitting in their room while activities were taking place in the common area. Resident did not respond to greetings, did not respond to queries of how are you? What is your name? do you need anything? Resident #7 made no attempts to speak, but did make eye contact with writer.During an observation on 7/02/2025 at 12:01 PM, Resident #7 was observed in the main dining room on first floor. Resident #7 was sitting at a table alone near window. Activities Director #1 was observed attempting to have conversation with Resident #7. Resident #7's responses were delayed and could not be understood.During an interview on 7/02/2025 at 11:08 AM, Licensed Practical Nurse #6 stated Resident #7 had been a resident for many years; staff were familiar with resident's routine and needs. Resident made some grunts and responds to yes/no questions. Resident did not have a communication board. During an interview on 7/02/2025 at 12:01 PM, Activities Director #1 stated Resident #7 did best with one-to-one activities or engagements. Resident #7 did not like to be around others. When attempt to include Resident #7 in group activities, Resident #7 would push others away. Activities consists of coloring and watching television.During an interview on 7/02/2025 at 12:24 PM, Director of Rehabilitation #1 stated Resident #7 no longer attended speech language therapy. The last time they attended speech language therapy was in 2021 for evaluation and treatment of dysphagia (difficulty swallowing). Director of Rehabilitation #1 stated Resident #7 did not have a communication board or any other adaptive device for commutation. Communication had not been addressed since resident admitted several years ago. Staff communicate using closed ended yes/no questions. During an interview on 07/02/2025 at 12:57 PM, Director of Nursing #1 stated resident was able to make their needs known. The staff were familiar with resident and could understand them. If a new or agency staff were on the unit, they would ask another staff member to assist with communicating with resident. Director of Nursing #1 stated they were not sure whether Resident #7 had a communication board. 10 New York Codes, Rules, and Regulations 415.12(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that is in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preference for three (3) (Resident #'s 41, 128, and 245) of six (6) residents reviewed for oxygen administration. Specifically, (a.) for Resident #'s41 and 245, supplemental oxygen tubing was not dated and labeled to reflect when the tubing was changed; and (b.) for Residents #128 and #245, nebulizer equipment was not stored in a proper manner. This is evidenced by: The policy and procedure titled, Oxygen Concentrator Maintenance, revised 4/2023, documented tubing is to be changed weekly. The policy and procedure titled, Nebulizer Treatments, revised 2/2023, documented after the nebulizer treatment was completed, the reservoir was to be disconnected from the compressor, cleaned per manufacturer’s instructions, and placed in a plastic bag. Resident #41: Resident #41 was admitted to the facility with diagnoses of respiratory failure with hypoxia (occurs when the lungs cannot adequately oxygenate the blood, leading to low blood oxygen levels), pulmonary hypertension (high blood pressure specifically within the arteries of the lungs), and chronic obstructive pulmonary disease (a progressive lung disease that makes it hard to breathe). The Minimum Data Set (an assessment tool) dated 5/05/2025, documented that the resident had intact cognition and could be understood and understand by others. During an observation on 6/27/2025 at 11:44 AM, Resident #41 was in their wheelchair receiving oxygen at three (3) liters via a nasal cannula that was connected to an oxygen concentrator (a device that provides a continuous supply of oxygen). The oxygen tubing was labeled and dated for 6/09/2025, the date it was changed. A review of the Medication Administration Record dated June 2025, documented that the oxygen tubing (nasal cannula) was to be changed one time weekly on Sundays, during the 11:00 PM-7:00 AM shift, and was documented as being changed on 6/08/2025, 6/15/2025, and 6/22/2025. During an interview on 6/27/2025 at 12:23 PM, Licensed Practical Nurse #5 stated the oxygen tubing change was usually done weekly. They stated that they were unsure when the residents' oxygen tubing was to be changed. Licensed Practical Nurse #5 reviewed Resident #41's Medication Administration record and stated that it was documented that it was changed on 6/08/2025, 6/15/2025, and 6/22/2025 during the 11:00 PM - 7:00 AM shift. Licensed Practical Nurse #5 showed Resident #41’s oxygen tubing and the date of 6/09/2025 on the tubing. They stated that it should not have the 6/09/2025 date on the tubing, as it was documented that the oxygen tubing was changed on the specific dates in the Medication Administration Record. Licensed Practical Nurse #5 stated that they were unsure of why the tubing was not changed, and it was documented that it was. Resident #128: Resident #128 was admitted to the facility with diagnoses of displaced intertrochanteric fracture of right femur (break in leg and hip bones), hyperlipidemia (high blood cholesterol), and hypertension. The Minimum Data Set (an assessment tool) dated 5/28/2025 documented the resident was understood by others, could understand others, and was moderately cognitively impaired. During an observation on 6/27/2025 at 9:55 AM, the nebulizer mouthpiece was observed to be on the floor. During an observation on 7/01/2025 at 11:20 AM, the nebulizer mouthpiece was observed to be wrapped around and hanging off the flowmeter on the concentrator. During an interview on 7/02/2025 at 12:59 PM, Licensed Practical Nurse #1 stated that nebulizers should be stored in a bag after using. Resident #245: Resident #245 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, supraventricular tachycardia (a faster than normal heart rate beginning above the heart’s two lower chambers), and gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the lining of the esophagus). The Minimum Data Set, dated [DATE] documented the resident was understood by others, could understand others, and was cognitively intact. During an observation on 6/26/2025 at 12:05 PM, the oxygen tubing was not dated, and the nebulizer mask was on the floor. During an observation on 6/27/2025 at 10:43 AM, the oxygen tubing was not dated, and the nebulizer mask was not stored in a bag. A Physician’s Order dated 6/17/2025 documented oxygen tubing change every night shift every Sunday for prophylaxis. During an interview on 7/02/2025 at 12:59 PM, Licensed Practical Nurse #1 stated that nebulizers should be stored in a bag after using. They stated oxygen tubing should be changed and labeled every week, usually on the night shift. During an interview on 7/03/2025 at 11:00 AM, Director of Nursing #1 stated oxygen tubing should be changed weekly as ordered and labeled with the date it was changed. Nebulizers should be rinsed out and stored in a plastic bag. If a nebulizer was on the floor, it should be discarded. 10 New York Codes, Rules, and Regulations 415.12(k)(6)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices, as accurately documented and completed for one (1) (Resident #120) of the 28 residents reviewed. Specifically, for Resident #120, the medical record contained documentation of wound vacuum (a wound management device that uses negative pressure that draws out excess fluid and promoting blood flow to the area) monitoring when there was no wound vacuum present. This is evidenced by:Resident #120Resident #120 was admitted to the facility with the diagnoses of morbid obesity (a serious health condition characterized by a very high body mass index), infection (when microorganisms like bacteria, viruses, or fungi invade and multiply within the body, potentially causing harm)), and asthma (a chronic respiratory disease characterized by inflamed and narrowed airways, leading to breathing difficulties). The Minimum Data Set (an assessment tool) dated 4/03/2025 documented the resident was understood, could understand others, and was cognitively intact. During an observation on 6/26/2025 at 11:27 AM, Resident #120 had a dry dressing on the left knee. A Physician's Order dated 6/16/2025 documented Prevena drain (a wound management system that applies negative pressure to a closed incision to promote wound healing), monitor placement and function every shift for wound care. Needs to be charged overnight.The Medication Administration Record for June 2025 documented nursing staff monitored the Prevena drain that was not present on 6/25/2025 10:00 PM - 6:00 AM shift, 6/26/2025 all shifts, 6/27/2025 all shifts, 6/28/2025 all shifts, 6/29/2025 10:00 PM - 6:00 AM shift, 6/30/2025 2:00 PM - 10:00 PM shift and 10:00 PM - 6:00 AM shift.The Medication Administration Record for July 2025 documented nursing staff monitored the Prevena drain that was not present on 7/01/2025 10:00 PM - 6:00 AM shift and 7/02/2025 6:00 AM - 2:00 PM shift.During an interview on 6/26/2027 at 11:27 AM, Resident #120 stated they had recently had a left knee replacement and did have a wound vacuum, but it was removed on 6/25/2025.During an interview on 7/03/2025 at 10:24 AM, Licensed Practical Nurse #2 stated the resident did not have a wound vacuum to monitor and they marked accordingly on the Medication Administration Record.During an interview on 7/03/2025 at 10:27 AM, Nurse Practitioner #1 stated the resident did not have a wound vac. They were not aware the order was still active.During an interview on 7/3/2025 at 11:00 AM, Director of Nursing #1 stated the nurses should not have been signing for treatments/medications that were not done. They stated if a medical appliance like a wound vacuum had been discontinued, they should not sign that they were monitoring the placement and drainage.10 New York Codes, Rules, and Regulations 415.22 (a)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during the recertification survey (NY00376034), the facility did not develop and implemented comprehensive person-centered care plans for each resident that included measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two (2) (Resident #'s 5 and 27) of 28 residents reviewed for care plans. Specifically, (a.) Resident #5 was care planned for 2- person assist for when transfer. Certified Nurse Aide #1 did not follow care plan resulting in Resident #5 falling and breaking both legs; (b.) Resident #27 had difficulty hearing and had hearing aids. There was no documented evidence that a comprehensive person-centered care plan was developed and implemented for their hearing impairment. This is evidenced by:A facility policy and procedure titled, Baseline/Comprehensive Person-Centered Care Plan dated 3/2023, documented that the comprehensive care plan would utilize the process to address resident strengths, needs and/or problems as identified on the admission discharge summary, as well as other professional assessments and orders from the healthcare provider, dietary team, therapy, social services and Preadmission Screening and Resident Review (PASARR) and Minimum Data Set. The Person-Centered Care Plan was developed to include information necessary to properly care for the resident and would address the resident's preferences, goals, desired outcomes, and plan for discharge. All clinical department heads were responsible to ensure that there was a system for monitoring implementation of the resident care plans. This was accomplished via quality assurance auditing, observation on rounds, and interview with staff, residents, and families. Corrective action would be carried out when problems with implementation of care plans have been modified. Resident #5:Resident #5 was admitted to the facility with diagnoses of heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), osteoarthritis of hip (a condition where the cartilage in joints gradually wears away, leading to pain, stiffness, and reduced mobility), unspecified glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging the optic nerve). The Minimum Data Set (an assessment tool) dated 3/11/2025, documented the resident was cognitively intact, could be understood and could understand others. The Comprehensive Care Plan for Daily Living, initiated 7/27/2022, documented Resident #5 was dependent on physical assistance from two (2) or more staff to perform transfers. The care plan was updated 4/09/2025 to include that Resident #5 required a mechanical lift for transfers with two (2) staff and was dependent of two (2) staff members for all mobility-based activities of daily living. The Facility Investigation, dated 3/24/2025, documented Resident #5 required the assistance of two (2) nursing staff to transfer the resident in and out of bed. It further documented that on 3/24/2025 at approximately 7:20 AM, Certified Nurse Aide #1 attempted to transfer the resident from their bed to a chair without the assistance of another staff. During the transfer attempt, Resident #5 was unable to follow Certified Nurse Aide #1's directions; the resident fell to the floor with slide assistance from Certified Nurse Aide #1. Licensed Practical Nurse #4 assisted Certified Nurse Aide #1 in calling Registered Nurse #2 to come and assess Resident #5. Resident #5 reported pain at the time of the event; the physician was notified as well as the family, and the resident was transferred to the hospital for further evaluation. The facility investigation report documented that hospital records confirmed Resident #5 sustained fractures (bone breaks) in both legs. The facility's investigation report documented that Certified Nurse Aide #1 did not follow Resident #5's care plan. Certified Nurse Aide #1 was suspended immediately and taken out of work during the investigation. Certified Nurse Aide #1 was terminated after choosing to not return to work. An Investigation Statement dated 3/24/2025 written by Certified Nurse Aide #1 documented that Certified Nurse Aide #1 acknowledged they were aware Resident #5 required two (2) staff for transfer, however, they thought they were capable of providing the care by themself. Resident #27:Resident #27 was admitted with diagnoses of type 2 diabetes (a dysfunction of the endocrine system causing inability to regulate blood sugar), bilateral hearing loss, and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). The Minimum Data Set, dated [DATE] documented the resident was cognitively intact, could be understood, and understand others.The Minimum Data Set, dated [DATE] also documented that Resident #27 had hearing aids and glasses. The Comprehensive Care Plan initiated 7/02/2025, after the hearing aids were pointed out to the floor staff, documented that Resident #27 had a communication problem, hearing deficit. The goal documented that the resident would be able to communicate needs daily through the review date. The interventions documented refer to ear nose and throat doctor, refer to speech therapy for evaluation and treatment as needed or ordered, and allow adequate time to respond, repeat as necessary and do not rush.There was no documentation regarding the use of hearing aids by Resident #27.During an interview on 7/02/2025 at 11:20 AM, Registered Nurse #1 stated that they were unaware that Resident #27 had hearing aids and if they did, the care plan should have reflected that.During an interview on 7/02/2025 at 12:00 PM, Registered Nurse #1 stated that family had brought in hearing aids but did not tell the staff which was why they did not know. Resident #27 knew how to use them, changed the battery for Registered Nurse #1. Registered Nurse #1 stated they would update the resident's care plan now that they knew.During an interview on 7/02/2025 at 11:25 AM, Certified Nurse Aide #2 stated they would check the Kardex (resident care card used by Certified Nurse Aides to provide care) to see what assistance a resident required prior to providing care. Certified Nurse Aide #2 stated that they did not normally take care of Resident #27. On the occasions where they did need to help care for Resident #27, they did not recall needing to yell to make sure the resident heard them. Certified Nurse Aide #2 stated they did not know if they had a hearing aid.During an interview on 7/03/2025 at 9:19 AM, Medical Director #1 stated that Resident #5 was admitted to the facility with difficulty transferring and was a two (2) person assist for transfers. Medical Director #1 stated that in the incident, one (1) Certified Nurse Aide was helping Resident #5, and the resident fell. Medical Director #1 stated that there was a quick root cause analysis of the incident done, and it was determined that the problem was because the Certified Nurse Aide did not follow the care plan. They further stated that Resident #5's fall risks were known, and care planned for, preventions were in place to prevent reoccurrences, the incident would continue to be discussed, and the quality assurance committee would continue to discuss how to avoid any repeat issues. During an interview on 7/03/2025 at 9:56 AM, Director of Nursing #1 stated that they were not there when Resident #5 was injured. When Director of Nursing #1 returned to work, they were informed of what happened. Director of Nursing #1 stated that their understanding was that Certified Nurse Aide #1 was suspended at the time of the incident, and was so upset by what happened, that they never returned to the building. Director of Nursing #1 stated that there was facility-wide education done on abuse, Kardex (resident care card used by Certified Nurse Aides to provide care) reading and in following care plans that indicate two (2)-person assistance for transfers. Director of Nursing #1 stated that it was the facility's expectation that staff would check resident's care card and ensure resident safety when providing care. Director of Nursing #1 stated that Resident #27's family had brought in hearing aids recently, but did not tell the staff. Director of Nursing #1 could not speak to how long the hearing aids had been being used by the resident. When asked how it could be possible that staff would have been interacting with the resident frequently throughout the day and not notice hearing aids in Resident #27's ears, Director of Nursing #1 stated that they did not understand how it could have been missed. During an interview on 7/03/2025 at 11:51 AM, Administrator #1 stated that they believed that the aide had made a bad decision and had never had any issues at the facility prior to this event. Administrator #1 stated that there was a facility-wide education on care planning and looking at a resident's care card before providing care. 10 New York Codes, Rules, and Regulations 415.11(c)(1)

Based on observation and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for one (1) (Passport unit) of three (3) medication carts reviewed. Specifically, (a.) two (2) open multi-dose Humalog (insulin) vials were not labeled with a resident's name and (b.) one (1) open multi-dose bottle of Lantus (insulin) was not clearly marked with an open date. This is evidenced by:During an observation on 6/30/2025 at 9:07 AM, the medication cart on the Passport unit was reviewed. Two opened multi-dose vials of Humalog were found in the first draw of the medication cart. A labeled multi-dose bottle of Lantus was also found with an unclear opened date. During an interview on 6/30/2025 at 9:07 AM, Licensed Practical Nurse #3 stated they were unable to state if the open date on the bottle of Lantus was 6/04/2025 or 6/11/2025. They also stated the two bottles of Humalog were pulled out of the emergency stock because a resident's medication had not yet arrived from pharmacy. They stated a resident name label should have been put on the bottles and stated each resident had a page of adhesive stickers with their names on it in each respective binder.During an interview on 7/02/2025 at 12:07 PM, Registered Nurse #1 stated that when a vial of insulin is taken out of the emergency stock for a resident, it should be immediately labeled. They stated that a vial of insulin, though multi-dose, should only be used for one resident and absolutely should not be shared among residents.During an interview on 7/02/2025 at 1:36 PM, Director of Nursing #1 stated that vials should be labeled with the resident's name when pulled from the emergency stock. They stated that opened dates should be clearly marked on each pen and vial. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation and interviews conducted during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in four (4) of four (4) resident unit nutrition rooms and the central kitchen. Specifically, the area of the main kitchen and resident kitchenettes was not clean. This is evidenced by:During the initial inspection in the central kitchen on 6/26/2025 at 11:20 AM, coffee cups, containers, pots, and trays were put away wet and contained moisture.During an inspection in the central kitchen on 7/02/2025 at 10:45 AM, the storage area for clean pots, pans, and food containers had multiple containers stacked together that were not thoroughly dried. Containers, pots, and trays were put away wet and contained moisture.During an observation on 7/02/2025 at 11:00 AM, the 3rd floor west unit nutrition room had a microwave that was unclean with dirt and particles, cabinet doors and handles were broken and unsecured, counters were covered with dirt and debris, dirt and grime were on the edge of cupboards and drawers, and a staff persons orange drink was in a cupboard.During an observation on 7/02/2025 at 11:08 AM, the 3rd floor east unit nutrition room had a microwave that was unclean with dirt and grime.During an observation on 7/02/2025 at 11:13 AM, the 2nd floor east unit nutrition room had a microwave that was unclean with dirt and particles, a refrigerator seal had dirt and grime, and the bottom of the refrigerator was not cleaned and had spilled substance.During an observation on 7/02/2025 at 11:17 AM, the 2nd floor west unit nutrition room had counters that were covered with dirt and debris, and the toaster was uncleaned with dirt and debris.During an interview on 7/02/2025 at 11:45 AM, Director of Food Services #1 stated that their staff was responsible for the overall cleanliness of the nutrition rooms. They stated they would have to have the staff be more diligent in cleaning the equipment and kitchen areas. They stated that the individual who was washing the pots, pans, and containers did not let them dry thoroughly and put them away too soon, as it takes several hours to fully dry. They stated that they have not received any complaints about the cleanliness of the rooms, and the staff were expected to clean the areas within the rooms. They stated that staff should not be placing their personal drinks in the cupboard, as they have an area where they could store those items. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation, record review, and staff interviews conducted during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the facility did not ensure that two (2) of five (5) trash bins were pest and rodent-proof by having damaged/broken lids. This was evidenced by:During an observation of the trash collection area on 7/02/2025 at 11:05 AM, two trash bins had broken lids and were unable to be fully closed, preventing the disposal of garbage and refuse appropriately, and were pest and rodent-proof.During an interview on 7/02/2025 at 11:30 AM, Director of Maintenance #1 stated that they usually contacted the refuse company to have them replaced periodically because they got broken. They stated that they were unsure of the last time that they had to be replaced. 10 New York Codes of Rules and Regulations 814.14(h)

Based on interview and record review conducted during the recertification survey, the facility did not use the services of a Registered Nurse for at least eight (8) consecutive hours a day, seven (7) days a week. Specifically, a review of staffing revealed a Registered Nurse was not scheduled for eight (8) consecutive hours on 1/25/2025.This is evidenced by:The Facility's Policy and Procedure titled Quality of Life - Accommodation of Needs, issued 9/2024, documented, the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed as needed throughout the residents stay in the facility. Staff shall interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity. Resident #7 was admitted to the facility with diagnosis of Parkinson's Disease (a progressive neurological disorder that primarily affects movement, but also involves non-motor symptoms like cognitive and emotional changes); Cerebral Palsy (group of neurological conditions that affect movement and posture); and profound mental retardation (the presence of significantly sub average general intellectual functioning). The Minimum Data Set (an assessment tool) dated 3/05/2025 documented the resident's cognition was unable to be assessed, but they usually were able to be understood and understand others. The Comprehensive Care Plan titled, Communication, dated 4/24/2025, documented Resident #7 has a communication problem. Goal: Resident #7 will maintain current level of communication function by making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, writing messages. Problem: Resident has Cerebral Palsy. Goal: The resident will be able to function at the fullest potential possible as outlined by the treatment team.During an observation on 6/26/2025 at 12:20 PM, Resident #7 was observed in their room eating lunch independently with adaptive utensils. Resident with food in lap, clothing and face. Resident did not respond when writer said hello.During an observation on 6/27/2025 at 11:14 AM, resident observed sitting in their room while activities were taking place in the common area. Resident did not respond to greetings, did not respond to queries of how are you? What is your name? do you need anything? Resident #7 made no attempts to speak, but did make eye contact with writer.During an observation on 7/02/2025 at 12:01 PM, Resident #7 was observed in the main dining room on first floor. Resident #7 was sitting at a table alone near window. Activities Director #1 was observed attempting to have conversation with Resident #7. Resident #7's responses were delayed and could not be understood.During an interview on 7/02/2025 at 11:08 AM, Licensed Practical Nurse #6 stated Resident #7 had been a resident for many years; staff were familiar with resident's routine and needs. Resident made some grunts and responds to yes/no questions. Resident did not have a communication board. During an interview on 7/02/2025 at 12:01 PM, Activities Director #1 stated Resident #7 did best with one-to-one activities or engagements. Resident #7 did not like to be around others. When attempt to include Resident #7 in group activities, Resident #7 would push others away. Activities consists of coloring and watching television.During an interview on 7/02/2025 at 12:24 PM, Director of Rehabilitation #1 stated Resident #7 no longer attended speech language therapy. The last time they attended speech language therapy was in 2021 for evaluation and treatment of dysphagia (difficulty swallowing). Director of Rehabilitation #1 stated Resident #7 did not have a communication board or any other adaptive device for commutation. Communication had not been addressed since resident admitted several years ago. Staff communicate using closed ended yes/no questions. During an interview on 07/02/2025 at 12:57 PM, Director of Nursing #1 stated resident was able to make their needs known. The staff were familiar with resident and could understand them. If a new or agency staff were on the unit, they would ask another staff member to assist with communicating with resident. Director of Nursing #1 stated they were not sure whether Resident #7 had a communication board. 10 New York Codes, Rules, and Regulations 415.12(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey dated 3/14/2022 through 3/18/2022, the facility did not develop and implement baseline care plans that included instructions needed to provide effective and person-centered care for 9 (Residents #'s 10, 13, 17, 68, 77, 83, 86, 89, and #104) of 18 residents reviewed. Specifically, for Resident #'s 68, 83, 86, 89 and #104, the facility did not ensure the baseline care plans included the required minimum healthcare information necessary to properly care for each resident immediately upon their admission and did not address resident-specific health and safety concerns by identifying needs for supervision, behavioral interventions, and assistance with activities of daily living and for Resident #'s 10, 13, 17, and #77, the facility did not ensure that baseline care plans were developed with 48 hours of the resident's admission. This is evidenced by: The Policy and Procedure titled Baseline/Comprehensive Person Centered Care Plan revised 10/2017, documented the baseline care plan must be developed within 48 hours of admission. The baseline care included at least a minimum of healthcare information necessary to provide the proper care for the resident, establish initial goals and orders from the physician, dietary, therapy, social services and PASARR (Preadmission Screening and Resident Review). Resident #13: Resident #13 was admitted to the facility with diagnosis of end stage renal disease (ESRD), diabetes mellitus, and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS- an assessment tool) dated 12/18/2021, documented the resident was cognitively intact, could understand others and could make self-understood. Review of the resident's medical record on 3/17/2022 at 2:41 PM, did not include documentation of a baseline care plan. During an interview on 3/17/2022 at 3:04 PM, Licensed Practical Nurse Unit Manager (LPNUM) #7 stated baseline care plans should be completed within 48 hours of admission. LPNUM #7 stated the baseline care plan should be developed by the registered nurse who completed the admission within 48 hours and a copy should be documented in the medical record. LPNUM #7 reviewed the medical record for Resident #13 and stated the record did not include the baseline care plan. During an interview on 3/18/2022 at 12:25 PM, the Director of Nursing (DON) stated baseline care plans should have been developed by the admitting nurse soon after admission and filed in the paper chart. The DON did not give a time frame for the development of the baseline care plans after new admissions were admitted to the facility. Resident #68: Resident #68 was admitted with diagnoses of Alzheimer's disease, anxiety disorder and generalized osteoarthritis. The Minimum Data Set (MDS-an assessment tool) dated 2/12/2022, documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The Hospital Discharge summary dated [DATE], documented the resident had a diagnosis of Alzheimer's dementia, with intermittent confusion and chronic anxiety. The resident was discharged on Zyprexa (antipsychotic medication) 2.5 mg by mouth at bedtime. The Baseline Care Plan, dated 2/5/2022, did not address the use of antipsychotic medication, the resident's diagnoses of Alzheimer's disease and anxiety disorder, or the resident's specific needs related to supervision, behavioral interventions, and assistance with activities of daily living. During an interview on 3/17/2022 at 3:06 PM, the Director of Nursing (DON) stated the Admissions Nurse or the registered nurse completing the new admission was responsible for completing the baseline care plan and reviewing it with the resident or family. The DON stated the baseline care plan was a 1-page form that was filled out and kept in the resident's chart on the unit. The DON stated a copy of the baseline care plan, the 1-page form, was provided to the resident or family as the summary. During an interview on 3/18/2022 at 10:30 AM, Registered Nurse (RN) #1 stated they were the Admissions Nurse and completed the baseline care plan for the residents they admitted . RN#1 stated the baseline care plan was very basic. RN#1 used documents from the hospital to complete the the baseline care plan, including the transfer summary and the Patient Review Instrument (PRI) as well as interviews with the resident and family. RN#1 stated an antipsychotic medication and diagnoses, such as dementia, would not be documented on the baseline care plan but would be on the initial care plan in the computer. RN#1 stated the 1-page baseline care plan was reviewed and provided to the resident or family. The physician orders were not documented on the baseline care plan, but RN#1 would ask the resident or family if they wanted a copy of the physician orders. RN#1 stated the form they used for the baseline care plan was what the facility provided to them to use with each new admission. Resident #83: Resident #83 was admitted to the facility with diagnoses of retention of urine, neuromuscular dysfunction of the bladder and hemiplegia and hemiparesis following other cerebrovascular disease. The Minimum Data Set (MDS - an assessment tool) dated 2/17/2022 documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The MDS dated [DATE], documented the presence of a urinary catheter on admission. The Hospital Discharge summary dated [DATE] documented the resident had an indwelling urinary catheter. The undated Baseline Care Plan (BCP) did not address resident-specific health and safety concerns including the presence of a urinary catheter, supervision needs and the resident's specific needs related to the care of the urinary catheter, and assistance with activities of daily living. The Progress Note dated 3/22/2021 documented the presence of a urinary catheter on admission. During an interview on 3/18/2022 at 10:30 AM, Registered Nurse (RN) #1 stated they were the Admissions Nurse and completed the baseline care plan for the residents they admitted . RN#1 stated the baseline care plan was very basic. RN#1 used documents from the hospital to complete the the baseline care plan, including the transfer summary and the Patient Review Instrument (PRI) as well as interviews with the resident and family. RN#1 stated the physician orders were not documented on the baseline care plan, but RN#1 would ask the resident or family if they wanted a copy of the physician orders. RN#1 stated the form they used for the baseline care plan was what the facility provided to them to use with each new admission. During an interview on 3/18/22 at 10:41 AM, LPNUM #3 stated they could not start a care plan on their own but could update a care plan. LPNUM #3 stated the Admissions Nurse was the one who completed the admission paperwork for new admissions including a baseline care plan. 10NYCRR 415.11

Based on observation, record review, and interviews during a recertification survey and abbreviated survey (Case #NY00261370) dated 3/14/2022 through 3/18/2022, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 10 (Resident #'s 34, 43, 68, 82, 89, 101, 104, 108, 119, and #127) of 26 residents reviewed. Specifically, for Resident #34, the facility did not ensure the Activities of Daily Living (ADL) Comprehensive Care Plan (CCP) intervention to check and change the resident every 2 hours was implemented, and ensure the resident received supervision while eating in bed was implemented; for Resident #43 the facility did not ensure the Respiratory CCP intervention for oxygen administration at two liters per minute via nasal cannula was implemented; for Resident 68, did not ensure a behavior management program was implemented as documented on the psychotropic medication care plan; for Resident #82, did not ensure a CCP was developed for the resident's ongoing complaints of and treatment for diarrhea; for Resident #89, did not ensure the resident was weighed in accordance with the nutrition care plan; for Resident #101, did not ensure the resident received the documented liter flow of oxygen (O2) in accordance with the care plan for chronic obstructive pulmonary disease (COPD); for Resident #108, did not ensure a CCP was developed for a rash to the resident's bilateral upper and lower extremities; for Resident #104, did not ensure the resident was provided with bi-weekly showers as documented on the ADL care plan; for Resident #119, did not ensure a care plan was developed to address small circular areas covered with fresh blood and dried blood on the resident's right and left arms; and for Resident #127, did not ensure the intervention for monthly weights was consistently implemented as documented on the CCP for the resident's potential for nutritional problem. This was evidenced by: The facility Policy & Procedure (P&P) titled Comprehensive Care Plan dated 2/2015, documented the CCP was developed to provide individualized plans of care that addressed the resident's identified needs and assisted the resident to achieve their highest practicable quality of life. The interdisciplinary team would be responsible to maintain the CCP current at all times and to update the care plan when a new problem/goal/intervention was identified that required a team member to intervene. The P&P documented all clinical department heads were responsible to ensure that there was a system for monitoring the implementation of the resident care plans. Resident #82: Resident #82 was admitted with diagnoses of heart failure, diverticulitis of the large and small intestines, and depression. The Minimum Data Set (MDS-an assessment tool) dated 2/6/2022 documented the resident was without cognitive impairment and could understand and be understood. The Medication Administration Record (MAR) dated 3/1/2022 through 3/31/2022 documented the resident received Imodium (a medication used to treat diarrhea) on 3/3/2022, 3/9/2022, 3/10/2022, 3/11/2022 and 3/2022. A document titled, Documentation Survey Report (a form used to document Certified Nurse Assistant (CNA) care provided) dated March 2022 documented the resident had a bowel movement with loose/diarrhea consistency on: Day Shift: 3/1/2022, 3/2/2022, 3/3/2022, 3/6/2022, 3/7/2022, 3/8/2022, 3/9/2022, 3/10/2022, 3/12/2022, 3/13/2022, 3/14/2022, 3/15/2022, 3/16/2022 and 3/17/2022 Evening Shift: 3/1/2022, 3/2/2022, 3/7/2022, and 3/13/2022 Night Shift: 3/8/2022 During an interview on 3/15/22 at 9:46 AM, Resident #82 stated they do not get out of bed often or attend activities at the facility secondary to frequent loose stools. During an interview on 3/18/2022 at 9:44 AM, CNA #4, stated they have worked with the resident for the previous six months, and the resident regularly has loose stools. The CNA stated the nurse was made aware with each loose stool the resident had. During an interview on 3/18/22, Licensed Practical Nurse Unit Manager (LPNUM) #7, stated they were aware the resident continued to have loose bowel movements for several months, and the resident would refuse to get out of bed or attend activities at the facility due to loose stools. LPNUM #7 stated the resident should have a CCP in place for loose stools. LPNUM #7 stated Unit Managers were expected to ensure the resident's care plan accurately reflected the care and services needed to care for the resident. During an interview on 3/18/2022 at 12:01 PM, the Director of Nursing (DON) stated the Unit Manager was responsible for ensuring the CCPs were updated and accurate and the Unit Manager should contact an RN (Registered Nurse) in the facility to develop a care plan when needed. Resident #108: Resident #108 was admitted to the facility with the diagnoses of dementia, cerebral infarction, and diabetes. The Minimum Data Set (MDS- an assessment tool) dated 2/26/2022, documented the resident had a significant cognitive impairment, could understand and be understood. During an observation on 3/14/2022 at 2:01 PM, the resident was observed scratching both their arms. During an observation on 3/15/2022 at 12:12 PM, the resident was observed in the dining room with their right pant leg raised, and their right leg was red. During an observation on 3/16/2022 at 3:07 PM, the resident's arms appeared bright red with raised skin and had scratch marks with dried blood. During an observation on 3/17/2022 at 12:38 PM, both of the resident's arms were bright red with slightly raised skin. Nursing Progress Notes documented the resident had a rash present on: 2/2/2022 to bilateral arms and right ankle; 2/4/2022 to bilateral arms and legs; 2/8/2022 to bilateral arms and legs; 2/11/2022 to arms and back; 2/14/2022 to bilateral arms and legs; and on 2/19/2022 a full body rash was noted that the resident was digging at angrily. A Nursing Progress Note dated 2/23/2022 documented the resident was readmitted to the facility and a rash was noted to the resident's entire body. Nursing progress notes dated 2/25/2022 and 2/27/2022 documented the resident had a rash on their body and the resident was scratching and picking at their skin. During an interview on 3/18/2022 at 10:06 AM, LPNUM #1 stated the resident has had a rash on their body for several weeks. LPNUM #1 stated the resident should have a care plan in place for the rash on their body and they requested the DON to develop a CCP for the resident's rash. During an interview on 3/18/2022 at 12:19 PM, the Director of Nursing (DON) stated the Unit Manager was responsible for ensuring the CCPs were updated and accurate and the Unit Manager should contact an RN in the facility to develop a care plan when needed. Resident #119: Resident #119 was admitted with the diagnoses of diabetes, chronic kidney disease, and chronic respiratory failure. The Minimum Data Set (MDS-an assessment tool) dated 3/3/2022 documented the resident had moderately impaired cognition, could understand others and could make self understood. During an observation on 3/14/2022 at 10:30 AM, the resident's right arm was visible and there were multiple small circular areas covered in fresh red blood and some covered with dried blood (scabbed over) on their forearm. There were drops of dried blood on the resident's yellow blanket that covered their lap and on the right sleeve of their short-sleeved white t-shirt. During an observation on 3/15/2022 at 12:21 PM, the resident's right and left arms were visible. Both arms had multiple small circular areas that were either covered with fresh red blood or dried blood. The resident stated their arms itched but they did not know why their arms itched. The resident stated the staff would sometimes put lotion on the resident's arms but stated they did not receive a regularly scheduled treatment to their arms. The Comprehensive Care Plan (CCP) did not include a care plan to address the small circular areas covered with fresh and dried blood on the resident's right and left arms. During an interview on 3/17/2022 at 3:21 PM, the DON stated the resident was very anxious and noncompliant with care. The DON stated they did not know about the resident's arms. The DON stated the resident had a renal condition and chronic kidney disease so it would make sense if the resident scratched their skin. The DON stated that to the best of their knowledge the open areas on the resident's arms was not a known condition or a known behavior. The DON stated open areas on the resident's arms would be picked up on the weekly skin evaluations and it would not necessarily be on the care plan. The DON stated they would have to go look at the resident's arms. During an interview on 3/18/2022 at 9:05 AM, Licensed Practical Nurse (LPN) #6 stated Resident #119 was admitted to the facility with those areas on their arms. LPN #6 stated the resident was a scratcher and the LPN would sometimes use lotion on the resident's arms because the resident would say their arms itched. The LPN stated they had seen blood on the resident's shirt from the open areas on the resident's arms. The LPN stated the resident had a lot of health issues and anxiety that contributed to the resident's scratching. The LPN stated those areas should be on a skin check and everyone should be aware of them because the resident has had them on their arms since they came into the facility. The LPN stated the areas on the resident's arms should be on the resident's care plan because it was an ongoing issue. The LPN stated the areas would close over but the resident would scratch again re-opening the areas and they would bleed. During an interview on 3/18/2022 at 9:55 AM, LPNUM #2 stated the areas on the resident's arms had not been reported to them. Prior to becoming Unit Manager earlier this week, LPNUM #2 stated they worked as an LPN on the opposite end of the hallway and did not provide direct care to Resident #119. LPNUM #2 was not aware of the open areas on the resident's arms. The LPNUM stated if the skin condition was new for the resident, it would be on the care plan and any condition that was ongoing would be care planned. LPNUM #2 stated LPNs could not initiate care plans, but LPNs could add to the existing care plan. 10NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey dated 3/14/2022 through 3/18/2022, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Resident #'s 24, 77 and #104) of 4 residents reviewed for ADL's. Specifically, for Resident #34,who required extensive assistance of staff for ADL care, the facility did not ensure incontinence care was provided as documented in the resident's care plan; for Resident #77, who was dependent on staff for ADL care, did not ensure the resident was shaved daily in accordance with the resident's preference and as documented on the resident's care plan, and for Resident #104, who was dependent on staff for ADL care, the facility did not ensure the resident was bathed or showered as documented on the resident's care plan. This is evidenced by: The facility did not provide a Policy and Procedure for Activities of Living (ADL) related to resident showers, incontinence care, personal hygiene and grooming. A document titled CNA (Certified Nursing Assistant) Standard of Care/Information Sheet dated 2/2019 documented Daily Morning Care: 1. Toilet as needed 2. Wash hands and face 3. Peri care 4. Dress in day clothes and non-skid footwear 5. Oral hygiene 6. Shave as needed 7. Make-up as requested 8. Nail care daily prn except diabetics. It documented to report all resident complaints and concerns regarding care, meals, activities and general expressions of unhappiness to the charge nurse. Resident #34: Resident #34 was admitted to the facility with the diagnosis of Multiple Sclerosis, heart failure and dysphagia. The Minimum Data Set (MDS-an assessment tool) dated 3/8/2022, documented the resident had moderate cognitive impairment, could understand others and could make themselves understood. The MDS documented the resident required extensive assistance for toileting and toileting hygiene. The Comprehensive Care Plan (CCP) titled, Overactive Bladder incontinence/ neurogenic bladder revised on 9/9/2019 documented the resident would be checked and changed every 2 hours. The CCP titled, ADL self-care performance deficit revised on 12/21/2021, documented the resident required extensive assistance of two staff for toileting use. The CNA [NAME] (caregiving instructions) dated 3/16/2022 documented the resident required extensive assistance by two staff members for bed mobility and toileting. Additionally, for bowel/bladder care it documented the resident would be checked and changed every two hours. During an interview on 3/14/2022 at 11:22 AM, Resident #34 stated they did not receive incontinence care from before dinner on 3/13/2022 until after 6:30 AM on 3/14/2022. The resident stated this was reported to the day shift CNA and the CNA brought the nurse into the room to show the nurse how wet I was. During an observation and interview on 3/15/2022 at 9:25 AM, the resident was eating breakfast in bed and stated they received incontinence care by the night shift around 5:00 AM. Resident #34 stated they had not been checked or changed since that time. During an interview on 3/15/2022 at 2:19 PM, Resident #34 stated they were provided incontinence care today by the night shift CNA around 5:00 AM and by the day shift CNA around 11:00 AM when they received wound care by the nurse. The resident stated they did not refuse care today; it was not offered. During an observation and interview on 3/16/2022 at 9:54 AM, CNA #5 exited Resident #34's room with a bag of soiled linen in their hand. CNA #5 stated that was the first time since the start of their shift at 6:00 AM today that the resident was checked and changed and provided incontinence care. CNA #5 stated they regularly worked the day shift and were assigned to care for Resident #34. CNA #5 stated they regularly provided care to Resident #34 twice between 6:00 AM and 2:00 PM, once around 10:00 AM or 10:30 AM and again after lunch around 1:00 PM. CNA #5 stated they were unsure how frequently the resident was care planned for incontinence care. CNA #5 reviewed the resident's CNA [NAME] during the interview and identified the resident was supposed to be checked and changed every two hours and stated they did not do that. During an interview on 3/16/2022 at 1:55 PM, Licensed Practical Nurse (LPN) #12 stated they were assigned to the resident on 3/14/2022 until 9:30 AM and was not made aware that Resident #34 had not been provided incontinence care on the overnight shift on 3/13/2022. During an interview on 3/17/2022 at 8:12 AM, LPNUM #7 stated they were unaware of the resident's allegations that they did not receive incontinence care from before dinner on 3/13/2022 until after 6:30 AM on 3/14/2022. The staff had not reported it to the LPN on 3/14/2022. LPNUM #7 stated CNA #6 and LPN #11 were assigned to the resident. The contact information for CNA #6 and LPN #11 was requested but was not provided to the survey team. Additionally, LPNUM #7 stated they began interviewing staff yesterday following the surveyor's interview with LPN #12 and identified at that time staff were not following the resident's CCP for incontinence care. During an interview on 3/17/2022 at 12:02 PM, the Director of Nursing (DON) stated they would expect staff to follow the resident's CCP to check and change the resident every two hours. The DON stated the LPNUM and LPN should ensure all care and services were being provided to the resident as per the CCP. Resident #77: Resident #77 was admitted with diagnoses of wedge compression fracture of first thoracic vertebra, spinal stenosis (narrowing of the spine), and depression. The Minimum Data Set (MDS-an assessment tool) dated 2/4/2022 documented the resident had moderately impaired cognition, could usually understand others and could make self understood. The CCP for ADL self-care performance deficit, last updated on 11/17/2021, documented the resident required limited assist of 1 staff for personal hygiene. The CNA [NAME] dated 3/17/2022 documented the resident required extensive assist of 1 staff for personal hygiene. The [NAME] did not document the resident preferred to have a beard. The [NAME] also did not document the resident's preference was not to be shaved daily. A Documentation Survey Report dated 3/1/2022 - 3/16/2022, documented Resident #77 was provided personal hygiene, including shaving daily with an extensive assist of 1 staff. During an observation and interview on 3/14/2022 at 12:05 PM, Resident #77 was lying in bed and had a moderate amount of facial hair. The resident rubbed both sides of their face and chin and stated their beard was driving them crazy. The resident stated they preferred to be shave every day but was not longer able to shave independently. The resident stated the staff only shaved them once or twice a month, not daily. During an observation and interview on 3/15/2022 at 1:11 PM, Resident #77 was lying in bed and had a moderate amount of facial hair. The resident stated morning care was provided at 5:30 AM and staff did not shave them. During an observation and interview on 3/16/2022 at 11:02 AM, Resident #77 was sitting up in bed and a moderate amount of facial hair. The resident stated they had received morning care but had not been shaved. During an interview on 3/16/2022 at 11:11 AM, Licensed Practical Nurse (LPN) #10 stated residents should be offered to be shaved daily with morning care. The LPN stated the CNA [NAME] would document when a resident's preference was not to be shaved. All other residents would be offered to be shaved. During an interview on 3/16/2022 at 11:30 AM, CNA #4 stated Resident #77 preferred to be shaved daily. The CNA stated the resident would explain this to new caregivers who may not be aware of their preferences. During an interview on 3/16/2022 at 12:46 PM, LPNUM #7 stated a resident's preference to maintain a beard and/or facial hair would be documented in the care plan, and if it was not specified on the care plan, then the resident should be shaved with morning care. LPNUM #7 stated they were not aware that Resident #77 was receiving assistance to shave during morning care. The LPNUM stated they would expect to have been notified if care was not provided, or when the staff were unable to complete a task for any reason. During an interview on 3/18/2022 at 11:38 AM, the Director of Nursing (DON) stated shaving was a resident preference and should be offered with morning care. Resident #104: Resident #104 was admitted with the diagnoses of schizoaffective disorder, diabetes, and anxiety disorder. The Minimum Data Set (MDS-an assessment tool) dated 3/1/2022 documented the resident had moderately impaired cognition, could understand others and could make themselves understood. During an observation and interview on 3/14/2022 at 11:08 AM, the resident's hair was greasy (oily), and the resident stated they were supposed to get a shower 2x a week but had not had a shower since they were admitted to the facility. The resident stated they could use a shower and their hair was dirty. During an observation and interview on 3/15/2022 at 12:15 PM, the resident's hair was greasy (oily), and the resident stated they were offered a shower last evening, but the resident declined because they were not feeling well. The resident stated that was the first time they had been offered a shower and the first time they had declined. The resident stated they were not re-offered a shower last evening or this morning. The resident stated they wanted to shower, and their hair needed to be washed. The CCP for ADLs, last revised 3/2/2022, documented: Bathing/Showering- the resident required extensive assistance of 1 staff and was scheduled on Monday and Thursday evenings. A review of the CNA Documentation for Showers dated 2/22/2022 - 3/15/2022 documented: 2/28/2022- n/a (not applicable); 3/7/2022- no; 3/14/2022- n/a A review of Progress Notes dated 2/22/2022 - 3/15/2022 did not include documentation the resident refused to be bathed or showered and did not include documentation the resident was re-offered a shower from last evening (3/14/2022) after the resident reported they declined their shower due to not feeling well. During an interview on 3/17/2022 at 9:06 AM, CNA #1 stated the residents were supposed to be showered 2x a week. CNA #1 stated all of the showers did not get done and honestly, showers were missed. CNA #1 stated it was possible that both showers scheduled in the same week could be missed and not provided to the resident. The CNA stated they would re-offer the shower or communicate to the next shift to let them know when a shower was missed or refused. The shower would sometimes get picked up by the next shift and sometimes it did not. CNA #1 stated Resident #104 did not necessarily refuse care but dictated when they wanted care done. The CNA stated CNAs documented showers in the computer and documented the following for showers: Yes, No, Refused or N/A. During an interview on 3/17/2022 at 11:37 AM, CNA #2 stated when a CNA was unable to get a shower done on their shift, the shower would be given on the next shift or the next day. If a resident refused a shower, the CNA would let the charge nurse know and then the nurse and CNA would document the resident refused their shower. During an interview on 3/18/2022 at 9:59 AM, Licensed Practical Nurse Unit Manager (LPNUM) #2 stated Resident #104 was forgetful and noncompliant. The resident was particular when they wanted things done for them. The LPNUM stated staff had not reported to them that Resident #104 had refused to shower. The LPNUM stated if Resident #104 refused, then they would get a good bed bath with a shampoo shower cap or get a shower at another time. LPNUM stated if the resident's hair was greasy hair, the staff could have given the resident a bed bath and used a shampoo shower cap to wash the resident's hair. The LPNUM stated it had not been reported to them by staff that showers were not getting done. The LPNUM stated they would document in the resident's medical record if a shower was declined. During an interview on 3/18/2022 at 1:11 PM, the Director of Nursing (DON) stated prior to survey it had not been brought to their attention that Resident #104 had not received their showers. The DON stated the residents were showered 2x a week. The DON stated showers were specified on the care plan and the care plan was what the CNAs should go by when providing care. The DON stated if a CNA was busy, they would let nurse know, and the nurse would talk to the resident to see when the shower could be done. If the resident refused the shower, it should be re-offered. If the resident did not want to take a shower, the staff would give a bed bath and shampoo shower caps were offered to wash their hair. 10NYCRR415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey dated 3/14/2022 through 3/18/2022, the facility did not ensure each resident was free from accident hazards for 2 (Resident #'s 34 & #101) of 5 residents reviewed. Specifically, for Resident #34, who had difficulty swallowing, the facility did not ensure the resident was supervised during eating and was evaluated for the ability to chew after their dentures were broken and for Resident #101, the facility did not ensure the resident was not self-administering inhalers in their room after being assessed not to be a potential candidate for self-medication administration. This is evidenced by: Resident #34: The resident was admitted to the facility on with the diagnosis of Multiple Sclerosis, heart failure and dysphagia. The Minimum Data Set (MDS-an assessment tool) dated 3/8/2022, documented the resident had moderate cognitive impairment. The resident could understand and be understood. The resident required the supervision of 1 person while eating. During an observation on 3/16/2022 at 9:02 AM, the resident was in their room with the door closed. Upon entering Resident #34's room at 9:07 AM, the resident was observed in bed eating cereal. Staff were not present during this encounter and the door remained closed until 9:11 AM, when a staff member opened the door to the resident's room to retrieve the breakfast tray. The Comprehensive Care Plan (CCP) titled, Behavior problem, revised on 9/6/2020, documented the resident refused to meet dietary safety recommendations for safety and refused to get out of bed for meals and constant supervision. Resident #34 would accept intermittent supervision with the door open during mealtimes. The CCP titled ADL (Activities of Daily Living) revised on 12/21/2021, documented: Eating -encourage resident to get out of bed or keep bed at ninety degrees while eating; resident wears dentures and the resident required set up and supervision. The Certified Nurse Aide (CNA) [NAME] (resident specific care instructions) documented: Resident #34 refused (to be) out of bed for meals and constant supervision - however would accept intermittent supervision during meals with the door open during mealtimes. Additionally, it documented, for Eating and Nutrition, the resident wore dentures and the bed set at ninety degrees while eating. - Resident is safe to have meals in bed and needs to be fully upright in bed for meals; Preferred dining location - Cluster or bedroom. If in room eating, ensure door is left open to visualize resident while eating. A Speech Therapy evaluation completed on 1/14/2022 documented the resident was evaluated for oral and pharyngeal swallow function. The reason for the referral was the resident was experiencing difficulty swallowing. An untitled document provided by the facility that included the meals Resident #34 was served, documented the resident received a burger on a bun five (5) times for either lunch or dinner during the time period from 3/8/2022 through 3/15/2022, . A Therapy Progress Note dated 3/17/2022 at 1:50 PM, documented Resident #34 was screened by a speech language pathologist (SLP) and their diet was downgraded to mechanical soft as their dentures were broken and sent out for repair. During an interview on 3/14/2022 at 11:29 AM, Resident #34 reported their dentures broke about a month ago and they had difficulty chewing several items, especially burgers. The resident reported to staff their difficulty chewing burger since their dentures were broken. During an interview on 3/16/2022 at 10:07 AM, Certified Nurse Assistant #5 stated the resident regularly ate in their room alone with the door closed. CNA #5 stated the resident complained to them about always getting burgers for dinner and reported difficulty chewing them since the resident's dentures were broken. CNA #5 stated it was difficult to supervise the resident during meals as they had to feed a resident across the hall. CNA #5 stated they tried to check on the resident during eating, but often did not have time to do this. During an interview on 3/16/2022 at 10:14 AM, SLP #1 stated when a resident had a history of dysphagia and reported difficulty chewing foods, or there was a change in the resident's ability to chew, such as when dentures were being repaired, a request for a swallowing evaluation would be placed. During an interview on 3/17/22 at 8:23 AM, Licensed Practical Nurse Unit Manager (LPNUM) #7 stated the resident's dentures were broken prior to 2/2/2022. LPNUM #7 stated a swallowing evaluation was not placed, as the LPNUM was not aware the resident reported difficulty chewing foods. LPNUM #7 stated they were aware the resident complained of receiving too many burgers but were not informed this was due to chewing difficulties. LPNUM #7 stated they were aware the resident refused to get out of bed for meals and required supervision with the door to their room open, however they were not aware staff were not completing this task. During an interview on 3/17/2022 at 12:16 PM, the Director of Nursing (DON) stated they would expect the resident to be supervised for meals as per the CCP. The DON stated they would only expect a swallowing evaluation to be completed when a resident was observed to have difficulty swallowing and the nurses aides should observe the resident for any difficulties chewing or swallowing. The DON stated they thought the resident had a swallowing evaluation completed after Resident #43's dentures were broken. Resident #101: Resident #101 was admitted with diagnoses of chronic obstructive pulmonary disease (COPD), fibromyalgia, and hypertension. The Minimum Data Set (MDS-an assessment tool) dated 2/27/2022 documented the resident was cognitively intact, could understand others and could make self understood. The undated facility Policy and Procedure titled Self Medication documented to maximize and promote resident independence, self-administration of medication was encouraged for all residents capable of performing this function. The interdisciplinary care team used various factors in determining a resident's capacity to self-medicate. The resident must desire to participate in the self medication program and agree to adhere to safety rules and open communication with nursing staff as they monitored compliance and effectiveness of the medication program. During an observation and interview on 3/14/2022 at 11:15 AM, the resident was sitting in their wheelchair and had 2 inhalers on the over bed table in front of them. The resident stated the blue inhaler was Ventolin and was full. The resident stated the orange inhaler was Combivent and was empty. The resident stated the Combivent was supposed to be refilled by the facility. The resident stated they self-administered the Combivent inhaler 3 times a day and as needed in between. The resident stated they self-administered the Ventolin inhaler as needed when they felt short of breath. The resident stated they were on these inhalers at home and self-administered the inhalers in the facility. The resident stated they always had the inhalers in their room and staff were aware they had them and used them. The resident stated they had difficulty breathing and was on oxygen at 3 liters at all times and used the inhalers when they needed it. During a subsequent observation on 3/14/2022 at 12:28 PM, the resident was sitting in their wheelchair and had 2 inhalers on the over bed table in front of them. During an observation and interview on 3/15/2022 at 12:13 PM, the resident had the 2 inhalers (blue and orange) on the over bed table in front of them. The resident stated the Ventolin inhaler still had some left and the Combivent was empty. The resident stated they were being discharged and the facility was supposed to refill the Combivent. The resident stated nursing may have the Combivent in the medication cart. The Nursing admission Evaluation dated 2/23/2022, documented the resident was not a potential candidate for self-medication administration. The Comprehensive Care Plan (CCP) for COPD dated 2/25/2022, documented to give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. The CCP did not include a care plan for the resident to self- administer medications. The physician orders documented: -2/23/2022, Ventolin HFA Aerosol Solution (an inhaled medicine used to treat or prevent bronchospasm; when the airways go into spasm and contract) 108 (90 Base) MCG/ACT (Microgram/Actuation)- 2 inhalation inhale orally every 6 hours as needed for wheezing. -2/23/2022, Combivent Respimat Aerosol Solution (an inhaled medicine used to treat COPD) 20-100 MCG/ACT- 1 inhalation inhale orally four times a day for COPD. Review of the physician orders did not include an order that the resident was able self-administer medications. Review of the Medication Administration Record (MAR) from 3/1/2022 to 3/14/2022, did not include documentation that Ventolin PRN was administered. The MAR documented the resident was administered the Combivent inhaler 4 times as day. During an interview on 3/17/2022 at 8:47 AM, Licensed Practical Nurse Unit Manager (LPNUM) #2 stated when they were on the medication cart they would give the resident their inhalers from the medication cart and the resident did not keep the inhalers in their room. LPNUM #2 stated they never had to administer the Ventolin inhaler to the resident. The LPNUM stated there would have to be an order for the resident to self-administer their inhalers. During an interview on 3/17/2022 at 8:57 AM, LPN #3 stated Resident #101 did not keep the inhalers in their room regularly. The LPN would keep the inhalers in the medication cart. The LPN stated there would have to be an order for the resident to self-administer the inhalers. During an interview on 3/17/2022 at 9:10 AM, Certified Nursing Assistant (CNA) #1 stated Resident #101 always had 2 inhalers on their over bed table. CNA #1 stated one inhaler was blue and one was orange. CNA #1 stated they remembered watching the resident take the orange inhaler in their room by themselves. CNA #1 stated in addition to the 2 inhalers on the over bed table, the resident also kept 1 inhaler in their purse. CNA #1 stated they frequently saw the resident self-administer the orange inhaler. CNA #1 stated the resident would usually self-administer the orange inhaler after the CNA helped the resident to the bathroom. CNA #1 had not seen the resident use the blue inhaler but stated that did not mean they resident did not use it. It was on the resident's over bed table. CNA #1 stated they had also seen inhalers in other resident's rooms on occasion. CNA #1 stated they would not know if a resident was supposed to have inhalers in their room, but the nurses knew Resident #101 had inhalers in their room. The CNA stated Resident #101 had 2 inhalers in their room every day on the over bed table. During an interview on 3/17/2022 at 9:32 AM, Physical Therapy Assistant #1 stated they had seen 1 inhaler in the resident's room when they treated the resident for therapy at the beginning of the resident's rehab stay. PTA #1 stated they saw the resident had an orange inhaler and saw the resident self-administer the inhaler. The PTA stated they saw the resident use the inhaler occasionally when the resident was anxious. The PTA stated they would not necessarily know if the resident was supposed to have the inhaler in their room and did not know if the nurses knew the inhaler was in the resident's room. During an interview on 3/17/2022 at 3:06 PM, the Director of Nursing (DON) stated they did not know of any residents who self-administered medications in the facility. The DON stated Resident #101 did not ask to self-administer medications and if a resident said they wanted to self-administer medication, the facility had a process to follow for resident's who wanted to self-administer medication and they would have an evaluation completed. The DON stated if staff saw the inhalers in the resident's room, they should ask the nurse if the resident should have them. The DON stated medications should not be hanging out in the room. The DON stated they did not recall ever seeing anything on the resident's bed side table and it was never reported to the DON that the resident had the inhalers in their room. The DON stated they should not have been in the resident's room and the nurses should have noticed. The DON stated they did not think the resident would be able to properly administer the inhalers. The DON stated the resident was alert and oriented and their roommate was alert and oriented and no one wandered on the unit near their room so the DON would not consider the inhalers being in the resident's room an accident hazard. The DON stated it was concerning if the resident was self-administering because the nurses would not know what the resident was taking. The DON was made aware of the Surveyor's observations on 3/14/2022 and 3/15/2022. The DON stated the resident was very anxious and they could see the resident wanting to hang on to the inhalers because the resident was very anxious about their breathing. The DON stated it would make sense if the resident wanted to keep the inhalers in their room. 10NYCRR415.12(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey and an abbreviated survey (Case #NY00261370) dated 3/14/2022 through 3/18/2022, the facility did not ensure each resident maintained acceptable parameters of nutritional status for 3 (Resident #'s 17, 89, and #126) of 5 residents reviewed for nutrition. Specifically, for Resident #17, the facility did not ensure the resident was weighed upon admission and re-admission in accordance with professional standards, for Resident #89, did not ensure the resident was weighed in accordance with professional standards as documented in the Nutritional Evaluation dated 2/21/2022, the physician order and the Comprehensive Care Plan for Nutrition; and for Resident #127, did not ensure the resident was weighed in accordance with professional standards. This is evidenced by: The Policy and Procedure (P&P) titled Weight Policy & Procedure dated 11/24/2021, documented each residents weight will be obtained and documented upon admission to the facility. New admission: Initial weight will be obtained and recorded within 24 hours of admission. Re-admissions: Weight will be obtained and recorded upon return to facility. New admissions will be weighed weekly for four (4) weeks. Subsequent weights will be monthly, unless physicians' orders or the resident's condition warrants more frequent as determined by the Interdisciplinary Team (IDT). Monthly weights are to be obtained and recorded in the beginning of each month. Resident #17: Resident #17 was admitted with diagnoses of congestive heart failure, hypertension and diabetes mellitus. The Minimum Data Set (MDS-an assessment tool) dated 12/28/2021, documented the resident had moderately impaired cognition, could usually understand others and could make self understood. The Comprehensive Care Plan (CCP) for Unplanned/Unexpected Weight Loss related to acute illness and poor food intake updated on 1/18/2022, documented to monitor and evaluate any weight loss, weigh weekly and record. During a record review on 3/16/2022 at 9:14 AM, the medical record did not document a weight within 24 hours of the resident's admission on [DATE]. The resident was weighed 8 days later on 12/29/2021 at 167.5 #s. During a record review on 3/16/2022 at 9:14 AM, the medical record did not document a weight within 24 hours of the resident's re-admission on [DATE]. The resident was weighed 5 days later on 2/6/2022 at 145.8 #s. During an interview on 3/17/2022 at 11:21 AM, Certified Nursing Assistant (CNA) #1 stated residents admitted in the afternoon were usually weighed the next morning. CNA #1 also stated, honestly weights were very important and the staff lacked in getting the weights timely. During an interview on 3/17/2022 at 10:31 AM, Registered Dietician (RD) #1 stated admission and re-admission weights should be obtained and documented in the computer within 24 hours of admission. RD #1 stated the admission weights were often not documented in the computer and they would use the weights documented in the hospital transfer packet to complete the initial nutritional evaluation or assessment by day 7 of the resident's admission. The RD would ask the CNAs to get the admission weight. During an interview on 3/18/2022 at 12:09 PM, the Director of Nursing (DON) stated residents should be weighed shortly after admission, within 24 hours. The DON stated they were aware that obtaining admission and weekly weights was an ongoing struggle for the facility and currently had physician orders in place for admission and weekly weights. Resident #89: Resident #89 was admitted with diagnoses of Parkinson's disease, femur fracture, and chronic pulmonary embolism. The Minimum Data Set (MDS-an assessment tool) dated 2/21/2022 documented the resident had moderately impaired cognition, could understand others and could make self understood. The Comprehensive Care Plan for Nutrition related to severe malnutrition, last revised 3/16/2022, documented the goal was for the resident to have a weight gain towards >105# (pounds). An intervention dated 2/21/2022, documented to weigh the resident weekly x 4 weeks then monthly and record. The Physician Order dated 2/19/2022, documented to obtain a weight for 4 weeks on the day shift every Saturday for 4 weeks. A Nutritional Evaluation dated 2/21/2022, documented to weigh the resident weekly x 4 weeks. The medical record documented the following weights: 2/21/2022- 83.0# 3/5/2022- 82.8# The medical record did not include weekly weights for 4 weeks after admission and did not include documentation that the resident refused to be weighed. During an interview on 3/17/2022 at 8:51 AM, Licensed Practical Nurse Unit Manager (LPNUM) #2 stated residents were typically weighed as soon as possible on admission, then weekly 4x weeks, and then monthly. The LPNUM stated if there was a concern with a resident's weight, the Registered Dietitian (RD) would also ask nursing to weigh the resident. The LPNUM stated the Certified Nursing Assistants (CNAs) obtained the weights for each resident, but nurses would get weights too. The nurses knew a weight was needed when it popped up on the Medication Administration Record (MAR) for that resident. The LPNUM stated weights were a joint effort and both nurses and CNAs could document the weights in the medical record. The RD was responsible for reviewing the weights to make sure they were being done. During an interview on 3/17/2022 at 9:10 AM, CNA #1 stated it was the CNAs responsibility to obtain the weights for the residents. The CNAs would know a weight was due because it would show up in the computer to let them know. The CNA stated monthly weights would show up in the computer on the 1st of every month and weekly weights would show up every Monday. The CNAs or LPNs would document the weights in the medical record. The CNA stated the CNAs did not have access to compare a resident's current weight with their previous weight. During an interview on 3/17/2022 at 2:03 PM, RD #1 stated facility policy and best practice was to obtain an admission weight within 24 hours, then weigh the resident weekly for 4 weeks, then monthly after that. It was the responsibility of the RD to monitor weights and to ensure weights were being done. The RD stated they were aware weights were missing and the facility was trying to improve that by putting an order in for weights so it would show up on the MAR for LPNs to sign off. This was a way for more staff to keep an eye on the weights and ensure they were being done and documented. The RD stated the frequency of the weights for a resident was also on their care plan because not all residents needed to be weighed at the same frequency. The RD stated ultimately, it should be the LPN documenting the weights in the medical record because it was on the MAR as part of the physician order and the CNAs were responsible for obtaining the weights. The RD stated the care plan should match physician order and that was what should be followed for that resident. During an interview on 3/18/2022 at 1:09 PM, the Director of Nursing (DON) stated the residents were weighed upon admission, weekly for 4 weeks, and then monthly. The CNAs were responsible for obtaining the weights and the nurses were responsible to see that the weights were obtained. The RD monitored the residents' weights. The DON stated the care plan and physician order for weights should match for each resident. Resident #127 Resident #127 was admitted to the facility with the diagnoses of protein calorie malnutrition, heart disease and heart disease. The Comprehensive Care Plan (CCP) for Potential Nutritional Problem, created on 8/14/2019, documented an intervention dated 9/13/2019 for monthly weights. A facility document titled, Weights and Vital Signs documented Resident #127's weight on: 1/06/2020 at 138.6# 2/10/2020 at 132.6# 4/15/2020 at 133.6# 5/18/2020 at 130.6# 7/18/2020 at 105.0# A review of the Medical Record did not include weights for March 2020 or June 2020. Additionally, it did not document that Resident #127 refused weights. A Dietary/ Nutrition Note dated 2/17/2020 documented a quarterly review was completed and the resident had a weight loss of 8.2 pounds, the resident was at high risk due to variable oral intake. A Dietary/Nutrition Note dated 7/17/2020 documented the resident had a 28.6-pound weight loss. It documented Resident #127 was at risk for weight loss due to dementia, very particular food likes and multiple stated food allergies. During an interview on 3/17/2022 at 2:03 PM, the Dietician stated all residents should be weighed upon admission, weekly for 4 weeks and then monthly. The Dietician stated it was their responsibility to ensure weights were completed and monitor the resident for weight loss. They stated the facility was aware weight monitoring was not being completed per professional standards of practice and the facility recently implemented new measures to improve consistent weight monitoring. 10NYCRR415.12(i)(1)

Based on observation, record review and interview conducted during a recertification survey dated 3/14/2022 through 3/18/2022, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for one (1) (Resident #43) of two (2) residents reviewed. Specifically, for Resident #43, the facility did not ensure a physician's order for the prescribed flow rate for oxygen administration was followed. This is evidenced by: Resident #43: Resident #43 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease, chronic kidney disease and heart failure. The Minimum Data Set (MDS - an assessment tool) dated 3/4/2022, documented the resident was cognitively intact, could understand others and could make self-understood. The undated Policy and Procedure titled Oxygen Therapy- Mask and Nasal Cannula, documented oxygen was administered by licensed staff under a physician order to improve oxygenation and provide comfort to residents experiencing acute or chronic respiratory difficulties. A physician's (MD) order dated 5/15/2020, documented the resident was to receive oxygen at two liters per minute continuous via nasal canula every shift. During observations Resident #43 received oxygen via nasal cannula at three liters per minute on: 3/14/2022 at 2:47 PM at three liters per minute. 3/15/2022 at 9:54 AM at three liters per minute. 3/15/2022 at 12:13 PM at three liters per minute. 3/15/2022 at 12:26 PM at three liters per minute. 3/16/2022 at 9:15 AM at three liters per minute. 3/16/2022 at 10:18 AM at three liters per minute. 3/16/2022 at 11:00 AM at three liters per minute. During an interview on 3/16/2022 at 11:00 AM, Licensed Practical Nurse Unit Manager (LPNUM) #7 stated residents should receive oxygen per Medical Doctor (MD) orders. LPNUM #7 stated licensed staff should change a resident between an oxygen concentrator and an oxygen tank. LPNUM #7 confirmed Resident #43 was receiving oxygen at three liters per minute via nasal canula during the interview and then confirmed the MD orders indicated the resident was to receive two liters per minute of oxygen. During an interview on 3/17/2022 at 11:47 AM, the Director of Nursing (DON) stated the licensed nurse was responsible for ensuring the resident received oxygen per MD orders. The Unit Manager was responsible for ensuring all staff were following MD orders. 10NYCRR415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey dated 3/14/2022 through 3/18/2022, the facility did not ensure residents diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 (Resident #68) of 4 residents reviewed for dementia care. Specifically, for Resident #68, who had a diagnosis of Alzheimer's disease, the facility did not ensure individualized, non-pharmacological approaches to care were consistently implemented to maximize the resident's dignity, autonomy, privacy, and socialization. Additionally, the facility did not ensure the Comprehensive Care Plan (CCP) for Cognition included person-centered interventions related to the resident's diagnosis of Alzheimer's disease. This is evidenced by: Resident #68: Resident #68 was admitted with diagnoses of Alzheimer's disease, anxiety disorder and generalized osteoarthritis. The Minimum Data Set (MDS-an assessment tool) dated 2/12/2022 documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The undated facility Policy and Procedure (P&P) titled Dementia and Behaviors (Alzheimer's/ Dementia Type Illnesses), documented residents with behaviors that were problematic and or/dangerous for themselves, or others would be identified. A Behavior Management Plan would be developed based on the residents with Alzheimer's Disease/Dementia and other related illnesses and the resident's individual needs and would be implemented. Ongoing education and training on managing residents with aggressive or catastrophic behaviors would be provided upon hire and then at least annually. The facility P&P titled Dementia Training Hand in Hand dated 3/2020, documented the mission of the Hand in Hand training was to provide nursing home staff with a high-quality training program that emphasizes person-centered care in the care of persons with dementia and the prevention of abuse. The CCP for Cognition, last revised 2/22/2022, documented the resident had impaired cognitive function or impaired thought processes related to dementia. The care plan interventions documented to encourage the resident to make choices/decisions regarding daily Activities of Daily Living (ADLs) and to administer medications as ordered and monitor/document for side effects and effectiveness. The CCP for Cognition did not include person-centered interventions related to the resident's diagnosis of Alzheimer's disease. The CCP for Behaviors, last revised 2/22/2022, documented the resident had the potential to be physically and verbally aggressive related to dementia and poor impulse control. The care plan interventions included: a CD player was available to play a specific singer and Gospel music, to monitor and document observed behavior and attempted interventions in behavior log, to modify the environment: adjust room temperature to comfortable level, reduce noise, dim lights, and place familiar objects in room. The CCP for Activities, last revised 2/7/2022, documented the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to the resident's cognition. The CCP documented the resident stated it was not very important to do their favorite activities. The care plan interventions included: The resident needed 1:1 bedside/in-room visits and activities if unable to attend out of room events. A CD played was placed in the room with Gospel music for use during periods of agitation and the resident played cards in the past, liked country music and enjoyed going to church. The Care Card (caregiving instructions), as of 3/16/2022, documented to offer the resident a nap after lunch, to monitor and document observed behavior and attempted interventions in behavior log, to modify the environment: adjust room temperature to comfortable level, reduce noise, dim lights, and place familiar objects in room, a CD player was available to play a specific singer and Gospel music for use during periods of agitation and the resident played cards in the past, liked country music and enjoyed going to church, ensure resident has access to thin liquids whenever possible, toilet after meals, offer the resident a Geri-chair by the nurses' station when out of bed as tolerated. During an observation on 3/15/2022 at 2:24 PM, Resident #68 was sitting in the hallway in their wheelchair near the nurses' station next to room [ROOM NUMBER]. Resident #68 was calling out Will someone give me a hand. The staff that were behind the nursing station did not come to assist the resident. -At 2:28 PM, the resident wheeled their wheelchair over to the handrail and used the handrail to stand up. The chair alarm went off. The resident took 3 steps away from their wheelchair and stood in the doorway of room [ROOM NUMBER]. Licensed Practical Nurses (LPNs) #8 and #9 came from the nurses' station to assist the resident when the alarm sounded. The LPNs asked the resident to sit back down their wheelchair. -At 2:30 PM, Certified Nursing Assistant (CNA) #3 was walking past the resident and LPN #8 and #9. The CNA asked what the LPNs were doing. LPN #8 stated Just trying to get (the resident) to relax, and as CNA #3 continued to walk by toward to the housekeeping closet, CNA #3 stated, that's not in (the resident's) blood. The LPNs had the resident sit back in their wheelchair. The resident was not offered meaningful activities or diversional activities. -At 2:39 PM, the resident stood up from their wheelchair, the alarm sounded, and LPN #8 and #9 assisted the resident to sit back down. The LPNs did not offer the resident meaningful activities or diversional activities. -At 2:49 PM, the resident stood up from their wheelchair, the alarm sounded, and the resident walked 2 steps inside room [ROOM NUMBER]. CNA #4 attended to the resident and asked where the resident was going? Did the resident need something? Did the resident need help? The resident stated no. CNA #4 asked the resident to stay out of other residents' rooms. The CNA assisted the resident back into the wheelchair and moved the wheelchair to the other side of the hall across from room [ROOM NUMBER]. The CNA did not offer the resident meaningful activities or diversional activities. -At 2:56 PM, the resident was calling out for their family member. CNA #4 and another CNA walked past the resident as the resident called out for their family member. Staff did not engage with the resident while they were calling out for their family member. During an observation on 3/17/2022 at 8:55 AM, the resident was brought out of the dining room after having breakfast and was sitting in the hallway in their wheelchair near the nurses' station next to room [ROOM NUMBER]. The resident fell asleep and was snoring in the hallway. At 9:49 AM, the resident continued to sleep in their wheelchair in hallway. At 11:36 AM, the resident remained sleeping in their wheelchair in the hallway. The resident was not offered meaningful activities, to sit in a Geri chair (reclining chair on wheels), or to go back to bed. At 12:00 PM, the resident was brought to the dining room for lunch. During an observation on 3/18/2022 at 9:06 AM, the resident was in their wheelchair and placed next to room [ROOM NUMBER] near the nurses' station. The resident remained sleeping until the observation ended at 10:35 AM. The resident was not offered meaningful activities, to sit in a Geri chair, or to go back to bed. A review of Resident-Specific Activity documentation from 3/2/2022 to 3/15/2022 included: -Social Programs: 2 entries on 3/5/2022 at 11:56 AM, a group movie and on 3/6/2022 at 11:49 AM, a 1:1 interaction; -Spiritual Programs: 1 entry on 3/9/2022 at 1:59 PM, attended church; -Room Visits: 14 entries (10 room visits were in the 8:00 AM hour; 3 room visits were in the 9:00 AM hour; 1 room visit was in the 10:00 AM hour.) All 1:1 daily room visits occurred in the morning before lunch. A review of progress notes from 2/22/2022 - 3/15/2022 related to meaningful activities: -3/2/2022 at 2:38 PM, documented the resident attended religious services this afternoon for Ash Wednesday service. The resident was pleasant and calm and happy to be there. The resident was actively engaged. The resident was a Sunday School teacher at their church and was very happy to see the Pastor -3/10/22 at 10:37 AM, documented the resident attended Lutheran Chapel yesterday. The resident was engaged actively and was calm and happy to be there. During an interview on 3/17/2022 at 9:04 AM, Licensed Practical Nurse (LPN) #3 stated the staff re-directed Resident #68 when needed and the resident attended activities. The LPN stated the resident had more behaviors on the evening and nights shifts and less on the day shift. During an interview on 3/17/2022 at 9:17 AM, CNA #1 stated the resident was not on a behavior management program. The CNA stated the resident did well with religious services. On the unit, the staff would try to walk the resident and give the resident a snack when they were agitated. The CNA stated a lot of times there was very little that could be done to contain the resident safely when the resident was agitated. The CNA stated the resident was kept in the hallway with a clip alarm so the resident could be seen and heard if the resident got up from the wheelchair. The CNA stated the night shift would have the resident in the Geri-chair and on the day shift, the staff tried to leave the resident in their wheelchair as much as possible. The CNA stated they had not received dementia care training and had been told to walk away when a resident was having behaviors. The CNA stated they could not just walk away and risk the resident falling when they were having behaviors. The CNA stated the resident was on the Rehab Unit and was not a Rehab candidate. During an interview on 3/17/2022 at 3:48 PM, CNA #3 stated the resident could be very confused, combative and could become agitated. The CNA stated they would talk to the resident and offer the resident something to drink. The CNA stated the CNAs told the nurses when a resident had behaviors and the nurses documented, or should document, resident behaviors in the medical record. The care card had interventions on it that the CNAs could use with the resident, but the interventions did not always work. CNA #3 stated they worked on the Rehab Unit on 3/15/2022, and although they did not recall specifically saying that's not in (the resident's) blood, the CNA stated they just meant that the resident was not going calm down because the staff kept telling the resident to sit down when the resident kept standing up. The CNA stated when there was enough staff, one staff would sit with the resident, but when there was not enough staff, they kept the resident close to the nurses' station or by the nurse passing medications. The CNA stated the resident mostly stayed in their wheelchair. CNA #3 stated they received dementia care training because they worked on the dementia unit. The CNA did not recognize the name Hand in Hand for dementia training and did not know how often they received dementia care training. During an interview on 3/18/2022 at 9:10 AM, LPN #6 stated the resident was a sundowner and around 1:30 PM the resident's behavior would escalate, and the resident would start saying they wanted to go home or wanted their family. The LPN stated they tried to orient the resident, but the resident could be physically aggressive with staff. The LPN stated the resident was not a good sleeper at night and the staff usually put the resident in the Geri chair. The LPN stated the resident was content in the Geri chair. During an interview on 3/18/2022 at 9:28 AM, CNA #4 the resident was confused and would look for their significant other. The resident was always trying to stand up and the staff just tried to get the resident to sit back down. The CNA stated sometimes they offered the resident a walk, but the resident was mostly in their wheelchair with an alarm. The CNA stated they received dementia care training upon hire and yearly. During an interview on 3/18/2022 at 10:07 AM, Licensed Practical Nurse Unit Manager (LPNUM) #2 stated the resident never really had any behaviors on day shift and the resident slept in their wheelchair by the nursing station. The LPNUM stated the resident was sitting right there and gestured where the resident was sleeping in their wheelchair near the nurses' station. The LPNUM stated right there might not be the best for the resident, but the resident was calm right now. The staff did not bother the resident if the resident was quiet and sleeping. The LPNUM stated the resident was physical with staff and constantly up and down from their wheelchair. The LPNUM stated the resident's behaviors started around 4:00 PM and continued on the night shift. The LPNUM stated the resident was on the Rehab Unit and the Rehab Unit was not the right place for the resident. The resident would be better upstairs on the dementia unit. The LPNUM stated the staff tried non-pharmacological interventions including music, calling the resident's significant other, and snacks. The resident was not on a behavior management program and the resident did not have a behavior log. The LPNUM stated they had not received dementia care training as they had always been a Rehab Nurse and never worked a dementia unit. The LPNUM stated since they had not had dementia training, they would talk to the psychiatrist about dementia and the progression of dementia. During an interview on 3/18/2022 at 12:46 PM, Director of Nursing (DON) stated they had not observed Resident #68's behavior firsthand. The DON had seen the resident in their wheelchair and wandering on the unit in their wheelchair. The DON stated Nurse Managers or the Registered Nurses in the facility assisted with dementia care planning. The DON stated Resident #68's care plan documented to play music for the resident and staff could bring the music out of the resident's room to where the resident was sitting on the unit. Sometimes it helped, sometimes it did not. The DON stated it was not on the care plan, but staff could offer the resident food. The DON stated the staff knew what interventions to do based on the resident's care card. The DON was made aware of the observation on 3/15/2022 with the resident standing up from their wheelchair and setting off the alarm. The DON stated the resident was pretty wabbly when they stood and staff could stand with the resident and depending on how many times the resident was standing up, the staff could figure out something else that worked, like putting the resident back to bed. The DON stated the resident had their nights and days mixed up and the staff could offer to put the resident in a Geri chair. The DON did not like the use of the Geri chair because the DON did not want the resident to climb out of it. The DON stated the Geri chair had worked to some extent when it was tried. The DON stated the resident was on their Rehab Unit, but the DON wanted the resident to go to a quieter unit. The Rehab Unit might get the resident going but moving to another unit would be another adjustment for the resident. When asked about making the resident's care plan for dementia person-centered as it included 2 interventions, the DON stated they were still trying to figure the resident out. The DON stated staff were provided with dementia care training annually and during orientation. 10NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey dated 3/14/2022 through 3/18/2022, the facility did not ensure residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #68) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #68, who received Zyprexa (anti-psychotic medication), the facility did not ensure the medical record from 2/22/2022 to 3/10/2022 included documentation that the resident was experiencing a change in behavioral symptoms or that non-pharmacological interventions were attempted prior to increasing the anti-psychotic medication from once a day to twice a day on 3/10/2022. This is evidenced by: Resident #68: Resident #68 was admitted with diagnoses of Alzheimer's disease, anxiety disorder and generalized osteoarthritis. The Minimum Data Set (MDS-an assessment tool) dated 2/12/2022, documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The Policy and Procedure titled Psychoactive Drug System dated 10/2019, documented residents who used antipsychotic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. When the psychoactive drugs were prescribed, a specific condition or targeted behavior that warrants the use of psychoactive medications would be documented in the Clinical Record in: The physician's progress notes, the physician's order sheet, Behavioral Monitoring Flowsheet, and care plan. The physician would document in a Progress Note (or medical/psychiatric consult) the rationale for such therapy based on sound risk-benefit analysis of the resident's condition and potential adverse effects of the psychotropic drug therapy. The Monthly Monitoring Flowsheet would be instituted for each resident receiving antipsychotic, for mental illness or specific targeted behavior to provide ongoing assessment and monitoring the efficacy of the drug regime. Behavior monitoring should evaluate: Number of occurrences or episodes, the intervention attempted, the outcome of the intervention, and any side effects of the intervention implemented. The Comprehensive Care Plan (CCP) for Psychotropic Medication Use, last revised 3/11/2022, documented the resident used psychotropic medications (Zyprexa, an anti-psychotic and Remeron, an anti-depressant) related to behaviors, dementia, depression, anxiety. The care plan interventions included: a behavior management program, to monitor/record occurrence of for target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol, and to administer psychotropic medications as ordered by physician and monitor for side effects and effectiveness. The CCP for Behaviors, last revised 2/22/2022, documented the resident had the potential to be physically and verbally aggressive related to dementia and poor impulse control. The care plan interventions included: a CD player was available to play a specific singer and Gospel music, to monitor and document observed behavior and attempted interventions in behavior log, to modify the environment: adjust room temperature to comfortable level, reduce noise, dim lights, and place familiar objects in room. The CCP for Falls, last revised 3/10/2022, documented the resident had a history of fall with/without injury related to poor balance and being unsteady. The CCP documented the resident had 5 incidents since admission on [DATE], 2/14/2022, 2/20/2022, 3/9/2022, and 3/10/2022. The care plan interventions included: a clothing alarm, offer Geri chair by nurses' station when out of bed as tolerated, provide activities that promote exercise and strength building where possible; provide 1:1 activities if bedbound and to toilet after meals. Physician Orders documented: -2/5/2022, Zyprexa 2.5 mg; give 1 tablet by mouth at bedtime for dementia (discontinued on 2/22/2022) -2/22/2022, Zyprexa 5mg; give 1 tablet by mouth one time a day for anxiety (discontinued on 2/24/2022) -2/24/2022, Zyprexa 5mg; give 1 tablet by mouth one time a day for anxiety/mood disorder with aggressive behaviors (discontinued on 3/10/2022) -3/10/2022, Zyprexa 5mg; 1 tablet by mouth BID (2 times a day) for mood disorder with aggressive behaviors A Physician Order dated 2/11/2022, documented to: Document occurrence, intervention, and outcome. Target Behavior: Every shift for Monitoring of behavior interventions. 1. Re-direct behavior by calling daughter (named) 2. toilet. 3. reading from the Bible will calm the resident. Outcomes: + = improved, - = worsened, nc = no change note, na = no behavior Adverse effects: specify: no noted adverse effects. A review of the Treatment Administration Record (TAR) from 2/22/2022 to 3/10/2022 did not include documentation the resident had any occurrences, interventions, or outcomes for 51 of 51 shifts (17 days) and of the 51 shifts, 44 shifts were documented as NA and 7 shifts were documented 0. A review of Progress Notes dated 2/22/2022 - 3/10/2022 documented: -2/22/2022 at 12:55 PM, written by the Nurse Practitioner, increased behaviors: belligerent, kicking, hitting, and attempting to block the door. A urinary tract infection (UTI) was ruled out. The note documented to increase Zyprexa to 5mg by mouth daily. -3/2/2022 at 2:38 PM, the resident attended religious services this afternoon for Ash Wednesday service. The resident was pleasant and calm and happy to be there. The resident was actively engaged. The resident was a Sunday School teacher at their church and was very happy to see the Pastor. -3/9/2022 at 8:48 PM, the resident had a fall that documented the resident did not have a change observed in mental status, had a fall, and had physical & verbal aggression, and was a danger to self or others. The resident was observed sitting on the floor behind the nurses' station with their wheelchair behind them. The progress note did not include documentation that the resident had a room change in the afternoon on 3/9/2022 from a private room to a semi-private room. -3/10/2022 at 10:37 AM, the resident attended Lutheran Chapel yesterday. The resident was engaged actively and was calm and happy to be there. -3/10/2022 at 10:56 AM, a new order per the psychiatrist to discontinue Xanax (an anti-anxiety medication) as needed (PRN), and to increase Zyprexa to BID and to follow up in 2-4 weeks. The Resident Census documented on 3/9/2022 at 2:41 PM, the resident had a room change from private room [ROOM NUMBER]A to semi-private room [ROOM NUMBER]B (the opposite end of the hallway). A Psychiatry Note dated 3/10/2022, documented the resident had been very agitated and was physically aggressive towards caregivers and other female residents. The resident had significant agitation and aggressive behaviors secondary to delusions and confusion. The note documented to increase Zyprexa to 5mg by mouth 2 times a day and follow up in 2-4 weeks. The facility did not provide documentation regarding Resident #68's physical aggression toward other female residents as documented by the psychiatrist. (Note: The Director of Nursing stated in an interview on 3/18/2022, the psychiatrist wrote the resident had physical aggression toward other female resident in error and the psychiatrist would correct it.) A review of the resident's medical record from 2/22/2022 to 3/10/2022 did not include documentation the resident was experiencing a change in behavioral symptoms or that non-pharmacological interventions were attempted prior to increasing the Zyprexa 5mg from once a day to twice a day on 3/10/2022. During an interview on 3/17/2022 at 9:04 AM, Licensed Practical Nurse (LPN) #3 stated the nurses charted Resident #68's behaviors in the medical record. The LPN stated the resident had been combative with staff in the past. The LPN stated the nurses usually monitored behaviors after a medication change and after an increase in the dosage of a medication. The nurses would write a nursing progress note for monitoring behaviors and when there were changes in medications. The LPN stated medications were increased with increased behaviors. The LPN stated the resident was not on a formal Behavioral Management Program. The Certified Nursing Assistants (CNAs) would let nursing know when a resident was having behaviors and the nurses would document those behaviors in the progress notes. During an interview on 3/17/2022 at 9:17 AM, CNA #1 stated the nurses on the unit would document a resident's behaviors. The CNAs could put in a Stop and Watch alert when a resident was having a behavior, but CNA #1 stopped documenting Stop and Watch alerts because nothing would ever come of them. The CNA stated the resident was not on a behavior management program. The CNA stated the resident did well with religious services. On the unit, the staff would try to walk the resident and give the resident a snack when they were agitated. The CNA stated a lot of times there was very little that could be done to contain the resident safely when the resident was agitated. The CNA stated the resident was kept in the hallway with a clip alarm so the resident should be seen and heard if the resident got up from the wheelchair. The CNA stated the night shift would have the resident in the Geri-chair and on the day shift, the staff tried to leave the resident in their wheelchair as much as possible. The CNA stated the resident had a Foley catheter that was emptied once a shift and the resident was continent of bowel. The resident would let the staff know when they needed to use the bathroom. The CNAs did not toilet the resident on a schedule. During an interview on 3/17/2022 at 3:48 PM, CNA #3 stated the resident could be very confused, combative and could become agitated. CNA #3 stated they would talk to the resident and offer the resident something to drink. CNA #3 stated there was nothing in the computer system for the CNAs to document a resident's behaviors. CNA #3 stated the CNAs told the nurses when a resident had behaviors and the nurses documented, or should document, resident behaviors in the medical record. CNA #3 stated they did not know what medications the residents received or when there had been a change in medication. CNA #3 stated they referred to the care card when caring for resident. The care card had interventions on it that the CNAs could use with a resident. CNA #3 stated Resident #68 mostly stayed in their wheelchair. During an interview on 3/18/2022 at 9:10 AM, LPN #6 stated the resident was a sundowner and around 1:30 PM the resident's behaviors would escalate, and the resident would start to say they wanted to go home or wanted their family. The LPN stated they tried to orient the resident, but the resident could be physically aggressive with staff. The LPN stated they had never seen the resident have aggressive behaviors with other residents. The LPN stated the nurses documented the resident's behaviors in nursing progress notes and the CNAs could put in a Stop and Watch which alerted the nurses of a behavior. The LPN stated the psychiatrist put the resident on antipsychotic medication because the resident's behavior had escalated and that was why the Zyprexa was adjusted. The LPN stated the resident also had a room change that confused the resident. The room change was what really upset the resident and the resident was confused. The LPN stated that was why the resident wandered, looking for their old room. The LPN stated nurses also monitored for side effects of medications including lethargy and not eating. The LPN stated the monitoring was not necessarily documented but communicated verbally by staff. The LPN stated any resident who was on psychotropic medication had a behavior questionnaire on the MAR (Medication Administration Record) and nursing documented under Target Behavior on the MAR when a resident was having behaviors. During an interview on 3/18/2022 at 9:28 AM, CNA #4 stated the resident was confused and would look for their significant other. The resident was always trying to stand up and the staff just tried to get the resident to sit back down. The CNA stated sometimes staff offered the resident a walk, but the resident was mostly in their wheelchair with an alarm. The CNA stated the CNAs should document resident behaviors and tell the nurses, but everyone knew Resident #68's behaviors. During an interview on 3/18/2022 at 10:07 AM, Licensed Practical Nurse Unit Manager (LPNUM) #2 stated they were there when the psychiatry saw the resident and increased the Zyprexa from once a day to twice a day. LPNUM #2 stated the reasoning for the increase was that the resident was not in any sedation mode, but the resident's behaviors were escalated. LPNUM #2 stated the night shift was worse for the resident and that was why psych increased the Zyprexa. LPNUM #2 stated the resident was physical with staff and constantly up and down from the resident's wheelchair. The psychiatrist did their review and talked to the nurses when making a determination about medications. LPNUM #2 stated the resident never hurt any other resident or had physical aggression with other residents. LPNUM #2 stated the nurses documented the resident's behaviors on the MAR every shift and the CNAs could put in a Stop and Watch that alerted the nurse on their computer dashboard of a behavior and then the nurse would go talk to the resident and the CNA to get more detail. LPNUM #2 stated on day shift there was never really any behaviors and the resident slept in their wheelchair by the nursing station. The staff did not bother the resident if the resident was quiet and sleeping. The LPNUM stated the room change was hard for the resident. The resident was on the Rehab Unit and the Rehab Unit was not the right place for the resident. The resident would be better upstairs on the Dementia Unit. LPNUM #2 stated the staff tried non-pharmacological interventions including music, calling the resident's significant other, and snacks. Then the psychiatrist came to do their review and reviewed the documentation on the MAR and the behavior notes before increasing the frequency of the Zyprexa from once a day to twice a day. LPNUM #2 stated monitoring for any psychotropic medication included documenting the target behaviors and the interventions used. LPNUM #2 stated Resident #68 was not on a behavior management program and the resident did not have a behavior log. During an interview on 3/18/2022 at 12:46 PM, the Director of Nursing (DON) stated they had not observed Resident #68's behavior firsthand. The DON had seen the resident in their wheelchair, wandering on the unit in the wheelchair. The DON stated it had been reported to them that the resident had been combative with care, but the resident had not been combative with other residents. The DON stated behavior monitoring was documented as an order on the TAR, as well as any side effects of medications would be documented on the TAR. The DON stated n/a indicated the resident had no behaviors. The DON stated the behavior monitoring on the TAR and the progress notes were used to justify an increase in medication. Also, the Psychiatrist's assessment and staff interviews were also used to justify increasing a medication. The DON stated they talked to the Psychiatrist and the Psychiatrist documented the resident had physical aggression toward other female residents in error and the Psychiatrist would correct their note. The DON stated the resident had not had aggressive behaviors with other residents. The resident was delusional and could get combative with staff and was restless. The DON stated the non-chemical interventions were on the care plan and did not work for the resident, so medications helped the resident, and the resident was doing better since the increase in Zyprexa from once a day to twice a day. The DON stated when non-chemical interventions did not work that was when medication was used. The DON stated the staff monitored the resident's adjustment after a room change and helped the resident to adjust. The resident fell on 3/9/2022 but the DON did not think the resident really knew they had a room change earlier that day. The DON stated the staff monitored the resident after the increase in Zyprexa as documented in the progress notes and on the TAR. The DON stated based on the documentation in the resident's medical record, there was sufficient documentation to justify an increase in the Zyprexa for Resident #68 from once a day to twice a day. During the interview with the DON on 3/18/2022, Regional Nurse #1 entered the room at 12:59 PM and stated the provider ruled out a UTI on 2/22/2022. The Regional Nurse stated the resident was looked at medically and to the Regional Nurse, the decision to increase the medication was between the physicians. The Regional Nurse stated the provider was on the unit on 2/22/2022, saw the resident and documented the resident was belligerent. Then a referral was made to psychiatry. When asked if one note would justify an increase in the frequency of Zyprexa on 3/10/2022, the Regional Nurse stated no, not just one instance would justify a medication change, but they are the physicians. 10NYCRR415.12(l)(2)(i)

Based on observation and staff interview during the recertification survey dated 3/14/2022 through 3/18/2022, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Specifically, food temperature thermometers were not in calibration, and equipment and floors required cleaning or repair. This is evidenced as follows: During the inspection of the main kitchen and unit kitchenettes on 03/14/22 at 9:56 AM, two (2) food temperature thermometers were found out of calibration when checked by the standard ice-bath method as follows: 35F, 38F. The floor linoleum below the dishwashing machine was separating forming a gap revealing the subfloor, and the linoleum coving was peeling away from the wall. On the unit kitchenettes (west-side dining room, 2 east, 2 west, 3 east, 3 west), microwave ovens, refrigerators, cabinetry, and/or the wall behind sinks required cleaning. On the west-side dining room kitchenette, the linoleum on cabinetry doors was chipped or missing and cabinet doors would not close and seat. On the 2-east kitchenette, wooden framing was in place where cabinetry would be located. On the 3-east kitchenette, the backsplash behind the sink was warped. During an interview on 3/14/22 at 11:13 AM, the Food Service Director stated that the Director of Maintenance must be asked for the tool to make thermometer calibrations, the floor under the dishwashing machine is scheduled to be fixed, the unit refrigerators will be cleaned, nursing will be notified that the cabinetry needs cleaning, and maintenance will be notified of the chipped linoleum, warped backsplash, and loose cabinet doors. During an interview on 3/16/22 at 2:24 PM, the Administrator stated that new thermometers will be purchased, the kitchen floor will be repaired, and the kitchenettes will be cleaned and repaired. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.85, 14-1.110, 14-170, 14-180

Based on record review and interview the facility did not refer residents with newly evident mental illness for a level II review for one (Resident #93) of three residents reviewed for PASRR (Pre-admission Screening and Resident Review). Specifically, for Resident #93, the facility did not ensure the resident, who was newly diagnosed with a mental illness, received a level 1 screen to determine if a level II screen was needed. This is evidenced by: Resident #93: The resident was admitted to the nursing home on 6/18/18, with diagnoses of schizoaffective disorder, dysphagia, and hypothyroid. The Minimum Data Set (MDS-an assessment tool) dated 8/5/19, assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others and that the resident had a diagnosis of schizoeffective disorder. The Screen Form dated 6/18/18, Level 1 Review for Possible Mental Illness (question #23) documented the resident did not have a serious mental illness. A Progress Note dated 9/20/18, documented that per the Nurse Practitioner the resident was to continue Haldol (antipsychotic medication) as written for a diagnosis of schizoaffective disorder. During an interview on 9/04/19 at 11:02 AM, the Social Work Director (SWD) stated the resident did not have a past history of mental illness and he did not know a new SCREEN form had to be done on a resident without a long history of psychiatric issues. During an interview on 9/05/19 at 9:04 AM, the Psychiatric Nurse Practitioner stated the resident did not have schizoaffective disorder. She had noticed that whenever facilities put someone on Haldol they use the diagnosis of schizoaffective disorder and the resident was on Haldol in July 2018. During an interview on 9/05/19 at 12:32 PM, the Director of Nursing (DON) stated that the Nurse Practitioner was called to go over the resident's symptoms and the psychiatric note and she gave the resident a schizoaffective disorder diagnosis. 10NYCRR 145.11(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it developed and implemented a comprehensive person-centered care plan (CCP) for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for four (4) (Resident #'s 38, 85, 114, and #123) of twenty-six residents reviewed. Specifically: for Resident #38, the facility did not ensure that a CCP to address blepharitis (inflamation of the eye lids) was developed; that Resident #101, had a CCP developed to address a pressure sore; that Resident #114, had CCP's developed to address constipation and dermatitis (inflamation of the skin); that Resident #85, had a CCP developed for pain management; and did not ensure that Resident #123's personal goals and preferences for nutrition were included in the resident's nutrition care plan. This is evidenced by: Resident #114: The resident was admitted to the nursing home on 4/12/19, with diagnoses of dementia with behavior disturbances, constipation and psoriasiform dermatitis. The Minimum Data Set (MDS-an assessment tool) dated 8/14/19, assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. Medical Doctor (MD) Orders documented: - Colace (a stool softener) 100 milligrams (mg) twice daily for constipation. - Senna (a stimulant laxative) 8.6 mg twice daily for constipation. - hydroxyzine HCL 25 mg three times a day for psoriasiform dermatitis for itch. During an interview on 09/04/19 at 10:37 AM, Registered Nurse Manager (RNM) #4 stated she was responsible for care planning. She did not see a CCP to address the resident's constipation or skin issues, but there should have been. Resident #85: The resident was admitted to the facility on [DATE], with diagnoses of right shoulder pain, congestive heart failure, and chronic respiratory failure. The Minimum Data Set (MDS - an assessment tool) dated 8/1/19, documented the resident had moderately impaired cognition, could understand others and could make self understood. During a record review on 9/04/19 at 9:31 AM, the medical record did not include a CCP for pain management. Physician order dated 8/17/19, documented Hydrocodone-Acetaminophen 5/325mg (a narcotic pain medication)1 tablet by mouth every 4 hours as needed for pain. During an interview on 9/05/19 at 9:27 AM, RN #1 stated the resident should have a pain care plan in place and thought a pain care plan had been developed for the resident. She stated she has an order for as needed pain medication and the care plan should include non-pharmacological interventions to help with pain management, for example repositioning, providing ice and activities of interest. Resident #123: The resident was admitted to the facility on [DATE] with diagnoses of aphasia, dysphasia, and cerebral infarction. The Minimum Data Set, dated [DATE], documented the resident had severely impaired cognition, could usually understand others and could sometimes make self understood. A comprehensive care plan (CCP) for Assisted Nutrition and Hydration by PEG (feeding) tube, last revised 8/9/19, did not include the resident's goals and preferences for nutrition. During an interview on 9/06/19 at 9:25 AM, Registered Dietician #1 stated the nutrition care plans did not document the resident's nutrition goals and preferences. She stated that was not something she normally included in the care plans for nutrition. She stated the resident's goals and preferences for nutrition regarding his tube feed and intake by mouth could be better documented. 10NYCRR 415.11(c)(2)

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, the facility did not ensure that time frames were established for the steps in the MRR process. This is evidenced by: The Facility Policy and Procedure titled, Pharmaceutical Reviews dated 8/2014, did not address the time frames for the different steps in the medication regimen review process. During an interview on 6/09/19 at 2:45 PM, the Administrator stated the policy dated 08/2014 was the current policy. It was discussed that the current policy does not include necessary time frames for each step in the process. 10NYCRR415.18(c)(2)