**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review conducted during the Standard survey completed on 4/18/25, the facility did not ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents for one (1) (Resident #9) of two (2) residents reviewed for accidents. Specifically, Resident #9's wheelchair left pedal was in disrepair and missing the leg rest, exposing a sharp edge at the hinge point. The sharp edge was noted at times pressing against the residents left lower leg. The finding is: The policy titled Assistive Devices and Equipment dated 2/2025 documented the facility maintained and supervised the use of assistive devices and equipment for residents. Certain devices and equipment that assist with resident mobility, safety, and independence were provided for residents like wheelchairs, walkers, etc. Device condition was addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment, devices and equipment were maintained on schedule and according to manufacturer's instructions. Defective or worn devices were discarded or repaired. If a device or equipment was not functioning or was noted to be in poor repair, the device/equipment must be immediately removed from use. Replacement devices and equipment should be implemented in a timely manner to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individuals clinical condition demonstrated that such a diminution was unavoidable. Resident assistive equipment devices such as wheelchairs (to include cushions, brakes and leg rests) were evaluated quarterly and PRN (as needed). The policy titled Resident Safety and Accident Prevention dated 1/2025 documented the facility would commit to safety by implementation of a system based on assessed risk and need of the resident in order to put individualized interventions into place as well as to minimize any environment hazards for prevention and quality. The facility would ensure that the resident environment remained free of accident hazards as was possible and each resident received adequate supervision and assistant devices to prevent accidents. Resident #9 had diagnoses including diabetes mellitus with diabetic neuropathy (nerve pain) and circulatory complications, complete traumatic amputation of left foot, and vascular dementia. The Minimum Data Set (a resident assessment tool) dated 2/12/25 documented Resident #9 was understood, understands and was cognitively intact. The comprehensive care plan initiated 12/1/21 (identified as current) documented Resident #9 used a standard wheelchair and was independent for transferring, dressing, and bed mobility. Resident #9 required skin inspections every shift for Left AFO (ankle-foot orthosis; device worn to support and stabilize the ankle and foot). Observe for redness, open areas, scratches, cuts, bruises. Educate and encourage resident to use ankle-foot orthosis to provide increased function. Additionally, the comprehensive care plan documented Resident #9 had a history of ulcers. The Visual Bedside/[NAME] (a guide for staff to provide care) dated as of 4/17/25 documented Resident #9 preferred to sleep in their wheelchair at times, and staff were to encourage to lay in bed when tired. Review of Wound Weekly Registered Nurse assessment dated [DATE]- 3/18/24 documented Resident #9 had stasis ulcers to their left inner and outer calf that healed. Review of Maintenance Work Order Log dated 3/1/25 to 4/17/25 revealed there was no evidence a work order request was put in for Resident #9's leg rest on their wheelchairs left foot pedal. During intermittent observations on 4/15/25 at 9:17 AM and 3:12 PM, 4/16/25 at 8:06 AM, and 4/17/25 at 8:03 AM, Resident #9 was sitting in their wheelchair in their room wearing sweatpants, the leg rest was missing from their wheelchairs left pedal. The black plastic hinge had sharp edges and was pressing against Resident #9's left calf, they did not have their left ankle-foot orthosis in place. During an observation and interview on 4/17/25 at 1:05 PM, Resident #9 was sitting in their wheelchair with jeans on and their left ankle-foot orthosis on. The leg rest remained missing from their left wheelchair pedal, and the hinge continued to press into their left calf in between the braces Velcro straps. Resident #9 stated they were not sure how long the left leg rest had been missing/in disrepair. During an observation and interview on 4/17/25 at 1:06 PM, Certified Nurse Aide #1 stated Resident #9's left leg rest was broken, and the hinge with sharp edges was exposed. They stated the resident independently transferred and the broken hinge could cause a skin injury if it was not fixed. Additionally, Certified Nurse Aide #1 stated whoever noticed a broken wheelchair piece was responsible for reporting it to therapy if it could be replaced or maintenance if it could be fixed. They stated they did not know how long Resident #9's left leg rest had been broken for and did not know if it had been reported to anyone. During an observation and interview on 4/17/25 at 1:08 PM, the Assistant Director of Nursing stated Resident #9's left leg rest was broken with exposed edges and that could cause a skin issue. Resident #9 transferred independently and slept in their wheelchair often so there was a high potential for skin breakdown or injury if the leg rest was not replaced. During an interview on 4/17/25 at 1:26 PM, Certified Occupational Therapy Assistant #1 the leg rest hinge could be sharp when broken and Resident #9 transferred independently so, anything was possible when it came to potential accidents or skin injuries. Additionally, they stated someone should have been altered, so that the pedal could have been repaired. During an interview on 4/18/25 at 8:12 AM, Nurse Practitioner #1 stated having a broken leg rest on their wheelchair put Resident #9 at risk for skin injury. They stated Resident #9 had edema (swelling) in their legs recently that had improved, and they were diligently working on getting their blood sugars more controlled, these things put Resident #9 at a higher risk. During an interview on 4/18/25 at 8:30 AM, the Director of Maintenance stated there was a clip board at the nurse's station that staff wrote any maintenance work orders on; they reviewed the log daily. They stated they did not recall any work order put in for Resident #9's left wheelchair pedal. During an interview on 4/18/25 at 10:17 AM, the Director of Nursing and Administrator stated Resident #9 had an order to have their skin monitored twice a day so they would have expected staff to notice the broken wheelchair leg rest during one of those inspections. They stated Resident #9 could potentially acquire a skin injury if the leg rest was not fixed. 10 NYCRR 415.12 (h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during a complaint investigation (Complaint #NY00312696) during the Standard survey completed on 12/1/23, the facility did not ensure residents had the right to be free from physical abuse for one (Resident # 31) of three residents reviewed for abuse. Specifically, the facility did not ensure Resident #31 was free from physical abuse when Resident #12 punched them resulting in a hematoma (collection of blood under the skin) above their eye. The residents had a history of physical altercations. The finding is: The policy and procedure titled Abuse-Investigation, Protection, and Reporting dated 10/24/22, documented resident to resident physical altercations must be reported and include any willful action that results in injury. The document titled Your Rights as a Nursing Home Resident in New York State documented residents have the right to be free from physical abuse. 1. Resident #31 had diagnoses including seizures, cerebral infarction (a stroke), and aphasia (absence or difficulty with speech). The Minimum Data Set (MDS- a resident assessment tool) dated 1/4/23 documented Resident #31 had moderate cognitive impairment, physical behaviors directed toward others, and wandering behaviors. The untitled comprehensive care plan dated 2/24/22 documented Resident #31 had the potential to be physically and verbally aggressive related to poor impulse control and a short temper. Interventions included to monitor the resident for signs of posing a danger to self or others. Another intervention dated 5/30/22 was to encourage distance between the resident and their peer (Resident #12). During an observation and interview on 11/27/23 at 10:17 AM, Resident #31 was lying in bed on top of their blankets. The resident stated they didn't have any problems with anyone at the facility including other residents and that nobody hit them. Resident #12 had diagnoses including vascular dementia, type 2 diabetes mellitus (DM), and hypertension (HTN- high blood pressure). The MDS dated [DATE] documented Resident #12 was understood, understands and cognitively intact. Review of the untitled comprehensive care plan date initiated 5/30/23 documented Resident #12 could be physically aggressive related to anger, and poor impulse control as they had a history of hitting Resident #31 on 5/28/22. Interventions included keeping resident away from Resident #31 and a stop sign placed on their bedroom door. During an interview on 11/27/23 at 1:22 PM, Resident #12 stated Resident #31 came into their room and tried stood over them. The resident stated they kept telling Resident #31 to leave and they wouldn't, and Resident #31 kept coming towards them (#12). That was when I hit Resident #31 with my leg brace. Resident #12 stated they did not get along with Resident #31, they (#31) were always in the way, would not move or made unwanted gestures towards them. The Investigation Summary dated 5/28/22 at 8:00 PM, documented Resident #31 was sitting in front of Resident #12 in the hallway, both residents were yelling, and Resident #12 punched Resident #31 in their left eye. The investigation concluded that physical abuse occurred. Resident care plans were updated, and Resident #12 was educated to not put their hands on anyone and to let staff intervene when needed. The Investigation Summary dated 3/14/23 at 12:45 PM, documented Resident #31 went into Resident #12's room and when they wouldn't leave, Resident #12 struck Resident #31 in the left side of their face above the eyebrow. A Registered Nurse (RN) assessment was done and found a golf ball size hematoma above Resident #31's left eye. The investigation concluded that physical abuse occurred. Review of the Progress Note dated 3/14/23 at 12:59 PM, a Nurse Practitioner (NP) documented Resident #31 sustained a head injury because of an altercation with another resident (#12). The resident (#31) had a small laceration at their left eyebrow with tissue edema (swelling). The plan was for staff to monitor for a concussion and provide safety measures including seizure precautions. During a telephone interview on 11/30/23 at 10:08 AM, Licensed Practical Nurse (LPN) #1 stated they were at the nurse's station when Resident #31 approached the area coming from the direction of their room with an injury above their eye. LPN #1 stated they couldn't remember the last time they saw Resident #31 prior to the incident (3/14/23). LPN #1 stated Resident #12 didn't like it when Resident #31 went into their room and staff would need to redirect Resident #31 to their room. During a telephone interview on 11/30/23 at 10:16 AM, Certified Nurse Aide (CNA) #4 stated Resident #31 didn't always remember where their room was. CNA #4 stated the resident (#31) usually ate lunch in the dining room and left whenever they wanted when they were finished eating. CNA #4 stated they weren't sure of any care plan interventions to keep Resident #12 and #31 away from each other and not sure if they've had previous interactions. During a telephone interview on 11/30/23 at 11:14 AM, CNA #3 (assigned to Resident #31 on 3/14/23) stated they remembered seeing a knot on Resident #31's forehead and it was bleeding. CNA #3 asked what happened and they said another resident punched them. CNA #3 stated they weren't sure the last time they saw the resident prior to this but that they ate in the dining room and lunch was served around 12:00 PM. CNA #3 stated they weren't sure if the resident was care planned to stay away from any other residents prior to this incident but was pretty sure they were afterwards. CNA #3 stated they did not see Resident #31 in Resident #12's room that day or morning. During an interview on 11/30/23 at 11:27 AM, LPN #2 stated they were working with Resident #31 on 3/14/23 and had seen him attempting to go into Resident #12's room that morning and they redirected the resident away a couple times. LPN #2 stated they weren't sure if there was a prior incident between the residents. LPN #2 stated they considered a resident punching another resident abusive and if that happened, the Director of Nursing (DON) and Administrator get notified within two hours. During an interview on 11/30/23 at 3:50 PM, the Director of Social Work (SW) stated after Resident #31 and Resident #12's first altercation they told both residents to stay away from each other and their rooms were moved further apart. The second altercation was when Resident #31 went into Resident #12's room and was punched. The SW stated residents had the right to be free from abuse and that Resident #12 abused Resident #31 when they punched them. During an interview on 12/1/23 at 8:55 AM, the DON stated Resident #31 went into Resident #12's room thinking it was their own room and it probably startled Resident #12 who mostly does their own thing in their room. Resident #12 asked Resident #31 to leave and they wouldn't, so they decided to hit Resident #31 in their forehead resulting in a hematoma. These residents did have a prior incident that happened in the hallway, Resident #31 didn't move out of Resident #12's way quick enough and they struck Resident #31. After the initial incident, there was increased monitoring and they kept the residents separate. The DON stated this was mostly likely considered abuse when there's hitting involved. 10 NYCRR 415.3(d)(1)(vii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 12/1/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for one (Resident #32) of two residents reviewed. Specifically, there was lack of glove changes and hand hygiene after providing bowel incontinence care and applying a clean brief. Additionally, the Certified Nurse Assistant (CNA) touched objects (resident's bed linen, and heel booties) while wearing the same gloves used to provide incontinence care. The finding is: The policy and procedure titled Personal Protective Equipment dated 7/2021 documented gloves should be changed after providing incontinent care and before putting on clean briefs and to wash hands after removing gloves. 1. Resident #32 had diagnoses including dementia, anxiety, and depression. The Minimum Data Set (MDS - a resident assessment tool) dated 8/30/23 documented Resident #32 had severe cognitive impairment and was always incontinent of bowel and bladder. The [NAME] (a guide used by staff to provide care) dated 11/30/23 documented Resident #32 required extensive assistance of two staff members for incontinent care. The comprehensive care plan dated 8/7/23 documented Resident #32 required extensive assistance of two staff for incontinent care. During an observation of incontinent care for Resident #32 on 11/30/23 at 1:29 PM, CNA #1 and CNA #2 transferred the resident into their bed. CNA #1 removed the soiled brief and provided urinary incontinence care. The resident was turned onto their right side and CNA #2 assisted by holding the resident on their side. CNA #1 wiped the rectal area; a moderate amount of stool was on the washcloth. CNA used both hands to fold the washcloth to a clean section and cleaned more stool from the resident two more times. Without changing their gloves and washing their hands, CNA #1 applied a clean brief to the resident, removed the resident's heel booties and pants, reapplied the heel booties and covered the resident with a sheet. CNA #1 removed their gloves and used the bed remote to lower the bed. CNA #1 donned new gloves and discarded the basin water into the toilet and placed the basin under the sink. CNA #1 removed one of their gloves and using their gloved hand, gathered up the soiled linen bag and brought it to the soiled utility room, where they disposed of the soiled items and then washed their hands. During an interview on 11/30/23 at 1:49 PM, CNA #1 stated they didn't change their gloves after providing incontinence care because they forgot. During an interview on 11/30/23 at 1:52 PM, CNA #2 stated normally staff were supposed to change their gloves when they were soiled (after incontinence care) to prevent cross contamination. During an interview on 12/1/23 at 9:04 AM, the Director of Nursing (DON) stated they expected staff to change their gloves after providing incontinence care and before touching clean items to prevent contaminating anything because you don't know what's on your gloves. 10 NYCRR 415.12(a)(3)

Based on interview and record review conducted during the Standard survey completed on 3/11/22, the facility did not inform the resident's representative of a change in physical status and a transfer to the hospital for one (Resident #34) of one resident reviewed for notification of change. Specifically, the resident's representative was not notified when Resident #34 tested positive for COVID -19 on 12/31/22 and was subsequently transferred to the hospital on 1/6/22. The findings are: Review of the facility policy and procedure (P/P) titled Change in Status Notification dated 9/2021 documented it is the facilities policy that in accordance with State and Federal Regulations; notification to the resident, and the resident's representative(s), consistent with his/her authority, will be made when there is an a significant change in the resident's physical, mental or psychological status in either life threatening conditions or clinical complications; a need to alter treatment significantly or to commence a new form of treatment; or a decision to transfer the resident from the facility. 1. Resident #34 had diagnoses including Down syndrome, Alzheimer's disease, and dementia. The Minimum Data Set (MDS-resident assessment tool) dated 1/24/22 documented Resident #34 sometimes understood, understands and was severely cognitively impaired. During an interview on 3/8/22 at 1:49 PM, Resident #34's responsible party stated the resident tested positive for COVID-19 in December of 2021 and was sent to the hospital in January 2022 and they were not notified. Review of the Progress Notes dated 12/31/21 completed by Licensed Practical Nurse (LPN) #2 documented Resident #34 tested positive for COVID, had sinus congestion with rhinorrhea (runny nose), an occasional nonproductive cough (NPC) and general malaise (general feeling of discomfort, illness, or uneasiness). The resident was to be monitored and fluids encouraged. The resident's vital signs were stable. Review of the Progress Notes dated 1/6/22 completed by LPN #3 documented a late entry: resident was having low O2 (oxygen) level and was told by DON (Director of Nursing) to send to ER (emergency room). Review of the Progress Notes from 12/31/22 and 1/6/22 revealed there was no documented evidence that the responsible party was notified of either event. During an interview on 3/10/22 at 1:03 PM, LPN #2 stated I did not call the family to tell them the resident tested positive for COVID. I was told the Administrator calls everybody when someone tests positive. I did not know at the time it was a 'general' robo call to everyone and not specifically to the residents family. During an interview on 3/10/22 at 1:06 PM, Regional Registered Nurse (RNS) #1, Interim Director of Nursing (DON) stated we should notify a family with any change of status. There should be a family notification when a resident becomes COVID positive and when they are sent to the hospital. Staff should document this in the medical record. I do not see any family notifications for either of these two changes of status. 415.3(e)(2)(ii)(b)(d)

Based on observation, interview and record review conducted during an Extended Standard survey completed on 3/11/22, the facility did not ensure each resident was free from exploitation (taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion) for one (Resident #18) of two residents reviewed. Specifically, Certified Nurse Aide (CNA) #4 requested and accepted money from Resident #18 to provide the resident with sexually explicit photos. The finding is: The facility policy and procedure (P&P) titled Accident/Incident - Investigation & Reporting dated 6/2021 documented all accidents and incidents occurring within and related to the facility will be investigated. The investigation should rule out or confirm abuse, exploitation or neglect. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 11/22/17 documents facility staff are in a position that may be perceived as one of power over a resident. As such, staff may be able to manipulate or unduly influence decisions by the resident. Staff must not accept or ask a resident to borrow personal items or money, nor should they attempt to gain access to a resident's holdings, money, or personal possessions through persuasion, coercion, request for a loan, or solicitation. A resident's apparent consent is not valid if it is obtained from a resident lacking the capacity to consent, or consent is obtained through intimidation, coercion or fear, whether it is expressed by the resident or suspected by staff. 1. Resident #18 had diagnoses that included post traumatic stress disorder (PTSD), anxiety, and depression. The Minimum Data Set (MDS, a resident assessment tool) dated 1/25/22 documented Resident #18 understands, was understood and cognition was not assessed. The 11/17/21 MDS documented Resident #18 was cognitively intact. During intermittent observations 3/7/22 through 3/11/22, Resident #18 was alert, oriented, and cognitively intact. The facility Disciplinary Action Report dated 8/20/21 and signed by CNA #4 documented the following reasons for action: Sexual or other unlawful harassment; Immoral conduct that would be widely regarded as improper or inappropriate in a work group; Soliciting loans/kickbacks from residents, families or vendors; Willful violation of Corporate Compliance Program - Code of Conduct or Ethics Policy; and Other extreme instances of improper conduct not specifically listed. Additionally, the reason for action documented CNA #4 provided resident with sexually explicit photos, and CNA #4 requested and accepted money from Resident #18. The report also documented the pornographic photos were on file. The Human Resources status update dated 8/20/21 documented on 8/20/21 CNA #4 was asked if they would like union representative present for the disciplinary action report that was being presented to them. CNA #4 was informed that this was regarding the indecent and inappropriate material involving them. CNA #4 verbally refused to have representation and signed off on the disciplinary written report. At that time, CNA #4 stated that things were bad at their home, and they knew their actions were wrong and wanted to leave rather than proceed with any further discussion. Review of an email dated 8/23/21 at 10:23 AM to the Director of Nursing provided by the facility revealed a text message chain from CNA #4 to LPN #5 that documented CNA #4 sent pictures to Resident #18 for cash due to having no money. During an interview on 3/10/22 at 11:16 AM, Resident #18 stated they received sexually explicit photos of CNA #4 on their cell phone, and that they were aware CNA #4 was having domestic and financial problems. During an interview on 3/10/22 at 12:11 PM, the Administrator stated CNA #4 was terminated for the moral/ethical issues of sending sexually explicit photos of themselves to a resident. 415.4(b)

Based on observation, interview and record review conducted during an extended standard survey completed on 3/11/22, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #18) of two residents reviewed. Specifically, Certified Nurse Aide (CNA) #4 requested and accepted money from Resident #18 to provide the resident with sexually explicit photos that was not reported to the New York State Department of Health (NYS DOH) as required within the two-hour time frame. The facility policy and procedure (P&P) titled Abuse, Investigation & Reporting dated 10/1/2019 documented all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations). An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury to the State licensing/certification agency responsible for surveying/licensing the facility. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 11/22/17 documents facility staff are in a position that may be perceived as one of power over a resident. As such, staff may be able to manipulate or unduly influence decisions by the resident. Staff must not accept or ask a resident to borrow personal items or money, nor should they attempt to gain access to a resident's holdings, money, or personal possessions through persuasion, coercion, request for a loan, or solicitation. A resident's apparent consent is not valid if it is obtained from a resident lacking the capacity to consent, or consent id obtained through intimidation, coercion or fear, whether it is expressed by the resident or suspected by staff. Refer to F 602 Freedom from Misappropriation/ Exploitation scope/severity =D 1. Resident #18 had diagnoses that included post-traumatic stress disorder (PTSD), anxiety, and depression. The Minimum Data Set (MDS, a resident assessment tool) dated 1/25/22 documented Resident #18 understands, was understood, and cognition was not assessed. The 11/17/21 MDS documents Resident #18 was cognitively intact. During intermittent observations 3/7/22 through 3/11/22, Resident #18 was alert, oriented, and cognitively intact. The facility Disciplinary Action Report dated 8/20/21 and signed by CNA #4 documented the following reasons for action: Sexual or other unlawful harassment; Immoral conduct that would be widely regarded as improper or inappropriate in a work group; Soliciting loans/kickbacks from residents, families or vendors; Willful violation of Corporate Compliance Program - Code of Conduct or Ethics Policy; and Other extreme instances of improper conduct not specifically listed. Additionally, the reason for action documented CNA #4 provided resident with sexually explicit photos, and CNA #4 requested and accepted money from the resident. Review of the NYS DOH Automated Complaint Tracking System (ACTS, software that logs and tracks nursing home complaints) 8/1/21 through 8/31/21 revealed the solicitation of Resident #18, by CNA #4 was not reported. During an interview on 3/11/22 at 8:55 AM, the Director of Nursing (DON) stated they had spoken with the Corporate Quality Assurance (QA) Nurse and the Corporate DON who had stated the incident was not reportable to the NYS DOH secondary to the exchange of money for sexually explicit pictures was consensual between CNA #4 and Resident #18. During an interview on 3/11/22 at 9:42 AM, the Administrator stated the incident was not reported to the NYS DOH secondary to Resident #18 and CNA #4 were able to consent to the transaction, and that the photos were not taken inside the building. 415.4(b)(4)

Based on interview and record review conducted during the Standard survey completed on 3/11/22, the facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week and the facility did not have a designated RN to serve as the Director of Nursing (DON) on a full-time basis. Specifically, reviewed for staffing revealed an RN was not scheduled for eight consecutive hours per day on multiple dates December 4, 2021 through March 6, 2022, and an RN was not designated as DON from 12/30/21 through 3/7/22. The findings are: Review of a facility policy and procedure (P&P) titled Contingency Staffing Plan dated 3/13/2020 documented; it is the facility's policy to ensure that in the event of a disaster or emergency that a contingency staffing plan is in place so that all residents can be provided the necessary care. In the event of a disaster, whether environmental or health- related, it is crucial to ensure that there are plans in place for contingency staffing in the event additional licensed and /or non-licensed personnel are needed. Review of a facility undated Job Description for DON provided by the Administrator documented; the DON assumes authority, responsibility and accountability for the delivery of nursing services in the facility. In collaboration with facility Administration, allocates department resources in an efficient and economic manner to enable each resident to attain and / or maintain the highest practical physical, mental and psychosocial well-being. Collaborates with other departments, medical professionals, consultants and organizations, including government agencies and advocacy groups, to develop, support and coordinate resident care, related administrative functions and to represent the interests of the facility. Essential Job Functions included; oversees nursing schedules to assure they meet resident needs/ as well as, regulatory and budgetary standards. Review of a facility report, untitled, identified as the facility census report by the Administrator dated 12/1/21 through 3/7/21 revealed the census was between 29 to 40 residents daily. Review of an untitled form, identified as the facility daily shift staffing sheets by the Administrator dated 12/1/21 through 3/6/22 revealed there was no documented evidence that a Registered Nurse (RN) was scheduled for eight consecutive hours on the following dates: December 4, 11, 19, 25, 26, and 30 2021; January 1, 8, 9, 10, 15, 16, 18, 22, 23, 29, and 30 2022; February 1, 2, 3, 4, 5, 6, 9, 10, 12, 13, 19, 20, 26, and 27 2022 and March 3 and 6 2022. Review of the facility Daily Nurse Staffing Forms from 12/1/21 through 3/6/22 revealed there was no documented evidence that an RN was scheduled for eight consecutive hours on the identified dates. Review of facility daily reports titled; Punched In and Out; dated 12/1/21 through 3/6/21 revealed there was no documented evidence that an RN was scheduled for eight consecutive hours on the identified dates. Review of a titled report, Time Cards, dated 12/1/21 through 3/6/22 for the DON, Regional RN Interim DON #1, Regional Director Quality Assurance, and Regional RN #2, revealed there was no documented evidence that an RN was scheduled for eight consecutive hours on the identified dates. Review of a handwritten sign hanging on the nurses station documented; Nurses: The sister facility will be available to take any calls from this facility that require an RN, between 7 PM to 7 AM. They can assist over the home to provide guidance. Day issues can be addressed with RN in the building. From the hours of no RN please call Administrator starting 2/11/22. During an interview on 3/7/22 at 10:41 AM the Administrator stated the DON has not been here for a while related to medical issues, there has not been an RN appointed to be the interim DON and the New York State Department of Health has not been informed of the lack of full time DON coverage. The Administrator stated the facility corporate nurses have been assisting with RN tasks. The Administrator appointed RN Interim DON #2 at this time during the interview. During an interview on 3/7/22 at 11:07 AM RN Interim DON #2 stated they started working for the facility on 2/17/22 as an agency nurse and was appointed as the interim DON this morning during the entrance conference interview. During another interview on 3/9/22 at 6:33 AM RN Interim DON #2 stated prior to 3/7/22 they were aware there was a sign at the nurse's station to contact a sister facility that require an RN guidance between 7 PM - 7 AM dated 2/11/22. During an interview on 3/7/22 at 11:13 AM Regional RN /Interim DON #1 stated they were aware the DON was out on medical leave, they had worked covering some RN duties in the building and had not been appointed to be the interim DON during the DON's absence until today (3-7-22). During an interview on 3/7/22 at 11:18 AM the Regional Administrator stated they were aware the DON had been out on medical leave and Regional RNs have been covering some RN duties. The Regional Administrator stated there should be a full time DON and doesn't know who is covering the DON duties and referred the question to the Administrator. During an interview on 3/8/22 at 12:06 PM the Administrator stated the DON's last day worked was 12/29/21 related to medical issues. During a phone interview on 3/9/22 at 8:57 AM the DON stated the facility's corporation was aware they had been out on medical and unable to work. The DON stated Regional RN Interim DON #1 and Regional Administrator were aware and believes corporate provided some RN coverage for specific RN duties and does not know who is covering DON duties or making DON decisions. The DON stated the facility should have appointed a full time RN to be the acting interim DON while they were out sick. In addition, the DON stated there should be an RN in the facility at least eight consecutive hours ever 24-hour period and was not aware the facility was not meeting this requirement. The DON stated the Scheduling Coordinator is responsible for scheduling and the Daily Nurse Staffing Form should be accurate at all times. During an interview on 3/10/22 at 8:25 AM LPN #2 stated they were aware there is a regulation the facility is to schedule an RN for eight consecutive hours every 24-hour period and the facility has not met that requirement especially on weekends. LPN #2 stated since the DON has been out on medical leave the frequency of a lack of RN coverage has increased. LPN #2 state they had not been informed or educated on a change in DON status until yesterday (3-9-22). During an interview on 3/10/22 at 9:56 AM LPN #5 stated they are aware the facility should have an RN at least 8 hours / 24 hours coverage and stated there is a lack of RN coverage on multiple days especially on the weekends. LPN #5 stated they had not been informed or educated on a change in DON status until yesterday (3-9-22). During a second interview on 3/10/22 at 4:00 PM Regional RN / Interim DON #1 stated they had not returned to work until mid-February 2022 and started working at this facility to cover some RN hours and realized the facility did not have an RN scheduled daily for eight hours as required. Regional RN / Interim DON #1 stated they had hired Agency RN / Interim DON #2 as a full time RN, but there continued to be a lack of RN 8-hour coverage in the building and the Administrator was aware. During an interview on 3/11/22 at 9:43 AM Human Resources Director / Scheduling Coordinator stated they had been in charge of scheduling since November 2021 and is aware there should be an RN scheduled for eight hours / 24 hours per requirement. They stated they were unable to schedule an RN daily and aware there was not eight hours of RN coverage as required for all the dates indicated. The Human Resource Director / Scheduling Coordinator stated the Administrator, and the Regional Director of Quality Assurance (QA) was aware, and they were not provided any further direction how to staff the facility with an RN. During an interview on 3/11/22 at 10:53 AM the Administrator stated they anticipated the DON to return and did not appoint or delegate an RN as an interim DON and did not delegate all the DON's job tasks to other RNs. The Administrator stated the Ownership and Corporate Administrator was aware the DON was not in the building and out on medical leave since 12/29/21 and was not directed to appoint an interim DON. The Administrator stated there was no direction provided to the nursing staff of who to call in the DON's absence until a note was posted at the nurse's station on 2/11/22 for the nurses to call the sister facility for assistance if an RN is required on the off shifts. In addition, the Administrator stated they were aware the facility did not have an RN scheduled for eight consecutive hours per 24 hours as required on multiple dates. The Administrator reviewed the dates identified and agreed the information was correct. The Administrator stated they should have notified Corporate and Ownership that the facility was unable to schedule an RN as required. During a phone interview on 3/11/22 at 11:59 AM the Chief Operating Officer (COO) stated they were not aware the facility was unable to schedule an RN eight consecutive hours per 24 hours as required. The COO stated they should have been notified and would have offered bonuses and provided additional assistance if they were aware. During an interview on 3/11/22 at 12:18 PM the Corporate Administrator stated they were not aware the facility was unable to schedule an RN eight consecutive hours per 24 hours as required and would have expected the Administrator to have notified Corporate. 415.13(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during an Extended Standard survey started on [DATE] and completed on [DATE], the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administrator did not ensure a Registered Nurse (RN) was scheduled eight consecutive hours per 24-hour period as required and did not designate a full time Director of Nursing (DON) when the DON was off for an extended period. In addition, the Administrator did not ensure there was an effective system in place when there was no RN coverage in the building to respond to an emergency in accordance with facility policy and protocols. The findings are: Refer to: F 678 - Cardio-Pulmonary Resuscitation (CPR) - scope/severity (S/S)= J F 727 - RN 8 hours/ 7 days/ Week, Full Time DON - S/S = F Review of an undated Administrator Job Description provided by the facility documented position purpose was to supervise all clinical and administrative functions within the nursing facility. Essential functions included: develop and implements facility management systems, and ensures compliance with all Federal, State and company policies and regulations. Personnel Functions documented to oversees all department's schedules to assure they meet resident needs and monitors regulatory standards; participates in the recruitment and selection of all department personnel and assures sufficient staff are hired; and assures staff is trained in emergency procedures. a.) Concerns rising to the level of immediate risk to resident health and safety/Substandard Quality of Care (SQC) included the provider's failure to provide basic life support, including CPR to an unresponsive resident who had full code status. This was an isolated incident that resulted in actual harm with the likelihood to affect all residents with a full code status. On [DATE] Licensed Practical Nurse (LPN) #1 was notified by Certified Nurse Aide (CNA) #1 at approximately 4:30 AM that Resident #86 was unresponsive. LPN #1 observed Resident #86, who was unresponsive without a pulse, respirations, or blood pressure and had bubbling excretions from their mouth. LPN #1 failed to initiate a Code Blue (emergency response) to summon additional help, failed to activate the 911 (EMS) system, and failed to provide CPR efforts for a resident who was a full code. LPN #1 instead contacted the Director of Nursing (DON) by telephone, without response. LPN #1 stated during interview it was their professional judgment to not perform CPR. LPN #1 did not provide documented clear evidence to support clinical signs for The American Heart Association (AHA) guidelines of irreversible death at the time the resident was observed unresponsive. During an interview on [DATE] at 10:53 AM, the Administrator stated the DON had been out on leave since [DATE] and they did not designate an RN to act as a full -time interim DON. The Administrator stated there was no direction provided to the nursing staff of who to call in the DON's absence until a note was posted at the nurse's station on [DATE]. In addition, the Administrator stated they were aware the facility did not have an RN scheduled for eight consecutive hours per 24 hours as required. During an interview on [DATE] at 11:00 AM, the Administrator stated they would have expected the LPN to have initiated CPR and follow the Code Blue policy and initiate 911. The Administrator stated LPNs cannot assess and determine the time of death of a resident because it is not within their scope of practice and should have contacted an RN. b.) The facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week and the facility did not have a designated RN to serve as the Director of Nursing (DON) on a full-time basis. Review of facility daily reports titled Punched In and Out dated [DATE] through [DATE] revealed there was no documented evidence that an RN was scheduled for eight consecutive hours on the following dates: [DATE], 19, 25, 26, and 30 2021; [DATE], 9, 10, 15, 16, 18, 22, 23, 29, and 30 2022; February 1, 2, 3, 4, 5, 6, 9, 10, 12, 13, 19, 20, 26, and 27 2022 and [DATE] and 6 2022. During an interview on [DATE] at 10:53 AM, the Administrator stated they did not designate an RN as an interim DON to cover while the DON was out on leave, and did not delegate all the DON's job tasks to other RNs. The Administrator stated the Ownership and Corporate Administrator was aware the DON was out on leave since [DATE] and was not directed by them to appoint an interim DON. The Administrator also stated they were aware the facility did not have an RN scheduled for eight consecutive hours per 24 hours as required and should have notified Corporate/Ownership that the facility was unable to schedule an RN as required. During a telephone interview on [DATE] at 11:59 AM, the Chief Operating Officer (COO) stated they were not aware the facility was unable to schedule an RN for eight consecutive hours per 24 hours as required. The COO stated they should have been notified and would have offered bonuses and provided additional assistance if they were aware. During an interview on [DATE] at 12:18 PM, the Corporate Administrator stated they were not aware the facility was unable to schedule an RN eight consecutive hours per 24 hours as required and would have expected the Administrator to have notified Corporate. 415.26