**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during an Abbreviated Survey (NY00352779), the facility did not ensure that the alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property were reported immediately, but not later that two (2) hours after the allegation is made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not involve serious bodily injury, to the administrator of the facility and to other officials (including to the State Agency). This was evident for one (1) out of four (4) residents (Resident #1) sampled. Specifically, Resident #1 was observed on the floor in their room bleeding from their nostrils at around 7:03 AM on 08/20/2024. Resident #1 was transferred to the hospital and was diagnosed with nasal bone fracture. Resident #1 was re-admitted to the facility on [DATE] with diagnosis of nasal fracture. The facility did not report the unwitnessed fall with injury to New York State Department of Health after becoming aware on 08/23/2024. The findings are: The facility's Policy and Procedure titled of Abuse Prevention review date of 11/2024 documented the facility residents will be protected from Abuse, Neglect, Mistreatment, Exploitation, or Misappropriation of resident's property in accordance with State and Federal Regulations. All alleged or suspected incidents of Abuse, Neglect, Mistreatment, Exploitation, or Misappropriation of resident's property will be thoroughly investigated, and findings documented. All allegations of abuse must be immediately reported to the Administrator and no later than two (2) hours to other officials (including to the State Survey Agency) after the allegation is made, if the events that caused the allegation involved abuse or results serious bodily injury. The violations must be reported no later than 24 hours to State Survey Agency if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. The facility's Policy and Procedure titled title Fall, Accident and Incident Report with a last review dated of 2/2024. documented that the Nursing Supervisor must be informed of any resident related incident. A fall risk assessment will be completed for all residents upon admission, readmission, quarterly, annually, significant change in status, and after an accident/Incident has occurred. The Registered Nurse will assess resident's condition and render immediate first aide. If Registered Nurse assess that resident's has a fracture or other injury which requires that the resident not be moved, the resident is to be kept as comfortable as possible until 911 arrives. The policy also states the accident/ incident will be investigated and report within two (2) hours per New York State Department of Health regulations. Resident #1 was admitted to the facility on with diagnoses including Cerebral Ischemia, Cerebral Vascular Accident, Non-Alzheimer's Disease. The Minimum Data Set, an assessment tool, dated 05/09/2025 documented Resident #1 cognition was severely impaired. A Nursing Progress note by Registered Nurse Supervisor #1 dated 08/20/2024 at 8:31 AM documented Resident #1 was lying on their right side in a pool of coagulating blood. An icepack was applied to the nose and face. Medical Doctor #1 was notified and ordered Resident #1 to be transferred to the hospital. An Unwitnessed Fall Report (Accident/Incident) and Summary of Report dated 08/20/2024 at 7:03 AM documented at around 7:03 AM Certified Nursing Assistant #1 observed Resident #1 on the floor in a right-side lying position on the right side of their bed bleeding from their nose. Body assessment revealed a hematoma to the forehead and bleeding from both nostrils. Resident #1 was transferred to the hospital. The facility investigation concluded that abuse, mistreatment, or neglect did not occur. The Hospital Discharge summary dated [DATE] documented Resident #1 had a computed tomography scan of the facial bone which showed a fracture of the right nasal bone. During an interview on 04/21/2025 at 2:39 PM, the Director of Nursing stated they were informed of the incident on 08/20/2024 by Registered Nurse Supervisor #1. The Director of Nursing stated that the facility was only aware Resident #1 had a nosebleed and that Resident #1 was transported to the hospital for medical evaluation. The Director of Nursing stated the incident was not reported to the New York Stated Department of Health because Resident #1 was on an anticoagulant and that there were no indications of a fracture. The Director of Nursing stated they became aware of the x-ray result and nasal fracture after receiving the Patient Review Instrument and the hospital discharge summary on 08/23/2024. The Director of Nursing stated the incident would have been reported to the Department of Health within 2 hours if the injury was of unknown origin or if they had suspected abuse. The Director of Nursing stated that their investigation concluded that abuse, mistreatment, or neglect did not occur. The Director of Nursing added that Resident #1's impaired cognition and being unaware of their surroundings might have contributed to fall. During a telephone interview on 04/29/2025 at 4:33 PM, the Administrator stated they were notified of the incident on 08/20/2024 at around 9:30 AM during their morning meeting. The Administrator stated it was determined that Resident #1 had an unwitnessed fall and was found on the floor. The facility was not aware Resident had a nasal fracture. The facility became aware three days after Resident #1 was discharged from the hospital. The Administrator stated when they became aware of the fracture on 08/23/2024, the timeframe had already passed, and they did not believe they needed to report the accident. 10 NYCRR 415.4 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during an abbreviated survey (NY00352779), the facility did not ensure that each resident received adequate supervision to prevent accidents. This was evident in one (1) out four (4) residents (Resident #1) sampled. Specifically, Resident #1 who was at risk for fall, was observed on the floor next to their bed bleeding from their nostrils at around 7:03 AM on 08/20/2024 during morning round. Resident #1 was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE] with diagnosis of nasal bone fracture. Record review of Resident #1's plan of care revealed Resident #1 has had multiple falls into their room, however, the facility had no documented evidence that the effectiveness of the interventions implemented were evaluated. Additionally, there were no documented evidence of the frequency of monitoring. The findings include: The facility's Policy and Procedure titled title Fall, Accident and Incident Report with a review date of 02/2024 documented that the Nursing Supervisor must be informed of any resident related incident. A fall risk assessment will be completed for all residents upon admission, readmission, quarterly, annually, significant change in status, and after an accident/Incident has occurred. The Registered Nurse will assess resident's condition and render immediate first aide. If Registered Nurse assess that resident's has a fracture or other injury which requires that the resident not be moved, the resident is to be kept as comfortable as possible until 911 arrives. The policy also states the accident/ incident will be investigated and report within 2-hours per New York State Department of Health regulations. Resident #1 was admitted to the facility on with diagnoses including Cerebral Ischemia, Cerebral Vascular Accident, Non-Alzheimer's Disease. The Minimum Data Set, an assessment tool, dated 05/09/2024 documented Resident #1 cognition was severely impaired. Resident #1 was non-ambulatory and used a wheelchair. Resident #1 was dependent on one staff for toileting and had had one fall. Resident #1 also required partial/moderate assistance for bed mobility. A Fall Risk Assessment/Safety Measures dated 02/16/2024 documented Resident #1 was at risk for fall related to confusion, mobility deficits, altered elimination status, medications and Cardiovascular accident. Safety measures implemented included orienting resident to their room, unit, safety precaution, call bell usage, call bell and frequently used items within reach, attempt to keep resident in high visibility area when out of bed, non-skid footwear, and Psych evaluation. The Fall Risk Assessment did not identify the level of fall risk. An Actual Fall Care Plan dated 03/30/2024 documented Resident #1 was observed on the floor on the left side of their bed. The resident was observed with a small bump on the left forehead. The interventions documented to monitor the resident every 30 minutes as order by Medical Doctor. The Resident Nursing Instruction dated 03/30/2024 documented fall precaution, frequent room checks for safety, ensure pathway in room clutter free, assist with toileting every 2-hours throughout the day and night for safety; toilet one assist early in the morning around 5:00 AM to 6:00 AM for safety and as needed. The Individual Monitoring sheet dated 03/30/2024 to 04/01/2024 showed Resident #1 was monitored every 30 minutes for 48-hours post fall. An updated Fall Care Plan dated 06/20/2024 at approximately 5:25 AM documented Resident #1 was observed lying on their left side next to their bed with no visible injury. The interventions documented to always keep room well lit, placed call bell within easy reach, placed bed in lowest position, and placed the resident in a high visibility area during waking hours for safety. The Individual Monitoring sheet dated 06/20/2024 at 5:45 AM to 06/22/2024 at 6:30 AM showed Resident #1 was monitored every 30 minutes for 48-hours post fall. The Resident Nursing Instruction dated 06/20/2024 documented fall precaution, frequent room checks for safety. Ensure pathway in room is clutter free. Assist to toilet every 2-hours throughout the day and night for safety. One assist for toileting early in the morning at around 5:00 AM to 6:00 AM for safety and as needed. A Nursing Progress note by Registered Nurse Supervisor #1 dated 08/20/2024 at 8:31 AM documented Resident #1 was lying on their right side in a pool of coagulating blood. An icepack was applied to the nose and face. Medical Doctor #1 was notified and ordered Resident #1 to be transferred to the hospital. A Nursing Progress late entry note dated 08/20/2024 at 8:39 PM by Licensed Practical Nurse #1 documented Resident #1 was observed lying on their right side (on the floor) on the right side of their bed. Resident #1 was alert with confusion. Resident #1 had a full body assessment done with positive range of motion to all extremities and was able to follow commands. Resident #1 had a hematoma to their forehead and was bleeding from both nostrils. A cold compress was applied, and neurological check was initiated. Resident #1 had no facial grimacing or grunting when checked for pain. An Unwitnessed Fall Report (Accident/Incident) and Summary of Report dated 08/20/2024 documented at around 7:03 AM Certified Nursing Assistant #1 observed Resident #1 on the floor in a right-side lying position on the right side of the bed with blood coming from their nose. Body assessment revealed a hematoma to the forehead and bleeding from both nostrils. Resident #1 was transferred to the hospital. The facility investigated the fall and concluded that abuse, mistreatment, or neglect did not occur. The updated Fall Care Plan dated 08/23/2024 documented Resident #1 was sent to the hospital and was admitted on [DATE] status post fall with nose bleeding. A computed tomography scan diagnostic test was and showed Resident #1 sustained a nasal bone fracture. Resident #1 was readmitted on [DATE]. Safety precaution maintained. Review of the Fall Risk Assessment interventions dated 03/30/2024, 06/06/2024, and 08/23/2024, revealed that the interventions remained the same. The interventions documented Orient the resident to room, unit, and safety precautions, call-bell usage, call-bell and frequently used items within reach, every 30 minutes monitoring times 48-hours, and physical/Occupation Screen/Evaluation. The facility did not have documented evidence that they evaluated the effectiveness of the interventions implemented. There was no documented evidence of the frequency of monitoring after 48-hours post fall. During a telephone interview on 04/24/2025 at 8:56 AM Certified Nursing Assistant #2 stated they were assigned to Resident #1 on 08/19/2024 from 11:00 PM-7:00 AM. Certified Nursing Assistant #2 stated at the beginning of their shift (at 11:00 PM) they notice Resident #1 kept hanging their feet off the bed while verbalizing ground. Certified Nursing Assistant #2 stated they informed assigned Registered Nurse #1 and that they stayed close by the resident's room for most of their shift. Certified Nursing Assistant #2 stated that they made rounds every 30 minutes for safety precaution. Certified Nursing Assistant #2 stated they provided care to Resident #1 between 5:00 AM-5:30 AM and left Resident #1 sleeping in bed that was in the lowest position. Certified Nursing Assistant #2 stated that they last saw Resident #1 at 6:35 AM sleeping. During a telephone interview on 04/23/2025 at 2:00 PM, Certified Nursing Assistant #1 stated during their morning rounds at the start of their shift at 7:00 AM, they observed Resident #1 lying on the floor next to the right side of their bed. Certified Nursing Assistant #1 stated Resident #1 had blood coming out of their nose and they immediately notified Licensed Practical Nurse #1. During a telephone interview on 04/24/2025 at 9:30 AM Registered Nurse #1 stated they were assigned to Resident #1 on 08/19/2024 on the 11:00 PM-7:00 AM shift. Registered Nurse #1 stated they were aware Resident #1 was confused and was on fall precaution. Registered Nurse #2 stated Resident #1 was frequently monitored by the assigned Certified Nursing Assistant #1 during their shift. Registered Nurse #1 stated they saw Resident #1 in their bed asleep at 6:00 AM during medication pass. Registered Nurse #1 stated at approximately 7:00 AM, Licensed Practical Nurse #1 who worked on the 7:00 AM - 3:00 PM shift informed them Resident #1 was observed on the floor. During an interview on 04/18/25 a5 2:52pm, Registered Nurse Supervisor #1 stated they were notified by Licensed Practical Nurse #1 (exact time unsure) that Resident #1 was found on the floor. Registered Nurse Supervisor #1 stated they went into Resident's room and observed Resident #1 lying on the floor in coagulated blood and bleeding from their nostrils. Registered Nurse Supervisor #1 stated they assessed Resident #1 and observed swelling to the resident's nose and forehead. Registered Nurse Supervisor #1 stated they applied an icepack to the nose and placed Resident #1 back in bed. Registered Nurse Supervisor #1 stated that the Physician ordered for Resident #1 to be transferred to the hospital for further evaluation. Registered Nurse Supervisor #1 stated that Resident #1 was kept in a highly visible area when they were out of bed and was monitored every 30 minutes to every hour. Registered Nurse Supervisor #1 stated that staff anticipated the resident's need and safety. Registered Nurse Supervisor #1 stated Resident #1's bed was kept in the lowest position and the call bell was within reach. During a telephone interview on 04/23/2025 at 11:12 AM the Assistant Risk Manager stated Resident #1 had severe cognitive impairment, dementia, unaware of their physical boundaries, and had a history of noncompliance to safety. They investigated the accident and abuse, mistreatment, and neglect was ruled out. The Assistant Risk Manager also stated Resident #1 was on visual monitoring. During an interview on 04/21/2025 at 2:39 PM, the Director of Nursing stated they were informed of the incident on 08/20/2024 by Registered Nurse Supervisor #1. The Director of Nursing stated after the resident fell on [DATE] and 06/20/2024 the resident was placed on every 30 minutes monitoring for two days to see if additional monitoring was need and no additional monitoring was no indication, and the resident remained safe for those two days. The Director of Nursing stated after the fall incident on 03/30/2024, Resident #1 was encouraged to stay in the dayroom with activities, but Resident #1 refused and wanted to stay in their room and that was when the fall occurred on 06/20/2024 incident occurred. The Director of Nursing stated they became aware of the x-ray result and nasal fracture after receiving the Patient Review Instrument and the hospital discharge summary on 08/23/2024. The Director of Nursing stated that the incident was not reportable because it was not an injury of unknown origin. The resident sustained the fracture from the fall. The Director of Nursing stated that their investigation concluded that abuse, mistreatment, or neglect did not occur. The Director of Nursing added that Resident #1's impaired cognition and being unaware of their surroundings contributed to fall. During a follow-up interview with the Director of Nursing on 05/20/2025 at 2:50 PM, the Director of Nursing stated that the Fall Risk Assessment does not capture the risk level jut the risk factors. The Director of Nursing stated that all the residents in the facility is at risk for fall. During a telephone interview on 04/28/25 at 2:07PM, the Assistant Director of Nursing stated on 08/20/24 at 9:00 AM they received a report that Resident #1 was transfer the hospital for nosebleed after being observed on the floor. Resident #1 resided in a private room that was close to the nursing station. The Assistant Director of Nursing stated Resident #1's unawareness of their physical surroundings and impaired balance and gait might have contributed to the fall. The Assistant Director of Nursing stated they initiated 30 minutes monitoring for 48-hours after Resident #1 was re-admitted on [DATE], ensuring safety. The Assistant Director of Nursing stated Resident #1 was also offered toileting every 2-hours to see if their toileting needs had change from 5:00 AM-6:00 AM and staff to anticipate toileting needs every two-hours. The Assistant Director of Nursing stated most of Resident #1's fall was between 5:00 AM and 7:00 AM and that staff performs frequent rounds to anticipate Resident needs. The Director of Nursing stated Resident #1 was frequently monitor by the validation of the unit nurse who ensures that the assigned staff are adhering to Resident Nursing Instruction and signing of the Resident Nursing Instruction. The Assistant Director of Nursing stated Certified Nursing Assistants have been educated and instructed to let the nurses know any changes in Resident's condition immediately. The Assistant Director of Nursing stated frequent monitoring means every 2-hours and that is the facility's standard of time for monitoring Resident #1. 10NYCRR415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification survey from 03/04/2024 to 03/08/2024, the facility did not ensure that the resident's right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences was maintained. This was evident for 1 of 1 resident reviewed for Accommodation of Needs out of 38 sampled residents. Specifically, Resident #186 was not able to enter the bathroom in their room. The closet, which was placed in a corner of the resident's room, prevented the bathroom door from opening fully to permit Resident #186 to enter the bathroom in their wheelchair. The findings are: The facility policy and procedure titled Routine Maintenance revised 12/23 documented that the maintenance department will ensure that the physical environment, furniture, and equipment is maintained in good repair throughout the facility. The routine maintenance program will ensure a safe and comfortable environment for residents and staff by maintaining the facility in good repair and free of hazards as well maintaining compliance with all applicable codes. Resident #186 was admitted with diagnoses including Paraplegia, Depression and Neurogenic Bladder. The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #186 as cognitively intact and required set up with oral hygiene, personal hygiene, substantial/maximal assistance with toileting, hygiene, and supervision with bed mobility. During an interview on 03/05/24 at 09:52 AM, Resident #186 stated that they can go in and out of bed, but they cannot get into the bathroom because the closet door blocks the door from opening wide enough for them to get in there while in their wheelchair. Resident #186 also stated that although they are unable to use the bathroom, they would prefer to empty the urinal themselves but instead must wait for staff to empty it for them and this can take a long time on some days. Resident #186 further stated that if they wanted to wash their hands, they would use handwipes or a basin with water provided by staff because they cannot get into the bathroom. On 03/05/24 at 09:52 AM, the bathroom door was observed ajar, however the door could not open fully as the closet protruded from the corner and prevented full opening to permit access to the bathroom for Resident #186 who ambulates via wheelchair. During multiple observations from 3/5/24 to 3/8/24, the closet remained in the same place preventing full opening of the bathroom door. On 03/07/24 at 11:19 AM, Certified Nursing Assistant #24 was interviewed and stated that Resident #186 transfers themselves from the bed to the wheelchair. Certified Nursing Assistant #24 also stated that Resident #186 would not be able to open the door to the bathroom because the closet is blocking it from opening. Certified Nursing Assistant #24 stated that they had not reported that issue to anyone, but that maintenance would be responsible for taking care of a situation like that. Certified Nursing Assistant #24 further stated that Resident #186 is given a water and a basin to wash their hands, and the resident always has wipes for their hands. During an interview on 03/08/24 at 11:42 AM, the Director of Environmental Services stated that they make rounds on all resident units daily. They make a list of any concerns in all common areas, check the books on the unit, walk through the corridors, and then assign anything that needs to be fixed. The Director of Environmental Services also stated that they check individual rooms twice a week and look for any type of safety hazards. If there are any concerns they are informed by the nurses or the residents. The Director of Environmental Services further stated that they do not go into resident's rooms unless they are called, was not aware of the situation in Resident #186's room, and furniture should have been placed differently in the room to allow Resident #186 to access the bathroom. 10 NYCRR 415.5(e)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The policy titled Routine Maintenance revised 12/23 documented that the maintenance department will ensure that the physical environment, furniture, and equipment is maintained in good repair throughout the facility. The routine maintenance program will ensure a safe and comfortable environment for residents and staff by maintaining the facility in good repair and free of hazards as well maintaining compliance with all applicable codes. On 03/05/24 at 10:14 AM, the bathroom faucet in room [ROOM NUMBER] was observed to be dripping continuously, a white plastic pipe cover was laying on bathroom floor under the sink, and a ceiling tile was observed stained with brown colored substance. Resident #186 stated that the facility was aware of it, but they did not report it to anyone because they are not able to access the bathroom. Review of Maintenance/Work Order book on 3rd contained no documentation regarding the leaking faucet or loose pipe covering in room [ROOM NUMBER]. During an interview on 03/08/24 at 11:18 AM, Housekeeper #2 stated that their job is to clean the rooms, dust, pick up the garbage, clean window sills, shower room, and bathroom. Housekeeper #2 also stated that anyone who sees any issue can log into the maintenance book because it is everybody's responsibility. Housekeeper #2 further stated that the leaking faucet in Resident #186 room has been an on and off issue, and they report have reported it to maintenance who came and fixed it. During an interview on 03/08/24 at 11:39 AM, Maintenance Technician #2 stated that they were the regular assign to the unit and stated that when they come in the facility, they check the book daily and reviews the work report to determine which issues to prioritize. Maintenance Technician #2 also stated that the leaking faucet was considered a priority but they were not aware of any leaking faucets on unit 3 recently. During an interview on 03/08/24 at 11:42 AM, the Director of Environmental Services stated that they begin facility rounds at 6:00 AM each day and they make a list what they see in common areas, then they check the book, and they distribute the list of work to their staff. The Director of Environmental Services also stated that twice a week they go to each room to check for any safety hazards. The Director of Environmental Services further stated that no one told them about the leaking faucet in room [ROOM NUMBER]. 3. The policy titled Linen Par Levels revised 12/2023 documented that it is the policy of the facility to ensure par levels and an emergency supply of items (example: linen, briefs) are adequately maintained to meet the needed demand of the facility's census. The facility is responsible for delivering the right amount and correct type of such items needed for the units. On 03/07/24 at 11:46 AM, Certified Nursing Assistant #21 stated that they do not receive chucks (disposable pads used in the beds of residents who are incontinent) in the morning, and if so, they get one chuck for 8 residents on their assignment. Certified Nursing Assistant #21 also stated that when they work on the evening shift, they received 2 chucks with 12 residents in their assignment and they have to decide which of the 12 resident to give the two chucks to. During an interview on 03/07/24 at 12:00 PM, Resident #165 stated that they heard that other residents were buying their own chucks. During an interview on 03/07/24 at 12:20 PM, Registered Nurse #5 stated that they have scant number of chucks and some residents purchase their own chucks. During an interview on 03/08/24 at 08:48 AM, Central Supply/Purchasing Clerk stated that they order medical supplies for the building, and order 8 boxes of chucks every week. Each box contains 10 bags with 10 chucks per bag for a total of 800 chucks per week. During an interview on 03/08/24 at 08:57 AM, Housekeeping Aide stated that the linens come every morning except holidays. The Housekeeping Aide also stated that the chucks and incontinent briefs are delivered on Thursday and are distributed as follows: 7AM-3PM 3rd Floor= 20, 6th Floor =0, 5th Floor=10, 4th Floor=0, 2nd Floor=10. 3PM-11PM 3rd Floor=10, 6th Floor=10, 5th Floor=10, 4 Floor=0, 2nd Floor=0 11PM-7AM 3rd Floor=10, 6th Floor=10, 5th Floor=10, 4 Floor=0, 2nd Floor=0. The Housekeeping Aide also stated that they always try to leave a box out in case the staff need and in the past they used to get a larger number of chucks. Housekeeping Aide stated that they order 8 boxes only because that was the PAR. The Housekeeping Aide stated that the 2nd and 4th floor did not usually get chucks because the residents were independent and mostly continent, but that is not the case anymore and they now need more chucks. The Housekeeping Aide stated that they barely have enough supplies to make it to each Thursday, and they have had a couple of bad weeks where I have run out. The Housekeeping Aide also stated that they do not have an emergency supply and are scared when there is a storm because the facility is in Zone 2. The Housekeeping Aide stated that the number of chucks ordered has been 800 for the past 5 or 6 years despite the type of residents changing. The Assistant Director of Nursing provided a document that documented the following: Incontinent Resident per unit: 2nd floor= 17 residents 3rd floor= 34 4th floor= 23 5th floor= 40 6th floor= 37 During an interview on 03/08/24 at 10:05 AM, the Housekeeping Supervisor stated that they get a certain amount of chucks every month based on the census and if they needed more, they contact the company. Housekeeping Supervisor stated that they have good supply of chucks, and each shift has different supply. Housekeeping Supervisor stated that the Director of Nursing will notify them if they need a larger supply of chucks. The Housekeeping Supervisor stated that sometimes the Certified Nursing Assistants on Unit 2 and 4 inform them that they need more chucks, and they bring them on the unit. During an interview on 03/08/24 at 09:36 AM, the Director of Nursing stated that the housekeeping staff does the ordering of chucks and incontinent briefs and deliver them to the units. The Director of Nursing also stated that as the census changes, the PAR level changes to accommodate residents. The Director of Nursing further stated that if their Certified Nursing Assistants inform them that the supply is not enough, the Director of Nursing communicates directly to the Administrator and housekeeping. The Director of Nursing stated that they have bariatric residents who ask for chucks and when they do, they provide them. The Director of Nursing also stated that if the resident is continent and asking for chucks, they educate them and still provide them. The Director of Nursing stated that primarily it is the bariatric residents who are provided with chucks. 10 NYCRR 415.12(h)(1)(2)(3) Based on observation, record review, and interviews conducted during the Recertification survey from 3/04/2024 to 3/08/2024, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident on 4 of 5 resident floors (Floors 3, 4, 5 and 6) during review of the Environment. Specifically, 1) Air Conditioning/Heating (AC/H) units were noted to have dirty with debris and in disrepair, missing baseboards in multiple resident rooms and a room noted with discolored floor tiles and a persistent urine odor in a Resident's room, 2) a resident room with a persistently dripping faucet, and 3) a room that did not accommodate resident preference to use toilet in their room. The findings are: #1.On 03/04/2024 at 07:56 AM, On 03/05/2024 at 11:30 AM, 03/06/2024 at 11:56AM and 04:45PM and 03/08/2024 at 11:29 AM, room [ROOM NUMBER] was observed with missing baseboards, ripped wallpaper approximately 6 inches to left of headboard and by AC/heater unit at wall. On 03/04/2024 at 08:01 AM, in room [ROOM NUMBER] there was torn veneer on sitting chair, baseboards in room with brown and black colored debris. On 03/04/2024 at 08:19 AM, in room [ROOM NUMBER] the bathroom tiles surrounding toilet had holes approximately 2 inches to right and 4 areas approximately 1 inch x 2 inches and a hole in tile under sink where pipe is. On 03/04/2024 at 08:29 AM, room [ROOM NUMBER] the mounted air conditioning/heater unit has cracks in dry wall (approximately 7 inches x ¼ inch to 1-inch, top edge crack in dry wall 3 width x 2 inches right side) and a brown colored water stain in the dry wall. On 03/04/2024 at 08:34 AM, room [ROOM NUMBER] the bathroom tile with grimy black colored edges. On 03/04/2024 at 08:42 AM, room [ROOM NUMBER] the bathroom wall has a hole approximately 4 inches width x 3 inches height. Missing tile on bottom edge at door entrance to the bathroom. On 03/04/2024 at 09:03 AM, in room [ROOM NUMBER], there was missing dry wall by the headboard, missing base board on wall under air conditioning/heater unit and black colored and the bedside table cracked veneer. On 03/04/2024 at 09:08 AM, room [ROOM NUMBER] the base board tile raised to left entrance of room door. On 03/07/2024 at 09:56 AM, the 5th floor dining room/pantry was observed, and the air conditioning/heater had a crack in top edge that was held by silver tape black colored debris, paper and food debris and the grate area was dust by refrigerator side. On 03/07/24 10:05 AM, the 4th floor dining room/pantry was observed the air conditioning/heater unit noted with gray colored dust on top edge by wall, food debris, dust and paper debris in vent area, peeling silver tape with black colored debris and or food debris. The second air conditioning/heater unit had a gray basin underneath it and a piece of wood under right side. On 03/08/2024 at 11:22 AM, the 4th floor dining room/pantry was observed the refrigerator was observed with the bottom edge with brown colored rusty area. The debris noted the air conditioning/heater unit and peeling metal foil tape. On 03/08/2024 at 11:03 AM, the 3rd floor dining room/pantry was observed the air conditioning/ heater units was observed with gray colored debris, gray colored dust, food debris and pieces of paper on vent slats, edges that were not affixed to the unit tightly. The second units noted with gray colored dust in middle, the top edge not tightly affixed. A resident sitting in the day room stated that the air conditioning/ heater unit don't work. On 03/08/2024 at 11:12 AM, the 2nd Floor dining room was observed the refrigerator was noted with rusty brown colored bottom edge below the refrigerator door. Peeling baseboard under the hand washing sink, air conditioning/heater units with silver tape with black colored buildup on some grates of the air conditioner/heater unit. Ripped veneer noted on a green sitting chair was noted on the left to middle and back right top edge and a bariatric siting chair was noted with a rip on the bottom edge. On 03/04/24 at 08:45 AM and 03/04/24 02:41 PM, in room [ROOM NUMBER] the bathroom tile noted with light black colored debris on tile, wet brown colored, room smells like urine and bedside table missing cream paint on bottom edge (middle 1/2 On 03/05/24 at 11:40 AM, 03/06/2024 at 11:58 AM, 03/06/24 04:48 PM, and 03/07/24 at 10:26 AM there was a urine-like odor detected in the room. On 03/08/2024 at 11:37 AM, Housekeeper #1 was interviewed and stated that room [ROOM NUMBER] is cleaned daily, and this is the last room they clean because the resident urinates on the floor and will not let them touch anything, but they will let them clean their bathroom states will clean their room self. The room needs to be clean because of germs and the food no good and they will eat it. On 03/08/2024 at 01:43 PM, the Director of Maintenance was interviewed and stated that they do environmental rounds every 2 weeks and they do not look at individual resident rooms unless they are invited to take a look at a resident's room. The air conditioning/heater unit's vents and screens are cleaned once a month. When an air conditioning/ heater unit is replaced they put the metal tape on it to keep the drafts from the resident. They look at dining room area every month and they did not notice rust on the bottom edge of the refrigerator. They stated that they have 12 air conditioning units on order and when they get them, they will change the units. They stated that they have started some environmental projects in the building where they have ripped out the walls, sanded and plastering is planned for building repairs and the repair were started on the 6th floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Complaint (NY00326272) survey from 03/04/2024 to 03/08/2024, the facility did not ensure that a resident was free from misappropriation of property. This was evident for 1 (Resident # 172) of 3 residents reviewed for Abuse out of 38 total sampled residents. Specifically, a Certified Nursing Assistant used Resident #172's Electronic Benefit Transfer (EBT) card to purchase items totaling about $1000.00 without Resident #172's consent. The findings are: The facility policy titled Abuse Prevention with effective date 2/2022 and last review 10/2023 documented the resident will be protected from misappropriation of resident property. It also documented the misappropriation of resident property means deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Resident #172 had diagnoses which included chronic respiratory failure, chronic combined systolic and diastolic heart failure, and chronic obstructive pulmonary disease. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #172 was cognitively intact and did not have any behavior symptoms towards others. The Comprehensive Care Plan related to Abuse/Neglect: At risk for abuse/neglect initiated 8/25/22 and last updated 12/22/23 documented interventions which included to in-service staff on abuse/neglect, investigate accident as needed, and maintain a safe environment at all times. On 03/04/24 at 07:04 AM, Resident #172 was interviewed and stated their Electronic Benefit Transfer card was stolen and about $1,000 was used during their hospitalization from 9/16/23 to 9/25/23. Resident #172 called Human Resource Administration and was directed to report the theft to the police which they did. Resident #172 also stated that the alleged Certified Nursing Assistant #16 was arrested by the police after the investigation, and they received a letter dated 2/5/24 to inform them that an order of protection had been issued. The Complaint/Grievance Form dated 10/17/23 documented Resident #172 reported on 10/17/23 that they were missing their Electronic Benefit Transfer card, social security card, and birth certificate from their pocketbook. Resident #172 stated these items were found missing on 9/26/23 and they did not inform the facility until 10/17/23. Resident #172 informed the Social Worker that they were in the hospital from [DATE] to 9/25/23 and left their pocketbook in the room. The Social Worker was made aware of the misappropriation on 10/17/23 after the police arrived for investigation. The police identified and arrested a suspect. A statement by the Director of Nursing documented that they made follow up call with a detective from the New York City Police Department on 10/17/23. The Certified Nursing Assistant #16 admitted to the police that they used Resident #172's Electronic Benefit Transfer card without Resident #172's consent. Certified Nursing Assistant #16 was removed from the schedule indefinitely. The facility Summary of Investigation dated 10/18/23 documented Resident #172 was admitted to the hospital on [DATE] and was re-admitted to facility on 9/25/23. Resident #172 found their Electronic Benefit Transfer card was missing on 9/26/23 and contacted Human Resource Administration (HRA) on 9/27/23. Resident #172 filed a police report as per Human Resource Administration instructions. The facility investigation documented that the facility had an onsite visit from the police on 10/17/23 to identify Certified Nursing Assistant #16. The police informed the facility that they had video surveillance showing Certified Nursing Assistant #16 utilizing Resident #172's missing Electronic Benefit Transfer card. The Certified Nursing Assistant #16 was immediately arrested and removed from the premises by the New York City Police Department. The facility investigation also documented the Director of Nursing followed up with the New York City Police Department and was informed the Certified Nursing Assistant # 16 had admitted using Resident #172's Electronic Benefit Transfer card without Resident #172's consent. The facility made several attempts to contact Certified Nursing Assistant #16 via telephone and were not successful. A letter dated 1/5/2024 was sent to the Certified Nursing Assistant # 16 to inform their employment with the facility was terminated immediately. The cause for the termination was due to their involvement of misappropriation of resident's property. The Core Competency assessment dated [DATE] documented that Certified Nursing Assistant #16 demonstrated understanding that included the Elder Justice Act, Abuse Prevention and Reporting, and Code of Conduct. The Job description for Certified Nurse Aide with reviewed date 01/2021 documented under specific requirement that the Certified Nurse Aide must be free of any criminal activity which could pose a danger to the safety and wellbeing of residents or the facility. It was signed by the Certified Nursing Assistant #16 in 6-2021. On 03/05/24 at 11:30 AM and 03/06/24 at 03:03 PM, Certified Nursing Assistant #16 was called, no one answered the calls, and calls were forwarded to a voice mail box. Voice messages were left and requested a call back. Certified Nursing Assistant #16 did not return either call. On 03/06/24 at 02:32 PM, the Human Resources Coordinator was interviewed and stated that Certified Nursing Assistant #16 was hired as a housekeeping staff on 10/1/2003 and switched to Certified Nursing Assistant on 3/1/2004. The Human Resources Coordinator also stated they did the criminal results check for the Certified Nursing Assistant before hiring them as staff, and they did not have any report of resident property misappropriation against them before. Certified Nursing Assistant #16 was terminated due to misappropriation of Resident #172's property. The Human Resources Coordinator further stated that they were not able to reach Certified Nursing Assistant #16 after their removal from the facility by the police on 10/17/23. On 03/06/24 at 03:15 PM, the Director of Nursing was interviewed and stated the police came to the facility in the evening on 10/17/24. The police showed them a videotape footage for them to determine if the person on the video worked at the facility. The Director of Nursing recognized the person in the video as Certified Nursing Assistant #16. And the police arrested Certified Nursing Assistant #16. The Director of Nursing also stated that they followed up with the police after few days and was informed the police had videotaped evidence of Certified Nursing Assistant #16 using Resident #172's Electronic Benefit Transfer card at a store, and Certified Nursing Assistant #16 admitted using Resident #172's card without Resident #172's consent. The Director of Nursing stated that Certified Nursing Assistant #16 was terminated based on their removal by the police from the facility on 10/17/24 and the information obtained from the police. The Director of Nursing also stated they did not have a statement from Certified Nursing Assistant #16 before they were removed from the facility by the police, and they were not able to reach Certified Nursing Assistant #16 by calls afterwards. 10 NYCRR 415.4(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification survey from 03/04/2024 to 03/08/2024, the facility did not ensure an effective discharge planning process was developed and implemented. This was evident for 1 (Resident #186) of 1 resident reviewed for Discharge out of 38 total sampled residents. Specifically, there was no documentation of additional follow-up on a discharge referral for Resident #186. The findings are: The policy titled Discharge Planning/Implementation dated 10/2023 documented that it is the policy of the facility that the Social Work department, along with the Interdisciplinary Team, begin discharge planning for each resident upon admission to the facility. Discharge planning options are also reviewed during quarterly and annual comprehensive care plan meetings. The policy also documented that the Social Worker would maintain contact with the Interdisciplinary team to facilitate an appropriate discharge for the resident and ample time to coordinate plans with the resident's designated representative and appropriate community agencies. Resident #186 was admitted with diagnoses including Paraplegia, Depression, and Neurogenic Bladder. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #186 was cognitively intact, no one participated in assessment and goal planning, discharge plan was not occurring for Resident #186 to return to the community, and Resident #186 wanted to be asked about discharge planning. During an interview on 03/05/24 at 09:58 AM, Resident #186 stated that they are trying to help from the Social Worker to get back into the community and that Social Worker #3 told Resident #186 that was not their job and that they would need to call the agency themselves. Resident #186 also stated they called the agency themselves last month and was told that the Social Worker must make the referral for them. The Social Worker note dated 01/11/23 documented that per Resident Representative requested to continue to look for transfer to facilities closer to them. Resident #186 Patient Review Instrument (PRI) was faxed to 3 facilities. Confirmation receipts for all 3 obtained. Disposition pending for all 3 facilities pending. The Social Worker note dated 02/21/23 documented met Resident Representative today to discuss transferring Resident #186 as previously requested. Social Worker sat with Resident Representative and went through different facilities. Another Patient Review Instrument (PRI) was completed and will be sent to the 7 facilities that were picked. Social Worker will continue to follow up. There was no additional follow-up documented until 02/12/24. There was no care plan created for discharge planning. The Social Worker note dated 02/12/24 at 04:49 PM documented Resident #186 was referred to a community support agency. Resident #186 informed Social Worker that their worker from the community support agency wanted to speak to the Social Worker regarding the referral for Resident #186. The note also documented that the Social Worker spoke to the community support agency, and they indicated that Resident #186 was not returning their calls and was no longer on their case load. Another referral was sent. The community support agency's Referral Form dated 02/12/24 documented that a referral was made, and Resident #186 was referred before. An email from the community support agency dated 02/13/24 documented the referral for Resident #186 was received and entered. It was documented that Resident #186 has an active case with the agency. The email also documented that they provided Transition Specialist and their Supervisor. The email stated that Social Worker #3 can communicate directly with the Transition Specialist and their Supervisor to discuss discharge planning and any barriers which may exist. There was no documented evidence of follow up after the email received from the community support agency dated 2/13/24. During an interview on 03/07/24 at 02:39 PM, Social Worker #3 stated that the first referral to the community support agency was made on 08/10/23 when Resident #186 expressed interest in affordable housing. Social Worker #3 also stated that a representative from the agency contacted Resident #186 resident and they were referred for a second time on 02/12/24. Social Worker #3 said they would check to see if there was any further follow up after the 02/13/24 correspondence. Social Worker #3 did not return to survey team with additional information. During an interview on 03/08/24 at 12:30 PM, Social Worker #2 stated in the absence of Social Worker #3 they would check if there was any follow up on any additional correspondence but they were not able to locate any additional correspondence. On 03/08/24 at 04:00 PM, Social Worker #2 stated that they could not locate a care plan for discharge planning, and one should have been created for this resident by a Social Worker. 10 NYCRR 415.11(d)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification and Complaint Survey, from 03/04/2024 to 03/08/2024, the facility did not provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice, and the resident's care plan. This was evident for 1(Resident #225) of 3 residents reviewed for Respiratory Care out of 38 total sampled residents. Specifically, Resident #225's oxygen cannula/tubing was found on the floor on multiple days, and there was no date on the tubing indicating when the tubing was changed. The findings are: The facility policy Care of Oxygen-Nasal Cannula revised 09/2023, included that oxygen tubing/cannula must not be permitted to touch the floor and to document date and initial on tape attach to the tubing/cannula when changed. If the cannula/tubing touches the floor, it should be changed immediately. Resident #225 had diagnoses including mild intermittent Asthma with (acute)exacerbation, and Chronic Obstructive Pulmonary Disease. The Minimum Data Set assessment dated [DATE], documented that the resident had moderate impaired cognitive skills for daily decision making, needs substantial/maximal assistance for sit to stand, chair/bed-to-chair transfer, they were receiving Oxygen therapy. The Physician orders dated 01/31/2024 included to administer Oxygen per nasal cannula at 2 liters per minute every shift. The Comprehensive Care Plan revealed that Resident #225 was to receive Oxygen via nasal cannula at 2 liters per minute every shift for asthma. On 03/04/24 at 08:35 AM, Resident #225 was receiving Oxygen via nasal cannula and the tubing was observed lying on the floor. There was no date or staff initial on the tubing. On 03/05/24 at 12:34 PM, Resident #225 was seated in wheelchair with Oxygen via nasal cannula attached to portable oxygen tank. There was no date observed on the oxygen tubing. On 03/06/24 at 04:35 PM, Resident #225 was in the room with Registered Nurse #9. The oxygen tubing was observed lying on the floor, no date nor staff initial on the tubing. On 03/07/24 at 10:42 AM, Resident #225 was observed in bed receiving oxygen via nasal canula. The oxygen tubing was observed lying on the floor and no date was observed on the tubing. During an interview on 03/07/24 at 11:43 AM, Registered Nurse #8, stated that they did observe Resident #225's oxygen tubing touching the floor and there was no date or staff initial on the tubing. Registered Nurse #8 also stated that they did not know why the oxygen tubing has no label as it should be labeled as per policy, and going forward they will make sure the tubing has date and staff initial. During an interview on 03/07/24 at 11:48 AM, Licensed Practical Nurse #6, stated they observed the oxygen tubing had no date and was touching the floor, so they and Registered Nurse #8 lifted the tubing because it was touching the floor and immediately placed a label on the tubing. During an interview conducted on 03/08/2024 at 1:00 PM, the Director of Nursing, who is also the Infection Preventionist, stated that the Registered Nurse Supervisor makes frequent rounds on the unit making sure infection control practices are observed. This includes changing and labeling oxygen tubing and making sure oxygen tubing is not in contact with the floor. The Director of Nursing further stated that they were not aware that Resident #225's oxygen tubing was not labeled or dated and was lying on the floor. The Director of Nursing also stated that the Registered Nurse Supervisor will give staff education immediately to prevent that occurring again. NYCRR 415.12(K)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification and Complaint (NY00327102) survey from 03/04/2024 to 03/08/2024, the facility did not ensure that a resident with missing dentures was promptly referred for dental evaluation. This was evident for 1 (Resident #9) of 5 residents reviewed for Dental out of 38 sampled residents. Specifically, the facility policy did not identify those circumstances when the loss or damage of dentures is the facility's responsibility. The findings are: The facility policy titled Dental Services revised 12/23 it is the policy that resident complaining of toothache or other oral problems, or with broken, ill-fitting, or missing dentures will be referred to the dentist for evaluation and treatment within 3 days. In the event that dentures are lost or broken, a grievance report will be completed, and the matter investigated within 3 days. Resident #9 had diagnoses of Bipolar Disorder, Morbid Obesity, and COPD. The Minimum Data Set (MDS) dated [DATE] documented Resident #9 was cognitively intact. The Comprehensive Care Plan Titled Dental Care effective 5/24/18 revised 1/22/24 documented Resident #9 will be free of oral/dental pain and discomfort x 90 days. Interventions included assist with or provide oral hygiene daily to prevent infection and cavities, observe for changes in resident's ability to chew food and notify Medical Doctor, refer for dental services. During an interview on 03/04/24 at 10:21 AM, Resident #9 stated that they lost their dentures on the 3rd floor right before they were transferred to the 5th floor like a month ago. Resident #9 also stated that they went to the hospital for a week and the dentures were never found. Resident #9 further stated that they were told that the dentures could not be replaced for 5 years. Resident #9 was observed on multiple occasions from 03/04/24 at 10:21 AM through 03/07/2024 at 9:18 AM with no dentures in their mouth. On 03/07/2024 at 9:18 AM, Resident #9 stated that they had filed grievance regarding their missing dentures and but had not been seen by the dentist yet. The facility Complaint/Grievance Form dated 01/09/24 documented that Resident #9 reported on 01/08/24 that they lost their dentures approximately 1 month ago. Investigation initiated by Director of Nursing dated 01/11/24 documented Resident #1 reported missing dentures for a month. Resident #9 continues to tolerate prescribed diet and oral intake was not affected. Rooms were checked and dentures were not found. Social Worker documented Resident #9 was referred to dentist for consult and possible replacement. Dentist reports on 01/09/24 that Resident #9 was provided new dentures 3 years ago and Resident #9 insurance does not cover replacement until after 8 years. The resolution rejected by Resident #9. Investigation concluded that there was no reasonable suspicion of misappropriation of Resident #9's personal property. Resident #9 refused to sign dated 01/18/24. Dental consult dated 05/05/23 documented annual exam. Resident #9 refused. Reviewed medical/dental history, fully edentulous. There was no documented evidence that Resident #9 had been evaluated by the dentist following loss of their dentures. Speech Therapy note dated 01/10/24 at 11:26am documented Resident #9 tolerated trials with regular consistency with effective bolus formation and oral clearance. Recommended to continue a regular consistency diet with thin liquids. The facility policy did not identify those circumstances when the loss or damage of dentures is the facility's responsibility. During an interview on 03/08/24 at 01:37 PM, Director of Nursing stated that they have dentist that comes once a week. The Director of Nursing stated that if dentures were missing, they order speech evaluation, dietitian, and dental referral. The Director of Nursing stated that the dentist had records that Resident #9 did not qualify for replacement and it is up to the administration to replace them. The Director of Nursing stated that they would check the facility policy to see where it outlines who is responsible for replacing dentures, but they did not provide documentation that this information was included in the current facility policy. During an interview on 03/08/24 at 01:39 PM, the Administrator stated that if anything comes up will undergo grievance process and would receive the final report. The Administrator also stated that they collaborate with the team, and they will replace. The Administrator further stated that they would check the facility policy to see where it outlines who is responsible for replacing dentures, but they did not provide documentation that this information was included in the current facility policy. 10 NYCRR 415.17(a-d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #165 had diagnoses that included Adjustment Disorder, Morbid Obesity and Spinal Stenosis. The Annual Minimum Date Set dated 02/07/24 documented Resident #165 was cognitively intact and required dependent assistance with toileting hygiene, showering, lower body dressing, bed mobility, and substantial/maximal assistance with upper body dressing and personal hygiene. The Annual Minimum Date Set also documented that Resident #165 was always incontinent of bowel and bladder. The Comprehensive Care Plan for Bowel Incontinence dated 06/14/23 revised 01/30/24 with goals resident will be free of skin breakdown secondary to incontinence. Interventions to check and change incontinence briefs every 2-4 hours and as needed and lubricate skin every shift and as needed. The Comprehensive Care Plan for Activities of Daily Living Function/Rehabilitation Potential dated 01/31/24 revised 03/04/24 with goals that resident will improve mobility functional abilities. Interventions to encourage resident to perform mobility as independently as possible, observe for safety and monitor for decline in mobility function. The Certified Nursing Assistant Documentation Record for January 2024 contained no documentation for personal hygiene given on 7 occasions on the 7:00 AM-3:00 PM shift, 9 occasions not performed and not documented on 5 occasions on the 3:00 PM-11:00 PM shift, and 14 occasions not performed, and 5 occasions not documented and 1 refusal on 11:00 PM -7:00 AM shift. Toilet use was not documented on 7 occasions on the 7:00AM - 3:00 PM shift, 5 occasions on the 3:00 PM- 11:00 PM shift, 5 occasions on the 11:00 PM- 7:00 AM shift and not performed on 1 occasion on the 11:00 PM -7:00 AM shift. On The Certified Nursing Assistant Documentation Record for February 2024, personal hygiene was not documented on 6 occasions on 7:00 AM-3:00 PM shift, 4 occasions on 3:00 PM -11:00 PM shift and 6 occasions on 11:00 PM-7:00 AM shift. Toilet use was not documented on 6 occasions on the 7:00 AM - 3:00 PM shift, 4 occasions on 3:00 PM- 11:00 PM shift and 6 occasions on 11:00 PM -7:00 AM shift. During observation from 03/04/24 through 03/08/24, Resident #165 was observed in bed throughout the days of observation and was never seen out of bed. During an interview on 03/04/24 at 11:46 AM, Resident #165 stated that staff were always short in all shifts, and when staff were short, they must wait. Resident #165 stated that the weekends had the worst staffing particularly on the day shift. Resident #165 stated that last Friday after the 3:00 PM to 11:00 PM shift, the next morning their incontinent brief was changed at 4:00 AM, then Saturday after between 2:30 PM or 3:30 PM. Resident #165 said that they have no problem with their regular aide but when they have floater, they always say to Resident #165 that they will come back. Resident #165 stated that when there was one Certified Nursing Assistant on the unit on the 3:00 PM to 11:00 PM shift they were not changed at all. Resident #165 stated that they get them out of bed before the end of the morning shift and the staff on the next shift will put them back to bed. During an interview on 03/07/24 at 11:46 AM, Certified Nursing Assistant #21 stated that Resident #165 is able to help them wash their face, upper body and both arms but requires total care for the lower part of their body and for toileting. Certified Nursing Assistant #21 also stated that Resident #165 urinates a lot and they try to change them 2 times in their shift but sometimes they are only able to change once. Certified Nursing Assistant #21 further stated that when they are short of staff, they cannot give full care to their residents. Certified Nursing Assistant #21 also stated that when staff calls out, they get extra residents in their assignment. Certified Nursing Assistant #21 said that weekends were always short and getting residents out of bed was tough and residents get agitated. Certified Nursing Assistant #21 stated that on some weekends they do not get up residents because of shortage of staff. 3. Resident #98 had diagnoses of Anxiety Disorder, Depression, Chronic Obstructive Pulmonary Disease and Morbid Obesity. The Quarterly Minimum Data Set, dated [DATE] documented Resident #98 was cognitively intact, required dependent assistance with toileting hygiene, shower, lower body dressing, bed mobility, partial/moderate assistance with upper body dressing, personal hygiene and was always incontinent of bowel and bladder. The Comprehensive Care Plan for Activities of Daily Living Function/ Rehabilitation Potential dated 08/13/18 revised 01/10/24 with goal resident will be clean, dry, and groomed daily x 90 days. Interventions included encourage resident to participate in activities of daily living as per ability, provide assist for dressing, bathing, toileting, personal, hygiene and grooming and provide shower/bed bath twice a week and as needed. On the Certified Nursing Assistant Documentation Record for January 2024, personal hygiene was not documented on 11 occasions on the 7:00 AM-3:00 PM shift and on 1 occasion on the 11:00 PM-7:00 AM shift. Toilet use was not documented on 12 occasions during the morning shift (time 1:00 PM-3:00 PM), 3 occasions on the evening shift (9:00 PM- 11:00 PM) and 1 occasion on the night shift (5:00 AM -7:00 AM). On the Certified Nursing Assistant Documentation Record for February 2024, personal hygiene was not documented on 13 occasions on the 7:00 AM-3:00 PM shift, 2 occasions on the 3:00 PM- 11:00 PM shift and 4 occasions on the 11:00 PM-7:00 AM shift. Toilet use was not documented on 15 occasions in the morning shift (time 1:00 PM-3:00 PM), 6 occasions on the evening shift (9:00 PM- 11:00 PM) and 10 occasions on the night shift (5:00 AM -7:00 AM). During an interview on 03/04/24 at 12:39 PM, Resident #98 stated that they do not get help right away and this has been happening for the last 6 months. Resident #98 also stated that on the night shift they must wait for over an hour to be changed and staffing was very short on the weekends especially on Saturdays. During an interview on 03/07/24 at 10:59 AM, Certified Nursing Assistant #22 stated that Resident #98 able to participate of washing their face and upper body and Certified Nursing Assistant #22 stated that they provide total care from lower part of the body down to the lower extremities. During an interview on 03/07/24 at 10:59 AM, Certified Nursing Assistant #22 stated that staffing fluctuates on the unit. Certified Nursing Assistant #22 stated that they get 8 residents in their assignment but the most they get was 10 when there were staff called out, especially on weekends. Certified Nursing Assistant #22 stated that even when they are short they try their best to get their work done and go home on time.4. Resident #67 was admitted to the facility with diagnoses that include Morbid Severe Obesity, Diabetes Mellitus, Coronary Artery Disease, and Congestive Heart Failure. The Annual Minimum Data Set 3.0 set dated 12/13/23, documented that Resident #67 had intact cognition, no behavioral symptoms, supervision or touching assistance needed for eating, substantial/maximum assistance for bed mobility, transfer, and toilet use. The Minimum Data Set also documented Resident #67 is frequently incontinent of urine and bowel. The Comprehensive Care Plan titled Activities of Daily Living (ADL) Functional Rehabilitation/Potential, created 09/14/23, last revised 3/5/24, documented self-care deficits as evidenced by decrease in dressing, grooming, feeding, bathing, toileting, and personal hygiene tasks. Goals include resident will maintain current level of participation in ADL care x 90 days, resident will be clean, dry, and groomed daily x 90 days. Interventions include provide assist for dressing, bathing, toileting, personal hygiene, and grooming. The Physician's Orders dated 09/13/23 documented out of bed and ambulate to bedside commode using rolling walker with one person assist. On 03/05/24 at 09:40 AM, Resident #67 was observed sitting in their wheelchair, and was interviewed. Resident #67 stated that it takes a long time to get help to come out of bed, and to get dressed, especially on the weekends. Resident #67 also stated that they can help themselves get dressed and uses the toilet in the daytime but needs assistance when they are in bed. The New York Department of Health Intake #NY00326246 dated 10/17/2023 documented that Resident #67 had their call light on to be cleaned and the Certified Nursing Assistant never came in their room to change them. The Certified Nursing Assistant Accountability Record for October 2023 was reviewed and revealed that there was no documented evidence that care was rendered on the following days for the following days and shifts: 10/8/23- 7AM-3PM shift, 10/14/23-3PM-11PM shift, 10/17/23-3PM-11PM shift, 10/18/23-3PM-11PM shift, 10/29/23- 11PM-7AM shift. On 03/06/24 at 09:45 AM, Certified Nursing Assistant #10 was interviewed and stated that they have been the primary Certified Nursing Assistant, on the 7am-3pm shift assigned to Resident #67 for the past 6 months. Certified Nursing Assistant #10 said that Resident #67 can assist in their care, turn, and position themselves, and assists with the transfer from bed to wheelchair. Resident #67 uses the commode by themselves and when they finish, rings the call bell for assistance. Certified Nursing Assistant #10 also stated that on some days they have a full complement of nursing assistants, but some days there are less. When there are only four nursing assistants, they are assigned 15 residents to take care of and often on the weekends there are only four nursing assistants. There was no reason given why there were blank areas on the Certified Nursing Assistant Accountability Record. On 03/06/24 at 04:54 PM, Certified Nursing Assistant #9 was interviewed and stated they are the primary Certified Nursing Assistant for Resident #67 on the 3pm-11pm shift. Resident #67 is scheduled for showers in the evening, so the staff will set up the shower supplies, and Resident #67 will do most of the washing. Resident #67's bedtime varies and they uses the urinal most of the time, and when Resident #67 uses the commode, they will need assistance to be cleaned afterwards. Certified Nursing Assistant #9 also said that there are four Certified Nursing Assistants with 2 assistants placed on each assignment which works out to 15 residents each. Certified Nursing Assistant #9 also stated that not all residents need total care, so they have to share the workload. There was no reason given why there were blank areas on the Certified Nursing Assistant Accountability Record. On 03/07/24 at 08:44 AM, Registered Nurse Supervisor #4 who works on the 7-3 shift on Unit 2, was interviewed, and stated that they have been the Registered Nurse Supervisor since April 2023. Registered Nurse Supervisor #4 stated that Resident #67 needs extensive assistance with activities of daily living. Registered Nurse Supervisor said that Resident #67 has never voiced a complaint or reported a concern that they had to wait a long time for care. Registered Nurse Supervisor #4 said that each supervisor is responsible for each shift and that they work every other weekend and it is their responsibility to ensure that staffing on the units is covered. Sometimes they have concerns on the weekends that they are short staffed, and then the Certified Nursing Assistants are distributed and assigned based on the acuity of the units, such as the 5th and the 4th floors, since those are the units that need more help. On 03/07/24 at 12:09 PM, Social Worker #2 was interviewed and stated that Resident #67 never voiced any concerns about staffing or care rendered. Social Worker #2 stated that they see Resident #67 all the time, and the resident is very vocal but never reported any issues about the staff. On 03/07/24 at 12:17 PM, the Staffing Coordinator was interviewed and stated that they have been the Staffing Coordinator for the past 4 years. Scheduling is floor specific, and since each shift must be staffed according to the par levels, for 2nd floor, 6 Certified Nursing Assistants and 2 nurses are assigned on the 7AM-3PM shift, 5 Certified Nursing Assistants and 2 nurses on the 3PM-11PM shift and 4 Certified Nursing Assistants and 2 nurses on the 11PM-7AM shift. For the unit assignment, either the Registered Nurse Supervisor or the nurse on the floor, does the assignment. The daily staffing schedule is done by the Staffing Coordinator, and they will split the assignment on the unit, based on how many nursing assistants they have on each floor. The Staffing Coordinator also stated that when someone calls sick, they would call a per diem person or part time staff to replace them, or also call someone from the agencies. The weekend can be a bit challenging with getting staff. 10 NYCRR 415.12(a)(3) Based on observations, record review, and interviews conducted during the Recertification and Complaint survey (NY00326246) from 03/04/2024 to 03/08/2024, the facility did not ensure that residents who are unable to carry out activities of daily living receive the necessary services and assistance to maintain grooming, and personal hygiene. Specifically, resident care was not provided to ensure proper hygiene and grooming. This was evident for 4 of 11 residents reviewed for Activities of Daily Living out of a sample of 38 residents (Resident #21, Resident #165, Resident #98, and Resident #67) The findings include: The facility's policy titled Activities of Daily Living, revised 03/2024, documented that all residents will be provided care for the activities of daily living based on the amount of assistance needed. Activities of daily living include bathing, dressing, eating, toileting, transfers, and ambulation. Bathing including bed bath, showers, oral care, hair care, nail care. Toileting includes use of bed pan/commode and incontinence care. 1. Resident was admitted to the facility with diagnoses that included Hypertension, Heart Failure, Peripheral Vascular Disease, and Diabetes Mellitus. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #21 was cognitively intact, required supervision with eating, oral hygiene, dependent with toileting hygiene, showering, lower body dressing, bed mobility, substantial/maximal assistance with upper body dressing and personal hygiene, toilet transfer was not attempted and Resident #21 was always incontinent of bowel and bladder. The Comprehensive Care Plan titled ADL (Activities of Daily Living) Functional/ Rehabilitation Potential dated 10/12/2023 revised 2/23/24 with goal resident will be clean, dry, and groomed daily x 90 days. Interventions included encourage resident to participate in activities of daily living as per ability, provide assist for dressing, bathing, toileting, personal hygiene and grooming and provide shower/be bath twice a week and prn. The Comprehensive Care Plan titled Elimination: Urinary Incontinence dated 10/22/2019 revised 2/23/24 documented Resident is incontinent of bladder function, with goals included: - Resident will be free of skin breakdown secondary to incontinence. Interventions included check and change incontinent briefs every 2-4 hours and as needed, monitor for signs/symptoms of Urinary Tract Infection (e.g., change in color, amount, odor, clarity), mental status and behavior changes and report to physician promptly, monitor redness or skin breakdown during toileting every 2 - 4 hours, and provide incontinent care after every diaper change. The Physician's order dated 2/25/24 documented: Cleanse left and right legs venous wound with soap and water, pat dry and apply Xeroform dressing and kerlix daily. On 03/04/24 at 07:27 AM, Resident #21 was observed in bed and was interviewed. Resident #21 stated that sometimes they are put to bed at 11pm, and will not get changed until 5am, Resident #21 also stated that sometimes on the 3pm-11pm shift no aide comes in to change them and they will call and call several times waiting for help. Resident #21 further stated that for three days, the treatment on both legs were not done, and it is supposed to be changed daily. On 03/04/24 at 07:27 AM, dressings were observed on both of Resident #21's lower legs; there was no date on either dressing. On 03/07/24 at 10:40 AM, Resident #21 was observed in bed ringing call bell to call for help. Resident #21 stated they had been ringing the bell all morning to get changed but has not seen the assigned aide yet today. On 03/07/24 at 10:43 AM, an interview was conducted with Certified Nursing Assistant #11 who stated that Resident #21 requires total care in all activities of daily living. Certified Nursing Assistant #11 also stated they had not been able to go and take care of Resident #21 yet because they had been assigned to the unit late. Certified Nursing Assistant #11 further stated that they had first been assigned to another floor before being moved to this unit around 8 am, and had been busy taking care of other residents that needed to come out of bed early. On 03/07/24 at 11:11 AM, an interview was conducted with the Registered Nurse #1 who stated that the staff are told to prioritize giving care. Registered Nurse #1 also stated that when they arrived on the unit this morning there was shortage of Certified Nursing Assistants and the Certified Nursing Assistant assigned to the resident was moved from another unit and has not been able to go and change the resident, because they were busy giving care to other residents. Registered Nurse #1 stated that they do not work on the evening shift, but they believe that the delay in attending to resident needs in a timely manner on the evening shift will also be due to shortage of staff. Registered Nurse #1 further stated that Resident #21's dressings on the legs were supposed to be done daily, but had not being changed most of the weekend while they were off which could also be due to shortage of staff. On 03/08/24 at 08:39 AM, Registered Nurse #2 was interviewed and stated that the Staffing Coordinator does staffing, and the supervisor makes sure that every unit is adequately staffed to take care of the residents. Registered Nurse #2 also stated that sometimes staff call out and they are unable to get replacement staff to work, especially on weekends.

3. The facility's policy titled Wound Care Aseptic Dressing Change, reviewed 11/23, documented that dressings are changed as per physician's orders using aseptic technique. The procedure documents don clean gloves and cleanse wound surface with saline moistened gauze. Cleanse wound with gauze, moving from center of wound to outer surface. Gently clean wound with moistened gauze after each wipe. Discard gloves and wash hands. [NAME] clean gloves. Resident #288 was admitted to the facility with diagnoses that included Stage 4 Pressure Ulcer and Chronic Obstructive Pulmonary Disease. The admission Minimum Data Set 3.0 dated 1/30/24, documented resident's cognition as intact, at risk for Pressure Ulcer, and has 1 or more Pressure Ulcer, Stage 4 Pressure Ulcer. The Physician's Orders renewed 2/25/24 documented Medi Honey (honey) 100 % topical paste by topical route, cleanse left buttock with normal saline and apply Medi honey and calcium alginate daily. On 03/07/24 at 10:05 AM, a wound care observation was conducted with Licensed Practical Nurse #2. Licensed Practical Nurse #2 entered the room of Resident #288 with a plastic basin filled with wound care supplies which they placed on Resident #288's bedside table next to the residents lotion, a small tin container, and a television remote control. Licensed Practical Nurse #2 changed their gloves and proceeded to date the bordered gauze, opened the bottle of normal saline solution, changed their gloves again. Licensed Practical Nurse #2 took a packet of gauze, the bottle normal saline solution, the bordered gauze with the Medi honey (treatment for the wound), and placed it on the resident's bed, and proceeded to clean Resident's #288 wound by moistening a gauze pad with normal saline solution, and wiping the wound in a circular motion, then discarded the gauze in the garbage bag, and repeated the procedure before placing the bordered adhesive gauze with the Medi honey on it, onto the resident's wound. Licensed Practical Nurse #2 then placed the gauze pad and saline back in the plastic container, removed their gloves and washed their hands. Licensed Practical Nurse #2 did not change their gloves or wash their hands after cleaning Resident's #288 wound and before applying the treatment and protective dressing. On 03/07/24 at 10:10 AM, an interview was immediately conducted with Licensed Practical Nurse #2 who stated that the facility does not provide any drapes, so the staff does not use any drapes. Licensed Practical Nurse #2 also stated that they were in-serviced on using a drape to place the wound supplies, and not place the supplies directly on the bed. Licensed Practical Nurse #2 further stated that they just forgot to use the drape and to change their gloves after cleansing the wound. Licensed Practical Nurse #2 stated that they should have removed the Resident's #288 property, prior to placing the wound supplies. On 03/08/24 at 08:07 AM, the In-service Director was interviewed and stated that they are responsible for onboarding the staff and orientation which includes discussing the facility policies and procedures. The In-service Director also stated that the competencies are done later on in the orientation process. The expectation is that nurses complete the competencies during the period of the orientation with the supervisors, and if there is a concern with a nurse, the In-service Director would also sign off on the competencies which include wound care and hygiene. The In-service Director further stated that Licensed Practical Nurse #2 had their competency done specifically for wound care in January 2024. The Nurses were taught to bring the treatment cart outside of the room, clean the surface area where their supplies will be placed, and use drapes that are supplied, for the surfaces. The nurses should always have hand sanitizers available to use during the wound care. On 03/08/24 at 12:36 PM, Registered Nurse Supervisor #5 was interviewed and stated that as part of their responsibility they oversee the nurses on the units as they perform their duties, and that the In-service Coordinator oversees the competencies, but the Registered Nurse Supervisor #5 would monitor what the nurses are doing to ensure that they follow protocol. Registered Nurse Supervisor #5 also stated that the treatment cart should be outside the door, and the nurse should get the supplies that are needed, including the drapes that are located in the medication room. The nurse would check the treatment orders prior to administering the treatment, and no containers should be used to carry the supplies. There should be a barrier on the resident's bed, placed under the area of the resident's wound. A drape should be placed on the bedside table after it is cleaned with the purple wipes. The Registered Nurse Supervisor #5 further stated that the nurses should sanitize or wash hands each time the gloves are changed and hand sanitizer is always available on the unit and on each cart. The nurses were taught that once the soiled dressings are removed, they should change gloves and don new gloves. On 03/08/24 at 01:12 PM, the Director of Nursing was interviewed and stated that they have orientation initially after which the nurses are then buddied up with another nurse, then there is medication pass and a treatment pass for competency, before the nurses work independently. Wound care competencies are done annually and as needed. For wound care, the treatment cart should be brought to the resident's room, and then the supplies are taken from the cart. Nurses are to use the drape barrier both for the wound and the supplies. They are also trained to change gloves, clean their hands, and don clean gloves after cleaning the wound. Nurses are monitored by the Registered Nurse Supervisor, the Director of Nursing, and the Inservice Coordinator during rounds. The Director of Nursing also stated that if there were a need for retraining, they would take the nurses off the unit, retrain them, and then have the nurses do return demonstration to ensure competence. 10 NYCRR 415.19 (a)(1)(b)(4) Based on observation, and interviews conducted during the Recertification survey from 03/04/2024 to 03/08/2024, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) Staff did not offer hand hygiene to three residents during meal in the dining area. (Residents #26, 32 and 239), 2) Staff did not sanitize hands prior beginning of medication administration procedure, and prior putting on the gloves to administer Resident's medication via tube feeding. 3) During wound care treatment, the Licensed Practical Nurse failed to practice hand hygiene after cleaning the resident's wound and did not change gloves after cleaning the wound. (Resident's # 288). This was evident for 3 observed during the Dining task, on 1 of 5 units observed during the Medication Administration task, and 1 of 3 residents reviewed for Pressure Ulcer/Injury. The findings are: 1. The facility policy titled Nursing Dietary: Dining Rooms Meal Service last reviewed 12/2023 documented the Certified Nursing Assistant provide the resident with hand wipes and water prior to the meal service. On 03/04/24 at 07:27 AM, an observation was conducted in the 5th floor dining room for breakfast. Breakfast arrived on unit and three residents (#26, #32 and #190) were seated in the dining area, along with Registered Nurse #1 and Certified Nursing Assistant #4. On 03/04/24 at 07:33 AM, Resident #239 was seated in the dining area. Resident #239 was given breakfast tray by Registered Nurse #1 in the dining area. Resident #239 was not offered hand hygiene by Registered Nurse #1 before they were given their breakfast tray. Resident #239 was able to eat without assistance. On 03/04/24 at 07:34 AM, Resident #26 was seated in dining area, Resident #26 was given tray by Certified Nursing Assistant #4 Certified Nursing Assistant #4 did not offer Resident #26 hand hygiene prior to the meal. Resident #26 was able to eat without assistance. On 03/04/24 at 07:34 AM, Resident #32 was seated in the dining area. Resident was given tray by Certified Nursing Assistant #4. Certified Nursing Assistant #4 did not offer Resident #32 hand hygiene prior to the meal. On 03/04/24 at 07:39 AM, an interview was completed with Certified Nursing Assistant #4 who stated that they usually give the residents a hand wipe in a small packet to clean their hands before giving the residents their tray. Certified Nursing Assistant #4 also stated that before the start of breakfast they checked in the cupboard in the dining room and there were no hand wipes. Certified Nursing Assistant #4 further stated they did not report this to anyone and should have called or reported this to nurse. On 03/04/24 at 07:56 AM, an interview was conducted with Registered Nurse #1 who stated that they gave a tray to Resident #239 in the dining room and entered the dining after the aides were already in the dining area and the Certified Nursing Assistants usually give the hand towelette to the residents before the Registered Nurse enters the dining area. Registered Nurse #1 also stated there are hand towelette inside the medication room which are given to each resident before each meal. Registered Nurse #1 further stated they did not give the towelettes because they assumed that the Certified Nursing Assistants had already given the towelettes to the residents before the trays were served. Registered Nurse #1 stated they were not aware that the resident hands were not sanitized and was told by the Certified Nursing Assistant after the fact. Registered Nurse #1 also stated that the staff did not report there were no towelettes in the dining room. Registered Nurse #1 stated before every meal the residents are given hand toilettes by the staff to clean hands, as well as the staff performing hand hygiene before touching the trays and in between trays. On 03/08/24 at 01:40 PM, an interview was conducted with the Director of Nursing who is also the Infection Preventionist for the facility. The Infection Preventionist stated the staff must perform hand hygiene themselves, then offer hand hygiene to the residents. The Infection Preventionist also stated that the residents can choose to accept hand hygiene, and then after the hand hygiene is done staff will serve the food. The Infection Preventionist further stated that the staff uses small towelettes and there is an ample supply of these in the facility. If there are no towelettes available, staff can wash each resident's hands in the sink in the dining area which is low enough to accommodate all residents, including residents seated in wheelchairs. The Infection Preventionist stated there is no excuse for staff not performing hand hygiene on the residents before meals, and all staff was in-serviced on hand hygiene before meals. 2. The facility policy titled Infection Control -Standard Policy last reviewed 11/2023 documented hand hygiene is a major component of standard precautions and one of the most effective methods to prevent transmission of pathogens associated with health care. The policy further documented all individuals including residents should comply with infection control practices in the health-care setting. During an observation of Medication Administration on the 6th Floor on 03/04/24 at 08:30 AM, Registered Nurse #1 was observed administering medication to Resident #80. Registered Nurse #1 removed the resident's medications from the cart and poured the liquid medication into a medication cup, removed, and crushed the tablets, and poured them into the medication cups. Registered Nurse #1 was not observed sanitizing their hands before or after preparing the medication. Registered Nurse #1 then entered Resident #80's room, turned off the tube feeding, adjusted the bed control, donned gloves, and then proceeded to administer the medication without sanitizing their hands. On 03/04/24 at 08:44 AM, Registered Nurse #1 was interviewed and stated that they realized that they forgot to sanitize their hands prior to and during medication administration to Resident #80. Registered Nurse #1 also stated that they should have sanitized their hands. On 03/08/24 at 08:45 AM, an interview was conducted with Registered Nurse Supervisor (Registered Nurse #2) who stated that they go on the unit to monitor staff to ensure that staff are practicing proper infection control when giving care to the resident, and if any staff is found breaching the protocol, an in-service is given. Registered Nurse #2 also stated that not sanitizing hands prior to medication administration is not a mistake that a licensed nurse is supposed to make. On 03/08/24 at 09:55 AM, an interview was conducted with the Director of Nursing who stated that all newly hired staff are given orientation and competency on infection control prevention protocol, among other things. Unit inspection is done regularly and they are continuously making rounds on the unit to ensure that the staff are performing proper infection control practice when giving care to the residents. The Director of Nursing also stated that it is difficult to explain why the staff are still being observed not doing the right things.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review conducted during the Recertification and Complaint survey (NY00330312) from 03/04/2024 to 03/08/2024, the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) multiple residents reported during confidential interviews and the Resident Council meeting that the facility was short staffed at times especially at night and on the weekends, there was a lack of timely staff response to call bells, 2) multiple nursing staff members reported a lack of sufficient staffing; and 3) analysis of the actual staffing schedule showed that on multiple occasions from January 05, 2024 through February 25, 2024, the facility was below the minimum levels documented on the Facility Assessment. The findings included but were not limited to: 1. During an interview on 03/04/24 at 11:46 AM, Resident #165 stated that staff were always short in all shifts, and when staff were short, they must wait. Resident #165 stated that the weekends had the worst staffing particularly on the day shift. Resident #165 stated that last Friday after the 3:00 PM to 11:00 PM shift, the next morning their incontinent brief was changed at 4:00 AM, then Saturday after between 2:30 PM or 3:30 PM. Resident #165 said that they have no problem with their regular aide but when they have floater, they always say to Resident #165 that they will come back. Resident #165 stated that when there was one Certified Nursing Assistant on the unit on the 3:00 PM to 11:00 PM shift they were not changed at all. Resident #165 stated that they get them out of bed before the end of the morning shift and the staff on the next shift will put them back to bed. During an interview on 03/04/24 at 12:39 PM, Resident #98 stated that they don't get help right away for the last 6 months. Resident #98 stated that the night shift they must wait for over an hour to be changed. There were no staff on the weekends especially Saturday. During an interview on 03/07/24 at 11:46 AM, Certified Nursing Assistant #21 stated that when they were short of staff, they cannot give full care to residents. Certified Nursing Assistant #21 also stated that when staff calls out, they get extra residents in their assignment. Certified Nursing Assistant #21 said that weekends were always short and getting residents out of bed was tough and residents get agitated. Certified Nursing Assistant #21 stated that on some weekends they do not get up residents because of shortage of staff. During an interview on 03/07/24 at 10:59 AM, Certified Nursing Assistant #22 stated that staffing fluctuates. Certified Nursing Assistant #22 stated that they get 8 residents in their assignment but the most they get was 10 when there were called out staff especially weekends. Certified Nursing Assistant #22 stated that even when they are short they try their best to get their work done and go home on time.4. Resident #196 was admitted to the facility with diagnoses that include Respiratory failure. The Quarterly Minimum Data Set 3.0 dated 1/5/24 documented resident's cognition as intact, no behaviors, impairment on both sides to upper extremities. The Minimum Data Set also documented dependent (helper does all the effort) with eating, bed mobility, and transfers, no toilet use not attempted and always incontinent of bowel and bladder. The Annual Minimum Data Set 3.0 dated 10/9/23 documented resident's cognition as intact, no behaviors, that resident is the primary respondent for daily and activity preferences, that it is very important to choose own bedtime, what clothes to wear and choose between a tub bath, shower, bed bath or sponge bath. The Minimum Data Set also documented resident needs maximum assistance with eating, dependent with bed mobility, transfers, toilet use not attempted and always incontinent of urine and bowel. The Physician's orders renewed 2/24/24 documented out of bed status: out of bed status to wheelchair with 2 persons assist via Hoyer lift. On 03/05/24 at 11:17 AM, Resident #196 was observed in bed awake and was interviewed. Resident #196 stated that they sometimes must lie in bed all day, more than 24 hours to get changed. Resident #196 also stated that they are paralyzed and relies on staff to assist them, and that it takes a long time for staff to respond at times. The New York State Department of Health Intake #NY00330312 dated 12/21/2023 documented that hotline call from Resident #196 who claims to have been lying in soiled diaper since 11:00 PM last night (12/20/23). The complaint also documented that the complainant stated that the call bell was answered at 3 AM and the Certified Nursing Assistant told them they needed to find someone to help change Resident #196 as they are paralyzed however, no one came back. Call bell continues to ring unanswered. It is now 1:20 PM on 12/21/23 and still not changed. This is unacceptable. The Comprehensive Care Plan titled nursing Activities of Daily Living, Dressing, Grooming, Feeding, Bathing, Toileting, Personal Hygiene, effective 2/14 /23, review date 4/1/24, included a goal that resident will be clean, dry, and groomed and had interventions which included observe for decline in Activities of Daily Living and notify Medical Doctor, provide shower/ bed bath twice a week and as needed, provide assist for dressing, bathing, toileting, personal hygiene, and grooming. The Certified Nursing Assistant Accountability Record for December 2023 was reviewed and revealed that there was no documentation that care was rendered on the following days for the following shifts:12/18/23 on the 3pm -11pm shift and 12/31/23 on the 7am-3pm shift. On 03/06/24 at 03:33 PM, Certified Nursing Assistant #6 was interviewed and stated that they were the resident's primary caregiver on the 3pm-11pm shift. Certified Nursing Assistant #6 stated that Resident #196 needs total assistance for activities of daily living, including being fed, and being transferred via a Hoyer lift with 2 persons assistance. CNA #6 said that for most of the 3pm -11pm shift, Resident #196 is out of bed, and that the resident always complains that during the shift, they do not get the help that Resident #196 needs. Certified Nursing Assistant #6 also stated that during the 3pm-11pm shift, they would have mostly 5 Certified Nursing Assistants assigned to the unit and they would have 13 residents to take care of on their assignment. Certified Nursing Assistant #6 said that often on the weekends, there are only 4 Certified Nursing Assistants assigned to the unit, so they try to give the necessary care. During an interview on 03/06/24 at 03:42 PM, Licensed Practical Nurse #1 who works the 7am-3pm shift on the unit stated that the assignments are scheduled by the Staffing Coordinator, and it has been already prearranged for at least 4 years with the current assignment. Licensed Practical Nurse also stated that Resident's #196 has complained of waiting too long for care and sometimes it may take a little longer to place the resident back to bed. Usually there are 8 Certified Nursing Assistants: 4 on East side and 4 on [NAME] side, but sometimes there are 6 Certified Nursing Assistants, and sometimes there are only 5 Certified Nursing Assistants, so when there are less Certified Nursing Assistants, the Licensed Practical Nurse #1 must get the Resident#196 out of bed. Licensed Practical Nurse #1 further stated that that when they do not have the full staffing level, it also can become time consuming. Licensed Practical Nurse #1 stated that things are better there are two nurses on the unit, but sometimes if there were not enough Certified Nursing Assistants, they would have to take care of Resident #196. Licensed Practical Nurse #1 stated that on this shift there are usually 5 Certified Nursing Assistants assigned for whole unit (East and West) but today there are only 4, so with a census of 57 residents the assignments must be split and make adjustments as they do every day. On 03/08/24 at 09:26 AM, Certified Nursing Assistant #7 was interviewed and stated that Resident #196 is totally dependent on staff for activities of daily living, which includes total assistance with transfers with Hoyer lift, and must be fed since there are limitations with their hands. Resident #196 can turn themselves in bed, but some days, needs assistance. Resident #196 usually gets out of bed at around 10:30AM and stays out of bed throughout the shift. Certified Nursing Assistant #7 said that when they have 8 Certified Nursing Assistants on that shift for the unit, they will have 8 residents to take care of, but when they work with less, which is very often, like today, they have 7 Certified Nursing Assistants assigned, so today they would have 9 residents to take care of. Certified Nursing Assistant #7 stated that when there are more residents to take care of, then sometimes the residents will have to wait longer for care. The weekends can be more difficult since the patient load increases. When this happens and they let Resident#196 know that they may have to wait a little longer, Resident #196 can become belligerent, since they are very impatient so they would talk to Resident #196 and try to give care as soon as they can and do their best to get the Resident #196 out timely. On 03/08/24 at 10:30 AM, Registered Nurse Supervisor #3 was interviewed and stated that they are the supervisor for the 5th and 6th floor for the past two years. Registered Nurse Supervisor #3 also stated that today they are the Medication Nurse since they do not have a nurse to cover half of the unit. Registered Nurse Supervisor #3 stated that sometimes when they do not have the full complement of Certified Nursing Assistants which is 8, the nurses are the ones that go and clean up Resident #196 to get them out of bed. It takes a longer time at times when all the Certified Nursing Assistants assigned are not there since Resident #196 needs total assist for personal hygiene, transfers and for eating. 2. On 03/05/2024 at 10:03 AM, during the Resident Council Meeting, 12 out of 12 resident council members stated that staff takes too long to respond to call bells, and they sometimes it takes up to two hours for someone to respond or they have to wait for the next shift to have somebody answer the call bell. Resident #180, stated that staffing is an issue in this facility, that it takes too long for a staff to answer the call bell and when they inquire why staff is so late in answering the call bell, the staff will respond that they are short staffed. During an interview with Resident #119's representative on 03/06/2024 at 11:00 AM, they stated that they noticed that it takes a long time for call bells to be answered and it is a concerned for them because there could be an emergency situation. On 03/08/2024 at 12:11 PM, Certified Nursing Assistant #20 was interviewed stated there are a lot of sick calls in this facility and the Staffing Coordinator called them many times to cover sick calls, and sometimes they can come and sometimes they cannot. On 03/08/24 at 01:14 PM, Licensed Practical Nurse #4 was interviewed and stated that the 4th floor unit should have 5 Certified Nursing Assistants during the day shift when the census is 60 residents but most of time there are only 4 Certified Nursing Assistants because of sick calls and the facility cannot cover sick calls. 5. The facility policy titled Staffing dated 10/2023 documented it is the policy of the facility to provide sufficient staffing numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The Facility Assessment updated 01/2024 documented the following staffing pattern for the facility: Certified Nursing Assistants/ Direct Care Staff: 2nd Floor: approximately Days: 1: 20 , evenings: 1:30 evenings, nights: 1:30 nights. 3rd Floors: approximately Days: 1: 7 days; evenings: 1:10 evenings, nights: 1:15. 4th Floor: approximately 1:12 days; 1:15 evenings, 1:30 nights (plus 24/7 security guard), 5th and 6th floors: approximately 1: 7 days; 1:12 evenings, 1:15 nights. The Facility Assessment further documented the average daily census for the facility was 285 residents, and that residents required the following assistance with Activities of Daily Living: Dressing: Independent: 2, Assistance of 1-2 staff: 230, and Dependent: 18 Bathing: Independent: 0, Assistance of 1-2 staff: 198, and Dependent: 49 Transfer: Independent: 2, Assistance of 1-2 staff: 181, and Dependent: 67 Eating: Independent: 2, Assistance of 1-2 staff: 235, and Dependent: 13 Toileting: Independent: 2, Assistance of 1-2 staff: 235, and Dependent: 13 Mobility: Independent: 4, Assistance of 1-2 staff: 140, and Dependent: 106 The facility document titled Nursing Staffing Pattern dated 08/10/2023 provided by the Staffing Coordinator documented the following staffing pattern for Certified Nursing Assistants for each unit: Day shift (7 am-3pm): 2nd Floor: 6, 3rd Floor: 9, 4th Floor: 6, 5th Floor: 9 and 6th Floor: 9 for a total of 39 Certified Nursing Assistants; Evening shift (3pm-11pm): 2nd Floor: 5, 3rd Floor: 6, 4th Floor: 5, 5th Floor: 6, and 6th Floor: 6 for a total of 29 Certified Nursing Assistants; Night Shift (11pm -7 am): 2nd Floor: 4, 3rd Floor: 5. 4th Floor: 4. 5th Floor: 4, and 6th Floor: 4 for a total of 22 Certified Nursing Assistants for a daily total of 90 Certified Nursing Assistants. The Facility assessment dated [DATE] documented that the following: 7-3= approx. 30-34 3-11= approx. 20-23 11-7=approx. 14-17 Total CNAs=approx. 70. Review of the Daily Staffing sheets from 1/5/2024 to 2/25/2024 revealed that staffing on the following weekend dates (Friday through Sunday) did not meet the minimum number of staff required as per the facility's Nursing Staffing Pattern document or the Facility Assessment on the following dates and shifts: 1/5/24: Day: 28 (-11), Night: 20 ( -1), 1/6/24: Day: 29 (-10), Evening: 22 (-7), Night: 17 (-4), 1/7/24: Day: 27 (-12), Evening: 27 ( -1), Night: 19 (-2). 1/12/24: Day: 26 (-13), Evening: 22 (-6), 1/13/24: Day: 27 (-12), Evening: 22 (-6), Night: 20 (- 1), 1/14/24: Day: 28 (- 11), Evening: 27 (-1), Night: 20 (-1). 1/19/24: Day: 30 (- 9), Evening: 27 (- 1), Night: 20 (-1), 1/20/24: Day: 21 (-18), Evening: 25 (-3), Night: 16 (- 5), 1/21/24: Day: 27 (-12), Evening: 22 (-7), Night: 13 (-8). 1/26/24: Day: 24 (-15), Evening: 24 (-4), 1/27/24: Day: 28 (-11), Evening: 26 (-21), 1/28/24: Day: 25 (-14), Evening: 23 (-5), Night: 17 (-4) 2/2/24: Day: 29 (-10), Evening: 26 (-2), 2/3/24: Day: 28 (-11), Evening: 24 (-4), Night: 15 (- 6), 2/4/24: Day: 29 (-10), Evening: 23 (- 5), Night: 15 (-6). 2/9/24: Day: 27 (-12), Evening: 24 (- 4), Night: 16 (- 5), 2/10/24: Day: 31 (- 9), Evening: 26 (-2), Night: 18 (-3), 2/11/24: Day: 27 (-12), Evening: 21 (- 7), Night: 14 (-6). 2/16/24: Day: 31 (-8), Night: 19 (- 2), 2/17/24: Day: 26 (-13), Evening: 22 (- 6), Night: 14 (-6). 2/18/24: Day: 31 (-8), Evening: 20 (-8), Night: 16 (-5). 2/23/24: Day: 29 (-10), Evening: 24 (- 4), Night: 19 (-2). 2/24/24: Day: 28 (- 11), Evening: 24 (- 4), Night: 16 (-5). 2/25/24: Day: 26 (-13), Evening: 23 (-5), Night: 19 (- 2). The number of Certified Nursing Assistants documented on the facility Nursing Staffing Pattern and the Facility Assessment were not consistently met on weekends from 1/5/24 through 2/25/24 on 24 out of 24 instances for the Day shift, 22 out of 24 times on the Evening shift, and 20 out of 24 times on the Night shift. On 03/06/24 at 10:11 AM, an interview was conducted with Certified Nursing Assistant #11 who works on Unit 5. Certified Nursing Assistant #11 stated there are supposed to be 8 Certified Nursing Assistants assigned, but many times there are 7 or less. When there are 8 Certified Nursing Assistants each staff will have 7-8 residents but today each staff have 8-9 residents, and they are not all total care, as some are partially independent. Certified Nursing Assistant #11 also stated that because of less staffing they will have to put off the shower today for another day when there is full staff. Certified Nursing Assistant #11 stated when staff are assigned bariatric residents it is very hard. Certified Nursing Assistant #11 stated that call outs are the major cause of less staffing on the units. Certified Nursing Assistant #11 declined to answer if they feel rushed when giving care. Certified Nursing Assistant #11 stated the units are short most of the time because the staff call out and the facility cannot find staff to replace them, and all staff that comes to work does the best they can. On 03/06/24 at 02:53 PM, an interview was conducted with Certified Nursing Assistant #2 who stated the staffing level is not very good as they are short every weekend, and staff must share an assignment when the staff is not present. Certified Nursing Assistant #2 stated 8 Certified Nursing Assistants are assigned to be present every day, but this is not the case. Certified Nursing Assistant #2 stated they have spoken to the Staffing Coordinator, and management is aware of the staffing problem. Certified Nursing Assistant #2 stated they feel rushed when doing work and do not sit down until lunch time and at times no one takes break on time because of the shortage and this happens very often. Certified Nursing Assistant #2 stated they still give showers to their residents and but has to give up a break or lunch to do this. Certified Nursing Assistant #2 stated just feel rushed and at times when doing the bariatric have to do by self because there is not enough staff. On 03/07/24 at 12:07 PM, an interview was completed with Licensed Practical Nurse #3 who stated they work on the night shift and was asked to stay today on the day shift because they are short staffed. Licensed Practical Nurse #3 stated the unit is supposed to have a treatment nurse, but most times there is no treatment nurse and when called in to do overtime to do treatments, they end up administering medications also. Licensed Practical Nurse #3 stated many times they spend time helping the Certified Nursing Assistant to give care, assisting them to turn the residents, helping them to use the Hoyer Lift, and then they feel rushed and cannot get their work completed and leave at the end of their scheduled shift. Licensed Practical Nurse #3 stated when there are 7 Certified Nursing Assistants assigned and only 4 come into work many of the residents cannot be taken out of bed or given showers. Licensed Practical Nurse #3 stated at times the morning fingerstick are done in the evening, because the License Practical Nurse is acting as a Certified Nursing Assistant. On 03/08/24 at 10:18 AM, an interview was completed with the Staffing Coordinator who stated most staff is fulltime and they were given a staffing pattern by the Director of Nursing. All the slots must be filled in by using facility staff as well as agency, and per diem staffing. When staff is needed they will call the part timers, per diems, and reach out to agency staff, as well as use the facility full time employee as over time to fill in. The Staffing Coordinator also stated that when staff called out on the weekend 7am-3pm shift, will call the 3pm-11pm staff as well as the 11pm-7am staff to come in early, but they are not always able to come in so therefore there is no staff to replace the call outs. The weekend is a challenge and even though they put extra staff on the schedule, they will call out, leaving the units short. when scheduled. The Staffing Coordinator stated staff have complained that the work is too hard, especially with not having enough staff to manage the bariatric residents and the salary is too low. The Staffing Coordinator did not respond when asked if there is a staffing issue in the facility, but stated they are doing all they can to meet the staffing requirements for the facility. The Staffing Coordinator also stated some floors need nine Certified Nursing Assistants but somedays they just cannot meet the staffing pattern. On 03/08/24 at 09:59 AM, an interview was completed with the Facility Administrator who stated the facility assessment is completed, staffing levels are based on the acuity levels and so staffing is done according to the resident needs. The Administrator stated the facility have pars levels, and if cannot meet the staffing levels they will ask staff to work overtime, as well as work with the Director of Nursing Services, Human Resources, and the Staffing Coordinator to do wherever it takes to get staff in the building. The Administrator stated that if the residents complain they will make phone calls and do whatever it takes to get staff, including giving incentives to get staff in the building. The Administrator did not respond when asked based on assessment if there is a staffing issue in the facility but stated that they are doing all they can to get the enough staffing in the facility. On 03/08/24 at 10:49 AM, an interview was conducted with the Director of Nursing who the facility has staffing concerns, and when the schedule is created staffing is adequate but there are cancellations. The Director of Nursing stated they try to give incentives for the staff to come in to work but at times they are unable to fill the slots. The Director of Nursing Services stated encourage the staff to pick up overtime shifts, but when it come to the weekend there is a pattern with the staffing, a difference in the week and weekends. The Director of Nursing Services stated they reach out to agencies, per diem staff and use staff as overtime, and well as put extra staff on the schedule to balance out the schedule and address the call outs. The Director of Nursing Services stated when the residents complaint about the staffing will directly address the issues. The Director of Nursing Services stated have ongoing orientation to address the staffing concerns and will hire any staff that comes for work. The Director of Nursing Services stated the facility hires all staff who wants to work and places advertisements online and in the local newspaper and actively hire staff. The Director of Nursing Services stated the staff gets overwhelmed and Director of Nursing will give them support, but sometimes the staff just quit because of the bariatric residents. The Director of Nursing Services stated the work with the Staffing Coordinator to ensure there is adequate staffing on the unit to give care. 10 NYCRR 415.13 (a)(1)(i-ii) 3. Resident #21 was admitted to the facility with diagnoses that included Hypertension, Heart Failure, Peripheral Vascular Disease, and Diabetes Mellitus. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #21 was cognitively intact, required supervision with eating, oral hygiene, dependent with toileting hygiene, showering, lower body dressing, bed mobility, substantial/maximal assistance with upper body dressing and personal hygiene, toilet transfer was not attempted and Resident #21 was always incontinent of bowel and bladder. The Comprehensive Care Plan titled ADL (Activities of Daily Living) Functional/ Rehabilitation Potential dated 10/12/2023 revised 2/23/24 with goal resident will be clean, dry, and groomed daily x 90 days. Interventions included encourage resident to participate in activities of daily living as per ability, provide assist for dressing, bathing, toileting, personal hygiene and grooming and provide shower/be bath twice a week and prn. The Comprehensive Care Plan titled Elimination: Urinary Incontinence dated 10/22/2019 revised 2/23/24 documented Resident is incontinent of bladder function, with goals included: - Resident will be free of skin breakdown secondary to incontinence. Interventions included check and change incontinent briefs every 2-4 hours and as needed, monitor for signs/symptoms of Urinary Tract Infection (e.g., change in color, amount, odor, clarity), mental status and behavior changes and report to physician promptly, monitor redness or skin breakdown during toileting every 2 - 4 hours, and provide incontinent care after every diaper change. The Physician's order dated 2/25/24 documented: Cleanse left and right legs venous wound with soap and water, pat dry and apply Xeroform dressing and kerlix daily. On 03/04/24 at 07:27 AM, Resident #21 was observed in bed and was interviewed. Resident #21 stated that sometimes they are put to bed at 11 PM, and will not get changed until 5 AM, Resident #21 also stated that sometimes on the 3 PM-11 PM shift no aide comes in to change them and they will call and call several times waiting for help. Resident #21 further stated that for three days the treatment on both legs were not done, and it is supposed to be changed daily. On 03/04/24 at 07:27 AM, dressings were observed on both of Resident #21's lower legs; there was no date on either dressing. On 03/07/24 at 10:40 AM, Resident #21 was observed in bed ringing call bell to call for help. Resident #21 stated they had been ringing the bell all morning to get changed but has not seen the assigned aide yet today. On 03/07/24 at 10:43 AM, an interview was conducted with Certified Nursing Assistant #11 who stated that Resident #21 requires total care in all activities of daily living. Certified Nursing Assistant #11 also stated they had not been able to go and take care of Resident #21 yet because they had been assigned to the unit late. Certified Nursing Assistant #11 further stated that they had first been assigned to another floor before being moved to this unit around 8 am, and had been busy taking care of other residents that needed to come out of bed early. On 03/07/24 at 11:11 AM, an interview was conducted with the Registered Nurse #1 who stated that the staff are told to prioritize giving care. Registered Nurse #1 also stated that when they arrived on the unit this morning there was shortage of Certified Nursing Assistants and the Certified Nursing Assistant assigned to the resident was moved from another unit and has not been able to go and change the resident, because they were busy giving care to other residents. Registered Nurse #1 stated that they do not work on the evening shift, but they believe that the delay in attending to resident needs in a timely manner on the evening shift will also be due to shortage of staff. Registered Nurse #1 further stated that Resident #21's dressings on the legs were supposed to be done daily, but had not being changed most of the weekend while they were off which could also be due to shortage of staff. On 03/08/24 at 08:39 AM, Registered Nurse #2 was interviewed and stated that the Staffing Coordinator does staffing, and the supervisor makes sure that every unit is adequately staffed to take care of the residents. Registered Nurse #2 also stated that sometimes staff call out and they are unable to get replacement staff to work, especially on weekends.

Based on observation, record review and interviews during an abbreviated survey (Case # NY 00321675), the facility did not ensure a resident's right to be free from verbal abuse for 1 (Resident #1) of 3 residents reviewed. Specifically, on 08/06/2023 at 10:35 PM, the Facility's Surveillance camera shown Resident #1 was pacing up and down the hallway on the unit in front of the nursing station. On 08/06/2023 at approximately 10:15 PM, License Practical Nurse (LPN) #1 was then seen talking to Resident #1 in the presence of three Certified Nursing Assistants (CNA)s #1, #2 and #3 at the nurses' station. Resident #1 was holding a cell phone and pointing it to LPN #1. LPN # 1 attempted to take Resident #1's cellphone. CNA #1, #2, and #3 separating LPN# 1 and Resident #1 to prevent any physical contact. CNA #1, CNA #2 and CNA #3 reported to the Registered Nursing Supervisor (RNS) that LPN #1 used inappropriate cursing language at Resident #1. The findings are: The Facility's Policy and Procedure Titled Abuse Prevention dated 08/07/2023, documented that residents will be protected from Abuse, Neglect, Mistreatment, Exploitation, or Misappropriation of resident property in accordance with State and Federal Regulation. Resident #1 was admitted to the Facility with diagnoses of Bipolar Disorder, Anxiety, and borderline personality disorder. The Minimum Data Set (MDS- a resident's assessment tool) dated 06/14/2023, documented that Resident #1 was cognitively intact and required extensive assist of one person with activities of daily living. The Risk for Abuse/Neglect Care Plan (CP) dated 06/08/2023, documented interventions to always maintain a safe environment, observe resident for unusual skin marks, discoloration, ecchymosis, and to report promptly. The Facility's Surveillance Camera Video footage recording from 08/06/2023 at approximately 10:13 PM, showed that LPN 1 was standing by the medication chart. At 10:15 PM, Resident #1 was seen coming out of the elevator and sat on the rollator in the hallway. At 10:17 PM, Resident #1 got up from the rollator and went inside the elevator. At 10:18 PM, Resident #1 got off the elevator with the rollator and headed towards the medication room. At 10:20 PM, Resident #1 headed to nurses' station and then sat in their rollator in front of the nursing station. At 10:23 PM, CNA #1 and CNA #2 were seen in the hallway standing near to Resident #1. Resident #1 got up and went on the elevator. At 10:27 PM, Resident #1 was seen coming out of the elevator and headed toward the nursing station. Resident #1 observed to be throwing several items on the floor in the nursing station. At 10:30 PM, Resident #1 walked toward dayroom and was observed throwing the rollator towards the dayroom and then walked away without the rollator toward the treatment cart. Resident #1 then threw the basin and other items from the cart on the floor. Resident #1 then return to sat on their rollator by the nursing station. CNA#1 and CNA #2 were present. At 10:35 PM, Resident #1 stood up and walked away from the rollator toward the medication room. LPN # 1 was coming from the medication room and Resident #1 followed LPN # to the nursing station. Resident #1 was observed pacing up and down the hallway in front of the nursing station. At 10:35 PM, LPN #1 was seen talking to Resident #1 at the nursing station with CNA #1 and CNA #2 present. Resident #1 was seen holding their cellphone pointing it toward LPN #1. CNA #1 and #2 intervene and separate both Resident #1 and LPN #1. At 10:36 PM, LPN #1 and the CNAs walked away from the area. At 10:40 PM, Resident #1 observed going into the elevator with their rollator. The Facility's Accident/Incident investigation report dated 08/07/2023 at 10:30 PM, documented that Resident #1 reported on 08/06/2023, LPN #1 hit them while they were recording LPN #1 on their cell phone. A complete full body assessment was done by RNS and there were no apparent injuries. The Facility Summary of Investigation dated 08/11/2023, documented on 08/07/2023 at approximately 9:15 AM, The Assistant Administrator reported that they were doing morning rounds on the second floor when Resident #1 alerted them of a video with an incident that had occurred the night before. The Administrator and Director of Nursing (DON) were immediately notified. 911 was called and a facility investigation was initiated. On 08/07/2023, Resident #1 was immediately interviewed by Administrator and DON stated that were inquiring about their medication. Resident #1 acknowledged that they were wrong for targeting LPN #1 who was not the assigned nurse. Resident #1 stated that they were aware that they were not due for their pain medication and LPN #1 did not make physical contact with them. Three CNAs and the President of the Residents counsel were interviewed and verified that Resident #1 displayed aggresse verbally and physical behavior to LPN#1. LPN#1 attempted to redirect Resident #1. On 08/06/2023 at approximately 4:00 PM, RNS responded to Resident #1 and provided redirection and administered the pain medication. On 08/06/2023 at approximately 10:1 5 PM, Resident #1 became restless, agitated, and impulsive towards LPN #1 and use their cellphone camera and threatened to record LPN #1 without their consent. LPN #1 attempted to remove the cellphone from Resident #1 but CNA #1, #2 and #3 intervene and prevented any physical contact with LPN #1 and Resident #1. LPN #1 used disparaging verbiage towards Resident #1. The Facility concluded that there was an inappropriate interaction between LPN #1 and Resident #1. A Psychiatry Progress Note dated 08/08/2023 at 2:34 PM, documented Resident #1 was assessed after the incident between staff on 08/06/2023. Resident with borderline personality and Post Traumatic Stress Disorder. No new anxiety, and there was no new effect from the incident. A Physician's order dated 06/07/2023, documented Ibuprofen 600 milligram (mg), give 1 tablet by oral route 3 times a day for Pain. A Physician's order dated 06/26/2023, documented Hydromorphone 4 mg tablet, give 1 tablet by oral route every 8 hours as needed Pain. A Medication Administration Record dated 8/6/2023 at 5:15 AM, Pain Medication Hydromorphone 4 milligram tablet every 8 hrs. administered, 8/6/2023 at 6:36 AM, Pain medication administered, 8/6/2023 at 5:00 PM. Pain medication administered 8/6/2023 at 11:23 PM pain medication administered. A Nursing Progress Note dated 08/10/2023 at 11:22 AM, documented that at 10:30 AM, Resident #1 was discharged to community with family. During an interview 08/14/2023 at 12:05 PM, RNS #1 who worked on 08/06/2023 on the 3 PM to -11 PM shift stated that between 3:30 PM and 4:00 PM, the RN #1 called and informed them that Resident #1 wanted to throw the dinner tray in their face because Resident #1 did not receive their 2:00 PM medications. There were no medications on the unit to give Resident #1 because the facility had the medication in stock. RNS #1 went on the unit and deescalated the situation. RNS #1 informed Resident #1 that they will get their 2 PM medications before the end of the shift. The medication is written as a as needed order for every 8 hours. The medication was given to Resident #1 and Resident #1 was calm. At approximately 10:07 PM, a text was received from RN #1 stated that Resident #1 was requesting their medications and RN #1 did not give the medication because it was too early. RNS #1 stated that they were informed that Resident #1 was trashing the unit and Resident #1 was on their way down to them. Resident #1 came to the nursing office and informed RNS #1 that the RN #1 did not give them their medications. RNS #1 inform Resident #1 that they are the one who will give them their medication and it was too early. Resident #1 got upset and stated that they wanted to go home. RNS #1 stated that they asked the staff members to write statements regarding Resident #1 threatening to throw a tray in the RN #1 face. RNS #1 stated that it was the changed of shift and staffs stated coming in. RNS #1 stated that they had no knowledge of the incident occurring between Resident #1 and LPN #1. RNS #1 stated that no staff members of residents reported any incident. RNS #1 stated LPN #1 worked out their 3-11 shift. RNS #1 stated that they became aware of the incident the following morning when they got back to work. During an interview on 08/14/2023 at 12:25 PM, CNA #1 stated that they worked a double shift. Resident #1 was acted up from in the morning, RNS #1 came on the unit and give Resident #1 their medication (not sure of the time). CNA #1 stated that approx. 5:00PM Resident #1 had their dinner tray and approached the RN #1 stated that they are going to hit them with tray. The RN #1 called RNS and reported it. CNA #1 stated that approx. 10:30 PM, Resident #1 started back again and asked CNA #1 to call the RNS #1. CNA #1 stated with the help of other CNAs they separated Resident #1 from LPN #1. Resident #1 went over on the East side and started following LPN #1. Resident #1 and LPN #1 started arguing and the staff continued to try to separate them when Resident #1 took out their cellphone and started video recording LPN #1. CNA #1 stated that they did not see LPN #1 hit Resident #1. During an interview on 08/14/2023 at 12:52 PM, CNA #2 stated that at approximately 5:00 PM, they gave Resident #1 their dinner tray in their room. Resident #1 came out of the room and said to the LPN #1 to call the RNS #1 right now. Resident #1 stated that if LPN #1 does not call RNS #1 right now they are going to throw the tray on LPN #1. Resident #1 stated that they did not get their morning medications. RNS #1 came to the unit and spoke with Resident #1 received their pain medication at that time. Later in the night (not sure of the time) Resident #1 came from their room and stated that they need their pain medication now. LPN #1 told Resident #1 it was too early for the next dose. The LPN #1 was walking away when Resident #1 approached LPN #1 and threatened LPN #1. Resident #1 and the LPN #1 started cursing using inappropriate language. CNA #2 stated that they did not see LPN #1 hit Resident #1 while Resident #1 was video recording them. During an interview on 08/14/2023 at 2:05 PM, CNA # 3, stated that they were by the nursing station on 08/06/2023 at approximately 10:15 PM when Resident #1 came out of their room and was agitated. CNA #3 stated that Resident #1 was acting very angry and started throwing everything off the nurse's desk onto the floor. CNA #3 stated that there were some cups and plate on a table and Resident #1 threw them on the floor and started kicking them. CNA #3 stated that they called LPN #1, and as soon as Resident #1 saw LPN #1, Resident #1 was ready to get physical with LPN #1. CNA #3 stated that they informed LPN #1 to walk away and leave Resident #1. CNA #3 stated that while they were present, they did not observed LPN #1 hitting Resident #1. During an interview on 08/14/2023 at 1:30 PM, the DON stated they became aware of the incident on 08/07/2023 at 9:30 AM, by The Administrator. DON #1 stated that they immediately call 911 and they responded. DON stated that they interview Resident #1 and Resident #1 informed them of the incident and showed DON the video recording. DON stated that they observe LPN #1 cursing at Resident #1. DON stated that they did not observe LPN #1 hitting Resident #1. DON stated that when they interview Resident #1, the Resident #1 stated that LPN #1 did not hit them. DON #1 stated that Resident #1 stated they were only holding up their cellphone and videotaping LPN #1. Resident #1 stated that they were okay and did not have any complaint at the time. During an interview on 08/22/2023 at 3:05PM, Resident #1 stated that on 08/06/2023, they did not receive their pain medication that was due at 2:00 PM. Resident #1 stated that they waited until the 3 PM-11PM shift started to asked for the pain medication. Resident #1 stated that at approximately 4:00 PM they went to LPN #1 and requested their pain medication. Resident #1 stated that there was not pain medication on the floor and LPN #1 must call RNS #1 to get it from downstairs. Resident #1 stated that RNS #1 came on the unit and provided them with their pain medication and informed them that they will ensure that they received the next dose before they leave the shift. Resident #1 stated that they went to LPN #1 at 10:00 PM and asked for the next dose of pain medication. Resident #1 stated that LPN #1 refused to give it to them. Resident #1 stated that they took out their cellphone and started to videotape LPN #1 while they were talking to them to ensure that they got LPN #1 on video. Resident #1 stated that LPN #1 slapped them in their face when they were trying to take away their cellular phone. Resident #1 stated that they called the Police but when the Police interviewed them, the Police stated that it was a harassment. Resident #1 stated the Police give them their card and left the facility. 10 NYCRR 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview conducted during the Recertification and Complaint Survey (NY00282786), the facility did not ensure that residents' representatives were immediately notified about residents' conditions. Specifically, the facility did not notify the resident's representative immediately of the resident's COVID-19 status (Resident #143). This was evident for 1 of 3 residents reviewed for Notification of Change out of a sample of 38 residents. (Resident #143) The findings are: The facility's policy Notification of Change renewed on 11/2014 documented that it is the policy of the facility that the facility will immediately notify the resident, consult with the resident's physician, and if known, notify the resident's legal representative or interested family member. On 09/08/21 a complaint was made with an addendum on 10/08/21, that complainant, resident's representative was not informed that resident was tested positive for COVID-19 on 10/08/21. Resident #143 was admitted to the facility with diagnoses that include General Anxiety Disorder, Seizures, Insomnia, and Alcohol liver disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was cognitively intact. The Comprehensive Care Plan (CCP) titled COVID 19, At risk for alteration in psychosocial wellbeing related to restriction on visitation, no communal dining, and limited socialization/activities due to COVID-19 was created on 03/16/20. The CCP documented a goal of resident will not experience any adverse effects of visitation restriction and other limitations such as: Depression, Stress. Interventions include to provide 1:1 staff visits from social worker & activity staff, encourage alternative communication with visitors such as telephone conversations, emails, facetime. Nursing Progress note dated 10/07/21 at 5:18 PM, documented received resident in stable condition, complained of body aches, stuffy nose, and headache. Resident tested positive on the COVID 19 rapid test. Documented that Director of Nursing (DNS) and Assistant Director of Nursing (ADON) made aware. Nursing Progress note dated 10/08/21 at 3:38 AM, documented that Resident #143 is alert and responsive. On Contact/droplet precautions. Not in distress and no shortness of breath (SOB). Denies any pain or discomfort. Awaiting Chest X-ray ordered and faxed. Will continue to monitor. Temperature is 97.4 Oxygen saturation (O2 Sat) is 96%. Physician's note dated 10/08/21 at 4:05 PM, documented that resident was seen on routine follow up rounds. The note also documented that a review of the resident's recent labs was notable for a positive COVID-19 PCR test. A late entry Nursing note dated 10/08/21/at 9:54 PM, documented a rapid COVID -19 test done on 10/07/2021, and was positive. A Social Services note dated 10/14/21 at 1:40 PM, documented that Social Services met with resident for 1:1 supportive visit due to passing of their peer. Resident was provided with emotional support. Documented no issues or concerns noted at this time. Social worker will remain available in this setting. Laboratory findings dated 10/08/21 documented collected (SARS2020) and SARS CoV-2RT-PCR results on 10/09/21 at 1:43pm documented detected- abnormal. There was no documented evidence that the resident's representative was made aware of resident's diagnosis of COVID-19. On 01/07/22 at 12:10 PM an interview was conducted with Resident #143 who stated that their representative is very involved in their care and care plan meeting. Resident #143 also stated that the Social Worker will tell them what is going on and will notify their representative about their condition. On 01/12/22 at 01:00 PM, an interview was conducted with Registered Nurse (RN) #1. RN #1 stated that any changes that occur with the residents, the family must be notified. RN #1 also stated that either the Nurse and or the Supervisor can call the family and let them know. In the case of Resident #143, when the resident tested positive, the family should have been notified of resident's change in condition. On 01/12/22 at 01:56 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that families are notified individually of any change in condition and that it's the Supervisors, together with the Social Workers who would notify the family of the resident's COVID-19 status. The DON also stated that this would be documented in the progress notes, and that if the family asks to be notified, then the family needs to be made aware of any change in condition. 415.3(e)(2)(ii)(b)

Based on interviews and record review conducted during the Recertification survey, the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency. Specifically, the facility did not report a resident-to-resident altercation to the New York State Department of Health (NYSDOH). This was evident for 2 of 9 residents reviewed for Abuse out of a sample of 38 residents. (Resident #65 and Resident #162). The findings are: The facility policy titled Abuse, Neglect, Mistreatment, with revision date of 01/2020, documented that all residents of the Brookhaven Rehab and Health Care Center, will be protected from abuse, mistreatment, neglect, or misappropriation of property in accordance with state and federal regulations. The policy also documented that this also includes resident to resident abuse. Resident #65 was admitted with diagnoses that included Dementia, Hypertension, Diabetes Mellitus type 2, Parkinson's disease, and Psychosis. Resident #162 was admitted to the facility with diagnoses that included Schizoaffective Disorder- Bipolar type, and Major Depressive Disorder. The Resident Altercation Occurrence Report dated 12/27/21 documented that on 12/27/21 at 1:40 PM, Resident #65 stated that they were in the hallway and Resident #162 pushed them behind their head, knocking them to the floor. Both residents were separated, and Resident # 162 was transferred to the hospital ER for evaluation. There was no documented evidence that the incident had been reported to the State Survey Agency. On 01/12/22 at 09:58 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the altercation was not reported since no injury occurred and Resident #162 is delusional and has a history of accusatory behavior. The ADON also stated that as per the guidelines, that it was not a reportable offense and that as the resident had other altercations with other residents in the past, they were on a close observation such as 30 minutes regular monitoring. The ADON further stated that as the Risk Manager, they are also responsible for reporting to the Health Commerce System and in their absence the Director of Nursing (DON) will do the review of the incidents. On 01/12/22 at 02:12 PM, an interview was conducted with the Administrator. The Administrator stated that the ADON reviewed the Incident Reporting Manual and there was no injury and that the aggressor was sent immediately to the hospital. The Administrator also stated that the victim did not recall the events of what transpired, and the residents were separated immediately. The Administrator further stated that the incidents are reviewed by the DON, and after reviewing this incident it was determined that it did not fit the criteria to be reported. On 01/12/22 at 02:22 PM, an interview was conducted with the DON. The DON stated that this incident was not witnessed, there was no injury, and the residents could not give a detailed description of the incident and based on that information, the incident was not reported. The DON further stated that as a team, a decision is made if an incident is reportable or not. 415.4(b)2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, the behavioral symptoms of a resident was not captured on the Minimum Data Sets (MDS). This was evident for 1 of 9 residents reviewed for Abuse out of total sample of 38 residents (Resident # 100). The findings are: The facility policy and procedure titled Minimum Data Set Assessments reviewed 10/2012, documented: To accurately complete the MDS each assessor should review the medical record, interview, and observe the resident, interview direct care staff, and interview family/significant others. and Section E: The social Worker will evaluate identifying the frequency and impact of behavioral symptoms. Resident # 100 was admitted with diagnoses which included Mood Disorder, Essential Hypertension, and Type 2 Diabetes Mellitus. The Comprehensive Care Plan (CCP) for Behavior, created on 8/10/21 and updated 1/6/22, documented: Resident exhibits verbal behavioral symptoms directed toward others: threatening others, screaming at others, cursing, disruptive sounds, and refusing medical evaluation. The Certified Nurse Aide (CNA) documentation history dated 10/20/2021-10/26/2021, during the 7 day look back period for the Quarterly MDS dated [DATE], documented behaviors which included yelling/screaming, verbally abusive language, socially inappropriate/disruptive behavior, resists care, negative statements, persistent anger with self/others, repetitive anxious complaints/concerns, abusive language, and threatening behavior. The Care Plan Activity Report note dated 10/21/21 documented resident refused transport to hospital for dental evaluation. The Behavior Note dated 10/26/21 documented the resident with aggressive behavior and cursing at maintenance staff. The Quarterly MDS dated [DATE] documented in Section E0200 Behavior Symptom-Presence and Frequency and Section E0800 Rejection of Care-Presence and Frequency that the resident exhibited no behavioral symptoms. The MDS did not accurately capture the resident's behavioral symptoms. On 01/10/22 at 11:15 AM, Resident #100 was observed wheeling self to nurse's desk. Resident then screamed and cursed at nurse. On 01/12/2022 at 2:34 PM, Social Worker (SW) #1 was interviewed. SW #1 stated that Section E of MDS which captures behavioral symptoms is completed by Social Services staff. SW #1 also stated they did not capture behavioral symptoms during the 7 day look back period for the Quarterly MDS dated [DATE] and did not notice the behavioral note dated 10/26/21. SW #1 further stated they were never instructed to review CNA Documentation Record for coding MDS and only reviewed progress notes to determine if the resident had any behaviors. On 01/12/22 02:43 PM, the Social Services Director (SSD) was interviewed. The SSD stated that in order to complete Section E they look at Care Plans and check progress notes for information. The SSD also stated they were never taught to check the CNA Documentation Record and therefore did not know to check this document for information on the resident's behavior. 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview conducted during the Recertification survey, the facility did not ensure that a resident and their representative was provided a summary of the baseline care plan. This was evident for 1 of 5 residents reviewed for Care Plan out of a sample of 38 residents. (Resident # 323) The finding is: The facility policy and procedure titled Comprehensive Care Plans/Baseline Care Plans revised in 6/2019 documented this facility shall develop and implement a Comprehensive Care plan, including a baseline care plan for each residents that includes instructions needed to provide effective and person-centered care of the resident that meet the professional standards of quality of care within 48 hours of a resident's admission. The policy also documented that the baseline care plan shall be given to the resident/resident's representative at the completion of the CCP by the RN Supervisor/designee and signature should be obtained from the receiving party. Resident # 323 was admitted to the facility on [DATE] with diagnoses that included Deep Vein Thrombosis, Cellulitis, and Pulmonary Embolism. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident with intact cognition and independent with most of Activities of Daily Living. On 01/10/2022 at 10:56 AM, during an interview Resident #323 stated that had not received a copy of a baseline care plan since admission to the facility. Review of the medical record contained no documented evidence that a copy of the baseline care plan had been provided to the resident. On 1/08/2022 at 1:14 PM, the MDS Coordinator (MDSC) was interviewed. The MDSC stated that due to the current staffing there are not always Registered Nurses on each unit. The MDSC also stated that the MDS staff usually does the baseline care plan. The MDSC further stated that the residents are not provided with a copy of the baseline care plan unless they request it. 415.11 (c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility policy and procedure titled Wound Care - Aseptic Dressing Change revised on 11/2012 documented dressings are changed as per physician's orders using aseptic technique. Resident #623 (NY 00286634) was admitted to the facility with diagnoses which included Septicemia, Cellulitis of right lower limb s/p debridement, Morbid Obesity, and Venous Insufficiency. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The Documents of Wound Assessment dated 11/4/21 documented right lower leg wound that measured 20 L x 12 W x 2.0 D and recommended treatment with ¼ Dakin's solution and Xeroform dressing. The Documents of Wound Assessment dated 11/11/21 documented right lower leg wound that measured 22 L x 10 W x 1.5 D and to continue orders for ¼ Dakin's solution and Xeroform dressing. The Documents of Wound Assessment dated 11/17/21 documented right lower leg wound that measured 24 L x 10 W x 3.0 D and to continue orders for ¼ Dakin's solution and Xeroform dressing. The assessment further documented a second wound site to right foot that measured 2 L x 1 W x 0.3 D and recommended treatment with Calcium alginate and Xray of the right foot. The Comprehensive Care Plan for titled Skin Integrity related to right leg cellulitis s/p leg debridement was initiated 11/3/21 with interventions that included apply local treatments as ordered by MD, assess for pain, effectiveness of pain medication as per MD order, refer for follow up with the Wound Care Team, refer to Dietary for nutritional supplementation and Wound care consults as needed. Physician Orders effective on 11/28/21 documented the following treatment orders: -Wash Right lower extremity wound with Dakin's solution, apply Xeroform over wound bed, moisten gauze pads with Dakin's solution and apply to wound over the Xeroform, then cover with DPD BID and PRN. Schedule: Every Day at 7:00 AM-3:00 PM; 3:00 PM-11:00 PM. -Wash Right lower extremity wound with Dakin's solution, apply Xeroform over wound bed, moisten gauze pads with Dakin's solution and apply to wound over the Xeroform, then cover with DPD BID and PRN. Every Day at 7:00 AM-3:00 PM; 3:00 PM-11:00 PM. -Cleanse left foot opening with NS, pat dry then apply Calcium alginate and cover with DPD QD and PRN. Every Day at 7:00 AM-3:00 PM. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 11/3/21 to 11/30/21 contained no documented evidence that Calcium Alginate, Dakin's Solution and Xeroform Petrolatum Dressing were administered during 7:00 AM to 3:00 PM shift on 11/28/21. On 1/12/2022 at 12:40 PM, the Licensed Practical Nurse (LPN #3) was interviewed. LPN #3 stated wound treatment was not administered during 7:00 AM to 3:00 PM shift for Resident #623 on 11/28/21. LPN #3 also stated there was no time to do wound care treatment during 7:00 AM to 3:00 PM shift on 11/28/21 due to short staffing and insufficient time. LPN #3 further stated Resident #623 was informed that the wound care treatment would be administered during 3:00 PM to 11:00 PM shift on 11/28/21. LPN #3 stated RN Supervisor was made aware that residents with wound care treatments were not administered during 7:00 AM to 3:00 PM shift on 11/28/21 due to short staffing and insufficient time. On 1/12/2022 at 12:26 PM, Registered Nurse Supervisor (RN #6) was interviewed. RN #6 stated they were not made aware that Resident #623 did not receive wound care treatment during 7:00 AM and 3:00 PM shift on 11/28/21. RN #6 further stated that it may be an oversight that the treatment was not administered on 11/28/21. On 1/12/2022 at 1:36 PM, Director of Nursing (DON) was interviewed. DON stated LPN is responsible to notify RN supervisor on duty to receive support. The DON also stated that the RN supervisor is responsible to provide support when assistance is needed. 415.12 Based on observation, record review and staff interviews conducted during the Recertification and Complaint survey (NY 00286634), the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person centered care plan and the resident's choices. Specifically, 1) compression devices were not applied as per physician's order for a resident with Lymphedema, and 2) wound care treatments were not provided as per physician's orders. This was evident in 2 of 4 residents reviewed for Quality of Care out of a sample of 38 residents. (Resident #81 and Resident #623) The findings are: 1. The facility Policy and Procedure titled Consultations revised in 07/2018 documented all residents will receive comprehensive medical services. In addition to attending Physicians, the resident will receive services from Consultants if ordered by the Attending Physician. Resident # 81 was admitted to the facility Bariatric specialty unit with diagnoses that included Morbid Obesity, Peripheral Vascular Disease, Depression, and Chronic Bilateral Lower Extremities Lymphedema. On 01/06/2022 at 12:41 PM, Resident #81 was observed with swelling of bilateral lower extremities. During an interview, Resident #81 stated that they had not been receiving manual lymph drainage treatment for bilateral lymphedema at a center in [NAME] because of the COVID-19 pandemic. Resident #81 also stated that the treatment center had instructed the facility to apply a compression device twice a day which the facility had not done and as a result the swelling had increased and they were not able to ambulate. On 1/11/2022 at 1:12 PM, Resident #81 was observed in their room. An ace wrap bandage was observed on both lower extremities. Resident stated that these were not the right type of bandage that had been recommended by the treatment center so they would not be helpful to the resident. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident with intact cognitive status. The MDS also documented resident was not steady, only able to stabilize self with staff assistance for balance during transitions and walking and ambulated with wheelchair and walker. The MDS also documented resident extensive assistance of 1 staff for all Activities of Daily living except locomotion and eating for which they required supervision and set up only. The Comprehensive Care Plan (CCP) Lymphedema to Bilateral Lower legs related to lymphedema to bilateral lower extremities was last updated on 05/21/2021 with the goal set as will not have skin breakdown. Interventions included administer treatments as ordered, apply compression stockings to bilateral legs daily, to remove at bedtime (HS), place Daytime Compression stockings. Knee high goes on first with blue slide to assist with donning knee high stocking, then footless thigh high stocking goes on and pulled up all the way over the thigh to groin to remove at bedtime, place Night time Velcro compression garments bilateral lower extremities post skin clean, wash, dry and moisturize skin and remove in the morning. Physician's order created 5/21/21 dated 12/30/2021 documented the following: Apply brace to bilateral leg while in bed and remove before OOB, apply cotton wrap and ace bandage to right lower leg daily and PRN, place daytime compression stockings, knee high goes on first with blue slide to assist with donning knee high stocking, then footless thigh high stocking goes on and pulled up all the way over the thigh to groin. (REMOVE AT BED-TIME) Place Night time Velcro compression garments- BLE- post clean skin, wash, dry and moisturize skin. (REMOVE in the AM). Physician's Order dated 10/05/2021, renewed 12/30/2021 documented place Compression Pump to bilateral lower extremity once daily for 60 mins. The Treatment Administration Record (TAR) dated 12/02/2021 to 01/11/2022 contained no documented evidence that the staff were applying the daytime compression stockings and using the night time compression device. Nursing Progress note dated 11/24/2021 documented Resident with ongoing treatment Gentian [NAME] 1 % topical solution to left lower leg skin opening, apply DPD and ACE wrap for light compression daily and PRN, area shows progressive healing. With order for Compression Pump to bilateral lower extremity once daily for 60 min's, Daytime Compression stockings and Night time Velcro compression garments- for lymphedema management, not administered as resident is no longer able to don garments- due to increase in size of BLE. Discussion made with Optum NP, received order to put on HOLD. Wound Care note dated 12/02/2021 documented that the resident was seen by Wound Care MD for left lower leg, now resolved. Discontinue treatment with Gentian violet and light compression with Ace bandage for light compression. Recommendation for Lymphedema treatment. On 01/10/2022 at 11:00 AM, the Director of Rehab was interviewed and stated that all staff on the unit were provided inservice by a representative from the company on the use of the compression garment and device. On 01/11/2022 at 2:40 PM, and interview was conducted with Registered Nurse (RN) #7. RN #7 stated stockings have not been used since they do not fit the resident. RN #7 also stated that the Nurse Practitioner (NP) ordered an ace wrap which is what is being used. RN #7 also stated that they had not seen the compression device in use while making rounds on the unit. On 01/11/2022 at 3:56 PM, the Licensed Practical Nurse (LPN) # 6 who worked on the 3-11 shift was interviewed. LPN #6 stated that sometime in October 2021 the resident developed a wound and cellulitis which was treated and resolved as of 12/02/2021. LPN #6 also stated there was a recommendation to continue the treatment recommended by the Lymphedema Center, The lower extremities had gotten bigger and the stockings could not be used because they did not fit the resident so the NP placed an order to apply ace wrap. LPN #6 further stated the night compression device was not being applied and they did not provide a reason for why this was not being done. LPN #6 stated the compression device is available in the resident's room in a bag on top of the resident's closet. On 01/11/2022 at 4:00 PM, an interview was conducted with RN #2. RN #2 stated recommendations of the treatment center were not resumed after the resident's wound resolved because the garment no longer fit the resident. The NP who ordered the Ace bandage was no longer employed at the facility and could not be reached for interview. On 01/12/2022 at 2:00 PM, an interview was conducted with the NP. The NP stated that they did not see any documentation regarding communication with the Treatment Center and they had not communicated with the Vascular team that was treating the resident to discuss the plan of care. The NP also stated that they did call the center once but they did not answer the phone and they did not do any follow-up. The NP further stated that they know the resident was scheduled to go for follow up but that did not materialize for one reason or another. On 01/12/2022 at 11:30 AM, an interview was conducted via telephone with the Medical Director. The Medical Director stated that the physician/NP should have communicated and collaborated with treatment center with the plan of care for this resident. The Medical Director further stated that there may have been concerns with the equipment but this should have been communicated with the treatment center for follow-up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of facility undated policy on Discarding Expired Medication documented nurse checks all medications for expiration dates and must discard all expired medications and notify the pharmacist immediately. On 01/11/2022 at 11:49 AM, during an observation of 5th Floor medication cart a box of Arginaid powder box containing 5 packets was observed with an expiration date of 12/1/2021. Licensed Practical Nurse # 2 was immediately interviewed and stated that at the beginning of the shift the medication cart is check by the medication nurse and if any medication is expired, pharmacy will be called for replacement, medication is discarded and the nursing supervisor is notified. LPN # 2 further stated the expired medication was not seen that morning and that it should have been removed from the cart. On 01/12/2022 at 10:23 AM, RN #4 was interviewed. RN #4 stated expired medications should have been removed/discarded by the medication nurse. On 01/12/2022 at 11:00 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated the medication carts are check by nurses for medications nearing expiration and if expired needs to be discarded. The ADON further stated that expired med found in the cart should have been discarded by the nurse in the unit. 415.18 (a) Based on observation, record review and staff interview conducted during the Recertification survey the facility did not ensure that pharmaceutical services were provided to meet the needs of each resident. Specifically, 1) the facility did not ensure that resident's prescribed medication was made available in a timely manner by the pharmacy as per order, and 2) the facility did not ensure that expired medications were removed and discarded according to the manufacturer's recommendation. This was evident for 1 of 1 resident reviewed for Vision/Hearing out of a sample of 38 residents and for 1 of 5 medication carts observed. (Resident #99, and 5th Floor) The findings are: 1). The facility policy and procedure titled Delivery, Receipt, Storage, and Inventory of Medications/Products last revised on 04/2014 documented each facility has routine deliveries to meet the facility's needs and ensure timeliness of medication availability. If any item ordered is not received, check for a communication slip indicating back orders. Contact pharmacy if no reason for missing medication is evident. Resident #99 was admitted to the facility with diagnoses that included Hypertension, Anxiety Disorder, and Depression. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had intact cognitive status and required supervision with set up for most Activities of Daily Living. The Comprehensive Care Plan (CCP) for Sensory Deficit dated 11/25/2019 documented that resident has visual deficit as evidenced by unable to read fine prints. On 01/06/22 at 10:24 AM, an interview was conducted with Resident #99. Resident #99 stated that their left ear was clogged with wax, and very painful, and had been reported to staff some time ago, but nothing had been done yet. On 01/07/22 at 09:34 AM, Resident #99 was observed in room and stated that the ear drop is not being administered yet. Resident #99 also stated that they had been informed by the nurse that they are still waiting for the medication to arrive from the pharmacy. Physician's Order dated 1/4/2022 documented Debrox 6.5 % ear drops, instill 5 drops by (ear) route 2 times per day for 7 days each ear. Nursing Progress note dated 01/04/2022 at 02:28 PM documented Resident c/o (complained of) ear pain. NP (Nurse Practitioner) assessed resident, ordered Debrox 6.5 % ear drops instill 5 drops by (ear) route 2 times per day for 7 days each ear, order in. Medical Progress Note dated 01/06/2022 documented that resident was seen and f/u (followed up) on c/o ear wax, was examined at bedside with nursing staff prior to report. Debrox added to regimen Will continue with the other plan of care as before ordered. The Medication Administration Record (MAR) for January 2022 documented that the medication was ordered for the resident on 01/04/2022 and the first dose was administered on 01/08/2022 at 9:00 AM. On 01/11/22 at 12:16 PM, an interview was conducted with Registered Nurse (RN) #1. RN #1 stated that as per resident's chart review, resident complained of ear pain on 1/4/22, was examined by the Nurse Practitioner who ordered ear drops on 1/4/22, which are currently being administered. RN #1 also stated that the medication was started late because it was not delivered until 1/8/22. RN #1 further stated that pharmacy was notified when the medication was ordered but it was not delivered until 1/8/22 and there was no documented evidence of when pharmacy was called. On 01/12/22 at 09:37 AM, an interview was conducted with a Pharmacy Technician. The Pharmacy Technician stated that any resident's prescription is immediately filled and sent as soon as the order is received from the facility. The Pharmacy Technician also stated that review of the resident's record revealed that the order was received on January 6, 2022 and delivered to the facility that same day. The Pharmacy Technician further stated that they apologized for the delay but could not explain the reason the medication was delivered late, and that only the Account Manger that can explain the reason for the delay. Several efforts to get the Account Manager unsuccessful. On 01/12/22 at 11:08 AM, the Director of Nursing (DON) was interviewed. The DON stated that residents' medication is delivered to the facility on 2 runs daily; the mid-day run is delivered about 5 PM and overnight run delivered at about 4 AM. The DON also stated that there is cut off time for medication order, if the physician orders medication for the resident before 10 AM, it is supposed to be delivered on the first run, and if it is ordered after 10 AM, it should be delivered on midnight run at 4 AM. The DON further stated that they are not aware that resident's medication was not delivered on time. The DON further stated that when pharmacy was asked for the cause of delay in sending the resident's medication, it was reported that they thought the medication was only ordered as a profile on 1/4/22 until a facility staff called for the medication on 1/6/22 when the medication was dispensed and processed for delivery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/6/22 at 10:28 AM, during the tour of the 6th Floor, the following was observed: In room [ROOM NUMBER] closet door missing, debris all over floor, holes on wall and floor, paint scraped off of wall, vent broken on heating unit, bathroom tiles in disrepair, and bathroom sink not draining well. Floor was observed to be dirty during observations on 1/6/22, 1/7/22, and 1/10/22. In room [ROOM NUMBER]-a hole was observed in right lower wall upon entering. In Rooms #621 and #618 broken blinds observed. In room [ROOM NUMBER] heating unit had chipped paint and damaged vents. On 01/11/22 at 9:25 AM, an interview was conducted with HK #3. HK #3 stated nursing staff documents what needs to be fixed in the maintenance log book that is located on nurse's desk. HK #3 also stated that room [ROOM NUMBER] has scraped paint on the walls because the resident hits it with their wheel chair when they go by. HK #2 further stated they clean floors in residents' rooms every day. 01/11/22 at 05:24 PM, Maintenance logs reviewed for Unit 6 from November 2021 through January 4, 2022. There was no documented evidence that the above issues had been noted or repaired. On 01/12/22 at 09:56 AM, an interview was conducted with the Housekeeping/Maintenance Director (HMD). The HMD stated that normally, if anything is to be fixed in the resident's living area, it is logged in to the maintenance book on every unit, the maintenance staff goes to the unit every morning to pick up the report which are taken downstairs and then assigned. Once the repair has been made, they sign off on the work order that the job is completed. The HMD also stated that the work order is kept in the office after the completion of the work. The HMD further stated that they are aware that a lot of things need to be fixed and the facility is working on them and staff have been mobilized to get the repair work done as soon as possible. 415.5(h)(2) On 01/12/2022 at 01:38 PM, Resident # 273 was interviewed. Resident # 273 stated that their clothes are all over the bed, chair, and tables as they do not have a place to put personal belongings because there is no closet or drawers in the room. No closet or drawers were observed in the room. On 01/12/2022 at 01:39 PM, Resident # 20's closet was observed to be missing a door and closet was observed to be cluttered and disorganized and overflowing with clothes. On 01/12/2022 at 1:40 PM Resident # 473 was interviewed and stated since admission on [DATE] they have had no closet and had to store clothing on chair and tables. On 01/12/2022 at 1:40 PM, Resident # 152 was interviewed and stated the closet door remains open and cannot be closed. Closet door has observed with missing screws and with holes on the side of the door. On 01/12/2022 at 01:48 PM, the Housekeeping/Maintenance Director (HMD) was interviewed and stated the staff log in the maintenance book what needs to be done on the unit. Review of the maintenance log book for Unit 2 contained no evidence that any of the observed concerns had been documented or reported. On 01/12/2022 at 2:52 PM, HK #1 was interviewed and stated when there is a problem with the closet or drawer, it gets reported verbally to the Housekeeping supervisor. On 01/06/22 at 09:53 AM, Resident # 221 stated that there is mold all over the room which is causing a lot of discomfort. Resident also pointed to the broken and loosely fitted window blinds and stated, it has been broken since they put me here. Resident further stated that the bathroom is not good, and when they shower upstairs, water comes down to the bathtub and block it. Resident #221 also stated that the complaints have been made several times, but nothing was done. In Resident #221's room broken seals were observed on the base of walls by the window, and by bathroom entrance. The bathtub was noted with sediments. On 01/06/22 at 10:08 AM, Resident #187's room was observed with faded and rusted floor tiles and mismatched paint surrounding the air-conditioner. Resident stated, it's been like that since I came here. On 01/06/22 at 10:35 AM, Resident #20, was observed sitting on wheelchair in the room. Broken wall with a large hole was observed on the bottom part of bathroom wall. The bathtub was observed clogged with black sediment on the surface of the bathtub. The resident's closet was noted with missing door. Resident #20 stated that the bath has been clogged for a long time, and one side of the closet door has been missing for more than a year. On 01/06/22 at 10:56 AM, Resident #110 was observed in the room and stated that the hook that controls the window blind is not working, the air conditioner knob to adjust the heat/cold is also not working. In Resident #110's room paint on the bottom side of the walls and base board were observed to be peeling off. Resident #110 stated that it has been like that since they were admitted to the room. The maintenance book located on the Unit 2 contained no entries and only blank copies of work orders were noted in the binder. Copies of work order collected and signed off from Unit 2 between November 2021 and January 10, 2022 contained no documented evidence that the above issues had been noted or repaired. On 01/10/22 at 10:24 AM, an interview was conducted with Certified Nursing Aide (CNA) #1. CNA #1 stated that if any concern or issue is noted with the resident or in the resident's living area, it is reported to the Charge nurse and documented in the Maintenance book. CNA #1 also stated that they are not regular on the unit and had not noticed or reported any of the identified issues. On 01/10/22 at 10:28 AM, an interview was conducted with Housekeeper (HK) #1. HK #1 stated that the blocked bath in the residents' rooms were reported a long time ago to the supervisor and the maintenance department; it was documented in the maintenance book, and verbally reported. HK #1 also stated that when there is water in the bath, it is pulled out manually. HK #1 further stated that the broken base board, the faded and rusted tiles, and the broken blinds in the residents' rooms have also been reported a long time ago. On 01/11/22 at 12:07 PM, an interview was conducted with Registered Nurse (RN) #1. RN #1 stated that any nurse that noted anything needed to be repaired on the unit/residents' rooms documents it in the maintenance book, the maintenance department makes rounds daily to check the book and collect the work order for the job to be done. RN #1 also stated that the issues are discussed at the morning report on the needed repairs to be carried out. RN #1 further stated that some of the identified issues have been reported in the maintenance book, which are always removed by the maintenance staff and they did not know where the reported notes were kept. On 01/06/2022 and 01/07/2022, broken window blinds were observed in room [ROOM NUMBER] on Unit 2. Based on observations, record reviews, and interviews conducted during the Recertification survey, the facility did not ensure that necessary housekeeping services were provided to maintain a safe, clean, comfortable, and homelike environment. Specifically, disrepaired handrails, broken and loosely fitted window blinds, broken walls, unpainted areas, mis-matched paint, a blocked bathtub, and cluttered floors were observed in residents' living areas. This was evident in multiple rooms on several units. (Units 2, 3 and 6). The findings are: The facility policy and procedure titled Environmental Rounds revised on 05/2012 documented it is the policy to ensure the safety and cleanliness of the facility. The facility will be properly maintained and in compliance with Federal and NYS regulations All issues/conditions must be entered in logs books for Maintenance or Housekeeping .Examples of Maintenance issues include stained ceiling tiles, broken furniture, holes in walls, loose moldings, broken venetian blinds, heating/air conditioning problems, etc. Administration, Maintenance, and Housekeeping department heads will make Environmental rounds on a regular basis. On 01/06/2022 at 10:00 AM, during a tour on the Unit 3, handrails with missing elbows and metal exposed was observed between Rooms # 307, 324, 325 and 326, near the elevator, the shower room, and the clean utility room. On 01/12/2022 at 2:33 PM, the Housekeeping/Maintenance Director (HMD) was interviewed. The HMD stated they were aware that the elbows were missing and they had become damaged as a result of carts banging against them. The HMD also stated that they do environmental rounds occasionally with the Administrator but could not say when last this had occurred. A log of reported repairs requested for the unit was requested but was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #143 was admitted to the facility with diagnoses that included General Anxiety Disorder, Seizures, and Insomnia. The Quarterly Minimum Data Set (MDS) dated [DATE] documented that resident was cognitively intact. Social Services note dated 10/1/21 documented special review meeting was scheduled today; however, meeting will have to be rescheduled for a later date. Next of kin (NOK) and family is made aware. Social Services note dated 10/22/21 documented that a comprehensive care plan (CCP) meeting was held today, quarterly review. The note also documented that the interdisciplinary team met via phone conference call to discuss the resident's quarterly plan of care. Social Services note dated 11/09/2021 documented that a CCP meeting was held today, quarterly Review. Comments: IDT met via phone conference call to discuss the resident's plan of care for quarterly review. Multidisciplinary goals were reviewed and accepted by all participants. On 01/11/22 at 12:55 PM, an interview was conducted with SW #2. SW #2 stated that the SW assistant calls the family a week in advance, then they go to the unit and have the residents sign the letter confirming that they were invited to attend the meeting. SW #2 also stated that residents do not have to be invited to quarterly meetings so they are not invited to those. SW # further stated that the letters that are given and signed are for the annual, initial, special review, and significant change. On 01/11/22 at 01:06 PM, an interview was conducted with the Social Services Director who stated that the resident/family member is usually invited to Annual, readmission and Initial care plan meetings but are not invited to participate in the quarterly meetings which are usually only discussed with the IDT and not the residents. 3. Resident #65 was admitted with diagnoses that included Dementia, Hypertension, Diabetes Mellitus Type 2, Parkinson's Disease, and Psychosis The Annual Minimum Data Set (MDS) assessment dated [DATE] documented that resident was cognitively intact and displayed no behavioral symptoms or rejection of care. The Resident Altercation Occurrence Report dated 12/27/21 documented that on 12/27/21 at 1:40 PM, Resident #65 stated that they were in the hallway and Resident #162 pushed them behind their head, knocking them to the floor. Both residents were separated, and Resident # 162 was transferred to the hospital ER for evaluation. A Comprehensive Care Plan (CCP) titled Abuse /Neglect/Mistreatment/Victimization at risk for abuse/neglect created on 03/16/2018, documented resident is a potential risk of victimization, Related to Dementia, Unspecified psychosis and Major depressive disorder, single episode, severe with psychotic features. Goal included resident will be free from injury from others through next review on 02/13/22, and resident will not inflict injury on others through next review on 02/13/22. Interventions included intervene if resident shows signs of anger or hostility, remove potentially dangerous objects from environment, remove resident to a quiet environment. A CCP titled Falls, at risk for falls/injury created on 03/16/2018 documented resident was at risk for falls/injury /fracture related to gait disturbance and antipsychotics. Goals was fall risk and injury will be minimized through individualized interventions and evaluation of effectiveness x 90 days. Interventions included counsel to seek staff assist with care as necessary, observe environment for environmental hazards and clutter and remove. There was no documented evidence in that comprehensive care plans were updated to reflect resident-to-resident interaction or fall on 12/27/21. On 01/12/22 at 11:33 AM, an interview was conducted with Registered Nurse #1. RN#1 stated that care plans are updated by the Supervisors and MDS assessors. The Unit Nurse or the RN, must update the care plan including putting in the notes about everything that was done for the resident. RN #1 also stated that when the incident occurred, the abuse care plan should have been updated to include that the incident happened and an assessment should have been done. RN #1 further stated that if it entails an assessment, an RN should be the one to update and put in the assessment. On 01/12/22 at 02:31 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that it is the responsibility of the RN Supervisor on duty who did the assessment of the residents to update the resident's care plan. The DON also stated that it should have been updated when the incident occurred. 415.11(c)(2) (i-iii) Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that each resident or resident representative was offered the opportunity to participate in the revision and/or review of the Comprehensive Care Plan (CCP) and the facility did not ensure a resident's CCP was revised. Specifically, residents were not invited to quarterly care plan meetings and the facility did not revise a resident's CCP following a resident to resident interaction. This was evident for 2 of 5 residents reviewed for Care Planning and 1 of 8 residents reviewed for Accidents out of 38 sampled residents (Resident #177, #143, and #65). The findings are: The facility policy and procedure titled Comprehensive Care Plan/Baseline Care Plan revised 8/2021 documented: Resident and Resident Representatives are invited to discuss their anticipated plan of care and to participate in the actual care planning process. and The CCP will be reviewed and revised daily and episodically during the development phase of the Comprehensive Plan and episodically, as the plan of care changes. 1. Resident # 177 was admitted to the facility with diagnoses which include Morbid Obesity, Major depressive disorder, and Lymphedema. Minimum Data Set (MDS) assessments dated 2/4/21, 4/29/21, 7/14/21, 8/28/21 and 11/07/2021 documented that resident had intact cognition with a brief Interview for Mental Status (BIMS) score of 15. Care Plan Meeting Notes dated 02/10/2021, 05/05/2021, 07/28/2021 and 11/26/2021 contained no documented evidence that Resident # 177 participated in the quarterly care meeting. The Care Plan Meeting Report dated 02/10/2021 and 05/05/2021, documented Resident # 177 did not attend the quarterly care plan meetings. There was no documented evidence in the medical record that Resident # 177 was invited to the quarterly care plan meetings held on 02/10/2021, 05/05/2021, 07/28/2021, and 11/26/21. On 01/06/2022 at 2:35 PM, an interview was conducted with Resident # 177. Resident #177 stated that they had never been invited to a quarterly care plan meeting. Resident #177 also stated that they would like to attend care plan meetings. On 01/11/22 at 4:14 PM, an interview was conducted with the Social Services Director (SSD). The SSD stated that the resident and family are invited to the admission, annual, significant change, and if the resident or family requests an additional care plan meeting. The SSD also stated they deliver a form to the resident that has the date and time of the scheduled Care Plan meeting which the resident signs when they received this form. The SSD further stated that quarterly meetings are usually discussed with the Interdisciplinary Team (IDT) and not the residents, but prior to the meetings, discussions are made with the residents about their goals of care. On 01/12/22 at 12:11 PM, the Social Worker (SW) #1 was interviewed. SW #1 stated residents or families are not invited to quarterly Care Plan meetings. SW #1 also stated that residents are invited to the admission, annual, significant change, and if an additional meeting is requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 01/11/2022 at 10:00 AM to 10:20 AM and from 2:00 PM to 2:30 PM in the 2nd floor hallway, the following was observed: 1. Resident # 52, in the hallway, face mask covering the mouth, nose was exposed, 2. Resident # 473, seated in a wheelchair with a face mask covering the mouth only. Resident's nose was exposed and they were speaking to Resident # 5, 3. Resident # 143, was in the hallway and was not wearing a mask, and 4. Resident # 274, was in the hallway, and was not wearing a mask. On 01/11/2022 at 10:00 AM, Registered Nurse #1 was observed in the hallway and was not observed offering residents masks or redirecting residents who were wearing masks incorrectly. The Quarterly Minimum Data Set, dated [DATE] for Resident # 52 documented that resident had intact cognition. The admission MDS dated [DATE] for Resident # 473 documented resident had intact cognition. The Quarterly MDS assessment dated [DATE] for Resident # 143 documented resident had intact cognition. The Annual MDS assessment dated [DATE] for Resident # 274 documented resident had moderately impaired cognition. Rapid COVID-19 testing conducted by the facility on 01/03/2022 documented that Residents # 52, # 473, # 143, # 274 tested negative for COVID-19. On 01/11/22 at 02:32 PM, RN #1 stated that there were currently 6 residents on the second floor who tested positive for COVID-19 and were being maintained on Contact and Droplet Precautions. On 01/11/22 at 03:03 PM, an interview was conducted with CNA # 5. CNA #5 stated when they see residents wearing mask inappropriately, not covering both nose and mouth they go to them and show them the right way or assist them to put the mask properly. CNA #5 stated they did not observe the residents wearing masks incorrectly because they were assisting other residents. On 01/12/2022 at 1:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident is wearing mask inappropriately or no mask at all, the staff should supply them with a mask, and assist them to wear correctly. The DON also stated that residents observed on the 2nd floor should have been corrected by the staff. On 01/12/2022 at 2:35 PM, an interview was conducted with RN # 1. RN #1 stated some residents remove their mask, some do not wear them properly, and they try to get them to wear them correctly but still some residents take it off. 415.19 (a)(1-3) Based on observations, and interviews conducted during the Recertification survey conducted 01/06/2022 to 01/12/2022, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases, infections, and COVID-19 within the facility. Specifically, 1) oxygen tubing was undated and was observed lying on the floor, and 2) residents wore their face masks in a manner that did not cover their nose and mouth. This was observed on 2 of 5 units. (Unit 2 and Unit 3) The undated facility policy titled BIPAP/CPAP Filler, Tubing and Mask Change documented it is the policy of the facility to change BIPAP bacteria viral filter, tubing and mask as needed. The policy also documented that the BIPAP bacteria viral filter will be changed monthly and prn by Respiratory Therapist. 1(a). Resident # 123 was admitted to the facility with diagnoses that included Heart Failure, Obstructive Sleep Apnea, Atrial Fibrillation and Diabetes Mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that resident was cognitively intact, required extensive assistance of 2 staff for bed mobility and transfer and walking did not occur. Physician's order dated 12/30/2021 documented BIPAP use at bedtime and as needed (PRN) and oxygen by nasal cannula at 3/liters (l) continuous. On 01/06/2022 at 11:00 AM, Resident #123 was observed in bed with an oxygen concentrator attached to oxygen tubing which was laying on the floor. There was no date on the tubing. On 01/11/2022 at 1:00 PM, the oxygen concentrator was observed with tubing laying on the floor. The resident's BIPAP mask was observed with uncovered on top of the concentrator and was not dated. (b). Resident # 185 was admitted to the facility with diagnoses that included Coronary Heart Disease, Heart Failure, Hypertension, Respiratory Failure, and Chronic Obstructive Pulmonary Disease (COPD). The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident with intact cognition. The MDS also documented required dependent assistance of 2 staff for bed mobility and transfer and walking did not occur. On 01/06/2022 at 10:34 AM, Resident #185 was observed in bed with oxygen by nasal cannula via oxygen concentrator and the tubing was on the floor. On 1/11/2022 at 12:11 PM, Resident #185 was observed in bed and nasal cannula tubing attached to the oxygen concentrator was again found lying on the floor. Physician's order dated 12/12/2021 documented Oxygen 3 liters via nasal cannula and monitor oxygen saturation. On 01/11/2022 at 2:30 PM, Registered Nurse (RN) # 2 was interviewed. RN #2 stated that the nurses and staff are supposed to date the tubing when it is changed, which is once a week and as needed. RN #2 also stated that the BIPAP machine tubing and mask are changed by staff from Respiratory Therapy. RN #2 further stated that the tubing should not be lying or touching the floor. On 01/12/2022 at 11:00 AM, Certified Nursing Aide (CNA)# 7 was interviewed. CNA #7 stated that it is everybody's responsibility to see to it that tubings from the oxygen or catheter are not touching the floor. On 01/12/2022 at 11:30 AM, the Respiratory Therapist (RT) was interviewed. The RT stated they make rounds daily on residents with BIPAP and check the masks and that the equipment is in good working condition. The RT also stated that the tubing and mask are to be dated. The RT further stated that there is a sticker that is placed on the tubing and mask which must have fallen off.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey the facility did not ensure that Accident/Incident (A/I) Reports related to falls were thoroughly investigated. This was identified for 1 (Resident #244) of 1 resident reviewed for accidents. Specifically, Resident #244 had a fall on 5/16/19. The A/I Report did not thoroughly investigate the fall incident regarding the functioning of the resident's call bell, whether the call bell was placed within the resident's reach, and if the resident was wearing footwear at the time of the incident. The finding is: The facility's policy and procedure dated 5/2019 titled A/I Report documented . 6. The Accident/Incident Investigation Report will be completed by the unit nurse, and provide all information required on the form . Resident #244 has diagnoses including Type 2 Diabetes Mellitus (DM), Loss of Hearing, and Restlessness and Agitation. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident was moderately impaired in cognition with long and short term memory problems. The MDS documented the resident required extensive assistance of one person for toileting and personal hygiene and that walking in the room did not occur. The MDS also documented the resident had no range of motion impairment and was frequently incontinent of urine and bowel. The Comprehensive Care Plan (CCP) developed for falls dated 5/17/19 documented the resident fell on 5/16/19 with no apparent injury. The resident complained of minimal right hip pain. Tylenol 325 milligram (mg) 2 tablets was administered. Interventions included to place the call bell within reach of the resident at all times. The A/I Report dated 5/16/19 at 10:50 PM documented the resident was found lying on the floor near the bathroom door. The resident complained of minimal pain over the right hip. The report did not document if the resident's call bell was functional, sounded, or was within reach of the resident. An interview with the Certified Nursing Assistant (CNA) #1 was conducted on 6/3/19 at 10:59 AM. CNA #1 stated that the resident had deteriorated 1-2 weeks ago and could not use the call bell now. However, CNA #1 stated that during the time of the fall, the resident was still able to use the call bell. An interview with the Registered Nurse (RN) Unit Supervisor was conducted on 6/3/19 at 11:05 AM. The RN Supervisor stated the resident, at that time of the fall incident, was able to use the call bell. . An interview with the RN A/I Coordinator/Assistant Director of Nursing Services (ADNS) was conducted on 6/4/19 at 9:30 AM. The ADNS stated that the call bell investigation should be included in the A/I Report since call bell is part of the information required on the form. 415.4(b)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not ensure that each resident's assessment must accurately reflect the resident's status. This was identified for 1 (Resident #161) of 3 residents reviewed for nutrition. Specifically, Resident #161 had a Quarterly Minimum Data Set (MDS) Assessment that was completed on 4/2/19. The MDS documented the resident lost and gained weight during the review period. Review of the resident's weights revealed the resident lost weight throughout the review period, no weight gain had occurred. The finding is: Resident #161 has diagnoses including Morbid Obesity, Major Depressive Disorder, and Type 2 Diabetes Mellitus (DM). The resident was admitted to the facility on [DATE]. The Quarterly MDS assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating the resident was independent for daily decision making and that the resident required supervision and setup for eating. The MDS documented the resident's weight was 220 pounds (lbs), a weight loss occurred and the resident was not on a Physician-prescribed weight-loss regimen in the last 6 months; and a weight gain occurred and the resident was not on a Physician-prescribed weight gain regimen in the last 6 months. The resident's weights were monitored monthly and recorded in the Electronic Medical Record as follows: 12/5/18= 245.3 lbs 1/28/19= 243 lbs 2/4/19= 241.7 lbs 3/7/19= 220.1 lbs An interview with the Registered Nurse (RN) MDS Coordinator was conducted on 6/04/19 at 9:00 AM. The RN stated that the Dietitian is responsible to complete Section K (Swallowing/Nutritional Status) of the MDS. The RN stated she would refer the issue to the Dietitian. An interview with the Chief Dietitian was conducted on 6/04/19 at 9:32 AM. The Dietitian stated that the weight gain documentation on Section K0310 (Weight Gain) was an error. It should have documented only a physician weight loss regimen. The Director of Nursing Services (DNS) was interviewed on 6/04/19 at 10:00 AM. The DNS stated that a correction of the Quarterly MDS assessment dated [DATE] would be submitted. 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the Recertification Survey the facility did not ensure that comprehensive person-centered care plans were developed and implemented for each resident and that care was provided in accordance with each resident's Comprehensive Care Plan (CCP). This was identified for 1 (Resident #3) of 1 resident reviewed for Insulin/Anticoagulant use; 3 (Resident #206, #235 and #161) of 6 residents reviewed for Positioning/Mobility; and 1 (Resident #117) of 6 residents reviewed for Unnecessary Medications. Specifically, 1) Resident # 3 had a physician's order to monitor the blood glucose level via fingerstick and to notify the physician if the results were below 70 milligrams/deciliter (mg/dl). On six occasions in April 2019 the fingerstick results were identified at less than 70 (mg/dl) and the physician was not notified; 2) Residents #206 and #235 had Physician's order to apply Spenco boots to feet at all times. Both residents were observed not wearing Spenco boots. Resident #161 had a Physician's order to elevate bilateral legs while in bed. Resident #161 was observed in bed with bilateral legs not elevated; and 3) Resident # 117 had a Physician's order for Trazodone 25 milligrams (mg) for a diagnosis of Insomnia, and there was no documented evidence that a CCP with specific goals and interventions was developed for Insomnia. The findings include but are not limited to: 1) Resident #3 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Depression, and Peripheral Vascular Disease. The 2/17/19 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident was rarely or never understood. Active diagnoses included Diabetes Mellitus. A Physician's order, dated 8/9/18 and renewed on 5/2/19, ordered to monitor fingerstick once daily before breakfast at 7:30 AM and to call the MD if the fingerstick result is less than 70 mg/dl or greater than 250 mg/dl. A Comprehensive Care Plan (CCP), effective 3/9/16 and last updated 5/17/19, had an intervention to monitor blood glucose level as ordered. Review of the April 2019 Medication Administration Record (MAR) revealed the following: 4/1/19 at 7:30 AM fingerstick was 67 mg/dl; 4/5/19 at 7:30 AM fingerstick was 65 mg/dl; 4/11/19 at 7:30 AM fingerstick was 65 mg/dl; 4/24/19 at 7:30 AM fingerstick was 60 mg/dl; 4/25/19 at 7:30 AM fingerstick was 62 mg/dl; 4/26/19 at 7:30 AM fingerstick was 65 mg/dl. Review of April 2019 nursing progress notes revealed no documentation that the Physician was notified regarding the fingersticks that were below 70 mg/dl on 4/1/19, 4/5/19, 4/11/19, 4/24/19, 4/25/19, and 4/26/19. The Licensed Practical Nurse (LPN) who performed the fingersticks on the dates indicated above was interviewed on 5/31/19 at 12:25 PM. She stated that she would document that she notified the Physician in the comments section of the MAR. Review of the April 2019 MAR comments section revealed documentation that on 4/1/19, 4/5/19, and 4/11/19 orange juice was given. There was no documentation that the Physician was notified. In addition, there were no interventions or comments for 4/24/19, 4/25/19, or 4/26/19. The LPN was re-interviewed on 6/3/19 at 9:45 AM. She stated that when the fingerstick is below 70 she tells the Registered Nurse (RN) Supervisor and the RN Supervisor calls the doctor. She stated the intervention to give orange juice on 4/1/19, 4/5/19, and 4/11/19 was per the doctor's instruction, and that there should have been documentation that the doctor was notified. She did not have an explanation for 4/24/19, 4/25/19, or 4/26/19. The RN Supervisor was interviewed on 6/3/19 at 9:56 AM. She stated she does not recall being notified regarding the blood sugars that were below the parameter of 70 mg/dl. She stated that if she had called the doctor and received an intervention, she would have documented a progress note. The Director of Nursing Services (DNS) was interviewed on 6/3/19 at 12:15 PM. She stated the nurse should have notified the doctor when the fingerstick was below 70 mg/dl, as per the Physician's order. 3) Resident 117 was admitted to the facility on [DATE] with diagnoses that include Insomnia and Major Depressive Disorder. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was 12 which indicted moderate cognitive impairment. The resident had no behavior problems and had trouble concentrating. The resident received Antidepressant medication for seven of seven days during the assessment period. A Psychiatry Consult dated 9/23/18 documented the resident had a history of Bipolar Disorder and has remained stable, had been mostly calm with no irritability or agitation present. The resident has been sleeping fairly well and had been mostly compliant. The Primary diagnosis was Insomnia. The consult documented to continue Trazodone 50 milligram (mg) at hour of sleep (HS) for temporary relief of Insomnia. A Psychiatry Consult dated 3/17/19 documented the resident had been generally calmer, no mood swings, irritability or agitation noted, had fair sleep and appetite. The resident's primary diagnosis was Insomnia and the Psychiatrist recommended to reduce Trazodone to 25 mg by mouth (po) every (Q) HS. A Physician's order dated 3/18/19 documented Trazodone 25 mg by oral route once daily at bedtime for Insomnia. A Comprehensive Care Plan (CCP) dated 5/20/16 for Psychotropic Drug Use documented the resident was on Trazodone related to diagnosis of Bipolar Depression. A Review of the resident's medical record lacked documented evidence that a person-centered CCP with specific goals and interventions was developed for the diagnosis of Insomnia for which the resident was receiving Trazodone. During an Interview conducted on 5/31/19 at 11:54 AM with the Registered Nurse (RN) Supervisor, she stated that CCPs are initiated by the unit nurse and are updated as needed. The RN stated the diagnosis of Insomnia was given by Psychiatry and that a CCP for Insomnia should have been developed. The RN stated that she would initiate the CCP for Insomnia as the diagnosis of Insomnia was documented as a primary diagnosis for the use of the Trazodone. An interview was conducted on 6/4/19 at 12:33 PM with the RN on 5 East who stated that it was the responsibility of the unit RN to initiate the CCP as needed. The RN stated the RN that receives the order for the medication should initiate the CCP and that a CCP for Insomnia should have initiated. 415.11(c)(1) 2) Resident #206 has diagnoses including Vascular Dementia with Behavioral Disturbance, Hemiplegia, and Pain in the Right Foot. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 14 indicating the resident was cognitively intact and independent for daily decision making. The MDS documented the resident required total assistance of two persons for bed mobility. The resident had impairment in functional range of motion of both lower extremities. The Physician's Order dated 5/15/19 documented to apply Spenco Boots to both feet while in bed. The Comprehensive Care Plan (CCP) developed for Nursing Rehabilitation (Brace and Splint Program) for Actual /Potential for Development of Contractures dated 4/8/19 documented the resident had Hemiplegia. Interventions included to apply assistive devices as ordered. On 5/29/19 at 12:36 PM and on 6/03/19 at 8:10 AM, the resident was observed in bed with Spenco boots not applied as ordered. An interview with the Registered Nurse (RN) Supervisor was conducted on 6/3/19 at 8:15 AM. The RN stated that the resident should be wearing the Spenco boots as ordered. An interview with the Certified Nursing Assistant (CNA) #2 was conducted on 6/3/19 at 8:20 AM. CNA #2 stated that the 11 PM-7 AM shift CNA applies them, but she did not check if the resident was wearing the boots when she started her shift. CNA #2 also stated that the resident should be wearing the Spenco boots as ordered.