**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure the resident's right to be treated with respect and dignity was maintained. This was evident in 2 (Resident #32 and #40) of 23 total sampled residents. Specifically, 1.) Resident #32's urinary drainage bag was not placed in a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag, so it is not visible) and was visible from the hallway, and 2.) Licensed Practical Nurse #2 remained standing while feeding Resident #40. The findings are: The facility's policy titled Promoting/Maintaining Resident Dignity with a revised date of 07/2024 documented it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. The facility's policy titled Foley Catheter Management with a last revision date of 01/2024 documented that privacy bags should be always provided. 1. Resident #32 was admitted to the facility with diagnoses of Cerebrovascular Accident and Seizure Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #32 had intact cognition and had an indwelling catheter, Resident was dependent for bed mobility. A Comprehensive Care Plan for urinary incontinence and indwelling catheter was initiated on 03/30/2022 and was last reviewed on 06/01/2025. The facility interventions include to observe for changes in continence status. During observation on 03/02/2025 at 1:59 PM, 03/03/2025 at 8:57AM, and on 03/04/2025 at 8:46 AM, Resident #32 was observed in bed in their room with their urinary catheter drainage bag uncovered and hanging on the bed frame. The urinary drainage bag was visible to people passing in the hallway. On 03/04/2025 at 8:46 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #32 was in their assignment. They stated they thought the urinary dignity bag is only used when resident is out of bed. On 03/04/2025 at 8:51AM, Registered Nurse #1 was interviewed and stated Resident #32 should always have the urinary drainage bag must be inside a dignity bag and that the staff are aware of this. On 03/07/2025 at 12:19 PM, the Director of Nursing was interviewed and stated that dignity bags must always be used for residents with urinary catheters, whether resident is in bed or on the chair. Surveyor: [NAME], [NAME] 2. Resident #40 was admitted with diagnoses that include Dysphagia following Cerebral Infarction, Major Depressive Disorder, and Non-Alzheimer's Dementia. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #40 had moderately impaired cognition required total assistance of one-person for eating. The physician orders dated 02/09/2025 documented Resident #40 was on comfort care and needs total assistance in eating to prevent food aspiration secondary to diagnosis of Dysphagia. During observation on 03/02/2025 at 11:32 AM, Licensed Practical Nurse #2 was observed standing next to Resident #40 while spoon feeding the Resident. Resident #40 had their head raised to catch the food. On 03/06/2025 at 10:54 AM, Licensed Practical Nurse # 2 was interviewed and stated Resident #40 needs total assist with meals and is spoon fed. They stated they were standing while they spoon fed Resident #40 and knew this was inappropriate. On 03/07/2025 at 11:01 AM, the Director of Nursing was interviewed and stated staff should be seated next to the resident while spoon feeding them to ensure appropriate precaution is observed and dignity is preserved. 10 NYCRR 415.3(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services, including provision of equipment, to prevent further decline in range of motion. This was evident in 1 (Resident #41) of 2 residents reviewed for positioning / mobility out of 21 total sampled residents. Specifically, Resident #41 was observed multiple times without a left-hand roll in place as per physician's order. The findings are: The facility's policy titled Adaptive Devices with a last reviewed date of 10/2023 stated it was the policy of the facility to provide adaptive devices to its residents. All adaptive devices with current orders with physician and nursing staff will be picked up by nursing staff and entered to the Certified Nursing Assistant Accountability with correct don/on/off devices with appropriate wearing schedule. Resident #41 had diagnoses of Huntington Disease, Dementia, and Depression. The Minimum Data Set assessment dated [DATE] documented that Resident #41 had moderately impaired cognition and was dependent in all areas of activities of daily living. The assessment also documented that Resident #41 had and an impairment on one side of the upper extremity. A care plan with focus on restorative nursing rehabilitation was initiated for Resident #41 on 04/24/2024 and was last reviewed on 3/02/2025. The facility interventions included left hand roll to be worn at all times except for skin check and hygiene. A physician's order dated 10/31/2024 and was last renewed on 03/01/2025 documented orders for left hand roll to be worn at all times except for skin check and hygiene. During multiple observations on 03/03/2025 at 1:09 PM, on 03/03/2025 at 3:00 PM, on 03/04/2025 at 12:03 PM, and on 03/04/2025 at 1:45 PM, Resident #41 was observed without a left-hand roll in place. On 03/04/2025 at 1:46 PM, an interview was conducted with Certified Nursing Assistant #8 who was assigned to Resident #41. Certified Nursing Assistant #8 stated they started working with Resident #41 about one month ago and that Resident #41 is totally dependent for care. Certified Nursing Assistant #8 stated they did not apply the left-hand roll and does not know where it was. On 03/04/2025 at 1:54 PM, Registered Nurse #1 was interviewed and stated Resident #41 is fully dependent on activities of daily living and requires extensive assistance. Registered Nurse #1 stated Resident #41 was prescribed a left hand roll due to left hand stiffness. They stated staff are to document and sign off when they place the device on the hand of the Resident. On 03/04/2025 at 2:40 PM, the Director for Rehabilitation was interviewed and stated that Resident #41 had tightness in their left hand and was prescribed a hand roll. They stated they observed Resident #41 earlier in the day without a left-hand roll applied, and they placed a new hand roll on the left hand. They further stated Certified Nursing Assistants are responsible for putting the hand roll on. On 03/07/2025 at 11:09 AM, the Director of Nursing was interviewed and stated if the left-hand roll is not in place for Resident #41, Resident #41 may develop contractures which can worsen over time. The Certified Nursing Assistants are responsible for applying the left-hand roll. The Registered Nurses and Licensed Practical Nurses on the unit are responsible for ensuring that the Certified Nursing Assistants are applying the device. 10 NYCRR 415.12 (e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that a therapeutic diet was provided when there is a nutritional problem, and the health care provider orders a therapeutic diet. This was evident in 1 (Resident #3) of 2 residents reviewed for Activities of Daily Living out of 23 total sampled residents. Specifically, Resident #3, who had a physician's order for thickened liquid, was observed drinking juice without a thickener. The findings are: The facility's policy titled Thicken Up with a last revised date of 12/2024 documented that there are Thicken Up Instant Food Thickener on the trays based on Physician's, Dietician's, Nursing, and Speech Therapist evaluations of swallowing ability related to fluids. Thicken Up is ordered for those with swallowing issues for fluids. The facility's policy titled Activities of Daily Living with a last revised date of 11/2024, documented that nursing staff are in serviced upon new hire and as needed on following the plan of care. Resident #3 was admitted to the facility with diagnoses that include Anemia, Bipolar Disorder, Dysphagia, and Muscle Wasting. The Minimum Data Set assessment dated [DATE] documented Resident #3's cognition as intact, required moderate assistance for eating, and complained of difficulty or pain with swallowing. A Speech Therapist's progress note dated 01/28/2025 documented Resident #3 presented with anterior spillage when eating / drinking and coughing episodes with thin liquids. Recommended puree, honey thick liquids, skilled speech therapy services for dysphagia, and consistency modification. A Comprehensive Care Plan for dysphagia (impaired swallowing) was initiated for Resident #3 on 01/30/2025. The facility interventions include ongoing dysphagia assessment and treatment, and diet as ordered by the physician. A care plan notes dated 01/30/2025 by Registered Dietitian #1 documented Resident #3's diet was downgraded to pureed with moderately thick liquids as resident having difficulty time coordinating respiration and swallowing function. A physician's order dated 02/24/2025 documented the following dietary orders: Regular with pureed consistency and thickened liquids, mildly Thick 2 (Nectar). During dining observation on 03/02/2025 at 11:40PM, Resident#3's meal tray ticket documented nectar thick liquids, regular-puree. A packet of thickener and 3 cups of juice were observed on the tray. There was no staff observed putting thickener on Resident #3's juice. Resident #3 was observed on 2 occasions drinking juice without a thickener and started coughing. On 03/07/2025 at 12:53 PM, the Speech Language Pathologist was interviewed and stated that Resident #3 had orders for nectar thick liquid because Resident has dysphagia and is high risk for aspiration. On 03/07/2025 at 2:38 PM, Certified Nursing Assistant #2 was interviewed and stated it is the nurses' responsibility to put thickener on residents' drink. They stated thickener packets would usually be on the residents' tray, and they would notify the nurse who would put it in the residents' drinks. On 03/07/2025 at 2:45 PM, Licensed Practical Nurse #1 was interviewed and stated that nurses are responsible for thickening the liquids for residents on thickened liquids. On 03/07/2025 at 11:54 AM, the Director of Nursing was interviewed and stated that Certified Nursing Assistants are responsible for adding the thickener on the residents' drink when they serve the resident's meal tray. They stated all Certified Nursing Assistants received an in-service education and were trained that if there was a thickener on the tray, then it was supposed to be given. 10 NYCRR 415.12(i)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure maintenance services necessary to maintain a sanitary, orderly and comfortable interior were provided to the residents. This was evident during environmental observation. Specifically, resident rooms were observed with mismatched paint, uneven floor, and ripped door kick plate, mattress in disrepair, and broken side tables. The findings include but are not limited to: The facility's undated policy titled Environmental Services documented it is the policy of the facility to safely and properly clean floor surfaces, the purpose of the procedure was to provide guidelines for cleaning and disinfecting resident rooms. The policy documented housekeeping surfaces, including tabletops, will be cleaned on a regular basis when spill occurs and when these surfaces are visibly soiled. During observation on 03/02/2025 between 10:00 AM and 2:00 PM and on 03/07/2025, the following were observed: 1. West Wing room [ROOM NUMBER] had a ripped door kick plate, with the first half of the panel missing. 2. West Wing room [ROOM NUMBER] had mismatched paint and stained and uneven floor. 3. Resident's Main dining room had uneven floor and floor tiles were discolored. 4. East Wing room [ROOM NUMBER] had unpainted walls, and bedside table was in disrepair. 5. East Wing room [ROOM NUMBER] had broken and worn looking bedside tables, and mattress in disrepair. 6. The baseboard in the hallway and the porter's closet were observed with dirt and grime. The Maintenance and Housekeeping logbook showed no documentation of repairs needed in [NAME] Wing room [ROOM NUMBER], #18, and in the resident's Main Dining room. On 03/07/2025 at 9:41 AM, during environmental rounds with the Surveyor, the Director of Housekeeping and Maintenance stated terminal cleaning is performed on a daily basis, cleaning 2 rooms per day in each unit. They stated they were waiting for the resident in room [ROOM NUMBER] on the East Wing to get out of bed before they paint the wall. The Director stated they swap the old bed side tables when in disrepair and that they change the mattress, if needed, during terminal cleaning. They stated they were in the process of doing a building refresh program when the State Surveyor walked in for survey. On 03/07/2025 at 11:33 AM, the Director of Housekeeping and Maintenance was interviewed and stated they were in the process of cleaning and replacing the tiles when the State Surveyors walked in. The Director stated the missing half panel of the door kick plate will be replaced and that the rooms with uneven floors and discolored tiles will be replaced with new ones to match the rest of the floor. On 03/07/2025 at 11:45 AM, the Administrator was interviewed stated repairing and fixing is a big challenge for them since the facility is an old building. They stated they will do what is right for the residents because this is the residents' home, and the environment should be taken care of properly. The Administrator stated they will make sure the concerns will be corrected. 10 NYCRR 415.5(h)(2)

Based on record review and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility reported short staffing on weekends for the quarter of July- September 2024 which was confirmed by a review of the Weekend Staffing and the Payroll Based Journal Staffing Data Report. The findings include but are not limited to: The facility policy titled Staffing Guidelines with a last reviewed date of 09/2024 documented that the facility will promote resident quality care and safety by ensuring adequate and competent staffing levels that are based on the facility assessment. The Payroll Based Journal Staffing Data Report for the 4th quarter of 2024 (07/01/2024 to 09/30/2024) documented excessively low weekend staffing was triggered. The Facility Assessment Tool which was last updated on 01/07/2025 documented a facility capacity of 102 residents with a staffing plan by shift as follows: Day shift by units (7:00 AM - 3:00 PM) East Wing: 1 Registered Nurse, 2 Licensed Practical Nurse and 5 Certified Nursing Assistants West Wing: 1 Registered Nurse, 2 Licensed Practical Nurse and 5 Certified Nursing Assistants Evening Shift by Unit: (3:00 PM - 11:00 PM) 1 House Registered Nurse East Wing: 2 Licensed Practical Nurse and 3 Certified Nursing Assistants West Wing: 2 Licensed Practical Nurse and 3 Certified Nursing Assistants Night Shift by Unit: (11:00 PM - 7:00 PM) 1 House Registered Nurse East Wing: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants West Wing: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants The facility assessment does distinguish that on the weekends there is 1 House Registered Nurse for each shift while the number of Licensed Practical Nurses and Certified Nursing Assistants remain the same. Review of the actual weekend facility staffing schedule from 07/01/2024 to 09/30/2024 documented the following: On 07/06/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the [NAME] Wing. On 07/07/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the [NAME] Wing. On 07/13/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing. On 07/13/2024 on the 3:00 PM - 11:00 PMshift, there was a shortage of: 1 Licensed Practical Nurse on the [NAME] Wing. On 07/14/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 2 Certified Nursing Assistants on the East Wing and 1 Certified Nursing Assistant on the [NAME] Wing. On 07/14/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 2 Certified Nursing Assistants on the East Wing On 07/21/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing and 1 Certified Nursing Assistant on the [NAME] Wing On 07/27/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing On 08/3/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing and 1 Certified Nursing Assistant on the [NAME] Wing On 08/4/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the [NAME] Wing On 08/4/2024 on the 11:00 PM - 7:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing On 08/10/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the East Wing On 08/10/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the [NAME] Wing On 08/11/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse and 1 Certified Nursing Assistant on the East Wing On 08/17/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the [NAME] Wing On 08/17/2024 on the 11:00 PM - 7:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the [NAME] Wing On 08/18/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the East Wing and 1 Certified Nursing Assistant on the [NAME] Wing. On 08/18/2024 on the 11:00 PM - 7:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing On 08/25/2024 on the 11:00 PM - 7:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the [NAME] Wing On 09/01/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the [NAME] Wing On 09/01/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the [NAME] Wing On 09/21/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing. On 03/02/2025 at 10:00 AM, Resident #67 was interviewed and stated it takes too long for the staff to come when they ask for assistance. On 03/02/2025 at 2:05 PM, Resident #32 was interviewed and stated the facility does not have enough staff and they wait a long time for assistance, especially at nights. 03/05/2025 3:39 PM, Certified Nursing Assistant #4 was interviewed and stated they work from 3:00 PM to 11:00 PM on the weekends and are assigned 15 residents. They stated there are 3 aides usually assigned on their shift but when there are call outs, they get assigned more residents. On 03/06/2025 at 2:40 PM, Certified Nursing Assistant #5 was interviewed and stated they work 7:00 AM to 3:00 PM on weekends and are assigned around 11 residents regularly. Certified Nursing Assistant #5 stated there are times when there is staffing shortage in the weekends at which time they will be assigned 14 residents. On 03/06/2025 at 3:10 PM, the Staffing Coordinator was interviewed and stated they were hired in September 2024 and at that time they were informed that there was a slight staffing shortage in the 11:00 - 7:00 PM shift for both weekdays and weekends. They stated staffing shortages occur on the weekends due to call outs. On 03/07/2025 at 10:57 AM, the Director of Nursing was interviewed and stated that they do the best they can to maintain staffing levels. They stated they were not aware of low weekend staffing between July to September 2024 or that the Payroll Based Journal was triggered for low weekend staffing for that quarter. Director of Nursing Services #1 further stated that the Administrator is primarily responsible for Payroll Based Journal Submission. On 03/07/2025 at 3:07 PM, the Administrator was interviewed and stated they were aware Payroll Based Journal was triggered for low staffing but is unsure as to why. Administrator #1 stated the staffing levels have not changed much and that in fact, it has improved compared to the previous years at which time the facility was not triggering this low. The Administrator further stated that since the Centers of Medicare Services updated the measures in the middle of 2024, the facility has been triggering worse even though staffing levels have not changed. They stated staffing for the weekends and weekdays is generally the same, however, there may be call outs during the weekend. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews during Recertification Survey conducted from 03/02/2025 to 03/07/2025 the facility did not ensure safe food storage was practiced. This was evident during Kitchen Observation. Specifically, outdated food items were observed in the kitchen refrigerator. The findings are: The facility's policy titled Storage and Holding Timeframe for Food Items with a last reviewed date 09/2023 documented to ensure safe food consumption, food items will be dated, placed in a container and if not consumed will be discarded. During the initial tour of the kitchen on 03/02/2025 from 10:00 AM to 10:30 AM, the following expired items were observed stored in the kitchen refrigerator: 1. Dietary prepared snack of 20 plastic cups of 4 ounces cottage cheese with a labeled date of 02/24/2025. 2. 8 plastic cups of 4 ounces skim milk with a labeled date of 02/24/2025. 3. 4 plastic cups of 4 ounces cut pears with a labeled date of 02/24/2025. 4. 20 plastic cups of 4 ounces cranberry juice with a labeled date of 01/01/2025. On 03/03/2025 at 11:08 AM, Dietary Aide #1 was interviewed and stated that outdated food items were overlooked and should have been discarded. On 03/04/2025 at 12:13 PM, the Dietary Supervisor was interviewed and stated they had not worked for 2 days and had not realized they have outdated or expired residents' snacks in the refrigerator. They stated expired food are health hazard and should not be consumed. 10 NYCRR 415.14 (h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, during the recertification survey 10/2/23 through 10/11/23, the facility did not ensure the individual financial record was made available to the resident and/or resident representative through quarterly statements. This was evident for 1 (Resident #61) of 2 residents reviewed for Personal Funds out of a sample of 25 residents. Specifically, there was no evidence quarterly statements were provided to a resident or their representative. The findings are: A facility policy and procedure titled Conveyance of Funds revision date 4/23 documented statements are prepared quarterly and provided to residents and/or their responsible parties. A Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #61 had moderately impaired cognition and was diagnosed with Non-Alzheimer's Dementia and Depression. On 10/02/23 at 9:34AM, an interview was conducted with Resident #61's next of kin (NOK) who stated that they do not receive a quarterly bank statement unless they ask for one. A Personal Needs Account (PNA) Ledger as of 10/2/23, documented resident #61 had a balance of $12,857.98. There was no documented evidence that the resident and/or their representative had been provided with a quarterly statement. An interview was conducted with the Director of Recreation (DR) on 10/4/23 at 3:08PM. The DR stated the business office provides a ledger with patient fund account information, including balances. The DR stated that they track withdrawals and send the information to the business office for updating. The statements are given quarterly or when asked for. The DR further stated that if the resident is not oriented, it goes to the representative on file. If they go to the representative, they will put the statement in an envelope and bring it to the business office to mail; the ledger comes preprinted with the address and it goes into a window envelope. An interview was conducted with the Comptroller on 10/4/23 at 3:57PM, who stated they get the statements from the Director of Recreation, already in the envelope, all they do is stamp it and mail it out. This is done every quarter. The Comptroller stated they do not have proof of mailing, as it is not sent out certified mail and no copies of the envelope are made. The Comptroller stated some are sent by email. They checked their computer records and did not find that a copy of an email documenting same for Resident #61. The Comptroller stated that the NOK sends in receipts for items that they have purchased, and the business office sends a check. The Social Worker is the one who is responsible or should be verifying the address. The Director of Recreation verified that the mailing address was correct. An interview was conducted with the Administrator on 10/4/23 at 4:40PM, who stated that personal funds quarterly statements, are sent to them by the outside billing company quarterly. They further state that the Comptroller gives the statements to the Director of Recreation who, along with the Social Worker, will distribute to the residents who can get it. If the resident is not competent/not oriented, it is mailed to the family. The Director of Recreation will give the statements to the business office in an envelope to mail. The Administrator further stated that if someone is telling us that they are not getting their statements, they would make sure that they got it. 415.26(h)(5)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Room [NAME] 5, observed the floor in room appeared dull with multiple blacken linear marks on the floor. Resident stated it could be cleaner. Strong urine odor noted in room especially the bathroom. An empty uncovered urinal observed on floor in bathroom. Open urinal observed on the handrail in the bathroom. room [ROOM NUMBER] on [NAME] Unit bathroom smell of urine open urinal hung on bathroom rail. Bathroom Floor with badge tiles in between the titles black built up dirt in all corners of bathroom and in-between tiles. The floor in room with multiple black scratch marks in all directions built up black dirt behind door with visible rat glue trap. Broken tile at the entrance of bathroom at the right corner. The [NAME] Side Unit with strong odor of urine despite surveyor wearing KN95 Mask. No specific resident observed smelling urine. All residents are out of bed and dressed in own clothing. Resident who remained in the room choose to stay in room watching TV. West Nurses station floor with rust color built up dirt under tables, computers keyboard with white built-up dirt visible between keys on keyboard, the floor with built up stuck on black dirt along all equipment edges resting on the floor and built-up dirt in all corners of nurses' station. room [ROOM NUMBER] [NAME] observed. The room floor contains black linear marks all over the floor. The small garbage bin under the sink was overflowing with plastic materials, blue gloves. One blue glove was observed on the floor in room next to the garbage bin. On 10/05/23 at 02:10PM, an interview was conducted with Housekeeper #1 (HK#1), for the [NAME] Side Unit. HK #1 stated they use green spray which is a 3 M disinfectant cleaner and disinfectant wipes to clean the unit. They clean the toilet with a brush and was trained to use the disinfectant cleaner with a mop to clean the floors. HK #1 is new to the facility and the floor has black multiple marks, was mopped, but the floor cannot be cleaned. HK #1 stated the mop was not able to clean the black dirt built in between tiles and stated they are not able to remove the dirt. They are not sure where the urine smell is coming from, but always clean the rooms every day at work. On 10/05/2023 at 2:14 PM, Housekeeper #2 was interviewed and stated, that during the day, the facility has four housekeepers. Two housekeepers on the East side and two housekeepers on the [NAME] side. As per HK #2, the cleaning supplies are not doing the job properly. Housekeeper #2 further stated that a meeting is already settle with the Director of Housekeeping and the housekeeping staff to come up with better cleaning supplies. On 10/05/2023 at 3:54 PM, the Director of Nursing (DON) was interviewed and stated that they are aware of the urine smell. They have a new housekeeping Director who started last August. The Director's plan is to strip and wax all the rooms to take away the smell. On 10/06/2023 at 10:45AM, the Director of Housekeeping was interviewed and stated that the housekeeping staff is aware of the smell and that we will be updating the cleaning materials. Housekeeping staff will also be updating through in-service, training, stripping and waxing the rooms. On 10/10/23 at 12:31 PM, an interview was conducted with The Administrator who stated the Director of Housekeeping is new and is making progress. . 415.5 (h) (2) Based on observations, record review, and interviews during the Recertification survey conducted from 10/02/23 to 10/11/23, the facility did not ensure that a clean, comfortable, and homelike environment was provided to residents. Specifically, rusty brown color, dirty shower wall tiles, build up dirt in the bathroom tiles, were observed in resident's rooms, hallways, a urine odor in the common areas, debris on the floor, and a garbage bin overflowing. This was evident in multiple areas on the [NAME] Side unit. The findings are The facility policy and procedure titled, Daily General Cleaning -All Residents Areas last dated 11/2022 documented sweep all flooring using chemical treated mop, empty and clean all waste basket receptacles, damp dust daily. The policy further stated, after daily through cleaning, all residents areas will be polished periodically throughout the day. All floors will be mopped daily using a germicidal solution. During observations of the environment conducted on the [NAME] Side unit from 10/02/2023 at 10:17 AM to 10/10/23 at 10:14 AM, the following was observed : Room [NAME] 7 - bathroom floor was noted with build up dirt in between the tiles. Room [NAME] 19 - bathroom floor was noted with build up dirt in between the tiles. Room on the [NAME] side labeled Resident Shower Room in the hallway noted with rustic brown color in between the floor tiles. Left side of the shower wall noted very dirty. Shower wall tiles across the entrance door are filled with rustic brown dirt. Rustic marks seen where the water is turning off. Room located in hallway near the bathroom are [NAME] 5 and [NAME] 6 Residents bathroom in the hallway labeled Resident Rest Room, the bathroom floor was noted with build up black dirt between tiles and large rustic brown color area. Tiles noted with black residue on entrance to rest room and black dirt behind the door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the Recertification survey conducted from 10/02/23 to 10/11/23,and complaint (NY00306641 ) survey, the facility did not ensure that a resident was free from financial abuse. This was evident for 1 of 3 residents reviewed for abuse in a sample of 25 (Resident # 155). Specifically, a resident complained that a staff borrowed money and has not paid back the loan. The finding is: The facility Policy and Procedure titled, Prohibition of Residents Abuse/Neglect and Misappropriation of Property with a revised date of 07/2023 documents, Residents have the right to be free from exploitation and misappropriation of property and neglect. The procedure documents, To comply with New York State and Federal regulations, provide patients/residents with considerate and respectful care which promotes independence and dignity in an environment free from abuse, mistreatment, neglect, exploitation and misappropriation of property. The policy defines Exploitation as The illegal or improper use of an adult funds, property assets or resources by another individual including but not limited to fraud, social media, false pretences, embezzlement, conspiracy, forgery, falsifying records, coerced property transfer of denial access of assets. Resident # 155 was admitted to the facility on [DATE] with diagnoses including: Anemia, Atrial Fibrillation, Hypertension, Schizophrenia, Malignant Neoplasm of the Stomach and Diabetes Mellitus. Resident was discharged from the facility to the community on 01/06/2023. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified the resident with a score of 12 on the Brief Interview for Mental Status (BIMS),with short and long term impairment. On activities of daily living (ADLs) needing assistance in most area of care like bathing, ambulation, transfer, mobility and dressing. Review of the Comprehensive Care Plan (CCP) dated 10/14/2022 on Victimization related to resident at risk for victimization due to congregate living. The goal set was resident will not experience any form of abuse or mistreatment and will report concerns to staff. For intervention: address resident concerns as they occur, encourage resident to voice any concerns to staff, observe for changes in mood, manner, behavior and observe resident during routine care and daily activities. Review of the Nurses notes from 10/01/2022 to 01/30/2023 reveals no documentation of resident's complaint of staff borrowing money. Review of the Social Worker (SW) notes from 10/01/2022 to 01/30/2023 reveals no documentation of resident's complaint of staff borrowing money. Review of the Accident/Incident report Summary of Investigation documented on 12/2/2022 at approximately 3:55 PM, the SW was informed by Resident #155 that a Certified Nursing Assistant (CNA) had borrowed money from her about a week ago and to this date the money had not been returned. During the SW interview Resident #155 stated, I was sitting in the hallway and CNA #3 asked for the money which I had on hand as I just got the money from my brother who came visiting. The SW asked why they gave the money and was told, I was trying to be nice. On 12/5/2022, CNA #3 was interviewed by the Director of Nursing (DNS) and stated, I did not take the money and I don't not know what the resident was talking about. A statement was written to the effect that CNA# 3 did not borrow or take any money from the resident. CNA #3 was sent home and told not to report for duty pending an investigation. On 12/06/2022, CNA # 3 rescinded their previous statement and rewrote a new statement in which they stated, I borrowed money from Resident #155. I was out with COVID for a week and when I returned, I gave the money back. CNA # 3 was terminated from service on 12/14/2022. On 10/06/2023 at 2:45 PM the Director of Nursing Services (DNS) was interviewed and stated, The 101st Police Precinct, covering the facility's area was called to report the incident. Police officers came and upon learning the complainant had some Psychiatric diagnoses, did not interview the resident. There was no report taken as the Police stated, This is an internal investigation. The CNA did not have a history of borrowing money and they have no knowledge of previous incidents of the CNA borrowing from residents. 415.4 ( b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Recertification and Complaint survey (NY 00306641) ,the facility did not ensure all alleged violations involving abuse, neglect , including misappropriation of property were reported in a timely manner to the Department of Health. This was evidenced in 1 of 5 residents reviewed for abuse in a sample of 25. (Resident #155) . Specifically, a resident complained that a staff member borrowed money and has not paid back the loan. The finding is : The facility Policy and Procedure titled Prohibition of residents Abuse/Neglect and Misappropriation of property with a revised date of 07/2023 documented it is illegal to improperly use adult funds, property assets or resources by another individual including but not limited to fraud , social media , false pretences, embezzlement, conspiracy, forgery, falsifying records, coerced property transfer of denial access of assets . Resident # 155 was admitted to the facility on [DATE] with diagnoses : Anemia, Atrial Fibrillation, Hypertension, Schizophrenia, Malignant Neoplasm of the Stomach and Diabetes Mellitus amongst other . The Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified the resident with a score of 12 on the Brief Interview for Mental Status(BIMS),with short and long term impairment. On activities of daily living(ADLs) needing assistance in most area of care like bathing, ambulation, transfer, mobility and dressing. Review of the Comprehensive Care Plan (CCP) dated 10/14/2022 on Victimization related to resident at risk for victimization due to congregate living. The goal set was resident will not experience any form of abuse or mistreatment and will report concerns to staff. For intervention: address resident concerns as they occur, encourage resident to voice any concerns to staff, observe for changes in mood, manner, behavior and observe resident during routine care and daily activities. Review of the Accident/Incident report Summary of Investigation documented, On 12/2/2022 at approximately 3:55 PM , the SW was informed by Resident #155 that a Certified Nursing Assistant (CNA) had borrowed money from her about a week ago and to this date. The money had not been returned. During the SW interview, Resident #155 related the incident as, I was sitting in the hallway and CNA #3 asked for the money which I had on hand as I just got the money from my brother who came visiting. The SW asked why she gave the money and stated, I was trying to be nice . On 12/5/2022 CNA #3 was interviewed by the Director of Nursing (DNS) and stated, They did not take the money and does not know what the resident was talking about. A statement was written to the effect that CNA# 3 did not borrow or take any money from the resident. CNA # 3 was sent home and told not to report for duty pending the investigation. On 12/06/2022 , CNA # 3 rescinded his previous statement and rewrote a new statement in which was stated I borrowed the money from Resident #155. I was out with COVID for a week and when I returned , I gave the money back. CNA # 3 was terminated from employment at the facility on 12/14/2022. On 10/06/2023 at 2:45 PM , the Director of Nursing (DNS) was interviewed and stated the incident was reported to the NYSDOH on 12/07/2022 and was not reported immediately because the DNS was still doing interviews and investigations. 415.4 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interviews conducted during the Recertification survey of 10/2/23 through 10/11/23, the facility did not ensure that person-centered care plans (CCP) with measurable goals, time frames and interventions were developed to address a resident's concerns. This was evident for 1 of 4 residents (Resident #304) reviewed for Nutrition and 1 of 5 residents (Resident #36) reviewed for unnecessary medications, out of a sample of 25 total residents. Specifically, 1) a CCP was not developed for Resident #304 with liver cancer and hepatitis C, and 2) a CCP was not developed to address the care needs of Resident #36 with a Foley catheter. The findings are: The facility policy and procedure titled Comprehensive Care Plan (CCP) dated 5/23 documented all residents will have a CCP completed in accordance with federal and state requirements. The CCP will include measurable goals with time frames to meet the resident's medical, nursing, and psychosocial needs. 1. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #304 was cognitively intact and diagnosed with Liver cancer, Viral Hepatitis C, and Diabetes mellitus. Physicians' orders include megestrol 400 mg/10 mL oral suspension give 10 milliliters (400 mg) by oral route once daily dated 9/23/23 for malignant neoplasm of liver and Lenvima 4 mg capsule give 1 capsule by oral route every other day at the same time each day, dated 9/24/23 for Liver Cell Carcinoma. Based on record review, there was no evidence that a CCP was developed and implemented for the Resident #304's diagnosis of Liver Cancer and Viral Hepatitis C. An interview was conducted on 10/10/23 at 10:11AM with Registered Nurse (RN) #1, who stated that the night nurse starts the care plans and then they will go over it or the Director of Nursing (DNS) will go over it. RN #1 stated they check to make sure there are interventions and look at the resident's diagnosis and make sure there is a corresponding CCP. RN #1 was unable to produce a CCP related to Resident #304's liver cancer or hepatitis C diagnosis. An interview was conducted on 10/10/23 at 12:21 pm with the DNS who stated the 11-7 shift is responsible for initiating CCPs. The DNS makes sure that all the necessary care plans are in place. Resident #304 did not have a CCP for liver cancer and hepatitis in place and it was an oversight. 2. Resident # 36 was admitted to the facility with diagnoses Anemia and Peripheral Vascular Disease. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented Resident #36 was moderately cognitively impaired and had a Suprapubic catheter. Review of the Physician order dated 09/18/2023 documented an order of Suprapubic catheter french 22 with 30 centimeter (cc) of normal saline (NSS) balloon for neuromuscular bladder dysfunction. Catheter care daily as per facility protocol . There was no documented evidence a CCP related to Suprapubic catheter was developed and implemented for Resident #36. The Director of Nursing (DNS) was interviewed on 10/05/2023 at 4:09 PM and stated CCPs are initiated by Registered Nurse (RN) in the unit. The DNS confirmed there is no catheter CCP for Resident #36 and there should be. 415.11 (c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and abbreviated survey of 10/2/23 through 10/11/23, the facility did not ensure that the comprehensive care plans (CCP) were reviewed and/or revised after each assessment and as needed. Specifically, a resident with a new order for a positioning device did not have their CCP updated for that intervention. This was evident for 1 of 1 (Resident #44) reviewed for limited range of motion (ROM). The findings are: The facility policy and procedure titled Comprehensive Care Plan (CCP), issue date 5/2015, review date 5/23, states all residents will have a CCP completed in accordance with federal and state requirements. The CCP will include measurable goals with time frames to meet the resident's medical, nursing, and psychosocial needs as identified in the Minimum Data Set (MDS). The CCP will be developed, reviewed, and revised by the interdisciplinary team as follows: initial admission, re-admission from hospital, quarterly after completion of MDS core elements, whenever a significant change occurs, special reviews, episodically, as plan of care changes and annually. Resident #44 was observed sitting in their room, in the wheelchair or in bed on 10/4/23 at 10:40AM, 10/5/23 at 10:10AM, and 10/6/23 at 10:01AM with a contracture on the left hand and no hand roll in place. The quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 7/15 (severely impaired cognition), functional status requiring extensive assistance of 2 for bed mobility, transfer, and toilet use; extensive assistance of 1 for dressing, eating, and personal hygiene. The diagnoses include cancer, hypertension, cerebral vascular accident, and non-Alzheimer's dementia. A Physician's Order dated 9/15/2023 at 10:47AM indicates small gauze roll to be worn in left hand at all times except for hygiene and skin check. A CCP titled Contractures, last updated 8/31/23 documents resident has contractures. The goal is contractures will not increase in severity x 90 day. Interventions are to monitor for changes. There is no evidence that the CCP was reviewed and revised for the gauze roll order dated 9/15/23. On 10/10/2023 at 10:11 AM, Registered Nurse (RN) Supervisor #2 was interviewed and stated that the care plans are started by the night nurses then the day shift RN supervisor or the Director of Nursing will go over them. The RN supervisor further stated that for each diagnosis there is a corresponding care plan and the care plans are updated as needed. On 9/15/2023, a Physician order for hand roll was given for left hand contracture. The Resident's care plan on contracture was not updated to include the order for th left hand. 415.11(c)(2) (i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, during the Recertification survey , the facility did not ensure that residents who need respiratory care, including tracheostomy care and suctioning are provided such care including supplies, as consistent with current professional standards of practice, the comprehensive care plan and resident's goal and preferences. It was observed there was no extra tracheal cannula on the resident's bedside. Furthermore, available supplies had an expiration dated of 2005, 2018 and 01/2023 . This was evidenced in 1 of 1 resident investigated for respiratory care in a sample of 25. Resident #56. The finding is : The facility Policy and Procedure titled tracheostomy Care with a revision date of 08/2023 on the purpose documented, Oceanview Nursing and Rehabilitation Center provides appropriate care for any resident presented with tracheostomy as prescribed by the physician, to maintain airway patency, maintain Infection Control standards and prevent skin breakdown at stoma site. Suction machine and suction equipment with appropriate size disposable inner cannula must be readily available at bedside. Resident # 56 was admitted to the facility with diagnoses including: Malignant neoplasm of the larynx, Cancer, Malnutrition, Depression, Asthma and Atrial Fibrillation. The Minimum data Set (MDS) 3.0 assessment dated [DATE] on activities of daily living documents- needing assistance and supervision, able to propel self with use of wheelchair and able to communicate with lip reading and nodding the head. On [DATE] at 4:00PM , resident was observed and spoken too in the room. A suction machine and suction kit was observed on the bed side table. On [DATE] at 3:24PM , the resident was observed again in their room. It was noted that there was no extra inner cannula kit available at bedside in case of an emergency. Review of the Physician orders dated [DATE] documented, Tracheostomy care, suction as needed, change ties as needed and tracheal care every shift and as needed (PRN) . Review of the Comprehensive Care Plan (CCP) on Respiratory care dated [DATE] documented, Resident requires tracheostomy due to inability to maintain airway due to Cancer. Goal set is that resident will remain free of signs and symptoms of infection and the interventions were: allay fear, answer call light promptly and ensure that emergency kit with secondary airway, ambu bag and suction machine present in the room, Evaluate and monitor lung sounds, signs and symptoms of respiratory distress, provide and monitor oxygen saturation and treatments as per physician's order. Pulmonologist consult as needed and use of aseptic technique when re-inserting tracheostomy tube . On [DATE] at 3;27 PM , Unit Registered Nurse Supervisor # 1 was interviewed and stated There has to be an extra shiley there on the bedside. The State Agent (SA), went back to the room and observed there was none available. RNS#1 stated, We have them available in my closet and in the nurses station. Observation of the supplies available reveals that the facility 5 tracheal cannula are all expired dated 2005 / 2018 and 01/2023 . RNS #1 was further asked what is the size of the tracheal tube used and stated honestly speaking I don't know . RNS#1 further stated, We normally don't admit residents with tracheal care. I come in the morning and I suction the resident. If needed in the evening or night the licensed nurses will do it. 415.12 (k) (6)

Based on observation, interviews, and record review conducted during the Recertification and Complaint survey conducted 10/02/2023 to 10/11/2023, the facility did not ensure the Director of Nursing (DNS) served as a charge nurse/Supervisor, only when the facility has an average daily occupancy of 60 or fewer residents. Specifically, there was documented evidence the DNS worked as a Nursing supervisor on multiple occasions when the facility had no registered Nurse assigned. The findings are: The facility policy titled Director of Nursing/Administration dated last reviewed October 2023 documented the DNS should delegate unit-level responsibilities to appropriate nursing staff members and support addressing concerns and complaints, taking corrective action. Actual Daily Staffing Schedules documented the DNS assigned as Nursing Supervisor on the Evening shifts on the following dates: June 2023: 6/3/2023, 6/7/2023, 6/9/2023, 6/15/2023, , 6/16/2023, 6/18/2023, 6/24/2023, 6/27/2023, 6/28/2023, and 6/29/2023. July 2023: 7/5/2023, 7/6/2023, 7/12/2023, 7/14/2023, 7/18/2023, 7/21/2023, 7/25/2023, 7/26/2023, 7/28/2023, and 7/29/2023. August 2023: 8/1/2023, 8/7/2023, 8/8/2023, 8/9/2023, 8/22/2023, 8/25/2023, 8/26/2023, 8/27/2023 and 8/29/2023. September 2023: 9/3/2023, 9/7/2023, 9/8/2023, 9/12/2023, 9/13/2023, 9/15/2023, 9/19/2023 and 9/24/2023. October 2023: 10/2/2023, 10/3/2023, 10/7/2023, and 10/08/2023. On 10/10/23 at 09:00 AM, an interview was conducted with Director of Nursing Services (DNS). DNS stated they act as nursing supervisor because do not have a 3-11PM staff to cover the shift. The DNS was not aware that the DNS cannot also be in the role of nursing supervisor. They have no choice but to cover the building if there is no Registered Nurse (RN). On 10/10/23 at 12:27 PM, an interview was conducted with the Administrator who stated it is very difficult to find RNs to cover the unit. The DNS covering as nursing supervisor is a last resort. The Administrator stated they were aware the DNS cannot work as a charge nurse and hired an Assistant Director of Nursing (ADON). 415.13(b)(1)

Based on observation, interviews, and record review conducted during the Recertification survey of 10/2/23 through 10/11/23, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during the Kitchen observation. Specifically, items were observed stored undated and with opened packaging, observation of staff not washing hands or changing gloves before handling food after entering and exiting the walk-in refrigerator, and staff were observed not wearing facial hair coverings. The findings are: The facility's policy titled Labeling and Dating Stored Food, effective date 11/2008, review date 8/2023, states the procedure of How to Properly Store, Label and Date Foods in Various Areas of the Kitchen: keep all foods on shelves, off the floor, opened packages should be wrapped or otherwise sealed; refrigerators: always remove any leftovers of canned foods from the original container, transfer to a sealed container and label and date the container for storage; indicate the date on which a container, jar, etc. was opened; freezers: label (if packaging doesn't identify the contents clearly) and date all items. An undated document titled Dress Code, documents kitchen personnel must wear protective hair covering. An undated document titled Personal Hygiene How to Wash your Hands, documents when to wash your hands, including a handwritten notation immediately before on gloves, and after touching unclean equipment or work surfaces. A brief tour of the kitchen was conducted on 10/2/23 at 9:06AM with [NAME] #1. During the tour, the walk-in freezer was observed with a box of Morning Star bacon without a date, and an open box of Morning Star Veggie Sausage links in an open plastic bag, links exposed, and without a date. On 10/2/23 at 9:16AM, Dietary Aide (DA) #1 was observed exiting the walk-in refrigerator, wearing a pair of gloves, and observed returning to their workstation and started preparing cheese sandwiches. DA #1 was asked when they are supposed to wash their hands. DA #1 responded (via staff translator DA # 4, that they are supposed to wash their hands and then use gloves to touch everything. The State Agency (SA) told DA #1 that they were observed leaving the walk-in refrigerator and going back to their workstation, picked up a 6 paper plate, then 2 slices American cheese, without having replaced the gloves/or washing hands. A second tour of the kitchen was conducted on 10/5/23 at 11:29AM. [NAME] #2 was observed serving the lunch meal without covering their facial hair (beard and mustache). [NAME] #2 was asked at that time about the use of hair restraints to cover facial hair. [NAME] #2 responded that they were not aware of beard nets. DA #3 was also observed with facial hair without a cover. DA #3 was also asked about the use of hair restraints/rules for to cover hair, specifically facial hair (DA #3 was noted with a beard and mustache) DA #3 stated that they were told if it was trimmed, it is okay and does not need to wear a covering. An interview was conducted with the Food Service Director (FSD) on 10/5/23 at 11:33AM, who stated that it is policy and procedure to cover hair by using a net to cover hair; if they have beard and it is long, they have to cover it. The FSD further stated that when it is low cut then they do not need to cover it. 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey the facility did not ensure an effective infection prevention and control program. This was evident during review of the Legionella Plan and the [NAME] Unit during Medication Administration. Specifically, 1) there were no remediation plan put in place after greater than 30 percent samples tested for legionella were positive, and 2) blood pressure (BP) cuffs were not disinfected after use between Resident #81, #69, and #87. The findings are: The facility policy titled Infection Control Policy: Multipurpose Equipment Cleaning dated last reviewed October 2023 documented all multipurpose equipment must be cleaned and disinfected between resident use. The policy further stated cleanse multipurpose equipment with germicidal/antimicrobial disinfectant disposable wipe. 1) On October 6 2023, during the Annual Recertification survey of the facility, legionella testing results were reviewed from June 29 2023, and it was noted that thirty percent or more of the samples tested were positive. On October 6, 2023 at approximately 1:30 pm, in an interview with the Administrator, stated that contractor is due to come in on Monday (10/9) for further sampling and no further remediation was conducted up to present time. Surveyor: [NAME]-[NAME], Lyd 2)On 10/04/23 at 09:18 AM, Licensed Practical Nurse (LPN) #4 was observed using the BP machine on Resident #81 without sanitizing the BP cuff prior to placement on the resident's right arm. LPN#4 did not sanitize the BP cuff after use with Resident #81 and rolled the machine to Resident #69. LPN #4 placed the BP cuff on Resident #69's left arm, took their BP, did not sanitize the BP cuff, and moved on to Resident #87. LPN #4 did not sanitize the BP cuff and placed the cuff on Resident #87's left arm. On 10/04/23 at 10:00 AM, an interview was conducted with LPN #4 who stated they are supposed to clean the BP cuff in between each resident use. They have no excuse for not cleaning the BP cuff in between use with Resident #81, #69, and #87. On 10/05/23 at 03:10 PM, an interview was conducted with the Director of Nursing Services (DNS) who stated all medical reusable equipment such as BP cuffs are supposed to be cleaned after each resident use. The staff are all in-serviced on Infection Control Protocols and the need to clean the reusable equipment between use. 415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** (2) Resident #3 was admitted to the facility on [DATE], with diagnoses that included Anemia and End-Stage Renal Disease (ESRD). The Quarterly Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 05/12/2021 documented the resident had intact cognition. There was no documentation that resident received Dialysis while a resident in Section O - Special Treatment and Programs of the MDS. On 06/15/21 at 09:27 AM, Resident #3 was observed in room noted with Left arm fistula Shunt Access, covered with dry dressing. Resident stated that the shunt has been in use for dialysis for over 13 years, and the dialysis is scheduled for every Monday, Wednesday, and Friday at 4:30 am. The Comprehensive Care Plan (CCP) for Dialysis dated 1/16/2020 documented that Resident is currently on dialysis due to DX. of ESRD. The Physician's order dated 06/14/2021 documented: Hemodialysis Treatments at Dialysis Center on Monday, Wednesday, Friday - 3 days per week. (3) Resident #34 was admitted to the facility 03/22/2019, with diagnoses that included Non-Alzheimer's Dementia, Seizure Disorder or Epilepsy, Asthma, Chronic Obstructive Pulmonary Disease (COPD). The Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) 05/28/2021 documented the resident had moderately impaired cognition; has clear speech, with distinct intelligible words, makes self-understood, and understands others. MDS documented that Antipsychotics were received on a routine basis; GDR (Gradual Dose Reduction) has been documented by a physician as clinically contraindicated on 3/10/2021. There was no documentation that resident had a diagnosis of psychosis or mood disorder on Section I - Active Diagnosis of the MDS. Physician's order dated 6/14/2021 documented: Risperidone 2 mg tablet by oral route once daily for Mood disorder due to known physiological condition (First Became Standing 02/10/2020). There was no documentation that resident has diagnosis of Mood Disorder on Active Diagnosis of Quarterly MDS ARD 2/25/2021. Psych Consult note dated 5/4/2019 documented that resident verbalized being a white supremacist and began yelling racial slurs at and punched one of their peers. Staff had a difficult time redirecting the resident, and the resident was sent to the hospital and returned with diagnosis of Mood Disorder. Continued to be verbally aggressive with staff, calling them black bitches, often pacing unit and tries to leave facility. Medications: Divalproex 1000mg BID and risperidone 3mg PO daily. There was no documentation that resident has diagnosis of Mood Disorder on Active Diagnosis of Annual MDS ARD 11/26/2019. On 06/17/21 at 09:50 AM, an interview was conducted with the RN/MDS Assessor (MDSA). The MDSA stated that when completing the MDS, the residents are assessed and interviewed, Physician's orders and progress notes are reviewed along with the resident's medical diagnosis. MDSA stated that Resident#3 has always been on dialysis, the resident's current MDS that was not coded as being on dialysis was an oversight and was corrected. MDSA further stated that resident #34 has diagnosis of Non-Alzheimer's Dementia, Seizure Disorder or Epilepsy, and Asthma/ COPD, and is on antipsychotic medication for mood disorder. MDSA stated that diagnosis of Mood disorder is supposed to be coded in the current resident's MDS on the section I (Active Diagnosis), but it was omitted. The omission has been rectified. MDSA also stated that someone from outside used to come and check for the accuracy before submission prior to the COVID-19 outbreak, but the responsibility has been taken over by the Director of Nursing. On 06/17/2021 at 10:15 AM, an interview was conducted with the director of Nursing (DON). The DON stated that staff who complete their assigned sections are responsible for checking for the accuracy before submission, and the nurse that signs off on the book is responsible to make sure that all sections of the MDS are completed. The DON further stated that MDS assessment and documentation have just been taken over, and the issues with the MDS have been recently identified and will be addressed in the next QA meeting. 415.11(b) Based on record reviews and interviews during the recertification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 assessments were completed accurately to reflect the resident's status. Specifically, two (2) residents diagnoses were not accurately coded for mood disorder (Resident #34) and Schizophrenia (Resident #8), one (1) resident was inaccurately coded for having a mechanical ventilator (Resident #8), and one (1) resident was not accurately coded for receiving dialysis services (Resident #3). This was evident for 3 of 27 sampled residents investigated (Resident #3, #8, and #34). The findings are: The facility policy and procedure titled, Minimum Data Set (MDS) Completion (Dated 07/2020) documented that the assessment should accurately reflect the resident's status. AN accurate assessment required collecting information from multiple sources. Assessors will review supporting documentation available during the look back periods to ensure accuracy. (1) Resident #8 was admitted on [DATE] with diagnoses which include Schizophrenia, Anxiety Disorder, and Non-Alzheimer's Dementia. The resident's diagnoses list documented resident with diagnosis of Schizophrenia dated 10/01/2020. There was no diagnosis listed for mechanical ventilator. Physician orders were reviewed. The resident was prescribed Risperdal 50 milligram (mg)/2 milliliter (ml), inject 2 ml intramuscular every 2 weeks dated 02/11/2021 with indication for Schizophrenia. There was no physician order for a mechanical ventilator. The Minimum Data Set (MDS) 3.0 Quarterly assessment dated [DATE] documented Resident #8 had moderately impaired cognition. The active diagnoses did not include Schizophrenia. The MDS also documented Resident #8 had an invasive mechanical ventilator. On 06/17/2021 at 08:10 AM, the Director of Nursing (DON) was interviewed. The DON stated they completed the quarterly MDS, and it was a mistake the resident was miscoded for mechanical ventilator and the Schizophrenia diagnosis was left out. On 06/16/2021 at 02:21 PM, The DON stated all staff who complete their assigned sections are responsible for the accuracy of it. The nurse who signs off on the book is responsible for ensuring the MDS is completed. The DON stated issues with the MDS have been recently identified. Specifically, the tardiness in completing and submitting the MDS, and the accuracy of the MDS which will all be addressed at the next quality assurance meeting.

Based on observations, record review, and staff interview during the recertification survey, the facility did not ensure proper sanitation procedures were followed for the prevention of foodborne illnesses. Specifically, the low temperature dishwasher machine did not meet manufacturer's instructions and regulatory requirements with a wash temperature of 120- to 140- degrees Fahrenheit. The wash temperature on the dishwasher machine read 100- and 90-degrees Fahrenheit during two observations. This was evident during completion of the Kitchen task. The finding is: The facility policy and procedure titled, Low Temperature Dishwasher (Dated 05/15/2020) documented dishes will be sanitized at low temperature between 120- and 140-degrees Fahrenheit. Procedures to operate the machine also documented to check temperatures and follow the manufacturer's recommendations of 120 to 140 degrees Fahrenheit. The operating instructions for the low temperature dishwasher documented the recommended temperature of 140 degrees Fahrenheit for the wash to be used. The dishwasher temperature and chlorine concentration log for the month of June 2021 documented all wash temperatures were 100 degrees Fahrenheit. On 06/15/2021 at 12:20 PM and 12:30 PM, the dishwasher machine wash temperature was observed to be 100 degrees Fahrenheit. On 06/16/2021 at 01:30 PM, the dishwasher machine wash temperature was observed to be 90 degrees Fahrenheit. On 06/15/2021 at 12:30 PM, the Food Service Director (FSD) stated that 100 degrees Fahrenheit is the recommendation made from the manufacturer of the machine and was unaware of the regulation for the temperature to be 120 degrees Fahrenheit. Later on, the FSD stated the vendor remarked that the machine is for cold temperatures and that as long as they use the sanitize solution, the temperature is acceptable. 415.14(h)