Based on observation, record review, and interview during the Recertification Survey from 03/02/2025 to 03/07/2025, the facility did not ensure residents' right to personal privacy and confidentiality of medical records were maintained. This was evident in 2 (Units 2 and 3) of 4 units observed. Specifically, licensed nurses left computer screens unlocked and unattended exposing private medical information during medication administration. The findings are: The undated facility policy titled Privacy Policy and Personal Health Information Pledge of Confidentiality documented the facility was committed to maintaining the highest level of confidentiality for resident information and Personal Health Information in accordance with the Healthcare Insurance Portability and Accountability Act. The policy stated it is every employee's responsibility to protect the confidentiality, privacy, and integrity of confidential resident information and Personal Health Information as required by law and professional ethics. 1. During medication pass observation in Unit 2 on 03/02/2025 at 9:31 AM, Licensed Practical Nurse #1 walked away from the medication cart and entered Resident #115's room to take the Resident's blood pressure. Licensed Practical Nurse #1 left the computer in the medication cart unlocked, with the computer screen open exposing residents' health information. Licensed Practical Nurse #1 was interviewed on 03/02/2025 at 10:30 AM. They stated they should have minimized the computer screen to maintain confidentiality of residents' information. On 03/02/2025 at 11:31 AM, Registered Nurse #1 was interviewed and stated confidentiality of residents' information must be maintained. They stated they make random rounds during medication administration to ensure nurses' lock the computer when they leave the medication cart. 2.) During medication pass observation on 03/02/2025 at 10:52 AM, Licensed Practical Nurse #2 walked away from the medication cart and entered Resident #325's room to administer medications. Licensed Practical Nurse #2 left the computer in the medication cart unlocked, with the computer screen open exposing residents' health information. On 03/02/2025, Licensed Practical Nurse #2 was interviewed immediately after and stated it is important to keep residents' health information private and confidential because of mandated privacy laws of health information. On 03/05/2025 at 8:49 AM, the Director of Nursing was interviewed and stated there is a Health Insurance Portability and Accountability Act that the facility must maintain to ensure residents' information is kept private and confidential. 10 NYCRR 415.3(e)(1)

**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 comprehensive person-centered care plan for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident in 1 (Resident #95) of 4 residents reviewed for care planning out of 37 total sampled residents. Specifically, Resident #95 had no comprehensive care plan developed to address comfort/palliative care. The findings are: The facility's policy titled Comprehensive Care Plan with a revision date of 01/2023 documented it is the policy of the facility that residents will have a Comprehensive Care Plan completed in accordance with the federal and state requirements which includes measurable goals and time frames. Resident #95 had diagnoses that include Cancer, Anemia, and Hypertension. The Minimum Data Set assessment dated [DATE] identified Resident #95 had severe impairment in cognition. Resident #95 was totally dependent on staff for activities of daily living and was spoon fed by staff in all meals. On 03/03/2025 at 10:36 AM, Resident #95 was observed in their room, alert but non- responsive to verbal command. Resident #95 had intravenous infusing on the right anticubital area and had oxygen via nasal cannula at 2 liters per minute connected to an oxygen concentrator. The physician's order dated 02/11/2025 documented comfort care/palliative. A nurse practitioner notes dated 03/03/2025 at 8:11 AM documented Resident #95 was on comfort/palliative care. A review of the Comprehensive Care Plan revealed no documented evidence that a care plan for comfort/palliative care was developed for Resident #95. On 03/05/2025 at 3:16 PM , Registered Nurse #1 was interviewed and stated it is the Social Worker's responsibility to develope and initiate Resident #95's care plan for comfort/palliative care. On 03/05/2025 at 3:24 PM, the Director of Social Services was interviewed and stated they were not aware they have to develop a care plan for comfort/palliative care. They stated they thought they are done once they completed the necessary documentation. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #92 was admitted to the facility with diagnoses of Hypertension , Neurogenic Bladder with Suprapubic Catheter , Schizophrenia and Injury of Cervical Cord . The Minimum Data Set assessment dated [DATE] documented Resident #92 had intact cognition and was dependent on staff for transfers, bed mobility, dressing, and eating . A physician's order dated 02/04/2025 included bilateral heel protectors at all times and Thoracic Lumbar Sacral Orthosis when out of bed. A Comprehensive Care Plan on Range of Motion which was last updated on 11/14/2024 documented Resident #92 was on nursing rehabilitation with passive range of motion to bilateral lower extremities, apply bilateral heel protectors at all times, and Thoracic Lumbar Sacral Orthosis brace when out of bed. On 03/04/2025 at 3:29 PM, Resident #92 was observed in the unit seated on their wheelchair with no heel protectors and no Thoracic Lumbar Sacral Orthosis brace. On 03/05/2025 at 12:18 PM, Resident #92 was observed in their room seated in their wheelchair, with no heel protectors and no Thoracic Lumbar Sacral Orthosis brace. On 03/05/2025 at 12:18 PM, Certified Nursing Assistant #2 was interviewed and stated they did not apply the heel protectors and the Thoracic Lumbar Sacral Orthosis brace and that it was the Resident who applies the devices. On 03/05/2025 at 12:40 PM, Licensed Practical Nurse #4 stated they were not aware Resident #22 has not been using the heel protectors and the Thoracic Lumbar Sacral Orthosis brace. On 03/06/2025 at 10:45 AM, the Director of Nursing was interviewed and stated adaptive devices are ordered by the physician and is documented in the Certified Nursing Assistant Accountability Record or the Treatment Administration Record. They stated they are surprised that the nurses and nursing supervisors have not noticed this noticed this error to ensure that necessary interventions are carried out for the residents. 10 NYCRR 415.12 (e)(1) 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 appropriate services, care, and equipment are provided to assure that residents with limited range of motion and mobility maintain or improve function based on the residents' clinical condition. This was evident in 3 of 3 residents reviewed for Limited Range of Motion out of 37 total sampled residents. Specifically, 1.) Resident #22 was observed without an abductor wedge as per physician's order. 2.) Resident #92 was observed with no bilateral heel protectors and Thoracic Lumbo Sacral Orthosis as per physician's order. The findings are: The facility's policy for Adaptive/Assistive Devices/Positioning Devices dated 01/2025 documented that residents will be supplied with adaptive/assistive/positioning devices that will enhance their quality of life and increase their ability to be independent in Activities of Daily Living. 1. Resident #22 was admitted to the facility with diagnoses that included Coronary Artery Disease, Non-Alzheimer's Dementia, and Unspecified Fracture of Upper End of Right Humerus. The admission Minimum Data Set assessment dated [DATE] documented that Resident #22 had severe impairment in cognition and required substantial/maximal assistance and partial/moderate assistance of staff for most activities of daily living. A Comprehensive Care Plan for alteration in bone integrity due to acute Fracture was initiated on 12/20/2024. The care plan documented Resident #22 had fracture of the right hip status post right hemiarthroplasty. The facility interventions include use of immobilizing device as ordered. A physician's order dated 02/11/2025 documented to keep right upper extremity sling in place, remove for skin checks and hygiene every shift and as needed. It also included orders for abductor wedge in both lower extremities when in bed and while sitting on wheelchair. The Certified Nursing Assistant Accountability Records and Treatment Administration Records reviewed from the month of December 2024 until March 2025 showed no documented evidence that the abductor wedge was being applied for Resident #22. On 03/03/2025 at 11:37 AM, Resident #22 was observed sitting on the wheelchair with no abductor wedge. On 03/04/25 at 9:18 AM, Resident #22 was observed participating in rehabilitative therapy. There was no abductor wedge in use. On 03/05/2025 at 7:58 AM, Resident #22 was observed sitting in the dining room with no abductor wedge in place. On 03/05/2025 at 12:01 PM, Resident #22 was observed in the day room with no abductor wedge in place. On 03/06/2025 at 8:54 AM, Resident #22 was observed at Rehabilitative Therapy with no abductor wedge noted. On 03/06/2025 at 8:55 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #22 is in their assignment and that they were not aware that Resident #22 has an abductor wedge that need to be applied in between resident's legs. They stated they had never seen the abductor wedge for Resident #22. On 03/06/2025 at 9:27 AM, Registered Nurse #3 was interviewed and stated that Resident #22 had physician's order for an abductor wedge to be applied in between the legs when sitting on the wheelchair. They stated that either the nurse or aides may apply the abductor wedge. Registered Nurse #3 stated there was no documentation in the Certified Nursing Assistant Accountability Record or in the Treatment Administration Record for the abduction wedge and they were not able to tell when the abductor wedge was last applied. On 03/06/2025 at 9:52 AM, the Director of Rehabilitative Therapy was interviewed and stated that the abductor wedge was recommended by the orthopedic surgery after Resident #22's hip replacement procedure to be worn in bed and when sitting on wheelchair to prevent abduction and crossing of leg when the Resident is not walking. They stated the abductor wedge is not placed on the Resident during therapy exercise and they normally place it when resident is in bed or when sitting on the chair.

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 all medications and biologicals were stored properly. This was evident in 1 (Unit 2) of 4 units observed during Medication Administration Task. Specifically, medications were pre-poured and left unattended on the medication cart, and the medication cart was left unattended and unlocked. The findings are: The facility's policy titled Medication Administration dated January 2025 documented that it is the policy of the facility to handle, store, and administer medications in accordance with best practice standards, including but not limited to not leaving medications unattended on the medication cart and carts will be locked when not within view of the nurse. On 03/02/2025 at 9:31 AM, during medication pass observation on Unit 2, Licensed Practical Nurse #1 crushed and pre-poured the following medications for Resident #115: Gabapentin 100 milligram 2 tab, Calcium 600 milligram + D 600 milligram 1 tablet, Lisinopril 10 milligram, Metoprolol Tartrate 50 milligram, Eliquis 5 milligram, Metformin 1,000 milligram, Amlodipine 10 milligrams, and 15 milliliter of liquid solution Levetiracetam 100 milligram/milliliter. Licensed Practical Nurse #1 entered Resident #115's room to obtain the Resident's blood pressure. Licensed Practical Nurse #1 left all of the above medications on top of the medication cart unattended. The medication cart was not locked. Licensed Practical Nurse #1 was interviewed on 03/02/2025 at 10:30 AM and stated the medication cart and medications need to be secured because they have wanderers and they could take the medications left on top of the cart. On 03/02/2025 at 11:21 AM, Registered Nurse #1 was interviewed and stated the cart must be locked at all times. On 03/05/2025 at 8:49 AM, the Director of Nursing was interviewed and stated medications are not to be left unattended on top of the medication cart and the cart must be kept locked at all times when left unattended no matter for how long or short a time. 10 NYCRR 415.18(e)(1-4)

**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 failed to maintain each resident's right to a safe, clean, comfortable, and homelike environment. This was evident in 3 (Units 2, 3, and 4) of 4 units observed. Specifically, resident's room, bathroom, and medical equipment were observed with dirt and rust, wheelchairs were soiled, peeled paints, and window treatments were not in good condition. The findings include but are not limited to: The facility policy titled Safe,Clean, Comfortable, and Homelike Environment dated 11/2024 documented it is the policy of the facility to provide a safe, clean, comfortable, and homelike environment in such a manner to acknowledge and respect resident rights to the extent possible.The policy documented housekeeping staff will ensure the rooms and common areas are kept clean and sanitary. 1. During multiple observations from 03/02/2025 to 03/07/2025, the following were observed in Unit 2: a. The sphygmomanometer stand was layered with dirt and dust. b. room [ROOM NUMBER]'s oxygen concentrator had accumulated dust and dirt. c. The oxygen stand at the nurse station had rust and wheels had dust. d. The mechanical lift had rust and dusty base. e. The nurse station was dusty. f. The dining room fans were layered with dust. g. The suction machine table in the dining room had rust stains and dust accumulation. h. The window shades in the dining room were missing, and some were torn and dirty. i. The chairs in the dining room had missing back cushions. j. The hand rail across room [ROOM NUMBER] had missing end caps. k. There was a soiled wheelchair in room [ROOM NUMBER]b. l. room [ROOM NUMBER]a had torn and dirty floor mats. m. The clothes bin in room [ROOM NUMBER] was embedded with black substance and debris. n. room [ROOM NUMBER]d had torn window shades and soiled wheelchair. o. room [ROOM NUMBER]b had dusty and rusty bed frame. A signed construction contract dated 02/11/2025 documented the target date for remodeling of 2nd floor unit will be in April/May 2025 pending availability of material and supplies. On 03/07/2025 at 9:23 AM, Housekeeper #1 was interviewed and stated they are responsible for maintaining a clean place for the residents. They stated their responsibility includes dusting and mopping the rooms and corridors, and cleaning the dining room after breakfast and lunch. They stated it is challenging to keep the unit clean because some residents have behaviors. They stated wheelchairs are cleaned weekly by the housekeeper on a different shift. On 03/07/2025 at 9:47 AM, the Director of Environmental Services was interviewed and stated wheelchairs are cleaned weekly and that they only clean the wheelchairs that were placed outside the rooms. They stated housekeeping staff are required to clean the blood pressure stands and intravenous poles. On 03/07/2025 at 10:20 AM, the Director of Maintenance was interviewed and stated there is a plan to remodel the 2nd floor. 2. During observations on 03/05/2025 at 11:05 AM and on 03/06/2025 at 12:57 PM, the following were observed in Unit 3: a. The chairs in the nurses' station were peeling and the medical charts are fading. b. In room [ROOM NUMBER], part of the floor linoleum was missing. c. In room [ROOM NUMBER], radiator had crusty brown substance. d. In room [ROOM NUMBER], the linoleum on the window base was peeling off. e. In room [ROOM NUMBER], radiator had crusty brown substance. f. In room [ROOM NUMBER], the door frame had peeling paint and the radiator and window frames had crusty brown substance. g. In room [ROOM NUMBER], the window shade was broken, the closet had black marks, the room entrance door base was peeling, and the bathroom entrance had a peeling frame on the floor. h. In room [ROOM NUMBER], the wall was dirty. i. In room [ROOM NUMBER], the radiator had crusty black substance. j. In room [ROOM NUMBER], the window shade and window base had a lot of dirt. k. In room [ROOM NUMBER], the wall base near the sink was broken, and the door frame had cursy brown substance. On 03/06/2025 at 3:33 PM, the Maintenance Director was interviewed and stated they have no painter in the facility and there are only 2 maintenance staff includin the Director. They stated they are looking to hire another maintenance staff. 3. During observations on 03/02/2025 at 11:19 AM and on 03/03/2025 at 12:21 PM, the following were observed in Unit 4: a. The residents' common bathroom was observed with multiple holes in the wall between the toilet and sink, peeling paint, chipped tiles around the bathtub, missing tiles on the wall beside the toilet, large gaps and brown stains on the ceiling tiles. b. room [ROOM NUMBER]a had peeling paint and multiple brown marks on the wall. On 03/02/2025 at 11:19 AM, Resident #225 was interviewed and stated they would like their room to be repainted. On 03/07/2025 at 09:54 AM, [NAME] #1 was interviewed and stated their job responsibilities include cleaning toilets, sweeping and mopping floors, and cleaning windows. They stated that they are not responsible for repairing things such as peeling paint or chipped tiles, but that they are responsible for reporting it to the Maintenance through the unit's Maintenance Repair Book. [NAME] #1 acknowledged the concerns that were observed in Unit 4 and stated that they were unsure if they had reported it to the Maintenance Department. [NAME] #1 further stated that they were not aware of the peeling paint and dirty wall in Resident #225's room but did state that they enter the resident's room daily to mop the floors. On 03/04/2025 at 8:10 AM, the Administrator was interviewed and stated that the building is old and needs a lot of work. They stated the first floor was newly renovated and is planning to do the same on the rest of the units. They stated they had signed a contract to begin renovation on the second floor with the start date of April / May 2025. The Administrator stated they currently do not have remodelling proposals for Units 3 and 4, but it is in the plan. The Administrator stated they made rounds and had observed that the facility need a lot of work. They stated they have a Maintenance Director and housekeepers assigned in each unit. They stated housekeeping is challenging because some residents pull the shades and smear feces. 10 NYCRR 415.5(h)(2)

Based on observation, interview, and record review conducted during the recertification survey from 6/26/23 - 7/3/23, the facility did not ensure garbage was disposed of and maintained to prevent potential feeding and harborage for pests. This was observed during review of the Kitchen. Specifically, the garbage compactor area, located outside, adjacent to the parking lot, was observed with a discolored liquid with a foul odor and flies on the ground next to the compactor. The findings are: A facility policy titled Non-Hazardous Waste dated 1/2023 documented non-hazardous waste is collected and discarded by housekeeping on a routine schedule and by all other personnel as needed (i.e., kitchen staff). Place the trash into the dumpster and close it. Do not leave any trash alongside or on top of the dumpster. On 6/30/23 at 11:32 AM, the Dietary Aide (DA) was observed removing a garbage bin from the kitchen and bringing it to the trash compactor. A brown liquid spill was observed on the ground by the end of dumpster. There were several flies present. A used face mask was also observed on the ground. The DA stated that when they dispose of trash, liquid comes out of the compactor. On 6/30/23 at 11:42 AM, the Housekeeping Director (HD) was interviewed and stated that Housekeeping is responsible to keep the dumpster area clean. The HD comes in at 7 am and checks the dumpster area. There is also housekeeping staff from 3-11 who checks the trash compactor area and hoses it down as needed. The dumpster is collected 2-3x/week by the vendor. The facility also power washes the dumpsters. There is a hose there so dietary can clean up the area as needed. The HD stated dietary knows the hose is there as they use it to wash down the garbage bin they use for transporting. 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Citation Text for Tag 842 Based on observation, record review, and interviews conducted during the Recertification Survey from 6/26/2023 to 7/3/2023, the facility did not ensure that the resident record were accurately documented in accordance with professional standards of practice. This was identified for one (Resident #101) of three residents reviewed for Pressure Ulcers out of 36 total sampled residents. Specifically, the Nurse Practitioner (NP) and Primary Care Physician (PCP) did not accurately document in the resident's medical record pressure ulcer on right elbow has healed. The finding is: The facility's policy titled, Charting and Documentation dated January 2023 documents all services provided by Premier Nursing and Rehab Center of Far Rockaway to the residents, or any changes in the resident's medical or mental condition, shall be documented accurately in the resident's medical record. Resident #101 has diagnoses that include Peripheral Vascular Disease, Diabetes Mellitus, Non-Alzheimer's Dementia, Pressure ulcer on right elbow stage 3. The Minimum Data Set (MDS) quarterly review assessment dated [DATE] documented that the resident has a severe impaired cognitive skill for daily decision making. Resident is totally dependent on staff on all functional status for activities of daily living, has pressure ulcer on right elbow, receiving pressure reducing device for chair and bed, Occupational Therapy from 1/17/2023 to 2/2/2023, Physical Therapy from 4/8/2023 to 4/26/2023. The Physician's Order dated 4/18/2023 documented Resident #101 to have Santyl solution followed by hydrogel topical ointment to right elbow stage 3 pressure ulcer and cover with dressing pads then wrap with Kling daily and as necessary. The NP Progress Note dated 5/16/2023 and 6/16/2023 documents Resident # 101 was seen and examined, right elbow noted with stage 3 pressure injury, pinkish tissue and moist. NP corrected the medical documentation on 6/28/2023 documenting right elbow with healed pressure ulcer. The PCP monthly physical exam documented on 5/31/2023 stated Resident #101 with pressure ulcer on right elbow and wound care. The Wound Care RN documented on 5/16/2023 right elbow stage 3 pressure ulcer was healed. The Comprehensive Care Plan dated 5/16/2023 documents right elbow pressure ulcer was healed. On 07/03/23 at 09:25 AM NP was interviewed stated documentation dated 5/16 /2023 and 6/16/202023 regarding Resident# 101 right elbow with stage 3 pressure ulcer were erroneous, they realized later that pressure ulcer was healed already. NP further stated they are not the regular NP for that unit and was reading the previous NP notes and taught resident still have pressure ulcer on the right elbow and stated did not examine the resident at those times. On 07/03/23 at 10:03 AM PCP was interviewed via phone at # 718 781 0935 stated they apologize for wrong documentation on 5/31/2023 and they will improve their assessment and documentation going forward. They acknowledged the mistake on the documentation, and they will examine the resident more carefully. 07/03/23 10:17 AM CNA #1 was interviewed, stated Resident #101 has no skin problem on the right elbow, they only put the elbow pad every morning for protection. 07/03/23 11:37 AM Administrator was interviewed and stated they will have a meeting with medical practitioners and instructions that all documentation must accurately reflect current residents' conditions. 10 NYCRR 415.22(a)(1-4)

Based on observation, interviews, and record review conducted during the Recertification Survey from 6/26/23 to 7/3/23, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident in the laundry room. Specifically, the laundry room was dirty and contained an eye wash station that was dirty and not functional. The findings are: The facility policy titled General Facility Maintenance dated January 2023 documented the facility provides a safe, comfortable environment for residents and staff by maintaining the facility in good repair, in compliance with all applicable codes and free of hazards. The facility policy titled Laundry Services dated January 2023 documented all laundry machines, folding tables, carts. bins, and equipments used in the laundering process are to be wiped clean with disinfectant on a daily basis. On 06/26/23 at 11:00 AM the following were observed: a) Laundry room with dirty sink, blackened materials observed , faucet dirty b) Laundry room eye wash station dirty and not in working condition, not functional when tested. There was no documented evidence the laundry room concerns were reported to the Maintenance Department. On 07/03/23 at 10:33 AM, the Director of Housekeeping (DH) was interviewed and stated they check the maintenance books on the units and handle whatever is listed in the book. Emergencies come up and the biggest problem becomes priority. Residents putting napkins in the sink and clog it or incontinence briefs in the toilet. The water overflows and trickles down so Housekeeping is constantly cleaning the ceilings. The DH works 3 days a week. Every other weekend, the DH works alone in the Housekeeping Department. The DH does rounds on the units. Usually, the staff will call Housekeeping for something. On 07/03/23 at 10:23 AM, the Administrator was interviewed and stated the building has ongoing repairs that are being fixed in the resident rooms. The Administrator will make sure the environmental concerns are corrected. 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey, the facility did not ensure appropriate liability and appeal notices were provided to Medicare beneficiaries. This was evident for 3 (Resident #114, 319 and # 419) of 3 residents reviewed for Beneficiary Protection Notification Rights out of a sample size of 36 residents. Specifically, the facility did not provide residents with the Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123 at the termination of their Medicare Part A benefits to Resident #114, #319, and #419 at the completion of Medicare Part A coverage. The findings are: Policy titled Minimum Data Set (MDS) reviewed January 2023 contained a copy of the Notice of Medicare Non-Coverage form and an article from the Department of Health and Human Services. The article stated a NOMNC must be delivered by the Skilled Nursing Facility at the end of Part A stay or when all of the part B therapies are ending. Resident #319 was admitted to the facility its 12/9/22. The resident was started on Medicare Part A Skilled Services on 12/9/22. The last covered day by Medicare Part A was 1/20/23. The resident was discharged from the facility on 1/20/23. There was no documented evidence that the NOMNC form was provided to the resident or legal representative, informing them of their potential liability for payment. Resident #419 was admitted to the facility on [DATE]. The resident was started on Medicare Part A Skilled Services on 2/24/23. The last covered day by Medicare Part A was 5/14/23, and the resident remained in the facility. There was no documented evidence that the NOMNC form was provided to the resident or legal representative, informing them of their potential liability for payment. The facility only offered the resident or legal representative the SNF ABN form. Resident #114 was admitted to the facility on [DATE]. The resident was started on Medicare Part A Skilled Services on 3/24/23. The last covered day by Medicare Part A was 6/9/23, and the resident remained in the facility. There was no documented evidence that the NOMNC form was provided to the resident or legal representative, informing them of their potential liability for payment. The facility only offered the resident or legal representative the SNF ABN form. On 06/30/23 at 10:49 AM Bookkeeper (BK) #2 was interviewed. BK #2 reported they are the person who gives the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) to residents who ask for a copy. BK #2 reported the Minimum Data Set (MDS) Coordinator and Assistant Administrator notifies them which residents have exhausted their days, is coming off Medicare Part A and needs a SNFABN letter. BK #2 reported a lot of residents are not aware so they talk to family and guardians, and notify them via phone and document I spoke to them. BK #2 reported they do not mail the forms to the family after speaking to them. BK #2 reported all three of residents reviewed for Beneficiary Notice got letters except resident #319. Resident #319 did not get a letter because they were discharged out of the building and they found out after the resident left. BK #2 reported they usually give the SNFABN letter 2 to 3 days before residents are being discharged . BK#2 reported no one supervises them on which letters they send out and no one trained them which letters to send. BK #2 reported they have only been giving residents the SNFABN form and not the NOMNC. BK #2 reported they found out 2 weeks ago from the MDS Coordinator that there is another form they should be giving. BK#2 was asked which forms should given when and they stated they were not sure. On 06/30/23 at 11:15 AM the MDS Coordinator was interviewed. The MDS Coordinator reported every week we have a Utilization Review meeting with all departments and discuss all residents on skilled services and how they are progressing and how long we expect them to continue on skilled services. MDS, social worker, dietary, and bookkeeping are all informed verbally of residents who are coming up for ending a skilled services stay. We say what is the projected day and discuss if that is appropriate. The MDS Coordinator reported they have a utilization spreadsheet that gets updated with residents benefit days. Each discipline updates for each resident. The MDS Coordinator reported the spreadsheet is a Google document the departments have access to. The spreadsheet says if a resident exhausted days or how many remaining days there are. The MDS Coordinator reported the NOMNC forms are given to residents being discharged from skilled services and if residents stay in the facility they get NOMNC and SNFABN. The MDS Coordinator reported the beneficiary notice forms is assigned to bookkeeper. The Bookkeeper was trained by the person who was sending the forms before them. On 07/03/23 at 09:09 AM the Administrator was interviewed. The Administrator reported they are overseeing the beneficiary notice forms, but other departments are disseminating the information. The Administrator reported they are not involved in the training for which forms to send out. 415.3(g)(2)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 07/03/23 at 10:16 AM Maintenance Worker (MW) #1 was interviewed. MW#1 stated they will check the maintenance books in the morning to see if there are any complaints. They do not do rounds on the units. After checking the book they will report to their boss, who tells them what projects to work on first. MW #1 stated sometimes the boss has different priorities than what is listed in the maintenance book. The maintenance books are checked on each unit every morning. MW #1 reported if there is nothing in the book sometimes staff will tell us about things they need us to do. Sometimes we have projects. MW# 1 reported if there is nothing in maintenance we don't know what needs to be repaired. MW#1 reported there are constant projects they are working on and assigned to. MW#1 reported related to missing blinds or blinds off the windows it is because residents can pull them off or we are waiting for blinds to be delivered to install them. On 07/03/23 at 10:25 AM MW#2 was interviewed. MW# 2 reported besides the supervisor there are only 2 of them in the department. Each MW is assigned to work every other weekend so they are only in the facility together 2 to 3 days a week. MW#2 reported other days when they are working alone so sometimes projects have to wait. MW #2 reported they are busy if they are alone and sometimes not able to get to have everything done. On 07/03/23 at 10:33AM the Director of Maintenance (DOM) was interviewed. The DOM reported in the morning the men go check the maintenance books on the units and handle whatever they have on the book. The DOM reported a lot of times there are emergencies that come up that need to be prioritized and taken care of. The biggest problem is residents putting napkins in the sink or diapers in the toilet, clogging them. When there is a clog the water overflows onto the floors and trickles down to the unit below so the facility is constantly redoing ceilings. The DOM reported he works with the two maintenance workers on Monday, Wednesday and Friday during the week. They work alone every other weekend. The DOM reported the maintenance workers have assignments and they work on the weekend. The DOM reported they do rounds on the unit and take notes of things that need repairs. Usually staff will call maintenance if they need something. The DOM reported the air conditioning has been turned on 3 weeks now. The insulation for the pipes is [AGE] years old and the facility has been working on taking out old insulation if there are any leaks, so they have been working on the ceilings. The DOM reported the residents will put things in the radiators. The baseboard can't be fixed without fixing the entire wall. Any baseboard that is put on now will tear and will falls off the wall. The DOM reported all staff are aware of the maintenance books in the nursing stations and how to use them. 07/03/23 11:23 AM Administrator was interviewed stated the building has on going repairs and fixing the problems on all room and they will make them sure the broken, missing tiles or mismatched bathroom tiles will be corrected. 415.11 Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure residents were provided with a clean and homelike environment. This was observed on 3 out of 4 units (Units 2, 3, and 4). Specifically, windows were noted with missing blinds, closet doors were missing paint, radiator/ac units were rusty, dirty, and missing paint, bathrooms were missing tiles, bathroom ceilings missing parts, bathroom ceilings were noted with dried leak marks, privacy curtains were off the track, and baseboard covering missing leaving raw cement exposed. The findings are: The facility policy and procedure titled General Facility Maintenance reviewed January 2023 documented it is the policy of Premier Nursing and Rehab Center of Far Rockaway to provide a safe, comfortable, environment for residents and staff by maintaining the facility in good repair, in compliance with all applicable codes, and free of hazards. There is a maintenance log on each nursing unit for the requisition on non-emergency repairs. The maintenance staff member who checks the log must sign and date the repair was made. 1) On 06/26/23 at 10:10 AM, and on 06/29/23 12:30 PM Unit 2 was observed with the following: a) room [ROOM NUMBER] Privacy curtain not all hook to the track line, loose curtains parts observed falling off. b) room [ROOM NUMBER] radiator in the resident's bathroom observed dirty, paint in the radiator peeling off c) room [ROOM NUMBER] baseboard covering missing, raw cement observed d) room [ROOM NUMBER] baseboard covering missing e) room [ROOM NUMBER] resident's cabinet paint peeling off f) room [ROOM NUMBER] mismatch bathroom tiles g) room [ROOM NUMBER] resident's bathroom with missing floor tiles, ceiling with peeling off paints h) Dining room on the second floor, 2 ac/radiator dirty, control box no cover, control knob exposed The 2nd floor unit Maintenance Book did not document reports of the observations listed above from 6/1/23 to 7/3/23. On 07/03/23 11:24 AM Resident # 63 stated they were unhappy with the state of their room. They did not like having mismatched floor tiles, missing floor tiles. 2) On 06/26/23 through 7/2/23 the following environmental concerns were observed on the 3rd floor a) room [ROOM NUMBER]: no blinds on the windows, radiator/ac rusty and missing paint, bed closest to the door had approximately five marks where paint was peeled off behind the bed b) room [ROOM NUMBER]- right window was missing blinds c) room [ROOM NUMBER]- the radiator was noted with chipped paint and rusty. Radiator also making loud noise. d) room [ROOM NUMBER]- left window was missing blinds e) room [ROOM NUMBER]- closet door closest to the door was missing paint f) Dining room- blinds for the far right window noted to be off and rolled up leaning against the wall next to the window g) Third floor maintenance log was reviewed from January 2023- present. There was no documented evidence the observed concerns were reported or written down. 3) On 6/26/2023 at 10:50 AM, 06/27/23 at 09:55 AM and 7/3/2023 at 11:35 AM, the following was observed on unit 4th a) room [ROOM NUMBER] bathroom floor with 34 small missing tiles at the bathroom entry way. b) room [ROOM NUMBER] Window sea with rusty brown color c) room [ROOM NUMBER] bathroom floor with 7 small missing tiles at doorway. d) room [ROOM NUMBER] 1 tile missing at the bathroom base. e) room [ROOM NUMBER] bathroom floor with rusty brown color f) room [ROOM NUMBER] bathroom floor with rusty brown color g) room [ROOM NUMBER] bathroom floor corner with missing tiles and window seal with rusty brown color. h) room [ROOM NUMBER] bathroom wall with missing tiles i) room [ROOM NUMBER] bathroom ceiling with broken/missing piece j) room [ROOM NUMBER] bathroom ceiling with a dried leak k) room [ROOM NUMBER] bathroom floor with 8 missing small tiles. Aging cracked caulk around back of the sink. The bathroom sink is not steady. l) room [ROOM NUMBER] Exposing opened area at base of bathroom wall with 7 missing tiles. Resident's bathroom where the residents take shower is located across the residents dining room. In that room, on the tub top right upper corner, tiles crakes and broken. 2 missing tiles on the wall next to the toilet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey from 6/26/23 to 7/3/23, the facility did not ensure that the comprehensive care plans (CCP) were reviewed and revised after each assessment. This was evident for 3 (Resident #126, #80, and #128) of 36 total sampled residents. Specifically, The 1) CCP related to dementia care and unnecessary medication were not reviewed and revised for Resident #126, 2) multiple CCPs for Resident #80 were not reviewed and revised upon assessment, and 3) the CCP related to psychotropic medications was not reviewed and revised for Resident #128. The findings are: A facility policy titled Comprehensive Care Plan, reviewed 1/2023, documents It is the policy of Premier Nursing and Rehabilitation Center of Far Rockaway that residents will have a CCP competed in accordance with the federal and state requirements. The CCP will be reviewed and revised periodically by the interdisciplinary team to reflect changes in the resident and the care that the resident is receiving. The CCP will be kept current by all disciplines on an ongoing basis which will include evaluation of goal and appropriateness of interventions. Involved disciplines will evaluate goals within the expected time frame but no later than quarterly. Specifically, 1) Resident #126's diagnoses include unspecified dementia with behavioral disturbance, Hypertension, Type 2 diabetes mellitus, bipolar disorder, major depressive disorder, aphasia following cerebral vascular event. The annual Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview of Mental Status (BIMS) of 4 out of 15 (severely cognitively impaired); the mood included feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy 7-11 days (score 10 - moderate depression); no behaviors were indicated. The medications included 7 days insulin and antipsychotic; gradual dose reduction (GDR) has been documented by a physician as clinically contraindicated on 3/17/23. The quarterly MDS dated [DATE] indicated a BIMS of 4 out of 15; the mood included feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy 7-11 days (score 10 - moderate depression). no behaviors were indicated. The medications included 7 days insulin and antipsychotic, GDR has been documented by a physician as clinically contraindicated on 12/18/22. The MDS schedule documented assessments as quarterly 9/16/22; quarterly 12/13/22; quarterly 1/13/23 and an annual 3/21/23. The CCP titled Cognitive loss/dementia effective 1/15/2020 and was last reviewed on 4/28/23. Prior to that date, the care plan had not been reviewed and revised from 9/12/22 until 3/28/23. There is no evidence that the care plan was reviewed and revised for the quarterly assessments of 12/13/22 and 1/13/23. The CCP titled Mood State effective 1/22/2020 and was last reviewed 4/28/23. The CCP documents the Resident has a diagnosis of bipolar disorder, with potential for depressive symptoms as indicated by feeling down or depressed, sleep cycle issues, feeling tired or having little energy. The goals include the resident will be allowed to ventilate feelings and will not display increased signs of depression x 90 days. The interventions include to address resident concerns as they arise; encourage participation in programs of choice; monitor for changes in mood/manner, and Zyprexa Zydis 20 mg by oral route once daily in the evening. There is no documented evidence that the CCP was reviewed and revised for the quarterly assessments of 12/13/22 and 1/13/23 and the annual of 3/21/23. There is no documented evidence that the care plan was reviewed and revised to include the medication of Zyprexa 5 mg. by oral route once daily, start date 8/31/21 for bipolar disorder. The CCP titled Behavioral Symptoms (physically/verbally abusive/aggressive/wanders/paces) effective 2/24/2020, last reviewed 6/2/23. Prior to this date, the care plan had not been reviewed and revised from 9/12/22 until 3/6/23. There is no documented evidence that the care plan was reviewed and revised for the quarterly assessments of 12/13/22 and 1/13/23 and the annual of 3/21/23. The CCP titled Behavioral symptoms (placing self on the floor) effective 7/20/2020, last reviewed 4/20/23. Prior to this date, the last review was noted as 9/12/22. There is no documented evidence that the care plan was reviewed and revised for the quarterly assessments of 12/13/22 and 1/13/23 and the annual of 3/21/23. The CCP titled Behavior symptoms (Sexually inappropriate) effective 6/22/2020, last reviewed 4/20/23. Prior to this date, the last review was noted on 9/12/23. There is no documented evidence that the care plan was reviewed and revised for the quarterly assessments of 12/13/22 and 1/13/23 and the annual of 3/21/23. The CCP titled Behavioral Symptoms (suicidal ideation) effective 10/23/2020, last reviewed 5/15/23. Prior to this date, the last reviews were noted on 9/12/22 and 2/13/23. There is no evidence that the care plan was reviewed and revised for the quarterly assessments of 12/13/22 and 1/13/23 and the annual of 3/21/23. 2) Resident #80's diagnoses include, Schizophrenia, anxiety, major depressive disorder, bipolar disorder, Hypertension, and type 2 Diabetes Mellitus. The quarterly MDS dated [DATE], documented a BIMS score of 10 out of 15 (moderately impaired). They received 7-days of insulin, antipsychotic, antidepressant. The annual MDS dated [DATE], documented a BIMS score of 10 out of 15 (moderately impaired). They received 7-days of insulin, antipsychotic, antidepressant, and antianxiety medication. The MDS schedule documented assessments as 5-day 11/3/22 and 12/6/22; quarterly 1/3/23 and 3/31/23; and annual 2/9/23. The CCP titled Cognitive Loss/Dementia, effective 6/07/2022, last reviewed 4/4/23. Prior to this date, the last review date was 12/2/22: There is no documented evidence that the CCP was reviewed and revised for the quarterly of 1/3/23 and annual of 2/9/23. The CCP titled Mood State effective 6/07/2022, last reviewed 5/10/23. Prior to this date, the last review date was 12/2/22. There is no documented evidence that the CCP was reviewed and revised for the quarterly of 1/3/23 and 3/31/23, and the annual of 2/9/23. The CCP titled Advanced Directive effective 6/07/2022, last reviewed 6/28/23. Prior to this date, the previous reviews were 9/2/22, 1/19/23 and 4/26/23. There was no documented evidence that the CCP was updated for the annual of 2/9/23 and was reviewed after the completion date of the MDS assessment period. The CCP titled Non-compliance to Medical/Nursing Regimen effective 1/7/2020, last reviewed 5/12/23. Prior to this date, the last review date was 6/12/22. There is no evidence that the CCP was reviewed and revised for the 5-day assessments of 11/3/22 and 12/6/22; a quarterly of 1/3/23 and 3/31/23, and annual of 2/9/23. 3) Resident #128 diagnoses includes Parkinson's disease, dementia, schizoaffective disorder bipolar type and Hypertension. The annual MDS dated [DATE], documented a BIMS of 15 out of 15 (cognitively intact). Medications included 7-days insulin. The MDS schedule documented assessments for a 5-day on 9/26/22 and 12/23/22; a quarterly for 11/3/22 and 1/27/23; and an annual for 4/29/23. The CCP titled Cognitive Status, effective 5/23/22, last reviewed 4/4/23. Prior to this date, the last review date was 12/19/22. There was no documented evidence that the CCP was reviewed and revised for the following assessments: quarterly 1/27/23; 5-day of 9/26/22 and 12/23/22. The CCP titled Falls, effective 5/20/22, last reviewed 5/31/23. Prior to this date, the last review dates were 11/13/22 and 3/7/23. There was no documented evidence that the CCP was reviewed and revised for the following assessments: 5-day of 9/26/22 and the quarterly of 1/27/23. The CCP titled Mood State/depression, effective 5/23/22, last reviewed 5/10/23. Prior to this date, the last review date was 12/19/22. There was no documented evidence that the CCP was reviewed and revised for the following assessments: 5-day of 9/26/22, the quarterly of 11/2/23 and 1/27/23 and the annual 4/29/23. The CCP titled Advanced Directives, effective 5/20/22, last reviewed 5/24/23. Prior to this date, the last review date was 1/18/23. There was no documented evidence that the CCP was reviewed and revised for the following assessments: quarterly of 11/3/22 and 1/27/23; the 5-day of 9/26/22 and 12/23/22, and the annual of 4/29/23. The CCP titled Activities, effective 6/1/22, last reviewed 6/30/23. Prior to this date, the last review date was 9/1/22. The CCP was updated after interview with the State Agency (SA) by the Director of Recreation. There was no documented evidence that the CCP was reviewed and revised for the following assessments: 5-day 9/26/22 and 12/23/22; quarterly of 11/3/22 and 1/27/23 and annual 4/29/23. The CCP titled Room Change, effective date 11/8/22, had no goals, interventions, or notes. There was no documented evidence that the CCP was reviewed and revised for the following assessments: 5-day 12/23/22, quarterly 1/27/23 and annual 4/29/23. An interview was conducted on 6/28/23 at 2:37 PM with the Social Worker (SW), who stated that I perform the behavior, mood, cognitive status, advance directives, and psychosocial well-being/name preference care plans. I review and revise the care plans quarterly, significant change, annually, based on the MDS schedule. The SW further stated, there is no excuse that the care plans were not updated, It was a mistake on their end. An interview was conducted on 6/29/23 at 2:40 PM with the Registered Nurse ((RN) MDS Coordinator who stated, that a base line care plan is initiated, and then the regular care plans are created. The care plans are reviewed and revised every 3 months unless something acute happens, such as a fall, change in condition, then done sooner. They are updated every 3 months in conjunction with the MDS schedule. The MDS Coordinator stated they do the MDS and care plans for nursing; each department does their specific care plan. They further stated that on the electronic medical record (EMR) dashboard, it indicates which care plans need to be done; I remind the other departments about updating their care plans. An interview was conducted on 6/29/23 at 2:57 PM with the Director of Social Work (DSW) who stated that care plans are done by the social work team. They update quarterly, annually, and as needed, based on the MDS schedule. They will put a note in under the monitoring/evaluation date. The DSW stated there is no system in place to audit and they were not aware of the large gap in the care plan updating. The DSW stated they will move forward and address with social work staff. An interview was conducted on 6/29/23 at 3:12PM with the Director of Recreation (DTR), who stated that they do all of the care plans for activities for the entire building. They review and revise when they are due. The DTR stated they are due based on the review date on the care plan, every 3-months - 90 days - based on the goal date. They stated that even though they do not do quarterly MDSs, they follow the schedule for review and revision. For auditing, they stated they just check as they go, with every MDS schedule they are reviewing care plan. The DTR was shown the CCP for Resident # 126 for Activities which had not been reviewed and revised since 7/2022. The DTR stated that moving forward, they are going to train staff to complete the care plans. An interview was conducted on 6/29/23 at 3:25 PM with the Director of Nursing (DON) who stated that on admission, they do a baseline care plan; then they do care plans, quarterly, annually, and significant change for review and revision. There is an evaluation note on the care plan. The SA and DON did a review of the EMR dashboard which shows the goal date is overdue but does not reflect the fact that the care plan was not reviewed/revised in the evaluation/monitoring section. 415.11 (c)(2) (i-iii)

Based on observation, interview, and record review conducted during the recertification survey from 6/26/23 - 7/3/23, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service safety. This was observed during the Kitchen review. Specifically, cold sandwiches were observed being held at an unsafe temperature above 41 F. The findings are: A facility policy titled Food Temperatures dated 3/2023 documented it is the practice to ensure that all residents' meals are served at the appropriate temperatures. The Food Service Director/Supervisor will record temperatures of all food on the tray line. The Food Service Director/Supervisor/Designee will record the temperature of all items. The Food Service Director/ Supervisor will follow up with preparation procedures to assure compliance with meal service temperatures thereafter. On 6/30/23 at 11:21 AM, the lunch tray line service was observed. The Food Service Supervisor was observed bringing a pan of cheese sandwiches (on a pan of ice) to the tray line. The temperature of a cheese sandwich was taken and was 50 F. The Food Service Director was present and was immediately interviewed. The Food Service Director (FSD) was interviewed on 6/30/23 at 11:31 AM and stated they take the temperature of the sandwich product (such as tuna or egg salad) during production, but not on the tray line. 415.14

Based on observation, record review and staff interviews conducted during the recertification survey, the facility did not ensure that residents and/or families were informed and provided with written information concerning the right to formulate an advance directive. Specifically, advance directives were not explained to or discussed with a cognitively intact resident. This was evident for 1 of 1 resident reviewed for Advance Directives (Resident #301). The finding is: The facility policy on Advance Directives, updated 02/2018, documented the Social Worker will review Advance Directives upon admission. The initial advance directives review form will be used to document that the conversation and review of Advance Directives has taken place. Resident #301 was admitted to the facility (initial admission) 03/17/2021 with diagnoses that included Anemia, Gastroesophageal Reflux Disease, and Septicemia. The admission Minimum Data Set (MDS), Assessment Reference Date (ARD) 03/24/2021 documented the resident had intact cognition. The assessment further documented the resident was able to make needs known and required extensive assistance of 1 for Activities of Daily Living. On 04/28/21 at 02:38 PM, the resident was interviewed and stated that nobody discussed Advance Directives with them upon admission and up to present. The Comprehensive Care Plan (CCP) for Advance Directives dated 3/17/2021 documented Incomplete for goals and interventions. No specific goal and interventions were documented on the care plan. The Physician's order dated 04/12/2021 contained no documentation regarding Advance Directives. admission notes by Nursing and Medical dated 3/17/2021 were reviewed and contained no documentation that advance directives were discussed with the resident. Progress Note Social Services - Initial meeting dated 3/18/2021 documented Resident's current plan of care discussed. Medications, Physical functioning, diet and weight, mood, behavior, and participation in facility activities, and interactions with staff and peers discussed. Current plan of care is effective in addressing any concerns, and interventions are ongoing to maintain current level of functioning. There was no documented evidence in the medical record that Advance Directives were discussed with the resident by nursing, Social Services, or the medical staff. On 04/28/21 at 03:04 PM, an interview was conducted with the Registered Nurse RN #3. The RN stated that when an alert and oriented resident is admitted , advance directive is discussed and documented in the care plan. RN stated that Social Worker also discuss and document advance directive with alert and oriented resident during admission assessment, and family member is contacted if the resident is not able to make decision. RN further stated that advance directive is discussed during the quarterly assessment of all residents and updated in the care plan. RN was not sure why advance directive was not discussed with resident #301, and why it was not documented in the resident's chart. On 04/28/21 at 03:16 PM, an interview was conducted with the Social Worker (SW). SW stated that when a resident is admitted , advance directive is discussed, initiated, and documented in the admission note and care plan. SW is unable to produce documented evidence that Advance Directive was discussed with resident #301 on admission when the resident's progress notes, and care plan records were reviewed. SW stated that advance directive is always discussed with every resident upon admission, and that documentation for resident #301 must have been an oversight. Staff interviewed were not sure why resident #301's record did not contain documented evidence that Advance directives were discussed with the resident on admission. 415.3(e)(1)(ii)