**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #13 was admitted to the facility with diagnoses that included Non-Alzheimer's Dementia, Multiple Sclerosis, and Bipolar Disorder. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #13 had moderately impaired cognition. Section Q of the Minimum Data Set Assessment documented that Resident #13 participated in assessment and goal setting. On 12/02/2024 at 10:50 AM, Resident #13 was interviewed, and they stated they do not participate in their care plan meetings. The Annual Care Plan meeting note dated 05/16/2024 documented Resident #13's family was contacted and continues to be highly involved in Resident #13's plan of care. The Quarterly Comprehensive Care Plan meeting note dated 10/29/2024 documented family were contacted and participated in the meeting with the interdisciplinary team via telephone conference. Resident #13's care, current conditions, well-being, and possible discharge plans in the future were discussed. Social Worker will continue to provide support to resident and responsible party as needed. There was no documented evidence that Resident #13 was invited to or participated in the care plan meeting. During an interview on 12/06/2024 at 10:41 AM, the Director of Social Work stated that alert residents, Certified Nursing Assistants, next of kin, Social Worker, Nursing Supervisor, Dietary, and Minimum Data Set Coordinator are in attendance for the care plan meetings. The Director of Social Work also stated that Resident #13 was asked if they wanted to participate and refused and requested that their family be called. The Director of Social Work further stated that they did not document that Resident #13 refused to participate in the care plan meeting and they should have. During an interview on 12/06/2024 at 3:47 PM, the Assistant Director of Nursing stated Nursing, Dietary, Activity, Rehabilitation, Minimum Data Set Coordinator, and the Resident are present during the care plan meetings. The Assistant Director of Nursing also stated that the Social Worker is responsible for inviting the resident to the care plan meeting. 10 NYCRR 415.3(f)(1)(v) Based on record review, and interviews conducted during the Recertification survey from 12/2/2024 to 12/9/2024, the facility did not ensure the resident's right to participate in the development and implementation of their person-centered plan of care. This was evident for 2 (Resident #111 and Resident #13) of 3 residents reviewed for Care Planning out of 37 total sampled residents. Specifically, Resident #111 and Resident #13 were not invited to attend their scheduled Comprehensive Care Plan and quarterly meetings. The findings are: The facility policy titled Comprehensive Care Planning revised 09/24 documented each capable resident will receive a written and/or verbal invitation to attend the initial, quarterly, annual, and significant change care plan meetings. The policy also stated that their response to written/verbal invitations will be documented on the Comprehensive Care Plan meeting schedule sheet. 1. Resident #111 was admitted to the facility with diagnoses that include Liver disease, Hyperlipidemia, and Seizure Disorder. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented that Resident #111 was cognitively intact. On 12/9/2024 at 09:30 AM, Resident #111 was interviewed and stated that they have not been invited to a care plan meeting since being admitted into the facility one year ago. Resident #111 also stated that they did not recall anyone ever coming to discuss their care with them. The Care Plan Meeting Sign In sheets dated 3/12/2024 6/4/2024, 8/7/2024 and 11/12/2024 were signed by members of the interdisciplinary team and did include a signature for Resident #111. Progress Notes dated 03/12/2024, 06/04/2024, 08/07/2024 and 11/12/2024 documented that Resident #111's child attended the meeting via teleconference. There was no documented evidence Resident #111 was invited to or attended their scheduled care plan meetings. On 12/09/24 at 09:41 AM, an interview was conducted with the Director of Social Worker who stated Resident #111 does and has participated in their care plan meetings along with their adult child. The Director of Social Worker also stated that there is no documentation that Resident #111 was present or was invited to the care plan meetings. The Director of Social Worker further stated that residents are notified of the care plan meetings verbally and there is a sign in sheet that all attendees must sign. The Director of Social Worker stated they were told by the Department of Health that residents do not have to be invited to the quarterly meetings only the annual, significant change, and by request. On 12/09/24 at 12:30 PM, an interview was conducted with Social Worker #1 who stated that they schedule the care plan meetings, and they verbally invite cognitively intact residents to attend meetings the day before and the day of the meeting. Social Worker #1 also stated that the families are called and invited to attend the care plan meeting for residents that are not cognitively intact. For residents who cannot come down to the conference room or if the resident refuses to come out of their rooms to attend the care plan meeting, the interdisciplinary team will go to the resident's room to conduct the care plan meeting. Social Worker #1 further stated that there should be documentation in the progress notes if the resident and/or family members attended or refused to attend the meeting and there is a sign in sheet that the residents sign to document that they attended the care plan meetings. Social Worker #1 stated that they do not know if it is always documented in the system when residents attend the meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews conducted during a Recertification survey from 12/02/2024 to 12/09/2024 the facility did not ensure that each section of the Minimum Data Set assessment accurately reflected the residents' status. This was evident for 1 (Resident #37 of 5 residents reviewed for Unnecessary Medication and 1 (Resident #130) of 3 residents reviewed for Behavioral-Emotional out of 37 sampled residents. Specifically, the most recent Minimum Data Set Assessment did not accurately document that Resident #37 and Resident #130 displayed wandering behavior. The findings are: The facility policy and procedure titled Minimum Data Set Comprehensive Assessments revised 09/2024 documented that comprehensive assessments will be conducted to assist in developing person-centered care plans. The policy also documented that comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information and then monitoring results and adjusting interventions. When assessing the individual, relevant information from multiple sources are gathered. The policy did not address accuracy of the assessment. 1. Resident #37 was admitted to the facility with diagnosis of Non-Alzheimer's Dementia, Anxiety Disorder, and Mood disorder. The Quarterly Minimum Data Set assessments dated 09/04/2024 and 11/27/2024 documented that Resident #37 had severe cognitive impairment. Section E of the assessments documented that Resident #37 did not exhibit wandering behavior. A Comprehensive Care Plan titled Wandering/Elopement dated 01/13/2021 documented as a goal that resident will not wander outside of the facility for 90 days. Interventions included to engage in group activity and place a wander guard. The Evaluation note dated 11/28/2024 documented Resident #37 continues on hourly visual check for safety. Resident #37 observed walking on and off unit carrying their personal items at all times without seeking exits and remains calm in a supervised area. The Elopement and Unsafe Wandering Screen dated 10/10/2024 documented Resident #37 verbalized a desire to leave the facility without proper permission or authorization. Resident #37 was determined to be at risk for elopement and wandering. On 12/03/2024 at 09:54 AM, Resident #37 was observed at the reception desk, at the entrance of the facility. The Quarterly Minimum Data Set Assessment did not accurately document Resident #37's wandering behavior. During an interview on 12/09/2024 at 9:27 AM, Certified Nursing Assistant #7 stated Resident #37 goes to the lobby and tried to leave the facility. Certified Nursing Assistant #7 stated security called them to redirect Resident #37 when they stand by the door. They stated that behavior does not happen daily. 2. Resident #130 was admitted to the facility with diagnosis of Non-Alzheimer' s Dementia, Malnutrition, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #130 had severe cognitive impairment. Section E documented that Resident #130 did not exhibit wandering behavior. A Comprehensive Care Plan titled Wandering/Elopement dated 04/06/2023 documented as a goal that resident will be redirected to a safer area and wandering episode will decrease for 90 days. Interventions included to engage resident in group activities of their choice and monitor resident' location at regular intervals. The Evaluation note dated 11/10/2024 documented that Resident #130 had made no attempt to leave the facility. Resident #130 required constant redirection. Resident #130 continues on hourly visual check monitoring for safety. A Comprehensive Care Plan titled Therapeutic Recreation dated 11/10/2022 documents as a goal that resident will demonstrate fewer episodes of disruptive behaviors. Interventions included to provide one to one visits to prevent social isolation and respect resident's rights to refuse invites. The Evaluation note dated 06/12/2024 documented Resident #130 is due for quarterly update and within that time frame their care plan have remain the same since the last note. Resident #130 continues to refuse invitation to therapeutic recreation and continues to wander around and off the unit. Resident #130 was very confused and comes off the unit looking for their family and sometimes bangs the walls. The Evaluation note dated 09/04/2024 documented Resident #130 has a quarterly assessment, during this update Resident #130's care plan has remained the same since the last note. Resident #130 continues to wander around and off the unit and that Resident #130 is very confused. Resident #130 comes off the unit and looks for their family and bangs on the walls. Activity Leader provides Resident #130 with tactile and visual sensory stimulations at least twice a week. The Evaluation note dated 11/27/2024 documented Resident #130 is due for annual update within that frame, Resident #130's care plan remained the same. Resident #130 continues to refuse therapeutic reaction, continues to look for their family and roams the halls. Resident #130 is redirected by staff because Resident #130 is looking for an exit to leave. The Elopement and Unsafe Wandering Screen dated 09/07/2024 documented Resident #130 is at risk for wandering and elopement. On 12/02/2024 at 10:50 AM, Resident #130 was observed exiting the dining room, entering the bathroom stall, exiting, and returning to the dining room. On 12/04/2024 at 11:11 AM, Resident #130 exited the unit and staff was observed redirecting Resident #130 back to the unit. On 12/06/2024 at 12:42 PM, Resident #130 walked out of the dining room, went into the bathroom, exited the bathroom from the other entrance and returned to the dining room. On 12/09/2024 at 11:31 AM, Resident #130 exited the unit and staff was observed escorting Resident #130 back to the unit. During an interview on 12/02/2024 at 10:52 AM, Activity Leader #1 stated they were informed by the supervisor that Resident #130 will wander into other resident's room. Activity Leader #1 also stated that Resident #130 exits the dining room and staff would have to redirect them back into the dining room. During an interview on 12/06/2024 at 12:35 PM, Certified Nursing Assistant #5 stated that Resident #130 wanders on and off the units and goes into other resident's room. Certified Nursing Assistant #5 also stated that Resident #130 does not like to sit, and they redirect Resident #130 by providing coloring activity to distract them from wandering. During an interview on 12/06/2024 at 12:38 PM, Licensed Practical Nurse #3 stated Resident #130 wanders on the unit. Licensed Practical Nurse #3 also stated they try to engage Resident #130 in activity. During an interview on 12/06/2024 at 4:03 PM, the Minimum Data Set Coordinator stated they are responsible for completing all sections of the Minimum Data Set Assessment. The Minimum Data Set Coordinator also stated that 7 days prior to the Quarterly review, they conduct interviews with staff and residents, and observe the residents' behavior. The Minimum Data Set Coordinator further stated that during that time if the residents do not present any wandering behavior they will not document in section E of the Minimum Data Set Assessment. The Minimum Data Set Coordinator stated Resident #37 did not have any recent wandering or elopement behavior, so they did not document it in the Minimum Data Set Assessment. The Minimum Data Set Coordinator stated Resident #37 ambulates at liberty on and off the unit and does not wander. During an interview on 12/09/2024 at 9:39 AM, Licensed Practical Nurse #2 stated Resident #130 wanders daily to the North Unit and was observed knocking on other residents' door looking for their family. During an interview on 12/09/2024 at 1:33 PM, Certified Nursing Assistant #6 stated Resident #130 walks around and sometimes tries to go into the kitchen. 10 NYCRR 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during the Recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure that a Comprehensive Care Plan was developed and implemented to meet a resident's needs. This was evident for 1 (Resident # 111) of 2 residents reviewed for Skin Conditions out of 37 sampled residents. Specifically, a care plan was not developed for Resident #111 who complained of itchy skin and had ongoing skin issues. The findings are: The facility's policy and procedure titled Comprehensive Care Planning with a revised date of 09/24, did not specifically referenced how Comprehensive Care Plans would be created. The policy states that a Comprehensive Care Committee would be created which consists of each healthcare discipline involved in providing health care services. The policy also states that an objective of the Comprehensive Care Committee is discussion and assessment of all acute, subacute, or chronic management problems that interfere with the ability of any one discipline to manage resident care effectively. Resident #111 was admitted to the facility with diagnoses that included Chronic Liver Disease, Rash, and Skin Interruption. The admission Minimum Data Set assessment dated [DATE] documented Resident that #111 was cognitively intact. On 12/09/24 at 09:20 AM, Resident #111 was interviewed and stated they had skin problems that started when they came into the facility one year ago. Resident #111 also stated that the facility was supposed to provide cream, but they did not. The Dermatology consult dated 1/3/2024 documented Resident #111 was examined for lesions and rashes to lower legs and arms with little improvement with topicals. The Dermatology consult also documented that Resident #111 skin is described as erythematous papules widespread to bilateral lower extremities and few scattered on upper arms and diagnosed as having Prurigo Nodularis (a skin condition that causes itchy bumps on your skin). Resident #111's medical record revealed there was no comprehensive care plan related to skin condition was developed and implemented for Resident #111 since their admission to the facility. On 12/09/24 at 11:08 AM during an interview with Medical Doctor stated that Resident #111 has a history of chronic Hepatitis associated with elevated liver enzymes and the itchiness is possible related to that. The Medical Doctor also stated that they discontinued the statin medications, that can play a role in liver functions and did not renew the Cortisone creams because it causes the skin to thin out and the resident does not complain of being itchy every day. The Medical Doctor further stated that Resident #111 has flare ups from time to time and when there is a flair up, they will reorder the Cortisone cream, but currently, they do not believe that Resident #111 requires the Cortisone cream. On 12/9/2024 at 12:35 PM, the Director of Nursing was interviewed and stated that the Minimum Data Set Coordinator and nurse supervisors are responsible for initiating and revising the care plans quarterly. 10 NYCRR 415.11(c)(1)

Based on record review, and interviews during a Recertification survey and Abbreviated survey (NY00325169, NY00359202) from 12/02/2024 to 12/09/2024, the facility did not ensure that care plans were reviewed and revised by the interdisciplinary team after each assessment. This was evident in 1 (Resident #17) out of 1 resident reviewed for Dental out of 37 sampled residents. Specifically, the care plan related to Oral/Dental Care was not revised quarterly. The findings include: The facility's policy and procedure titled Comprehensive Care Planning with a revised date of 09/24, documented review as necessary and at intervals not to exceed 92 resident days after the last assessment reference date, response to current plan of care and the establishment treatment of new goals and treatment plans, as necessary. Quarterly team reviews must be completed within the 92 days of Minimum Data Set 3.0 Quarterly time frame. Resident #17 (NY00325169, NY00359202) was admitted to the facility with diagnoses that included Anxiety Disorder, Dysphagia, and Type 2 Diabetes Mellitus. The Quarterly Minimum Data Set (a resident assessment tool) dated 10/02/2024 documented Resident #17 had a Brief Interview of Mental Status score of 12, indicating moderately impaired cognition. A Comprehensive Care Plan for Dental dated 08/11/2023, documented interventions to provide adequate oral hygiene daily, dental consult annually/as needed, and inspect mouth for any abscesses, sores, and/or signs of infection to physician as necessary. The Care Plan for Oral/Dental Care was created on 08/11/2023 and the last evaluation note was dated 04/18/2024. There was no documented evidence that the Oral/Dental Care plan had been reviewed and revised after the Quarterly assessment on 04/18/2024, 07/10/2024, and 10/02/2024. During an interview on 12/9/2024 at 03:26 PM, the Director of Nursing stated they try their best to review and revise care plans but sometimes it does not get done. The Director of Nursing also stated that it is the responsibility of the Minimum Data Set Coordinator and the Registered Nurse supervisors to develop and update the care plans. Where is the interview with the MDS Coordinator or Nurse Supervisor who was responsible for creating this care plan? They should be interviewed before the Director of Nursing as they oversee all operations and are responsible for supervision of nursing staff and not the actual creation of the care plan. I did not interview the MDS Coordinator. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interview during the Recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure that a resident who used psychotropic drugs received gradual dose reductions unless clinically contraindicated, to discontinue the drug. This was evident for 1 (Resident #153) of 5 residents reviewed for Unnecessary Medications out of 37 sampled residents. Specifically, Resident #153 had a Dementia diagnosis and was receiving antipsychotic medication. There was no evidence that a gradual dose reduction had been attempted and there was no documented evidence that Resident #153 displayed any mood or behavioral symptoms that warranted continued use of the medication. The finding is: Resident #153 was admitted to the facility with diagnoses which include Non-Alzheimer's Dementia, Major Depressive Disorder, and Malnutrition. The Quarterly Minimum Data Set 3.0 Assessments dated 06/26/2024 and 09/19/2024 documented that Resident #153 was severely cognitively impaired with long and short-term memory problems and had no potential indicator for psychosis. The Minimum Data Set further documented that Resident #153 had diagnoses of Dementia and Depression, did not display psychosis behavior, and received antipsychotics on a routine basis. Physician's Order Form as of 12/03/2024 documented that Resident #153 had been prescribed Seroquel 125mg by mouth in the evening and Seroquel 50mg by mouth daily for Unspecified Mood Disorder effective 03/22/2024, and Valproic Acid 250mg twice daily for Unspecified Mood Disorder. On 12/04/24 at 10:50 AM, Resident #153 was observed sitting in activity in the day room, no psychotic behavior noted. On 12/05/24 at 11:16 AM, Resident #153 was observed in the main dining room during music activity, no psychotic behavior was noted. Review of progress notes from March 2024 to 12/09/2024 revealed no documented psychotic behaviors for Resident #153. The Medication Administration Records dated March 2024 to present documented that Resident #153 received Seroquel 125mg in the evening and Seroquel 50mg in the morning as ordered by the Physician. The Psychiatric Consultation dated 4/10/24 and 7/15/2024 documented that the Psychiatrist wants to try a gradual dose reduction on the Seroquel, but son keeps on refusing the gradual dose reduction. On 12/5/24 at 11:42 AM, the Psychiatric Nurse Practitioner was interviewed and stated that Resident #153 was admitted to the facility from the hospital with the Seroquel order. The Psychiatric Nurse Practitioner also stated that they wanted to attempt a gradual dose reduction on several occasion however the Resident #153's son did not agree to it, so it was never attempted. The Psychiatric Nurse Practitioner further stated that the only behavior that Resident #153 has was repeatedly saying oh my God. On 12/9/24 at 1:49 PM, the Director of Nursing was interviewed and stated that the child of Resident #153 kept on refusing the gradual dose reduction and so they could not it. 10 NYCRR 415.12(l)(2)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On unit 1 East the following was observed: a The hallway wall between rooms [ROOM NUMBERS] had patches of unpainted areas. b. Ceiling above the double door had patches of unpainted areas. c In room [ROOM NUMBER], and in the sitting area across from room [ROOM NUMBER] and 17 the windows were visibly dirty with whitish smudges on the window panes. d. In room [ROOM NUMBER] the plaster surrounding the light fixture on the ceiling and the wall across from the bed was cracked. e. In room [ROOM NUMBER] hooks on the privacy curtain were missing, walls were damaged, and the windowsill was cracked. During an interview on 12/09/2024 at 12:03 PM, Maintenance Worker #1 stated when repairing a damaged area, the area is supposed to be compounded then painted. Maintenance Worker #1 also stated that if the repair is light then the compound takes a day to dry and then is painted the following day. If the damage is large it would be three days before the area is painted. Maintenance #1 further stated that they are responsible for ensuring the hooks for the privacy curtains are in place. During an interview on 12/09/2024 at 12:19 PM, Housekeeper #2 stated they are responsible for cleaning every room on the unit, including the nurse's station. Housekeeper #2 also stated that they wipe the windows daily. Housekeeper #2 further stated they did not clean the windows in room [ROOM NUMBER] because the residents were in there. During an interview on 12/09/2024 at 12:22 PM, Maintenance Worker #2 stated they are responsible for fixing the holes, cracks and/or any damages to the ceilings on the units. Maintenance Worker #2 stated after patching the damage they have to wait for the plaster to dry and then paint it later. Maintenance #2 stated there was a water leak in room [ROOM NUMBER] and they repaired the wall and cemented it but have not returned to paint the wall because other priority assignments were called in and had to be done. 3. On the 2nd Floor the following was observed: a. In room [ROOM NUMBER] there were multiple areas of mismatched paint on the walls in the room. b. Above the window in room [ROOM NUMBER] there were mismatched patches of white paint over yellow paint and the entrance door had peeling brown paint. c. In room [ROOM NUMBER] there were unpainted white patches above bed A, and three large unpainted areas around the head of Bed B. There were large unpainted areas on the wall at the foot of bed, and the window treatments were tattered with pieces of fabric hanging. d. In room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] the window treatments were tattered with pieces of fabric hanging, and the white window blinds was discolored with brownish stains. e. The air conditioner unit located in the hallway just outside the Patio door was loose, and the base board under air conditioner unit was loose and split at the sides. On 12/09/24 at 12:20 PM, an interview was completed with a Housekeeper #1 who stated that they did observe the mismatched paint and blinds that are in disrepair and the maintenance department was aware and stated they will change all the blinds soon. Housekeeper #1 also stated that they attempted to clean the blinds several times, but they cannot be cleaned, and they were told they will change all the blinds soon, but they are not sure when this would be done. Housekeeper #1 further stated maintenance is working on fixing all the mismatched paint in the rooms and some rooms had already been taken care of. Housekeeper #1 stated they always report to the Maintenance Director if they see something that needs to be fixed. Based on observations and staff interviews during the Recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure that the residents' environment was maintained in a safe, sanitary, and comfortable manner. Specifically multiple observations were made of resident room walls with mismatched paint patches, discolored blinds, worn window treatments, torn wall paper, damage furniture and dirty, dusty areas. This was observed during the Environment task and was evident on 4 (1 North, 1 East, 2nd floor and 1 West) of 5 units. The findings include but are not limited to: The facility policy and procedure revised 09/01/24 titled Safe, Clean, Comfortable and Homelike Environment documented that it is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect residents rights to the extent possible. The policy also documented that this includes providing housekeeping and maintenance services necessary to maintain a sanitary environment. 1. On unit 1 North the following was observed: a. The baseboard and door corners in male and female shower room/bathroom were in disrepair. b. In room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] there were large unpainted areas near the radiator. 4. On unit 1 [NAME] the following was observed: a. In Room W 49 b, an unmade bed was heavily stained and there was a worn blue colored mattress cover, the wooden bed frame was heavily worn and stained, and a wooden closet was missing a door handle and the bottom drawer was broken and placed on the floor. In addition, the top area of the room air conditioner located below the window was dusty and dirty. b. In Room W 65 the wall by the radiator had white unpainted plaster, broken window blinds, and the window sill was dusty and dirty with crumbed broken plaster. In addition, the bathroom wall tiles were dirty and stained. c. In Room W 47 b, the air conditioner was missing the front panel which was observed on the floor, and broken plaster was observed on the room walls. d. Torn wall paper on the walls in the corridor across from room W 50. e. In Room W 52 dried food and splatters were on the room walls. Review of the Maintenance Log Books for November and December revealed no written concerns as identified by the State Surveyors. On 12/09/24 at 08:20 AM, an interview was conducted with Housekeeper #3 who stated that they are responsible for cleaning the 1st floor [NAME] Wing and part of the 1st floor North Wing. Housekeeper #3 also stated that they perform daily routine cleaning of rooms and bathrooms and that there is a Maintenance log Book located on each unit for anyone to report issues that the Maintenance Department needs to address. Housekeeper #3 further stated that they can verbally inform the Maintenance Director of any issues and had not reported any issues recently. Housekeeper #3 stated that they do the best they can to keep the facility clean. On 12/09/24 at 12:04 PM, the Director of Housekeeping and Maintenance was interviewed and stated that their role is to maintain and ensure the environmental safety and cleanliness of the facility for residents, visitors, and staff. The Director of Housekeeping and Maintenance also stated that they make daily morning rounds on every unit to ensure that life safety concerns are identified and addressed, and they also see if staff are maintaining a clean environment. The Director of Housekeeping and Maintenance further stated that they have a lot of challenges and try to meet the demands, and recently hired a painter whose role is to paint and fix the walls and they have completed all the hallways on the 1st floor. On 12/09/24 at 01:23 PM, the Administrator was interviewed and stated that their Environmental policy means that the residents have a right to an environment that is clean, that their furniture is in good condition and that a homelike appearance is maintained, for not only the residents, but for staff and visitors as well. The Administrator also stated that they hired a painter approximately 3 months ago to address the concerns of torn wall paper, broken plaster and chipped paint. All units hallways and common areas were plastered and painted and completed a month ago. The painter has begun to plaster and paint the 3rd floor resident rooms. All rooms on the 3rd floor were completed for plaster and painting approximately 2 weeks ago. The 2nd floor resident rooms began approximately 2 weeks ago to plaster and paint and is ongoing. The Administrator also stated that they make daily environmental rounds together with my Assistant Administrator and when they come across identified environmental concerns they notify the Maintenance Director to ensure corrective action is immediately taken. When issues with the cleanliness of the environment are identified, this is addressed at the moment. The Administrator also stated that currently they no proposal or receipts for purchased furniture to provide to the surveyors. 10NYCRR 415.5(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility policy titled Accident/Incident Reporting dated revised 9/2024 documented it is the responsibility of all staff to report all incidents that occur at the facility. Results are reported to the Department of Health, if appropriate, by the Administrator/designee. Resident #71 was admitted to the facility with diagnoses that included Coronary Artery Disease, Hemiplegia, and Cerebral Vascular Accident. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented that Resident #71 was moderately cognitively impaired and required partial to moderate assistance with Activities of Daily Living. The Physician order dated 09/19/2024 documented transfer Resident #71 to Flushing Hospital for further evaluation of the right hand. The Nursing progress note dated 09/18/2024 at 07:36 PM documented called at 4:45 PM for resident who was observed on the floor in the hallway near room [ROOM NUMBER]. Staff responded after they heard a cry for help. Resident #71 was observed lying on their left side and pointed out that they were repositioning chairs in the hallway. Resident #71 sustained no visible injuries and was able to move all extremities within normal range. Assessed to have no swelling, break in skin integrity or discoloration. Physician was notified with recommendations to continue to monitor. The Nursing progress note dated 09/18/2024 at 10:15 PM documented Resident #71 had fall from their wheelchair to the floor and found in a sitting position. Resident #17 was alert, conscious, and responsive. Assessed to have no bruises or visible injuries. Mild edema noted to the left thumb. Cold Compress applied for the relief of pain and swelling. Vital signs taken. Nursing supervisor was made aware of the incident. A review of an x-ray report from Precision Health Inc. dated 09/19/2024 documented the findings of the right hand demonstrate an acute angulated fracture of the distal fifth metacarpal. There is no dislocation or involvement of the articular surface. No other fracture or dislocation is seen. There is minimal arthritic change of the interphalangeal joints, mild at the wrist. Osteoporosis is appreciated. The facility Investigation of Incident/Accident Form dated 09/18/2024 at 4:45 PM documented Resident #71 has diagnosis of Ataxic Gait, Bipolar, Stroke, Difficulty Walking, and Seizures. Able to make simple needs known. On 09/18/2024 around 4:45 PM, Resident #71 was observed on the floor next to room [ROOM NUMBER], calling out for help. No visible injury noted. On 09/19/2024, Resident #71 complained of pain to their right hand with swelling observed. X-ray was ordered and documented Resident #71 to have a right-hand oblique fracture to the distal fifth metacarpal. Resident #71 was ordered to be transferred out to the hospital for further evaluation of the right hand. Resident #71 returned to the facility on [DATE] with soft cast on the right hand. Pain management in place. Fracture was a result of a fall on 09/18/2024. There was no documented evidence that the injury of unknown origin for Resident #71 was reported to the Department of Health. During an interview on 12/09/24 at 09:45 AM, the Administrator stated any injury that is found must be reported to the Department of Health. The Administrator stated that if it is a known, immediate injury, it should be reported within 2 hours. If the injury is brought to the attention of the facility by way of x-ray or hospital, then it should be reported within 24 hours of knowing that an injury has occurred. Anything such as a fall, bruising, abuse, neglect, is and should be reported to the Department of Health as per the state guidelines. During an interview on 12/09/24 at 09:12 AM, the Director of Nursing stated that they were on vacation at the time of the alleged incident and only knows that Resident #71 had a fall and sustained a fracture. The Director of Nursing also stated they did not know if the incident was reported to the Department of Health and the Nurse Supervisor that was on duty at that time should be asked about this. During an interview on 12/09/24 at 09:20 AM, the Assistant Director of Nursing stated the incident occurred on 09/18/2024 around 4:45 PM and was unwitnessed. The Assistant Director of Nursing stated Resident #71 was trying to move a wheelchair and they slid out of their wheelchair on to the floor in a sitting position. As a result, Resident #71 sustained a fracture to their right hand. The Assistant Director of Nursing further stated that the incident was not reported to the Department of Health because Resident #71 health condition has not changed, it did not hinder care and therefore there was no need to report it to the Department of Health. 10 NYCRR 415.4 (b)(2) 2. Resident #103 was last admitted Non-Alzheimer's Dementia, Hypertension, and Osteoporosis. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #103 was moderately cognitively impaired, required dependent care for all Activities of Daily Living, is non-ambulatory, and had impairment on one side of the upper extremities and both sides of the lower extremities. The Physician order dated 6/18/2024 documented transfer to Flushing Hospital for further management. The Nursing progress note dated 6/16/2024 at 9:39 PM documented that resident was alert and responsive was called by Certified Nursing Assistant who was doing care and noted bluish discoloration to the left elbow swollen which was tender to touch. Registered Nurse supervisor was called and notified safety-maintained ice pack applied left in no apparent distress. The Nursing progress noted dated 6/17/2024 at 5:24 AM documented resident remains alert and responsive. Discoloration and swelling persist to left elbow. Site tender to touch, unable to extend upper extremity, x ray ordered by Registered Nurse. Due nursing care rendered; anticipated needs met without incident. As needed Tylenol given with good effect. Resident is currently resting comfortable. Plan of care continues. The Nursing progress note dated 6/18/2024 at 11:40 AM documented writer called by Certified Nursing Assistant to see the resident who is holding the left elbow by chest, upon arrival resident observed in Geri Chair, left elbow blue and yellow discoloration, resident guarding the arm, unable to extend the arm as resident crying. Tylenol given as ordered. Doctor [NAME] made aware. New order x ray STAT left elbow ordered. Will continue to monitor for any further signs and symptoms of pain. The Nursing progress notes dated 6/18/2024 at 2:52 pm documented x ray done; result received Acute fracture at the base of olecranon with intra articular extension into the anterior sigmoid cavity cortex. Joint diffusion with elevation of the anterior distal humeral fat pad. Osteoporosis. Diffuse soft tissue swelling. Doctor made aware. Xray results dated 6/18/2024 from Precision Health Incorporated Med Fax documented Findings Acute Fracture at the base of the Olecranon with Intra-articular extension into the anterior sigmoid cavity cortex. Joint effusion with elevation of the anterior distal humeral fat pad. Osteoporosis. Diffuse soft tissue swelling. The facility Investigation of Incident/Accident Form dated 6/18/2024 documented Resident is an [AGE] year-old with diagnosis of Dementia, status post fracture, Pulmonary Embolism, Age related Cataract, and Schizophrenia Disorder. The resident was alert and responsive to all stimuli, not able to make needs known and all needs are met by staff. On 6/16/24 at 9:39 PM Certified Nursing Assistant reported bluish discoloration to left elbow and tender to touch with swelling, Tylenol was given for pain with good effect. On 6/18/2024 at about 11:40 am, resident was holding the elbow with blue, yellow discoloration and x ray was ordered by medical doctor, which was done with result fracture left elbow. Resident was transferred to Hospital for evaluation, returned with negative for fracture. Hospital records show x ray of the right elbow was done instead of the left elbow. Resident was transferred back to the hospital on 6/19/2024 and returned with soft cast on left upper arm with sling. Evaluated by medical doctor completed on 6/20/2024 and Therapy evaluation and follow up with orthopedics. Pain management as needed. Facility concluded no abuse neglect, mistreatment regarding this resident and resident had a nondisplaced fracture of last elbow. No history of Trauma/Fall. History of Osteoporosis. Patient transfer to Hospital emergency room for treatment. The document titled Nursing Home Facility Incident Report stated submitted successfully on 6/18/2024 at 17:33. There was no documented evidence that the injury of unknown origin for Resident #103 was reported to the Department of Health as required when first observed on 6/16/2024. On 12/09/24 at 10:30 AM, an interview was conducted with the Administrator for the facility who stated that multiple things such as injury of unknown origin, or abuse must be reported timely based on injury to the Department of Health. The Administrator also stated for abuse when there is a suspected or confirm case according to the manual and policy of the facility it must be reported within 2 hours, if there is no confirm injury it must be reported within 24 hours. The Administrator stated the difference is if injury is present. The Administrator stated any discoloration or bruising must be brought to the attention the proper person such as the supervisor who will inform the Director of nursing and the Administrator. On 12/06/24 at 10:23 AM, an interview was conducted with the Director of Nursing who stated they were not made aware of any incident with Resident #103 until 6/18/2024, and as soon as they become aware they reported to the Department of Health. The Director of Nursing also stated that the discoloration, and tenderness with swelling to left elbow area was not reported or placed on the 24-hour report, and they did not call the Supervisor or inform the Director of Nursing. The Director of Nursing further stated that the fracture was discovered on 6/18/2024 and the resident was immediately sent to the hospital, and this was also reported the same day 6/18/2024 to the Department of Health. Based on observation, record review, and interviews conducted during a recertification and complaint survey (NY00358667, and NY00345814, from 12/02/2024 to 12/09/2024, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, and mistreatment, are reported immediately, but not later than 2 hours after the allegation is made. This was evident for 2 (Resident # 139 and Resident #103) of 6 residents reviewed for Abuse and 1 (Resident #71) of 6 residents reviewed for Accidents out of 37 sampled residents. Specifically, and allegation of sexual Abuse for Resident #139 and an injury of unknown origin for Resident #103 was not reported in a timely manner and an injury of unknown origin for Resident #71 was not reported to the Department of Health. The findings are: 1.The facility policy and procedure titled Abuse Prevention Program dated revised 9/2024 stated that all individuals (Employees, Managers, Operators, Agents, and Contractors) have personal responsibility to report any suspicion of abuse/neglect. The policy also stated that if suspected abuse/neglect involved serious body injury it must be reported not more than two real time hours after forming suspension. The policy further stated serious body injury defined as extreme pain, substantial risk for death and injury that required medical intervention. Resident #139 ((NY00358667) was admitted with diagnoses that included Acquired Absence of Kidney, Visual Loss, and Cardiac Pacemaker. The admission Minimum Data Set assessment dated [DATE] documented that Resident #139 had intact cognition. The facility Accident and Incident report dated 10/27/24 documented that Resident #139 reported to Registered Nurse #1 that at around 4:30 AM a resident walked into their room and touched them on their penis. The resident called 911 and was transported to the emergency room for evaluation. The resident returned to the facility on [DATE] with no apparent injury at 7:45 PM. The Nursing Home Facility Incident Report revealed that the New York State Department of Health was notified of the alleged sexual abuse on 10/27/24 at 12:27 PM. This was reported greater than 2 hours from the time the allegation was first made. On 12/06/24 at 9:33 AM, Registered Nurse #3 was interviewed and stated that they responded to the residents allegation on 10/27/24 in the early morning about having been inappropriately touched by another resident who wandered into their room. Registered Nurse #3 also stated that they notified the medical doctor. Registered Nurse #3 further stated that they did not believe the allegation that was being made and did not notify the Director of Nursing. Nurse #3 stated that it was several hours later when they did notify the Assistant Director of Nursing when they arrived at the facility. On 12/06/24 at 07:50 AM, the Assistant Director of Nursing was interviewed and stated that while they were on their way to the facility Registered Nurse #3 notified them of the alleged sexual abuse by phone at around 10:30 AM or 11:00 AM. The Assistant Director of Nursing also stated that they immediately reported this allegation once they arrived at the facility and gathered some information. The Assistant Director of Nursing further stated that the reporting time to the Department of Health is 2 hours once an allegation of abuse is made. On 12/06/24 at 9:39 AM, the Director of Nursing was interviewed and stated that the required reporting time for reporting any allegations of abuse to the Department of Health is 2 hours. The Director of Nursing also stated that they were made aware of the incident around 11:30 AM or 12:00 PM by the Assistant Director of Nursing, and the night shift Registered Nurse should have notified it immediately once the allegation was made.

Based on observations, interviews, and record review conducted during the recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure a safe functional environment for residents, staff, and public. This was evident for the Lobby area, hallways, and nursing station. The facility policy and procedure revised 09/01/24 titled Safe, Clean, Comfortable and Home-Like Environment documented, it is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect residents rights to the extent possible. The findings are: During multiple observations in the facility from 12/02/2024 at 9:30 PM and 12/09/2024 at 3:00 PM the following was observed: 1.In the Lobby Area, the bathroom near Main Dining Room area had holes in the wall, rusty call bell panel and broken molding. 2. in 1 [NAME] Nurse Station cable wires were layered with dirt and dust. 3. In the 2nd floor Nurses station 2 black swivel chairs had torn vinyl armrests, and there was a desk with broken and rough-edged Formica paneling. 4. In the 3rd Floor Nurses Station there was peeling and torn wall paper underneath the nurse station desk area, a desk with rough bottom edges and broken Formica panels, the bottom desk drawer did not close properly and was in disrepair, and the staff bathroom had a leaking, loose faucet. 5. In the 1 North Nursing station dusty areas were noted and there were unpainted patches in the ceiling. On 12/09/24 at 01:23 PM, the Administrator was interviewed and stated that their Environmental policy means that the residents have a right to an environment that is clean, that their furniture is in good condition and that a homelike appearance is maintained, for not only the residents, but for staff and visitors as well. The Administrator also stated that when we come across identified environmental concerns we notify the Maintenance Director to ensure corrective action is immediately taken. The Administrator further stated that their plan is to replace the furniture and retain furniture that is in good condition, however they did not have a current proposal or receipts of purchased furniture to show at this time. 10 NYCRR 415.29

Based on record review and interviews conducted during the Recertification Survey from 12/02/2024 to 12/09/2024 , the facility did not ensure 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 well-being of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report. The findings include but are not limited to: The facility policy titled Staffing Guidelines reviewed 9/2024 stated that the facility will promote resident quality care and safety by ensuring adequate and competent staffing levels are based on the Facility Assessment. The facility staffing physiology is designed to support professional Nursing practice in accordance with our mission and vision. The policy further stated that on a regular basis, a minimum of annually and upon changes in the facility population and care needs, the facility will evaluate the overall number of staff needed to ensure sufficient qualified staff are available to meet each resident needs. The Payroll Based Journal Staffing Data Report for the 3rd quarter of 2024 (04/01/2024 - 06/30/2024) documented that excessively low weekend staffing was triggered. The Facility Assessment last updated 8/7/2024 documented facility capacity of 180 residents with a weekend staffing plan by shift distributed as follows: Day shift by units: Unit 3: 1 Registered Nurse, 1 Licensed Practical Nurses and 5 Certified Nursing Assistants Unit 2: 1 Registered Nurse, 1 Licensed Practical Nurses and 6 Certified Nursing Assistants Unit East: 1 Registered Nurse, 1 Licensed Practical Nurses and 3 Certified Nursing Assistants Unit North: 1 Registered Nurse, 1 Licensed Practical Nurses and 2 Certified Nursing Assistants Unit West: 1 Registered Nurse, 1 Licensed Practical Nurses and 4 Certified Nursing Assistants Total = 5 Registered Nurses, 5 Licensed Practical Nurses, and 20 Certified Nursing Assistants. Evening Shift: Registered Nurse Supervisor: 1 Unit 3: 1 Registered Nurse, 1 Licensed Practical Nurses and 3 Certified Nursing Assistants Unit 2: 1 Registered Nurse, 1 Licensed Practical Nurses and 4 Certified Nursing Assistants Unit East: 1 Registered Nurse, 1 Licensed Practical Nurses and 3 Certified Nursing Assistants Unit North: 1 Registered Nurse, 1 Licensed Practical Nurses and 2 Certified Nursing Assistants Unit West: 1 Registered Nurse, 1 Licensed Practical Nurses and 3 Certified Nursing Assistants Total= 5 Registered Nurses, 5 Licensed Practical Nurses, and 15 Certified Nursing Assistants. Night Shift: Unit 3: 1 Registered Nurse, 1 Licensed Practical Nurses and 2 Certified Nursing Assistants Unit 2: 1 Registered Nurse, 1 Licensed Practical Nurses and 3 Certified Nursing Assistants Unit East: 1 Registered Nurse, 1/2 Licensed Practical Nurses and 2 Certified Nursing Assistants Unit North: 1 Registered Nurse, 1/2 Licensed Practical Nurses and 2 Certified Nursing Assistants Unit West: 1 Registered Nurse, 1 Licensed Practical Nurses and 2 Certified Nursing Assistants Total=5 Registered Nurses, 4 Licensed Practical Nurses, and 11 Certified Nursing Assistants 1 Nurse cover East and North units on the Night shifts. Review of the actual weekend facility staffing schedule from 04/06/2024 to 04/28/2024 documented the following: On 04/06/2024 on the 7 AM-3 PM shift there was a shortage of 4 Registered Nurses for 3rd, 2nd, East, North and Units and 1 Certified Nursing Assistant on the 3rd and East unit, 2 Certified Nursing Assistants for the 2nd unit. On 04/06/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] Units and 1 Certified Nursing Assistants for the 2nd and East unit. On 04/06/2024 on the 11 PM-7 AM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] Units, and 1 Certified Nursing Assistant for the 3rd, East, North and west Units, 2 Certified Nursing Assistant on the 2nd unit. Total staff shortage in a 24-hour period was 14 Registered Nurse, and 11 Certified Nursing Assistants with no replacement of staff. On 04/07/2024 on the 7 AM-3 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] Units and 1 Certified Nursing Assistants for the 2nd and 3rd floor. On 04/07/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for the 2nd, East, North and [NAME] units, 1 Licensed Practical Nurse on 3rd Floor, and 1 Certified Nursing Assistant for the East and North units. On 04/07/2024 on the 11 PM-7 AM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] units, and 1 Licensed Practical Nurse for the North unit, and 1 Certified Nursing Assistant for the 2nd, East, North and [NAME] units. Total staff shortage in a 24-hour period was 14 Registered Nurse for 3rd, 2nd, East, North and [NAME] units, 2 Licensed Practical Nurses, and 8 Certified Nursing Assistants with no replacement of staff. On 04/13/2024 on the 7 AM-3 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] units, and 1 Certified Nursing Assistant for the 2nd and [NAME] units. On 04/13/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] units, 1 Licensed Practical Nurse for the East Unit and 1 Certified Nursing Assistant for the 2nd unit. On 04/13/2024 on the 11 PM-7 AM shift there was a shortage of 1 Registered Nurse for 3rd, 2nd, East, North and [NAME] units, and 1 Certified Nursing Assistant on the 2nd unit. Total staff shortage in a 24-hour period 15 registered Nurse, 1 Licensed Practical Nurse, and 4 Certified Nursing Assistants with no replacement of staff. On 04/14/2024 on the 7 AM-3 PM shift there was a shortage of 1 Registered Nurses for the 3rd, 2nd, East, North and [NAME] units and 1 Certified Nursing Assistant for the 3rd, 2nd, and North units. On 04/14/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for 3rd, 2nd, East, North and [NAME] units, 1 Licensed Practical Nurse for East unit, and 1 Certified Nursing Assistant for the 2nd and East units. On 04/14/2024 on the 11 PM-7 AM shift there was a shortage of 4 Registered Nurse for 3rd, 2nd, East, North and [NAME] units, and 1 Certified Nursing Assistant on the 2nd and North units. Total staff shortage in a 24-hour period 14 Registered Nurses, 1 Licensed Practical Nurse and 8 Certified Nursing Assistants with no replacement of staff. On 04/20/2024 on the 7 AM-3 PM shift there was a shortage of 1 Registered Nurse for 3rd, 2nd, East, North and [NAME] units, 1 Certified Nursing Assistant on the 2nd, East and North units. On 04/20/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] units, and 1 Certified Nursing Assistant for the 2nd and East unit. On 04/20/2024 on the 11 PM-7 AM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] units, and 1 Certified Nursing Assistant for the 2nd, North, and [NAME] units. Total staff shortage in a 24-hour period 15 Registered Nurses and 8 Certified Nursing Assistants with no replacement of staff. On 04/21/2024 on the 7 AM-3 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] units, 2 Certified Nursing Assistants for 2nd unit, and 1 Certified Nursing Assistant for the 3rd unit. On 04/21/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] units, and 1 Certified Nursing Assistant for 2nd, North, and [NAME] units. On 04/21/2024 on the 11 PM-7 AM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North, and [NAME] units, and 1 Certified Nursing Assistant for the North unit. Total staff shortage in a 24-hour period 15 Registered Nurses and 7 Certified Nursing Assistants with no replacement of staff. On 04/27/2024 on the 7 AM-3 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] units, 1 Certified Nursing Assistant for the 3rd ,East and [NAME] units, 2 Certified Nursing Assistant for 2nd unit. On 04/27/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] units, 1 Certified Nursing Assistants for the 2nd and East units. On 04/27/2024 on the 11 PM-7 AM shift, 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] units, 1 Certified Nursing Assistant for 2nd and East units. Total staff shortage in a 24-hour period 15 Registered Nurses and 9 Certified Nursing Assistants with no replacement of staff. On 04/28/2024 on the 7 AM-3 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] units, 1 Certified Nursing Assistants on 3rd, North and [NAME] units, 2 Certified Nursing Assistants on the 2nd unit. On 04/28/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] units, 1 Certified Nursing Assistant on 2nd , East and North units. On 04/28/2024 on the 11 PM-7 AM shift, 1 Registered Nurse for the 3rd, 2nd, East, North and [NAME] units, and 1 Certified Nursing Assistant for the 2nd , East and North units. Total staff shortage in a 24-hour period was 14 Registered Nurses, and 11 Certified Nursing Assistant with no replacement of staff. Review of the actual weekend facility staffing schedule from 05/04/2024 to 06/30/2024 revealed that the facility had an ongoing pattern of shortage of staff for both Registered Nurses and Certified Nursing Assistants. On 12/06/24 at 11:57 AM, Certified Nursing Assistant #14 was interviewed and stated that the staffing was worst, and they worked short on multiple occasions, but it is slowly getting better. Certified Nursing Assistant #15 also stated that when working short they will do the most important tasks like giving person care and feeding the residents. Certified Nursing Assistant #15 further stated that a lot of staff call out because of emergencies or when they need a day off as it is very hard to work short and they become tired. On 12/06/24 at 12:08 PM, Certified Nursing Assistant #15 was interviewed and stated most of the times they work short because staff call out and some do not show up. If someone calls out, they will ask the night staff to stay but most of the time they do not get anyone to stay, so the staff has to work short. Certified Nursing Assistant #15 also stated that when working with short staff they will have 11 - 12 residents each, and the residents who want to get out of bed are taken out. Certified Nursing Assistant #15 further stated that it can be stressful at times, and they must rush to get care done, but they ensure that the residents do get the care. Certified Nursing Assistant #15 stated all staff work together to get the work done and to monitor all the residents. On12/06/24 at 12:54 PM, Licensed Practical Nurse #4 was interviewed and stated the census for the unit today is 40, a full house. Licensed Practical Nurse #4 also stated that they are responsible for giving all medications to all the residents despite having another nurse on the unit. Licensed Practical Nurse #4 further stated that the 2nd nurse is only responsible for the treatments, and they feel stressed, and rushed all the time because they must always give medication to all the residents. Licensed Practical Nurse #4 stated it would be helpful to have a second person as they always feel rushed to complete their work and it is a difficult thing to do all the time. On 12/06/24 at 03:14 PM, the Payroll Supervisor was interviewed by telephone, and stated they are responsible for uploading the information for the Payroll Based Journal Staffing Data Report and did upload the data for the last quarter. The data is collected based on staff clocking in and out at the start and end of their shift. The Payroll Supervisor also stated they are not responsible for staffing, and just responsible for payroll. The Payroll Supervisor further stated that whatever is reported in the Payroll Based Journal Staffing Data Report system is based on the staffing the facility had for the period. On 12/06/24 at 03:36 PM, Certified Nursing Assistant #11 was interviewed and stated they work as a floater and has worked on every unit. Certified Nursing Assistant #11 also stated the floors are always short and needs more staff because there are a lot of dependent, and combative residents on the 3rd floor. Certified Nursing Assistant #11 further stated that when they work short, they must rush to complete everything and that is an issue, but they do the best they can to complete their work. On 12/06/24 at 03:40 PM, an interview was completed with Licensed Practical Nurse #3 who stated that sometimes they must cover two units and at times the supervisor will help. Licensed Practical Nurse #3 also stated that the staffing has been short but seems to be improving. On 12/09/24 at 09:27 AM, Certified Nursing Assistant #13 was interview and stated work on the unit with 42 residents, and the residents need total care. Certified Nursing Assistant #13 also stated sometimes they staff on the unit is 3 or 4 staff, and although working short they must make time to watch the dining area and do lounge duties in the morning and during activities. Certified Nursing Assistant #13 further stated that more staff is needed especially on the [NAME] unit. On 12/09/24 at 09:56, the Human Resources Director was interviewed and stated they are responsible for staffing the facility and works with the Director of Nursing, and Assistant Director of Nursing as a group effort to get the appropriate staffing. Some units need more staffing than others, and they talk with the staff and who can tell if they need extra staff on the unit. The Human Resources Director also stated that they reviewed the last quarter Payroll Journal reports did not see where there was an issue with staffing. The Human Resources Director further stated that the weekend is always difficult, and the staff is really cut in half on weekends. The Human Resources Director stated that the staffing listed on the Facility Assessment is the amount of staff the facility has. The Human Resources Director also stated if someone call out there is a log it is placed on, and then tries to cover the person calling out by calling other staff, asking staff already in the building. There has been a major push in the last few months to hire and to ensure the facility is staffed, and the problem is not hiring but to make staff stay. The Human Resources Director further stated that they increased the par levels for the past few months and the Payroll Based Journal Staffing Data Report for April to June reflected the staffing at a minimum. On 12/09/24 at 10:08 AM, the Director of Nursing was interviewed and stated the staffing for the facility is satisfactory at present and they were not sure why the Payroll Based Journal Staffing Data Report for April to June the 3rd quarter was triggered. The Director of Nursing also stated there are no Registered Nurses on day or any shift as listed on the Facility Assessment. The Director of Nursing further stated that there may be some Registered Nurses on the unit on the day shift at times, but they are not if there are 5-6 Registered Nurses as listed including the supervisors. A Registered nurse usually works on the 2nd unit, but most units are staffed with Licensed Practical Nurses, and they are not sure why that number of Registered Nurses is listed on the Facility Assessment. The Director of Nursing stated that the number of staff listed on the Facility Assessment on the shifts is not what is on the units. On 12/09/24 at 10:30 AM, the Administrator was interviewed and stated the Director of Nursing, the Human Resources Director, the Minimum Data Set Coordinator, and themselves are all involved in the process of discussing the staffing requirements for the facility as listed in the Facility Assessment. In order to designate staffing of the units they look for the acuity, the census and if the unit is short term and or long term to determine the staffing pattern. The Administrator also stated that to ensure the residents are receiving the proper care there was an increase in the par levels for staffing in 10/2023 on all units. The Administrator further stated they are aware that the facility was flagged for staffing in the Payroll Based Journal Staffing Data Report as the facility is not reaching the Centers for Medicare and Medicaid mandate of 3.5 hours per patient per day. The Administrator stated they think that the Centers for Medicare and Medicaid Services Payroll Based Journal Staffing Data did not take into consideration the acuity of the facility, and they think the staffing is adequate for this facility based on the acuity. The Administration stated the facility continues to hire staff and have hire more Registered Nurses, Licensed Practical Nurse, and Certified Nursing Assistants across the boards. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00351262), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, and mistreatment, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident in one out of four residents sampled (Residents #1). Specifically, on 08/13/2024 at 12:45 PM, Resident #1 identified Maintenance Employee #1 by name to the Administrator and stated that Maintenance Employee #1 entered their room on 08/06/2024 around 5:00 PM to fix something in their room. Maintenance Employee #1 touched and pulled Resident #1's breast prior to leaving the room. Maintenance Employee #1 was suspended pending the investigation. The facility did not report the alleged sexual abuse to law enforcement. The findings include: The Facility's Policy and Procedure on Abuse Prevention Program revised 07/2024, documented that any case in which abuse, neglect, or mistreatment has been suspected will be reported in accordance with State and Federal regulations. The facility's policy further documented on page 4, Federal Elder Justice Act: Suspicions must be reported to at least one local law enforcement agency as well as to the New York State Department of Health. Resident #1 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia, Depression, and Major Depressive Disorder. The Minimum Data Set (an assessment tool), dated 07/26/2024, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 15 associated with intact cognition. The Potential for Victimization Comprehensive Care Plan dated 12/06/2022, documented interventions to provide emotional support, redirection, and reality orientation. The facility's Investigation Summary dated 08/19/2024 documented Resident #1 alleged being touched inappropriately by Maintenance Employee #1. After an investigation was conducted, which included, interviews with staff, reviews of surveillance footage and examination of relevant records, there were no definitive proof to support the allegation. No further action against Maintenance Employee #1 was warranted. Maintenance Employee #1 was removed from Resident #1's unit for added safety and security. Corrective Actions included enhanced staff training on professional boundaries and residents' rights. During an interview on 08/15/2024 at 9:15 am, Administrator stated they asked Resident #1 if they wanted law enforcement to be contacted. Resident #1 refused, so they did not call law enforcement. 10 NYCRR 415.4(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the abbreviated survey (NY 00329642) on 08/15/2024-08/16/2024, the facility failed to ensure that the resident is free of significant medication errors. This was evident for one out of five sampled residents (Resident #4). Specifically, on 12/06/2023, Licensed Practical Nurse #1 did not identify the right resident for tube feeding and started to administering tube feeding formula through Resident #4's Gastrostomy tube with no Medical Doctor's orders. The findings are: The facility policy titled Medication Administration and Documentation, revised on 12/2023, documented that medications shall be administered and documented in a safe and timely manner. The individual administering medications must verify the resident 's identity before giving the resident his/her medications. Methods of identifying the resident include checking identification band. A review of the Facility's Incident Report Summary dated 12/07/2023, documented on 12/06/2023, Resident #4 was accidentally administered tube feeding, which was not their medical order. Resident #4 was assessed by the Registered Nurse Supervisor #1, and no adverse effects were noted. The Gastrostomy tube was flushed as per the Medical Doctor's Order. Resident #4 was monitored for 24 hours for any changes, and none were observed. All staff members were educated on medication rights. Licensed Practical Nurse #1 was re-educated on medication administration. Resident #4 was admitted to the facility with a diagnosis including Cerebral Infarction, Aphasia, and Hemiplegia. The Minimum Data Set, dated [DATE], identified that Resident #4 had a Brief Interview on Mental Status and scored 3 out of 15, which identified the Resident #4's cognition as severely impaired. Physician Orders dated 11/24/2023, documented an order to flush the feeding tube with 50 milliliters of water to keep the feeding tube [NAME] and clean the Gastrostomy feeding tube site with normal saline. The Care Plan for Tube Feeding dated 12/06/2023, documented that Resident #4 was inadvertently administered approximately 50 milliliters of feeding formula via Resident #4's Gastrostomy feeding Tube. No adverse reaction was noted. Continue to monitor. A Nurse's note dated 12/07/2023 at 8:47 PM, written by the Registered Nurse Supervisor #1 documented on 12/06/2023, staff inadvertently attached the Resident #4 to the external pump, and Gastrostomy Tube feeding formula was started. Resident #4 received approximately 50 milliliters of the feeding formula before the feed was removed, and the Gastrostomy feeding tube was flushed with water. During an interview on 08/16/2024 at 11:23, Registered Nurse Supervisor #1 stated that on 12/06/2023, they were called by Resident #4's spouse to come to the resident's room because the nurse started tube feeding on their spouse and Resident #4 should not be getting feed via Gastrostomy tube. Registered Nurse Supervisor #1 stated that upon arrival to Resident #4's room, they observed that the feeding tube was connected to Resident #4's Gastrostomy tube. Feeding was running, but they could not recall what it was. Registered Nurse Supervisor #1 stated that Resident #4 had no order for feeding, just flushing Gastrostomy tube with water. Registered Nurse Supervisor #1 stated the feeding was immediately stopped. Nurse Supervisor #1 stated on their observation the feeding had just started entering the Gastrostomy tube. During an interview on 8/16/2024 at 2:40 pm, the Assistant Director of Nursing stated Registered Nurse Supervisor #1 made them aware on 12/06/2023 afternoon, that Licensed Practical Nurse #1 connected Gastrostomy tube feeding to the wrong resident. The Assistant Director of Nursing stated the incident was investigated with the Director of Nursing. The Assistant Director of Nursing stated that Licensed Practical Nurse #1 connected Resident #4 to the feeding pump but there were orders to flush the Gastrostomy tube with water. The Assistant Director of Nursing stated they assessed Resident #4, and there was no harm to the resident. The Assistant Director of Nursing stated that Licensed Practical Nurse #1 did not follow the five rights of medication administration. During an interview on 08/16/2024 at 3:20 PM, the Director of Nursing stated they became aware of a Gastrostomy feeding incident on 12/06/2023 and investigated the incident. The Director of Nursing stated Licensed Practical Nurse #1 did not follow facility policy for medication administration and did not check the right resident before attaching the Gastrostomy tube feeding to Resident #4. The Director of Nursing stated Licensed Practical Nurse was re-educated on safe medication administration, suspended, and terminated. During a follow-up telephone interview on 08/21/2024 at 11:35 am, Licensed Practical Nurse #1 stated that they prepared feeding for residents who had medical orders first. They checked the orders in the Electronic Medication Administration Record and identified the resident, labeled the feeding bottle, primed it, and hung it on the machine to administer it later when it was time to start feeding. Licensed Practical Nurse #1 stated that in Resident #4's room, there was another resident with a feeding tube, and feeding was prepared for that resident. Licensed Practical Nurse #1 stated when they returned to start feeding, the machine was next to Resident #4 (they don't know who moved it, maybe the aids during care), and they connected it to their Gastrostomy without checking the Identification bracelet. Licensed Practical Nurse #1 stated the resident was alert and agreed to start feeding. Licensed Practical Nurse #1 stated they realized that feeding was for Resident #4's roommate within five minutes by checking the medical chart and was coming to the resident's room to fix it. Licensed Practical Nurse #1 stated the family was there and told them that they had started feeding on Resident #4, who had no doctor's order for Gastrostomy feeding. 10 NYCRR 415.12 (m)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey from 12/22/22 to 12/30/22, the facility did not ensure alleged violations involving abuse, including injuries of unknown source, were reported to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident #109) of 3 residents reviewed for abuse out of 31 total sampled residents. Specifically, the facility did not report to the NYSDOH when Resident #109 sustained a right hip fracture of unknown origin. The findings are: The facility policy titled Abuse Prevention Program revised on 6/2022 documented any case in which abuse, neglect, mistreatment, or misappropriation of residents' property has been suspected will be reported in accordance with State and Federal regulations. Resident #109 had diagnoses of displaced intertrochanteric fracture of right hip and osteoporosis. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #109 had moderately impaired cognition and required assistance of person to complete activities of daily living. Nursing Note dated 9/16/2022 documented Resident #109 was observed with right hip swelling and pain and was transferred to the hospital for evaluation and x-ray. X-Ray results dated 9/18/2022 documented Resident #109 sustained a comminuted and displaced intertrochanteric fracture of the right femur. Nursing Note dated 9/21/22 documented Resident #109 was readmitted from the hospital with diagnosis of right hip intertrochanteric fracture. The Accident/Incident (A/I) Report, initiated 9/22/2022 and concluded 9/27/22, documented Resident #109 reported right hip pain on 9/16/22. Swelling was observed and Resident #109 was transferred to the hospital for x-ray and evaluation. Resident #109 was readmitted from the hospital on 9/21/22 with diagnosis of right intertrochanteric hip fracture. There was no documented evidence the facility reported Resident #109's injury of unknown origin to the NYSDOH. On 12/29/22 at 4:37 PM, the Assistant Director of Nursing (ADON) was interviewed and stated the investigation into Resident #109's injury of unknown origin was never reported to the NYSDOH because the facility did not know Resident #109 had a fracture until the resident was readmitted from the hospital. The doctor stated the right hip fracture was pathological due to diagnoses of osteoporosis and osteopenia. The facility does not report resident injuries to the NYSDOH if the facility knows what caused the injury. On 12/30/22 at 1:33 PM, the Director of Nursing (DON) was interviewed and stated the ADON discussed Resident #109's hip fracture with the doctor and determined the fracture was not a result of abuse, neglect, or mistreatment. Resident #109 was alert and, during interview, stated no one hurt them. The resident was unable to explain what caused right hip fracture. The investigation concluded the right hip fracture was pathological and therefore there was no need to report this to the NYSDOH. The DON stated the A/I investigation into Resident #109's right hip fracture occurred while the DON was on vacation. The DON would have reported the resident's injury upon return from vacation, but the report would have been late, and the facility would have been cited anyway. The DON always recommends and believes it is better to report incidents to the NYSDOH. 415.4 (b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews conducted during the Recertification survey from 12/22/2022 to 12/30/2022, the facility did not ensure an assessment accurately reflected resident status. This was evident for 1 (Resident #137) of 1 resident(s) reviewed for Accidents and 1 (Resident #395) of 1 resident(s) reviewed for Hospice Care out of 31 total sampled residents. Specifically, 1) the Minimum Data Set 3.0 (MDS) assessment did not document Resident #137's wandering behavior, and 2) the MDS assessments did not document Resident #395 received hospice care. The findings are: The facility policy titled MDS Comprehensive Assessment revised 3/22 documented that individual are assessed by gathering relevant information from multiple sources, including observation, resident and family interview, and evaluations from other disciplines. 1) Resident # 137 had diagnoses of unspecified dementia without behavioral disturbance and major depressive disorder. The MDS dated [DATE] documented Resident # 137 was severely cognitively impaired and did not wander. On 12/27/22 at 02:28 PM, 12/28/22 at 08:54 AM, 12/28/22 at 10:53 AM, and 12/29/22 at 09:02 AM, Resident # 137 was observed walking up and down the unit hallway without a specified course or known direction. The Nursing Note (NN) dated 11/17/22 documented Resident #137 was newly admitted to the facility and the resident representative reported Resident #137 had a history of wandering behavior. NN dated 11/18/22, 11/19/22, and 11/21/22 documented Resident #137 exhibited wandering behavior on the unit. The Comprehensive Care Plan (CCP) related to cognitive loss and dementia initiated 11/19/22 documented Resident #137 required reminders, reassurance as needed, and redirection. The CCP was revised on 12/01/22 and documented a picture of Resident #137 was placed next to their room for redirection. On 12/27/22 at 02:37 PM Certified Nursing Assistant (CNA) # 1 was interviewed and stated they were assigned to Resident # 137 who can ambulate without assistance and is cognitively impaired. Resident # 137 walks up and down in the hallway several time a day and their picture were posted by the room label to help the resident find their room. Resident #137 enters the room next to theirs up to 3 times on CNA #1's shift because the doors are right next to each other. On 12/28/22 at 11:10 AM, Registered Nurse (RN) # 1 was interviewed and stated Resident # 137 was confused and walks back and forth on the unit several times a day. Resident #137 exhibits wandering behavior and the behavior is documented in the nursing notes. On 12/28/22 at 02:07 PM, the MDS Coordinator (MDSC) was interviewed and stated they did complete Resident #137's MDS dated [DATE]. There was a miscommunication between the unit staff and the MDSC about Resident # 137's wandering behavior. The MDSC did not know nursing notes documented Resident # 137 had wandering behavior and, as a result, the MDSC did not trigger Resident #137 for wandering behavior on the MDS. The MDSC also did not review the MDS for accuracy once it was completed. On 12/29/22 at 11:07 AM, Director of Nursing (DON) was interviewed and stated they misunderstood the definition of wandering and it was an error that wandering was not triggered on Resident #137's MDS. 2. Resident # 395 had diagnoses of Alzheimer's disease and unspecified dementia without behavioral disturbance. The MDS dated [DATE] documented Resident # 395 was severely cognitively impaired and did not receive hospice care. The physician note dated 12/14/22 documented Resident # 395 had end-stage dementia and family requested hospice care. The Comprehensive Care Plan (CCP) related to Hospice Care initiated 12/17/22 documented a physician order would be obtained for Resident #137 to receive hospice care. The physician order dated 12/17/22 documented Resident # 395 began receiving hospice care. The nursing note dated 12/17/22 documented Resident # 395 was placed on hospice with the facility's contracted hospice agency. On 12/28/22 at 11:35 AM, Registered Nurse (RN) # 1 was interviewed and stated Resident # 395 began receiving hospice care 12/17/22. On 12/28/22 at 02:07 PM, the MDS Coordinator (MDSC) was interviewed and stated Resident # 395 was on hospice care before the MDS dated [DATE] was completed and it was an error that hospice care was not triggered on the MDS. The MDSC only checked for completion and not accuracy of the MDS prior to submitting them. 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the Recertification survey from 12/22/2022 to 12/30/2022, the facility did not ensure infection prevention and control standards were maintained. This was evident for 1 (Unit E) of 4 units. Specifically, Licensed Practical Nurse (LPN) #1 was observed improperly wearing a personal protective equipment (PPE) on multiple occasions. The findings are: The facility policy titled Infection Prevention and Control Program last revised 10/2022, documented appropriate use of PPE reduces the risk of transmission of infectious agents among healthcare workers, residents, and visitors. Resident #21 had diagnoses of multiple sclerosis and vascular dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #21 was severely cognitively impaired and required total assistance from staff to perform activities of daily living. On 12/23/22 at 09:58 AM, LPN #1 was observed walking throughout Unit E, entering, and exiting various resident rooms, wearing a surgical face mask. LPN #'s surgical mask was pulled down exposing the nose while only covering the mouth. On 12/23/22 at 12:07 PM, LPN #1 was observed in the Unit E hallway standing next to and feeding Resident #21 while the resident sat in their Geri-chair. LPN #1's surgical face mask was pulled down exposing their nose while only covering their mouth. On 12/28/22 at 12:02 PM, LPN #1 was observed in the Unit E dining room during lunch serving trays to residents and then feeding Resident #21. LPN #1's surgical face mask was pulled down exposing their nose while only covering their mouth. On 12/29/22 at 02:56 PM, an interview was conducted with LPN #1 who stated staff must use surgical face masks at all times. LPN #1 pulls down the surgical mask when they are not around residents because they are asthmatic and feel like they need air. LPN #1 does their best to keep their mask over their mouth and nose when around residents and did not realize they were wearing the mask improperly exposing their nose. On 12/28/22 at 12:14 PM, an interview was conducted with the Infection Preventionist (IP), who stated that staff are required to wear surgical face masks in the facility. The IP conducts spot checks and encourages the staff to wear their surgical masks properly during meetings. On 12/30/22 at 12:34 PM, the Director of Nursing Services (DNS) was interviewed and stated surgical mask wearing has been a daily struggle and the DNS goes after the staff every day to encourage the proper use of surgical face masks. 415.19 (b)(4)

Based on observation, record review, and interviews conducted during the Recertification survey from 12/22/22 to 12/30/22, the facility did not ensure the daily staffing was posted in a prominent place readily accessible to residents and visitors. This was evident for 2 (Unit 2 and Unit 3) of 5 units. Specifically, daily staffing was not observed posted in a prominent place for residents and visitors of Unit 2 and Unit 3. The findings are: The facility policy titled Daily Staffing Numbers dated 4/21 documented the number of Licensed Nurses and the number of unlicensed personnel directly responsible for resident care will be posted daily in a prominent location (accessible to residents and visitors) and in a clear readable format. On 12/27/22 at 9:00 AM, 12/29/22 at 3:15 PM, and 12/30/22 at 9:45 AM, observations of facility entryway were made. Visitors of resident Unit 2 and Unit 3 were required to make a left after entering the facility, and travel through a hallway leading to an elevator bank. Daily staffing sheets were observed posted in the hallway to the right of the entrance that leads directly to resident Unit N, Unit W, and Unit E. On 12/30/22 at 9:50 AM, an interview was conducted with the Staffing Coordinator (SC) who stated the SC is responsible for posting staffing daily on Unit E across from the Social Services office. Visitors of Unit E and Unit W pass by the daily staffing posting as they proceed to the units. The daily staffing was not posted in a prominent area in the building with Unit 2 and Unit 3. The SC will now post the daily staffing by the elevator that leads to Unit 2 and Unit 3 so that visitors of those units can view the staffing. On 12/30/22 at 1:27 PM, an interview was conducted with the Director of Nursing (DON) who stated daily staffing was posted across from the Social Service office because the facility only allowed visiting in a designated room in that area, and it was accessible to all visitors at the time. The facility began allowing visitors to meet in resident rooms approximately 1 month ago and the DON did not realize visitors of residents on Unit 2 and Unit 3 would not be able to view the staffing posted on Unit E. 415.13

Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure safe food storage and handling was practiced to prevent food-borne illness and the facility did not to meet professional food service standards. This was evident during review of the kitchen. Specifically, there were 8 expired packages of 12-ounce chicken breast nuggets observed in the kitchen freezer. The findings are: The facility policy titled Dating and Labeling Policy last revised October 2022 documented Discard all foods that expire immediately. On 12/27/2022 at 11:02 AM, a tour of the kitchen was conducted and 8 expired packages of 12-ounce chicken breast nuggets with manufacturer's stamped expiration date of 11/15/22 were observed in the kitchen freezer. On 12/27/2022 at 11:02 AM, [NAME] #1 was interviewed and stated they try to look at the dates on food each day before lunch but sometimes they are not able to. Expired food is disposed of and should not be in the freezer. On 12/27/2022 at 01:48 PM, the Assistant Director of Dining Services (ADDS) was interviewed and stated they round in the kitchen once a week and look at the expiration dates daily. The ADDS has thrown away expired food, checks for mold, and checks that food is being rotated. It is important that there are no expired foods in the freezer. On 12/30/2022 at 11:02 AM, the Director of Dining Service (DDS) was interviewed and stated they round in the morning and go through items in the fridge. The DDS looked at the Received By date on the packages of chicken nuggets because, if the packages are unopened, they can be kept for 3-6 months. An Activities Department event was cancelled, and the packages of chicken nuggets were placed in the kitchen freezer. The DDS discards expired items, but the chicken nuggets packages were overlooked. 415.14 (h)