**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an Extended Recertification survey completed on 8/2/24, the facility did not make prompt efforts to resolve grievances for two (Residents #25 and #45) of three residents reviewed. Specifically, there were no grievance forms filed and there was lack of follow through and resolution for missing property. The findings are: The New York State Department of Health packet titled Your Rights as a Nursing Home Resident in New York State dated 2022 documented Residents had the right to expect the facility to promptly investigate and try to resolve their concerns. The policy and procedure titled Grievances dated 2/28/2017 documented the facility will specifically notify the resident/representative of the right to file a complaint with the facility concerning misappropriation of resident property in the facility. Residents and representatives may file a complaint personally or in writing to the Grievance Officer. The Social Work Director has been designated as the Grievance Officer who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigations as appropriate, communicate with residents throughout the process to resolution and coordinate with other staff including the Administrator as may be indicated by specific allegations. Grievances can also be filed with the administrator, supervisors, department heads, or social work. All grievances will be reviewed and investigated, a response will be given within 5 business days. Written responses are available upon request. The facility will promote the grievance process throughout the organization by notifying residents of their rights related to grievances as well as educating all those affected by potential grievances or concerns on the facility grievance process. 1. Resident #25 had diagnoses which include diabetes mellitus type II, chronic obstructive pulmonary disease (lung disease), and major depressive disorder. The Minimum Data Set (a resident assessment tool) dated 5/22/24 documented the resident was cognitively intact. During an interview on 7/29/24 at 10:23 AM, Resident #25 stated they had clothing go missing at the facility. They stated they had received two pairs of pants and a 6-pack of various color short sleeve T-shirts for Christmas in December 2023. They stated they had taken the T-shirts and pants to get tagged and the items were never returned to them. Resident #25 stated they had notified Registered Nurse #1 and Social Worker #1 of the missing items and had been told there was nothing they could do. The items were gifts received for Christmas. Review of the facility's Clothing to be Labeled list dated 12/24/23 revealed two pairs of bottoms (one green and one black) had been logged on 12/24/23. During an interview on 7/31/24 at 3:50 PM, Clerical Assistant #1 stated the process for clothing brought in for residents was to log the items on the Clothing to be Labeled sheet and then place them in a separate area behind the reception desk for housekeeping to pick the items up and label them, wash them, and return them to the resident. Clerical Assistant #1 stated they were the staff member who made the entry regarding two pairs of bottoms on the log for Resident #25. They stated they did not remember if there were T-shirts handed in along with the bottoms. During an interview on 7/31/24 at 4:08 PM, Social Worker #1 (designated by the facility as the Grievance Officer) stated they were aware of Resident #25's missing clothing items (pants/T-shirts) as they had been informed of the missing items by Registered Nurse #1, and they sent out an email regarding the missing items to facility staff, and another e-mail to Administrative Assistant #1 inquiring how to go about having a resident reimbursed for missing items. Social Worker #1 stated they did not follow up on these e-mails after sending them. Review of an e-mail dated 1/15/24 at 3:15 PM documented that Social Worker #1 had informed unit managers, clerical assistants, and department leaders of Resident #25's missing clothing items and requested they let Social Worker #1 know if any of the items were located. Review of an e-mail dated 3/20/24 at 2:06 PM from Social Services Worker #1 to Administrative Assistant #1 documented that Social Worker #1 inquired about how to reimburse Resident #25's family member for 2 pairs of sweatpants and 6 T-shirts they had purchased for Resident #25, as the items were missing. In the email Social Worker #1 also inquired about a missing beard trimmer and razor and requested reimbursement by Resident #45. Social Worker #1 was instructed by Administrative Assistant #1 to obtain the actual replacement cost of the missing items and notify the Administrator for approval of payment. During an interview on 7/31/24 at 4:08 PM, Social Worker #1 stated they did not have any further documentation of follow-up actions regarding missing personal property of Residents #25 and #45. During an interview on 7/31/24 at 4:26 PM, the Administrator stated that if personal property was to be reported missing, they would expect Social Worker #1 to file a grievance, follow the grievance process, and notify departments in the facility of the missing items. The Administrator stated the departments would conduct a search and hopefully, the items would be found. If items were not found, reimbursement by the facility would be based on whether the facility could substantiate that the resident, in fact, had the items at the facility prior to them missing. Then an online search for price comparison would assist with reimbursement amounts if there were no receipts available. When asked specifically about missing items for Residents #25 and #45, the Administrator stated they had not been made aware of missing items for these residents. During an interview on 8/1/24 at 10:44 AM, Social Worker #1 stated they had not been aware that missing property required a grievance to be filed and followed. They had only filed grievances if a family or resident requested to file a grievance. Social Worker #1 stated it was important to follow the grievance process for residents with missing property, because residents had a right to have their own property and have property replaced as appropriate, after a report and investigation did not help locate the property. Social Worker #1, who is the designated as the facility's grievance officer, stated no grievance was filed for resident #25's missing pants and T-shirts. 2. Resident #45 had diagnoses which include diabetes mellitus type II, osteomyelitis (bone infection) of vertebra and hypertension. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact. During an interview on 7/29/24 at 9:39 AM, Resident #45 stated they had a razor and beard/ nose hair trimmer and when they moved rooms approximately 4 months ago it was lost. They stated they informed the nursing staff and the Social Work Department Director. Resident #45 stated that the Social Work Department Director had informed them they would look into it, and they haven't received any follow-up. Resident #45 stated the Social Work Department Director should have completed a grievance form. Review of the Resident #45's medical record revealed there was no evidence of a personal item list upon admission. Review of facility logging system for personal items of a form titled Clothing to be Labeled from 12/15/23 through present revealed there was no evidence of items logged in on admission. Resident #45 had clothing items logged on 2/24/24, 3/12/24, and 6/11/24. During an interview on 7/31/24 at 10:22 AM, Social Work Department Director stated they do not have any loss/ grievance forms for Resident #45 from admission date 12/15/23 through present. During an interview on 8/1/24 at 12:16 PM, the Social Work Department Director stated upon further review of Resident #45's concern of a missing razor and beard/ nose trimmer they recalled sending an email to Administrative Assistant #1 March 2023 concerning the lost razor and beard/ nose trimmer but had forgotten to follow up on the matter. The Social Work Department Director stated they should have completed a grievance form, informed the Administrator, and provided either a replacement or reimbursed the Resident for the items. They further stated they didn't follow their grievance process. In addition, the Social Work Department Director stated there should have been a personal property list completed upon admission to know what the resident had but does not know who is responsible or if there is a logging system for personal items upon admission. Review of an email dated March 20, 2024, at 2:17 PM from Administrative Assistant #1 to Social Work Department Director documented you need to get actual replacement costs for the items and then run it by the Administrator, if approved then it can be paid. Review of an email dated March 20, 2024, at 2:20 PM from Social Work Department Director to Administrative Assistant #1 documented Okay, Resident #45 stated both items totaled approximately $60.00. During an interview on 8/1/24 at 12:32 PM the Administrator stated they were unaware Resident #45 was missing a razor and beard/ nose trimmer. The Administrator stated they would have expected the Social Work Department Director to complete a grievance form, investigate and search for the reported lost item, had the investigation concluded within 5 days and report provided to them for review if reimbursement should had occurred if Resident #45 brought one into the facility. In addition, the Administrator stated they were unable to locate Resident #45's personal item list from admission and the facility does not have a process to log resident's personal property items on admission and does not have a policy to safeguard resident's personal property. 10 NYCRR 415.3(d)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an Extended Recertification Survey completed on 8/2/24, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living received the necessary services to maintain nutrition and grooming for two (Resident #29 and #63) of four residents reviewed. Specifically, staff did not offer or provided assist with removing facial hair (#63) and staff did not provide staff assistance as planned for meals (#29). The findings are: Review of the nursing policy and procedure titled Activities of Daily Living dated 1/14/15 documented activities of daily living are those activities which must be accomplished each day in order for the resident to care for his own needs and participate in the society of others. The nursing staff will assist the resident with any of the activities that he/she is unable to perform by him/herself. Review of the nursing policy and procedure title Shower dated 10/7/14 documented provide hygiene care including hair washing and/or shaving if necessary. 1. Resident #29 had diagnoses which included Parkinson's (progressive brain disorder that causes damage to parts of the brain over many years), chronic kidney disease, and dysphagia (difficulty swallowing). The Minimum Data Set (a resident assessment tool) dated 6/26/24 documented Resident #29 was cognitively intact, was understood and usually understands. The Minimum Data Set further documented the resident required a partial moderate assist for eating. The Comprehensive Care Plan documented that Resident #29 had impaired functional status with activities of daily living. An intervention dated 6/27/24 documented the resident required a limited assist of 1 person for eating and was on all aspiration (choking) precautions. The Certified Nursing Assistant Worksheet (guide used by staff to provide care) dated 6/27/24 documented Resident #29 was a limited assist of 1 person for eating and was on all aspiration precautions. Resident #29's meal tickets dated 7/29/24 through 8/1/24 documented limited assist at the bottom of the meal ticket in all capital letters in red and the resident required level 5 diet (minced meat) and regular liquids. The Nursing Progress note dated 7/29/24 at 9:41 AM documented Resident #29 had complaints of trouble swallowing water. The Nursing Progress noted dated 7/29/24 at 1:15 PM documented a new order was placed per the nurse practitioner (NP): Swallow Therapy evaluation and treatment as indicated- trouble swallowing water. The Interdisciplinary Noted on 7/30/24 at 3:26 PM writer by the Speech Pathologist documented a swallow evaluation was completed on this date due to difficulty swallowing water. No further intervention warranted at this time. Continue with current diet recommendations. During a continuous observation on 7/31/24 from 10:22 AM to 2:22 PM Resident #29 was seated in the recliner in their room. At 11:57 AM Resident #29 was served their lunch tray and staff exited the room and closed the door behind them. At 12:06 PM Resident #29 was observed in their recliner in their room attempting to eat their lunch. During an interview at this time Resident #29 stated they were having difficulty getting food onto the fork. Resident #29 stated staff never come into the room to help them eat unless they ask for assistance. At 12:45 PM a Unit Helper #1 knocked on the resident's room and asked if they were finished with their meal, took the tray, and exited the room. No staff helped or checked on the resident while they were eating their meal. The resident consumed 50 percent of their meal. During a continuous observation and interview on 8/1/24 from 8:12 AM to 8:49 AM Resident #29 was in recliner in their room. Residents breakfast tray was delivered at 8:18 AM. At 8:19 AM. The certified nurse aide exited the room and continued passing meal trays. At 8:46 AM, Certified Nurse Aide #7 entered Resident #29's room to collect their breakfast tray. At this time Certified Nurse Aide #7 looked at the meal ticket and stated Resident #29 was a limited assist. Certified Nurse Aide #7 stated when a resident was a limited assist for eating it means they need help, and the staff should be always there to assist them. At 8:49 AM Certified Nurse Aide #7 pulled up Resident #29's care plan on the kiosk and stated the resident was on aspiration precautions. When residents were on aspiration precautions it meant they may need a nurse present to watch them, so they don't choke and potentially die. Certified Nurse Aide #7 stated Resident #29 should have had someone in the room to assist them during meals because they could have choked, and no one would have been there to help them eat. The resident consumed 50 percent of their meal. During an interview on 8/1/24 at 10:32 AM, the Speech Pathologist stated all aspiration precautions meant the resident must be supervised while eating. The Speech Pathologist stated Resident #29 was on all aspiration precautions because they pocket their food (to hold food in the mouth for an extended amount of time without swallowing) and drinks and could be at risk of aspirating which could lead to pneumonia or death. During an interview on 8/1/24 at 10:44 AM, Certified Occupational Therapy Aide #1 stated Resident #29 was a limited assist for eating. Limited assist means supervision touching assist, meaning they can be checked in on during self-feeding. Certified Occupational Therapy Assistant stated they would expect staff to at least check in after the start of the meal and to make sure everything was okay, make sure they aren't having any difficulty with feeding or swallowing. Certified Occupational Therapy Assistant stated if a resident was supposed to be assisted with meals but was not, this could result in poor intake and weight loss. To their knowledge, Resident #29 has not had any weight loss or choking episodes. During an interview on 8/1/24 at 10:58 AM, Registered Nurse Unit Manager stated if a resident was a limited assist for meals they should be supervised. Registered Nurse Unit Manager stated Resident #29 was on an altered diet and at increased risk of aspirations. During an interview on 8/2/24 at 11:12 AM, the Acting Director of Nursing stated a limited assist for feeding would be touching supervision. This meant that supervising for some of the meal. Staff do not have to sit with them for the entirety of the meal, but someone should be visualizing them from time to time. The Acting Director of Nursing stated Resident #29 had a diagnosis of Parkinson's so they may need assistance because they cannot reach, may have increased spillage, trouble swallowing, have a grip strength issue or needed prompts to increase their intake. 2. Resident #63 had diagnoses which included dementia, hypertension (high blood pressure), and cognitive communication deficit (a condition that makes it difficult to communicate). The Minimum Data Set, dated [DATE] documented Resident #63 was sometimes understood, sometimes understands and was severely cognitively impaired. Additionally, the Minimum Data Set documented that Resident #63 was dependent on staff for personal hygiene including combing hair, shaving, applying makeup, washing/drying face, and hands. The comprehensive care plan dated 7/11/24 documented Resident #63 had impaired functional status for: bed mobility, transfers, walking, toileting, locomotion, eating, grooming, personal hygiene, and bathing. Interventions included dependent on staff for personal hygiene/grooming. The Certified Nursing Assistant Worksheet dated 7/11/24 documented Resident #63 was dependent on staff for personal hygiene and grooming. Review of the nursing progress notes dated 7/9-7/31/24, revealed there was no evidence of Resident #63 refusing care. During an observation on 7/29/24 at 10:43 AM, Resident #63 had numerous 0.25-inch-long white hairs covering their chin. During an observation on 7/31/24 at 6:55 AM, Certified Nurse Aide #10 and Certified Nurse Aide #16 provided morning care to Resident #63. After Certified Nurse Aide #10 and Certified Nurse Aide #16 transferred Resident #63 to their chair, Certified Nurse Aide #16 left the room while Certified Nurse Aide #10 combed Resident #63's hair. Certified Nurse Aide #10 did not offer or attempt to remove Resident #63's facial hair, before the completion of morning care. During observations and interviews on 7/31/24 at 7:28 AM, Certified Nurse Aide #10 stated facial hair was removed on shower days and as needed. Licensed Practical Nurse #4 entered the room to assist with the foot pedals of the wheelchair. Certified Nurse Aide #10 looked at Resident #63's chin, felt their facial hair, and then stated, this is presentable. Licensed Practical Nurse #4 then looked at Resident #63's chin and stated they needed their facial hair to be removed. Certified Nurse Aide #10 stated they would go get razors. During an interview on 7/31/24 at 7:30 AM, Licensed Practical Nurse #4 stated Resident #63 had facial hair that needed to be removed. They stated it was important to remove the facial hair because it was a dignity concern for Resident #63. During an interview on 7/31/24 at 7:33 AM, Certified Nurse Aide #16 stated they had noticed Resident #63 had facial hair and removal of the facial hair should have been completed during morning care. Certified Nurse Aide #16 stated Resident #63 was unable to make their needs known and was dependent on staff for all their needs. During an interview on 8/1/24 at 11:07 AM, Registered Nurse #1 stated they would expect personal hygiene, including facial removal, to be completed during morning care, especially for Resident #63. Registered Nurse #1 stated it was not ok for the certified nurse aide not to provide facial hair removal for Resident #63 because it was a dignity concern. During an interview on 8/2/24 at 11:06 AM, Acting Director of Nursing #1 stated it was expected that the certified nurse aides provided appropriate grooming for the residents including removal of facial hair. Acting Director of Nursing #1 stated facial hair was considered a dignity issue and staff members needed to remember what Resident #63 would have wanted prior to admitting to the skilled nursing facility. They stated even when Resident #63 was on Covid precautions, it was still an expectation to provide all morning care including facial hair removal. 10NYCRR 415.12(a)(3)

Based on interview and record review conducted during the Extended Recertification Survey completed on 8/2/24, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and the Director of Nursing (DON) were acted upon. The attending physician must document in the medical record that the identified irregularity has been reviewed and what action should be taken. Specifically, the facility did clarify the providers orders to continue or discontinue a medication based on the pharmacy consultant's recommendation. The finding is: The policy and procedure titled Unnecessary Drugs dated 8/6/15 documented that during the monthly medication regimen review, the pharmacist evaluates resident-related information for dose, duration, continued need, and the emergence of adverse consequences for all medication. When evaluating the resident's progress, the practitioner reviews the total plan of care, orders, the resident's response to medication and determines whether to continue, modify, or stop a medication. The policy and procedure documented that the pharmacist must report any irregularities to the attending physician, and the director of nursing and these reports must be acted upon. The practitioner will document an acceptable clinical indication for use of medication. Resident #19 had diagnoses that included Alzheimer's disease, delirium, and cognitive communication deficit. The Minimum Data Set (a resident assessment tool) dated 6/12/24 documented that Resident #19 was severely cognitive impaired. The Minimum Data Set documented Resident #19 was taking an antidepressant and antipsychotic medications. Review of the Comprehensive Care Plan with dated 6/14/24, documented Resident #19 was receiving psychotropic therapy relate to the diagnosis of dementia. Their target behaviors were weepiness. Medications included Zyprexa (olanzapine), Lexapro (escitalopram) and Trazodone (an antidepressant medication). Interventions included medication reductions as indicated, pharmacy consultant review as need, and psychology consults as indicated. The Physician's Orders dated 8/2/24 documented Resident #19 had a current order for escitalopram 5 milligrams once a daily with a start date of 12/28/24; Trazadone 50 milligram twice a day with a start date of 4/25/24; and olanzapine 5 milligrams daily with a start date of 10/18/23. Review of the Consultant Note for April 15, 2024, revealed the Pharmacy Consultant documented that Resident #19 was due for a gradual dose reduction (GDR) review for Trazadone and olanzapine. The Pharmacy Consultant documented to consider decreasing Trazadone 50 milligrams twice a day and to consider decreasing olanzapine to 2.5 milligrams daily. Nurse Practitioner #1 signed and dated the recommendation on 4/25/24 with a notation to decrease Trazadone to 50 milligrams twice daily. Nurse Practitioner #1 did not document a rational to agree or disagree with the recommendation to consider a decrease of the olanzapine. Review of the Consultant Note for June 13, 2024, the Pharmacy Consultant documented that Resident #19 was due for a gradual dose reduction review for escitalopram. The Pharmacy Consultant documented to consider discontinuing the escitalopram. Physician Assistant #1 signed and dated the recommendation on 6/24/24 with a notation decline GDR (gradual dose reduction). Nurse Practitioner #1 signed and dated the recommendation on 6/25/24 to discontinue the escitalopram. During an interview on 8/2/24 at 8:57 AM, Licensed Practical Nurse #1 stated they were not involved in the pharmacy consultant recommendation process but if a new order was handed to them, they would transcribe the new order. After review of the pharmacy consultant recommendation dated 6/13/24 for Resident #19, they stated that Physician Assistant #1 wrote decline GRD dated 6/24/24 and was unsure what that meant. Licensed Practical Nurse #1 stated Nurse Practitioner #1 also documented on the 6/13/24 pharmacy consultant recommendation on 6/25/24 to discontinue Resident #19 escitalopram. After review of Resident #19's medical provider orders, Licensed Practical Nurse #1 stated the resident remained on escitalopram and it should have been discontinued. Licensed Practical Nurse #1 stated the pharmacy consultant recommendation from 6/13/24 was not handed to them and that was the first time they reviewed the recommendation. During a telephone interview on 8/2/24 at 9:09 AM, after review of the pharmacy consultant recommendation for Resident #19 on 6/13/24 Physician Assistant #1 stated on 6/24/24 they documented on the consultant form they declined the recommendation to discontinue the escitalopram. They stated then on 6/25/24 Nurse Practitioner #1 documented to discontinue Resident #19's escitalopram. Physician Assistant #1 stated they would have expected the nursing staff to follow the most recent documented order and Resident #19 escitalopram should have been discontinued. During a telephone interview on 8/2/24 at 9:15 AM, Nurse Practitioner #1 stated pharmacy consultant recommendations were placed into the book for review. They stated after they agree/disagree with the recommendation they will hand the consult to the nurse to transcribe any new orders. After review of the 4/15/24 pharmacy consultant recommendation, they stated they agreed to a gradual dose reduction for Resident #19's Trazadone. Nurse Practitioner #1 stated they disagreed to reducing Resident #19 olanzapine and did not write a note or give a rational as to why they did not agree. Nurse Practitioner #1 added they did not feel they needed to write a justification note as to why they disagreed with the recommendation to decrease Resident #19's olanzapine. After review of the 6/13/24 pharmacy consultant recommendation, Nurse Practitioner #1 stated on 6/24/24 Physician Assistant #1 recommended not to discontinued Resident #19's escitalopram and on 6/25/24 they recommended to discontinue the escitalopram. Nurse Practitioner #1 stated they were unsure why the consult was still in their book for review if Physician Assistant #1 had already review the recommendation. Nurse Practitioner #1 stated when they signed the recommendation on 6/25/24 they want the escitalopram to be discontinued but would have expected the nursing staff to contact a provider for clarification. During a telephone interview on 8/2/24 at 9:42 AM, the Pharmacy Consultant stated they did not receive the pharmacy consultant recommendation for Resident #19 that a medical provider addressed from 4/15/24 and 6/13/24. They stated the past few months it was hit or miss if they received any of their recommendation addressed from the providers of any resident from the facility. The Pharmacy Consultant stated they would expect there to be documentation from the medical provider as to why they declined a gradual dose reduction/discontinuation for Resident #19 on the 4/15/24 recommendation. The Pharmacy Consultant stated they were unaware of the conflicting orders on Resident #19's 6/13/24 recommendation to discontinue the escitalopram. They stated they would have expected the staff to call the medical providers for clarification to be able to act upon those recommendations accordingly. During an interview on 8/2/24 at 11:57 AM, the Acting Director of Nursing stated that they were unsure of the pharmacy consultant recommendation process. After review of the pharmacy consultant recommendation for Resident #19 on 6/13/24 they stated that Physical Assistant #1 and Nurse Practitioner #1 had documented conflicting orders and was unsure which order to follow. They stated they would expect the nursing staff to follow up with a medical provider for clarification. In a further interview at 1:30 PM, the Acting Director of Nursing stated they were unable to located documented evidence that a clarification was completed, and Resident #19 remained on escitalopram. During a telephone interview on 8/2/24 at 12:34 PM, Register Nurse Unit Manager #1 stated that pharmacy consultant recommendations were printed from the electronic medical record and place into the provider acute log books for the provider to review. They stated the provider would either agree/disagree and write an order if need be. Register Nurse #1 stated the order then would be given to themselves or a floor nurse for transcription of the new order. Register Nurse #1 stated that if the medical provider disagreed with the recommendation, then the provider should be writing an explanation as to why. Register Nurse #1 stated they were unaware of the miscommunication on the 6/13/24 consultant recommendation and the nursing staff should have contacted a medical provider for clarification. 10 NYCRR 415.18 (c)(2)

Based on interview and record review, conducted during the Extended Recertification Survey completed on 8/2/24, the facility did not ensure there were services of a Registered Nurse for at least 8 consecutive hours, 7 days a week except when waived. Specifically, the facility did not have 8 consecutive hours of Registered Nurse coverage on 7/6/24, 7/19/24 and 7/21/24 as required and did not have a waiver. The finding is: 1. The Facility Assessment, dated 6/30/24, documented the facility's bed capacity was 120 beds and the average daily census at the time of the assessment was 75. The facility assessment documented the minimum number of staff required to meet the needs of the residents in a 24-hour period. For the current census, they required 8 Licensed Practical Nurses, 15 Certified Nurse Aides, and 1 Registered Nurse to safely care for their residents. The policy and procedure titled Emergency Staffing Strategies, revised 1/6/24, documented when facility staffing is at a critical level impeding on resident care, the following actions will be taken: Administrator and Director of Nursing will be notified, all current on duty staff we be asked to remain duty until it's resolved, incentives would be offered to enlist any available staff, staff agencies would be contacted, and staff from other Heritage facilities would be requested. The daily staffing sheets, reviewed from 6/29/24 through 8/1/24, documented they did not have a Registered Nurse for 8 consecutive hours, in the facility, on the following dates: 7/6/24, 7/19/24 and 7/21/24. During an interview on 8/1/24 at 11:34 AM, Scheduler #1 stated they were aware they were supposed to have a Registered Nurse in the facility for 8 hours a day, every day. They stated they thought there was coverage on 7/6/24 because there were 2 Registered Nurses on for 4 hours each, however, they were both on the same 4 hours so there was not 8 hours of coverage. On 7/19/24 the Director of Nursing was supposed to be the Registered Nurse covering, but they were unavailable. Scheduler #1 stated the Director of Nursing, and the Administrator were both made aware that there was no Registered Nurse coverage on those dates 7/19/24 and 7/21/24. Scheduler #1 stated they told them to keep trying to find coverage, but there was no coverage available. During an interview on 8/2/24 at 11:07 AM, the Acting Director of Nursing stated stated they were aware the facility had days where there was no Registered Nurse in the building. They stated if they were told there was no Registered Nurse coverage they would notify the Administrator and try to help find coverage. They themselves have been assigned to be the Registered Nurse for the facility, act as supervisor or even take a medication cart. The Acting Director of Nursing stated they thought the Administrator could contact corporate and ask for a float Registered Nurse from another building. During an interview on 8/2/24 at 12:09 PM, the Administrator stated they were aware there were days the facility did not have a Registered Nurse for the required 8 consecutive hours. They stated when they were notified there was no Registered Nurse available, they notified Corporate and attempted to find coverage. The Administrator stated Corporate was unable to provide a Registered Nurse for those days. They stated it was important to have a Registered Nurse in the facility to conduct resident assessments and to provide care that a Licensed Practical Nurse could not perform. They understood that it was essentially the Administrators responsibility to ensure safe nursing coverage in the facility. 10 NYCRR 415.13 (b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an Extended Recertification Survey completed on 8/2/24 the facility did not ensure that all residents were free from neglect and mistreatment for five (Residents #15, #19, #20, #30, and #40) of ten residents reviewed. Specifically, the facility did not check, offer, and provide incontinence care to meet the needs of the residents. The findings are but not limited to: The policy and procedure titled Resident Abuse Prevention Reporting System revised on 1/29/24, documented that it is the facility's policy that residents have the right to be free from neglect and mistreatment, and it is the facility's mission to provide the highest quality, safest, and most compassionate care to all residents. The policy documented neglect was the deprivation of goods or services that are necessary to attain or maintain, physical, mental, and psychosocial well-being. Review Your Rights as a Nursing Home Resident in New York State dated 2022 documented as a resident in this facility, you have rights guaranteed to you by state and federal laws. Your rights strongly emphasize individual dignity and self-determination, promoting your independence and enhancing your quality of life. You have the right to be free be cared for in a manner that enhances your quality of life and receive adequate and appropriate care. Review of the nursing policy and procedure titled Care of Incontinent Resident with a revision date of 10/7/21 documented the objective is to keep the resident with problems of involuntary elimination, clean and dry in order to promote cleanliness, comfort, dignity and to prevent skin issues. Per Acting Director of Nursing this policy is the equivalent to the check and change system in place in the facility. 1. Resident #19 had diagnoses that included Alzheimer's disease, cognitive communication deficit and need for assistance with personal care. The Minimum Data Set (a resident assessment tool) dated 6/12/24 documented Resident #19 was severely cognitively impaired, was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. The comprehensive care plan dated 6/14/24, documented Resident #19 required total assist of two staff members with a mechanical lift for transfers; total assist of two staff members to/from bed for check and change for toileting. The care plan documented Resident #19 had urinary incontinence used incontinence briefs. The Certified Nursing Assistant Worksheet (guide used by staff to provide care) dated 7/31/24 documented Resident #19's required total assist of two staff members for a check and change for toileting. Resident #19 used incontinence briefs. During an observation on 7/31/24 at 9:22 AM, Resident #19 was observed to be sleeping in their wheelchair at a table in the activity/dining room on the North Unit wearing pants and a shirt. At 10:00 AM, Resident #19 was observed in the same location and position. A continuous observation was started. Resident #19 remained in the room until 1:22 PM when Certified Nurse Aide #6 and #4 exited the room with the resident. During this time staff did not check, change or toilet the resident. Certified Nurse Aides #6 and #4 wheeled Resident #19 to their room and provided care. There was a strong urine odor noted when Resident #19 was lifted out their wheelchair with the mechanical lift. The resident's pants were visibly wet, and their incontinence brief was heavily saturated with urine and a small amount of stool. During an interview on 7/31/24 at 2:06 PM, Certified Nurse Aide #6 stated at 7:15 AM they provided Resident #19 with morning care and got them out of bed. They stated they did not provide any further care to Resident #19 until 1:22 PM. Certified Nurse Aide #6 stated per Resident #19's care plan they were a check and change for toileting which meant Resident #19 did not use the toilet. Certified Nurse Aide #6 stated Resident #19 should have been placed into bed, checked for incontinence, and if needed, had incontinence care provided. Certified Nurse Aide #6 stated they did not have enough time to check the resident after breakfast because they were still providing morning care to the other residents on their assignment and helping the other staff get residents out of bed. They stated it was important to provide incontinence care to maintain the resident's dignity, to keep them clean and prevent sores. In a further interview on 8/2/24 at 10:15 AM, Certified Nurse Aide #6 stated that definition of neglect would be not tending to a resident in a timely manner. They stated not being able to provide timely incontinent care would be neglect. During an interview on 7/31/24 at 2:31 PM, Licensed Practical Nurse #1 stated that check and change meant that an incontinent resident needed to be checked every two hours and changed if soiled. They stated Resident #19 should have been provided incontinence care every two hours because they could not verbalize when they needed to use the bathroom. Licensed Practical Nurse #1 stated Resident #19 had a recent history of pressure ulcers on their sacrum. During an interview on 8/1/24 at 2:30 PM, Licensed Practical Nurse #1 stated they would consider not providing residents with timely incontinence care a form a neglect because the facility was not able to meet the needs of the residents. During an interview on 7/31/24 at 6:40 PM, Registered Nurse #2 (Nursing Supervisor) stated on average there were two aides per unit, and they cannot complete all their duties with that ratio. Registered Nurse #2 stated that incontinence care did not get completed every 2-4 hours and should be. They stated the off-going aides give report to the oncoming aides as to which residents did not receive incontinence care so those residents would be a care priority. Registered Nurse #2 stated then that process rolls from shift to shift. Registered Nurse #2 stated the residents are safe, but they are getting an inadequate amount of nursing care. During an interview on 8/1/24 at 2:33 PM, Registered Nurse Unit Manager #1 stated they knew incontinence care was not being delivered timely but would not consider it neglect because the facility was attempting to do something about it. Registered Nurse #1 stated the reason certified nurse aides were doing walking rounds at change of shift was to identify which resident were not toileted appropriately and those residents needed top priority by the oncoming shift. During an interview on 8/2/24 at 8:58 AM, Certified Nurse Aide #4 stated it was neglectful to the residents if they were not provided with incontinence care at every two hours and as needed. 2. Resident #40 had diagnoses which included dementia, dysphagia (difficulty swallowing), and urinary incontinence. The Minimum Data Set, dated [DATE] documented Resident #40 was severely cognitively impaired and was dependent on staff for all aspects of care. Resident #40's comprehensive care plan dated 5/23/24 documented the resident had urinary incontinence and skin will break down due to incontinence. Resident #40 required a total assist of 2 persons for toileting and was on a check and change schedule. During a continuous observation on 7/31/24 from 10:20 AM to 2:22 PM Resident #40 was seated in their Geri-chair in the activity/dining room. The staff did not offer, check, change or provide the resident with toileting or incontinence care. During an observation on 7/31/24 at 3:43 PM Resident #40 was still seated in the same location in the activities/dining room. There were 7 other residents present in the room. Resident #40's pants in their groin area were visibly wet with urine. During an interview and observation on 7/31/24 at 3:44 PM Certified Nurse Aide #1 stated they were assigned Resident #40 that morning and was working until 6:00 PM because they were short staffed. They stated they reported off to the oncoming shift that Resident #40 had not been changed since 9:30 AM and would be a priority for them. During an observation of incontinence care completed by Certified Nurse Aide's #1 and #8. Resident #40's brief was heavily saturated with dark urine and there were indentations on the resident's buttocks from their incontinence brief. Certified Nurse Aide #1 stated the brief was saturated with urine and Resident #40 should have been changed sooner. We typically try to change residents every 2-4 hours, but they just don't have enough time to get everyone done. During an interview on 8/1/24 at 10:58 AM, Registered Nurse Unit Manager #1 stated Resident #40 should not have had soaked pants and when that occurs, they expected staff to prioritize and immediately remove them from any public area and change them. During an interview on 8/1/24 at 12:56 PM, Certified Nurse Aide #1 stated by Resident #40 not being changed in the 2-4-hour time frame on 7/31/24 was neglect. Not intentional neglect but it falls on the fact that there was not enough staff and enough time. They stated this could lead to falls, skin break down, and urinary tract infections. 3. Resident #20 had diagnoses which included dementia, anxiety disorder, and cognitive communication deficit. The Minimum Data Set, dated [DATE] documented Resident #20 was severely cognitively impaired, does not exhibit behaviors of rejection of care and was always incontinent of urine and occasionally incontinent of bowels. Resident #20's comprehensive care plan dated 2/27/24 documented the resident required extensive assistance of one with rolling walker/ grab bar for transfers to and from toilet. Staff to assist with all tasks. Additionally, it documented the resident was at increased risk for urinary incontinence. Interventions included the resident used incontinence products and the resident's incontinence would be managed. Resident #20's Certified Nursing Assistant Worksheet dated 7/31/24 documented the resident required extensive assistance of one with rolling walker/ grab bar for transfer to and from toilet. Staff to assist with all tasks and the resident used incontinence products. During a continual observation on 7/31/24 at 12:03 PM to 2:33 PM Resident #20 was sitting in their wheelchair at a table in the dining room. During an interview on 7/31/24 at 2:15 PM, Certified Nurse Aide #6 stated they heard Certified Nurse Aide #7 tell Certified Nurse Aide #5 they were unable to provide incontinent care to Resident #20 because they didn't have time. During an interview on 7/31/24 at 2:18 PM, Certified Nurse Aide #5 stated they were informed by Certified Nurse Aide #7 that they were unable to provide incontinence care to Resident #20 because they didn't have time. They stated they assumed Resident #20 last received incontinence care around breakfast time (8 AM). They stated that Resident #20's care plan does not specify how often incontinence care was to be provided but it was expected that Resident #20 was to be offered toileting or incontinence care every 2 hours. During an observation and interview on 7/31/24 at 2:33 PM, Certified Nurse Aide #5 provided toileting and incontinence care to Resident #20. Resident #20's brief was odorous and heavily saturated with urine from the front waistline to back waistline of the entire brief. Certified Nurse Aide #5 stated the brief was saturated with urine and the resident should have been provided with incontinence care every 2 hours and can't ask to be toileted. During an interview on 7/31/24 at 2:43 PM, Registered Nurse #1 Unit Manager stated they expected incontinent residents to be toileted every 2 - 4 hours. During an interview on 8/1/24 at 8:08 AM, Licensed Practical Nurse #4 (Infection Preventionist /Nurse facilitator) stated they would expect the staff to check and provide incontinence care at least every 4 hours to promote skin integrity, resident dignity and prevent urinary tract infections. They stated if incontinence care was not completed at least every 4 hours it was considered neglect. During an interview on 8/1/24 at 8:55 AM, Certified Nurse Aide #7 stated they toileted Resident #20 at 7:30 AM on 7/31/24 and were unable to provide toileting or incontinence care the remainder of that day. They stated they had reported to the oncoming aide Certified Nurse Aide #5 that Resident #20 needed to be provided with toileting and incontinence care. They stated Resident #20 was always incontinent and should have been provided incontinence care every 2 to 3 hours and wasn't. During an interview on 8/1/24 at 9:48 AM, the Administrator reviewed the facility policy Care of Incontinent Resident and stated the policy does not provide direction how often an incontinent resident requires care therefore they don't know how often staff should provide incontinence care. During an interview on 8/2/24 at 11:07 AM, Acting Director of Nursing #1 stated incontinence care should be done twice a shift and as needed. Certified Nurse Aides should check for signs like the resident being antsy or if there was an odor. It was important for skin, comfort, and dignity. Acting Director of Nursing #1 stated the residents that were left in their soiled briefs for extended amounts of time (6-8 hours), based on policy and the definition of neglect, they would have to agree that the situation meets the definition of neglect. During an interview on 8/2/24 at 12:09 PM, the Administrator reviewed of the facilities policy and definition of neglect and stated they do not feel the facility was being neglectful by not providing timely incontinence care. During a telephone interview on 8/2/24 at 10:26 AM, the Medical Director stated that appropriate toileting time frame for an incontinent resident would be every two to four hours. They stated that there would be concerns for skin breakdown with a resident was not being toileted or changed for 6 or more hours. 10NYCRR 415.4(b)(1)(i)

Based on observation, interview and record review conducted during the Extended Recertification Survey completed on 8/2/24 for two (North Unit and East Unit) of two resident care units the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not have adequate nursing staff based on the facility's established minimum number of staff for each shift. Additionally, there was a lack of sufficient nursing staff to provide timely care to meet the needs of the residents. This involves residents #15, 19, 20, 29, 30, 40, 45, 51, & 64. The findings are: Refer to F600 Neglect- scope and severity = F During the entrance conference on 7/29/24 at 9:40 AM, the Administrator stated the current facility census was 71 residents. The policy and procedure titled Emergency Staffing Strategies, revised 1/6/24, documented when facility staffing is at a critical level impeding on resident care, the following actions will be taken: Administrator and Director of Nursing will be notified, all current on duty staff we be asked to remain duty until it's resolved, incentives would be offered to enlist any available staff, staff agencies would be contacted, and staff from other Heritage facilities would be requested. a. The Facility Assessment, dated 6/30/24, documented the facility's bed capacity was 120 beds and the average daily census at the time of the assessment was 75. The facility assessment documented the minimum number of staff required to meet the needs of the residents in a 24-hour period. For the current census, they required 8 Licensed Practical Nurses, 15 Certified Nurse Aides, and 1 Registered Nurse to safely care for their residents. The Minimum Nursing Staff breakdown provided by Scheduler #1, on 7/30/24 at 9:04 AM, documented the day shift (6:00 AM to 2:00 PM) minimum staffing was 3 nurses and 6 Certified Nurse Aides, evening shift (2:00 PM to 10:00 PM) minimum staffing was 3 nurses and 6 Certified Nurse Aides, and night shift (10:00 PM to 6:00 PM) minimum staffing was 2 nurses and 3 Certified Nurse Aides. The document did not list the requirement of a Registered Nurse. The daily staffing sheets, reviewed from 6/29/24 to 8/1/24, documented the facility did not meet their minimum number of staff on the following dates: 6/29/24 6:00 AM to 2:00 PM down 1 Certified Nurse Aide 7/5/24 6:00 AM to 2:00 PM down 1 Certified Nurse Aide 7/6/24 6:00 AM to 2:00 PM down 1 Certified Nurse Aide 10:00 PM to 6:00 AM down 1 Certified Nurse Aide and no Registered Nurse 7/7/24 6:00 AM to 2:00 PM down 0.5 Certified Nurse Aide 7/8/24 6:00 AM to 2:00 PM down 2 Certified Nurse Aides 2:00 PM to 10:00 PM down 2 Certified Nurse Aides 7/9/24 2:00 PM to 10:00 PM down 1 Certified Nurse Aide 7/11/24 6:00 AM to 2:00 PM down 1 Certified Nurse Aide 7/13/24 6:00 AM to 2:00 PM down 1 Certified Nurse Aide 2:00 PM to 10:00 PM down 1 Certified Nurse Aide 7/14/24 6:00 AM to 2:00 PM down 1 Certified Nurse Aide 7/15/24 6:00 AM to 2:00 PM down 1 Certified Nurse Aide 2:00 PM to 10:00 PM down 1 Certified Nurse Aide 7/16/24 6:00 AM to 2:00 PM down 2.5 Certified Nurse Aides 2:00 PM to 10:00 PM down 1.5 Certified Nurse Aides 7/17/24 6:00 AM to 2:00 PM down 3.5 Certified Nurse Aides 10:00 PM to 6:00 AM down 1 Licensed Practical Nurse, Director of Nursing as staff 7/18/24 6:00 AM to 2:00 PM down 3.5 Certified Nurse Aides, down 1 Licensed Practical Nurse & 1 Licensed Practical Nurse worked as Certified Nurse Aide 2:00 PM to 10:00 PM down 1 Certified Nurse Aide 10:00 PM to 6:00 AM down 1 Licensed Practical Nurse, Director of Nursing as staff 7/19/24 6:00 AM to 2:00 PM down 3 Certified Nurse Aides, no Registered Nurse 7/20/24 6:00 AM to 2:00 PM down 1.5 Certified Nurse Aides 7/21/24 6:00 AM to 2:00 PM down 3.5 Certified Nurse Aides, no Registered Nurse 7/22/24 6:00 AM to 2:00 PM down 2 Certified Nurse Aides 2:00 PM to 10:00 PM down 1 Certified Nurse Aide 7/23/24 6:00 AM to 2:00 PM down 3 Certified Nurse Aides 2:00 PM to 10:00 PM down 1.5 Certified Nurse Aides 7/25/24 2:00 PM to 10:00 PM down 1 Certified Nurse Aide 7/26/24 6:00 AM to 2:00 PM down 1.5 Certified Nurse Aides 2:00 PM to 10:00 PM down .5 Certified Nurse Aide 7/27/24 6:00 AM to 2:00 PM down .5 Certified Nurse Aide 7/28/24 6:00 AM to 2:00 PM down 2 Certified Nurse Aides 10:00 PM to 6:00 AM down 1 Licensed Practical Nurse & Director of Nursing as staff 7/29/24 6:00 AM to 2:00 PM down 1 Certified Nurse Aide 2:00 PM to 10:00 PM down 1 Certified Nurse Aide 8/1/24 6:00 AM to 2:00 PM down 3.5 Certified Nurse Aides During an interview on 8/1/24 at 11:34 AM, Scheduler #1 stated they knew staffing was bad. Scheduler #1 reviewed the staffing sheets and stated the facility did not meet their minimum staffing numbers. They stated they used the Minimum Nursing Staff numbers as a guide when they made the schedule. When there was not enough staff they would offer incentives, including double hourly pay, plus overtime, and they requested staff from agencies and the float pool. Scheduler #1 stated there were 5 agencies contracted, but only 1 was currently supplying staff to the facility. Scheduler #1 stated the Director of Nursing, and the Administrator were both aware they were not meeting their minimum staffing numbers. b. Review of the Resident Council minutes on 7/29/24 revealed staffing concerns were discussed in April 2024. May 2024 minutes residents complained of not getting their showers. The facility response was to add new staff agencies to their staff pool. In June 2024 they discussed the new agency staff during the meeting, but the residents' responses were not documented. During an interview on 7/30/24 at 11:36 AM, the Ombudsman stated the residents had concerns with staffing at the facility. They stated the Administrator was aware of the residents' concerns. During an interview at the Resident Council meeting on 7/30/24 at 1:41 PM, Resident #45 stated there was one time when they sat on the toilet for two hours before staff answered the call bell and assisted them off the toilet. During an interview on 7/30/24 at 1:41 PM, Certified Nurse Aide #12 stated they frequently worked with just one nurse aide on the North Unit. Certified Nurse Aide #12 stated they did not have time to provide incontinence care every two hours as they should or have time to give residents their showers. During an observation on 7/30/24 at 3:11 PM, Resident #51 and Resident #64 were observed to be sitting in the North Unit common area wearing hospital gowns. The residents were not able to be interviewed. During an interview on 7/30/24 at 3:26 PM, Certified Nurse Aide #3 stated they put Resident #51 and #64 in hospital gowns after they provided incontinence care. They stated that they had two other residents on the bed pan and needed to change Resident #51 and #64 quickly out of their clothes because they were wet with urine. Certified Nurse Aide #3 stated that it was common practice for the outgoing aide not to have enough time in their shift to provide incontinence care. During an interview on 7/31/24 at 6:01 AM, Certified Nurse Aide #2 stated they had worked as the only aide on night shift at times (census 37). Certified Nurse Aide #2 stated they were able to get through 2 rounds on night shift but were unable to complete a 3rd round. They stated the first round of the night took longer, about 3-4 hours, to clean up everything from the evening shift. During an interview on 7/31/24 at 7:04 AM, Certified Nurse Aide #4 stated they were frequently short staffed and worked with only 2 aides on the day shift. They stated when there were 2 Aides, they were unable to provide incontinence care to all the residents, especially after lunch because they assisted residents with their meal and their shift ended at 2:00 PM. They stated they have had family members complain to them that there was not enough staff. Certified Nurse Aide #4 stated when there was only 1 aide on the North Unit (census 34) it was not possible to follow the care plans for all the residents. During an interview on 7/31/24 at 7:32 AM, Certified Nurse Aide #6 stated they have worked with 2 aides on the day shift in the last 7 days and it was not possible to provide care to all the residents that require incontinence care according to their plan. During an interview on 7/31/24 at 7:34 AM, Licensed Practical Nurse #1 stated the facility was short staffed almost every day, and it was reported to them almost daily, that the aides were unable to complete all their work before they leave at 2:00 PM. They had reported the concerns to Registered Nurse Unit Manager #1 on multiple occasions. Licensed Practical Nurse #1 stated the Director of Nursing was aware incontinence care was not being completed timely, but the staff were informed they must complete their charting before they leave the facility making staff choose charting over care. During an interview on 7/31/24 at 8:24 AM, Registered Nurse Unit Manger #1 stated they were the Manager for both the East and North Units, and the Supervisor for the day shift. Frequently there were 2 aides on the day shift and were aware the aides were voicing concerns that they were unable to provide care timely and follow the resident's care plans. Registered Nurse Unit Manager #1 stated corporate had a staff meeting which they attended May 8th, 2024; and stated many of the nurse aides voiced they were unable to provide care according to care plans because of the short staffing. During an observation on 7/31/24 at 9:22 AM, Resident #19 was sleeping in their wheelchair at a table in the activity/dining room on the North Unit. At 10:00 AM, Resident #19 was in the same location and position. A continuous observation was started, and Resident #19 was not removed from the room until 1:22 PM when Certified Nurse Aides #6 and #4 exited the room with the resident. Certified Nurse Aides #6 and #4 wheeled Resident #19 to their room to provide incontinence care. During the care observation, a strong urine odor was noted while Resident #19 was being lifted out of their wheelchair with the mechanical lift. The resident's pants were visibly wet, their brief was saturated with urine and a small amount stool. During an interview on 7/31/24 at 2:06 PM, Certified Nurse Aide #6 stated at 7:15 AM they provided Resident #19 with morning care and got them out of bed. They stated they did not check Resident #19 after breakfast for incontinence because they were still providing morning care to the other residents on their assignment and helping other staff get residents out of bed. They stated when they provided care after lunch, the resident had a strong odor of urine, and their pants were wet. During an interview and observation on 7/31/24 at 11:14 AM, Resident #29 stated they were told at 9:00 AM the aide would be in to do their morning care and get them dressed. The aide did not return until after 11:00 AM. Resident #29 stated they would like to be dressed before they ate their breakfast. During a continuous observation on 7/31/24 from 10:20 AM to 2:22 PM Resident #40 was seated in their Geri chair (a reclining chair with wheels) in the activity/dining room on the East Unit. At 3:43 PM, Resident #40 was still in the same location and the resident's pants were visibly wet in their groin area. During an observation on 7/31/24 at 2:00 PM Certified Nurse Aide #1 was heard giving report to the oncoming shift. They stated at least 4 residents on that hall (East Unit) had not been changed since before breakfast. During a continuous observation on 7/31/24 from 10:20 AM to 2:15 PM Resident #15 was in the activity/dining room on the East Unit. Resident #15 was not checked for incontinence or provided with incontinence care. During an interview and observation on 7/31/24 at 3:44 PM, Certified Nurse Aide #1 stated they were assigned Resident #40 that morning and were working until 6:00 PM because they were short staffed. They reported off to the next shift that Resident #40 was a priority because they had not been changed since 9:30 AM. During an interview on 8/1/24 at 12:56 PM, Certified Nurse Aide #1 stated they were not able to properly care for all the residents on their assignment because of the lack of staffing. Certified Nurse Aide #1 stated they received calls and texts from facility messaging system daily asking to pick up shifts. They stated they were tired and burned out from working so many 12 to 16-hour shifts. Certified Nurse Aide #1 added sometimes there were other duties like showers that do not get completed. During an interview on 7/31/24 at 2:18 PM, Certified Nurse Aide #5 stated they received report from Certified Nurse Aide #7 that they were unable to provide incontinence care to Resident #20 this afternoon because they were short staffed and ran out of time. They stated, that almost daily, some residents didn't receive incontinence care according to their care plan. During an observation on 7/31/24 at 2:33 PM Certified Nurse Aide #5 took Resident #20 to their room and provided incontinence care. The resident's incontinence brief was saturated with urine. During a continuous observation on 7/31/24 from 10:30 AM until 2:30 PM, Resident #30 was seated in their Geri chair (a reclining chair with wheels) in the activity/dining room on the North Unit. Resident #30 was fidgety, placed legs over arms of Geri chair and at times attempting to stand. Resident #30 was not checked or provided incontinence care during this time. During an interview on 7/31/24 at 6:45 PM, Certified Nurse Aide #5 stated they provided incontinence care to Resident #30 at 4:45 PM. They stated that the off going aide did not report to them that Resident #30 was a priority and when they provided care, the resident's brief was saturated with urine. Certified Nurse Aide #5 stated they only complete a toileting round at the beginning of the shift and then when they put the resident to bed for the night because of low staffing numbers. During an interview on 7/31/24 at 6:21 PM, Certified Nurse Aide #11 stated they normally work with one or two other aides on the evening shift and cannot get their work completed. Sometimes it took them until 7:45 PM to finish assisting residents with their dinner and they would have to leave some residents for night shift to put to bed. During an interview on 7/31/24 at 6:40 PM, Registered Nurse #2, Nursing Supervisor stated there had been a shortage of nursing staff in the building. On average there were two aides per unit, and they could not complete their duties and meet the residents needs with that ratio of aides to residents. Registered Nurse #2 stated when there was only one or two aides per unit there was not enough minutes in a shift to complete toileting every 2-4 hours per resident. Registered Nurse #2 stated the residents were safe, but they were getting an inadequate amount of nursing care due to the low staffing numbers. During an observation on 8/1/24 at 8:20 AM, revealed the North Unit was in the process of assisting the residents with their breakfast. At 8:37 AM Resident #30 was wheeled into the activity/dining on North Unit and their breakfast tray placed in front of them. Resident #30 reached for a slice of toast and began eating it before they were placed in proper position and their tray completely set up. During an interview on 8/1/24 at 8:32 AM, Licensed Practical Nurse #1 stated that they arrived to work at 2:00 AM and they were working (at the time of the interview) as a nurse and an aide due on the North Unit. They stated that breakfast trays were usually delivered between 7:30 AM - 7:45 AM and Resident #30 was eating breakfast almost an hour late. During an interview on 8/1/24 at 8:55 AM, Certified Nurse Aide #7 stated they provided incontinence care once on 7/31/24 at 7:30 AM and was unable to offer toileting or provide incontinence care the remainder of the day because of short staffing. They stated they had not informed the nurses that day regarding the inability to complete care and follow care plans because it was an ongoing issue. The nurses, the Director of Nursing and Administrator all knew this was a daily issue and we were told to do the best we can. During an interview on 8/1/24 at 10:29 AM, Licensed Practical Nurse/ Nurse Facilitator #4 stated with the low staffing numbers, they did not feel staff could provide good care for the residents. Licensed Practical Nurse #4 stated the Director of Nursing, the Administrator and Corporate were all aware that staff were unable to provide good care for the residents, and follow their care plans, with the current staff levels. During an interview on 8/1/24 at 10:44 AM, Registered Nurse #1 Unit Manager stated they expected staff to provide incontinence care timely and for staff to try their best. It was expected the on-coming shift make those residents who were not provided incontinence care a priority. During an interview on 8/2/24 at 11:07 AM, the Acting Director of Nursing, stated they were aware the facility was not meeting their minimum staffing numbers and they did not feel that staff could get their work done, including incontinence care, and serving meals. They stated the Administrator and Corporate were aware they were not meeting their minimum staffing numbers. They stated there were meetings with administration and corporate, where staff voiced their concerns about not being able to provide care to the residents. During an interview on 8/2/24 at 12:09 PM, the Administrator stated the Facility Assessment did reflect accurate minimum staffing numbers. They stated they were aware they were not meeting their minimum staffing. The Administrator stated that staff had come to them and told them they could not get their work done because of low staffing. During an interview on 8/2/24 at 1:49 PM, the Corporate Director of Skilled Nursing Facilities Administration stated they were aware the facility was not meeting their minimum nurse staffing numbers. They felt the staff could get their work done with the numbers they had, but that was not their goal. They did attend the corporate/staff meetings but did not recall staff specifically saying they could not get their work done. 10 NYCRR 415.13 (a)(1)(i)

Based on observation, interview and record review conducted during the Extended Recertification survey completed on 8/2/24, the facility did not ensure a Quality Assurance and Performance Improvement program (QAPI) developed, implemented, monitored, maintained effective systems, and used feedback to develop an appropriate plan of action to correct identified deficiencies. Specifically, the facility administration was aware of the continued non-compliance with sufficient nursing staff and the concerns brought forth by staff, resident council, and advocates. The facility QAPI plan was ineffective and was not maintained to a correct a quality deficiency identified on the previous recertification survey to ensure there was sufficient nursing staff to meet the needs of each resident. The finding is: Review of the facility document titled QAPI Plan (Quality Assurance Performance Improvement) dated 2024 documented the organization is to take a proactive approach to continually improve the way we care for and engage with the residents, caregivers, and other partners. The Plan documented that aspect of service and care are measured against established performance goals and the key monitors are measured and trended on a quarterly basis. The plan documented that the if a performance goal is not being met the facility will conduct a root cause and analysis and develops a performance improvement projection utilizing plan, do, study, act cycles to meet the goal by an established date. The plan documented that a facility goal would be to review and enhance the quality of care of its residents in the following area (unity in action): activities, hairdressers, resident meals, and staffing modifications to help resident care. The plan also documented that a facility goal would be to develop a stable workforce by decreasing the annual turnover at or below 33% for all departments. Refer to F725 Sufficient Nursing Staff scope and severity F Refer to F600 Free from abuse and neglect scope and severity F Refer to F727 Registered 8 hours/7 days/week scope and severity E Review of Recertification Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date of 8/12/22 revealed the facility was cited at F-725 for the lack of sufficient nurse staffing to meet the care needs of the residents. The facilities corrective action plan included adequate staff will be provided to ensure residents will be served and fed in an appropriate amount of time. Call bell wait times will be adequate, showers/baths will be provided. Trend analysis data will be reviewed by QAPI trends or issues will be discussed and recommendations for improvement will be made as needed. Review of the facility's Continuous Quality Improvement Quarterly Report agenda dated July 25, 2023; October 31,2023; and February 6, 2024, documented that turnover statistic were review at the meeting. Review of the Facility Continuous Quality Improvement Quarterly Report agenda date April 23,2024 documented that turnover statistics and current nursing coverage was reviewed at the meeting. Review of the Resident Council minutes on 7/29/24 revealed staffing concerns were discussed in April 2024. May 2024 minutes residents complained of not getting their showers. The facility response was to add new staff agencies to their staff pool. In June 2024 they discussed the new agency staff during the meeting, but the residents' responses were not documented. During an interview on 7/30/24 at 11:36 AM, the Ombudsman stated the residents had concerns with staffing at the facility. They stated the Administrator was aware of the residents' concerns. During an interview on 8/2/24 at 11:07 AM, the Acting Director of Nursing, stated they were aware the facility was not meeting their minimum staffing numbers and they did not feel that staff could get their work done, including incontinence care, and serving meals. They stated the Administrator and Corporate were aware they were not meeting their minimum staffing numbers. The Acting Director of Nursing also stated they were aware the facility had days where there was no Registered Nurse in the building for the required 8 consecutive hours. During an interview on 8/1/24 at 11:34 AM, Scheduler #1 stated the facility did not meet their minimum staffing numbers on several days. Scheduler #1 stated there were 5 agencies contracted, but currently only 1 was able to be used. Scheduler #1 stated the Director of Nursing, and the Administrator were both aware they were not meeting their minimum staffing numbers. During an interview on 8/2/24 at 12:09 PM, the Administrator stated they were aware that there were days the facility did not have a Registered Nurse for the required 8 consecutive hours. They stated when they were notified that there was no Registered Nurse available, they notified Corporate and attempted to find coverage. They understood that it was essentially the Administrators responsibility to ensure safe nursing coverage in the facility. The Administrator stated they were aware they were not meeting their minimum staffing. The Administrator stated that staff had come to them and told them they could not get their work done because of low staffing. During an interview on 8/2/24 at 1:07 PM, with the Acting Director of Nursing present, the Administrator stated that Quality Assurance Committee meets quarterly for a formal meeting and involves the interdisciplinary team members, the Medical Director, and a board member. The Administrator stated they were aware the facility had a cited deficiency for insufficient nursing staffing on the last recertification survey that involved the inability of staff to perform adequate care needs for the residents. The Administrator stated that had discussed as an interdisciplinary team about the need for more nurse staffing and developed interventions. The Administrator stated that they had communicated with cooperate administration about the lack of staff retention and were given more access to staffing agencies and staff incentives. The Administrator stated that the quality improvement plan was effective because it was brought out awareness that more nursing staff was needed. The Administrator stated they strive to meet the facilities minimal staffing numbers but due to call offs it is too hard to react on a short-term basis. The Administrator added the facility could always use more staff. During an interview on 8/2/24 at 1:49 PM, the Corporate Director of Skilled Nursing Facilities Administration stated they were aware the facility was not meeting their minimum nurse staffing numbers. They felt the staff could get their work done with the numbers they had, but that was not their goal. 10 NYCRR 415.27 (c)(2)(3)(v)

Based on observation, interview and record review conducted during the Standard survey started on 8/8/22 and completed on 8/12/22, the facility did not ensure the resident's right to be free from abuse for one (Resident #30) of two residents reviewed for abuse. Specifically, Certified Nursing Assistant (CNA) #4 was observed treating Resident #30 roughly and was overheard calling Resident #30 a derogatory name. The finding is: The facility policy and procedure (P&P) revision dated 11/21/2019, titled Resident Abuse Prevention Reporting System documented the facility does not condone resident abuse by anyone, including staff members. Residents have the right to be free from verbal, sexual, physical, and mental abuse. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It is also defined as, but not limited to slapping, hitting, kicking, bumping, pushing, punching and rough handling. Verbal abuse includes yelling, threatening, belittling, making rude or sarcastic remarks (whether the resident actually hears or even is incapable of hearing). 1. Resident #30 had diagnoses which included dementia, atherosclerotic heart disease (ASHD, hardening of the arteries), and osteoarthritis. The Minimum Data Set (MDS, a resident assessment tool) dated 6/8/22 documented Resident #30 had severe cognitive impairment and exhibited physical behavioral symptoms directed towards others (e.g., hitting, kicking pushing, scratching, grabbing, abusing others sexually) that occurred 1 to 3 days during the assessment period. The Comprehensive Care Plan (CCP) documented the problem area of Behavior Problem dated 10/18/21, secondary to a history of rejection of care and behavioral issues related to dementia, delusions, paranoia, and agitated behavior. Approaches included to approach Resident #30 in a calm manner, explain all care, and maintain a regular routine. During an observation on 8/10/22 at 4:25 AM Resident #30 was heard yelling stop that and get out of here from their bedroom. Resident #30 was observed flailing their right arm towards CNA #4. CNA #4 roughly pushed Resident #30's right arm, causing the residents arm to swing over and hit the left side of the residents upper body. Immediately after Resident #30's right arm made contact with their left upper body, CNA #4 stated, there, you just hit yourself (derogatory word for a spiteful, unpleasant, or disliked person), I hope that didn't feel good. During an interview on 8/10/22 at 4:31 AM, CNA #4 stated Resident #30 was combative with care, striking out. CNA #4 stated they called Resident #30 a derogatory name while stating you hit yourself, hope that didn't feel good. Additionally, CNA #4 stated they should not have called Resident #30 the derogatory name. The facility Incident Type: Verbal Abuse and Mistreatment signed and dated 8/10/22 by the Administrator documented the following: -The Administrator was notified at 4:56 AM on 8/10/22 of inappropriate physical and verbal interaction between CNA #4 and Resident #30. -The handwritten Incident/Accident Investigation Statement signed and dated 8/10/22 by CNA #4 documented Resident #30 was combative during hands on care, and accidentally hit themselves. CNA #4 documented they responded, I hope that didn't hurt you and called Resident #30 a derogatory name. -CNA #4 was terminated on 8/11/22 for verbal abuse and mistreatment to a resident. During an interview on 8/12/22 at 9:29 AM, the Administrator stated staff are educated to ensure resident safety when residents are combative, and to reapproach at a later time. Additionally, the Administrator stated staff should never roughly push a resident's extremity nor call a resident a derogatory name. 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review completed during the Standard survey conducted from 8/8/22 through 8/12/22, the facility did not ensure that a resident with an indwelling catheter (Foley-tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections (UTI) to the extent possible for two (Resident's #8, 138) of two residents reviewed. Specifically, the lack of maintaining infection control measures that included improper handling and storage of the catheter drainage bag and tubing. The findings are: The facility P&P titled Catheterization (Male) revised/reviewed 5/24/16 and the facility P&P titled Catheterization (Female) revised 1/14/15 documented to check the drainage system, urine must run directly from the level of the bladder to the drainage container without being kinked or squeezed off. Make sure that no loops of tubing fall below the level of the drainage connector. Ensure bag and tubing do not touch floor. 1. Resident #138 was admitted to the facility with diagnoses which included multiple rib fractures, hypertension (HTN), and diabetes mellitus (DM). The Minimum Data Set (MDS, a resident assessment tool) dated 7/27/22 documented the resident had modified independence with daily decision-making skills, an indwelling catheter, and had a UTI within the past 30 days. The physician's orders dated 7/20/22 documented to collect a urine sample for urinalysis (U/A) and Culture and Sensitivity (C&S). The laboratory Interim Report documented the urine culture specimen was collected on 7/27/22, and on 7/29/22 the urine culture result documented greater than 100,000 cfu (colony forming unit - number of bacteria cells/ml (milliliters)) for Citrobacter Sedlakii (bacteria) (indicating urinary tract infection). The Physicians Order dated 7/29/22 documented to place 18 Fr (French) Foley catheter for urinary retention. The physician's orders dated 7/29/22 documented an order to start ciprofloxacin (antibiotic) 250 mg (milligrams) every 12 hours for UTI and had an end date of 8/6/22. The 7/2022 and 8/2022 Medication Administration Records (MAR) documented Resident #138 was administered ciprofloxacin every 12 hours 7/30/22 through 8/5/22. During an observation on 8/9/22 at 7:45 AM Resident #138's catheter drainage bag and tubing were lying directly on the floor. At 10:37 AM the catheter drainage bag, in a privacy cover, and the tubing were lying directly on the floor. During an observation on 8/10/22 at 6:16 AM approximately 10 inches of Resident #138's catheter tubing was lying directly on the floor. At 8:04 AM the catheter tubing remained directly on the floor. During observations on 8/11/22 at 8:15 AM and 9:14 AM Resident #138's catheter drainage bag was attached to a garbage can with the bottom of the catheter drainage lying directly on the floor. During an interview on 8/11/22 at 9:24 AM, Certified Nurse assistant (CNA) #1 stated the catheter drainage bag and tubing should not touch the floor directly nor be attached to a garbage can due to bacteria and the increased risk for infection. Additionally, CNA #1 stated it is the responsibility of the CNAs to ensure proper placement of catheter drainage bag and tubing. During an interview on 8/11/22 at 9:55 AM, Licensed Practical Nurse (LPN) #1 stated the catheter drainage bag and tubing should not touch the floor nor be attached to a garbage can due to bacteria and the increased risk for infection. During an interview on 8/11/22 at 11:41 AM, the Nurse Practitioner (NP) Infection Preventionist (IP) stated the catheter drainage bag and tubing should not touch the floor because bacteria can travel up the tubing into the bladder causing UTI's. 2. Resident #8 had diagnoses including congestive heart failure, neuromuscular dysfunction of the bladder (bladder with diminished sensation), retention of urine and UTI. The MDS dated [DATE] documented Resident #8 had moderate cognitive impairment, was understood, and usually understands. The MDS documented Resident #8 had an indwelling urinary catheter. The Comprehensive Care Plan (CCP) dated 8/11/22 documented Resident #8 had a suprapubic catheter (a tube inserted into the bladder, through the abdomen, to drain urine). The CCP documented that Resident #8 required total assist with the care of the suprapubic catheter. Intermittent observations of Resident #8 from 8/9/22 through 8/10/22 revealed the following: -8/9/22 at 9:46 AM, Resident #8 was laying in their bed. Cloudy yellow urine with mucous shreds were observed in the catheter drainage tubing. -8/10/22 at 8:36 AM, Resident #8 was laying in their bed. Cloudy yellow urine with mucous shreds were observed in the catheter tubing with the drainage bag laying directly on the floor next to the bed. The drainage bag was laying drain valve side down and there was no barrier between bag and the floor. -8/10/22 at 11:42 AM, Resident #8 was in seated in their wheelchair in their room. The catheter drainage bag was inside of a privacy bag attached to the wheelchair and the drainage tubing was touching the floor. -8/10/22 at 3:09 PM, Resident #8 was seated in their wheelchair in the activity room. The catheter drainage bag was inside of a privacy bag attached to the wheelchair and the drainage tubing was touching the floor. During an interview on 8/11/22 at 10:18 AM, CNA #3 stated the urinary drainage bag and tubing should never touch the floor because it could cause an infection. During an interview on 8/12/22 at 10:25 AM, Registered Nurse (RN) # 2 stated the urinary drainage bag and tubing should never touch the floor because germs can travel up the tubing into the resident's bladder. During an interview on 8/12/22 at 10:57 AM, Nurse Practitioner (NP) #2 stated that their expectation was for a catheter drainage bag to be placed in a privacy bag and never to be touching the floor. They stated that the catheter drainage tubing should not be touching the floor. NP #2 stated that infection could be a potential outcome if either the tubing or the drainage bag was touching the floor. 415.12 (d)(2)

Based on observations, record review and interviews conducted during a Complaint investigation (NY00282395, NY00280350, NY00288158) during the Standard Survey completed 8/8/22 through 8/12/22, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident as determined by resident assessment and individual plans of care. Specifically, three (east, north and south) of three resident care units did not have adequate nursing staff as evidence by delays in meal service, care observations, resident and staff interviews, and review of nursing schedules. The findings are: The Facility Assessment date 2022 documented the facility will ensure that there is sufficient and competent nursing staff 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, as determined by resident assessments and individual plans of care. The facility will make decisions on required staffing based on resident census, resident acuity/needs, facility odors, complains, call-lights and staff's ability to complete assignments. Review of the Facility Assessment in its entirety revealed that there was no overall number of facility staff needed included in the assessment to ensure the resident's needs were being met. 1.) During an interview on 8/9/22 at 2:49 PM, the Administrative Assistant to the Director of Nursing (DON) stated they, along with the DON were responsible for staffing the nursing department. The Administrative Assistant stated the minimum staffing requirements with a facility census of 88-90 would be: 6:00 AM - 2:00 PM Shift - 1 nursing supervisor, 3 nurses and 6 Certified Nursing Assistants (CNAs) 2:00 PM - 10:00 PM Shift - 1 nursing supervisor that would be responsible for a unit, 2 nurses and 6 CNAs 10:00 PM - 6:00 AM Shift -one nursing supervisor that would be responsible for a unit, 2 nurses and 4 CNAs. The Administrative Assistant stated that more times than not they do not meet the minimum staffing requirements. Additionally, the Administrative Assistant stated when the schedule is created and it does not meet the minimum staffing requirement, they notify the DON, ask staff to work extra hours, ask management staff to work as a nurse, or a CNA, or the facility will just go short. Review of the nursing schedules dated 7/11/22 through 8/11/22 revealed the facility was understaffed per the stated minimum staffing requirement provided by the Administrative Assistant's interview on the following days: 6:00 AM - 2:00 PM Shift: 7/11/22 - 5 CNAs (down 1) 7/15/22 - 4 CNAs (down 2) 7/16/22 - 4 CNAs (down 2) 7/17/22 - 4 CNAs (down 2) 7/18/22 - 4 CNAs (down 2) 7/19/22 - 4 CNAs (down 2) 7/21/22 - 5 CNAs (down 1) 7/23/22 - 2 nurses(down 1) 7/26/22 - 4 CNAs (down 1) and 3 nurses (including the shift supervisor) 7/27/22 - 5 CNAs (down 1) 7/28/22 - 5 CNAs (down 1) 7/30/22 - 4 CNAs (down 2) 7/31/22 - 3 CNAs (down 3) and 3 nurses (including the shift supervisor) 8/01/22 - 5 CNAs (down 1) 8/03/22 - 5 CNAs (down 1) 8/05/22 - 4 CNAs (down 2) 8/06/22 - 4 CNAs (down 2) 8/08/22 - 5 CNAs (down 1) 8/09/22 - 5 CNAs (down 1) 8/10/22 - 5 CNAs (down 1) 8/11/22 - 5 CNAs (down 1) and 3 nurses (including the shift supervisor) 2:00 PM -10:00 PM Shift: 7/16/22 - 5 CNAs (down 1) 7/17/22 - 5 CNAs (down 1) 7/18/22 - 4 CNAs (down 2) 7/22/22 - 5 CNAs (down 1) 7/23/22 - 5 CNAs (down 1) 7/24/22 - 5 CNAs (down 1) 7/28/22 - 5 CNAs (down 1) 7/30/22 - 5 CNAs (down 1) 8/05/22 - 4 CNAs (down 2) 8/06/22 - 5 CNAs (down 1) 8/07/22 - 5 CNAs (down 1) 8/08/22 - 4 CNAs (down 2) 8/11/22 - 5 CNAs (down 1) 10:00 PM - 6:00 AM Shift: 7/18/22 - 3 CNAs (down 1) 7/20/22 - 3 CNAs (down 1) 7/22/22 - 2 CNAs (down 2) 7/25/22 - 3 CNAs (down 1) 7/28/22 - 3 CNAs (down 1) 7/30/22 - 2 CNAs (down 2) 7/31/22 - 3 CNAs (down 1) and 2 nurses (including the shift supervisor) 8/03/22 - 3 CNAs (down 1) 8/06/22 - 3 CNAs (down 1) During an interview on 8/11/22 at 2:37 PM, the DON stated the facility does not have a written policy for ideal/minimum staffing numbers. The DON stated that minimum staffing for a census of approximately 88 residents would be one nurse and two CNAs for the day and evening shift on each unit. The DON stated that the minimum staffing on night shift should be a total of three nurses and 5 CNAs. During a further interview at 4:00 PM the DON stated after reviewing the past month of nursing schedules there were approximately 18 days that the nursing department were staffed below minimum. The DON stated that the facility has a surge of COVID-19 on 7/5/22 and then again 8/5/22 that had resulted in a lot of staff call-ins. The DON stated they felt resident were safe and being care for appropriately. Based on the review of the schedules, neither the Administrative Assistant's or the DON's minimums staffing numbers were met on the dates listed above. 2.) Review of the undated Schedule of Meal -Times & Locations documented breakfast tray line begins at 7:20 AM and supper tray line begins at 5:20 PM. Review of a hand-written document provided by the Administrator the south unit had 5 residents that were a total or extensive assist for eating; the north unit had 9 residents that were a total or extensive assist for eating; and the east unit had 14 residents that were a total or extensive assist for eating. a.) During a breakfast observation of the east unit on 8/9/22 between 8:30 AM and 10:02 AM the following was observed: 8:30 AM - there were 3 meal carts sitting on the unit by the nursing office. All 3 carts still had multiple resident meal trays in them. There was 1 Registered Nurse (RN) and 2 CNAs on the unit passing trays at this time. 8:46 AM - there were 14 resident meal trays remaining in the carts. At this time 2 staff members (unit secretary, Licensed Practical Nurse (LPN #2) from the south unit arrived at the unit to assist with meal tray pass. 9:09 AM - there were 7 meal trays still left in carts. 9:15 AM - the south unit secretary/(CNA #1) called dietary for 7 new breakfast trays to replace the 7 trays still in the cart. 9:51 AM - the 7 replacement breakfast trays arrived. 10:02 AM- the last breakfast tray was passed. During an interview on 8/9/22 at 8:54 AM, RN #3 stated today I am working as the charge nurse on this unit the east wing and responsible for the medication pass and treatments for the entire unit and was also supervising the entire building. I usually work per diem 1-2x/ week and they are usually short staffed like this. The breakfast trays are being passed really slow, but we do the best we can with what staff is available. During an interview on 8/9/22 at 9:14 AM, LPN #2 stated they were sent down to east unit to help them get through breakfast, as the staff on the unit were having a hard time getting the trays passed and the residents fed. During an interview on 8/9/22 at 9:15 AM, south unit secretary/CNA #1 stated I am on the south wing and usually work as a unit secretary, but I came down here to help with assisting the residents with the breakfast trays today. I come over here when needed. I am a certified nurse aide, so I am able to help out with CNA duties when needed. My main job though is unit secretary. During an interview on 8/9/22 at 9:39 AM, CNA #5 stated breakfast was not going good, and that they do not have enough staff to pass trays and to sit down and assist all the residents. We normally have 2 CNAs but sometimes it is just me. Yesterday I was the only CNA here during the day which happens at times. The CNAs from the third shift had to help by getting the residents dressed, but I would then have to get them out of bed. When I am the only one here, I will ask the nurse or the unit attendant who are CNAs for assistance to get the two assist residents out of bed. I am not able to get everything done especially when I am here alone. I have had to leave residents in bed on the day shift and not be able to get them up. At times I am unable to do rounds on all the residents to check to see if they are dry or wet. I am only taking care of residents who I am told needs assistance or put their call lights on. Today I am not going to be able to get everyone up before lunch. I just do not have time to do everything. b.) During a supper meal observation on the east wing unit on 8/10/22 at 5:25 PM there were 2 CNAs, 1 LPN and 1 Unit Attendant on the unit to assist with the dinner meal. Review of a hand-written document provided by the Administrator the east unit had 14 residents that were a total or extensive assist for eating. -5:53 PM the first cart arrived on unit and 1 CNA sat down in the connections room (daily interactive memory care programing/room) to assist a resident with their meal. -6:00 PM the second cart arrived at the unit. -6:04 PM the last tray was passed from first cart. -6:10 PM last tray from second cart was passed. -6:11 PM the third cart arrived on the unit. After third cart arrived on unit the Administrator came to the unit and helped with the meal tray pass. -6:40 PM a CNA (unidentified) from another unit arrived at the unit and started to assist a resident with their meal tray. -7:00 PM a CNA (unidentified) sat down in the resident's room and started to assist the last resident whose meal tray was placed on the over the bed table unopened. During an interview on 8/10/22 at 5:32 PM, Unit Attendant #1 stated they were allowed to re-direct residents, pass trays, encourage residents to eat but cannot physically feed them, get clean linens, or supplies for the CNAs or residents rooms and make beds. Unit Attendant #1 stated they were often short-handed on this unit (east) and that frequently there was only one aid and one nurse. Sometimes the residents have a wait a long time to be attended too. Some residents were sitting in connections (memory care program room) all day without being changed and they were wet. When there are only the two here, they feed all the residents, but they cannot sit and feed them the whole entire tray. They may feed them half the tray just so each resident can have some food in their bellies. During an interview on 8/10/22 at 6:37 PM, LPN #3 Supervisor stated being shorthanded has been happening often. The Administrator normally does not come down and help because they are not here after 5:00 PM. We normally do not get other aides from other units because those units only have 2 CNAs, and they have to get their residents fed and ready for bed. It was hard to get all the residents who need assistance on this unit (east) to get fed in a timely manner. When I am on the south unit it is hard for me to get the work done. Sometimes I cannot get the charting done and sometimes I am unable to get treatments done. c.) Additional observations and interviews During an interview on 8/8/22 at 10:40 AM, Resident #73 stated they have to wait up to one hour and 45 minutes for staff to answer the call light. Additionally, the resident stated they need staff assistance to get to the bathroom, and they have had several episodes of not making it to the bathroom on time (and were incontinent). During an interview on 8/08/22 at 11:17 AM, Resident #47 they stated there was not enough staff and they have to wait over hour to go to use the bathroom. They stated have to use the bedpan instead of the bathroom because it is faster for staff. During an interview on 8/8/22 at 12:51 PM, Resident #26 stated there was not enough staff, and they had to go to the bathroom alone. Resident #26 stated they become incontinent of urine if they wait too long to use the bathroom because they are on Lasix (medication used to treat fluid retention). During an observation and interview on 8/9/22 at 7:55 AM, Resident #73's nightgown and incontinent pad on the bed was visibly wet with urine, and the resident's brief appeared saturated. At the time of the observation Resident #73 stated they had not been changed since 9:30 PM the evening prior (8/8/22). During an interview on 8/10/22 at 4:06 AM, CNA #2 stated they work the 10:00 PM to 6:00 AM shift on the south unit, and they were the only CNA on for the 8/9/22 to 8/10/22 10:00 PM - 6:00 AM shift. CNA #2 stated there were several residents that required HS (hour of sleep) care when they arrived on the unit at 10:00 PM. CNA #2 stated they completed HS care at 1:00 AM on 8/10/22. Additionally, CNA #2 stated they were unable to complete incontinence rounds on the residents, sometimes only going into a resident's room once or twice per shift. During an interview on 8/10/22 at 5:28 PM, LPN #4 stated they usually work the 2:00 PM -10:00 PM shift on the north unit. LPN #4 stated that they usually are the only nurse on the unit and 1 to 2 times a week they cannot get their treatments completed. LPN #4 stated that sometimes the next shift will complete their treatments that they did not have time to do. During an interview on 8/10/22 at 5:30 PM, CNA #6 stated they were per diem and normally worked the evening shift around 24 hours per 2 weeks. CNA #4 stated they were short-handed often and when they were short, they cannot check the residents on the last set of rounds; to check for incontinency or if they need to be changed. They stated it was tough at times to get all their work done. During an interview on 8/11/22 at 10:09 AM, CNA #3 stated they usually work the 10:00 PM - 6:00 AM shift on the north unit with just themselves and a nurse. CNA #3 stated that most nights, residents that require mechanical lifts are left in the lounge. So they with the assist of the nurse, will put the residents to bed, resulting in the first incontinent rounds not being completed until 1:00 AM. During an observation and interview on 8/11/22 at 2:20 PM, Resident #35 was lying in bed wearing a hospital gown and their hair was combed back with a greasy appearance. CNA #3 stated Resident #35's shower was scheduled to be given today (8/11) on the day shift but they did not have time to provide Resident #35 with a shower. During an interview on 8/12/22 at 8:59 AM, the DON stated staffing was challenged and critical at the nursing home. The staff need to hustle to complete their assignments, and the facility does not have the staff to schedule more than the bare minimum. During an interview on 8/12/22 at 9:29 AM, the Administrator stated they were aware of staffing issues at the facility. The Administrator stated the facility formed a committee to discuss strategies to mitigate the staffing issues such as: staggering mealtimes; cart order and tray timing; and medication passes to reduce unnecessary medications. Additionally, the Administrator stated the committee has discussed strategies but has not implemented any of the strategies. The Administrator stated they felt the residents were safe and they were getting the care that they needed. 415.13 (a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a complaint investigation (Complaint #NY000241499) during the Standard survey completed on 9/23/19, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than two hours later 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 appropriate officials (including to the State Survey Agency and the Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures. Specifically, five (Residents #3, 39, 40, 58 and 109) of five residents reviewed for alleged abuse the facility did not report incidents of physical abuse to the New York State Department of Health (NYSDOH) within the required timeframe. Resident #64 also involved. The findings are but not limited to: The facility policy and procedure (P&P) titled Resident Abuse Prohibition Protocol dated 8/7/18 documented Resident to Resident abuse must be reported to the Department of Health if the other resident is mentally or physically harmed by the aggressor. The P&P further documented Resident to resident abuse must be reported to the NYSDOH if there is inappropriate physical contact resulting in injury or likely to harm a resident. When an alleged or suspected case of mistreatment, neglect, or abuse is reported the facility administrator, or his/her designee, will notify the NYSDOH when the have reasonable cause to suspect that abuse has occurred. 1. Resident #109 was admitted to the facility on [DATE] with diagnoses including dementia, delusional disorder and altered mental status. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 8/28/19 revealed the resident is understood, usually understands and is severely cognitively impaired. Review of the untitled and undated facility investigation summary completed by the Administrator revealed on 6/19/19 at approximately 8:20 PM she was notified that a resident to resident incident occurred. Per witness statement Resident #109 entered the Connections Room and was upset that another resident (Resident #64) was on the couch that she waned to lye on. Resident #109 grabbed the right hand of the resident on the couch trying to get her to move. In turn the Resident #64 on the couch slapped Resident's #109 hand. The residents were immediately separated and assessed for injuries with no injuries noted to either resident. Review of a Complaint/Incident Investigation Report submitted to the NYSDOH Centralized Intake Program (CIP) for the facility revealed the 6/19/19 resident to resident abuse was reported on 6/21/19. During an interview on 9/20/19 at 1:00 PM, the Director of Nursing (DON) stated the facility was aware of the reporting guide lines and they report everything. During an interview on 9/23/19 at 10:22 AM, the Administrator revealed the resident to resident abuse that occurred on 6/19/19 involving Resident #109 should have been called to the NYSDOH with in two hours and they have recently just started doing that. 2. Resident #40 was admitted to the facility on [DATE] with the diagnosis of vascular dementia with behavioral disturbances, major depressive disorder, and delusional disorders. The MDS dated [DATE] documented the resident was moderately cognitively impaired, was usually understood and sometimes understands. Resident #3 was admitted to the facility on [DATE] with the diagnosis including dementia with behavioral disturbance, delusional disorders, and anxiety disorder. The MDS dated [DATE] documented the resident was moderately cognitively impaired, understood, and usually understands. Review of a facility incident report dated 7/12/19 at 4:00 PM revealed Resident #40 was sitting next to Resident #3 in the East Wing Lounge. Resident #40 who felt Resident #3 was not speaking loudly enough started to shout at her. Resident #3 in turn started shouting back at her. Resident #40 was witnessed grabbing Resident #3's left arm with both hands. Both residents were immediately separated by staff members and an investigation was initiated. Review of a Complaint/Incident Investigation Report submitted to the NYSDOH Centralized Intake Program (CIP) for the facility revealed the resident to resident abuse was reported on 7/17/19 at 5:47 PM. 3. Resident #39 was admitted to the facility on [DATE] with the diagnosis of obsessive- compulsive disorder (OCD), dementia with behavioral disorder, and delusional disorders. The MDS dated [DATE] documented the resident was severely cognitively impaired, rarely understood, and rarely understands. Review of a facility incident report dated 7/22/19 at 2:30 PM revealed Resident #40 was in the East Wing Lounge arguing with staff and other residents. While staff were trying to redirect the residents, Resident #40 was witnessed reaching out and hitting Resident #39 left arm three times. Both Residents were immediately separated by staff members and an investigation was initiated. Review of a Complaint/Incident Investigation Report submitted to the NYSDOH Centralized Intake Program (CIP) for the facility revealed the resident to resident abuse was reported on 7/26/19 at 4:13 PM. During an interview on 9/23/19 at 10:22 AM, with the Administrator revealed the resident to resident abuse that occurred on 7/12/19 and 7/22/19 involving Residents #3, 39, 40 should have been called to the NYSDOH with in two hours and they have recently just started doing that. 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review conducted during the Standard survey completed on 9/23/19, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices, that were complete and accurately documented for one (Residents #26) of one resident reviewed. Specifically, the medical record lacked documentation by the nursing staff the medical provider was notified the resident's Coreg (medication used for high blood pressure) was held 12 times from September 1st through the 23rd, because the resident's blood pressure (B/P) or pulse (P) was not within the medication parameters. The finding is: A facility policy and procedure (P&P) titled Medication Administration dated 1/15/18 documented the nurse will assist the physician with reviewing and reordering medications and treatments on his every 60-day rounds visit and/or when indicated. If a medication is withheld document as not administered, notify the nursing supervisor of the medication being withheld and reason why as appropriate and assess the resident periodically to determine effect of the medication. 1. Resident #26 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD) on dialysis, diabetes mellitus (DM) and hypertension (HTN, high blood pressure). The Minimum Data Set (MDS, a resident assessment tool) dated 7/3/19 documented the resident was cognitively intact, understands and was usually understood. Review of the Physicians Orders dated 9/23/19 revealed an order for Coreg 3.125 mg (milligrams) by mouth (PO) twice daily (BID) with instructions to hold for SBP (systolic blood pressure) less then 110 or HR (heart rate) less than 60. Review of the Comprehensive Care Plan (CCP) with a start date of 7/17/19 revealed the resident was at risk for altered circulation secondary to diagnosis of HTN, on dialysis and DM. Interventions included to monitor for chest pain, discomfort, shortness of breath (SOB) and report to MD/NP (Medical Doctor/Nurse Practitioner) as needed, medications per order, vital signs and lab work per order and notify NP/MD of abnormal values. Review of the Medication Administration Record (MAR) dated 9/2019 revealed the resident's medication Coreg 3.125 mg BID was on Hold (H) due to out of perimeters for the 7:30 AM administration time on September 5th, 6th, 7th, 8th, 12th, 14th, 17th, 18th, 19th, 21st, 22nd, and the 23rd. Review of the Nurse Practitioner (NP) progress note dated 9/9/19 revealed the resident was seen for a routine visit and had complaints of (c/o) nausea. The resident's B/P was documented at 108/64 (normal 120/80). There was no documented evidence in the progress note the NP was notified the resident's Coreg was held because the resident d/t out of perimeters on September 5th through the 8th at the 7:30 AM dose. Review of the Interdisciplinary Notes dated September 1st through 23rd, 2019 revealed there was no documented evidence the medical provider was notified when the residents Coreg was held multiple times. During an interview on 9/23/19 at 10:08 AM, Licensed Practical Nurse (LPN #1) stated the resident's Coreg was held today because she was out of perimeters, we are supposed to notify the NP if the medication is held, I'll see the NP in passing and tell her it was held. I document she was notified if it was held. During an interview on 9/23/19 at 10:20 AM, with the Director of Nursing (DON) revealed the NP should be notified if a B/P medication is held for a couple days, she would expect the nurse to document the NP was notified and would expect the NP to document regarding the medication being held when the resident was seen. The interview further revealed the DON was unaware the resident medication was held for 12 days. 415.22 (a)(1,2)