Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that the resident and resident representative had the right to participate in the development and implementation of their person-centered plan of care by facilitating the inclusion of the resident and resident representative in the planning process for 1 1(Resident #6) of 1 resident reviewed for care planning. Specifically, for Resident #6, their family member was not afforded the opportunity to participate in quarterly care plan meetings. This is evidenced by: Facility policy titled Interdisciplinary Care Plan Committee effective 09/1992 last revised 04/2024 stated a comprehensive care plan was developed within seven days after the completion of a comprehensive assessment by the interdisciplinary team with participation of the resident and revised with significant changes. Care plans were reviewed at the interdisciplinary care plan meeting every three months and as indicated by a significant change or change in condition. The policy also stated the resident and/or their designated representative would be encouraged to participate in the development of initial, significant changes, and annual care plan. Resident #6 was admitted to the facility with diagnoses of history of cerebral vascular accident (a medical condition that occurs when blood flow to the brain is suddenly interrupted which can damage brain cells and lead to neurological damage), type 2 diabetes mellitus (a chronic condition when a person has persistently high blood sugar levels), and atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart). The Minimum Data Set (an assessment tool) dated 05/07/2024 indicated Resident #6 was cognitively intact, could be understood, and understand others. Resident was able to make decisions regarding tasks of daily life. Section Q of the Minimum Data Set documented that Resident #6 participated in the assessment and goal setting. Family did not participate with the assessment and goal setting. During an interview on 02/10/2025 at 3:34 PM, Family Member #1 stated they came to visit Resident #6 every day for five-six hours a day. They stated they came to one care plan meeting when Resident #6 was first admitted to the facility. They have not been made aware of or invited to quarterly care plan meetings. During an interview on 02/13/2025 at 3:49 PM, Director of Social Work #1 stated care plan meetings occur initially when a resident was admitted to the facility, quarterly, annually, and if a significant change occurred or if a family member requested a meeting. Residents and families were invited to attend the meetings initially, annually, and for significant changes. Director of Social Work stated Family Member #1 attended Resident #6's initial care plan meeting on 05/21/2024 and a follow up meeting pertaining to discharge planning on 06/10/2024. Director of Social Work #1 stated family members were not notified of quarterly care plan meetings. If the interdisciplinary team had a concern regarding the resident to discuss with a family member, they could reach out to the family member via phone call to discuss the concern. 10 New York Code Rules & Regulations 415.11 (c)(2)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification and abbreviated survey (Case #sNY00368587 and NY00370779), the facility did not ensure that residents were free from neglect for 2 (Resident #s 10 and 19) of 25 residents reviewed. Specifically, (a.) Resident #10 was not monitored, turned and positioned or received personal care for at least one full shift on 11:00 PM-7:00 AM, 1/29/2025 - 1/30/2025; (b.) Resident #19 rolled out of bed and hit their head on furniture when receiving care by a Certified Nurse Aide on 1/21/2024 at 10:35 AM. This is evidenced by: The Facility's Policy and Procedure titled, Resident Abuse revised 8/2024, documented the facility would investigate all cases of suspected resident abuse, including allegations of neglect, misappropriation, mistreatment or injuries of unknown origin. Of those cases that the facility found reasonable cause and/or evidence that a resident has been abused, corrective action would take place with those involved: In the case of an employee involvement - the corrective action procedure would be initiated by the employee's immediate supervisor and may result in suspension and/or discharge without prior warning. The term neglect meant failure to provide timely, consistent, safe, adequate and appropriate services, treatment and/or care to a resident, while under the supervision of the facility, including, but not limited to: nutrition, medication, therapies, sanitary clothing and surroundings, and activities of daily living. (NY Public Health Law 2803-d). Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. [See Older Americans Act, 302 (a) (19)]. It may include, but not be limited to, being left to sit or lie in urine or feces, isolating dependent residents by leaving them in their rooms or other isolated locations apart from temporary monitored separation occurring in the context of assessment and care planning, or failing to answer call bells to provide assistance. Resident #10: Resident #10 was admitted with a diagnoses of malnutrition (a state of nutritional deficiency); anxiety (repeated episodes of sudden feelings of intense fear or terror), and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls). The Minimum Data Set (an assessment tool) dated 11/15/2024, documented the resident could understand and be understood by others. The facility's Investigative Report dated 1/30/2025, documented an aide told Registered Nurse #1 at 7:00 AM on 1/30/2025 that Resident #10 was soaked and there was no way they had been cared for. Two other staff were in the room and changing resident. Resident also had a bowel movement. Investigation revealed that the resident did not receive care by staff on the previous night shift (1/29/2025-1/30/2025). There was no injury related to this incident; however, staff should have recognized that the resident was not attended to. During an interview on 02/13/2025 at 11:11 AM, Registered Nurse #1 stated a Certified Nurse Aide reported to her that Resident #10 had no care during overnight shift. Registered Nurse #1 in turn reported the incident to Director of Nursing #1. Registered Nurse #1 stated they believed it was a miscommunication. Resident #10 was a no male caregiver. The Certified Nurse aide assigned to that hall was a male, Certified Nurse Aide #4. Certified Nurse Aide #3 was fairly new at time of incident, and it was not communicated to them that they were assigned to a resident on the opposites side of the unit. Both Certified Nurse Aides #3 and 4 were educated on the no male caregiver system, which was a pink dot on door of resident to indicate no male caregiver. In addition, Certified Nurse Aide #4 was counseled on documentation. Certified Nurse Aide #4 documented care was provided to Resident #10 on 1/29/2025 through 1/30/2025, when in fact they admitted they did not provide any care to this resident. During an interview on 02/13/2025 at 12:52 PM, Director of Nursing #1 stated the incident was a result of miscommunication. They stated Certified Nurse Aide #s 3 and 4 were 'very good aides,' and the assignment for Resident #10 should have been updated on the assignment sheet. They stated that Registered Nurse #3 wrote out the assignment prior to end of their shift, and at change of shift, Registered Nurse #4 was given a report. Director of Nursing #1 stated they educated both Registered Nurse #s 3 and 4 on the responsibility of making out assignments and in communication. Resident #19: Resident # 19 was admitted to the facility with diagnoses of diabetes type 2 (a disease of inadequate control of blood levels of glucose), diabetic retinopathy (having too much sugar in your blood that damages the part of the eye that detects light and sends signals to the brain), and a cataract (a clouding of the lens in the eye). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, could be understood and understand others. The Mobility Comprehensive Care Plan dated 1/2024, documented plan of care, Toileting Hygiene, Shower/Bathe, Self-Upper Body Dressing, Lower Body Dressing, Putting On/Taking Off Footwear, Personal Hygiene all Dependent Substantial/Maximal Assistance. Adaptive Equipment used: Mechanical Lift, Geriatric chair. The facility Investigate Report dated 01/21/2024 documented Resident #19 was receiving care (in bed with a soft mattress pad called an overlay). Resident was rolled to their left side and when they moved, the overlay moved causing them to slide to the floor. Resident assessment noted bump on eyebrow/forehead on Right side. Neurological checks completed as per protocol with changes noted. Resident was sent to the emergency department at 11:15 AM. A Computed Tomography Scan (CT) (imaging of the brain) was negative, and resident returned to facility. On 01/22/2024, Resident #19 complained of Left arm and shoulder pain. X-rays were ordered which revealed osteopenia/osteoporosis, and no fracture. The facility Investigative Summary documented Certified Nurse Aide #5 acknowledged that they should have had 2 for turning this resident. Attempts to reach Certified Nurse Aide #5 by phone were unsuccessful. During an interview on 02/14/2025 at 10:57 AM, Director of Nursing #1 stated Certified Nurse Aide #5 did not state why they did not use a second person when caring for Resident #19. Stated Certified Nurse Aide #5 was no longer employed at the facility, the overly went on top of the mattress, with four ends that tucked underneath the mattress. Director of Nursing #1 further stated that particular type of overlay was no longer in use at the facility following this incident. During an interview on 02/18/2025 at 12:09 PM, Administrator #1 stated they removed the overlay from Resident #19's bed. 10 New York Codes, Rules, and Regulations 415.4 (b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification and abbreviated survey (Case #NY00370103) , the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency for 1 (Resident #7) of 1 resident reviewed for reportable incident. Specifically, an injury of unknown origin was discovered for Resident #7 on 01/23/2025. This injury of unknown origin was not reported until 01/25/2025 at 10:51 AM. This was evidenced by: The Policy titled Resident Abuse effective 10/24/2022 last reviewed 09/2023 documented resident abuse and/or misappropriation of resident property should not be tolerated by the facility. The facility shall investigate all cases of suspected resident abuse, including allegations of neglect, misappropriation, mistreatment, or injuries of unknown origin. Each covered individual (anyone who is an owner, operator, employee, manager, agent, or contractor of the facility) shall report immediately, but not later than two hours after forming the suspicion, if the events that cause suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. In addition, the facility must report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframes. In addition, employees are required to immediately report any resident incident, including all suspected cases of resident abuse, mistreatment or neglect including injuries of unknown source and misappropriation of resident property to their supervisor, department head, and/or administrator. Resident #7 was admitted to the facility with diagnoses of dementia (loss of memory, language, problem solving, and other thinking abilities that are severe enough to interfere with daily life), history of cerebral vascular accident (a medical condition that occurs when blood flow to the brain is suddenly interrupted), and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). The Minimum Data Set (an assessment tool) dated 04/03/2024 documented Resident #7 had severe cognitive impairment, could be understood, and understand others. Skin check work list for Resident #7 dated 01/23/2025 completed by Licensed Practical Nurse #3 documented there was a purple/blue area on the right foot. Nursing home facility incident report submitted to the Department of Health on 01/25/2025 at 10:51 AM by Director of Nursing #1 with incident date of 01/25/2025 and the time of occurrence as 8:56 AM indicated that a Certified Nurse Aide noted during morning (AM) care that Resident #7 had a discolored purplish -blue area on the 4th and 5th toe on the top side of the right foot. An investigation was in progress. No non-residents were accused of abuse, mistreatment, neglect, or misappropriation. There were no witnesses to this incident. Progress note dated 01/25/2025 by Provider #1 indicated Resident #7 was seen due to right foot swelling and discoloration. The resident was not able to recall when they noticed swelling in their foot and could not recall an injury or something that could have occurred to cause the swelling. Assessment included an x-ray to rule out fracture. It was unclear if Resident #7 had an injury as there were no reports of any falls or trauma at that time. Accident and incident form completed on 01/25/2025 stated at incident time of 8:45 AM during AM care, Resident was noted to have an edematous right foot. Top of the right foot was discolored, and the 4th inner toe and little toe were purple in color. Provider #1 was notified on 01/25/2025 at 10:45 AM and an x-ray of the right foot was ordered. This form indicated this was a reportable incident of quality of care due to an injury of unknown origin. emergency room History and Physical stated Resident #7 was treated in the emergency room on [DATE] at 3:46 PM for further treatment of right foot fracture. Mechanism of unknown injury. Resident #7 developed bruising and swelling to right foot which prompted imaging. Resident #7 sustained an impact fracture of the 4th and 5th metatarsal (five long bones in the midfoot that connect the ankle to the toes). Follow up undated investigation report completed by Administrator #1 and Director of Nursing #1 documented Resident #7's 4th and 5th toe on the right foot were discolored and edematous and were x-rayed on 01/25/2025. Impression was severe osteopenia (loss of bone density). Resident #7 sustained a displaced slightly impacted fracture of the 4th and 5th metatarsal necks. Resident #7 had moderate osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time). Provider #1 stated on 1/26/2025 that Resident #7 had fairly significant osteopenia, and the fracture was likely due to minimal impact against the geri chair/bed and Resident #7 continued to be at risk for these kinds of fractures from minimal impact on turning and when sleeping. The report documented it could not be determined how the injury occurred. It was determined that this area was initially found on 01/23/2025 by Licensed Practical Nurse #3 during a routine skin check but Licensed Practical Nurse #3 failed to report the discovery to a Registered Nurse for further assessment. During an interview on 02/14/2025 at 12:50 PM, Director of Nursing #1 stated they were on call on 01/25/2025 when Resident #7's foot was noted to be purple in color by the 4th and 5th toe. They reported the incident to the Department of Health on 01/25/2025 within 2 hours of them being notified as it was an incident with unknown source and they started the investigative process. Director of Nursing #1 stated Licensed Practical Nurse #3 should have immediately notified a Registered Nurse after completing the skin check work list on 01/23/2025 so the Registered Nurse could have completed an assessment of Resident #7 and determined what to do. Director of Nursing #1 stated this incident should have been reported to the Department of Health two days earlier when it was discovered on 01/23/2025. 10 New York Codes, Rules, and Regulations 483.12 (c) (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or the resident's representative upon transfer to the hospital for 1 (Residents #12) of 1 resident reviewed for notice of bed hold policy before/upon transfer. Specifically, for Resident #12 a written notice of the facility's bed hold policy was not provided to the resident and/or their representative upon transfer to the hospital on [DATE]. This is evidenced by: The policy titled Admission, Discharge and Transfer effective 10/24/2022, last revised 03/2024 documented facilities must develop and implement policies for bed-hold and permitting residents to return following hospitalization or therapeutic leave. When residents were sent emergently to an acute care setting, these scenarios were considered facility-initiated transfers, -not discharges, because the resident's return was generally expected. For facility-initiated transfers or discharge of a resident, prior to the transfer or discharge, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. Resident #12 was admitted to the facility with diagnoses of dementia (loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), history of cerebral vascular accident (a sudden interruption of blood flow to the brain which can damage brain cells and lead to neurological damage), and type 2 diabetes (a chronic condition that happens when a person has persistently high blood sugar levels). The Minimum Data Set (an assessment tool) dated 11/19/22 documented Resident #12 had severe cognitive impairment. It further documented Resident #12 made decisions regarding tasks of daily life. Physician order dated 12/06/2024 documented Resident #12 was to be transferred Emergency Department due to a fall and possible fracture. There was no documented evidence that a written notice of the facility's bed hold policy was provided to the resident and/or the resident's representative upon transfer to the hospital on [DATE]. During an interview on 02/14/2025 at 10:57 AM and 12:50 PM, Director of Nursing #1 stated nursing, social work, and the business office were all responsible for making sure the bed hold policy notification was completed. When a resident was transferred to the hospital, the notice of discharge was completed which included the bed hold policy notification. Director of Nursing #1 acknowledged the notice of discharge had not been done consistently and they were working on putting together a better plan to make sure it was completed. 10 New York Codes Rules Regulations 415.3(h)(4)(iii)(a)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 (Resident #10) of 25 residents reviewed. Specifically, Residents #10 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by: The Facility's Policy and Procedure Titled, Recreational Therapy, revised 9/2024, documented the Department of Recreational Therapy was responsible for providing meaningful leisure time programs for all residents on a seven-day-per-week basis. Each resident, regardless of their physical and cognitive status, would be offered an activities program designed to meet, in accordance with the comprehensive resident assessment, his or her interests and to encourage quality of life, preservation of leisure skills and maintenance of an optimal level of psychosocial functioning among residents. The activities should be designed to promote the physical, social and mental well-being of residents and to maintain contact and interaction with the community. Residents would be encouraged to voluntarily participate in planned group and individual programs of their choice, reserving the right to refuse to participate in any program. Such programs would consist of both individual and group activities at various times of the day, evening and weekends and shall include but would not be limited to animals, children and other community agencies. Resident #10 was admitted with a diagnoses of malnutrition; anxiety (repeated episodes of sudden feelings of intense fear or terror), and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls). The Minimum Data Set (an assessment tool) dated 11/2024, documented a Brief Interview for Mental Status (BIMS) score of 99- unable to complete. It further documented resident could understand and be understood by others. During observations on 2/10/2025 at 12:45 PM, 2/11/2025 at 10:30 AM, and 2/12/2025 at 11:00 AM, Resident #10 was noted to be in bed, mattress wedges alongside of bed and double mattresses on floor of each side of bed. Resident arousable, but non-verbal. Resident was wearing a hospital gown. Resident had an extremely thin, frail appearance. Resident was observed all three days in same position. The lights and television were off. On 2/13/2025 at 11:00 AM resident was sitting up in bed, more alert on this day, television was on. The Comprehensive Care Plan for Social Work dated 4/29/2024 documented, Resident will continue to have ongoing needs met through next review, Resident/family will recognize need for 24-hour care, to maintain present level of functioning. Encourage resident to voice concerns, encourage participation in activities of choice, encourage interest in daily routine, Encourage participation in activities of daily living. Resident will have increased ability to cope with feelings of anxiety. Encourage activities of resident's choice in and out of their room, Offer 1:1 to provide socialization and support as needed. During an interview on 02/12/2025 at 2:22 PM, Activities Director #1 stated resident #10 was assessed upon admission of likes and dislikes for activities. The Activities Department provided activities 7 days per week, which were posted on announcement board. For those residents who were unable to attend group activities, 1:1 visits were held with resident. Activities Director #1 provided an attendance roster for group activities, but unable to provide any documentation of 1:1 activity visits for Resident #10. Activities Director #1 stated at that time 1:1 visits were not documented, but going forward would document 1:1 visits. Activities Director #1 stated the radio and television are turned on for Resident #10. During an interview on 02/13/2025 at 12:52 PM, Director of Nursing #1 stated they were informed that Activities Department had not been documenting 1:1 activities. They stated going forward each visit would be documented. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification and abbreviated survey (Case #sNY00368587 and NY00370779), the facility did not provide needed care and services that were resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 1 (Resident # 62) of 25 residents reviewed. Specifically, Resident #62 sustained a fall; 3 Certified Nurse Aides assisted resident from the floor and did not notify a nurse or report the incident, and no assessment or interventions were put into place after the fall and prior to discharge. This is evidenced by: Resident #62 was admitted to the facility with diagnoses of diabetes mellitus (a disease of inadequate control of blood levels of glucose), chronic obstructive pulmonary disease(a common lung disease causing restricted airflow and breathing problems), and end stage renal disease (the final, permanent stage of chronic kidney disease, where kidneys can no longer function on their own). The Minimum Data Set (an assessment tool) dated 10/2024, documented resident had mild cognitive impairment, could be understood, and understand others. The facility Investigate Report dated 01/10/2025 documented Resident #62 reported they fell on [DATE] prior to discharge to home on [DATE]. It was not report, however staff responded. During an interview on 02/18/2025 at 02:56 PM, Director of Nursing #1 stated the family of Resident #62 called Social Worker #1 on 01/06/2025 and notified them that resident had a fall prior to discharge. Director of Nursing #1 stated they were unaware of fall and at that time they initiated an investigation. They watched the video footage and identified staff who were involved that included Certified Nurse Aides #6, 7, 8 and 9, and Licensed Practical Nurse #3. Certified Nurse Aide #8 lead the other Certified Nurse Aides during the incident. Certified Nurse Aide #6 was seen entering room then left after noting other staff were in the room. They stated they obtained statements from staff involved. The video revealed Certified Nurse Aides #7, 8 and 9 entering into Resident #62's room, and Resident #62 was on floor leaning against the door frame. They placed gait belt around resident and got them up into wheelchair at the direction of Certified Nurse Aide #8. Certified Nurse Aide #8 then informed Licensed Practical Nurse #3 that Resident #62 was short of breath, but did not report resident had been on the floor. Director of Nursing #1 stated Certified Nurse Aide #8 received a final written warning and was still employed at the facility. All staff involved received education and counseling on reporting. Random care audits were now conducted. During an interview on 02/18/2025 at 03:20 PM, Certified Nurse Aide #9 stated they were walking by and heard Resident #62 yelling for help. They went into the room along with two other Certified Nurse Aides #7 and 8. Resident was on the floor sitting on buttocks resting on hands, in the doorway. Certified Nurse Aide #8 told them to get resident up from floor and put them in the wheelchair. Certified Nurse Aid #9 stayed in the room a few minutes with resident and assumed that someone had reported the incident. After they got resident up from the floor resident was a little short of breath, but there was no pain or any signs of bruising. Certified Nurse Aide #9 stated this was their first Certified Nurse Aide job. They were told during orientation that if a resident falls or was found on the floor that it should be reported to a nurse. They were not to move resident until a nurse came to assess resident. They were following the direction of Certified Nurse Aid #8 because they were more experienced aide. During an interview on 02/18/2025 at 03:33 PM, Licensed Practical Nurse #3 stated Certified Nurse #8 reported Resident #62 was short of breath, but never mentioned resident was found on the floor. They stated Resident #62 had a history of shortness of breath with an order for nebulizer treatments as needed. After they were told resident was short of breath, they went into resident's room. Resident #62 was sitting in wheelchair, but also did not mention they had fallen. Resident #62 was anxious to go home and had been for several days. They attributed the shortness of breath to be related to patient's anxiety, which they had in the past. They noted resident respirations to be 20 and administered nebulizer treatment as orders. They stated resident had good affect and was discharged the following morning. Licensed Practical Nurse #3 stated if they had known resident was found on the floor, they would have notified the Registered Nurse Supervisor. During an interview on 02/18/2025 at 03:42 PM, Social Worker #1 stated they placed a follow up call per protocol to resident who had been discharged on 01/07/2025. It was at that time Resident #62's wife informed them that resident was in the hospital and that they had a fall the day before discharge. Resident #62 was discharged to home with home care services. The home nurse visited resident, resident had persistent shortness of breath and home care nurse sent resident to the emergency room where resident was admitted . Resident had since been discharged back to home and was in stable condition. Social Worker #1 notified Director of Nursing of the call and reported fall incident. During an interview on 02/18/2025 at 03:58 PM, Certified Nurse Aide #8 stated they heard the sound of a fall and went into Resident #62's room and found them on the floor leaning against the bathroom door. They stated resident had history of shortness of breath and was not wearing their oxygen. They stated because patient had noted shortness of breath, they immediately got resident off the floor so that they could place their oxygen back on. Certified Nurse Aide #8 stated they thought one of the other aides notified supervisor and they did notify Licensed Practical Nurse #3 that resident was short of breath. They were not aware they could initiate the incident and accident report. Certified Nurse Aide #8 stated they were aware that when a resident was found on the floor, they are to call nurse to assess resident. They stated they were just worried about resident's shortness of breath and getting oxygen placed, so they got resident off floor as soon as possible. They acknowledge they should have called for nurse and took full responsibility. 10 New York Codes, Rules, and Regulations 415.12

Based on record review and interviews conducted during a recertification survey, the facility did not ensure that residents received proper treatment and assistive device to maintain vision abilities for 1 (Resident #19) of 1 resident reviewed. Specifically, Resident #19 did not receive an eye exam, glasses, and or a follow up ophthalmology appointment. This is evidenced by: Regulation 483.25(a) Vision and hearing, documented the facility is responsible to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident 83.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. Resident # 19 was admitted to the facility with diagnoses of diabetes type 2 (a disease of inadequate control of blood levels of glucose), diabetic retinopathy (having too much sugar in your blood can damage your retina - the part of your eye that detects light and sends signals to your brain), and significant right eye cataract (a clouding of the lens in your eye). The Minimum Data Set (an assessment tool) dated 11/2024, documented resident was cognitively intact, could be understood, and understand others. During an interview on 02/11/2025 at 11:24 AM, Resident #19 stated they had difficulty with vision. They stated they did not wear their glasses anymore because they really do not help. The glasses were really old, and they had been asking to see the eye doctor, but no appointment had been made. Ophthalmology consult dated 7/27/2020 documented diagnosis of diabetic retinopathy, significant right eye cataracts and corneal dystrophy (eye diseases that involve changes in the cornea). Recommended follow up in three months. The Comprehensive Care Plan dated 12/2024, for Resident #19 did not include a plan for vision and or glasses. During an interview on 02/14/2025 at 10:57 AM, Director of Nursing #1 stated resident was seen by ophthalmology in 2020, which was prior to their admission the facility. Resident had not been seen by ophthalmology since admission. They stated residents were seen by specialist as needed, but generally once per year. It was the responsibility of the unit manager to coordinate follow up specialist visits. During an interview on 02/14/2025 at 12:47 PM, Registered Nurse #1 stated Resident #19's Comprehensive Care Plan did not include vision and or glasses. They stated were not aware resident wore glasses and would update the care plan. 10 New York Codes, Rules, and Regulations 415.12(2)(b)

Based on observations, record review, and interviews during a recertification survey, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, residents were observed to be fed by staff wearing gloves in the west dining room and by the east nurses station. This is evidenced by: Policy titled Quality of Life- Dignity effective 05/2020 last reviewed 05/2024 documented each resident should be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Interpretation and implementation of this policy included residents should be treated with dignity and respect at all times. Treated with dignity meant the residents would be assisted in maintaining and enhancing their self-esteem and self-worth. During an observation on 02/10/2025 at 12:10 PM in the [NAME] dining room, staff wore gloves while feeding residents. During an observation on 02/12/2025 at 12:33 PM in the [NAME] dining room, staff wore gloves while feeding residents. During an observation on 02/13/2025 at 12:05 PM in the [NAME] dining room, staff wore gloves while feeding residents. During an observation on 02/14/2025 at 12:28 PM in the [NAME] dining room, staff wore gloves while feeding residents. During an observation on 02/18/2025 at 12:25 PM in the hall by the East Nurses station, a staff member wore gloves while feeding a resident. During an observation and interview on 02/14/2025, Certified Nurse Aide #1 was feeding a resident in their room and they were not wearing gloves. Certified Nursing Aide #1 stated they do not wear gloves when feeding residents because it was a dignity issue. During an interview on 02/14/2025 at 12:33 PM, Certified Nurse Aide # 2 stated they wore gloves when feeding residents to prevent the spread of germs. They stated they did not think it was a dignity concern, but they did not know how the residents felt about it. During an interview on 02/14/2025 at 12:28 PM, Licensed Practical Nurse #1 stated when they feed residents, they wear gloves to prevent their germs from spreading to the resident. It is a part of facility procedure to wear gloves when feeding residents. Licensed Practical Nurse # 3 stated they did not feel there was a dignity concern to feed residents while wearing gloves. During an interview on 02/14/2025 at 12:50 PM, Director of Nursing #1 stated if a resident needed total assist with feeding, staff should wear gloves. Director of Nursing #1 could not find in a facility policy where it stated staff should wear gloves when feeding a resident and stated it should be written in a policy. Director of Nursing #1 stated staff wearing gloves when feeding a resident was not a dignity concern because they want to keep the residents safe. If the residents had issues relating to dignity while being fed by staff members wearing gloves, they could put it in the resident's care plan so the staff would not wear gloves when feeding the resident. During an interview on 02/18/2025 at 11:37 AM, Nurse Manager #1 stated when a staff member fed a resident, they were to wash their hands and wear gloves. They stated it could be a dignity concern as it could make the residents feel like the staff thought they were dirty, and the residents may not realize they were wearing the gloves to protect the residents. 10 New York Code, Rules and Regulations 415.11 (c)(2)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews during a recertification survey, the facility did not ensure a safe, comfortable home-like environment and effective housekeeping and maintenance services were maintained for 2 (East and West) of 2 resident units. Specifically, (a.) the floors were soiled with dirt next to walls, in corners, along door thresholds, and where door frames meet the floor in the corridors on the East and [NAME] Units; (b.) door frames and doors were in disrepair for multiple resident rooms; walls in the East and [NAME] units were in disrepair with scrapes, smudge, chips, and marks; (c.) resident room NH. 44 wall was in disrepair and unfinished; (d.) ceiling tiles in the television rooms had water stains; (e.) shower rooms were soiled with dirt next to walls, and in corners, and (f.) handrails through unit were scuffed and scrapped exposing the underlying wood of the rails. This is evidenced by: The undated Policy &Procedure, titled Maintenance/Housekeeping Work Order Policy, documented that it was the facility's policy to ensure all areas maintained a clean, comfortable, and well-functioning environment. When problems were identified, employees were required to complete a Maintenance/Housekeeping Work Order. During observations on 02/13/2025 at 12:43 PM, the following items were observed; -Floors were soiled with dirt next to walls, in corners, along door thresholds, and where door frames meet the floor in the corridors on the East and [NAME] Units for room #s 2, 5, 18, 21, 25, 31, 36, 44, and 48. -Door frames and doors were in disrepair with scrapes, chips, and gouges for resident rooms 2, 5, 18, 21, 25, 31, 36, 44, and 48. -Walls in the East and [NAME] Units in all corridors were in disrepair with scrapes, chips, and unpainted. -Resident room NH. 44 wall was in disrepair and unfinished. -Several ceiling tiles in the East and [NAME] Unit television rooms had water stains -The floors and walls behind fire doors on the East and [NAME] Units were soiled with dirt and grime. -Shower rooms in the East and [NAME] Units were soiled with dirt next to walls, and in corners and appeared to have a dark black substance on walls. -Handrails through the East and [NAME] Units were scuffed and scrapped exposing the underlying wood of the rails. During an interview on 02/14/2025 at 11:45 AM, Environmental Services Director #1 stated that their staff was responsible for the overall cleaning of the facility. They stated that the cleanliness of the areas that had been lacking. They stated that they were in the process of developing a duty list of responsibilities the environmental service individuals were to complete daily. In showing the areas of concern the Environmental Service Director #1 stated that the areas should have been cleaned and that was the reason they wanted to develop the lists. During an interview on 02/18/2025 at 10:22 AM, Engineering Supervisor #1 stated that they oversee the overall appearance of the facility. They stated that they do have staff that worked with them daily and took care of the daily general workload of the facility. They stated their staff were responsible for fixing minor issues on a day-to-day basis such as lighting issues, Call bell issues, and general maintenance. Engineering Supervisor #1 stated that they received approximately 6- 8 work orders per day from staff on issues in the facility. They stated that they did a walk-through each morning to identify issues for repair or maintenance. They stated that approximately a year ago they had staff do a full facility touch-up on walls and door frames. They stated that they had a 3-month plan for renovations on the unit which included but was not limited to fixing the resident room doors, installing kick plates on the doors to protect them from damage, floors in the resident rooms, and general overall appearance. Engineer Supervisor #1 stated that resident room [ROOM NUMBER] had a water pipe break in the wall of the room. They stated that before they could finish fixing the entire wall a resident was moved into the room. They stated they had a work order to finish the wall in the room. 10 New York Codes of Rules and Regulations 415.5(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during a recertification survey, the facility did not develop and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 (Residents #s 3, 9, and 19) of 25 residents reviewed for Care Plans. Specifically, (a.) Resident #3 did not have a care plan for falls that documented interventions that were in place including the use of multiple mattresses in their room; (b.) Resident #9's intervention for treatment of edema (swelling caused by fluid buildup in the body's tissues) was not care planned, and Resident #19 did not have a care plan that addressed their vision problems. This is evidenced by: A facility policy titled Interdisciplinary Care Plan Committee effective 09/1992 last revised 04/2024 documented the plan of care is a working tool that provided a profile of the needs of each resident, identified the roles of each service in meeting these needs, and the supportive measures each service, along with the resident, will use to accomplish the overall goals of care. Each discipline was responsible for identifying a problem/concern if any existed for their discipline and identify an intervention for any problem/concern that was relevant to their discipline. Resident #3 Resident #3 was admitted to the facility with diagnoses of diffuse Lewy body disease (a neurodegenerative disorder characterized by dementia, fluctuations in mental status, hallucinations, and parkinsonism), Parkinson's Disease Dementia (dementia that is associated with Parkinson's disease), and coronary atherosclerotic heart disease (buildup of plaque which causes coronary arteries to narrow, limiting blood flow to the heart). The Minimum Data Set (an assessment tool) dated 12/05/2024, documented the resident had severe cognitive impairment, and rarely or never could be understood or understand others. During an observation on 2/11/2025 at 10:21 AM, resident was sitting in a lounge chair in their room. The resident's bed was at its lowest position and has multiple mattresses propped up against the walls in the room. A record review documented Resident #3 has a Care Plan for fall risks developed upon initial entrance to the facility on [DATE]. Resident #3 was discharged to the hospital on [DATE] and returned several days later on 12/05/2024. The resident care plan for falls did not include the use of mattresses in their room. A record review of the Certified Nurse Aide's daily assessment documented the daily safety precautions were to have the bed in the lowest locked position with mattresses next to the bed. During an interview on 2/13/2025 at 10:45 AM, Certified Nurse Aide #2 stated that Resident #3 had the mattresses in their room due to having multiple falls. They stated that the mattresses were there to protect the resident from falls. They stated that their daily plan was to have the bed in the lowest locked position with mattresses next to the bed. Certified Nurse Aide #2 stated that the daily assessment was populated from the resident's care plan. They stated they did not know where in the care plan it was located as they do not deal with care plans. During an interview on 2/18/2025 at 2:33 PM, Nurse Manager #1 stated that the resident had a care plan for falls and that the mattresses on the residence floor were to be care planned. Nurse Manager #1 stated that they could not locate in the care plan where the mattress for the resident was documented. During that time Assistant Director of Nursing #1 was in the office with the Nurse Manager #1 and stated that the care plan was not implemented when the resident returned from the hospital. Resident # 9 Resident #9 was admitted to the facility with the diagnoses of hypertension (high blood pressure, a condition in which the force of the blood against the artery walls is too high), chronic kidney disease stage IV (longstanding disease of the kidneys leading to renal failure) and bilateral lower extremity edema (swelling in both legs below the knees). The Minimum Data Set, dated [DATE] documented Resident #9 had intact cognition and made decisions regarding tasks of daily life. The Comprehensive Care Plan for Edema initiated 04/11/2024 documented Resident #9 has chronic bilateral lower extremity edema. The outcome with a start date of 04/11/2024 and a target date of 04/08/2025 was Resident #9 would not have an alteration in skin integrity related to edema through the next review in 90 days. Intervention for Edema included: elevate legs as much as possible, avoid tight fitting shoes/socks, monitor skin integrity, medication as ordered, monitor weight, monitor for complaint of pain, and make provider aware of any changes/increases in amount. There was no intervention that included wrapping Resident #9 bilateral lower extremities with ACE bandages daily. Physician order with start date 01/14/2025 documented wrap bilateral lower extremities with ACE wraps daily and remove at hour of sleep. The diagnosis code/problem on this order was listed as edema, unspecified. Nurses progress note dated 01/14/2025 documented Resident #9 was seen by provider regarding bilateral lower extremity edema. New order was received to wrap bilateral lower extremities with ACE wraps during the day and off at hour of sleep. Resident #9 was agreeable to this plan. During an interview on 02/10/2025 at 11:27 AM, Resident #9 stated they have a severe case of edema, and their legs need to be wrapped with ACE bandages. They stated the nurses wrapped their legs when they get situated in the morning, and they come off in the evening. During an interview on 02/14/2025 at 11:29 AM, Licensed Practical Nurse #4 stated ACE bandages were applied to Resident #9's bilateral lower extremities after they were cleaned up in the morning and they were removed at night. Licensed Practical Nurse #4 stated they did not know if it was care planned for Resident #9's legs to be wrapped. During an interview on 02/14/2025 at 11:30 AM, Registered Nurse #2 Charge Nurse stated ACE bandages were applied to Resident #9's bilateral lower extremities in the morning and they were removed at night due to edema. The Licensed Practical Nurse was responsible for wrapping the legs in the morning and removing the wraps in the evening. Registered Nurse #2 Charge Nurse stated the use of these wraps should be care planned because Resident #9 has edema. They checked Resident #9's care plan for edema and skin breakdown and said the intervention for wrapping Resident #9's legs should be on one of those two care plans, but it was not on either of those care plans. During an interview on 02/14/2025 at 12:50 PM, Director of Nursing #1 stated if a resident had their legs wrapped due to edema, this intervention should be indicated on their care plan. They would expect to see it on their edema care plan for Resident #9 and Director of Nursing #1 acknowledged this intervention was not on Resident #9's edema care plan. Resident #19 Resident # 19 was admitted to the facility with diagnoses of diabetes type 2 (a disease of inadequate control of blood levels of glucose), diabetic retinopathy (having too much sugar in your blood can damage your retina - the part of your eye that detects light and sends signals to your brain), and Significant Right Eye Cataract (a clouding of the lens in your eye). The Minimum Data Set, dated 11/2024, documented resident was cognitively intact, could be understood, and understand others. The Comprehensive Care Plan dated 12/2024, for Resident #19 did not include a plan for vision and or glasses. During an interview on 2/11/2025 at 11:24 AM, Resident #19 stated they had difficulty with vision. They did not wear their glasses anymore because the glasses really do not help. The glasses were really old, and they had been asking to see the eye doctor, but no appointment had been made. Ophthalmology consult dated 7/27/2020 documented diagnosis of diabetic retinopathy, significant right eye cataracts and corneal dystrophy (eye diseases that involve changes in the cornea). Recommended follow up in three months. During an interview on 02/14/2025 at 10:57 AM, Director of Nursing #1 stated resident was seen by ophthalmology in 2020, which was prior to their admission to the facility . They stated Resident #19 had not been seen by ophthalmology since admission. Residents were seen by specialist as needed, but generally once per year. They stated it was the responsibility of the unit manager to coordinate follow up specialist visits. During an interview on 02/14/2025 at 12:47 PM, Registered Nurse #1 stated Resident #19's Comprehensive Care Plan did not include vision and/or glasses. They were not aware resident wore glasses and would update the care plan. 10 New York Code of Rules and Regulations 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 2 (Resident #s 4 and 38) of 16 residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of 8%. This is evidenced by: The facility's policy and procedure titled Medication Administration last revised 11/2024 documented, all Registered Nurses and Licensed Practical Nurses must have successfully passed the written medication exam and the medication administration competency to administer medications as outlined below. Registered Nurses and Licensed Practical Nurses have the responsibility to administer medications in accordance with this policy and any other relevant education and/or certification. Right Documentation - Administration is recorded in the electronic Medication Administration Record. If medication is held or refused or not given on time, a reason for such is recorded in the electronic Medication Administration Record. If there are any signs of adverse reaction or change in resident's medical condition, there is documentation in the electronic Medication Administration Record. Check expiration date prior to administration. Verify that the medication selected is stable based on visual inspection for particulates or discoloration and that the medication has not expired. Do not administer single dose vial if seal has been broken. Check expiration date prior to administration. The Registered Nurses or Licensed Practical Nurses would make an evaluation, prior to administering any medication, of the resident's physical condition, lab values, and vital signs as indicated. Any contraindication to administering the medication would be discussed with the physician. Refused/Omitted/ Missed Dose: a. When medication is refused or omitted, select reason in electronic Medication Administration Record, selecting from drop downs. b. State reason for refusal/omission, any communication to physician and action taken in a Clinical Note. A Registered Nurse Supervisor and provider must be notified when a medication was not available. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, had determined that they have the decision-making capacity to do so safely. Resident #4: Resident # 4 was admitted to the facility with diagnoses of diabetes mellitus (a disease of inadequate control of blood levels of glucose), hip Fracture and depression (a mental health condition that involves a low mood and loss of interest in activities). The Minimum Data Set (an assessment tool) dated [DATE], documented resident had moderate cognitive impairment, could be understood, and understand others. Resident #4's current physician orders dated [DATE] and the Medication Administration Record dated 01/2025 documented, before meals give Insulin Lispro Injection 300 unit/3 milliliter three times a day at 08:00, 12:00, and 17:30 per sliding insulin scale. At 11:17 AM, Resident #4 had a documented blood glucose fingerstick of 347 Milligrams per deciliter. At 12:40 PM, Licensed Practical Nurse #2 administered 10 units of Lispro insulin based on the sliding insulin scale. Resident #4 had already consumed their lunch at approximately 12:10 PM. During an interview at 12:40 PM, Licensed Practical Nurse #2 stated insulin was ordered to be given before meals and should be given immediately after finger stick had been recorded. They stated it was wound rounds that day and they did not get to give the insulin until 12:40 PM. Licensed Practical Nurse #2 stated they should have prioritized and given the insulin first before passing other resident medications. Licensed Practical Nurse #2 did not obtain another blood glucose fingerstick, and did not report the late medication administration to a Registered Nurse and or physician. During an interview on [DATE] at 02:52 PM, Assistant Director of Nursing #1 stated insulin coverage should be given before meals per physician order. They stated insulin should be given as soon as possible after the blood glucose fingerstick. One hour and 20 minutes was considered an extended time between taking fingerstick and giving insulin coverage. In this case, a repeat fingerstick should have been taken and the physician should have been notified. Resident #38: Resident #38 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung); diabetes mellitus (a disease of inadequate control of blood levels of glucose), and depression (a mental health condition that involves a low mood and loss of interest in activities). The Minimum Data Set (an assessment tool) dated 04/2024, documented resident had moderate cognitive impairment, could be understood, and understand others. Resident #38's Medication Administration Record dated [DATE] documented, Ipratropium/Albuterol (0.5-3 milligrams/3 milliliters). Nebulized two times daily at 07:30 and 16:30. Administered [DATE] at 07:17 signed by Licensed Practical Nurse #1. During an observation on [DATE] at 11:43 AM, Resident #38 was noted receiving a nebulizer treatment. During an interview on [DATE] at 11:45 AM, Resident #38 stated the medication in nebulizer was left at their bedside that morning [DATE] by Licensed Practical Nurse #1. They stated staff always left the medication at the bedside, and they took it when they were ready. Licensed Practical Nurse#2 stated, resident had the nebulizer applied and turned off nebulizer themselves when done. If the medication was not completed, the resident would restart the nebulizer when ready. Licensed Practical Nurse #2 stated, although the nebulizer was placed that morning by Licensed Practical Nurse #1, they would have done the same thing. During an interview on [DATE] at 11:50 AM, Licensed Practical Nurse #1 stated they signed for Resident #38's nebulizer treatment at 07:30 AM indicating it was administered. They stated they did not go back into resident's room to ensure medication was consumed and or to have resident rinse mouth following nebulizer treatment. During an interview on [DATE] at 12:57 PM, Director of Nursing #1 stated they had no residents at the facility who self-administered medications. They stated if resident wished to self-administer medications, they would have to be assessed for competency along with obtaining an order to self-administer medication by the physician, and a care plan would be put in place. Director of Nursing #1 stated nurses who administer medications should not leave medications at the bedside. Staff were to ensure the medication was consumed. 10 New York Codes, Rules, and Regulations 415.12 (m)(1)]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for 1 (West Unit Team 1) of 2 medication carts reviewed. Specifically, (a.) opened medications had no open and or expiration dates (b.) open bottles of eye drops had no label identifying patient and had no open and or expiration dates. This is evidenced by: The facility's policy and procedure last revised 11/2024 documented, Multiple-Dose Vials a. Multiple-dose vials would not be used beyond the manufacturer's expiration date. Any multi-dose vial that has been opened or punctured would have an expiration date of 28 days-label the container when opened with the date of expiration (28 days from date of opening, or manufacturer's date of expiration if that is sooner) and initials. They must be stored under manufacturer's recommended conditions and discarded if potentially contaminated. Exceptions: Exceptions include when the manufacturer's stability is less than 28 days. For example, Mucomyst (Trademark) (acetylcysteine) vials should be dated upon initial entry. Acetylcysteine expires in 96 hours under refrigeration. Acetylcysteine would be issued with a fill-in-the-blank label for completion and application after the first use. Insulin vials would be dispensed as resident specific. Insulin removed from pyxis would be assigned to the resident for whom it was removed. Check expiration date prior to administration. Verify that the medication selected is stable based on visual inspection for particulates or discoloration and that the medication has not expired. Do not administer single dose vial if seal has been broken. Check expiration date prior to administration. During an observation on [DATE] at 11:34 AM, the [NAME] Unit Team 1 Medication Cart contained 1 open vial of Lispro insulin, and 1 open vial of glargine insulin both with no open and or expiration dates. The following open bottle of eye drops had no label identifying resident and had no open or expiration dates: 1 bottle each of Timolol; Brimonidine; Atropine; Ketorolac, GenTeal and Alaway. During an interview on [DATE] at 11:23 AM, Licensed Practical Nurse #1 stated medication was labeled when it came from the pharmacy. The label on the eye drops fell off, but they knew which patient the eye drop belonged to. Licensed Practical Nurse #1 stated they did not write the expiration date on the bottles, the pharmacy wrote the expiration date. During an interview on [DATE] at 02:52 PM, Assistant Director of Nursing #1 stated all medications came labeled from the pharmacy. They stated the fill date was different from the open date. The nurse opening the medication should write the open and expiration dates on the medication. When labels fall off, for example on eye drops, it was the nurse's responsibility to re-apply the label or request another medication from the pharmacy. During an interview on [DATE] at 10:45 AM, Director of Nursing #1 stated upon opening a medication the nurse should label the medication with open and expiration dates. Each nurse received medication administration training upon hire. Medication administration training included checking medication expiration dates prior to administration. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in 2 of 2 resident unit nutrition areas and the main kitchen. Specifically, the area of the main kitchen and resident kitchenettes were not clean. This is evidenced by: During the initial inspection in the main kitchen on 2/10/2025 at 11:05 AM, the following observations were made: • The manual can open had a build-up of debris in the cutting area of the device • The mixer had dirt and debris on and under the device. • Dust and dirt were on top of two fire extinguishers in the main kitchen. During an inspection of the East nutrition area on 2/12/2025 at 12:48 PM, the following observations were made: • Temperature logs for the refrigerator and freezer for February 6, 8, 9, 10, and 12/2025 were missing. • There was dirt and grime on the top of the refrigerator/freezer unit. • There was dirt, grime, and food particles on the freezer bottom and shelves. • There was dirt, grime, and food particles on the refrigerator bottom and shelves. • There was dirt and grime on the seals of the refrigerator and freezer. • There was dirt, grime, and food particles within the microwave. • There was dirt, grime, and food particles built up on the drawers under the microwave. During an inspection of the East nutrition area on 2/12/2025 at 12:58 PM, the following observations were made: • Temperature logs for the refrigerator and freezer for February 9, 10, and 12 were missing. • Dirt and grime on the top of the refrigerator/freezer unit. • Dirt, grime, and food particles on the freezer bottom and shelves. • Dirt, grime, and food particles on the refrigerator bottom and shelves. • Dirt and grime on the seals of the refrigerator and freezer. • Dirt, grime, and food particles within the microwave. • Dirt, grime, and food particles built up on the drawers under the microwave. During the follow-up inspection in the main kitchen on 2/13/2025 at 11:45 PM the following observations were made: • The walk-in refrigerator had a large pool of free-standing water on the floor. • The storage area for clean pots, pans, and food containers had multiple containers stacked together that were not fully dried. Containers, pots, and trays were put away wet and contained moisture. • The rolling toaster contained a large amount of debris under and behind the apparatus. • Dirt and grime on the shelving unit above the grill cooking area. • Final rinse pressure on the dishwasher was 13 pounds per square inch. The signage on the device had a recommendation of 20 pounds per square inch. During an interview on 2/13/2025 at 12:22 PM, Director of Food Services #1 stated that their staff were responsible for the cleaning of the equipment being used in the kitchen. They stated they would need to be more diligent in cleaning the equipment and kitchen areas. They stated that they were made aware of the water in the cooler this morning and engineering was working on a potential leak but unsure of what they found or the progress that had been made with it. They stated that the individual who was washing the pots, pans, and containers did not let them dry fully and put them away too soon as it took several hours to fully dry. They stated that they would have to educate the individuals washing the pans on the proper time for drying. Food Service Director #1 stated that the main dishwasher was out of service on Tuesday 2/11/2025 due to a malfunction. The Administrator was made aware, and the service company was called immediately to repair the machine. It was found that a sensor wire corroded away causing the malfunction. Food Service Director #1 stated that they had the service individuals look at the gauges for the dishwashing machine and it was found that the water pressure gauge was not working appropriately and had a faulty sensor. They stated that the service company ordered a new part and would be back to fix it as soon as the part came in. The service individual stated that the recommended pressure on the system was 20 pounds per square inch plus or minus 5 pounds. In observing the rinse pressure of the machine, Food Service Director #1 stated that the final rinse pressure was below the recommended amount. Food Service director #1 stated that the Environmental Services was responsible for the cleanliness of the nutrition areas, but the temperature logs were the responsibility of the dining ambassador. When asked about the missing dates of the temperature logs, Food Service Director #1 stated that people were not doing their jobs, and they would make sure they were completed daily. During an interview on 2/14/2025 at 11:45 AM, Environmental Services Director #1 stated that their staff were responsible for the overall cleaning in the nutrition areas. They stated that the cleanliness of the areas had been lacking. They stated that they were in the process of developing a duty list of responsibilities the environmental service individuals were to complete daily. In showing the areas of concern, Environmental Service Director #1 stated that the areas should have been cleaned and that was the reason they wanted to develop the lists. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on record reviews, and interviews conducted during a recertification survey, the facility did not ensure that Quality Assessment and Assurance Committee consisted at a minimum of the Director of Nursing, Medical Director or designee, Administrator, and Infection Preventionist. The failure to meet to coordinate and evaluate the need for performance improvement projects had the potential to affect all residents of the facility. Specially, Director of Nursing was also the Infection Preventionist. This is evidenced by: A review of the facility's undated Quality Assurance and Performance Improvement Plan, revealed that the Quality Assurance and Performance Improvement Plan provides leadership through its committee. The Quality Assurance and Performance Improvement committee shall be comprised of the Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Registered Nurse Manager, Registered Nurse Supervisors, Chief Executive Officer, [NAME] President of Operation, and other ancillary department heads. The Administrator is the chairperson of the Quality Assurance and Performance Improvement committee and is responsible for ensuring that Quality Assurance and Performance Improvement are implemented throughout the facility. The Quality Assurance and Performance Improvement Committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees. The overall responsibility of the steering committee is to develop and modify the Quality Assurance and Performance Improvement, identify teams who will problem solve as well as set priorities for the Performance Improvement Projects. A Review of the Policy and Procedure titled Infection Prevention and Control created in November 1977 and revised in August 2024 documented under Mission/Goal of the Infection Control Program: Through oversight of the Quality Assessment and Assurance Committee, the Infection Prevention and Control Committee, shall oversee the implementation of infection control policies and practices, and help department heads and managers implement infection prevention and control measures within their departments: and, inquiries concerning infection control policies, procedures, and facility practices should be referred to the Infection Preventionist or Director of Nursing Services. During the entrance interview conducted on 02/10/2025 at 10:30 AM, Director of Nursing #1 stated they were the current Infection Preventionist as well as the Nurse Educator. They stated that many staff members have multiple roles due to staffing issues. During an interview on 2/19/2025 at 11:15 AM, Administrator #1 stated that they held meetings every month and it was the responsibility of the staff to sign in for the meetings. They stated they were unaware that the Infection Control Preventionist was their own role and could not be a dual role with the Director of Nursing. 10 New York Code of Rules and Regulations 415.27(b)(3)

Based on observation and interviews during the recertification survey, the facility did not designate one or more individual(s) as Infection Preventionist (s) responsible for the facility's Infection Prevention Control Practices. Specifically, the facility did not have a specified designated individual as their Infection Control Preventionist, and the Director of Nursing had performed a dual role since May 10, 2023. This is evidenced by: A Review of the Policy and Procedure titled Infection Prevention and Control created in November 1977 and revised in August 2024 documented under Mission/Goal of the Infection Control Program: Through oversight of the Quality Assessment and Assurance Committee, the Infection Prevention and Control Committee, shall oversee the implementation of infection control policies and practices, and help department heads and managers implement infection prevention and control measures within their departments. Inquiries concerning infection control policies, procedures, and facility practices should be referred to the Infection Preventionist or Director of Nursing. The Infection Preventionist implements corrective action plans for infection control in affected problem areas with the assistance of the Chief Executive Officer, Medical Staff, Quality Assurance Performance Improvement Committee, and Nurse Executive. A review of the Infection Preventionist documentation of sufficient training documented that the Director of Nursing #1 completed their nursing home infection prevention training course on 05/10/2023. This was the day they assumed the role of the infection preventionist. A review of key personnel from May of 2023 documented that the designated Infection Preventionist listed for the facility was Director of Nursing #1. During the entrance interview conducted on 02/10/2025 at 10:30 AM, Director of Nursing #1 stated they were the current Infection Preventionist as well as the Nurse Educator. They stated that many staff members have multiple roles due to staffing issues. During an interview on 02/19/2025 at 11:15 AM, Administrator #1 stated that they were unaware that the Infection Control Preventionist was to have their own specific role and could not have a dual role with the Director of Nursing. 10 New York Code of Rules and Regulations 483.80 (b) (1)-(4) (c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during a recertification survey dated 05/02/2022 through 05/06/2022, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 3 (Resident #'s 9, 19, and #46) of 15 residents reviewed. Specifically, for Resident #9, the facility did not ensure personalized interventions were included in the dementia care plan, for Resident #19, the facility did not ensure personalized interventions were included in the depression/anxiety care plan, and for Resident #46, the facility did not ensure a care plan was developed for discharge. This was evidenced by: The Policy and Procedure (P&P) titled Interdisciplinary Care Plan Committee dated 04/2017 documented, each discipline along with the resident/family member will be responsible for identifying a problem/concern if any exist for their discipline and identifying an intervention for any problem/concern that is relevant to their discipline and can assist in achieving a goal for each resident. Resident #9: Resident #9 was admitted to the facility with the diagnoses of dementia, depression, and anxiety. The Minimum Data Set (MDS-an assessment tool) dated 02/01/2022, documented the resident had severely impaired cognition, could make self understood and could understand others. The physician's note dated 04/18/2022 documented; patient being seen for psychotropic medication evaluation and to assess behavior. The resident is being evaluated for the Seroquel (treats schizophrenia, bipolar disorder, and depression) nightly therapy. Resident #9 continues to do well with not as many behaviors although she still does have behaviors which include kicking at staff and other residents and pushing tables and other objects. The resident has some occasional verbal outbursts, but not many. The Comprehensive Care Plan (CCP) titled Dementia dated 02/07/2022 documented: I have a diagnosis of dementia and will need help from staff and family with decision making; I am physically combative with care; I refuse medications and procedures at times; I will have my needs met and will have help from staff and family as needed. The Certified Nurse Aide (CNA) Care Card (used by the CNAs to know what care the resident required) dated 05/03/2022, documented under the title behaviors; resident can be verbally abusive, hits and shoves during care, unpredictable disruptive behavior, noisy/screams, sometimes attempts to kick at staff and push things out of the way with her feet when independently wheels in scoot chair. The CCP did not include documentation of personalized interventions for staff to utilize when caring for the resident when the resident exhibits the behaviors described on the CNA Care Card. Resident #19: Resident #19 was admitted to the facility with the diagnoses of dementia, depression, and anxiety. The Minimum Data Set (MDS-an assessment tool) dated 02/07/2022, documented the resident had severely impaired cognition, could make self understood and usually could understand others. The physician's note dated 05/03/2022 documented, patient seen today for annual evaluation and behavioral/psychotropic medication evaluation. Nursing staff report that patient has had increased episodes of yelling and accusatory behavior with foul mood. Patient had Seroquel reduced from every 12 hours to just at bedtime greater than two months ago. Patient also continues to be on Alprazolam (antianxiety) twice daily as this helps with her anxiety. The Comprehensive Care Plan (CCP) titled Depression/Anxiety dated 02/14/2022 documented; I have a diagnosis of Depression/Anxiety and will receive medication for it, I will verbalize my feelings and demonstrate effective coping behavior. There were no personalized interventions documented for staff to utilize when caring for the resident. Resident #46: Resident #46 was admitted to the facility with the diagnoses of dementia, atherosclerosis and hypothyroid. The Minimum Data Set (MDS-an assessment tool) dated 04/02/2022, documented the resident had severely impaired cognition, could make self understood, could understand others, and there was an active discharge plan in place. The Social Work Note dated 04/05/2022 documented, called daughter to schedule a meeting to discuss discharge planning. The resident's daughter said they would be in one day this week but was not sure when. The document titled Discharge Documentation dated 04/15/2022, documented the discharge date of 04/18/2022 at 1:30 PM. Discharge destination was to be home with a family member. A review of the CCP and a request for the Discharge Planning CCP made on 05/04/2022, revealed there was no CCP for discharge planning. During an interview on 05/06/2022 at 10:45 AM, Registered Nurse Manager #2 stated the nurse managers write the nursing care plans, the other disciplines do their own. The things that we are trying with Resident #9 to calm were a warm blanket, and lollipops work well, Resident #19 likes sweets, these should be on the care plan. The personal interventions should be on the care plan. The interventions for behaviors should also be on the certified nurse aide (CNA) [NAME]. Resident #46 was here for short term rehab. Part of the admission process is the question were they short term or long term. There should have been a discharge care plan done by Social Work for Resident #46. During an interview on 05/06/2022 at 11:06 AM, the Administrator (Adm) stated Resident #46 was a planned discharge from the beginning of the stay. Prior to the admission Resident #46 was living alone, across the street from the daughter. We saw the resident would need more care after discharge and spoke with the daughter about it. The Adm stated they were covering the Social Work role until the new Social Work started but thought they had done a care plan for discharge. During an interview on 05/06/2022 at 12:01 PM, the Director of Nursing (DON) stated the Registered Nurse Managers review the care plans and the DON tries to help review them. The care plans are reviewed at the care plan meetings. The care plans interventions for Resident #9 and Resident #19 should have been more detailed. 10 NYCRR 415.11(c)(1)

Based on record review and interviews during a recertification survey from 5/2/2022 through 5/6/2022, the facility did not ensure that a resident who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #51) of 1 resident reviewed for dialysis. Specifically, for Resident #51, the facility did not ensure there was a physician order for dialysis treatment, did not ensure the resident received ongoing assessments of their condition before dialysis and monitoring for complications before dialysis treatments, did not ensure there was ongoing communication from the facility to dialysis center regarding dialysis care and services, and did not ensure the comprehensive care plan for chronic renal failure was person-centered and met the individual needs of the resident related to dialysis treatment. This is evidenced by: Resident #51: Resident #51 was admitted with the diagnoses of end stage renal disease, diabetes, and major depressive disorder. The Minimum Data Set (MDS-an assessment tool) dated 4/8/2022, documented the resident was cognitively intact, could understand others and could make self understood. The Policy and Procedure (P&P) titled Dialysis Care of Resident dated 2/2018, documented the resident must have written provider's orders stating facility name, nephrology doctor (MD) and frequency of dialysis treatment. Communication would be maintained with the communication log book that would be sent with the transfer for treatment. The P&P documented pre-dialysis, to perform and document a baseline resident assessment. Obtain pre-treatment vital signs and post-dialysis, the RN would do a full assessment upon dialysis return including vital signs every shift x 3, the RN was to check the catheter site every shift x 24 hours, and/or inspect access graft/fistula to assess for bleeding. The Comprehensive Care Plan for Chronic Renal Failure dated 4/19/2022, documented the resident was admitted with renal failure and was currently receiving dialysis 3x a week. The interventions included: 1. Medications as ordered, 2. Monitor labs as ordered, 3. Monitor for s/s of acute renal failure such as anorexia, confusion, disorientation, muscle twitching, lethargy, and edema, 4. Monitor output as ordered, and 5. Monitor for dialysis disequilibrium syndrome due to rapid shift of fluid and electrolyte levels. The physician orders did not include an order for dialysis treatment. During a record review from 4/20/2022 to 5/3/2022, the medical record did not include documentation that: -a Registered Nurse consistently checked the catheter site every shift x 24 hours post dialysis and/or consistently inspected the graft/fistula in accordance with the facility policy, -pre dialysis assessments were completed, and -there was ongoing communication from the facility to the dialysis center in the medical record. The Dialysis Communication Book did not include documentation from the nursing home to the dialysis center. During an interview on 5/5/2022 at 11:07 AM, Licensed Practical Nurse (LPN) #2 stated the LPNs obtained a set of vital signs when the resident returned from dialysis. The vital signs were documented in the progress notes and the RNs would also document vital signs under the Vital Sign tab in the electronic medical record. The LPN stated the dialysis book was for the dialysis center to document the resident's pre and post vital signs. The dialysis book was kept at the nurses' station for the nursing staff to review upon the resident's return from dialysis. The facility staff did not document in the dialysis book. Any communication the facility had with the dialysis center was done by phone. The LPN stated prior to sending the resident to dialysis, the staff did not take vital signs because the dialysis center obtained vitals before and after dialysis. During an interview on 5/6/2022 at 12:01 PM, the Director of Nursing (DON) reviewed the resident's physician orders and stated there was not an order for dialysis. The DON stated the order for dialysis should include the days of the week the resident went to dialysis, the name of the dialysis center, and the time of the resident's dialysis. The DON stated fistula monitoring would be a nursing protocol. The assessment of the fistula/graft site should be done, but the DON was not sure what the policy meant when it documented to check the catheter site every shift x 24 hours. The DON stated the dialysis care plan for Resident #51 should have been more detailed. The RNUMs were to review the care plans and the DON also tried to help review care plans. Care plans were also reviewed in the care plan meetings. The DON stated they had not seen nursing do pre-assessments prior to a resident going to dialysis. The DON stated a lot of the communication with dialysis was done on the phone. The resident's dialysis needs were coordinated between the facility, the dialysis center, and the physicians but was not documented in the medical record. During an interview on 5/6/2022 at 1:17 PM, the Registered Nurse Unit Manager (RNUM) #1 stated the physician orders should include an order for dialysis and the fistula assessment would be completed per facility protocol. The RNUM stated they relied on the dialysis center to do the pre dialysis assessment. The facility staff did not complete a pre dialysis assessment prior to sending the resident to dialysis. The RNUM stated the nursing home staff did not write in the dialysis book to communicate with the dialysis center. If there was something abnormal going on with the resident, they would call the dialysis center to let them know. The RNUM stated they were struggling with care plans, and it was very hard to make them resident specific. 10NYCRR 415.12

Based on observation, record review and interviews during the recertification survey and abbreviated survey (Case #NY00294316) from 5/2/2022 through 5/6/2022, the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and complete for 2 (Resident #'s 36 and #368) of 2 residents reviewed for catheter use. Specifically, for Resident #36, who had an indwelling catheter and history of urinary tract infections (UTIs), the facility did not ensure the Comprehensive Care Plan for an indwelling catheter's interventions for catheter care every shift, and that urinary catheter assessments were consistently documented in the medical record. Additionally, for Resident #36, the medical record did not include documentation that the resident was experiencing pain and discomfort related to their indwelling catheter on 5/4/2022; and for Resident #368, who had an indwelling catheter and history of UTIs, the facility did not ensure catheter care was documented every shift and urinary catheter assessments were consistently documented in the medical record. Additionally, for Resident #368, the medical record did not include documentation the provider was notified when the resident's catheter, ordered to be changed on 12/25/2021, was not changed until 12/29/2021, did not ensure the resident's medical record did not include inaccurate documentation on 12/28/2021 when it was documented the resident was on an antibiotic for a UTI, and did not ensure the medical record included documentation the provider was notified when Resident #368 was complaining of pain in the bladder area and had a small amount of urinary output after their catheter was changed on 12/30/2021. This is evidenced by: The Policy and Procedure (P&P) titled Foley Catheter Irrigation dated 10/2010 documented catheters would be irrigated by the nursing staff as ordered by the physician and staff were to document tolerance, color, and any abnormalities in the nurses notes and notify the physician of any signs or symptoms of infection or decreased urine flow. The P&P titled Urinary Catheter Care dated 2/2019, catheter care would be delivered by the Certified Nursing Assistant (CNA) once a shift and as necessary for bowel incontinence to prevent urinary tract infections and to promote optimal urine flow. The Foley catheter bag was to be emptied at 5 AM, 1 PM, and 9 PM and to report the amount to the nurse. The nurse was to be immediately notified of any blood, sediment, mucous in urine or any decrease flow of urine. The CNAs were to report all findings to the nurse and record on the Team Report Sheet. The P&Ps did not address the nurses' responsibility to complete the Assess/Manage Urinary Catheter section in the medical record. Resident #36: Resident #36 was admitted with diagnoses of urinary tract infection, chronic pain syndrome, and indwelling Foley catheter calcification. The Minimum Data Set (MDS-an assessment tool) dated 3/8/2022, documented the resident had moderately impaired cognition, could usually understand others and could make self understood. During an observation on 5/4/2022 at 10:33 AM, Resident #36 was crying out and moaning. The resident stated they could not urinate, and the pressure hurt so bad they could not stand it. The pain was unbearable. Urine was not observed in the tubing of the catheter. The resident stated the nurses were aware but did not know of anything being done. The Comprehensive Care Plan (CCP) for ESBL (extended spectrum beta-lactamase- an enzyme found in some strains of bacteria that can be found in the urinary tract), dated 4/5/2022, documented the resident had been diagnosed with colonized ESBL in their urine. Care plan approaches included: contact precautions to prevent the spread of infection, monitor for temp elevation and treat accordingly, and to notify the physician of any concerns. The CCP for Indwelling Foley, dated 3/13/2022 documented the resident had a Foley catheter to related to outlet obstruction and urinary retention. Care plan approaches included Catheter care every shift; to note amount, color, consistency, and odor and report abnormalities; and to change the urinary catheter per facility policy and/or physician's order. The facility did not provide a physician order for the resident's Urinary Foley Catheter. A Nursing Assistant note dated 4/30/2022, documented the resident's Foley was leaking and the staff member was unable to obtain an output. A review of nurses' progress notes from 4/29/2022 through 5/4/22 did not include documentation that the resident's Foley was leaking on 4/30/2022 and did not include documentation of the resident's complaint of feeling pressure and pain related to feeling the inability to urinate on 5/4/2022. A review of Assess/Manage Urinary Catheter in the medical record from 4/29/2022 through 5/3/2022, did not include an assessment on 2 (4/30/2022 and 5/1/2022) of 5 days. An Assess/Manage Urinary Catheter dated 5/4/22 at 1:45 PM, documented the resident's Foley catheter was changed at 11:30 AM. A review of Certified Nursing Assistant (CNA) documentation from 4/29/2022 through 5/3/2022, did not include documentation that Indwelling Urinary Catheter Care was provided on 6 of 15 shifts. During an observation and interview on 5/4/2022 at 10:41 AM, Registered Nurse Unit Manager (RNUM) #2 went into Resident #36's room with the Surveyor. The resident was crying out and stating they were in pain due to feeling pressure and feeling like they were unable to urinate. The RNUM checked the Foley bag and stated there was very little urine in the bag, but stated they did not know when the bag was last emptied. RNUM #2 stated the Foley needed to be flushed and they would have a nurse flush it. During an interview on 5/6/2022 at 10:21 AM, CNA #5 stated the CNAs emptied the Foley catheter bags and measured the output. The CNA stated Foley care was completed 2 times a shift but documented once a shift. The CNAs were to report any changes to the nurse. Changes would include low urinary output, blood in the urine or blood or irritation around the catheter site. During an interview on 5/6/2022 at 10:29 AM, CNA #4 stated Foley care was done once every shift by the CNAs but did not think Foley care was documented in the medical record. The CNA stated catheter care was part of the resident's routine care. The CNAs also emptied and measured the urine output about 2 hours prior to end of the shift and as needed. The CNAs verbally told the nurses the resident's output and documented it in the medical record. The CNAs were to report it to the nurse if there was a small amount of urine in the bag, if the urine was dark in color, had a strong odor, or they noticed blood or irritation. During an interview on 5/6/2022 at 12:39 PM, RNUM #1 stated Assess/Manage Urinary Catheter in the medical record was auto populated by the order for the Foley catheter. RNUM #1 was unsure how often the nurses were supposed to document under the Assess/Manage Urinary Catheter section in the medical record. During an interview on 5/6/2022 at 1:34 PM, the Director of Nursing (DON) stated Foley catheters were emptied by CNAs or LPNs and the CNAs were responsible for catheter care every shift and were to document the care every shift. The CNAs would report any issues to the nurses. The DON was currently responsible for the monitoring of the care documented but that responsibility would eventually be passed down to Unit Managers to oversee the care was being documented. The DON stated it was an area to work on. The DON stated they tried to monitor the care and documentation the best they could. The DON stated Assess/Manage Urinary Catheter could be documented by any of the nurses and should be completed but was not sure of the frequency it should be documented. The DON stated Resident #36 sometimes had issues with their Foley and it would have to be replaced or flushed. The nurses should document in the nurses note if they had to flush the Foley or if there were any issues with the Foley. During a subsequent interview on 5/6/2022 at 1:43 PM, RNUM #2 stated they did not know what the outcome was with Resident #36's Foley on 5/4/2022. RNUM #2 stated they did not know if the catheter was kinked or had to be flushed. RNUM #2 stated they had another nurse take care of the resident's Foley on 5/4/2022 and they did not see anything documented under nursing notes from that date. RNUM #2 stated the nurse should have written a note about what was done with the Foley on 5/4/2022. The nurse had not reported back to the RNUM with what the issue was on the morning on 5/4/2022. RNUM #2 stated the CNAs provided catheter care and documented catheter care under Activities of Daily Living. The CNAs also documented urinary intake and output. The RNUM stated Resident #36 had ESBL in their urine and the nurses were responsible for changing the resident's catheter, flushing the catheter, and documenting any issues related to the catheter. The RNUM reviewed the medical record and stated they did not know the frequency for documenting under the heading Assess/Manage Urinary Catheter. The RNUM stated it was an area where the nurses were to document about the resident's catheter. Resident #368: Resident #368 was admitted with diagnoses of chronic kidney disease, urinary retention, and chronic pain syndrome. The Minimum Data Set (MDS-an assessment tool) dated 11/9/2021 documented the resident had severely impaired cognition, could usually understand others and could make self understood. The Comprehensive Care Plan (CCP) for Urinary Tract Infection (UTI) dated 11/10/2021, documented the resident had a diagnosis of UTI. Care plan approaches included: to monitor for complaint of burning, frequency, painful urination, color, and amount of voiding; administer medications as ordered and monitor for temp elevation and treat accordingly. The CCP for Foley Catheter dated 11/16/2021, documented the resident had a Foley catheter due to urinary retention. Care plan approaches included: Monthly catheter changes and antibiotic prior to each scheduled medication, catheter care every shift, noted amount, color, consistency, odor and report abnormalities, and leg bag in place when out of bed. A physician order dated 12/25/2021, documented Insert urinary catheter. The order was completed on 12/29/2021. The physician orders from 12/25/2021 to 12/31/2021, did not include an order for an antibiotic to treat a UTI. A review of Assess/Manage Urinary Catheter from 12/25/2021 to 12/31/2021 did not included documentation on 5 (12/26/2021, 12/27/2021, 12/28/2021, 12/29/2022 and 12/31/2022) of the 7 days. A review of Certified Nursing Assistant (CNA) documentation from 12/25/2021 through 12/31/2021, did not include documentation Indwelling Urinary Catheter Care was provided on 13 of 21 shifts. A review of progress notes dated 12/25/2021 to 12/31/2021 documented: -12/25/2021 at 10:09 PM, the resident was very combative and aggressive. Provider notified and a new order for Zyprexa (antipsychotic) 10 milligrams (mg) Intramuscular (IM). Foley to be changed using Urojet (local anesthetic agent) and Urinalysis (UA) and Culture and Sensitivity (C&S) to be obtained and sent to lab. -12/27/2021 at 4:53 AM, the resident was very restless and wandering around. The nurse was unable to change the resident's Foley catheter due to the resident not going to bed. - 12/28/2021 at 5:21 AM, UA (urine analysis) C&S (Culture and Sensitivity) sent. Resident is on antibiotic for the UTI. Note in doctor's (MD) book to look at results. - 12/28/2021 at 2:56 PM, the provider was on the unit, reviewed chart, reviewed clinical data, examined resident. The resident will start on long-acting pain medication. The provider did not document the resident's exam, the chart review, or the clinical data review in the resident's medical record. -12/30/2021 at 10:07 PM, Resident #368 complained of pain in bladder area. There was no urine output and irrigated without success. The Foley was removed with a small (sm) clot in the tip. The Registered Nurse Supervisor (RNS) attempted another #18 French coude (catheter specifically designed to maneuver around obstructions or blockages in the urethra) without any urine returns. The RNS inserted a #16 French with 5 cubic centimeters (cc) balloon and obtained 10 cc of clear yellow urine. A small amount of urine was coming thru but the resident continued to complain of the need to urinate. They attempted to administer the antibiotic prior to the Foley change but the resident spit them out. Zyprexa 5 mg IM was administered due to agitation and combativeness. The note documented continuing to monitor the resident for output and agitation. -12/31/2021 at 10:58 PM, the nurse was called to assess the resident as resident was not themself. Upon entering the room, the resident had their eyes closed and was shaky all over. The resident was nonresponsive to verbal or tactile stimulus. The catheter was draining clear yellow urine. The Nurse Practitioner (NP) was aware. The resident will be monitored through the night and will call the NP if the resident further deteriorates. During an interview on 5/6/2022 at 10:21 AM, CNA #5 stated the CNAs emptied the Foley catheter bags and measured the output. The CNA stated Foley care was completed 2 times a shift but documented once a shift. The CNAs were to report any changes to the nurse. Changes would include low urinary output, blood in the urine or blood or irritation around the catheter site. CNA #5 was not aware if Resident #36 had any issues with their catheter. During an interview on 5/6/2022 at 10:29 AM, CNA #4 stated Foley care was done once every shift by the CNAs but did not think Foley care was documented in the medical record. The CNA stated catheter care was part of the resident's routine care. The CNAs also emptied and measured the urine output about 2 hours prior to end of the shift and as needed. The CNAs told verbally the nurses the resident's output and documented it in the medical record. The CNAs were to report it to the nurse if there was a small amount of urine in the bag, if the urine was dark in color, had a strong odor, or they noticed blood or irritation. CNA #4 stated Resident #368 would pull on their catheter and pull it out. The resident wore a leg bag when they were out of bed to help prevent the resident from pulling on the catheter. During an interview on 5/6/2022 at 10:51 AM, Licensed Practical Nurse (LPN) #1 stated prior to going to the hospital on 1/1/2022, the resident was receiving an antibiotic for their toe. The resident was not receiving an antibiotic for a UTI, The LPN stated the LPN did not document daily catheter checks for residents with catheters. They documented in the medical record if there was an issue with a resident's catheter, if they had to flush the catheter, or if the catheter had to be changed. During an interview on 5/6/2022 at 11:46 AM, RNS #2 stated Foley care was provided by the CNAs once a shift and the RNS was not sure if the CNA documented that care. The RNS stated they would look at a resident's Foley if an issue was brought to their attention. They would notify the provider. The progress note from 12/30/2021 was reviewed with RNS #2. RNS #2 stated they would have notified the PA right then and they would have also notified the PA if they could not change the resident's catheter on 12/25/2021. In both situations, on 12/25/2021 and 12/30/2021, the RNS stated they would have documented the response of the PA. During an interview on 5/6/2022 at 11:59 AM, RNS #1 stated they notified the provider only if there was an issue with a resident that did not resolve during their shift. The progress note from 12/30/2021 was reviewed with RNS #1 and RNS #1 stated they normally would have called the physician and documented that they called the physician. RNS#1 stated Resident #368 prone to UTIs and had conversations with the physician that the resident's UTIs were becoming more and more resistant to antibiotics. The conversations were not necessarily documented in the medical record. The RNS stated the CNAs emptied the Foley bags, measured the output, and notified the nurse. The RNS stated after a UA C&S was obtained, they would notify the physician and then the physician would decide what antibiotic would work. The RNS stated Resident #368 had constant UTIs. The RNS stated that the Assess/Manage Urinary Catheter in the medical record was done every shift and documented in nursing notes. During an interview on 5/6/2022 at 12:39 PM, RNUM #1 stated the nurse should notify the provider if they were unable to change Foley on 12/25/2021. RNUM #1 stated the Assess/Manage Urinary Catheter in the medical record was auto populated by the order for the Foley catheter. RNUM #1 was unsure how often the nurses were supposed to document under the Assess/Manage Urinary Catheter section in the medical record. RNUM #1 reviewed the medical record and stated they did not see that the Physician Assistant (PA) documented their visit with the Resident on 12/28/2021 and the PA should have documented their exam of the resident. RNUM #1 stated the resident was not on an antibiotic for a UTI as documented on 12/28/2021. The RNUM #1 stated the provider should have been notified and documented by the nurses when catheter was unable to be changed on 12/25/2021 and on 12/30/2021 when there was difficulty with the catheter. During an interview on 5/6/2022 at 1:11 PM, the Director of Nursing (DON) stated Foley catheters were emptied by CNAs or LPNs and the CNAs were responsible for catheter care every shift. The CNAs were to document the care every shift. The CNAs would report any issues to the nurses. The DON was currently responsible for the monitoring of the care documented but that responsibility would eventually be passed down to unit managers to oversee the care was being documented. The DON stated it was an area to work on. The DON stated the nursing staff should have notified the provider if they were unable to change the resident's Foley in 12/25/2021. The DON stated the resident was not on an antibiotic for a UTI as documented in the nursing note dated 12/28/2021. The DON stated the only antibiotics ordered at that time were for the resident's toe and for the resident's monthly catheter changes. The DON stated the PA should have a corresponding note in the medical record to the nursing note on 12/28/2021 that documented the resident was examined by that provider. The DON stated the provider should have been notified on 12/30/2021 based on the nursing progress note. The DON stated normally nursing would call the physician to notify them of any changes or concerns. The DON stated there should also be documentation if the resident's urine came back and the decision whether to treat or not with an antibiotic. The DON stated there may be verbal discussions with the provider, but those discussions should also be documented. The RNUM reviewed the medical record and stated they did not know the frequency for documenting under the heading Assess/Manage Urinary Catheter. The RNUM stated it was an area where the nurses were to document about the resident's catheter. The DON stated they saw there was a lack of documentation in the resident's medical record. During an interview on 5/6/2022 at 2:03 PM, PA #1 stated if they saw a resident, they documented their visit in the medical record. The PA stated there should have been a note written by them if they examined Resident #368 on 12/28/2021. 10NYCRR415.22(c)

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, the facility did not ensure that on two (2) of 2 resident units wheelchairs and floors were clean, and resident room walls were in good repair. This is evidenced as follows: During observations on 05/05/2022 at 10:55 AM, the floors were soiled in resident rooms numbered 2, 9, 10, 12, 17, 19, 31, 32, 39, and 40, and the corridor floors were soiled next to walls and by all door thresholds on the East Unit and [NAME] Unit. Walls and/or doors were scraped in resident rooms numbered 2, 4, 9, 10, 12, 17, 19, 31, 32, 39, and 40. The wheelchairs assigned to the residents in resident rooms numbered 4, 9, and 25 were soiled with dust, dirt, and/or drip marks. During an interview on 05/05/22 at 11:35 AM, the Environmental Services Supervisor stated that the facility is aware that the floors need stripping and resealing, but the facility has been having trouble getting vendors or the needed staff to complete the work. The Environmental Services Supervisor stated that staff are supposed to notify the Environmental Service Department when wheelchairs require cleaning. During an interview on 05/05/22 at 11:35 AM, the Director of Engineering stated that the resident rooms are being remodeled to fix the wall scrapes, but COVID has slowed the process down. During an interview on 05/05/22 at 2:30 PM, the Administrator stated that the wheelchairs and floors identified will be cleaned, and the scrapped walls and doors identified will be touched up. The Administrator stated contractors have been brought in either to refinish or replace floors, but the floor work is not finished in every resident room. 483.10(i)(3); 10 NYCRR 415.5(h)(4)

Based on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Automatic dishwashing machines are to operate according to the manufacture specifications, and equipment and floors are to be kept clean. Specifically, the dishwashing machine final rinse water pressure was too high, and the cooking line table fan, cooking line shelf, floor below the cooking line, and the 4 fire extinguishers in the main kitchen and microwave ovens, refrigerators, and floors on three (3) of 3 resident unit kitchenettes were soiled with food particles, grime, or dirt. This is evidenced as follows: During an inspection of the main kitchen on 05/02/2022 at 10:23 AM, the automatic dishwashing machine final rinse water pressure was 44 pounds per square inch (psi); the manufacturer's instructions require the final rinse water pressure is to be 20 psi. The cooking line table fan, cooking line shelf, floor below the cooking line, and the 4 fire extinguishers were soiled with food particles or grime. During an inspection of the resident unit kitchenettes on 05/03/2022 at 9:44 AM, the microwave ovens and refrigerators were soiled with food particles and the floors were soiled with dirt. During an interview on 05/02/2022 at 4:04 PM and again on 05/05/22 at 12:27 PM, the Nutritional Services General Manager stated that the dishwashing machine manufacturer final rinse water pressure was too high but can be adjusted. The Nutritional Services/EVS General Manager stated that the resident unit microwave ovens, refrigerators, and floors will be cleaned. During an interview on 05/05/2022 at 2:45 PM, the Administrator stated that the dishwashing machine water pressure will be adjusted, and the soiled areas identified will be cleaned. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110, 14-113(a), 14-1.170

Based on record review and interview during the recertification survey, the facility did not ensure their policy regarding foods brought to residents by family and other visitors included information on the safe and sanitary storage, and handling and consumption of food. Specifically, the facility does not provide information for family and other visitors on safe food handling practices or safe reheating of food that is brought in to residents. This is evidenced is as follows. The facility policy for foods brought in by visitors was reviewed on 12/04/2019. This policy does not include a process to ensure family and other visitors are provided information on safe food handling practices. The Clinical Nutrition Manager stated in an interview on 12/04/2019 at 2:27 PM, that the facility does not provide information on safe food handling to families or visitors that bring food in to residents.

Based on observation and staff interview during the recertification survey, the facility did not adhere to adopted food safety regulations. Automatic dishwashing machines are to operate in accordance with manufacturer specifications, and foods time/temperature controlled for safety (TCS foods), formerly identified as potentially hazardous foods, are to be cooled to 41 degrees Fahrenheit (F) within 6 hours provided the food is cooled from 135F to 70F within the first two hours. Specifically, the automatic dishwashing machine and the automatic pot washing machine were not operating within the manufacturer's specifications required to sanitize food surfaces, and TCS foods were not cooled safely. This is evidenced as follows. The main kitchen was inspected on 12/04/2019 at 09:48 AM. When checked, the automatic dishwashing machine final rinse was 170 F at 13 pounds per square inch (psi) water pressure, and the automatic pot washing machine final rinse was 203 F at 55 psi. The automatic dishwashing machine information date plate states that the minimal final rinse water temperature is to be 180 F at 20 psi, and the automatic pot washing machine information date plate states that the final rinse water pressure is to be 20 psi ± 5 psi. Cooked noodles found in the walk-in refrigerator were 45 F when checked on 12/04/2019 at 10:30 AM. The label on the noodles stated that they were prepared on 12/01/2019. The Director of Nutrition stated in an interview on 12/04/2019 at 11:10 AM, that he will have the main kitchen dishwashing machine adjusted so as to properly sanitize and will educate staff on safe cooling procedures. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.40(b), 14-1.113

Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in all areas with gas operated equipment. Specifically, carbon monoxide detection was not installed in an area with gas fuel fired equipment. This is evidenced as follows. Observations on 12/09/2019 at 10:20 AM, revealed a fuel burning appliance, gas clothing dryer, in the laundry room without carbon monoxide detection. The Environmental Services Supervisor/Safety Officer stated in an interview on 12/09/2019 at 10:25 AM, that the laundry room has gas dryers and does not have carbon monoxide detection in this area or anywhere in the nursing home. 483.70 (b); 2015 International Fire Code, Section 915