Based on interviews and record review conducted during the recertification survey, the facility did not provide proper treatment and assistive devices to maintain the vision ability for 1 (Resident #70) of 2 residents reviewed for communication. Specifically, for Resident #70, the facility did not ensure the resident, who had impaired vision, was provided with an optometry consultation to be evaluated for vision aids. This is evidenced by: Resident #70: Resident #70 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (a long-term breathing problem), hypertension (high blood pressure), and seizures (sudden, uncontrolled electrical discharges in the brain that can cause temporary changes in movement and consciousness). The Minimum Data Set (an assessment tool) dated 11/21/2024, documented the resident was understood, able to understand others, and was cognitively intact. The Minimum Data Set documented the resident had impaired vision and used corrective lenses. The Policy and Procedure titled, Physician – Consultations, dated 8/2019, stated it was the policy of the organization to ensure all residents receive medical care in a timely manner. The Consult Form dated 3/07/2023 documented the resident had been examined by an optometrist. The form documented the next follow up should be scheduled for 3/2024. Review of the medical record showed no further optometry consults were documented for the resident or a comprehensive care plan developed for the resident regarding their vision. During an interview on 12/11/2024 at 1:03 PM, Resident #70 stated they would like to see the eye doctor. During an interview on 12/17/2024 at 11:12 AM, Registered Nurse #1 stated the resident should see the optometrist every 6-12 months. They stated they would forward any recommendations to Medical Records #1 to schedule follow-up appointments. During an interview on 12/18/2024 at 10:04 AM, Medical Records #1 stated they receive an email from the nurse managers to schedule appointments. They stated they keep a list of the doctors that come to the facility (dental, optometry, podiatry) and give that list of residents to be seen to the doctors. 10 New York Codes, Rules, and Regulations 415.12(2)(b)

Based on record reviews, and interviews during the recertification and abbreviated survey (Case # NY00355835), the facility did not ensure maintenance of acceptable parameters of nutritional status for 1 (Resident #97) of 3 residents reviewed for nutrition. Specifically, Resident #97 did not have weekly weights measured for monitoring of significant weight loss as ordered by the dietician for the weeks of 11/25/2024 and 12/09/2024. This is evidenced by: Cross-referenced to F804: Nutritive Value/Appearance, Palatable/Prefer Temp A facility policy titled, Weight Management, with a current revision dated of 3/01/2024, documented that the resident's weight shall be obtained within twenty-four hours of admission, weekly for four weeks, then monthly thereafter and more frequently as clinically indicated for the residents, and documented in the clinical record. It further documented that the registered dietician will review the resident weights monthly, with a significant unplanned weight change and as needed. Parameters for evaluating the significance of unplanned and undesired weight is as follows: 1 month - 5 percent weight change is significant, greater than 5 percent is severe. 3 months - 7.5 percent weight change is significant, greater than 7.5 percent is severe. 6 months - 10 percent weight change is significant, greater than 10 percent is severe. Resident # 97 was admitted to the facility with diagnoses of dementia (a degenerative neurological condition causing memory problems), protein-calorie malnutrition (lack of adequate food intake to maintain health), and history of falling. The Minimum Data Set (an assessment tool) dated 8/09/2024, documented that the resident had intact cognitive ability, could be understood, and understood others. Review of Resident #97 ' s Care Plan revealed a focus of nutritional problem or potential nutritional problem related to malnutrition diagnosis, low weight for age; variable intakes since admission; dementia diagnosis; dislike of facility food with declining alterative options; and unintentional weight loss (initiated 8/19/2024). There was a goal of receiving adequate nutrition and hydration without unplanned significant weight changes (initiated 8/19/2024) and maintain stable weight with minimal change of 3 percent by next review (initiated 11/07/2024). Interventions/tasks documented were follow weights as ordered weekly weights until stable (initiated 8/19/2024), identify and honor food preferences, and monitor meal and fluid consumption records. Resident #97 ' s December 2024 Medication Administration Record and Treatment Administration Record revealed an order for Weigh on Admission/readmission x1, then weekly x 4, then monthly every day shift every 1 month(s) starting on the 1st for 1 day(s). Monitor Weight (Must customize weekly weight to shift and day specified for your facility and remove these directions) Monthly Weights must be obtained by the 7th of each month -Start Date- 10/01/2024 0700. Record review of active orders showed no order for weekly weights. Record review revealed that on 08/14/2024, the resident weighed 119 lbs. On 12/04/2024, the resident weighed 107 pounds, which was a -10.08 percent Loss. During an interview on 12/11/2024 at 1:42 PM, Resident #97 stated the food was cold at times and could be better. A Dietary Weight Change Progress note dated 11/07/2024 at 8:03 AM documented a weight warning, with the resident ' s weight on 11/05/2024 being 107.8 pounds which was 6.9 percent over 30 days and was significant weight loss. Resident stated the food was unappealing to them; dietician added supplement shake to increase intake. In addition, the Dietician documented the plan of care included monitor weights weekly for four weeks. A Dietary Weight Change Progress note dated 11/13/2024 at 9:53 AM documented the resident ' s weight was 107.6 pounds on 11/11/2024; the plan of care documented weekly weights were ordered due to significant weight loss over 30 days and to continue weekly weighs and supplement. A Provider Progress note on 11/18/2024 documented that Family Nurse Practitioner #1 saw Resident #97 due to a chief complaint of periodic dizziness; blood work was ordered, extra fluids were ordered every shift, blood pressure and pulse reviewed were taken 10/03/2024. Weight loss was not addressed according to the provider note. A provider progress note dated 12/05/2024 by Family Nurse Practitioner #1 documented, resident has had some gradual weight loss over the past 30 days. The resident saw a dietician. They stated that they do not like the food, so they do not have much of an appetite. That is likely where the weight loss is stemming from. Please order nutritional shakes and see a dietician for fortified foods to add to their diet. A Dietary Weight Change Note dated 12/05/2024 at 9:27 AM documented a weight warning and showed the resident ' s weight on 12/04/2024 was 107.4 pounds; the resident was consuming on average 50-75 percent of meals; the resident told the dietician the sandwiches provided had stale bread so the resident could not eat them and the resident did not like the taste of many items on the menu. The Dietician noted to continue weekly weights. A Rehabilitation Referral Progress note dated 12/17/2024 at 9:49 AM documented that Resident #97 was unable to get in and out of bed and the resident felt they were requiring more assistance; the most recent weight was documented as 107.4 pounds on 12/04/2024. Record review of weights revealed the following weights for Resident #97: 8/06/2024 - 114.64 pounds 8/14/2024 - 119.0 pounds 8/19/2024 - 119.0 pounds 8/28/2024 - 118.2 pounds 9/01/2024 - 116.2 pounds 10/02/2024 - 115.6 pounds 11/04/2024 - 107.8 - struck out by Dietician and comment re-weighed on 11/8/2024 11/08/2024 - 112 pounds 11/11/2024 - 107.6 pounds 11/19/2024 - 108.6 pounds 12/01/2024 - 105.4 - struck out and comment re-weighed on 12/02/2024 12/02/2024 - 105.0 - struck out and comment re-weighed by Dietician 12/05/2024 12/04/2024 - 107.4 pounds No weights were found for the week of 11/25/2024, 12/09/24, 12/16/24 During an interview on 12/17/2024 at 10:54 AM, Registered Nurse #3 stated that the Dietician would send an email every Monday that listed which residents required weekly weights, when the dietician was not out on leave. Registered Nurse #3 checked their emails and did not find an email dated 12/09/24 and could not find weights for resident for 11/25/24 nor 12/09/24. 10 New York Code Rules and Regulations 415.12(c)(2)

Based on interview and record review during a recertification survey, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents ' goals and preferences for 1 (Resident #112) of 1 residents reviewed for pain management. Specifically, the facility failed to administer Resident #112 ' s pain medication in a manner that managed the resident ' s pain and which resulted in the resident expressing their pain was 10 out of 10, and Family Member #2 calling 911 to have Resident #112 sent to the hospital for care. This is evidenced by: A facility policy titled Medication Administration – Documentation, last revised 1/2019, documented that when administering medications, documentation must include, as a minimum, a. Name and strength of the drug; b. Dosage; c. Method of administration; d. Date and time of administration; e. Reason(s) why a medication was withheld, not administered, or refused; and f. Signature and title of the person administering the medication. A facility policy titled, Pain Management last revised 3/2020, documented that the facility would determine appropriate intervention to manage pain and side effects, review interdisciplinary assessments and documentation, include the resident and family in determining the resident ' s pain goal and acceptable level of pain, identify the potential cause(s) for resident pain, evaluate alleviating and/or exacerbating factors. Appropriate interventions may include pharmacologic as well as non-pharmacologic interventions. Document pain management interventions. Evaluate effectiveness of pain management intervention(s) within 30-60 minutes. Notify physician if interventions are not effective in achieving resident comfort and/or functional goals and re-assess resident status as indicated including, but not limited to level of pain, side effect management, effectiveness of interventions and need for increasing/decreasing amount of medication due to tolerance or side effects. Resident #112 was admitted to the facility with diagnoses of fracture of the lumbar vertebra (lower back bone), malignant neoplasm of the uterine adnexa (uterine cancer), and secondary malignant neoplasm of the bone (bone cancer). The resident was not at the facility long enough to have a Minimum Data Set (a resident assessment) completed. The discharge summary from the hospital, dated 09/19/2024, documented that Resident #112 suffered a compression fracture to the lumbar vertebra #1 (lower back fracture) which required intravenous narcotics, thenan increase in the resident ' s oral narcotics until the pain was controlled. The hospital discharge summary documented Resident #112 should continue to take ropinirole 0.25 milligram (medication for restless leg syndrome which causes uncontrollable spasms of the legs) tab oral daily at bedtime. Additionally, the hospital summary documented that Resident #112 use a diclofenac 1.3 percent patch every 12 hours, acetaminophen (Tylenol extra strength) 500 milligram tab, take 1000 milligrams oral 3 times per day, and oxycodone 5 milligram tab every 4 hours as needed for pain not to exceed 40 milligrams per day. Specifically, the hospital summary documented the following parameters for oxycodone administration: 5-10 milligrams: give 5 milligrams (1 tab) for pain level 3-5 and 10 milligrams for pain level 6-10. Resident #112 ' s Comprehensive Care Plan for alteration in comfort due to cancer and fracture, documented a goal of Resident was able to verbalize pain and request pain medications as needed. Interventions/tasks documented included: • to administer medications as ordered • Notify physician is interventions were unsuccessful or is current complaint was a significant change from residents past experience of pain • Report to Nurse resident complaints of pain or requests for pain treatment • Resident was able to verbalize pain and request pain medications as needed. Resident #112 ' s Comprehensive Care Plan for Fracture/Joint Replacement: Alteration in physical function related to fracture dated 09/19/2024 documented a goal of resident will be free of complications from fracture. The documented Interventions/Tasks included giving medications as ordered and monitor for increased signs or symptoms of pain ad notify provider of any change. A Physician order dated 09/19/2024 documented that the resident needed a pain evaluation every shift and to have the pain recorded on a 0-10 scale. Resident #112 ' s Order Summary Report for September 2024 documented orders as follows: • Acetaminophen extra strength oral tablet 500 milligrams, give 2 tablets by mouth three times a day for pain, ordered 9/19/2024. • Acetaminophen tablet 325 milligrams, give 2 tablets by mouth every 6 hours as needed for pain (not to exceed 3 grams in 24 hours), ordered 9/19/2024. • Oxycodone 5 milligrams, give 1 tablet by mouth every 4 hours as needed for pain, ordered 9/19/2024. • Oxycodone 5 milligrams, give 2 tablets by mouth every 4 hours as needed for pain, ordered 9/19/2024. • Oxycodone 5 milligrams, give 2 tablets by mouth one time only for pain for 1 day, ordered 9/19/2024. • Ropinirole .25 milligrams, give 1 tablet by mouth at bedtime for restless legs, ordered 9/19/2024. No order for diclofenac 1.3 percent patch every 12 hours was found on the order summary for Resident #112. During an interview on 12/16/2024 at 10:45 AM, Family Member #2 stated that Resident #112 was initially admitted to the facility from the hospital because this facility was the only one with a bed open and Resident #112 needed some rehab before they could return home; the resident was transported in the afternoon of 09/19/2024. Around 9:00 AM on 09/20/2024, Resident #112 called Family Member #2 and was in great distress. The resident stated to them they had laid in their bed without medication for pain, had soiled clothing, and did not have food. Family Member #2 stated that when they heard this, they called 911 so the resident could be transported back to the hospital. A nursing note dated 09/20/2024 at 10:00 AM, documented that Family Member #2 came to speak with the staff regarding the resident ' s condition. Family Member #2 stated they had called 911 and informed the dispatch that Resident #112 needed to be transferred back to the hospital. When asked what was going on Family Member #2 stated Resident #112 was in pain. Staff educated Family Member #2 on the resident ' s current meds including meds that had been administered. Offered to call the provider to review pain and alternate pain relief. Family Member #2 declined and continued to state, I think its better the resident goes back to the hospital. Provider made aware. During an interview on 12/16/2024 at 1:01 PM, Emergency Medical Technician #1 stated the family met the ambulance outside when they arrived at the facility; the family requested transport for Resident #112 back to the hospital. Emergency Medical Technician #1 stated it was a while ago and from what they recalled, the resident had increased pain, and the facility gave the resident pain medication right before or when the ambulance arrived on 09/20/2024. Resident #112 ' s Medication Administration Record for September 2024 documented the following medication administrations for pain: • 09/19/2024 4:00 PM, Acetaminophen 1000 milligrams. • 09/19/2024 5:51 PM, oxycodone 5 milligrams, 2 tablets given. • 09/19/2024 8:00 PM, Acetaminophen 1000 milligrams. • 09/20/2024 8:00 AM, Acetaminophen 1000 milligrams. • 09/19/2024 10:36 PM, Acetaminophen 650 milligrams for 10 out of 10 pain. • 09/20/2024 5:07 AM, Acetaminophen 650 milligrams for 5 out of 10 pain. Total of 4300 milligrams of acetaminophen in 13 hours and 7 minutes, order was not to exceed 3000 milligrams in 24 hours. The narcotic log for Resident #112 documented the following: • 09/19/2024 5:46 PM oxycodone 5 milligrams, 2 tablets were administered. • 9/20/2024 10:41 AM oxycodone 5 milligrams, 2 tablets were administered (this administration was not documented in the Medication Administration Record). Resident #112 ' s September 2024 progress notes documented: • 09/19/2024 10:36 PM 325 milligram acetaminophen, 2 tablets given as needed for pain, not to exceed 3 grams in 24 hours given by Registered Nurse #4. • 09/20/2024 1:34 AM documented by Registered Nurse #5 that the as needed administration of Tylenol at 10:36 PM was effective and the follow-up pain scale was 0; this was not documented within 30 minutes-60 minutes required by the facility policy. • 09/20/2024 5:07 AM Registered Nurse #5 documented that 325 milligrams acetaminophen, 2 tablets were given as needed for pain, not to exceed 3 grams in 24 hours. • 09/20/2024 6:11 AM Registered Nurse #5 documented that the as needed administration of acetaminophen had a follow-up pain scale of 2. • 09/20/2024 10:10 AM the Director of Nursing documented that Family #2 spoke to them and had called 911 to transport Resident #112 back to the hospital because the resident was in pain. • 09/20/2024 11:22 AM Registered Nurse #6 documented that prior to leaving, Resident #112 was given their due medications and was still complaining of pain and restless legs and was given oxycodone (which was not documented in the medication administration record), and vital signs were taken with a blood pressure of 147/65 and pulse rate of 80 beats per minute. Record review of Resident #112 ' s vital signs revealed that on 09/19/2024 at 10:36 PM, Registered Nurse #4 recorded that Resident #112 verbalized their pain at a 10 out of 10. Record review of the 09/2024 Medication Administration Record revealed that Registered Nurse #4 administered 650 milligrams of Tylenol when Resident #112 communicated they were experiencing 10 out of 10 for pain. The emergency room summary for admission date 09/20/2024 and discharge date of 09/21/2024 documented the following: The chief complaint was restless leg. The hospital administered ropinirole, which resolved the leg symptoms. Later that evening, the patient requested a dose of oxycodone, which was given. The resident rested comfortably the rest of the evening. During an interview on 12/18/2024 at 9:10 AM, Director of Nursing #1 stated that staff administered Tylenol in response to Resident #112 stating they were in pain. When asked if that was appropriate intervention for a 10 out of 10 pain that was verbalized by the resident, Director of Nursing #1 did not answer. Director of Nursing #1 stated that Resident #112 should have verbally requested oxycodone because the order was written as needed. On 12/18/2024 at 10:24 AM, surveyor attempt to contact Registered Nurse #4 was unsuccessful. 10 New York Codes Rules and Regulations 415.12

Based on observations, record review, and interviews conducted during the Recertification Survey, the facility did not ensure that it provided or obtained emergency dental services to meet the needs of each resident for 1 (Resident #75) of 1 resident reviewed for Dental Services. Specifically, Resident #75 had broken a front tooth the week of 12/02/2024 and had not been seen by the dentist. This is evidenced by: The facility policy titled, Dental Services, last revision date 9/2019, documented both routine and emergency dental services were available to meet the oral needs of each resident. Resident #75 had diagnoses which included hypertension (high blood pressure), chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty breathing), and depression (a mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities). The Minimum Data Set (a resident assessment tool) dated 8/14/2024 documented Resident #75 was able to be understood by others and could understand others, had mild cognitive impairment, and had no mouth or facial pain, or difficulty chewing. Resident had obvious cavities and broken natural teeth. On 12/12/2024 at 11:33 AM, Resident #75 was observed in their room and their top front teeth were broken. During an interview 12/12/2024 at 11:33 AM, Resident #75 stated they had broken their teeth 2 weeks ago and they had not seen the dentist yet and continued to have slight pain. During an interview on 12/18/2024 at 10:55 AM, Licensed Practical Nurse #1 stated they would give the information to the Finance Director #1, who was responsible for setting up dental appointments. During an interview on 12/18/2024 at 10:55 AM, Finance Director #1 stated that Resident #75 had seen the dentist on 6/20/2024, but that they would add Resident #75 to the list to see the dentist on their next visit. 10 New York Code Rules and Regulations 415.17(b)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #73 Resident #73 was admitted to the facility with the diagnoses of acquired absence of right leg below the knee (right leg amputation below the knee), anemia (a condition characterized by a low levels of red blood cells), and depression (a mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities). The Minimum Data Set, dated [DATE] documented the resident was able to be understood, could understand others, and was cognitively intact. The Medication Administration Record for December 2024 documented the following duplicate vital signs: • 12/01/2024: Blood Pressure 110/66, Temperature 97.3, Pulse 72, Respirations 16, Oxygen Saturation 96 percent on room air • 12/02/2024: Blood Pressure 110/66, Temperature 97.3, Pulse 72, Respirations 16, Oxygen Saturation 96 percent on room air • 12/04/2024: Blood Pressure 118/68, Temperature 97.7, Pulse 78, Respirations 18, Oxygen Saturation 97 percent on room air • 12/05/2024: Blood Pressure 118/68, Temperature 97.7, Pulse 78, Respirations 18, Oxygen Saturation 97 percent on room air • 12/06/2024: Blood Pressure 118/68, Temperature 97.7, Pulse 78, Respirations 18, Oxygen Saturation 97 percent on room air During an interview on 12/17/2024 at 11:12 AM, Registered Nurse #1 stated a resident having the same vital signs several days in a row was odd. They stated that data such as vital signs should not be copied and pasted from one day to the next, but individual vital signs taken per the provider orders. 10 New York Code of Rules and Regulations 415.12 Resident #89 Resident #89 was admitted to the facility with the diagnoses of cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue), displaced fracture of head of unspecified radius (fractured elbow), and hypertension (high blood pressure). The Minimum Data Set, dated [DATE] documented the resident was understood, could understand others, and was cognitively intact. The Physician ' s Order dated 2/23/2024 stated vital signs (blood pressure, pulse, respirations per minute, temperature, and oxygen saturation) to be obtained and recorded every month starting on the 1st for 7 days for monitoring. The June 2024 Medication Administration Record documented vital signs were obtained and recorded on 6/01/2024, 6/02/2024, 6/03/2024, 6/05/2024, and 6/06/2024. On 6/04/2024 and 6/07/2024 the response 9 was documented, The Medication Administration Record ' s Chart Codes documented 9 as Other/See Nurse ' s Notes. The November 2024 Medication Administration Record documented vital signs were obtained and recorded on 11/01/2024, 11/02/2024, 11/03/2024, 11/04/2024, and 11/06/2024. On 11/05/2024 the response 9 was documented, The Medication Administration Record ' s Chart Codes documented 9 as Other/See Nurse ' s Notes. There were no vital signs documented on the Medication Administration Record on 11/07/2024. The November 2024 Medication Administration Record documented the following duplicate vital signs: • 11/01/2024: Blood Pressure 130/61, Temperature 97.9, Pulse 56, Respirations 18, Oxygen Saturation 93 percent • 11/02/2024: Blood Pressure 130/61, Temperature 97.9, Pulse 56, Respirations 18, Oxygen Saturation 93 percent • 11/03/2024: Blood Pressure 130/61, Temperature 97.9, Pulse 56, Respirations 18, Oxygen Saturation 93 percent Based on interview and record review conducted during a recertification and abbreviated survey (Case # NY00346208), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident ' s choices for 10 (Resident #s 365, 368, 112, 56, 29, 73, 109, 75, 18, and 89) of 10 residents reviewed for quality of care, which included residents in every unit of the facility. Specifically, the facility failed to place and read the purified protein derivative test for tuberculosis (an infectious disease) for Resident #365 and Resident #368; the facility failed to notify a provider when Resident #365 ' s blood sugar was 61; the facility failed to monitor the vital signs of Resident #368 when the resident was newly admitted to the facility. The facility failed to ensure that Resident #112 received treatment and care to prevent hospitalization, the facility administered 4300 milligrams of Tylenol in a 13-hour period, and the facility documented vital signs for Resident #112 after the resident discharged from the facility. The facility failed to obtain and document monthly vital signs according to provider orders for Residents #29, 89, and 73. This is evidenced by: Cross-referenced to F697: Pain Management The facility policy titled, Vital Signs and last revised 12/2020, documented that the facility would ensure vital signs were being monitored according to physician orders . and verify that there was a physician ' s order for frequency if regularly monitoring . document findings in the resident ' s medical record . alert the medical doctor of any findings outside of the resident ' s baseline. The facility policy titled, Tuberculosis - Residents and last revised 8/22/2024, documented that the facility shall conduct a baseline screen of residents for tuberculosis infection on admission including a tuberculosis skin test, also referred to as a purified protein derivative test. The results of the Tuberculin Skin Test must be read by a qualified nurse or healthcare practitioner (i.e., Registered Nurse) forty-eight (48) to seventy-two (72) hours after administration. Residents were not allowed to read or interpret their own Tuberculin Skin Test results. A. If the reaction to the first Tuberculin Skin Test is negative, administer a second Tuberculin Skin Test 1 to 3 weeks after the first test. 1. If the test reading/interpretation was not completed within 72 hours, the Tuberculin Skin Test must be repeated. Resident #365 Resident #365 was admitted with diagnoses of diabetes (an endocrine system dysfunction causing difficulty maintaining normal blood sugar levels), high cholesterol (high amounts of cholesterol in the blood which can cause limited blood flow), and depression (a mental health condition characterized by persistent feelings of sadness, hopelessness and loss of interest or pleasure in activities). The Minimum Data Set (an assessment tool) dated 11/14/2024 documented that the resident was cognitively intact, could understand others and could be understood by others. The Physician ' s Order dated 12/06/2024 stated that for blood sugar less than 70 to notify the medical doctor of the low blood sugar. Resident #368 Resident #368 was admitted with diagnoses of unspecified atrial fibrillation (abnormal heart rhythm), congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively), and hypertension (high blood pressure). The Minimum Data Set, dated [DATE] documented that the resident had intact cognitive ability, could be understood and understood others. The Medication Administration Record for 12/2024 documented the Purified Protein Derivative test was placed 12/11/2024 at 1:08 AM and was scheduled to be read on 12/12/2024. During an interview on 12/12/2024 at 12:13 PM, Director of Nursing #1 agreed it was not appropriate to read the test on 12/12/2024 and stated they would update the scheduled reading of the test and re-educate the staff. The Physician ' s Order dated 12/03/2024 stated vital signs (blood pressure, pulse, respirations per minute, temperature, and oxygen saturation) every shift for 30 days, then monthly every day shift every 1 month starting on the 1st [of every month] for 7 days for monitoring. The December 2024 Medication Administration Record/Treatment Administration Record documented the following duplicate vital signs: • 12/07/2024 11 PM shift: not done • 12/10/2024 3PM shift: blood pressure 123/73, temperature 97.2, pulse 84, respiration 18, oxygen saturation 98 percent • 12/10/2024 11PM shift: blood pressure 123/73, temperature 97.2, pulse 84, respiration 18, oxygen saturation 98 percent Resident #112 Resident #112 was admitted to the facility with diagnoses of fracture of the lumbar vertebra (lower back bone), malignant neoplasm of the uterine adnexa (uterine cancer), and secondary malignant neoplasm of the bone (bone cancer). The resident was not at the facility long enough to have a Minimum Data Set (a resident assessment) completed. Resident #112 ' s Order Summary Report for September 2024 documented orders as follows: • Begin Medication Regime When Available, ordered 9/19/2024. • Acetaminophen extra strength oral tablet 500 milligram, give 2 tablets by mouth three times a day for pain, ordered 9/19/2024. • Acetaminophen tablet 325 milligram, give 2 tablets by mouth every 6 hours as needed for pain (not to exceed 3 grams in 24 hours), ordered 9/19/2024. Resident #112 ' s Medication Administration Record for September 2024 documented the following medication administrations for pain: • 9/19/2024 4:00 PM, Acetaminophen 1000 milligrams • 9/19/2024 5:51 PM, Oxycodone 5 milligrams, 2 tablets given • 9/19/2024 8:00 PM, Acetaminophen 1000 milligrams • 9/20/2024 8:00 AM, Acetaminophen 1000 milligrams The facility administered a total of 4300 milligrams of Acetaminophen in 13 hours and 7 minutes, but the order was not to exceed 3000 milligrams in 24 hours. During an interview on 12/16/2024 at 10:45 AM, Family #2stated that Resident #112 was transported to the facility in the afternoon of 9/19/2024. Around 9:00 AM on 9/20/2024, Resident #112 called Family #2 and was in great distress. The resident stated they laid there without medication for pain, soiled clothing, and without food. Family #2 called 911 for transport back to the hospital. Resident #112 was in a great amount of pain and had been all night. Review of Resident #112 ' s vital signs revealed on 9/21/2024 at 2:33 AM a blood pressure of 139/79 was performed in the lying position on the right arm, the pulse was 83 beats per minute, 19 breaths per minute, and a temperature of 97.9; all of these vital signs were taken after the resident left the faciity on 9/20/2024 around 11:00 AM and did not return to the facility. Resident #29 Resident #29 was admitted to the facility with the diagnoses of bipolar disorder (a mental health condition characterized by extreme shifts in mood, energy, and behavior), Parkinson ' s disease (a progressive neurological disorder that affects movement, balance, and coordination), and hypothyroidism (an abnormally low activity of the thyroid gland). The Minimum Data Set, dated [DATE] documented the resident was rarely/never understood, rarely/never understood others, and was severely cognitively impaired. The Physician ' s Order dated 9/6/2023 stated vital signs (blood pressure, pulse, respirations per minute, temperature, and oxygen saturation) to be obtained and recorded every month starting on the 1st for 7 days for monitoring. The September 2024 Medication Administration Record documented the following duplicate vital signs: • 9/4/2024: Blood Pressure 122/78, Temperature 97.4, Pulse 76, Respirations 18, Oxygen Saturation 95 percent • 9/5/2024: Blood Pressure 122/78, Temperature 97.4, Pulse 76, Respirations 18, Oxygen Saturation 95 percent • 9/6/2024: Blood Pressure 122/78, Temperature 97.4, Pulse 76, Respirations 18, Oxygen Saturation 95 percent The October 2024 Medication Administration Record documented vital signs were obtained and recorded on 10/01/2024, 10/05/2024, and 10/06/2024. On 10/02/2024, 10/03/2024, 10/05/2024, and 10/07/2024 the response 9 was documented, The Medication Administration Record ' s Chart Codes documented 9 as Other/See Nurse ' s Notes. The November 2024 Medication Administration Record documented vital signs were obtained and recorded on 11/02/2024 and 11/03/2024. On 11/01/2024, 11/04/2024, 11/05/2024, and 11/06/2024 the response 9 was documented, The Medication Administration Record ' s Chart Codes documented 9 as Other/See Nurse ' s Notes. The December 2024 Medication Administration Record had no documentation of vital signs being obtained and recorded. On 12/01/2024-12/07/2024 the response 9 was documented. The Medication Administration Record ' s Chart Codes documented 9 as Other/See Nurse ' s Notes. Progress Notes dated 11/01/2024 through 12/13/2024 were reviewed. Progress Notes that correspond with the Medication Administration Record Chart Codes were reviewed. • 11/01/2024 at 10:23 AM the Progress Note titled eMar - Medication Administration Note documented the order text Vital Signs Q shift (every shift) x 30 days then Monthly every day shift every 1 month starting on the 1st for 7 day(s) for Monitoring with no free text. • 11/04/2024 at 11:39 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. • 11/05/2024 at 10:54 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. • 11/06/2024 at 11:00 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. • 11/07/2024 at 10:25 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. • 12/01/2024 at 11:34 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. • 12/02/2024 at 8:58 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. • 12/03/2024 at 10:28 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. • 12/04/2024 at 11:14 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. • 12/05/2024 at 9:06 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. • 12/06/2024 at 7:31 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. • 12/07/2024 at 1:17 PM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. During an interview on 12/13/2024 at 11:56 AM, Registered Nurse #2 stated the vital signs were to be documented on the Medication Administration Record. When asked to review the Medication Administration Record, Registered Nurse #2 stated they were unable to locate the documentation of Resident #29 ' s vital signs for December 2024 and located 2 documented vital signs for November 2024. They stated the vital signs were not done as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the recertification and abbreviated survey (Case # NY00355835), the facility did not ensure that food and drink were palatable and attractive for 4 (Resident #s 97, 75, 8, and 107) of 7 residents reviewed for palatable and attractive food and drink. Specifically, Residents #97, #75, #8 and #107 complained of food being cold, unattractive, and not palatable. Additionally, Resident # 97 and #75 lunch ticket did not match what the resident received during their lunch service on 12/17/2024. This is evidenced by: A facility policy titled Food and Nutrition Services dated 1/2024 documented that the facility would provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Resident # 107 Resident # 107 was admitted to the facility with diagnoses of peripheral vascular disease (a circulatory condition that occurs when blood vessels outside the brain and heart narrow, spasm, or become blocked), atherosclerotic heart disease (a condition where plaque builds up in the arteries of the heart), and hyperlipidemia (a condition where there are high levels of fats or lipids in the blood). The Minimum Data Set (an assessment tool) dated 9/25/2024, documented that the resident had intact cognitive ability, could be understood, and understood others. During an interview on 12/12/2024 at 1:05 PM, Resident #107 stated that the food is always cold and not very appealing or appetizing. Resident #107 stated that the trays for meals never arrive on the unit at a consistent time. Resident #107 was asked if the food was cold would staff reheat it for them and they stated that they do not bother as it would take a long time to get it back. During a follow-up interview on 12/17/2024 at 10:45 AM, Resident #107 was asked if the surveyor was allowed to take their lunch tray to be temperature and taste tested since they made a concern about the food temperature and taste. The resident was assured that they would receive a replacement tray immediately after theirs was taken. Resident #107 agreed to surrender their lunch tray for testing purposes. During an observation on 12/17/2024 at 12:08 PM the cart with lunch trays arrived on the C-unit by the front nurse's station desk. The lunch tray cart arrived at the resident's hall at 12:17 PM. Resident #107 lunch tray was obtained from Certified Nurse Aide at 12:24 PM and a new tray was obtained by Certified Nurse Aide and delivered at 12:28 PM. During an observation of Resident #107 lunch ticket, they were to receive 8 ounces of Beef Stroganoff, a half cup of Pasta Noodles, a side lettuce salad with dressing, half cup of Mixed Fruit Cobbler, 8 fluid ounces of 2% milk, 6 fluid ounces of Hot Tea, 8 fluid ounces of Water, 1 salt packet, 1 pepper packet, 2 sugar packets, and one half and half creamer. In a comparison of the lunch ticket and meal tray, the resident did not receive their Mixed Fruit Cobbler, milk, or water. During a test tray on 12/17/2024, temperature and taste were performed on Resident #107 ' s lunch. Pasta noodles were temped at 116.2 degrees Fahrenheit and tasted overcooked and sticky. The beef was temped at 114.4 degrees Fahrenheit and tasted as expected, beef was easily chewed and broken down. During a follow-up interview on 12/17/2024, Resident #107 was asked how their lunch was. They stated that it was just fine, and they ate it. When asked about the temperature of their lunch they stated that it was very warm stating that it just came from the kitchen and did not spend a long time on the delivery carts. During an interview on 12/17/2024 at 01:04 PM, Dietician #1 stated that they identify resident's preferences and place them into the facility system. They stated that the resident's meal tickets should be verified by the Certified Nurse Aides as they serve the tray to the resident. They stated that the individuals who are preparing the resident's trays in the kitchen should be verifying the tickets as well and checking again before the tray leaves the kitchen. Dietician #1 stated that they have a system for menus and they meet quarterly with residents to determine preferences. Resident # 97 Resident # 97 was admitted to the facility with diagnoses of dementia, protein-calorie malnutrition (lack of adequate food intake to maintain health), and history of falling. The Minimum Data Set, dated [DATE], documented that the resident had intact cognitive ability, could be understood, and understood others. During an interview on 12/11/2024 at 1:42 PM, Resident #97 stated the food was cold at times and could be better. A progress note dated 11/7/2024 at 8:03 AM documented that Resident #97 stated the food was visually unappealing to them; the Dietician discussed with Resident #97 that they had 6.9% weight loss in 30 days, which was significant. A provider progress note by Family Nurse Practitioner #1 dated 12/5/2024 documented the resident had some gradual weight loss over the past 30 days. They saw a dietician. They stated that they did not like the food, so they did not have much of an appetite. That's likely where the weight loss is stemming from. Please order nutritional shakes and see a dietician for fortified foods to add to their diet. Resident # 75 Resident # 75 was admitted to the facility with diagnoses of weakness, protein-calorie malnutrition (lack of adequate food intake to maintain health), and depression. The Minimum Data Set, dated [DATE], documented that the resident had intact cognitive ability, could be understood, and understood others. During an interview on 12/12/2024 at 11:33 AM, Resident #75 stated that no snacks were provided at night, the coffee and food was cold and did not taste good and the resident wanted more fresh fruit. Request to perform night observation to verify night snack availability denied by state agency management. During a follow-up interview on 12/17/2024 at 11:45 AM, Resident #75 was asked if the surveyor was allowed to take their lunch tray to be temperature and taste tested since they made a concern about the food temperature and taste. The resident was assured that they would receive a replacement tray immediately after theirs was taken. Resident #75 agreed to surrender their lunch tray for testing purposes. During an observation on 12/17/2024 at 12:08 PM, the cart with lunch trays arrived on the C-unit by the front nurse's station desk. Resident #75 ' s lunch tray was obtained from a Certified Nurse Aide at 12:15 PM and a new tray was requested, but the Certified Nurse Aide stated they were the only one on the hall and the request would cause other residents ' trays to be cold and delayed; surveyor requested replacement tray from the Administrator on the surveyor ' s way to the kitchen to request a replacement tray. During an observation of Resident #75 ' s lunch ticket, they were to receive 4 ounces of Beef Stroganoff, 2 ounces of beef gravy, a half cup of Pasta Noodles, a half cup of wax beans, half cup of Mixed Fruit Cobbler, 4 ounces of apple juice, two 6 fluid ounces of coffee, 8 fluid ounces of Water, 1 salt packet, 1 pepper packet. In a comparison of the lunch ticket and meal tray, the resident did not receive the second cup of coffee. During a test tray on 12/17/2024, temperature and taste were performed on Resident #75 ' s lunch. The beef stroganoff mixed with noodles was temped at 119.1 degrees Fahrenheit and the texture was acceptable but the beef lacked flavor and were warm but not hot and the noodles were without issues; the fruit cobbler was temped at 88.2 degrees Fahrenheit and was unpalatable; the wax beans were 112.0 degrees Fahrenheit and not tasted; the apple juice was 63.7 degrees Fahrenheit; and the water was temped at 58.8 degrees Fahrenheit. During a follow-up interview on 12/17/2024 at 12:53 PM, Resident #75 stated that the replacement tray arrived, but the food did not look appealing to the resident; staff entered to collect the tray and asked if Resident #75 would like an alternate meal and the resident stated that the food on the tray had ruined their appetite. The resident also voiced their frustration that multiple creamers were brought daily with the coffee and the resident drinks the coffee black and had informed multiple staff of that preference. Resident # 8 Resident #8 was admitted to the facility with diagnoses of weakness, need for assistance with personal care, and muscle weakness. The Minimum Data Set, dated [DATE], documented that the resident had intact cognitive ability, could be understood, and understood others. During an interview on 12/12/2024 at 11:33 AM, Resident #8 stated that they did not like oatmeal, but it was served to them most mornings; they further stated that the food on the ticket was not what was brought to the resident and that the food was constantly served cold. A facility grievance dated 11/10/2024 revealed a grievance related to late meal service which caused a resident to miss an activity; facility responded appropriately to address the concerns of this grievance to accommodate the specific resident. 10 New York Code of Rules and Regulations 415.14(d)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during a recertification and abbreviated (NY00346208 and NY00351484) survey, the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, 1) an analysis of the actual staffing schedule showed that on multiple occasions from 12/01/2024 to 12/18/2024, the facility was below the minimum levels required. 2) several nursing staff members reported a lack of sufficient staffing, and 3) multiple residents reported during interviews that the facility was short-staffed at times, and this resulted in call bells not being answered timely and residents not getting out of bed in time for appointments and therapy. This is evidenced by: Upon entrance to the facility on [DATE] there were 115 residents residing in 3 units. The Facility Assessment, which was conducted on 2/27/2024 and updated on 10/03/2024, documented the facility's staffing plan for direct residential care. The assessment documented that they were to have a certain minimum number of Certified Nurse Aides for the day, evening, and night shifts. The facility was to maintain daily average staffing hours equal to 3.5 hours of care per resident per day by a Certified Nurse Aide, Registered Professional Nurse, Licensed Practical Nurse, or Nurse Aide. Out of such 3.5 hours, no less than 2.2 hours of care per resident per day shall be provided by a Certified Nurse Aide. A review of staffing sheets provided by the facility from 12/01/2024 through 12/18/2024 documented the following: -12/01/2024: The facility had 26 Certified Nurse Aides scheduled for a total of 208 hours of direct care. For a census of 111 residents, the amount of direct care should have been 244.2 hours. -12/02/2024: The facility had 26 Certified Nurse Aides scheduled for a total of 208 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248.6 hours. -12/03/2024: The facility had 28 Certified Nurse Aides scheduled for a total of 224 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/04/2024: The facility had 27 Certified Nurse Aides scheduled for a total of 216 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/05/2024: The facility had 24 Certified Nurse Aides scheduled for a total of 192 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/06/2024: The facility had 27 Certified Nurse Aides scheduled for a total of 216 hours of direct care. For a census of 117 residents, the amount of direct care should have been 257.4 hours. -12/07/2024: The facility had 28 Certified Nurse Aides scheduled for a total of 224 hours of direct care. For a census of 117 residents, the amount of direct care should have been 257.4 hours. -12/08/2024: The facility had 27 Certified Nurse Aides scheduled for a total of 216 hours of direct care. For a census of 117 residents, the amount of direct care should have been 257.4 hours. -12/09/2024: The facility had 28 Certified Nurse Aides scheduled for a total of 224 hours of direct care. For a census of 114 residents, the amount of direct care should have been 250.8 hours. -12/10/2024: The facility had 26 Certified Nurse Aides scheduled for a total of 208 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/11/2024: The facility had 24 Certified Nurse Aides scheduled for a total of 192 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/12/2024: The facility had 25 Certified Nurse Aides scheduled for a total of 200 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248.6 hours. -12/13/2024: The facility had 22 Certified Nurse Aides scheduled for a total of 176 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248.6 hours. -12/14/2024: The facility had 22 Certified Nurse Aides scheduled for a total of 176 hours of direct care. For a census of 114 residents, the amount of direct care should have been 250.8 hours. -12/15/2024: The facility had 26 Certified Nurse Aides scheduled for a total of 208 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248.6 hours. -12/16/2024: The facility had 24 Certified Nurse Aides scheduled for a total of 192 hours of direct care. For a census of 114 residents, the amount of direct care should have been 250.8 hours. -12/17/2024: The facility had 22 Certified Nurse Aides scheduled for a total of 176 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248.6 hours. -12/18/2024: The facility had 24 Certified Nurse Aides scheduled for a total of 192 hours of direct care. For a census of 114 residents, the amount of direct care should have been 250.8 hours. During an interview on 12/11/2024 at 1:47 PM, Resident #105 stated the facility was short on staff and sometimes the resident had to wait for a long time to get help. They stated that they could easily wait for over an hour on average depending on which staff person is working. During an interview on 12/12/2024 at 12:00 PM Resident #89 stated when they rang their call bell, they had to wait for 2 hours to be taken to the bathroom, and on several occasions, the staff did not attend to their bathroom needs, and would only come to assist them when they were doing their cares. Resident #89 also stated that they were late for their therapy session on several occasions because the staff got them out of bed late resulting in decreased time in therapy. During an interview on 12/12/2024 at 12:22 PM, Resident #80 stated that they always have to wait on staff to get care as they do not have enough people at times. They stated they could wait anywhere from 45 minutes to an hour at times for staff to come in to help. During an observation on 12/17/2024 at 1:35 PM, there were 3 rooms with call lights activated on the C unit. There were no staff members present in the unit. A family member came out to the main desk area to see if there were any staff present and voiced their displeasure that there was no one available. During an interview on 12/17/2024 at 2:22 PM Certified Nurse Aide #1 stated they needed to have more staff to perform all their duties. They stated that they feel very stressed and overworked due to the lack of staffing. Certified Nurse Aide #1 stated that they do multiple double shifts for the facility at least three times per week. They stated that there have been numerous times when they were unable to get the resident's afternoon care completed and had to either stay late to finish or turn the care over to the staff coming in during the evening. During an interview on 12/17/2024 at 2:48 PM Certified Nurse Aide #2 stated there were times it was impossible to get all the residents out of bed when the facility was short-staffed. They stated that they prioritized the residents who had therapy first when they were short-staffed. They stated they did double shifts for the facility two to three times per week. During an interview on 12/17/2024 at 3:22 PM Licensed Practical Nurse #2 stated that usually they feel there is enough staff, and everyone works together to provide the care for the residents. They stated that residents do wait an extended period for care during the evening (3 PM – 11 PM) shift because of staffing issues, especially between 6 PM – 9 PM. During a follow-up interview on 12/18/2024 at 9:45 AM Certified Nurse Aide #1 stated that they had only 2 aides for the day, and they were going to be very busy. They stated that they do not know the reason why they are extremely short-staffed for the day. During an interview on 12/18/2024 at 10:19 AM Registered Nurse #3 stated that staffing levels were an issue they were dealing with. On a regular day, they would have 3 Certified Nurse Aides and 2 Licensed Practical Nurses for the unit of 40 residents. They stated that the staffing levels are not ideal as they have numerous residents on the unit who require additional staffing for daily care. They stated that residents have waited extended periods due to aides taking care of other residents. They stated today they have only 2 aides for the unit and would help when needed. During an interview on 12/18/2024 at 11:05 AM Administrator #1 stated that staffing has been an issue, but they feel it is getting better however not ideal. They stated that they believe since they are in a remote location they do not have a pool of candidates to pick from. They stated that they had 6 Certified Nurse Aides leave in the past week due to different circumstances. They stated that they have a lot of agency and contract individuals working but they are trying to get more individuals locally to be employed by the agency. Administrator #1 stated that they believe that the facility is improving on its history, and they are getting more applicants. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case # NY00278217), the facility did not provide needed care and services that are resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 1 (Resident #5) out of 11 residents reviewed. Specifically, the facility did not ensure the resident was assessed and that the physician was notified when Resident #5, a resident prescribed an anticoagulant (blood thinning) medication, developed a nosebleed. The resident was not assessed by nursing staff when the nosebleed occurred; the resident then called for emergency services and was subsequently admitted to the hospital for treatment. This is evidenced by: The Policy and Procedure titled, Change in Condition Notification, dated August 2019, read in pertinent part that it was the policy of the facility to monitor residents for changes in their condition, to respond appropriately to those changes and then notify the physician. The Policy and Procedure titled, Anticoagulation Therapy, dated March 2019, read in pertinent part that nursing staff and the physician should monitor for possible complications in individuals who were being anticoagulated and were to manage related problems. The physician should identify where risk factors constituted contraindications to anticoagulation. Resident #5 Resident #5 was admitted to the facility on [DATE] with diagnoses which included repeated falls, atherosclerotic heart disease of native coronary artery and ischemic cardiomyopathy (the heart's decreased ability to pump blood properly, due to heart muscle damage brought upon by restricted or reduced blood flow). The Minimum Data Set (an assessment tool) dated 6/04/2021 documented the resident could be understood and could understand others with intact cognition for decisions of daily living. A Physician Order dated 6/04/2021 documented warfarin sodium tablet (blood thinning medication) three milligram tablet by mouth at bedtime for treating/preventing blood blots. Review of the Comprehensive Care Plan, initiated on 6/9/2021, revealed there was no comprehensive plan for nursing care in place for the resident. A Nursing Progress Note dated 6/20/2021 at 8:49 AM documented the resident was sent to the hospital that morning of 6/20/2021 due to calling 911 on their own authority. The nurse documented they were unaware of an emergency with the resident. The nurse documented they first became aware of the nosebleed at 3:30 AM but wasn't overly alarmed as the resident had been the hospital multiple times since admitting to the facility and had been on anticoagulation since they admitted . The nurse documented they offered the resident a prescribed nasal decongestant, which the resident declined, and then told the resident to keep pressure on it. The note read that at approximately 6:45 AM, the nurse was informed by an unexpected visit from the police that the resident had called 911 asking for an ambulance transport, before they could do anything about the situation. A Nursing Progress Note dated 6/20/2021 at 2:24 PM documented that the hospital Nurse Practitioner reported that the resident was going to be staying overnight at the hospital and would most likely be seen by the Ear, Nose and Throat physician to see if there might have been something going on inside of their right nostril causing nose bleeds. Review of the resident record revealed no documentation of the resident previously experiencing a nosebleed at the facility. During an interview on 12/12/2023 at 2:26 PM, Licensed Practical Nurse Unit Manager #4 stated when a resident had a change in condition, the resident should be assessed, and the physician and resident's family notified. They stated they would follow through with any new orders given by the physician or to have the resident sent out to the hospital. During an interview on 12/13/2023 at 9:57 AM, Licensed Practical Nurse #5 stated that if a resident who was prescribed anticoagulant medication had a nosebleed, they would try to stop the bleeding, clean the resident up, check the resident's vital signs, and call the physician. They further stated they would let the physician know the resident was prescribed anticoagulant medication and then take orders from the physician. They stated the physician should be notified right away when a resident on anticoagulant medication experienced bleeding. During an interview on 12/18/2023 at 1:12 PM, the Director of Nursing stated they vaguely recalled the resident but did not recall that they were ever informed of the resident calling 911 and going to the hospital. They stated that the resident had a diagnosis of nosebleeds when they admitted to the facility. Upon review of the resident's record, they stated the resident was not documented have had any other nose bleeds while at the facility. The Director of Nursing stated the resident was prescribed anticoagulant medication. They further stated the physician should be notified if a resident was prescribed anticoagulant medication and had nosebleed so that the physician could make the decision on whether the anticoagulant medication should be withheld, or any other treatment provided. They stated the resident's comprehensive care plan should include monitoring for side effects of anticoagulant medication use such as bleeding. The Director of Nursing stated, upon review of the resident's care plan, that it appeared the activities staff and dietary department had completed their portions of the resident care plan, however, the nursing care plan was not completed and could not be reviewed. During an email correspondence on 12/19/2023 at 12:27 PM, the Nursing Home Administrator documented that a comprehensive nursing care plan was not put in place due to the resident having been sent out to the hospital after they were admitted . They stated the resident had not been in the facility for seven consecutive days in order to complete a comprehensive care plan. They documented a baseline care plan was completed for the resident. 10 NYCRR 415.12

Based on record review and interviews during an abbreviated survey (Case #s NY00271205, NY00271568, NY00272306, and #NY00278116), the facility did not ensure the resident has the right to be free from abuse. The facility must not use verbal abuse for 1 (Resident #7) of 8 residents reviewed for abuse. Specifically, the facility did not ensure Resident #7 was free from verbal abuse when Certified Nursing Assistant #1 (CNA) was overheard by the Activities Director (AD) yelling at the resident using abusive language. Additionally, the Administrator (ADM) witnessed CNA #1 swearing in front of residents seated around the nurses' station. This was evidence by: The Policy and Procedure titled Abuse dated 2/2019, documented the facility prohibits the mistreatment, neglect, and abuse of residents by anyone including staff. It defined verbal abuse as disparaging and derogatory terms willfully spoken to the resident, or within their hearing distance to describe the resident, regardless of their ability to comprehend. Resident #7: Resident #7 was admitted to the facility with diagnoses of Alzheimer's disease, dementia with behavioral disturbance, and delusional disorders. The Minimum Data Set (MDS-an assessment tool) dated 2/21/2021, documented the resident had severe cognitive impairment, was usually understood, and could usually understand others. The Investigation Form dated 3/2/2021, documented CNA #1 assisted resident into the library at 5:45 PM, and was overheard by the Activities Director, who was in their office adjacent to the library with their door closed, yell at Resident #7 to Sit your ass down, then yelled at the resident to Shut up and go to sleep, and Who the hell do you think you are? The Comprehensive Care Plan (CCP) initiated 10/16/2020 for At Risk for Being a Victim, documented the resident was at risk due to inability to understand their surroundings, related to dementia and dependence on others for activities of daily living. The CCP initiated 11/3/2020 for At Risk for Abuse Related to Behaviors and Dementia, documented to investigate all allegations of abuse and neglect promptly, to provide support, and ensure the resident is free from abuse. A General Progress Note dated 3/2/2021 at 10:25 AM, documented the resident was in a pleasant mood and conversing per their baseline. Staff were to continue to monitor for any changes in behaviors. During an interview on 1/5/2021 at 1:37 PM, the AD, stated they recalled Resident #7. They stated they were in their office (on 3/1/2021), which was located in the library, with the door shut. CNA #1 brought Resident #7 into the library and CNA #1 did not know the AD was in their office while the CNA #1 was yelling at the resident. The AD stated they opened their door and when the CNA #1 saw them, they darted out of the library. The AD had no idea where they went. The AD stated they did not recognize CNA #1 because they did not usually work that late. The AD stated they asked staff who the CNA #1 was, and once they found out, they went straight to the Administrator's office to report the incident. The AD stated CNA #1's tone of voice was loud, angry, and they were screaming when they asked the resident Who the hell do you think you are? During an interview on 1/5/2021 at 2:06 PM, the ADM stated the AD immediately reported what they had heard and saw regarding the (3/1/2021) incident to them. The ADM went to the unit where CNA #1 was working, but CNA #1 was not on the unit at the time. They waited for them to return. The ADM stated they had no idea where CNA #1 was, but when CNA #1 returned to the unit, they told them they were suspended because of an allegation of verbal abuse pending outcome of an investigation. The ADM stated CNA #1 did not leave, so they told them a second time they were suspended and had to leave the building. The ADM stated then CNA #1 tried to call their employment agency, so they had to tell CNA #1 a 3rd time they were suspended and to leave the building. The ADM stated CNA #1 was mouthy and started swearing in front of the residents. The ADM stated they told CNA #1 they could not use that language in front of residents. They needed to tell CNA #1 a minimum of 3 times to leave. The ADM stated they stayed with CNA #1 the entire time and they escorted them out of the building. 10 NYCRR 415.4(b)(1)(i) x

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews during an abbreviated survey (Case #s NY00271205, NY00271568, NY00272306, and #NY00278116), the facility did not ensure that all alleged violations involving abuse, and neglect are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse/neglect/or mistreatment or result in serious bodily injury for 4 residents (Resident #s 1, 2, 7, and 8) of 8 residents reviewed for abuse reporting. Specifically, the facility did not ensure it reported allegations of abuse/neglect/mistreatment for Resident #1 who reported they had been hit and fell, Resident #2 who had a fall with a fractured arm that the facility reported as a care plan violation, and Resident #7 who was witnessed to be verbally abused by Certified Nurse Aide (CNA) #1 within 2 hours of each occurrence. This was evidenced by: The Policy and Procedure titled, Abuse dated 2/2019, documented to notify the local law enforcement and appropriate State Agency (s) immediately (no later than 2 hours after allegation/identification of allegation). Resident #1: Resident #1 was admitted to the facility with diagnoses of schizoaffective disorder, history of traumatic brain injury, and chest pain. The Minimum Data Set (MDS- an assessment tool) dated 7/1/2021, documented the resident was cognitively intact, could be understood, and could understand others. An untimed Facility Grievance Form dated 6/28/2021, documented on 6/26/2021, Resident #1 called 911 and reported to police someone had hit them and they fell out of bed. The resident became increasingly accusatory and continued to state someone had hit them and they fell. The NYS Department of Health (DOH) Nursing Home Incident Form documented the incident occurred on 6/26/2021 at 6:00 PM. The form was submitted to DOH on 6/28/2021 at 5:34 PM. Resident #2: Resident #2 was admitted to the facility with diagnoses of dementia, stroke, and diabetes. The MDS dated [DATE], documented the resident had moderate cognitive impairment, could be understood, and could understand others. The untimed facility Investigation Form dated 2/15/2021, documented the incident that involved Resident #2 was a fall with injury and care plan violation. The resident sustained a fractured right arm. The DOH Nursing Home Incident Form documented the incident occurred on 2/15/2021 at 6:45 AM. The form was submitted to DOH on 2/15/2021 at 12:57 PM. Resident #7: Resident #7 was admitted to the facility with diagnoses of Alzheimer's disease, dementia with behavioral disturbance, and delusional disorder. The MDS dated [DATE], documented the resident had severe cognitive impairment, was usually understood, and could usually understand others. The untimed facility Investigation Form dated 3/2/2021, documented CNA #1 assisted Resident #7 into the library at 5:45 PM on 3/1//2021 and was overheard by the Activities Director (who was in their office adjacent to the library with their door closed) yell at the resident to sit your ass down, then yelled at the resident to shut up and go to sleep, and Who the hell do you think you are? The DOH Nursing Home Incident Form documented the incident occurred on 3/1/2021 at 5:45 PM. The form was submitted to DOH on 3/2/2021 at 11:44 AM. Interviews: During an interview on 1/5/2023 at 11:16 AM, the Director of Nursing (DON) stated abuse was to be reported within 24 hours if there was no injury, and within 2 hours if injury occurred. During an interview on 1/5/2023 at 2:06 PM, the Administrator (ADM) stated reportable incidents needed to be reported to the DON within 24 hours, or if the incident involved serious injury, within 2 hours. 10 NYCRR 415.4(6)

Based on record review and interviews during the recertification survey, the facility did not ensure there was immediate notification of the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #108) of 5 residents reviewed for notification of change. Specifically, for Resident #108, the facility did not ensure the physician was notified immediately after a change in mental status was identified on the morning of 7/21/2022. This was evidenced by: Resident #108: Resident #108 was admitted to the facility with diagnoses of Alzheimer's disease, anxiety disorder, and hypothyroidism. The Minimum Data Set (MDS - an assessment tool) dated 5/19/2022, documented the resident had severely impaired cognition, could usually understand others, could usually make themselves understood, and had no signs or symptoms of a swallowing disorder. The Policy and Procedure (P&P) titled Notifications, dated 4/2019, documented the facility must notify the resident's physician immediately when there was a significant decline in the resident's physical, mental, or psychosocial status. Immediately shall mean as soon as possible. The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADLs) reviewed 5/23/2022, documented Resident #108 was supervision with setup help for eating. A change in condition note dated 7/21/2022 at 1:21 PM, documented Resident #108 had experienced a change in condition of altered mental status evidenced by increased confusion, needing more assistance with ADLs, general weakness, and decreased mobility. A nursing note dated 7/21/2022 at 2:59 PM, documented Resident #108 had increased lethargy in the morning and was brought to the feeding assist room for breakfast. Attempts to feed the resident resulted in the food rolling out of the resident's mouth. The resident remained at their table until 12:30 PM, at which time they were observed to be unresponsive with drool pouring out of their mouth. The resident received three sternal rubs, with no response; a faint pulse rate was felt. The Nurse Practitioner (NP) was notified, and the resident was sent to the hospital. During an interview on 09/22/2022 at 2:41 PM, Registered Nurse (RN) #1 stated that during breakfast on 7/21/2022, approximately 8:30 AM, Resident #108 appeared lethargic, and food was falling out of their mouth when staff attempted to feed them; this was new for the resident. After breakfast, the resident's mental status still appeared to be diminished from their baseline and they were still not acting like themselves. Later in the afternoon, the resident became unresponsive. The Nurse Practitioner (NP) was notified, and the resident was sent to the hospital. RN #1 stated the facility policy regarding physician notification was that if a resident had a change in condition, including a change in mental status, the provider should be informed immediately. They stated when Resident #108's change in mental status was identified at breakfast on 7/21/2022, they did not notify the physician. The NP was not notified of Resident #108's change in condition until the resident was unresponsive around lunchtime. During an interview on 09/22/2022 at 4:01 PM, Licensed Practical Nurse (LPN) #1 stated they were assigned to Resident 108's unit on 7/21/2022. Around lunchtime on that day, the resident was minimally responsive, which was a change in their mental status from their baseline. Staff informed them the resident had been that way since breakfast, and they reported this to the resident's nurse (LPN #2) and the nurse manager (RN #1). Shortly afterwards, the NP arrived on the unit, and the resident was sent to the hospital. During an interview on 09/23/2022 at 8:09 AM, LPN #2 stated they were assigned to Resident #108 on 7/21/2022, and they had not seen Resident #108 so lethargic that they were unable to keep food in their mouth like they were in the morning of 7/21/2022; that was new and a change in mental status for the resident. When the change of condition was identified during breakfast, the physician was not notified immediately. Around lunchtime, the NP was notified after the resident was unresponsive, and they were sent to the hospital. During an interview on 09/23/2022 at 12:25 PM, the Director of Nursing (DON) stated when a change in condition was identified, the resident needed to be assessed and the physician notified. When the change in condition involved a change in mental status, the physician needed to be notified immediately. The DON stated that on 7/21/2022, when nursing identified the change in Resident #108's mental status at breakfast, the physician should have been contacted immediately. 10 NYCRR 415.3(e)(2)(ii)(b)

Based on record review and interview during the recertification survey, the facility did not ensure that a Level 1 Screen was completed prior to admission to the nursing home for 1 (Resident #35) of 19 residents reviewed for pre-admission screening. Specifically, for Resident #35, the facility did not complete a Level 1 Screen prior to the resident's admission to the facility. This is evidenced by: Resident #35: Resident #35 was admitted to the facility with diagnoses of Alzheimer's disease, diabetes mellitus, and hypertension. The Minimum Data Set (MDS - an assessment tool) dated 8/5/2022, documented the resident had severe cognitive impairment and was rarely/never able to make needs known. A Policy and Procedure titled PASRR/SCREENS dated 12/2019 documented, every admission to the facility would have a completed Level 1 Screen prior to admission to ensure the resident was appropriate for admission to the facility. Upon admission, the social worker would be responsible to ensure the completed Level 1 Screen (and Level 2 PASRR if required) was in the medical record. On 9/20/2022, the resident's medical record did not include a Level 1 Screen. During an interview on 9/23/2022 at 2:50 PM, the Director of Nursing (DON) stated after searching for the Level 1 Screen for Resident #35, the facility was unable to locate the document. During an interview on 9/23/2022 at 2:51 PM, Social Worker (SW) #5, stated the corporate admissions team reviewed all screens prior to accepting residents for admission and the Level 1 Screen should have been included with the admission paperwork from the hospital. SW #5 stated on 4/13/2022 and again on 8/25/2022, they had requested that corporate admissions staff provide a copy of Resident #35's Level 1 Screen to be placed in the resident's medical record. SW #5 stated they had not received a copy of the Level 1 Screen and could not verify it was completed. 10 NYCRR415.11(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews during the recertification survey, the facility did not ensure food that accommodated resident allergies, intolerances, and preferences, or appealing options of similar nutritive value were provided for 2 (Resident #'s 20, and 42) of 3 residents reviewed for food. Specifically, for Resident #20, the facility did not ensure that all the items on the resident's meal ticket, or appealing options of similar nutritive value were provided on 9/20/2022 and 9/23/2022 and for Resident #42, the facility did not ensure that all the items on the resident's meal ticket, or appealing options of similar nutritive value were provided on 9/23/2022. This was evidenced by: Resident #20: Resident #20 was admitted to the facility with diagnoses of chronic heart failure, morbid obesity, and depression. The Minimum Data Set (MDS - an assessment tool) dated 7/15/2022, documented the resident was cognitively intact, able to make themselves understood, and able to understand others. During an interview on 9/20/2020 at 9:03 AM, Resident #20 stated they did not always receive what was on their meal ticket at mealtime. When this occurred, they were usually told that the kitchen was out of items that were not provided. They stated they typically did not receive items that were on their meal ticket approximately three times a week. Resident #20's meal ticket dated 9/20/2022, documented for one banana to be provided with breakfast. The breakfast meal tray did not include a banana, and no substitution was present. During an interview on 09/22/22 at 9:18 AM, Registered Nurse (RN) #1 stated that they received complaints from residents regarding incorrect items on their meal trays a few times a day, and that it was always different residents each day with issues. When residents were missing items on their ticket, they would call the kitchen. Usually, the kitchen told them that they were out of items that they were calling about. Resident #20's meal ticket dated 9/23/2022, documented for one banana to be provided with breakfast. The breakfast meal tray did not include a banana, and no substitution was present. During an interview on 9/23/2022 at 11:22 AM, the Food Service Director (FSD) stated that when items were missing from meal trays or unavailable on resident meal trays, an alternative item needed to be sent. Resident #20 should have had alternative items sent on their tray for the bananas that were not provided on 9/20/2022 and 9/23/2022. Resident #42: Resident #42 was admitted to the facility with diagnoses of diabetes, urinary retention, and hyperlipidemia. The MDS dated [DATE], documented the resident was moderately cognitively impaired, able to make themselves understood, and able to understand others. Resident #42's meal ticket dated 9/23/2022, documented for corn flakes, moistened with milk, to be provided with breakfast. The breakfast meal tray did not include corn flakes, and no substitution was present. During an observation and interview on 9/23/2022 at 8:55 AM, Resident #42 was eating their breakfast. Their meal ticket documented for corn flakes; there were no corn flakes on the meal tray, and the resident stated they did not receive them. Resident #42 stated they would have liked to have received the corn flakes, but what was on their tray was all that was provided to them for breakfast. During an interview on 9/23/2022 at 11:22 AM, the FSD stated prior to going to the floors, meal trays were spot checked for accuracy. When errors were identified on the meal tickets, they needed to be corrected and all the remaining trays needed to then be checked for accuracy before they were sent to the units. 10 NYCRR 415.14(d)(4)

Based on record review and interview during a recertification and abbreviated surveys conducted 9/19/2022 to 9/23/2022, the facility did not ensure residents were provided a safe, clean, comfortable, and homelike environment on 3 of 3 units observed. Specifically, on Unit A, a strong, stale urine odor was noticed throughout the unit each day of the survey and resident rooms lacked a homelike environment in the absence of personalized items and décor. On Unit B the floors and ceiling tiles were soiled, and on Unit C the laminate trim was peeling away from the wall in a resident room. Additionally, the facility did not ensure that appropriate dishware was consistently utilized in accordance with facility policy on the B-wing nursing unit on 9/19/2022 and in the main dining area on 9/21/2022. This is evidenced by: A facility policy titled, Home Like Environment created 9/19/2022 documented Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Procedure: The facility staff and management shall maximize, to the extent possible, the characteristics of the facility. That reflect a personalized homelike setting. These characteristics include. A. Cleanliness and order. C. Inviting colors and décor. D. Personalized furniture and room arrangements. E. Pleasant, neutral scents. The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include: B. Institutional odors. Unit A: During observations on 09/19/22 at 10:37 AM and 02:21 PM, a strong, stale urine odor was noted immediately upon entering the unit. The odor was perceived to be the same throughout the unit. During observations on 09/20/22 at 9:39 AM and 2:48 PM, the odor noted on previous day was significantly stronger throughout the unit, with added intensity near the Unit desk. During observations on 09/21/22 at 8:41 AM and 3:08 PM, the odor noted on previous days remained throughout Unit A. During observations on 09/21/22 at 9:51 AM and again on 09/22/22 at 10:29 AM, the floors were soiled with dirt including in corners and next to walls in the A-Unit Assisted Dining Room and a ceiling tile was stained in resident room #A-11. During observations on 09/22/22 at 9:44 AM and 1:25 PM, the odor noted on previous days remained throughout Unit A, perceived as intense as it was during 09/19/22 (day 1 of survey) observation. During an observation on 09/23/22 10:34 AM, in resident room A-11 the walls were unembellished, and surfaces were without decorative items except for one small basket of artificial flowers in the window, not visible to the resident in the bed on the door side of the room. In resident rooms A-20 and A-36 the walls were unembellished, and surfaces were without decorative items. During an interview on 09/19/2022 at 3:34 PM, the Maintenance Director stated that about 2 weeks ago a new ventilation unit was ordered for the long hall on the A-unit and is waiting for the weather to clear to install the unit. During an interview on 09/20/22 at 09:13 AM, Resident #36 reported they keep the door closed to try to keep out the odor. States staff say there's nothing they can do about it. During an interview on 09/23/22 at 10:18 AM, Resident #20 stated that the A-wing unit smelled like urine and feces most of the time. They noticed that it smelled particularly worse when they had been off the unit and returned, for example, when they return from therapy. They stated that in the past they have mentioned to staff that the unit smelled bad, but staff had told them that it happens and it is a nursing home. During an interview on 09/23/22 at 10:21 AM, Housekeeper #1 reported they had noticed the odor a few weeks ago and have tried to get rid of it but can't. Believes it is coming from some of the mattresses that hold the odor and possibly the floor wax. Has discussed with supervisor, not sure if they are doing anything about it. During an interview on 09/23/22 at 1:05 PM, the Housekeeping Supervisor reported they have known about the odor problem for over a month maybe closer to two months. Believes part of the problem was the air circulator that was replaced by maintenance on Tuesday. The Housekeeping staff try very hard to eliminate the odor including extra cleaning of rooms and items that are known to be urinated on frequently, but it's not enough. When asked if they thought the facility had provided an environment free of institutional odor, the Housekeeping Supervisor stated, no, not even half of the time. During an interview on 09/23/22 1:20 PM, the Social Worker Director (SWD) stated residents and family are encouraged to bring personal items, however they do not know who's responsible for telling them that. The SWD does not know if the facility provides anything for those that have no family to bring items in, and stated it might be Activities' responsibility. During an interview on 09/23/22 at 1:28 PM, the Activities Director reported they did not regularly discuss with residents or family about bringing personal items into the facility and did not know if it was an Activity or Social Work Department responsibility. During an interview on 09/23/22 at 1:30 PM, Activities Aid #2 stated there was information in the welcome pack about bringing in personal items. They also stated, if a resident has no family to bring items in the facility could provide decorative items for their room if they ask, it is not done routinely though. During an interview on 09/23/22 at 1:56 PM, the Administrator stated they were not aware of the odor on Unit A until Monday when a surveyor asked about it. There was an exhaust fan that was not functioning, and it was repaired on Wednesday. There is also a resident on the unit that refuses to bath and that may be part of the problem. We will try to figure out where the odor is coming from and correct. The Administrator also stated they would expect activities to let them know if a resident needed anything, including decorative items for their room. They were not aware of rooms with no decorative items. During an interview on 09/23/22 at 2:26 PM, the Maintenance Director stated they have been working on the exhaust units to correct the odor problem. In the past 6 weeks they have replaced two of three units. Unit B: During observations on 09/21/22 at 9:51 AM and again on 09/22/22 at 10:29 AM, the floors were soiled with dirt including in corners and next to walls in resident rooms #B-25, #B-26, #B-31, #B-37, and #B-38. Unit C: During observations on 09/21/22 at 9:51 AM and again on 09/22/22 at 10:29 AM, the laminate trim was peeling from the wall in resident room #C-8. During interviews on 09/23/22 at 10:33 AM, the Administrator, Maintenance Director, and Director of Housekeeping and Laundry stated that stripping and waxing the floors on the B-wing was slowed due to the pandemic and issues with staffing, it is being discussed within the facility to finished stripping the floors as soon as possible, an alternate product may need regarding gluing the laminate trim, and the facility will be audited for stained ceiling tiles. The Administrator stated that the rooms identified will be the initial focus and priority. The Policy and Procedure (P&P) titled Meal Tray Pass, revised 1/2020, documented trays for room service would be set up in the dietary department, and dishes would be utilized unless otherwise ordered by the physician. During an observation on 9/19/2022 at 12:57 PM, 13 unpassed trays were observed on the B-unit dining cart. All 13 trays contained a bowl of orange gelatin served in a disposable paper bowls. During an observation on 9/21/2022 at 11:55 AM, cinnamon apples were served in disposable paper bowls to 17 residents in the main dining area. During an observation on 9/22/2022 at 9:14 AM, 5 resident meal trays on the B-wing dining cart contained 30 milliliter (mL) clear medicine cups that were filled with a white liquid. During an interview on 9/22/2022 at 9:14 AM, Licensed Practical Nurse (LPN) #2 stated that the white liquid in the 5 plastic medicine cups on the B-wing dining cart was Lactaid. Staff were using the medicine cups, because the facility ran out of coffee creamers, and yesterday, they ran out of half and half, so this was what was being provided to the residents. During an interview on 9/22/2022 at 9:18 AM, Registered Nurse (RN) #1 stated that yesterday the facility ran out of coffee creamers, so they began providing residents half and half in 30 mL medication cups at mealtime. Since the facility was out of half and half today, the staff were serving Lactaid to the residents in the medication cups at mealtime. During an interview on 9/23/2022 at 10:51 AM, Licensed Practical Nurse Unit Manager (LPNUM) #1 stated that according to the facility's meal tray pass policy, ceramic/plastic dishes should be used for all residents unless a physician's order documented otherwise. They were not aware of any reason that disposable cardboard bowls should have been utilized for large groups of residents during a meal pass. During an interview on 9/23/2022 at 11:22 AM, the Food Service Director (FSD) #1 stated that ceramic plates, 6 oz. non-disposable tumblers, and 9 oz. non-disposable bowls should be used for food service at each meal, unless a resident had alternative orders from the physician. FSD #1 stated that the orange gelatin and cinnamon apples observed on 9/19/2022 and 9/21/2022 respectively, should have been served in non-disposable bowls instead of the disposable cardboard bowls they were served in. They also stated that the directive to use medication cups to distribute half and half and Lactaid on 9/21/2022 and 9/22/2022 respectively did not come from the kitchen; they assumed that the half and half and Lactaid was going to be added directly to the coffee in one of the carafes that were sent to the unit. Using the medication cups to distribute the half and half and Lactaid was probably not the best way to ensure a homelike environment for the residents. During an interview on 9/23/2022 at 12:25 PM, the Director of Nursing (DON) stated that when the facility ran out of coffee creamers and half and half, staff should have implemented an alternative solution rather than using medication cups to distribute these fluids to ensure a homelike environment was maintained for the residents. 10 NYCRR 415.5(h)

Based on observation and interviews during the recertification survey dated 09/19/22 through 09/23/2022, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen and two (2) of 3 nourishment areas. Specifically, in the main kitchen, one #10 can of tomato sauce found in the common stock had a V-shaped dent; the pressure gauge servicing the automatic dishwashing machine was broken; the faucet servicing the 2-compartment sink was leaking. Additionally, multiple surfaces and equipment in the main kitchen and unit areas were soiled with food particles, splatters and grime. This is evidenced as follows: The main kitchen and unit kitchenettes were inspected on 09/19/22 at 11:30 AM. In the main kitchen, one #10 can of tomato sauce found in the common stock had a V-shaped dent; the pressure gauge servicing the automatic dishwashing machine was broken; the faucet servicing the 2-compartment sink was leaking; and the microwave oven, can opener holder, door gaskets and bottom inside of the roll-in refrigerator, kitchen floor fan, kitchen doors, ceiling above the cooking line, exhaust hood above the dishwashing machine, wall fan left of the dishwashing machine, dishwashing machine room floor including the floor below the dishwashing machine, fire extinguishers, and mop and bucket were soiled with food particles, splatters, or grime. And the floor in the A-Unit nourishment area, and the cabinet below the sink in the C-Unit nourishment area were soiled with food particles. During an interview on 09/19/22 at 12:57 PM, the Food Service Director stated that worker orders will be submitted for the dishwashing machine pressure gauge, faucet leak, and ceiling tiles; and a cleaning list will be developed in general and for the items found. During an interview on 09/20/22 at 1:24 PM, the Administrator stated that the items found in the kitchen and nourishment areas will be addressed. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.32, 14-1.110, 14-1.115, 14-1.170

Based on observation and interviews during the recertification survey, the facility did not ensure each resident was treated with dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 3 units and 1 (Resident #118) of 1 resident reviewed for dignity. Specifically, for Resident #118, the facility did not ensure the resident was treated with dignity and respect when he/she requested to use a bedpan. This was evidenced by: Resident #118: The resident was admitted to the facility with the diagnoses of diabetes, morbid obesity and sepsis due to methicillin susceptible staphylococcus aureus. The Minimum Data Set (MDS - an assessment tool) dated 2/26/20, documented the resident was cognitively intact, could understand others and could make self-understood. The MDS documented the resident was total dependence of 2 staff for toilet use and transfer and was occasionally incontinent of urine. The Facilities Policy and Procedure titled ADL Support dated 10/2019, documented appropriate care and services will be provided for residents who are unable to carry out activity of daily living (ADL's) independently, with the consent of the resident, and in accordance with the plan of care, including support and assistance with elimination (toileting). The Comprehensive Care Plan for Activities of Daily Living related to limited mobility, dated 1/24/20, documented the resident required extensive assist of 2 for bed mobility and was totally dependent with 2-assist for toilet use. During an interview on 3/03/20 at 9:28 AM, Resident #118 stated he/she had to use the bedpan around dinner time last night and had his/her call light on. A Certified Nursing Assistant (CNA) came in and told the resident that he/she could not help because he/she was passing out dinner trays. The CNA placed an adult brief and 2 poise pads (bladder control pads) under the resident by pushing them under her from the front of her groin. The resident stated he/she did not see the CNA again, until he/she put the call light on at 7:00 PM, the CNA stopped in and asked the resident if he/she was still waiting to urinate and told the resident to urinate on the pads that he/she placed under the resident and left the room. The resident stated the nurse came into at 8:00 PM with medications and he/she told the nurse of the interaction with the the CNA. The resident could not hold the urine any longer and the pads/protective pad was wet. Care was provided by 2 Nurses and the resident was advised to fill out a grievance. During an interview on 03/04/20 at 09:14 AM, Licensed Practical Nurse (LPN) #3 stated there were 2 poise pads and an adult brief under the resident last evening. The brief and pads were bunched up under the resident and not placed properly so the protective pad was wet and they provided incontinence care. The LPN stated CNA #5 was scheduled all shift but was not on the floor half of the night and LPN #3 and another nurse assisted the resident in cleaning up. During a subsequent interview on 3/4/20 at 10:40 AM, the resident stated it made her feel awkward and weird with the brief/posie pads were shoved under her. He/she stated if the CNA took the time to do that, she could have put him/her on the bed pan. During an interview 3/4/20 at 10:28 AM, Registered Nurse Manager (RNM) #4 stated she had heard of the incident on Monday because LPN #3 called her at home and grievance was filled out. RNM#4 stated he/she could not say whether the incident was related to staffing or not, or what the CNA was thinking at the time. RNM #4 stated it was a dignity issue to place incontinence pads under a resident from the front and incorrectly and have the resident urinate on them instead of using the bedpan. During an interview on 03/05/20 at 9:43 AM, the Acting Director of Nursing (DON) stated the CNA was under the perception that the staff were not to provide care during mealtime and the CNA stated the incontinence products were placed under the resident in case of leakage, but that the way they were placed would not have worked anyways. The DON stated it was not a dignified situation and the CNA would need re-education. 10 NYCRR 415.3(c)(1)(i)

Based on observation, record review and interview during the recertification survey the facility did not ensure there was evidence that all alleged violations of abuse, neglect or mistreatment were thoroughly investigated for 1 (Resident #105) of 3 residents reviewed for accidents. Specifically, for Resident #105, the facility did not ensure there was evidence of an investigation to rule out abuse, neglect, or mistreatment after the resident had an unwitnessed fall on 12/29/29 that resulted in a laceration over the left eyebrow, decreased consciousness, and a transfer to the hospital. This was evidenced by: Resident #105: The resident was admitted to the facility with the diagnoses of Parkinson's disease, anxiety disorder and osteoarthritis. The Minimum Data Set (MDS-an assessment) dated 1/27/20, documented the resident was cognitively intact and was able to understand others and make herself understood. The P&P titled Accidents-Incidents dated 8/2019, documented it was the policy of the facility to monitor and evaluate all occurrences of accidents or incidents or adverse events occurring on the facility's premises which was not consistent with the routine operation of the facility or care of a particular resident. Any unwitnessed incident or accident must be investigated for potential abuse. The P&P documented if the resident sustained a suspected or actual significant injury, was sent to the hospital or abuse was suspected the supervisor must immediately notify to the Director of Nursing (DON) or Administrator; the supervisor would begin an investigation for root causes of the occurrence; the Nurse Supervisor would ensure that the Incident and Accident Packet was complete and submitted to the DON at the end of the shift; and the DON and Administrator were responsible to review the incident/investigation and the conclusion to determine if the incident required reporting to an outside agency. During an observation/interview on 3/1/20 at 10:37AM, the resident was lying in his/her bed and touched a scar on his/her left forehead. He/She stated he/she fell and cut his/her forehead open and was unconscious a few months ago and had to go to the hospital. He/She stated he/she fell because he/she had to go to the bathroom and could not wait any longer for staff to answer his/her call bell. He/She got up from his/her bed without assistance and fell. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADL) dated 2/6/19, documented the resident required assistance related to Parkinson's disease and muscle weakness. Interventions included: 8/9/19-limited assist of 1 staff with walker for locomotion; 1/9/20- extensive assist of 1 staff for ambulation, transfers, and bed mobility. The CCP for At Risk for Falls dated 2/19/19, documented the resident has had an actual fall related to psychotropic drug use, Parkinson's Disease, poor safety awareness, history of vertigo, muscle weakness and non-compliance with ADL recommendation. Interventions included: 12/20/19 remind resident to use her walker or wheelchair for locomotion; 2/6/19 encourage to wear appropriate footwear and encourage to use call bell for assistance as needed; on 1/6/20 a bed alarm. The Fall Risk Evaluation dated 12/16/19, documented a recent fall, 1-2 falls within the last 6 months. Medication use included: Antihypertensive, benzodiazepine, narcotic, psychotropic, anti-Parkinson medications. The resident's memory and recall ability were intact. The evaluation also documented the resident was frequently incontinent bladder. The resident exhibited a loss of balance while standing, used short discontinuous steps, exhibited jerking or instability when making turns, used an assistive device and had decreased in muscle coordination. The Nurse Practitioner Tele-Health Progress Note dated 12/29/19 at 6:28 PM, documented the resident had a fall and head injury (laceration 2.5 cm above left eyebrow). The fall was not witnessed, and first aid was provided to stop bleeding. No headache or dizziness, pupils equal and reactive to light. The resident was on Eliquis (anticoagulant) and at her baseline. A telephone order was given for neurological checks, body audits, steri-strip to head laceration, Bacitracin and dressing, and to follow-up with primary physician for consideration for CT scan (computed tomography) of head. A nursing progress note dated 12/29/19 at 6:48 PM, written by a Registered Nurse (RN) documented the resident fell forward onto his/her forehead and had 2.5-centimeter (cm) laceration over the left eyebrow that bled profusely and had an ice pack in place. The incident occurred at 6:10 PM. The note documented the resident had previous falls and was transferred the hospital status post this fall and laceration. The Nurse Practitioner Tele-Health Progress Note dated 12/29/19 at 8:37 PM, documented the resident was transferred to the emergency room for CT scan of head secondary to decreasing consciousness. The Change in Condition form (hospital transfer form) dated 12/29/19, written by the RN, documented the resident fell forward onto forehead, 2.5-centimeter laceration over the left eyebrow, bled profusely, had ice pack in place. The resident took Eliquis (anticoagulant-blood thinner), left pupil 1 millimeter (mm), right pupil 4 mm. The resident had decreased consciousness and increased or new onset weakness. The resident was transferred to the hospital. A review of the medical record did not include documentation that the facility investigated the the resident's fall with injury and decreased consciousness on 12/29/19 incident to rule out abuse, neglect or mistreatment. During an interview on 3/03/20 at 11:15 PM, the Administrator stated they were unable to find documentation that an I&A or investigation was completed for the resident's fall on 12/29/19. An I&A or investigation should have been completed. During an interview on 3/03/20 at 12:55 PM, Certified Nurse Aide (CNA) #1 stated the resident used to get up every day and sit in his/her chair, but not much anymore because of staffing. He/She will push his/her call bell and wait for help when he/she needs to get up, but if he/she had to go to the bathroom, he/she would get up by himself/herself if the call bell was not answered timely. During an interview on 03/04/20 at 11:08 AM, the Licensed Practical Nurse Manager (LPNM) #1 stated the medication nurses were responsible for overseeing resident care, when they were short staffed there were some residents who would stay in bed. She stated some residents needed to be watched closely and when they were short of staff. Resident #105 will get himself/herself up without assistance if he/she had to go to the bathroom. On 12/29/19, the Registered Nurse Supervisor was also working as a medication nurse and she only completed the SBAR Note (an assessment tool) for the resident to be transferred to the hospital. She stated an incident report and/or investigation was never completed for the fall on 12/29/19 and there should have been an incident report and/or investigation started on the day of the fall. 10 NYCRR 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during a recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 2 (Resident #'s 16 and 45) of 3 residents and 1 (Resident #49) of 1 unsampled resident reviewed for Activities of Daily Living (ADLs). Specifically, for Resident #'s 16, 45 and #49, the facility did not ensure the residents, who could not independently carry out activities of daily living, received incontinence care to maintain good personal hygiene and reduce their care planned risk for impaired skin integrity. This is evidenced by: The Policy and Procedure (P&P) titled ADL- Personal Hygiene last revised 10/2019, documented peri-care would be given with each incontinence episode, with AM/PM care and shower day. The P&P documented toileting/incontinence care for a resident would occur every 2-4 hours or as needed for each individual resident per care plan and [NAME] (care card). Resident #16: The resident was admitted to the facility with the diagnoses of cerebral infarction, vascular dementia and chronic pain. The Minimum Data Set (MDS - an assessment tool) dated 11/4/19, documented the resident had moderately impaired cognition, could usually understand others and could make self understood. The MDS documented the resident was always incontinent of bowel and bladder. During an observation on 03/01/20 at 10:28 AM, the resident was lying in bed wearing a hospital gown. A strong odor of urine was noted coming from the resident's room and the odor was stronger when standing next to the resident's bed. Based on continued observation, the resident did not receive incontinence care as of 12:08 PM and the strong smell of urine remained. The Comprehensive Care Plan (CCP) for Activities of Daily Living, last revised 1/14/20, documented the resident required a total mechanical lift (Hoyer) for transfers, was totally dependent with 2 staff for toilet use and was totally dependent with 1 staff for personal hygiene. The CCP for Risk of Impaired Skin Integrity related to Incontinence, last revised 1/14/20, documented to minimize extended exposure of skin to moisture by providing frequent incontinence care and prompt removal of wet/damp clothing or sheets as needed. The Certified Nursing Assistant (CNA) care card, with a print date of 3/5/20, documented the resident required a total mechanical lift for transfers; was totally dependent with 2 staff for toilet use and was totally dependent with 1 staff for personal hygiene. CNA documentation on 3/1/20 at 3:37 AM and 7:54 PM, revealed the resident was toileted and personal hygiene was provided. The CNA documentation did not include that the resident was toileted or that personal hygiene was provided on the day shift on 3/1/20. During a medical record review from 2/19/20 - 3/3/20, documentation did not include that the resident received frequent incontinence care as documented on the care plan and did not include documentation of incontinence care every 2-4 hours or as needed per the facility policy. During an interview on 3/3/20 at 1:14 PM, CNA #1 stated she started her shift at 7:00 AM and she helped care for the resident on Sunday 3/1/20, but not until lunchtime around 12:00 PM (7:00 AM to 12:00 PM = 5 hours). She stated the resident was probably last changed on night shift and was not changed again until just before lunchtime on Sunday. She stated she and another CNA provided the resident with care and washed the resident up for the first time on the day shift around lunchtime on Sunday. She stated Sunday morning there were 2 CNAs on the day shift and the resident did not receive care timely. She stated the resident would normally be washed up earlier in the morning, but there was not enough staff to get all the residents washed and up Sunday morning. During an interview on 3/4/20 at 10:30 AM, the Director of Nursing (DON) stated she was aware the resident was dependent for all ADL care and although staffing was a challenge in the facility and even more so on the weekends, she had not had staff come to her saying they could not get their assignments completed timely. She stated it was unacceptable for a resident to not receive morning ADL care from approximately 7:00 AM to after 12:00 PM. She stated the 2 CNAs on the unit and the 2 Licensed Practical Nurses (LPNs) should have teamed up together to provide the care timely. She stated supervision and oversight of the CNAs was the responsibility of the unit managers on the day shift and on off hours shifts and weekends was the responsibility of the Licensed Practical Nurse (LPN) charge nurse to ensure residents were being properly cared for. She stated the nurses should be overseeing and assisting to ensure incontinence care was provided. During an interview on 3/4/20 at 12:55 PM, LPN Unit Manager #1 stated it was not acceptable for the resident to go from approximately 7:00 AM to after 12:00 PM without receiving morning care. She stated it was the facility's policy to check and change every resident every 2-4 hours and it was expected that the 2 CNAs on the unit would complete the resident care with the help of the 2 LPNs on the unit. She stated it was more often than not that there were only 2 CNAs working on the unit, especially the last couple of months and weekends tended to be even worse. She stated she was aware that residents went more than 4 hours without receiving incontinence care and when she asked the CNAs why care was not provided, the staff responded they documented the Activity Did Not Occur because there were only 2 CNAs and they did not get around to changing all the residents. During an interview on 3/5/20 at 9:17 AM, the Administrator stated the expectation was that every resident was checked every 2 hours at a minimum and if resident was found to be incontinent or soiled, the staff would take care of them at that time. She stated staffing levels were not an excuse for care not to be provided. She stated if care was not given due to resident refusal then it should be documented the resident refused, otherwise the care should be provided as documented on the care plan and care card. Resident #45: The resident was admitted to the facility with the diagnoses of dysphagia, Alzheimer's disease, and schizophrenia. The Minimum Data Set (MDS - an assessment tool) dated 11/17/19, documented the resident had moderately impaired cognition, could rarely/never understand others and could rarely/never make self understood. The MDS documented the resident was frequently incontinent of bowel and bladder. During an observation on 3/1/20 from 10:37 AM to 12:11 PM, the resident was in bed wearing a hospital gown and did not receive morning ADL care during that time. At approximately 12:15 PM, CNA #5 provided morning care to the resident. The resident remained in bed and was not assisted out of bed for lunch. The CCP for Activities of Daily Living, last revised 12/4/19, documented the resident required a total mechanical lift for transfers; was totally dependent with 2 staff for bathing and was totally dependent with 1 staff for personal hygiene. The CCP for Risk of Impaired Skin Integrity, last revised 12/4/19, documented the resident was to receive incontinence care every 2-4 hours as needed and to encourage to turn and reposition every 2-4 hours. The CNA care card, with a print date of 3/3/20, documented the resident required a total mechanical lift for transfers; was totally dependent with 2 staff for toilet use and was totally dependent with 1 staff for personal hygiene. The care card documented the resident was to receive incontinence care every 2-4 hours as needed. CNA documentation on 3/1/20 at 1:28 PM, documented the resident was bathed (washed up) and personal hygiene was provided. CNA documentation at 3:41 AM and 7:54 PM documented bathing was not applicable. CNA documentation at 3:41 AM, documented personal hygiene was not applicable and at 7:55 PM personal hygiene was provided. During a medical record review from 2/19/20 - 3/3/20, documentation did not include that the resident received incontinence care every 2-4 hours as needed as per the facility policy and comprehensive care plan. During an interview on 3/1/20 at 10:15AM, CNA #1 stated there were at least 6 residents on the unit who were not provided with personal care on the day shift, including Resident #45. She stated there were 2 CNAs on the unit, herself and another CNA. She stated the resident should already be out of bed but was not due to not having staffing on the unit. During an interview on 03/01/20 at 12:28 PM, CNA #5 stated she was called into work and arrived at the facility between 11:30 AM and 12:00 PM. She stated she provided the resident with his/her morning care at approximately 12:15 PM. She stated the resident was incontinent of urine, was wet, and needed to be changed. She stated the resident was supposed to be changed every 2 hours and did not know when the resident was last changed. During a subsequent interview on 3/1/20 at 12:31 PM, CNA #1 stated she started her shift at 7:00 AM and there were 2 CNAs on the unit, including her, until about 12:00 PM when CNA #5 was assigned to the unit. She stated she had been working with the other CNA to try to provide care to all the residents on the unit, but personal care and incontinence care had not been provided to Resident #45. She stated the resident had not received care since the night shift, which was before 7:00 AM, until CNA #5 provided care after 12:00 PM. She stated CNA #5 was the only staff to have provided the resident with care so far on the day shift. She stated additional staff were called in to help, but that was not the norm. During an interview on 3/4/20 at 10:30 AM, the DON stated she was aware the resident was dependent for all care and stated it was unacceptable for morning care, including incontinence care, not to be provided by 10:30 AM. She stated when there were 2 CNAs on the unit, the 2 LPNs should also help to provide the residents with care. During an interview on 3/4/20 at 1:00 PM, LPN Unit Manager #1 stated the resident should have been care for, up and out of bed by 10:30 AM. She stated the facility policy was for every resident to be checked and changed every 2-4 hours. During an interview on 3/5/20 at 9:17 AM, the Administrator stated the expectation was that every resident was checked every 2 hours at a minimum and if the resident was found to be incontinent or soiled, the staff would take care of them at that time. She stated the resident should have been washed and transferred out of bed and should have not have in bed from approximately 7:00 AM to 12:00 PM. She stated staffing levels were not an excuse for care not to be provided. She stated if care was not given due to resident refusal then it should be documented the resident refused, otherwise the care should be provided as documented on the care plan and care card. Resident #49: The resident was admitted to the facility with the diagnoses of dementia, anxiety disorder and osteoporosis. The Minimum Data Set (MDS-an assessment) dated 12/2/19, documented the resident had severe cognitive impairment and was usually able to understand others and make self understood. During an observation on 3/01/20 at 1:32 PM, Resident #49 was in a semi-sitting position in her bed, wearing a hospital gown and covered with a sheet. A strong odor of urine was noticeable upon entering the room and at the resident's bedside. The resident was observed again at 2:30 PM, lying in the same area of the bed and the urine odor was still present. The Comprehensive Care Plan (CCP) for: -Activities of Daily Living (ADL) dated 3/8/18, documented the resident required extensive assistance of one person for transfers, and was totally dependent on one staff for toileting, bathing, and dressing. -Risk for Impaired Skin Integrity dated 3/8/18, documented the resident had fragile skin and to apply protective and/or preventative skin care. -Bladder incontinence dated 9/4/18, documented apply incontinence devices; extra-large brief. -Bowel Incontinence dated 11/27/18, documented to check the resident every 2-4 hours and provide peri-care after each incontinence episode. The Certified Nurse Aide (CNA) care card dated 3/3/20, documented to encourage the resident to get out of bed during waking hours to prevent skin breakdown, provide peri-care after each incontinent episode, and to use an extra-large brief. The CNA documentation dated 3/01/20, documented the resident consumed her lunch meal. It did not include documentation the resident received incontinence care, and bathing or personal hygiene on the day shift (7:00 AM - 3:00 PM). During an interview on 3/01/20 at 1:32 PM, CNA #1 stated Resident #49 received incontinence care that morning, but the resident had not received incontinence care after that. She stated there were only 2 CNAs working that day and more recently, the usual number of CNAs was 2 on the day and 2 CNAs on evening shift and 1-2 CNAs on the night shift. During an interview on 3/03/20 at 12:55 PM, CNA #1 stated when the unit was short staffed, they staff had to leave some of the residents in bed. She stated Resident #49 sometimes yells out with care so the staff would leave her in bed when they were short. She stated no one followed up with CNAs to see why certain residents were left in bed or checked in with the staff to see who had or had not received care. The CNAs were told to document even if a resident does not get done. She stated on the weekends the CNAs did not have the time to document everything. During an interview on 3/04/20 at 9:50 AM, LPN #5 stated Resident #49 liked to stay in bed if she could, so the staff would leave her in bed when they were short staffed. She stated the resident should not be left in bed for three days in a row and stated she told the staff even if they were short staffed, she would help them. She stated every resident was at risk for problems when the facility was short staffed. During an interview on 3/04/20 at 10:00 AM, LPN #8 stated Resident #49 was left in bed sometimes, but she should be out of bed every day. The LPN stated there were not enough CNAs to get all the resident care completed done, and the nurses must help with care. 10 NYCRR 415.12(a)(3)

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, dumpsters were not closed. This is evidenced as follows. The garbage dumpsters were inspected on 03/01/2020 at 11:42 AM. The side doors of both dumpsters were open. Refuse was found in the dumpsters The Maintenance Director stated in an interview on 03/01/2020 at 11:42 AM, that he will speak with housekeeping about keeping the dumpsters closed. 10 NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure it maintained an infection control program designed to help prevent the development or transmission of infection for 1 (Resident #19) of 2 residents reviewed for wound care. Specifically, for Resident #19, the facility did not ensure that standard precautions to include hand hygiene, and glove use were maintained during a dressing change. Also, the facility did not ensure the table was cleansed to prevent the transmission of infectious agents prior to the placement of dressing supplies on the table. This is evidenced by: Resident #19: The resident was admitted to the facility on [DATE], with diagnoses of injury of right quadriceps muscle (large muscle in the upper leg), type 2 diabetes, and peripheral venous insufficiency (reduced blood flow to extremities). The Minimum Data Set (MDS- as assessment tool) dated 2/10/20, documented the resident was cognitively intact, could be understood, and could understand others. The Policy and Procedure dated 12/2019 for Sterile Dressings, documented the bedside stand was to be cleaned and a clean field established. Wash hands, wear clean gloves, and remove the soiled dressing, pull glove over dressing and discard into plastic bag. Wash hands, put on gloves, cleanse wound from center outward, per orders and pat dry with gauze. Apply the ordered dressing and secure with tape. Discard disposable items, remove gloves and wash hands. Clean the bedside stand and then wash hands again. Observed wound care for Resident #19 on 03/04/20 at 11:12 AM. Licensed Practical Nurse (LPN) #3 washed her hands and put on clean gloves. She did not cleanse the over the bed table prior to placing the clean field. The right lower leg dressing was removed followed by the removal of the left lower leg dressing. The scissors used to remove both dressings were not cleansed before or after each use. LPN #3 did not change gloves or wash/sanitize hands between the removal of the dressings on each leg. LPN #3 removed her gloves and washed her hands after the dressings were removed, donned (put on) clean gloves, completed the treatment to the right and left lower legs without changing gloves or performing hand hygiene between the dressing changes to each leg. A Comprehensive Care Plan (CCP) for Alteration in Skin Integrity- stasis ulcers both lower extremities, revised on 2/9/20, documented to assess wound weekly, document wound measurements, wound bed appearance, odor, drainage, and surrounding tissue. A Medical Doctor (MD) order dated 2/14/20, documented to cleanse both lower legs with wound cleanser, pat dry, cover wound beds with medi honey, wrap with gauze kling and secure with Coban with 50% tension toes to 2 finger breadths below knee. During an interview on 3/4/20 at 11:29 AM, LPN #3 stated she probably should have changed her gloves between wound care to the right lower leg and the left lower leg. During an interview on 3/4/20 at 11:54 AM, the Acting Director of Nursing stated LPN #3 should have cleaned the over the bed table prior to setting up her clean field and she should have changed her gloves after completion of wound care on one leg, before starting the wound care on the other leg. 10NYCRR415.19(b)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure each resident received adequate supervision for 2 (Resident #45 and #272) of 4 sampled residents and 1 (Resident #61) of 1 unsampled residents reviewed for accidents hazards. Specifically, for Resident #'s 45 and 61, the facility did not ensure the residents, with the diagnosis of dysphagia (difficulty swallowing) and who received altered consistency diets, received adequate supervision and assistance while eating according to the comprehensive care plan; and for Resident #272, the facility did not ensure the resident, who was a high fall risk and had 6 falls in the month of February, had bilateral floor mats in place next to the his/her bed. This was evidenced by: Resident #45: The resident was admitted to the facility with the diagnoses of dysphagia (difficulty swallowing), Alzheimer's disease, and schizophrenia. The Minimum Data Set (MDS - an assessment tool) dated 11/17/19, documented the resident had moderately impaired cognition, could rarely/never understand others and could rarely/never make self understood. The resident's comprehensive care plan documented the resident was to be up for all meals and was to eat meals in the dining room where he/she could be assisted. The Policy and Procedure (P&P) titled Modified Food Consistency Policy last revised 2/2018, documented individuals with observed indicators of dysphagia (coughing, choking, delayed swallow, pocketing food, inability to manipulate food in the mouth, wet, gurgly voice, etc.) would be referred to the Speech Language Pathologist (SLP) for evaluation of dysphagia and the SLP would work with the Registered Dietitian or designee to make appropriate recommendations for proper food and fluid consistency. During an observation on 3/1/20 at 12:50 PM, the resident was sitting in bed eating lunch. A Certified Nursing Assistant (CNA) was standing at the bedside. The Comprehensive Care Plans for: -Activities of Daily Living, last revised 12/4/19, documented the resident required limited assistance with eating, to encourage self-feeding, and was to be up for all meals. -Dysphagia, last revised 12/4/19, documented the resident was to sit upright for all meals at least 60-90 degrees and was to eat in the assist room for meals. The CNA [NAME], print date 3/3/19, documented the resident required limited assistance with eating, to encourage self-feeding and was to be up for all meals and documented the resident was to sit upright for all meals at least 60-90 degrees and was to eat in the assist room for meals. A Physician Order dated 9/20/19, documented the resident received a consistent carbohydrate diet, pureed texture, honey fluid consistency; No Added Salt; Use sippy cup to facilitate oral intake. A Speech Therapy evaluation and Plan of Treatment dated 6/3/15, documented due to the documented physical impairments and associated functional deficits, the patient was at risk for; falls, aspiration, and pneumonia. An Occupational Therapy Screen dated 1/29/20, documented the resident was a limited assist for feeding with built up utensils and covered mugs. The medical record did not include documentation that the resident declined to get out of bed on 3/1/20. During an interview on 3/3/20 at 12:33 PM, CNA #4 stated she cared for the resident on the evenings of 2/29/20 and 3/1/20 and did not get the resident out of bed for dinner on Saturday or Sunday. She stated the resident ate dinner by herself in bed those 2 evenings and it was not unusual for the resident to eat alone in her room in bed. She stated the resident was a 2 assist to transfer out of bed and when there was not enough staff or time to get all of the residents out of bed for dinner, the resident often stayed in bed for dinner. During an interview on 3/3/20 at 10:49 AM, CNA #2 stated the resident was supposed to be up for all 3 meals. She stated she knew that the evening staff did not get the resident up for dinner because she had recently helped on the evening shift. She stated when staff did not get the resident up for dinner, the resident ate in her room. CNA #2 was aware that the resident was not supposed to eat in her room at any time of the day and stated the reason was because the resident choked a lot and she needed to be supervised in the dining room. She stated it was not safe for her to eat in her room and she needed assistance to eat. She stated her care card documented the resident was to be up for all 3 meals, which she stated meant for the resident to be out of bed for all meals. She stated she helped on the evening shift last Monday and Resident #45 and several other 2-assist residents were not gotten up for dinner. She stated the evening shift faced a lot of the same problems as the day shift. They did not have enough staff to care for the residents. During an interview on 03/03/20 at 1:14 PM, CNA #1 stated the resident ate breakfast in her room alone on Sunday, 3/1/20. She stated the resident did not need her assistance to eat and there were only 2 CNAs on the unit, and they could not get every resident up in time for breakfast, so the resident had breakfast in her room, in bed, unsupervised and unassisted. She stated the resident was changed around 12:30 PM after more staff where called into work and the resident was still not up for lunch. She stated the resident ate breakfast and lunch in bed on 3/1/20. During an interview on 3/4/20 at 9:38 AM, the Speech Language Pathologist (SLP) stated the resident was not supposed to eat in his/her room. She stated safest way for the resident to eat was to be out of bed and supervised. She stated the resident had a diagnosis of dysphagia and was on an altered diet. She stated the resident should be out of bed to eat for breakfast, lunch, and dinner. She stated her recommendation was for the resident to be out of bed for all meals for safety. She stated she would consider it an accident hazard for the resident to be eating in the bed, and an even bigger accident hazard if the resident was left unsupervised. She stated the resident was at risk for aspiration and choking. The SLP stated she believed it when staff reported to the surveyor that the resident was left in bed for meals unsupervised because there was a lack of staff to get residents out of bed for meals. She stated she saw that staffing was an issue, but also thought it was facility policy that any resident with dysphagia received supervision at meals. She stated she documented on the resident's care plan when a resident needed to be out of bed and supervised for meals, so all staff are aware. During an interview on 3/4/20 at 10:30 AM, the Acting Director of Nursing (DON) stated if the care plan documented the resident was to be up for all meals, then the expectation was that the resident was out of bed and up for all meals, unless it was documented that the resident declined to get out of bed. She stated it was not acceptable that the resident remained in bed on Sunday for meals because of short staff. She stated she did not necessarily see the resident eating in bed unsupervised as an accident hazard, but more as the staff not following the resident's plan of care. She stated the staff should look at the resident's care card before providing care and follow what was documented on the care card. During a subsequent interview on 3/4/20 at 11:15 AM, CNA #4 stated she knew the resident was supposed to be for meals, but they did not have enough staff to get everyone out of bed, so the resident ended up eating in her room alone. She stated the resident was a full mechanical lift which needed to staff members to get her out of bed. She stated the resident fed herself and no one was in the room with her because there was not enough staff to supervise every resident that was eating in their room that needed supervision. She stated the resident was supposed to eat in the blue room, which is the dining room where residents who needed assistance ate. She stated she was not sure why the recommendation was for the resident to be in the blue room, except probably for choking reasons. She stated the biggest issue for the resident was that he/she tended to spill her food and drinks when the top cap off the sippy cups. During an interview on 3/4/20 at 12:55 PM, LPN Unit Manager #1 stated she was never made aware that the resident ate in her room unsupervised. She stated the resident had a diagnosis of dysphagia and needed supervision. She stated resident could eat in their bed if they were supervised, but it should be reported to the nurse on the unit if the resident was going to be supervised while eating in bed. She was not aware if a nurse was notified that a resident ate in bed on 3/1/20. During an interview on 3/5/20 at 9:17 AM, the Administrator stated she expected the resident's care card to be followed regardless of the amount of staff on the unit and that it was not acceptable for the resident to be eating meals in bed. She stated there was a potential for an accident hazard especially if the resident was eating in his/her bed unsupervised. She stated she was not aware that residents were not getting up for meals due to staffing. Resident #272: The resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, type 2 diabetes, and major depressive disorder. The MDS dated [DATE], documented the resident was cognitively intact, could be understood, and could understand others. The P&P titled Falls Management and Prevention dated 11/2019, documented the interdisciplinary team identified and implemented appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independent. During an observation on 3/2/20 at 8:32 AM, the resident was in his/her bed. Floor mats were not placed on either side of the resident's bed. During an observation on 3/2/20 at 1:52 PM, the resident was in his/her bed. Floor mats were not placed on either side of the resident's bed. During an observation on 3/2/20 at 2:44 PM, the resident was in his/her bed. Floor mats were not placed on either side of the resident's bed. CNA #14 placed a floor mat beside the left side of the bed. There was no other floor mat in the room to place at the right side of the resident's bed. During a record review on 03/02/20, Accident/Incident reports for Feb. 2020 documented the resident fell on 2/4, 2/12, 2/14, 2/19, 2/21, and 2/28/20. There were no apparent injuries from the falls, however, the resident required a thoracic (mid back) spine x-ray following the 2/4/20 fall due to complaints of back pain. Nursing Progress notes dated 2/4, 2/12, 2/14, 2/19, 2/21, and 2/28/20 documented the resident's falls, and RN assessment was completed, and the medical provider was notified. The Comprehensive Care Plan (CCP) for Falls revised on 2/10/2020, documented the resident was to have floor mats at all times due to the resident had actual falls r/t incontinence, psychoactive drug use, desire to complete tasks independently, impulsive behaviors, poor safety awareness, and decline in functional mobility. The care plan documented the resident was to have floor mats at all times. The CNA [NAME] on the inside of his/her closet door documented the resident was to have floor mats when in bed. During an interview on 3/2/20 at 2:39 PM, CNA #14 stated she was aware the resident had frequent falls. She stated the CNA Kardexes were on the inside of residents' closet doors. She looked at the [NAME] of residents she was not familiar with every other day because sometimes the care changed. She stated for residents she knew, she'd review the Kardexes from time to time in case something had changed. The resident was supposed to have floor mats when she got out of bed and when she went back to bed. The CNA stated the mats were placed on the floor at both sides of his/her bed whenever he/she was in bed. His/her bed was to be in the lowest position and the call light within reach. Following this interview, the Surveyor went with CNA #14 to the resident's room at 2:44 PM (see observation documentation above). During an interview on 3/2/20 at 2:48 PM, Licensed Practical Nurse (LPN) #6 stated the resident was supposed to have mats on the floor beside both sides of his/her bed. Res. non-compliant with req. help to go back to bed. She stated she did room checks of her residents during the day to ensure their call lights were within reach, and other safety measures in place, such as floor mats were down. She stated she did not notice the floor mats were not on the floor while the resident was in bed. During an interview on 3/2/20 at 2:59 PM, Registered Nurse (the unit manager) #5, stated safety rounds were completed at the change of every shift. The CNAs were supposed to actually see each resident and check to ensure their call lights were within reach, their beds were in the lowest position, and if the resident had floor mats, they were in place. There was no system in place to document safety rounds were completed. She was not aware the resident's mats were not at the bedside until she was notified by LPN #6 when it was brought to her attention by the Surveyor. She stated CNAs were supposed to look at the care cards each time they went into a resident's room to provide care. She also had a notebook at the nurses' station that documented current changes made to care cards that the CNAs were supposed to review. During an interview on 3/3/2020 at 9:56, the Acting Director of Nursing (DON) stated CNAs were expected to look at resident's care cards prior to starting care. Safety rounds were done at change of shift and at least every 2 hours. The Charge Nurse made sure the rounds were being done. The CNAs did the rounds. She did not believe the safety rounds were documented. When making safety rounds, the CNAs were to look for positioning of the resident, they had call bells in reach, look for anything on the floor that would pose a tripping hazard, ensure floor mats were down, and any safety devices. Whenever a resident was bed and were care planned for floor mats, the floor mats were to be on the floor. 10NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review during the recertification survey, the facility did not ensure provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility did not ensure that the minimum staffing levels for Certified Nursing Assistants was met on 14 out of 14 days from 2/17/20 through 3/1/20; the facility did not ensure there was sufficient CNA staff on 3/1/20 to provide 6 (Resident #'s 16, 36, 40, 45, 77, and #320) of 20 residents on A Wing Side-1 with personal hygiene care in a timely manner and in accordance with each resident's care plan; For Resident #49, on A Wing Side-2, the facility did not ensure the resident received incontinence care in accordance with the resident's care plan; and for Resident #'s 45 and 61, with the diagnosis of dysphagia (difficulty swallowing) and who received altered consistency diets, the facility did not ensure there was sufficient staffing to provide adequate supervision and assistance with eating according to their comprehensive care plans; and for Resident #105, the facility did not ensure resident that have a risk to falls received adequate supervision and assistance to prevent falls. This is evidenced by: Finding #1: The facility did not ensure that the minimum staffing levels for Certified Nursing Assistants (CNA) was met on 14 out of 14 calendar days from 2/17/20 through 3/1/20. Upon entrance to the facility on [DATE] at 10:00 AM, there were 117 residents in the facility. The facility's total capacity was 122. The Facility Assessment, last updated 2/24/20, documented the staffing levels for CNA's was 12 on the day shift, 12 on the evening shift and 6 on the night shift. A review of the Daily Staffing Sheets for the 14 days from 2/17/20 through 3/1/20, facility's staffing levels for CNAs, were not met according to their Facility Assessment on 14 of 14-day shifts, 14 of 14 evening shifts, and 10 of 14 nights shifts. The Daily Staffing Sheets documented: 02/17/2020 - 6 CNAs on the day shift, 6.5 CNAs on the evening shift, 02/18/2020 - 7 CNAs on the day shift, 6.5 CNAs on the evening shift, 6 (4 after 12:30 AM) CNAs on the night shift 02/19/2020 - 6.5 CNAs on the day shift, 5 CNAs on the evening shift, 6 (3 after 3:00 AM) CNAs on the night shift 02/20/2020- 7 (5 after 11:00 AM) CNAs on the day shift, 5 CNAs on the evening shift, 02/21/20207 - 6 CNAs on the day shift, 5 CNAs on the evening shift, 5 CNAs on the night shift 02/22/2020 - 6 CNAs on the day shift, 6 CNAs on the evening shift, 5.5 CNAs on the night shift 02/23/2020 - 7.5 CNAs on the day shift, 6 CNAs on the evening shift, 02/24/2020 - 9.5 CNAs on the day shift, 6 CNAs on the evening shift, 02/25/2020 - 10 CNAs on the day shift, 7 CNAs on the evening shift, 5 CNAs on the night shift 02/26/2020 - 9 (7 after 11:00 am) CNAs on the day shift, 6 CNAs on the evening shift, 4 CNAs on the night shift 02/27/2020 - 7 CNAs on the day shift, 4.5 CNAs on the evening shift, 5 CNAs on the night shift 02/28/2020 - 6 CNAs on the day shift, 6.5 CNAs on the evening shift, 6 (4 after 3:00 AM) CNAs on the night shift 02/29/2020 - 7 CNAs on the day shift, 6 CNAs on the evening shift, 4 CNAs on the night shift 03/01/2020 - 7 (10 after 11:00 AM) CNAs on the day shift, 7 (6 after 7:00 PM) CNAs on the evening shift, 5 CNAs on the night shift During an interview on 3/4/20 at 10:44 AM, the Staffing Coordinator stated Corporate's guidance to her was that the maximum staffing levels for CNA's was 12 on the day shift, 9 on the evening shift and 6 on the night shift. She stated she could not staff the facility any higher than those staffing numbers. She stated she tried to schedule 12, 9, 6, but recently she had not been able to schedule those staffing levels. She stated the day and evening shifts had been running short. She stated she made the Administrator and Corporate aware and it was reported every morning in morning meeting what her daily staffing was and what her needs were. She stated the facility was not fully staffed Sunday, 3/1/20 and staff were called into work when the Survey team entered. She stated the facility used agency staff for CNAs and LPNs and the facility offered incentives to the staff when the schedule was not full. During an interview on 3/5/20 at 9:17 AM, the Administrator stated despite the review of the Facility Assessment on 2/24/20, the assessment should have documented staffing levels for CNAs as 12 CNAs on days, 9 CNAs on evenings, and 6 CNAs on nights. She stated the facility was not meeting those levels as staff have recently left and it was difficult to get staff in that area. She stated the facility relied heavily on agency staff. She stated Corporate was aware of the staffing issues at the facility. The facility was trying to work with agencies for staffing, offering sign-on bonuses and incentives. She stated in the meantime, the facility was utilizing ancillary staff in the facility to assist as much as possible within their scope of practice. Finding #2: The facility did not ensure there was sufficient CNA staff on 3/1/20 to provide 6 (Resident #'s 16, 36, 40, 45, 77, and #320) of 20 residents on A Wing Side-1 with personal care (hygiene) in a timely manner and in accordance with each resident's care plan. Resident #49 on A Wing Side-2 did not receive incontinence care in accordance with the resident's care plan. Refer to F-Tag 677 The Policy and Procedure (P&P) titled ADL- Personal Hygiene last revised 10/2019, documented peri-care would be given with each incontinence episode, with AM/PM care and shower day. The P&P documented toileting/incontinence care for a resident would occur every 2-4 hours or as needed for each individual resident per care plan and [NAME] (care card). Resident #16: The resident was admitted to the facility with the diagnoses of cerebral infarction, vascular dementia and chronic pain. The Minimum Data Set (MDS - an assessment tool) dated 11/4/19, documented the resident had moderately impaired cognition, could usually understand others and could make self-understood. The MDS documented the resident was always incontinent of bowel and bladder. During an observation on 3/01/20 at 10:38 AM, Resident #16 was in bed in a hospital gown, and there was a very strong smell of urine coming from his/her room. The Comprehensive Care Plan (CCP) for Activities of Daily Living, last revised 1/14/20, documented the resident required a total mechanical lift (Hoyer) for transfers; was totally dependent with 2 staff for toilet use and was totally dependent with 1 staff for personal hygiene. The CCP for Impaired Skin Integrity related to incontinence, last revised 1/14/20, documented to minimize extended exposure of skin to moisture by providing frequent incontinence care and prompt removal of wet/damp clothing or sheets as needed. During an interview on 3/1/20 at 10:38 AM, CNA #1 stated the resident was in bed per his/her preference but had not been provided with morning care. Resident #36: The resident was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease, diabetes, and pulmonary hypertension. The Minimum Data Set (MDS - an assessment tool) dated 11/22/19, documented the resident was cognitively intact, could understand and was understood by others. The MDS documented the resident was an extensive assist of one for dressing and toilet use. During an observation on 3/01/20 at 10:37 AM, Resident #36 was in his/her room, sitting in a wheelchair wearing a hospital gown. There was a very strong smell of urine coming from the resident. He/She stated staff had gotten him/her up for breakfast, but that he/she had not been washed up for the day. The CCP for Activities of Daily Living, last revised 2/5/20, documented the resident required extensive assist of one staff member for dressing and toilet use. The CCP for Bladder Incontinence, last revised 2/5/20, documented to apply pull-ups, monitor signs and symptoms of urinary tract infections including urinary frequency and foul-smelling urine, and to document and report any changes in incontinence to the physician as needed. During an interview on 3/1/20 at 11:39 AM, Resident #36 stated there were only 2 CNAs for 40 people. And he/she did not get washed up and dressed by staff until after 10:45 AM. The resident liked to get washed and dressed earlier than 10:45 AM in the morning and always ate breakfast in his/her room, but this morning he/she ate breakfast in a hospital gown and before he/she had received morning care. During additional observations on 3/1/20: 10:23 AM, Resident #40 was in bed and stated he/she had not received assistance for morning care and that he/she needed it. 10:28 AM, Resident #320 was out of bed and had placed himself/herself on the toilet in his/her room. The resident stated he/she needed assistance to get cleaned up because he/she had to put himself/herself on the toilet. There was a very strong odor of a bowel movement. 10:37 AM, Resident #77 was in a hospital gown lying in bed. Supplies and clean linen to provide morning care were on the resident's bedside stand. He stated he had not been washed up. 10:37 AM, Resident #45 was in bed in a hospital gown. Interviews: During an interview on 3/1/20 at 10:15 AM, CNA #1 stated there were at least 6 (Resident #'s 16, 36, 40, 45, 77, and #320) of 20 residents on A Wing Side 1 who had not been provided with morning personal care on the day shift that started at 7:00 AM. She stated there were 2 CNAs on the unit, herself and another CNA. She stated the residents should be washed and up, but were not, due to staffing. During an interview on 03/01/20 at 12:28 PM, CNA #5 stated she was called into work and arrived at the facility between 11:30 AM and 12:00 PM to work on A Wing. She stated the residents were supposed to be changed every 2 hours. She did not know when the residents were last changed, but she was called in to work to help. During an interview on 3/2/20 at 9:46 AM, the Resident Council (6 out of 6 residents who attended) stated there was not enough staff working in the facility on a regular basis. The 5 members of the Council stated that while the lack of staff was not necessarily an issue for them to get up and to get assistance because they could speak for themselves, they stated it was an issue for the residents who could not speak for themselves. The Council stated most of the residents who stayed in bed all day and who were not supposed to stay in bed also could not speak for themselves. The Council stated the residents were left in bed all day because there was not enough staff to get them up. During the Resident Council Interview, Resident #97, stated she was independent and could do things for herself, but her roommate (Resident #36) was not independent and often had to wait long periods of time for staff to come help. She stated her roommate often waited up to an hour and half for assistance after putting the call bell on. She stated her roommate often needed to be changed because she was wet with urine, but had a difficult time getting staff to help her timely when there was not enough staff on the unit. During an interview on 3/4/20 at 10:30 AM, the Director of Nursing (DON) stated she was aware staffing was a challenge in the facility and even more so on the weekends. She stated she had not had staff come to her saying they could not get their assignments completed timely and it was unacceptable for morning care, including incontinence care, not to be provided by 10:30 AM. She stated the 2 CNAs on the unit and the 2 Licensed Practical Nurses (LPNs) should have teamed up together to provide the care timely. She stated supervision and oversight of the CNAs was the responsibility of the unit managers on the day shift and on off hours shifts and weekends was the responsibility of the LPN charge nurse to ensure residents were being properly cared. She stated the nurses should be overseeing and assisting to ensure incontinence care was provided. During an interview on 3/5/20 at 9:17 AM, the Administrator stated the expectation was that every resident was checked every 2 hours at a minimum and if resident was found to be incontinent or soiled, the staff would take care of them at that time. She stated staffing levels were not an excuse for care not to be provided. She stated if care was not given due to resident refusal then it should be documented the resident refused, otherwise the care should be provided as documented on the care plan and care card. Resident #49: The resident was admitted to the facility with the diagnoses of Dementia, Anxiety Disorder and Osteoporosis. The Minimum Data Set (MDS-an assessment) dated 12/2/19, documented the resident had severe cognitive impairment, was usually able to understand others and make him/herself understood and was always incontinent of urine and bowel. During an observation on 03/01/20 01:32 PM, Resident #49 was in a semi-sitting position in her bed, wearing a hospital gown and covered with a sheet. A strong odor of urine was noticeable upon entering the room and at the resident bedside. The resident was observed again at 02:30 PM, lying in the same area of the bed. The odor of urine was still present. The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADL) dated 3/8/18, documented the resident required extensive assistance of one person for transfers, and was totally dependent on one staff for toileting, bathing, and dressing. The CCP titled Bowel Incontinence and dated 11/27/18, documented check every 2-4 hours, provide peri-care after each incontinence episode. The CCP titled Bladder incontinence and dated 9/4/18 documented apply incontinence devices, extra-large brief. The Certified Nurse Aide (CNA) care card dated 3/3/20, documented encourage to get out of bed during waking hours to prevent skin breakdown, provide peri-care after each incontinent episode, extra-large brief. The CNA documentation dated 03/01/20, documented the resident consumed her lunch meal. There was no documentation that the resident received incontinence care, bathing or personal hygiene on the day shift. During an interview on 03/01/20 at 01:32 PM, CNA #1 stated Resident #49 had received incontinence care that morning, but she had not received care after that. There were only 2 CNAs working that day. The usual number of CNAs is 2 on the day and evening shifts and 1-2 CNAs on the night shift. When there are only two CNAs the residents receive care once and they do not get changed again on that shift. During an interview on 03/03/20 at 12:55 PM, CNA #1 stated when we are short staffed, we leave some of the residents in bed. Resident #49 sometimes screams with care so we will leave her in when we are short. No one follows up with CNAs to see why certain residents are in bed or who had or had not received care. The CNAs are told to document even if a resident does not get done. On the weekends we do not have the time to document everything. During an interview on 03/04/20 at 10:00 AM LPN #8 stated the Resident #49 is left in bed sometimes, but she should be out of bed every day. There are not enough CNAs to get all the residents done, the nurses help when they can. During an interview on 03/04/20 at 10:23 AM CNA #8 stated Sunday 3/1/20, there were only two CNAs and we worked as a team. Each resident gets one time of care and there is no time to document. It was impossible to go back to a resident to turn and position or change again. Working with two CNAs happens a lot lately and showers do not get done either. During an interview on 03/04/20 at 10:50 AM, CNA #3 stated working a unit with two CNAs happens often. No one monitors or asks the CNAs which residents did or did not receive care. When there is only two CNAs on a shift, each resident will only get one session of care, there is no further care, turn and position and little to no toileting. During an interview on 03/04/20 at 11:08 AM, the Licensed Practical Nurse Manager (LPNM) stated the medication nurses were responsible for overseeing resident care, when they were short staffed there were some residents who would stay in bed. She stated some of the residents needed to be watched closely and when they were short of staff it could be scary. She did not know that each resident received only one session of care when there were only two CNAs on a unit. There are certain residents who will stay in bed when staffing is short. Resident #49 should get up during the day and if not, she should be turned and positioned throughout the shift. We just started looking at the CNA documentation for completion, we do not look at the actual care each resident received. No one was looking to see what was done and not done when a shift was short staffed. Finding #3: Refer to F-Tag 689 For Resident #'s 45 and 61, the facility did not ensure the residents, with the diagnosis of dysphagia (difficulty swallowing) and who received altered consistency diets, received adequate supervision and assistance while eating according to their comprehensive care plan due to insufficient CNA staffing levels throughout the facility. Resident #45: The resident was admitted to the facility with the diagnoses of dysphagia, Alzheimer's disease, and schizophrenia. The Minimum Data Set (MDS - an assessment tool) dated 11/17/19, documented the resident had moderately impaired cognition, could rarely/never understands others and could rarely/never make self-understood. During an observation on 3/01/20 at 10:37 AM, Resident #45 was in bed in a hospital gown and was supposed have been up for breakfast in the assist dining room (the dining area where residents who required assistance to eat ate their meals) according to CNA #1. The Comprehensive Care Plans for: -Activities of Daily Living, last revised 12/4/19, documented the resident required limited assistance with eating and was to be up for all meals. -Dysphagia, last revised 12/4/19, documented the resident was to sit upright for all meals at least 60-90 degrees and was to eat in the assist room for meals. Resident #61: The resident was admitted to the facility with the diagnoses of dysphagia, chronic kidney disease, and cognitive communication deficit. The Minimum Data Set (MDS - an assessment tool) dated 12/23/19 documented the resident had severely impaired cognition, could sometimes understand others and could sometimes make self-understood. The CCPs for: -Activities of Daily Living, last revised 10/16/19, documented the resident required limited assistance with eating, out of bed for all meals and to supervise and assist as needed and was a total mechanical lift for transfers. -Dysphagia, last revised 10/16/19, documented to encourage the resident to remain as upright as possible during meals. Interviews: During an interview on 3/3/20 at 12:33 PM, CNA #4 stated it was not unusual for residents to eat alone in their rooms in bed if the resident was a 2 assist to transfer out of bed. She stated when there was not enough staff or time to get all of the residents out of bed for dinner, the 2 assist residents often stayed in bed for dinner even when they were care planned to be up out of bed for meals. During an interview on 3/3/20 at 10:49 AM, CNA #2 stated she knew that the evening staff did not get residents up for dinner because she had recently helped on the evening shift. She stated when staff did not get residents up for dinner, the residents ate in their rooms unsupervised. She stated it was not safe for every resident to alone in their rooms due to possible choking risks. She stated when a care card documented the resident was to be up for all meals that meant the resident was to be out of bed for all meals. She stated the evening shift faced a lot of the same problems as the day shift. They did not have enough staff to care for the residents. During an interview on 3/4/20 at 9:38 AM, the Speech Language Pathologist (SLP) stated Resident #'s 45 and 61 were not supposed to eat in their rooms. She stated the safest way for the residents to eat was to be out of bed and supervised. She stated the residents had a diagnosis of dysphagia and were on altered diets. She stated her recommendation was for the residents to be out of bed for all meals for safety. She stated she would consider it an accident hazard for the residents to be eating in the bed, and an even bigger accident hazard if the residents were left unsupervised. She stated the residents were at risk for aspiration and choking. The SLP stated she believed it when staff reported to the surveyor that residents were left in bed for meals unsupervised because there was a lack of staff to get residents out of bed for meals. She stated she saw that staffing was an issue, but also thought it was facility policy that any resident with dysphagia received supervision at meals. During an interview on 3/4/20 at 10:30 AM, the Acting Director of Nursing (DON) stated if the care plan documented the resident was to be up for all meals, then the expectation was that the resident was out of bed and up for all meals, unless it was documented that the resident declined to get out of bed. She stated the staff should look at the resident's care card before providing care and follow what was documented on the care card. During an interview on 3/5/20 at 9:17 AM, the Administrator stated she expected the resident's care card to be followed regardless of the amount of staff on the unit. She stated there was a potential for an accident hazard especially if the resident was eating in his/her bed unsupervised. She stated she was not aware that residents were not getting up for meals due to staffing. Finding #4: For Resident #105, who had a history of falls, the facility did not ensure that a sufficient number of CNA staff were available to provide adequate supervision and assistance to prevent falls. Resident #105: The resident was admitted to the facility with the diagnoses of Parkinson's Disease, anxiety disorder and osteoarthritis. The Minimum Data Set (MDS-an assessment) dated 1/27/20 documented the resident was cognitively intact and was able to understand others and make herself understood. The Daily Staffing Sheet dated 12/29/19 documented there were 7 CNAs on the day shift and 7 CNAs on the evening shift. During an observation/interview on 3/1/20 at 10:37AM, Resident #105 was lying in bed and touched a scar on his/her left forehead. He/she stated he/she fell and cut his/her forehead open and was unconscious a few months ago and had to go to the hospital. He/she fell because he/she had to go to the bathroom and could not wait any longer for staff to answer his/her call bell so got up without assistance and fell. The comprehensive care plan (CCP) titled Activities of Daily Living (ADL) dated 2/6/19, documented the resident required a limited assist of 1 staff for ambulation, transfers, and bed mobility. The CCP titled At risk for falls dated 2/19/19, documented the resident had actual falls. Interventions included: 12/20/19 remind resident to use her walker or wheelchair for locomotion; 2/6/19 encourage to wear appropriate footwear and encourage to use call bell for assistance as needed; on 1/6/20 a bed alarm. The nursing progress note dated 12/29/19 at 6:48 PM, a Registered Nurse (RN) documented the resident fell forward onto his/her forehead and had 2.5-centimeter (CM) laceration over the left eyebrow that bled profusely and had an ice park in place. The incident occurred at 6:10 PM. The note documented the resident had previous falls and was transferred the hospital status post this fall and laceration. The Nurse Practitioner Tele-Health Progress Note dated 12/29/19 at 8:37 PM, documented the resident was transferred to emergency room for CT scan of head secondary to decreasing consciousness. The Change in Condition form (hospital transfer form) dated 12/29/19, RN documented the resident fell forward onto forehead, 2.5-centimeter laceration over the left eyebrow, bled profusely, had ice pack in place. The resident took Eliquis, left pupil 1 millimeter (mm), right pupil 4 mm. The resident had decreased consciousness and increased or new onset weakness. The resident was transferred to the hospital. During an interview on 03/03/20 at 12:55 PM, Certified Nurse Aide (CNA) #1 stated the resident used to get up every day and sit in his/her chair, but not much anymore because of staffing. He/she will push his/her call bell and wait for help when he/she needs to get up, but if he/she had to go to the bathroom, he/she would get up by himself/herself if his/her call bell was not answered timely. During an interview on 03/04/20 at 09:50 AM, Licensed Practical Nurse (LPN) #5 stated she told the staff she would help with resident care when they were short staffed because when the facility was short staffed it felt like every resident was at risk of falls. Resident #105 would get up by himself/herself if he/she needed to go to the bathroom. The LPN stated the facility should have been more alert to him/her after his/her previous falls and he/she should not be left in his/her bed all day. During an interview on 03/04/20 at 11:08 AM, the Licensed Practical Nurse Manager (LPNM) #1 stated the medication nurses were responsible for overseeing resident care, when they were short staffed there were some residents who would stay in bed. She stated some residents needed to be watched closely and when they were short of staff it could be scary. Resident #105 will get himself/herself up without assistance if he/she has to go to the bathroom. On 12/29/19, the Registered Nurse Supervisor was also working as a medication nurse and she only completed the SBAR (assessment) Note for the resident to be transferred to the hospital. 10NYCRR415.13(A)(1)(i-iii)

Based on interview and record review during a recertification survey, the facility did not ensure performance reviews of every nurse aide were completed at least once every 12 months and regular in-service education was provided based on the outcome of the reviews, and that the in-service training complied with the requirements of §483.95(g) for 5 (CNA #'s 1, 2, 3, 6, and #7) of 5 randomly selected Certified Nurse Aides (CNA's). Specifically, the facility did not ensure that CNA #'s 1, 2, 3, 6, and #7 had performance reviews at least once every 12 months and based on the review of the CNA education files, did not ensure at least 12 hours per year of in-service education that complied with the requirements of §483.95(g) related to dementia management training was provided. This is evidenced by: Refer to F tag 947 - In-service training must comply with the requirements of §483.95(g). The Policy and Procedure titled Inservice Programming/Training CNA, dated 9/2019, documented the facility must provide and track a minimum of 12 hours of continued education to the CNAs and to address areas of weakness as determined in the nurse aide's performance reviews. On 3/5/20 at 8:50 AM, the Administrator provided CNA education files for CNA's 1, 2, 3, 6, and #7: Review of the CNA files included the following: -CNA #1's yearly tracking record dated 11/12/19, did not include documentation that 12 hours of CNA in-service education was provided. -CNA #2's education file did not include a yearly tracking record. -CNA #3's yearly tracking record dated 11/11/19, did not include documentation that 12 hours of CNA in-service education was provided. -CNA #6's yearly tracking record dated 11/12/19, did not include documentation that 12 hours of CNA in-service education was provided. -CNA #7's yearly tracking record dated 11/11/19, did not include documentation that 12 hours of CNA in-service education was provided. On 3/5/20 at 9:15 AM, a facility staff member from Human Resources provided Certified Nurse Aides Evaluation forms for: -CNA #1's evaluation with a prepared date of 2/18/17 was not signed and dated by the CNA. -CNA #2's evaluation with a prepared date of 1/18/18 was signed and dated by the CNA on 3/15/18. -CNA #3's evaluation with a prepared date of 5/15/19 was signed and dated by the CNA on 5/15/19. -CNA #6's evaluation with a prepared date of 1/2/19 (documented wrong year) was signed, but not dated by the CNA. -CNA #7's evaluation with a prepared date of 5/15/19 was signed and dated by the CNA on 5/15/19. On 3/5/20 at 11:00 AM, additional CNA education records were provided for CNA #'s 1, 2, 3, 6, and #7. The CNA files included documentation of in-services the CNAs attended, but did not include documentation that the CNA's were provided with twelve hours of in-service education per year based on their individual performance review. During an interview on 3/5/20 at 8:25 AM, CNA #2 stated she had never had a performance review and had never had annual dementia care training. During an interview on 3/5/20 at 8:36 AM, CNA #3 stated she had performance review in May 2019, but did not receive a review yearly and stated she did not know when she last reviewed dementia training as part of her yearly trainings. During an interview on 3/5/20 at 8:56 AM, CNA #1 reviewed the CNA Yearly In-Service Tracking Record with her name on it and stated she did not recall sitting through 4-5 hours of training on 11/12/19. She stated I think I would remember something like that. She stated she had not had a yearly performance review and did not know when she last received dementia training. During an interview on 3/5/20 at 9:00 AM, Human Resources (HR) stated the CNA evaluations were based on the CNA's performance and were completed every 18 months. She stated the evaluations corresponded with when the facility gave staff raises in pay every 18 months. She stated evaluations were not completed on a yearly basis. During an interview on 3/5/20 at 9:10 AM, Licensed Practical Nurse (LPN) #2 stated she had been assisting with education in the facility and was recently made responsible for providing general orientation to new hires or agency staff. She stated she was not responsible for tracking that the CNA staff received 12 hours of in-service every 12 months. She stated general orientation touched on dementia care with a brief overview. During an interview on 3/5/20 at 9:17 AM, the Administrator stated she was aware the facility was lacking in education and there would an issue with education records during survey. She stated her goal was to have the staff complete one hour of in-service each month and there would be a monthly calendar of in-services. She stated as the Administrator, since there was not an Assistant Director of Nursing, she would be picking up the education piece for the staff to ensure 12 hours of in-services every 12 months. She stated the Regional Educator came into the facility and in-serviced all the staff on the same day back in November. She reviewed the CNA Yearly In-Service Tracking Records and stated if there was not documentation in the CNA's education file, then the CNA did not receive the required yearly education or trainings. She stated Corporate told the facility to do performance reviews every 18 months and was not aware the reviews had to be done annually. 10NYCRR 483.35(d)(7)

Based on record review and interviews conducted during the recertification survey, the facility did not ensure required in-service training for nurse aides included dementia management training. Specifically, for 5 (CNA #'s 1, 2, 3, 6, and #7) of 5 randomly selected Certified Nurse Aides (CNA's), the facility did not ensure the required yearly in-service trainings included dementia management training. This is evidenced by: The Policy and Procedure titled Inservice Programming/Training CNA, dated 9/2019, documented the facility must provide and track a minimum of 12 hours of continued education to the CNAs with certain components including dementia management training. On 3/5/20 at 8:50 AM, a review of the CNA education files provided by the Administrator included the following: -CNA #1's yearly tracking record dated 11/12/19, did not include documentation that the CNA received dementia management training. -CNA #2's education file did not include a yearly tracking record and did not include documentation that dementia training was provided or received within the yearly requirement period. It included a Dementia Training Certificate dated 3/14/18. -CNA #3's yearly tracking record dated 11/11/19, did not include documentation that the CNA received education on dementia management training. -CNA #6's yearly tracking record dated 11/12/19, did not include documentation that the CNA received education on dementia management training. -CNA #7's yearly tracking record dated 11/11/19, did not include documentation that the CNA received education on dementia management training. During an interview on 3/5/20 at 8:25 AM, CNA #2 stated she had never had annual dementia care training and had been employed at the facility 25+ years. During an interview on 3/5/20 at 8:36 AM, CNA #3 stated she did not know when she last reviewed dementia training as part of her yearly trainings and had been employed at the facility 15+ years. During an interview on 3/5/20 at 8:56 AM, CNA #1 stated she did not know when she last received dementia training. She stated she had been employed at the facility for more than 5 years. During an interview on 3/5/20 at 9:10 AM, Licensed Practical Nurse (LPN) #2 stated she had been assisting with education in the facility and was recently made responsible for providing general orientation to new hires or agency staff. She stated general orientation touched on dementia care with a brief overview, but she was not responsible for the annual Dementia Training. During an interview on 3/5/20 at 9:17 AM, the Administrator stated she was aware the facility was lacking in education and there would an issue with the education records during survey. She stated the regional educator came into the facility and in-serviced all the staff on the same day back in November 2019. She reviewed the CNA Yearly In-Service Tracking Records and stated if there was not documentation of dementia management training then the CNAs did not receive it. 10NYCRR415.26(c)(1)(iv)