Based on observations, interviews, and record review conducted during the Recertification Survey from 03/17/2025 to 03/21/2025, the facility did not ensure that all residents had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive (a resident's preferences for medical interventions in the event of a life-threatening episode) that would be honored for one (1) (Residents #89) of 32 residents reviewed for advanced directives. Specifically, the facility did not ensure that Resident #89's advanced directives preferences were consistently identified. This is evidenced by the following: The facility policy Advanced Directives, last reviewed May 2025, included it is the policy of the facility to honor the advance directives of all residents and if no advance directives are available and the resident or family have not stated their wishes to execute an advance directive, the resident will be designated as full code status (attempt cardiopulmonary resuscitation in the event of cardiac or respiratory arrest). 1. Resident #89 had diagnoses that included Parkinson's disease, diabetes, and high blood pressure. The Minimum Data Set (a resident assessment tool), dated 03/11/2025, included the resident was cognitively intact. During an interview on 03/17/2025 at 11:41 AM, Licensed Practical Nurse #1 stated the resident's name tag (outside the residents' rooms) is colored blue which indicated the resident was a full code and a white colored name tag means the resident is a DNR (do not resuscitate meaning cardiopulmonary resuscitation would not be started if the heart or breathing ceases). Licensed Practical Nurse #1 stated they use the name tag indicator in an emergency to know if a resident was a full code or a DNR. During an observation on 03/17/2025 at 3:01 PM, Resident #89's name was printed on a blue name tag (indicating their wishes for full code) on the wall next to the resident's door to their room. Review of Resident #89's electronic health record revealed a Medical Order for Life Sustaining Treatment (also known as a MOLST) signed by Nurse Practitioner #1 on 12/05/2025 that included wishes for DNR or to not be resuscitated in the event of an acute medical episode. Current physician's orders, dated 12/05/2025, included the resident had an advanced directives that included wishes were for DNR and do not intubate (insert a tube into the windpipe to assist with breathing). During an interview on 03/18/2025 at 2:38 PM, Licensed Practical Nurse #2 stated they would use the door tag indicator for code status in an emergency to see if a resident was a full code or not and check the Medical Order for Life Sustaining Treatment. They stated if they found a discrepancy they would treat the resident as a full code and start cardiopulmonary resuscitation. Licensed Practical Nurse #2 stated they had identified discrepancies between name tags, physician's orders, and Medical Order for Life Sustaining treatment forms in the past. During an interview on 03/18/2025 at 3:07 PM with Unit Clerk #1 and Registered Nurse Manager #1, Unit Clerk #1 stated they were responsible for placing and updating the name tags if code status changes. They stated they placed a blue name tag for Resident #89 when they were admitted because they did not have a Medical Order for Life Sustaining Treatment but did not update it when Resident #89 became a DNR. Registered Nurse Manager #1 stated Resident #89 had a blue name tag on their door, but it should have been white. They stated that if the code status indicators (name tag, physician's order, and Medical Order for Life Sustaining Treatment) did not match it would cause confusion and a resident's wishes for life staining treatment may not be followed. During an interview on 3/18/2025 at 3:28 PM, the Director of Nursing stated all code status indicators should match, and nursing staff should confirm residents' code status in the electronic health record and not use the door indicator alone. If there is a discrepancy, nursing staff should go by the Medical Order for Life Sustaining Treatment. 10 NYCRR 415.3(f)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during a Recertification Survey completed on 3/24/23, it was determined that for one (Resident #46) of three residents reviewed for skin conditions, the facility did not revise the resident's care plan to reflect the resident's current needs. Specifically, Resident #46's Comprehensive Care Plan (CCP) and Certified Nursing Assistant (CNA) [NAME] (care plan used by CNA for daily care) was not revised to include the presence of recurring skin issues with related goals, and interventions to prevent such. This is evidenced by the following: Review of facility policy Care Planning Process, dated revised April 2022, revealed that the CCP includes a health assessment beginning on the day a resident is admitted and at least every 90 days after the resident's initial review, and more often if their medical condition changes. CCP changes are communicated to the appropriate staff at the time that the changes are made. The CCP also includes ongoing, regular assessment of a resident's condition to see if their health status had changes, with adjustments to the care plan as needed. Review of facility policy Skin Care, dated reviewed September 2021, revealed that during a resident's admission, skin checks are done weekly for four weeks and then at least quarterly by the Licensed Practical Nurse (LPN) staff, and any changes or new areas of concern are reported. Interventions are placed on the resident's care card ([NAME]) and are updated as needed. The resident's care plan would address preventive measures, and if an actual skin issue existed (skin tear, wound, ulcer), it would address appropriate care and services, and would be updated as needed. Communication of any changes to the skin/wound or necessary treatment should be discussed with the Unit Manager and provider. Resident #46 had diagnoses of Parkinson's disease, Alzheimer's disease and frequent falls. The Minimum Data Set assessment dated [DATE], documented that Resident #46 was cognitively intact, had skin tears, and had a skin condition requiring the application of ointments and nonsurgical dressings. Current Physician orders included the following: a. Opti foam (protective wound treatment) to bilateral knee abrasions daily as needed (PRN) for abrasions dated as ordered 4/20/22. b. Alginate (wound treatment often used for draining wounds) with Opti foam to two skin tears on left knee every three days dated as ordered 2/20/23. c. Alginate and Opti foam to the left knee every day for a skin tear dated as ordered 3/20/23. Review of the current CCP and CNA [NAME] revealed that Resident #46 was at risk for pressure ulcers, with related interventions including pressure reducing devices, protective and preventive skin care, and weekly skin audits. The CCP also included to make sure the resident had shoes or non-slip socks on at all times when out of bed due to self-transferring and falls and required contact guard (one or two hands on the resident but not weight bearing) with a 4-wheeled walker and a gait belt. The CCP and the CNA [NAME] did not include that the resident had any current or recurring skin wounds with related goals or interventions. During an observation on 3/22/23 at 1:34 p.m., the CNA [NAME] hanging in Resident #46's room was dated September 2022 and included that the resident required supervision (nearby but not hands on) and a 4-wheeled walker for transfers and for ambulation the resident required supervision with a gait belt and 4-wheeled walker. The room [NAME] also included protective and preventive skin care daily and as needed but no interventions for current skin issues related to frequent falls. In a nursing progress note dated 3/18/23 LPN #5 documented that staff had found Resident #46 on the toilet with their left leg bleeding resulting in a skin tear to the left knee measuring approximately four centimeters (cm) by five cm. The resident stated they had gotten up to go to the bathroom without putting their call light on and lost their balance and fell. During an interview on 3/22/23 at 1:27 p.m., LPN #1 stated that the [NAME] in a resident's room tells the nursing staff what level of assistance and care each resident's needs. LPN #1 stated that Resident #46 required a contact guard assist with transfers, meaning that a staff member should be near the resident. During an interview on 3/23/23 at 12:51 p.m., CNA #1 stated that the [NAME] is based on the therapy recommendations and that things are added to the [NAME] along the way as staff learn more about a resident. During an interview on 3/23/23 at 3:09 p.m., the Registered Nurse Manager (RNM) stated that the CCP is reviewed quarterly or more frequently if needed, and that all facility disciplines are involved in revising a resident's CCP. The RNM stated that skin breakdown, preventative interventions and skin treatments should be included on the CCP, and this information is transferred to the [NAME], which is then printed and placed in the resident's room. The RNM stated that Resident #46 has had abrasions on and off for the several weeks, and had bumped their knees, which reopened the scabbed-over areas. The RNM stated that Resident #46's care plan did not include their skin issues (skin tears, lacerations, or abrasions) and related interventions which could have been an oversight. During an interview on 3/24/23 at 10:43 a.m., the Director of Nursing (DON) stated that they would expect the CCP and the [NAME] to include all the information that would drive a resident's care, as well as identified concerns or issues and goals and interventions. The DON stated skin issues and treatments should be included on the CCP. 10 NYCRR 415.11(c)(2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Recertification Survey completed on 3/24/23, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 20 residents reviewed for quality of care. Specifically, Resident #64 was not provided positioning devices for their [NAME] chair (specialized wheelchair), per therapy recommendations and the residents Comprehensive Care Plan (CCP). The finding is: The facility policy Rehabilitative and Functional Maintenance Services, revision dated March 2012, documented the facility will provide rehabilitative and maintenance services such as but not limited to walking, transfer training, bed mobility, Range of Motion (ROM), splint and brace, needs for adaptive equipment, eating and/or swallowing, amputation/prostheses care and communication, when necessary as indicated by the individualized assessment and input of the interdisciplinary team. Resident #64 had diagnoses including dementia, depression, and hypertension. The Minimum Data Set (MDS, a resident assessment tool) dated 2/9/23 documented the resident had severe cognitive impairment, required total assist by two+ staff members for transfers, and extensive assist for one staff member for wheelchair locomotion. The Occupational Therapy Discharge summary, dated [DATE], documented discharge recommendations of bilateral arm troughs (positioning device), and calf/foot support (positioning device) to the residents [NAME] chair. Resident #64's CCP, dated 7/19/21 and the Certified Nursing Assistants (CNA) [NAME] (care plan used by CNAs for daily care) included the use of a [NAME] chair with bilateral arm troughs for positioning secondary to poor upright sitting posture and bilateral leg rests and calf support/board. Multiple observations included the following: a. On 3/20/23 at 1:25 PM, Resident #64 was in the [NAME] chair leaning to the left with both feet dangling, making no attempt to self-propel. The bilateral arm troughs and bilateral leg rests with calf support/board were not on the [NAME] chair. b. On 3/21/23 at 11:34 AM, Resident #64 was seated at table, in the [NAME] chair leaning approximately 45 degrees to the left with both feet dangling, making no attempt to self-propel. The bilateral arm troughs and bilateral leg rests with calf support/board were not on the [NAME] chair. c. On 3/22/23 at 8:45 AM, Resident #64 was in a common area in the [NAME] chair leaning to the left with both feet dangling, making no attempt to self-propel. The bilateral arm troughs and bilateral leg rests with calf support/board were not on the [NAME] chair. During an interview on 3/22/23 at 10:01 AM the Director of Rehabilitation stated Resident #64 utilized bilateral arm troughs to assist with proper positioning and comfort secondary to poor trunk strength and the bilateral leg rests with calf support/board to prevent legs from dangling. During an interview on 3/22/23 at 10:10 AM the Registered Nurse (RN) #2/Resident Care Coordinator (RCC) stated they expected the care planned interventions to be implemented. RN #2/RCC stated that Resident #64 should have the bilateral arm troughs and bilateral leg rests with calf support/board in place when in the [NAME] chair. During an interview on 3/24/23 at 8:29 AM the Director of Nursing stated they expected adaptive equipment, including bilateral arm troughs and bilateral leg rest with calf support/board, to be implemented per the plan of care. 10 NYCRR 415.12

Based on observations and interview conducted during the Recertification Survey completed on 3/24/23, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are: Observations on 3/24/23 at 11:52 a.m. included two natural gas-powered dryers located in the skilled 3 ground-floor laundry room, and there were no carbon monoxide detectors within or in the vicinity of the laundry area. In an interview at this time the Maintenance Staff Member stated there were carbon monoxide detectors in the generator room, the boiler room, and the kitchen. The Maintenance Staff Member also stated that they test the carbon monoxide detectors and change the batteries but do not keep any logs. No documentation was provided to show that any of the carbon monoxide detectors in the facility were being tested. The 2015 edition of the International Fire Code (IFC), requires 1) carbon monoxide detection to be provided in an approved location between the fuel burning appliance and the dwelling unit, sleeping unit, or classroom; or on the ceiling of the room containing the fuel-burning appliance 2) carbon monoxide alarms shall be maintained in accordance with NFPA 720. The 2012 Edition of NFPA 720, Standard for the Installation of Carbon Monoxide Detection and Warning Equipment, requires that single-station carbon monoxide alarms shall be inspected and tested in accordance with the manufacturer's published instructions at least monthly. 10NYCRR: 415.29(a)(2), 711.2(a)(1); 42 CFR: 483.70(b), 2015 IFC: Section 915, 915.1, 915.1.4, 915.6, Section 1103.9 2012 NFPA 720: 8.7.1

Based on interviews and record reviews conducted during a Recertification Survey, completed on 7/23/21, it was determined that the facility did not ensure that prompt efforts were made to resolve resident grievances for six of six (Residents #6, #26, #39, #55, #80 and #81) residents reviewed. Specifically, there was no documented evidence that concerns and issues, identified by residents on a Resident Council Precautionary Isolation Questionnaire provided to residents (in place of resident council meetings during COVID-19), completed April 2021 through June 2021, were addressed. This was evidenced by the following: Review of the facility policy Grievance Procedure, dated May 2006, included that a grievance is brought to the attention of the Social Worker (SW) by the resident, family, or staff member verbally or in writing. The SW will meet with the resident or family and document the grievance in the Grievance Log. Upon resolution of the grievance, the complainant will be notified of the findings within 21 days of receipt. During a resident council meeting on 7/20/21 at 1:30 p.m., with the surveyor, Residents' #6, #26, #39, #55, #80 and #81 shared that they had not been able to meet due to the pandemic, but had been asked if they had any specific concerns or issues. The resident's stated they did not know how to file a grievance, but they filled out questionnaires instead. Resident #6 stated, at this time, that they had missing clothes they reported on previously, and had not received any resolution. Residents #80 and #81 voiced several food issues that had not been resolved. Review of Resident Council Precautionary Isolation Questionnaires for the months of April 2021 through June 2021, revealed 14 questionnaires were completed for April 2021, 14 for May 2021, and 7 for June 2021 with concerns or issues that included, but were not limited to, food quality, short staffing concerns and the attitudes of several staff members. Review of the Complaint/Grievance Logs for May 2021 through July 2021 revealed that none of the concerns or issues raised by the residents on the Resident Council Precautionary Isolation Questionnaires were documented on the Complaint/Grievance Log. There was no documented evidence that any of these concerns or issues were resolved or reviewed with the residents. During an interview 7/21/21 at 10:24 a.m., the Activities Director stated activities staff went around to all residents and asked if they had any concerns or issues. She said the Administrator was the Grievance Officer, but that she forwarded the grievances to the SW. When interviewed on 7/21/21 at 10:24 a.m., the SW stated that they were the Grievance Officer and that the Activities Director provided them with the completed surveys. The SW stated they emailed specific concerns or issues to the appropriate department heads for review and resolution. The SW stated the concerns or issues received were not always grievances, but more about food issues which were reviewed at morning report. On 7/21/21 at 3:28 p.m., the Administrator stated he and the SW were the Grievance Officers. The Administrator stated he received calls from residents with concerns, but did not always formally document them. The Administrator stated the SW conducted surveys during COVID-19 when Resident Council was not meeting and expected the SW to report to him any resident concerns or issues identified and to follow up to resolve the specific concerns. The Administrator stated they did not have any evidence that the concerns or issues identified in the questionnaires had been addressed. 10 NYCRR 415.3 (c)(1)(i)