**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Complaint investigation (NY00363355-806626 and NY00359730-806683) completed on 09/12/2025, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility did not ensure there was sufficient nurse staffing to meet the needs of the resident in accordance with their preferences and plans of care.The findings are:Review of the Dear Administrator letter 23-11 dated 06/30/23 sent to the nursing home administrators informing them that starting 04/01/2022 nursing homes were required to have an average daily staffing of 3.5 hours of care per resident per day with 2.2 hours for Certified Nurse Aides and 1.1 hours for Licensed Practical Nurses or Registered Nurses.The Facility Assessment, review dated 01/30/2025, documented the assessment is required by the nursing home Requirements of Participation to identify and analyze the facility's resident population and identify the personnel, physical plant, environmental and emergency response resources needed to competently care for the residents during the day-to-day operations and emergencies, including nights and weekends. The facility is licensed for 146 beds with an average daily census of 134. The facility will ensure that there is sufficient and competent staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Additionally, the Facility Assessment documented the following total number needed or average or range of nursing staff including days, evenings, nights, and weekends:- Licensed nurses providing direct care 2.5-8- Nurse Aides 4.5-17Review of the Direct Care Staffing report dated 08/10/2025=09/10/2025 of nursing staff directly responsible for nursing care documented the following:- 08/30/2025 - resident census 121; Licensed Practical Nurse and Registered Nurse hours 84.24 or .7 hours per resident per day; Certified Nurse Aide hours 140.93 or 1.1 hours per resident per day. Based on the census there was not the required number of Licensed Nurse or Certified Nurse Aide hours per day.- 08/31/2025 - resident census 121; Licensed Practical Nurse and Registered Nurse hours 89.95 hours or .7 hours per resident per day; Certified Nurse Aide hours 13.69 hours or 1.0 hours per resident per day. Based on the census there was not the required number of Licensed Nurse or Certified Nurse Aide hours per day.- 09/05/2025 - resident census 123; Licensed Practical Nurse and Registered Nurse hours 97.76 or .75 hours per resident per day; Certified Nurse Aide hours 110.5 hours or .7 per resident per day. Based on the census there was not the required number of Licensed Nurse or Certified Nurse Aide hours per day.The Aspen Complaints/Incidents Tracking System (ACTS) complaint #NY00359730, Internet Quality Improvement & Evaluation System (iQIES) complaint #806683, documented the complainant reported 11/05/2024 Resident #9 for three (3) days, had an incontinent brief soaked with urine and was not cleaned up for the day related to staffing concerns.The Aspen Complaints/Incidents Tracking System (ACTS) complaint #NY00363355, Internet Quality Improvement & Evaluation System (iQIES) complaint #806626, documented the complainant reported 12/09/2024 Resident #10 did not have their brief changed regularly and would sit in the same incontinent brief from 8 AM to midnight related to staffing concerns.Resident #1 had diagnoses which included dysphagia (define), vascular dementia, and hypertension (high blood pressure) The Minimum Data Set (resident assessment tool) dated 06/18/2025 documented the resident had severe cognitive impairment and required substantial/maximal (helper does more than half the effort) assistance with eating.During an observation on 09/10/2025 at 8:45 AM Resident #1 was observed eating breakfast in their room with no staff present.Resident #2 had diagnoses which included protein calorie malnutrition, dementia, and chronic kidney disease. The Minimum Data Set, dated [DATE] documented the resident had severe cognitive impairment. The undated Comprehensive Care Plan documented Resident #2 required partial/moderate assistance with eating.During an observation on 09/10/2025 at 8:46 AM Resident #2 was observed eating breakfast in their room with no staff present.During an observation on 09/08/2025 at 12:05 PM Resident #8 was observed just given their lunch tray by Certified Nurse Aide # 3. Certified Nurse Aide #3 set the tray on the overbed table and exited the room. The resident was not dress and wearing a soiled incontinence brief. Resident #8 was struggling to sit up in bed to reach their meal tray.During an observation on 09/08/2025 at 12:20 PM Resident #6 was observed eating lunch in bed.During observations on the second floor on 09/10/2025 from 8:29 AM through 9:10 AM several residents that required supervision/touching assistance with eating were observed eating in their rooms with no staff present. Additionally, no staff were observed entering those rooms during the time frame.During an interview on 09/10/2025 at 8:22 AM, Certified Nurse Aide #1 stated they were the only aide on the unit, responsible for 38 residents. They stated they do the best they can but cannot do it all.During an interview on 09/10/2025 at 9:16 AM, Licensed Practical Nurse #1 stated there was not enough staff on the unit to supervise the residents eating in their rooms that required supervision or hands on assistance.During an interview on 09/10/2025 at 9:38 AM, the Occupational Therapy Assistant stated any resident that required supervision level of assistance or more should be out of their rooms and in the dining room for meals. We don't have the staff to get residents out of bed in the mornings, and it's happening more and more lately. One (1) or two (2) aides are not able to properly care for that many residents.Durning an interview on 09/08/2025 at 10:17 AM, Certified Nurse Aide #3 stated they have worked at facility since January. The assignment sheet for today documents four (4) aides but have only have two (2). They have 19 residents on their assignment today and that's usually the normal number of aides for this unit, they try to get the work done but it's very difficult. Showers usually don't get done.During an interview on 09/09/2025 at 9:42 AM, a family member stated they come to the facility every day from about 8:30 AM to 2:30 PM to provide care for their parent. They stated care is difficult because there is no staff. I provide all care and assist with all meals, I return each evening for supper because staffing is abysmal.During an interview on 09/09/2025 at 10:10 AM, Certified Nurse Aide #2 stated staffing was pretty bad, usually working with only two (2) aides on the unit. Additionally, they try their best, going room by room but were unable to complete showers and they were only able to provide care to each resident once a shift.During an interview on 09/12/2025 at 8:55 AM, Resident #3 stated they waited for over an hour to have their call light answered to use the restroom and have had accidents (incontinent episodes) waiting for assistance.During an interview on 09/12/2025 at 9:00 AM, Resident #4 stated they no longer bother putting on their call light because there was no staff to answer the light, so they just do things (going to restroom) on their own.During an interview on 09/12/2025 at 9:08 AM, Resident #5 stated they had some urinary problems from holding their urine for extended lengths of time and that it took over an hour to have their call light answered for assistance to use restroom when they were mechanical lift and needed the assistance of two (2) staff members. The resident also stated weekends are the worst, it's nightmarish here on weekends because there is even less staff than during the week.Durning an interview on 09/12/2025 at 9:09 AM, Resident #6 stated they usually must wait over an hour to use the bed pan and sometimes will have an accident (incontinent episode). At night they have to lie in a wet bed because there was only one (1) aide on and they can't get to everyone. Also they like to go to activities but a lot of times they cannot because there was not enough staff to get them out of bed.Durning an interview on 09/12/2025 at 9:14 AM, Resident # 7 stated they were independent and can go to the bathroom by themselves, but their roommate has to wait a long time to get help.During an interview on 09/12/2025 at 9:58 AM, the Director of Nursing stated the following were the minimum number of nursing staff:- 7 AM - 3 PM shift: four (4) nurses, seven (7) Certified Nurse Aides- 3 PM - 11 PM shift: four (4) nurses, seven (7) Certified Nurse Aides- 11 PM - 7 AM shift: three (3) nurses, 4.5 Certified Nurse AidesThe Director of Nursing stated it had been a very long time since the facility had ideal nursing staff and the facility depends on ancillary staff to assist on the units. The Director of Nursing stated residents that required a supervision level of assistance or above with eating would be monitored intermittently by the staff answering call lights and monitoring halls. A nurse or Certified Nurse Aide could not realistically have a resident in sight at all times. The Director of Nursing stated they did not know if showers were being given regularly.During an interview on 09/12/2025 at 10:05 AM, the Administrator stated the facility had not met minimum nurse staffing levels in a while. The facility offers staff incentives to get the staff to work and agency staff. The facility should have 17 certified nurse aides and nine (9) nurses for the day shift, and they were not even close to those numbers.10 NYCRR 415.13 (b)(1) (i-ii) (2)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (#NY00332288) during the Standard survey completed on 3/1/24, the facility did not ensure that all alleged violations of abuse, were reported immediately, but not later than two hours after the allegation was made, to the Administrator and other officials including the State Survey Agency for one (Resident #92) of five residents reviewed. Specifically, alleged resident to resident sexual abuse was not reported to the Administrator of the facility and the New York State Department of Health within the required time frame. The finding is: The policy and procedure titled Resident Abuse Prevention Reporting System, revised 1/6/23, documented that it is the responsibility of employees to promptly report to facility management any incident or suspected incident of resident abuse. Any suspected abuse must be reported immediately. Immediately, in this context, means after ensuring the resident has been removed from any possibility of harm and is safe. All employees receive annual training pertaining to prevention, identification and reporting of resident abuse, and the consequences for failure to report allegations. Resident #92 had diagnoses that included mild cognitive impairment (may include problems with memory, language, or judgement), morbid obesity, and difficulty walking. The Minimum Data Set (a resident assessment tool) dated 1/24/24 documented Resident #92 was cognitively intact, was understood and usually understands. The assessment documented the resident exhibited no behaviors. The Care Plan, dated 12/11/23, documented Resident #92 had the potential for a communication deficit related to an intellectual delay and had the potential for unintentional re-traumatization from being admitted to a skilled nursing facility from living independently in the community. Interventions included ensuring respectful and professional boundaries and to ensure physical and emotional safety. Resident #104 had diagnoses that included alcohol dependence withdrawal delirium (may result in confused thinking and reduced awareness of surroundings), altered mental status and encephalopathy (a brain disease that alters brain function). The Minimum Data Set, dated [DATE] documented Resident #104 was cognitively intact, understood and usually understands. The assessment documented the resident exhibited no behaviors. The Care Plan revised in February 2024, documented Resident #104 had inappropriate behaviors towards a female resident with interventions including redirecting female residents away from resident as able and to remind resident that inappropriate behavior toward females was not acceptable. Ordered anti-depressant medication (Prozac) and to follow up with psychiatric services as ordered. Review of the facility investigation dated 1/26/2024 revealed it was reported by Activities Assistant #2 that Resident #92 made a statement to them that Resident #104 had tried to rape them a couple nights ago. They stated that Resident #92 then changed the subject and remained cheerful and giggling. The investigation did not include the date or time the resident reported the allegation to Activities Assistant #2. The New York State Complaint Tracking System Complaint/Incident Investigation Report received on 1/26/24 at 2:20 PM, documented that the Administrator was made aware of the allegation of resident to resident sexual abuse on 1/26/24 at 11:00 AM. During an interview on 3/1/24 at 8:51 AM, Activities Assistant #2 stated they were in the lobby at the end of their shift on 1/25/24, waiting for a taxi cab. Resident #92 was in their wheelchair next to them, when Resident #104 wheeled themselves into the lobby. Resident #92 then stated Resident #104 made them nervous because they tried to rape them last night. Activities Assistant #2 asked Resident #92 if they told anyone else about the incident and Resident #92 said no. Resident #104 left the lobby soon after they entered and there had been no interaction between the residents. Activities Assistant #2 then left the facility in their cab. Activities Assistant #2 stated they reported the incident to their manager the following day. They did not recall the exact time. During an interview on 3/1/24 at 9:01 AM, the Activities Supervisor stated they were told about the allegation of sexual abuse the morning of 1/26/24. They did not recall the exact time. The Activities Supervisor stated they explained to Activities Assistant #2 the incident was a reportable incident and should have been reported within two hours. They educated them about reportable incidents and then immediately reported the allegation to the Administrator. During an interview on 3/1/24 at 9:08 AM, the Administrator stated that the Activities Supervisor reported the allegation of sexual abuse to them on the morning of 1/26/24. They did not recall the exact time. They stated that Activities Assistant #2 was re-educated on reportable incidents and the responsibility of the employee to report them immediately, even when off the clock. 10NYCRR 415.4(b)(2)

Based on observation, interview and record review conducted during a Standard survey completed on 3/1/24, the facility did not ensure a resident who required respiratory care, including tracheostomy (an opening into the trachea (windpipe) to help air reach the lungs) care, provided such care consistent with professional standards of practice for one (Resident #51) of three residents reviewed for respiratory care. Specifically, during an observation of tracheostomy care, the nurse did not perform adequate hand hygiene/glove changes and did not clean the stoma (a surgically made hole) area. The finding is: Review of policy and procedure titled Cleansing Inner Cannula (a tube within the outer tube that can be removed and cleaned easily without having to change the whole (outer) tracheostomy tube) of Tracheostomy Tube/Trach Care tube revised on 4/27/17, documented that the care should provide wiping and washing of the neck around and under the cannula with a gauze. Review of policy and procedure titled Procedure for Handwashing review date 12/22/14, documented that hands should be washed after handling a resident's articles, dressing, supplies, or equipment used in their care. Review of the facility suction and trach care check list dated 5/15/2000, documented that staff were to cleanse around the outer cannula with gauze and wash their hands after the procedure. Resident #51 was admitted with a tracheostomy, anoxic brain damage (a disorder of the brain caused by decreased oxygen), and epilepsy (disorder of the brain causing recurring seizures). Review of the Minimum Data Set (a resident assessment tool) dated 1/10/24, documented that the resident was in a persistent vegetative state/no discernible consciousness and was dependent on staff for all care. Review of the Comprehensive Care Plan dated 2/8/23, documented Resident #51 was to receive trach care every shift and as needed. Review of the Physician Orders dated 5/18/23 documented that trach care should be completed every shift, three times a day and as needed. During an observation on 2/28/24 at 7:55 AM, Licensed Practical Nurse #3 was performing trach care for Resident #51. Licensed Practical Nurse #3 performed hand hygiene, gathered supplies needed, and set up the supplies on a sterile field on a tray table. Licensed Practical Nurse #3 did not wash their hands before donning sterile gloves and then removed the inner cannula, placed the inner cannula in a solution of hydrogen peroxide and sterile saline, and used the brush provided in the trach kit to clean the mucous from the inner cannula. Without changing their gloves and washing their hands, the Licensed Practical Nurse #3 rinsed the cannula with sterile saline, placed the inner cannula on the sterile barrier, dried it with gauze and placed it back into the outer cannula. Licensed Practical Nurse #3 removed the soiled gauze from around the stoma site, which had a small amount of yellow mucus on it. Licensed Practical Nurse #3 did not clean the stoma area, and using the same gloves, placed a sterile piece of gauze around to the stoma area and proceeded to clean the nebulizer equipment with the same gloves. During an interview on 2/28/24 at 8:05 AM, Licensed Practical Nurse #3 stated that they did not change their gloves after cleansing the inner cannula, removing the soiled gauze, and prior to replacing the cleansed inner canula and the clean gauze. They stated they forgot to change their gloves and that it was important to change their gloves to avoid cross contamination. During an Interview on 2/28/24 at 9:00 AM, Registered Nurse #1, the Unit 2 Manager, stated that they expected Licensed Practical Nurse #3 to follow the policy and procedure for tracheostomy care. They stated that the training on competencies for trach care should be completed every year and that the Licensed Practical Nurse #3 should have used clean gloves to remove and clean the inner cannula as well as removing the gauze. They stated when performing trach care, clean gloves should be worn while removing the inner cannula and soiled gauze, then gloves should be removed, hands should be washed, and sterile gloves should be donned prior to replacing the inner cannula and the new gauze. During an interview on 2/29/24 at 9:05 AM, the Licensed Practical Nurse #4, Educator Facilitator, and Infection Control Preventionist, stated they do not train the staff on trach care, the respiratory therapist does the training, and that staff were trained yearly. During a telephone interview with the Respiratory Therapist on 2/29/24 at 11:21 AM, they stated that they would expect Licensed Practical Nurse #3 to remove the reusable inner cannula, clean the inner cannula, and remove the dirty gauze with clean gloves, remove dirty gloves, wash hands, and then put on sterile gloves. They stated that they do not teach the nurses to use sterile gloves throughout the entire procedure but to use clean technique and then sterile. They stated that clean gloves should be worn when removing the soiled gauze, cleaning the stoma, and while cleaning the inner cannula. They stated that sterile gloves should be worn when replacing the inner cannula and when applying the clean gauze around the stoma cite. During an interview on 3/1/24 at 12:26 PM, with the Director of Nursing and the Administrator present, the Director of Nursing stated that they were aware that Resident #51 had a history of respiratory infections. The Director of Nursing stated that training for trach care was completed by the respiratory therapist. The Administrator stated they would expect the Licensed Practical Nurse to review the policy and procedures prior to performing trach care. The Administrator and the Director of Nursing both stated that they did not know if the Licensed Practical Nurse #3 should have cleaned the stoma area and that they would have to review the policy and procedure for trach care. 10NYCRR 415.12(k)(4)

Based on interview, and record review conducted during a Complaint investigation (NY00308641) during the Standard survey completed on 3/1/24, the facility did not ensure sufficient nursing staff to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three (First floor, Second floor, Third floor) of three resident care units. Specifically, the facility did not ensure they met their minimum staffing numbers. In addition, minimum staffing numbers were not included in the facility assessment. Resident #s 36, 52, 85 and 114 were involved. The finding is: The policy and procedures titled Nursing Policy & Procedure Benefit Improvement and Protection Act (BIPA) revised 8/22/18 and Emergency Staffing Strategies revised 1/6/24 had no documentation regarding minimum nursing staffing numbers. 1a. Review of the Facility Assessment completed in January 2024 revealed that the assessment did not include minimum staffing numbers. During an interview on 2/29/24 at 8:57 AM, Scheduler #1 stated they were instructed by administration to have minimum staffing numbers scheduled as 10 Certified Nurse Aides for the 7:00 AM to 3:00 PM and the 3:00 PM to 11:00 PM shifts and 5 for the 11:00 PM to 7:00 AM shift. Scheduler #1 also stated that they did not work on weekends and that they completed the schedule and the nurse supervisors for each shift were responsible to make calls and fill needed shifts. Review of the facility's BIPA (Benefit Improvement and Protection Act) staffing provision sheets dated 2/17/24 7:00 AM to 3:00 PM shift to 2/26/224 7:00 AM to 3:00 PM shift documented the facility did not meet their minimum staffing number of Certified Nurse Aides on the following dates: -2/17/24 3:00 PM to 11:00 PM shift - 6 (down 4) -2/18/24 7:00 AM to 3:00 PM shift - 8.25 (down 1.75) -2/19/24 3:00 PM to 11:00 PM shift - 9 (down 1) -2/21/24 3:00 PM to 11:00 PM shift - 7.5 (down 2.5) -2/22/24 3:00 PM to 11:00 PM shift - 7.5 (down 2.5) -2/23/24 3:00 PM to 11:00 PM shift - 6.25 (down 3.75) -2/24/24 7:00 AM to 3:00 PM shift - 8 (down 2) -2/24/24 3:00 PM to 11:00 PM shift - 6.5 (down 3.5) -2/25/24 7:00 AM to 3:00 PM shift - 9 (down 1) -2/25/24 3:00 PM to 11:00 PM shift - 8 (down 2) -2/26/24 7:00 AM to 3:00 PM shift - 8 (down 2) The facility census for these dates was between 136 and 139 residents. 1b. Review of Resident Council Meeting Minutes revealed the following: 2/15/24 meeting notes documented that residents raised concerns about nursing staff and the facility was aware of the staffing challenges and were working to get more Unit Assistants hired to enter the Certified Nurse Aide program. Individual personal concerns would be addressed separately. During a Resident Council meeting held on 2/27/24 at 11:05 AM with 10 residents participating, residents stated that getting assistance by using the nurse call light can take 20 minutes to as long as 5 hours, that staffing was an issue, and that residents' beds were not made until the 11:00 PM to 7:00 AM shift arrived, at times. 1c. Interviews with Residents and Family Members: During an interview on 2/27/24 at 10:38 AM, Resident #85 stated they sometimes had to wait for an hour to an hour and a half for assistance and sometimes did not make it to the bathroom on time. During an interview on 2/26/24 at 11:45 AM, Resident #114 stated that the facility was so short staffed on evenings that sometimes they don't even offer them a shower and they had to clean themselves on the side of the bed. They also stated that weekends were horrible with not enough aides working or only working partial shifts. During an interview on 2/27/24 at 9:28 AM, Resident #36 stated there was not enough staff. Sometimes staff answered their call light instantly, other times not. During a family interview on 2/29/24 at 12:58 PM, Resident #52's spouse stated that the facility did not have enough staff. They stated that sometimes they wait a half hour when they ring the call bell. 1d. Interviews with Facility Staff During an interview on 2/28/24 at 3:29 PM, Certified Nurse Aide #3 stated that sometimes they worked the unit with only two aides and that on Saturday (2/24/24) they worked as the only Certified Nurse Aide from 3:00 PM to 7:00 PM. Certified Nurse Aide #3 stated they were not able to get resident's showers done and the last resident got to bed at 10:50 PM that evening. During a telephone interview on 2/29/24 at 1:18 PM, Certified Nurse Aide #2 stated they usually worked the 11:00 PM to 7:00 AM shift on the First-Floor unit and there were usually 2 Certified Nursing Aides scheduled, but at times there was only one. They stated weekend nights were the shifts with the lowest staffing. There could be only one Certified Nurse Aide and one nurse per floor. On those nights, the supervising nurse will be working the floor and take a medication cart at the same time. During an interview on 2/29/24 at 2:45 PM, Certified Nurse Aide #1 stated they worked the 11:00 PM to 7:00 AM shift on the Third-Floor unit and that most nights they were the only Certified Nursing Aide working on this unit. They also stated they stayed late to get their work finished. During an interview on 2/29/24 at 2:59 PM, Certified Nurse Aide #4 stated they always worked with two (total) aides on their unit on their weekend shifts and had 22 residents on their assignment. They usually couldn't get showers done and it was exhausting. During an interview on 2/29/24 at 1:20 PM, Licensed Practical Nurse #1 stated they worked on 2/18/24 during the day shift as a supervisor and worked on a cart passing medications from 7:00 AM to 11:00 AM on the first floor. Staffing included three Certified Nurse Aides plus one orientee and two nurses on the first floor, two Certified Nurse Aides and one nurse for the second floor, and two Certified Nurse Aides and one nurse for the third floor. Licensed Practical Nurse #1 stated the facility census was 136 and the facility usually tried to have three Certified Nurse Aides per unit at a minimum on day and evening shifts. Licensed Practical Nurse #1 stated they asked the Administrator to send out a mass text to get more staff in, but the Administrator didn't get any answers from that request. The Licensed Practical Nurse #1 stated nobody from administration was in the facility during that day shift. During an interview on 2/29/24 at 10:40 AM, Registered Nurse #1 stated they did shift assignments for the 3:00 PM to 11:00 PM shift, as they worked the 7:00 AM to 3:00 PM shift. The stated they received a schedule from the Scheduler #1 and that Scheduler #1, and the Administrator would make calls for call-offs during the day. Registered Nurse #1 stated the absolute staffing minimum for Certified Nurse Aides on the 7:00 AM to 3:00 PM and the 3:00 PM to 11:00 PM shifts would be 4 Certified Nursing Aides on Floor 1, and 2 each on Floor 2 and Floor 3. They also stated that on the 3:00 PM to 11:00 PM shift it would be most important to have the needed number of Certified Nursing Aides on after 7 PM, as they needed to get residents ready for bed. Nurses could assist with lifts; however, when there was only one nurse per floor, medications and treatments could be done, but it would be hard and depend on the nurse to be able to get the work done. Registered Nurse #1 stated there were 17 residents on the Third-Floor unit who needed the assistance of 2 staff for transfers and lifts: 14 residents on the Second-Floor unit, and 10 or 11 residents on the First Floor unit. When asked specifically about the 3:00 PM to 11:00 PM shift on 2/23/24, Registered Nurse #1 stated that they knew the shift was short-staffed for Certified Nurse Aides and that one Certified Nurse Aide scheduled for that shift had been approved to have that day off. During an interview on 2/29/24 at 3:10 PM Registered Nurse #2 stated that the number of Certified Nurse Aides for the 3:00 PM to 11:00 PM shift should be 5 for the First-Floor unit, and 3 each for the Second and Third floor units. Registered Nurse #2 stated the facility used to operate with 6 Certified Nurse Aides on the First-Floor unit, and 4 each on the Second and Third Floor units. Registered Nurse #2 stated they made the assignments for the 11 PM to 7 AM shifts and there should be at least 2 Certified Nurse Aides per unit during that shift. If the Certified Nurse Aides were available, the First-Floor unit could use three, due to workload, and the Second-Floor unit could use three, as there were residents who were awake and moving about the unit at night. Registered Nurse #2 stated it was most important to have the needed number of Certified Nursing Aides from 5:30 PM to 9 PM, as they were needed for mealtime and getting residents ready for bed. Registered Nurse #2 stated that when there were only three other nurses on the shift with them, the supervising nurse would take on a medication cart for at least half of the shift, and this would impede their ability to immediately respond to any incidents happening in the facility, take them from being able to make calls to fill shifts on the 11:00 PM to 7 AM shift, and answer calls that were coming in. Registered Nurse #2 stated that when Certified Nurse Aides struggled to get their work done, nurses would be required to assist with providing feeding assistance and transfers of residents, which would delay the nurse's ability to pass medications and provide ordered treatments. They stated that they were to contact the Administrator and DON #1 when shifts could not be filled, and that administration did not usually come in to assist. During an interview on 2/28/24 at 3:41 PM, Registered Nurse #3 stated the facility tried to have 2 nurses on each unit during the 7:00 AM to 3:00 PM and the 3:00 PM to 11:00 PM shifts and 1.5 nurses per unit on the 11:00 PM to 7:00 AM shifts, where they would split a nurse for two units. RN #3 stated that often the 3 PM to 11 PM supervisor will be working on a medications cart and supervise the building at the same time. During an interview on 2/29/24 at 4:03 PM, the Administrator stated they did not have minimum staffing numbers in the Facility Assessment, and they did not meet their minimum staffing for the above shifts (see section 1a). They stated that the minimum staffing for these shifts was not met because there either were call-offs or no-call no-shows and there were some staff who would be willing to pick up other shifts and a group of staff will not pick up extra shifts. The Administrator stated they were not aware that the Facility Assessment required actual minimum staffing numbers and thought a general statement that the facility would do their best to ensure staffing needs were met was enough. 10 NYCRR 415.3(b)(1)(ii)

Based on observation, interview, and record review during the Standard survey completed on 3/1/24, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Issues included undated and outdated food in refrigerators, potentially hazardous foods in refrigeration above 41 degrees Fahrenheit, a refrigerator missing a thermometer, and multiple soiled surfaces. This affected two (First Floor, Second Floor) of three resident use floors and the kitchen. The findings are: The undated policy and procedure titled Refrigerated Food Storage Labeling and Dating documented coolers will be maintained below 41 degrees Fahrenheit. All opened and prepared food items will be covered, labeled and dated so as to indicate a consume by or expiration date. Once the product is opened or prepared, keep it a maximum of four days (with today as day one). Exceptions to this are refrigerated staples/ condiments, which may include catsup, mustard, relish, pickles, salad dressing, jelly, syrup, dried or candied fruit, salsa, horseradish, minced garlic in water, or lemon juice. These items will have a storage date of 60 days. [NAME] the product with the date by which it must be consumed. If the food processor has marked the product with a use-by date, honor that date first. If you still have the product on the consume-by date, discard the food. Any product that is not dated must be discarded. The undated policy and procedure titled Storage documented two easily visible thermometers, interior and exterior, will be in place to record refrigerator temperature. Monitor and document refrigerator temperature a minimum of three times daily. Refrigerator air temperature should be approximately two degrees lower than desired internal temperature, desirable product temperature is 41 degrees Fahrenheit or lower. The policy and procedure titled Use and Storage of Food and Beverage Brought in for Residents, Food Procurement, revised 6/13/18, documented facility staff will be appointed to check resident refrigerators for proper temperatures, food containment and quality, and disposal of items per facility policy and food procurement regulations. A potential cause of foodborne illness is improper storage of PHF/ TCS (potentially hazardous foods and time/ temperature controlled for safety) foods. Refrigerators must be in good repair and keep foods at or below 41 degrees Fahrenheit. Routine audits will be conducted of the internal refrigerator gauges, and if temperatures are out of range, notify maintenance and follow facility policy for food disposal. 1a. Observation in the kitchen on 2/26/24 at 9:40 AM revealed the following food items were in the walk-in refrigerator: -An opened five-pound container of yogurt, with manufacturer's stamp best if used by 3/17/24 and hand-written label opened 2/10 -A bin that contained two cups of cooked cubed carrots in water dated 4-17-24 -A bowl that contained one cup of egg salad with illegible red writing on the plastic wrap covering -A bin that contained three cups of tuna fish dated 2/21 Continued observation in the kitchen at this time revealed a bin that contained ten pickle spears that was undated was located in the single door reach-in refrigerator. Continued observation in the kitchen at this time revealed the following food items were in the double door reach-in refrigerator: -One half of a ham and cheese sandwich wrapped in plastic wrap that was undated -Three and one half uncooked grilled cheese sandwiches wrapped in plastic wrap that were undated -A poured cup of orange juice labeled 240 -Two poured cups of orange and grape juice that were undated -An individual cup of prepared salad that was undated During an interview at the time of the observations, the Food Service Director stated the yogurt container could be kept in the refrigerator until the manufacturer's best if used by date, unless the package stated to discard after a certain number of days after opening. They also stated staff should not write on plastic wrap in red, because it smudges and is hard to read, but the date written in red on the egg salad was probably 2/19/24. The Food Service Director stated they kept products like egg salad and tuna fish for three days and discarded on the fourth day. The sandwiches were made last night or this morning, and should be dated. The 240 label on the orange juice indicated the amount of juice, not a date. Also at this time, the Dietician Assistant stated they were not sure why the carrots were labeled with an April date, but they should be discarded. 1b. Observation in the kitchen on 2/26/24 at 10:00 AM revealed the thermometer inside the double door reach-in refrigerator indicated the air temperature was 50 degrees Fahrenheit. This Surveyor's digital thermocouple thermometer was placed in the refrigerator and indicated the air temperature was 51.5 degrees Fahrenheit. On 2/26/24 at 10:10 AM, the temperature of milk inside the refrigeratorr was measured as 41 degrees Fahrenheit with the facility's analog stem thermometer and 45.1 degrees Fahrenheit with this Surveyor's digital thermocouple. At this time, the potentially hazardous foods in this refrigerator included milk, juice, Mighty Shakes (nutrient-fortified shakes with a manufacturer's stamp keep frozen), sandwiches, prepared omelets, and a prepared salad. During an interview at the time of the observation, the Food Service Director stated they have had trouble with this refrigerator maintaining temperatures, so they only kept food in the refrigerator for about a half hour at a time, during tray line service. They stated they wanted the air temperature inside the refrigerator to be below 41 degrees Fahrenheit. The Food Service Director also stated the items should be removed from this refrigerator now because tray line service was done and workers must be busy with other tasks and have not yet gotten a chance to remove the items. Additionally, on 2/29/24 at 8:15 AM, the Food Service Director stated the analog stem thermometer they used on 2/26/24 was not able to be calibrated and they chose to discontinue using it. 1c. Observation on the First Floor on 2/26/24 at 12:55 PM revealed the following items were in the Multipurpose Room refrigerator: -A 16-ounce glass jar that contained an unknown peach-colored substance, labeled with a resident name, room number, and opened 8/24/23, expire 8/28/23 -A peanut butter and jelly sandwich labeled with date in/ open 2/22, expiration 2/24 -A white box that contained a half-eaten pastry with no name or date -An opened grocery store brand container of sliced Swiss cheese with three slices left with no name or date opened -An opened 8-ounce bag of pepperoni with no manufacturer's date stamp and not labeled with the date opened, pepperoni had a slightly gray color -Two cups of poured milk that were undated -An opened 32-ounce container of coffee creamer labeled with a resident name and room number, with manufacturer's date stamp best by 25Dec2023 and not labeled with the date opened -An opened 12-ounce container of cream cheese with a manufacturer's date stamp 5/2/24 and keep refrigerated and use within ten days of opening, not labeled with the date opened -An opened 8-ounce container of cream cheese with a manufacturer's date stamp 4/11/24 and keep refrigerated and use within ten days of opening, not labeled with the date opened, and on the inside wall of the container was a one-half of an inch diameter black, moldy-looking substance Additional observation at this time revealed the Multipurpose Room refrigerator had a log called Daily Refrigerator & Freezer Temperature Log and the most recent entry was 6/9. At the time of the observation, the Food Service Director stated the Nursing department took care of this refrigerator, and Dietary staff did not maintain any refrigerators outside of the kitchen. They also stated it was the facility's policy to toss any food item that was not labeled or dated, and the unknown food in the glass jar, the pastry, the pepperoni, and the coffee creamer needed to be thrown out. The Food Service Director also stated none of the identified foods in the Multipurpose Room refrigerator came from the facility's kitchen, except the sandwich and the poured milks, which should have been dated. Continued observation at this time revealed a sign on the front of the refrigerator that said, Everything must have a label to identify ownership. Label must include date of placement/ opening and expiration date (four days including open/ placement date). All items that are not labeled or are past expiration date will be disposed of. During a second observation of the refrigerator in the Multipurpose Room on 2/28/24 at 9:25 AM, the thermometer inside of the refrigerator indicated the air temperature was 45 degrees Fahrenheit. This Surveyor's digital thermocouple thermometer was placed in the refrigerator and indicated the air temperature was 50.0 degrees Fahrenheit. At this time, according to the digital thermocouple, the temperature of the cream cheese in the 12-ounce container was 45.3 degrees Fahrenheit and the temperature of the cream cheese in the 8-ounce container was 46.9 degrees Fahrenheit. During an interview at the time of the second observation, the Food Service Director stated they did not know what date the cream cheese containers were opened and they did not know how long they had been above 40 degrees Fahrenheit, so they should be tossed. The Food Service Director also stated they reminded residents at Resident Council meetings that their personal foods needed to be labeled and a reminder sign was placed on the refrigerator and there were label stickers available at the refrigerator too. They stated the air temperature inside this refrigerator should be 35 to 40 degrees Fahrenheit. 1d. Observation on the Second Floor on 2/26/24 at 12:55 PM revealed the refrigerator in the Connections Room did not have a thermometer. The following potentially hazardous food items were in the Connections Room refrigerator: -One four-ounce Mighty Shake (nutrient-fortified shake) with a manufacturer's stamp keep frozen -One five-ounce Greek yogurt -One four-ounce plastic leftover container of cottage cheese, with no name or date -One opened 46-ounce container of orange juice with a manufacturer's stamp refrigerate after opening, but not labeled with the date opened During a second observation on 2/28/24 at 9:50 AM, the Connections Room refrigerator did not have a thermometer, and it contained the following potentially hazardous foods: -Two four-ounce Mighty Shakes -Two four-ounce yogurts - One opened 46-ounce container of orange juice with a manufacturer's stamp refrigerate after opening, but not labeled with the date opened -One re-usable lunch bag Continued observation revealed the front of the Connections Room refrigerator had a sign that stated, Resident Only Refrigerator. At the time of the second observation, Activities Assistant #1 stated the cottage cheese from 2/26/24 and the re-usable lunch bag belonged to staff members, and staff food should be stored in the staff refrigerator in the basement. Activities Assistant #1 also stated they were not sure who was in charge of maintaining this refrigerator and the food inside of it. Also, at the time of the second observation, this Surveyor's digital thermocouple thermometer was placed in the refrigerator and indicated the air temperature was 52.0 degrees Fahrenheit. At this time, according to the digital thermocouple, the temperature of the yogurt was 43.1 degrees Fahrenheit and the temperature of the orange juice was 47.2 degrees Fahrenheit. During an interview on 2/28/24 at 10:00 AM, Licensed Practical Nurse #2 stated Activities staff was mainly in the Connections Room and they would presume that Activities staff would check the refrigerator. Licensed Practical Nurse #2 also stated staff food should not be in the Connections refrigerator, but belonged in the staff Café area in the basement. They also stated they did not see a thermometer in the Connections refrigerator, and there should be one, and Maintenance staff needed to look at this refrigerator to check its temperature. 1e. Observation on 2/26/24 at 12:50 PM revealed the refrigerator in the First Floor Dining Room contained a full 32-ounce glass jar of a soup or stew that was labeled with a resident name, room number, and 5/26. During an interview on 2/27/24 at 9:18 AM, Resident #114 saw the glass jar and stated, Oh my God, is that still in there? Give that to me. At this time, the resident threw it in the garbage. Resident #114 stated that their spouse made the soup last year and it was never sealed like canning a fruit, it was just put in the jar and was definitely garbage. During an interview on 2/28/24 at 10:10 AM, the Activities Supervisor stated Dietary staff supplied the food for the Connections Room and Multipurpose Room refrigerators and Dietary staff checked and maintained them, as far as they knew. They stated checking and maintaining the refrigerators was not a duty of Activities staff. During an interview on 2/29/24 at 1:30 PM, the Education Facilitator/ Infection Control Preventionist stated they personally checked the refrigerators in the Multipurpose Room, the Connections Room, and all unit Dining Rooms on a daily basis, or at least a couple of times per week. They stated they checked for dates and temperatures, and ideal air temperature in a refrigerator was between 38 and 42 degrees Fahrenheit. The Education Facilitator/ Infection Control Preventionist stated if they saw a refrigerator air temperature above 42 degrees Fahrenheit, they would let Maintenance staff know. They stated they threw out food by the third or fourth day after opening, and they would let the resident know that their food was out of date, and if a food item had no name or date, they would throw it away. The Education Facilitator/ Infection Control Preventionist also stated residents could get sick if they ate foods that were outdated or out of temperature. Additionally, on 3/1/24 at 11:02 AM, the Education Facilitator/ Infection Control Preventionist stated they did not log the refrigerator air temperatures during their checks, and the refrigerator in the Connections Room should have had a thermometer. They also stated they usually checked foods for dates, and did not know the glass jar of soup or stew was in the First Floor Dining Room refrigerator, it must have been overlooked. During an interview on 2/29/24 at 12:45 PM, the Administrator stated the facility did not have a policy and procedure about monitoring refrigerators. The Administrator further stated Dietary staff maintained all refrigerators in the kitchen and in the resident dining rooms. They stated the refrigerator was added to the Multipurpose Room less than a year ago and the Connections Room had been closed during the COVID-19 pandemic but reopened about three months ago. The Administrator also stated no one had an assigned duty to check the Multipurpose Room's refrigerator, and they assumed it was done by Dietary staff, and the Infection Control Nurse, who performed audits which included refrigerators. 1f. Observation in the kitchen on 2/26/24 at 10:20 AM revealed the following environmental conditions: -Rear wall under the extinguishment hood was soiled with black debris at the base -Real wall under the extinguishment hood had brown streaks and splatters throughout -Floor under the metal shelf in the extinguishment hood had rust marks in a three foot long by three foot wide area and also a six inch diameter area of broken and missing floor tiles -Front and right side of convection oven had greasy streaks and dried food stains -Front and left side of stove/ oven had greasy streaks and dried food stains -Floors under most equipment, including reach-in refrigerators, stainless steel shelves on wheels, slicer table, toaster table, ice machine, juice rack, and coffee station, were discolored with brown debris -Solid layer of food debris on top of the automatic dishwashing machine, plus a drink lid, a pencil, a used paper towel, a used glove, and a piece of paper were on top of the automatic dishwashing machine -Two in-use wall fans in the dishwashing room had visible dust accumulation on their front and back cages During an interview at the time of the observations, the Food Service Director stated an employee was assigned to do extra cleaning tasks once every other week on the third shift to handle the cleaning tasks that were hard to do during the day when the equipment was in use. The Food Service Director also stated the kitchen floor was stripped and waxed about two months ago, but all furniture and equipment was not moved during the process. They also stated the Dietary staff swept the kitchen floor throughout the day and wet mopped the kitchen floor each night, but could not get under all of the equipment. The Food Service Director also stated some spots on the floor did not get thoroughly stripped and was waxed over, and could not be cleaned with regular wet mopping. They also stated they were not sure who cleaned the top of the dishwashing machine or how often, but it should be cleaned now, and the two fans also needed to be cleaned now. During an interview on 2/29/24 at 10:45 AM, the Housekeeping Supervisor stated they and the Director of Environmental Services stripped and waxed the kitchen floor overnight, but could not recall when. They stated they removed most kitchen equipment before stripping and waxing, with the exception of the refrigerators and ovens. The Housekeeping Supervisor stated they applied four coats of wax and it looked fine when they were done, but it did not hold up because the kitchen floor gets beat up with traffic. During an interview on 2/29/24 at 11:35 AM, the Director of Environmental Services stated they stripped and waxed the kitchen floor with the Housekeeping Supervisor in late October 2023 and it looked great when they were done. They also stated the rust under the extinguishment hood did not come up with the strip and wax. During an interview on 2/29/24 at 12:45 PM, the Administrator stated the facility did not have a policy and procedure about kitchen sanitization. 10 NYCRR 415.14(h) SubPart 14-1 - Food Service Establishments 14-1.40, 14-1.44, 14-1.110(d),14-1.170, 14-1.171

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review completed during the Standard survey conducted from 5/2/22 to 5/6/22 the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #270) of one resident reviewed for dialysis. Specifically, the pressure dressing was not removed from the AV fistula (arteriovenous - a tube or device surgically implanted to create an artificial connection between an artery and a vein) access site for greater than two hours as recommended by the dialysis center. The finding is: The facility policy and procedure (P&P) titled Hemodialysis dated 1/14/15 documented the hospital supplies a Nursing Home/Dialysis Communication sheet that is filled out and sent with the resident for every appointment. The hospital in turn completes their section and returns it after each visit. Upon return the nurse reviews the communication sheet and looks for any changes or new orders requested by the hospital. Upon return the nurse will check the site for any problems including bleeding or infection. Will determine that bruit and thrill are present in the shunt. The policy did not address care of the access site post dialysis related to the pressure dressings on shunt. 1. Resident #270 was admitted with diagnoses including end stage renal disease (ESRD), dependence on renal dialysis, and cerebral vascular accident (stroke, CVA) with left sided hemiplegia (paralysis on one side of body). The Minimum Data Set (MDS-a resident assessment tool) dated 2/7/22 documented Resident #270 had moderately impaired cognition. Review of the MDS dated [DATE] documented the resident was on dialysis. The Care Plan (CP) dated 4/25/22 documented under under Resident #270 had end stage renal disease and had dialysis at 5:30 AM Tuesday, Thursday, and Saturday. The Baseline CP (BCP) dated 4/25/22 documented the resident had a dialysis fistula in their left arm, and to monitor site post dialysis treatment (tx). The BCP interventions did not provide guidance for removal of the pressure dressing from the LUA AVF. The Physician's Orders dated 4/25/22 and signed by the physician did not provide guidance for left upper arm AV fistula (LUA AVF) site monitoring or dressing removal. Review of the electronic medical record (EMR) Physician's Orders dated 5/3/22 documented post dialysis weight three times weekly for dialysis. Review of the Medication and Treatment Records dated 4/2022 through 5/2022 lacked documented evidence of monitoring or pressure dressing removal from the LUA AVF. Review of Nursing Home/Dialysis Communication dated 4/30/22 documented the dialysis unit used the fistula for dialysis access. Treatment comments contained an asterisk (*) and documented to please remove dressings from LUA access 2 hours after returning to facility. Intermittent observations of Resident #270 5/3/22 through 5/6/22 between 8:37 AM to 3:49 PM identified the following: -5/4/22 at 8:37 AM Resident sitting in wheelchair (w/c) in room pressure dressings intact to LUA AVF. Resident stated they goes to dialysis on Tuesday, Thursday, and Saturday and asked, are you going to take them off now? -5/4/22 at 1:10 PM Resident in room watching TV. Pressure dressings intact to LUA AVF. -5/4/22 at 3:15 PM Watching TV. Pressure dressings intact to LUA AVF. The resident stated, no one has taken them off yet. -5/5/22 at 3:49 PM Resident in room listening to TV. States had dialysis this morning. Pressure dressings intact to LUA AVF. The resident asked, are you here to take them off? -5/6/22 at 7:47 AM Pressure dressings intact to LUA AVF. The resident stated they don't go to dialysis today (5/6). I still have my dressings on my arm, they will take them off tomorrow when I go to dialysis. Review of Interdisciplinary (ID) Notes dated 4/25/22 through 5/5/22 documented the following: -4/30/22 5:26 PM Resident returned from dialysis this morning. No new orders received from dialysis. Pressure dressing to LUA AVF is dry and intact. -5/2/22 at 7:56 PM Fistula site remains without signs or symptoms of infection. Dry dressing remains in place. -5/3/22 at 11:33 AM Picked up for dialysis at 5:00 AM. -5/3/22 at 12:12 PM Returned from dialysis at 11:20 AM. -5/3/22 at 12:56 PM Pressure dressing dry and intact to LUA with no drainage noted. -5/5/22 at 10:50 AM Returned from dialysis at 10:35 AM without incident. Fistula left arm, pressure dressing intact. No complaints. -5/5/22 2:06 PM Pressure dressing in place LUA due to dialysis. There was no documentation regarding bleeding or dressing removal. During a telephone interview on 5/5/22 at 12:53 PM, Registered Nurse (RN) Charge Nurse at the Dialysis Center stated the pressure dressings to Resident #270 LUA AVF were still on when the resident arrived for dialysis treatment today (5/5). The RN stated it happens often that when Resident #270 comes in the next day for treatment and the pressure dressings are still on the LUA AVF. The pressure dressing should be taken off about two to four hours after dialysis because they can cause damage to the fistula. The AVF site should be monitored for bleeding, signs of infection and there should be no blood pressures or blood draws in the left arm. During interview on 5/6/22 at 9:26 AM, Licensed Practical Nurse (LPN) #1 stated the AVF is monitored for infection, redness, thrill (a buzzing vibration felt by palpation) and bruit (whooshing sound of blood flow). LPN #1 stated the RN will assess the site when the resident returns from dialysis and the pressure dressing comes off two hours after they return from treatment. LPN #1 stated the RN was responsible for assessing the AVF and removing the dressing. During interview on 5/6/22 at 9:36 AM, RN #1 Nurse Manager stated when a resident returns from dialysis the AVF was to be monitored for bleeding, thrill and bruit. The bandage is left in place until we make sure it is not bleeding then it can be removed. RN #1 stated they would think any nurse could remove the pressure dressing but would have to double check policy. During interview on 5/6/22 at 11:30 AM, RN Supervisor #2 stated they reviewed the Nursing Home/Dialysis Communication dated 4/30/22 when resident #270 returned from dialysis. Normally, most places leave the pressure dressings on for a couple of hours then remove gently. Any nurse can do it. I would think everyone knows they are to be left on for a bit until you make sure the shunt is not bleeding. It should be a standing order and be on the Medication/Treatment Record, so the nurse knows it has to be removed. It should be reflected on the CP as well. During interview on 5/6/22 at 10:48 AM, the Director of Nursing (DON), in the presence of the facility Administrator, stated the expectation was that if a resident on dialysis had a shunt with a pressure dressing in place it should be removed as recommended by dialysis. Additionally, any nurse could remove the presure dressing. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard Survey completed on 4/26/19, the facility did not ensure that alleged violations involving abuse are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the officials (State Survey Agency) in accordance with State Law as required for two (Residents #108, 113) of two residents reviewed for alleged abuse. Specifically, the facility did not report an incident of resident to resident verbal abuse to the state survey agency as required. The finding is: Review of a facility policy and procedure entitled Resident Abuse Prohibition Protocol dated 7/8/18 revealed the purpose of this policy is to establish a mechanism for educating all responsible parties, and to create a procedure for reporting and investigating all allegations of resident neglect, mistreatment and abuse. Resident to Resident Abuse must be reported to the Department of Health if another resident is mentally or physically harmed by the aggressor. Verbal Abuse must be reported immediately if it puts the Resident in fear of harm. Abuse - According to CMS guidelines means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal abuse: yelling, threatening, belittling, making rude or sarcastic remarks (whether the resident actually hears or even is incapable of hearing). 1. Resident #108 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, dementia with behavioral disturbance and hypertension. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 3/27/19 revealed the resident is severely cognitively impaired, is understood and usually understands. Resident #113 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, major depressive disorder and weakness. The MDS dated [DATE] documented the resident is cognitively intact, understood and understands. Review of a Resident Incident Report (for Resident #108) dated 2/16/19 at 1:50 PM revealed the resident was accused of threatening her roommate Resident #113. Resident #108 did not deny the accusation. No physical contact was made. The physician and family were notified. Recommendations were made to change the resident's room. Statement taken from Resident #108 revealed I can recall no specific event from last night. But there is always something between us. Resident #113 is a nice lady and is always doing something nice for others, but we are different people. When specifically asked if she threatened her, Resident #108 stated, Probably, I say probably because we both have said things to one another. We were good friends, but not anymore. A Resident Incident Report (for Resident #113) dated 2/16/19 at 1:40 PM revealed Resident #113 claimed that Resident #108 threatened her on the evening of 2/15/19 with a reacher and no physical contact was made. The physician and family were notified. No injury and vital signs were taken. A statement obtained from Resident #113 revealed she walked into the room and was undressing near the glass cabinet and told Resident #108 she was going to shut off the lights to go to bed. Resident #108 from her wheelchair began shaking the reacher and yelling at Resident #113. Resident #113 got in bed without incident. Resident #113 stated, I'm afraid to stay here with her. Resident #108's comprehensive Care Plan (CCP) for behavior dated 3/4/14 documented she exhibits occasional episodes of agitation, can be verbally and physically aggressive towards staff. Diagnosis of bipolar. The section entitled Behavior/Nursing dated 3/18/19 revealed Resident #108 has behavior issues related to diagnoses of bipolar disorder manic with psychosis, depression and dementia. Can be verbally and physically aggressive towards staff and others. 2/16/19 - verbal disagreement with Resident #113. Resident #113's CCP dated 3/28/19 documented the resident has behavior issues related to a diagnosis of major depressive disorder/ recurrent episodic, anxiety, and dementia. 2/16/19 - verbal disagreement with Resident #108. Will be easily redirected from Resident #108 and room change made for Resident #108. Review of Interdisciplinary Notes for Resident #13 revealed the following: - 2/16/19 at 6:07 AM - Alert and oriented, explained to writer that roommate had taken her grabber and was shaking it in her face. Resident #113 is very weepy, complaining about roommate and back pain. Refuses to take shower this morning reporting that roommate kept her awake. - 2/16/10 at 2:26 PM - Resident (#113) refused all AM (morning) medications and treatments related to not moving roommate out of room. Resident was crying all morning saying roommate was being mean to her and wanted her roommate moved out of the room. Roommate refused staff to bring her out of room. Supervisor aware and issues are being looked into. - 2/16/19 at 2:50 PM - Statement obtained (from Resident #113) regarding threatening behavior from roommate. Roommate moved at this time for safety of both. Administrator aware of incident and recommended moving roommate out at this time. Son notified of incident. - 2/18/19 at 10:32 PM - Resident #113 discussed the altercation with her roommate over the weekend. She stated that her roommate came after her with her grabber. Resident #113 was upset saying, I've never been anything but nice to her and this is how she treats me. She stated that it scared her. Roommate was relocated and will not return to the room. Review of an untitled report of the investigation, completed by the Assistant Administrator, dated 2/18/19 revealed the following: - On 2/16/19, it was reported that a verbal altercation occurred between Resident #108 and Resident #113. - Per Resident #113's statement, on 2/15/19 at approximately 8:45 PM, Resident #108 shook her grabber at Resident #113 and yelled at her. Per interview with Nurse Supervisor, Resident #113 stated Resident #108 was threatening her and she was afraid to stay in the room with her. - Per Resident #108 interview with Nurse Supervisor, she states that she couldn't recall events of the evening prior but also didn't deny threatening Resident #113. - Per Resident #113, no physical contact was made. Upon report of the event, Resident #108 was moved to another room temporarily to avoid further conflict during the investigation. Additional review of the untitled investigation revealed the Assistant Administrator documented with further investigation of this incident it was agreed that the action of Resident #108 was not aggressive and there was no intent of harm. This event was reviewed with Director of Nursing and Administrator; hence this incident was not reported to NYSDOH (New York State Department of Health). Review of a Social Work Interdisciplinary Note dated 2/18/19 revealed Resident #108 was moved to another room on Saturday 2/16/19 after getting into an altercation with her roommate. Per the roommate's report, Resident #108 became angered and came at her with a grabber. Staff notes that verbal conflict between the roommates has been evident but neither wanted to move and they would eventually forgive each other. It was explained to son that current room was temporary and offered another long term semi-private room which would allow the resident to remain on the first floor. Son was told that the roommate in the semi-private room isn't as verbal and shouldn't distract or aggravate his mother. Review of a Physician Interdisciplinary Note for Resident #108 dated 3/6/19 revealed there was a room change due to an altercation with her roommate. There was no physical contact, but the other resident said she went after me with a reacher. There were no other witnesses to the event. During an interview on 4/25/19 at 1:51 PM, Resident #113 stated she entered the room and told her roommate (Resident #108) she was going to turn the lights off. Resident #108 began shaking her grabber at Resident #113 saying I am going to hit you, you son of xxxxx. Resident #113 stated she was so scared and screamed. Resident #113 stated she was really scared and when she sees this resident in the hallway she is still afraid of her. During an interview on 4/25/19 at 2:51 PM, the Assistant Administrator stated, I believe we did not report this incident to the NYSDOH because there was no physical contact and Resident #113 did not report the incident until the next morning. Resident #108 was moved to another room during the investigation. When asked why Resident #108 was not moved back to the room if the facility felt that there was no issue, no answer was given. When interviewed on 4/25/19 at 2:51 PM, the Administrator stated, They were roommates and squabbled often. Resident #108 was across the room when she shook the grabber at her, but I do not think she could have physically hit her with it. Staff called me on the day it was reported, and I did have them move Resident #108 to another room until we could do an investigation. 415.4(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 4/26/19, the facility did not ensure that a resident who is unable to carry out Activities of Daily Living (ADLs) receives the necessary services to maintain grooming, personal hygiene. Specifically, one resident (Resident #95) of three residents reviewed who are dependent on staff for ADL's had an issue with incomplete urinary incontinence care. The finding is: The policy and procedure (P&P) entitled Care of the Incontinent Resident, dated 10/14 documented it was the facilities policy to keep the resident with problems of involuntary elimination, clean and dry in order to promote cleanliness, comfort, dignity and to prevent skin issues. The P&P entitled Peri Care dated 1/16 documented for the female resident use soap and water. Separate the female external genitals and wash from front to back (away from the urinary meatus (the point where urine exits the urethra) with the washcloth. Using a different part of the wash cloth for each swipe, begin with a swipe down the middle and then one on each side of the external genitals. Then wash the groin using a different area of the washcloth. With a clean washcloth, rinse the area in the same manner and dry thoroughly. 1. Resident #95 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM), cognitive decline, and urinary tract infection (UTI). The Minimum Data Set (MDS, a resident assessment tool) dated 4/3/19 documented the resident had severe cognitive impairments, was usually understood and usually understands. The MDS also documented the resident required extensive assist of two people for personal hygiene and was always incontinent of bowel and bladder. The Comprehensive Care Plan (CCP) dated 4/22/19 documented the resident required total assist of two for toilet transfers and change in bed. The CCP further documented the potential for frequent UTI's, and occasional urinary incontinence. During an observation of morning care on 4/24/19 at 8:40 AM Certified Nurse Aide (CNA) #1 removed a soiled incontinent brief containing a moderate amount of yellow urine. CNA #1 washed the pubic bone (area of the body between the lower abdomen and genitalia) with a washcloth and then proceeded to wash the right and left groin. CNA #1 did not wash the external folds of female genitalia. During an interview on 4/24/19 at 9:43 AM CNA #1 stated the procedure for peri care included swiping down the right and left side of the (external folds of female genitalia) and then down the center after folding sections of the washcloth, so each swipe is done with a clean portion of the washcloth and would rinse the same way. CNA #1 stated he stays away from the lady parts and typically would ask a female co-worker to take over but did not. During an interview on 4/25/19 at 10:07 AM, Registered Nurse (RN) #1 Unit Manager stated she would expect the (external folds of female genitalia) to be separated and washed down the middle, then the sides of the (external folds of female genitalia) with a soapy washcloth and would expect the same procedure for rinsing. During an interview on 4/25/19 at 10:44 AM, RN #3 stated the expectation was to wash using a soapy wash cloth, make three swipes from front to back. First down each side and then the middle of the (external folds of female genitalia) using a different section for each swipe to prevent urinary tract infections. During an interview on 4/26/19 at 9:02 AM, the Director of Nursing (DON) stated peri care was expected to be done properly and efficiently to prevent urinary tract infections and eliminate odors. 415.12(a)(3)

Based on interview and record review during the Standard survey completed on 4/26/19, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified one (Employee #1) of six employees who were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their employment. The finding is: Record review on 4/23/19 of the personnel file for Employee #1 (Dietary Aide) revealed Employee #1 was hired on 10/2/18 and the New York State Nurse Aide Registry Verification Report was dated 4/23/19. Further review revealed Employee #1 worked in the facility a total of 515 hours between 10/2/18 and 2/13/19 before the New York State Nurse Aide Registry was checked on 4/23/19. Additional review of the personnel file revealed Employee #1 received a negative determination letter from the New York State Criminal History Record Check (CHRC) system dated 2/12/19, and also a letter dated 3/29/19 stating the negative determination had been reversed. During an interview on 4/23/19 at 1:55 PM, the Director of Human Resources stated she usually checks the New York State Nurse Aide Registry for new employees at the time she calls them to schedule a job interview. She additionally stated she could not locate the Nurse Aide Registry verification sheet for Employee #1, so she printed one today from the Registry website. Continued interview revealed Employee #1 last worked at this facility on 2/13/19, but remains a current employee. Review of the Dietary Aide job description, signed by Employee #1 on 10/2/18 revealed the following essential position functions: delivers food carts and prepared meals to resident dining rooms, ensures carts are returned to the kitchen, may be responsible for assisting in serving the meals to residents, collects and removes trash, and delivers nourishments to nursing units and/or resident rooms as required. Review of the facility's document called Hiring Policy and Procedure, dated 8/1/18, revealed all employees, agency staff, contracted staff, medical director, consultants, contractors, volunteers, nurse aide trainees, students, and any caregiver who provides care and services to residents on behalf of the facility, will be screened through the New York State Nurse Aide Registry. 415.4(b)(1)(ii)(a)(b)