**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews during the recertification and abbreviated surveys (Intake #2569939), the facility did not ensure sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the Daily Nurse Staffing Rosters reviewed from 08/10/2025 through 09/12/2025 documented on four (4) of 34 days, there was one (1) certified nurse aide documented for the A unit night shift (1:35 or 1:36 ratio ) and on one (1) of 34 nights, there was one (1) certified nurse aide assigned to B unit (1:36 ratio). On 29 of 34 days reviewed, assigned staff did not complete their assigned shift (came in late or left early). A nurse supervisor was not assigned on 4 of 34 dates reviewed for day shift, 15 of 34 dates for evening shift and 26 of 34 dates for the night shift. Additionally, during the 11:00PM to 7:00 AM shift on 09/11/2025, Resident #32 sustained a fall and there was only one staff member, a licensed practical nurse, working on the A unit. Resident #56 dislodged their urinary catheter and nursing staff did not address in a timely manner. Residents, family members, and staff expressed concerns about low staffing, long wait times in response to call bells, and delays in receiving care.The findings included:The Facility assessment dated [DATE] documented the maximum capacity as 77 residents and an average daily census range of 70-77 residents. The Staffing Plan documented one registered nurse/licensed practical nurse per unit, per shift; two certified nurse aides per unit, day and evening shift (1:19 ratio); and one certified nurse aide per unit, night shift (1:38 ratio). Unit Acuity levels provided by the Director of Nursing documented six (6) residents were scheduled to get up prior to 7:00 AM on the A unit and one (1) resident on the B Unit. Seven (7) residents were on wander guard list on the A unit and two (2) on the B unit. Two (2) residents on A unit required supervision checks. Twenty residents on the A unit required incontinence cares and 11 required assistance with toileting. Thirteen residents on the B unit required incontinence cares and 11 required assistance with toileting. Eleven residents on the A unit and 11 residents on the B unit required a mechanical lift for transfers requiring two staff members. Five (5) residents on the A unit and one (1) resident on the B unit required total care assistance.On 4 of 34 days reviewed from 08/10/25 through 09/12/2025, a nurse supervisor was not assigned on the day shift.On 15 on 34 days reviewed from 08/10/2025 through 09/12/2025, a nurse supervisor was not assigned on the evening shift.On 26 of 34 days reviewed from 08/10/2025 through 9/12/2025, a nurse supervisor was not assigned for the night shift.On 08/23/2025, 08/30/2025, and 09/10/2025 there was one certified nurse aide documented for A unit night shift on the Daily Staffing Report.There were staffing inconsistencies noted between review of the Daily Certified Nurse Aide Assignment Sheets and the Daily Staffing Reports reviewed. For example, the Daily Certified Nurse Aide Assignment Sheets documented one certified nurse aide on the A unit on 08/17/25 for the 11:00 PM to 7:00 AM shift which was inconsistent with the Daily Staffing Report staffing of two (2) certified nurse aides assigned to A unit. On the 09/11/2025 11:00 PM to 7:00 AM shift, the Daily Staffing Report documented one (1) certified nurse aide was assigned to the A unit. The Certified Nurse Aide Schedule Form documented the name of an aide who called out. During interviews with staff, there was no aide assigned to Unit A unit until after Resident #32 sustained a fall at 2:00 AM.During a Resident Council meeting on 09/10/2025 at 11:06 AM, Resident #15's representative stated staff were not responsive to call bells. They stated Resident #15 was not taken out of bed at times due to low staffing and frequently had to return to bed early because there would not be enough staff to get them back into bed. Resident #67 stated turning and repositioning was not completed according to facility policy because of low staffing. All residents in attendance stated that the overnight shift was the worst for low staffing. During an observation on 09/10/2025 at 11:34 AM, a strong smell of urine was present in Resident #12's room.During interviews on 09/11/2025 at 4:20 PM and 09/12/2025 at 11:36 AM, the Director of Human Resources/Staffing Coordinator stated the night shift frequently did not have a supervisor in the building. They stated they had been instructed by Administrator to staff up to four (4) certified nurse aides on Unit A and Unit B for the day and evening shift and a minimum of two (2) certified nurse aides on Unit A and Unit B for the night shift and this was accomplished most of the time. They stated they had not been instructed to add more certified nurse aides during any shift based on acuity needs/changes and had been instructed to reduce staffing of certified nurse aides if the facility census dropped. They stated recruitment of nursing staff was on-going and licensed practical nurse recruitment was particularly difficult with main deterrent being salary. During interviews on 09/09/2025 at 9:03 AM and 09/12/2025 at 2:28 PM, the Administrator stated the Facility Assessment Staffing Plan was lowered after last survey in November 2024. They stated the staffing numbers listed on the Facility Assessment were based on the minimum number of staff needed to ensure safety of residents. They stated the facility expectation was that the unit registered nurse or licensed practical nurse staff assisted certified nurse aides with resident cares as needed, and that unit staff assisted the other unit staff as needed. The Administrator stated the night shift was the most difficult to staff due to frequent callouts and not being able to cover at last minute. They stated they provided the Staffing Coordinator with the number of staff for each shift and the goal was four (4) certified nurse aides each unit day shift, three (3) to four (4) certified nurse aides evening shift and two (2) certified nurse aides for night shift per unit. The Administrator stated the facility needed an additional registered nurse supervisor and a licensed practical nurse night shift supervisor and recruitment had been ongoing for the position. They stated that nursing staff were required to work complete shifts and there were times when adjustments had been made allowing staff to come in late/leave early due to covering callouts. The Administrator stated they were aware of one (1) star rating and believed it had recently improved, and that staffing was a work in progress with recruitment always ongoing. During interviews on 09/12/2025 at 9:05 AM and 09/13/2025 at 12:32 PM, Registered Nurse Unit Manager #21 stated Resident #32 sustained a fall about 2:00 AM on 09/12/2025. They stated staffing on Unit A was only one licensed practical nurse at the time of fall due to a callout which was not replaced and there was no night supervisor scheduled for the night shift. Registered Nurse Unit Manager #21 stated they were contacted at the time of fall by the licensed practical nurse and a telehealth assessment was completed. After the fall, Unit A received a certified nurse aide from the B unit. They stated Unit A frequently had only one (1) certified nurse aide assigned to night shift resulting in cares not always being completed. They stated staffing was reduced by administration due to budget concerns. They stated the Certified Nurse Aide Schedule Form for the night shift on 09/11/2025 contained the name of the certified nurse aide who called out and a replacement aide was not assigned to unit.During an interview on 09/12/2025 at 9:38 AM, Licensed Practical Nurse #19 stated staffing was low most of the time with both nursing and in particular, certified nurse aide staff during evenings and nights. They stated when there was only one certified nurse aide on each unit during the night shift, resident cares were not completed. When the day shift arrived, when only one certified nurse aide worked night shift, residents were soaking wet and complained that call bells were not answered during night. Residents requiring two (2) person assistance for cares were particularly affected. They stated that the licensed practical nurse/registered nurse on unit assisted with cares, but with only one nurse passing medications and providing treatments, it was not always feasible to assist certified nurse aides. They stated another staffing concern was that staff reported to shifts up to two hours late or left early. They stated this affected resident cares, medication administration and blood glucose testing/finger sticks which ended up being completed late. They stated when they present for 7:00 AM shift, they had often been forced to care for 40 residents due to another nurse being late.On 09/12/2025 at 11:56 AM, Resident #4 was interviewed and stated they were passing by Resident #56's room at approximately 5AM on the night shift in the end of May 2025 and observed Resident #56 trying to get out of their bed unassisted. Resident #4 stated they knew Resident #56 was confused and had fallen previously so they (Resident #4) attempted to find a staff member to attend to Resident #56. Resident #4 stated they were unable to find any staff member on the entire unit to assist Resident #56. Resident #4 decided to stay with Resident #56 until a staff member appeared, so the resident was safe. Resident #4 stated they noticed Resident #56's foley catheter had become dislodged. Resident #4 saw Licensed Practical Nurse #6 pass by in the hall giving out medication. Resident #4 stated they informed Licensed Practical Nurse #6 of Resident #56's condition and was told by the nurse that they were not allowed to go into Resident #56's room. Licensed Practical Nurse #6 did not get another nurse to address Resident #56. Resident #4 stated they stayed with Resident #56 for 2 hours until the morning shift nurse arrived at 7 AM and addressed Resident #56's fall risk and reinserted the foley catheter. During an interview on 09/12/2025 at 4:47 PM, Licensed Practical Nurse #6 stated they were scheduled to work a double shift, covering the evening and night shifts. Licensed Practical Nurse #6 stated they expressed frustration to the Administrator and the Director of Nursing regarding discrepancies between the posted nursing staff schedule and the actual hours worked by nursing staff. For example, a certified nurse aide on the night shift had an agreement with administration that they were able to leave at 5:00 AM, the most hectic time of the shift, on many nights. Licensed Practical Nurse #6 stated the Director of Nursing and Human Resources Director knew this aide would leave early, but did not communicate this to the nursing staff, creating confusion and more work for the rest of the staff. Licensed Practical Nurse #6 stated a nurse supervisor was not scheduled to be present in the facility most nights and aides walked out without informing the nurses. In addition, the nurse supervisors had the access key to the kitchen and stock room and if they were not present in the building, staff were unable to access these rooms. They stated earlier this morning, at approximately 2:00 AM, the licensed practical nurse from Unit A requested their assistance because a resident fell. After visiting the A Unit, they realized Unit A did not have a Certified Nurse Aide working on the 11:00 PM to 7: 00 AM shift. The Unit A license practical nurse asked Licensed Practical Nurse #6 to reassign one of their aides to the A Unit. Licensed Practical Nurse #6 stated this left the B Unit with only one Certified Nurse Aide for approximately 34 residents for the rest of the night shift. When asked about the incident in May 2025 with Resident #56, they stated they were not allowed to provide care for Resident #56 and had to get a nurse from the other unit to administer the resident's medications. No one was available to coordinate staff coverage or completion of assignments at night. Licensed Practical Nurse #6 stated there was one aide on the night Resident #56's catheter was dislodged and the aide left early. They were addressing call bells and trying to pass medications to residents timely.During an interview on 09/13/2025 at 6:48 AM, Certified Nurse Aide #11 stated scheduling one certified nurse aide per resident unit on the night shift was unmanageable. They stated workload was heavy due to callouts and staff not working their entire shift, either leaving early or coming in late. They stated when staff left early or came in late, it was not communicated to other staff members and workload became increased at busiest times. Certified Nurse Aide #11 stated unreliable nursing staff were routinely scheduled without a plan to prevent the unit from working short-staffed. Certified Nurse Aide #11 stated prior to the interview, they had four call bells ringing on three separate wings of Unit B and they had to rush to address resident needs because there were residents at risk for falls who tried to get out of bed, residents who requested ice and water in the morning, and some residents who wanted to start getting dressed or out of bed. Certified Nurse Aide #11 stated caring for all 34 residents on Unit B while the Licensed Practical Nurse passed medication was too much for them to handle and they were overwhelmed. Certified Nurse Aide #11 stated Unit A consisted of long-term residents with higher acuities who required more staff assistance and supervision. They stated it was impossible to manage Unit A with one certified nurse aide on the night shift. Certified Nurse Aide #11 stated they worked the 11PM to 7AM shift last night and started out on Unit B with one other aide. Certified Nurse Aide #11 stated their assignment was manageable until a resident fell at approximately 2:00 AM on Unit A. Licensed Practical Nurse #6 went to Unit A to help the other licensed nurse and became aware that no certified nurse aide showed up to work that night on Unit A and the licensed nurse was on the unit alone. Certified Nurse Aide #11 stated they were reassigned to Unit A for the rest of their shift and the resident needs were too much for them to address. Certified Nurse Aide #11 stated they were often unable to end their shift on time, including today, due to their relief not showing up on time for their shift. Certified Nurse Aide #11 stated they did not get paid for the time they had to stay past the end of their shift and were unable to take a break most nights because of the workload. During an interview on 09/13/2025 at 11:08 AM Certified Nurse Aide #14 stated they worked a variety of different shifts including working mostly double shifts and frequently seven (7) days a week. They stated callouts were not replaced had a big impact on resident cares not being completed. They stated when the units are short-staffed, they frequently must skip breaks. They stated the A unit has more early morning get ups and sometimes not all of them are completed and are left to the day shift to complete. Certified Nurse Aide #14 stated that many staff do not work their entire shift (leave early, come in late) causing workload to be divided between the remaining staff present. During an interview on 09/13/2025 at 11:28 AM, Certified Nurse Aide #20 stated the facility was always short staffed and callouts occurred daily each shift. They stated units mostly had three (3) certified nurse aides for day shift and evening and nights could have two (2) certified nurse aides. Due to low staffing, the units were extremely busy, and cares were always rushed. They stated they were frequently not able to take breaks properly because of the workload. Certified Nurse Aide #20 stated they work double shifts at least five (5) times a week and worked seven (7) days a week most of the time. They stated there were usually two nurses per unit each shift and a supervisor only sometimes during night shift. They stated that on night shift when only one certified nurse aide assigned to a unit, the residents complained that they were not changed but it was impossible for one (1) aide to provide cares for about 40 residents, especially on the A unit where residents required more incontinence cares and had dementia. During an interview on 09/13/2025 at 2:18 PM, the Director of Nursing stated staffing had room for improvement, was a work in progress, and recruitment was on going. The Director of Nursing stated daily callouts were the biggest concern /hindrance to meeting desired staffing ratios and sometimes extra staff were added to the shifts to cover potential callouts. They stated they believed residents were receiving quality care when there was only (one) 1 licensed practical nurse and one (1) aide on a unit during night shift. They stated it might not be ideal, but cares were completed, and safety was maintained. They stated they were aware that there was not always a nurse supervisor in the building during evening and night shifts and recruitment for an additional Registered Nurse Supervisor was ongoing. The Director of Nursing stated they were aware of Resident Council concerns regarding low staffing and staff had been disciplined and re-educated regarding call bell response and activities of daily living preferences as a result. The Director of Nursing stated that on the 09/11/2025, 11:00 PM to 7:00 AM shift, when Resident #32 sustained a fall, Certified Nurse #11 was assigned to Unit A along with one licensed practical nurse for the shift. 10NYCRR 415.13(a)(1)(i-iii)

2) The facility Clinical Competency Assessment Skill: Transfers revised 7/24 documented Position wheelchair or chair at the bedside, lock brakes if transferring to a wheelchair. Resident #23 was admitted to the facility with diagnoses including heart failure, obstructive uropathy, diabetes mellitus. The admission Minimum Data Set (resident assessment tool) dated 10/30/24 documented Resident #23 was cognitively intact, received substantial assistance for sit to stand, chair to bed transfer, and toilet transfer. During interview on 11/18/24 at 1:47 PM Resident #23 stated the left brake on their wheelchair has been broken for the past three weeks. During observation on 11/18/24 at 1:54 PM Certified Nurse Assistant #2 and Certified Nurse Assistant #7 transferred Resident # 23 from bed to the wheelchair. Certified Nurse Assistant #2 did not lock the wheelchair's left brake. During an interview on 11/18/24 at 1:56 PM Certified Nurse Assistant #2/Certified Nurse Assistant #7 stated the left brake on Resident #23's wheelchair had been broken for at least a week. They stated that despite the broken brake they transferred Resident #23 from bed to the wheelchair. They stated Maintenance and Rehabilitation were notified about a week ago. During an interview on 11/18/24 at 02:13 PM the Occupational Therapist stated they had worked with Resident #23 for transfers. They stated they were aware of the broken wheelchair brake and had notified the Therapy Director. During an interview on 11/18/24 at 02:16 PM the Therapy Director stated they were not aware that the brake on Resident #23's wheelchair was broken. During an interview on 11/19/24 at 10:34 AM the Director of Maintenance stated they were notified about the broken brake on the resident's wheelchair yesterday. 10 NYCRR 415.5 (h)(2) Based on observation and interview conducted during a recertification survey (11/14/24-11/22/24), the facility did not ensure a safe, clean, comfortable, and homelike environment was provided on 3 of 4 units (West, East and North). Specifically, North Unit had noticeable dirt and food throughout the hallway, a resident over bed table was dirty with food stains and caked on food in room [NAME] 7, and Resident #5 had no privacy curtain dividing the toilet area from the resident's room, allowing anyone entering the room to see the resident on the toilet and 2) Resident #23 was transferred into a wheelchair with a broken left wheel brake. The findings are: During observation on the North Unit on 11/14/24 at 11:16 AM, the floor area in the hallway near double doors had dirt, dust, and food crumbs and dirt was on the floor outside room B-15-N. During an interview on 11/15/24 at 12:03 PM Resident #5 stated they were able to use the toilet but, would like a curtain because it was embarrassing because anyone could see them while they are on the toilet. During observation on 11/15/24 at 12:07 PM, 11/18/24 at 9:38 AM and 11/19/24 at 12:29 PM there was no privacy curtain that could be pulled closed while the resident was on the toilet in Resident #5's room. During observation on 11/15/24 at 12:12 PM, 11/18/24 at 9:39 AM and 11/19/24 12:37 PM, the over bed table in room [NAME] 7 had dried coffee stains and caked food on the top/sides of the table. During an interview on 11/19/24 at 12:26 PM Certified Nurse Aide #16 stated it has been awhile since there was a privacy curtain in the room. They stated they did not know why it was not there. During an interview on 11/19/24 at 12:29 PM Certified Nurse Aide #16 stated they often wipe down the over bed table, but the table looks dirty. They stated housekeeping comes around and should do a better job. During an interview on 11/19/24 1:04 PM Registered Nurse #1 stated housekeeping was supposed to come around and clean inside the rooms including the over the bed table after meals. They stated anyone could clean the over bed table/s. Registered Nurse #1 stated residents need their privacy when using the bathroom and they had not noticed the curtain was missing. They stated the Director of Maintenance should be doing rounds and checking on this. During an interview on 11/19/24 at 1:33 PM the Director of Maintenance stated they were not aware of the missing privacy curtain but, should have noticed that during rounds. During observation on 11/20/24 at 10:33 AM there was dirt, dust balls and food crumbs along hallway walls. During observation on 11/20/24 at 10:54 AM there was dust, dirt, food particles,rubber bands behind the closed doors. During an interview on 11/20/24 at 10:56 AM the Director of Housekeeping (Corporate) stated they use a machine but it's not cleaning the floors good enough.

Based on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY00336704) from 11/14/24-11/22/24, the facility did not ensure for 1 of 3 residents reviewed for Abuse (Residents #176) that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation is made, to the State Agency. Specifically, 1) Resident #176's family reported Resident #176 was found with bruises on their forehead when transferred to the hospital for altered mental status. A 2/19/24 Investigation/Accident Report statement written by Licensed Practical Nurse documented on 2/17/24 they overheard Resident #174 yelling and screaming at their family ouch you're hurting me and they beat me up last night, and the facility did not report the allegations to the State Agency. The findings are: The Policy titled Abuse last reviewed on 6/1/24 documented the facility is to notify the local law enforcement and appropriate State Agency(s) immediately (no later than 2 hours after) by the agency's designated process after identification of alleged/suspected incident. Resident #176 was admitted with diagnosis including but not limited to anxiety, cerebral infarction, right hemiplegia, and unspecified psychosis. The 2/1/24 admission Minimum Data Set Assessment documented Resident #176 had severely impaired cognition. The Accident and Incident Reports documented Resident #176's last fall was 2/5/24, and there were no injuries noted. The 2/18/24 Employee Statement Form written by Certified Nurse Aide #11 documented Resident #176 stated they are being beat up by everyone all day. The 2/19/24 Accident and Incident Report documented Alleged Physical Abuse was reported by Resident #176's family. Bruises were noted to the left and right side of the forehead upon return from the hospital. The allegation was made by the residents sister while the resident was at the hospital and the facility immediately began an investigation. The 2/19/24 Accident and Incident Investigative Report Statement by Licensed Practical Nurse #9 documented on Sunday 2/17/24, while they were working at their medication cart, Resident #176 was yelling and screaming at their family, and yelled ouch you're hurting me. The resident then yelled they beat me up last night. The 2/19/24 Investigation Form findings documented bruising noted has been identified from previous falls. The 2/20/24 Abuse Care Plan documented Resident #176 is at risk for misappropriation, neglect, abuse and/or exploitation related to cognitive status/cognitive impairment after a cerebrovascular accident and is dependence on others for care. Interventions included monitor the resident for signs/symptoms of abuse, neglect, misappropriation, and/or exploitation and report to the facility's abuse officer and medical provider. The 2/20/24 Notice of Discipline form documented Certified Nurse Aide #11 received verbal warning for not alerting administration of alleged abuse. The 2/20/24 Notice of Discipline form documented Licensed Practical Nurse #9 received a verbal warning for not alerting administration of alleged abuse right away. During an interview on 11/20/24 at 3:13 PM, Registered Nurse Unit Manager #1 stated they initiated an investigation for alleged abuse because Resident #176 came back from the hospital with bruises on their forehead and they were not consistent with previous falls. Registered Nurse Unit Manager #1 stated they gave Notice of Discipline to Licensed Practical Nurse #11 and Certified Nurse Aide #9 because they did not report statements of alleged abuse. The Director of Nursing stated they were instructed by the Regional Director of Nursing to initiate an investigation and the Administrator would report the abuse allegation to the State Agency. During an interview on 11/21/24 at 1:56 PM, the Medical Director stated they saw Resident #176 on 2/20/24 for a brief visit upon their readmission from the hospital. They stated they were not aware of the alleged abuse incident. The Medical Director stated if there is alleged abuse, they expect staff to notify them immediately. During an interview on 11/21/24 at 5:41 PM, Resident #176's Health Care Proxy stated on numerous occasions, they reported to the facility that Resident #176 verbalized to them that staff were beating them up, and that they had meetings with Registered Nurse Unit Manager #1 and the Administrator to address their concerns and nothing was done. During an interview on 11/22/24 at 10:27 AM, Licensed Practical Nurse #11 stated they received a verbal counseling for not reporting to the facility that while Resident #176 was being visited by family, they heard Resident #176 yelling and screaming that someone was hurting them. They stated they did not tend to the resident because the resident was always fighting with the boyfriend, and they did not think much of it. Licensed Practical Nurse #11 stated the reason they did not get written up is because the union representative informed the facility they could not write them up if they did not report the alleged abuse to the State Agency. Licensed Practical Nurse #11 stated on a few occasions, they would hear Resident #176's boyfriend being verbally abusive to them. They stated Resident #176 made statements they were raped by two men and were being abused, and the facility was aware, but they did not remember if an investigation was done. During an interview on 11/22/24 at 1:42 PM, the Administrator stated the initial accusation of alleged abuse was from Resident #176's family and they explained to the family that the bruises were from falls and confirmed that Resident #176's last fall with no injury was on 2/5/24. The Administrator stated the Accident and Incident form should not have been titled Alleged Abuse, but they wanted to appease the family due to their constant abuse allegations, and that they were afraid the family would report the incident to the Department of Health. The Administrator stated the investigation was a precautionary measure because the family was not educated on the resident falling and obtaining bruises from falls and wanted to make them happy. The Administrator stated their understanding is that if the facility had an alleged abuse, they have 2 days to report to the State Agency and if the facility rules out abuse and neglect they did not have to report it. The Administrator stated despite having two statements from Licensed Practical Nurse #11 and Certified Nurse Aide #9 documenting they witnessed Resident #176 stating they were being abused they ruled out abuse and neglect because they obtained statements from staff, interviewed residents and no one ever witnessed or saw anything. During an interview on 11/22/24 at 2:39 PM, the Director of Nursing stated staff should not delay reporting alleged abuse to them. The Director of Nursing stated all reports of alleged abuse must be reported to the State Agency despite the facility's investigation. They stated they can report abuse but in a nursing home, the Administrator normally reports. 10 NYCRR 415.4(b)

Based on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY00336704) from 11/14/24-11/22/24, the facility did not ensure for 1 (Resident #176)) of 3 resident reviewed for Abuse that all alleged violations involving abuse, mistreatment, or neglect, were thoroughly investigated. Specifically, there was no documented evidence the facility conducted a complete thorough investigation after Resident #176's family member reported Resident #176 had multiple bruises on their forehead when they were transferred to the hospital on 2/19/24. The findings are: The facility policy titled Abuse last reviewed on 6/1/24 documented that Allegations / reports of suspected abuse, neglect, mistreatment, distortion, injury of unknown etiology or misappropriation shall be promptly and thoroughly investigated by facility management. Resident #176 was admitted with diagnosis including but not limited to anxiety, cerebral infarction, right hemiplegia, and unspecified psychosis. The 2/1/24 admission Minimum Data Set documented Resident #176 had severely impaired cognition. The 2/18/24 Employee Statement Form written by Certified Nurse Aide #11 documented Resident #176 stated they are being beat up by everyone all day. The 2/19/24 Investigation Form documented staff statements demonstrated no abuse took place and that the bruising was documented due to falls in the facility. The 2/19/24 Accident and Incident Report documented that Alleged Physical Abuse was reported by Resident #176's family. Bruises were noted to the left and right sides of their forehead. The allegation was made by the sister while the resident was out of the facility at the hospital and the facility immediately began an investigation. The 2/19/24 Accident and Incident Report Investigative Statement by Licensed Practical Nurse #9 documented on Sunday 2/17/24, while they were working at their medication cart, Resident #176 was yelling and screaming at their family, and they yelled ouch you're hurting me. The resident then yelled they beat me up last night. The 2/19/24 Investigation Form documented bruising noted have been identified from previous falls. The 2/20/24 Abuse Care Plan documented Resident #176 is at risk for misappropriation, neglect, abuse and/or exploitation related to cognitive status/cognitive impairment after a cerebrovascular accident and is dependence on others for care. Interventions included monitor the resident for signs/symptoms of abuse, neglect, misappropriation, and/or exploitation and report to the facility's abuse officer and medical provider. During an interview on 11/20/24 at 03:13 PM, Registered Nurse Unit Manager #1 stated Resident #176 came back from the hospital with bruises on their forehead that were not consistent with falls they had. They stated the investigation was not done thoroughly because there were reports from staff that the resident's family and the resident were verbally abusive to one another. Registered Nurse Unit Manager #1 stated based on the Licensed Practical Nurse #11 and Certified Nurse Aide #9, abuse and/or neglect should not have been ruled out. During an interview on 11/21/24 at 01:56 PM, the Medical Director stated they were never made aware of an abuse allegation. They stated an investigation would not be complete until they are notified that they need to assess the resident. During an interview on 11/21/24 at 05:41 PM, the Complainant stated that on numerous occasions, they reported to the facility that Resident #176 verbalized to them that staff were beating them up, and that they had meetings with Registered Nurse Unit Manager #1 and the Administrator to address their concerns and nothing was done. The Complainant stated that Resident #176 had bruises in places not consistent with the falls and that when they would visit and they saw a new bruise, they would ask if the resident fell, and they would get told no. During an interview on 11/22/24 at 10:27 AM, Licensed Practical Nurse #11 stated a few days prior to the facility investigating alleged abuse, they heard Resident #176 yelling and screaming that someone was hurting them, and that they did not go tend to the resident because the resident was always fighting with the boyfriend, and they did not think much of it. Licensed Practical Nurse #11 stated on a few occasions, they would hear Resident #176's boyfriend being verbally abusive to them. They stated the resident made statements that they were raped by two men and were being abused and the facility was aware but they did not remember if an investigation was done. During an interview on 11/22/24 at 01:42 PM, the Administrator stated the previous Director of Nursing did the investigation for alleged abuse and documented the bruises were from prior falls and confirmed that Resident #176's last fall was on 2/5/24 in which they had no injuries noted. The Administrator stated they ruled out abuse and neglect because they received statements from staff, interviewed residents and no one ever witnessed or saw anything. When asked why they did not take Licensed Practical Nurse #11 and Certified Nurse Aide #9 statements into consideration, the Administrator had no response. During an interview on 11/22/24 at 02:39 PM, the Director of Nursing stated if a resident's family reports they observed bruises on a resident's skin, they would look at prior Accident and Incident Reports and see if the bruises are consistent with falls. The Director of Nursing stated based on the investigation, it was not done thoroughly and the statements from Certified Nurse Aide #9 and Licensed Practical Nurse #11 should have been taken seriously, especially since they wrote statements that they heard Resident #176 yelling someone was hitting them prior to the family reporting the bruises. 10 NYCRR 415.4(b)(3)

Based on record review and interview conducted during the recertification survey from 11/14/24 to 11/22/24, the facility did not ensure that the resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood and that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 resident (Resident #63) reviewed for hospitalization. The findings are: Resident #63's diagnoses included Acute Kidney Failure, Neuromuscular Dysfunction of Bladder and Encephalopathy. The 5/7/24 Situation Background, Assessment and Recommendation documented send to the hospital for further evaluation Blood in stool, Gastrointestinal bleed. Family notified. The 5/7/24 Nursing Progress note documented called family representative to notify them the resident was being transferred to the hospital for possible Gastrointestinal Bleed. The 5/8/24 Nursing Progress Note documented Resident #63 was sent to the emergency room for evaluation due to an abnormal hemoglobin 6.9 or hematocrit 20.5 (low). The 5./8/24 Transfer Report documented the reason for transfer and that the family representative was notified by telephone of transfer. During an interview on 11/19/24 at 12:46 PM with Resident #63's family representative, they stated they were informed by telephone of the plan to send Resident #63 to the hospital in May 2024 and were in agreement with the plan. They stated they did not receive notification of transfer in writing. During an interview on 11/20/24 at 4:36 PM the Director of Nursing stated they were not able to locate/provide a copy of written transfer notification. They stated when a resident is transferred to the hospital, the nurse who is in charge of transfer is responsible for filling out the form. They stated the form is a triplicate and one copy goes to hospital with resident, one goes to medical record paper at the facility, and one is sent to the resident contact/family. They stated the Ombudsman is notified monthly via email or sometimes at the time of transfer. They stated the Social Worker would be responsible for notifying the Ombudsman and resident family. They stated the facility Social Worker terminated employment on September 25, 2024, and has not yet been replaced. They stated they were unable to locate Ombudsman notification from May 2024 for Resident #63. 10 NYCRR 415.3(h)(1)(iii) (a-c)

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure the comprehensive care plan was revised for 1 of 5 resident ( Resident #53) reviewed for Accidents. Specifically, for Resident #53, who sustained falls on 8/20/24, 9/27/24 and 10/9/24 there was no documented evidence that care plan interventions were reviewed and/or revised to address the falls. Findings include: The Policy and Procedure titled Falls Management and Prevention last revised on 1/2023 documented if the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will reevaluate the continued relevance of current interventions. Resident #53 was admitted with diagnoses including but not limited to encounter for hip fracture, muscle weakness, benign prostatic hyperplasia. The 5/23/24 Care Plan titled Risk for Falls/Actual Falls documented anticipate and meet the resident needs/occupational and Physical Therapies to evaluate and treat as ordered. The 5/28/24 Quarterly Minimum Data Set (assessment tool) documented Resident #53 was cognitively intact, cognition was intact frequently incontinent of bowel and bladder, required partial assistance with sit to stand, chair to bed, and toilet transfers, and was independent with wheeling 50 feet in wheelchair. The 8/20/24 at 2:15 am Accident and Incident Report documented Resident #53 had an unwitnessed fall to the floor while transferring to their wheelchair from the bed. Investigation conclusion documented the resident able to self-report attempting to transfer from wheelchair to bed without required level of assistance resulting in fall to the floor. Gait analysis documented Resident was unable to independently come to standing. Uses an assistive device. The 8/20/24 Fall Risk Assessment documented Resident #53 was at moderate risk for falls. There was no documented evidence to indicate the Fall Care Plan was reviewed and or revised after the 8/20/24 fall. The 8/28/24 Quarterly Minimum Data Set (assessment tool) documented supervision with toilet transfers, chair to bed transfers, and was independent with ambulation 150 feet and locomotion in wheelchair. The 9/27/24 at 8:45 am Accident and Incident Report documented Resident #53 had an unwitnessed fall and was found in supine position on the floor adjacent to bed. Investigation conclusion documented the resident stated they were seated on the edge of the bed and fell as they turned and shifted their positioning. The resident was assessed with no injuries, musculoskeletal deviations, or acute pain. Screened by rehab and continued rehab services for strengthening and safety. No abuse/neglect indicated at this time. There was no documented evidence to indicate the Fall Care Plan was reviewed and or revised after the 9/27/24 fall. The 10/9/24 at 4:34 pm Accident and Incident Report documented Resident #53 had witnessed fall by staff. The resident was standing, losing their balance, and falling on window side of room. Investigation conclusion documented skin tear to right hand and forming hematoma to posterior aspect of head. The order from medical doctor was to transfer to emergency room for further evaluation and rule out injurious head trauma, no acute findings. Fall self-directed with no indication of abuse/neglect currently. There was no documented evidence to indicate the Fall Care Plan was reviewed and or revised after the 10/9/24 fall. During observations on 11/14/24 at 9:38 AM and on 11/18/24 at 10:03 AM Resident #53 was propelling themselves in the wheelchair in their room without assistance. During an interview on 11/19/24 at 1:39 PM Certified Nurse Aide #2 stated they assisted the resident with dressing, breakfast set, toilet transfer, most of the activities the resident did by themselves. Certified Nurse Aide #2 stated the resident was able to raise the height of their bed too high with a remote control, reached for things on the floor, tries to be independent and keeps their room door closed. Certified Nurse Aide #2 stated they always remind the resident to use a call bell for assistance and leave the room door cracked open so the staff could observe the resident. They stated in general the staff check on the resident every 2 hours. During an interview on 11/19/24 at 1:49 PM Licensed Practical Nurse #5 stated they provide care for the resident. The resident always tries to be independent as much as they can with their daily activities, They stated the resident ignores staff members reminder about calling for assistance. They stated that was the main reason why the resident fell has fallen in the past. They stated they always remind the resident to use a call bell for assistance. Licensed Practical Nurse #5 stated before the last hospitalization the resident was transferred closer to the nurse station for frequent observations. Licensed Practical Nurse #5 could not find care plan interventions following the falls on 8/20/24 and falls on 9/27/24 and 10/9/24. During an interview on 11/19/24 at 2:16 PM the Director of Nursing stated care plans are initiated and updated by the Registered Nurses. In case of fall, the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries. The staff would document risk factors for falling in the resident's record, discuss the resident's fall risk and implement interventions in the care plan based on the resident's needs. If the resident continues to fall, the staff will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued consequence of current interventions. Director of Nursing stated that specifically for Resident #53, risk factors were the resident's preference to be in their room and keeping their room door closed, refusing to participate in recreational activities, and the desire to do many things on their own despite on the staff's reminder to use a call bell for assistance. The Director of Nursing could not provide documented evidence that the facility revised the care plan with new interventions following falls on 8/20/24, 9/27/24 and 10/9/24. 10 NYCRR 415.11

Based on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY00336697 and NY00324141) from 11/14/24 to 11/22/24, the facility did not ensure 2 (Residents #174 and #177) of 2 residents reviewed for Quality of Care received treatment and care in accordance with the professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, 1.) for Resident #174 who was admitted with a wearable defibrillator (Life Vest) related to a history of Sudden Cardiac Arrest, became unresponsive on 3/16/24 the nurse tending to the resident documented they pushed the response button. Additionally, there were multiple omissions on the March Medication Record that the nurses were not addressing and signing for the Life Vest as per physician order and 2.) for Resident #177 with diagnosis of Type 1 Diabetes Mellitus and history of Diabetic Ketoacidosis there were multiple omissions in the Medication Administration Record for insulin administration/ blood sugar monitoring from 5/2024-7/2024. The findings are: The facility policy title Life Vest last revised on 2/2020 documented only the resident is responsible for pressing response buttons. If you're with the patient when the life vest alarms and sends out a voice alert, don't press the response button. 1. Resident #174 was admitted with diagnosis including but not limited to atherosclerotic heart disease, cardiomyopathy, heart failure, and ventricular tachycardia. The 3/15/24 Defibrillator Care Plan documented Resident #174 has a wearable defibrillator (Life Vest) related to a history of Sudden Cardiac Arrest. Interventions included determine responsiveness, and only the resident is responsible for pressing the response button. The 3/13/24 Physician Order documented monitor every shift for correct placement and functioning of the Life Vest. Resident is to always wear the life vest except when showering/vigorous cardiac rehabilitation. The Physician Order to monitor the Life Vest every shift for correct placement and functioning, and resident to always wear the Life Vest except when showering/vigorous cardiac rehabilitation was not documented in the March Medication Administration Record on 3/13/24 (3pm), 3/12/24 and 3/15/24 (7 am/11pm). The 3/13/24 Physician Order documented to change the battery on the Life Vest daily, every shift to maintain battery charge and replace the used battery on the charger. The Physician Order every day shift for maintenance, change Life Vest battery was not documented in the March Medication Administration Record on 3/15/24 at 7am. The Physician Order March 2024 Medication and Treatment Administration ensure Life Vest every shift ensure backup battery was not documented in the March 2024 Medication and Treatment Administration on 3/12/24 and 3/13/24 (3pm), 3/12/24 and 3/15/24 (7am/11pm). The 3/12/24 Medical Order Form from the heart center documented Life Vest to be started on 3/13/24. The 3/13/24 Physicians Order documented care/maintenance and monitor placement of life vest always worn except for hygiene (do not get wet), battery is to be removed before removing Life Vest by the Licensed Staff. Monitor circulation and skin integrity. The Physician Order care/maintenance and monitor placement of life vest always worn except for hygiene (do not get wet), battery is to be removed before removing Life Vest by the Licensed Staff. Monitor circulation and skin integrity was not documented in the March 2024 Medication and Treatment Administration on 3/13/24 (3pm), 3/12/24 and 3/15/24 (7 am/11pm). The 3/16/24 Life Vest Inservice Attendance Record documented only the resident is responsible for pressing the response button/do not touch the patient when there are loud two-time sirens broadcasting from the Life Vest. The patient may be in the progress of receiving a shock and you can be shocked if you are touching them at this time. The 3/16/24 at 7:57 am Nursing Progress Note by Licensed #2 documented approximately 1:55 am Unit B Licensed Practical Nurse heard a beeping sound coming from Resident #174's room and noticed Resident #174 was unresponsive and the Life Vest was alarming. As the resident was unable to hit the shock button, the Licensed Practical Nurse delivered shock. During an interview on 11/18/24 at 10:07 am, Complainant #1 stated when Resident #174 became unresponsive, there were no Registered Nurses in the building. Complainant #1 stated the Director of Nursing knew on Friday 3/15/24, that Resident #174 was declining and did not put care instructions in place for the weekend or call the facility to check on Resident #174. Complainant #1 stated they had no staff to care for the highly medically complex resident. Complainant #1 stated Resident #174 had a Life Vest that is supposed to send a shock to the heart if they have an abnormal rhythm, and Resident #174 was unable to shock themselves. They stated when the alarm on the Life Vest went off, the Nurse caring for Resident #174 pushed the response button, although they were in serviced that only the resident can push the response button. During an interview on 11/18/24 at 3:44 pm, Licensed Practical Nurse #2 stated while doing rounds on 3/15/24 during the night shift, they found Resident #174 unresponsive, and the Life Vest was beeping. Licensed Practical Nurse #2 stated they pushed the response button because the resident was unable. Licensed Practical Nurse #2 stated they received Life Vest training and knew how to operate it, but they were unsure if they should have pushed the button but, were thinking quickly and wanted to help the resident. Licensed Practical Nurse #2 stated there were no Registered Nurses in the building at the time, They stated a Licensed Practical Nurse and Certified Nurse Aide helped with the full code. During an interview on a 11/19/24 at 9:24 am Registered Nurse Unit Manager #1 stated Licensed Practical Nurse #2 called them after initiation of the emergency response system and informed them they pushed the Life Vest response button when Resident #174 became unresponsive. Registered Nurse Unit Manager #1 stated nurses were trained to not push the response button even if the resident becomes unresponsive/ if doing cardiopulmonary resuscitation. During an interview on 11/21/24 at 1:34 pm the Medical Director stated when a resident is wearing a Life Vest, only the resident is supposed to deliver the shock. They stated the Life Vest detects rhythm automatically. The Medical Director stated they expect nurses to document and sign off on all physician orders. During an interview on 11/22/24 at 3:16 pm, the Director of Nursing stated all staff should follow the Life Vest policy and procedure and should not push the response button if a resident becomes unresponsive. They stated staff has been trained and receive refresher courses on the Life Vest. The Director of Nursing stated the unit manager should review the dashboard to see if medications were given. and review with the team and if anything is noted, it should be investigated and addressed, and if meds are not given for anything, they should be documenting, and if the resident refuses, the physician must be notified to receive orders and interventions to be implemented. 2. The Policy titled Insulin Administration last reviewed on 1/2020 documented resident blood sugar and insulin administration should be documented. Resident #177 was admitted with diagnosis including but not limited to diabetes mellitus Type 1, colostomy status, and protein calorie malnutrition. The 4/22/24 admission Minimum Data Set documented Resident #177 had intact cognition and was receiving insulin. The 4/21/24 Diabetes Care Plan documented diabetes mellitus type 1, administer medication as ordered and monitor blood glucose finger stick as per physicians' orders. The 6/27/24 Physician Order documented 30 units of Insulin Glargine in the morning for diabetes mellitus The 6/27/24 Physician Order documented 8 units of Humalog two times a day with breakfast and dinner for diabetes mellitus. There was no documented evidence in the May 2024 Medication Administration Record for blood sugar monitoring on 5/4/24 at 7:30am and 11:30am-BS 300 on 5/6/24 at 7:30am and 11:30 am-BS 315 at 5 pm, 5/18/24 at 5pm. The May 2024 Medication Administration Record documented blood sugar monitoring on 5/11/24 was 228 at 7:30 and 228 at 11:30 am There was no documented evidence in the May 2024 Medication Administration Record for administration of Humalog Kwikpen (5 units) on 5/4/24 at 9am/1pm and 5/18/24 at 6:30pm and Humalog Kwikpen (8 units) on 5/4/24 at 8am, 5/6/24 at 8am, and 5/8/24 at 5pm, The May 2024 Medication Administration Record for blood sugar monitoring on 5/26/24 at 7:30 was 400 and 8 units were given, and 5/27/24 at 7:30 am was 489. There was no documented evidence in the June 2024 Medication Administration Record for administration of Humalog Kwikpen(8 units) on 6/5/24 at 5pm and blood sugar monitoring on 6/4524 at 9pm. During an interview on 11/21/24 at 1:43 pm, the Medical Director stated they should be notified if a resident's blood sugar is over 400 or below 70, and residents should receive physician ordered insulin. They stated if insulin is not administered, staff should document the reason in the progress notes/medication administration record and notify the physician. The Medical Director stated they review blood sugar monitoring/administration of insulin in the electronic record and if not accurately documented they would not know if the diabetes is being managed properly. The Medical Director stated if the resident is on a sliding scale, they cannot receive coverage if the blood sugar is not done. They stated if something is not documented in the Medication Administration Record, then it was not done. During an interview on 11/22/24 at 12:27pm, Registered Nurse Unit Manager #1 stated nurses are responsible for ensuring they sign off on medications, and the facility started coming down on the nurses for not signing for medications. Registered Nurse Unit Manager #1 stated if nurses did not sign for administration of insulin and sliding scale, then it was not given, and stated they would not know if a resident received the insulin. Registered Nurse Unit Manager #1 stated it was important for Resident #177 to receive the physician ordered insulin because they always had high blood sugars. During an interview on 11/22/24 3:35 pm, the Director of Nursing stated nurses are responsible to check the medications on dashboards, and nurses are responsible for ensuring residents get their medications according to physician orders. The Director Nursing stated if medications are not documented in the Medication Administration Record, they were not given, and that if the resident had a sliding scale, the findings of the blood sugar should be documented in order to be able to administer the insulin. 10NYCRR415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview conducted during the recertification and complaint (NY00336704) surveys from 11/14/24 to 11/22/24, the facility did not ensure adequate supervision to prevent accidents for 1 (Residents #176) of 5 residents reviewed for Accidents. Specifically, fall risk assessments were not completed to identify Resident #176's risk for accident and need for supervision after falls on 1/26/24, 1/28/24, and 2/1/24. There was no documented evidence of enhanced monitoring and one to one supervision as per the 2/27/24 Accident and Incident Report after Resident #176 verbalized suicidal ideation. Additionally, Resident #176 had one unwitnessed fall on 1/28/24, two on 2/1/24, two on 2/22/24, 2/27/24, 2/29/24, 3/11/24, and one on 3/19/24 and there was no documented evidence neurological checks were done to assess for neurological status or underlying conditions. Findings include: The facility policy titled Falls Management and prevention last revised 1/2023 documented obtain neurological checks per policy for any unwitnessed fall or any fall with evidence of injury to the head. Fall risk assessments will be completed for all residents; initially on admission / readmission, quarterly, significant change and after an identified fall. Resident #176 was admitted with diagnosis including but not limited to anxiety, cerebral infarction, right hemiplegia, and unspecified psychosis. The 1/26/24 Accident and Incident Report documented at 3:30 pm, Resident #176 had a witnessed fall in the common area and slid from their wheelchair at 3:30 pm. No injuries were noted. There was no documented evidence of a fall risk assessment after the 1/26/24 fall. The 1/28/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall and was found on the floor next to their bed in their room at 1:45 am. There was bruise on the left knee, they guarded their hip. Sent to the emergency department for evaluation. There was no documented evidence of a fall risk assessment/neurological checks after the 1/28/24 fall. The 1/30/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall in their room at 5:00 pm, and neurological checks were initiated. There was no documented evidence of neurological checks being initiated after the 1/30/24 fall, as per the Accident and Incident Report. The 2/1/24 admission Minimum Data Set Assessment documented Resident #176 had severely impaired cognition, and required extensive assist with toileting and bed mobility. The 2/1/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall and was found lying on the floor in their room at 4 pm. There bruises noted to the right and left hips. There was no documented evidence of neurological checks being initiated after the he 2/1/24 at 4 pm fall. The 2/1/24 Accident and Incident report documented at 11:15 am, Resident #176 had an unwitnessed fall in the dining room and was found sitting on the foot/leg rests of their wheelchair. There was no documented evidence of a fall risk assessment/neurological checks after the 2/1/24 at 11:15 am fall. The 2/22/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall and was observed lying on their side on the floor next to the door in their room at 10:35 pm. There was no documented evidence of neurological checks after the 2/22/24 at 10:35 pm fall. The 2/22/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall in their room and was found lying on the floor with their head against the wall at 1:45 pm. Neurological checks initiated. There was no documented evidence of neurological checks being initiated after the 2/22/24 at 1:45 pm fall, as per the Accident and Incident Report. There was no documented evidence of the Fall Care Plan being reviewed and revised until 2/27/24. The 2/27/24 Accident and Incident Report documented at 3:00 pm, Resident #176 verbalized suicidal ideation. No injuries were noted. Care plan was updated. Resident was placed on enhanced monitoring and one on one supervision implemented. There was no documented evidence of enhanced monitoring/one to one supervision was initiated after the 2/27/24 at 3:00 pm incident, as per the Accident and Incident Report. There Suicide Care Plan was last revised on 2/5/24.There was no documented evidence of a care Plan update to to reflect the 2/27/24 suicidal ideation. The 2/27/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall in their room and was found on the floor lying on their left side next to the radiator at 3:00 pm. Resident #176 complained of back pain, had a laceration to right their eyebrow, and an abrasion to their right lower leg. Resident transferred to the emergency room due to complaints of back pain. The 2/29/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall in their room and was found sitting on the floor at 10am. No injuries were noted. There was no documented evidence of neurological checks after the 2/29/24 fall. The 3/11/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall in their room and was found lying on the floor next to their bed at 9:11 am. There was no documented evidence of neurological checks after the 3/11/24 fall. The 3/19/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall in their room and was found lying next to their bed at 2:30 pm. No injuries noted. Sent to emergency department for evaluation. Staff noticed the resident had another bruise on their forehead. Resident does maintain another bruise 1-cmx13cm light purple in color, skin is intact. Certified Nurse Aide was walking in the room and noted the resident on the floor off the mattress. The 3/19/24 change in skin condition evaluation due to falls documented there was discoloration to the forehead and no other changes noted. Resident #176 was sent to the emergency department for further work up. The 3/20/24 emergency room discharge summary documented Resident #176 was admitted on [DATE] with ecchymosis to their periorbital/forehead, and a skin avulsion was noted to their right shin. During an interview on 11/20/24 at 3:13 pm, Registered Nurse Unit Manager #1 stated when a resident is on one to one supervision, the staff document on paper and there is no solid method to keep track/papers get lost, and that neurological checks should have been uploaded into the computer. Registered Nurse Unit Manager #1 stated if a resident has an unwitnessed fall, neurological checks must be done. Registered Nurse Unit Manager #1 stated Resident #176 should have been placed on permanent one to one supervision because the resident had multiple falls, and had no impulse control. They stated the facility does not like placing resident/s on one to one supervision due to staffing. Registered Nurse Unit Manager #1 stated if a resident has suicidal ideation , they are immediately placed on one to one supervisor and the care plan must be updated. On 11/21/24 at 12:15 pm, the Administrator stated they were unable to locate neurological checks for Resident # 176. During an interview on 11/21/24 at 1:56 pm,the Medical Director stated they will place a resident on one to one supervision when the resident is suicidal, and they must be cleared by the Psychiatrist before removing the one to one supervision. The Medical Director stated if a resident has an unwitnessed fall or hit their head. During an interview on 11/21/24 at 5:41 pm, the Complainant stated every time they visited, Resident #176 was always lying on the floor, and stated that on one visit, the resident had their head against the wall. They stated they requested on multiple occasions to move the radiator that was in the residents room up against the wall due to the corners and it being unsafe for the resident because the resident goes on the floor. During an interview on 11/22/24 at 11:20 am, Certified Nurse Aide #5 stated when a resident is having falls, the nurse will verbally tell them the resident is on one to one supervision, but the instructions will not go to the Certified Nurse Aide [NAME]. Certified Nurse Aide #5 stated they have been employed in the facility since 2013 and never documented one to one supervision or 15 min checks, and has never seen such instructions in the [NAME]. Certified Nurse Aide #5 stated even when a resident is on one to one supervision, they do not have the staff and the resident will go without one to one supervision. During an in interview on 11/22/24 02:39 pm, the Director of Nursing stated prior to 9/2024, neurological checks were not being done consistently and they were supposed to be uploaded.They stated they were unable to locate any of Resident #176's neurological checks. The Director of Nursing stated, starting 9/2024, they implemented a new system to keep track of neurological checks. They stated neurological checks are now kept in a binder on the unit and the nurses should be communicating to each other. The Director of Nursing stated all care plans should be reviewed and noted, everything should be documented even if there are no new revisions. 10NYCRR415.12(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification from 11/14/24 to 11/22/24, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the staffing schedule from 10/10/24 through 11/21/24 revealed the facility did not consistently provide adequate staffing on all units/shifts to meet the needs of the resident/s 35/43 days reviewed. The findings are: The Facility Wide assessment dated [DATE] documented Day shift, Units A and B: 2 nurses/5 certified nurse aides per unit. Evening shift: 2 nurses/4 certified nurse aides per unit. Night shift: 1 nurse/2 certified nurse aides per unit. The facility staffing from October 10, 2024 through November 21, 2024 and the staffing plan based on Facility Wide Assessment, documented the facility was understaffed 35/43 days for Certified Nurse Aides. During a Resident Council meeting on 11/15/24 ad 1:32 PM, Resident #23 stated call bells are not being answered timely. Residents can wait almost 30 minutes for a response, especially on B unit. Resident #23 stated at night staffing is short and needs are not being met. During an interview on 11/14/24 at 10:41 AM, Resident #57 and Representative stated staff ignore residents at night and can be rude. They stated staffing appears short all shifts, but the night shift is particularly bad. The representative stated staff sleep, are on phones, or watching television at night. Resident and representative stated call bells are not answered at night. During an interview and observation on 11/14/24 at 12:01 PM, Resident #25 stated staff treat them well, however, the facility is short-staffed often. The short-staffing varies by shift. Resident #25 stated they have to wait extended times for requested pain medications. During an interview on 11/19/24 at 01:09 PM, family representative of Resident #61 stated the facility is short staffed daily. They stated staff are not friendly and often have attitudes. They stated there can be long wait time for services such as medication administration and feeding of residents. During an interview on 11/20/24 at 10:17 AM the Staffing Coordinator stated daily staffing is determined by census and the minimum staffing requirements for each unit. Five certified nurse assistants for 7:00AM-3:00PM shift on both units and 2 nurse staff for each unit. The 3:00PM - 11:00PM shift: 4 certified nurse assistants per unit and 2 nurse staff. The 11:00PM to 7:00AM shift: 2 certified nurse assistants and 1 nurse per unit. They stated there have been shifts when units are understaffed. They stated call-outs are handled by calling staff that is off. Staff on duty are offered to stay and given a shift off for covering. Overtime is offered. Bonuses not frequently offered and require approval. They stated some certified nurse staff have discussed workload concerns with them in the past. They stated when this has occurred, certified nurse aides will be offered time off and attempts made to improve staffing on units.They stated contract travel agencies are used for certified nurse aide recruitment and local agencies rarely used for licensed practical nurses only. They stated the facility is always recruiting for local staff. During an interview on 11/21/24 at 10:32 AM the Director of Nursing stated staffing difficulties are present and universal in the industry. They stated since July 2024 when they started employment at the facility, there have been staffing challenges, but tremendous progress has been made. The facility continues recruiting for certified nurse assistants, licensed practical nurses and registered nurses. They stated the facility recently hired a registered nurse unit manager, a registered nurse Assistant Director of Nursing, and a registered nurse Supervisor. They stated certified nurse aides are primarily hired through a travel agency. Local recruitment is difficult due to competition in the area. During an interview on 11/22/24 at 10:45 AM Licensed Practical Nurse #3 stated staffing has been horrible at times, especially at weekends. They stated the shortage of certified nurse aides affects residents because cares are hurried. They stated they have to perform certified nurse aide duties frequently because of short staffing. They stated there have been occasions at night when there is only one or no certified nurse aide was on duty. When this occurs, they perform medication administration and certified nurse aide duties. They stated the facility has a high turnover due to the use of traveling certified nurse aides. They stated training for traveling aides could be improved, such as training on New York State regulations (allowable certified nurse aide tasks vary from state to state. They stated residents are not happy with constant turnover of staff. During an interview on 1/22/24 at 02:22 PM the Administrator stated the facility has had a lot of difficulty hiring locally and staffing could be challenging. The Administrator stated the use of travel certified nurse aides has assisted the facility meet their staffing numbers. NY CRR 415.13(a)(1)(i-iii)

Based on interview and record review conducted during the recertification survey from 11/14/2024 to 11/22/2024, the facility did not ensure the attending physician documented in the resident's medical record that the identified drug regimen review recommendations were reviewed, and any action taken to address recommendations were completed. This was evident for 1 (Resident #42) of 5 residents reviewed for unnecessary medications, psychotropic medications and medication regimen review. Specifically, there was no documented evidence the Medical Director reviewed and responded to Resident #42's Drug Regimen Reviews dated June 2024. The findings are: The facility policy title Medication Regimen Reviews (revised 11/2021) documented the Consultant Pharmacist reviews the medication regimen of each resident at least monthly. The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. The attending physician documents in the medical record that the irregularity has been reviewed and (if any) action was taken to address it within 30 days of receiving the report. Resident #42 was admitted with diagnoses including but not limited to Diabetes Mellitus II with Hyperglycemia, Cardiac Arrythmia and Depression. The Drug Regimen Review for Resident #42 dated June 2024 documented Discrepancy between psychiatry recommendation and actual prescription Psychiatry consult 6/18/24 recommendations: Increase Sertraline to 100 mg. PO daily for depression. Current order Sertraline HCL tablet. Give 75 milligrams by mouth one time day for depression. The Drug Regimen Review was not signed or dated by Medical Director, disagreement or recommendation was not documented in electronic medical record, and an order for an increase in sertraline hcl to 100 milligrams was not documented in electronic medical record. The physician order dated 6/4/24 documented Sertraline HCl Tablet Give 75 milligrams by mouth one time a day for Depression. The physician order dated 8/29/24 documented Sertraline HCl Tablet 50 Milligrams. Give 1.5 tablet by mouth one time a day for Depression. The physician order dated 10/7/24 documented Sertraline HCl Tablet 50 milligrams. Give 1.5 tablet by mouth in the evening for Depression. The Drug Regimen Review dated June 2024 documented consider a lipid profile to monitor Atorvastatin Calcium tablet 20 milligram. Statin monitoring lipid panel 4-12 weeks after statin initiation then every 3 to 12 months. Consider dose reduction if two consecutive LDL measurements are less than 40 mg. dl (1.03 mmol/L). Check ALT at baseline. Repeat if symptoms of hepatotoxicity occur. The Drug Regimen Review was not signed or dated by Medical Director, disagreement or recommendation was not documented in electronic medical record. A lipid profile was completed on 7/5/24 and 10/16/24. The Physician Order dated 10/3/24 documented: Lipid Panel (thyroid profile I). One time only related to presence of cardiac pacemaker. During an interview on 11/21/24 at 10:26 AM the Director of Nursing stated Drug Regimen Reviews from the pharmacy are printed monthly or as needed if a change/recommendation is indicated and provided to attending physician for review. They stated they email Pharmacy Drug Regimen reviews to Unit Managers to print and place in the Medical Director review folder located at the nurse stations. They stated the June 2024 Drug Regimen Reviews for Resident #42 were not signed and dated by the physician and there was no documented reply to the recommendation. During an interview on 11/21/24 at 2:20 PM the Medical Director, stated Pharmacy sends the Drug Regimen Reviews to the facility, facility prints them out and places in Medical Director folders on each unit. They stated they are present in facility about four days a week and they review Medical Director folders on units daily when present. They stated upon review of Drug Regimen Reviews, they agree, disagree, or provide alternative recommendation, if applicable. They sign and return reviewed Drug Regiment Reviews to the folder for unit managers to review and upload to electronic medical record or provide to Director of Nursing. During the interview, the two Drug Regimen Reviews from June 2024 were observed. The Medical Director stated since there was no signature or date on the form, they did not receive the form for review. They stated if they provide a new order after reviewing a Drug Regimen Review, the Unit Manager or Director of Nursing would enter the order into electronic medical record for Medical Director to approve. 10 NYCRR 415.18(c)(2)

Based on observation, record review and interview conducted during a recertification survey 11/14/22-11/22/24, the facility did not ensure necessary dental services were provided in a timely manner for 1 of 1 resident (Resident #25) reviewed for Dental Services. Specifically, Resident #25 was not provided routine dental services since their 2/29/24 admission to facility. The findings are: The facility policy titled Dental Services, last revised 9/2019, documented routine and emergency dental services are available to meet the resident's oral health care needs based upon resident assessment and plan of care. Resident #25 was admitted with diagnoses including but not limited to Peripheral Vascular Disease, Major Depressive Disorder, and Acquired Absence of Left Leg above Knee. The Quarterly Minimum Data Set (resident assessment tool) dated 11/3/24 documented Resident #25 had intact cognition. There was no documented evidence of a Dental Consult for Resident #25. During an interview and observation on 11/19/24 at 9:31 AM, Resident #25 stated they have not received a routine dental consultation since their 2/29/24 admission. Resident #25 was observed edentulous during interview. Resident #25 stated they have had dentures (upper) in the past, prior to admission, which required adjustment and never fit right. Resident #25 stated they did not have dentures in place upon admission to facility. Resident #25 stated they would like to have dentures in place to assist with eating. During an interview on 11/22/24 at 05:31 PM the Director of Nursing stated the facility has a dental consultant who visits the monthly and as needed. They stated residents are followed routinely and have follow-up visits for episodic issues. Long-term residents seen routinely. They were not sure of exact visit cycle. Community dental appointments are assisted through the facility and transportation provided. They stated that any member of the nursing team can report observed resident concerns to the unit manager or Assistant Director of Nursing. The Director of Nursing stated they will discuss Resident #25's concern with the physician and if in agreement, an order can be placed for a dental consult. 10 NY CRR 415.17(a-d)

Based on observation, record review and interview conducted during the Recertification Surveys from 11/14/24 to 11/22/24, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, there was undated ice cream in the meat freezer and vegetable freezer, a dietary aide was observed in the kitchen without a beard covering, there was 8 boxes of deluxe original cheddar macaroni noodles with an expiration date of 11/1/24 in the emergency food supply room, and the ceiling in the emergency food room was peeling and had black/brown stains. The findings are: The facility policy titled Food service last revised on 5/10/24 documented dry storage rooms must be well ventilated. All storage areas should have adequate illumination with temperature and humidity controls to prevent condensation of moisture and growth of mold. All refrigerated foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. All frozen foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. All frozen leftovers must be used within 30 days. The facility policy titled Sanitation Policy last revised on 1/2023 documented the food service area shall be maintained in a clean and sanitary manner. The facility policy titled Maintenance Services last revised 8/2019 the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. During an initial tour of the kitchen on 11/14/24 at 10:08 AM, there were three buckets of chocolate, vanilla, and strawberry ice cream undated in the meat freezer, there were unlabeled and undated individual packs of three 4 ounce burgers, there was a 10 lb box of opened and undated 2.5 ounce steak sandwiches, there was an opened and undated box of cheese pizza with 6 of 54 slices remaining, there was an opened and undated bag of frozen boneless skinless chicken breast, there was an opened and undated pack of hot dogs, there was one box of undated and opened precooked flat lasagna sheets, there was an opened and undated 10 lb box of whole strawberries with freezer burn, there was a bag of opened and undated French toast(5 left) and full bag of French toast with ice accumulation inside, there was 3 bags of garlic toast with 6 loose toast unlabeled and undated, there was an open and undated 20 pound box of diced carrots in the vegetable freezer, there was a loose bag of peas opened and undated with no box on the bottom of the vegetable freezer, a dietary aide was observed in the kitchen without a beard covering, there was 8 boxes of deluxe original cheddar macaroni noodles with expiration date of 11/1/24 in the emergency food supply room, and the ceiling in the emergency food room was peeling and had black/brown stains. On 11/14/24 at 10:31 AM, Dietary Aide #3 was observed in the kitchen near food, with a beard and was not wearing a beard covering On 11/15/24 at 1:13 PM, there were 8 boxes of deluxe original cheddar macaroni noodles with an expiration date of 11/1/24 in the emergency food supply room, and the ceiling in the emergency food supply room was peeling and had a black/brown substance. During an interview on 11/15/24 at 01:13 PM, the Food Service Director stated hey became employed at the facility in March and the ceiling in the emergency food supply room has been damaged since that have been there On 11/18/24 at 9:57 AM, the corner and middle of the ceiling in the emergency room supply was peeling/stained. During an interview on 11/18/24 at 10:00 AM, the Food Service Director stated all dietary workers/staff entering the kitchen must wear a hair net and anyone with a beard must wear a beard covering while in the kitchen. The Director of Food Service stated all food items that are opened must be labeled and dated, and that there should not be freezer burn on the items. The Food Service Director stated they have been speaking to staff about labeling and dating foods in the kitchen. During an interview on 11/19/24 at 10:18 AM, the Director of Maintenance stated they were unaware the ceiling in the emergency food supply room had mold since they do not go in there and do not have anything to do with the room unless staff report to maintenance tat something is wrong. The Director of Maintenance stated it is probably a water leak. The Director of Maintenance stated the facility does not do work orders, and that maintenance is told verbally by staff what needs to be repaired. During an interview on 11/19/24 at 11:14 AM, the Director of Maintenance stated they scraped the ceiling in the emergency food supply room of flaking dead paint and that it was a water leak but they were unable to tell if it was mold. They stated they were not aware of the damaged ceiling and that it must have happened years ago. During an interview on 11/22/24 at 10:50 AM, Dietary Aide #3 stated they are aware they need to wear a beard covering when in the kitchen especially while preparing food, and that they forgot to wear one. 10NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey from 11/14/24 to 11/22/24, the facility did ensure that a Registered Nurse worked eight cosecutive hours a day, seven days a week. Specifically, the facility was unable to provide documented evidence that a Registered Nurse worked 10/20/24, 11/2/24, 11/3/24, 11/16/24, 11/17/24. Findings include: The Facility Wide assessment dated [DATE] documented the staffing plan as follows: Day shift unit A and B: 2 nurses each unit. Evening shift units A and B: two nurses each unit. Night shift Units A and B: 1 nurse each unit. The Facility Wide Assessment does not include Registered Nurse for at least eight consecutive hours per day, seven days per week as per the regulations. The 10/10/24-11/21/24 Daily Nurse Staffing Roster documented the facility did not have a Registered Nurse at least 8 consecutive hours a day for 7 days a week on 10/20/24, 11/2/24, 11/3/24, 11/16/24, 11/17/24. During an interview on 11/20/24 at 10:17 AM the Staffing Coordinator stated there have been occasions on weekends when the facility has not had a Registered Nurse in the building. They stated the facility have a Registered Nurse on staff who works every other weekend from 7:00AM-3:00PM and the remaining weekends are covered by Licensed Practical Nurse staff. They stated the Director of Nursing and/or Unit Managers are on-call when a Registered Nurse in not in the building. They stated the facility is actively recruiting for Registered Nurse staff. During an interview on 11/21/24 at 10:32 AM the Director of Nursing stated there have been weekends when there has not been a Registered Nurse in the facility. During days when there is no Registered Nurse in the facility there is a telehealth line at the nurse station which provides mid-level coverage by a Physician Assistant/Nurse Practitioner. They stated they are also on-call and live locally so they can present to the facility if a Registered Nurse is needed. They stated there are other Registered Nurses in the facility who also participate in the on-call rotation. They stated staffing has been challenging and efforts are in place to hire additional Registered Nurses. During an interview on 11/22/24 at 10:45 AM Licensed Practical Nurse #3 stated the facility does not have a Registered Nurse at night or every other weekend days. They stated they work every other weekend and at times there is no Registered Nurse in the building. If a situation occurs where a Registered Nurse is needed, they call the Director of Nursing who is on-call. They stated the Director of Nursing or on-call Registered Nurse will present to the facility. During an interview on 1/22/24 at 02:22 PM the Administrator stated the facility has had a lot of difficulty hiring locally and that staffing could be challenging. 10NYCRR 415.13(b)(1)

Based on record review and interview conducted during the recertification survey from 11/16/2024 to 11/22/2024, the facility did not ensure Annual Performance Reviews were completed at least once every 12 months. Specifically, the facility was unable to provide Annual Performance Reviews for 3 of 5 Staff Members (#9, #10, #12) reviewed. The findings are: The facility policy titled Employee Evaluations, dated 9/29/2019, documented: A performance evaluation will be completed on each employee at least annually. During an interview and record review with the Assistant Director of Nursing/Nurse Educator on 11/20/24 at 11:07 AM, they stated they were not able to provide documentation of an Annual Performance Review for Staff Members (#9, #10, #12). They stated they are new to the facility and have not completed annual performance reviews as of yet. During an interview and record review with the Director of Nursing on 11/20/24 at 11:07 AM, they stated they were aware the Assistant Director of Nursing/Nurse Educator was not able to provide documentation of an Annual Performance Review for Staff #9, #10, and #12. 10NYCRR 415.26 (c)(2)(iii)

Based on observation and interview during the Recertification survey from 11/14/24 to 11/22/24, the facility did not ensure residents were provided food and drink that is palatable, attractive, and at a safe and appetizing temperature. Specifically, food was not served at palatable and safe temperatures for 2 of 3 residents (Resident #17 and Resident #23) reviewed for Food. The findings are: The Policy titled Food Temperatures last reviewed 3/2023 documented temperatures of cold and hot food items will be recorded on all menu items and substitutions for meal service to maintain a high level of quality and to monitor potentially hazardous food temperatures as per state and federal regulations thus ensuring that food is provided in a safe, palatable manner. All employees are responsible to notify their supervisor of any food item that does not meet the regulated safe acceptable service ranges (at or below 41 degrees Fahrenheit or above 135 degrees Fahrenheit). During an interview on 11/15/24 at 11:27 AM Resident #17 stated they do not like the food, the food is always cold. During an interview on 11/14/24 at 12:55 PM and on 11/15/24 at 11:24 AM Resident #23 stated they do not like the food, the food is served cold. On 11/21/24 at 1:01 PM temperatures were checked on a test tray by the Dietary Technician and registered as follows: pork gravy 103.3 degrees Fahrenheit, mashed potatoes 123.4 degrees Fahrenheit, cooked carrots 102.6 degrees Fahrenheit, cranberry juice 62 degrees Fahrenheit. The Dietary Technician stated they could not explain the reason food had a low temperature. During an interview on 11/21/24 at 1:03 PM the Dietary Technician stated the food and cold beverages were at acceptable temperatures when they left the kitchen. 10NYCRR 415.14 (d)(1)(2).

Resident #23 was admitted to the facility with diagnoses including Heart Failure, Obstructive Uropathy, Diabetes Mellitus. The 10/30/24 admission Minimum Data Set documented Resident #23 was cognitively intact. had an indwelling catheter, was frequently incontinent for bowel, had 2 stage 3 Pressure Ulcers and 1 unstageable- deep tissue injury that were present upon admission. During observation on 11/18/24 at 1:51 PM Enhanced Barrier Precaution signage was outside Resident #23's room and documented apply gown and gloves before room entry and remove them prior to room exit. During observation on 11/18/24 at 1:56 PM Certified Nurse Assistant #2 applied gloves and emptied the resident's drainage bag. Certified Nurse Assistant #2 was not wearing a gown at the time they performed the drainage bag care. Certified Nurse Assistant #7 assisted Certified Nurse Assistant #2 with Resident #23 transfer. Certified Nurse Assistant #7 applied gloves and was not wearing a gown at the time they transferred the resident. During an interview on 11/18/24 at 1:59 PM Certified Nurse Assistant #2 and #7 stated they were aware Resident #23 was on Enhanced Barrier Precaution and they were supposed to wear the gown, but at the time they forgot to put the gown on. 10 NYCRR 415.19(b)(4) Based on observation, record review and interview conducted during a recertification survey from 11/14/24-11/22/24, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infections. Specifically,1) the Water Management Plan had not been updated annually and the Environmental Risk Assessment had not been performed annually to identify areas where Legionella could spread, 2) Resident #13's urine collection bag was not maintained or emptied in a manner to prevent infection, 3) Resident #51 consented to receive the Respiratory Syncytial Virus vaccine but did not receive it until almost two months later. 4) 4 of 10 Staff, Certified Nurse Aide #4, Minimum Data Set Coordinator, Dietary Aide #1, and Cook, reviewed for vaccinations were not screened, offered, or given the opportunity to accept or decline pneumococcal vaccination. 5) Staff did not apply proper Personal Protective Equipment while assisting Resident #23 and #26, who were on Enhanced Barrier Precautions. The findings are: The facility policy titled Enhanced Barrier Precautions last revised on 5/30/24 documented Enhanced Barrier Precaution is applicable for residents with any of the following: wounds (e.g., any type of wound requiring a dressing) and/or indwelling medical devices (e.g., urinary catheter, tracheostomy/ventilator, etc.) regardless of Multiple Drug Resistant Organisms colonization status. Enhanced Barrier Precaution is primarily intended to apply to care that occurs within a resident's room where high-contact resident care activities are commonly bundled together - e.g., AM/PM care, transfers, toileting, etc. Enhanced Barrier Precaution requires wearing disposable gloves and an isolation gown prior to high contact activity. High contact resident care activities include dressing, transferring, device care or use: urinary catheter. 1)The Environmental Risk Assessment was reviewed and dated 5/18/2021. The facility's Water Management Plan did not have the last review date on the document. During an interview on 11/20/24 at 1:30 PM the Director of Maintenance stated they were responsible for Water Management Program but was not aware the Water Management Plan needed to be reviewed and revised, if necessary, annually. They further stated they did not know the Environmental Risk Assessment should be performed annually but stated it made sense since the team members do change. 2)Resident #13 was admitted with diagnoses including Spinal Stenosis, Type II Diabetes Mellitus, and Urinary Retention. The Minimum Data Set (an assessment tool) dated 9/25/24 documented Resident #13 was cognitively intact and had an indwelling urinary catheter. During an observation on 11/20/24 at 9:05 AM Resident #13 was in bed and the urine collection bag and drainage port were in contact with the floor. During observation on 11/20/24 at 10:41 AM and 11/20/24 at 5:08 PM Resident #13's leg bag (used to collect urine) was observed hanging over the toilet handrail without a cap cover on the end that would be connected to the catheter tubing. During an observation on 11/20/24 at 10:39 AM the Certified Nurse Aide #1 applied a gown and gloves, removed the Resident #13's used urinal from the toilet area, rinsed it with water and attended to the resident's urine collection bag to drain the urine. The urinal was placed on the floor, the collection bag drainage port was put inside the urinal and touched the sides of the urinal. During an interview on 11/20/24 at 10:39 AM Certified Nurse Aide #1 stated sometimes there are no caps for the urine collection bags and that is just the way it is. Certified Nurse Aide #1 stated if they don't wedge the collection bag drainage port end inside the urinal, the urine can get all over the floor and was not aware the technique could be spreading infections. During an interview on 11/20/24 at 3:38 PM the Infection Preventionist/Assistant Director of Nursing stated new bags should be used after disconnecting the old bags and not stored hanging over the toilet handrail. The Infection Preventionist stated leaving urine collection bags uncapped is not a clean practice. They stated Certified Nurse Aides need constant reminding and education to perform tasks correctly, making sure the collection bag tips don't touch the inside of the urinals which may lead to infections. 3) Resident #51 was admitted with diagnoses including Hypothyroidism, Bipolar Disease and Neurogenerative Lewy Body Neuropathy. The Minimum Data Set (an assessment tool) dated 10/10/24 documented Resident #51 had moderate cognitive impairment. During an interview on 11/15/24 at 10:33 AM Resident #51 stated they were offered the Respiratory Syncytial Virus vaccination when they were admitted to the facility and signed the consent form, but they have not received the shot yet. The Consent for Vaccine Form documented on 10/3/24, Resident #51 signed that they wanted to receive the vaccine. There was no documented evidence the vaccine was given. During an interview on 11/20/24 at 3:38 PM the Infection Preventionist/Assistant Director of Nursing stated there was a supply on hand for the vaccine and it was not given but should have been given by the Unit Manager. 4) The Vaccine Records for Certified Nurse Aide #4, Minimum Data Set Coordinator, Dietary Aide #1 and the [NAME] #1, determined there was evidence the staff were screened for eligibility, offered, was administered or declined the pneumococcal vaccination. During interview on 11/20/24 at 3:58 PM the Infection Preventionist/Assistant Director of Nursing stated they were not aware they needed to screen for the vaccine and had not been obtaining declinations or providing education to staff about the vaccine but will make sure it is done. 5) Resident #26 had diagnoses including but not limited to Parkinson's Disease, Seizure and Peripheral Vascular Disease. The 10/21/24 Care Plan titled Enhanced Barrier Precautions documented wear Personal Protective Equipment (gowns, gloves) when providing high contact activities including wound care. The 11/20/24 Physician Order documented cleanse right elbow opening with normal saline, cover with dressing, wrap with Kerlix every day shift. During wound observation on 11/22/24 at 3:46 PM Licensed Practical Nurse #10 did not apply a gown when removing the wound dressing, cleaning the wound and applying a new dressing. During an interview on 11/22/24 at 3:46 PM Licensed Practical Nurse stated they were aware the Resident was on Enhanced Barrier Precautions which meant staff needed to wear a gown and gloves during dressing changes but could not provide a reason why they did not follow precautions.

Based on record review and interview conducted during a recertification survey from 11/14/24 to 11/22/24, the facility did not ensure Certified Nurse Aides were provided the required 12 hours of training and/or annual in-services to ensure safe delivery of care. Specifically, the facility was unable to provide documentation that 3 of 6 Certified Nurse Aides (#10, #14, and #15), reviewed for Certified Nurse Aide training, were provided 12 hours of mandatory training. The findings are: The facility policy titled: Staff Development and In-service Programming, revised 1/18/23, documented: Personnel shall participate in in-service training to remain current in knowledge which affects the delivery of services within the facility and meets Federal and State Requirements. Policy Implementation: Certified Nurse Aides shall complete any additional in-services / education as required by topic and numbers of hours in accordance with state and federal regulations (e.g., 12 hour minimum). Certified Nurse Aide #10: 6.5 hours of annual in-service training documentation was provided. Certified Nurse Aide #14: 3.5 hours of annual in-service training documentation was provided. Certified Nurse Aide #15: 3.0 hours of annual in-service training documentation was provided. During an interview on 11/20/24 at 12:04 PM the Assistant Director Nursing, stated they were not able to provide 12 hours of annual in-service training for Certified Nurse Aides #10, #14, and #15. They stated they have been employed by the facility since September, 2024, but had contacted the previous Assistant Director of Nursing and they were not able to provide additional hours of in-service training for Certified Nurse Aide #10, #14, and #15. During an interview on 11/20/24 at 12:04 PM, the Director of Nursing stated the Assistant Director of Nursing was not able to provide 12 hours of annual in-service training for Certified Nurse Aide #10, #14, and #15. 10 NYCRR 415.26 (c)(1)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews conducted during an abbreviated survey (NY00329438), the facility did not ensure that care and treatments were provided to prevent the development of new pressure ulcers for 1 of 3 (Resident #3) residents reviewed for pressure ulcers. Specifically, Resident #3 was admitted to the facility with a deep tissue injury and skin integrity care plan was not put in place; physician orders for the use of a CAM boot (controlled ankle movements, a walking boot) when out of bed and skin checks every shift were not followed; Resident #3 developed a pressure ulcer to the left heel and treatments were not completed as ordered. Findings include: Resident #3 had diagnoses including fracture of the shaft of the left fibula (fracture of the long bone in the lower leg), Type 2 Diabetes, and Depression. The Nursing admission Evaluation dated 11/2/23 at 6:44 PM, documented Resident #3 had an unstageable pressure injury to the left dorsal (top) foot that measured 4 centimeters by 1.5 centimeters by 0.0 centimeters (length x width x depth). The weekly skin monitoring form dated 11/2/23 documented the resident's skin was intact. The admission Minimum Data Set (MDS, assessment tool) dated 11/9/2023 documented Resident #3 cognition was intact, and the resident required moderate assistance of 1 staff for transfers, bed mobility, and toilet use, and set up assistance of 1 staff for personal hygiene and dressing. The resident had 2 unstageable deep tissue injury present on admission, and treatments included pressure-reducing devices for the chair and bed, and pressure ulcer care. Physician orders dated 11/2/23 included: 1) Inspect skin under CAM boot every shift and report any abnormal finding. 2) Weekly skin evaluation done on Monday during the day shift, with additional instructions to complete Weekly Skin Monitoring form to start on 11/6/23. Physician order dated 11/3/2023 documented weight bearing tolerated to the left lower extremity CAM boot when out of bed. Review of physician admission note dated 11/3/23 did not document the unstageable pressure injury to the left dorsal (top) foot that was documented in the Nursing admission Evaluation of 11/2/23. The registered nurse progress note and Initial Event Documentation form, dated 11/13/23 at 10:00 AM, documented a new wound was observed under the CAM boot on the left heel, measured 3.5 centimeters by 3.5 centimeters and a new order for Skin Prep was received. The resident was wearing the CAM boot most of the time, even when in bed however only needed when out of bed. The resident and staff were educated. The comprehensive care plan initiated on 11/13/23 documented that the resident was at risk for developing pressure ulcers due to impaired mobility. Interventions included applying moisturizer to the skin as needed and monitoring and documenting skin changes with the physician. The comprehensive care plan initiated on 11/13/23 documented that the resident had an unstageable pressure ulcer on the left heel related to the CAM boot. Interventions included to avoid clothing/devices and footwear that may impede healing; evaluate the wound weekly and as needed, and monitor the dressing daily to ensure it is clean and dry. The physician order dated 11/14/23 documented to apply Skin Prep Wipes to top of left foot and left heel topically every evening shift for Deep Tissue Injury. Cleanse with normal saline, pat dry and apply skin prep daily. The registered nurse progress note dated 11/15/23 at 10:06 AM documented the resident had deep tissue injuries to the left heel (new) and top of foot (present on admission) under the CAM boot. The resident had not been wearing the CAM boot properly and was wearing it at all times. The physician was made aware and stated to continue weight bearing as tolerated and wear the CAM boot when out of bed as per the hospital recommendation. The wound care consult notes dated 11/14/23, 11/21/23, and 11/28/23 documented that the resident's wounds were measured and to continue Skin Prep treatment once a day. The November 2023 Treatment Administration Record documented: - To inspect the skin under CAM boot every shift and report any abnormal findings every shift for CAM boot (initiated 11/2/23). There was no documentation for the 7 AM to 3 PM shift on 9 of 28 days; for the 3 PM to 11 PM shift on 6 of 28 days; for the 11 PM to 7 AM shift on 14 of 29 days. - Skin Prep Wipes to the left heel and top of the left foot (start date 11/15/23) had no documentation for 9 of 16 days. - Weekly skin evaluation done on Monday during day shift with instructions to complete the Weekly Skin Monitoring form was not documented as completed for the month of November 2023. Weekly Skin Monitoring forms dated 11/9/23 at 8:41 PM, 11/16/23 at 8:41 PM, and 11/23/23 at 8:42 PM were all completed on 11/28/23. The wound care consult note dated 12/05/23 documented a Stage 2 pressure wound of the left heel wound measured 2.4 centimeters x 1.7 centimeters x 0.1 centimeters (Length x width x depth) and the treatment was changed to Medihoney. The unstageable deep tissue injury to the left dorsal foot was resolved. A physician order dated 12/5/23 documented to apply Medihoney Wound Gel to the left heel topically every day shift starting 12/6/23. Review of the December Treatment Administration Record revealed the treatment was not done on 12/6/23 and there was no documented reason for the omission. During an interview on 5/21/24 at 11:00 AM, Certified Nurse Aide # 2 stated they did not remember if the resident's CAM boot had come off. During an interview on 5/21/2024 at 11:14 AM, Licensed Practical Nurse # 8, responsible for 4 of the missed Skin Prep treatments on the November 2023 Treatment Administration record, stated they signed up for all the treatments they performed. They stated the CAM boot did come off when the resident was in bed. During an interview on 5/21/2024 at 11:30 AM, Licensed Practical Nurse # 9 stated all the treatments they performed were documented. They did not remember if the CAM boot came off or was worn all the time. During an interview on 5/21/2024 at 11:45 AM, Director of Rehabilitation # 10 stated that the resident came from Orthopedics with the CAM boot in place and weight bearing as tolerated when wearing the CAM boot. During a phone interview with the Administrator and Director of Nursing #2 on 9/11/2024 from 9:31 AM to 9:58 AM, they reviewed the resident's record and stated Resident #3 was admitted on [DATE]. They stated the skin integrity care plan was initiated on 11/13/23 but the nutritional care plan dated 11/5/24 had interventions for skin monitoring. They stated there was an unstageable ulceration to the left foot on admission. They were unaware if any interventions or treatments were put in place at that time or if the physician was notified. When reviewing the November 2023 Treatment Administration Record, they stated the Skin Prep treatments for the left heel and left dorsal foot were ordered 11/14/23 to be initiated on 11/15/23 and from 11/15/23 to 11/30/23 the treatment was performed 9 of 16 days. They stated the resident was non-compliant with the CAM boot and at times difficult. The facility was unable to provide documentation including care plan interventions for skin integrity prior to the development of the heel pressure injury, physician notification of the dorsal foot pressure injury present on admission, and the resident's non-compliance with treatments. 10NYCRR 415.12(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during an abbreviated survey (NY00336418) the facility did not maintain adequate supervision to prevent an elopement for 1 of 4 residents reviewed for accidents (Resident #2). Specifically, Resident #2 left the building on 1/22/24 and staff did not notice the resident's absence until 1/23/24 when the nurse could not find the resident for morning medications. The facility called a Code Gray (missing resident alert) and the resident was located by phone at a friend's house. The resident returned to the facility around 2 PM on 1/23/24. Findings include: The policy and procedure titled Elopement - Missing Resident, revised 1/2020 documented it was the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as practical. Should an employee discover that a resident is missing from the facility, they should announce on the overhead paging system CODE GRAY. Upon return to the facility examine the resident, complete and file an incident report; and make appropriate entries into the resident's medical record. The facility policy and procedure titled Out on Pass / LOA (leave of absence) documented it was the policy of the facility to safeguard the health and welfare of all residents in its care. The facility honors the residents' right to temporarily leave the facility if they are determined to be safe to do so. The procedure included that the resident and/or responsible party would complete the Out On Pass Agreement with the unit manager/designee, including their destination, relationship to the resident, contact information and expected time of return to the facility before leaving. The resident or representative will be advised to inform nursing in advance if the time Out on Pass will exceed 4 hours, to ensure there will be no interruption to the resident's medication administration, treatment, therapies, or any nursing care. The procedure also included leaving a copy of the agreement with the receptionist. The Elopement assessment dated [DATE] documented that the resident was not at risk for elopement. A physician order dated 12/11/2023 documented the resident may go out on a leave of absence with the responsible party. Review of Certified Nurse Aide documentation for January 2024 revealed that the Certified Nurse Aide responsible for the resident, did not sign for Resident #2's cares on shift beginning at 11 PM on 1/22/24 and ending at 7 AM on 1/23/24. The facility monthly census dated January 2024, documented the Resident #2 was in attendance at the facility for 31 of 31 days. An Out-on-Pass Agreement form dated 1/22/24 was signed by the resident, their representative and Registered Nurse #6 and documented the resident was leaving the facility on 1/22/24 and returning on 1/23/24, however the form was not complete and did not have the date or time the resident returned. A Nursing Progress note by Registered Nurse #6, dated 1/23/2024, documented that the resident arrived at the facility at approximately 2:00 PM. Upon returning to the facility, the resident was evaluated and denied any discomfort or distress, showed no signs of injury, and showed no bruising. They discussed the leave of absence policy to the resident and the resident verbalized understanding. A physician progress note dated 1/24/24 documented the resident went on a leave of absence overnight with the responsible party and was counseled on the facility process for leave of absence. During an interview on 5/20/24 at 1:10 PM Receptionist #4 stated they covered the front door for the evening shift on 1/22/24. They stated when they left the desk for breaks, someone always relieved them. They stated they were unaware the resident left that evening and there was not an Out on Pass Agreement form left at the front desk. During an interview on 5/20/24 at 1:30 PM, Unit Clerk #5 stated that on 1/23/24 at 8:00 AM, they were covering the front desk and Registered Nurse #6 called Code Gray. They stated there was not an Out on Pass Agreement at the desk. They stated they called Resident #2's designated representative, and found out the resident was there. During a phone interview on 5/23/2024 at 9:53 AM, Resident #2 stated they went on an overnight visit with a friend in late January. They said when they left the building there was no one at the front desk so there was no one to tell. They stated they left around 5 PM or 6 PM and returned the next day in the afternoon. They stated when they returned, they were asked to sign something. During an interview on 5/23/24 at 3:28 PM, Licensed Practical Nurse #12 stated they worked the night shift and did not know the resident was out on pass. The resident was discovered missing during the medication pass on the morning of 1/23/24. The Director of Nursing and the Registered Nurse #6 were notified, and a Code Gray (missing person alert) was called. During the search, Unit Clerk #5 suggested calling the resident's friend and found that the resident was with him. Resident #2 returned to the facility on 1/23/24 at 2:00 PM. During an interview on 6/14/24 at 11:18 AM, Registered Nurse # 6 stated that the resident went out on pass on 1/22/24 and there was no documentation as to when they left the facility. On 1/23/24, staff could not locate the resident, so Code Gray was called. The resident's designated representative was called and said the resident was with them. Registered Nurse #6 stated upon the resident's return, on 1/23/24 at 2:00 PM, they counseled the resident, checked the resident's body, and updated the care plan. During a phone interview on 6/20/2024 at 1:37 PM., the Director of Nursing #1 stated that the resident did not elope, they were out on pass. They stated an elopement was when a resident with low cognition left the building unwitnessed. They did not do an incident form as they did not classify the event as an elopement. The resident took a leave of absence, and the paperwork was not completed. During a follow-up interview on 08/29/24 at 12:06 PM, Registered Nurse #6 stated that on 1/23/24 upon Resident #2's return to the facility from being out overnight, they provided Resident #2 and their representative education on leaving the facility without notifying staff. The education was provided by having Resident #2 and their designated representative sign the Out On Pass Agreement form, which was agreeing to the policy. Staff #6 stated that there was a lack of communication between the nursing staff because a nurse was aware that Resident #2 went out on pass on 1/22/24 and did not alert other staff. Staff #6 stated that they did not know Resident #2 was out of the facility until he was reported missing by staff, and they called a Code Gray. Registered Nurse #6 stated that at the point that the Code Gray was called, Resident #2 was considered missing, because it was not communicated or documented that they went out on pass. During an interview on 08/29/2024 at 01:58 PM, the Administrator stated that the census was done by the Business Office Manager in the morning. The Administrator stated the Business Office was supposed to be notified of resident's not in the building, especially for an extended period. The Administrator stated that anyone would be able to see in the computer if a resident was not in in the building. The Administrator stated there was a drop-down box in the computer system to document when a resident was on a leave of absence. The Administrator signed into the computer system showed the surveyor that there was no documentation that the resident was out of the building. They stated the section for leave of absence in the computer should have been completed. During an interview on 08/29/2024 at 02:55 PM, Certified Nurse Aide #14 stated that when they came in for duty the night of the 1/22/24, they were not given report and were not informed that Resident #2 was missing. Certified Nurse Aide #14 stated that when they did their rounds, they checked Resident #2's room, and reported to the nurse on the unit that Resident #2 was not in their room. 415.12(h)(a)

Based on record review and interviews conducted during an abbreviated and extended survey (#NY00318363), from 6/16/2023 to 6/20/2023, the facility did not ensure that all alleged incidents involving abuse, neglect, exploitation, mistreatment, or injury of unknown origin were reported immediately, but not later than 2 hours to the New York State Department of Health (NYSDOH). This was evident for 1 of 12 residents (Resident #1) reviewed for accidents. Specifically, Resident #1 exited the facility undetected on 5/31/23. The facility did not report the incident to the NYSDOH. The findings include: A Facility policy titled Elopement- Missing Resident, revised 1/2020, documented that after a resident elopement, the facility administration should complete a thorough investigation and notify appropriate state agencies as required. Resident #1 was admitted to the facility with diagnoses that included Schizophrenia, Aphasia (difficulty speaking), and Hypertension. The Quarterly Minimum Data Set (MDS, a resident assessment tool) dated 4/8/23 documented Resident #1 had moderate cognitive impairment, had physical and wandering behaviors, wore a wander/elopement alarm, and received psychotropic medications. A facility Accident/Incident Report dated 5/31/23 documented Resident #1 eloped from the facility on 5/31/23, returned to the facility by local emergency medical services and was transferred to the hospital for evaluation and treatment of injuries attained during the elopement incident. There was no documented evidence the facility reported Resident #1's elopement on 5/31/2023 to the NYSDOH. During an interview on 6/15/2023 at 10:35 AM, the Director of Nursing stated the Administrator was responsible for reporting incidents to the NYSDOH and they were unsure why the Administrator did not report Resident #1's elopement on 5/31/23. During an interview on 6/16/2023 at 4:50 PM, the facility's Administrator stated they were responsible for reporting resident incidents to the NYSDOH. The Administrator was unable to provide a reason why they did not report Resident #1's elopement to the NYSDOH. The Administrator further explained they should have reported Resident #1's elopement to the NYSDOH, and they did not. 10NYCRR415.4(b)(2)(3)

Based on observations, record review and interviews conducted during a recertification survey, it was determined that the facility did not ensure proper food storage in the facility kitchen according to professional standards for food safety practice to prevent foodborne illness. The findings include: The Food Storage Policy created 4/2017 and last revised 3/9/2018 was reviewed. The Policy states sufficient storage policies will be provided to keep foods safe, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Perishable food such as meat, poultry, fish, dairy products, fruits, vegetable, and frozen products must be frozen or stored in the refrigerator or freezer immediately after receipt to assure nutritive value and quality. Refrigeration temperatures should be thermostatically controlled to maintain food temperatures at or below 41 degrees F and freezer temperatures to keep food frozen solid. Refrigerated food storage: all foods should be covered labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by date, or frozen or discarded. During the initial tour of the facility kitchen on 12/29/21 at 9:22 AM the following observations were noted: In the produce walk-in refrigerator, a box of Romaine Lettuce containing one large plastic bag of several bunches of spoiled romaine lettuce was observed. Beneath the box was dark drainage on the produce shelf. A plastic bag of undated carrots that were darkened in color and had a darkened liquid inside the bag. Walk- in pantry that had large undated cans of fruit, and six (6) quarts of nectar thick dairy product expired as of 12/21/21. On 12/29/21 at 9:38 AM an interview was conducted with the facility Food Service Manager #1 (FSM) regarding the above issues. They stated they were unaware of the above issues and did not have an explanation as to how or why they occurred. They stated the expired or spoiled foods will be disposed of and they will have the walk-in freezer cleaned. On 12/29/21 at 10:01 AM an interview was conducted with the Regional FSM(RFSM) who stated they arrived at the facility the day before. They stated they did realize upon arrival that there were some issues that needed to be addressed but had not yet done so. On 12/30/21 at 8:45 AM Upon entering the kitchen a new FSM #2 was introduced to the surveyor. They stated they were directed to the facility last evening as the prior FSD had left the facility and taken the cook and food service aides with them They stated upon arriving at the facility they assessed that the kitchen had numerous needs and will be addressing them by priority as quickly as possible. 483.60(i)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the most recent recertification survey, the facility did not ensure that necessary dental services were provided in a timely manner for one of two residents reviewed for dental services (Resident #12). Specifically, a dental follow-up visit recommended by the dentist was not scheduled to address the resident's need for a partial lower denture. The findings are: Resident #12 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and Seizure Disorder. The quarterly Minimum Data Set ( MDS-a resident assessment tool) dated 9/5/19 showed that the resident obtained a BIMS (brief interview for mental status) score of 7 indicating severe cognitive impairment. A review of the dental consultation notes dated 9/3/19 showed that the resident wears an upper denture and that his lower jaw has few remaining teeth. The dentist recommended that the resident be seen for a follow-up visit for a partial lower denture. A review of the medical record showed no documented evidence that the resident was scheduled for any follow-up dental services. During an interview on 12/3/19 at 1:07 PM, the resident stated that he had a dentist appointment in September 2019 because he had trouble eating certain foods and needed a lower denture. During this interview, the surveyor observed that the resident has few remaining teeth on his lower jaw. An interview with the Unit Manager on 12/5/19 revealed that when residents returned to the facility after seeing a specialist, the Unit Clerk reviews the reports and schedules follow up visits for future appointments. The Unit Manger further stated that this was not done as the Unit Clerk was new and missed scheduling the resident's follow-up appointment. 415.17(b)