**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #65: Resident #65 was admitted to the facility with diagnoses of respiratory (lung) failure, coronary artery disease (heart disease that occurs when the arteries that supply blood to the heart narrow), and anxiety. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and was able to understand others. The assessment documented impairment to upper extremities on both sides and impairment to lower extremity on one side. The resident required partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathing, and upper body dressing. The resident required substantial/maximal assistance with lower body dressing and personal hygiene. The resident was frequently incontinent of bowel and bladder. During an interview on 1/08/2025 at 1:41 PM, Resident #65 stated they had problems with some of the Certified Nurse Aides. Stated their regular aide was good, but some of the aides were very rude and short with them. Stated they were often left in a wet bed for hours. Resident #65 stated they wait all night to get assistance. Stated they would put their call light on, and the aide would come into the room and turn the light off. Stated they would leave the room and never come back. Stated they had to ask for assistance with activities of daily living such as washing up and toileting. Stated the aide would tell them to do it yourself. Stated they could not do it alone all the time secondary to having the tracheostomy and shortness of breath. Stated the aides were very abrupt and then leave the room. Resident #65 stated they had spoken to the nurse manager and there has been no resolution. Stated that one aide told them it was the nurse manager's problem. Resident #65 could not identify the Certified Nurse Aides but said some of them still worked in the facility and some have left. Stated they thought they were Certified Nurse Aides who were from a travelling agency. During an interview on 1/08/2025 at 1:48 PM, Registered Nurse #2 stated there was a turnover of staff, specifically Certified Nurse Aides. Stated Certified Nurse Aides would stay for a few months and then leave. Stated it was mostly the travel Certified Nurse Aides that would leave. Stated they had not received any complaints from residents. Stated Resident #65 preferred certain staff. Stated that in the past, Resident #65 had a problem with a Certified Nurse Aide, stating they were rude. They stated they talked to the aide at that time and provided them with an onsite in-service. Stated it was a female Certified Nurse Aide and they did not notify Administrator #1 or Director of Nursing #1. During an interview on 1/08/2025 at 1:53 PM, Director of Nursing #1 stated they did not recall a staff member reporting a Certified Nurse Aide that was being inappropriate. Stated they had addressed an issue in the past with another resident who had a preferred Certified Nurse Aide because they felt they had to argue with Certified Nurse Aide staff. 10 New York Code Rules and Regulations 415.5(a) Based on record review and interview during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life for 2 (Resident #s 39 and 65) of 106 residents reviewed. This is evidenced by: The Policy and Procedure titled, Resident Rights and Dignity, revised 11/2018, documented it was the facility's policy to ensure that all residents' rights were ensured and respected. In addition, the facility would maintain strict adherence to state and federal guidelines with regards to granting residents' rights, maintaining resident dignity, and ensuring a pleasant and home-like environment for residents and their families. Resident #39: Resident #39 was admitted to the facility with diagnoses of acute and chronic respiratory failure with hypoxia (low levels of oxygen in blood), tracheostomy (surgical procedure that creates an opening in the trachea (windpipe) through the front of the neck, and injury of the spinal cord (at the neck level). The Minimum Data Set (an assessment tool) dated 10/23/2024, documented the resident was cognitively intact. The resident was able to make themselves understood and was able to understand others. The Care Plan fo Activities of Daily Living documented the following: Dressing, Grooming, Feeding, Bathing, Toileting, Personal Hygiene, revised 10/24/2024, with a goal that the resident would be clean, dry, and groomed daily. Care plan interventions documented to check and change incontinent briefs every 2-4 hours and as needed. During an interview on 12/30/2024 at 2:57 PM, Resident #39 stated that the night before, 12/29/2024, they had to wait 5 or 6 hours during the evening shift to get changed when their brief was wet. During a subsequent interview on 1/08/2025 at 12:46 PM, Resident #39 stated they were offended by staff who were always angry and would scold them. Resident #39 stated they had asked a Certified Nurse Aide to put their medicated powder on them and was told it was in an angry tone it was not their job; it was the nurse's job. Resident #39 stated, 'The Certified Nurse Aides make it look like I am being taken care of when I am not.' Resident #39 stated that it 'seemed to be a policy here.' They further stated they would activate their call light, for the Certified Nurse Aide to come in and turn it off, and would not help them. Resident #39 stated Certified Nurse Aides 'leave them wet half the night.' During an interview on 1/7/2025 at 11:45 AM, Licensed Practical Nurse #2 stated Resident #39 was dependent on 1 staff for their personal care needs. Stated they were not aware the resident had been left in a wet brief for 5-6 hours on 12/29/2024. Stated Certified Nurse Aides should be checking the resident's brief as care planned. Stated Certified Nurse Aides should be answering the resident's call light in a timely manner and assisting the resident at that time.

Resident #64 Resident #64 was admitted to the facility with diagnoses of major depressive disorder, generalized anxiety disorder, and psychotic disorder with delusions (disorder characterized by disconnection from reality which results in strange behavior). The minimum Data Set (an assessment tool) dated 10/24/2024 documented that the resident could understand, be understood, and was cognitively intact. The Preadmission Screening and Resident Review dated 07/12/2021 for Resident #64 was incomplete, with questions 31, 32 (danger to self or others), and 33 (level 2 referrals) unanswered. During an interview on 01/03/2025 at 12:21 PM, Admissions Staff #1 stated the screen was completed at the hospital and reviewed by admission staff for completion, dates and signature. During an interview on 01/03/2025 12:30 PM, Director of Nursing #1 stated the Screen forms should have been reviewed by the Admissions department and sent back to the hospital if it they were incomplete. 10 New York Code of Rules and Regulations 415.11(3) Based on record review and interviews during the recertification survey, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 2 (Resident # ' s 30 and 64) of 24 residents reviewed. Specifically, the Preadmission Screening and Resident Review (PASARR, New York State Department of Health form 695) was incomplete for Residents #30 and 64. This is evidenced by: The facility Policy titled, Assessment Prior to Admission, last revised September 2011 documented recipient was to be admitted without an assessment prior to admission of the need for the intended level of care using New York State mandated forms. The screen must be completed and signed by a qualified professional. Resident #30 Resident #30 was admitted to the facility with diagnoses of anoxic brain damage (brain damage caused by lack of oxygen), anxiety disorder, and chronic respiratory (lung) failure. The Minimum Data Set (an assessment tool) dated 12/05/2024 documented that the resident was in a persistent vegetative state. The Preadmission Screening and Resident Review dated 10/30/2024 for Resident #30 was incomplete, with questions 23 through 26 (level 1 review for mental illness, mental retardation, and developmental disability) unanswered.

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for 1 (Resident #10) of 3 residents reviewed. Specifically, Resident #10 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by: The facility's Policy and Procedure titled, Activities, effective 9/30/2023, documented, the purpose was to provide structured and engaging activities that promoted the physical, mental, and emotional well-being of all participants, ensuring compliance with New York State Department of Health and Centers for Medicare & Medicaid Services regulations. Resident #10 was admitted to the facility with diagnoses of anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells), chronic respiratory failure ( shortness of breath and or difficulty breathing that develops over time), and asthma (inflammation and muscle tightening around the airways, which makes it harder to breathe). The Minimum Data Set (an assessment tool) dated 11/2024, documented the Brief Interview for Mental Status was not completed, and that the resident could understand and be understood by others. The Comprehensive Care Plan dated 10/2024, documented Resident #10 needed 1-to-1 structured multi-sensory activities to stimulate cognitive functioning through religious visits, conversation, tactile therapy, music therapy, and light hand massage. They were unable to develop meaningful routine daily, staff must anticipate all activity needs and interventions. Interventions: Turn on animated cartoons daily. Weekly 1-to-1 visit to promote sensory, cognitive, and social stimulation. During observations on 12/30/2024 at 1130 AM, 12/31/2024 at 10:00 AM, 1/02/2025 at 2:40 PM, 1/03/2025 at 1:00 PM, and 1/06/2025 at 9:45 AM, Resident #10 was observed in their room, in bed alone with the television on. During an interview on 1/07/2025 at 11:11 AM, Director of Activities #1 stated residents who did not attend group therapy had 1-to-1 activities once per week. They stated there were multiple staff members in and out of resident room daily such as medication nurse, respiratory therapists, certified nurse aides that were considered part of daily activity. A barber service visits the facility twice per month to give haircuts and shave. Director of Activities #1 stated they had 5 Activities Staff members for their department. In order to provide more frequent 1-to-1 activity sessions, the Activities Department would need an additional 10 staff members. Resident #10's December 2024 Activity Log for 1-to-1 sessions was blank with the exception of 12/28/2024 and 12/31/2024. During an interview on 1/07/2025 at 12:07 PM, Director of Activities #1 stated Resident #10 did not tolerate sitting in wheelchair. Director of Activities #1 also stated for ventilator-dependent residents to attend group therapy, they must be able to tolerate out of bed to chair, and respiratory therapy and or family member must be present during activity. During an interview on 1/07/2025 at 12:09 PM, Licensed Practical Nurse #2 stated Resident #10 did not attend group activities. They stated not every resident got up and out of bed daily. It depended on staffing, and if an aide had them frequently, sometimes the aide would get them up. Licensed Practical Nurse #2 stated some residents had daily routines where they got up daily and some did not. Licensed Practical Nurse #2 stated that it was also related to staffing for the day. They stated Resident #10 had not gotten out of bed in a week and did not attend group activities. During an interview on 1/07/2025 at 12:32 PM, Director of Respiratory Therapy #1 stated all residents at this facility could attend group activities; Ventilator dependent residents who attended activities would use the same ventilator that they used while in their room; When leaving the room, the ventilator would be disconnected from the outlet and then function on its battery; The ventilator also had a portable monitor that went along with it. Director of Respiratory Therapy #1 further stated residents who were ventilator dependent did not have any restriction for getting out of bed or leaving their rooms. Director of Respiratory Therapy #1 stated they were never informed of Resident #10 having respiratory difficulty when out of bed. During an interview on 1/07/2025 at 12:45 PM, Director of Nursing #1 stated some residents did not get out of bed daily because they could not tolerate it clinically. For those cases, residents would receive 1-to-1 therapy and or activities. Residents who were ventilator dependent had no restrictions for getting out of bed or engaging in activities. During an interview on 1/07/2025 at 3:17 PM, Administrator #1 stated the facility conducted group activities daily and 1-to-1 individual activity as frequently as possible; The Activities Department was recently changed with a new director; Staffing was increased to meet demands for staff to patient ratio. Administrator #1 stated they were currently working on new ideas to enhance all activities. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Facility assessment dated [DATE], documented the average daily census was 109. The number of residents dependent on assistance with activities of daily living documented: 95 residents for both bathing and dressing 90 residents for transfer 69 residents for eating 102 residents for toileting 99 residents who were in a chair most of the time were dependent for mobility The facility assessment documented a Certified Nurse Aide Staffing Plan (the number of Certified Nurse Aides for each unit and shift) for 7 days as follows for the Traumatic Brain Injury unit: -- 4 for the 7:00 AM to 3:00 PM day shift, -- 4 for the 3:00 PM to 11:00 PM evening shift, and -- 2 for the 11:00 PM to 7:00 AM night shift. The facility assessment documented a Certified Nurse Aide Staffing Plan (the number of Certified Nurse Aides for each unit and shift) for 7 days as follows for the Sub-Acute/Ventilator unit: -- 4 for 7:00 AM to 3:00 PM day shift, -- 4 for the 3:00 PM to 11:00 PM evening shift, and -- 2 for the 11:00 PM to 7:00 AM night shift. The facility assessment documented a Certified Nurse Aide Staffing Plan (the number of Certified Nurse Aides for each unit and shift) for 7 days as follows for the Pediatrics unit: -- 3 for the 7:00 AM to 3:00 PM day shift, -- 3 for the 3:00 PM to 11:00 PM evening shift, and -- 1 for the 11:00 PM to 7:00 AM night shift. A review of the Facility Scheduling Worksheets (daily staffing sheets) dated from 12/07/2024 to 1/08/2025 documented the following units were short Certified Nurse Aides: Saturday, 12/07/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift, 2 on the evening shift, and 1 on the night shift until 5:15 AM. Sunday, 12/08/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 2 Certified Nurse Aides on the day shift, 2 on the evening shift, and was short 1 on the night shift until 5:15 AM. -- The Sub Acute/Vent had a census of 33 and was short 2 Certified Nurse Aides on the day shift, 2 on the evening shift, and 1 on the night shift. Wednesday, 12/11/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift, 1 at the start of the evening shift at 3:00 PM and was short 2 as of 3:50 PM. Saturday, 12/14/2024: -- The Traumatic Brain Injury) unit had a census of 39 and was short 2 Certified Nurse Aides on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 36 and was short 1 Certified Nurse Aide on the evening shift. Sunday, 12/15/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 1 Certified Nurse Aide on the day shift, 1 on the evening shift, and 1 on the night shift until 5:30 AM. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift, and 1 on the evening shift. -- The Pediatrics unit had a census of 36 and was short 1 Certified Nurse Aide on the evening shift. Monday, 12/16/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 2 on the evening shift. Tuesday, 12/17/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 2 Certified Nurse Aides on the evening shift. -- The Sub Acute/Vent unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Wednesday, 12/18/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Thursday, 12/19/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift and 1 on the night shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift. Friday, 12/20/2024: -- The Traumatic Brain Injury unit had a census of 38 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift. Saturday, 12/21/2024: -- The Traumatic Brain Injury unit had a census of 38 and was short 1 on the day shift and 1 on the night shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day, evening, and night shifts. Sunday 12/22/2024: -- The Traumatic Brain Injury unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 2 Certified Nurse Aides on the day shift and 2 on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Monday 12/23/2024: -- The Traumatic Brain Injury unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Tuesday, 12/24/2024: -- The Traumatic Brain Injury unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Wednesday, 12/25/2024: -- The Traumatic Brain Injury unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift, 1 on the evening shift, and was short 1 on the night shift, as of 12:30 AM. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift. Saturday, 12/28/2024: -- The Traumatic Brain Injury unit had a census of 38 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 2 Certified Nurse Aides on the day shift and 2 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Sunday, 12/29/2024: -- The Traumatic Brain Injury unit had a census of 37 and was short 3 Certified Nurse Aides at the start of the day shift at 7:00 AM and as of 10:00 AM was short 2 Certified Nurse Aides. At the start of the evening shift at 3:00 PM, was short 2 Certified Nurse Aides and at 8:00 PM was short 3 Certified Nurse Aides. -- The Sub Acute/Vent unit had a census of 34 and was short 2 Certified Nurse Aides on the day shift as of 7:18 AM. At the start of the evening shift at 3:00 PM, the unit was short 2 Certified Nurse Aides, and as of 8:00 PM, was short 3 Certified Nurse Aides. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift. On the evening shift at 3:00 PM, was short 1, and at 5:00 PM was short 2. Monday, 12/30/2024: -- The Traumatic Brain Injury unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 2 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Tuesday, 12/31/2024: -- The Traumatic Brain Injury unit had a census of 37and was short 2 Certified Nurse Aides on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 2 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Wednesday, 1/01/2025: -- The Traumatic Brain Injury unit had a census of 36 and was short 2 Certified Nurse Aides on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 2 Certified Nurse Aides on the day shift and 1 on the evening shift. -- The Pediatric unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Thursday, 1/02/2025: -- The Traumatic Brain Injury unit had a census of 35 was short 1 Certified Nurse aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift. Friday, 1/03/2025: -- The Traumatic Brain Injury unit had a census of 35 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the evening shift. Saturday, 1/04/2025: -- The Traumatic Brain Injury unit had a census of 35 and was short 1 Certified Nurse Aide on the evening shift. On the night shift, was short 1 until 5:00 AM. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift. Sunday, 1/05/2025: -- The Traumatic Brain Injury unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Monday, 1/06/2025: -- The Traumatic Brain Injury unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Tuesday, 1/07/2025: -- The Traumatic Brain Injury unit had a census of 35 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Wednesday, 1/08/2025: -- The Traumatic Brain Injury unit had a census of 36 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift. -- The Pediatrics unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift. Census data for the Traumatic Brain Injury, Sub Acute/Ventilator, and Pediatrics units for December 2024 and January 2025 provided by the facility documented the following: CENSUS DECEMBER 2024 Day-Month, Traumatic Brain Injury Unit Census, Sub-Acute/Ventilator Unit Census, Pediatrics Unit Census, Total Census 1-December 39 33 36 108 2-December 39 33 36 108 3-December 39 33 36 108 4-December 39 33 36 108 5-December 39 33 35 107 6-December 39 34 35 108 7-December 39 33 35 107 8-December 39 33 35 107 9-December 39 33 35 107 10-December 39 33 35 107 11-December 39 33 35 107 12-December 39 33 35 107 13-December 39 34 36 109 14-December 39 34 36 109 15-December 39 34 36 109 16-December 39 34 36 109 17-December 39 33 35 107 18-December 39 34 35 108 19-December 39 34 35 108 20-December 38 34 35 107 21-December 38 34 35 107 22-December 37 34 34 105 23-December 37 34 34 105 24-December 37 34 34 105 25-December 37 34 34 105 26-December 37 34 35 105 27-December 38 34 35 107 28-December 38 34 35 107 29-December 37 34 35 106 30-December 37 34 35 106 31-December 37 34 35 106 CENSUS JANUARY 2025 Day-Month, Traumatic Brain Injury Unit Census, Sub-Acute/Ventilator Unit Census, Pediatrics Unit Census, Total Census 1-January 36 34 35 105 2-January 35 34 35 104 3-January 35 34 35 104 4-January 35 34 34 103 5-January 34 34 34 102 6-January 35 34 34 103 7-January 35 34 33 102 8-January 36 34 33 103 During an interview on 12/30/2024 at 2:55 PM, Resident #64 stated they stayed in bed all when there was not enough staffing because they required the assistance of 2 staff and a mechanical lift for transfers out of bed. During an interview on 12/30/2024 at 12:07 PM, Family Member #1 stated there were times when the facility was short staffed. During an interview on 12/30/2024 at 2:57 PM, Resident #39 stated the facility was 'severely' understaffed on a regular basis and was short staffed on all shifts. They stated that last night, 12/29/2024, they had to wait 5 or 6 hours during the evening shift to get changed when their incontinence brief was wet. The resident stated there had been recent turnover with staff. During an interview on 12/30/2024 at 3:59 PM, Resident #52 stated there was a staffing problem. They stated the 3:00 PM to 11:00 PM shift was the worst and stated there was usually 1 Certified Nurse Aide on the unit. Resident #52 stated they could not get their shower on the 3:00 PM to 11:00 PM shift because the aide stated they could not handle the shower without another staff member to assist. They stated the evening shift did follow the care plan for brushing their teeth and changing them because they were short staffed. The resident stated they usually had to wait 30 minutes to one hour for care. During an interview on 12/31/2024 at 10:21 AM, Resident #260 stated that every time they needed to go to the bathroom, they were told to wait. During an interview on 12/31/2024 at 11:24 AM, Family Member #2 stated they were concerned there were not enough staff to correctly turn and position the resident. They stated there was often only 1 to 2 Certified Nurse Aides on the unit. During an interview on 1/08/2025 at 10:12 AM, Staffing Coordinator #1 stated they were also a Certified Nurse Aide and helped in many areas of the facility. They stated they looked at the facility census when they assessed the staffing needs and stated they had to 'balance' staff; They gave the units what they required and was aware of the number of nursing staff required for each unit. They stated the facility had been very good about staffing, but the gastrointestinal illness effected staffing on the (Pediatrics) unit. Traveler staff came and then they went back home to their home states. Stated staffing was bad this past week. Stated supervisors call them about weekend staffing. Staffing Coordinator #1 stated they would come in on Sunday to work. Stated they worked closely with supervisors, especially with staffing. Surveyor asked specifically about staffing on 12/29/2024. They stated that on the Sub Acute/Vent unit, a Certified Nurse Aide left at 7:18 AM due to a personal issue and another aide that was scheduled from an agency cancelled, leaving 2 aides on unit for the shift. They stated the Agency would just cancel and would not give a reason. They stated for 3-11 shift, there were 2 Certified Nurse Aides but 1 left at 8:00 PM, leaving 1 aide on the unit. On the Traumatic Brain Injury unit during the 3-11 PM shift, there were 2 aides and then 1 left at 8:00 PM to accompany a resident to the hospital. Stated the facility utilized Agency staff and had a sheet of agencies/staff/phone number they provide to the supervisors. The facility had 5 contracted agencies but only 3 were providing nursing staff. The facility requires 3 days of training for agency staff. Staffing Coordinator #1 was called when by staff when they were not coming in or staff would call the off-shift supervisor. Stated December staffing was 'hit or miss' due to flu or flu-like symptoms. Stated the facility did float staff to other units. During a subsequent interview on 1/08/2025 at 12:46 PM, Resident #39 stated there was a lot of staff in the building today. They stated when the unit was short staffed, they had to wait for care. They stated The Certified Nurse Aides would come into the room after they (the resident) puts their call light and then is told by them to give them a minute but then they do not come back for 2 hours. They stated it was a problem during the weekend more than the week when sometimes they only had 1 person (aide) on the unit who had 18-20 people to provide care to. During an interview on 1/10/2025 at 10:27 AM, Administrator #1 stated there was turnover from out of state staffing in December. Stated several staff left with no notice: 4 in early December, and then 2 in the week of 12/30/2024. Stated the out-of-state Certified Nurse Aide staff were not contracted and were facility employees. Stated that during the sudden staff shortage in December, the facility brought in agency staff for the short term. Stated the facility had new hires as of 1/7/2025 and were orienting 7 new Certified Nurse Aides. The biggest issue was Criminal History Record Check which took 'months.' Stated the facility did not bring in staff without clearance due to the vulnerable population. The facility currently offered a sign on bonus, had increased the base rate of pay, and offered a shift differential. Stated there was continuous overtime pay. Stated that although the facility had stressed to new hires that it was a 'different' facility, staff often state they were not aware of the heavy patient care load and then resign. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii) Based on observation, record review, and interviews during the recertification survey, the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's minimum staffing level of Certified Nurse Aides was not consistently met every day on 3 of 3 Nursing units from 12/07/2024 to 1/08/2025. This is evidenced by: Upon entrance to the facility on [DATE], there were 106 residents residing on 3 units. The Policy and Procedure titled, Nursing Services and Sufficient Staff, revised 5/2023, documented it was the facility's policy to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population would be considered based on the facility assessment. The facility would supply services by sufficient numbers of staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans except when waived, licensed nurses and other personnel, including but not limited to nurse aides.

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, (a.) an opened medication had no open and/or expiration date; (b) 3 medications were passed expiration dates; (c.) medication requiring refrigeration were stored in the medication cart unrefrigerated, and (d.) shift change narcotic count signatures were missing on several dates, for 3 out of 3 medication carts reviewed. This is evidenced by: The Facility's Policy and Procedure titled, Medication Storage, revised 1/03/2017, documented, Medications listed in Schedules II, III, IV, and V would be stored under double locked conditions. The access key to the controlled medications was not the same key that allowed access to other medications. The medication nurse on duty would maintain possession of a key to the controlled medications and does not relinquish the key until a count has been completed and thus, the transfer of responsibility for the key and controlled medications has been completed. Controlled medications would be counted every eight hours (at change of shift 7:00 AM, 3:00 PM, and 11:00 PM) and as needed with the nurses beginning and ending a tour of duty with assignment of medication administration for a particular patient grouping. The oncoming nurse handled and counts the remaining controlled medications and the outgoing nurse records the amount noted. The actual amount of the controlled medication present would be compared to the remaining amount Indicated on the Controlled Substance Record and the amount remaining would be recorded on the Controlled Medication Change of Shift Audit form. Both nurses Involved in the count would sign the Controlled Medication Change of Shift Audit form verifying the integrity of the Information represented. The Facility's Policy and Procedure titled, Insulin Administration and Safety, revised July 2015, documented, Storage in of insulin Vials and FlexPen: The individual manufacturer's storage recommendations and expiration dates must be followed. These usually suggest that o Insulin vials and FlexPen pen must never be frozen. o Direct sunlight or warming (in hot climates) damages insulin. o Unused insulin vials and FlexPen should be stored in a refrigerator. o After opening, an insulin vial and FlexPen should be discarded per manufacturer recommendation. MIX insulin-Novolog 70/30=14 days; Rapid acting- Novolog R =28 days and Long acting- Levemir/ Lantus= 42 days. The Facility's Policy and Procedure titled, Medication Administration, revised 3/19/2018 documented, pre-mixed medications from pharmacy with a label 'Refrigerate' should be kept in the refrigerator at all times. Never give a medication that has expired. During an observation on 1/02/2025 at 10:36 AM on the Traumatic Brain Injury Unit, the Shift Change Narcotic Count for Cart B was noted to have missing signatures on the following dates: 12/23/2024 7-3 PM and 3-11 PM shifts; 12/25/2024 7-3 and 3-11 PM shifts; 12/27/2024 3-11 PM shift; 1/1/25 3-11 PM shift. The Ventilator Unit, Cart B was noted to have no signatures for 1/2/2025 7-3 PM shift. There were no discrepancies in the medications. During an observation on 1/02/2025 at 10:40 AM on the Traumatic Brain Injury Unit, Medication Cart B contained 1 bottle of artificial tears with an expiration date of 12/08/2024. At the time of observation, Registered Nurse #1 stated they were unaware the medication had expired 30 days after opening, and they were not aware of medication that had shortened expiration dates after opening. During an observation on 1/02/2025 at 11:00 AM on the Traumatic Brain Injury Unit, Medication Cart A, contained an opened bottle of Omeprazole liquid medication labeled 'keep refrigerated.' At the time of observation, Registered Nurse #2 stated this was an oversight and immediately placed medication in medication room refrigerator. During an observation on 1/02/2025 at 11:30 AM on the Ventilator Unit, Medication Cart B contained 1 bottle of Systane eye drops with an expiration date of 11/30/2024; 1 bottle of Alphagan 0.1% eye drops with an expiration date of 12/30/2024, and 1 Lantus insulin pen with no open and expiration date. At the time of observation, Licensed Practical Nurse #1 stated expired medications should be discarded and not used. During an interview on 1/02/2025 at 10:54 AM, Nurse Educator #1 stated there was a grid of medications with shortened expiration dates posted in the medication room; All nursing staff received training upon hire on the administration of medication including checking expiration dates; During orientation each nurse was observed and signed off on proper shift change narcotic count; During shift change narcotics were counted and signed by two nurses, the outgoing and oncoming nurse. During an interview on 1/2/2025 at 10:56AM, Director of Nursing #1 stated all clinical staff received Inservice training upon hire and annually on medication shortened expiration dates after opening. In addition, each nurse was observed and signed off on proper shift change narcotic count. During shift change narcotics were counted and signed by two nurses, the outgoing and oncoming nurse. This included nurses who we worked double consecutive shifts. Director of Nursing #1 stated they were not aware there were missing signatures in the narcotic signoff sheets; It was the responsibility of the unit manager to monitor narcotic signoff sheets daily. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation, record review and interviews during the recertification survey on 04/13/2022 through 04/19/2022 and abbreviated survey (Case #NY00290615), the facility did not maintain medical records in accordance with accepted professional standards and practices that are accurately documented and complete for 3 (Resident #'s 2, 32, and 89) of 21 residents reviewed. Specifically, the facility did not ensure daily Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) care was complete and accurate. This was evidenced by: The Policy and Procedure titled Documentation and dated 05/2019 documented, the clinical team shall document all relevant data and information pertaining to the provision of care and services to the residents in the medical record. Documentation is relevant as evidence of clinical practice. Resident #2: Resident #2 was admitted to the facility with the diagnoses of acute respiratory failure, tracheostomy, and anxiety disorder. The Minimum Data Set (MDS-an assessment tool) dated 04/05/2022, documented the resident had no cognitive impairment, could make self understood and could understood others. The Certified Nurse Aide (CNA) Assignment Summary documented the resident required extensive assistance of one person for bed mobility, dressing, and transfer. Documented the resident required total assistance of one person for locomotion, personal hygiene, and toilet use. The CNA Accountability for ADL Care dated 04/01/2022 thru 04/17/2022, did not include documentation of care provided on the following shifts and dates: -11:00 PM to 7:00 AM shift: 4/01/2022 through 4/07/2022 and 4/10/2022 through 4/12/2022, 4/15/2022 and 4/16/2022 -7:00 AM to 3:00 PM shift: 4/06/2022, 4/08/2022 through 4/16/2022, -3:00 PM to 11:00 PM shift: 4/02/2022 through 4/16/2022, Resident #32: Resident #32 was admitted to the facility with the diagnoses of respiratory failure, dependence on respirator, and neuromuscular scoliosis. The Minimum Data Set (MDS-an assessment tool) dated 1/19/2022 documented, the resident had moderate cognitive impairment and could usually make self understood and usually understood others. The Certified Nurse Aide (CNA) Assignment Summary documented the resident required total assistance of one person for bed mobility, dressing, locomotion, personal hygiene, and toilet use. The CNA Accountability for ADL Care dated 01/15/2022 thru 01/31/2022, did not include documentation of care provided on the following shifts and dates: -11:00 PM to 7:00 AM shift: 1/15/2022, 1/16/2022, 1/17/2022, 1/20/2022 through 01/31/2022. -7:00 AM to 3:00 PM shift: 1/15/2022, through 1/20/2022, 1/22/2022, 1/23/2022, through 1/31/2022. -3:00 PM to 11:00 PM shift: 1/15/2022, 1/16/2022, 1/17/2022, 1/19/2022, 1/24/2022, 1/26/2022, 1/27/2022, 1/29/2022, 1/30/2022. Resident #89: Resident #89 was admitted to the facility with the diagnoses of acute respiratory failure, dependence on respirator, and Multiple Sclerosis. The Minimum Data Set (MDS-an assessment tool) dated 03/23/2022 documented, the resident had severe cognitive impairment and could sometimes make self understood and sometimes understood others. The Certified Nurse Aide (CNA) Assignment Summary documented the resident required total assistance of one person for bed mobility, dressing, locomotion, personal hygiene, and toilet use. The CNA Accountability for ADL Care dated 4/01/2022 thru 4/14/2022, did not include documentation of care provided on the following shifts and dates: -11:00 PM to 7:00 AM shift: 4/01/2022, through 4/07/2022, 4/10/2022 through 4/12/2022. -7:00 AM to 3:00 PM shift: 4/01/2022 through 4/14/2022. -3:00 PM to 11:00 PM shift: 4/02/2022 through 4/14/2022. Interviews: During an interview on 4/15/2022 at 10:00 AM, CNA #3 stated they document the resident care in the computer every shift. Sometimes they are so busy that they do not get to finish all the documentation. During an interview on 4/18/2022 at 01:43 PM, Registered Nurse Manager #2 (RNM #2) stated, ideally, the Certified Nurse Aides (CNA) should have documented on each resident once they were done with care. The Nurse Managers and Supervisors were responsible to make sure the documentation was done. RNM #2 stated, the lack of CNA documentation was a surprise to them. During an interview on 4/18/2022 at 02:05 PM, Licensed Practical Nurse Manager #1 stated, the CNAs were supposed to document when all care was done on a resident. The Nurse Managers and Unit Nurses were supposed to oversee that the CNAs were completing their documentation. We knew there was an issue with CNA documentation, the Director of Nursing (DON) had talked to us about it. The Administrative Nurses from downstairs come up to help with care when needed as well as the therapists and they completed the CNA documentation for what they did. During an interview on 4/18/2022 at 2:42 PM the MDS Coordinator (MDS) stated the CNAs try to document when they can. The facility was aware of the problem with CNAs documentation. The MDS would help on the units when needed and would document the care provided, and would also help to document the intakes and bowel movements. During an interview on 4/19/22 at 10:02 AM, the Director of Nursing (DON) stated, they had spoken with the Nurse Managers about the CNA documentation not getting done and it was getting better. The residents were being cared for and that was the priority. The DON was working with the people from the computer company to come up with an easier way for the CNAs to document. We have all staff in the building trained to do certain things and help on the Units anytime they are needed. 10 NYCRR 415.22

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for one (Resident #24) of one reviewed for activities. Specifically, facility did not ensure that the resident received ongoing and appropriate activities based on the resident's abilities. This is evidenced by: Resident #24: The resident was admitted with diagnoses of chromosomal anomalies, epilepsy, and reflux. The Minimum Data Set (MDS-an assessment tool) dated 2019, assessed the resident as being in a persistent vegetative state. A Therapeutic Recreation and Arts assessment dated [DATE], documented preferred recreation consisted of movies, listening to music, radio reading and television. The resident showed little to no signs of response to activity stimuli and would mainly benefit from sensory stimulation 3-4 times a week. During observations; 12/04/19 at 10:30 AM, the resident was in a crib in the room. There was no music, television (TV), or lights on in the room. 12/05/19 at 9:30 & 10:35 AM, and 1:03 PM, the resident was in a crib in the room with the lights off. The was on and stationed on a news program broadcasting impeachment hearing. A Comprehensive Care Plan for Activities dated 10/2/12, documented the resident needed structured multi-sensory activities to stimulate cognitive functioning through religious visits, conversation, music, tactile therapy and light hand massages. Interventions documented to turn on the TV daily and encourage/provide one to one multi-sensory activities. The last assessment note dated 9/24/19 documented the resident received visits 3-4 times weekly for soft reading and light music. Progress note dated from 11/1/19 - 12/12/5/19, did not include documentation that the resident had any illness or respiratory issues during that time frame. Daily Activity Program Attendance Records (documentation of each resident that received activity for that day), dated from 11/2/19 - 21/5/19 did not include documentation that Resident #7 was provided with any activities for those days. Monthly Activity Attendance Records dated from 11/1/19 - 12/5/19, documented 8-15 minute units of music, sensory, and 1-1 social visits for each of the days and 10-15 minute units in each of the days for TV/movies. During an interview on 12/06/19 09:13 AM, the Activities Director (AD) stated the resident only got 1:1 visits as he/she did not have the ability to respond. They documented the resident had TV and movies because she expected CNAs or nurses to put the TV on and it should be on animation an or soft music. It was not appropriate to have no lights or music or to have new programs on. As long as the resident was awake staff were to have the lights on and appropriate music or TV on. She has staff visits on the evening shift. Sensory would be TV music or light hand massage depending on the resident. They do 15-minute increments. Daily activity attendance sheets do not have the resident in any activity. She is getting monthly attendance record info based on the assumption that all disciplines are participating in the act of providing activities. She does walk throughs on the units and yesterday she did not notice the TV station. There was an Activity Aide (AA) on the unit doing one to one visits but she was not sure if the resident received one. Is aware of a lack of activities and has been brought up with administration. Activity staff are not able to get medically compromised residents up (vents/airways). During an interview on 12/09/19 at 01:30 PM, the Director of Nursing (DON) stated that her expectation was that the resident had recreational activities in his/her room and that TV and music should be appropriate for the child. During an interview on 12/09/19 at 02:57 PM, AA #8 stated she worked full time days and was responsible for one to one activities for the whole building when she was there. She came to the Pediatric unit from 2:30 PM - 4:30 PM daily. They do the best they can and if the residents name was not on the daily Activity Program Attendance Record, then he/she was not seen. 10NYCRR 415.5(f)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 2 (Resident #'s 41 & #76) of 3 residents reviewed. Specifically, for Resident #'s 41 and #76, the facility did not ensure the residents were provided with ROM with morning care. This was evidenced by: The Policy and Procedure (P&P) titled Range of Motion (undated) documented ROM should be performed at least two times per day; Once with AM care and once with PM care. Do each exercise/stretch 3-5 times or move the joint to the end range and hold for 10-15 seconds. Resident #41: The resident was admitted to the facility with the diagnoses of anoxic brain damage, respiratory failure and dysphagia. The Minimum Data Set, dated [DATE], documented the resident had no discernible consciousness, and had limited ROM to all four extremities. During an observation of AM care on 12/5/19 at 9:00 AM, CNA #7 washed and dried resident's face, torso and extremities while using minimal movement of his extremities. The resident was not provided with ROM. The CNA Care Card (instructions related to a resident's level of care required) did not include instructions for ROM. During an interview on 12/5/19 at 1:00 PM, the Rehabilitation Director stated that Resident #41 received Rehabilitation Maintenance ROM by a Rehab aide 2-3 times per week. The CNAs are supposed to provide ROM with care for every resident, regardless of any therapy program the resident received. During an interview on 12/9/19 at 10:16 AM, CNA #5 stated she had been working at the facility for years. She gets her residents care instructions from the kiosk (CNA Care Card) prior to starting care. If there was no documentation on the kiosk to do the ROM, then it is not done. Resident #76: The resident was admitted to the facility with the diagnoses of anoxic brain damage, respiratory failure and rheumatoid arthritis. The Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment and was usually able to be understood by others and was rarely/never able to understand others. It documented the resident had limited ROM to all four extremities. During an observation of AM care on 12/9/19 at 9:51 AM, Certified Nurse Aide (CNA) #6 provided morning care to Resident #76. While washing the upper body, each arm was lifted three times, by holding the wrist and raising the arm to allow for washing, drying and application of deodorant. Each leg was lifted once for the washing and drying. There was no ROM done on the elbow, wrist, fingers or legs. The CNA Care Card did not include instructions for ROM. During an interview on 12/9/19 at 10:54 AM, CNA #6 stated that rehab staff does some of the residents for ROM 2-3 times per week. If the therapy aide does ROM, then CNAs do not have to do it. I just did ROM when I was washing Resident #76, I lifted her arms and legs up with her bath. During an interview on 12/9/19 at 11:00 AM the Licensed Practical Nurse Manager (LPNM) stated every resident was supposed to get ROM done with bathing and care. The LPNM and other nurses monitor the residents and care but not specifically to see if ROM was being done. She was not aware that ROM was not being done. During an interview on 12/9/19 at 11:33 AM, the Registered Nurse (RN) Educator stated the Rehab Department has their own maintenance ROM program for certain residents but the CNAs are still required to do ROM on every resident no matter their rehab program. The CNAs are supposed to be doing ROM on every resident during care paying particular care to the contractures and ranging as far as the resident can tolerate, and ranging the hips, knees, ankles and the shoulder, elbows and hands. ROM is reviewed with all CNAs on orientation and they learn it in their CNA certification class, they should be doing it correctly. She recently realized the CNAs were not doing the correct ROM or ROM at all and they needed new instruction. Before the survey started, she was planning on developing a new ROM in-service. During an interview on 12/5/19 at 1:00 PM, the Director of Nursing stated that all residents should receive ROM every day with care regardless of their rehab program. ROM is not documented on the CNA Care Card because it is part of the AM and PM care. When the CNA signs that the resident care was done that included ROM. 10NYCRR415.12(E)(2)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that its medication error rates are not 5 percent or greater. Specifically, during a medication pass observation, the facility did not ensure that the medication rate was at or below 5%. This is evidenced by: A facility policy titled Metered Dose inhalers (MDI) and dry powder inhalers (DPI) last revised 2/15/18, documented that nursing staff will administer medications via MDI or DPI to maintain airway patency and improve respiratory function. When using a MDI, allow at least one minute for resident to rest between inhalations and for a DPI to allow at least one minute between inhalations and to repeat process until the total number of inhalations ordered is administered. Medical Doctor (MD) order dated 11/28/19, documented the following: - Symbicort 160 micrograms (mcg) -4.5 mcg/actuation HFA aerosol inhaler (MDI); 2 puffs BID - Spiriva with Handihaler 18 mcg and inhalation capsules (DPI); 1 capsule by inhalation route once daily two inhalations. During a medication pass observation on 12/09/19 10:16 AM, the nurse placed the Symbicort and the Spiriva in front of the resident. The resident took 2 inhales of the Spiriva without a rest between inhales. The resident asked the nurse if she should do the Symbicort, the nurse responded yes, and the resident did two consecutive inhales of the Symbicort without taking a rest between inhales. Package insert information for Symbicort documented if you are using other inhalers at the same time, wait at least one minute between the use of each medication. Package insert information for Spiriva documented if prescribed dose is 2 puffs, wait at least one minute between puffs and if using other inhalers at the same time, wait one minute between the use of each medication. During an interview on 12/09/19 at 11:16 AM, Registered Nurse (RN) #4 stated there should have been intervals between inhales of her medication. During an interview on 12/09/19 at 1:23 PM, the Director of Nursing (DON) stated there should have been a minute between different inhalers and between each puff of the same inhaled medication. 10NYCRR 415.12(m)(2)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #96) of three residents observed for dressing changes. Specifically, for Resident #96, the facility did not ensure infection control measures were maintained during a dressing change. This is evidenced by: Resident #96: The resident was admitted to the facility with diagnoses of dementia, cerebral infarction, and mood disorder. The Minimum Data Set (MDS - an assessment tool) dated 11/14/19 documented the resident had severely impaired cognition, could understand others and could make self understood. The Policy and Procedure titled Dressing Change Policy and Procedure last revised 3/2018, documented it was the policy of the facility to cleanse all wounds in order to clear exudates, bacterial contamination and debris from the wound bed. This process was done since optimal healing cannot proceed until the inflammation-producing substances were removed from the wound surface. The Comprehensive Care Plan for Skin Integrity, last updated 9/26/19, documented the presence of moisture associated dermatitis (MASD) on 7/18/18 to the resident's coccyx that progressed to an unstageable pressure injury, and then to stage 4 pressure ulcer. A Physician Order dated 12/5/19, documented Dakin's Solution 0.25%; wash by topical route 3 times per day to coccyx wound bed and undermining then pack Dakin's moistened gauze (use roll gauze) followed by a silicone dressing to the stage 4 pressure ulcer of the sacral region. During a dressing change observation on 12/09/19 at 11:00 AM, the nurse cleansed the inside of the resident's wound with Dakin's (a bleach solution used in wound care) soaked gauze and then with same gauze cleansed the peri wound (tissue surrounding skin) area. The nurse discarded the gauze and repeated this process two more times. During an interview on 12/09/19 at 11:16 AM, Registered Nurse (RN) #4 stated she cleaned the cleanest part of the wound first; clean inside the wound and then the outside but stated a different gauze should have been used. During an interview on 12/09/19 at 1:38 PM, the Infection Control Preventionist (ICP) stated the wound and peri wound area should have been cleansed with separate gauze and that cleansing the wound then the peri wound with the same gauze was a break in infection control. 10NYCRR 415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs for 6 (Resident #12, 23, 26, 30, 86, and #91) of 22 residents reviewed for comprehensive care plans (CCPs). Specifically, the facility did not ensure CCPs were individualized and included person-centered interventions for Resident #12's mood state and cognitive function; for Resident #'s 26 and #30's mood state; for Resident #91's communication, behavior, and mood state; for Resident #86's behavior and mood state; and for Resident #23, the facility did not ensure the CCP included Range of Motion (ROM) care needs. This is evidenced by: The Policy and Procedure titled Comprehensive Care Plan last revised 9/2015 documented a comprehensive, accurate, standardized and reproducible assessment and plan of care for the resident's individualized problems would be formulated by the Interdisciplinary Team. The policy documented the CCP would have goals and objectives that were specific, measurable, and within a stated timeframe and interventions would be specific. Resident #12: The resident was admitted to the facility with the diagnoses of anoxic brain injury, dementia, and persistent mood disorder. The Minimum Data Set (MDS - an assessment tool) dated 11/25/19, documented the resident had severely impaired cognition, could sometimes understand others and could make self understood. The CCP for Mood State, last revised 3/14/19, documented to monitor mood state or feelings as manifested by resident showing signs of sadness, reduced social interaction and to administer medications as prescribed, encourage decision making, encourage family involvement and visits, and encourage verbalization of feelings. The CCP did not include individualized and person-centered interventions. The CCP for Cognitive Function, last revised 3/15/19, documented an alteration in cognitive function due to anoxic brain injury and history of dementia. The CCP interventions were to explain procedures prior to performing them, introduce self upon approaching resident, observe for signs of decline in cognitive, notify MD as needed, and obtain psychiatric consult as needed. The CCP did not include individualized and person-centered interventions. During an interview on 12/09/19 at 10:58 AM, Registered Nurse (RN) #2 stated the mood state care plans were personalized to the resident if needed and if not, interventions were chosen from a care plan library. RN #2 stated the care plans should include person centered approaches. The Social Work Department was responsible for initiating the mood state care plans, but the care plans were also reviewed by the Interdisciplinary Care Team to ensure care plans were resident specific. RN #2 stated Resident #12's mood state and cognitive function care plans were considered personalized. and the facility did not have a dementia specific care plan. During an interview on 12/09/19 at 2:56 PM, the Director of Social Work (DSW) stated a mood state care plan was initiated for every resident upon admission and if the resident was not having a mood issue, the care plan would not necessarily be tailored to the individual resident. Resident #26: The resident was admitted to the facility with the diagnoses of dysphagia, hypertension, and major depressive disorder. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, could usually understand others and could usually make self understood. The CCP for Mood State, last revised 12/28/18, documented to monitor mood state or feelings as manifested by resident showing signs of sadness, reduced social interaction and to encourage participation in leisure activities, encourage family involvement, and administer medications as prescribed. The CCP did not include individualized and person-centered interventions. During an interview on 12/09/19 at 10:58 AM, RN #2 stated the mood state care plans were personalized to the resident if needed and if not, interventions were chosen from a care plan library. RN #2 stated the care plans should include person centered approaches. During an interview on 12/09/19 at 2:56 PM, DSW stated Resident #26's mood state care plan could probably be more specific to him and there should definitely be something on the care plan for the staff to try in terms of non-pharmacological interventions. The DSW stated a mood state care plan was initiated for every resident upon admission and if the resident was not having a mood issue, the care plan would not necessarily be tailored to the individual resident. Resident #91: The resident was admitted to the facility with the diagnoses of respiratory failure, ventilator dependent, and dementia. The Minimum Data Set, dated [DATE], documented the resident had severely impaired cognition and was rarely able to make himself understood or understand others. The CCP for Communication-Language barrier, last revised 10/25/19, documented the resident speaks in native language. Communication skills are not functional for ADL's in native language. Resident is not able to use a communication board. The interventions included, meet and anticipate needs; encourage use of communication board; obtain interpreter as needed. The CCP did not include individualized and person-centered interventions to include the native language. The CCP for Mood State, last revised 10/25/19, documented monitor mood state or feelings as manifested by resident showing signs of sadness, reduced social interaction. The interventions included; support self-esteem through positive feedback, encourage participation in leisure and self-care activities, encourage family involvement and visit and administer medications. The CCP did not include individualized and person-centered interventions. The CCP for Behavior Symptom, last revised 10/29/19, documented potential for resident to exhibit inappropriate behavioral problem as evidenced by-resident pulling at trach tubing's. The interventions included; identify pattern of behavior, documented in the progress notes the intensity, duration or frequency of behavior, notify MD immediately for changes in behavior; assess participation in ADLs, Social service evaluation and follow-up; redirect negative behaviors; orient to daily routines as needed; refer to Psychiatrist for further consultation related to behavior and administer medications as ordered by physician. During an interview on 12/10/19 at 8:45 AM, Licensed Practical Nurse Manager (LPNUM) #3 stated the interdisciplinary team met every morning and talked about resident behaviors related to diagnosis, incident reports, falls and any new issue that had come up. They added interventions to the care plans at the meeting. LPNUM #3 stated the care plan for Resident # 91 could be more resident centered and will do much better with the care plans going forward. During an interview on 12/10/19 at 9:07 AM, the MDS Coordinator stated she did not attend the care plan meetings. She did some editing and reviewing of care plans and she stated at times the care plans were not resident centered. During an interview on 12/10/19 at 9:15 AM, the Director of Nursing (DON) stated she did attend some of the care plan meetings. The facility was working on the pediatric care plans and improving the interventions. She stated the interventions need to be more resident centered. 10NYRR415.11(c)(1)