Based on observation, record review, and interview during a recertification and abbreviated survey (Case # NY00343395), the facility did not ensure that all allegations of abuse were thoroughly investigated for one (1) (Resident #3) of seven (7) residents reviewed for abuse. Specifically, Certified Nurse Aide #8 reported an allegation of verbal abuse and rough treatment of Resident #3 during care on the evening shift on 5/24/2024, to the evening supervisor. The facility initiated the investigation on 5/24/2024 at 11:00 PM, when informed of the allegation. There was no documented evidence that all staff involved were interviewed before the determination was made that the allegation was inconclusive. This is evidenced by: The facility's policy titled Resident Abuse Reporting revised on 11/29/2021 and last reviewed on 10/24/2024 documented: 1. When there is reasonable cause to suspect resident abuse the responsible individual would immediately be suspended without pay while the investigation is being conducted. 2. All claims of abuse and allegations are thoroughly investigated. The designated Nursing Supervisor initiates investigation and notifies the Director of Nursing. 3. Identify the following: a. Name of person or persons suspected of abuse, b. Mistreatment or neglect, name of the resident, c. Name of witnesses, d. Date, time and place incident occurred e. Nature and extent of abuse, mistreatment or neglect 4. Notify the Administrator as appropriate 5. All relevant staff who may have information about the abuse allegations would be obtained from all witnesses, to include an accurate description of the occurrences. These would be signed and dated. These statements will be kept confidential and will be provided to the investigator from the New York State Department of Health/Attorney General's Office, et al. If there are any staff who are not interviewed the facility must document, why that staff was not interviewed. 6. Interviewers questions should be documented. Resident #3 was admitted to the facility with diagnoses of non- Alzheimer's dementia (condition that occurs with memory loss and cognitive functioning) without behavioral disturbances, hypertension (a condition where the force of your artery walls blood against your artery walls is consistently too high), and depression (a persistent feeling of sadness and loss of interest or pleasure in the activities of daily living). The Minimum Data Set (an assessment tool) dated 3/06/2025, documented the resident was sometimes understood and could sometimes understand others with severely impaired cognition for daily decision making. An ACTS (Aspen Complaints Tracking System) complaint/incident report date 5/28/2024 documented that a complaint was submitted to the New York State Reporting division on 5/25/2024 at 2:01 AM, that alleged Resident #3 had been verbally abused with rough handling during care on 5/24/2024 during the 3:00 PM to 11:00 PM shift by Certified Nurse Aide #9. The facility investigation and summary dated 5/29/2024 documented a log of 9 witnesses were listed on the investigation that were working the night the incident occurred on 5/24/2024 on the 3 to 11 PM evening shift. Certified Nurse Aide #8 was orienting Certified Nurse Aide #9, and they were providing care for Resident #3 preparing the resident for bed. Certified Nurse Aide #8 reported to the Licensed Practical Nurse #4 at the end of the shift that Certified Nurse Aide #9 had handled Resident #3 roughly during care and used foul language during transferring the resident and said they had them leave the room and looked at the residents back to see if there was any injury and found none. Certified Nurse Aide #9 stated they had hurt their back and left the building before Certified Nurse #8 reported the incident. The incident was reported to the Registered Nurse Supervisor #1 who then notified the Director of Nursing. The resident was interviewed by the Registered Nurse Supervisor #1 and a skin assessment was done with no injury found, Resident #3 could not recall the incident and denied psychological harm. Staff was interviewed and reported no care concerns with Certified Nurse Aide #9, who was interviewed and denied allegations. Certified Nurse Aide #9 was suspended at 5/25/2024 at 1:30 AM, pending the outcome of the investigation. The outcome of the investigation was inconclusive because the allegation could not be verified or refuted because there was insufficient information to determine whether the allegation had occurred. During an interview on 4/21/2025 at 11:47 AM, Director of Nursing #1 stated all interviews of staff involved were not completed. Some of the staff interviews were done by phone because the incident was reported to the nurse at the end of the shift and Certified Nurse Aide #9 had already left the building. The investigation was started on 5/24/20/24 at 11:30 PM, and called into the New York State Department of Health reporting bureau as soon as it was reported to the supervisor, who immediately contacted the Director of Nursing #1 within 2 hours of the allegation being reported. The facility was unable to come to a determination that the allegation was substantiated. The resident had no injuries, and they had no witnesses that could collaborate Certified Nurse Aide #8's allegation of abuse by other staff or residents. Certified Nurse Aide #9 was suspended until the outcome of the allegation was investigated. Certified Nurse Aide #9 never returned to the facility and accused staff of behaving unprofessional in front of residents and resigned. A signed letter by Certified Nurse Aide #9 was sent to the facility and allegations of inappropriate language and care around residents was reported to the facility. Director of Nursing stated they followed up with interviews about these allegations but had no written or signed statements by staff when this was done. Some of the staff were no longer employed by the facility. There was reeducation started immediately with abuse and neglect and reporting done by the Registered Nurse Educator #1. Certified Nurse Aide #8 was given a verbal warning and reeducated because they had delayed reporting the incident to the Supervisor. 10 New York Code of Rules and Regulations 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 three (3) (Resident # ' s 9, 31, and 91) of 23 residents reviewed. Specifically, there was no documentation that a Preadmission Screening and Resident Review (PASARR, New York State Department of Health Form 695) was completed for these three (3) residents by a qualified screener prior to admission to the facility. This is evidenced by: A facility policy titled, Pre-admission Screening & Resident Review (PASRR) Assessments, effective 9/2005 and last reviewed 7/2023, documented that all residents admitted for placement at the facility who met the requirements of mental disability via the Level 1/Level 2 Screen would have a referral completed to the appropriate agency for a federal per-admission screening and resident review (PASARR). The Purpose documented was to assure residents with diagnoses of mental retardation or mental illness were assessed by the appropriate Preadmission Screening and Resident Review agency to determine if specialized services were indicated. Under General Information, the policy documented that all residents who sought admission to this Skilled Nursing Facility would have a Level 1 Screen completed by the referring agency/hospital. If a resident ' s Level 1 Screen demonstrated a potential need for specialized services, the referring agency/hospital would contact the appropriate agency for a Preadmission Screening and Resident Review to be completed. Resident #9 Resident #9 was admitted to the facility with the diagnoses of bipolar disorder (a mood disorder associated with episodes of mood swings ranging from depressive lows to manic highs), acute respiratory failure with hypoxia (a condition where the lungs fail to adequately oxygenate the blood, leading to a low oxygen level in the blood), and pneumonia (lung inflammation caused by bacterial or viral infection). The Minimum Data Set (an assessment tool) dated 4/01/2025, documented the resident was able to understand others, be understood, and was minimally cognitively impaired. Resident #9 ' s Preadmission Screening and Resident Review, dated 3/12/2025, documented ' No ' for Question #23 that read, ' Does this person have a serious mental illness? ' There was no documented evidence that Resident #9, who had a diagnosis of bipolar disorder, was screened for a serious mental illness. There was no documented evidence that the Preadmission Screening and Resident Review was completed prior to admission to the facility on 3/03/2025. Resident #31 Resident #31 was admitted to the facility with the diagnoses of morbid obesity (severe form of obesity characterized by a significantly excessive amount of body fat), adjustment disorder with anxiety (a mental health condition characterized by a strong emotional or behavioral reaction to a stressful event or change in life, specifically involving anxiety as a primary symptom), and depression (a mood disorder characterized by persistent feelings of sadness and loss of interest or pleasure in activities). The Minimum Data Set, dated [DATE], documented the resident could be understood, was usually understand others, and was significantly cognitively impaired. Resident #31 ' s Preadmission Screening and Resident Review, dated 10/17/2024, documented ' No ' for Question #23 that read, ' Does this person have a serious mental illness? ' There was no documented evidence that that Resident #31, who had a diagnoses of adjustment disorder with anxiety and depression, was screened for a serious mental illness. There was no evidence that the Preadmission Screening and Resident Review was completed prior to admission to the facility on 3/30/2023. Resident #91 Resident #91 was admitted to the facility with the diagnoses of depression (a mood disorder characterized by persistent feelings of sadness and loss of interest or pleasure in activities), panic disorder (a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks), and multiple sclerosis (a chronic, neurological disease that affects the central nervous system, primarily the brain and spinal cord). The Minimum Data Set, dated [DATE], documented the resident was able to understand others, be understood, and was cognitively intact. There was no evidence that the Preadmission Screening and Resident Review was completed prior to admission to the facility on 3/28/2024. During an interview on 4/22/2024 at 11:12 AM, Director of Nursing #1 stated that social work reviewed the Preadmission Screening and Resident Review before residents were admitted to the facility. During an interview on 4/22/2024 at 11:35 AM, Director of Social Work #1 stated that Preadmission Screening and Resident Review were filled out prior to admission by the hospital or facility sending the resident. Director of Social Work #1 stated that the dates on the screens could be confusing because a resident might go back and forth from the hospital or go home and come back, causing the admission dates and screen dates look like they did not line up. Additionally, Director of Social Work #1 stated that for a resident to have been considered to have a serious mental illness, they would have had to have inpatient treatment for treatment of the mental illness, or the mental illness would have to be an active issue at the time of the screen. If the resident was not presenting as having psychiatric issues, they would have a screen that would reflect no mental illness. It was not enough just to have a diagnosis of a serious mental illness. Director of Social Worker #1 stated that if the Preadmission Screening and Resident Review no longer matched the psychiatric presentation of the resident, they would complete a new screen. Additionally, Director of Social Work #1 stated that all 3 of the residents with questionable Preadmission Screening and Resident Reviews were being provided psychiatric services either through the facility or had community providers they continued to see and that all 3 residents were appeared stable and had not had any issues. 10 New York Code of Rules and Regulations 415.11(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during the recertification survey, the facility did not ensure the development of comprehensive person-centered care plans, that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (1) (Resident #72) of 23 residents reviewed for comprehensive care plans. Specifically, for Resident #72, comprehensive care plan was not developed to address the resident's medical issues requiring medications. This is evidenced by: The facility policy titled, Comprehensive Care Plans, last reviewed date 5/2024, documented the purpose to meet each resident's preference and goals, and address each resident's medical, physical, mental, and psychosocial needs. Under Procedures, documented routine data was collected, e.g. physical signs and symptoms, lab values, resident history, medications, activities of daily living, preferences and resident goals from the time of admission. Charge nurses were responsible for noting all resident changes (including medications, treatments and behaviors) on the 24-hour report. A nurse was designated at each interdisciplinary Tier II morning huddle to document pertinent reported changed on the Daily Changes Report for Care Planning log. Each item noted would be addressed in the individual's care plan as indicated as soon as possible. The date completed was noted on the log. Non-nursing departments were likewise responsible for noting non-significant, but pertinent changes would be noted on the care plan with the indicated problem, goal and/or approach changes at the time such were noted. Resident #72 was admitted to the facility with the diagnoses of unspecified dementia, moderate, with agitation, anxiety disorder (a mental condition characterized by excessive fear or apprehension about real or perceived threats), and functional intestinal disorder, unspecified (a group of conditions where the digestive tract does not operate properly). The Minimum Data Set, dated [DATE] documented resident had severe cognitive impairment, could be usually understood, and understand others. Resident #72's Comprehensive Care Plan for Psychotropic Drug Use: Anxiety State/Dementia, dated 6/29/2023, documented the resident was taking Seroquel. The goal listed was resident would not experience negative side effects from psychotropic med use. The interventions documented monitor for side effects of medication such as: No documented side effects were listed in the comprehensive care plan. The Physician Order dated 3/22/2025 at 10:14 AM, documented Seroquel 25 milligram tablet, give 0.5 tablet (12.5 milligrams) by oral route once daily at bedtime for unspecified dementia, moderate, with agitation, daily at 9:00 PM. The original order date was noted to be 1/31/2025, and the resident had a gradual dose reduction completed, lowering the dose from 25 milligrams to 12.5 milligrams. During an interview on 4/22/2025 at 10:07 AM, Registered Nurse #5stated that care planning was lacking because they did not have enough time in the day to take care of all the resident's needs on the unit, and review or revise resident care plans. They stated that they did the best that they could and that Register Nurse #5did a lot of the care plan paperwork. Registered Nurse #5 did not have an answer as to why no side effects were listed on the comprehensive care plan. During an Interview on 4/22/2025 at 11:22 AM, Director of Nursing #1 stated that Registered Nurse #7 worked mostly remote and did a lot of the work on care plans. All facility Registered Nurses were responsible for updating care plans, but Registered Nurse #7 did mostly the initial care plans, and some updating. In specific regards to Resident #71's care plan, Director of Nursing #1 stated that the side effects should have been listed. 10 New York Codes, Rules and Regulations 415.11(c)(1)

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 of each resident for one (1) (Resident #35) of 3 residents reviewed. Specifically, Residents #35, was not provided with any meaningful, accommodating activities to maintain their highest quality of life. This is evidenced by: The facility's Policy and Procedure Titled Activities Department Policy, revised 12/2024, documented it's policy is: To help residents maintain their optimal level of physical, mental, psychosocial, spiritual, and emotional functioning and independence. Facility promotes individual achievements, self-expression, creativeness, recognition, security, growth through diversified activities, to assist in developing social relationships, a sense of usefulness, a sense of pride in accomplishments, and a sense of self-respect. The Activities Department would document progress every 90 days, indicating participation in activity programs. Provide materials and supplies for residents based on their needs and interests. Offer appropriate accommodations for each resident based on their sensory requirements. Provide 1:1 visit offer large/small group activities to socially engage, cognitively/sensory stimulate, comfort, educate, and offer physical activity depending on residents needs and likes. Resident #35 was admitted to the facility with diagnoses of macular degeneration (a disease that affects a person's central vision); legally blind; and polyneuropathy (multiple nerves become damaged). The Minimum Data Set (an assessment tool) dated 3/22/2025, documented resident had intact cognition, could be understood, and understand others. The Patient Centered Comprehensive Care Plan titled, Focus Activity dated 1/22/20255 documented, Resident is alert/oriented and makes their needs known regarding activity involvement. Resident has no interest in attending group activities at this time. Resident does have independent activities of interest and notes their husband visits daily. Resident does have bilateral hearing deficit and utilizes bilateral hearing aids. Resident is legally blind. Resident requires occasional invitations to see if their interest in attending group activities changes. Resident would maintain independent activities that were enjoyable and interest them daily. Resident would express satisfaction with supplies for independent activities and level of socialization. Interventions: Offer materials to aid in intended activities of interest: (TV channel guide, large print, magnifier, audiobooks). During an observation on 4/14/2025 at 01:29 PM, Resident #35 was sitting in recliner with feet elevated in their room. Resident was able to engage in conversation with surveyor. Resident's hearing was adequate. There were no assistive devices noted in room. During an interview on 4/14/2025 at 1:29 PM, Resident #35 stated they did not really come out of their room due to poor vision. They preferred to stay in their room. Resident #35 stated they could only see a few things likes shapes and colors. They love to read but no longer could read due to macular degeneration. Resident stated they had no adaptive devices. During an interview on 4/18/2025 at 10:04 AM, Director of Activities #1 stated Resident #35 preferred to stay in their room, they did not want to attend group activities. Resident #35 liked to do things in their room, such as watch television or listen to music. Upon admission, Resident #35 was assessed for social preferences and needs. They were offered audio books in January of 2025 and declined. Since then, they had not been offered any other audio books. There were no documented 1:1 visit. During an interview on 4/18/2025 at 10:36 AM, Social Worker #1 stated residents who were hearing and visually impaired were assessed by Speech and Language Therapy. Communication Boards and visual aids were provided as need by therapy. Resident #35 had no visual aids or accommodations. Social Worker #1 stated Resident #35's sister-in-law visited daily and they were hoping to have Resident #35 move into the same room as their husband who is also a resident at the facility. During an interview on 04/18/2025 at 10:30 AM, Resident #35 stated they would very much like to listen to audio books but thought they might be expensive. They stated if there were no cost, they would really like to listen to audio books. During an observation on 4/21/2025 at 10:00AM, Resident #35 was noted to have audio book playing in their room. Resident #35 stated they were very appreciative, and looking forward to doing this daily. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed five (5) percent for two (2) (Resident #s 4 and 78) of four (4) residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of eight (8) percent. This is evidenced by: The facility ' s policy and procedure titled, Medication Administration, revised 5/01/2024, documented, medications may be administered by Registered Nurses and Licensed Practical Nurses after satisfactory completion of the medication orientation requirements. Oral Medications: Read Electronic Medical Record, remove medication from drawer and compare label with Electronic Medical Record. Open medication into medicine cup, read label, and leave package. Blister pack must be initialed and dated when blister is opened. Record review of Manufacturer guidelines assessed at https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022516lbl.pdf documented the following: 'Cymbalta (duloxetine extended release) should generally be administered once daily without regard to meals. Cymbalta should be swallowed whole and should not be chewed or crushed, nor should the capsule be opened, and its contents be sprinkled on food or mixed with liquids (2.1).' Resident #4 was admitted to the facility with diagnoses of squamous cell carcinoma scalp and neck (a type of cancer that starts as a growth of cells on the skin), depressive disorder (a common mental disorder that involves a depressed mood or loss of pleasure or interest in activities), and urinary tract infection. The Minimum Data Set (an assessment tool) dated 2/14/2025, documented the resident was cognitively intact, could be understood, and understood others. Resident #78 was admitted to the facility with diagnoses of type two (2) diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), dementia (loss of memory, language, problem-solving and other thinking abilities) and depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities). The Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment, could be understood and usually understood others. During an observation on 4/17/2025 at 9:03 AM, Licensed Practical Nurse #7 reviewed Resident #4 ' s Medication Administration Record. They stated Resident #4 was to receive Duloxetine 60 milligram capsule, delayed release at 9:00 AM, pulled the medication blister pack from medication cart, and then showed the surveyor. Upon observation, it was noted the Medication Administration Record showed order for Duloxetine 60 milligrams to be given at 9:00 AM, but the blister packet given to surveyor was for Doxycycline, 100 milligram capsule. The surveyor pointed out discrepancy to Licensed Practical Nurse #7 at the time of observation. During an interview on 4/17/2025 at 9:03 AM, Licensed Practical Nurse #7 stated they picked up the wrong medication in error and always checked medication again before administering it to residents. During an observation on 4/17/2025 at 9:38 AM, Resident #78 ' s Medication Administration Record documented to give Duloxetine 30 milligrams, delayed release at 9:00 AM. Licensed Practical Nurse #9 removed one (1) Duloxetine, 30 milligrams delayed release capsule, opened the capsule, and poured into a 30-milliliter medication cup. During an interview on 4/17/2025 at 9:38 AM, Licensed Practical Nurse #9 stated they were allowed to crush medications for Resident #78 and that they crushed all medications for this resident. During an interview on 4/17/2025 at 12:04 PM, Director of Nursing #1 stated all nurses had undergone medication administration training upon hire in general orientation, during preceptorship, and with annual competencies. They stated that all nursing staff who administered medication followed the facility policy including the six (6) rights for medication administration: 1. Right Patient, 2. Right Medication, 3. Right Time, 4. Right Dose, 5. Right Route, 6. Right Documentation. Director of Nursing #1 stated instructions for how resident took their medication was located in the information box in electronic medical records They further stated that staff would confirm with the hospital pharmacy that Duloxetine extended-release capsules should not be opened or crushed. Director of Nursing #1 stated Resident #78 took their medication crushed and that the pharmacy and or physician should had been notified so that an alternative drug could had been prescribed. 10 New York Codes, Rules, and Regulations 415.12 (m)(1)

Based on observations and interviews conducted during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the automatic dishwashing machine was not sanitizing, floors were not clean, and concentration of the chemical sanitizing rinse in the 3-compartment sink was low. This is evidenced by: During observations on 4/14/2025 at 10:32 AM through 11:08 AM: The automatic dishwashing machine thermometer read 140 degrees Fahrenheit during the final rinse cycle. The walk-in freezer floor and floor under cooking equipment was soiled with food particles and/or a black build-up. The concentration of quaternary ammonium compound that was used to sanitize food contacted equipment in the 3-compartment sink was zero parts per million of quaternary ammonium compound measured at 74 degrees Fahrenheit. During an interview on 4/14/2025 at 10:52 AM, Food Service Worker #1 stated that the automatic dishwashing machine drain lever may have been dislodged from the closed position by a bus cart; this would cause the dishwashing machine to keep cycling new and lower temperature water into the sanitizing final rinse, would not achieve 180 degrees Fahrenheit, and would cause a low thermometer temperature. During an interview on 4/14/2025 at 11:09 AM, Culinary Director #1 stated that they would contact the vendor to have the concentration of chemical sanitizer adjusted and would have the floors cleaned. 10 New York Codes, Rules, and Regulations 415.14(h) Chapter 1 State Sanitary Code Subpart 14-1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during a recertification survey, the facility did not ensure each resident was treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of their quality of life for five (5) (Resident #s 21, 31, 32, 64, and 99) of 23 residents reviewed for dignity and respect. Specifically, (a.) Resident #s 31 and 32 had Foley catheters that were fully visible from the hallway, outside resident rooms and in common areas, and not in cover bags; (b.) Resident #64 reported that staff spoke to them 'like they were retarded' and ignored their requests to open the room dividing curtain when their roommate was not in the room; (c.) Resident #99's repeated request to be toileted was ignored by staff while the surveyor was on the resident's unit; and (d.) Resident #21 stated that staff did not provide care in a dignified way, handled them roughly, and that staff would smell of marijuana and cigarettes which the resident found offensive. This is evidenced by: The Policy and Procedure titled, Resident's Rights and Responsibilities, last reviewed May 2012, read that the resident had the right to privacy during medical treatment and care and in personal hygiene matters. The residents have the right to make choices of their life that were significant to them. The facility would meet the resident's individual needs and preferences to the extent possible, and a right to a homelike environment and to use their personal belongings and furnishing to the extent these can be used in accordance with health and safety regulations. A Right to privacy during medical treatment and care and in personal hygiene matters. (a) Right to meet the resident's individual needs and preferences. Resident #21 was admitted to the facility with the diagnoses of squamous cell carcinoma of skin of scalp and neck (cancer cell that form on the surface of the skin), type 2 diabetes mellitus with diabetic neuropathy (endocrine dysfunction causing issues regulating blood sugar that causes damage to nerves in the legs, feet and hands), and morbid obesity (excessive body fat causing a body mass index of 40 or higher). The Minimum Data Set, dated [DATE] documented that the resident was able to be understood and understand others, with minimal cognitive impairment. The Comprehensive Care Plan for Compassionate and Personal Caregiving Visitors, dated effective 6/11/2021, documented that Resident #21 would have access to compassionate and personal caregivers as needed. The interventions documented that the resident or sponsor would designate preferences or changes for designated caregivers as desired but at least quarterly. During an interview on 4/15/2025 at 11:24 AM, Resident #21 stated that most of the staff were fine, however there were a few staff that were rough with residents. Resident #21 stated that they had told the administrator about it but nothing was done. Additionally, staff smoked marijuana outside the facility and came into work smelling of marijuana that the resident found very bothersome. During an interview on 4/21/2025 at 12:01 PM, Administrator #1 stated that they had no recall of anyone reporting smelling of marijuana recently but had had an issue of Certified Nurse Aide #4 that was reported for smelling of cigarette smoke but had been educated on staff expectations. Administrator #1 stated that they had received reports of rude and/or inappropriate interactions with some Certified Nurse Aides. Administrator #1 stated that some Certified Nurse Aides had louder voices that might be misconstrued as rude. Additionally, Administrator #1 stated that Resident #21 and Certified Nurse Aide #3 had a personal history outside of the facility and that there had been previous conversations with Certified Nurse Aide #3 regarding their shared history. Administrator #1 stated that any issues were addressed as soon as they were brought to their attention. Resident #99 was admitted to the facility with the diagnoses of unspecified severe dementia with agitation (a progressive degenerative memory disease that can cause severe physical or verbal aggression), type 2 diabetes mellitus without complications (an endocrine dysfunction that causes irregular blood sugar levels), and obstructive sleep apnea (a sleep disorder that causes episodes of complete airway collapse or partial collapse with decrease in oxygen saturation). The Minimum Data Set, dated [DATE], documented that was sometimes understood and sometimes understand others, with severe cognitive impairment. The Comprehensive Care Plan for Compassionate and Personal Caregiving Visitors, effective 8/09/2024, documented the goal of the resident will have access to compassionate and personal caregivers as needed. The Comprehensive Care Plan for Cognitive impairment/poor judgement/memory loss, effective 8/20/2024, documented the resident would participate in self-care within mental and physical limitations. Interventions documented to encourage self-performance in making decisions and assisting with care needs each day. The Comprehensive Care Plan for Elimination: Urinary Incontinence, effective 8/22/2024, documented the goal of the resident will not experience complications related to incontinence as evidenced by no signs or symptoms of urinary tract infections, skin breakdown or rashes, and utilize prompted voiding every one to two (1-2) hours with positive reinforcement. During an observation on 4/16/2025 at 10:01 AM, Resident #99 was noted to be in the common area of the unit while activities took place in dining room. Resident #99 was observed repeatedly requesting to go to the bathroom. At the time of the observation, Licensed Practical Nurse #6 was made aware that the resident was asking repeatedly to go to the bathroom. Licensed Practical Nurse #6 stated that Resident #99 had just gotten off the commode and that Certified Nurse Aide #11 would get to them. Resident #99 was eventually taken to the bathroom at 10:50 AM, after Certified Nurse Aide #12 came from another unit to assist Certified Nurse Aide #11. (B) Right to privacy during medical treatment and care and in personal hygiene matters. Resident #31 was admitted to the facility with the diagnoses of morbid obesity (severe form of obesity characterized by a significantly excessive amount of body fat), acquired absence of a leg above the knee (amputation of one leg above the knee joint), and neuromuscular dysfunction of the bladder (condition where the bladder's muscles and nerves don't function properly due to damage to the brain, spinal cord, or nerves that control bladder function). The Minimum Data Set (an assessment tool) dated 2/28/2025, documented the resident usually could be understood, understand others, and was significantly cognitively impaired. Resident #31's Comprehensive Care plan for Elimination related to Foley catheter, dated 7/22/2024 and last reviewed 4/20/2025, documented that the resident would not experience complications related to catheter as evidenced by no signs or symptoms of urinary tract infection or kinked tubing. There was no documented intervention of placing the Foley bag in a cover bag to provide the resident privacy regarding their medical conditions. A Physician order dated 3/07/2025 at 10:45 AM documented that the resident had a Foley catheter to gravity drainage to be changed monthly and as needed. During an observation on 4/15/2025 at 10:43 AM, Resident #31's Foley catheter was visible from the hallway, not covered, hanging from the resident's bed. During an observation on 4/18/2025 at 9:00 AM, Resident #31's Foley catheter was visible from the hallway, not covered, hanging from the resident's bed. Additionally, there was a urine smell emanating from the resident's room. Resident #32 was admitted to the facility with the diagnoses of obesity (disorder that involves having too much body fat), acute gastroenteropathy due to Norwalk agent (a viral infection that causes inflammation of the stomach and intestines, leading to symptoms like vomiting, stomach cramps, and fever), and neuromuscular dysfunction of the bladder (condition where the bladder's muscles and nerves don't function properly due to damage to the brain, spinal cord, or nerves that control bladder function). The Minimum Data Set, dated [DATE], documented the resident was able to understand others, able to make themselves understood, and was cognitively intact. Resident #32's comprehensive care plan for Foley catheter dated 2/19/2024 and last reviewed 5/23/2025, documented that the resident would maintain clear yellow urine via Foley catheter and will have no urinary tract infection during the review period. There was no documented intervention of placing the Foley bag in a cover bag to provide the resident privacy regarding their medical conditions. A Physician order dated 3/11/2025 at 10:49 AM documented that the resident had a Foley catheter to gravity drainage to be changed monthly and as needed. During an observation on 4/16/2025 at 9:58 AM, Resident #32's Foley catheter was visible from the hallway, not covered, hanging from the resident's bed. During an observation on 4/17/2025 at 11:47 AM, Resident #32's Foley catheter was visible from the hallway, not covered, hanging from the resident's bed. During an observation on 4/18/2025 at 10:41 AM, Resident #32's Foley catheter was visible from the hallway, not covered, hanging from the resident's bed. (c) Right to make choices of their life that were significant to them. Resident #64 was admitted to the facility with the diagnoses of obesity, type 2 diabetes mellitus (an endocrine dysfunction causing irregular blood glucose levels), and obstructive sleep apnea (a condition involving constriction of the airways and difficulty or discomfort in breathing). The Minimum Data Set, dated [DATE], documented the resident was able to understand others, able to make themselves understood, and was cognitively intact. The Comprehensive Care Plan for environmental check dated 1/15/2025 documented keeping the floor uncluttered, kept dry, bed in lowest position, and that water, food and personal items were kept within reach. There was no documented intervention of keeping the resident's privacy curtain open when Resident #64 was alone in their room. During an interview on 4/16/2025 at 10:33 AM, Resident #64 stated that they felt the staff treated them like they were a retard and that they had requested the staff leave the curtain open when their roommate was not in the room, but the staff refused to answer their request. During an observation on 4/17/2025 at 10:53 AM, Resident #64's call bell was going off. It was not answered until 11:03 AM. At that time, the staff member that entered Resident #64's room stated they would come back. By 11:34 AM, no staff had returned to the room, except one other staff that turned off the resident's light and stated they would be back. Resident #64 stated they had been trying to be changed since 9:30 AM but the staff had not been able to get to them yet. The curtain was observed to be open, and Resident #64 was in the room with their family member. During an observation on 4/21/2025 at 10:58 AM, Resident #64's curtain was open. During an interview on 4/22/2025 at 9:44 AM, Registered Nurse #4 stated that dignity was part of annual education and that Foley should be covered in a blue bag. During an interview on 4/22/2025 at 10:44 AM, Resident Nurse #5 stated that Foley bags should have been covered with a blue bag, or if those were not available a pillowcase could be used, and that Foley should be not visible to the public eye. Registered Nurse #5 had returned from vacation that day and saw that multiple Foley bags were not covered. Registered Nurse #5 could not state why the staff were not following the rules. During an interview on 4/22/2025 at 11:12 AM, Director of Nursing #1 was asked for examples of issues that might arise that would impact resident's feelings of being treated with dignity. Director of Nursing #1 stated that people being covered up so that personal body parts were not visible would be an example. Additionally, knocking on resident's doors before entering would be considered dignified, speaking to the residents in kind and respectful ways, and making sure that Foley catheters were covered and not visible to visitors. 10 New York Codes, Rules, and Regulations 415.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #109 Resident #109 was admitted to the facility with diagnoses of generalized osteoarthritis (when the cartilage that cushions the ends of bones in the joints gradually wears away), transient ischemic attacks (a short period of symptoms similar to those of a stroke), and repeated falls. The Minimum Data Set (an assessment tool) dated 2/09/2024 documented the resident could understand and be understood by others. The comprehensive care plan titled Activities of Daily Living, last revised 4/11/2024, documented Resident #109 required assistance with Activities of Daily Living task performance as follows: Effective 1/08/2024, Resident #109 was a supervision at mealtime; partial moderate one (1) staff member assist for bed mobility; partial moderate one (1) staff member assist for grooming, bathing and dressing. Partial/moderate one (1) staff member assist for transfers and toileting. Non-ambulatory. There was no documented evidence the resident ' s care plan was revised on 3/08/2024, to include the resident required a maximum of two (2) staff members for bed mobility. During an interview on 4/21/2025 at 11:33 AM, Rehabilitation Director #1 stated Resident #109 was discharged from Physical Therapy on 3/08/2024. They further stated that at the time of discharge, Resident #109 ' s bed mobility was at a maximum assist. requiring two (2) staff members, also known a total dependence. During an interview on 4/21/2025 at 11:45 AM, Director of Nursing #1 stated after physical therapy assessed a resident and updated a resident ' s treatment plan, they would bring a written document of it to the nursing staff. Director of Nursing #1 stated that it was the responsibility of the nurse manager, or nursing supervisor, to update the resident ' s care plan. They further stated that the 3/08/2024 Physical Therapy note for Resident #109 was not updated in the care plan to indicate that the resident was a maximum assistant with two (2) staff members for bed mobility. Resident #3 Resident #3 was admitted to the facility with diagnoses of Non-Alzheimer ' s dementia (condition that occurs with memory loss and cognitive functioning) without behavioral disturbances, hypertension (a condition where the force of your artery walls blood against your artery walls is consistently too high), and depression (a persistent feeling of sadness and loss of interest or pleasure in the activities of daily living). The Minimum Data Set, dated [DATE], documented the resident was sometimes understood and could sometimes understand others with severely impaired cognition for daily decision making. A Physicians Order dated 3/2025, documented Resident #3 was to receive Zyprexa (an antipsychotic, a medication ordered to treat mental health conditions) 2.5 milligrams one (1) time a day. Physicians Order dated 4/02/2025, documented Resident #3 was to receive Zyprexa (an antipsychotic, a medication ordered to treat mental health conditions) 1.25 milligram one (1) time a day. An electronic Medication administration record dated March 2025 documented Resident #3 received Zyprexa 2.5 milligrams 1 time a day for 31 days. An electronic Medication administration record dated April 2025 documented Resident #3 received Zyprexa 2.5 milligrams one (1) time a day for one (1) day on 4/01/2025. An electronic Medication administration record dated April 2025 documented Resident #3 received Zyprexa 1.25 milligrams one (1) time a day for 20 days beginning on 4/02/2025 through 4/21/2025. A psychiatric tele health progress note dated 4/02/2025 documented a trial gradual dose reduction was being attempted and the resident ' s antipsychotic medication was being decreased to 1.25 milligrams beginning 4/02/2025. Review of Resident #3 ' s comprehensive care plan for psychotropic medications implemented on 10/16/2023, did not include the gradual dose reduction performed on 4/02/2025, and did not include goals and intervention with signs and symptoms to monitor while the gradual dose reduction was being attempted. During an interview on 4/21/2025 at 11:17 AM, Registered Nurse #6 stated that Resident #6 had been seen by telehealth and had a gradual dose reduction performed. The gradual dose reduction should have been documented in the resident ' s care plan under behaviors or in the psychotropic care plan. Registered Nurse #6 could not provide any evidence that demonstrated documentation had been placed in the resident ' s comprehensive care plan, but it should have been updated when this was done in case the resident had complications with the decrease in the medications. During an interview on 4/22/2025 at 11:30 AM, Director of Nursing #1 stated Physical Therapy was to provide documentation after their assessment of a resident, and the resident ' s care plan would be updated accordingly. They further stated that all care plans were reviewed and updated quarterly, if needed. 10 New York Codes, Rules, and Regulations 415.11(c)(2)(i-iii) The facility ' s policy and procedure titled, Comprehensive Care Plans, last reviewed 05/2024, documented the following: The facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with their rights. Care plans would include measurable objectives and timeframes to meet a resident ' s medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment. Within 14 days of admission, quarterly and with each significant change, the Inter-Disciplinary Care Plan Team would conduct appropriate assessments, including those in the Minimum Data Set, to determine each resident ' s physical, mental and psychosocial needs. Assessments would identify strengths, weaknesses, preferences, abilities, and needs and take into consideration the resident ' s wishes and goals. Charge nurses were responsible for noting all resident changes (including medications, treatments and behaviors) on the 24-hour report. A nurse was designated at each interdisciplinary Tier II morning huddle to document pertinent reported changes on the Daily Changes Report for Care Planning Log. Each item noted would be addressed in the individual ' s care plan as indicated as soon as possible. Based on record review and interview conducted during a recertification and abbreviated survey (Case # NY00345612), the facility did not ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for two (2) out of three (3) residents (Resident #s 3 and 109) reviewed for care planning. Specifically, (a.) Resident #109 ' s comprehensive care plans for Activities of Daily Living, Bed Mobility were not revised following Physical Therapy assessment and recommendations on 3/08/2024. Resident #109 was assessed by physical therapy on 3/08/2024 as having total dependence on staff and required maximum assistance of two (2) staff members for bed mobility. As a result of the facility not communicating the physical therapy recommendations, Resident #109 rolled out of bed and suffered a fractured (broken) hip while receiving care from one (1) staff member on 4/28/2024 at 5:05 PM. Specifically: (b.) Resident #3 ' s comprehensive person center care plan for antipsychotics had not been revised with goals and interventions when a gradual dose reduction was performed on 4/02/2025, and the residents Zyprexa was decreased from 2.5 milligrams to 1.25 milligrams daily. This is evidenced by:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during a 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, residents were not assisted with care when requested, staff complained of not able to complete all the required tasks assigned and provide resident care, and the staffing sheets provided while on site did not accurately reflect the needs of the facility population. This is evidenced by: Facility Assessment The facility assessment dated 8/2024 documented that the staffing plan was based on the resident population and their needs for care and support. The staffing plan documented the following daily staffing needs: Average daily census: 103 (Unit 1 with 1-24 residents, Unit 2 with 2-45 residents, Unit 3 with 3-34 residents). The total facility's certified beds numbered 130, with one respite bed (Unit 1 with 1-40, Unit 2 with 2-46, Unit 3 with 3-45). Per shift, per unit, the number of minimum staff required were as follows: • Days: Unit 1 required 1 nurse and 2 Certified Nurse Aides; Unit 2 required 2 nurses and 4 Certified Nurse Aides; Unit 3 required 2 nurses and 3 Certified Nurse Aides. • Evenings: Unit 1 required 1 nurse and 2 Certified Nurse Aides; Unit 2 required 1.3 nurses and 4 Certified Nurse Aides; Unit 3 required 1.3 nurses and 3 Certified Nurse Aides. • Nights: Unit 1 required 1 nurse and 1 Certified Nurse Aide; Unit 2 required 1 nurse and 2 Certified Nurse Aides; Unit 3 required 1 nurse and 2 Certified Nurse Aides. [Note: Where Days = 7:00 AM to 3:00 PM, Evenings = 3:00 PM to 11:00 PM, Nights = 11:00 PM to 7:00 AM] Observations: Upon entrance to the facility on 4/13/2025 there were 108 residents residing on 3 units and at no time was the facility census less than 105 residents in the building. During general observations on 4/14/2025 at 11:00 AM, a strong odor of feces was noted in the hallway near room [ROOM NUMBER]. During general observations on 4/15/2025 at 9:30 AM, a strong odor of feces was noted in the 100-unit common room. A Licensed Practical Nurse was made aware and stated that they would tell the aide. After twenty minutes, no care had been provided. Director of Nursing #1 was notified, and they sent a Certified Nurse Aide to assist. During an observation on 4/15/2025 at 10:58 AM, the call bell for room [ROOM NUMBER] was noted to have been on for a number of minutes and was not answered until 11:15 AM by a Licensed Practical Nurse who asked the resident in the room what they needed. The resident stated they needed to go to the bathroom. The Licensed Practical Nurse stated they would be right back, turned off the resident's light, went down the hall, turned off the call bell light going off in room [ROOM NUMBER], and then returned to room [ROOM NUMBER] to provide care. During general observations on 4/16/2025 at 10:49 AM, a foul odor was noted in the Unit 2 hallway near room [ROOM NUMBER] and 208. During general observations on 4/17/2025 at 10:34 AM, a strong urine odor was noted throughout the 200-unit hallways. Staffing Sheets: A review of staffing sheets provided by the facility from 4/14/2025 through 4/22/2025 documented the following: • On 4/18/2025, evening shift, Unit 2 and Unit 3 each had only 1 nurse scheduled to work. • On 4/19/2025, evening shift, Unit 3 only had 1 nurse scheduled to work, requiring the nurse supervisor to take a cart assignment. • On 4/20/2025, evening shift, Unit 3 only had 1 nurse scheduled to work, requiring the nurse supervisor to take a cart assignment. • On 4/21/2025, evening shift, Unit 2 had 1 nurse scheduled, and Unit 3 did not have any nurses scheduled to work on the unit. Based on facility census, there were not the required number of Registered Nurses or Licensed Practical Nurses on 4/20/2025, and 4/21/2025. • On 4/20/2025, the facility census was 105. There were 14 licensed nurses (Licensed Practical Nurses and Registered Nurses) scheduled to work on that day. The required hours of licensed care for the facility were 115.5 hours based on the census. The licensed staff scheduled accounted for 112 hours of care. • On 4/21/2025, the facility census was 108. There were 14 licensed nurses scheduled to work on that day. The required hours of licensed care for the facility were 118.8 hours based on the census. The licensed staff scheduled accounted for 112 hours of care. A review of staffing sheets provided by the facility from 4/14/2025 through 4/21/2025 documented the following: Based on facility census, there were not the required number of Registered Nurses or Licensed Practical Nurses on 4/20/2025 and 4/21/2025. To fulfill the staffing requirement for licensed nursing care (Registered Nurses and Licensed Practical Nurses) per resident per day, a facility with a census of 108 would need to schedule at least 15 staff members with nursing licenses for the entire day. • On 4/20/2025, the facility census was 105. The number of scheduled nurses was 14 which equaled 112 hours of nursing care hours. The number of nursing care hours required for a census of 105 residents would be 115.5 hours. • On 4/21/2025, the facility census was 108. The number of scheduled nurses was 14 which equaled 112 hours of nursing care hours. The number of nursing care hours required for a census of 108 resident would be 118.8 hours. Based on facility census, there were not the required number of Certified Nurse Aides on any day between 4/14/2025 through 4/21/2025. To fulfill the staffing requirement for Certified Nurse Aide care per resident per day, a facility with a census of 108 would need to schedule at least 33 staff members with Certified Nurse Aides certifications for the entire day. • On 4/14/2025, the facility census was 108. The number of scheduled Certified Nurse Aides were 27 which equaled 216 hours of nursing care hours. The number of nursing care hours required for a census of 108 residents was 264.6 hours. • On 4/15/2025, the facility census was 108. The number of scheduled Certified Nurse A ides was 30 which equaled 240 hours of nursing care hours. The number of nursing care hours required for a census of 108 residents was 264.6 hours. • On 4/16/2025, the facility census was 106. The number of scheduled Certified Nurse Aides were 28 which equaled 224 hours of nursing care hours. The number of nursing care hours required for a census of 106 residents was 259.7 hours. • On 4/17/2025, the facility census was 108. The number of scheduled Certified Nurse Aides were 29 which equaled 232 hours of nursing care hours. The number of nursing care hours required for a census of 108 resident was 264.6 hours. • On 4/18/2025, the facility census was 108. The number of scheduled Certified Nurse Aides were 30 which equaled 240 hours of nursing care hours. The number of nursing care hours required for a census of 108 resident was 264.6 hours. • On 4/19/2025, the facility census was 108. The number of scheduled Certified Nurse A aides were 27 which equaled 216 hours of nursing care hours. The number of nursing care hours required for a census of 108 resident was 264.6 hours. • On 4/20/2025, the facility census was 105. The number of scheduled Certified Nurse Aides were 26 which equaled 208 hours of nursing care hours. The number of nursing care hours required for a census of 105 resident was 257.25 hours. • On 4/21/2025, the facility census was 108. The number of scheduled aides were 27 which equaled 216 hours of nursing care hours. The number of nursing care hours required for a census of 108 resident would be 264.6 hours. Interviews: During an interview on 4/14/2025 at 12:25 PM, Certified Nurse Aide #3 stated that the facility had lost a lot of staff and even though there was a sign on bonus offered, staffing was still an issue, especially on the weekend. Certified Nurse Aide #3 stated that resident care was affected by the staffing issues because staff only had enough time to do the bare minimum tasks like feeding and changing residents. To the best of their knowledge, residents were not left sitting in soiled clothing, but the work ethic of some of the staff was lacking. During an interview on 4/18/2025 at 10:53 AM, Licensed Practical Nurse #1 stated there were not enough staff on the unit. They stated Unit 2 was the hardest unit in the building and four (4) staff on the unit was not enough. Multiple residents required two (2)-person assistance and the staff struggled to get to everyone in a timely manner. During an interview on 4/22/2025 at 10:07 AM, Registered Nurse #5 stated that they lacked time to do all the paperwork and take care of the residents on the unit. Registered Nurse #5 stated they did a review of care plans but there was not enough time for them to comb through the care plans and ensure that they were updated as often as they should be. During an interview on 4/22/2025 at 11:12 AM, Director of Nursing #1 stated that they were aware of the staffing regulations and that they believed staffing was both a problem and not a problem. Director of Nursing #1 stated that they believed they staffed the facility as well as they could and even helped out on the units by working a medication cart occasionally, if it was needed. Director of Nursing #1 stated they had a lot of nurses and maybe they needed to be repurposed so that the hours per resident day could be fully met. Some nurses were doing so many jobs that they struggled to keep up. Director of Nursing #1 stated that the facility worked with nursing students from the hospital and colleges. The facility advertised at jobs fairs and offered recruitment bonuses. 10 New York Code Rules and Regulations 415.13(a)(1) (i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 for two (2) (Unit 100 and Unit 300) of two (2) Medication Rooms; and three (3) (Unit 100, 200 and 300) of three (3) Medication Carts reviewed. Specifically, (a.) two medications had expired; (b.) one open bottle of tuberculin Purified Protein Derivative (PPD) solution had expired; (c.) one Humalog Kwik pen had an illegible open date; (d.) four open inhalers had no open or expiration date; one unopened inhaler had an open date; (e.) one bottle of eye drops had no open and or expiration date (f.) two bottles of eye drops had open and or expiration date discrepancies; (g.) an unopened Solostar Kwik insulin pen was in medication cart unrefrigerated. This is evidenced by: Regulation 483.45(g) Labeling of Drugs and Biologicals, documents Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. During an observation on [DATE] at 11:35 AM, Unit 300, Medication Room contained 1 bottle of sleep aid stock medication with an expiration date of 9/2024; and 1 bottle of melatonin stock medication with an expiration date of 5/2024. Unit 300 medication cart #6 contained 1 Humalog Insulin Kwik pen with an illegible date; 1 unopened bottle of carboxymethylcellulose sodium 0.5% eye drops dated 3/2025. 1 opened bottle of carboxymethylcellulose sodium 0.5% eye drops with date discrepancy. The box had date of [DATE] the bottle was dated [DATE]. Unit 300 mediation cart #6 also contained an open albuterol inhaler dated [DATE] and no expiration date, and an unopened albuterol inhaler with date of [DATE]. During an interview on [DATE] at 11:35 AM, Licensed Practical Nurse #2 was unable to verbalize open and or expiration dates for insulin, eye drops or inhalers. They were not aware of any resources from pharmacy of medications with shortened expiration dates after opening. During an observation on [DATE] at 12:34 PM, Unit 100 Cart #1 was observed with laptop open revealing medication administration record for Resident #99. Unit 100 medication room contained 1 open bottle of tuberculin Purified Protein Derivative (PPD) that had expired as of [DATE]. Unit 100 cart #1 contained 1 open bottle of Systane eye drops; 2 Breo Ellipta inhalers; 1 Anoro Ellipta inhaler with no open and or expiration dates. During an observation on [DATE] at 1:20 PM, Unit 200 cart #3 contained 1 Breo Inhaler with no open and or expiration dates; 2 Admelog Solostar insulin kwik pens; 1 pen was dated [DATE] with no expiration date; the other pen was unopened and stored in mediation cart. During an interview on [DATE] at 01:20 PM, Licensed Practical Nurse #3 stated unopened insulin should be kept in refrigerator until ready for use. During an interview on [DATE] at 12:04 PM, Director of Nursing #1 stated all nursing staff were responsible for ensuring the medication cart and room they had been assigned to were clean and orderly. All medications should be labeled with an open and expiration date. Medications with shortened expiration dates after opening were covered during initial and annual nurse competencies. In-house pharmacy was available as a resource. 10 New York Codes, Rules, and Regulations 415.18(e)(1-4)

Based on observations, record reviews, and interviews during the recertification survey, the facility did not ensure that food was prepared by methods that conserved the food ' s nutritive value, flavor and appearance and were palatable for 18 (Resident #s 1, 2, 4, 9, 21, 23, 31, 32, 39, 48, 59, 63, 64, 68, 90, 91, 92, and 94) of 22 residents who were reviewed for palatable and attractive food and drink. Specifically, (a.) During an interview during Resident Council held on 4/15/2025, six (6) residents complained that the food was inedible and cold, that drinks were warm, vegetables were hard and under cooked, and that the meat was tough. (b.) Resident # ' s 1, 9, 21, 23, 31, 32, 63, 64, 68, 90, 91, 92, and 94 complained of food being of not palatable with meat being overcooked and vegetables undercooked, tasteless and without variety. (c.) Residents on one (1) of three (3) units received expired milk. This is evidenced by: The facility policy titled, Resident Rights and Dignity, dated 5/2012, documented that the facility was responsible to offer food substitutes of similar nutritive value if the food offered was refused. Additionally documented was that the facility would provide assistance with eating and special eating equipment or assistive devices and utensils if needed. The facility policy titled, Use and Storage of Food Brought to Resident from Outside the Facility, dated 1/2023, documented that nursing was responsible for keeping the personal refrigerator in the resident ' s room in compliance with food safety by verifying and documenting refrigerator temperatures as well as checking content dates/condition once daily. Maintenance Department would be notified for corrective action if a temperature was found to be non-compliant (above 41 degrees). Dining Service would provide the appropriate training to nursing. During an interview during Resident Council held on 4/15/2025, 6 residents complained that the food was inedible and cold, that drinks were warm, vegetables were hard and under cooked, and that the meat was tough. During an interview conducted during resident lunch service on 4/14/2025 at 1:09 PM, Resident #94 statedthey had complaints about the chicken they received. They stated it was not what they ordered, and it was dry. Resident #94 stated that they had ordered a hamburger, but they were hungry, so they would eat what they were given. During an observation of resident lunch service on 4/14/2025, several residents complained that the chicken was dry and that the rice was not good. During an interview on 4/15/2025 at 10:41 AM, Resident #31 stated the food was not good. During an interview on 4/15/2025 at 11:13 AM, Resident #9 stated the food was not great, and that they did not get what they asked for frequently. During an interview on 4/15/2025 at 11:21 AM, Resident #21 stated that the food was awful, the residents were given bad cuts of meat, and the food was not prepared properly. During an interview on 4/15/2025 at 2:32 PM, Resident #94 stated that food was never what they ordered, did not have any taste and was dry. During a test of lunch trays on 4/21/2025 at 12:30 PM, Resident #92 ' s tray was noted to have the following items (and observed conditions of them in parentheses): Ensure (a liquid nutritional supplemental drink), cooked carrots (which were noted to be hard to bite), potatoes, beef (noted not to have much flavor), juice (which was noted to be warm at 60 degrees), and hot coffee. During a test of lunch trays on 4/21/2025 at 12:53 PM, Resident #21 ' s tray was noted to have the following items (and observed conditions of them in parentheses): pot roast (noted to be difficult to cut with a knife), roasted potatoes, and cooked carrots and celery (noted to be too hard to be cut with a fork). During a test of lunch trays on 4/21/2025 at 1:04 PM, Resident #31 ' s tray was noted to have the following items (and observed conditions of them in parentheses): whole milk (that expired on 4/17/2025 and warm at 56.1 degrees), orange juice (noted to be warm at 50 degrees), factory packaged diced pears, Ensure (noted to be warm at 68.8 degrees), grilled cheese (noted to be crispy on the bottom and soggy on the top), mixed vegetables (noted to be hard and crunchy), beef with gravy (noted to have some chewy pieces), and mashed potatoes (noted to be watery looking and without taste). Upon discovery of the expired milk on Resident #31 ' s tray (which was one of the last trays to be passed on the unit), Licensed Practical Nurse #7, called down to the kitchen and stated that they needed to check the milk, that expired milk had been sent to the floor and ' you know who found it. ' During an interview on 4/22/2025 at 12:00 PM, Activities Aide #1 stated residents had been complaining since the food service changes occurred a month ago. They stated residents complainted vegetables and meats were cooked in such a fashion that they were unable to chew, cut, and struggled to chew food served to them. During an interview on 4/22/2025 at 11:33 AM, Food Service Director #1 stated there were some concerns voiced at the food council meeting held on 4/08/2025. They had been addressing what they believed was the most pressing issue, that food trays were not being delivered in a timely fashion. There were separate food meetings from resident council and that there were concerns and the concerns were being worked on and addressed. They stated the warm temperature juice and milk were most likely because they were in the tray carts with the warm food. They hadn ' t met with any residents individually, just during resident council meetings and food meetings. After they were made aware that expired milk was found on the unit, they were called by the staff and had the kitchen staff go through all of the drinks stored in the kitchen and pull anything outdated. During a telephone interview on 4/22/2025 at 11:40 AM, Clinical Nutrition Manager #1 stated there had been a change in food service, they had some complaints of food being under or over cooked. Clinical Nutrition Manager #1 stated that the residents could have their diets changed to ground meat and pureed vegetables if they were unable to chew the food that was served. Clinical Nutrition Manager #1 stated that they had not met individually with any residents and that they were all still getting used to the new system being used at the facility. The Clinical Nutrition Manager stated that during the menu planning and food service committee meeting, residents complained about a fish dinner that was so inedible that the dish was removed from options for a meal. They stated there were no complaints made regarding food temperatures from residents to the best of their knowledge. 10 New York Code of Rules and Regulations 415.14(d)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure they 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 five (5) (Resident # ' s 21,35,92, 95, and 99) of 15 residents reviewed for infection control. Specifically, (a.) Resident #s 21, 35, 92, and 95 had wounds that required dressing changes and were not placed on Enhanced Barrier Precautions; and (b.) for Resident #99, infection control practice was not maintained during a dressing change and skin treatment. This is evidenced by: The facility policy, Nursing Home Infection Prevention and Control Program, revised 1/2023, documented the following: • Under Policy: There is an active, effective, facility wide infection control program for the surveillance, prevention and control of infections as well as reporting of communicable diseases and increased incidence of infections. • Under Responsibility: To maintain a record of incidents and corrective actions related to infections and report them to the Infection Control Committee. The Infection Preventionist will: (a) perform surveillance and investigation to prevent, to the extent possible, the onset and spread of infection; (b) prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions; (c) use records of infection incidents to improve its infection control processes and outcomes by taking corrective actions, as indicated; (d) implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination; and (e) properly store, handle, process, and transport linens to minimize contamination. Resident #21 Resident #21 was admitted to the facility with diagnoses of squamous cell carcinoma of skin of scalp and neck (cancer cells that form on the surface of the skin), type 2 diabetes mellitus with diabetic neuropathy (endocrine dysfunction that causes issues regulating blood sugar that causes damage to nerves in the legs, feet and hands), and morbid obesity (excessive body fat that causes a body mass index of 40 or higher). The Minimum Data Set (an assessment tool) dated 3/07/2025, documented that the resident was able to be understood and understand others, with minimal cognitive impairment. A review of Resident #21 ' s physician orders on 4/21/2025 showed evidence that Resident #21 required a dressing change to their heel every three days, and as needed, and to check the dressing condition every shift, daily. There was no documented evidence that Resident #21 had an order for Enhanced Barrier Precautions. Resident #35 Resident #35 was admitted to the facility with diagnoses of unspecified benign neoplasm of penis (non-cancerous growth or tumor that arises on the penis), severe protein-calorie malnutrition (a condition characterized by a combination of severe protein deficiency and calorie deficiency, leading to significant physical consequences), and intellectual disabilities (condition characterized by limitations in cognitive functioning and skills). The Minimum Data Set, dated [DATE], documented the resident to be had minimal cognitive impairment, could be understood, and understand others. A review of Resident #35 ' s physician orders on 4/21/2025 documented Resident #35 required a dressing change to their bilateral heels every 3 days, and as needed. There was no documented evidence that Resident #35 had an order for Enhanced Barrier Precautions. Resident #99 Resident #99 was admitted to the facility with diagnoses of unspecified severe dementia with agitation (a progressive degenerative memory disease that can cause severe physical or verbal aggression), type 2 diabetes mellitus without complications (an endocrine dysfunction that causes irregular blood sugar levels), and obstructive sleep apnea (a sleep disorder that causes episodes of complete airway collapse or partial collapse with decrease in oxygen saturation). The Minimum Data Set, dated [DATE], documented that the resident was sometimes understood and sometimes understand others, and had severe cognitive impairment. Resident #99 ' s Comprehensive Care Plan for Skin Integrity, effective 8/22/24 and revised 9/18/2024, documented Resident #99 had bilateral unstageable heel wounds that required care. The note update by Registered Nurse #7 on 11/15/2024 documented Resident #99 ' s treatment; cleanse the right heel, allow to dry, and cover with Mepilex dressing every 3 days and as needed. The left heel was noted to be closed but received the same treatment. The care plan was again updated on 2/14/2025 with Registered Nurse #7 ' s note indicating that the wound care team was following wound progress and interventions were to continue. The Physician order dated 3/21/2025 at 3:44 PM documented Resident #99 was to have the right heel cleansed with Vashe skin cleanser, allow to dry and cover with heel Mepilex dressing every 3 days and as needed. Document/report any signs or symptoms of infection or change. During an observation on 4/21/2025 at 3:20 PM, Licensed Practical Nurse #7 was observed changing the dressing to Resident #99 ' s heel. They applied a gown and gloves and removed the old dressing. Licensed Practical Nurse #7 did not change the gloves they were wearing after removing the soiled dressing. Licensed Practical Nurse #7 washed Resident #99 ' s wound area from the outside in, instead of inside to out with Vashe wound cleanser and when they pulled the clean dressing from its wrapper, Licensed Practical Nurse #7 fanned the open wound with the dressing to help increase drying time. The dry dressing was applied and covered with a heel Mepilex. During an interview on 4/21/2025 at 3:30PM, Licensed Practical Nurse #7 was asked when they were last trained on infection control and dressing changes. Licensed Practical Nurse #7 stated that they had been out for two (2) months and were catching up on their competencies. They stated that they did not know when they had their last training. During an interview on 4/22/2025 at 10:37 AM, Infection Preventionist Supervisor #1 (supervisor of the facility ' s Infection Preventionist) stated they were able to speak to general policies but not specific facility practices. Infection Preventionist Supervisor #1 stated that Enhanced Barrier Precautions were ordered for residents with foley catheters or wounds. Contact Precautions were used for residents with active infections, not residents colonized with multiple drug resistant organisms, like Methicillin-resistant Staphylococcus aureus (a group of gram-positive bacteria that are genetically distinct from other strains of Staphylococcus aureus and is responsible for several difficult-to-treat infections in humans) or Escherichia coli (E coli, a gram-negative coliform bacterium that is commonly found in the lower intestine of warm-blooded organisms). Infection Preventionist Supervisor #1 stated that the facility aimed for the least restrictive barrier precaution and that there were studies that showed that residents with contact precautions received fewer social interactions, and it increased the likelihood of staff avoiding residents with contact precautions. Infection Preventionist Supervisor #1 stated that Infection Preventionist #1 had done audits and observed staff compliance with donning and doffing personal protective equipment, and that the facility strived to have good infection control policies and procedures. During an interview on 4/22/2025 at 11:12 AM, Director of Nursing #1 stated that precautions used were based on devices used by residents, such as foley catheters or central lines, and resident conditions, such as open wounds, and infections. The type of precautions used were based on if infections were active versus chronic. The examples given included a resident with an infected open wound would require Contact Precautions, but a resident with a wound infection that had been treated, and did not require antibiotics, would only need Enhanced Barrier Precautions. When asked if a resident with a multiple drug-resistant organism in their urine, and with a foley catheter, would require Contact or Enhanced Barrier Precautions, Director of Nursing stated that only active infections required Contact Precautions and colonized, but not active organisms, required Enhanced Barrier Precautions. Director of Nursing #1 stated that when Infection Preventionist #1 returned, they would have an in-depth discussion on the difference in precautions and what they should be for residents colonized with multiple drug-resistant organisms, wounds, and foley catheters. Director of Nursing #1 stated that any order for precautions of any kind required a physician ' s order. 10 New York Codes, Rules and Regulations 415.19(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during a recertification survey from 4/14/2025 - 4/22/2025, the facility did not ensure the environment was functional, sanitary, and comfortable for residents, staff, and the public. Specifically, all three units (100, 200 and 300) had foul smelling odors of urine and feces. Unit 100 carpet was soiled with multiple stains throughout; Unit 200 had dirty linens under sink and Unit 300 had smelled consistent with cannabis. This is evidenced by: The Facility ' s Policy and Procedure titled, Personal Appearance, revised 3/17/2025, documented the policy intends to provide a general expectation for personal appearance for facility ' s employees and is not meant to capture all necessary dress and appearance requirements nor represent a complete listing of clothing or items of apparel acceptable throughout the facility. All employees are to take positive steps toward ensuring that they present an overall professional image. Employees with offensive odor upon their person or clothing, including but not limited to tobacco or marijuana, will be sent home to change clothes or eliminate the smell (e.g. brushing teeth, bathing, etc.). During an observation on 4/14/2025 at 11:00 AM, noted strong odor of feces in hallway that included room [ROOM NUMBER]. The carpeted floor had multiple stains. During an observation on 4/15/2025 at 9:30 AM, a strong odor of feces on unit 100 common area was noted. Licensed Practical Nurse #6 was made aware at the time of the observation. They stated they would tell the aide. There was no care provided to any resident sitting in the common area for 20 minutes. During an observation on 4/17/2025 at 10:45 AM, there was a heavy urine and feces smell on 200-unit, outside of room [ROOM NUMBER]. Dirty linen was observed on the floor under the sink. During an observation on 4/17/2025 at 10:53 AM, there was a smell of urine in the hallway outside of room [ROOM NUMBER]. During an observation on 4/17/2025 at 11:40 AM on the 300-unit, a strong odor of smoke consistent with cannabis was noted near Medication Cart #6. During an interview on 04/17/2025 at 11:00 AM, Director of Nursing #1 stated staff identified one (1) resident on unit 100 sitting in common area that required care. They further stated that housekeeping cleaned units throughout the day. Units 200 and 300 carpets were replaced with laminate flooring, but that at this time, the carpet on unit 100 was not budgeted for replacement. During an interview on 04/17/2025 at 11:40 AM, Licensed Practical Nurse #6 stated they recently came in and had smoked prior to coming into the building. Upon this interview, surveyor relayed this interview to Administrator #1, and Licensed Practical Nurse #6 was immediately sent home. During an interview on 04/17/2025 at 12:04 PM, Director of Nursing #1 stated staff were only to smoke in designated smoking areas. They stated staff who enter the building with the smell of smoke were in violation of the facility ' s Personal Appearance Policy, and if identified would be sent home to change into appropriate clothing. During an interview on 04/21/2025 at 12:01 PM, Administrator #1 stated they did not recall the smell of cannabis in the past. They stated they had reports from residents complaining of staff smelling of cigarette smoke. They stated one example was a Certified Nurse Aide who smoked in their car and then came back into building smelling of smoke; the staffer was educated on the facility ' s personal appearance policy. 10 New York Codes, Rules, and Regulations 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during an abbreviated survey (Case #NY00297324 and NY00311039), the facility did not ensure residents were free from neglect for 2 (Resident #1 and #2) of 2 residents reviewed for neglect. Specifically, Resident #1, who required two staff to transfer via mechanical lift, was injured when Certified Nursing Aide # 3 transferred Resident #1 by themselves. Additionally Resident #2, who was care planned for having a chair alarm, sustained injury when they attempted to transfer themselves and no chair alarm was present. This is evidenced by: The facility Abuse Prohibition policy and procedure revised 12/31/2021 documented all nursing home residents had the right to be free from verbal, physical, sexual, and mental abuse. All claims of abuse, neglect or mistreatment must be investigated. The facility Mechanical Lift policy and procedure revised 11/19/2021 documented all mechanical lifts required two-person assist. Resident #1 Resident #1 was admitted to the facility with diagnoses of venous insufficiency (when leg veins become damaged and struggle to send blood back up to the heart), age-related osteoporosis (weakening of bones), and shortness of breath unspecified. The Minimum Data Set (an assessment tool) dated 12/13/2023, documented the resident could be understood, could understand others, and was cognitively intact. Comprehensive Care Plan titled, Activities of Daily Living, revised on 2/05/2022, documented Resident #1 required two staff-person assist with mechanical lift using medium-sized sling. Resident Care [NAME] (resident care card) dated 3/04/2021 documented Resident #1 was two-person-assist with transfers. The Facility Investigative Report dated 6/12/2022 documented Certified Nurse Aide #3 transferred Resident #1 via mechanical lift without assistance from another caregiver. Resident #1 was care planned as a 2-person assist transfer. Resident #1 complained of pain to groin area during transfer that lined up with straps from mechanical lift pad. Registered Nurse assessment identified 5 centimeter by 5 centimeter bruising to right groin. Certified Nurse Aide #3 admitted to transferring resident independently. Certified Nurse Aide #3 stated they were unable to locate a second caregiver. They acknowledged understanding that Resident #1 was a two-person assist transfer per care plan. Certified Nurse Aide #3 did not know why they failed to approach the nurse for assistance. Nursing progress note dated 6/11/2022 documented Resident #1 complained of swollen area on right inner thigh with bruising noted. Resident #1 stated it occurred during transfer when mechanical lift sling pushed into their leg. During an interview on 3/06/2024 at 2:00 PM, Resident #1 stated they had a bruise on their right thigh after the transfer. During an interview on 3/07/2024 at 10:40 AM, Director of Nursing #1 stated they interviewed Resident #1, who stated they received a bruise from mechanical lift transfer on 6/11/2022. Director of Nursing #1 further stated that Resident #1 indicated Certified Nurse Aide #3 did the transfer alone. Director of Nursing #1 interviewed Certified Nurse Aide #3, who stated they were in a rush to get the resident up and did not get help with mechanical lift transfer They stated training on mechanical lift transfer was given upon hire and annually; and abuse and neglect training was given upon hire, annually and when there was an allegation of abuse or neglect. Resident #2 Resident #2 was admitted to the facility with diagnoses of morbid obesity; epilepsy (a seizure disorder), and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). The Minimum Data dated 1/28/2023, documented the resident could be understood and could understand others. Resident # 2 was cognitively intact. The Comprehensive care Plan titled, Falls Risk, dated 11/07/2022, documented use of a chair alarm for Resident #2 at all times. The facility Incident Report dated 2/16/2023 documented, Resident #2 was found on the floor with abrasion to left knee 0.5 centimeters by 0.8 centimeters, a pink area on top of head, left cheekbone with pinkish 3 centimeters by 2 centimeters area and 1 centimeter by 1 centimeter light purple bruise to left bridge of nose towards left eye from glasses nose piece. Resident #2 stated they wanted to transfer from straight back chair to recliner. Resident #2's Care [NAME] documented chair alarm to be placed on resident at all times. Certified Nurse Aide #2 stated they forgot to place chair alarm on the resident after caring for them. The Facility Investigative Report dated 2/20/2023 documented Resident #2's chair alarm was not placed on the resident, and resident sustained injury during fall. Certified Nurse Aide #2 admitted to failing to place chair alarm on resident's wheelchair. During an interview on 3/08/2024 10:54 AM, Certified Nurse Aide #2 stated they worked until 7:00 PM on 2/16/2023, sat the resident in their chair and forgot to put chair alarm on them. After they left the room, Resident #2 stood and fell to floor. During an interview on 3/08/2024 at 11:40 AM, Director of Nursing #1 stated Certified Nursing Aide #2 had worked a double shift on 2/16/2023 and was re-educated on reading Resident Care Card and Resident safety. 10 New York Codes, Rules, and Regulations 415.4 (b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case # NY00304461), the facility did not ensure residents were free from any significant medication errors for 2 (Resident #'s 5 and 6) of 3 residents reviewed for significant medication errors. Specifically, Resident #'s 5 did not receive their Synthroid on 3/27/2022, and Resident #6 did not receive Aspercreme patch applied on 10/27/2022 as ordered. This is evidenced by: The Policy and Procedure titled, Medication Administration Documentation, revised on 5/2023, documented omission of medications was unacceptable except in the case of resident refusal, or when warranted by resident condition. Resident #5 Resident #5 was admitted to the facility with diagnosis of mild cognitive impairment; hypothyroidism (the thyroid gland does not make enough thyroid hormone), and chronic venous insufficiency (leg veins do not allow blood to flow back up to your heart). The Minimum Data Set (an assessment tool) dated 8/17/2022, documented the resident could be understood and could understand others with a Brief Interview of Mental Status indicating moderate impairment. The Medication Administration Record documented Resident #5 had an active order initiated on 10/26/2022, for levothyroxine (Synthroid) 50 microgram tablet. 1 tablet by mouth once daily before breakfast. On 10/27/2022 the medication was signed given by Licensed Practical Nurse #1. Resident #5 was originally prescribed 75 micrograms Synthroid. On 10/26/2022 dosing of Synthroid was decreased to 50 micrograms. During the facility investigation on 10/27/2022, Synthroid 50 micrograms was found in the sharps container. Synthroid 75 micrograms was not removed popped from the blister pack. During an interview on 3/07/2024 at 11:30 AM, Resident #5 stated some mornings they did not receive their 5:00 AM Synthroid medication. Resident #6 Resident #6 was admitted to the facility with diagnosis of Cerebral Palsy (a group of conditions that affect movement and posture), essential hypertension (high blood pressure), and osteoarthritis of both hips. The Minimum Data Set, dated [DATE], documented the resident could be understood and could understand others and was cognitively intact. The Medication Administration Record dated 3/27/2022, documented Resident #6 had an active order initiated 4/25/2021, for Aspercreme (lidocaine HCL) 4% topical patch. Apply 1 patch by topical route once daily to left groin area, 12 hours on and 12 hours off. On 10/27/2022 the Aspercreme (lidocaine HCL) 4% topical patch was signed given by Licensed Practical Nurse #1. The Investigative Report dated 11/02/2022, documented Resident #6 reported they did not receive their Aspercreme patch on 10/27/2022. Undated skin assessment revealed there was no Aspercreme patch on Resident #6. Aspercreme patch count was the same before and after alleged administration for which Licensed Practical Nurse #1 signed for the medication administration. Resident #6 stated they usually received their medicine but sometimes on overnights they did not receive their Aspercreme patch. Resident #6 stated when they did not receive their pills, they had back pain and felt shaky. During an interview on 3/07/2024 at 2:15PM Licensed Practical Nurse #2 stated Resident #5 had not informed them [Licensed Practical Nurse #2] that they did not receive their medication. During an interview on 3/08/2024 at 11:42 AM, Director of Nursing #1 stated the plan of correction was discontinued May 2023 as it was not doable. They continued to monitor alert and oriented residents that medications were being administered as ordered. During the investigation on 10/27/2022, Synthroid 50 micrograms was found in the sharps container and Synthroid 75 micrograms was not popped from the blister pack. 10 New York Codes, Rules, and Regulations 415.12(m)(2)

Based on observation, record review and interviews during the recertification survey from 05/22/2022 through 05/26/2022, the facility did not ensure residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, to discontinue these drugs for 1 (Resident #s 69) of 5 residents reviewed for psychotropic drug use. Specifically, the medical record for Resident #69 did not include documentation to address a GDR for Mirtazapine (antidepressant) between 11/09/2020 and 05/25/2022. This was evidenced by: The Policy & Procedure titled Psychotropic Medication Tapering dated 9/18/2021 documented; Psychotropic medication will be prescribed only as necessary to treat a specific diagnosed condition and subsequent to a comprehensive assessment. Those receiving a psychotropic medication will have gradual dose reductions and behavioral interventions unless clinically contraindicated. Within the first year after admission or medication initiated, a GDR (gradual dose reduction) must be attempted in two separate quarters with at least one month between the attempts, unless clinically contraindicated. Resident #69: Resident #69 was admitted to the facility with the diagnoses of dementia with behavioral disturbance, anxiety disorder and hallucinations. The Minimum Data Set (MDS-an assessment tool) dated 4/20/2022, documented the resident had severe cognitive impairment, could sometimes make self understood and sometimes could understand others. The physician orders dated 05/16/2022 documented; Mirtazapine (antidepressant) 7.5 mg (milligrams) once daily at bedtime, for depression. The original order date was 11/09/2020. The comprehensive care plan (CCP) titled Mood state-Depression-sadness-husband has passed away dated 10/30/2020, documented resident has a diagnosis of depression, continues to be very sad at the passing of her husband, however, will say they are in a better place now. Resident #69 has been expressing her grief as she desires. Intervention documented to encourage verbalization of feelings and encourage decision making. The comprehensive care plan (CCP) titled Psychotropic Drug Use dated 10/25/2019 documented the resident is on an antidepressant related to diagnosis of depression. The interventions did not include a GDR. A review of Physician notes, Nurse Practitioner notes and Physician Assistant notes did not include documentation of a clinical contraindication or attempted GDR from 11/09/2020 to 05/25/2022. A review of Physician orders did not include documentation of a Mirtazapine dose reduction between 11/09/2020 and 05/25/2022. A review of monthly pharmacy reviews did not include a recommendation to attempt a GDR of the Mirtazapine between 11/09/2020 and 05/25/2022. During an interview on 05/25/2022 at 09:15 AM, the Director of Nursing (DON) stated, the note from Doctor #1 dated 12/21/2021 stated no changes in medications. The DON stated we do GDRs, not sure about the GDR for the Mirtazapine. The DON stated they were not aware of all the regulations about GDRs, assumed the documentation of no changes in medications was sufficient. During an interview on 05/25/2022 at 09:31 AM, Pharmacist #1 (Pharm) stated when the pharmacist did the chart reviews, they would look at the psychiatry notes and Doctor notes and if they did not document something Pharm #1 would let them know that maybe it should be looked at. If the Doctor notes documented to continue medications as is Pharm #1 did not try to interject. Did not know why they did not address the Mirtazapine. Pharm #1 stated they did not know there was an actual schedule to be followed or tracked for GDRs, they had always gone off of doctor notes and made suggestions. During an interview on 05/25/2022 at 09:44 AM, MDS Coordinator #1 (MDSC) stated in order to complete the MDS section for the date of the last GDR they would look into the bimonthly doctors notes where they list all of the medications a resident was on, look at the medication administration record (MAR) to see the dates the medication was ordered and will do a search of those medications that require a GDR to find the dates. MDSC stated from my perspective, when they were doing the doctor notes, they are making a determination to continue the medications or not. During an interview on 05/25/2022 at 02:02 PM, Physician Assistant (PA) #1 stated it was their understanding that the pharmacist was doing the GDRs. We did provide the DOH Surveyor with the Doctor note that they documented, to continue all medications for Resident #69. I did not know there had to be a note with more information documented about the specific medication. During an interview on 05/26/2022 at 09:15 AM, the Administrator (Adm) stated before they worked here, the facility discontinued the monthly GDR meetings, and they were now planning on starting new GDR monthly meetings. The Adm stated they were not aware GDRs were not taking place, the pharmacist was thought to be looking at the GDRs. 10NYCRR415.12(l)(2)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during a recertification survey and an abbreviated survey (Case #NY00283532) dated 5/22/2022 through 5/26/2022, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 6 (Resident #'s 25, 35, 50, 54, 69, 81) of 20 residents reviewed. Specifically, the facility did not ensure that a care plan was developed for Resident #25 to address the stage 2 pressure ulcer [NAME] was identified on their left heel on 5/11/2022; for Resident #35, the facility did not ensure the resident's toileting schedule was followed in accordance with the care plan for urinary incontinence; for Resident #50, the facility did not ensure the CCP addressed the resident's bowel and bladder incontinence, did not ensure the Activities of Daily Living (ADLs) care plan was implemented to consistently assist the resident with eating and did not ensure the At Risk for Skin Breakdown care plan was implemented for turning and positioning every 2 hours; for Resident #54, the facility did not ensure the Certified Nursing Assistant (CNA) implemented the care plan to provide the resident with an extensive assist of 2 when transferring the resident from the bed to the wheelchair which resulted in the resident being lowered to the floor and sustaining a skin tear to the top of their left hand; for Resident #69, the facility did not ensure personalized interventions were included in the comprehensive care plans for dementia, behavior symptoms and mood state; and for Resident #81, nursing care plans were not developed to address the resident's diagnoses of atrial fibrillation, stenosis of the right carotid artery, asthma, allergic rhinitis, hypertension, gastroesophageal reflux disorder, and osteomyelitis. This is evidenced by: The Policy and Procedure titled Comprehensive Care Plans dated 11/26/2019, documented a Comprehensive Care Plan will be initiated on admission and completed within 21 days on all residents in the Nursing Home and reviewed quarterly by each discipline and as needed as the resident's condition warrants. The nursing instructions will be initiated upon admission by the Registered Nurse (RN) completing the RN Assessment. Especially important are entries relating to active diagnosis and special care needs such as oxygen use, pressure ulcers, aphasia, pain management, potential fall risk, Activities of Daily Living (ADLs), and behaviors that would impact others. The nursing instructions including ADLs and Certified Nursing Assistant (CNA) care will be printed and kept inside the residents' closet. These will be reprinted by the Unit Secretary when needed. All disciplines will be involved in care plan development. Resident #25: Resident #25 was admitted to the facility with diagnoses of dementia, diabetes, and chronic venous insufficiency. The Minimum Data Set (MDS - an assessment tool) dated 3/5/2022, documented the resident was usually able to make themselves understood, usually able to understand others, and moderately cognitively impaired. A Wound and Skin assessment dated [DATE], documented an unavoidable (the resident developed a pressure ulcer/injury even though the facility had evaluated the resident's clinical condition and risk factors) stage 2 (shallow open ulcer) pressure ulcer on the resident's left heel measuring 0.4 cm x 0.05 cm. The Comprehensive Care plan (CCP) did not include a care plan to address the stage 2 (partial-thickness loss of skin with exposed dermis) pressure ulcer on the resident's left heel. During an interview on 05/25/22 at 12:13 PM, Registered Nurse (RN) #1 stated when a new pressure ulcer was identified on a resident, a new care plan must be developed. When Resident #25's stage 2 pressure ulcer on their left heel was identified on 5/11/2022, no care plan was initiated, and as of 5/25/2022, one had not yet been developed. RN #1 stated that their care plans were not as up to date as they should be. During an interview on 05/25/22 at 01:44 PM , the Director of Nursing Services (DON) stated that care plans were initiated by the facility's MDS Coordinator upon admission, and after that the Registered Nurses were responsible for their continued development and implementation. When a new pressure injury was detected on a resident, a new care plan addressing the actual pressure injury needed to be developed, even if the resident was already care planned as At Risk for skin integrity concerns. The DON stated that Resident #25 did not currently have a care plan in place addressing the stage 2 pressure injury on their left heel, and that this should have been in place. Resident #54: Resident #54 was admitted with diagnoses of primary lateral sclerosis (a rare neuromuscular disease with slowly progressive weakness in voluntary muscle movement), ataxia (the loss of full control of bodily movements), and muscle spasms of the calf. The Minimum Data Set (MDS-an assessment tool) dated 4/6/2022 documented the resident was cognitively intact, could usually understand others and could usually make self understood. The Resident Nursing Instructions dated 7/7/2021, documented the resident required extensive assistance of 2 for transfers. A Physical Therapy (PT) progress note dated 7/7/2021, documented the resident was for a PT evaluation due to increased difficulty in transfers and ambulation. The resident required an extensive 2 assist with a front wheeled walker for transfers. The Facility Investigation dated 9/21/2021, documented during a transfer from the bed to the wheelchair, Resident #54 was lowered to the floor after they started to sit prior to reaching the chair. The resident was an assist of 2 and was transferred with an assist of 1 with a gait belt. The resident obtained a 1 x 1 centimeter horseshoe shaped skin tear to the top of their left hand. The CNA did not follow the care plan when transferring the resident which resulted in a minor injury. A review of CNA documentation for the month of 9/2021, documented the resident required extensive assistance of 2 for transfers. The Comprehensive Care plan (CCP) for Activities of Daily Living (ADLs) updated 9/26/2021, documented the resident required assistance with ADL (activities of daily living) tasks and required a 2 assist stand pivot for transfers. Prior to 9/26/2021, the care plan documented the resident required a 1 assist stand pivot transfers. During an interview on 5/24/2022 at 1:29 PM, CNA #2 stated they recalled the incident with Resident #54. CNA #2 was transferring the resident by themself when they had to lower the resident to the floor because they did not have the strength to hold the resident up on their own. The resident got a skin tear on their hand. CNA #2 stated they knew the resident was an assist of 2 for transfers. CNA #2 stated it was just one of those times when CNA #2 wanted to get the resident transferred from the bed to the wheelchair and tried to do it without the assitance of another staff. CNA #2 stated they learned about changes to a resident's care plan on the kiosk through an email notification and by looking at the residents' statuses on the TAR (Transfer, Ambulation, Range of Motion) sheets printed by therapy that were hung in the staff break room on the unit for staff to refer to as needed. During an interview on 5/24/2022 at 1:48 PM, Physical Therapist (PT) #1 stated Resident #54 was a 2 assist for transfers since 7/7/2021. PT #1 stated the resident was difficult to stand with a 1 assist and required extensive assistance of 2 staff to be tranferred. The resident's transfer status as a 2 assist had not changed since July 2021 and therapy had made the nursing unit aware by sending an updated TAR sheet printed that was hung in staff break room. During an interview on 5/25/2022 at 1:17 PM, the Director of Nursing (DON) stated Resident #54 required the assistance of 2 staff to be transferred and the nursing instructions were updated in the CNA kiosk when the CNA transferred the resident with a 1 assist. The DON stated CNA #2 knew that Resident #54's care plan documented the resident required an assist of 2 for transfers and stated the CNAs were instructed to follow the care plan/care card as written and to provide the assistance that was documented on the care card. The DON stated the care plan was not followed by CNA #2. The DON stated they were always reinforcing to the staff to check the residents' care cards because things could change in a second. The nurses on the unit were responsible for overseeing that care plans were being followed. The monitoring was done by observing staff on the unit. Resident #69: Resident #69 was admitted to the facility with the diagnoses of dementia with behavioral disturbance, anxiety disorder and hallucinations. The Minimum Data Set (MDS-an assessment tool) dated 4/20/2022, documented the resident had severe cognitive impairment, could sometimes make self understood and sometimes could understand others. The Psychiatric Follow-up Note dated 12/06/2021 documented: Psychiatric follow-up note; Resident was seen today, was quite tearful. Resident had numerous complaints about the food and care. Resident appears with worsening depression since the change in the antidepressant. Resident is also experiencing worsening anxiety and hallucinations. The comprehensive care plan (CCP) titled Dementia-Impaired Judgement dated 10/22/2019 documented; resident is noted with cognitive deficits with episodes of confusion and forgetfulness. At times resident becomes disoriented with the need for redirection and reorientation. There were no personalized interventions documented for staff to utilize when caring for the resident. The CCP titled Behavior Symptoms-Verbal abuse-Hallucinatins-Delusions dated 01/22/2020, documented the resident has a history of displaying verbal abuse to staff inclusive of using profanity. There were no personalized interventions documented for staff to utilize when caring for the resident. The CCP titled Mood State-Depression-sadness-husband has passed away dated 10/30/2020, documented the resident has a diagnosis of depression, continues to be very sad at the passing of her husband. There were no personalized interventions documented for staff to utilize when caring for the resident. During an interview on 05/25/2022 at 09:39 AM, the Director of Nursing (DON) stated personalized interventions for Resident #69 should be in the care plan. The DON stated the Nurse Managers try to review care plans for completion and thoroughness and the MDS Coordinator reviews care plans as well and starts some of them. During an interview on 05/24/2022 at 10:35 AM, the Director of Social Work (DSW) stated their dementia care was not a formal dementia care program, but they do have dementia care plans for those residents with dementia. There were many things Resident #69 likes, such as 1:1 visits, their stuffed puppy, reminiscing and pets. The care plan needs to be more personalized to include those things. During an interview on 05/24/2022 at 02:06 PM, the DON stated each department does their own care plans, and the care plans should be individualized to each resident. During an interview on 05/25/2022 at 09:44 AM, MDS Coordinator #1 stated that for the care plans that are triggered from the MDS, they try to look at them and personalize them from their perspective. MDS Coordinator #1 stated they knew the care plans were weak and needed to be more personalized. 10NYCRR 415.11(c)(1)

Based on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Food preparation and serving areas are to be kept clean, kitchen equipment is to be kept in good repair, and a test kit is to be available to measure the parts per million (ppm) concentration of the solution used to sanitize equipment. Specifically, doors in the main kitchen were not clean, plumbing for sinks in the main kitchen was not in good repair, and a compatible test kit to measure concentration of chemical sanitizer used to manually sanitize food contract equipment (test kit) was not provided. This is evidenced as follows: During observations of the main kitchen on 05/22/22 at 11:15 AM, the door to the linen closet and the back door were soiled with black grime; the faucet handles on the handwashing sink were stripped; and the entire faucet on the preparation sink was very loose and not secured to the sink. The label of the chemical concentrate used to manually sanitize food equipment titled J-512 Sanitizer and dated 2019 documented that the active ingredients are dimethyl benzyl ammonium chloride and dimethyl ethyl benzyl ammonium chloride. The label of the test kit being utilized titled Virex II 256 Test Paper and dated with an expiration date of 4/15/22 documents that the test kit measures n-alkyl dimethyl benzyl and/or n-alkyl dimethyl ethyl benzyl ammonium chloride. The Food Service Director stated in an interview on 05/22/22 at 12:44 PM that the wrong test papers were put in the kitchen, and the manufacturer will be contacted about getting the correct test papers; the doors will be cleaned; and the plumbing fixtures will be repaired. The Administrator stated in an interview on 05/22/22 at 2:44 PM that the issues with the test kit, faucet repairs, and cleanliness will be addressed. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.112(c), 14-1.140, 14-1.171

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during a recertification survey the facility did not ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #88) of one resident reviewed for ROM. Specifically, for Resident #88, the facility did not ensure bilateral (both) hand pillows were applied at all times for hand contractures. This is evidenced by: The Policy and Procedure titled Positioning last revised 11/6/18, documented all residents would be positioned in correct body ailment to prevent formation of or deterioration of contractures and positioning equipment included rolled washed cloths/hand pillows. The policy documented staff would follow the care plan and Certified Nursing Assistant (CNA) instructions. Resident #88: The resident was admitted to the facility on [DATE], with diagnoses of Parkinson's disease, intellectual disabilities, and aphasia. The MDS dated [DATE], documented the resident had severely impaired cognition, could rarely/never understand others and could rarely/never make self understood. During observations on 10/28/19 at 09:51 AM, 10/29/19 at 12:04 PM, 10/30/19 at 8:33 AM, and 10/30/19 at 10:22 AM, the resident was without the bilateral hand pillows. An Occupational Therapy (OT) progress note dated 4/1/19, documented the resident had been dependent in all ADLs related to her diagnosis with contractures present in all upper extremity joints and increased spasticity (stiff or rigid muscles) over the years. It documented to continue with proper positioning of patient as indicated. A physician order dated 6/8/12, documented to apply bilateral hand pillows at all times. The comprehensive care plan (CCP) for activities of daily living (ADL), last revised 8/29/19, documented the resident required total assistance for all ADL's due to Parkinson's disease and was to have bilateral (both sides) hand pillows at all times. The CCP for skin integrity, last revised 10/13/19, documented the resident was at risk for skin breakdown due to impaired mobility and contractures and was to have bilateral hand pillows applied at all times. The Resident Nursing Instructions (CNA care guide) under the heading CNA Care Provided, last updated 10/16/19, documented hand pillows to hands AATs (at all times). During an interview on 10/30/19 at 10:12 AM, the Director of Rehabilitation #6 stated hand pillows were something that OT would recommend and would issue to the resident for nursing staff to apply. She stated the bilateral hand pillows were documented on the nursing ADL care plan and the Certified Nursing Assistants (CNAs) would be responsible for applying the hand pillows during care. During an interview on 10/30/19 at 10:14 AM, Occupational Therapist #5 stated he tried hand splints with the resident in the past, but her hands were too contracted and the the splints did not work for her. He stated he recommended blue hand pillows or rolled up wash cloths to be placed in the palms of the resident's hands due to her hand contractures. The hand pillows were used to prevent skin breakdown from her contracted fingers/thumb pressing into the palm of her hand. He stated the resident was not currently on therapy, but the recommendation for the blue bilateral hand pillows had not changed and should be in place as care planned. During an interview on 10/30/19 at 10:19 AM, CNA #6 stated the resident was not supposed to have bilateral hand pillows applied and he had not seen hand pillows in the resident's room. He stated he did not believe hand pillows were listed on the resident's care card. During an interview on 10/30/19 at 10:22 AM, Licensed Practical Nurse #2 stated the resident should have bilateral hand pillows applied at all times. She stated the CNAs usually rolled up wash cloths and placed them in her hands if the pillows were not available. She reviewed the CNA care card hanging in the closest and stated the hand pillows were documented on the care card and the CNAs were responsible for reading the care card and following it. She stated LPNs were not responsible for overseeing that the CNAs had applied the hand rolls and did not know who was responsible for overseeing that the CNAs completed their tasks. During an interview on 10/30/19 at 11:25 AM, Registered Nurse #3 stated if the hand pillows were on the resident's care plan then she should have had them applied to her hands. She stated OT recommended and supplied the hand pillows and the CNAs were responsible for ensuring the hand pillows were in place. She stated it was the team leader (the LPN on that side of the unit) who would provide the oversight to ensure the CNA's were applying interventions documented on the care card. She stated as the RN, she would also look to see that positioning devices were in place. She stated she would check to see if things were done, and if they were not, would figure out why. She stated she did not know why the resident did not have the hand pillows or wash cloths in place. During an interview on 10/31/19 at 8:53 AM, the Director of Nursing stated the CNAs were able to see the CNA instructions in both the resident's closet and on the computer kiosk. The CNA should have known the resident was to have bilateral hand pillows applied based on the resident's current CNA instructions. She stated it was the responsibility of the CNA to check the CNA instructions and to notify the nurse if there was a care need they could not provide or if a positioning device was not available. She stated the nurse on the unit was not responsible for double checking the work of the CNAs and that it was the responsibility of the CNA to ensure all care was provide according the CNA instructions and to sign that they provided that care. She stated if the hand pillows were not available, the CNA should have used rolled washcloths in place of the hand pillows and should have reported it to the nurse so the nurse could notify therapy to get a new supply of hand pillows. 10NYCRR 415.12(e)(2)

**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 the resident's environment remained as free of accident hazards as was possible for 1 (Resident #75) of 1 resident reviewed for accidents. Specifically, for Resident #75, the facility did not ensure that the resident's refusal of care and behavior toward staff were adequately evaluated to assist in the prevention of falls and did not ensure causal factors leading to the resident's fall were identified to develop and implement relevant, consistent, and individualized interventions to prevent future falls. This is evidenced by: Resident #75: Resident #75 was admitted to the facility on [DATE], with diagnosis of diabetes, non-pressure chronic ulcer of lower leg, and chronic kidney disease. The Minimum Data Set (MDS - an assessment tool) dated 9/12/19, documented the resident had intact cognition, could understand others and could make self understood. The Policy and Procedure (P&P) titled Incident Reports dated 8/31/17, documented investigations were to be initiated for any resident fall, statements were to be obtained from staff members prior to the end of their shift, and all incident reports for falls were to be reviewed by the falls team, and the recommendation section was to be completed. The P&P titled Comprehensive Care Plans, dated 5/24/18, documented the care plan of approach must be very specific, individualized, include the frequency of which service is provided according to discipline involved, and include resident and/or family education. The Comprehensive Care Plan (CCP) for Falls, last updated 10/2/19, documented the resident was at high risk for falls, and the interventions included staff were to provide one person assistance to the resident for activities of daily living (ADLs). The CCP documented the resident fell after standing unassisted and slipping in urine on 10/1/19. The CCP for ADLs, last updated 9/11/19, documented the resident required extensive 1 assist with the use of forward wheeled walker for all transfers, and ensure proper footwear when transferring. The CCP documented the resident was non compliant with care at times due to her preference to have certain caregivers. The CCP for urinary incontinence, last updated 9/26/19, documented the resident had episodes of urinary incontinence, and the resident's formal toileting schedule was discontinued due to resident refusal to be toileted and/or receive incontinence care. A social work progress note dated 5/23/19, documented the resident was angry but conversive and had personality pathology that staff had to manage on a daily basis. The note documented the resident stated she was overwhelmed with 2 staff members in the room working on separate things for her, exploded verbally, and was happy after the CNA apologized to her. The note documented staff should not engage in emotionality with her, and that she was attention seeking and would like very personal interactions with one person at a time. A nursing progress note dated 6/27/19, documented the CNAs report that she had increased difficulty with transfers and increased urinary incontinence over the past few weeks. CNA Behavior Monitoring, dated 9/1/19 - 10/2819, documented the resident had the following behaviors; resisted care on 10/7/19, used abusive language on 10/17/19 and 10/25/19, and had frequent crying and tearfulness, yelling and screaming, abusive language, and resisting care on 10/28/19. The progress notes dated 9/1/19 - 10/28/19, documented the resident refused care on 21 out of 58 days. The Accident/Incident report dated 10/1/19, documented during a transfer from the wheelchair to the commode, the resident missed the proper grip of the commode when her weight shifted she fell to the side, and hit the over bed table with her left lateral forehead causing a minor open area. The report documented the corrective action was to put a towel on the floor to prevent slipping on dribbles of urine during transfer, and to continue with the current plan of care. The report identified the following risk factors; had altered safety awareness to safety hazards, had aggressive or resistant behaviors, and was transferred using a mechanical lift. The report documented Certified Nursing Assistants (CNAs) #'s 2 and 5 witnessed the resident's fall. The Registered Nurse (RN) investigative summary documented the care plan was being followed at the time of the fall, and the fall could have been prevented by dropping a towel on the floor between the wheelchair and commode to prevent the resident's feet from slipping in the urine. A post fall assessment dated [DATE], documented the resident had a witnessed fall in the residents room, included the wheelchair, and sustained a skin tear to the head. The assessment documented during transfer from the wheelchair to the commode, the resident missed the hand rail and fell with her weight out of control to the floor, which was wet with urine. The employee statement from CNA #5 dated 10/24/19, documented the CNA last saw the resident on 10/21/19, when she gave the resident her dinner tray, and did not include documentation related to the fall on 10/1/19. The employee statement from CNA #2 dated 10/22/19, documented the CNA last saw the resident while completing evening care right before the fall, and the resident urinated on the floor and slipped. During an interview with the resident on 10/28/19 at 10:18 AM, the resident stated she had a fall recently due to the ride side of her wheelchair not functioning correctly. She stated when she fell, the bedside table also hit her roommate. During an interview on 10/29/19 at 3:44 PM, CNA #5 stated she provided care to the resident often, and was not in the room when the fall occurred. She stated CNA #2 was in the room and witnessed the fall. She stated the resident would often be incontinent by choice. During an interview on 10/29/19 at 3:52 PM, CNA #2 stated she witnessed the resident's fall. She stated she was transferring the resident from the wheelchair to the commode, and the resident slipped. She stated the resident will usually sit back onto the wheelchair, however the wheelchair was unlocked. She stated if the wheelchair was locked she would have been able to catch the resident, but instead the resident hit the chair, rolled back on the floor and hit her head on the bottom of the bedside table. She stated she was told the wheelchair was addressed by a maintenance work order. She stated it can take up to half hour an a half to transfer her with one assist, she felt unsafe transferring her at times, and that changing her transfer status to two assist would cause a disruption to the resident. During an interview on 10/30/19 at 8:37 AM, RN #1 stated she was on vacation when the resident's fall occurred. She stated she was not aware of any concern with the wheelchair and was unaware of what the intervention was for the fall. She stated if the resident was refusing care there would be a care plan. She stated the refusal of care documented in the medical record could be any refusal of care and the resident has no medical reason for being incontinent on the floor. She stated nursing is responsible for updating the resident's care plan. During an interview on 10/30/19 at 1:58 PM, the Director of Nursing stated when a resident had the fall, the facility process would be to have staff complete statements prior to leaving their shift, and is unsure why the staff statements were obtained later in the month. She stated falls are reviewed in morning report, and she was not aware of any issue with the resident's wheelchair. During an interview on 10/31/19 at 1:55 PM, the Administrator stated he was pretty sure the team felt the towel was not a good plan and the decision during the interdisciplinary team review was not to implement it. He stated he was unsure if anything else was implemented and he would expect a root cause analysis for the fall would occur and that did not happen in this case. He stated the Unit Manager is responsible for the unit and should be overseeing the nursing staff on the unit. He stated if a resident had a pattern of refusing care, he would expect other members of the interdisciplinary team would be brought in, such as the social worker. 10NYCRR415.12(h)(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 a resident maintained acceptable parameters of nutritional status for 1 (Resident #112) of 4 residents reviewed for nutrition. Specifically, for Resident #112, who was initially assessed as a high nutritional risk secondary to diabetes, the facility did not ensure the resident's weight and significant weight loss was evaluated to determine whether it was unavoidable and addressed in accordance with the comprehensive nutrition careplan (2000 calories, 95-114 grams of protein, and 2000 ml of fluid daily), provide diet per physician order (consistent carbohydrate, vegetarian diet) and cater to the resident's food preferences. This is evidenced by: Resident #112: The resident was admitted to the facility on [DATE], with diagnoses of aftercare following joint replacement surgery, diabetes, and iron deficiency anemia. The Minimum Data Set (MDS - an assessment tool) dated 10/7/19, documented the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, could understand others and could make self-understood. The Policy and Procedure (P&P) titled Cultural, Religious, and Ethnic Food Preferences dated 02/19, documented the facility was to provide adequate food choices for patients whose needs are not met by the standard menu. The P&P titled Weighing Residents dated 7/16/19, documented Nurse Managers and Dietary staff were to monitor interim weights daily. The facility specific diet manual (undated) documented the consistent carbohydrate diet provided a daily average of 2015 calories and 101g protein. It did not include a vegetarian diet nutritional analysis or other menu planning guidance to ensure the menu was nutritionally adequate. The Comprehensive Care Plan (CCP) for Nutritional Status last updated 10/2/19, documented the resident's body mass index (BMI) of 28 was within target range for her age, had stable weight, and a goal of meal satisfaction with intake of 75% or more of meals. The CCP documented the resident was to receive a consistent carbohydrate (therapeutic diet), vegetarian diet, and staff were to identify and cater to the resident's food preferences and encourage the resident's participation in meal choices. The facility's Always Available Menu (undated) for the vegetarian diet documented the following lunch/dinner options: Peanut butter and jelly sandwich, egg salad sandwich, grilled cheese, veggie burger, rice and bean bowl, rice and vegetable bowl, and cream of tomato soup. The initial Nutrition assessment dated [DATE], documented the resident was 72 inches tall and weighed 208.2lbs with a usual body weight range of 197-210lbs. The assessment documented the resident preferred vegetarian foods, was a high nutritional risk, and required 2000 calories, 95-114 grams of protein, and 2000 ml of fluid daily. The medical record did not include an assessment regarding if the resident received adequate calories, protein, and fluids. The weight record for the resident documented the following: - 09/30/19 - 208.2 pounds (lbs). (admission weight) - 10/08/19 - 200lbs, indicating an 8.2lb (3.9%) significant weight loss. - 10/09/19 - 200lbs (reweight). - 10/15/19 - 196.4lbs, indicating a 3.6lb (5.7%) significant weight loss. - 10/15/19 - 194.6lbs (reweight). - 10/22/19 - 193.6lbs. - 10/29/19 - 191lbs, indicating a 17.2lb (8.3%) weight loss within the past month. A Nutrition Progress Note dated 10/10/19 written by the Registered Dietitian (RD), documented the resident had an 8lb weight loss, since admission related to a change in the scale used, an average intake of 75%, and weekly weights were initiated, a current standard of practice. The resident was reweighed on 10/9/19, indicating the resident had a significant weight loss. The progress note did not include that the resident's needs were assessed or re-assessed to determine if the weight loss was avoidable. The October 2019 intake record documented the following: - Daily average intakes less than 75% on 20 of 30 days, indicating the resident's intake did not meet the care planned goal. - Daily intakes averaged less than 95% on 25 of 30 days, indicating the resident's intake was not adequate to meet the assessed calorie and protein needs per the therapeutic diet and nutritional analysis of the therapeutic diet. A Nutrition Progress Note dated 10/17/19, documented the resident had a significant weight loss since admission, an average intake of 63%, and was developing food fatigue with vegetarian options offered and her food preferences. The note documented the Registered Dietitian (RD) was to purchase the resident foods and provide the resident with an updated list of options. The updated Always Available Menu for the vegetarian diet (dated 10/17/19) documented the following options: Amy's thai green curry, Amy's black bean and vegetable enchilada, Amy's pad thai, cheese sliced for grilled cheese, Morning Star chick'n nuggets, Pics soy chick'n burger, Pics flame grilled veggie burger, mac and cheese, Morning Star veggie dogs, and Morning Star grillers and Prime veggie burger. The current Physician order dated 10/23/19, documented the resident was to receive a consistent carbohydrate diet, vegetarian diet. A Nutrition Progress Note dated 10/23/19, documented the resident had continued weight loss, average intake of 80%, and recommended no change in the nutrition plan of care. A Nutrition Progress Note dated 10/29/19, documented the resident had continued weight loss, average intake of 60%, and the resident requested a nutrition supplement. The resident's lunch meal ticket for 10/29/19, documented a handwritten request of a soy chicken burger with mayonnaise and lettuce and vegetable tortellini soup with 1/2 saltines. During an interview on 10/30/19 at 9:08 AM, the resident stated she did not consistently receive items (such as macaroni and cheese, Pics soy chick'n burger, and cheese omelet) she had requested on her meal tickets, and she did not receive balanced meals when an item she requested was substituted. She stated she received the select menu and wrote in her selections from the always available vegetarian/vegan menu sheet. She stated her selection for lunch yesterday was a soy chicken burger with lettuce and vegetable soup, and when her meal tray arrived, she received 6 soy-based chicken nuggets as her meal. She stated she did not feel anyone was checking the trays for balance, she was not notified that they did not have the item she requested ahead of time to make another selection, and she had skipped at least one meal a day due to the facility not meeting her preferences. She stated she felt the rate she had lost weight was not healthy. She stated she had discussed her concerns with the RD. During an interview on 10/30/19 at 9:29 AM, the Food and Nutrition Services Director stated the facility is notified of the resident's diet order upon admission to the facility. She stated the prior Certified Dietary Manager initiated the vegetarian menu for residents who previously requested a vegetarian diet. She stated the menus are completed by the residents, checked by the diet clerk to ensure the selections are appropriate for the diet order, and a supervisor or manager checks the tray for accuracy before it is brought to the resident. She stated the resident selected the soy chicken sandwich, which was not available, and dietary staff substituted the soy chicken nuggets. She stated the vegetable soup they had available was made with a beef broth and was removed from the tray, and a tomato soup was sent up to the unit at a later time. She stated the diet clerk would be responsible for notifying the dietitian if a resident was making selections that did not include enough food items or consistent carbohydrate amounts at meals. During an interview on 10/30/19 at 10:01 AM, the RD stated she was not advised of the resident's dietary needs prior to admission. The diet order is communicated to the dietitian at the interdisciplinary staff meeting. She stated the resident was provided with a general list of what vegetarian foods were available when she was admitted , and then on 10/17/19 she and the resident discussed what the resident ate at home and developed an additional list of additional vegetarian options, and the dietitian went to the grocery store and purchased them. She stated diet clerk checks the ticket against the diet order, the dietitian monitors the resident's nutritional status, and she was not aware of any concern with the resident not receiving the items she requested. She stated she thought the resident received a good source of protein at every meal. She stated the accuracy of the resident's admission weight was questioned because a different scale was used, and if she had concerns about the calibration of the scale, she would discuss with the unit manager, who would report the concern to maintenance. She stated maintaince was not notified to check the calibration of the scale. During an interview on 10/30/19 at 2:05 PM, the Director of Nursing stated the dietary supervisor is responsible for checking for completeness of the tray. She stated she would expect a nutrition intervention would be looked at sooner for a resident with a significant weight loss. During the interview on 10/31/19 at 11:49 AM, Registered Nurse (RN) #2 stated she did not recall a conversation with the dietitian about the accuracy of the resident's admission weight. She stated she was unsure why the resident was losing weight, and there was nothing medical she could attribute the weight loss to. She stated she was aware the resident was a vegetarian, and when she responded to the resident's call bell at a recent lunch meal the resident had ordered a soy chicken sandwich and received soy chicken nuggets. She stated she offered to call down to order something else and the resident declined. She stated she discussed the resident's weight and diet with her on admission and thought everything was going well. During an interview on 10/31/19 at 1:55 PM, the Administrator stated the facility did not meet the resident's nutritional needs. He stated he was aware of issues with the Food Service Department, however the facility would not have been aware of the system issue related to the implementation of the consistent carbohydrate vegetarian diet if the Department of Health did not identify it. During an interview on 10/31/19 at 2:38 PM, the Medical Director (MD) stated significant weight loss could be caused by inadequate intake. He stated it is a challenge for the facility to provide the resident with a nutritionally adequate consistent carbohydrate vegetarian diet, however it is possible. He stated the weight loss should have been addressed earlier. 10NYCRR415.12(i)(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 received dialysis services consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #363) of 1 resident reviewed for dialysis. Specifically, the facility did not ensure dialysis specific policies and procedures were developed based on current standards of practice, the resident's medical record included orders for the provision of dialysis treatment, and the resident's care plan included resident specific parameters for monitoring of blood pressures before and after dialysis treatments. This is evidenced by: Resident #363: Resident #363 was admitted to the facility on [DATE], with diagnoses of end stage renal diasease on dialysis, diabetes, and chronic obstructive pulmonary disease. The history and physical exam, dated 10/21/19 documented the resident was alert and oriented, and able to follow commands. The dialysis agreement, dated 11/29/17 documented the facility would be responsible for the prompt transfer of patient care information and other documentation relevent to the proper care of the patient. The facility policies did not include a policy and procedure for residents on dialysis. The physician orders dated 10/18/19, documented the resident would have a blood pressure obtained every month on the first friday on the 3-11 shift, was to receive dialysis Tuesday, Thursday, and Saturday at the 12:30pm at the dialysis unit. The physician orders did not include documentation of the length of treatment time, the type of dialyzer, and specific parameters of the dialysis delivery system, or the resident's target weight. The baseline care plan, dated 10/18/19, did not include documentation of the resident's dialysis treatment. A nursing note dated 10/18/19, documented the resident had a fistula on her left arm. The Medication Administration Record dated October 2019, did not include documentation of the resident's blood pressure between 10/18/19 and 10/29/19. The clinical monitoring report dated 10/19/19 documented the resident had a blood pressure of 110/68. The office visit form, dated 10/24/19, documented the resident had a blood pressure of 180/76. During an interview on 10/30/19 at 8:58 AM, Registered Nurse (RN) #1 stated the facility used a standard form for all residents who attend outside appointments, including residents who receive dialysis, as a communication tool. She stated the resident had a recent change in location for dialysis, and the resident informed the facility of the change and the physician order was not updated. She stated there should be documentation in the medical record for no treatment in the resident's left arm (site of the fistula), and there may be a sign in the resident's room that directs staff on where to take the residents blood pressure. She stated there is no difference in how often the facility would monitor the blood pressure of a resident who was or was not receiving dialysis. She stated she would expect dialysis would be addressed on the resident's baseline care plan. During an interview on 10/30/19 at 1:55 PM, the Director of Nursing stated if a resident's dialysis center location changed, the facility may not be notified if it is the same time and date. She stated there should be some kind of alert to staff not to take the resident's blood pressure in the left arm. She stated there is no difference in how often the facility would monitor the blood pressure of a resident who was or was not receiving dialysis unless there is a clinical reason. She stated she would expect dialysis would be addressed on the resident's baseline care plan. She stated the communication sheets between the dialysis center and the facility are discarded after they are addressed. During an interview on 10/31/19 at 1:50 PM, the Dialysis Center Social Worker stated the resident started dialysis on 10/20/16, and was temporarily changed to another location for dialysis beginning on 10/29/19 due to a construction project that is expected to take 6 weeks. She stated the change was communicated to the nursing home. During an interview on 10/31/19 at 1:55 PM, the Administrator stated the dialysis communication sheets should not be discarded and should be filed in the resident's medical record, the medical record should include documentation of the resident's current dialysis location site and where the blood pressure should be monitored. 10NYCRR 415.12

Based on record review and interviews during the recertification survey, the facility did not ensure the menus were planned in advance, followed, and met the nutritional needs of residents in accordance with established national guidelines. Specifically, the facility did not ensure menus were developed and prepared to meet nutritional needs of residents on a vegetarian diet. This is evidenced by: The facility specific diet manual did not include documentation of a vegetarian diet. The Corporate Diet Manual dated 10/30/19, documented vegetarian diets were healthful and nutritionally adequate when appropriately planned, and included a variety of foods - fruits, vegetables, whole grains, legumes, nuts, seeds, tofu or other soy products, and if desired, dairy products and eggs. The manual documented nutrition considerations for vegetarians included a mix of different proteins from unrefined grains, legumes, seeds, nuts, and vegetables, and regular consumption of dairy foods, eggs, fortified foods or supplements to meet Vitamin B12 needs. A review of facility menus did not include documentation of a pre-planned vegetarian menu. A review of select meal tickets for 21 days documented the following: - Lunch meal tickets did not include documentation of a main entree on 18 out of 21 days. - Dinner meal tickets did not include documentation of a main entree on 18 out of 21 days. - Breakfast meal tickets did not include a source of protein on 14 of 21 days. During an interview on 10/30/19 at 9:29 AM, the Food and Nutrition Services Director stated the prior certified Dietary Manager created the vegetarian menu. During an interview on 10/30/19 at 10:01 AM, the Registered Dietitian stated the facility had a general list of vegetarian options provided to residents when admitted . She stated the nutritional adequacy of the menu would be the dietitians responsibility. She stated she did not have facility specific diet manual guidance for the vegetarian diet, and stated the pre-planned vegetarian diet was not available. She stated the select meal tickets would represent what the resident on a vegetarian diet would receive. 10NYCRR415.14(c)(1-3)

Based on record review and interview during the recertification survey, the facility did not provide a policy regarding foods brought to residents by family and other visitors that included information on the safe and sanitary storage, handling and consumption of food. Specifically, the facility does not provide information for family and other visitors on safe food handling practices or safe reheating of food that is brought in to residents. This is evidenced is as follows. Record review of the facility policy for foods brought in by visitors was reviewed on 10/28/2019. This policy does not include a process to ensure family and other visitors are provided information on safe food handling practices. The Director of Food and Nutrition Services stated in an interview on 10/28/2019 at 9:23 AM, her Department does not provide information on basic food safety practices to family and visitors that bring food to residents, . The Administrator stated in an interview on 10/28/2019 at 4:00 PM, that if the Dietary Department does not provide information on food safety to family and visitors then the information is not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs for 9 (Resident #'s 2, 19, 21, 59, 66, 67, 71, 79, and #81) of 24 residents reviewed for CCP's. Specifically, for Resident #2, the facility did not ensure a CCP was developed for diabetes management; for Resident #19, a CCP was developed for pain management; for Resident #21, a CCP was developed for an actual pressure ulcer; for Resident #59, a CCP was developed for aphasia; for Resident #66, a CCP was developed for a right elbow wound; for Resident # 67, a CCP was developed for a urinary tract infection; for Resident #71, a CCP was developed for respiratory care; for Resident #79 a CCP was developed for emphysema; and for Resident #81, a CCP was developed for long term use of anticoagulants related to atrial fibrillation. This is evidenced by: The Policy and Procedure titled Comprehensive Care Plans, last revised 5/24/18, documented each discipline will review the comprehensive care plan quarterly, adding approaches to already listed problems and develop additional problems as appropriate. Resident #2: The resident was admitted to the facility on [DATE], with diagnoses of diabetes, dementia with behavioral disturbance, and anxiety disorder. The Minimum Data Set (MDS - an assessment tool) dated 10/9/19, documented the resident had severely impaired cognition, could usually understand others and could make self understood. The MDS documented the resident received insulin injections 7 out of 7 days during the 7-day look-back period. During a record review on 10/29/19, the comprehensive care plan did not include a care plan to address the diagnosis of diabetes and the use of insulin. A physician order dated 4/19/17, documented Novolog U-100 insulin aspart 100 unit/ml subcutaneous solution; inject 5 units by subcutaneous route 3 times per day as needed for glucose greater than 400 and resident had eaten current meal for type 2 diabetes. A physician order dated 4/12/19, documented Basaglar Kwikpen U-100 insulin 100 unit/ml (3 ml) subcutaneous; inject 10 units by subcutaneous route once daily at bedtime. A physician order dated 6/17/19, documented Novolog U-100 insulin aspart 100 unit/ml subcutaneous solution; inject 5 units by subcutaneous route 3 times per day with meals for type 2 diabetes. During an interview on 10/30/19 at 11:22 AM, Registered Nurse (RN) #3 stated there should be a diabetic care plan and the use of insulin. She stated she thought the resident had a diabetic care plan and was uncertain why the resident did not have an active care plan for diabetes management. She stated diabetes is mentioned in the nutrition care plan, but the goals and interventions were not specific for diabetic care and insulin use. She stated any medical condition a resident had and the facility was treating should have a care plan in place. Resident #71: The resident was admitted to the facility on [DATE], with diagnoses of congestive heart failure, atrial fibrillation, and hypertension. The MDS dated [DATE], documented the resident was cognitively intact, could usually understand others and could make self understood. The MDS documented the resident received oxygen therapy. The Policy and Procedure titled Comprehensive Care Plans, last revised 5/24/18, documented when oxygen or respiratory therapy was used there must be a respiratory care plan. During a record review on 10/29/19, the CCP did not include a care plan for the use of oxygen therapy. During an interview on 10/30/19 at 11:48 AM, RN #3 stated the use of oxygen should be incorporated into the care plan. She stated a care plan should have been developed for respiratory care with oxygen use and was unsure why a care plan had not been developed. She stated she was responsible for care planning and the MDS Coordinator also assisted with care planning process. During an interview on 10/31/19 at 8:51 AM, the Director of Nursing stated care plans should be in place for all active conditions and did not know how the oxygen care plan was missed. Resident #81: The resident was admitted to the facility on [DATE], with diagnoses of chronic atrial fibrillation, heart failure, and chronic obstructive pulmonary disease. The MDS dated [DATE], documented the resident was cognitively intact, could understand others and could make self understood. The MDS documented the resident received an anticoagulant medication 7 out of 7 days during the 7-day look-back period. During a record review on 10/29/19, the CCP did not include a care plan to address atrial fibrillation and the long term use of anticoagulants. A physician order dated 7/11/18, documented Eliquis 2.5 mg tablet; give 1 tablet by oral route every 12 hours for chronic atrial fibrillation. During an interview on 10/30/19 at 10:31 AM, RN #1 stated there should be a care plan for long term use of anticoagulant medication. She stated she was responsible for care planning, as well as other members of the interdisciplinary team including the MDS Coordinator. She stated she would expect there to be a care plan for the use of a long term anticoagulant related to the resident's diagnosis of atrial fibrillation. 10NYCRR415.11(c)(1)

Based on observation and staff interview during the recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Food packages shall be in good condition so that the food is not exposed to potential contaminants; food under refrigeration is to be kept at 41 degrees Fahrenheit (F) or less, food contact surfaces shall be cleaned after use; a chemical test kit (test papers) is to be provided for checking chemical sanitizer levels; and floors are to be kept clean. Specifically, cans of food were dented, refrigerated food was above the maximum temperature, test papers were not provided, and food contact surfaces, non-food contact surfaces, and floors were not clean. This is evidenced as follows. The main kitchen was inspected on 10/28/2019 at 9:32 AM. One #10 can of fruit salad with a sharp dent in the top seam was found in the common stock. Sliced roasted pork found under refrigeration was measured at 48F; the label on the pan stated that the product was prepared on 10/27/2019. The slicer, microwave oven, can opener holder, 2-door refrigerator, stove, grill, fire extinguisher, shelving, cabinets, walls, and storage area doors, and floor were not clean. The test papers in use did not have the required graduations to determine the chemical sanitizer concentration. A section of the floor by the automatic dishwashing machine was chipped into the concrete subfloor and hard to clean. The Director of Food and Nutrition stated in an interview on 10/28/2019 at 9:32 AM, that the stock person is out on leave and the replacement probably missed the dent in the can of fruit, she thinks the sliced and panned pork roast was taken out of the walk-in refrigerator and allowed to warm before being returned to the refrigerator, the cleaning is a struggle due to a staffing shortage, she will be contacting the chemical company to provide the correct chemical test papers, and work orders had been submitted to repair the floor by the dishwashing machine. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.32, 14-40, 14-1.110, 14-112(c), 14-1.170