Based on observations, record review, and interviews during the recertification and abbreviated survey (reference # 532839 [NY00357482]) conducted 9/8/2024 - 9/12/2024, the facility did not ensure food was prepared, distributed, stored, and served in accordance with professional standards for the facility's food services. Specifically, the facility did not ensure prepared foods were cooled properly, stored properly, the food on the steam tables were served at an appropriate temperature during meal service, and nutrition rooms and storage areas were maintained in a clean sanitary condition. Findings included: The facility policy General Sanitation of Kitchen, reviewed 10/8/2024, required defined cleaning tasks, assigned responsibilities, and staff training. The facility did not follow this policy, as nutrition rooms and storage areas had not been maintained in clean and sanitary conditions.The facility did not have a food storage policy, food service policy, food handling policy, or pest policy as requested on 9/10/2025. Improper cooling:The facility's Cooling Log Sheet documented food must be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two (2) hours or less. On 6/5/2025, 6/30/2025, 7/8/2025, 7/16/25, 7/21/2025, and 7/26/2025 macaroni salad and pasta salad were documented with temperatures that ranged from 73 degrees Fahrenheit to 78 degrees Fahrenheit after two (2) hours of cooling had been completed. No corrective actions were documented on those dates. During an interview on 9/10/2025 at 11:35 AM, the Food Service Director stated proper cooling allowed for six (6) hours to cool foods down to 41 degrees Fahrenheit and it should have been checked every 2-hours during the cooling process. They were not aware that food was required to have been cooled from 135 to 70 degrees Fahrenheit within two (2) hours. They stated that no corrective action was done for the items listed on the cooling log that had temperatures over 70 degrees Fahrenheit, those items should have been discarded and the process started over. Improper food storage (raw over ready to eat foods):During an observation and interview on 9/9/2025 at 11:49AM, the activities room refrigerator contained a dozen raw eggs stored directly above a drawer full of bottles of pop. The Rehab Director stated they were not aware of the storage requirements for the raw eggs and switched the location of the eggs and pop to avoid any possible cross-contamination. During an interview on 9/10/2025 at 11:35 AM, the Food Service Director stated the raw eggs should not have been stored above the ready to eat food items (bottles of pop) because that was a potential source of cross-contamination. Improper hot holding:During an observation on 9/9/2025 at 12:31 PM, the first-floor dining tray line served food from three (3) of the four (4) bays on the steam table. Tomato soup in the first bay was measured at 156 degrees Fahrenheit, grilled cheese sandwiches in the second bay were measured at 130 degrees Fahrenheit, and the fourth bay contained gravy at 90 degrees Fahrenheit, mashed potatoes at 108 degrees Fahrenheit, and riblets at 122 degrees Fahrenheit. The fourth bay did not have the light on by the knob like the first two bays and it did not appear to have been turned on. During an interview on 9/10/2025 at 2:00 PM, Dietary Aide #32 stated the third bay on the first-floor dining room's steam table did not work, the first, second, and fourth bays worked properly. They stated if the light wasn't on for the bay, then they probably didn't turn it on, and nothing should have been located in there because it was important food was kept hot during service for food safety and to ensure the residents received an enjoyable meal. During an observation on 9/10/2025 at 2:10 PM, the fourth bay of the steam table was on, and the indicator light was illuminated. During an interview on 9/10/25 at 3:22 PM, the Food Service Director stated food service staff should not have used the steam table for service if it wasn't turned on. Staff were supposed to turn it on about 30-minutes before service so they could ensure it was hot and ready during service. They stated all hot foods should have been maintained at or above 140 degrees Fahrenheit during meal service. They stated it was important the temperature of the food was maintained during service to prevent the growth of bacteria and to prevent food borne illness. Unsanitary conditions:During an observation on 9/8/2025 at 6:30 PM, the walk-in cooler had some white spills (both liquid and dried) on the floor below the milk shelving. On 9/9/2025 at 12:58 PM, the walk-in cooler had a significant amount of liquid milk spilled beneath the shelving that was tracked across the cooler floor and again on 9/10/2025 at 11:30 AM. During an observation and interview on 9/9/2025 at 11:14 AM, the second-floor nourishments room contained a pitcher of brown stagnant water located in the cupboard beneath the sink. There was a leak in the plumbing and dried puddle of brown liquid present within the cupboard and a hole through the back wall. A brown stained bed sheet was also balled up under the sink. Food debris and spills were present under the sink and around the refrigerator. The Environmental Services Director stated they were not aware of the leak and staff should have notified them so they could have cleaned and repaired the area. During an interview on 9/10/2025 at 11:35 AM, the Food Service Director stated the walk-in cooler was cleaned as needed. They stated they have had a problem with the milk leaking and that stained the floor beneath the shelving. They stated staff mopped that when it leaked, and they were not aware that puddles of milk were observed on the floor of the cooler for three days of survey. They stated the nourishment rooms should have been clean, the leaking sink, hole in the wall, and food debris provided food, water and potential harborage for pests. The Food Service Director stated the kitchen and nourishment storage areas should have been clean, with smooth and easily cleanable surfaces, without leaks and spills, so they could provide a better-quality food environment for the residents. 10NYCRR 415.14(h)

Based on observation, record review, and interview during the recertification and abbreviated (NY00326851 and NY00327641) surveys conducted 2/12/2024-2/15/2024, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated and did not prevent further potential abuse for 1 of 4 residents (Resident #17) reviewed. Specifically, Resident #17 reported an allegation of abuse that was not investigated timely and did not remove the alleged perpetrator from access to residents pending the results of the investigation. Findings included: The facility policy Prevention of Resident Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property reviewed by the facility 6/23/2023 documented the facility was committed to providing residents with an environment that was free from verbal, physical, and mental abuse, mistreatment, neglect, exploitation, and misappropriation of resident property. All staff would be trained during orientation and annually on what constitutes abuse, neglect, and misappropriation of resident property and how to report abuse allegations. The resident would be protected from harm while the investigation was completed. Alleged violations were to be reported no later than two hours after notification and no later than 24 hours. Resident #17 was admitted to the facility with diagnoses including schizoaffective disorder (a mood disorder) and bipolar disorder (episodes of mood swings). The 12/26/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not exhibit behavioral symptoms, and required partial/moderate assistance with most activities of daily living. During an interview on 2/12/2024 at 11:00 AM, Resident #17 stated certified nurse aide #13 entered their room that morning when they asked for help getting into their chair. Certified nurse aide #13 said they would not help and punched them in the leg with a closed fist. They stated they reported it to licensed practical nurse #6. The comprehensive care plan initiated 8/21/2021 documented the resident had potential to be verbally and physically abusive at times. Interventions included a behavior flow sheet. The resident had a knowledge deficit related to mental illness. Interventions included giving alternatives for resident to choose from and providing positive feedback encouraging compliance. The resident had manipulative behaviors related to bipolar disorder and schizoaffective disorder. Interventions included utilizing a behavior flow sheet, setting limits on manipulative behavior, and giving positive feedback for non-manipulative behavior. The care instructions updated 6/14/2023 documented the resident required supervision with assistance of 1 for transfers from bed to chair. There was no documented evidence of nursing progress notes from 1/12/2024-2/14/2024. On 2/12/24 at 1:52 PM the surveyor notified the Director of Nursing Resident #17 had said during the resident screening they were punched by staff last evening. An undated and unsigned facility Accident and Incident form documented the date of the incident was 2/15/2024 and occurred in the hallway and was reported by a state worker. The resident made accusations about 2 certified nurse aides possibly hurting them on Monday (2/12/2024). The form was signed by the nurse practitioner #15 on 2/16/2024 at 8:00 AM. The Incident/Accident Follow-up completed by the Director of Nursing documented the date of the incident was 2/12/2024 at 10:00 AM. The documentation under contributing factors was illegible. The Resident statement was illegible. A progress note included with the Accident and Incident Report completed by the Director of Nursing dated 2/12/2024 documented the resident made statements to the State worker that 2 certified nurse aides had hit them. The Director of Nursing spoke to the resident and the resident's story kept changing. An assessment was completed and there were no signs and symptoms of injury or abuse. The social worker was made aware. The plan was to have medical see the resident for evaluation as resident had a history of making false allegations when upset. There was no documented evidence the certified nurse aides were removed from resident access pending the results of an investigation. An unsigned social services progress note dated 2/12/2024 documented the resident alleged 2 evening certified nurse aides hit them on the legs. The resident gave the name of one of the aides, The resident stated they reported their concerns and reddened legs to nursing staff. They spoke with the resident later and the resident stated they were in their bed and the aides came to answer the call bell, touched their legs, and they told them to get out. The resident was a reliable source of factual information and had a history of saying accusatory information about staff. The resident had intermittent confusion. The Interdisciplinary Team Review dated 2/15/2024 and signed by the Director of Nursing documented the resident made statements about certified nurse aides. The resident had a history of making false allegations. The camera verified that no abuse occurred. No physical signs or symptoms of abuse were noted. The resident was care planned for this type of behavior. During an interview on 2/14/2024 at 9:24 AM, licensed practical nurse #6 stated the overnight nurse reported Resident #17 had said certified nurse aide #13 hit them on their legs during the overnight shift when getting up in the morning on 2/12/2024. Licensed practical nurse #6 stated they immediately notified the Director of Nursing so the resident could be assessed, and an investigation could begin. During an interview on 2/15/2024 at 9:17 AM the Director of Nursing stated staff was to notify a nurse for all cases of witnessed or alleged abuse to allow for a proper investigation. Both the registered nurse and medical provider were notified to complete an assessment. The social worker was also involved in the investigation and all incidents were reported to the state. They stated they were notified on 2/12/2024 that Resident #17 had reported that a certified nurse aide hit them on their legs. They stated they did not get witness statements and should have gotten them. They stated they did not notify the medical provider for an assessment and should have notified the medical provider. They stated all abuse allegations required proper investigating so residents were safe, and they did not complete an investigation and should have. During an interview on 2/15/2024 at 10:06 AM, the Administrator stated the Director of Nursing, and the Administrator were notified of all alleged cases of abuse because the facility was required to report abuse to the Department of Health within two hours. They stated in all cases of abuse, the family and the medical provider were notified, and the resident was assessed by nursing and the medical provider. The family and the medical provider were not notified about this incident. The Administrator stated they were notified on 2/14/2024 that Resident #17 alleged a certified nurse aide hit them on their legs on 2/12/2024 and they should have been notified on 2/12/2024 so that a proper investigation was completed. The Administrator stated there were no witness statements obtained. They stated they realized they should have done an investigation and notified the Department of Health with their findings, and they did not. They stated when a complaint of abuse was not investigated properly, all residents were at risk for abuse and all residents were not safe. During an interview on 2/15/2024 at 10:27AM, Social Worker #3 stated they were notified sometime earlier this week by the Director of Nursing that Resident #17 had alleged a certified nurse aide hit them on their legs. The resident reported two certified nurse aides were in the room but only certified nurse aide #13 hit them in their legs. They did investigate the allegation and but did not ask who the second certified nurse aide was but should have. They did not notify the state of the alleged abuse. During an interview on 2/15/2024 at 11:26 AM, licensed practical nurse #6 stated it was unusual for Resident #17 to report abuse. They stated the resident had behaviors, but those behaviors did not include reporting staff abuse. Licensed practical nurse #6 stated they immediately reported the alleged abuse to the Director of Nursing on 2/12/2024 and was not asked for a witness statement. They stated certified nurse aide #13 allegedly hit Resident #17 in the legs when doing resident care and certified nurse aide #14 was in the room assisting with resident care. During an interview on 2/15/2024 at 12:21 PM nurse practitioner #15 stated they were notified of all allegations of abuse so the resident could be assessed and kept safe. They were not notified this week of any abuse allegations. They stated they were familiar with Resident #17 who had never reported abuse in the past. If Resident #17 reported abuse, it should have been investigated and they should have been notified. They stated they were not notified, and it was important to investigate abuse so that all residents were safe. 10NYCRR 415.4(b)

Based on observation, record review, and interview during the recertification and abbreviated (NY00306949) surveys conducted 2/12/2024-2/15/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 2 residents (Residents #6) reviewed. Specifically, Resident #6 was observed with dirty and untrimmed fingernails and was not provided a shower as planned. Findings include: The facility policy Activities of Daily Living Care Guidelines, reviewed by the facility 11/17/2021, documented residents received routine morning and evening activities of daily living care to have their hygienic and comfort needs met. Caregivers were to review resident nursing care instructions at the beginning of the shift to ensure the residents were provided care according to their plan of care. All residents received a partial bed bath daily which included washing the resident's face, hands, back, underarms, and peri area. A shower or whirlpool bath replaced the partial bed bath once weekly and as indicated. Refusals of care were to be reported to the licensed nurse. Resident #6 was admitted to the facility with diagnosis including multiple sclerosis (a neurological disease) and seizure disorder. The 10/02/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, had no behavioral symptoms, and was dependent for all activities of daily living except for eating. The Certified Nurse Aide Accountability Records and Assignment sheet (care instructions) dated 6/15/2023, documented the resident was alert but confused, required total assistance with hygiene and bathing, and was to receive a shower and nail care on Tuesday and Thursday during the 11:00 PM-7:00 AM shift. The 2/12/2024 shower schedule documented the resident was to receive showers on the night shift on Tuesdays and Thursdays. The resident was observed: - on 2/12/2024 at 12:22 PM, sitting in the dining room for the lunch meal. Their thumb and fifth fingernails of the right hand were long and had a black substance under the nails. - on 2/13/2024 at 8:38 AM, in their room sitting in a chair. There was a dark substance in the right corner of their mouth and the same patterned shirt from the previous day. Their right hand had a black substance under all the fingernails. The thumb, fourth, and fifth fingers of the right hand had long unkept nails. At 10:13 AM and 11:13 AM, the resident's right hand had a black substance under all the fingernails and the nails of the thumb, fourth, and fifth finger were long and unkept. The resident had a dark substance in the right corner of their mouth. The certified nurse aide documentation sheet for February 2024 documented the resident received one shower for the month on the morning shift of 2/14/2024. During an observation and interview on 2/15/2024 at 8:54 AM, the resident was sitting in their room in their positioning wheelchair with brown debris under their thumbnail. The thumb, fourth and fifth nail of the right hand were long. The resident stated they would their nails them clipped, and they liked showers and did not refuse them. During an interview on 2/14/2024 at 8:55 AM, certified nurse aide #11 stated residents were scheduled for a shower twice a week. If a resident refused a shower, they were offered a bed bath. Resident #6 had not regularly refuse care and their shower day was Tuesday on night shift. The certified nurse aides were responsible for cleaning resident nails. Resident #6 was not a diabetic so their nails could be clipped by a certified nurse aide. They would expect resident #6's nails to be clean and clipped. Certified nurse aide #17 observed Resident #6's nails and stated they needed to be cleaned and clipped. During an interview on 2/14/2024 at 9:24 AM, licensed practical nurse #6 stated Resident #6 did not refuse care and should have received a shower on their shower day. They stated showers should always be given as residents could get infections. They expected to be notified if a resident refused a shower. The certified nurse aides did nail care on a resident's shower day unless the resident was diabetic. Resident #6 was not diabetic. During an interview and record review on 2/14/2024 at 9:49 AM, registered nurse #4 stated they were responsible updating the shower sheets and Resident #6 was scheduled for Monday nights. They reviewed the shower sheet and stated the resident had not received a shower. If a resident refused a shower, it would be documented as refused and they would sign off on it. They expected to be notified if a resident refused care and would encourage the resident. If a resident was not showered, they should monitor the resident's skin as breakdown could occur and it could be an infection control issue. They stated nail care was done by a certified nurse aide unless the resident was diabetic. They stated they noticed Resident #6 had long nails and debris under their nails at breakfast that day. They would expect the resident's nails to be cleaned and clipped. Long nails with debris could lead to an infection and the resident could create a skin tear with long nails. During an interview on 2/14/2024 at 12:08 PM, certified nurse aide #17 stated if they gave a shower, they documented it. If a resident refused a shower, they would reapproach the resident or provide a bed bath. Resident #6 had not received a shower this week but had received one last week. The resident should have received a shower on the day they were scheduled. The resident did not refuse their shower. They did not clean the resident's nails because the resident had not had a shower. They stated they should have asked the resident if they wanted their nails clipped and cleaned but they had not. They stated lack of nail hygiene and care could lead to open sores and infections. During an interview on 2/15/2024 at 9:17 AM, the Director of Nursing stated they knew a shower had been completed as both the certified nurse aide and the licensed practical nurse both signed for the shower. If a shower was refused and documented, the resident was reapproached. They would expect to be notified if a resident refused their shower by the 24-hour report and there were no showers refused documented on the 24-hour report that week. They stated if Resident #6 had received a shower, they would not have been in the same clothes the next day. They reviewed the shower book and stated the last documented shower was 2/6/2024. They stated the resident should have had a shower since then and had their nails cleaned and trimmed. The resident was at risk for health decline and infections if activities of daily living were not completed. 10NYCRR 415.12(a)(3)

Based on observation, interview, and record review during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 2 medication carts (Unit 2) reviewed. Specifically, prescribed controlled drugs on the second-floor unit were stored in an untethered (free-moving) medication cart and not returned to the double-locked medication room narcotic storage cabinet after the medication passes were completed. Findings include: The facility policy Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles revised 6/2022, documented in New York, controlled substances must be securely locked in a double-locked cabinet, affixed to the wall or floor until the beginning of the medication pass. Upon completion of the medication pass, controlled substances must be returned to the cabinet. During an observation on 2/13/2024 at 11:18 AM, the Unit 2 medication cart was untethered against a wall in the hallway near the nurse's station. Licensed practical nurse #10 opened the locked drawer of the medication cart. The drawer contained controlled medications for 5 Residents (Residents #14, 30, 32, 35 and 36) on Unit 2. The controlled medications included: - tramadol (pain relief) 50 milligrams - 49 tablets - lorazepam (anti-anxiety) 2 milligrams -23 tablets - Oxycontin ER (extended-release opioid pain relief) 10 milligrams - 19 tablets - pregabalin (nerve pain medication) 75 milligrams - 19 capsules - oxycodone/APAP (oxycodone with Tylenol) 10/325 milligrams - 29 tablets During an interview on 2/13/2024 at 11:18 AM, licensed practical nurse #10 stated their medication pass was completed on Unit 2 at 10:00 AM. They stated their medication cart contained controlled medications for 5 residents (Residents #14, 30, 32, 35 and 36) and Resident #35 required a controlled substance for a medication pass at 2:00 PM. Licensed practical nurse #10 stated controlled substances should be locked away in the medication room when medication passes were completed. The risk of leaving controlled substances in the medication cart could result in a resident accessing their cart. During an observation on 2/13/2024 at 11:33 AM, the controlled medications remained in the untethered medication cart. During an observation on 2/13/2024 at 12:58 PM, licensed practical nurse #10 left the unit and the medication cart was against the wall untethered and unsupervised. At 1:04 PM licensed practical nurse #10 had returned to the unit and the controlled substances remained in the untethered medication cart. During an interview on 2/14/2024 at 9:10 AM, the Director of Nursing stated all licensed nurses were educated on medication administration and storage and when medication passes were completed, they expected nurses to put all the controlled medication away in a double locked cabinet. The Director of Nursing stated controlled medications should not remain in an unattended medication cart. Residents and visitors could gain access to them. 10NYCRR 483.45(h)(2)

Based on observation, record review, and interview during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 2 of 3 food preparation areas (the main kitchen and the first-floor kitchenette). Specifically, in the main kitchen there was expired and undated food, a dented can of fruit cocktail in the dry food storage, and the clean drying rack had two unclean cooking pans with food debris; the first-floor kitchenette had expired and undated food. Findings include: Food Storage: The following observations were made in the main kitchen on 2/12/2024: - At 9:00 AM, there was a 64-ounce jar of peanut butter on a shelf with a best by date of 11/19/2023, and a 108-ounce can of pre-made pasta with sauce with a best by date of 2/28/2023. - At 9:20 AM, there was a loaf of cinnamon raisin bread in the reach-in freezer with an expiration date of 9/08/2023, four loafs of cinnamon raisin bread with an expiration date of 2/03/2024, two packages of pureed ham with a best by date of 4/21/2023, an undated wrapped hamburger, undated ground Swedish meat balls in a container, and barbecued pulled pork dated 9/22. - At 9:30 AM, in the dry food storage room there was a dented 6-pound can of fruit cocktail. During an observation on 2/12/2024 at 10:50 AM, the first-floor kitchenette cabinet had an opened 13-ounce jar of sweetened hazelnut cocoa spread with a best by date of 7/01/2023. Cleanliness: During an observation on 2/12/2024 at 9:35 AM, the clean drying rack in the main kitchen had two cooking pans that were unclean and had baked debris. During an interview on 2/12/2024 at 11:18 AM, the Food Service Director stated they were unaware of outdated or undated food items, the dented can in the dry storage room, and the unclean pans that were in the drying rack. They stated it was not acceptable to have undated or expired items in the reach-in freezer as those items should not be defrosted and served. Cans that were dented along the seams could affect the safety of the food inside and could be unsafe for the residents. Unclean pans with baked on food could affect the food quality when used. It was important that the kitchen be maintained in a clean manner, with no expired or undated food items and no dented cans for resident safety. 10NYCRR 415.14(h)

Based on observation, record review, and interview during the recertification survey conducted 2/12/2024-2/15/2024 the facility did not establish and maintain 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 3 of 4 residents (Residents #2, #11, and #32). Specifically, Residents #2, #11, and #32 were on droplet and contact precautions and staff were observed not applying appropriate personal protective equipment when entering the resident rooms, not removing personal protective equipment in a safe, or sanitary manor to prevent the spread of infectious organisms, and not performing appropriate hand hygiene. Findings include: The facility Infection Prevention and Control Program Manual revised 12/2023 documented standard and transmission-based precautions would be followed to prevent the spread of infections: - Handwashing with soap and water or hand hygiene with hand sanitizer (when hands are not visibly soiled) would be expected prior to contact with a resident, after touching contaminated items, after gloves were removed and between resident contacts. - Contact Precautions gloves and gown were to be worn prior to room entry and removed. Hand washing was required after removal, and prior to exiting the room. - Droplet precautions required a mask to be worn over the mouth, nose, and chin and donned prior to entry and removal prior to exit. - Non dedicated equipment shall be sanitized with germicidal or bleach wipes per standard precautions upon removal of the item from the room or in between patients. - The facility shall monitor, audit and re-enforce infection prevention techniques in use, with immediate re-education of staff. A 2/12/2024 nurse practitioner #15 progress note documented Resident #32 was diagnosed with respiratory syncytial virus (a contagious respiratory virus). During an observation on 2/12/2024 at 10:12 AM Resident #32's room had 2 signs on the room door that documented: - Contact Precautions: Staff are required to sanitize their hands before entry and when leaving the room. Providers and staff must also: put on gloves before room entry, discard before room exit, put on gown before room entry and discard before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. -Droplet Precautions: Everyone must: Clean their hands including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove Face protection before room exit. A red garbage can, and a three-drawer bin stocked with yellow isolation gowns and red garbage can liners, were located outside of the resident's room in the main hallway. During an observation on 2/12/2024 at 10:46 AM the Director of Nursing and nurse practitioner #15 were in Resident #32's room dressed in yellow isolation gowns, gloves, and blue surgical masks. They were not wearing eye protection. At 10:48 AM the Director of Nursing and nurse practitioner #15 removed their gown and gloves inside the room and held them with their bare hands as they exited the room. They discarded the rolled-up gowns and gloves into the red garbage can outside of the room and did not change their masks or sanitize their hands after contact with the contaminated items. A 2/8/2024 nursing progress note documented Resident #2 tested positive for influenza A (a contagious respiratory virus). A 2/9/2024 nursing progress note documented Resident #11 tested positive for influenza A (a contagious respiratory virus). During an observation on 2/12/2024 at 10:53 AM Resident #2 and #11 shared a room. There were 2 signs on the room door documenting Contact Precautions and Droplet Precautions (the same signs as Resident #32's room). A red garbage can, and a three-drawer bin stocked with yellow isolation gowns and red garbage can liners were outside of the room, in the main hallway. During an observation on 2/12/2024 at 10:54 AM the Director of Nursing and nurse practitioner #15 exited Resident #2's and #11's room into the main hallway holding rolled up yellow gowns in their hands. They disposed of the gowns in the red bin outside of Resident #32's room. They did not change their masks and nurse practitioner #15 did not complete hand hygiene. No eye protection was observed. During an observation on 2/13/2024 at 11:50 AM licensed practical nurse #10 put on a yellow isolation gown and stood at the medication cart outside of Resident #2's and #11's room. They entered the room, exited the room, and returned to their medication cart, wearing the yellow isolation gown. They picked up a pen from the top of the medication cart and began writing. At 11: 57 AM they put on gloves and reentered the room. At 11:58 AM they exited the room, walked down the hallway to a sanitizing wipe container that was secured to the wall. At 12:00 PM they removed the contaminated gown and gloves in the main hallway and discarded the items in the red garbage bin that was located outside of Resident #32's room. During an observation on 2/13/2024 at 1:11 PM licensed practical nurse #10 put on a yellow isolation gown and gloves and entered Resident #32's room. At 1:13 PM they exited the room wearing the gown, gloves, and mask. They removed the gown and gloves, rolled the gown into a ball, and discarded the contaminated items into the regular trash bin located in the main hallway. They did not change their mask or complete hand hygiene after disposing of the contaminated items. They did not wear eye protection. During an observation on 2/13/2024 at 12:12 PM certified nurse aide #19 exited an identified isolation room wearing a yellow isolation gown and removed it as they walked down the main hallway. They discarded the gown in the red garbage bin located outside of Resident #32's room. The bin was overfull, and the lid would not shut. At 12:19 PM they put on a new yellow gown and gloves and entered Resident #2's and #11's room without changing gown, gloves, or performing hand hygiene. They assisted Resident #11 with their tablet and held the tablet with both gloved hands. They exited the room at 12:23 PM with their gown and gloves on, removed the gown while walking through the main hallway, and discarded the isolation items in the regular garbage bin. During an observation and interview on 2/15/2024 at 8:36 AM licensed practical nurse #10 was in an identified isolation room wearing only a surgical mask. They stated that they did not wear gown or gloves because this resident received treatment for 6 days and was feeling much better. They stated they only provided medications and felt that it would be safe to just provide pills. They stated they should wear gloves, gown, and a mask as they could catch flu or could pass it to someone else. They stated personal protective equipment could be removed in hallway. During an interview on 2/13/2024 at 1:16 PM, certified nurse aide #19 stated that residents on isolation were quarantined to their rooms and were in one area of the facility. The signs posted on the room door informed staff what personal protective equipment was required to enter the room. The isolation personal protective equipment included a gown, gloves, and a mask. They stated they should also wear a face shield and they should wash or sanitize their hands after they removed their isolation garments. During an interview on 2/13/2024 at 1:24 PM, licensed practical nurse #10 stated staff should wear gowns, gloves, masks, and face shields in the isolation rooms. They should remove the items and dispose of them in the garbage bin located inside of the room. They stated they did not change their masks. During an observation and interview on 2/15/2024 at 9:29 AM, registered nurse #4 stated the Infection Committee Team decided the level of isolation needed and the Director of Nursing provided the isolation precaution signs to hang on the affected resident room doors. The charge nurse should monitor donning and doffing as the sign would indicate. Staff should be corrected at that time if they did not follow procedures. Donning of personal protective equipment should occur prior to room entry and doffing would occur inside the room, before exiting and washing hands. Staff should not remove personal protective equipment outside of the contaminated space as they could spread infection. Bins were to be stocked with face shields, masks, gowns, and garbage bags. Registered nurse #4 checked the personal protective equipment bins outside of resident rooms on isolation and did not include surgical masks and they should. During an interview on 2/15/2024 at 10:02 AM, the Director of Nursing stated the facility had 7 residents that were positive for Flu on Monday 2/12/2024, and by Tuesday afternoon a few more residents tested positive. Precautions were determined by the illness, and they made that decision. They informed nursing what they needed to do and provided the specific isolation signs on the rooms. Donning should be done outside the room before room entry and removed and disposed of inside the room. They stated on 2/12/2024 they and nurse practitioner #15 wore new surgical masks they obtained from the nurse's station. When they exited Resident #32's room they did not discard infectious items in the room because there was no garbage can in the room. The gown and gloves were disposed of in a red bin outside the room. Staff should not take off gowns as they exit an isolation room as they could spread infection. During an interview on 2/15/2024 at 12:26 PM, nurse practitioner #15 stated flu would be considered an infectious agent and the resident required droplet precautions. Staff should wear a gown, gloves, and a mask to enter the room. They should remove the gown, gloves, and the mask and dispose of them in the room before exiting. It would not be appropriate for trash bins to be outside of an isolation room. Removing personal protective equipment outside of an isolation room could risk transmission of the disease. 10 NYCRR 483.80 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey conducted 2/12/2024 through 2/15/2024, the facility did not ensure each resident was offered influenza immunizations and received education regarding the benefits and potential side effects of the immunizations for 2 of 6 residents (Residents #11 and #43) reviewed. Specifically, there was no documented evidence Residents #11 or #43 were offered, educated, received, or declined the influenza immunization for the 2023-2024 influenza season. Findings include: The facility policy Immunizations: Influenza Vaccination of Residents, Staff and Volunteers updated 3/2020 documents all residents should receive the influenza vaccine annually unless there is a documented contraindication or declination. Education shall be provided to all individuals; they have the right to refuse vaccinations, and this will be properly documented. All immunizations will be documented in the medical record. Current and newly admitted residents will be offered influenza vaccines from October of each year through the end of March the following year. Informed consent in the form of a discussion regarding risks and benefits of vaccination will occur prior to vaccination: this may be with the residents authorized representative when appropriate. Document the administration of the vaccine, including the injection site, in the immunization record. The New York State Health Commissioner declared influenza was prevalent in New York State on 12/6/2023. Resident #11 did not have documented evidence of immunizations or declination of immunizations. Resident #43's Minimum Data Set assessment dated [DATE] documented their last documented Influenza vaccine was received on 11/2/2022. Resident #43 did not have documented evidence of education, declination, or administration of the influenza vaccine for the 2023-2024 season. During an interview on 2/14/2024 at 11:44 AM, licensed practical nurse #6 stated resident vaccinations were in the medical record under the immunization tab. If a resident declined a vaccine that was offered, they should have a completed declination form in that section. During an interview on 2/14/2024 at 12:29 PM, licensed practical nurse #12 stated resident immunization records were in the medical record. If a resident refused a vaccine, they would have a signed declination page for the vaccine that was offered and refused. During an interview on 2/14/2024 at 11:49 AM, registered nurse #4 stated immunizations for residents were documented in their medical record under the immunization section and it should be up to date. During an interview on 2/15/2024 at 10:02 AM, the Director of Nursing stated the facility offered the influenza vaccine annually. If the vaccine was administered, it was documented in the resident's chart in the immunization record. The facility kept track of all vaccines that were offered, administered, or declined in a book that was kept in their office. During an interview on 02/15/24 at 11:37 AM, the Administrator stated the influenza vaccine should be offered every year to all residents and a documented declination would be obtained if they refused. Registered nurse #4 and the Director of Nursing also had a book to keep track of who was offered, received, or declined a specific vaccine. The actual record of vaccinations for individual residents would be found in the immunization section of their medical record. 10NYCRR 415.19 (a)(1-3)

Based on record review and interview during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not electronically submit encoded, accurate and complete Minimum Data Set assessment data to the Centers for Medicare and Medicaid Services System within 14 days after the assessment completion date for 11 of 11 residents (Residents #2, 6, 8, 17, 19, 21, 23, 28, 35, 43, and 50) reviewed for resident assessments. Specifically, the Minimum Data Set assessments for Residents #2, 6, 8, 17, 19, 21, 23, 28, 35, 43, and 50 were not transmitted to the Centers for Medicare and Medicaid Services system within 14 days of completion. Findings included: The Centers for Medicare and Medicaid Services Minimum Data Set Resident Assessment Instrument Version 3.0 Manual documented that assessments must be transmitted electronically to the Quality Improvement Evaluation System Assessment Submission and Processing system using the Centers for Medicare and Medicaid Services wide area network within 14 days of the care plan completion date and all other Minimum Data Set assessments must be submitted within 14 days of the Minimum Data Set completion date. The facility [Minimum Data Set] 3.0 [Nursing Home] Final Validation Report and resident specific Minimum Data Set assessment documented the following: - on 11/26/2023 Resident #43 had a Minimum Data Set assessment with the target date of 10/3/2023. The Minimum Data Set assessment; Section Z documented a completion date of 10/17/2023. The Minimum Data Set assessment was transmitted on 11/26/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. - on 2/9/2024 Resident #23 had a Minimum Data Set assessment with the target date of 12/14/2023. There was no documented completion date. The Minimum Data Set assessment was transmitted on 2/9/2024. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. - on 2/9/2024 Resident #21 had a Minimum Data Set assessment with the target date of 12/21/2023. The Minimum Data Set assessment; Section Z documented a completion date of 1/4/2024. The Minimum Data Set assessment was transmitted on 2/9/2024. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. - on 2/13/2024 Resident #2 had a Minimum Data Set assessment with the target date of 12/23/2023. There was no documented completion date. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new comprehensive assessment. - on 2/13/2024 Resident #8 had a Minimum Data Set assessment with the target date of 12/23/2023. There was no documented completion date. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new comprehensive assessment. - on 2/13/2024 Resident #6 had a Minimum Data Set assessment with the target date of 12/26/2023. There was no documented completion date. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. - on 2/13/2024 Resident #17 had a Minimum Data Set assessment with the target date of 12/26/2023. The Minimum Data Set assessment; Section Z documented a completion date of 1/9/2024. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. - on 2/13/2024 Resident #28 had a Minimum Data Set assessment with the target date of 12/28/2023. There was no documented completion date. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. An additional warning documented assessment completed late, more than 14 days after the assessment reference date. - on 2/13/2024 Resident #50 had a Minimum Data Set assessment with the target date of 12/29/2023. The Minimum Data Set assessment; Section Z documented a completion date of 1/12/2024. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. - on 2/13/2024 Resident #35 had a Minimum Data Set assessment with the target date of 12/29/2023. The Minimum Data Set assessment; Section Z documented a completion date of 1/17/2024. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. An additional warning documented assessment completed late, more than 14 days after the assessment reference date. - on 2/13/2024 Resident #19 had a Minimum Data Set assessment with the target date of 1/1/2024. There was no documented completion date. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. An additional warning documented assessment and care plan completed late, more than 14 days after the assessment reference date. During an interview on 2/15/2024 at 11:02 AM, registered nurse Minimum Data Set Assessment Coordinator stated they used a software program for the Minimum Data Set assessments. They stated they went to the facility once a week to gather information from the resident's medical record. The information had to be entered into the Minimum Data Set assessment software within 7 days, then 7 days for completion of the Minimum Data Set assessment, and 7 days for care planning. They kept track of the Minimum Data Sets by running a report to make sure they were done timely. The Minimum Data Set assessments were not up to date. They stated they were not done because their availability had decreased and the number of residents in the facility increased. They notified the Administrator of the incomplete Minimum Data Set assessments. It was important that the Minimum Data Set assessments were kept current to provide up to date care to the residents. The lack of timely Minimum Data Set assessments could impact the quality of care and reimbursements. During an interview on 2/15/2024 at 12:04 PM, the Administrator stated they knew there were some Minimum Data Set assessments that were late. They stated the registered nurse Minimum Data Set Assessment Coordinator was aware they were behind schedule. The Minimum Data Set assessment impacted reimbursements. It was important to keep the Minimum Data Set assessments up to date as they drove the care plan, showed changes in condition, and impacted the care of the residents. 10 NYCRR 415.11 (a)(5)

Based on record review, observation, and interview during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (lunch on 2/13/2024 and breakfast on 2/14/2024) reviewed. Specifically, food was not served at palatable and appetizing temperatures during the lunch meal on 2/13/2024 and the breakfast meal on 2/14/2024. Findings include: The facility policy, Monitoring Food and Liquid Temperatures, reviewed by the facility 9/08/2023, documented the dietary department was to maintain acceptable food temperatures during serving. Temperatures of the food were to be taken and recorded prior to serving. Hot foods were to be held at least 140 degrees (Fahrenheit) and cold foods were to be held at 45 degrees or below. If food items were out of acceptable range, they would be returned to the kitchen to be reheated or cooled to accurate temperature. During the resident council meeting on 2/12/24 at 2:03 PM, there were 9 residents present. An anonymous resident stated the food was cold and unappetizing and the remaining 8 anonymous residents agreed that the food was cold. During an observation on 2/13/2024 at 1:07 PM, Resident #52's tray was delivered to their room, used for a test tray, and a new tray was ordered for the resident. At 1:09 PM, the food temperatures on the tray were measured with the following results: the milk was 48 degrees Fahrenheit, the cold four bean salad was 59 degrees Fahrenheit, the chicken soup was 130 degrees Fahrenheit, the cheeseburger was 115 degrees Fahrenheit, the cold mixed fruit was 57 degrees Fahrenheit, the coffee was 140 degrees Fahrenheit, and the apple juice was 50 degrees Fahrenheit. The milk, four bean salad, chicken soup, cheeseburger, mixed fruit, coffee, and apple juice were not served at palatable temperatures. During an observation on 2/14/2024 at 8:10 AM, Resident #21's original tray was taken from the hot box on the unit at 8:10 AM and a replacement was provided. At 8:12 AM, the food temperatures were measured with the following results: the milk was 47 degrees Fahrenheit, the oatmeal was 117 degrees Fahrenheit, the scrambled eggs were 100 degrees Fahrenheit, the toast was 80 degrees Fahrenheit, the coffee was 108 degrees Fahrenheit, and the orange/pineapple juice was 53 degrees Fahrenheit. The milk, oatmeal, scrambled eggs, toast, coffee, and orange/pineapple juice were not served at palatable temperatures. During an interview on 2/14/2024 at 10:25 AM, night cook #8 and day cook #9 stated hot food items were to be served at 135 degrees Fahrenheit or higher and the cold food items were to be served at 45 degrees Fahrenheit. They both stated the mixed fruit was partitioned into smaller bowls in the kitchen then stored in the freezer for 15 minutes prior to being brought to the first-floor dining room to be plated. Night cook #8 stated the cans of fruit and vegetables were placed in the refrigerator one day prior to use. They stated the temperatures observed during lunch on 2/13/2024 and breakfast on 2/14/2024 were not palatable nor acceptable temperatures. Night cook #8 stated they checked the temperatures of the food when it entered the first-floor steam table on the Daily Steam Table Food Temperature log, and after all residents were served, they would take the temperature of the food items again and these temperatures had been recorded on a separate form. The facility's Daily Steam Table Food Temperature logs for February 2024 documented that food temperatures were not consistently recorded prior to meal service and were not documented for the after-service food temperatures for most of the daytime meals. During an interview and record review on 2/14/2024 at 11:00 AM, the Food Service Director stated the hot food items were to be served at 135 degrees Fahrenheit or higher and cold food items were to be served at 45 degrees Fahrenheit or lower. The temperatures observed during lunch on 2/13/2024 and breakfast on 2/14/2024 were not palatable temperatures. They had not reviewed the daily steam table food logs for that day. The Food Service Director reviewed the food temperature logs and stated they were missing documented food temperatures prior to service, had food temperatures that were not clear, and the after-service food temperatures for daytime meals were not logged for the majority of February 2024. They were not aware of any food palatability issues. It was important to ensure the food for the residents was served at palatable and safe temperatures. 10NYCRR 415.14(d)(2)

Based on observation, record review and interview during the recertification survey conducted 10/12-10/14/21, the facility failed to ensure residents who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 of 3 residents (Resident #21) reviewed. Specifically, Resident #21 was not provided timely nail care. Findings include: The facility policy ADL Care Guidelines dated 4/25/19 documents caregiver will review resident nursing care instructions at the beginning of each shift to assure that care is given according to the individual's plan of care. Staff will perform hand hygiene at this time and as indicated throughout care. Resident #21 had diagnoses including depression and bipolar disorder. The 8/14/21 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required extensive assistance for personal hygiene. The 6/14/21 comprehensive care plan (CCP) documented the resident required supervision with grooming. The CCP was updated on 7/19/21 to include nail care to hands weekly and as needed (PRN). The undated care instructions documented the resident required supervision with upper body hygiene and nail care was to be provided. The resident was observed with dark build up/debris under their nails and chipped nail polish on 10/12/21 at 10:20 AM, 10/13/21 at 11:48 AM, and on 10/14/21 at 9:13 AM. During an interview with certified nurse aide (CNA) #1 on 10/14/21 at 9:13 AM, the CNA stated they had provided care to the resident on 10/12/21 and had provided care to the resident on this date and had not cleaned the resident's nails. The CNA stated the resident's nail polish was now chipping and they noticed the resident's nails needed cleaning. During an interview with the Assistant Director of Nursing (ADON) on 10/14/21 at 11:03 AM, they stated they would expect a resident's nails to be cleaned daily if needed. Any staff could provide nail care. 10NYCRR 415.12(a)(3)

Based on observation, record review and interview during the recertification survey conducted 10/12-10/14/21, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 3 residents (Residents #4 and 26) reviewed. Specifically, Resident #4 had an excoriated (abraded or chaffed) area on their skin that was not addressed timely by qualified nursing staff and Resident #26 was not provided with physician ordered TED (thrombo-embolus deterrent, compression) stockings. Findings include: The facility policy Urinary Incontinence dated 8/2009, documented residents will be kept clean and dry. Resident's skin condition will be monitored and assessed for signs and symptoms of skin irritation and skin breakdown during cares. Any skin breakdown will be reported to charge nurses and to the skin nurse via 24-hour Report. All incontinent and/or residents with incontinent dermatitis will be treated with moisture barrier ointment (A & D ointment) for every incontinence or during cares. If excoriations persist after 48 hours physician/skin nurse will be notified. 1) Resident #4 was admitted to the facility with diagnoses including diabetes, cataracts with blindness, and depression. The 9/22/21 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance of 2 with most activities of daily living (ADLs), was always incontinent of bladder and bowel and did not have any ulcers, wounds, and skin problems. The 8/26/20 physician order documented to check integrity of skin weekly on Tuesdays from 8:00 AM to 2:00 PM. The 9/3/21 care instructions documented the resident required extensive assistance of 2 for toileting and bed mobility. The area for skin integrity was blank. The 9/9/21 comprehensive care plan (CCP) documented the resident was at risk for skin breakdown related to immobility and incontinence. Interventions included keep skin clean and dry, change incontinent pad as soon as possible after voiding or after bowel movement, keep bed linen clean, dry, and free of wrinkles, assist resident to turn and position every two hours, inspect, and report any changes in skin integrity, apply barrier cream, avoid hot water, and skin assessment weekly and document on wound flow sheet. The 10/2021 treatment administration record (TAR) documented skin integrity check was completed on 10/5/21 and 10/12/21 by LPN #4. The 10/6-10/14/21 24-Hour Reports had no documentation of skin concerns for Resident #4. On 10/12/21 at 10:59 AM, the resident was observed wearing an incontinence brief. The resident stated that they had a rash to their peri-area and that the staff was putting cream on it. Nursing progress notes did not include documentation of skin assessments or alterations in skin integrity. When interviewed on 10/14/21 at 9:27 AM, CNA #1 stated the resident had redness in the peri-area. The resident had been incontinent of stool quite a bit. Staff had been using barrier cream on the redness, but the facility ran out of the barrier cream, Dermaseptin, and they began using Nystatin (antifungal) powder. The CNA stated the powder was not working as well as the barrier cream. The CNA stated the redness had been present a couple of weeks and the area was seen by the Assistant Director of Nursing (ADON) a week ago. The area had been clearing up but now was very red. The CNA stated when they went to clean stool off the resident that AM, the resident complained of pain in the reddened groin area. The CNA stated they had not yet told anyone about the redness or pain. When interviewed on 10/14/21 at 9:45 AM, LPN #4 stated they and the registered nurse supervisor (RNS) were made aware of the resident's area of redness by staff a week ago. The RNS told the LPN an order was going to be requested from medical for a cream and medical would assess the area. An order was obtained for a skin prep to the heels, but nothing else for the reddened groin. The LPN stated they did not do weekly skin checks as regular assessments were done by the RNS. If an RNS was not on duty for the assessment, a note was left for medical to address the area in the NP (nurse practitioner) book on the unit. They stated any discipline could write concerns for medical in the book. When interviewed on 10/14/21 at 10:05 AM, Assistant Director of Nursing (ADON) #2 stated they were not aware of the resident having any skin concerns and had never assessed the rash. The ADON stated they were unaware the barrier supply was low, The ADON stated Nystatin powder was to be applied by a nurse and not a CNA. CNAs were only allowed to apply barrier creams. Staff could write any skin concerns in the NP book and the ADON reviewed the NP book daily. The NP book was reviewed with the ADON and there was one sheet with several residents listed and did not include Resident #4. The notes in the NP book were not dated. The ADON stated the NPs took out the notes when they addressed issues and thought the sheets were then shredded. On 10/14/21 at 11:20 AM, the resident was observed in bed with the ADON present. The resident's peri-area was reddened between the thighs and there was scaly skin on the reddened scrotum. During a follow up interview with LPN #4 on 10/14/21 at 2:11 PM, they stated that when completing the weekly skin check noted on the TAR, they would check the resident's back side and legs as that was where the resident had most of their skin issues. They stated the weekly skin check order was left open to interpretation and was not specific. The LPN stated when they completed their 10/2021 skin checks for the resident, they did not check the resident's peri area. 2) Resident #26 had diagnoses including hypertension, hyperlipidemia, and chronic bilateral leg weakness. The 8/24/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, did not reject evaluation of care, required extensive assistance of 2 staff with dressing and the resident received a diuretic 7 of 7 days of the assessment period. The 6/9/21 care instructions documented the resident was non-ambulatory and was wheelchair dependent. There was no documentation regarding TED stockings. The active physician orders documented staff were to apply TED stockings to BLE (bilateral lower extremities, legs) in AM and remove in PM starting on 6/11/21. The comprehensive care plan (CCP), updated 9/2/21, documented the resident required assistance with activities of daily living (ADLs). Interventions included staff to provide extensive assistance with dressing. The resident had the potential for alteration in cardiac function related to hypertension, hyperlipidemia and as evidenced by BLE edema (fluid buildup). Interventions included administer medications as ordered and monitor for peripheral edema. There was no documentation of the application of TED stockings. A nurse practitioner (NP) progress note dated 9/15/21 documented the resident had a history of chronic bilateral lower leg edema and continued on furosemide (diuretic) 20 milligrams (mg) twice daily. The resident's edema had decreased and remained stable. The furosemide would be decreased to 20 mg once daily. Continue with TED Stockings to bilateral lower extremities on in AM off in PM. The resident was observed in their room sitting in a wheelchair, their ankles were edematous, and they were not wearing TED stockings: - on 10/12/21 at 10:31 AM, 11:49 AM, 12:49 PM, 1:07 PM, and 4:14 PM. - on 10/13/21 at 8:47 AM, 9:47 AM, 11:49 AM, 12:58 PM, 2:13 PM, and 3:54 PM. The 10/2021 treatment administration record (TAR) documented TED stocking were to be applied to BLE for edema in the AM and taken off in the PM. - on 10/12/21, LPN #4 documented TED stockings were applied on 10/12/21 in the AM and LPN #6 documented they were removed on 10/12/21 in the PM. -on 10/13/21, there was no documentation that the TED stockings were applied in the AM but were removed in the PM by LPN #17. During an interview with licensed practical nurse (LPN) #6 on 10/13/21 at 3:50 PM, they stated TEDs should be put on by the LPN when the resident was getting dressed and taken off when the resident went to bed. LPN #6 observed the resident and stated the resident did not have their TEDs stockings on. The LPN stated there was no documentation in the TAR that the resident refused the TEDs, and the resident should have them on. LPN #6 stated LPN #4 documented they applied the resident's TEDs stockings on 10/12/21 and LPN #6 documented they removed on them on 10/12/21. LPN #6 stated on 10/12/21 they placed the TEDs in the bathroom after washing them. When LPN #6 checked the resident's bathroom the TEDs stockings were not in the bathroom and they were unsure where the TEDs stockings were. LPN #6 stated it was important for the resident to wear the TED stockings because they were medically ordered, and they helped with the resident's edema. During an interview with LPN #4 on 10/14/21 at 7:54 AM, they stated if they signed off on the TAR the TED stockings were applied then the resident had them on. The LPN stated the resident might have taken them off, but they were unsure. The LPN could not recall if the resident had TEDs on 10/12/21 or 10/13/21. The LPN stated if they had noticed the resident did not have their TED stockings on, they would ask the resident if they would like them applied. The LPN stated it was important for the resident to wear the TED stockings to help with circulation and edema. During an interview the Assistant Director of Nursing (ADON) on 10/14/21 at 9:42 AM, they stated if a resident required TED stockings there would be a physician order in the computer. The order would be general for on in AM and off in PM and the ADON would expect the resident to wear their TED stockings if there was an order. If the nurse signed the TAR, the TEDs should be on. If the resident refused their TED stockings the nurse should document the refusal. It was important for the resident to wear their TED stockings to aid with circulation. During an interview with nurse practitioner (NP) #12 on 10/14/21 at 12:30 PM, the NP stated they expected the resident to be wearing their medically ordered TED stockings and would expect staff to document the resident was not wearing them. If the resident was not wearing the TEDs, it could lead to increased swelling of the legs. 10NYCRR 415.12

Based on observation, record review and interview during the recertification survey conducted 10/12-10/14/21, the facility failed to ensure residents received proper treatment and assistive devices to maintain vision and hearing abilities for 1 of 1 resident (Resident #19) reviewed. Specifically, the facility did not make arrangements for Resident #19's physician ordered optometry consult. Findings include: Resident #19 had diagnoses including dry eye syndrome, history of falls, and diabetes. The 5/11/21 admission Minimum Data Set (MDS) assessment documented the resident had intact cognition, impaired vision, and used corrective lenses. The resident required extensive assistance of one staff with most activities of daily living (ADLs). The 5/4/21 Director of Social Services progress note documented the resident liked to play cards, play games, watch TV, and complete puzzle books. The note documented the resident had poor eyesight, the resident said their eyeglasses were lost by staff at the previous facility and the plan was to have a scheduled eye appointment. The 5/4/21 resident inventory list, completed by the social worker, documented the resident had reading glasses. The 5/5/21 activities assessment documented the resident had reading glasses that had been missing from another facility. The assessment documented activities that were important to the resident including taking care of possessions, card games, crafts with glasses, and bingo. The Director of Social Services progress notes documented: - on 5/12/21, the resident had poor eyesight and family was bringing the resident new glasses. - on 5/28/21, the resident's family brought new glasses and a new phone during a visit. - on 6/25/21, the resident had poor eyesight and had glasses that they wore to play games and complete puzzle books. The 8/11/21 nurse practitioner (NP) order documented optometry consult for blurry vision. An 8/11/21 licensed practical nurse (LPN) #10 progress note documented the NP had been in and ordered an optometry consult for blurry vision. The 8/19/21 comprehensive care plan (CCP) documented the resident had visual impairment related to poor vision, diabetes, potential for injury related to impaired vision, and was socially isolated by not getting out of bed. Interventions included using reading glasses at times and monitor need for eye exam and refer if indicated. Staff were to investigate if the resident stopped wearing glasses or began rubbing their eyes, provide large print materials, provide adequate lighting, ophthalmologist consult if indicated, keep glasses clean and fit with adequate prescription if they were used. When interviewed on 10/12/21 at 10:01 AM, the resident stated their prescription eyeglasses had been missing at the prior facility, the pair the family gave to replace them were cheaters and were not the needed prescription. The resident stated they had difficulty seeing print while trying to read. On 10/13/21 at 12:39 PM, the consults schedule in a black binder schedule book at the nursing station did not document any eye appointments for the resident through 1/1/22. When interviewed on 10/14/21 at 8:51 AM, unit clerk #7 stated the process for a consult was the unit clerk received a copy of the physician/NP order, the clerk placed the copy in the scheduling book, a referral was sent to the consultant, and then an appointment date or verification of being on a wait list was received from the consultant. The unit clerk stated they did not remember seeing or receiving the 8/11/21 order for the resident's eye consult. The unit clerk verified the resident did not have a scheduled eye appointment. When re-interviewed on 10/14/21 at 9:13 AM, the resident stated the eyeglasses on the over bed table in the room were a pair of cheaters that were brought in by their family. The resident stated they were not bifocals that they required and were not adequate for reading. The resident liked to read almost any genre of books, could not read with the current eyeglasses on the table, and would begin reading again if they had the right glasses. When interviewed on 10/14/21 at 9:20 AM, the Director of Nursing (DON) stated consult orders went directly to the unit clerk for scheduling. The DON stated most consult orders occurred during the day shift and a copy of the order or a note should have been given directly to the unit clerk. The DON stated an appointment date should be received within a few days. The DON stated the resident's glasses were lost at the previous facility. The facility had an optician on staff, but they had not been in the facility in a while. The resident should have been sent to an outside provider. When interviewed on 10/14/21 at 9:42 AM, certified nurse aide (CNA) #1 stated the resident had read and done puzzle books during past stays at this facility but had not been since transferring from the other facility. The CNA stated they knew the resident wore glasses but did not know what kind they were or what they were used for. When interviewed on 10/14/21 at 9:58 AM, the Director of Activities stated the resident had a lot of books and completed crosswords books the resident had finished at the previous facility. They were not aware of the resident needing glasses. When interviewed on 10/14/21 at 10:06 AM, the Director of Social Services stated it was documented in social service progress notes the previous facility lost the resident's prescription glasses, family brought in glasses for the resident to use, and the glasses were added to the inventory list. The Director was unsure if the glasses were prescription or cheaters. The resident told the Director they were not able to see well and had preferences to read and do crossword puzzles. The Director stated they were unaware of the resident's reading difficulties. 10NYCRR 415.12(3)(b)

Based on observation, record review and interview during the recertification survey conducted from 10/12/21 -10/14/21, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 2 of 4 residents (Residents #26 and 236) reviewed. Specifically, Resident #26 had a significant weight gain and was not re-assessed timely, and Resident #236 had a preference to gain weight and the facility did not monitor the resident's weight to ensure they met the resident's nutritional goals. Findings include: The facility policy Weight Monitoring Program dated 8/2015 documented weight monitoring is used to assure that residents maintain acceptable parameters of nutritional status when clinically possible and that appropriate interventions are put into place. Evaluation by the registered dietitian (RD) and/ or physician will determine the need for appropriate interventions. This will take into account the resident's usual body weight (UBW), fluid status, medication, functional status, cognition, and medical diagnoses. The parameters for evaluating the significance of weight loss/ gain: - At 1 month (30 days) a weight change of 5 percent (%). - At 3 months (90 days) a weight change of 7.5%. - At 6 months (180 days) a weight change of 10%. The Nurse Manager and Food Service Director will discuss significant weight losses or gains each weekday during or after morning report. In the event of a significant weight change at 1 month/ 30 days, at 3 months/ 90 days, and 6 months/ 180 days the following interventions will be carried out: - Notification of the physician, family, or resident representative. - Notification of the RD by nursing staff or food service director. The RD will assess the resident, document the assessment, and make recommendations in the resident's medical chart. The RD will update the resident's care plan as appropriate. 1) Resident #26 had diagnoses including hypertension, hyperlipidemia, and chronic bilateral leg weakness. The 8/24/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, did not reject evaluation of care, was independent with set-up at meals, weighed 145 pounds (lbs), had no significant weight changes, and the resident received a diuretic 7 of 7 days of the assessment period. The 6/3/21 nutrition assessment documented the resident received a regular diet, a diuretic (water pill), and weighed 137 lbs. The 6/9/21 care instructions documented the resident was independent with tray set-up at meals and was on a regular diet. Physician orders documented: - on 6/11/21 discontinue ACE wraps, start TED stockings (compression stockings) apply to bilateral lower extremities (BLE, legs) on in AM and off in PM for edema. - on 3/16/21 furosemide (diuretic) 20 milligrams (mg) twice daily for edema (fluid accumulation), discontinued on 7/21/21. - on 7/21/21 furosemide 20 mg once daily in the morning for edema. The comprehensive care plan (CCP), updated 9/2/21, documented the following: - The resident was independent with tray set-up at meals. - potential for alteration in cardiac function related to hypertension, hyperlipidemia and as evidence by BLE edema. Interventions included administer medications as ordered, weights as ordered, monitor for peripheral edema. - potential for alteration in nutritional status related to decreased appetite. Interventions included to maintain a weight range of 130-135 lbs, provide a regular diet, and 8 ounces (oz) of whole milk at breakfast and dinner, 8 oz of orange juice at breakfast, 4 oz at lunch and dinner, and cola at lunch. The resident's 2021 weight record documented the following undated monthly weights: - March - 132 lbs; - April - 135 lbs; - May - 137 lbs; - June - 142 lbs; - July - 142 lbs; - August - 145.2 lbs; - September - 148.6 lbs (11%/16.6 pound weight gain at 6 months); and - October - 151.2 lbs (10%/16.2 pound weight gain at 6 months). A nurse practitioner (NP) progress note dated 9/15/21 documented the resident had a history of chronic bilateral lower leg edema and continued on furosemide 20 mg twice daily. The resident's edema had decreased and remained stable. The furosemide would be decreased to 20 mg once daily. Continue with TED Stockings to bilateral lower extremities on in AM off in PM. There was no documentation regarding the resident's weight gain. There was no documentation of a nutritional assessment since 6/3/21 or progress notes addressing the resident's significant weight gain. During an interview with the Food Service Director on 10/14/21 at 10:20 AM, they stated once resident weights were completed, they entered them in the computer to generate the weight report. Any resident with a significant weight change of 5 % at 1 month, 7.5 % at 3 months, or 10 % at 6 months they would let the RD know before providing them with the weight report. They would request that nursing staff obtain a re-weight for residents who had a 5 lb weight change at 1 month. The Food Service Director stated Resident #26 had a gradual weight gain and had not had any significant weight changes they were aware of. During the interview, the Food Service Director reviewed the weight book and stated Resident #26 had a significant weight gain in the last 6 months. During an interview with RD #12 on 10/14/21 at 10:43 AM, they stated they did not have a facility email and mostly communicated with the Food Service Director via written communication. Each resident was followed by nutrition at a minimum of every 3 months, upon an identified significant change, annually, and as needed. The RD stated they used the MDS schedule to keep track of who needed a nutrition assessment completed. The Food Service Director completed the weights and entered them into the weight tracking report which was left in the RD's mailbox. The weight tracking report showed a six-month progression of the resident's weight. They stated they had not yet completed weight notes for the month of October and ideally their weight notes should be completed by the middle of month. If a resident had a significant weight change, they would reassess the resident's nutritional needs and provide recommendations if needed. They were unaware that the resident had not had a nutritional assessment completed since 6/3/21and that was too long without an assessment. The RD was unaware the resident had a significant weight gain, or the resident had edema. The RD stated monthly weights were discussed during a monthly weight meeting. They attended the meeting once in August and they had not been notified if the meeting had occurred since then. During an interview with the Assistant Director of Nursing (ADON) on 10/14/21 at 11:03 AM, they stated weights were discussed at daily report. If there was a significant weight change a re-weight was obtained. Staff were notified by the Food Service Director if re-weights were needed. The Food Service Director would notify medical of any significant weight changes. During a follow up interview, the Food Service Director on 10/14/21 at 11:52 AM, they stated only the Food Service Director and the RD received a copy of the monthly weight tracking report. The weight meeting typically took place the 3rd Wednesday of each month and was attended by the Food Service Director, Director of Nursing (DON), ADON, therapy department, social worker, and the facility Administrator. The Food Service Director stated they gave the medical providers a summary of the meeting. They stated the RD did not provide any input for the monthly weight meeting and they gathered general information about the resident to discuss. The nutrition assessments were completed based on the MDS schedule. The Food Service Director stated they completed an informal chart audit on 8/6/21 and provided a copy to the RD so the RD would know when nutrition assessments were needed. The Food Service Director showed the surveyor the 8/6/21 Assessment Audit and it documented that Resident #26's next nutritional assessment was due 8/24/21. During an interview with nurse practitioner (NP) #16 on 10/14/21 at 12:30 PM they stated they expected to be notified of significant weight changes. The NP stated they were unaware Resident #26 had a significant weight gain and stated weight gain can occur due to increased intakes or due to fluid status changes. 2) Resident #236 was admitted to the facility with diagnosis of recurrent prostate cancer and cerebrovascular disease. The 10/1/21 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required supervision with activities of daily living (ADLs), weighed 128 lbs, had no significant weight changes at 1 or 6 months, and received a mechanically altered diet. The initial baseline care plan, dated 9/27/21, documented the resident received a regular mechanical soft diet and had a goal to maintain their current weight (no current weight documented). The 9/27/21 care instructions documented the resident required set up at meals and received a regular mechanically altered diet. The 9/27/21 nutrition progress note documented the resident was admitted to the facility with diagnoses of cerebrovascular accident and recurrent prostate cancer. admission weight was pending, and a nutritional assessment was to follow. The 9/28/21 physician progress note documented the resident was seen for a follow up visit for recurrent malignant neoplasm (cancer) of prostate. The physician documented the resident's general appearance was too thin. The 9/28/21 nursing progress note documented the resident was alert and was able to feed themself after set-up. The 10/1/21 physician note documented the resident was seen for a follow up visit. The physician documented the resident's general appearance was too thin. The 10/2/21 physician order documented 237 milliliters (mls) of Ensure Plus (a nutritional supplement) three times daily. The Nutrition Weight Record documented an undated 10/2021 weight of 127.6 lbs. No further weights were listed. The 10/5/21 updated comprehensive care plan (CCP) documented the resident was at nutritional risk due to dysphagia (difficulty swallowing) related to a cerebrovascular accident (stroke). The resident had a goal to maintain weight in range of 125-130 pounds. The 10/5/21 Initial Nutrition Assessment documented the resident received a regular mechanical soft diet, was 65 inches tall, weighed 127.6 lbs, their estimated daily nutritional needs were 1785-1947 calories, 73-87 grams of protein, and 1740-2030 mls of fluids. The resident had excellent intakes, averaging 100 % at meals, and weights would be monitored. The area noting goal weight was left blank and there was no documentation regarding the resident's weight preference in the assessment. The 10/6/21 physician progress note documented the resident was being seen for follow up regarding pain management. The physician documented the resident's general appearance was too thin. During an interview with the resident on 10/12/21 at 11:28 AM, the resident stated they would like to gain weight. During an observation on 10/13/21 at 12:56 PM, the resident was served their lunch meal. The meal ticket indicated the resident received a regular mechanical soft diet. They received 1 mechanical soft turkey club sandwich, 10 cheese puffs, 6 ounces (oz) of tomato soup, 8 oz of coffee, 8 oz of water, and a slice of banana cake. At 1:23 PM, the resident walked to their doorway. The resident had consumed 25 % of their tomato soup, 8 cheese puffs, 25 % of their sandwich, and 100% of their coffee and water. The banana cake was untouched. During an interview with certified nurse aide (CNA) #13 on 10/13/21 at 1:58 PM, they stated residents were weighed upon admission, but was unsure of the frequency that a new admission would be weighed. If a resident needed a re-weight, daily weight, or weekly weight they were told by the nurse. During an interview with CNA #14 on 10/14/21 at 8:10 AM, they stated residents were weighed monthly unless there was a medical order stating otherwise. The nurse would let the CNAs know which residents needed to be weighed. There was a list in the weight book. During an interview with the Food Service Director on 10/14/21 at 10:20 AM, they stated all new admissions were weighed within 24 hours after admission and were weighed weekly for weeks. Weekly weights were due on Wednesdays. The Director stated once the weights were completed, they entered them in the computer to generate the weight report. The Food Service Director stated the RD was responsible for tracking the new admission's weights. The list of requested weights was not kept on file. During the interview the Food Service Director reviewed the weight book and stated Resident #236 had only been weighed once since admission. During an interview with the RD on 10/14/21 at 10:43 AM, they stated they had not yet completed weight notes for the month of October. The RD stated ideally weight notes should be completed by the middle of month, but they were pressed for time when they came into the facility and it took a lot of time to research why the resident had a weight change. They were unsure how often new admissions were weighed, but knew they were written in the weight book. The RD stated they used the resident's weight to complete nutrition assessments. The Food Service Director completed the weights and entered them into the Weight Tracking Report. That report was then left in the RD's mailbox. During an interview with the DON on 10/14/21 at 11:11 AM, they stated CNAs were responsible to obtain resident's weights at least monthly or more frequently if it was indicated on the weight list. New admissions were weighed upon admission. The Dietary Department could request weights more frequently if needed. 10NYCRR 415.12(i)(1)

Based on observation and interview during the recertification survey conducted 10/12/21-10/14/21, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 nursing unit medication rooms (Unit 1) reviewed. Specifically, the facility had expired stock medications (Tylenol suppositories) and biologicals (influenza vaccine) in the Unit 1 medication room refrigerator. Findings include: The facility Medication Storage policy dated 5/2018 documented medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy documents outdated, contaminated medications are immediately removed from inventory and discarded according to procedures. Some medications have a shorter shelf life than the manufacturer's printed expiration date. All staff are to the date when the medication was opened which starts the countdown to the expiration date. During a medication storage observation on 10/12/21 at 4:42 PM with licensed practical nurse (LPN) #6, one Unit 1 medication refrigerator contained an opened 5 milliliter (ml) vial of Afluria (influenza vaccine) that did not have a documented opened date on the vial or box. A second medication refrigerator in the Unit 1 medication room contained 3 full 50 dose boxes (150 total doses) each of Tylenol 650 milligram (mg) suppositories with manufacturer expiration dates of 8/2021. When interviewed on 10/12/21 at 4:42 PM, LPN #6 stated the Tylenol suppositories were all expired according to the manufacturer expiration date. The LPN stated the vial of influenza vaccine should have an opened expiration date 30 days after opening and since the vial of influenza vaccine had no written opened date, it was considered expired. The LPN stated they checked the medication carts and refrigerator at least weekly and there was not a specific shift assigned to do so The LPN stated they were unaware of any resident receiving the medications after the expiration dates. When interviewed on 10/14/21 at 9:25 AM, the Director of Nursing (DON) stated opened vials have an expiration date of 28 days once opened. The DON stated staff were expected to date the vial with the opened date. The DON expected the night shift nurse to check the medication refrigerator and room a few times a week for expired medications and did not think the checks were documented. 10NYCRR 415.18(d)(e)(2-4)

Based on observation, interview, and record review during the recertification survey conducted from 10/12/21 - 10/13/21, the facility failed to provide carbon monoxide (CO) detection in compliance with Federal, State, and Local Laws and Professional Standards on 1 of 3 Units (basement) reviewed. The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection (adopted by New York State), requires carbon monoxide detection in all areas with fuel burning/gas operated equipment. Specifically, carbon monoxide detection was not installed in the basement level where there was fuel burning equipment. Findings include: There was no documented policy and procedure for a CO activation incident in the facility. During observations on 10/12/21 and 10/13/21 between 9:00 AM and 3:00 PM, there was no carbon monoxide detection installed in the basement level of the facility. The basement level contained a generator room (boiler room) with a natural gas generator, and a main kitchen fuel/gas burning appliances (stove and oven). When interviewed on 10/13/21 at 11:50 AM, the Administrator stated there was no carbon monoxide detection installed in the basement and there was no policy and procedure for the activation of CO alarms. When interviewed on 10/13/21 at 11:53 AM, the Environmental Director stated there were no CO detectors in the basement and there was a natural gas generator and fuel burning equipment in the kitchen located in the basement. The Director stated they were unsure if there was a policy and procedure on how to respond to an alarm activation or if staff had been trained. They stated they were not aware of the requirements for CO detection. 2012 NFPA 101: 2.2 2012 NFPA 720 2015 International Fire Code, Section 915 483.70 (b) 10NYCRR 400.2

Based on record review and interview during the recertification survey, the facility did not notify the Office of the State Long-Term Care Ombudsman of a facility-initiated transfer for 1 of 1 resident (Resident #39) reviewed. Specifically, Resident #39 was transferred to the hospital and the Ombudsman was not notified. Findings Include: The 11/21/17 facility Discharge/Transfer policy documented it is the policy to adhere to all the regulations regarding a resident's transfer and discharge rights. The policy did not document that the Office of the State Long-Term Care Ombudsman was to receive notification of facility-initiated transfers or discharges. Resident #39 was admitted to the facility with diagnoses including sepsis, right hip and right heel pressure ulcers and severe protein malnutrition. The Minimum Data Set (MDS) assessment was not available. The 2/15/21 nursing progress note documented at 5:00 AM the resident was having trouble breathing and was transported to the hospital. There was no documented evidence the Ombudsman was notified of Resident #39's emergency transfer to an acute care facility. When interviewed on 4/21/21 at 3:27 PM, Ombudsman #8 stated long term care facilities were supposed to notify their office of any facility-initiated discharges. The only recent discharge notice she had received from the facility was in 2/2021 and it was not for Resident #39. When interviewed on 4/22/21 at 12:10 PM, the Administrator stated they reported discharges to Ombudsmen #9, and they did not notify the ombudsman of hospitalizations unless they specifically asked. When interviewed on 4/22/21 at 2:29 PM, the Director of Social Services stated they were responsible for notifying the Ombudsman's Office of resident discharges. The Director of Social Services stated they did not notify the Ombudsmen of emergent hospital transfers. The Director of Social Services believed the Administrator was communicating with Ombudsman #9 regarding hospital discharges. The Director of Social Services did not notify the Ombudsmen of Resident # 39's hospital transfer. 10NYCRR 415.3(h)

Based on observation, record review and interview during the recertification survey the facility did not incorporate the recommendations from the Pre-admission Screening and Resident Review (PASRR) Level II determination into a resident's assessments and care planning for 1 of 1 resident (Resident #35) reviewed. Specifically, there was no documentation Resident #35's Level II Mental Health Screen recommendations for weekly behavioral counseling were followed and the resident's comprehensive care plan (CCP) was not specific to meet the resident's emotional and behavioral needs. Findings include: Resident #35 had diagnoses including borderline personality disorder, mood disorder, and schizoaffective disorder. The 3/24/21 Minimum Data Set (MDS) assessment documented the resident was not evaluated by Level II PASRR, was cognitively intact, had disorganized thinking, minimal depression symptoms of moving or speaking slowly or being restless half of the days in the previous two weeks, and required extensive assistance with most ADLs. Hospital records documented the resident was hospitalized between 1/21/21 and 3/18/21 for depression, suicidal thoughts, psychosis, and COVID-19. The 3/12/21 Level II PASRR documented the resident had been living in a nursing facility for over a year and recently had a change in mental status, which led to a hospitalization. The resident had a history of having trouble concentrating, irritability, euphoria, increased sleep, manic symptoms, mood swings, anxiety, restlessness, obsessive thoughts, fear that others were trying to harm the resident, and seeing/hearing what were not real. When first admitted to the hospital, the resident had thoughts of self-harm. The resident met the PASRR inclusion criteria for serious mental illness and needed hospitalization and the resident's day to day life was impacted by the illness. Recommendations included the resident receive ongoing psychiatric consultations and medication management by a psychiatrist or licensed prescriber; recovery-oriented clinical counseling focused on goal achievement by overcoming barriers due to the individual's mental illness; and therapeutic group interventions. Given the resident's current stability, psychiatric appointments were recommended every 10-12 weeks to monitor psychiatric symptoms. The resident would benefit from weekly counseling to treat psychiatric symptoms, counseling to help with depression and developing coping skills, and treating post-traumatic stress disorder (PTSD). The resident would also benefit from recreational and therapy groups to have more activities and opportunities to interact with others. The 3/2021 and 4/2021 physician orders did not include documentation for orders for mental health practitioner consults. The comprehensive care plan (CCP) last reviewed 3/18/21 documented the resident displayed physical and verbal behavioral symptoms. The resident cried easily and expected to have their needs met immediately. The resident was to use coping strategies and demonstrate emotional stability, provide daily 1:1, and supportive tender loving care. The resident would participate in psychiatric and psychology services as recommended by the mental health providers. The 3/18/21 social services progress note documented the resident returned to the facility from a behavioral health hospital. The resident became easily emotional and cried very easily. The resident would participate in monthly psychiatric services. Interventions included coloring, reading magazines, writing, cross-stitch, talking to friends and family on the phone, 1:1 with activities staff, reassurance, emotional support, and comfort. Social services progress notes between 3/30-4/21/21 had no documentation of supportive weekly mental health counseling for the resident as recommended by the PASRR Level II. Nursing progress notes between 3/21/21-4/20/21 documented the resident was emotional, disoriented following admission, felt trapped by staff, received Xanax (antianxiety medication) for weepiness, displayed aggressive anxious behaviors, was upset with their roommate, and was sobbing. The 4/1/21 psychiatric services note documented they were completing a follow up and medication check. The resident was depressed and anxious and wanted to live elsewhere. The anti-depressant medication was increased. Staff were to monitor mood, behaviors, offer non-pharmacological interventions, and socialization. The plan was to follow up in 4 weeks, or sooner if needed (prn). There was no further documentation of psychiatry services follow up. There was no documentation from the outpatient behavioral health services that weekly counseling was provided to the resident. On 4/19/21 at 11:01 AM, the resident was observed in bed. When addressed, the resident began sobbing and was inconsolable throughout the interview. During an interview with the Director of Social Services on 4/21/21 at 12:16 PM, they stated they did not provide weekly counseling to residents and that would be the responsibility of an outside consult psych service with a licensed social worker/therapist. If a resident was recommended for psych therapy, they would be seen by a local behavioral health agency. If someone had a mental health hospital visit, the outpatient behavioral health service was responsible for setting up the weekly counseling for the resident and calling the resident directly for the appointment. The Director of Social Services did not follow up with the outpatient behavioral health services to ensure the sessions were occurring. The Director of Social Services was familiar with the resident. They had established coping strategies with the resident, and they did not need the session notes. The Director of Social Services stated the CCP was the main plan of care for this resident. When someone had a Level II recommendation it was not specifically addressed on the CCP. The resident's admissions assessments would be updated by both nursing and social services regarding behavioral services. The Director of Social Services had thought the resident's individualized coping strategies were documented on the CCP but was unsure if it was documented on the current CCP. The resident had a prolonged hospitalization and their previous chart with CCP had been broken down, and the Director was unsure if the new CCP had documented individualized interventions for the resident. During an interview with the admissions coordinator on 4/22/21 at 10:20 AM, they stated the screen (PASRR) was collected from the location a resident was being admitted from, such as a hospital. Admissions then provided the screen to social services who was responsible for following up with recommendations. On 4/22/21 at 10:09 AM, the resident was observed in the hallway outside the administrative offices. The resident was yelling, sobbing, and not re-directable by staff. The resident repeatedly stated very loudly they needed to see someone immediately. The Director of Social Services and Administrator met with the resident and the resident was directed back to the unit at 10:35 AM. During an interview on 4/22/21 at 10:26 AM, the resident's representative stated they were concerned for the resident's mental health and emotional needs. They stated they did not think the facility was pushing for the resident's mental health needs. Some of the care was provided but it had been sporadic. During a combined interview with CNAs #13, 15 and 16 on 4/22/21 at 10:38 AM, they stated the resident displayed behavioral symptoms at least once a week and more often on the weekend when social services was not present in the building. They tried coloring books, magazines, puzzles in room, and music on the iPad in the resident's room. 10NYCRR 415.11(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 12 residents (Residents #15 and 35) reviewed. Specifically, Resident #15's care plan did not reflect the resident's medical diagnoses and nutritional status. Resident #35's care plan was not individualized for behavioral interventions. Findings include: The facility policy Comprehensive Care Planning updated 4/30/19 documents an individualized care plan must be initiated by a registered nurse (RN) upon admission for all residents and subacute patients. A care plan will be individualized for each resident using a person-centered approach. Problems will be identified from the Minimum Data Set (MDS) Care Area Triggers and review of the Care Area Assessments, as well as from resident assessment, interview, and direct observation. The care plan must be individualized for each individual. 1) Resident #15 was admitted to the facility with diagnoses including end-stage renal disease (ESRD) on hemodialysis, diabetes mellitus, and seizure disorder due to a stroke. The 2/9/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance for most activities of daily living. Care areas triggered and were to be addressed in the care plan included activities of daily living (ADLs) functional/rehab potential, urinary incontinence, psychosocial well-being, falls, nutritional status, dehydration/fluid maintenance, pressure ulcers and psychotropic drug use. The undated baseline care plan documented the resident received hemodialysis on Monday, Tuesday, and Wednesday. Outside coordination documented hemodialysis was received from an outside provider on Monday, Wednesday, and Friday. The resident received Novolog (rapid-acting) and Basaglar (long-acting) insulins and had blood glucose checks three times a day before meals. The resident had a diagnosis of depression and received Prozac (antidepressant). The comprehensive care plan (CCP) did not include person-specific, measurable objectives and timeframes to evaluate the resident's progress toward their goals for diabetes mellitus, psychotropic medications, noncompliance with medical recommendations, and end-stage renal disease on hemodialysis. The 2/3/21 social services progress note documented the resident had diagnoses of depression and anxiety; medications included Prozac and Ativan (anti-anxiety). The 2/3/21 psychosocial CCP documented the resident transferred from another skilled nursing facility. Diagnoses included closed fracture of the left patella (kneecap) and ESRD on hemodialysis. The CCP did not include documentation the resident received psychotropic medications. The 2/4/21 skin breakdown CCP documented the resident had a potential for skin break down related to decreased mobility and recent fall with fracture. The resident had a goal for skin issues to the left knee to be resolved. The interventions documented were pre-populated and did not reflect resident specific interventions for care of the left knee. The 2/9/21 nurse practitioner (NP) progress note documented the resident was being seen for noncompliance and diabetes. The resident was refusing to go to dialysis and had nausea due to poor dietary choices. The 2/9/21 social service progress note documented the resident had refused hemodialysis and three appointments. Compliance was discussed with the resident and possible decline in health if medical needs were not addressed. There was no documented evidence the CCP addressed the resident's noncompliance and refusal to attend hemodialysis. The 2/18/21 nutrition CCP documented the resident had a nutritional risk related to diabetes mellitus, MDD (major depressive disorder), gastro-esophageal reflux disorder (heart burn), and hyperlipidemia (high cholesterol). The resident's goal was left blank and nursing was circled as the discipline responsible. Interventions included a regular diet, regular consistency, with thin liquids. There were no other resident specific interventions documented to address the problem areas. The CCP documented 2/18/21 see Nutrition Assessment. Registered dietitian (RD) #11's 2/18/21 Nutrition Assessment documented a diagnosis of ESRD on hemodialysis and hypertension. The resident reported they disliked the foods offered at the facility and did not follow a specialized diet for ESRD or diabetes. Their blood sugars had been elevated since admission. Interventions included updating information with dialysis as needed and to update the resident's preferences. Monitoring and evaluation documented to see the care plan. The 2/19/21 nursing progress note documented the resident's right hand to forearm was red and slightly swollen. The 2/19/21 NP progress note documented the resident had pain in their right hand. The resident had a history of hemiparesis (weakness on one side of the body). The 2/21/21 nursing progress note documented the resident's right hand was red and edematous; the resident was encouraged to keep their hand elevated on a pillow. The 2/2021 through 4/2021 nursing progress notes continued to document the resident's right had was red and edematous which improved with elevation. The CCP did not document the resident's right hand redness and swelling or the plan to keep their hand elevated. The 4/9/21 NP progress note documented the resident was noncompliant with their diet and typically ordered out. The resident's insulin had been reduced the week prior due to their concerns of hypoglycemia. The resident's recent noncompliance of their diet and decreased insulin had contributed to elevated blood sugar levels. The NP discussed their diet to help control blood sugar levels. The 4/18/21 nutrition progress note by RD #11 documented the RD reviewed the resident's labs with the resident's RD from dialysis. The residents phosphorus was 7.5 mg/dl (milligram per deciliter; normal 2.5 to 4.5 mg/dl, high), potassium was 6.4 mEq/L (milliequivalents per liter; normal 3.7-5.2 mEq/L, high), and glucose was 485 mg/dl (normal fasting less than 100 mg/dl). The resident's dry weight was obtained. The resident had been consuming 75-100% of meals and insulin was adjusted by the medical staff. On 4/19/21 at 1:14 PM, the resident was observed with their lunch tray. The resident had a grilled ham and cheese sandwich and cottage cheese. The resident had requested the additional cottage cheese on their lunch tray. On 4/20/21 at 12:24 PM, the resident was observed in the hallway. Their right hand was very red in color; the resident was lightly rubbing and scratching their arm. On 4/20/21 at 1:06 PM, the resident was observed with their lunch tray. The resident was consuming an Italian sausage sandwich and cottage cheese, and there were two milks on the resident's tray; the resident was served the meatball sub with tomato sauce but requested the sausage instead. The resident stated they had a history of a stroke with right sided weakness and had edema in their hand due to the stroke and never had a device for the hand. The resident stated they limited food intakes when told their potassium and phosphorus levels were elevated. The resident was aware they had two milks on their tray (high in phosphorus) which they knew they should limit, but they stated they enjoyed milk. During an interview on 4/21/21 at 11:17 AM, occupational therapist #19 stated the resident's arm had been red throughout their admission to the facility which improved with elevation. During an interview on 4/22/21 at 10:42 AM, the Director of Nursing (DON) stated a registered nurse (RN) had to initiate a care plan and a licensed practical nurse (LPN) could update the care plan. One of the RNs from the facility had been out of the country and the other worked part-time. The DON had been responsible for creating the baseline care plans and was not aware of comprehensive care plans. The DON stated residents may have an issue which involved multiple disciplines and should be discussed as a team. The resident's noncompliance was known at the time of the care plan meeting; the resident refused dialysis or medications and ordered takeout food. None of these issues were reflected on the resident's care plan. The LPN Unit Manager did a lot of the care plan updates, but they were out due to medical reasons and no one had been operating in that position. During an interview on 4/22/21 at 12:48 PM, RD #11 stated she came into the facility about once a week; she documented at least quarterly on the care plan and nutrition assessments, then in between quarterly assessments if nutritional issues such as weight loss or skin issues arose. The CCP documented any nutritional risks based on the MDS assessments. If a resident was noncompliant with their recommended diet, the RD would provide education and would address noncompliance in the care plan if it was chronic. The resident was new to the facility and the RD had not known if the resident had started dialysis when they were first admitted to the facility. The resident had stated they disliked the food at the facility on admission and the RD addressed preferences with the resident first. The RD had communicated with the dialysis RD on 4/18/21 and obtained the resident's most recent lab work and dry weight. The resident's phosphorus had been high, and the RD discussed the resident's diet and provided education and did not document it. The resident was able to make their own decisions and the RD respected the residents' right to follow or not follow. The RD had not been contacted from nursing or medical regarding the resident's elevated blood glucose. The RD stated the resident's care plan should have documented more information, especially the resident's dry weight and dialysis. The RD was unaware that the resident had been requesting additional items at meals and requesting cottage cheese at most meals. 2) Resident #35 had diagnoses including borderline personality disorder, mood disorder, and schizoaffective disorder. The 3/24/21 Minimum Data Set (MDS) assessment had no documentation a PASRR Level II was required. The MDS documented the resident was cognitively intact; had disorganized thinking; minimal depression symptoms of moving or speaking slowly or being restless half of the days in the previous two weeks; and required extensive assistance with most ADLs. Hospital records documented the resident was hospitalized between 1/21/21 and 3/18/21 for depression, suicidal thoughts, psychosis, and COVID-19. The 3/12/21 Level II PASRR documented the resident had been living in a nursing facility for over a year and recently had a change in mental status, which led to a hospitalization. The resident had a history of having difficulty concentrating, irritability, euphoria, increased sleep, manic symptoms, mood swings, anxiety, restlessness, obsessive thoughts, fear that others were trying to [NAME] self, and seeing/hearing that that were not real. When first admitted to the hospital, the resident had thoughts of self-harm. The resident met the PASRR inclusion criteria for serious mental illness and needed a hospitalization where day to day life had been impacted by this illness. It was recommended the resident receive ongoing psychiatric consultations and medication management by a psychiatrist tor licensed prescriber; recovery-oriented clinical counseling focused on goal achievement by overcoming barriers due to the individual's mental illness; and therapeutic group interventions. Given current stability, psychiatric appointments were recommended every 10-12 weeks to monitor psychiatric symptoms; would benefit from weekly counseling to treat psychiatric symptoms; counseling to help with depression, develop coping skills, and treat post-traumatic stress disorder (PTSD). the resident would benefit from recreational and therapy groups to have more activities and opportunities to interact with others. The undated baseline care plan documented the resident displayed physical and verbal behavioral symptoms. The resident cried easily and expected to have her needs met immediately. Staff were to use coping strategies and demonstrate motion stability, provide daily 1:1, and supportive tender loving care. The resident would participate in psychiatric and psychology services as recommended by the mental health providers. The 3/18/21 comprehensive care plan (CCP) by the Director of Social Services documented the resident had diagnoses of schizoaffective disorder, mood disorder, dependent personality, and anxiety. The resident was talkative, participated in 1:1 activities, cried easily, and expected to have their needs met immediately. The resident's interventions included: staff would meet the daily needs of the resident and offer choices in ADLs; invite the resident to activities and encourage participation; staff to give daily 1:1, support, tender loving care and reassurance as needed; the physician will monitor and adjust medications; and the resident will actively participate in psychosocial services as recommended by mental health providers. There was no documentation regarding the resident's individualized coping strategies. The 3/18/21 social services progress note documented the resident returned to the facility from a behavioral health hospital. The resident got easily emotional and cried very easily. The resident would participate in monthly psychiatric services. Interventions included coloring, reading magazines, writing, cross-stitch, talks to friends and family on the phone, 1:1 with activities staff, reassurance, emotional support, and comfort. The 3/2020 through 4/2020 nursing progress notes documented the resident exhibited anxious, aggressive, loud yelling, weeping, and sobbing behaviors. The resident was offered 1:1 support or as needed medications when exhibiting behaviors. On 4/19/21 at 11:01 AM, the resident was observed in bed. When addressed, the resident began sobbing and was inconsolable throughout the interview. During an interview on 4/21/21 at 12:16 PM, the Director of Social Services stated she was responsible for updating resident's care plans for psychosocial status and mental health. Level 2 screen recommendations were not documented on the care plan. The resident had a lifelong history of mental illness and had the following coping strategies: music, specifically Christian music; watching Christian shows; coloring pictures; writing lists; calling friends and family; or calling their service providers for information. The resident's CCP should document the resident's individualized coping strategies. The resident had been at the facility last year, had been hospitalized for 11 weeks, and came back to the facility in 3/2021. The resident had a new chart created and their new care plan may not have included the resident's prior interventions. On 4/22/19 at 10:09 AM, the resident was observed in the hallway outside the administrative offices. The resident was yelling, sobbing, and not redirectable by staff. The resident stated they needed to see someone immediately. The Director of Social Services and Administrator met with the resident; the resident was able to be directed back to the unit at 10:35 AM. During an interview on 4/22/21 at 10:38 AM, certified nurse aides (CNAs) #13, 15, and 16 stated the resident exhibited behaviors and outbursts at least once a week. The resident enjoyed coloring, magazines, and puzzles in their room. When asked about music, the CNAs stated the resident had a tablet in their room they could utilize. The resident relied on the Director of Social Services when they were exhibiting behaviors. 10NYCRR 415.11(c)(1)

Based on observation, record review and interview during the recertification survey, the facility did not ensure the resident environment remained free of accident hazards for 1 of 3 residents (Resident #21) reviewed. Specifically, the facility did not re-educate staff to prevent reoccurrence when Resident #21 spilled a hot beverage on themselves. Additionally, the resident was observed unsupervised while consuming a meal. Findings include: Resident #21 had diagnoses including legal blindness, depression, and polymyalgia rheumatica (pain and stiffness of joints, especially shoulders). The 2/24/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance with bed mobility and supervision with eating. The 4/2021 certified nurse aide (CNA) instructions documented the resident required supervision with eating. A 4/13/21 at 8:20 AM accident/incident report documented the resident was legally blind and given a cup of hot cocoa. The resident had been at a 45 degree angle but was slouched down in their bed during the drink consumption. The investigation determined abuse, neglect, or mistreatment did not occur as it was an error in judgement but the incident was avoidable. The investigation noted activity aide #10 had provided the resident with the hot cocoa while in bed. The investigation documented that a specialty cup with a straw was added to the resident's care plan. There was no documentation the activity aide was re-educated on providing hot beverages to the resident or the resident's position/location when drinking. Activity aide #10's education record contained no documented evidence education had been provided related to the 4/13/21 incident. A 4/13/21 at 8:35 AM nursing progress note documented the resident had a red area to the right shoulder down to the elbow. The resident was having a morning cocoa with a cup and straw and while trying to tip the cup to reach the straw, they unknowingly spilled cocoa on themself, resulting in a first degree burn (a superficial burn affecting the first layer of skin). On 4/19/21 at 12:49 PM, the resident was observed in the lounge area in a geriatric chair with a side table parallel to the chair. There were no staff members observed in the vicinity. The resident's meal tray was on the table. The resident was slouched down in their chair and tilted to the right. They took a bite of grilled cheese, set it down, and the sandwich slid down the blanket on to the resident's chest on top of the blanket. At 1:01 PM, the grilled cheese was still sitting on the blanket. The surveyor mentioned the grilled cheese to the resident and the resident then felt for the bread and lifted it up. The resident had been reaching over their chest to reach for silverware on the bed side table. During an interview with registered dietitian (RD) #11 on 4/21/21 at 12:31 PM, they stated the resident usually ate in their room and did not know the resident had since been moved to the lounge area for meals. The RD stated the resident was visually impaired and needed staff to tell them where their meal items were. During an interview with activity aide #10 on 4/22/21 at 9:49 AM, they stated on the morning of 4/13/21 they went in to greet the resident and the resident asked for hot cocoa. After pouring a cup of hot cocoa they would leave it on the counter to cool a bit, but it did not seem hot, so they brought it into the resident and set it on the bed side table. The table was parallel to the right side of the resident's bed. The activity aide asked the resident to elevate the bed (electronically) and they thought the resident was centered in bed. The activity aide approached the Assistant Director of Nursing (ADON) and another CNA after the incident, but no one had re-educated them about the hot cocoa or any type of positioning for the resident. The activities aide said the ADON only said, don't do that again. During an interview with the ADON on 4/22/21 at 10:28 AM, they stated they had been notified the resident was in bed, tilted their cup while lying at an angle, and the beverage dumped down their shoulder and upper arm. A referral was made to therapy for a new cup, and the resident now had a cup with a lid. The ADON was not aware of anyone re-educating activity aide #10. The ADON stated on the investigation they documented the incident was avoidable, as the resident had been tilted to the side at a 35 degree angle and attempted to tilt the cup to drink it, leading to a spill. The ADON stated the resident did not have a burn, as noted by the nurse on the unit that day. During an interview with CNA #16 on 4/22/21 at 10:46 AM, they stated the resident recently started having their meals in the lounge area outside of their room. The CNA was not able to fully position the resident upright as the geriatric chair they used hurt the resident's knees when positioning upright. The resident was unable to bend their knees. During meals they put the bed side table to the right of the resident. The resident leaned and shifted to the side a lot in that chair. The resident had a slight visual impairment and now had a specialty cup with a lid related to a hot beverage incident recently. He stated no one had spoken to staff related to the resident's repositioning. 10NYCRR 415.12(h)(1)

Based on interview and record review during the recertification and abbreviated surveys (NY00247227 and NY00274733), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported to the New York State Department of Health (NYSDOH) in accordance with State law for 6 of 8 (Residents #5, 6, 14, 31, 37, and 237) reviewed. Specifically, the facility did not report incidents of resident to resident abuse for Residents #5, 14, 31, 37, and 237; a suicide attempt for Resident #31; and misappropriation of property for Resident #6. Findings include: The facility policy Prevention of Resident Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 10/27/20 documented the Administrator, DON (Director of Nursing), or designee has the responsibility to report all alleged violations in which there is reasonable cause to believe that abuse, neglect, or mistreatment has occurred, and all substantiated incidents, to the NYSDOH. Staff are to identify, correct and intervene in situations which abuse, neglect and/or misappropriation of resident property is more likely to occur. This includes an analysis of the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as residents with a history of aggressive behaviors, entering other residents' rooms, [and] self-injurious behaviors. The 11/20/20 facility Abuse Reporting policy documented whenever there is reasonable cause to believe that physical abuse, mistreatment, neglect, or misappropriation of resident property has occurred by staff, or a family member, the suspecting individual must call the NYSDOH. 1) Resident #237 had diagnoses including major neurocognitive disorder (decreased mental function due to a medical disease) and dementia. The 2/21/20 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired; did not exhibit behavioral symptoms affecting self or others; and was independent with locomotion on the unit. The comprehensive care plan (CCP), updated 6/2019, documented the resident had the potential to verbally and physically abuse others, wandered, and had the potential to be a victim of abuse. The following incidents involving Resident #237 were not reported to the NYSDOH as required: -The 7/13/19 at 7:20 AM accident/incident report documented Resident #237 took hold of Resident #37's hair and then hit Resident #37 with a closed fist on the right side of the shoulder, neck and face. The report documented the interdisciplinary team ruled out abuse, neglect, or mistreatment with documented reason there was no abuse. -The 8/7/19 at 3:20 PM accident/incident report documented Resident #237 was whipping another resident with their call bell. The report documented the interdisciplinary team ruled out abuse, neglect, or mistreatment with documented reason staff followed care plan. -The 10/5/19 at 5:24 AM accident/incident report documented Resident #237 went into Resident #14's room and would not leave, Resident #14 then slapped Resident #237. The report documented the interdisciplinary team ruled out abuse, neglect, or mistreatment with documented reason no abuse. -The 1/22/20 at 6:15 AM accident/incident report documented, per a certified nurse aide (CNA), Resident #237 walked into another resident's room. The other resident (name not noted) got up from a chair and slapped Resident #237. The report documented the interdisciplinary team ruled out abuse, neglect, or mistreatment with documented reasons, N/A. -The 3/11/20 at 1:25 PM accident/incident report documented Resident #237 entered Resident #5's room and Resident #5 grabbed and pushed Resident #237. The report documented the interdisciplinary team ruled out abuse, neglect, or mistreatment with noted reason that Resident #237 was unintentionally wandering/entering Resident #5's room. The report documented the event was avoidable. The Director of Nursing (DON) stated in an interview on 4/21/21 at 4:15 PM that they were not familiar with the NYSDOH Nursing Home Incident Reporting Manual and what incidents were to be reported to the NYSDOH. During an interview with the Director of Social Services on 4/22/21 at 2:29 PM, they stated if a resident was physically hurt, then it would be considered abuse. Resident #237 did have physical altercations with other residents. The Director of Social Services considered that inappropriate physical contact, as no one wants to be hit. The Director of Social Services stated when physical contact was made between residents it was reportable to the NYSDOH, but they were not the one responsible for reporting. During an interview with the Administrator on 4/22/21 at 12:10 PM, they stated at the time of the documented incidents the Director of Nursing (DON) was responsible for reporting them to the NYSDOH. At that time the DON did not feel the incidents required reporting. The Administrator stated the incidents involving Resident #237 and other residents with physical contact, should have been reported to the NYSDOH. The reports should also include a clear reason why abuse was ruled out. 2) Resident #6 was admitted to the facility with diagnoses including an above the knee amputation. The 8/7/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required limited or extensive assistance for most activities of daily living, and the resident felt it was very important to take care of their personal belongings or things. The 8/22/19 comprehensive care plan (CCP) documented the resident was alert and oriented; and was friendly and talkative. The 10/21/19 social work progress note documented the resident reported they had loaned $200 to an employee in 8/2019. The employee had signed a statement with a plan to repay the loan in monthly payments starting in 9/2019 and the employee missed the 10/2019 payment. The resident wanted their money back. The social worker and Activities Director interviewed the resident who reported they did not lend the money under duress. The resident was educated to not lend money to employees and employees could not accept any money or gifts from residents. The resident was educated on boundaries with employees and not to talk to them about their personal lives. The resident reported they were not traumatized, they loaned the money of their own free will, and they were not coerced. The resident wanted their $175 back. The 10/31/19 Investigation Summary documented the following: - Activities Aide #1 had borrowed $200 from Resident #6 around 8/20/19 which was discovered on 10/21/19. - Activities Aide #1 was issued a disciplinary notice and reviewed the Facility Policy/Employee Handbook and Corporate Compliance Plan. - Mandatory education was provided to the entire facility staff to prevent similar violations. - Reports and findings were forwarded to legal counsel and reported to the facility Operator. - There was no documentation the misappropriation was reported to the NYSDOH. During an interview on 4/19/21 at 10:03 AM, Resident #6 stated they had loaned the employee money a couple of years ago. The employee did not make a payment and the resident asked to be paid back in full. The facility paid the resident back after the resident reported it. The resident stated they were unaware they could not lend money to the staff. The resident stated they loaned the money because they felt bad for the employee. During an interview on 4/21/21 at 12:16 PM, the Director of Social Services stated Resident #6 had loaned money to Activities Aide #1. The resident had made an agreement with the Activities Aide to be repaid, and when the employee did not pay the resident back as agreed upon, the resident reported it to other staff and requested to be reimbursed in full. The Director of Social Services discussed the situation with the resident, who reported they gave the money of their own free will, was not traumatized, and was not coerced into giving the money. The incident was discussed with the Human Resources Director and the Administrator. The Social Services Director stated they did not reference the Nursing Home Reporting Manual and was not responsible for reporting. During an interview on 4/21/21 at 1:14 PM, the Human Resources Director stated they had been working as the Activities Director at the time of the incident. The Activities Director had been approached by an activities aide who stated that Resident #6 told them that they had loaned money to activities aide #1. The Human Resources Director and the Director of Social Services spoke with the resident. At that time they discovered the resident had loaned money to activities aide #1 a few months before and the activities aide had not paid the resident back. The Administrator was notified, and an investigation was conducted. Activities aide #1 was educated and given a written warning. Activities aide #1 had the remaining balance deducted from their next two paychecks to reimburse the resident. The Human Resources Director stated the Administrator was the facility's corporate compliance officer. During an interview with the Administrator on 4/22/21 at 12:10 PM, they stated the Director of Nursing (DON) was responsible for reporting incidents to the NYSDOH, but their current DON was new to the process. Incidents should be reported based the Incident Reporting Manual criteria. The Administrator stated they did not use the Incident Reporting Manual and did not report the misappropriation of Resident #6's property to the NYSDOH. 3) Resident #31 was admitted to the facility with diagnoses including schizoaffective disorder, bipolar disorder, and mild mental retardation. The 3/11/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, rejected care and took antipsychotic, antidepressant and antianxiety medications. The resident required extensive assistance or supervision for most activities of daily living (ADLs). The 11/20/20 updated comprehensive care plan (CCP) documented the resident was at risk for sexually, physically, and verbally aggressive behavior. Interventions included to monitor for behavioral status to determine if the resident represented an immediate harm to self or others and required immediate notification to registered nurse (RN) for intervention to prevent harm. The 4/9/21 11:00 PM-7:00 AM shift nursing progress note documented the nurse on the previous shift had sent the resident to the local hospital. The resident was sent out with aggressive behaviors as well as intent to hurt themself. Upon return from the hospital at 12:45 AM, the resident continued with increased agitation. As needed Ativan (sedative) was given at 12:45 AM with some positive effect. The resident had stated I want to kill myself and I don't want to live anymore. The 4/9/21 at 10:35 AM nursing progress note documented staff reported to the care team that the resident was trying to harm themself overnight by trying to wrap sheets and cords around their neck. The resident had stated they wanted to die. All cords and sheets were removed from the resident's room and the resident was placed on 1:1 supervision. The nurse practitioner (NP) evaluated the resident and the resident was to be sent to a different hospital able to provide psychiatric evaluation and treatment. The 4/9/21 Director of Social Services progress note documented the resident attempted to wrap a cord and sheet around their neck on 4/8/21 and was sent to the hospital. There was no documented evidence an investigation was completed, or the incident was reported to the NYSDOH. When interviewed on 4/21/21 at 4:15 PM, the DON stated there was no investigation done as they just wanted to get the resident treated. The DON did not know who reported facility incidents to the NYSDOH. The DON stated they had reported the incident and had not done any of the DOH reporting since she began working at the facility. The DON stated the Administrator was the only one who knew the reporting process. The DON stated they were not familiar with the NYSDOH Nursing Home Incident Reporting Manual. During an interview with the Administrator on 4/22/21 at 12:10 PM, they stated the incident was not reported to NYSDOH and it should have been. 10NYCRR 415.4 (b)(1)(ii)

Based on observation, interview and record review during the recertification survey, the facility did not ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls for 1 of 1 medication storage rooms (Unit 1) observed. Specifically, the facility did not monitor temperatures in 2 medication refrigerators which contained multiple insulin pens and vaccination and tuberculin testing vials. Findings include: The 5/2018 Health Direct Pharmacy services Medication Storage policy documented that medications and biologicals are stored safely, securely, and properly, following manufactures recommendations or those of suppliers. All medications are maintained within the temperature ranges noted by the United States Pharmacopeia; refrigerated at a temperature of 36-46 degrees Fahrenheit (F) with a thermometer to allow temperature monitoring. When keeping a log of temperatures remember to report any temperatures that were not within normal range. If vaccines are stored the temperature must be recorded twice a day. The proper storage of medications can have a direct effect on the efficacy of a medication. The 4/8/21 Centers for Disease Control Moderna COVID-19 Vaccine preparation and administration summary documents the Moderna COVID-19 vaccine unpunctured multiple-dose vials can be stored in a refrigerator between 36-46 degrees F for up to 30 days prior to first use. Prescribing information for insulins including Basaglar Kwikpen, Lantus Solostar, Levemir Flextouch, Seglee Pen, Humalog flex pen, Novolog flex pen, Aspart flex pen and Admelog Solostar documents the insulins should be stored in a refrigerator between 36-46 degrees F if unopened. Tuberculin (purified protein derivative), and influenza vaccine prescribing information all documented vials should be stored in a refrigerator between 36-46 degrees F. During an observation of the Unit 1 medication room on 4/20/21 at 11:30 AM with licensed practical nurse (LPN) #20, two small refrigerators were observed being used to store medications. One temperature log dated 03/2021 was completed. The log did not document which refrigerator the recorded temperatures were taken from. There were no temperature logs for 4/2021. Refrigerator #1 had no thermometer located inside and contained the following: -1 unopened multi-dose vial of Moderna COVID-19 vaccine. -29 unopened insulin pens. Refrigerator #2 contained a thermometer and the following biologicals were stored in this refrigerator: -1 unopened multi-dose vial of tuberculin serum (purified protein derivative); -1 opened multi-dose vial of tuberculin serum; -1 unopened multi-dose vial of Moderna COVID-19 vaccine; and -1 unopened multi-dose vial of influenza vaccine. During the observation LPN #20 stated the LPN who worked the nightshift was responsible for keeping track of the refrigerator temperatures. When interviewed on 4/20/21 at 12:01 PM, the Director of Nursing (DON) stated both refrigerators were supposed to have a thermometer and a temperature log. The LPN that worked on the nightshift was to monitor the temperatures of the refrigerators and log them per facility policy. The DON stated they would check with the nightshift LPN, but if there was a log for the 4/2021 temperatures, it should have been hung in front of the 3/2021 log and was not. When interviewed on 4/20/21 at 2:08 PM, pharmacy consultant #5 stated that insulin pens were to be at room temperature for 28 days once opened and refrigerated at 36-46 degrees F if unopened. If there were no temperature logs there was no way to know if the pens were stored colder or warmer than the manufacturer recommendations. The pharmacy consultant stated that vials of vaccines were to be stored at the appropriate temperature range and temperature logs were to be maintained. There was no way to determine if the vaccines and insulin pens had been frozen or if they were still able to be used. On 4/21/21, a copy of one temperature log dated 4/2021 was provided to the surveyor. The log documented that refrigerator temperatures were taken once each day from 4/1-4/16/2021, by LPN #6. There were missing entries on 4/6, 4/7, 4/11, and 4/12, and 4/17-4/21/21. All documented temperatures were within the range of 36-46 degrees F. There was no documentation on the form which refrigerator the log belonged to. When interviewed on 4/21/21 at 3:52 PM, LPN #6 stated she was aware there was only one thermometer for the two refrigerators. She had mentioned this to someone but could not recall who she told. She stated the 4/2021 temperature log was for the refrigerator with the insulin pens in it. She stated typically, the night shift staff checked the thermometers and the missing entries on the 4/2021 log were for those days she was off duty and that she had forgotten to record the temperature the last shift she worked. She stated she believed the temperatures were to be maintained between 38-43 degrees F. 10NYCRR 415.18(d)(e)(1-4)