**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that each resident's right to personal privacy and confidentiality of his or her medical record was maintained. This was identified for one (Resident #62) of nine residents observed for the Medication Administration Task. Specifically, Licensed Practical Nurse #4 left Resident #62's electronic medical record open in the hallway with the resident's personal and medical information visible to other staff, residents, and visitors. The finding is: Resident #62 was admitted with diagnoses that included Hypertension, Cerebral Infarction, and Hemiplegia. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 14, which indicated intact cognition. The resident received Antiplatelet and Anticoagulant medications. During a medication pass observation on 5/6/2025 at 9:35 AM for Resident #62, Licensed Practical Nurse #4 left the medication cart outside the resident's room, with the electronic medical record open, displaying the resident's personal and medical information accessible to other residents, staff, and family members. During an interview on 5/6/2025 at 9:35 AM, Licensed Practical Nurse #4 stated they should have closed the electronic medical record computer screen prior to walking away from the medication cart. During an interview on 5/6/2025 at 4:19 PM, the Registered Nurse Educator stated that the nurses should ensure the resident's medical record and other personal health information remain secure. The Registered Nurse Educator stated Licensed Practical Nurse #4 should have closed the computer screen prior to walking away from the medication cart. During an interview on 5/8/2025 at 11:59 AM, the Director of Nursing Services stated Licensed Practical Nurse #4 should close the screen to protect the resident's personal health information before leaving the medication cart. 10 NYCRR 415.3(e)(1)

Based on observation, record review, and interviews during the Recertification and abbreviated (Complaint #NY 00377877) Survey, initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that all alleged violations involving abuse, neglect, and mistreatment were reported immediately to the facility administration and not later than 2 hours to the Department of Health after the allegation was made. This was identified for one (Resident #108) of one resident reviewed for Abuse. Specifically, Resident #108 alleged that Certified Nursing Aide #4 pushed them off the bed, resulting in a fall without injury. There is no documented evidence that the facility reported the allegation of abuse to the New York State Department of Health. The finding is: The facility's policy, titled Abuse, Mistreatment, Neglect, and Exploitation, dated 7/14/2024, documents that the facility completes a full investigation when signs of Mistreatment, Neglect, Exploitation, or Abuse are noted by any personnel. The witness of such actions will immediately notify their Supervisor on duty. All reports/allegations of potential abuse, neglect, mistreatment, and or exploitation must be reported promptly to their direct supervisor and to the New York State Department of Health within two hours after the determination of suspicion during the investigation. Resident #108 was admitted with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side, Muscle Weakness, and Major Depressive Disorder. The 3/11/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 12, indicating the resident had moderate cognitive impairment. The resident was dependent on facility staff for bed mobility and was incontinent of both bowel and bladder. The Comprehensive Care Plan dated 12/8/2023 and last revised on 11/25/2024 titled Resident was at moderate risk for falls related to gait and balance problems documented interventions including bed in the lowest position, floor mats as the bed extenders while in bed and to ensure the resident is placed in the middle of the bed for all care rendered in bed. The care plan was updated on 4/5/2025 to include a two-person approach. A Comprehensive Care Plan titled Resident is Inappropriate to Female Staff Related to Mental/Emotional Illness and Poor Impulse Control, effective 1/18/2024, documented interventions including care provision by a male aide and or two female aides. A Comprehensive Care Plan titled The resident has a behavior problem including non-compliance with transfers, attempts to self-transfer at times, refuses care, has episodes of confabulation, and calls 911 without staff knowledge. Interventions included monitoring behaviors, attempting to determine the underlying cause, and explaining all procedures to the resident. The care plan was updated on 4/5/2025 to include a two-person approach. The Resident Nursing Instructions (care instructions for Certified Nursing Assistant), effective 4/6/ 2025, document under the heading Safety, Male Aides Only, and/or 2-person approach for care. During an interview on 5/8/2025 at 2:15 PM, Resident #108 stated they were provided hygiene care by Certified Nursing Aide #4 on 4/5/2025. The resident alleged that they were pushed off the bed by Certified Nursing Aide #4 on 4/5/2025 and reported the incident to the nurse supervisor (Licensed Practical Nurse #3), but felt that they didn't believe them. The occurrence report dated 4/5/2025 documented resident was observed lying on the floor on their right side on the floor mat. The resident received care from Certified Nursing Assistant #4 when the resident rolled themselves out of bed onto the floor. No injuries were noted. There was no statement obtained from the resident. Certified Nursing Assistant #4's written statement indicated while giving morning care the resident rolled themselves on the floor on the right side of the bed. The facility investigation summary report dated 4/10/2025 documented as per Certified Nursing Assistant #4 on 4/5/2025 at 11:00 AM when they were opening the resident's brief, the resident rolled off the bed so fast and Certified Nursing Assistant #4 was unable to stop the resident from falling out of bed onto the floor mat. At 3:00 PM the resident called Emergency Services (911) and their family member to take them to the Hospital without the staff's knowledge. The resident returned to the facility the next day. All testing was negative for acute fractures. A new nursing intervention was added to the care plan to have two persons during care. The investigation concluded there was no reasonable cause to believe that alleged abuse, neglect, or mistreatment occurred. No statements from the resident were included in the investigation. A review of the medical record revealed a struck-out note, written by Licensed Practical Nurse #3, on 4/5/2025 at 3:26 PM documented they received a message from the resident's family member informing them that the resident told the family member staff threw them out of bed during care. The strike-out reason was documented as incorrect documentation. During an interview on 5/8/2025 at 2:25 PM, Licensed Practical Nurse #3 stated that on 4/25/2025, they heard a thud while in the hallway and heard Resident # 108 yell, She pushed me. Upon entering the room, Licensed Practical Nurse #3 observed Certified Nursing Aide #4 next to the resident's bed, and Resident #108 was on the floor. Licensed Practical Nurse #3 stated that they immediately notified the Director of Nursing Services. During an interview on 5/8/2025 at 4:14 PM, Certified Nursing Assistant #4 stated they were assigned to Resident #108 on 4/5/2025 during the day shift. Certified Nursing Assistant #4 stated they performed hygiene care for Resident #108 alone on that day. Certified Nursing Aide #4 stated they did not know another staff member was supposed to be present during care for Resident #108. Certified Nursing Assistant #4 stated they reviewed the Certified Nursing Assistant Accountability record and only one Certified Nursing Aide was required to care for Resident #108. Certified Nursing Assistant #4 denied pushing resident #108 off the bed and maintained that the allegation was a fabrication by the resident. During an interview on 5/8/2025 at 4:20 PM, the Director of Nursing Services stated that they were unaware of the allegation of abuse made by the resident. They stated that the policy of the facility is to investigate every allegation of abuse and report to the Department of Health and the police within two hours. During an interview on 5/8/2025 at 4:30 PM, the Administrator stated they were aware of the allegation of abuse made by Resident#108. Resident #108 had a history of making false allegations and based on statements provided by the Certified Nursing Assistant, the Administrator believed no abuse investigation was necessary. They stated that the policy of the facility is to investigate every allegation of abuse and report it to the Department of Health and the police within two hours, except for this incident, because of the resident's history of making false allegations. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews during the Recertification and Complaint (NY 00377877) Survey, initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that all alleged violations involving abuse, mistreatment, or neglect were thoroughly investigated. This was identified for one (Resident #108) of one residents reviewed for Abuse. Specifically, Resident #108 alleged that Certified Nursing Assistant #4 pushed them off the bed, resulting in a fall without injury. The facility did obtain a statement from the resident and an investigation related to the allegation of being pushed out of bed was not completed. The finding is: The facility's policy, titled Abuse, Mistreatment, Neglect, and Exploitation, dated 7/14/2024, documents that the facility completes a full investigation when signs of Mistreatment, Neglect, Exploitation, or Abuse are noted by any personnel. The witness of such actions will immediately notify their Supervisor on duty. All reports/allegations of potential abuse, neglect, mistreatment, and or exploitation must be reported promptly to their direct supervisor and to the New York State Department of Health within two hours after the determination of suspicion during the investigation. Resident #108 was admitted with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side, Muscle Weakness, and Major Depressive Disorder. The 3/11/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 12, indicating the resident had moderate cognitive impairment. The resident was dependent on facility staff for bed mobility and was incontinent of both bowel and bladder. The Comprehensive Care Plan dated 12/8/2023 and last revised on 11/25/2024 titled Resident was at moderate risk for falls related to gait and balance problems documented interventions including bed in the lowest position, floor mats as the bed extenders while in bed and to ensure the resident is placed in the middle of the bed for all care rendered in bed. The care plan was updated on 4/5/2025 to include a two-person approach. A Comprehensive Care Plan titled The resident has a behavior problem including non-compliance with transfers, attempts to self-transfer at times, refuses care, has episodes of confabulation, and calls 911 without staff knowledge. Interventions included monitoring behaviors, attempting to determine the underlying cause, and explaining all procedures to the resident. The care plan was updated on 4/5/2025 to include a two-person approach. During an interview on 5/8/2025 at 2:15 PM, Resident #108 stated they were provided hygiene care by Certified Nursing Aide #4 on 4/5/2025. The resident alleged that they were pushed off the bed by Certified Nursing Aide #4 on 4/5/2025 and reported the incident to the nurse supervisor (Licensed Practical Nurse #3), but felt that they didn't believe them. The occurrence report dated 4/5/2025 documented resident was observed lying on the floor on their right side on the floor mat. The resident received care from Certified Nursing Assistant #4 when the resident rolled themselves out of bed onto the floor. No injuries were noted. There was no statement obtained from the resident. Certified Nursing Assistant #4's written statement indicated while giving morning care the resident rolled themselves on the floor on the right side of the bed. The facility investigation summary report dated 4/10/2025 documented as per Certified Nursing Assistant #4 on 4/5/2025 at 11:00 AM when they were opening the resident's brief, the resident rolled off the bed so fast and Certified Nursing Assistant #4 was unable to stop the resident from falling out of bed onto the floor mat. At 3:00 PM the resident called Emergency Services (911) and their family member to take them to the Hospital without the staff's knowledge. The resident returned to the facility the next day. All testing was negative for acute fractures. A new nursing intervention was added to the care plan to have two persons during care. The investigation concluded there was no reasonable cause to believe that alleged abuse, neglect, or mistreatment occurred. The facility investigation lacked documented evidence of a statement from the resident to identify the root cause of the fall and to rule out abuse, neglect, and mistreatment. A review of the medical record revealed a struck-out note, written by Licensed Practical Nurse #3, on 4/5/2025 at 3:26 PM documented they received a message from the resident's family member informing them that the resident told the family member staff threw them out of bed during care. The strike-out reason was documented as incorrect documentation. During an interview on 5/8/2025 at 2:25 PM, Licensed Practical Nurse #3 stated that on 4/25/2025, they heard a thud while in the hallway and heard Resident # 108 yell, She pushed me. Upon entering the room, Licensed Practical Nurse #3 observed Certified Nursing Aide #4 next to the resident's bed, and Resident #108 was on the floor. Licensed Practical Nurse #3 stated that they immediately notified the Director of Nursing Services. During an interview on 5/8/2025 at 4:14 PM, Certified Nursing Assistant #4 stated they were assigned to Resident #108 on 4/5/2025 during the day shift. Certified Nursing Assistant #4 stated they performed hygiene care for Resident #108 alone on that day. Certified Nursing Aide #4 stated they did not know another staff member was supposed to be present during care for Resident #108. Certified Nursing Assistant #4 stated they reviewed the Certified Nursing Assistant Accountability record and only one Certified Nursing Aide was required to care for Resident #108. Certified Nursing Assistant #4 denied pushing resident #108 off the bed and maintained that the allegation was a fabrication by the resident. During an interview on 5/8/2025 at 4:20 PM, the Director of Nursing Services stated that they were unaware of the allegation of abuse by the resident. They state that the policy of the facility is to thoroughly investigate every allegation of abuse and report the incident to the Department of Health and the police within two hours. During an interview on 5/8/2025 at 4:30 PM, the Administrator stated they were aware of the allegation of abuse made by Resident#108. Resident #108 had a history of making false allegations and based on statements provided by the Certified Nursing Assistant, the Administrator believed no abuse investigation was necessary. They stated that the policy of the facility is to investigate every allegation of abuse and report it to the Department of Health and the police within two hours, except for this incident, because of the resident's history of making false allegations. 10 NYCRR 415.4(b)(3)

Based on observation, record review, and interviews during the Recertification and Abbreviated (NY 00377877) Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that a comprehensive person-centered care plan was implemented for each resident to meet the resident's nursing, mental, and psychosocial needs. This was identified for one (Resident #108) of one resident reviewed for Abuse. Specifically, Resident #108 had a comprehensive care plan intervention to provide care by a male certified nursing aide and/or two aides due to verbally inappropriate behavior towards female staff. An accident/incident report dated 4/5/2025 revealed the resident received care from one female Certified Nursing Aide, Certified Nursing Assistant #4. The finding is: The facility's policy titled Care Plans, dated 6/2024, documented that care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. Resident #108 was admitted with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side, Muscle Weakness, and Major Depressive Disorder. The 3/11/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 12, indicating the resident had moderate cognitive impairment. The resident was dependent on facility staff for bed mobility and was incontinent of both bowel and bladder. The Comprehensive Care Plan dated 12/8/2023 and last revised on 11/25/2024 titled Resident was at moderate risk for falls related to gait and balance problems documented interventions including bed in the lowest position, floor mats as the bed extenders while in bed and to ensure the resident is placed in the middle of the bed for all care rendered in bed. The care plan was updated on 4/5/2025 to include a two-person approach. A Comprehensive Care Plan titled Resident is Inappropriate to Female Staff Related to Mental/Emotional Illness and Poor Impulse Control, effective 1/18/2024, documented interventions including care provision by a male aide and or two female aides. A Comprehensive Care Plan titled The resident has a behavior problem including non-compliance with transfers, attempts to self-transfer at times, refuses care, has episodes of confabulation, and calls 911 without staff knowledge. Interventions included monitoring behaviors, attempting to determine the underlying cause, and explaining all procedures to the resident. The care plan was updated on 4/5/2025 to include a two-person approach. The Resident Nursing Instructions (care instructions for Certified Nursing Assistant), effective 4/6/ 2025, document under the heading Safety, Male Aides Only, and/or 2-person approach for care. The occurrence report dated 4/5/2025 documented resident was observed lying on the floor on their right side on the floor mat. The resident received care from Certified Nursing Assistant #4 when the resident rolled themselves out of bed onto the floor. No injuries were noted. There was no statement obtained from the resident. Certified Nursing Assistant #4's written statement indicated while giving morning care the resident rolled themselves on the floor on the right side of the bed. The facility investigation summary report dated 4/10/2025 documented as per Certified Nursing Assistant #4 on 4/5/2025 at 11:00 AM when they were opening the resident's brief, the resident rolled off the bed so fast and Certified Nursing Assistant #4 was unable to stop the resident from falling out of bed onto the floor mat. At 3:00 PM the resident called Emergency Services (911) and their family member to take them to the Hospital without the staff's knowledge. The resident returned to the facility the next day. All testing was negative for acute fractures. A new nursing intervention was added to the care plan to have two persons during care. During an interview on 5/8/2025 at 2:15 PM, Resident #108 stated that at the time of their fall on 4/5/2025, they received hygiene care from Certified Nursing Aide #4. Resident #108 stated there were no other certified nursing aides present when they fell. During an interview on 5/8/2025 at 4:14 PM, Certified Nursing Assistant #4 stated they were assigned to Resident #108 on 4/5/2025 during the day shift. Certified Nursing Assistant #4 stated they performed hygiene care for Resident #108 alone that day. Certified Nursing Aide #4 stated they were unaware that a male aide or two aides were required for care at that time. Certified Nursing Aide #4 stated they referred to the Resident Nursing Instructions and recalled only one Certified Nursing Aide was required to care for the resident. During an interview on 5/8/2025 at 4:20 PM, the Director of Nursing Services stated that the Certified Nursing Aide instructions should match the care plan related to the assistance needs of the resident. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Record review, and staff interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that each resident's Comprehensive Care Plan was revised by the interdisciplinary team after each assessment to reflect the resident's current status. This was identified for one (Resident #97) of one resident reviewed for Bladder and Bowel Incontinence. Specifically, Resident #97's minimum data set assessments indicated the resident was frequently incontinent of bladder; however, the comprehensive care plan inaccurately documented the resident was occasionally incontinent of bladder. The finding is: The facility's Care Plan policy and procedure, effective 6/20/2024, documented assessment of the resident is ongoing, and care plans are revised as information about the resident and the resident's condition changes. The care planning/interdisciplinary team is responsible for the review and updating of the care plan when: there has been a significant change in the resident's condition; the desired outcome is not met; the resident has been readmitted to the facility from a hospital stay; and at least quarterly. Resident #97 was admitted with diagnoses that included Seizure Disorder, Depression, and Schizophrenia. The Annual Minimum Data Set, dated [DATE] documented the resident's Brief Interview Mental Status score was 14, which indicated the resident's cognition was intact. The Minimum Data Set assessment documented the resident was frequently incontinent of bladder and required partial/moderate assistance for toileting and personal hygiene. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident was frequently incontinent of bladder and required moderate assistance for toileting and supervision with set up help for personal hygiene. A Comprehensive Care Plan dated 10/18/2022 and last revised on 3/12/2025 documented the resident had occasional bladder incontinence. Interventions included to clean he peri-area with each incontinence episode and to monitor and document the signs and symptoms of Urinary Tract Infection. A Review of the Bladder Elimination Record (Certified Nursing Assistant Accountability Record) dated 4/25/2025 to 5/8/2025 documented that the resident was incontinent 1 to 3 times per shift (frequently incontinent). During an interview on 5/8/25 at 10:22 AM, the Minimum Data Set Coordinator stated usually, the Registered Nurse Managers are responsible for updating the Care Plan, and the Care Plan Nurse is responsible for initiating the Care Plans on admission. The Minimum Data Set Coordinator stated that the Care Plans are updated Quarterly, annually, and as needed. The Minimum Data Set Coordinator stated that the resident's Care Plan should have been updated to reflect the resident's current urinary status of frequently incontinent. During an interview on 5/8/25 at 11:51 AM, the Director of Nursing Services stated that the Nurse Manager, or the Care Plan Nurse, is responsible for updating the Care Plan during the review period prior to the Care Plan meeting. The Director of Nursing Services stated the Care Plans should have been updated at the time of the Quarterly assessment to ensure the Care Plans reflect the resident's current urinary status. 10 NYCRR 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure the resident's environment remained free of accident hazards as possible. This was identified for one (Resident #62) of nine residents observed for the Medication Administration Task. Specifically, during a medication administration pass for Resident #62, Licensed Practical Nurse #4 left the medication cart unattended and went into the resident's room without ensuring the medication cart was securely locked and was clearly visible to the nurse administering medication. The finding is: The facility's Administrating Medication policy and procedure dated 12/3/2024, documented during administration of medication, the medication cart is kept closed and locked when out of sight of the medication nurse. Additionally, the cart must be clearly visible to the personnel administering medication. Resident #62 was admitted with diagnoses that included Hypertension, Cerebral Infarction, and Hemiplegia. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 14, which indicated intact cognition. The resident received Antiplatelet and Anticoagulant medications. During a medication pass observation on 5/6/2025 at 9:35 AM for Resident #62, Licensed Practical Nurse #4 walked away from the medication cart and entered Resident #62's room without locking the medication cart. The resident's privacy curtain was drawn around the bed. Licensed Practical Nurse #4 went behind the privacy curtain to administer the medications, and the medication cart was not visible to Licensed Practical Nurse #4. During an interview on 5/6/2025 at 9:35 AM, Licensed Practical Nurse #4 stated they should have ensured the medication cart was securely locked when they walked away from the cart. During an interview on 5/8/2025 at 11:59 AM, the Director of Nursing Service stated Licensed Practical Nurse #4 should have ensured the medication cart was securely locked before stepping away from the cart. The Director of Nursing Services stated when the medication cart is left unlocked and unattended, anyone can open the cart, including staff and or residents, causing a potential accident hazard. 10 NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #55 had diagnoses that included Alzheimer's disease and Dysphagia (difficulty swallowing). The Minimum Data Set assessment dated [DATE] documented that the resident had severely impaired cognition and was dependent on staff for feeding. During an observation on 5/4/2025 at 12:05 PM, Certified Nurse Aide #1 was observed standing while feeding Resident #55 their lunch meal. Three unoccupied chairs were observed in the dining room. Certified Nurse Aide #1 was immediately interviewed and stated they did not sit to assist Resident #55 because it was not comfortable for them (Certified Nurse Aide #1). During an interview on 5/8/2025 at 11:51 AM, the Director of Nursing Services stated that Certified Nursing Assistants are expected to feed residents while seated at eye level with the resident to promote dignity. 10 NYCRR 415.3 (d)(1)(i) Based on observations, record review, and interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure each resident was treated with respect and dignity and provided care in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one unit (Unit B) of three units observed during the Dining Task. Specifically, 1) during the lunch meal observation on 5/4/2025, twelve residents were seated at a large table in the Unit B main dining room. Four (Resident #15, Resident #95, Resident #44, and Resident #56) of the twelve residents at the table did not receive their lunch meal until 30 minutes after the other eight residents were served. Resident #15 left the dining room and said they felt disrespected when they were not served their lunch meal at the same time as others. 2) Certified Nurse Aide #1 was observed standing over Resident #55 while assisting the resident with their lunch meal in the sencondary dining room on Unit B. The findings are: The facility's policy titled Person Centered Dining Approach, dated 3/24/2025, documented that each person will be treated like a special individual, with a focus on individualizing all interactions and interventions. All individuals will be treated with the utmost courtesy, respect, and dignity. The facility's policy titled Dining Experience Staff Responsibilities, dated 3/24/2025, documented that staff will sit next to a resident when assisting them with eating rather than standing over them. 1) Resident #15 was admitted with diagnoses that included Dementia, Acute Kidney Failure, and Hypokalemia. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 5, indicating the resident had severely impaired cognition. Resident # 95 was admitted with diagnoses that included Dementia, Rhabdomyolysis (muscle breakdown), and Chronic Heart Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Resident Interview for Mental Status score of 99, indicating the resident was unable to complete the interview and had severely impaired cognition. Resident #44 was admitted with diagnoses that included Cerebral Infarction, Dementia, and Acute Respiratory Failure. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 99, indicating the resident was unable to complete the interview and had severely impaired cognition. Resident #56 was admitted with diagnoses that included Alzheimer's Disease, Schizoaffective Disorder, and Major Depressive Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 3, indicating the resident had severely impaired cognition. During an observation in the Unit B main dining room on 5/4/2025 at 11:50 AM, twelve residents were seated around a large dining table when the first lunch meal truck arrived in the dining room. Eight of the twelve residents received their meals at 12:00 PM. The other four residents (Resident #15, Resident #95, Resident #44, and Resident #56) did not receive their meal trays and Resident #15 left the dining room. During an interview on 5/4/2025 at 12:05 PM, Resident #15 stated they did not get a meal tray when other residents on their table got their meals and were eating. Resident #15 stated, What did I do to deserve this? Resident #15 stated they often do not get a meal tray when other residents are served meals, and they have to watch the other residents eat. Resident #15 stated, What is wrong that I cannot get a meal tray? Why do they (the staff) put us in a group and not give us meal trays together? I feel disrespected, my stomach is too upset now. Resident #15 went back to their room and sat in the doorway of their room. During an observation on 5/4/2025 at 12:20 PM Resident #95, Resident #44, and Resident #56 were still in the dining room with no meal tray, while other residents on the table were finishing their meals. The second lunch truck arrived at 12:23 PM. Resident #95 received their lunch tray at 12:24 PM, Resident #44 received their lunch tray at 12:28 PM, and Resident #56 received their lunch tray at 12:33 PM. During an observation on 5/4/2025 at 12:34 PM, Resident #15 was offered a lunch tray in their room, and the resident refused. Resident #15 stated they may eat later. During an interview on 5/4/2025 at 12:38 PM, Registered Nurse #1 stated they would speak to Resident #15 and re-approach them to offer them lunch. During an interview on 5/8/2025 at 8:11 AM, the Food Service Director stated they expect restaurant-style dining where each resident at the table eats at the same time. The Food Service Director stated it is not appropriate to send up trays for only some of the residents who sit at the same table and not others. The Food Service Director stated the kitchen did not have a list of residents or seating arrangement information for residents who eat in the dining room. The Food Service Director stated the staff members in the dining should notify the kitchen if the resident's meals were not delivered timely according to the seating arrangement. During an interview on 5/8/2025 at 11:25 AM, the Director of Nursing Services stated that all residents should be served their meals at the same time when seated at a table. The Director of Nursing Services stated that meal trucks should be organized to follow the seating arrangements in the dining room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that all medications and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. This was identified for two (Unit H and Unit B ) of the four units reviewed during the Medication Storage Task. Specifically, Unit H medication carts were not clean and had items stored other than the medications. The Unit H medication refrigerator had yellowish-brown dried substances on the bottom shelf. Unit B Long Hall medication cart contained unidentifiable medication tablets and loose glucometer strips. The findings are: The facility's Routine Cleaning and Disinfecting Policy dated [DATE] documented routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include but not limited to: treatment and medication carts. The Medication Labeling and Storage Policy dated [DATE] documented that each resident's medications are assigned to an individual cubicle, drawer, or other holding area including but not limited to sealed storage bags, and labeled with individual names to prevent the possibility of mixing medications of several residents. Any loose pills found will be discarded in sharps containers. The Medication Cart Usage and Cleanliness policy dated [DATE] documented to ensure that all medication carts are used safely, securely, and hygienically in compliance with state and federal regulations, and to prevent cross-contamination or unauthorized access to medications. Spills must be cleaned immediately using appropriate disinfectants. Medication carts must undergo a thorough cleaning. This includes emptying drawers, removing expired or discontinued medications, and cleaning both internal and external surfaces. During an observation on [DATE] at 11:13 AM, the Unit H Short Hall medication cart was observed in the presence of Licensed Practical Nurse #5. There were three prescribed eye drops stored without an individualized zip lock bag, four loose glucometer strips, and a wander guard accuracy reader device in the first drawer. The Second drawer had two loose unidentifiable medication tablets. The third drawer had seven opened liquid medication bottles with no open date and the bottles were soiled with a dried yellow substance. During an interview on [DATE] at 11:17 AM, Licensed Practical Nurse #5 stated they knew that each eye drop medication should be stored in a separate bag. Licensed Practical Nurse #5 stated the blood glucose meter strips were loose, but they were not used. Licensed Practical Nurse#5 stated if the bottles contain over-the-counter liquid medications, they do not have to be dated when opened. Licensed Practical Nurse #5 stated there should not be any loose medications in the medication carts. All nurses are responsible for cleaning the medication carts. During an observation on [DATE] at 11:25 AM, the Unit H medication storage room was observed in the presence of the Assistant Director of Nursing. The medication storage room refrigerator had yellowish-brown dried substances on the bottom shelf. During an interview on [DATE] at 11:25 AM, the Assistant Director of Nursing stated the refrigerator should be kept clean at all times. During an observation on [DATE] at 11:35 AM, the Unit H High Unit medication cart was observed in the presence of Licensed Practical Nurse #6. There was a thermometer (not in a bag) and five insulin pens (none in a bag) in the first drawer. In the third drawer, there were five opened and undated liquid medication bottles and a blood pressure cuff with a blood pressure machine. During an interview on [DATE] at 11:36 AM, Licensed Practical Nurse #6 stated they did not know why the insulin pens were not stored in individual bags. Licensed Practical Nurse #6 stated all medications like eye drops and insulin pens are supposed to be stored in a separate bag. Licensed Practical Nurse #6 stated the thermometer did not belong in the medication cart drawer and did not know the thermometer was there. During an observation on [DATE] at 1:50 PM, the Unit B Long Hall medication cart was observed in the presence of Licensed Practical Nurse #7. There were six unidentifiable medication tablets and five loose blood glucose meter strips in the first drawer. The second drawer had twelve unidentifiable loose medication tablets. During an interview on [DATE] at 1:50 PM, Licensed Practical Nurse #7 stated there should not be loose pills in the medication carts and that all nurses are responsible for cleaning the medication carts. Licensed Practical Nurse #7 stated there should not be loose glucose strips and they were almost sure the blood glucose strips were not used. During an interview on [DATE] at 1:53 PM, the Director of Nursing Services stated the medication carts should not contain loose pills and loose glucose strips and the wander guard accuracy reader, blood pressure machines, blood pressure cuffs, and thermometers. They stated all eye drops and insulin pens should be stored in individualized bags. The Director of Nursing Services stated all liquid medication bottles should have an open date on them so that they can be discarded after a month from the opening date. 10 NYCRR 415.18(e)(1-4)

Based on observation, record review, and interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, two kitchen refrigerators contained numerous unlabeled and undated food items. The finding is: The facility's policy titled Food Storage with a revised date of 8/4/2024, documented that all food will be dated upon stocking if taken out of its original packaging. If not in the original packaging, all food items must be dated and labeled with the name of the contained food and discarded after three days. During the kitchen tour on 5/4/2025 at 10:21 AM, the refrigerator was observed with 18 egg salad sandwiches that were not labeled and dated. Another refrigerator used to store day-service food items was observed with five apple sauce cups, 30 chocolate pudding cups, six Jello cups, and seven single-serve salads that were not labeled with a use-by date. During an interview on 5/4/2025 at 10:30 AM, the [NAME] stated that the food items were likely prepared the day before, 5/3/2025; however, they were unsure because the food items were not labeled. During an interview on 5/5/2025 at 2:25 PM, the Food Service Director stated the kitchen staff should have dated and labeled all food items. The Food Service Director stated they were unsure which staff member prepared the identified items and when they were prepared. 10 NYCRR 415.14(h)

Based on observation and staff interviews during the Recertification Survey initiated on 5/04/2025 and completed on 5/08/2025, the facility did not ensure that it established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified for 1) two (Resident #82 and Resident #73) of five residents reviewed for Medication Administration and 2) laundry room observation conducted during the Infection Control Laundry Task. Specifically, 1) Licensed Practical Nurse #1 did not follow the manufacturer's instructions and did not use the appropriate Environmental Protection Agency (EPA) approved disinfectant to clean and disinfect the shared blood glucose meter between the two residents (Resident #82 and Resident #73). 2) Laundry Aid #1 did not use appropriate Personal Protective Equipment when handling soiled and clean laundry. The findings are: 1)The facility's policy titled Blood Glucose Testing/Glucose Control, dated 7/11/2024, documented cleaning the glucometer (blood glucose meter) with isopropyl alcohol or low-level disinfectant and allowing the glucometer to remain wet until dry. The blood glucose meter manufacturer's instruction manual instructed cleaning and disinfecting the device between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the glucose meter device: Dispatch® Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8). Clorox Healthcare® Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12). Medline Micro-KillTM Bleach Germicidal Bleach Wipes (EPA Registration Number: 37549-1). Medline Micro-Kill disinfecting, Deodorizing, Cleaning Wipes with Alcohol. Resident #82 was admitted with diagnoses that included Vascular Dementia, Hypertension, and Type 2 Diabetes Mellitus. The Minimum Data Set assessment, dated March 28, 2025, documented a Brief Interview for Mental Status score of 6, indicating the resident had severely impaired cognition. A physician's order dated 5/01/2025 documented the use of the FreeStyle Libre 3 Reader Device (Continuous Glucose System). Resident #73 was admitted with diagnoses that included Chronic Respiratory Failure, Type 2 Diabetes Mellitus, and Major Depressive Disorder. The Quarterly Minimum Data Set assessment, dated January 31, 2025, documented a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. A physician's order dated 12/08/2024 documented the use of the FreeStyle Libre 3 Reader Device (Continuous Glucose System). The Facility List identified a total of nine residents (Resident #110, #112, #53, #9, #69, #73, #2, #82, and #114) who had a physician's order for fingerstick blood glucose monitoring. During a medication administration observation on 5/6/2025 at 5:55 AM, Licensed Practical Nurse #1 was observed performing a fingerstick for Resident #82. The glucometer was a multi-use blood glucose meter for the unit. Licensed Practical Nurse #1 was observed using an alcohol wipe (70 % Isopropyl Alcohol) to clean the blood glucose meter. (Federal Drug Administration (FDA) guidance for manufacturers of blood glucose meters indicates that 70% ethanol (alcohol) solutions are not effective against viral bloodborne pathogens.) Licensed Practical Nurse #1 then collected supplies, including the same blood glucose meter, from the medication cart to check Resident #73's blood glucose. On 5/6/2025 at 6:00 AM, Licensed Practical Nurse #1 reached the door of Resident #73's room. Licensed Practical Nurse #1 was stopped before entering the resident's room and immediately interviewed. Licensed Practical Nurse #1 stated both residents had physician orders for continuous blood glucose monitoring systems; however, the continuous blood glucose monitors were not functioning for both residents. Licensed Practical Nurse #1 stated that to administer insulin coverage, they had to perform blood glucose testing via finger stick. Licensed Practical Nurse #1 stated they typically use alcohol wipes to cleanse the blood glucose meter after performing a fingerstick. Licensed Practical Nurse #1 further stated facility policy directs that an alcohol pad could be used in place of a germicidal wipe to clean items like the blood glucose meter. During an interview on 5/6/2025 at 12:21 PM, Licensed Practical Nurse #2 stated they have been employed by the facility for over 27 years, and they always cleaned the blood glucose meter with an alcohol wipe. Licensed Practical Nurse #2 stated it was the facility's policy to use alcohol wipes to disinfect the blood glucose meters. During an interview on 5/6/2025 at 2:06 PM, the Assistant Director of Nursing/Nurse Educator stated nurses were educated to clean the blood glucose meter with alcohol prep pads. The Assistant Director of Nursing/Nurse Educator stated that it is the facility's policy to use alcohol wipes to disinfect the glucometer between resident use. The Assistant Director of Nursing/Nurse Educator stated they did not develop the facility policy, but were involved in the Quality Assurance Committee review of the policy. The Assistant Director of Nursing/Nurse Educator stated that nursing staff can use the low-level disinfectants, including germicidal wipes, to disinfect the blood glucose meters. During an interview on 5/6/2025 at 2:43 PM, the Infection Preventionist stated it is the facility's policy to use alcohol and low-level disinfectants to disinfect the blood glucose meters. The Infection Preventionist stated they are not aware who created the facility policy or when the policy was last reviewed. The Infection Preventionist stated that the blood glucose meter's manufacturer's instructions indicated that the use of alcohol wipes would not kill pathogenic organisms. The Infection Preventionist stated they were unaware that germicidal wipes should be used to disinfect the blood glucose meter. The Infection Preventionist stated there were no known residents with bloodborne pathogens who require finger-stick blood glucose monitoring. The Infection Preventionist stated there is one resident in the facility on contact precautions for a Multidrug Resistant Organism; however, the resident did not require fingerstick blood glucose monitoring at the present time. During an interview on 5/6/2025 at 3:20 PM, Registered Nurse #3 stated that they cleaned the blood glucose meter with an alcohol wipe, and it was the facility's policy to use alcohol wipes to disinfect the glucometer machine. During an interview on 5/6/2025 at 4:56 PM, the Director of Nursing Services stated they had no concerns when they reviewed the Blood Glucose Testing/Glucose Control policy. The Director of Nursing Services stated that the policy has been implemented since 1997, and now they see that the policy needs to be updated. The Director of Nursing Services stated they should have considered the manufacturer's guidelines when reviewing the policy. 2) The facility's policy titled Laundry Procedures, dated 8/16/2024, documented that laundry personnel will wear protective gloves and gowns when sorting laundry. During an observation and interview on 5/7/2025 at 10:27 AM, Laundry Aid #1 was in the folding room with another aid folding and hanging up clean laundry. Neither of the aides was wearing a gown or gloves while folding and hanging up the residents' laundry. Laundry Aide #1 brought the surveyor to the laundry room, where they had two washing machines and two dryers. They put on gloves and demonstrated how they pulled a soiled laundry bag and transported the soiled laundry into the washing machine. Laundry Aid #1 stated they use gloves and do not wear a gown when they empty the soiled linen bags into the laundry machine. Laundry Aid #1 stated they only put on a gown when handling laundry for residents on isolation precautions. Laundry Aid #1 stated they put on a new pair of gloves to transfer the clean laundry in and out of the dryer. Laundry Aid #1 stated they do not wear a gown when doing laundry because they do not let the dirty or clean clothes touch their clothing. During an interview on 5/8/2025 at 10:05 AM, the Director of Housekeeping stated that laundry staff should wear a gown when handling soiled laundry as per the facility policy. During an interview on 5/8/2025 at 11:31 AM, the Director of Nursing Services stated that staff should be wearing gowns and gloves when handling dirty laundry as pr the facility policy. 10 NYCRR 415.19(a)(1-3)

Based on observations and interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not maintain all mechanical, electrical, and patient care equipment in a safe operating condition. This was identified during the laundry observation for the Infection Control Task. Specifically, during a tour of the laundry room, a washing machine was observed overflowing and causing the water to accumulate on the floor around the drain. Additionally, the back of the washing machine and dryers had an accumulation of lint and dust. The finding is: The facility's policy titled Laundry Procedures, dated 8/16/2024, documented at the end of each shift, the walls are washed down using disinfectant, washers are wiped down with disinfectant, and then wiped down with stainless steel cleaner. The floors are swept and mopped daily using all-purpose cleaner. The Porters will clean the room weekly. Infection control policies and procedures will be followed when applicable to this department. During an observation of the laundry room on 5/7/2025 at 10:32 AM, there was pooled, stagnant water on the floor around the drain in the middle of the laundry room. Overflowing water from the drainpipe was observed in the back of a washing machine. Additionally, the back of the washing machine and dryers had an accumulation of lint and dust. During an interview on 5/7/2025 at 10:32 AM, the Director of Housekeeping stated that the washing machine in the laundry room leaks when the machine is overloaded with soap or dirty laundry. The Director of Housekeeping stated that water spills out from the overflow pipe at the back of the machine. The Director of Housekeeping stated that the washing machine has been leaking for about a month. The Director of Housekeeping stated that the facility maintenance department staff inspected the machine and explained that the machine is designed to overflow if it is too full, and the floor drain is intended to catch any excess water. The Director of Housekeeping stated they have not contacted an outside repair company to examine the washing machine. The Director of Housekeeping stated that a porter is supposed to clean behind the machines once a month. The Director of Housekeeping stated that the area behind the machines appeared dirty and had not been cleaned this month. During an interview on 5/8/2025 at 11:30 AM, the Director of Nursing Services stated that the laundry room needs to be kept clean. 10 NYCRR 415.5(e)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024 the facility did not ensure that each resident had a call bell accessible to alert staff of the residents' needs. This was identified for one (Resident #29) of five residents reviewed for the Environmental Task. Specifically, Resident #29 was observed in their room on 1/28/2024 and 1/31/2024 with the call bell out of their reach. The finding is: The facility's policy for the Call System dated 9/18/2023 documented that residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized station. Resident #29 was admitted with diagnoses that included Cerebral infarction, Type 2 Diabetes Mellitus, and Osteoarthritis. Resident #29's admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 13 which indicated the resident had intact cognition. The Minimum Data Set documented the resident required the assistance of staff for all activities of daily living, used a manual wheelchair for mobility, and was dependent on staff to propel their wheelchair. During an initial tour on 1/28/2024 at 10:21 AM Resident #29 was observed in their room sitting in their wheelchair next to their bed and in front of their nightstand. Resident #29's call bell was observed lying across the top of their nightstand. Resident #29 was not able to reach their call bell. A second observation was conducted on 1/31/2024 at 10:20 AM. Resident #29 was observed sitting in their wheelchair towards the lower half of their bed. Resident #29's call bell was observed lying across the upper section of their mattress. Resident #29 was asked if they could reach their call bell. Resident #29 turned their body to the left while seated in the wheelchair and reached out their arm toward the call bell, but they were not able to reach the call bell. Resident #29 did not attempt to propel their wheelchair in order to position themselves closer to the call bell. Certified Nursing Assistant #2 was interviewed on 1/31/2024 at 10:31 AM. Certified Nursing Assistant #2 stated they last saw Resident #29 between 7:30 AM and 8:00 AM. At that time Resident #29 was dressed and sitting in their wheelchair. Certified Nursing Assistant #2 could not recall where Resident #29's call bell was located when they (Certified Nursing Assistant #2) observed Resident #29 this morning. Certified Nursing Assistant #2 stated the call bell should always be within reach of the resident. Licensed Practical Nurse #2 was interviewed on 1/31/2024 at 10:42 AM. Licensed Practical Nurse #2 stated they expected that the call bell would be placed where the resident could reach it. Registered Nurse #4 was interviewed on 1/31/2024 at 11:36 AM. Registered Nurse #4 stated the call bell should be placed within reach of the resident. The Director of Nursing Services was interviewed on 2/1/2024 at 1:12 PM. The Director of Nursing Services stated they expected the call bell to be placed within the reach of the resident. 10 NYCRR 415.5(e)(1)

Based on observation, record review, and interviews during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet the resident's medical and nursing needs. This was identified for one (Resident #120) of five residents reviewed for Respiratory Care. Specifically, Resident #120 did not have documented evidence that a care plan was initiated for the use of Oxygen at 2 Liters per minute via nasal cannula continuously every shift for Hypoxia (absence of enough oxygen in the tissues to sustain bodily function). The finding is: The facility's policy titled, Care Plans last revised on 4/20/2023 documented the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his or her representative, develops and maintains a comprehensive care plan that is based on a thorough assessment. Each resident's comprehensive care plan is designed to identify problems, reflect treatment goals, timetables, and objectives, identify the professional services that are responsible for each element of care, and reflect currently recognized standards of practice for problem areas and conditions. Resident #120 was admitted with diagnoses of Acute Respiratory Failure, Congestive Heart Failure, and Atrial Fibrillation. The Minimum Data Set (MDS) assessment was not completed for the resident's Brief Interview for Mental Status (BIMS) score. A Physician's admission order dated 1/2/2024 documented to administer Oxygen at 2 Liters per minute via nasal cannula continuously every shift for Hypoxia. There was no Comprehensive Care Plan (CCP) for continuous use of Oxygen prior to 1/28/2024. Resident #120 was observed on 1/28/2024 at 10:00 AM sitting in the wheelchair in front of the nurses' station. An oxygen tank was attached behind the resident's wheelchair. The oxygen tubing and the nasal cannula were wrapped around the oxygen tank. The oxygen tank regulator needle was in the green zone which indicated that there was enough oxygen for use. The oxygen tank flow setting was set at zero. A subsequent observation was completed on 1/28/2024 at 10:18 AM. The resident was sitting in the wheelchair in front of the nurses' station. An oxygen tank was attached behind the resident's wheelchair. The oxygen tubing and the nasal cannula were wrapped around the oxygen tank. The oxygen tank regulator needle was in the green zone which indicated that there was enough oxygen for use. The oxygen tank flow setting was set at zero. There were no staff members present at the nurse's station. A third observation was completed on 1/28/2024 at 11:40 AM. Resident # 120 was sitting in the wheelchair in front of the nurses' station. An oxygen tank was attached behind the resident's wheelchair. The oxygen tubing and the nasal cannula were wrapped around the oxygen tank. The oxygen tank regulator needle was in the green zone which indicated that there was enough oxygen for use. The oxygen tank flow setting was set at zero. There were no staff members present at the nurse's station. Licensed Practical Nurse #1 was approached to verify the resident's oxygen order. Licensed Practical Nurse #1 unwrapped the nasal cannula from around the tank. Licensed Practical Nurse #1 then applied the Oxygen cannula to Resident # 120 and turned the oxygen tank regulator to 2 Liters per minute. A new Physician's Order dated 1/28/2024 at 2:46 PM documented to administer Oxygen at 2 Liters per minute via nasal cannula as needed (PRN) for an Oxygen saturation level of less than 92 percent for a diagnosis of Hypoxia. The order for continuous oxygen use was discontinued. A Comprehensive Care Plan (CCP) initiated on 1/28/2024 documented that Resident #120 receives oxygen therapy related to Congestive Heart Failure and ineffective gas exchange. Interventions included to administer oxygen at 2 liters per minute via nasal cannula as needed for oxygen saturation level of less than 92 percent; Monitor for signs and symptoms of respiratory distress and report to the Physician; Promote lung expansion and improve air exchange by positioning with proper body alignment. Registered Nurse #2 was interviewed on 1/30/2024 at 10:30 AM and stated that the care plan was initiated after the Physician changed the oxygen order from continuous to as needed (PRN). Registered Nurse #2 could not provide any documented evidence that a comprehensive care plan for oxygen use was in place prior to 1/28/2024, which was 26 days after the resident's admission. The Director of Nursing Services was interviewed on 2/1/2024 at 8:45 AM and stated they did not know that Resident #120 had no comprehensive care plan developed for the use of oxygen therapy until the physician's order was changed from continuous oxygen use to as needed (PRN). Although a baseline care plan was developed for the use of oxygen therapy when the resident was first admitted , there should have been a comprehensive care plan developed for the resident's status and the use of oxygen therapy. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan. This was identified for one (Resident #114) of two residents reviewed for Skin Conditions. Specifically, Resident #114 was seen for a Vascular Consult on 1/22/2024 and returned with a dressing on their right lower leg. The resident's right lower extremity was observed on 1/28/2024 and 1/29/2024 with a dressing in place; however, there was no indication when the dressing was last changed. Additionally, there was no documentation regarding the assessment of the right lower extremity wound nor a physician's order for treatment and care of the right lower extremity until 1/29/2024, seven days after the resident was seen by the Vascular Consultant. The finding is: The facility's policy titled, Wound Care, last revised on 10/16/2023, documented guidelines for the care of wounds to promote healing. The policy included reporting type of wounds, the time wound care was given, obtaining a Physician's order, and developing a care plan to assess any special needs of the resident. Resident #114 was admitted with diagnoses that include Atrial Fibrillation, Type II Diabetes, and Acute Respiratory Distress. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated that Resident #114 was cognitively intact. Resident #114 was at risk for pressure ulcers and injuries and had pressure-reducing devices for the bed and wheelchair. A Vascular consult dated 1/22/2024 documented a history of bilateral lower extremity swelling and a calf (back of the lower leg) wound. The consult form documented multiple shallow wounds throughout both calves at various stages of healing consistent with minor trauma and tears from edema. Approximately three wounds were identified on each calf that were small and shallow. The recommendation was to apply an ace wrap from the mid-foot to the upper calf in the morning and remove at night. A review of the Physician's orders from 1/22/2024 through 1/29/2024 lacked documented evidence of an order to use the ace wrap to the lower extremities as recommended by the Vascular Consultant. Resident #114 was observed on 1/28/2024 at 12:48 PM. Resident #114 was sitting in a wheelchair with their legs elevated on the bed. There was edema (swelling) observed on both legs with two Band-Aid dressings on the right lower leg shin area (front of the lower leg). Resident #114 was observed on 1/29/2024 at 12:14 PM. Resident # 114 was sitting in a wheelchair with their legs elevated on the bed. There was edema (swelling) observed on both legs with two Band-Aid dressings on the right lower leg shin area (front of the lower leg). The resident stated that the Band Aids have not been changed for a week. Resident # 114 took off the Band Aids. An open wound measuring approximately half a centimeter was observed on the right shin area. The wound bed was observed with whitish macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) skin tissue. The area surrounding the wound was moist and a mild discharge was observed coming out of the wound. Resident # 114 asked the surveyor if someone could change the dressing. Licensed Practical Nurse #1 then came in to change the dressing. Resident # 114 was interviewed on 1/29/2024 at 12:29 PM. Resident #114 stated that they went to the Vascular Doctor a week ago. The Vascular Doctor put the Band-Aids on their (Resident #114) right lower leg because there were small open areas. Resident #114 stated no one had changed the dressing since they returned from the Vascular Doctor's office. Certified Nursing Assistant # 1 was interviewed on 1/29/2024 at 2:39 PM and stated they did not notice any dressing on the right lower leg when Resident #114 returned from the consult. Resident # 114 refused the shower the week before on both Monday and Friday. The nurses do a skin check during shower days. Certified Nursing Assistant # 1 stated that they should have checked the resident's skin every shift and reported any changes. Licensed Practical Nurse #1 was interviewed on 1/29/2024 at 12:15 PM and stated they (Licensed Practical Nurse #1) did not know anything about a wound on Resident # 114's right lower leg. Licensed Practical Nurse #1 stated that usually the Certified Nursing Assistants report any skin changes to them and they did not get any report for Resident # 114. Licensed Practical Nurse #1 was aware that Resident #114 went for a Vascular Consult a week ago; however, they did not review the consult note when Resident # 114 returned to the facility. A Physician Order dated 1/29/2024 at 12:24 PM documented to apply Xeroform oil emulsion 2 inch x 2 inch external pad to the right shin every day-shift (7 AM-3 PM) for edema-related skin tear. Registered Nurse #1, the Unit Manager, was interviewed on 1/29/2024 at 12:45 PM and stated that they were not aware of any wounds on Resident #114's right leg. Registered Nurse #1 stated they wrote a note when Resident #114 returned from the Vascular Consult; however, they did not assess Resident #114 for any skin issues. There was no treatment order recommended on the consult note. Registered Nurse #1 did not recall the recommendation for the use of an ace wrap. Registered Nurse #1 stated there were no physician's orders nor a care plan initiated to address the resident's lower extremities because they (Registered Nurse #1) did not see any skin issues at that time. The Director of Nursing Services was interviewed on 2/1/2024 at 11:54 AM and stated that the nurses should have reviewed the Vascular Consult and should have called the resident's Physician for any new orders. If the nursing staff reviewed the consult, they would have seen that Resident #114 had wounds on the lower extremities and addressed the treatment and the need for the ace wrap with the Physician. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews conducted during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024 the facility did not ensure that each resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was identified for one (Resident #8) of one resident reviewed for Limited Range of Motion. Specially, Resident #8 was observed on three occasions without the Physician ordered gauze handrolls in place to prevent decline in range of motion. The finding is: The facility's policy titled, Small Adaptive Devices for Activities of Daily Living Skills dated 9/10/2023 documented proper, safe, and consistent use of small adaptive devices can maximize the resident's level of independence. The policy also documented that gauze rolls are used to help protect and preserve the small joints in the hands and fingers. Resident #8 was admitted with diagnoses that included Cerebral Infarction, Hemiplegia (paralysis) and Hemiparesis (weakness). Resident #8's admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was not completed because the resident was rarely/never understood. The admission Minimum Data Set documented Resident #8 was dependent on a helper for all self-care and mobility needs. The Minimum Data Set documented Resident #8 had functional limitation in range of motion to both upper and lower extremities. A Physician's order dated 5/2/2023 documented to apply bilateral handrolls (to both hands) at all times, and remove once a shift for hygiene and skin checks. Resident #8's Comprehensive Care Plan for Activities of Daily Living Skills related to hand contractures initiated on 2/1/2022 and revised on 7/11/2023 documented bilateral hand palm guard or gauze roll for contracture management to be worn at all times and may be removed for feeding, dressing, bathing, and care. Check every shift for skin tears and skin redness. During an initial tour on 1/28/2024 at 11:19 AM Resident #8 was observed lying in bed with no handrolls in place. A second observation was conducted on 1/29/2024 at 8:50 AM. Resident #8 was observed lying in bed and the handrolls were not in place. A third observation was made with Certified Nursing Assistant #7 on 1/29/2024 at 5:12 PM. Resident #8 was observed lying in bed and the handrolls were not in place. Certified Nursing Assistant #7 was interviewed on 1/29/2024 at 5:12 PM. Certified Nursing Assistant #7 stated Resident #8 wears bilateral handrolls. Certified Nursing Assistant #7 stated they do not place the handrolls because the Licensed Practical Nurses are responsible for placing the hand rolls in the resident's hands. Certified Nursing Assistant #7 stated they remove the handrolls for care and if they (Certified Nursing Assistant #7) noticed the handrolls were not in place they would report it to the Licensed Practical Nurse on the unit. Licensed Practical Nurse #3 was interviewed on 1/30/2024 at 11:12 AM and stated they provided medications and treatments during the morning shift on 1/28/2024; however, they had not yet provided treatments when the observation was made at 11:19 AM. Licensed Practical Nurse #3 stated it was their responsibility to check that the handrolls were in place and to place them if they were not. Registered Nurse #6 was interviewed on 1/30/2024 at 11:29 AM and stated it was the Licensed Practical Nurse's responsibility to check that the handrolls were in place and to document on the Treatment Administration Record. Occupational Therapist #1 was interviewed on 2/1/2024 at 11:58 AM. Occupational Therapist #1 stated Resident #8 has hand contractures of both hands and the handrolls would help prevent further contracture development and pain. Occupational Therapist stated that the resident was not able to remove the handrolls on their own. The Director of Nursing Services was interviewed on 2/1/2024 at 1:12 PM and stated the treatment nurse, normally the Licensed Practical Nurse, is responsible for placing handrolls in the resident's hands. The Certified Nursing Assistants are responsible to inform the treatment nurse or the Registered Nurse on the unit if the handrolls were not in place. The Director of Nursing Services stated orders for assistive devices should be carried out as ordered. 10 NYCRR 415.12(e)(2)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure that residents who need respiratory care are provided such care consistent with professional standards of practice. This was identified for one (Resident # 120) of five residents reviewed for Respiratory Care. Specifically, Resident #120 had an order for continuous oxygen therapy via a nasal cannula at 2 Liters per minute every shift for Hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The resident was observed on three occasions without the use of the supplemental oxygen as ordered by the Physician. The finding is: The facility's policy and procedure titled, Oxygen Administration, last revised on 5/16/2023 documented to perform an assessment before and while the resident is receiving oxygen and to administer oxygen as ordered by the Physician. No smoking /Oxygen in Use sign to be placed as per the facility protocol for oxygen administration. Resident #120 was admitted with diagnoses of Acute Respiratory Failure, Congestive Heart Failure, and Atrial Fibrillation. The Minimum Data Set (MDS) assessment was not completed including the resident's Brief Interview for Mental Status (BIMS) score and oxygen use. A Physician's admission order dated 1/2/2024 documented to administer oxygen at 2 Liters per minute via nasal cannula, continuously, every shift for Hypoxia. Resident #120 was observed on 1/28/2024 at 10:00 AM sitting in the wheelchair in front of the nurses' station. An oxygen tank was attached behind the resident's wheelchair. The oxygen tubing and the nasal cannula were wrapped around the oxygen tank. The oxygen tank regulator needle was in the green zone which indicated that there was enough oxygen for use. The oxygen tank flow setting was set at zero. A subsequent observation was completed on 1/28/2024 at 10:18 AM. The resident sitting in the wheelchair in front of the nurses' station. An oxygen tank was attached behind the resident's wheelchair. The oxygen tubing and the nasal cannula were wrapped around the oxygen tank. The oxygen tank regulator needle was in the green zone which indicated that there was enough oxygen for use. The oxygen tank flow setting was set at zero. There were no staff members present at the nurse's station. A third observation was completed on 1/28/2024 at 11:40 AM. Resident # 120 was sitting in the wheelchair in front of the nurses' station. An oxygen tank was attached behind the resident's wheelchair. The oxygen tubing and the nasal cannula were wrapped around the oxygen tank. The oxygen tank regulator needle was in the green zone which indicated that there was enough oxygen for use. The oxygen tank flow setting was set at zero. There were no staff members present at the nurse's station. Licensed Practical Nurse #1 was approached to verify the resident's oxygen order. Licensed Practical Nurse #1 unwrapped the nasal cannula from around the tank. Licensed Practical Nurse #1 then applied the oxygen cannula to Resident # 120 and turned the regulator to 2 Liters per minute. Additionally, there was not a Oxygen in Use sign outside Resident #120's room on 1/28/2024, 1/29/2024 and 1/30/2024. A new Physician's order dated 1/28/2024 at 2:46 PM documented to administer oxygen at 2 Liters per minute via nasal cannula as needed (PRN) for an oxygen saturation level of less than 92 percent for a diagnosis of Hypoxia. The order for continuous oxygen use was discontinued. Certified Nursing Assistant #1 was interviewed on 1/29/2024 at 8:34 AM and stated they provide care to Resident #120 five days a week. Certified Nursing Assistant #1 stated that Resident #120 constantly takes off their oxygen cannula. Certified Nursing Assistant #1 stated that both the Nurses and the Certified Nursing Assistants are responsible for making sure that the residents receive oxygen therapy as needed. Licensed Practical Nurse #1 was interviewed on 1/30/2024 at 10:35 AM and stated that it is the responsibility of all Nursing staff to make sure that Resident #120 has the oxygen on as ordered by the Physician. Licensed Practical Nurse #1 stated that the resident was supposed to receive oxygen every shift continuously as per the Physician's orders. Licensed Practical Nurse #1 did not know why the oxygen was not on while the resident was sitting in front of the nurse's station. The Director of Nursing Services was interviewed on 2/1/2024 at 8:45 AM and stated that the continuous oxygen order by the Physician must always be followed. The Director of Nursing Services did not know why Resident #120 was sitting in front of the nurse's station without oxygen as per the Physician's order. The Director of Nursing Services stated that Resident #120 now has an order for oxygen at 2 Liters per minute via nasal cannula as needed and that an oxygen sign is now placed outside Resident #120's room. 10 NYCRR 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure that medical care for each resident was supervised by the Physician including providing orders for the resident's medical status. This was identified for one (Resident #114) of two residents reviewed for Skin Conditions. Specifically, Resident #114 was seen for a Vascular consultation on 1/22/2024. Recommendations were made for the use of bilateral ace wraps to be applied in the morning and to be removed at the hour of sleep to treat the resident's lower extremities edema (swelling caused by too much fluid trapped in the body's tissues). There was no documented evidence that any qualified professional addressed the recommendation made by the Vascular Consultant for Resident #114 to use the ace wraps for the lower extremity edema. The finding is: The facility's policy titled, Medical Consultation, last revised on 1/10/2024 documented that in the event the resident returns from a consultation visit, the Registered Nurse Supervisor is to monitor receipt of the report. The Physician will address the consult recommendations as indicated for potential orders including new orders per consult. Resident #114 was admitted with diagnoses that include, Atrial Fibrillation, Type II Diabetes, and Acute Respiratory Distress. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated that Resident #114 was cognitively intact. Resident #114 was at risk for pressure ulcers and injuries and had pressure-reducing devices for the bed and wheelchair. A Vascular consult dated 1/22/2024 documented a history of bilateral lower extremity swelling and a calf (back of the lower leg) wound. The consult form documented multiple shallow wounds throughout both calves at various stages of healing consistent with minor trauma and tears from edema. Approximately three wounds were identified on each calf that were small and shallow. The recommendation was to apply an ace wrap from the mid-foot to the upper calves in the morning and remove at night. A Progress note dated 1/22/2024 at 1:40 PM, written by Registered Nurse #3, documented Resident #114 returned from a Vascular appointment. Resident #114 was to be seen for a follow-up appointment on 2/15/2024 at 8 AM. The Physician was made aware that the consult was completed, and further testing was recommended. The progress note did not mention recommendations related to the use of the ace wraps. The Nurse Practitioner's progress note dated 1/23/2024 at 9:04 AM documented Resident #114 had a Vascular Consultation. The resident's edema improved. The note documented that the resident was in no pain and there was no Cyanosis (bluish discoloration of the skin due to inadequate oxygenation of the blood) noted. Resident #114 was observed on 1/28/2024 at 12:48 PM. Resident #114 was sitting in a wheelchair with their legs elevated on the bed. There was edema (swelling) observed on both legs with two Band-Aid dressings on the right lower leg shin (front of the lower extremity) area. Resident #114 was observed on 1/29/2024 at 12:14 PM. Resident # 114 was sitting in a wheelchair with their legs elevated on the bed. There was edema (swelling) observed to both legs with two Band-Aid dressings on the right lower leg shin area. The resident stated that the Band Aids have not been changed for a week. Resident # 114 took off the Band Aids. An open wound measuring approximately half a centimeter was observed on the right shin area. The wound bed was observed with whitish macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) skin tissue. The area surrounding the wound was moist and a mild discharge was observed coming out of the wound. Resident # 114 asked the surveyor if someone could change the dressing. Licensed Practical Nurse #1 then came in to change the dressing. Resident # 114 was interviewed on 1/29/2024 at 12:29 PM. Resident #114 stated that they went to the Vascular Doctor a week ago. The Vascular Doctor put the Band-Aids on their (Resident #114) right lower leg because there were small open areas. Resident #114 stated no one had changed the dressing since they returned from the Vascular Doctor's office. Registered Nurse #3 was interviewed on 1/30/2024 at 11:50 AM and stated that they did not review the recommendations from the Vascular Consult for the use of an ace wrap. Registered Nurse #3 stated they uploaded the consult in the Electronic Medical Record but did not call the Nurse Practitioner for any new orders from the consult. The Nurse Practitioner was interviewed on 1/31/2024 at 9:18 AM and stated that they had seen Resident #114 the day after the Vascular Consult. The Nurse Practitioner stated they reviewed the consultation paperwork and were aware that Resident #114 needed further testing; however, they did not recall recommendations related to the use of the ace wraps. The Nurse Practitioner stated they did not recall that Resident #114 also had a wound dressing on their right lower leg during their assessment. The Physician Assistant was interviewed on 1/31/2024 at 1:00 PM and stated that they (Physician Assistant) were not covering for the Physician on 1/23/2024; the Nurse Practitioner did an in-person visit on that day. The Physician Assistant stated they had seen Resident #114 on 1/29/2024 at 12:31 PM and ordered Xeroform dressing to the right shin edema-related skin tears. The resident's Physician was made aware and was agreeable. The Director of Nursing Services was interviewed on 2/1/2024 at 11:54 AM and stated that the nurses should have reviewed the Vascular Consult and should have called the Physician for any new orders. If the nursing staff reviewed the consult, they would have seen that Resident #114 had wounds on the lower extremities and addressed the treatment with the Physician. The Nurse Practitioner who had seen Resident #114 should have reviewed the consult, and written a progress note to address the recommendation for the use of ace wraps. 10 NYCRR 415.15(b)(1)(i)(ii)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was identified during a review of the Payroll Based Journal (PBJ) Staffing Data Report, and review of the Facility Assessment; concerns raised during the Resident Council meeting; and during the medication administration observation on Sunday (1/28/2024) on one of three nursing units. Specifically, review of the Payroll Based Journal (PBJ) Staffing Data Report and the Facility Assessment (FA) identified that the facility did not ensure adequate staffing was available to meet the residents' needs on multiple days; two of ten residents present at the Resident Council meeting held on 1/29/2024 voiced concerns regarding staffing shortage and receiving their medications late; an off-hour survey was conducted on 1/28/2024 and one Licensed Practical Nurse did not administer medications to six (Resident #72, Resident #12, Resident # 51, Resident# 82, Resident# 22, and Resident #92) of nine residents in the prescribed time frame due to staffing shortage. The findings are: The Facility's undated Policy for Administering Medications documented medications are administered in a safe and timely manner, and as prescribed. The Policy documented medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal). Medication administration times are determined by resident need and benefit, not staff convenience. The Facility's Policy Interpretation and Implementation on staffing dated March 2023 documented the facility provides adequate staffing to meet needed care and services for the resident population. Facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed Registered Nursing and Licensed Nursing staff are available to provide and monitor the delivery of resident care services. The facility furnishes information from payroll records setting forth the average numbers and types of personnel (in full-time equivalents) on each shift during at least one (1) week of each quarter to appropriate state agencies. The Facility Assessment for 2024 determined that on the 7:00 AM to 3:00 PM shift and the 3:00 PM to the 11:00 PM shift there should be 7 licensed nurses per shift. The facility has three nursing units. Two Licensed nurses are assigned to each unit and there is one Registered Nurse Supervisor assigned to each shift. The Night shift (11:00 PM to 7:00 AM) has one Licensed staff on each unit (total of three licensed nurses) and one Registered Nurse Supervisor for the entire facility. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year (FY) Quarter four 2023 (July 1-September 30) documented the facility triggered for the Metric of excessively low weekend staffing. A review of the weekend staffing from 7/1/2023 to 9/30/2023 revealed there was less licensed staffing than was documented as required on the facility assessment. Examples include but are not limited to: -On July 1 2023, the facility had 5.5 licensed staff for the evening shift instead of 7 licensed nurses. -On July 16, 2023, the facility had 3 licensed staff for the night shift instead of 4 licensed nurses. -On August 20, 2023, the facility had a total of 5 nurses for the evening shift instead of 7 licensed nurses. Additionally, a review of the actual staffing records during the survey from 1/28/2024 to 2/1/2024 revealed that on 1/28/2024, there was 5 licensed nurses on duty during the day shift instead of 7 licensed nurses as determined on the Facility Assessment. A Resident Council meeting was held on 1/29/2024 at 11 AM with 10 residents in attendance. Two residents stated that the nurses are overburdened on the weekends and on some days, they receive their medications late. A resident who attended the Resident Council meeting on 1/29/2024 was interviewed on 1/31/2024 at 3:26 PM and stated there were problems with staffing over the summer. There were less nurses and Certified Nurses' Aides to provide care. A Medication Administration was observed on a Sunday morning 1/28/2024 from 10:30 AM to 11:20 AM. Licensed Practical Nurse # 3 was observed administering 9:00 AM medications to six residents (Resident# 82, Resident # 51, Resident #12, Resident #72, Resident# 22, and Resident #92) from 10:38 AM to 11:20 AM. Licensed Practical Nurse #3 was interviewed on 1/28/2024 at 11:20 AM and stated that the medications they were administering for Resident# 82, Resident # 51, Resident #12, Resident #72, Resident# 22, and Resident #92 were due to be administered at 9:00 AM. Licensed Practical Nurse #3 stated that they were administering the medications late because there was a call out and they had to administer medications to 41 residents on the unit. Licensed Practical Nurse #3 further stated on weekends they have to cover the medication pass due to staff call outs on Unit B. During the weekday there is more staffing; two Licensed Practical Nurse giving medications and one charge nurse that is behind the desk. Licensed Practical Nurse #3 stated the 9:00 AM medications should have been administered no later than one hour after the due time of 9:00 AM. The Staffing Coordinator #1 was interviewed on 1/31/2024 at 12:14 PM and stated that there are difficulties staffing licensed nurses on the weekends. When nurses call out on the weekend, they try to get other nurses to volunteer. If it is critically low staffing, then the facility has to mandate nurses to stay over to the next shift. To mandate the facility has to have four or less nurses on the day shift and or the evening shift and two or less nurses on the night shift. Sometimes even with mandates the nursing levels are still below the ideal level of seven licensed nurses per day and evening shift. The facility does not contract out with staffing agencies for Nurses. Registered Nurse Supervisor #1 was interviewed on 2/1/2024 at 12:15 PM and stated they assist nurses that require assistance, intervene when there are emergencies, speak to families and Physicians, and perform other Nursing supervision tasks. Registered Nurse Supervisor #1 further stated they were not made aware that Licensed Practical Nurse (LPN) #3 was not able to complete the 9:00 AM medication pass timely. The Director of Nursing Services (DNS) was interviewed on 1/30/2024 at 3:30 PM and stated that the medications were administered late on 1/28/2024 and it was not acceptable to administer medications late. The Director of Nursing Services stated that the regularly assigned second nurse for the unit called out and another nurse was not found to substitute. The Director of Nursing Services stated Licensed Practical Nurse #3 should have asked for assistance and the Registered Nurse Supervisor could have assisted; however, the Registered Nurse supervisor could have been busy and may not have been able to assist. The Director of Nursing Services was re-interviewed on 1/31/2024 at 3:52 PM. The weekend staffing sheets from July 1 - September 30 were reviewed with the Director of Nursing Services. The Director of Nursing Services acknowledged that there were less than seven licensed nurses working on July 1st and July 2nd, 16th, and August 20th. There should have been a minimum of six nurses to ensure two nurses are assigned to each unit. On 1/28/2024 during the 7:00 AM- 3:00 PM shift, five nurses were assigned, and one Registered Nurse supervisor should have been helping out on unit B. If Licensed Practical Nurse #3 was having difficulties giving medications in a timely manner, the Registered Nurse Supervisor should have been notified. The Administrator was interviewed on 1/31/2024 at 2:29 PM and stated there is a nationwide nursing staffing shortage. The facility has had difficulties recruiting nurses. The shortage affects weekends the most. The Administrator stated the facility does not have an agency to recruit Licensed Practical Nurses and that the facility is having a difficult time finding nurses. Incentives are provided to Licensed Practical Nurses and increased salaries were provided to the Registered Nurse Supervisor. 10 NYCRR 415.13(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure that the facility's medication error rates are not five percent or greater. This was identified for 42 of 53 opportunities for six (Resident #82, Resident #51, Resident #12, Resident #72, Resident #22, and Resident #92) of nine residents observed during a medication pass observation. This resulted in a 79.25% medication error rate. Specifically, 1) Resident #82 did not receive eleven of the 9:00 AM Physician ordered medications until 10:56 AM. 2) Resident #51 did not receive three of the 9:00 AM Physician ordered medications until 11:10 AM. 3) Resident #12 did not receive seven of the 9:00 AM Physician ordered medications until 10:38 AM. 4) Resident #72 did not receive seven of the 9:00 AM Physician ordered medications until 11:00 AM. 5) Resident #22 did not receive five of the 9:00 AM Physician ordered medications until 11:05 AM; and 6) Resident #92 did not receive nine of the 9:00 AM Physician ordered medications until 10:49 AM. The findings include but are not limited to: The Facility's undated Policy for Administering Medications documented medications are administered in a safe and timely manner, and as prescribed. The Policy documented medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal). Medication administration times are determined by resident need and benefit, not staff convenience. A medication administration was observed on a Sunday morning, 1/28/2023. Licensed Practical Nurse #3 was observed administering medications to six residents from 10:38 AM to 11:10 AM. 1) Resident #82 was admitted with diagnoses that include Dementia and Hypertension (HTN). The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4 indicating the resident had severe cognitive impairment. During the medication administration observation task on 1/28/2024 at 10:56 AM, Licensed Practical Nurse #3 was observed administering the following Physician ordered 9:00 AM medications to Resident #82: -Razadyne Tablet 8 milligrams, Give 1 tablet by mouth two times a day for Dementia; -Memantine HCl Tablet 5 milligrams, Give 1 tablet by mouth one time a day for Dementia; -Metoprolol Tartrate Tablet 25 milligrams, Give 1 tablet by mouth every 12 hours for Hypertension, hold for Systolic Blood Pressure greater than 100 millimeters of Mercury; -Potassium Chloride Extended Release tablet 10 milliequivalent, Give 1 tablet by mouth one time a day for supplement; -Sennosides tablet 8.6 milligrams, Give 2 tablets by mouth two times a day for Constipation; -Seroquel Oral Tablet 50 milligrams, Give 1 tablet by mouth two times a day for Bipolar Disorder; -Sertraline HCl Tablet 25 milligrams, Give 1 tablet by mouth one time a day for Depression; -Amlodipine Besylate tablet 5 milligrams, Give 1 tablet by mouth one time a day for Hypertension, hold for Systolic Blood Pressure greater than 100 millimeters of Mercury; -GlycoLax Powder, Give 17 gram by mouth one time a day for Constipation. Dissolve 1 capful in 4-6 ounce fluids; -Hydrochlorothiazide Capsule 12.5 milligrams, Give 1 capsule by mouth one time a day for Hypertension; -Folic Acid Tablet 1 milligram, Give 1 tablet by mouth one time a day for Anemia. A total of eleven 9:00 AM Physician prescribed medications were administered late. 2) Resident # 51 was admitted with diagnoses that include Type 2 Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. The Minimum Data Set (MDS) assessment dated [DATE] documented that a Brief Interview for Mental Status (BIMS) was not completed due to severe cognitive impairment. During the medication administration observation task conducted on 1/28/2024 at 10:38 AM, Licensed Practical Nurse #3 was observed administering the following Physician ordered 9:00 AM medications to Resident #51: -Trintellix Tablet 10 milligram, Give 1 tablet by mouth one time a day for Depression; -Nuedexta Capsule 20-10 milligrams, Give 1 capsule by mouth every 12 hours for Pseudobulbar Affect; -Levetiracetam Solution 100 milligrams/milliliter, Give 5 milliliters by mouth two times a day for Seizure Disorder. A total of three 9:00 AM Physician prescribed medications were administered late. 3) Resident #12 was admitted with diagnoses that included Anxiety Disorder, Major Depressive Disorder, and Dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderately impaired cognition. During a medication administration observation task on 1/28/2024 at 11:10 AM, Licensed Practical Nurse #3 was observed administering the following Physician ordered 9:00 AM medication to Resident #12: -Norvasc Oral Tablet 5 milligrams, Give 1 tablet by mouth one time a day for Hypertension; -Paroxetine HCl Oral Tablet 40 milligrams, Give 40 milligrams by mouth one time a day for Major Depressive Disorder; -Os-Cal Extra D3 Oral Tablet 500 -15 milligrams-micrograms, Give 1 tablet by mouth in the morning for supplementation; -Multivitamin Oral Tablet Give 1 tablet by mouth one time a day for supplementation; -Seroquel Oral Tablet 50 milligrams, Give 50 milligrams by mouth one time a day for Anxiety; -Gabapentin Oral Capsule 100 milligrams, Give 1 capsule by mouth two times daily for Pain; -Metformin HCl Oral Tablet 500 milligrams, Give 1 tablet by mouth two times a day for Diabetes management. A total of seven 9:00 AM Physician prescribed medications were administered late. Licensed Practical Nurse #3 was interviewed on 1/28/2024 at 11:20 AM and stated that the medications they were administering for Resident# 82, Resident #51, Resident #12, Resident #72, Resident# 22, and Resident #92 were due to be administered at 9:00 AM. Licensed Practical Nurse #3 stated that they were administering the medications late because there was a call out and they were to administer medications to 41 residents on the unit. Licensed Practical Nurse #3 stated on the weekends, this is the norm on Unit B. During the weekdays there is more staffing; there is usually another nurse. During the weekdays, Licensed Practical Nurse #3 administers medications and there is one charge nurse behind the desk. Licensed Practical Nurse #3 stated the 9:00 AM medications should have been administered one hour prior or one hour after the due time of 9:00 AM. Registered Nurse (RN) #1 was interviewed on 2/01/2024 at 12:15 PM and stated they were supervising the whole facility and were never made aware about any medications not being given in a timely manner on 1/28/2024. Registered Nurse #1 stated if they were made aware, they would have assisted in the administration of medications to the residents. The Director of Nursing Services (DNS) was interviewed on 1/30/2024 at 3:30 PM and stated that the medications were administered late on 1/28/2024 which is not acceptable. The Director of Nursing Services stated that the regularly assigned second nurse for the unit called out and another nurse was not found to substitute. The Director of Nursing Services stated the nurse should have asked for assistance and the Registered Nurse (RN) Supervisor could have assisted. The Director of Nursing Services further stated that the Registered Nurse Supervisor could have been busy and may not have been able to assist. The Physician Assistant was interviewed on 2/01/2024 at 11:07 AM and stated that nurses sometimes administer medications late due to staffing issues. All six sampled resident's medications were reviewed with the Physician Assistant and none of their medications being given late were considered significant; however, some medications, if not given timely can cause complications. 10 NYCRR 415.12(m)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00272022) initiated on 7/21/2022 and completed on 7/28/2022, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately but not later than two hours after the allegation is made if the events that caused the allegation involve abuse to the administrator of the facility and to other officials (including to the state survey agency). This was identified for one (Resident #224) of three residents reviewed for Abuse. Specifically, on 2/22/2021 Social Worker (SW) #1 was informed by the hospital SW of an abuse allegation made by Resident #224 that a Certified Nursing Assistant (CNA) at the Nursing Home had inappropriately touched Resident #224 during perineal care. The facility did not report the allegation of abuse to the New York State Department of Health (NYSDOH) within two hours. The finding is: The Facility's policy for Resident Abuse, Mistreatment, Neglect, and Exploitation dated 1/5/2022 defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. All reports and allegations of abuse, neglect, mistreatment, and or exploitation must be responded to promptly, and reported by staff immediately to their direct supervisor. The procedure includes to notify the NYSDOH within two hours of the reasonable cause threshold being achieved followed by a written notification and the results of the facility investigation within five days. Resident #224 was admitted with diagnoses that include Cerebral Palsy, Paraplegia, and Major Depressive Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition. The resident had no behavioral symptoms and rejects care one to three days in the MDS look back period. The resident required extensive assistance of one staff member for personal hygiene. A Behavior Comprehensive Care Plan (CCP) updated on 4/1/2021 documented the resident has accusatory behaviors related to making false statements towards staff. Interventions included but were not limited to: a two-person approach, monitor behavior episodes, and to attempt to determine the underlying cause for the behavior. The facility's undated Resident Abuse Investigative Report for Resident #224 documented during an emergency room (ER) visit on 2/21/2021 Resident #224 reported to the ER Social Worker (SW) that during perineal care at the Nursing Home a CNA poked/touched them (Resident #224) inappropriately. The Report documented on 2/22/2021 the hospital SW spoke with SW #1 and informed them (SW#1) of Resident #224's complaint. SW #1 informed the hospital SW that Resident #224 had a history of manipulative/accusatory behavior due to their (Resident #224) diagnoses of Post-Traumatic Stress Disorder (PTSD). The facility's conclusion documented a meeting was held on 4/7/2021 and it was determined by the administrative staff that Resident #224's allegation of abuse was unsubstantiated and there was no cause to believe that any abuse, mistreatment, or neglect had occurred. A Social Service note written by (SW #1) dated 2/23/21 documented SW #1 met with Resident #224 and the resident stated that they (Resident #224) did not want to get into the details of their recent ER visit. A written statement by SW #1 dated 3/29/2021, in the facility's investigative report, documented on 2/22/2021 SW #1 received a call from the hospital SW to inform SW #1 of a complaint made by Resident #224 regarding a nurse's aide. There was no further details in this statement regarding the resident's allegations. A written statement Social Worker (SW #1) in the Investigative Report dated 4/9/2021 documented the Social Worker visited with Resident #224 on return from the hospital and that Resident #224 stated they (Resident #224) were touched inappropriately by a nurse aide. SW #1 was interviewed on 7/25/2022 at 12:40 PM and stated that they (SW #1) received a call on 2/22/2021 from the hospital SW regarding the resident's alleged abuse but stated they (SW #1) could not recall the details of the conversation. SW #1 stated they (SW #1) initiated the grievance report after Resident #224 returned from the hospital. The resident was readmitted from the hospital on 2/22/2021. SW #1 stated when a complaint of abuse is reported to them (SW #1) they (SW #1) initiate a grievance report and forwards the report to the Director of Nursing Services (DNS) and the Administrator. SW #1 stated an investigation into the allegation of Abuse was initiated by nursing. SW #1 stated that she reported the allegation of abuse to the DNS after speaking with the resident on 2/23/2021; however, they (SW #1) were unable to find the grievance report. The DNS was interviewed on 7/25/2022 at 3:18 PM and stated they (DNS) were not employed by the facility at the time of the allegation related to Resident #224. The DNS stated that when an allegation of abuse is reported, whomever receives the allegation report was responsible for notifying their supervisor. The DNS stated if the allegation of abuse was reported to the SW, that SW was responsible for notifying the DNS and the Administrator immediately as there is a two-hour window to report abuse to the New York State Department of Health (NYSDOH). The DNS stated after receiving the report an investigation should be initiated. All staff that cared for the resident should be interviewed. The DNS further stated that the expectation is that statements should be obtained from the resident's care givers, including the accused CNA, to rule out abuse. The Administrator (ADM) was interviewed on 7/25/2022 at 3:46 PM and stated when an allegation of abuse is reported by anyone, a full investigation is initiated including obtaining statements from all staff that had cared for the resident prior to the reported incident. The resident is assessed, a psychiatrist visit is conducted if warranted, and the Physician is notified. The ADM further stated that the expectation was that statements from the CNAs that cared for the resident, including the accused CNA, should have been obtained to rule out abuse, neglect, and mistreatment. 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00272022) initiated on 7/21/2022 and completed on 7/28/2022, the facility did not ensure that all incidents of alleged abuse are thoroughly investigated to rule out Abuse, Neglect, and Mistreatment. This was identified for one (Resident #224) of three residents reviewed for Abuse. Specifically, Resident #224 reported to the Social Worker (SW) #1 that a Certified Nursing Assistant (CNA) inappropriately touched Resident #224. The facility's Investigation Report lacked documented evidence that statements were obtained from direct care staff that cared for the resident. The finding is: The Facility's policy for Resident Abuse, Mistreatment, Neglect, and Exploitation dated 1/5/2022 defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. All reports and allegations of abuse, neglect, mistreatment, and or exploitation must be responded to promptly, and reported by staff immediately to their direct supervisor. The policy also documented a full investigation will be completed. Resident #224 was admitted with diagnoses that include Cerebral Palsy, Paraplegia, and Major Depressive Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition. The resident had no behavioral symptoms and rejects care one to three days in the MDS look back period. The resident required extensive assistance of one staff member for personal hygiene. A Behavior Comprehensive Care Plan (CCP) updated on 4/1/2021 documented the resident has accusatory behaviors related to making false statements towards staff. Interventions included but were not limited to: a two-person approach, monitor behavior episodes, and to attempt to determine the underlying cause for the behavior. The facility's undated Resident Abuse Investigative Report for Resident #224 documented during an emergency room (ER) visit on 2/21/2021 Resident #224 reported to the ER Social Worker (SW) that during perineal care at the Nursing Home a CNA poked/touched them (Resident #224) inappropriately. The Report documented on 2/22/2021 the hospital SW spoke with SW #1 and informed them (SW#1) of Resident #224's complaint. SW #1 informed the hospital SW that Resident #224 had a history of manipulative/accusatory behavior due to their (Resident #224) diagnoses of Post Traumatic Stress Disorder (PTSD). A Social Service note written by (SW #1) dated 2/23/21 documented SW #1 met with Resident #224 and the resident stated that they (Resident #224) did not want to get into the details of their recent ER visit. A written statement by SW #1 dated 3/29/2021, in the facility's investigative report, documented on 2/22/2021 SW #1 received a call from the hospital SW to inform SW #1 of a complaint made by Resident #224 regarding a nurse's aide. There was no further details in this statement regarding the resident's allegations. A written statement Social Worker (SW #1) in the Investigative Report dated 4/9/2021 documented the Social Worker visited with Resident #224 on return from the hospital and that Resident #224 stated they (Resident #224) were touched inappropriately by a nurse aide. SW #1 was interviewed on 7/25/2022 at 12:09 PM and stated that they (SW #1) spoke with the resident on readmission to the facility in 2/2021 and that the resident made a complaint that they (Resident #224) were touched inappropriately by a CNA. SW #1 stated that an investigation was conducted by the facility and that there were no signs of abuse. A subsequent interview with SW #1 was conducted on 7/25/2022 at 12:40 PM. SW #1 stated that they (SW #1) received a call on 2/22/2021 from the hospital SW regarding the resident's alleged abuse but stated they (SW #1) could not recall the details of the conversation. SW #1 stated they (SW #1) initiated the grievance report after Resident #224 returned from the hospital. The resident was readmitted from the hospital on 2/22/2021. SW #1 stated when a complaint of abuse is reported to them (SW #1) they (SW #1) initiate a grievance report and forwards the report to the Director of Nursing Services (DNS) and the Administrator. SW #1 stated an investigation into the allegation of Abuse was initiated by nursing. SW #1 stated that she reported the allegation of abuse to the DNS after speaking with the resident on 2/23/2021; however, they (SW #1) were unable to find the grievance report. The DNS was interviewed on 7/25/2022 at 3:18 PM and stated they (DNS) were not employed by the facility at the time of the allegation related to Resident #224. The DNS stated that when an allegation of abuse is reported, whomever receives the allegation report was responsible for notifying their supervisor. The DNS stated if the allegation of abuse was reported to the SW, that SW was responsible for notifying the DNS and the Administrator immediately. The DNS stated after receiving the report an investigation should be initiated. All staff that cared for the resident should be interviewed. The DNS further stated that the expectation is that statements should be obtained from the resident's care givers, including the accused CNA, to rule out abuse. The Administrator (ADM) was interviewed on 7/25/2022 at 3:46 PM and stated when an allegation of abuse is reported by anyone, a full investigation is initiated including obtaining statements from all staff that had cared for the resident prior to the reported incident. The resident is assessed, a psychiatrist visit is conducted if warranted, and the Physician is notified. The ADM further stated that the expectation was that statements from the CNAs that cared for the resident, including the accused CNA, should have been obtained to rule out abuse, neglect, and mistreatment. 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the Recertification Survey initiated on 7/21/2022 and completed on 7/28/2022 the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #25) of three residents reviewed for Activities of Daily Living (ADLs). Specifically, Resident #25 had a Physician's order for showers to be administered on the 3:00 PM-11:00 PM nursing shift on Wednesdays and Fridays. There was no documented evidence that Resident #25 Comprehensive Care Plan (CCP) was implemented to ensure the Physician's order for showers were followed. The finding is: Resident #25 was admitted with diagnoses that include Chronic Obstructive Pulmonary Disease, Hypertension, and Schizophrenia. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 12 which indicated moderately impaired cognition. The resident had no behavioral symptoms and required physical help of one staff member for bathing. During a Resident Council meeting conducted on 7/22/2022 Resident #25 stated that they have had showers skipped due to short staffing. Resident #25 stated that their scheduled shower days were twice a week during the 3:00 PM-11:00 PM shift. Resident #25 stated that occasionally their showers were skipped, however, could not give specific dates. A CCP for ADLs updated on 6/22/2022, documented the resident required extensive assistance of one staff member for bathing. A Physician's order dated 6/23/2022 documented to provide showers every evening shift on Wednesdays and Fridays. A Weekly shower sheet for Resident #25 dated 6/29/2022, 7/6/2022, 7/13/2022, and 7/27/2022 documented the resident was provided with a bed bath. The Licensed Practical Nurse (LPN) #2 was interviewed on 7/28/2022 at 10:00 AM and stated that Resident #25 is very cooperative and never refuses care or medications. LPN #2 stated the resident knows when their shower days are and would sometimes remind the Certified Nursing Assistant (CNA) when their shower days are. LPN #2 further stated that the resident did not report to them (LPN #2) that they (Resident #25) were not receiving their showers. The 7:00 AM-3:00 PM CNA #3 stated that Resident #25 told them (CNA #3) that they (Resident #25) had not received a shower in a while. CNA #3 stated that they (CNA #3) did not question the resident regarding how long the resident had not received a shower and that they (CNA #3) provided a shower per the resident's request (could not recall the date) CNA #3 further stated they (CNA #3) did not report the resident's concern regarding not receiving showers to the charge nurse and should have. Resident #25 was interviewed on 7/28/22 at 2:00 PM and stated that the staff have been giving them (Resident #25) bed baths on the day and evening shifts. Resident #25 stated when they asked for a shower, the staff told them that they (staff) were working short and could not give Resident #25 a shower. Resident #25 stated that recently they have only gotten a shower on 7/24/2022 (Sunday). The Director of Nursing Services (DNS) was interviewed on 7/28/22 at 2:44 PM and stated that the staff should have been administering showers as per the Physician's order unless the resident requests something different. The DNS stated that the 3 PM-11 PM shift nurses were responsible for ensuring the residents are receiving showers as per the Physician's order. 415.11(c)(1)