Based on interviews and record reviews conducted during the recertification and abbreviated surveys (NY 00361358) from 2/19/25-2/27/25 it was determined that for one (Resident #400) of two residents reviewed for notification of change, the facility did not notify the resident's representative timely when there was a change in their plan of care. Specifically, Resident #400's Seroquel (antipsychotic medication) and Sertraline (antidepressive medication) were discontinued after a gradual dose reduction, and their representative was not notified of the change in the plan of care. The findings are: The facility policy titled Psychoactive Drugs dated 9/2017, documented the attending physician will monitor and modify the medication regimen in conjunction with the resident and/or representative and other members of the Interdisciplinary Team including psychiatry. A resident or resident representative has the right to be informed about the resident's condition, treatment options, relative risks and benefits of treatment, required monitoring, expected outcomes of the treatment and has the right to refuse care and treatment. Resident #400 was admitted to the facility with diagnoses including dementia, anxiety insomnia and Alzheimer's disease. The 8/15/24 Minimum Data Set Assessment documented the resident's cognition was severely impaired. The resident ate meals with tray set up and walked independently in hallways with a cane. The physician order dated 11/21/23, documented Resident #400 was prescribed Seroquel 50 milligrams one tablet at bedtime by Attending Physician #1. Psychiatric Nurse Practitioner #3's note dated 3/19/24, documented a recommendation to reduce Seroquel to 25 milligrams at bedtime. The physician order dated 3/22/24, documented Resident #400 was prescribed Seroquel 50 milligrams 1/2 tablet (25 milligrams) at bedtime by Attending Physician #1. Psychiatric Nurse Practitioner #3's note dated 4/16/24, documented a recommendation to reduce Seroquel to 12.5 milligrams at bedtime. (There was no corresponding order or documentation as to a reason this was not done.) The physician orders documented on 5/9/24 Seroquel 50 milligrams 1/2 tablet (25 milligrams) at bedtime was discontinued. The physician order dated 5/10/24, documented Resident #400 was prescribed Sertraline 12.5 milligrams daily for depression by Attending Physician #2. The order was discontinued on 8/16/24. There was no documentation in the progress notes reviewed from 3/19/24 -5/9/24 that the resident's representative was notified about the gradual dose reduction for Seroquel on 3/19/24 or when it was discontinued. There was also no documented evidence the resident's representative was notified of the initiation of Sertraline on 5/10/24 and discontinuation on 8/16/24. During an interview with the Assistant Director of Nursing on 2/25/25 at 10:00 AM they stated the resident was admitted to the facility already on Seroquel and was tapered then discontinued. They stated when a resident was on psychotropic medications the family should be notified by the physician and they were not sure what happened in this case. They stated Attending Physician #1 was not good at contacting families and was no longer employed by the facility. During an interview with Attending Physician #2 on 2/25/25 at 12:08 PM, they stated when a report from the Psychiatric Nurse Practitioner comes in, they will go over the report with the Unit Manager and track Psychiatry notes and gradual dose reductions. They will call family or Unit Manager will call to inform the family the gradual dose reduction has been initiated. In this case, they did not recall if they spoke to the family because there was a changeover of attending physicians. Attending Physician #2 could not recall if they notified the resident's representative about the medication changes. During an interview with the Psychiatric Nurse Practitioner #3 on 2/25/25 at 12:28 PM, they stated they saw residents for medication review, loss or deterioration in cognition, and made recommendations. They did not notify families of gradual dose reductions. They stated they were only a consultant and did not know what happened in this case. 10 NYCRR 415.3(e)(1)(a)

Based on observations and interviews during the recertification and abbreviated (NY00368899) surveys from 2/20/25-2/27/25, the facility did not ensure that the environment was maintained in a safe, clean, comfortable and homelike manner. Specifically, 1.) the shower room on the 3A unit had black stains on the shower curtain, the tiles at the base of the toilet had brown discoloration, and the tile grout in the shower stall was discolored with black and orange stains. Furthermore, there was an air conditioner in the window next to the shower stall that caused a cold draft in the room. 2). Dirty linens were observed on the floor next to Resident #27's bed. 3) A broken handrail with a sharp edge was found on the right side of the entrance to the 3A dining room. The findings are: 1) During an interview on 2/20/25 at 11:39 AM, Resident #18 stated that the shower room on 3A was cold and had mildew. During observations of the shower room on the 3A unit on 2/20/25 at 11:59 AM and 2/25/25 at 10:23 AM, shower tiles along the base of the shower stall had black and orange discoloration. Black stains were on the bottom of the shower curtain. The white tiles around the toilet base were discolored brown. There was a cold draft coming from the window next to the shower stall where a window air conditioner unit was in place. During an interview on 2/25/25 at 10:46 AM, the Director of Housekeeping stated housekeeping was responsible for cleaning the shower rooms daily. If shower curtains were soiled, staff should have contacted them for washing or replacement. They stated housekeeping cleaned the tiles, but if the tiles could not be cleaned, maintenance would be contacted for regrouting or repair. They stated they had not received any reports from staff about conditions observed in the shower room on the 3A unit. They stated the tiles needed to be cleaned and the shower curtain should have been replaced. During an interview on 2/25/25 at 4:12 PM, the Director of Maintenance stated they were not aware of any issues in the 3A shower room and acknowledged that the grout in the shower stall was discolored and should be addressed. They stated the air conditioner could be the reason for drafts. 2) During observation of the Resident #27's room on 2/20/25 at 11:44 AM, linens soiled with feces were observed on the floor next to the resident's bed. During an interview on 2/20/25 at 12:02 PM, Certified Nurse Aide #19 picked up the soiled linen from the floor and placed it in a plastic bag. They stated that soiled linens should always be bagged and kept in linen hamper and not on the floor. 3) During an observation on 2/26/25 at 11:52 AM, the handrail on the right side of the dining room entrance was broken and had a sharp edge. When interviewed on 2/26/25 at 11:58 AM, the Maintenance Worker #31 stated they were not aware of the railing being broken in dining room. When interviewed on 2/27/25 at 3:28 PM, the Director of Maintenance stated they added handrails as an item on the to look at when doing rounds. 10 NYCRR 415.5(h)(2)

Based on observations, record reviews and interviews during the Recertification survey from 2/20/25 through 2/27/25, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 6 residents (Resident #27) reviewed for activities of daily living. Specifically, Resident #27 required staff assistance with personal hygiene was observed on 3 occasions with long and dirty fingernails. Findings include: The policy and procedure titled Clinical, Activities of Daily Living Protocol, Policy and Procedure last revised 11/2022 documented the facility will implement measures to assess the resident's ability to perform Activities of Daily Living and based on the assessment, will implement treatment and services, based on the resident's needs and choices, to maintain/improve and prevent decline due to reversible causes whenever possible. The facility provides services for the following Activities of Daily Living, which included but not limited to hygiene - bathing, dressing, grooming and oral care. The Resident #27 was admitted with diagnoses including rheumatoid arthritis, borderline personality disorder, and bipolar disorder. The 1/31/25 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented the Resident #27 had intact cognition, had impairment on both sides of upper and lower extremities and was dependent with self-care abilities. The 10/3/24 care plan titled Activities of Daily Living documented the resident was dependend ton staff for eating, hygiene, dressing, and bathing. The resident did none of the effort and staff did all the effort. The certified nurse aide was responsible for activities of daily living. The 2/20/25, 2/21/25 and 2/24/25 Certified Nurse Assistant Activity of Daily Living Tasks documented Resident #27 was dependent on staff for ability to maintain personal hygiene. During observation on 2/20/25 at 11:44 AM, Resident #27 was in bed. The resident had finger deformities on their both hands. Some fingers were twisted in an outward direction revealing long fingernails with dark brown matter underneath, other fingers in the middle joint bended inward, toward the palm. The resident stated that they would like to take care of their long fingernails, but they could not, and the staff told them that they were busy. During observations on 2/21/25 at 2:16 PM and 2/24/25 at 10:58 AM, Resident #27 was in bed, revealing long fingernails with dark brown matter underneath. During an interview on 2/26/25 3:58 PM, Certified Nurse Aide #19 stated that shaving and clipping fingernails were included under the personal hygiene care. They said that they documented performance of personal hygiene for residents, but there was no specific task for shaving or fingernail clipping to document. Certified Nurse Aide #19 stated that by observation or asking the resident's preferences the Certified Nurse Aide could perform these tasks. They stated these were Certified Nurse Aide responsibilities. The surveyor went to the resident's room accompanied by Certified Nurse Aide and observed the resident's short fingernails. The resident stated that the nurse clipped their nails yesterday. The Certified Nurse Aide #19 stated when they provided assistance with personal hygiene they did not remember if the nails were long, and did not remember when they were clipped last time. During an interview on 2/26/25 at 4:11 PM Licensed Practical Nurse #18 stated clipping of fingernails and shaving tasks were included under personal hygiene care. They said that they clipped the resident's fingernails on 2/25/25 and noticed how long they were. They stated they did not know when the resident's nails were last clipped and they sometimes clipped them when the certified nurse aides were busy. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the recertification survey from 2/20/25-2/27/25, the facility did not ensure that 1 of 4 residents (Resident #122) reviewed for positioning and limited range of motion, received treatment and care in accordance with professional standards of practice. Specifically, Resident #122 had a history of difficulty swallowing and was not positioned properly while eating. The finding are: The undated facility policy titled Resident Positioning Policy for Therapy and Nursing Staff documented that the purpose of the policy is to establish standardized guidelines for proper positioning to ensure optimal comfort, prevent complications, and promote the overall health and safety of residents. Assistive devices should be used whenever necessary to minimize risk and injury to residents and staff. Resident #122 had diagnoses including Huntington's Disease, Dysphagia (difficulty swallowing), and Gastroesophageal reflux disease (GERD). The Quarterly Minimum Data Set, dated [DATE] documented Resident #122 had severely impaired cognition and was dependent on staff for all activities of daily living and mobility. The Comprehensive Care Plan for Activities of Daily Living dated 11/18/24 documented the resident was dependent on staff for eating. There were no interventions regarding positioning while eating. A Speech Therapy evaluation note dated 11/14/24 documented Resident #122 was noted with increased coughing and gagging during meals. The diet was downgraded to pureed consistency with honey thickened liquids and assistance with feeding was recommended. During an observation on 2/21/25 at 12:28 PM, Resident # 122 was eating lunch with assistance from staff. They were sliding down and positioned very low in their chair and coughed intermittently. During an observation on 2/25/25 at 12:42 PM, Resident #122 was low in their chair while a staff member was assisting the resident with feeding. Resident #122 was observed sliding lower in their chair while eating and was not repositioned by staff. During an observation on 2/26/25 at 12:32 PM, Resident #122 was very low in their chair prior to starting lunch. Staff did reposition resident to a more upright position in chair prior to feeding. During an interview with the Registered Nurse Unit Manager #11 on 2/26/25 at 1:32 PM, they stated that staff attempted to feed Resident #122 the best they could, but it could be difficult at times and their intake fluctuated. They stated Resident #122 was on a pureed diet with honey thickened liquids and had not been evaluated by occupational or physical therapy for chair positioning during feeding. They stated Resident #122 should have been sitting upright in their chair and not reclined or sliding down while eating. During an interview with Occupational Therapist #13 on 2/27/25 at 10:18 AM, they stated a recent screen was requested by family and completed for Resident #122 for dexterity. They stated a screen for positioning in their chair while eating had not been requested. They stated they completed regular quarterly screens for residents, and nursing could request a screen if there was a concern. They stated there were devices that could be used to prevent the resident from sliding down in the chair and the resident should have been upright while eating. During a follow-up interview on 2/27/25 at 3:23 PM, Occupational Therapist #13 stated they evaluated Resident #122 during lunch and added a device to help prevent them from sliding down in the chair. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, during the Recertification Survey from 2/20/25 to 2/27/25 the facility did not ensure that needed services, care and equipment were provided to assure that resident with limited range of motion and mobility to maintain or improve function based on the residents' clinical condition for 1 of 4 residents reviewed for position mobility. Specifically, a resident #36 had limited range of motion in their lower extremities was observed to have right or left foot dangling off the foot pedal of their wheelchair, not appropriately positioned on the foot pedal. The findings are: Resident #36 was admitted to the facility, with diagnoses that included , Diabetes, Cerebral Vascular Accident, and Anxiety Disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident was independent in cognition. The MDS further documented the resident had limited range of motion in bilateral lower extremities. The 2/7/25 Comprehensive Care Plan (CCP) titled Need for restorative Occupational Therapy documented inability to self function as evidenced by decreased muscle strength. There was no documentation occupational therapy evaluated resident's wheelchair for proper positioning. The 2/7/25 Physician's order documented Occupational evaluation and treatment for wheelchair mobility. The 2/7/25 Occupational Therapy evaluation and treatment notes documented Resident #36 was evaluated for wheelchair mobility to increase strength for self-propelling wheelchair. There was no documentation of resident #36 being assessed for proper positioning in wheelchair. There was no documentation of wheelchair being assessed for repairs. On 2/21/25 at 12:18 PM, Observed resident #36 in their wheelchair at dining room table. The resident's right foot was dangling behind foot pedal. Resident was struggling to place it back on the foot pedal started to move foot but never placed it on the foot pedal of the wheelchair. On 2/21/25 at 12:38 PM, Observed resident #36 with right foot hanging off foot pedal of wheelchair. On 2/26/25 at 12:31 PM, Observed resident #36 observed with left foot hanging foot pedal and dangling while sitting in their wheelchair while in the dining room. On 2/26/25 at 4:50 PM, Occupational Therapist #13 stated the resident was asking about a new chair and stated they would be more comfortable in a bariatric broad wheelchair. Occupational Therapist #13 stated instead of downgrading the chair that would make them more dependent they put the resident on program to help get the resident to increase their mobility in the wheelchair and better propel themselves. Observed wheelchair with Occupational Therapist #13 left foot pedal has foot box to prevent foot from dropping because resident #36 had a left foot ankle inversion. The right foot has no inversion, so it didn't have a foot box. Occupational Therapist #13 stated the phalange is not set up the same on both sides and is not working correctly something needs to be fixed. Occupational Therapist #13 stated the phalange will not clip fully allowing foot pedal to swing out to the side and why resident would have trouble keeping foot in place. The left foot box on foot pedal was out of position and needed to be fixed. On 2/27/25 at 12:50 PM, Certified Nurse Aide #14 stated resident #36 never complained they were uncomfortable in the wheelchair. Certified Nurse Aide #14 stated they noticed the residents left foot pedal was swinging out yesterday and not locking. Certified Nurse Aide #14 stated they did not report it to anybody. On 2/27/25 at 1:05 PM Occupational Therapist #13 stated nursing staff usually would verbally report when a wheelchair is in need of repair, but did not receive any report from nursing. Occupational Therapist #13 stated they have no official rounding schedule for assessing wheelchairs and no documented audits. 483.25(c)(2)

Based on observation, record review and interview during the Recertification Survey conducted from 2/20/25 through 2/27/25, the facility did not ensure each resident received adequate supervision to prevent accidents and/or the residents' environment remained as free of accident hazards as possible for 2 of 10 residents (Residents #183 and #242) reviewed for accidents. Specifically, 1. Resident #183 was at risk for elopement related to wandering in and out other resident's rooms, roaming, trying to open exit doors and get in the elevator without staff supervision and 2. Resident #242 sustained falls on 11/15/24, 11/27/24, 1/10/25, 1/19/25 and 1/25/25. The findings are: Resident #183 was admitted with diagnoses including but not limited to non-Alzheimer's dementia, traumatic brain dysfunction, and seizure disorder. The 12/6/24 Care Plan titled Risk for Victimization documented encourage resident to attend specific task/activity of interest, separate from others as needed and engage in task/activity of interest, visual checks as indicated per protocol and plan of care, and keep resident at a safe distance from aggravating factors. The 12/16/24 Care Plan titled Dementia/Cognitive loss documented establish a consistent daily routine. The 1/31/25 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #183 had severely impaired cognition, was independent with mobility, and required partial assistance with toileting and personal hygiene. During observation on 2/20/25 at 11:48 AM, without staff supervision Resident #183 ambulated with a walker in the unit hallway and entered Resident #27's room (dependent with self-care abilities) Resident #183 stood in front of the closet located to the left of the room door looking over at Resident #27. Resident #27 screamed get out, get out, get out Resident #183 continued to stand in Resident #27's room, then exited the room and ambulated with a walker down the hallway. At 11:51 AM Resident #183 ambulated with a walker back down the hall and reentered Resident #27's room. Resident #27 yelled get out, get out, please get out. Certified Nurse Aide #19 entered Resident #27's room and redirected Resident #183 to exit Resident #27's room. At 12:03 PM Resident #183 ambulated with the walker down the hallway, without supervision entered Resident #27's room, left Resident #27's room and then proceeded to ambulate unsupervised into aother resident room. During observation on 2/20/25 at 2:30 PM, without staff supervision and without a walker Resident #183 was holding onto Resident #47's wheelchair while pushing Resident #47 who was sitting in the wheelchair down the unit hallway. During observation on 2/20/25 at 2:41 PM, without supervision Resident #183 ambulated with a walker, opened and entered Resident #151's room. During observation on 2/21/25 at 11:34 AM, without supervision Resident #183 ambulated in the hallway with a walker, stopped and attempted to open the stair 2 fire exit door. During an interview on 2/26/25 at 3:43 PM, Certified Nurse Aide #19 stated they always tried to stop and redirect Resident #18 from wandering into other residents' rooms. Certified Nurse Aide #19 stated Resident #183 thought they once worked at the facility. Certified Nurse Aide #19 stated Resident #19 refused to participate in morning activities most of the time. During an interview on 02/27/25 at 10:31 AM, the Recreation and Activities Director stated Resident #183 preferred to participate in afternoon activities. They stated Resident #183 liked social activities, coloring, watching TV, and received a lot of pastoral care. They stated unfortunately Resident #183 had a short attention span and would often leave the room in the middle of activities. During an interview on 02/27/25 at 10:37 AM, Licensed Practical Nurse #183 stated staff kept an eye on Resident #183 as much as they could and tried to engage them in activities. Licensed Practical Nurse #18 stated they were aware Resident #183 entered other resident rooms. They stated it was hard to prevent the resident's wandering due to advanced dementia. They stated if they had more staff, better supervision would be provided. 2. Resident #242 was admitted with the diagnosis of Huntington's Disease. The Comprehensive Care Plan titled Risk for Falls initiated on 10/28/24 documented gait balance problems/neurological disease. Stationary chair removed from room for safety, provide obstacle free environment, refer to rehabilitation as needed, provide assistance when walking to the room after meals. The Annual Minimum Data Set (a resident assessment tool) dated 11/6/24, documented Resident #242 had moderate cognitive impairment, used a walker for ambulation with moderate assistance and required moderate assistance with transfers. The Physician Order dated 12/6/24 documented physical therapy with frequency per rehabilitation. During observation on 2/21/25 at 12:25 PM Resident #242 with an unsteady gait ambulated with a walker, unassisted out of the dining room and into the hallway. During observation on 2/24/25 at 12:54 PM Resident #242 with an unsteady gait ambulated with a walker, and unassisted in the hall to their room after lunch. During interview on 2/25/25 at 12:58 PM Licensed Practical Nurse #10 stated Resident #242 no longer required assistance with ambulation. During interview on 2/26/25 at 5:35 PM the Assistant Director of Nursing stated there was no documentation in the care plan to indicate assistance when walking to the room after meals had been discontinued. The 2/26/25 Progress Note documented Resident #242 had a fall due to an abrupt turn, and loss of balance. During interview on 2/27/25 at 4:35 PM the Director of Nursing stated there should be a note correlating the removal of any intervention from the care plan. During interview on 2/27/25 at 10:19 AM Unit Manager #11 stated Resident #242 was not oriented to the unit at the time of admission and that was why the care plan interventions included staff assistance. Unit Manager #11 stated Resident #242 wandered less now to find their room and the intervention was no longer needed. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification Survey initiated on 2/20/2025 and completed on 2/27/2025 the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible for one (Resident #112) of one resident reviewed for bowel and bladder. Specifically, Resident #112 was not assessed and care planned to improve and restore continence to the extent possible. Findings include: The facility Policy and Procedure, dated 11/1/2026, titled Clinical Bladder Management, documented it is the policy of the facility to assess each resident's bladder continence status on a defined schedule. This assessment will enable the staff to implement a resident-specific re-training, toileting program that addresses the individual's bladder function needs. Resident #112 had diagnoses including fracture of the left patella, cellulitis, and hypertension. The admission Minimum Data Set (an assessment tool) dated 2/5/25 documented the resident's cognition was intact, they required supervision with eating, and substantial to maximal assist with all other activities of daily living. The resident's bowel and bladder status was documented as frequently incontinent. The Nurse admission assessment dated [DATE], documented the resident was occasionally incontinent. The Activities of Daily Living documentation revealed the resident was incontinent of bladder on 2/1/25,2/5/25, 2/7/25, 2/9/25, 2/10/25, 2/11/25, 2/13/25, 2/16/25, 2/21/25, and 2/25/25. The Activities of Daily Living Care Plan dated 1/30/25, documented the resident required extensive assistance for toilet hygiene and toilet transfers. The care plan did not include a voiding diary or a toileting program. During an interview on 02/21/25 at 11:39 AM, Resident #112 stated the facility had them wear a pullup, and they did not like to wear a pullup. They stated before they came to the facility, they were able to use the bathroom and had no accidents. They stated they would like to be able to use the bathroom and not wear a pull up. They did not recall being on a toileting schedule or being encouraged to use the bathroom every 2 hours. During an interview on 02/25/25 at 1:25 PM, Registered Nurse #2 stated if a resident had a new onset of incontinence, they would expect to complete an assessment and complete an incontinence care plan. They were unsure why the resident did not have a care plan for incontinence. During an interview on 02/25/25 at 04:45 PM, the Assistant Director of Nursing stated they were unsure why the incontinence care plan or a toileting program was not created for Resident #112. During an interview on 02/26/25 at 1:54 PM, Certified Nurse Aide #33 stated they usually toileted all residents every 2 hours on rounds. Resident #112 knew when they needed to go to the bathroom and rang the bell for assistance. They stated Resident #112 was put on a toileting program yesterday. 10NYCRR-415.12(d)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the recertification survey from 2/20-2/27/2025, the facility did not ensure that 1 of 3 residents (Resident # 93) reviewed for nutrition were monitored within acceptable parameters for nutritional status. Specifically, Resident #93's weight loss a 7.5% in three months, and a 13% weight in four months was not addressed. Additionally, the resident's weight was not recorded for the last 2 months. The findings include: Resident #93 had diagnoses that included Huntington's Disease, Dysphagia, and Disturbances in Salivary Secretion. Resident MOLST dated 1/27/2018 documented no limitation on medical interventions and long-term feeding tube if needed. Annual Minimum Data Set, dated [DATE] documented severely impaired cognition, dependent on assistance for activities of daily living, no swallowing disorder, no significant weight loss, height 65 inches, 134 pounds. The registered dietician's note dated 8/30/24 documented the resident weighed 134.4 pounds, remained within their usual weight range, and was the same as 6 months prior. They were fed by staff, on a puree diet and received Hi Cal and Ensure Plus. The plan was to continue the current plan of care to support weight maintenance. Comprehensive Care Plan for Nutrition updated 8/30/2024 documented the goal for Resident #93 was to maintain weight of 135 +/- 3% Quarterly Minimum Data Set, dated [DATE] documented severely impaired cognition, dependent on assistance for activities of daily living, no swallowing disorder, no significant weight loss, height 65 inches, 123 pounds. (The MDS did not document the 7.5% weight loss since the Annual MDS on 8/28/24). Review of the resident's record revealed no notes by the Registered Dietician after 8/30/24 and no evidence the weight loss was addressed. Weights for Resident #93 documented a 13.1% loss in 4 months from August to December 2024 and included the following: 8/06/24 134.4 pounds, 9/6/24 128 pounds, 10/4/24 122.8 pounds, 11/6/24 123.6 pounds, and 12/6/24 116.8 pounds. There was no documented evidence of weights for Resident #93 in January or February 2025. Meal Acceptance History for Resident #93 from August 2024 until February 2025 documented intake 0%-100% for meals with the majority documented as 100%. During an observation on 02/21/25 at 8:58 AM, Resident #93 observed in dining room, assisted by staff eating breakfast. Resident #93 needed to be roused to eat and had very poor intake. During an interview on 02/26/25 at 1:54 PM, Registered Nurse Unit Manager #11 reviewed Resident #93's electronic medical record and stated that Resident #93 had a weight loss from September to December 2024. The stated the dietician tracked the weights and was unaware the resident had no recorded weights for the last two months. During an interview on 02/27/25 at 11:36 AM, Registered Dietician #20 confirmed the last weight recorded for Resident #93 was on 12/6/24. No weights were recorded in the electronic medical record for January or February 2025. They stated nursing obtained the weights and they reviewed them and requested reweights as needed. They stated they requested that Resident #93 be reweighed in January and February, but it was not done. They stated they had not documented nutritional notes or put additional interventions in place because they were still waiting for the reweights. 10NYCRR 415.12(i)(1)

Based on observations, record review, and interviews conducted during the recertification and abbreviated (NY00368899) surveys from 2/20/25 to 2/27/25, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1) on sixty-nine (69) of ninety-six (96) shifts the facility did not provide the minimum number of staff documented in the facility Minimum Staffing Standard Matrix, and on nine (9) of thirty-two (32) night shifts the facility did not provide the minimum number of staff documented in the general staffing plan in the Facility Assessment, and several staff stated resident's care and resident's meals were delayed when they were short staffed, 2) observations were made of unsupervised residents on the dementia unit and 3) lunch was served late on the 3rd floor. Findings include: The facility Minimum Staffing Standard Matrix levels documented the facility staffing should include 3 certified nurse aides on all units on day shift and evening shifts, and 2 certified nurse aides on all units on night shift. On Sixty-nine (69) of ninety-six (96) shifts reviewed, from 1/19/25 to 2/20/25, the facility did not provide the minimum number of staff documented in the facility Minimum Staffing Standard Matrix. The general staffing plan in the 1/14/2025 Facility Assessment documented the staffing was based on acuity and census. It documented 3-4 certified nurse aides to 66 residents on the neurodegenerative unit on the night shift. On nine (9) of thirty-two (32) night shifts reviewed, from 1/19/25 to 2/20/25, the facility did not provide the minimum number of staff documented in the general staffing plan in the Facility Assessment. On 02/24/25 at 10:50 AM during an interview and review of the facility minimum staffing levels and 30 days of facility staffing from 1/19/25 to 2/20/25 with the Staffing Manager, they stated 2 Certified Nurse Aides should be working on each unit on night shift, and 3 Certified Nurse Aides should be working on each unit on day & evening shift. On 02/24/25 at 4:12 PM during an interview with the facility Administrator, they stated they used the general staffing plan in their 1/14/2025 Facility Assessment for their staffing minimums, which was based on acuity and census. The facility Administrator stated it was not ideal for any unit to drop below 2 Certified Nurse Aides on the night shift. During a review of the actual staffing from 1/19/25 to 2/20/25 with the facility Administrator, nine (9) night shifts were identified when there was only 1 Certified Nurse Aide working on a unit, which included 2/20, 2/18, 2/15, 2/14, 2/9, 2/8, 2/4, 2/3, and 2/2/25. On 02/25/25 at 1:01 PM during an interview, Licensed Practical Nurse #1 stated they worked the night shift. They stated they often were mandated to stay for the day shift against their will. They stated they were not a day person and when they were mandated, they were tired, and it was difficult for them to complete their work. They stated on night shift, at least 4 times per month, they work with only one Certified Nurse Aide although there should be 2 Certified Nurse Aides on the night shift. They stated that working with only one Certified Nurse Aide had a negative impact on the residents. Residents had to wait for assistance, and there were safety concerns depending on the acuity and behaviors of particular residents. They stated they were only able to assist the Certified Nurse Aide sometimes, as it depended on the residents' health and behaviors. They further stated the nursing supervisors did not come up to assist unless they were called for a concern. On 02/25/25 at 6:07 PM during an interview, Certified Nurse Aide #5 stated they work all 3 shifts. They stated they had worked short often lately, they worked alone on the night shift sometimes, and lately worked with only one other Certified Nurse Aide on the evening shift. They stated that short staffing affected the residents on night shift as the staff did not get any residents out of bed when they were working without another Certified Nurse Aide. They stated that more than 10 residents on Unit 2B were dependent on staff for assistance. On 02/25/25 at 6:16 PM during an interview, Certified Nurse Aide #6 stated they work nights. They stated they have been the only Certified Nurse Aide working on the night shift with one nurse a few times in the past month. They stated short staffing affects the residents on night shift because they do not get any residents out of bed when they are the only Certified Nurse Aide working that shift. They stated residents are not assisted with toileting timely when they are the only Certified Nurse Aide working that shift. On 02/25/25 at 06:22 PM during an interview, Certified Nurse Aide #7 stated they worked fulltime evening shift. They stated they had worked with only one other Certified Nurse Aide and one nurse on the evening shift. They stated having only 2 Certified Nurse Aides affected the residents because the residents were not provided assistance with toilet use timely, dinner was delayed, and transferring residents to bed was also delayed. They stated the nurse helped with the dining room but did not assist with resident care. They stated that approximately 14 residents required 2 staff assistance with transfers with mechanical lifts. On 02/25/25 at 06:27 PM during an interview, Certified Nurse Aide #8 stated they were the only Certified Nurse Aide working with one nurse on night shift and the residents were not assisted with toilet use timely and no residents were assisted out of bed. On 02/27/25 at 09:35 during a follow-up interview, the Staffing Manager stated they utilized the Minimum Staffing Standard Matrix for staffing and strived to have 2 Certified Nurse Aides on night shifts. 2) On 02/26/25 from 01:12 PM until 01:32 PM an observation was conducted on Unit 2B (the Dementia Unit). No staff was observed in the day room supervising 20 residents. Residents were observed appearing confused and unable to find seats. On 02/26/25 at 10:05 AM during an interview, Licensed Practical Nurse Unit Manager #9 stated sometimes they only have 2 Certified Nurse Aides on the dementia unit on day shift, and they always needed 3 Certified Nurse Aides. 3) During a lunch observation on 02/25/25 the following was observed: - at 12:46 PM, dietary staff was prepping meal trays for resident rooms on unit 3A and the last lunch tray was observed being delivered to a resident in the 3A dining room. - at 12:49 PM all trays were delivered in the 3B dining room. - at 12:57 PM, Resident #91 was standing in hallway by their room and stated they were hungry. - at 1:17 PM, Certified Nurse Aide #25 delivered a lunch tray to Resident #91. When interviewed on 02/25/25 at 1:21 PM Certified Nurse Aide #25 stated they were unaware Resident #34 took their own tray from the cart and said staff should be delivering the trays. On 02/26/25 at 11:53 AM during an interview, Dietary Aide #22 stated they usually arrived to unit around 11:45 AM to prep the food and put it on the steam table. Nursing staff brought the residents into the dining room and delivered the trays. They stated meals were delayed when nursing was short staffed. On 02/26/25 at 11:56 AM during an interview, Certified Nurse Aide #23 stated meals were delayed when nursing was short staffed or when they had to wait for the nurse to finish giving medications. Certified Nurse Aide #23 stated the Unit Manager was on leave and there was no organization on the unit with the Unit Manager out. 10NYCRR 415.13 (A)(1)(i-iii)

Based on observation and interview conducted during the recertification survey from 2/20/25 to 2/27/25, the facility did not ensure specific food items were maintained in accordance with professional standards for food safety and infection control prevention. Specifically, opened and not dated potentially hazardous foods were observed in one of the refrigerators and the dry pantry, and 3 of 4 dietary aides were observed wearing disposable gloves for meal service and did not change gloves after touching other non-meal service objects. The findings are: The facility policy last revised on 1/2025, 'Production, Purchasing, Storage: Food and Supply Storage' included documentation procedure to cover, label and date unused portions and open packages, using Medvantage/Freshdate labeling system. The facility policy last revised on 1/2024 'Sanitation and Infection Prevention/Control: Disposable Glove Use' included documentation procedure disposable gloves must be changed, and hands washed when moving from one task to another. The initial tour of the kitchen was conducted on 2/20/25 at 10:31 AM. The following items were observed: An opened, undated container of thickened milk in the refrigerator. An opened, undated bag of powdered sugar, wrapped with plastic wrap in dry storage. The Food Service Director was interviewed at that time of observation and stated they were unaware the two items were not dated after opening according to facility policy. On 2/21/25 at 11:45 AM Dietary Aide #26 on unit 5A was observed taking temperatures of food on tray line wearing disposable gloves. They held the ink pen and clipboard to write the temperatures while wearing the gloves, placed gloved hand on the wall while waiting for thermometer to register the temperature, and lifted the garbage lid to dispose of paper while wearing disposable gloves. Dietary Aide #26 continued to wear the disposable gloves to begin meal service. On 2/24/25 at 11:43 AM Dietary Aide #27 on unit 3A was observed taking temperatures of food on tray line wearing disposable gloves. They held the ink pen and clipboard to write the temperatures while wearing the gloves, touched door handle to leave the serving area, and then opened the refrigerator door to obtain bread while wearing disposable gloves and then returned to begin meal tray preparation. On 2/25/25 at 12:15 PM during dining observation on unit 5A, Dietary Aide #28 stop plating food for meal service, answered the phone, holding the telephone receiver wearing disposable gloves, and then continued to serve the meal without changing gloves. On 2/27/25 at 1:54 PM during an interview, the Food Service Director stated all dietary staff had been in-serviced on disposable glove use. Staff should have known to change gloves whenever moving from one task to another and when serving food on the resident units per policy on disposable glove use. 10 NYCRR 415.15(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, conducted during an abbreviated survey (NY00355382 and NY00362103), the facility did not provide adequate supervision/monitoring to prevent accidents for 2 of 3 residents (Resident #1 and #3) reviewed. Specifically, on 9/3/2024 Resident reported they were bumped by the elevator door [NAME] exiting and reported pain 3 out of 10 to their right hip. 2) On 9/30/2024 while exiting the core elevator on the 4th floor, the elevator door closed hitting Resident #1's right hip causing pain and discomfort. 2) On 11/25/2024, Resident #3 was found inside of the facility housekeeping closet on the 4th floor. Facility investigation revealed the housekeeping door was unsecure due to the striker plate being broken. Resident #3 who had a history of wandering behaviors, was able to gain entry to the unit 4A utility closet due to a screw being loose on the striker plate which prevented the door from closing and locking as expected. Findings include: The facility's policy on Accidents and Supervision dated 6/17/2021 documented the resident's environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents. The purpose of this policy is to prevent injury to the resident. Resident #1 had diagnoses that included Alzheimer's Disease, Type 2 Diabetes Mellitus and Hypertensive Heart Disease and a history of Right Hip Surgery. The Minimum Data Set (MDS, an assessment tool) dated 1/2/2025, documented the resident had a Brief Interview for Mental Status assessment (BIMS, used to determine attention, orientation, and ability to recall information) score of 7/15, associated with severe cognitive impairment. Resident #1 was independent with bed mobility and with walking with a rollator/walker and required occasional supervision or touching assistance with transfers, bathing and dressing. Review of Resident #1's Care Plan dated 9/5/2024 documented interventions that included monitor and report pain. Review of the Nurse's Progress note written by Licensed Practical Nurse #3 on 9/5/2024 at 1:53pm documented that at approximately 12:00pm, Resident #1 complained of a pain in their right hip area, which they felt during ambulation. Upon interviewing Resident #1, they stated that the pain was a result of an incident that occurred on 9/3/2024 during the day shift, where the elevator closed into their right hip. Resident #1 has a history of hip replacement in that hip. Review of the Nurse Practitioner Progress Notes written by Nurse Practitioner#1 on 9/5/2024 documented trauma to right hip. Residents #1 reported worsening pain to right hip with trauma from elevator. Resident #1 also reported having hip surgery on the right hip in the past and denied any fall during the elevator incident. No external rotation noted or difference with the length to the right leg. Reported slight discomfort rated 3/10, full range of motion without issues, ambulating well. An order for x-ray of the right hip for further assessment and planning to rule out fracture versus dislocation versus malfunctioning with hardware from possible hip surgery in the past. Review of the X-ray results dated 9/16/2024 revealed no radiographic evidence of acute fracture or dislocation. Review of the Accident/ Incident Report dated 9/5/2024, documented that Resident #1 reported to Licensed Practical Nurse #3 that they were feeling pain of 3/10, to the right hip. Resident #1 stated that they had gotten bumped by the elevator door earlier. No bruising was present. Nursing will monitor and medicate Resident #1 for pain. No evidence of abuse, mistreatment, or neglect. The facility plans to prevent reoccurrence included to remind Resident #1 to report any discomfort to nursing staff. Review of the Accident/Incident Report dated 9/30/2024 documented Resident #1 reported to Licensed Practical Nurse #2 they were attempting to exit the elevator and was bumped by the door on the right hip. Resident #1 has a history of pain to this area and multiple hip replacements. Plan was for elevator sensors to be cleaned, and this was completed on 9/30/2024. Review of the Nurse's Progress note written by Licensed Practical Nurse #2 on 9/30/2024 at 3:20pm, documented that Resident #1 reported to Licensed Practical Nurse #2 that they were riding the core elevator with a large group of people. When the resident needed to exit on the fourth floor, the group of people exited the elevator and Resident #1 was the last to exit. As they exited, the elevator door bumped on their right hip. Resident #1 complained of mild discomfort. All elevator sensors were cleansed by housekeeping. Review of Resident #1's Care Plan dated 9/30/2024 revealed interventions that included an order for Occupational therapy ordered for discomfort following being bumped by elevator door. During an interview conducted on 1/14/2025 at 2:05pm, the Social Services Director stated Resident #1's cognition had declined in the last couple of years. Resident #1 is now using the rollator all around the building. Resident #1 visits other residents and goes to activities. Resident #1 uses the elevator by the coffee shop and does not have a wander guard. The Social Services Director stated they were not aware of the elevator incident that happened September 2024. During an interview conducted on 1/14/2025 at 2:37PM, Resident #1 stated I think my room number is forty something. I have been living here for more than 10 years and I have never had to look at the number of my room, I just know where to come back to. Resident #1 stated they walk around the building with their walker and when asked which elevator they used, Resident #1 stated the elevator to the left (pointing to the unit 4B elevator). Resident #1 reported that they had pain to the right hip, and it came from the elevator doors hitting them one of the days when they were exiting the elevator When asked if the elevator doors had closed on them recently, Resident #1 responded no it hasn't happened again, and I am happy with the care I receive from the staff. During an interview with the Director of Support Services was conducted on 1/17/2025 at 3:42pm they stated they were not aware of the two elevator incidents that occurred in September 2024 involving Resident #1. They were only notified of these elevator incidents yesterday (1/16/2025). If they were aware of an issue with an elevator, the process would be to key out or lock the elevator to prevent access and call the company that does repairs and maintenance, so they can come out and fix the problem. This will be documented on the facility service log. The Director of Support Services stated they did not know why they were not informed of these incidents with the elevator. During an interview conducted on 1/17/2025 at 4:26pm, the Director of Nursing was asked why the Director of Support Services was only notified yesterday (1/16/2025) of the elevator incidents that occurred on 9/3/2024 and 9/30/2024. The Director of Nursing stated they were not sure how the incident was not reported to the Director of Support Services. During a follow up telephone interview with the Director of Nursing conducted on 1/22/2025 at 12:15pm they stated the Director of Support Services oversees the Maintenance, Housekeeping and Engineering Departments. When asked if Director of Support Services was the staff that would have been notified of the elevator incidents that happened in September 2024, the Director of Nursing stated yes, they would be the person to be notified. 2)Resident #3 had diagnoses that included, Severe Dementia with agitation, Fracture of the left clavicle and Seizures. The Minimum Data Set (MDS, an assessment tool) dated 11/13/2024, documented a Brief Interview for Mental Status assessment (BIMS, used to determine attention, orientation, and ability to recall information) score of 3/15, associated with severe cognitive impairment. Noted with behaviors present. A review of the discharge Minimum Data Set assessment dated [DATE], documented the resident was dependent with toileting, bathing and dressing and required supervision with transfers and walking. Review of the Medication Administration record for the month of 11/2024, revealed that the order for Wristband Placement, every shift, was ordered on 11/4/2024 and discontinued on 11/20/2024 and the order for Behavior/Intervention Charting, every shift, was ordered on 11/4/2024 and discontinued on 11/20/2024. Review of the Elopement Risk assessment dated [DATE], documented that Resident #3 had a score of 8.00, which translated to high risk for elopement. Resident #3's documented elopement risk factors were: Resident is cognitively impaired or demonstrated impaired decision making, resident verbalized they want to go home and was independently mobile. Review of the Physician's Orders revealed that an order for Wander guard Placement/Function to left wrist, every shift was ordered on 11/26/2024. Review of the Behavior note written by Licensed Practical Nurse #5 dated, 11/8/2024, documented that Resident #3 was removed from another resident's room at approximately 11:00pm. Review of the Behavior note written by the Assistant Director of Nursing, dated, 11/9/2024 documented that Resident #3 was wandering into other residents' rooms, this puts the resident at significant risk for physical illness or injury, this puts other at risk for physical injury and significantly intrude on the privacy or activity of others. Review of the Behavior note written by Licensed Practical Nurse #7 dated, 11/10/2024, documented that Resident #3 displayed behaviors of physical and verbal aggression towards caregivers, peers and visitors, excessive agitation and verbal disruption. This behavior impact on Resident #3 puts the resident at significant risk for physical illness or injury, significantly interferes with the resident's care and significantly interferes with the resident's participation in activities or social interactions. This behavior impact on others: puts others at risk for physical injury, significantly intrude on the privacy or activity of others and significantly disrupt care or living environment. Review of Resident #3's care plan dated, 11/22/2024 was reviewed and interventions included the resident ambulates independently (walking 150 feet) with no assistance from a helper. Resident #3 was noted with behavior symptoms of wandering on the unit and other units and into peers' rooms and interventions included to ensure proper placement and function of ankle alert. Review of the Elopement Risk assessment dated [DATE] documented Resident #3 had a score of 7 indicating the resident was at risk for elopement. Resident #3's elopement risk factors included the Resident exhibited wandering behavior and was independently mobile. Review of Resident #3's care plan dated, 11/23/2024, noted that Resident #3 was at risk for elopement related to wandering and roaming as evidenced by pacing, roaming or wandering in and out of peers' rooms; becoming agitated, oppositional and combative when re-directed; with noted interventions, assess for potential elopement, provide simple, clear directions and to use electronic monitoring devices. Review of the Accident/Investigation form signed statement by Certified Nurse Assistant #2 on 11/25/2024 stated, I was handed the dinner trays. I thought Resident #3 was behind me. I said, come and eat. I heard, no. Yes, I did not look behind me to see. I finished doing the trays and seen the child of Resident #3 come out of the bathroom and asked me where Resident #3 was, then I began to look for Resident #3. Review of the Accident/Investigation statement signed by Certified Nurse Assistant # 3 on 11/25/2024, stated, Around 5pm, the child of Resident #3 came looking around so I ask who they are looking for and I advised them to check the other residents room and they still weren't able to locate so I started check the rooms on unit 4A and 4B, the 3rd, 2nd and 1st floor even the ground floor while calling Resident #3's name and still nothing. So, I called the other aide and asked if they found Resident #3 and the other aide told me that they found Resident #3 in the housekeeping closet. So, I rushed there and saw the other aide re-directing the resident. I assisted Resident #3 to his room, cleaned the resident and put the resident to bed. Then I carried juice and a snack to Resident #3 though the resident was looking sleepy. I apologized to the resident's child and then left the room. Review of the Hospital Discharge Records dated 11/25/2024, revealed that Resident #3 was assessed in the Emergency Department on 11/25/2024 at 7:40pm. the Emergency Department physician documented Work up is not suggesting acute process, no Urinary Tract Infection (UTI), showing only chronic issues. It was decided that resident may return to the facility. Review of the Investigation Summary dated 12/2/2024, documented that on 11/25/2024 at around 5:55pm, Resident #3 who had a history of wandering behaviors, was able to gain entry to the unit 4A utility closet due to a screw being loose on the striker plate which prevented the door from closing and locking as expected. During the investigation, a facility maintenance staff checked the door to the 4th floor utility room to determine how Resident #3 was able to open it and maintenance staff discovered that the striker plate had a loose screw. During an interview with Housekeeper #2 on 1/17/2025, at 12:15pm, stated there are no chemicals kept in the housekeeping closet anymore because a resident was found in this closet a couple of months ago. The chemicals are now stored on the ground floor. During an interview with the Director of Admissions on 1/17/2025, at 1:02pm, they stated If we are admitting a resident with behaviors, we speak to the staff specifically the unit manager, if not, the nurse for that room, even with residents we are re-admitting. During an interview with the Director of Support Services on 1/17/2025 at 3:42pm stated they were notified of Resident #2 been found in the housekeeping closet at 7:00pm on 11/25/2024. It was the 4th floor housekeeping closet. The evening shift maintenance staff discovered that the striker plate was sticking out and it was loose. The Director of Support Services confirmed that all chemicals have now been moved to the ground floor to ensure residents' safety. The striker plate was repaired and the closet remains locked with no chemicals stored. 10NYRCC 415.12(h)(2)

Based on observation, interview, and record review conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure residents had a right to a dignified existence in an environment that promotes maintenance or enhancement of their quality of life. Specifically, Resident #133 was observed on multiple occasions, not shaved with a large amount of facial hair, and hair on the head was disheveled. The findings are: Resident # 133 was admitted to the facility with diagnoses including Alzheimer's disease, diabetes mellitus, and history of traumatic brain injury. The 02/17/24 Quarterly Minimum Data Set ( an assessment tool ) documented Resident #133 had severely impaired cognition, required partial assistance with personal hygiene, and had no behavioral symptoms and no rejection of care. The comprehensive care plan titled impaired activities of daily living, dated 1/18/22, documented Resident #133 would remain clean, neat, dressed appropriately for the season and free of body odor. Interventions included Resident #133 would be provided privacy, and dignity was to be always preserved especially during care. On 03/13/24 at 10:47 AM, Resident #133 was observed sitting in dayroom not shaved with a full whitish grayish beard and goatee, and disheveled hair. On 03/14/24 at 12:55 PM, Resident #133 was observed sitting in the dining room eating lunch with disheveled hair, and unshaved with a full whitish grayish beard and goatee. During an interview on 03/20/24 at 01:13 PM, Staff #10 (certified nurse aide) stated that Resident #133 was supposed to be shaved on shower days and as needed, and that Resident #133 used to be temperamental but had gotten better over the years. Staff #10 stated Resident #133 did allow staff to shave them and that it was not acceptable for them have a full beard. During an interview on 03/20/24 at 01:24 PM, Assistant Director of Nursing #1 stated that Resident #133 could either be shaved by the beauty parlor or certified nurse aides, and that there was no reason that Resident #133 should have any hair on their face unless it was their preference, and that they were unaware of Resident #133 refusing to be shaved. 10 NYCRR 415.5(a)

Based on observation and staff interviews during the recertification survey from 3/13/24 to 3/29/24, the facility did not maintain a homelike environment for 4 of 8 rooms observed on unit 5B. Specifically, for Residents #154, #210, #135 and #131, observations were made of ripped and peeled protective padding in bathrooms, particles of food and other debris on the floor, dirty adult briefs on the floor, and a toilet paper dispenser with fecal remains dried on over a period of 6 days. Findings include: On 3/13/24 at 11:16 AM, Resident #210's bathroom, located on unit 5B, was observed with an adult brief soiled with urine and feces lying on the floor. Feces were observed on the toilet and the toilet paper dispenser. A soiled gown was observed on the floor. A heavy urine odor was noted in the room. The resident's bed headboard was observed with protective padding that was ripped, peeling and damaged. On 3/13/23 at 3:33 PM, Resident #210's bathroom was observed with the soiled adult brief still on the floor. The feces were still on the toilet and the toilet paper dispenser and a soiled gown was observed still lying on the floor. On 3/19/24 at 9:52 AM, Resident #210 room and bathroom was observed with dried stains on the floor, food and other particles on the floor, and the room had a strong odor of urine. The bathroom was observed with feces still caked on toilet paper dispenser and had a heavy urine odor. When interviewed during the observation, the resident was asked if the room was cleaned, and they stated no. On 3/13/24 at 11:20 AM, Resident #135's bathroom, located Unit 5B, was observed with protective padding on sink that was ripped and peeling. On 3/19/24 at 9:50 AM, Resident #131's bathroom, located on Unit 5B, was observed with protective rail padding that was peeling, and particles from the peeling were observed on top of the toilet paper dispenser. On 3/19/24 at 11:04 AM, Resident #154's bedroom, located on Unit 5B was observed to have food and other particles on the floor. On 3/19/24 at 11:08 AM, the Director of Housekeeping observed the aforementioned rooms with the surveyor and stated they were not sure why the floors were not cleaned but stated it could have happened after the housekeeper was there and particles could have been dropped on the floor after they had already cleaned. The Director of Housekeeping stated they were aware of the peeling padding and stated it was an infection control issue, because the exposed fabric inside cannot be cleaned since it is porous. The Director of Housekeeping stated they were aware of Resident #210's behavior and the staff tried to clean the room as best they could. The Director of Housekeeping stated the resident refused to let them clean the floor, but stated they were aware they should make an effort to clean the room despite their behaviors. The Director of Housekeeping stated Resident #210's bathroom should have been cleaned and no soiled adult briefs should have been left on the floor. The Director of Housekeeping stated they would tell the housekeeper about the soiled toilet paper dispenser and tell them to clean all of the observed rooms. 415.5(h)(2)

Based on observations, record review, and interviews conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure 4 of 5 residents (Residents #114, 161, 216 and 258), reviewed for abuse, had the right to be free from abuse. Specifically, Resident #258 was observed on multiple occasions exhibiting physical and verbal aggression towards other residents including Residents #114, #161 and #216, and the facility did not ensure interventions were implemented to prevent abuse. Findings include: The facility policy titled Clinical, Resident Abuse Reporting and Investigation Protocol, Policy and Procedure dated 1/11/20 and last revised on 8/28/23 documented to protect residents' and ensure freedom from abuse, mistreatment, neglect, misappropriation of property, exploitation corporal punishment and involuntary seclusion. The facility takes all witnessed and/or suspicion of resident/patient abuse, mistreatment, neglect, misappropriation of funds and/or exploitation by anyone including facility staff, other residents, consultants, volunteers, staff of other agencies, family members, legal guardian's, friends, or individuals. The facility will adhere to the federal and state requirements that mandate the reporting of alleged violations of verbal , sexual, physical, or mental abuse. Resident #258 was admitted to the facility with diagnoses including Alzheimer's Disease, major depressive disorder, and metabolic encephalopathy. The At Risk for Victimization Comprehensive Care Plan dated 9/19/23 documented interventions that included separating from others as needed and engaging in task/activity of interest. The Behavior Symptoms Comprehensive Care Plan dated 10/16/23 documented interventions that included identifying the reason for behavior and identifying the pattern of behavior. The Behavior Notes documented: - On 3/6/24 the resident threw objects, hitting staff on the head and physically hit staff twice in the process of verbally redirecting her to a quiet area for her to calm down. - On 3/7/24 the resident was very agitated, upset and crying at start of shift, getting into other residents' personal space, yelling and threw an object at staff when trying to redirect her. - On 3/11/24 the resident was agitated and intrusive in other residents and staff space. - On 3/11/24, the resident was very disruptive during dinner, yelling at staff and residents. Getting in others faces and cursing. Attempts to redirect were unsuccessful. The 3/13/24 nursing progress notes documented the resident was noted with increased pacing and verbal agitation in the morning; and the resident was noted with increased verbal agitation. On 03/13/24 at 10:37 AM, Resident #258 was observed in the hallway near the nurses station calling Resident #161 derogatory names, and stated, I'm going to smack you in the face and proceeded to raise their hand at Resident #161. The charge nurse was nearby and overheard Resident #258 yelling and verbally attempted to move Resident #258 away from Resident #161. On 03/13/24 at 10:40 AM, Resident #258 was observed in the hallway at the nurses station agitated and anxious while yelling at multiple residents. On 03/13/24 at 10:52 AM, Resident #258 was observed in the unsupervised day room in front of Resident #114, touching their face and rubbing their hand, and the resident requested not to be touched. Resident #258 snatched a straw from Resident #114 hand, smacked their hand, then stated I would like to punch you in the throat, and then proceeded to pinch Resident #114's lips and began smacking them with the straw in their face. The surveyor had to summon Staff #50 (Certified Nurse Aide) to the unsupervised dayroom for assistance with the incident. On 03/13/24 at 11:01 AM, Resident #258 was observed walking up to Resident #216 while the resident was sitting in their wheelchair near the nursing station. Resident #258 began to yell at Resident #216, then grabbed their right hand and squeezed it tightly and bent their finger back. Resident #216 was screaming let me go you're hurting me. On 03/13/24 at 11:03 AM, Staff #50 was walking by, and surveyor summoned them to assist with separating Resident #258 and Resident #216. Staff #50, attempted to redirect Resident #258 and as they were walking towards the dayroom, Resident #258 walked towards Resident #114 who was sitting in the nursing station, and stated this the one I really want and proceeded to smack them. On 03/13/23 at 11:05 AM, Staff #50 was observed telling Staff #1(Licensed Practical Nurse) that something needed to be done because Resident #258 was going around smacking people. On 03/13/24 at 11:20 AM, Resident #258 was observed in the hallway near the nursing station and walked up to Resident #216, and told Resident #216 to move out of their way. During an interview on 03/13/24 at 10:40, Staff #1 (l Licensed Practical Nurse) stated Resident #258 was always on edge and that yelling and being agitated was their normal behavior. During an interview on 03/13/24 at 10:46 AM, Staff #1 stated that the residents, even those with behaviors could be alone in the dayroom. During an interview on 03/13/24 at 11:21 AM, Resident #34 stated that Resident #258 was always hitting people and staff did nothing about it. During an interview on 03/13/24 at 12:37 PM, Staff #7 (Certified Nurse Aide) stated that the resident got sent to hospital because she was attacking people. During an interview on 03/14/24 at 11:16 AM, the Director of Nursing stated that when they did rounds on 3/13/24 at 9:30 AM, Resident #258 was pacing and being verbally disruptive, and stated it was their normal behavior. The Director of Nursing stated that they were unaware that Resident #258 lashed out against residents and was only aware that the resident lashed out at staff. The Director of Nursing stated that Staff #1 notified them that Resident #258 was having problems with agitation and increased aggression and stated that they observed resident with increased behaviors and started an investigation. During an interview on 03/14/24 at 11:20 AM, Staff #1 stated that Staff #50 did not report any resident to resident altercation. Review of the Accident/Incidence/Occurrence worksheet for Resident #258 dated 3/14/24 documented it was reported that Resident #258 was in the dayroom standing near Resident #114 and was agitated and tapping resident on the forehead with a straw. Resident was at high risk for behaviors due to dementia with behaviors, and poor judgement. The resident had noticeable change in physical and/or verbal aggression towards others. The resident was noted with increased aggression and agitation towards staff and fellow residents and was sent to the hospital for further evaluation. During an interview on 03/15/24 at 01:24 PM, Staff #50 stated that on 3/13/24 they heard Resident #258 yelling in the dayroom and did not react stating they did not feel it was any different from another day and stated that physically and verbally aggressive behaviors was Resident #258 normal behavior, and when incidents happened in the past, they reported it to the nurse manager. Staff #50 stated that their memory was bad and they did not recall the incident when Resident #258 was physically aggressive towards other residents on 3/13/24. Staff #50 stated that they were unaware of interventions and was not trained on how to approach Resident #258 when exhibiting verbally and/or physically aggressive behaviors, and that they just redirected the resident when there was a behavior. During an interview on 03/28/24 at 06:52 PM, the primary care physician stated they were familiar with the Resident #258's physical and verbal behaviors towards residents and staff and stated the resident was very impulsive. The primary care physician said stated that Resident #258 could be very calm one minute and then physically/verbally aggressive the next minute. The physician stated the resident could become agitated at the smallest things and stated the resident could sometimes be redirected if able to get them out of an aggressive mindsight but sometimes could not. The primary care physician stated Resident #258 was recently physically aggressive to another resident and had to be sent out to the hospital, and then physically aggressive with another resident when they returned from the hospital. The primary care physician stated the behaviors were unavoidable and they could not anticipate when a rage was going to happen. They stated when the behaviors could not be managed the in the facility, the resident was sent out to the hospital. 10NYCRR 415.4(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #218 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, contractures of right and left hand, and dementia. The 02/25/2024 Quarterly Minimum Data Set assessment documented the resident had severely impaired cognition, required setup with eating, and dependent with bed mobility, toileting, and transfers. The 12/11/2023 Quarterly Minimum Data Set documented that Resident #218 had an unhealed Stage 4 pressure injury that was not present on admission. The comprehensive care plan titled Resident has a reopened Stage 4 pressure ulcer to right elbow dated 2/25/24 documented interventions including staff was to always ensure offloading of elbows. The comprehensive care plan titled Activities of a Daily Living dated 4/17/23 documented interventions including elevating the right arm on a pillow to prevent from being tucked underneath resident and causing increase in pressure to right elbow wound. The Activities of Daily Living Care Plan was last reviewed on 3/20/2024 and was not revised to include Resident #218's noncompliance with elevating their right elbow on a pillow to prevent from being tucked underneath and causing increase in pressure to their right elbow wound. On 03/13/24 at 01:38 PM, Resident #218 was observed lying in bed. The were no pillows in place under their right elbow. On 03/19/24 at 11:30 AM, Resident #218 was observed in bed and no pillows was in place underneath their right elbow. During an interview on 03/19/24 at 11:30 AM, Staff #9 (licensed practical nurse) stated that the resident was always in pain and did not like to be touched, and that the resident refused wound care and to have a pillow placed underneath their elbow. During an interview on 03/20/24 at 11:33 AM, Staff #10 (certified nurse aide) stated that Resident #218 was supposed to have a pillow in place under their right elbow and that they would not allow staff to place the pillow underneath their right arm. Staff #10 stated that they notified the nurse when the resident refused the pillow. During an interview on 03/21/24 at 11:47 AM, Staff #18 (certified nurse aide) stated that Resident #218 screamed with care and sometimes it was very difficult to do cares. They stated they had notified the nurse manager. During an interview on 03/21/24 at 11:55 AM, Staff #1 stated that Resident #218 refused cares and that they tried everything including reapproaching the resident, and that refusals were reported to them, and they were supposed to document the refusals. During an interview on 03/21/24 at 12:19 PM, the Assistant Director of Nursing stated that if a resident refused cares, the nurse and certified nurse aide should report it to the nurse manager, and the nurse should document the refusal in their progress notes. The Assistant Director of Nursing stated the care plan should document offloading, and turning and positioning, and be updated to reflect the resident's refusal of care. The Assistant Director of Nursing stated that the blanks in the treatment administration record for offloading elbows at all times every shift indicated that it was not done. During an 03/28/24 05:18 PM, Staff #22 (registered nurse) stated care plans were supposed to be reviewed and revised every 3 months, and as needed. Staff #22 stated if a resident refused wound care and/or pillows used for offloading, the care plan should be updated. 10 NYCRR 415.11(c)(1) Based on observations record review and interviews, during the recertification and abbreviated surveys (NY00306213 and NY00316087) from 3/13/24 to 3/29/24, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1 of 4 residents reviewed for accidents and for 2 of 6 reviewed for pressure ulcers. Specifically, (1) Resident #97 had suicide attempts on 11/23/22 and 11/29/22 and the Care Plan was not updated to reflect the second suicide attempt and was not revised with new interventions to prevent reoccurrence; (2) Resident #432 had a Stage IV pressure ulcer on the sacrum and their Care Plan was not revised with new interventions to reflect resident's current wheelchair being used, and (3) Resident #218 had a Stage IV pressure injury to the right elbow, and the Care Plan was not revised to include Resident #218's noncompliance with having pillows placed underneath their right elbow for offloading, and the Care Plan was not reviewed to determine the effectiveness of the interventions put into place to help promote wound healing. The findings are: 1. Resident #97 was admitted to the facility with diagnoses including Huntington's Disease, post- traumatic stress disorder, and bipolar disorder. The Quarterly Minimum Data Set (an assessment tool) dated 12/20/22, documented the resident had intact cognition. The assessment documented the resident was independent in transfer and bed mobility. The assessment documented that the resident had 1-3 days during this assessment period where resident had delusions/verbal or physical behavioral symptoms, and also documented Resident #97 received 7 days of each of the following medications; antipsychotic, antianxiety, and antidepressant medications. Facility Accident/Incident Reports documented Resident #97 had 2 incidents of attempted suicide dated 11/23/22 and 6 days later on 11/29/22. The Mood State Care Plan created 8/5/22 documented resident had Depression and Anxiety: Altered mood state or feeling depressed; threats of self-harm (cutting/scratching). Resident had a long history of being a victim of abuse and feelings of despair. Interventions documented were to assess and monitor for suicidal tendencies; and remove items in the room that could evoke self-harm. The Mood State Care Plan was updated 11/25/22 with a new intervention to do 15-minute checks. There was no further documented evidence the Mood State Care plan was revised with new interventions after second incident on 11/29/22. On 3/29/24 at 1:02 PM during an interview, Staff #45 (Registered Nurse) stated they did remember the attempted suicide with the air conditioner cord on 11/29/22 but stated they were unsure why the care plan was not updated. On 3/29/24 at 4:13 PM during an interview, the Director of Nursing stated they were not sure why the care plan was not updated regarding the incident on 11/29/22. 2. Resident #432 was admitted to the facility with diagnoses of Neurogenic bladder, Huntington's Disease, and Multiple Sclerosis. The Quarterly Minimum Data Set (an assessment tool) dated 1/19/24 documented resident had moderately impaired cognition and was frequently incontinent of bowel and bladder. Resident was dependent for mobility, transfer and toileting. The assessment further documented 1 Stage IV pressure ulcer not present upon admission or reentry. The Skin Integrity Care Plan created 7/19/23 documented the resident was at risk for skin breakdown or pressure ulcer injury. The following were documented interventions: complete pressure ulcer risk assessment (Braden Scale) and review quarterly and as needed; certified nurse aide inspection daily during care and report any skin abnormalities to nurse; use skin protectant/barrier when performing perineal care; weekly full body skin assessment by nurse; use pressure reducing cushion, Roho cushion when in Broda chair. The Activities of Daily Living Care Plan created 7/19/23 documented the following interventions: resident to sit in Broda chair with Roho cushion and foot box for optimal comfort and positioning when out of bed. When interviewed on 3/27/24 at 1:13 PM, the Occupational Therapist stated Resident #432's wheelchair was switched from a Broda chair to an Atlanta chair for positioning. The Skin Integrity Care Plan and Activities of Daily Living Care Plan were not revised to reflect the new chair which had been implemented on 12/8/23 which was an Atlanta chair that did not have a cushion. On 03/28/24 at 05:27 PM during an interview, Staff #22 (Registered Nurse Unit Manager) stated that the care plan should have been updated to reflect the current intervention of the wheelchair and cushion being used. They stated they were not sure why the care plans were not updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey from 3/13/2024-3/29/2024, the facility did not ensure residents received the necessary services to maintain good grooming and personal care for 1 of 5 residents (Resident #152) reviewed for activities of daily living. Specifically, Resident #152 was observed with untrimmed fingernails and visible scratch marks to scalp. Findings include: Resident # 152 admitted with diagnoses that include hypertension, dementia, and Huntington disease. The Quarterly Minimum Data Set (a resident assessment tool) dated 1/28/24 documented the resident was severely impaired and was dependent with eating, oral care, hygiene, toileting, shower, bath, and personal hygiene. The care plan dated 1/7/22 titled Skin integrity at risk for skin breakdown or pressure ulcer related to right hand contracture as evidence by right hand contracture, Resident #152 frequently scratched scalp. Interventions included to apply white glove as tolerated and to apply lotion to scalp morning and bedtime. The care plan dated 3/13/23 titled behavior symptoms: resident required ongoing redirection, monitoring and structured activities to alter behavior problems related to non-compliant with white gloves and palm guard splint. Physician order dated 3/15/23 documented white cotton gloves in place at all times to improve skin integrity, may remove for care. Physician orders dated 10/6/23 documented to apply lotion to scalp in morning and at bedtime, every shift. A progress note dated 2/2/24, written by a nurse practitioner, documented the resident had scratches that had scabbed over and were healing, history of movement resulting in scratches. Nails were trimmed, dry skin on forehead will start on Eucerin cream. The February 2024 Treatment Administration Record documented the white cotton gloves ordered for every shift had 24 omissions on the 7 AM to 3 PM shift, 25 omissions on the 3 PM- 11PM shift, and 17 omissions on the 11 PM - 7 AM shift. The February 2024 Treatment Administration Record documented the lotion to scalp morning and bedtime had 5 omissions on the 7 AM to 3 PM shift, 17 omissions on the 3 PM- 11PM shift, and 25 omissions on the 11 PM - 7 AM shift. The March 2024 Treatment Administration Record documented the white cotton gloves ordered for every shift had 9 omissions on the 7 AM to 3 PM shift, 10 omissions on the 3 PM- 11PM shift, and 5 omissions on the 11 PM-7 AM shift. The March 2024 Treatment Administration Record documented the lotion to scalp morning and bedtime had 4 omissions on the 7 AM to 3 PM shift, 2 omissions on the 3 PM- 11PM shift, and 10 omissions on the 11 PM - 7 AM shift. During an observation on 3/13/24 at 11: 33 AM resident was sitting in a Geri chair in the day room with multiple old and new scratch marks covering their scalp. Resident #152's fist was clinched, and not all fingernails could be observed. A fingernail on the right hand appeared to be short. The left hand was without the [NAME] guard and no gloves were on either hand. During an observation on 3/15/23 at 9:02 AM sitting in Geri chair in the day room scalp covered with old and new scratch marks. Resident #152's left hand 4th finger had nail approximately 1/4 of an inch in length. The left hand was without left [NAME] guard and no gloves to both hands. During an observation on 03/28/24 at 1:02PM, the occupational therapist delivered a package of white cotton gloves. During an observation on 3/28/24 at 1:10 PM the resident was in the Geri chair. Left hand third fingernail approximately ¼ inch in length and other nails with jagged edges. The white gloves were not worn. During an interview on 3/15/24 at 9:03 AM, Staff #38 stated the resident's nail looked like it needed to be cut because of the scratches to their scalp. They stated they were aware the [NAME], and the electronic medical records provided instructions about the resident's care. During an interview on 3/21/24 at 3:36 PM, the Occupation Therapist stated all adaptive devices were to be applied as ordered and if the staff was having difficult with the resident compliance, therapy should have been contacted. During an interview on 03/28/24 at 12:48 PM, Staff #39 stated they sometimes worked evening shift and shower the resident on Tuesday evenings. They stated there was not an order to apply lotion and filing and clipping nails was part of the resident's activities of daily living. They also stated they told therapy about the resident removing their gloves. During an interview on 03/28/24 at 1:02 PM, Staff #40 looked at the resident's scratches stated the resident was supposed to have the white gloves on and did not have them on during their shift. Staff #40 stated they were responsible to ensure care was being provided. During an interview on 03/28/24 at 01:26 PM, Staff #6 (Registered Nurse Unit Manager) stated the Certified Nurse Aide was responsible for applying the white gloves and they did not know why they did not have them or why the orders were not being transcribed. Staff #6 stated as the unit manager, they were responsible for the oversight. NY10CRR 415.12 (a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification and abbreviated surveys (NY00332770) from 3/13/24 to 3/29/24, the facility did not ensure the resident received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #382), reviewed for change of condition. Specifically, Resident #382 did not receive antibiotic Flagyl / Gentamicin topical treatment dressings as recommended by the wound care consultant physician; the resident was admitted to the hospital with a malodorous (bad smelling) wound and was started on antibiotics for wound cellulitis (infection of the skin). Findings include: The facility policy, 'Surgical Wounds', effective 5/2010 and reviewed 3/22/24 documented that all licensed nurses are responsible for assessing/observing the status of wounds, determining the effectiveness of the current treatment dressing, and to report and document any untoward findings to the health care provider. Resident #382 was admitted from the hospital with diagnoses which included surgical aftercare following surgery on the digestive system, colostomy, protein-calorie malnutrition, and morbid severe obesity. The Minimum Data Set (resident assessment tool) quarterly assessment dated [DATE] documented the resident had intact cognition, required assistance with activities of daily living. The Skilled Wound Care Surgical Note, by the Wound Care Consulting Physician, dated 1/18/24 documented the resident was seen for wound care for a wound on the mid abdomen and the 'Dressing Used: Flagyl / Gentamicin, Honey-based Gel, Calcium Alginate.' The 'Skilled Wound Care Communication Log' dated 1/18/24 documented mid abdomen surgical wound. 'Dressings: Flagyl / Gentamicin, Honey-based gel, calcium alginate.' Physician's treatment orders dated January 2024 documented: 1/6/24 Mid abdominal surgical site: Medihoney, Calcium Alginate, cover with Optifoam daily. The January 2024 Treatment Administration Record documented treatments included Medihoney, Calcium Alginate, cover with Optifoam daily. No documentation confirmed antibiotic Flagyl / Gentamicin topical treatment dressing. Nurse's notes reviewed from 1/18/24 through 1/25/24 did not document the recommended antibiotic Flagyl / Gentamicin topical treatment that was added to the dressing. No documentation could be located to confirm a physician's order for antibiotic Flagyl / Gentamicin topical treatment dressing to abdominal surgical wound per wound care recommendation. On 3/19/24 at 4:00 PM during an interview, Staff #1 (Licensed Practical Nurse Unit Manager) stated they could not find any documentation that antibiotic Flagyl / Gentamicin topical treatment dressing to abdominal surgical wound had been ordered or administered. On 3/20/24 at 7:30 AM during an interview, Staff #2 (Licensed Practical Nurse) stated they were the regular night nurse on the unit. Staff #2 stated they administered the resident's treatment to their abdominal surgical wound seven days between 1/18/24 and 1/25/24 and stated the treatment order did not document antibiotic Flagyl / Gentamicin topical treatment dressings to the wound. On 3/20/24 at 8:07 AM during an interview, Staff #4 (Registered Nurse Unit Manager) stated that regarding the wound care consultant physician's note which documented antibiotic Flagyl / Gentamicin topical treatment dressing, they stated they were responsible for reading the wound care notes and calling the primary physician to inform them of the recommendations and placing the orders if the primary physician had agreed with the recommendations, but stated they did not do so. On 3/20/24 at 9:24 AM during an interview, Staff #3 (Registered Nurse Certified Wound Nurse) stated that during wound rounds on 1/18/24, the wound care physician recommended antibiotic Flagyl / Gentamicin topical treatment dressing which was documented on the Skilled Wound Care Surgical note and on the Skilled Wound Care Communication Log. Staff #3 stated that the wound care consultant physician emailed the Skilled Wound Care Notes to the Certified Wound Nurse, and the Certified Wound Nurse sent the notes to the unit managers, physician, dietary and MDS facility staff by the end of the day or early the next morning. Staff #3 stated it was the responsibility of the unit managers to contact the resident's primary physician and make them aware of any new recommendations and enter any new orders in the resident's records. On 3/20/24 at 10:20 AM during an interview, the resident's primary physician stated they did not have the documentation as to why they did not order the recommended antibiotic Flagyl / Gentamicin topical treatment dressing. On 3/20/24 at 2:00 PM during an interview, the wound care consultant physician stated their recommendation was to add antibiotic Flagyl / Gentamicin topical treatment dressing to the wound. The wound care consultant physician stated they give the facility a Skilled Wound Care Communication log which documents measurements and recommendations and emails it to them the day of the wound care rounds. The wound care consultant physician stated they recommended antibiotic Flagyl / Gentamicin topical treatment dressing to the wound due to purple spots they observed in wound bed of unknown etiology. The wound care consultant physician stated that the purple coloration was not considered healthy tissue. On 3/21/24 at 12:19 PM during an interview, the Assistant Director of Nursing stated the Certified Wound Nurse fills out a 'Skilled Wound Care Communication Log' for each resident which documents all recommendations, all changes to treatments, and all directions for wound care. The Assistant Director of Nursing stated the 'Skilled Wound Care Communication Log' is scanned and emailed to the Director of Nursing and the Assistant Director of Nursing and the unit managers. The Assistant Director of Nursing stated that the unit managers were responsible for notifying the physician of any new recommendations and to enter any new orders into the resident's electronic medical record. The resident was transferred to the hospital and admitted on [DATE]. The Hospital Patient Information Record admit date [DATE] documented the resident had a maloderous (bad smelling) wound and was started on three antibiotics for pneumonia and abdominal wound cellulitis (infection of the skin). 10NYCRR 415.12 (m)(2)

Based on observations, record review and interviews conducted during the recertification survey from 3/13/24-3/29/24, the facility did not ensure for 2 (Residents #74 and #218) of 7 residents reviewed for positioning and limited mobility, that appropriate treatment and services were provided to improve and/or prevent a further decrease in range of motion. Specifically, Resident #74 was observed on multiple occasions not wearing a resting hand splint to the left hand as ordered and Resident #218 was observed with a right hand contracture and on multiple occasions, no adaptive devices were observed in place to prevent a further decrease in range of motion. The findings include: 1) Resident #74 was admitted to the facility with diagnoses including Alzheimer's disease, non-traumatic brain dysfunction, and hemiplegia and hemiparesis following a cerebrovascular infarction affecting the left dominant side. The 12/11/2023 Quarterly Minimum Data Set (an assessment tool) documented the resident had moderately impaired cognition, required setup with eating, and required extensive assist with bed mobility, toileting, and transfers. Resident #74 had upper and lower extremity impairment on one side. The physician order dated 2/6/2024 documented to always apply resting hand splint to the left hand and only remove during activities of a daily living and range of motion. The comprehensive care plan titled Musculoskeletal Disorder dated 02/15/2024 documented Resident #74 had a splint to left hand. On 03/13/24 at 02:06 PM, Resident #74 was observed in bed asleep, the left hand was severely contracted, and the resting hand splint was not in place. On 03/15/24 at 10:41 AM, Resident #74 was observed in bed asleep, the resting hand splint was not in place to the resident's left hand or in view. During an interview on 03/15/24 at 10:44 PM, Staff #13 (Registered Nurse) stated that Resident #74 should always be wearing the resting hand splint as per physician orders. Staff #13 was observed going into Resident #74 nightstand, retrieved the hand splint and stated that the resident hand splint should not have been in the nightstand and that should have been in place to the resident's left hand. During an interview on 03/15/24 at 10:45 PM, Staff #11(Licensed Practical Nurse Unit Manager) stated that the resting hand splint should be on Resident #74 left hand and reviewed the physician order and confirmed that the resting hand splint should have been on the resident's left hand, then proceeded to put the splint on Resident #74 left hand. During an interview on 03/19/24 at 10:43 AM, Staff #20 (Director of Rehab) stated that the physician orders documented Resident #74 must wear the resting hand splint to left hand at all times, only removing during activities of a daily living and range of motion, and that occupational therapy recommended that Resident #74 wear the left-hand resting splint 6-8 hours as tolerated. Staff #20 stated that Resident #74 went out to the hospital and there was an error in transcribing the orders by nursing. 2) Resident #218 was admitted to the facility with diagnoses including anxiety disorder, contractures of right and left hand, and dementia. The 02/25/2024 Quarterly Minimum Data Set (an assessment tool) documented the resident had severely impaired cognition, required setup with eating, and dependent with bed mobility, toileting, and transfers. Resident #218 had upper and lower extremity impairment on both sides. The comprehensive care plan titled Resident #218 has wound on palmar surface of right hand related to contractures dated 02/03/2024 documented interventions including occupational consult, keep clean and dry, perform treatment as ordered, and wound consult. On 03/13/24 at 01:38 PM, Resident #218 was observed in lying in bed. Their right hand was severely contracted, and no adaptive devices were in place. On 03/19/24 at 11:30 AM, Resident #218 was observed in bed and their right hand was contracted. When Staff #9 (Licensed Practical Nurse) attempted to open Resident #218 hand, the resident was flinching and screaming, indicating that they were in pain. On 03/21/24 at 11:30 AM, while attempting to observe a wound care treatment to Resident #218 right hand palmar, Staff #9 (Licensed Practical Nurse) was unable to perform wound care due to the resident's right-hand contractures, and Resident #218 screaming, flinching, and crying out when Staff #9 was trying to open their hand, despite Staff #9 explaining the process and talking gently. There were no adaptive devices in place to the right hand. During an interview on 03/21/24 at 11:30 AM, Staff #9 (Licensed Practical Nurse) stated that Resident #218 was contracted in the right hand, had a wound and that there were no physician orders for adaptive devices. Staff #9 stated the resident refused and that it was difficult putting anything in the resident's hand due to them taking it out. During an interview on 03/21/24 at 11:55 AM, Staff #1 (Licensed Practical Nurse Unit Manager) stated that Resident #218 should be wearing a hand roll or carrot in the right hand due to contractures, and that when the wound care treatment was done, the nurse should roll up gauze and place it in the resident's hand so that the resident's fingers will not dig into their hand to help promote wound healing. During an interview on 03/21/24 at 03:52 PM, Assistant Director of Nursing #1 stated that it was nursing's responsibility to put in an occupational therapy consult. The contracted hand resulted in a wound, and a consult should have been put in due to Resident # 218 right hand contractures and history of pressure injuries. The Assistant Director of Nursing #1 stated that they were unable to locate an occupational therapy consult and/or evaluation and stated that they would initiate one. During an interview on 03/25/24 at 03:00 PM, Staff #20 (Director of Rehab) stated that if a resident had a new found wound due to pressure or trauma, nursing should put in an occupational therapy screen. Staff #20 stated that Resident #218 was seen by occupational therapy on 3/22/24 due to nursing request for evaluation due to right hand wound on 3/21/24. Staff #20 stated that Resident #218 was not cooperative at all to apply any splint. Staff #20 stated that if residents are non-compliant with therapy evaluation, they will keep approaching and keep documenting. Furthermore, Staff #20 stated that if a resident refuses occupational therapy, nursing can put interventions into place to assist with the contractures using adaptive devices such as gauze and hand towels. During an interview on 03/27/24 at 01:58 PM, the wound care doctor stated that Resident #218 has trauma to the right hand palmar due to contractures and that they recommended occupational therapy to get involved because Resident #218 had a hard time putting adaptive devices in her hand. The wound care doctor stated that they have nothing to do with nursing entering orders after they make their recommendations. During an interview on 03/28/24 at 05:43 PM, the primary physician stated were unaware an occupational therapy evaluation was not ordered, and that one should have been put in by nursing staff after the wound care doctors recommendations. 10NYCRR 415.12(e)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #168 was admitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side and dementia. The 02/05/2024 Significant Change Minimum Data Set (assessment tool) documented that Resident #168 had severely impaired cognition, and required total assistance with bed mobility, eating, toileting, and transfers. The comprehensive care plan, dated 6/28/21, documented the resident was at high risk of fall and the goal was that Resident #168 would be free of injury. Interventions included ensuring proper positioning of resident in the center of the bed when resident was in their bed, bed in the lowest position, and reclining the Broda chair (specialized wheelchair) after all meals and when left in room. The Occurrence report dated 5/6/23 at 1:45 PM documented Resident #168 slipped out of the Broda chair to the floor. Review of the nursing progress note dated 5/6/23 documented at approximately 1:50 PM, resident was reported to have slipped out of their chair and was sitting up on the footrest of their chair leaning against the chair. No visible injuries observed, and the resident were assisted back in the bed. The Occurrence report dated 5/6/23 at 9:15 PM documented Resident #168 fell from the raised bed when the Certified Nurse Aide left the room briefly to get a clean draw sheet. There was no apparent injury, limited range of motion of the left arm and leg, unable to move on own. The resident stated everything hurts and was given Tylenol. The nursing progress note dated 5/6/23 documented at approximately 9:15 PM, while the certified nurse aide was performing care, the certified nurse aide went out to cart to get a clean draw sheet for resident's bed, and the resident fell off their bed. The resident reported that they hurt everywhere. The nursing progress note dated 5/7/23 documented resident was status post fall day 2 with new onset and complaint of pain to left lower extremity. The provider was made aware and an x-ray to left lower extremity was placed. The nursing progress note dated 5/7/23 documented x-ray results showed lower extremity fracture. The provider was notified, and order obtained to send to the emergency room for further evaluation. The X-ray results dated 5/7/23 documented Resident #168 left distal tibia had evidence of a spiral fracture, and an intercondylar fracture with impaction was noted to the left femur. Review of the hospital Discharge summary dated [DATE] documented the resident had a supracondylar fracture of left femur and a tibial fracture. On 03/13/24 at 11:08 AM, Resident #168 was observed in dayroom sitting in Broda chair and the chair was slightly reclined. During an interview on 03/28/24 at 01:37 PM, Staff #7 (certified nurse aide) stated they left the room to go get the Hoyer lift to put Resident #168 back to bed and that when they came back into the room, Resident #168 was slid out of the Broda chair and was sitting on the floor due to the positioning of the chair. Staff #7 stated that the resident's Broda chair was too straight up and should have been reclined. During an interview on 03/28/24 at 04:42 PM, the Director of Nursing stated Resident #168 fell twice on 5/6/23. The Director of Nursing stated the plan of care was not followed when the resident fell out of bed and the bed should have been in the lowest position when the certified nurse aide left the room. 10NYCRR 415.12(h)(1) Based on observation, record review, and interviews conducted during the recertification and abbreviated surveys (NY00306213 and NY00316087) from 3/13/24 to 3/29/24, the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accidents hazards as possible for 2 of 4 residents (Residents #97 and #168) reviewed for accidents. Specifically, (1) Resident #97's supervision was not maintained after an attempted suicide resulting in another attempt 6 days later, and (2) Resident #168 sustained two falls on 5/6/23, the second of which resulted in Resident #168 fracturing their tibia (lower leg) and femur (upper leg). The findings are: The facility policy titled Occurrence Reporting and Investigation Policy and Procedure dated 11/28/2017 documented an occurrence report is initiated so that the facility obtains information relevant to each occurrence and allegation as well as to obtain information for analysis of the cause of the event in order to prevent recurrence. An occurrence report is completed for each fall with or without injury, unexplained bruise, laceration/skin tear or abrasion, choking episode, burn, resident-to-resident or resident -to-staff altercation, or any other signs indicating that the resident has experienced an untoward event. 1. Resident #97 was admitted to the facility with diagnoses including Huntington's Disease, anxiety, bipolar disorder, and post-traumatic stress disorder. The Quarterly Minimum Data Set ( an assessment tool) dated 12/20/22, documented the resident had intact cognition, was independent with transfer and bed mobility, had 1-3 days (during the 7 day look back period) of delusions/verbal or physical behavioral symptoms, and received antipsychotic, antianxiety, and antidepressant medications 7 of 7 days. The Mood State Care Plan created 8/5/22 documented the resident had Depression and Anxiety: Altered mood state or feeling depressed; threats of self-harm (cutting/scratching). Interventions included to assess and monitor for suicidal tendencies; and remove items in room that could evoke self-harm. The Mood State Care Plan was updated 11/25/22 with new intervention to do 15-minute checks. The Psychiatry consult dated 11/8/22 documented Resident #97 had a short attention span and felt they made a mistake by coming to the facility. The resident had no suicidal ideations, thoughts of self-harm or evidence of psychosis. The Registered Nurse progress note dated 11/23/22 at 2:13 PM documented at approximately 11:15 AM, the resident was found lying prone on the floor under the window and air conditioner. When asked what happened the resident stated they fell over and wanted to kill themselves. The resident had two linear red marks on the right side of their neck and said they tried to hang themselves with the string from the blinds. Upon further assessment the size of the strings to the shades lined up with the red linear marks on the right side of the neck and measured approximately 8 centimeter and the other 6 centimeters. The Nurse Practitioner examined the resident, and the resident was sent to the psychiatric hospital. The Accident/ Incident report and investigation dated 11/23/22 documented, at 11:15 AM on 11/23/22, Resident #97 was found on the floor in their room and used the blind string around their neck. The following changes, to prevent recurrence, were documented on the accident/incident report; blinds removed from window; all cords removed from their room. The resident was given tap bell, suicide precautions would be in effect upon return from the hospital including 15-minute checks, and bathroom call bell cord shortened to a 6 length. The Registered Nurse progress note dated 11/24/22 at 2:28 AM documented at approximately 1:30 AM Resident #97 returned to the facility and was put on one-to-one supervision. The Registered Nurse progress note dated 11/24/22 at 2:56 PM documented Resident #97 was on one-to-one close observation and resting quietly in bed. The Registered Nurse progress note dated 11/25/22 at 7:38 AM documented Resident #97 was on 15-minute checks and slept throughout the night until 6 AM. The Registered Nurse progress note dated 11/25/22 at 2:46 PM documented the resident was pleasant and cooperative. The room was free from any cords or wires and the resident had a tap bell to use when she needed assistance from staff. The Nurse Practitioner was in to see resident and ordered clonazepam 0.5 mg as needed for anxiety. The resident continued on 15-minute checks. The Licensed Practical Nurse progress note dated 11/26/22 at 11:24 PM documented the resident continued on 15-minute checks. The Registered Nurse progress note dated 11/28/22 at 11:37 PM documented the resident refused all medications during the shift. (There was no documented level of supervision.) The Licensed Practical Nurse progress note dated 11/29/22 at 10:19 AM documented the licensed practical nurse went to Resident #97's room to administer medication; the door was ajar, and they could see the resident face down on the floor but could not get the door open. They went and got the Unit Manager, and the Unit Manager and another staff were able to get the door open. The Registered Nurse note dated 11/29/22 at 12:44 PM documented at approximately 9:45 AM they were notified by the floor licensed practical nurse that the resident was on the floor in her room and the door was jammed and staff were unable to get in. The bathroom door was open enough so that the bedroom door was only able to open about 12 inches. The resident could be seen through the opening and was lying in prone under the window with the air conditioner cord wrapped around their neck. When they got in the room they removed the cord, wrapped twice, from the resident's neck and observed a red mark on her neck above the collar bone. 911 was called and the resident was sent to the psychiatric hospital. Review of the Accident/Incident report and investigation dated 11/29/22 documented at 9:45 AM on 11/29/22, Resident #97 was found on the floor face down in her room with the air conditioner cord wrapped around their neck. Redness was noted to neck above collar bone. Resident had increased agitation and anxiety. The door was jammed with the bathroom door and a Certified Nurse Aide was able to reach through the top of the bedroom door with a hanger and pushed the bathroom door closed enough so they could get in to help resident. Cord was immediately removed, and the resident was sent to hospital for psychiatry evaluation. Review of the investigation found no documented evidence the resident was on 15-minute checks. The investigation included statements dated 11/29/22 for the incident on 11/29/22 at 9:45 AM as follows: -Staff #56 (Certified Nurse Aide) documented they last saw the resident at 8:50 AM by the nursing station. -Staff #46 (Certified Nurse Aide) documented they last saw the resident at 9:00 AM when they got to the unit and Resident #97 was standing at the nursing station. -Staff #47 (Certified Nurse Aide) documented they were assigned to the resident and last saw the resident at 9:00 AM in the hallway asking about their laundry. Resident #97 room was observed on 3/27/24 at 12:26 PM. There was not a call bell in the resident's room and when interviewed, Resident #97 stated they used the call bell in the bathroom. The call bell in the resident's bathroom had a shortened string and room had no blind strings. On 3/29/24 at 12:50 PM during an interview, Staff #46 (Certified Nurse Aide) and Staff #47 stated they floated to different units and did not always work with Resident #97. They both remembered the suicide attempt with the air conditioner cord. Staff #46 and Staff #47 stated since they floated, they did not really get to know everything about the residents. Staff #46 and Staff #47 stated they could not remember if Resident #97 was on 15-minute checks or any close monitoring at the time of the incident. On 3/29/24 at 1:02 PM during an interview, Staff #45 (Registered Nurse) stated they remembered the attempted suicide with the air conditioner cord. Staff #45 stated the resident had suicide attempts in the past and was on 15-minute checks. They stated they documented on the 15-minute check log and usually the Certified Nurse Aide did the documentation, but it could be done by anyone. On 3/29/24 at 1:19 PM documentation of 15-minute checks for the time between the 2 incidents (11/23/22 and 11/29/22) was requested from the Assistant Director of Nursing. When interviewed on 3/29/24 at 2:18 PM, the Assistant Director of Nursing stated they were unable to find the 15-minute checks for the resident. On 3/29/24 at 3:48 PM, Director of Nursing stated they found the 15-minute check log in a nursing office. Review of the 15-minute check sheet for 11/29/22 revealed the checks were done at 8:30 AM, 8:45 AM, 9:00 AM, 9:15 AM and 9:30 AM by Staff #47 and documented the resident was in a chair and calm at each check. However, Staff #47's written statement documented they last saw the resident in the hallway at 9 AM. When interviewed on 3/29/24 at 4:13 PM, the Director of Nursing stated they were not the Director of Nursing when these incidents occurred and was unable to provide further explanation as to how the resident was able to attempt suicide again on 11/29/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the post survey revisit (PSR) from 5/30/24 to 6/3/24, the facility did not ensure pain management was provided to residents who required such services consistent with professional standards of practice for 1 of 6 residents reviewed for pressure ulcers (Resident #500). Specifically, there was no documented evidence that Resident #500 received a 5/22/24 physician ordered fentanyl patch until 5/26/24. Additionally, there was no documented evidence of pain monitoring on 5/30/24 after Resident #500 received physician ordered as needed pain medication for a complaint of 8/10 pain and/or prior to the nurse performing a wound dressing change. Findings include: Resident #500 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain), pressure ulcer of the sacral region Stage 3, and urinary tract infection. The Nursing admission Assessment, dated 5/22/24, completed by Registered Nurse #22, documented occasional moderate pain of the buttocks was present in the last 5 days. Pain was expressed through facial expressions, the resident readily describing, and restlessness. Pain increased with movement, the pattern was intermittent, and interventions were necessary. The skin assessment documented a Stage 3 pressure ulcer to the sacrum. The physician's orders dated 5/22/24 documented Fentanyl 12 MCG/HR, apply 12 mcg/hour patch topically every 72 hours with a start date of 5/23/24, and an order to check the Fentanyl patch every shift. Tramadol 50 milligram tablet by mouth every 6 hours as needed (PRN) for pain 5-10; acetaminophen 325 milligram tablet, 2 tablets every 6 hours as needed for pain 1-4. The May 2024 Medication Administration Record documented the resident did not have a fentanyl patch until it was administered on 5/26/24 at 10:39 AM and the pain scale was 5 at that time. The 5/28/24 admission Minimum Data Set (resident assessment tool) documented Resident #500 had severely impaired cognition, a Stage 3 pressure ulcer was present on admission, moderate pain over the last 5 days, and received scheduled pain medications. The May 2024 Medication Administration Record documented on 5/29/24 at 7:56 AM, Registered Nurse #63 screened the resident for pain and the pain scale was 7. The fentanyl patch was applied as scheduled. There was no further documentation in the resident's record regarding pain. The May 2024 Medication Administration Record documented on 5/30/24 at 10:05 AM, Licensed Practical Nurse #62 gave Tramadol for pain of 8. Review of the resident's record revealed no documentation as to pain characteristics or effectiveness of the medication. During a wound care observation 5/30/24 at 1:36 PM, Certified Nurse Aide #60 and Registered Nurse #22 were in Resident #500's room and had the resident positioned on their right side. Resident #500 had a large sacral wound with dark tissue covering the most distal area and yellowish -tan tissue covering the rest. Registered Nurse #22 removed the dressing from the resident's sacrum, the wound care physician walked into the room, measured the resident's heel wound and sacral wound as the resident was screamed continuously yelling ow, ow, ow and often calling out their spouse's name. Registered Nurse #22 asked the resident where they hurt, and they continued to scream. Registered Nurse #22 continued to provide care to the resident and at 1:50 PM, Registered Nurse #3 entered the room and finished the dressing change while the resident continued to scream. When interviewed after the completion of the dressing change, Registered Nurse #3 stated they did not know if the resident had been medicated for pain. Certified Nurse Aide #60 stated they put the resident back in bed for the wound dressing change and did not see him get any medications. During an interview on 5/31/24 at 12:08 PM, Licensed Practical Nurse #62 stated the Fentanyl, was not available until 5/26/24 and when a medication was not available, they notified the physician and nursing supervisor. Licensed Practical Nurse #62 was unable to find documentation of the notification. Licensed Practical Nurse #62 further stated Resident #500 was in pain on 5/30/24 and was medicated for pain at 10:05 AM, they stated they gave the resident Tramadol and took vital signs which were within normal limits but did not document. They stated the Tramadol initially worked and the resident ate lunch and after lunch had discomfort and the Assistant Director of Nursing was notified. During an interview on 6/3/24 from 2:17 PM to 3:08 PM, Registered Nurse #22 stated they did the nursing admission assessment and took the orders. They stated the fentanyl should have been started on 5/23/24 and they were unaware it was not started until 5/26/24, and the physician should have been notified if it was unavailable. Registered Nurse #22 further stated that on 5/30/24 Resident #500 was very agitated and explained the yelling was agitation not necessarily pain. They stated the resident was screaming before the dressing change and may have been agitated. 10 NYCRR 415.12

2. Resident # 229 was admitted with diagnoses that included Huntington's disease, gastroesophageal reflux disease, and major depression. The Minimum Data Set (a resident assessment tool) documented moderate cognitive impairment, and the resident required one person assistance with eating, oral hygiene, showering or bathing, toileting, and transferring wheelchair mobility. The Care plan dated 11/14/23, titled Activity of Daily Living Eating, documented interventions included a scoop dish and straw at every meal. Physician order dated 12/14/23 documented assistive devices including cup at meals with two handles with straw, and assistive devices for plates with meals scoop dish; assistive devices oatmeal in mug. During an observation on 3/15/24 at 8:50 AM, the resident was in the dining room and ate 75% of breakfast with no adaptive bowel or cup in use. During an observation on 3/15/24 at 12:25 PM, the resident ate 50% of lunch in the dining room using an adaptive bowl and no adaptive cup as ordered. During an observation on 3/19/24 at 9:03 AM, the resident ate 75% of breakfast in the dining room, with an adaptive bowl but no adaptive cup. During an interview on 3/21/24 at 9:45 AM, the Registered Dietitian stated that the food service employee was responsible for plating the food according to the information on the ticket, and the certified nurse assistant was also responsible for checking the ticket to ensure everything was correct and all items were on the tray. If adaptive equipment was missing, they needed to let the nurse know to contact occupational therapy. During an interview on 03/21/24 at 03:43 PM, the Director of Rehabilitation stated that adaptive devices ordered on 8/23/23 scoop dish for all meals and two handle mugs with lid to be used for all meals with straws were not discontinued. During an interview on 03/21/24 at 4:10 PM with Occupation Therapy, the resident adaptive bowel and cup were ordered for each meal and would appear on the meal tray ticket. The resident was screened by Occupation Therapy Services on 11/7/23. The adaptive devices should be on their food tickets. The adaptive devices were not discontinued. 3. Resident #236 had diagnoses including Huntington's disease, seizure disorder, and traumatic brain injury. The 2/20/24 Quarterly Minimum Data Set documented severe cognitive impairment, and the resident was dependent on staff with eating, oral hygiene, shower/bath, personal hygiene, incontinent of bowel and bladder. Review of the care plan dated 2/15/2024 titled Nutrition concerns Huntington's disease dependent on staff for by mouth foods/fluid consumption intervention provide diet as prescribed puree, nectar thick liquid. Review of the care plan dated 2/15/24, titled Dehydration Risk for Dehydration r/t Huntington Disease dysphagia/nectar thick liquid diagnosis of severe chorea, total dependence on food/fluid. During observation of the lunch meal ticket dated 3/13/24, 3/14/24, and breakfast meal ticket on 3/15/24, all meal tickets documented maroon spoon. During observation on 3/13/24, the resident ate 25% of lunch without a maroon spoon; on 3/14/24, the resident ate 50% of meals without a maroon spoon; and on 3/15/24, the resident ate 75% of breakfast without a maroon spoon. Review of the care plan from February to March 2024 revealed that the use of adaptive equipment was not included prior to 3/15/24 at 9:30AM. Review of physician order from February to March 2024 revealed no orders for the use of the maroon spoon until 3/15/24. Review of meal tickets dated 3/15/24 and 3/19/24 at breakfast documented the adaptive equipment, the maroon spoon. During an interview on 3/15/24 at 8:50 AM Registered Nurse Unit Manager #6, stated they did not notice the resident was supposed to be fed with the maroon spoon. During an interview on 3/20/24 at 9:45 AM with the Registered Dietician stated the maroon spoon provided a smaller amount of food on the spoon, enough for the resident to swallow. The food service and the certified nurse assistant on the unit were responsible for plating food according to the meal ticket. During an interview on 3/21/24 at 4:04 PM, the Speech Therapist stated the maroon spoon was recommended when a regular spoon was too big, and the resident needed a small spoon with softer edges like the maroon spoon to deliver smaller potions to prevent choking. Resident #236 would benefit from the maroon spoon; it could be ordered by nursing, speech, or dietary. During an interview on 03/21/24 at 4:10 PM, the Occupational Therapist stated the meal tray ticket for Resident #236 included the use of a maroon spoon which could have been an old order that was printed on the meal tray ticket from prior admission. 10 NYCRR 415.14(g) Based on observations, record review and staff interview conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure that special eating equipment and utensils were provided for residents who need them. This was observed during dining observation for 3 of 15 residents reviewed for nutrition (Resident #135, #229, and #236). Specifically, Resident #135 was observed dropping food when trying to scoop an item from a regular plate. Resident #229 was observed on three occasions eating without the use of an adaptive bowl and cup as indicated in the meal tray ticket and ordered by occupation therapy. Resident #236 was observed on three occasions being fed without the use of the adaptive maroon spoon, as documented on their meal ticket. Findings include: 1. Resident # 135 was admitted with diagnoses that included dementia, Huntington's Disease, and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (an assessment tool) dated 2/24/24 documented the resident had modified independence in cognition and the resident required set up or clean up assistance with eating. The Activities of Daily Living Care plan created 12/16/21 documented the resident required assistance with Activities of Daily Living task performance as follows: supervision, set up and cues at mealtime. The intervention for eating documented to assist with meal set up every shift. On 3/13/24 at 12:23 PM Resident #135 was observed trying to eat lunch and while trying to get food onto their spoon, the food fell onto the table, floor and the resident's lap when scooping up food from plate. No scoop plate or special utensils were observed. On 3/14/24 at 12:19 PM Resident #135 was observed trying to eat lunch and while trying to get food onto their spoon, the food fell onto the table, floor and the resident's lap when scooping up food from plate. No scoop plate or special utensils were observed. There was no documented evidence of a rehabilitation evaluation for the use of adaptive equipment for adaptive equipment. On 03/28/24 at 01:32 PM during an interview, the Speech Therapist stated they did not evaluate Resident #135 for adaptive equipment and stated that occupational therapy did the evaluations for adaptive equipment such as utensils or plates. The Speech Therapist stated they did the referrals for adaptive equipment but when Resident #135 was seen by the Speech Therapist they were only evaluated for swallowing. The Speech Therapist stated they could recommend a bowl or something to help them eat in order to have the least restrictive diet. The Speech Therapist stated they evaluated Resident #135 a couple times and recently due to a decline, but were not aware that the resident was dropping food on their lap, table and floor. On 3/28/24 at 1:39 PM during an interview, the Occupational Therapist stated that they did evaluations for the adaptive equipment but they never got a referral for Resident #135. The Occupational Therapist stated they were not aware Resident #135 was dropping food on their lap, table and floor.

Based on observation, record review and interviews conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure that an infection prevention and control program designed to help prevent the development and transmission of infection was maintained for 4 of 5 residents (Residents #12, # 70, #93, #210) reviewed for infection control and prevention practices. Specifically, for Resident #12, during a wound care observation, the nurse did not wash their hands and don clean gloves after cleansing a pressure ulcer and before applying treatments The findings include: Review of the facility's policy entitled Infection Prevention and Control Manual last reviewed March 5, 2024. The facility policy stated they review infection control surveillance reports and statistics to implement corrective actions through monitoring aseptic techniques and procedures utilized within the facility. The facility hand hygiene/hand washing protocol stated the facility considers, hand hygiene the primary means to prevent the spread of infections. All staff are expected to perform hand hygiene/ hand washing for the prevention of healthcare associated infections. Residents/visitors and other healthcare personnel are encouraged to practice handwashing/ hand hygiene. Resident #12 was admitted with diagnoses including hypertension, anxiety disorder, and dementia. The annual Minimum Data Set (assessment tool) dated 11/23/23 documented the resident had moderately impaired cognition and was dependent on staff assistance with activities of daily living. On 03/19/24 at 11:12 AM, a wound care observation was conducted for Resident #12 by Staff #5 (Licensed Practical Nurse Unit Manager), with Staff #8 (Certified Nurse Aide) assisting with turning and positioning the resident. Staff #5 was observed not changing their gloves or performing hand hygiene after cleaning the resident's right buttock wound or before applying the treatment. During an interview after the wound care observation, Staff #5 stated they realized what they did wrong, that they should have performed hand hygiene after cleaning the resident's wound and before applying the treatment. On 3/29/24 at 10:28 AM during an interview, Staff #11 (Licensed Practical Nurse Unit Manager) stated hand hygiene should be performed before donning gloves and after doffing gloves and before and after cleaning wounds and applying treatments. On 3/29/24 at 10:36 AM during an interview, the Nurse Educator stated hand hygiene performance checks were done on all new employees before working in the resident care areas. They stated that at times an isolated situation occurs, and they would follow-up on the units if someone was not following the hand hygiene protocol. The Nurse Educator stated only Registered Nurses do hand washing/ hand hygiene assessments. 415.19 (b) (4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** (3) Resident #48 was admitted with diagnoses including rectal abscess, obstructive uropathy, and early Deep Tissue Injury /Unstageable. The admission Minimum Data Set (resident assessment tool) dated 1/23/24 documented Resident #48's cognition was intact and the resident was dependent on staff for mobility, transfers, and toilet use. The Minimum Data Set documented the resident was at risk for developing pressure injuries, had an unhealed pressure injury, and unstageable deep tissue injuries present on admission. The admission assessment dated [DATE], documented moisture associated skin damage to the sacrum. The comprehensive care plan dated 1/17/24 the resident was dependent on staff with bed mobility, to roll left and right. The comprehensive care plan dated 1/19/24 documented the resident was at risk for skin breakdown or pressure ulcer/injury. Interventions included to complete pressure ulcer risk assessment (Braden Scale) and review quarterly and when necessary, pressure-reducing mattress, cushion wheelchair, Vander-Lift, roll left and right (dependent); maintaining turn and positioning schedule by registered nurse, use skin barrier when performing perineal care, weekly full-body skin assessment by a registered nurse. The comprehensive care plan updated 1/22/24 documented impaired skin integrity, presence of skin breakdown related to limited mobility as evidenced by pressure ulcer early-deep tissue injury to right buttocks. Interventions included to assess the characteristics of ulcers daily during treatment care and document findings weekly. The wound care physician's notes documented: - On 1/18/24 the right sacral wound was documented as early right buttock deep tissue pressure injury and measured 3.5 centimeters x 3.5 centimeters and was 100% necrosis (dry dead tissue). Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol, and dressing change using Triad and foam. - On 1/25/24 the right sacral wound was documented as unstageable, measuring 2.0 centimeters x 2.0 centimeters x 0.1 centimeters , and decreased in size. Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol/policy and dressing change using Triad and foam. - On 2/1/24 the right sacral wound was documented as measuring 3.5 centimeters x 0.7 centimeters x 0.1 centimeters. - On 2/8/24 the right sacral wound was documented as measuring 5.0 centimeters x 1.0 centimeters x 0.1 centimeters with 20% granulation and 80 % epithelial tissue and increased in size. Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol/policy and dressing change using Triad and foam. - On 2/22/24 the right sacral wound was documented as 100% granulation tissue and measured 6.0 centimeters x 2.0 centimeters x 0.1 centimeters, and increased in size. Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol/policy and dressing change using Triad and foam. - On 2/29/24 the right sacral wound was documented as 7.5 centimeters x 2.3 centimeters x 0.1 cm wound increased in size. 80% granulation 20% epithelial tissue. Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol/policy and dressing change using Triad and foam. - On 3/5/24 the right sacral wound was documented as unstageable 8. 5 centimeters x 4.0 centimeters increased in size 10% granulation, 70 % epithelial , 20% necrotic tissue. Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol/policy and dressing change using Triad and foam. - On 3/16/24 the right sacral wound was documented as unstageable 7.5 centimeters x 6.0 centimeters x 0.1- 40% granulation, 60 % epithelial tissue. Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol/policy and dressing change using Triad and foam. The physician order dated 1/22/24 documented a daily wound care treatment order to cleanse the right buttocks and apply a thin layer of Triad and cover with Optifoam. The Treatment Administration Record for January, February, and March 2024 documented a daily wound care treatment order to cleanse the right buttocks, apply a thin layer of Triad and cover with optifoam daily. This treatment lacked documentation of completion on 5 of 14 occasions in January, 21 of 29 occasions in February, and 1 of 16 occasions in March 2024. The skin integrity review every 7 days lacked documentation for all of January and February 2024. The Certified Nurse Aide accountability record from January to March 2024 did not document turning and positioning. During an observation on 03/21/24 at 10:17 AM of wound dressing change for Resident # 48, Staff #14 (Licensed Practical Nurse) removed the dressing revealing bloody drainage and 2 separate wounds on the right buttock measuring 5 centimeters by 2.5 centimeters and 3 centimeters by 5 centimeters. A smaller wound was observed on the left buttock that License Practical Nurse #14 stated was not there before. When interviewed during the observation Staff #14 stated they did the dressing change the previous day and was not expecting to see the 2 open areas on the right side and had Assistant Director of Nursing #2 look at the wound. Staff #14 stated Assistant Director of Nursing #2 measured the 2 areas and determined the wound care physician measured both wounds as one. License Practical Nurse #14 stated no drainage was noted prior to today. The nurse continued the cleanse the wounds and applied Triad to the open areas and covered with Optifoam. Review of the nursing progress notes on 3/22/24 revealed no documentation regarding the new skin impairment on the left buttock and no documentation of Assistant Director of Nursing #2's assessment on 3/20/24. On 03/21/24 at 12:08 PM during an interview, Assistant Director of Nursing #2 stated they observed the wound on 3/20/24 with Staff #14. They measured both wounds and realized the wound care physician was measuring the wounds by clustering as one. The Assistant Director of Nursing #2 stated they were overseeing the unit as the Unit Manager had recently retired. They stated they saw the wound when the resident was admitted and did not go on wound rounds or track the wound. They stated they thought it was bigger, and the top of the wound looked like a Stage 2 but had no drainage. They did not document their assessment and stated the nurse was supposed to document their assessment of the wound daily. Assistant Director of Nursing #2 reviewed the treatment omissions on the Treatment Administration Record and stated missed treatments should have been reported to the physician and the Unit Manager was responsible for reviewing the treatment record but currently there was not a Unit Manager. On 03/26/24 at 4:25 PM during an interview, the Director of Nursing stated the plan of care intervention dated 1/22/24 should have populated to the Certified Nursing Assistant [NAME] to turn and position every two hours, but it did not because the Activity of Daily Living category was never initiated by the creator of the care plan; therefore, turning and positioning were not part of the Certified Nursing Assistant [NAME] as required care. The Unit Manager was responsible for checking the Certified Nurse Aide documentation and the nursing care plan. On 3/27/24 at 1:57 PM during an interview, the wound care physician stated they measure several areas as one by bridging the wounds for billing purposes because the Minimum Data Set wounds cannot be documented by specific areas such as the upper right buttock, middle right buttock, lateral right buttock, and lower right buttock. Resident #48's skin shifts because of their weight, and it could create various openings affecting the general area and wound dimension and that was why the wound was measured as an area. They stated the wound dressing stayed the same because the treatment worked. It was the facility's responsibility to monitor treatments between wound rounds, monitor if treatment were being done, and report any issues. On 3/28/24 at 4:27 PM during an interview, the Medical Director stated that nurses needed to document wounds at the time of treatment and communicate with the physician if a wound got bigger, signs of infection were observed, if treatments were not working, or if wounds frequently need to be debrided. The Medical Director stated that nurses should be monitored to ensure they are administering treatments correctly. The Medical Director also stated that documentation by the nurses was very important at the time of treatment administration, which should include the color of the wound bed, the color of any drainage, any pain, the size of the wound, and any odor. Nursing was responsible for measuring and documenting any changes between wound rounds and notifying the primary provider with any concerns. 415.12(c)(1)(2) 2.) Resident #218 was admitted to the facility with diagnoses including contractures of right and left hand, dementia, and anxiety disorder. The 02/25/2024 Quarterly Minimum Data Set (resident assessment) documented the resident had severely impaired cognition, required setup with eating, and was dependent with bed mobility, toileting, and transfers. The 12/11/2023 Quarterly Minimum Data Set documented that Resident #218 had an unhealed Stage 4 pressure injury that was not present on admission. The comprehensive care plan titled Resident has a reopened Stage 4 pressure ulcer to right elbow dated 2/25/24 documented interventions including treatments as ordered, staff is to always ensure offloading of elbows. The comprehensive care plan titled Activities of a Daily Living dated 4/17/23 documented interventions including elevating right arm on a pillow to prevent arm from being tucked underneath resident and causing increase in pressure to right elbow wound. Review of the physician's order dated 12/22/23 documented skin integrity review once weekly on Fridays. Review of the Treatment Administration Record dated 3/15/24, 3/22/24, and 3/29/24 had no documented evidence that a skin review was done and signed by the nurse. Review of the physician's order on the Treatment Administration Record dated 02/25/24 documented staff was to always ensure offloading of the elbows with a pillow every shift. Review of the Treatment Administration Record from 2/26/24-3/31/24 revealed no documented evidence that offloading of elbows with a pillow every shift was being done and signed by the nurse. Review of the surgical consult notes written by the wound care physician dated 2/29/24, 3/5/24, 3/16/24, and 3/23/24 documented offloading to include turning per facility protocol. Review of certified nurse aide accountability documentation from 2/25/24-3/26/24 revealed that turning and positioning was not being documented by the certified nurse aides. On 03/13/24 at 01:38 PM, Resident #218 was observed lying in bed on their back. There were no pillows in place under their right elbow. On 03/19/24 at 11:30 AM, Resident #218 was observed in bed lying on their back and no pillows was in place underneath their right elbow. On 03/20/24 at 11:33 AM during a wound care observation with Staff #9, Resident #218 was observed in bed, without a pillow underneath their right elbow that is to be used for offloading. On 03/20/24 at 01:04 PM, Resident #218 observed in bed laying on their left side. There were no pillows in place underneath their right elbow. On 03/19/24 at 11:30 AM during an interview, Staff #9 (Licensed Practical Nurse) stated that the resident was always in pain and did not like to be touched, and that the resident refused wound care and to have a pillow placed underneath their elbow, and that they did report it to the nurse manager. On 03/20/24 at 11:33 AM during an interview, Staff #10 (certified nurse aide) stated that Resident #218 was supposed to have a pillow in place under their right elbow and that they would not allow staff to place the pillow underneath their right arm. Staff #10 stated that they did notify the nurse when the resident refused. On 03/21/24 at 11:50 AM during an interview, Staff #9 (Licensed Practical Nurse) stated that they just did not have time to document in the Treatment Administration Record due to a large assignment and getting caught up with other issues on the unit. On 03/21/24 at 12:19 PM during an interview, Assistant Director of Nursing #1 stated that it was the nurse manager's responsibility for reviewing the surgical consult for the wound care physician's recommendations and instructions, and then transcribing the orders. Furthermore, the Assistant Director of Nursing stated that the unit managers were responsible for monitoring the Treatment Administration Record, and that the missing nurses' initials in the Treatment Administration Record for offloading elbows every shift, indicated that it was not being done. On 03/26/24 at 03:35 PM during an interview, Assistant Director of Nursing #1 stated that instructions for turning and positioning was generated from the resident's care plan and went in certified nurse aide accountability record. On 03/26/24 at 03:59 PM during an interview, Staff #1 stated that the turning and positioning instructions was not in the certified nurse aide accountability record for Resident #218 and that there was no documented evidence that turning and positioning was being done from 2/25/24-3/26/24. Staff #1 stated that the nurses should be documenting in the Treatment Administration Record and writing a progress note for refusals of offloading equipment, and that the skin assessments should be done on Fridays and documented in the Treatment Administration Record, and nurses should be writing a progress note about their findings. On 03/27/24 at 11:05 AM during an interview, Staff #10 (certified nurse aide) stated that they did not have time to document in the turning and positioning section in the certified nurse's aide accountability record. On 03/27/24 at 01:58 PM during an interview, the wound care physician stated that sometimes they cannot examine Resident #218 during wound rounds because Resident #218 has psychiatric issues and screams making it very difficult to perform wound care. On 03/28/24 at 05:43 PM during an interview, the primary care physician stated that stated they were made aware of Resident #218 refusals of wound treatments, and that they assumed it was pain but even before they move them, the resident starts screaming. Therefore, they are trying to get the psychiatrist involved to see if their medications can be optimized and see if anxiety is causing the discomfort to not accept cares.1. Resident #432 was admitted to facility with diagnoses of Neurogenic bladder, Huntington's Disease, and Multiple Sclerosis. A) Pressure Ulcer Development: The 6/21/23 Braden Scale (tool to determine risk for developing pressure injury) documented a score of 17 (mild risk) -blanchable redness to skin/intact. The 7/19/23 Skin Integrity Care Plan documented resident risk for skin breakdown or pressure ulcer injury. Interventions included certified nurse aide skin inspection daily during care and report, weekly full body skin assessment by nurse; use pressure reducing cushion, Roho (specialized wheelchair seat cushion) when in Broda chair. The 7/29/23 Minimum Data Set (resident assessment tool) documented Resident #432 had moderately impaired cognition, was always incontinent of bowel and bladder, was at risk for pressure ulcers, had no pressure ulcers, had a pressure reducing device for chair and bed, and received applications of medications and ointments other than to feet. The 8/8/23 Behavior Care Plan documented behavior symptoms: non-compliance with turn and position schedule - with new skin finding. There was no documented evidence of interventions to be used related to this noncompliance. The 8/13/23 nursing note documented Resident #432 had a dime sized opening on left buttocks. The area was cleansed with normal saline, barrier cream applied, and a note was placed in the medical book. The 8/28/23 nursing note documented occupational therapy evaluation and treat, and to assess for chair cushion. The 10/4/23 nursing note documented the nurse was made aware the resident had a wound on the coccyx. The wound was 5 inches long and 1 inch wide with bloody drainage, optifoam was applied, and the resident needed a wound consult. The 10/5/23 physician's order documented wound care consult open area to coccyx. Cleanse with normal saline and pat dry, apply skin prep to surrounding skin, apply a thin layer of Triad cream and cover with foam dressing daily on the night shift. The 10/10/23 nursing note documented no abrasions, redness, or ecchymosis. The 10/12/2023 wound care physician's consult note documented the initial visit and the resident had a Stage 4 pressure ulcer on the sacrum that measured 3.5 centimeters x 1.0 centimeters x 0.4 centimeters (length x width x depth). The recommended treatment was honey-based gel, calcium alginate, and foam dressing. The 10/12/23 Impaired Skin Integrity Care Plan documented presence of skin breakdown related to incontinence, non-compliance with offloading, as evidenced by pressure ulcer to sacrum. Interventions included to refer for follow up with the wound care team. Provide pressure relieving devices as appropriate. Apply local treatments as ordered by medical doctor. Back to bed after meals for offloading and an air mattress in bed. The 10/13/23 Physician's orders documented; Air mattress- check functioning every shift, cleanse coccyx wound with skin integrity and sterile gauze, apply Medihoney and opticel dressing to area, cover with optifoam protective dressing to area. The 10/25/23 Minimum Data Set documented Stage 4 pressure ulcer not present upon admission or reentry. When interviewed on 03/27/24 at 01:59 PM, the Wound Care Physician stated the first time they saw the resident was in October 2023 and the wound had progressed to a Stage 4. B) Pressure injury worsening and treatments not provided: The wound care physician's consultation notes and physician orders documented on: - 2/1/24 the wound measured 0.9 x 0.2 x 0.2 centimeters and had increased in size, and the order was Medihoney, calcium alginate, and Optifoam dressing, with Triad to peri wound daily. - 2/8/24 the wound measured 0.8 x 0.2 x 0.2 centimeters, had decreased in size, and the order was changed to cleanse soap and water, apply Triad and Optifoam daily. - 2/15/24 the wound measured 0.6 x 0.4 x 0.2 centimeters, and had increased in size. - 2/22/24 the wound measured 6.0 x 4.0 x undetermined, increased in size and the order was changed to Santyl, calcium alginate and foam to be administered daily. There was no documented evidence the physician was notified when the wound increased in size from 2/15/24 to 2/22/24. The February 2024 Treatment Administration Record (TAR) lacked documented evidence that the treatment was completed on 13 days from 2/1/24 to 2/22/24. The nursing progress note dated 2/27/24 documented the resident was sent to the hospital. The hospital record documented the resident was admitted to the hospital on [DATE] with septic shock due to a urinary tract infection and dehydration. Wound culture results on 2/29/24 revealed the Stage 4 pressure ulcer was infected. The Hospital Discharge paperwork dated 3/12/24 documented the resident had an extensive sacral ulcer, did not have acute osteomyelitis but was at high risk for progression given their general debility. The hospital course was complicated by sacral wound. Resident was followed by wound care and underwent surgical wound debridement on 3/8/2024. When interviewed on 3/20/24 at 12:29 PM, Staff #6 (Registered Nurse Unit Manager) stated they were new to the facility and did not know how wounds were monitored or tracked. They stated a wound care physician came in once a week and did rounds. Staff #6 stated none of the unit staff rounded with the physician and they did not have a tracking system. When interviewed on 3/21/24 at 3:50 PM, Staff #3 (Wound Care Registered Nurse) stated they expected nursing call if there were changes in the wounds between visits and did not recall getting any calls. Assistant Director of Nursing #1 stated the Registered Nurse Unit Manager was responsible for reviewing the Treatment Administration Record and making sure treatments were done. C) Wound dressing not as ordered: The physician order dated 3/16/24 documented treatment for the sacral wound included cleanse with Skintegrity (wound cleanser), pat dry, apply Santyl (debriding ointment) , calcium alginate (absorbent wound dressing) and Optifoam (adhesive foam dressing); and apply Triad (wound cream) to periwound twice daily. During a wound observation on 3/19/24 at 12:00 PM, Staff #12 (Licensed Practical Nurse) removed the old dressing which was saturated with tan drainage, cleansed the wound, applied Santyl with a cotton swab to the wound bed, packed the wound with gauze and applied 2 Optifoam dressings. When inteveiwed at 12:30 PM, Staff #12 stated the order was for Santyl, plain gauze and Optifoam and that was what she used. When interviewed on 3/20/24 at 12:29 PM, Staff #6 (Registered Nurse Unit Manager) stated the dressing order was for Santyl, calcium alginate and optifoam; it was not appropriate to substitute plain gauze for calcium alginate. Based on observations, record review, and interviews conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure 4 of 6 residents (Residents #432, #218, #48, and #54,) reviewed for pressure ulcers, received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically, (1) Resident #432 acquired a stage 4 sacral pressure ulcer at facility and treatments were not completed as ordered. (2) Resident #218 was observed 4 times without a pillow under their right elbow and their right elbow stage 4 pressure ulcer had re-opened, (3) Resident #48 was admitted with moisture associated skin damage to the right sacrum which developed into an deep tissue injury and an unstageable wound, and (4) Resident #54's sacral pressure ulcer increased in size during a time period when 3 of 10 topical wound dressing treatments were not documented as administered. Findings include: The facility's policy, 'Pressure injury care and prevention' last reviewed 12/23 documented to assess and observe all residents for the risk of pressure injury and to have an appropriate interdisciplinary preventative care plan implemented when indicated. Residents with existing pressure injuries will be evaluated and managed in accordance with established clinical practice guidelines.

Based on interviews and record review conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of the residents. Specifically, 1) multiple residents reported during confidential interviews and the group meeting that the facility was short staffed at times especially at night and there was a lack of timely staff response to call bells, 2) multiple nursing staff members reported a lack of sufficient staffing, 3) a review of one month of facility staffing revealed the facility did not ensure that the minimum staffing levels for certified nurse aides was met on the night shift. Findings include: Review of the facility staffing from 2/13/24-3/13/24 revealed: - on 2/13/24, 7 CNA slots were unstaffed on the night shift, - on 2/15/24, 3 CNA slots were unstaffed on the night shift, - on 2/19/24, 2 CNA slots were unstaffed on the night shift, - on 2/23/24, 2 CNA slots were unstaffed on the night shift, - on 2/27/24, 1 CNA slot was unstaffed on the night shift, - on 2/29/24 1 CNA slot was unstaffed on the evening shift and 1 CNA slot was unstaffed on the night shift, - on 3/2/24, 3 CNA slots were unstaffed on the night shift, - on 3/4/24, 1 CNA slot was unstaffed on the night shift, - on 3/7/24 1 CNA slot was unstaffed on the night shift, - on 3/9/24 3 CNA slots were unstaffed on the night shift, - on 3/10/24 1 CNA slot was unstaffed on the night shift, - on 3/11/24 1 CNA slot was unstaffed on the night shift, - on 3/12/24 1 CNA slot was unstaffed on the night shift, - on 3/13/24 2 CNA slots were unstaffed on the night shift. When interviewed on 03/13/24 at 5:07 PM, Resident #49 stated they had to wait for a long time for the staff to provide personal hygiene for them and take care of their soiled briefs. They stated that was why they had accidents with bowel and urination. When interviewed on 03/13/24 at 4:24 PM, Resident #130 stated there were not enough staff every night. During the Resident Council Meeting on 3/15/24 at 10:37 AM, 10 of 10 residents voiced their concerns that when they rang the call bell they waited a very long time. Some residents stated they wait for 1.5 hours before a response. In addition, the Resident Council Meeting reported that the Administrator stated This is nothing I have not heard before. The residents stated that 90 percent of the concerns that they have brought up had not been resolved and they never heard back from the administration. During an interview on 3/20/24 at 10:09 AM, Staff #31 (Staffing Coordinator) stated all full time and part time nursing staff had a regular schedule, and the per diem staff were booked per facility needs. They stated there was an app called ROBO which was accessed by the facility via text, their staffing needs two weeks in advance. They stated the facility did mandate staff as necessary based on the daily staffing needs. They stated the facility also reached out to staffing agencies on a daily basis, and stated the facility utilized 6 staffing agencies of which 2 were for travelers. During an interview on 3/26/24 at 11:20 AM, Staff #32 (certified nurse aide) stated they were assigned to 11 residents. They stated they had to assist the residents with their activities of daily living, get them up out of bed in the morning, do morning cares, serve the residents their meals as quickly as possible so the food would not get cold, give the residents their food preferences and assist the residents with toileting needs after breakfast. Staff #32 stated they have to do a flexed schedule of 16 hours per week, because they were constantly being mandated to do extra shifts because of the staffing shortage. During an interview on 3/26/24 at 11:25 AM, Staff #33 (certified nurse aide) stated they were assigned 8 residents today. They stated they used to get mandated at least 60 hours a week, but because of their family situation, they volunteered to come in early ,so they did not have to work the overnight shift. Staff #33 stated that when they were working the 7 am-3 pm shift, they did not plan anything for after work hours in case they were mandated. They stated they did not mind getting mandated but stated there was a limit. During an interview on 3/26/24 at 11:35 AM, Staff #11 (Licensed Practical Nurse Unit Manager) stated they sometimes volunteered to come in to cover an extra shift. During an interview on 3/27/24 at 11:02 AM, Staff #34 (Licensed Practical Nurse Unit Manager) stated they have 3 CNAs on this unit at times but when there are 2 CNAs, a CNA would be asked to come in around 8 am or 9 am to make the third CNA. There are mandations approximately 2 times a week for the CNAs, but for the nurses no, they are asked to volunteer. We are here for the residents so they are kept clean, fed, and happy. During an interview on 3/27/24 at 11:12 AM, Staff #17 (certified nurse aide) stated they work 3 days a week x 12 hours. They stated they do not get mandated since they are already working 12 hours. They stated if their replacement calls out sick, I would get mandated to cover another 4 hours. During an interview on 3/27/24 at 11:19 AM, Staff #49 (certified nurse aide) stated they work about 70 hours a week, based on the needs of the facility. During an interview on 3/27/24 at 11:36 AM, Staff #35 (certified nurse aide) stated they work 6 am-2 pm shift because of staffing issues. Staff #35 stated there is a need for improvement in the staffing conditions because they are burning out. During an interview on 3/27/24 at 11:41 AM, the Administrator stated during the pandemic a lot of people left the facility. The Administrator stated they felt the wage should be increased to include sign-on bonus incentives for Registered Nurses, Licensed Practical Nurses, and certified nurse aides which would increased the staffing ratio. The Administrator stated there were not a lot of Licensed Practical Nurses or Registered Nurses in this area. The Administrator stated they had a certified nurse aide training program and hoped the new certified nurse aides would stay on at the facility. The Administrator stated they encouraged the Licensed Practical Nurses to become unit managers. The Administrator stated they could still do better with staffing. The Administrator stated they had been talking with Human Resources Director and Corporate and wanted to create a weekend bonus, so interested staff can pick up extra shifts. The Administrator stated the Human Resources Director recently conducted another wage review for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides which was waiting for approval. The Administrator stated they had to be the most competitive with their rates, and they wanted to eliminate mandatory overtime, and they were also trying to initiate a float pool. 10NYCRR 415.13 (A) (1) (i-iii)

Based on observation, interview, and record review conducted during the Recertification Survey completed from 3/13/24 through 3/29/24, the facility did not ensure each resident received drinks, including health shakes and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 17 (Residents #1, 6, 11, 34, 53, 63, 65, 84, 85, 145, 177, 204, 216, 237, 250, 258, and 278) of 36 residents reviewed. Specifically, Residents #1, 6, 11, 34, 53, 63, 65, 84, 85, 145, 177, 204, 216, 237, 250, 258, and 278 did not receive coffee or tea, and health shakes as per meal ticket. Findings include: The undated facility policy titled Resident Meal Service, documented beverages were to be provided as listed on ticket or per resident preference. On 03/13/24 from 12:21 PM-01:05 PM, during the dining room lunch observation, Residents #1, 11, 84, 177, 237, 250, 258, and 278's meal tickets all documented 6 ounces of a hot beverage (tea, coffee, and decaffeinated tea or coffee). None of the residents received the hot beverages listed on their meal tickets and none were provided an alternate 6 ounce beverage in place of the hot beverage. During the same meal observation, Residents #6, 34, 53, 63, 65, 84, 85, 145, 204, 216, 250's meal tickets all documented 4 ounces of Health Shake on their meal tickets and none of the resident were provided with the Health Shakes. During an interview on 03/13/24 at 01:00 PM, Staff #56 (dietary aide) stated that the residents did not receive coffee, tea, and the health shakes because nursing staff was responsible for putting the items on the residents' trays. During an interview on 03/20/24 at 09:42 AM, the Registered Dietician stated that both the food service worker and nursing staff were responsible for making sure all items on the meal tickets were provided to the residents before the tray was taken away from the resident. They stated the health shakes should be brought up from the kitchen by the dietary aide for every meal and has had issues in past and was not able to provide health shakes due to supply chain issues. The Registered Dietician stated that coffee and tea was on the resident tickets and was needed for hydration and should have been provided to resident when the trays was served. During an interview on 03/20/24 at 01:09 PM, Staff #10(certified nurse aide) stated that the health shakes was supposed to be put on tray by dietary and that the nursing staff was only responsible for serving the coffee tea, ginger ale, juices, and milk. During an interview on 03/21/24 at 10:18 AM, Staff #30 stated that they were not aware the health shakes were not distributed to the residents, and that dietary was responsible for bringing the health shakes on the unit. 10NYCRR415.14(d)(4)

Based on observation, interview, and record review conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, 1. Portable food storage bins used for storing bulk dry foods were not maintained in a sanitary condition, 2. A cooling log was not used to monitor cooling of potentially hazardous cooked food (poultry), 3. Storage racks used to store cleaned and sanitized food preparation equipment were not maintained in a sanitary condition and the floor under the storage racks was not maintained in a sanitary condition, 4. Eight (8) food transport trucks used for transport of foods to the resident units were not maintained in a sanitary condition, and 6. A formica countertop located directly in front of 1 of 8 kitchenette hot food holding areas was in poor repair and presented a risk for food contamination and potential injury to residents. The findings are: During a follow up tour of the main kitchen on 3/19/2024 between 9:04 AM and 10:59AM the following were observed: 1) On 3/19/24 at 9:22 AM, three (3) portable bins used for storing bulk dry foods (rice, flour, and food thickener) were observed with black-ish colored grime and orange-ish colored soiling on both the exterior and interior rims of each of the 3 bins. During an interview at that time, the Food Service Director stated that each bin holds about forty (40) pounds of rice, flour, or food thickener, stated that their master cleaning schedule lists the portable storage container was to be scheduled for weekly cleaning, and stated that they did not have a weekly log to document the cleaning of the portable bins. When asked when the bins had last been cleaned, the Food Service Director stated that the bins had not been cleaned often enough, the utility man was responsible to clean the bins, but they did not have a utility man scheduled on a lot of days as they are short staffed. 2) On 3/19/24 at 9:45 AM, the general walk-in refrigerator was observed and found to contain sixteen (16) cooked 1/2 turkey breasts which had been cooked and held for service. The turkey breasts were dated 3/18/2024 and a use by date of 3/21/1024. Surveyor requested to see the cooling log for the turkey breasts. The Food Service Director produced the main kitchen/cooks' log for 3/18/2024 which did not document cooling temperatures for the ½ turkey breasts cooked on 3/18/2024. The Food Service Director stated that they do not having a cooling log for the ½ turkey breasts as they thought that the cooling of smaller pieces of turkey did not have to be recorded on a cooking log. 3) On 3/19/24 at 10:32 AM, three (3) racks with four (4) metal shelves each were observed in the pot washing area. The racks and shelves were soiled with greasy, sticky, and dried food debris, dust, and rust. The shelves each held cleaned and sanitized food preparation and service equipment including several dozen standard hotel pans, more than a dozen 1/2 hotel pans, greater than twenty (20) sheet pans, and various other pots, pans, and mixing bowls. The floor under the three metal racks were soiled with an accumulation of grime and food debris. In an interview on 3/19/24 at 10:42 AM, the Food Service Director stated that the cleaning schedule for the storage racks is scheduled weekly and the pot room floor cleaning is scheduled daily. The Food Service Director stated that, if they had close to the amount of staff they needed, the cleaning could be managed. 4) On 3/19/24 at 10:57 AM, the interiors of the eight (8) portable food transport trucks (used to transport hot and cold foods to each resident unit) were observed to contain sheet pans soiled with dried food debris, and the walls and pan sleeves were heavily soiled with grease, dried food debris, and grime. In an interview on 3/19/24 at 10:59 AM, the food service aide stated that the process was that the sheet pans would be given to the dishwasher after the meal was completed and the carts would be returned to the kitchen. The food service aide stated that the food transport trucks would be cleaned by the worker on the unit or by the utility worker. In an interview at that time, the Food Service Director stated the food transport trucks are to be cleaned daily and stated that they were not being cleaned consistently. 5) On 3/19/24 at 12:15PM Surveyor observation of the unit 4A kitchenette revealed a broken formica countertop located directly in front of foods held on the steam table. In an observation and interview on 3/19/24 at 12:31 PM, the Maintenance Supervisor stated the countertop was 1/16-inch formica, and they were not aware that the formica countertop had cracked and a piece was missing. When asked if it the condition of the formica countertop was safe for food service, the Maintenance Supervisor stated that the broken formica could get into the food and a resident could swallow it or break a tooth. The Maintenance Supervisor stated that staff could report equipment in need of repair by calling them, paging them, or submitting a work order. The Maintenance Supervisor stated they conduct environmental rounds, and they did not recall when they had last conducted environmental rounds on unit 4A. 10 NYCRR 415.14 (h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the recertification and abbreviated surveys (NY00334054) from 3/13/24 to 3/29/24, it was determined that the facility did not ensure an effective pest control program was maintained to ensure the facility was free of pests and rodents. Specifically, facility staff and residents reported mice sightings. Additionally, there were multiple observations of mice droppings in resident rooms. Findings include: During an interview on 3/13/24 at 4:15 PM Resident #206 stated that there were black mouse traps on the unit and in their room, pointing to their radiator. The trap killed about three mice within the past few weeks. During an observation on 03/14/24 at 09:54 AM in Resident #206 room, small black mouse droppings were noted on the floor around the black mouse trap at the base of the radiator. During an observation on 03/14/24 at 12:47 PM while in Resident # 93's room, a mat against the radiator was pulled back, and a black box mouse trap with black specks was found. During an observation on 3/19/24 at 9:08 AM in Resident #206's room, visible mouse droppings were noted on the floor near the mouse trap and around it. The resident saw this surveyor looking on the floor, and they stated, Mouse. During an observation on 03/19/24 at 09:48 AM while in Resident #93's room, behind the floor mat under the radiator there were black mouse traps with black particles on the floor. During an interview on 3/20/24 at 1:15 PM Staff #41 stated that there were lots of mice droppings in the residents' rooms and dining room and they had seen them about a week ago. The housekeeping manager had the housekeeper assigned to each unit clean each resident room every day, and there were still mice droppings the next day. Review of pest control logs documented on unit 5A dated 11/29/23 to 3/23/24: there were 4 mouse droppings documented and 21 mouse sightings, including on 1/26/24 one documented mouse sighting in Resident #206's room. Review of the pest management company invoice from February to March 2024 documented multiple mouse glue traps disturbed throughout the facility. On 3/4/24, rodent droppings were found on the 4th floor dining area and mouse capture on the same unit in another resident's room. On 3/8/2024, several mice were captured on the 3rd, 4th, and 5th floors. During an interview on 3/21/24 at 10:15 AM, the Director of Support Services stated that mice droppings were a long-standing problem because residents were keeping food in their rooms. There is a unit-based logbook for pest control for new or repeat sightings. They hired a new pest control company that comes twice a week to check and put down glue traps. Housekeeping was to clean the room more frequently if needed. During an interview on 03/28/24 at 12:00 PM Staff #24, who documented in the unit 5A pest control log dated 2/19/24, stated they recall seeing a mouse in the hallway by room [ROOM NUMBER], and put that incident in the binder, and told the supervisor, but did not recall which supervisor. They stated there was a mouse on Unit 2A on the 7 PM-7 AM over the weekend but did not put that information in the pest control log. During an interview on 03/29/24 at 09:21 AM, the Assistance Director of Nursing stated that while they were on the unit in late January or February 2024, Resident 206's family member complained of the resident's messy room and while they were in the resident's room, they saw a mouse run across the room under the tall dresser. They called maintenance; no mouse was found; maintenance removed the empty glue trap box and placed a new box. 10 NYCRR 415.29(j)(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 610 Based on record review and interviews conducted on a recent recertification survey, the facility did not ensure that a full investigation was conducted for one of three residents (R #189) reviewed for medication errors. Specifically, there was no documented evidence that a full investigation into a medication timing error involving psychotropic and benzodiazepine medications was performed, or that vital information was communicated to the physician. The findings are: The facility policy titled Medication Errors and dated July 2012 documents it is the policy of the facility that residents are to remain free from medication errors. The Licensed Nurse who identifies the error conducts an immediate evaluation and notifies the Nursing Supervisor. The Nursing Supervisor assesses the resident, initiates the investigation of the medication error and directs notification of appropriate staff (Attending Physician, Director of Nursing and Pharmacist are notified) Poison Control is to be contacted if necessary. Resident #189 was admitted to the facility on [DATE] for rehabilitation after discharge from the hospital for right knee MRSA (Methicillin Resistant Staph Aureus) skin infection, pulmonary embolism and chronic obstructive pulmonary disease. The 3/31/2021 admission MDS (Minimum Data Set) documents the resident was cognitively intact with a BIMS (Brief Interview for Mental Status, an assessment tool) of 15/15. The resident was able to make her needs known. The undated Medication Error Assessment form for the resident was reviewed on 4/16/2021 and documented: 1- Medications were administered at the wrong time due to failure to follow medication procedure related to time of administration. The form listed a partial record of eight medications with a dose and time prescribed to be given next to each drug (Alprazolam, Atorvastatin, Dicyclomine, Imipramine, Lyrica, Lamotrigine, Olanzapine and Quetiapine). Four additional medications were left off this list (Amatiza, Clindamycin, Omeprazole, and Latuda). 2- Corrective actions documented: Medical Doctor (MD) notified. 3- Re-education of the Nurse An interview was conducted during screening with the resident on 4/8/2021 at 10:00AM. The resident stated that on April 5 at about 4:00PM the medication nurse asked the resident if she wanted all her medications. The resident said yes and the nurse asked her to come to the door because the resident was on Contact Isolation and the nurse did not want to gown up to bring in her medications. The resident self-propelled to the door and the nurse gave the resident the medications which she thought were only 4:30PM medications Resident #189 further indicated once she placed the meds in her mouth and had difficulty swallowing the meds she realized she had been given all evening medications. She reported about a half hour later the resident repprted she felt groggy, dizzy and foggy in her head and called the nurse. The medication nurse RN#2 was interviewed on 4/16/2021 at 11:00AM and reported on 4/5/2021 she gave Resident #189 all of her 4:30PM, 5:00PM, 6:00PM and 9:00PM medications at approximately 4:30PM because she thought it would be more convenient for the resident. RN#2 indicated she did not know she could not change the times of medication administration without a physician order. An interview was conducted with the resident's physician on 4/16/2021 at 11:32AM he reported he did not know about the medication error that had occurred on 4/5/2021. An interview was conducted with the Director of Nursing (DON) on 4/16/2021 at 3:42PM who stated she found out about the error on the morning of 4/6/2021. The DON felt that Resident #189 should have been sent out to the hospital for evaluation and when the Nursing Supervisor could not reach the physician, she should have called the Medical Director. As far as the Medication Nurse RN#2, she would be provided Medication Administration training by the Nurse Educator. The DON could not offer an explanation as to why the training had not been provided as of 10 days after the medication error occurred. The Assistant Director of Nursing (ADON) was interviewed on 4/19/2021 at 10:05AM and stated once a medication error had been reported an investigation would be started. The investigation should include resident chart review. The Medication Error Assessment report for Resident #189 was reviewed by the ADON who indicated it was not a complete report. The ADON further Indicated the undated report did not inc;ude the names of all medications that had been administered what meds were given. The ADON added that based on what she reviewed regarding the medication error, the resident should have been sent out to the hospital for an evaluation. The ADON stated a correction plan with the nurses signature documenting her understanding would be expected in the report as well but was not included in the report. An interview was conducted on 04/19/2021 at 12:45PM with the Chief Clinical Officer who stated she received a text on 4/5/2021 at 10:15PM from medication nurse RN#2 informing her of the medication administration error and she told RN #2 she would need to see the DON for a formal warning notice in regard to the medication error. The Chief Clinical Officer was not made aware nor asked what the medications were that RN#2 gave at 4:30PM. 483.12 (c)(2-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a recent recertification survey, the facility did not ensure the comprehensive person-centered care plan was revised for 1 of 2 Residents (Resident # 252) reviewed for vision and hearing. Specifically, (1) Resident #252 Hearing Impairment Care Plan was not revised to reflect the resident's recent complaint of changes in hearing loss, (2) orders for audiology consultation for hearing aids; and (3) to determine if the interventions remained appropriate. The findings are: Resident # 252 is an [AGE] year-old who was admitted to facility on 12/5/2012. Diagnoses included Major Depression, Generalized Muscle Weakness, and Hearing Loss. According to the 9/2/2020 Annual Minimum Data Set (MDS; a resident assessment and screening tool), the resident had intact cognition, required extensive assistance with activities of daily living (ADLs), and had minimal difficulty hearing in some environment. This MDS stated the resident had no hearing aid. A subsequent Quarterly assessment dated [DATE] also stated the resident had minimal difficulty hearing and no hearing aid. A Hearing-Impaired Care Plan initiated 5/8/2014, and last updated 10/12/2020 revealed the resident had slight hearing impairment. Goals included resident would demonstrate ability to hear by answering questions appropriately. Interventions included to speak slowly and clearly, facing resident in a well-lit area, allow increased time for resident to respond, encouraged resident to speak slowly and clearly, and audiology consult. Review of an Audiology Evaluation dated 3/10/2020 revealed the resident was evaluated for hearing loss. The resident reported that her friends and family complained that she did not hear well. Pure tone testing revealed a mild sloping to severe sensorineural hearing loss. The resident was judged to be a good candidate for a trial with amplification. She met the NYS Medicaid criteria for hearing aid coverage. The resident agreed with the trial. Recommendations included returning for hearing aid dispensing appointment once authorization and clearance were obtained, and annual re-evaluation. Physician Renewal Orders dated 3/26/2021 had orders for Audiology Consult Evaluation for hearing aids related to complaint of difficulty hearing. The original order date for this consult was 2/24/2021. Review of the Hearing Impairment Care Plan revealed it was not revised to reflect the resident's recent complaint of changes in hearing loss, the ordered audiology consultation for hearing aids and to determine if the interventions remained appropriate. During an interview with the resident on 4/8/2021 at 12:13PM, the resident complained to surveyors that she had hearing problems and had informed the staff about it, but nothing was done. The resident exhibited difficulty in hearing both surveyors. Surveyors had to repeatedly speak loudly, but slowly, into the resident's ears, so that the resident could hear what was said. Resident #252 stated over a year ago, measurements for hearing aids were done at a doctor's office. The resident stated the hearing aids remained at the office because she was unable to get them related to the outbreak of COVID1-19 disease. The resident further stated that no one had scheduled an appointment for audiology or followed up with getting her hearing aids. During an interview with the Director of Nursing (DON) on 4/13/2021 at 3:15PM, she stated that she would check the resident's record to see if the 2/24/2021 or 3/26/2021 physician orders for audiology consults were carried out. In a follow up interview with the DON on 4/14/2021 at 2:48PM, she stated that Resident #252 audiology consultations were never scheduled until after the surveyor brought it to her attention. She stated residents were not cleared for outside appointments until in March 2021. The DON stated the lack of appointment was an oversight. She stated Licensed Practical Nurse (LPN) Managers are responsible for initiating/updating care plans. Registered Nurses are also responsible for initiating/updating care plans, as well as overseeing the LPN Managers work. During an interview with Licensed Practical Nurse (LPN # 1) Unit Manager on 4/14/2021 at 3:19PM, she stated that Resident #252 returned from another facility in January or February 2021. At that time, residents were not going on appointments related to COVID-19 and facility policy. LPN #1 stated the hearing consult information was never communicated with other staff members. The nurses who performed medication and treatment should have seen the orders on their computer dashboard and fill out the consults. That nurse would then have a transportation representative set up the audiology appointment. LPN #1 further stated that resumption of residents' appointments started in March 2021, and the lack of audiology appointment for Resident #252 was an oversight. LPN #1 stated that she was responsible for initiating and updating care plans, as well as Registered Nurses (RN). LPN #1 stated the resident's hearing care plan should have been updated by the RN when the resident returned from another facility on 2/24/2021. 415.11 (c) (2) (i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a recent recertification survey, the facility did not ensure that a resident receive proper treatment and assistive device to meet the resident's hearing needs. Specifically, 1of 2 residents (Resident #252) reviewed for vision/hearing complained to the facility staff about hearing difficulties and was not provided the audiology consultation or hearing aids ordered by the physician. The findings are: Resident #252 is an [AGE] year-old who was admitted to facility on12/5/2012. Diagnoses included Major Depression, Generalized Muscle Weakness, and Hearing Loss. According to the 9/2/2020 Annual Minimum Data Set (MDS; a resident assessment and screening tool), the resident had intact cognition, required extensive assistance with activities of daily living (ADLs), and had minimal difficulty hearing in some environment. This MDS stated the resident had no hearing aid. A subsequent Quarterly assessment dated [DATE] also stated the resident had minimal difficulty hearing and no hearing aid. A Hearing-Impaired Care Plan initiated 5/8/2014, and last updated 10/12/2020 revealed the resident had slight hearing impairment. Goals included resident would demonstrate ability to hear by answering questions appropriately. Interventions included to speak slowly and clearly, facing resident in a well-lit area, allow increased time for resident to respond, encouraged resident to speak slowly and clearly, and audiology consult. An entry note of this care plan dated 12/18/2019 showed the resident requested hearing aids and an audiology consult was scheduled. Another entry note dated 4/17/2020 stated awaiting audiology follow up. Review of an Audiology Evaluation dated 3/10/2020 revealed the resident was evaluated for hearing loss. The resident reported that her friends and family complained that she did not hear well. Pure tone testing revealed a mild sloping to severe sensorineural hearing loss. The resident was judged to be a good candidate for a trial with amplification. She met the NYS Medicaid criteria for hearing aid coverage. The resident agreed with the trial. Recommendations included returning for hearing aid dispensing appointment once authorization and clearance were obtained, and annual re-evaluation. Physician Renewal Orders dated 3/26/2021 had orders for Audiology Consult Evaluation for hearing aids related to complaint of difficulty hearing. The original order date for this consult was 2/24/2021. Review of clinical records, including nursing, physician progress notes, physician orders, consults, and care plans revealed no documented evidence that the facility staff scheduled the resident for her 2/24/2021 and most recent 3/26/2021 audiology consults for evaluation for hearing aids. There was no documented evidence that the physician's orders were carried out. The facility did not provide any evidence that the orders were carried out. Additionally, there was no documented evidence that the resident returned to the doctor's office for her hearing aid appointment as described in the 3/10/2020 audiology report above. During an interview with the resident on 4/8/2021 at 12:13PM, the resident complained to surveyors that she had hearing problems and had informed the staff about it, but nothing was done. The resident exhibited difficulty in hearing both surveyors. Surveyors had to repeatedly speak loudly, but slowly, into the resident's ears, so that the resident could hear what was said. Resident #252 stated over a year ago, measurements for hearing aids were done at a doctor's office. The resident stated the hearing aids remained at the doctor's office because she was unable to get them related to the outbreak of COVID1-19 disease. The resident further stated that no one had scheduled an appointment for audiology or followed up with getting her hearing aids. During an interview with the Director of Nursing (DON) on 4/13/2021 at 3:15PM, she stated that she would check the resident's record to see if the 2/24/2021 or 3/26/2021 physician orders for audiology consults were carried out. In a follow up interview with the DON on 4/14/2021 at 2:48PM, she stated that Resident #252 audiology consultations were never scheduled until after the surveyor brought it to her attention. She stated residents were not cleared for outside appointments until in March 2021. The DON stated the lack of appointment was an oversight. During an interview with Licensed Practical Nurse (LPN # 1) Unit Manager on 4/14/2021 at 3:19PM, she stated that Resident #252 returned from another facility in January or February 2021. At that time, residents were not going on appointments related to COVID-19 and facility policy. LPN #1 stated the hearing consult information was never communicated with other staff members. The nurses who performed medication and treatment should have seen the orders on their computer dashboard and fill out the consults. That nurse would then have a transportation representative set up the audiology appointment. LPN #1 further stated that resumption of residents' appointments started in March 2021, and the lack of audiology appointment for Resident #252 was an oversight. 415.12 (3)(b)

Based on interviews and record review during a recertification survey the facility failed to ensure adequate supervision and effective use of the facility's monitoring program to prevent elopement was provided for 1 of 1 resident (Resident #81). Specifically, Resident #81 entered an elevator on the 3rd floor and was found by staff on the 4th floor. The findings are: The facility occurrence report indicates on 4.6.21 the resident stated she was leaving, her boss said she could go. The resident, who resides on Unit 3A was found in the core elevator at 1:50pm on the 4th floor unit A. Staff on the 4th floor responded to the alarm and found the resident sitting her wheelchair in the elevator. The therapy aide who got on the elevator notified the 3rd floor unit manager that she was taking the resident outside for a few minutes. Upon returning to the unit 3A the Unit Manager assessed the resident and determined she was not harmed. The facility policy regarding Wander Guard dated 8.5.2005 and revised most recently on 1.14.2015 was reviewed and indicated for residents who are determined to be a wandering or elopement risk: determine if the resident is in other area of the building, staff are not to reset wandering alert alarms until they have identified the whereabouts of the resident and have returned them to safe area and the resident will be reassessed by the nurse upon return to the unit. Resident #81 was admitted to the facility on 11.29.18 with the following diagnoses: Peripheral Vascular Disease, Renal Insufficiency, Cerebrovascular Accident, and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set (MDS, a tool used to assess residents) dated 1.29.21 determined the resident to be moderately cognitively impaired as indicated by the Brief Interview for Mental Status (BIMS used to measure orientation and memory recall,) score of 12 out of 15. The MDS further documented the resident to be wearing a wander guard alarm daily to prevent elopement off the resident's unit. Review of the resident's Care Plan revealed Behavior Symptoms: Wandering, active and effective 10.15.20 through 7.10.21. The care plan titled Focus: Resident exhibits wandering behavior as evidenced by wandering behaviors and attempting to enter the elevator included the goal Resident will show decreases in wandering and had the following interventions: document in progress notes the frequency, intensity, and duration of wandering behavior, notify MD and refer resident for Psychological services as needed; administer medications as ordered by the physician, ensure proper placement of ankle alert and check for any malfunction and ensure resident is safe distance from elevator when resetting alarm On 4/16/21 at 12:39pm Interview was conducted with the Director of Nursing DON) who stated staff were educated upon hire and re-educated every 6 months regarding elopement. She stated the housekeeper who cleared the alarm on unit 3 when Resident #81 entered the elevator was provided re- education regarding what to do if the alarm in the elevator was sounding. On 4/16/21 at 12:42 pm interview was conducted with the Staff Educator who stated she re-educated the housekeeper who cleared the elevator when the resident was on it. On 4/16/21 at 12:46pm interview was conducted with housekeeper #1 who stated when hearing the alarm sounding, he cleared the alarm while resident #81 was in the elevator. He stated he knows that he should contact a nursing staff member whenever the alarm was sounding no matter who was in the elevator, but did not do that. 483.25 (d)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews during a recent recertification survey, the facility did not ensure that one (Resident # 189 ) of three residents reviewed for medication administration was free from significant medication error. Specifically, the nurse did not administer medications at the physican prescribed time placing the resident at risk for dangerous drug interaction/reactions. The findings are: The facility policy dated May 1, 2009 documented Medications and Treatments shall be administered in a timely manner that is safe, timely, and reduces the incidence of error as much as humanly possible. Medications may be administered one hour before and one hour after the scheduled ordered time. The facility policy titled Medication Errors and dated July 2012 documents it is the policy of the facility that residents are to remain free from medication errors. The Licensed Nurse who identifies the error conducts an immediate evaluation and notifies the Nursing Supervisor. The Nursing Supervisor assesses the resident, initiates the investigation of the medication error and directs notification of appropriate staff (Attending Physician, Director of Nursing and Pharmacist are notified) Poison Control is to be contacted if necessary. The facility policy on Clinical Notification of Changes Protocol dated 6/20/19 states the purpose is to assure the facility's staff provides timely notification of changes in a resident's condition to a physician, and the resident/resident representative. Nurses and other care staff are educated to identify changes in a resident status and define changes that require notification of the resident's physician to ensure best outcomes of care for the resident. Resident #189 was admitted to the facility on [DATE] for rehabilitation after discharge from the hospital for right knee MRSA (Methicillin resistant staph aureus) skin infection, pulmonary embolism, chronic obstructive pulmonary disease and had a history of Depression and Bipolar Disorder. The admission MDS (Minimum Data Set) documented the resident was cognitively intact with a BIMS (brief interview for mental status, an assessment tool) of 15/15. Review of the 3/24/21 Physician orders revealed the resident was prescribed the following medications: Imipramine 50mg, 1 tab daily at bedtime 09:00pm, Quetiapine 100mg tab give 2 tabs once a day at bedtime 09:00pm Lyrica 150mg 1 capsule once daily at bedtime 09:00pm Dicyclomine 10mg cap, 1 cap four times a day 09:00am, 01:00pm, 05:00pm, 09:00pm Atorvastatin 10mg 1 tab at bedtime 09:00pm Alprazolam 1mg once a day at bedtime 09:00pm and Olanzapine 10mg 1 tab daily at bedtime 09:00pm Omeprazole 40mg 1 cap 2 times a day before a meal- 6:45am and 4:30pm Lamotrigine 50mg 1 tab two times a day 09:00am, 5:00pm Amitiza 24mcg 1 cap two times a day 09:00am, 05:00pm Latuda 80 mg , 1 tab daily- 5:00pm and Clindamycin HCL 150mg , 2 cap every 6 hrs 12:00am, 06:00am, 12:00pm, 06:00pm During a screening interview on 4/8/21, Resident # 189 reported that on 4/5/21 at 4:00pm the Medication Nurse came to her door and asked her if she wanted all of her medications. Resident # 189 stated yes, she wanted all of her medications. She indicated since it was only 4:00PM she thought the nurse meant all the meds due to her at that time. The nurse handed Resident #189 a cup with medications and after she placed them in her mouth she noted she had difficulty swallowing them. It was at that time Resident #189 indicated she realized the nurse gave her all her medications for the shift. About a half hour later the resident indicated she began to feel dizzy, foggy in her head and was hearing voices. She notified RN#1. Resident #189 reported a supervisor came to see her some time after that. The medication nurse RN#2 was interviewed on 4/16/21 at 11:00am she reported on 4/5/21 at approximately 4:30pm she gave Resident # 189 all medications that were ordered to be given from 4:30pm to 09:00pm because she thought it would be more convenient for the resident. RN #2 stated she asked the resident if she wanted all her evening medications at one time and the resident responded yes RN #2 reported she took that as consent from the resident to give her all of the evening medications at one time. RN#2 stated she did not know she could not change the times of medication administration without a physician order. RN#2 stated she could not sign for the 09:00pm meds at 4:30pm because the computer still had a red box meaning it was too early to sign them. RN#2 waited until later in the evening as the time got closer to 09:00pm the box turned green and she was able to sign off the administered medications on the MAR (Medication Administration Record). An interview was conducted with the resident's physician on 4/16/21 at 11:32am he stated he was not aware of the medication error on 4/5/21 and would have had the resident sent to the hospital for evaluation or at very least ordered more frequent vital signs and monitoring. RN#1 was interviewed on 4/16/21 at 11:40am, he reported he was called to the room by the resident on 4/5/21 around 4:45pm. The resident complained of feeling dizzy and felt in a fog. RN#1 stated the resident appeared to be having a stroke because the resident had slurred speech and was very drowsy. The resident told him the medication nurse gave her a lot of pills. He was scared, took her vitals and called the Nursing Supervisor. RN#1 reported he did not document the incident including assessment and vitals in the resident's chart because he thought the Supervisor would do that. An interview was conducted with the Director of Nursing (DON) on 4/16/21 at 3:42PM who stated she found out about the error on the morning of 4/6/21. The DON felt that Resident#189 should have been sent out to the hospital for evaluation and when the Nursing Supervisor could not reach the physician, she should have called the Medical Director. 483.45 (f)(2)