**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Recertification Survey from [DATE] to [DATE], for one (Resident #127) of 36 residents reviewed, the facility did not ensure that all residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive (a resident's wishes to be or not to be resuscitated in the event of an acute cardiac or pulmonary arrest) that would be honored. Specifically, the facility did not ensure Residents #127's advance directive identifiers were consistent with the resident's wishes. This is evidenced by the following: The facility policy Advanced Directives and Code Blue, dated [DATE], included an advanced directive should be maintained in the resident's medical record and should the resident wish to review or revise their advanced directive, the Social Service/Nursing/Designee would be contacted to assist the resident if necessary. All follow-up education and interaction with the resident/significant other should be documented in the medical record by the individual designated to interact with the resident/significant other regarding their concerns surrounding advanced directives. Resident #127 had diagnoses that included a stroke, anxiety, and depression. Review of an Acute Visit Progress Note, dated [DATE] and signed by Nurse Practitioner #1, revealed Resident #127 was alert and oriented to person, place, and time. Review of Resident #127's Medical Orders for Life Sustaining Treatment (MOLST) form, dated [DATE], revealed the resident's advanced directive wishes were for Do Not Resuscitate (allow natural death). The Medical Orders for Life Sustaining Treatment form included Resident #127 was the individual making the decision and verbal consent had been obtained. Review of current Physician orders, dated [DATE], revealed Resident #127's advanced directive wishes were for full cardiopulmonary resuscitation ([CPR] meaning to initiate cardiopulmonary resuscitation in the event of acute cardiac or respiratory arrest). The order was entered into the electronic medical record by the Director of Nursing. Review of Resident #127's current Comprehensive Care Plan on [DATE] revealed the resident's advanced directive wishes were for Do Not Resuscitate. In an admission note (readmission from the hospital), dated [DATE], Nurse Practitioner #2 documented that Resident #127's advanced directive wishes were for Full Code. In a Nursing Progress Note, dated [DATE], Nurse Manager #1 documented that Resident #127 was readmitted from the hospital and a Do Not Resuscitate (Medical Orders for Life Sustaining Treatment) form was completed at the resident's bedside. Review of Interdisciplinary Progress Notes from [DATE] through [DATE] did not reveal any documentation related to a change of advanced directives since Resident #127's [DATE] Medical Orders for Life Sustaining Treatment form was filled out. During an interview on [DATE] at 9:18 AM, Licensed Practical Nurse #13 stated to determine a resident's advanced directive wishes, they would look in the computer (resident's electronic medical record) or the resident's Medical Orders for Life Sustaining Treatment form. During an interview on [DATE] at 1:47 PM, the Director of Nursing stated a resident's advanced directive wishes are determined on admission and the resident's Medical Orders for Life Sustaining Treatment form if they came in with one was reviewed (to ensure current wishes). The Director of Nursing stated nursing staff should refer to the Medical Orders for Life Sustaining Treatment form as primary place or refer to the resident's electronic medical record. The Director of Nursing stated Resident #127 was a Do Not Resuscitate per their Medical Orders for Life Sustaining Treatment form. During a review at this time with the surveyor, Resident #127's physician's orders included the resident was a Full Code. The Director of Nursing stated they entered the Full Code order on [DATE] as they may have received an email from the Social Worker that there was change, but could not recall. In a follow-up interview at 2:56 PM, the Director of Nursing stated they spoke with Resident #127 who verbalized their advanced directive wishes at this time were for Full Code. 10 NYCRR 415.3(f)(1)(ii)

Based on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for two (Residents #4 and #53) of six residents reviewed, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs including resident goals, desired outcomes and preferences related to their ongoing smoking habits. Specifically, the facility was aware that Residents' #4 and #53 continued to smoke against facility policy and there was no care plan in place to ensure the residents remained safe. This is evidenced by the following: 1. Resident #4 had diagnoses that included chronic respiratory failure, anxiety, and a tracheostomy (surgically created hole in the windpipe that provides alternative airway for breathing). The Minimum Data Set Resident Assessment, dated 09/23/2024, revealed Resident #4 was cognitively intact and used a wheelchair. Review of the Smoking Assessment Policy and Assessment form, dated 07/08/2024, and signed by Resident #4 revealed that the resident did smoke cigarettes daily, was on oxygen, was considered safe to smoke by themselves, and was educated that the facility was a non-smoking facility. Review of Resident #4's current Comprehensive Care Plan did not include any information related to the resident's non-compliance with the facility's smoking policy, safety concerns related to continuing to smoke, care of smoking materials, ongoing education, or cessation efforts if desired. During an interview on 12/04/2024 at 1:05 PM, Licensed Practical Nurse #5 stated Resident #4 had a pass to go outside to smoke independently. Licensed Practical Nurse #5 stated the nurses do not assist the resident to smoke and they thought they saw the resident locking their smoking materials in their room. During an interview on 12/06/2024 at 4:30 PM, Registered Nurse Manager #1 stated Resident #4 was noncompliant (with the facility's non-smoking policy), smoked off facility grounds, and this noncompliance with smoking should be on their care plan. 2. Resident #53 had diagnoses that included a below the knee amputation, pulmonary disease, and congestive heart failure. The Minimum Data Set Resident Assessment, dated 10/23/2024, documented the resident was cognitively intact and current tobacco use was indicated at the time. Review of the Smoking Assessment Policy and Assessment form, dated 02/27/2024 and signed by Resident #53, revealed the resident smoked for the past 40 years, declined smoking cessation support, and the resident acknowledged the facility's no smoking policy and does not comply with it. Review of Resident #53's current Comprehensive Care Plan did not include any information related to the resident's non-compliance with the facility's smoking policy, safety concerns related to continuing to smoke, care of smoking materials, ongoing education, or cessation efforts if desired. During an interview on 12/05/2024 at 11:39 AM, Resident #53 stated they went outside to smoke a cigar twice weekly despite being told that smoking was not allowed at the facility and had had their smoking supplies taken away by the Social Worker. The resident also stated they were also told by the Administrator where they could go if they insisted on smoking. Resident #53 stated they kept a lighter hidden in their dresser drawer to avoid having it stolen or confiscated. During an interview on 12/06/2024 at 9:55 AM, Certified Nurse Assistant #1 stated they had seen Resident #53 outside smoking while they were taking a break and the resident wore a pass around their neck to indicate they could leave the unit and building unsupervised. During an interview on 12/06/2024 at 11:01 AM, the Administrator stated they discouraged smoking at the facility and if they see on admission that a resident smokes, they encourage their admission planner to enforce that there was no smoking at the facility. The Administrator also stated they had spoken to Resident #53 in the past after the resident went out to smoke and was out of their eyesight and they were worried about the resident's safety. The Administrator stated that smoking assessments were conducted by their therapy department and if residents insisted on smoking, it should be documented on their care plan. During an interview on 12/09/2024 at 10:50 AM, the Director of Nursing stated the purpose of care plans were to inform the staff how to care for the residents. The Director of Nursing also stated as soon as they learn a resident smokes and is noncompliant, it should be put on their care plan. The Director of Nursing stated Resident #4 was not a smoker when they were first admitted , which is perhaps why the resident's care plan did not include any information related to smoking. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during a Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that residents received care in accordance with professional standards of practice, their person-centered care plan, and resident's choice for 2 (Residents #53 and #81) of 29 residents reviewed for quality of care. Specifically, Resident #53 was not wearing a physician ordered compression wrap following a recent amputation of their right lower extremity on multiple observations. Resident #81 had multiple falls, one resulting in a major injury, and there was no documented evidence that the resident had been assessed by a Registered Nurse or that neurological checks had been completed following a fall with a potential head injury. This is evidenced by the following: The facility's undated Resident Fall Policy documented that prior to moving a resident after a fall, the Registered Nurse/Licensed Practical Nurse must assess/evaluate the resident for physical injury. Care and transfer will be provided as determined by the Registered Nurse/Licensed Practical Nurse based upon the post fall assessment. Vital signs are obtained as allowed and documented. If a fracture is suspected, the resident should not be moved and made as comfortable as possible at the site of the fall or found on the floor. If a head injury is suspected, the protocol for possible head injury and neurological checks are initiated and a neuro check flow sheet utilized for documentation and the physician notified. 1. Resident #81 had diagnoses that included a cognitive communication deficit and Huntington's disease (disease of the nervous system that affects a person's movements, thinking ability, and mental health). The 09/05/2024 Minimum Data Set Resident Assessment documented the resident had moderately impaired cognition, did not have upper or lower extremity impairments, did not use any mobility devices, and required supervision or touching assistance with most activities of daily living. The resident had two falls with no injury and one fall with major injury since the previous assessment. Resident #81's Comprehensive Care Plan, dated as last revised 09/18/2024, and the current Bedside [NAME] (care plan used by the Certified Nursing Assistants for daily care) documented the resident had limited physical mobility, was at risk for falls, had a history of falls, impulsive behaviors, and had at times sat themselves on the floor. Interventions included, but were not limited to, the resident required supervision with transfers, did not use assistive devices, required supervision with ambulation, housekeeping should keep floors clean after meals as possible, and to follow facility fall protocol. In an Unwitnessed Fall Report, dated 08/05/2024 at 9:04 AM, Licensed Practical Nurse Manager #1 documented Resident #81 was found on their knees at 9:04 AM and that seconds prior to the incident, staff observed the resident seated in the dining room. The resident was unable to give a description of the event and the incident was unwitnessed. Immediate action taken included that vital signs were normal and range of motion of extremities was within normal limits. The resident denied hitting their head and it appeared they slid to the floor from how they were positioned. They had blanchable redness (redness that goes away and then comes back) on both knees, but the resident denied discomfort or pain. There were no observed injuries at the time of incident, the resident was alert and oriented, and had nonskid footwear on at the time. Predisposing physiological factors included impaired cognition and impaired judgment. The report notes, completed on 08/07/2024 (two days after the fall), by the facility's Administrator documented the resident had fallen with no injuries sustained and had been placed on 15-minute safety checks until bedtime. The Administrator documented that per the nursing supervisor, there were no care plan violations, mistreatment, neglect, or abuse identified. There was no documented evidence that a Registered Nurse has assessed Resident #81 either on-site or remotely following the fall. In an Unwitnessed Fall Report, dated 08/20/2024 at 12:39 PM, Licensed Practical Nurse Manager #1 documented Resident #81 was found sitting on their buttocks on the floor in the dining room with their legs extended. Staff had informed them that the resident may have bumped their head. Immediate action taken included that vital signs were normal and range of motion was normal. Neuro checks were initiated and predisposing environmental factors included a wet floor. The section titled 'injuries observed at time of incident' included fracture of right elbow and the section titled 'injuries report post incident' included no injuries observed post incident. The fall report did not include any follow-up related to a possible elbow fracture. Review of the Head Injury Flow Sheet, dated 08/20/2024, revealed the resident was to be monitored 12 times post incident for changes in neurological status and 6 of the 12 checks were not signed off as completed. In a nursing progress note, dated 08/21/2024 at 10:39 AM, Licensed Practical Nurse #10 documented Resident #81 complained of arm pain. Physician #1 was in for a follow-up visit and ordered an X-ray. At 2:49 PM, Licensed Practical Nurse Manager #4 documented the X-ray results showed a probable elbow fracture with soft tissue swelling and an orthopedic evaluation was recommended. Review of Resident #81's electronic medical record from 08/05/2024 to present revealed no documented evidence that a Registered Nurse had assessed the resident after either of the two unwitnessed falls. During an interview on 12/06/2024 at 4:18 PM, the Director of Nursing stated when a resident had an unwitnessed fall, staff should notify the nursing supervisor who should ensure the safety of the resident and start the incident report. Licensed Practical Nurses could only gather information and present it to the Registered Nurse as a Registered Nurse should assess the resident either physically or virtually if they were not present in the building. The Director of Nursing stated they do not see documentation that a Registered Nurse saw the resident on 08/05/2024 or 08/20/2024. The Director of Nursing stated residents should be assessed by a Registered Nurse after each incident and the Registered Nurse should document their findings in the resident's medical record. During a follow-up interview on 12/09/2024 at 9:03 AM, the Director of Nursing stated they thought a Registered Nurse did assess the resident after the 08/05/2024 and 08/20/2024 fall, but there was no documentation in the medical record, and it could not be assumed and that it was important for a Registered Nurse to assess the resident to rule out injury. They stated nursing staff should have completed the neurological checks after the unwitnessed fall to rule out any neurological changes. During an interview on 12/09/2024 at 10:57 AM Licensed Practical Nurse Unit Manager #1 stated sometimes they were the building supervisor (was not scheduled as such for the two incidents). If a resident had a fall, they would see the resident, gather information, look for any environmental factors or care plan violations, complete the incident report, and place a note in the medical book. If a resident was unable to describe what happened and it was an unwitnessed incident, they would check the resident's range of motion and skin. If they noticed any pain with range of motion or bruising, they would stop and notify the Registered Nurse, but if they did not observe any issues, they just document the incident and notify medical team via the communication book. They recalled the 08/20/2024 incident and recalled the nurse on the unit told them the resident had no new noted skin issues and was able to move their arms and legs without issues. In this case, they do not always call the Registered Nurse (on call). 2. Resident #53 had diagnoses that included a recent right below the knee amputation, arthritis, and diabetes. The Minimum Data Set Resident Assessment, dated 10/23/2024, documented the resident was cognitively intact and received scheduled and as needed pain medications. Review of a physician's orders, dated 11/19/2024, revealed Resident #53 required an ace wrap compression at all times to the right below the knee amputation to reduce swelling. Resident #53's Comprehensive Care Plan, revised on 10/31/2024, documented the resident had acute and chronic pain related to a surgical amputation of their right lower extremity, but did not include that the resident should wear an ace wrap compression. Review of the nursing progress notes for December 2024 did not reveal any documentation that Resident #53 had refused to wear the ace wrap compression to their right lower extremity. During an observation and interview on 12/04/2024 at 9:27 AM, Resident #53 was seated in their wheelchair in their room, wearing a sweatshirt and brief. There was no compression wrap to the right lower extremity. The resident stated their right leg was recently amputated and their stump should be wrapped, but no one wraps it because they were too busy. Resident #53 stated staff often say they would be right back, but then they do not return. During an observation on 12/04/2024 at 11:21 AM, Resident #53 was in the dining room playing BINGO. There was no ace wrap compression applied to their right lower extremity. During an observation and interview on 12/06/2024 at 9:41 AM, Resident #53 was lying in bed with complaints of pain and stated the severity was eight out of ten. There was no ace wrap compression to their right lower extremity. Resident #53 stated their ace wrap compression had been on, but it had come off during the night. The resident stated around 5:00 AM, the nurse came into their room with their morning medications, they asked if the nurse could reapply the ace wrap compression, they were told by the nurse they would come back to reapply it once they were done passing medications, but never returned. During an interview on 12/06/2024 at 9:55 AM, Certified Nurse Assistant #1 stated that Resident #53 often complained of pain due to their recent amputation and the resident is often without their compression wrap in place, but they could not apply it because it was the nurse's responsibility. During an interview on 12/06/2024 at 1:17 PM, the Director of Nursing stated the nurses should apply Resident #53's ace wrap compression as ordered and if the wrap needed to be reapplied, they would expect the nurse to do so as soon as possible but the resident should never have to wait hours. During an interview on 12/06/2024 at 1:55 PM, Licensed Practical Nurse Manager #1 stated that Resident #53 often complained of pain and they have instructed all nurses to look at the medical orders after their medication pass to see what orders needed to be completed, but due to the unit being acute, the orders did not always get completed promptly. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for one (Resident #11) of two residents reviewed for communication, the facility did not ensure the resident received treatment and/or assistive devices to maintain their hearing. Specifically, the facility did not ensure the resident's hearing aids were repaired in a timely manner. This is evidenced by the following: Resident #11 had diagnoses that included auditory hallucinations, high blood pressure, and depression. The Minimum Data Set Resident Assessment documented Resident #11 was cognitively intact, was hard of hearing, and wore hearing aids. During an observation and interview on 12/02/2024 at 10:00 AM, Resident #11 was not wearing either hearing aid. Resident #11 stated at this time they could not hear unless voices were raised as they normally wore hearing aids, but had not had them for the last two months because they were broken. The Comprehensive Care Plan, dated 11/01/2024, and the [NAME] (a care plan used by the Certified Nursing Assistants to provide daily care), dated 12/09/2024, documented Resident #11 had hearing aids to assist with communication. Review of the current physician's orders included an order, dated 04/03/2024, for hearing aids to be placed in the morning and removed at night. Review of the Treatment Administration Record and notes, dated 10/03/2024 to 12/02/2024, revealed multiple entries that the hearing aid(s) were broken and awaiting repair. In an email, dated 10/09/2024, to Long Term Care Management Provider #1, Quality Assurance and Performance Improvement Coordinator #1 documented Resident #11's hearing aid was broken and needed to be fixed. In an email, dated 10/15/2024, to Quality Assurance and Performance Improvement Coordinator #1, Long Term Care Management Provider #1 documented they were waiting to hear back from them to coordinate picking up Resident #11's hearing aid(s). During an interview on 12/05/2024 at 11:35 AM, Licensed Practical Nurse Manager #4 stated Resident #11 had a broken hearing aid and they had notified Quality Assurance and Performance Improvement Coordinator #1 to coordinate with Long Term Care Management Provider #1 to get the hearing aid(s) fixed. During an interview on 12/05/2024 at 11:45 AM, Quality Assurance and Performance Improvement Coordinator #1 stated they are responsible for coordinating with Long Term Care Management Provider #1 to have the hearing aids picked up to be sent out for repair, but they had not had any communication with them since 10/15/2024, and the broken hearing aid(s) was still in the facility (unrepaired). Quality Assurance and Performance Improvement Coordinator #1 stated Resident #11's hearing aids should have been picked up for repair sooner, but they were the only one handling appointments and transportation for the rest of the facility, and the hearing aids got lost in the shuffle. During an interview on 12/06/2024 at 5:06 PM, the Director of Nursing stated coordination with Long Term Care Management Provider #1 should have been done sooner and two months was too long of a time period for hearing aids to get fixed. 10 NYCRR 415.12(3)(b)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey and complaint investigation (NY00361034) from 12/02/2024 to 12/09/2024, the facility did not ensure acceptable parameters of nutritional status for one (Residents #127) of five residents reviewed. Specifically, nutritional assessments by a registered dietician were not performed during Resident #127's initial and readmission to the facility and documented weight losses were not identified timely. This is evidenced by the following: The undated facility policy Nutrition Assessment included that a registered dietician would perform a comprehensive nutrition assessment on residents to determine their risk for malnutrition or nutrition-related problems. A nutrition assessment would be completed on all residents on admission, annually, quarterly, and as needed. The assessment would include (but not limited to) review of documented weights, weight histories as available, clinical factors, and interviews with the resident as appropriate and available. Documentation would be provided in the electronic medical record. Resident #127 had diagnoses that included a stroke, dysphagia (difficulty swallowing), and adult failure to thrive. The Minimum Data Set Resident Assessment, dated 09/11/2024, revealed Resident #127 had a feeding tube, a documented weight of 152 pounds, and any weight loss had not occurred or was unknown. In an Acute Visit Progress Note, dated 11/15/2024, Nurse Practitioner #1 documented Resident #127 was alert and oriented to person, place, and time. Resident #127's current Physician orders, reviewed on 12/05/2024, included a regular diet, one carton of Very High Calorie Boost (nutrition supplemental drink) daily, and monthly weights between the first and third of every month. The current Comprehensive Care Plan, reviewed on 12/05/2024, included Resident #127 was independent with eating, required set-up assist, and was at risk for altered nutrition with interventions that included monthly and as needed weights. Review of a Hospital Nutritionist Note, dated 07/31/2024 (prior to Resident #127's admission to the facility), revealed Resident #127's weight of 113.5 pounds. Review of Resident #127's electronic medical record revealed a 26.6% weight loss over approximately three months (09/05/2024 to 12/02/2024) based on the following documented weights at the facility: - 08/11/2024: 157 pounds - 09/05/2024: 152 pounds - No weight documented after a readmission from the hospital on [DATE]. - No weight documented for October 2024. - 11/01/2024: 104.8 pounds - 12/02/2024: 111.6 pounds Review of a Hospital Nutritionist Note, dated 09/17/2024, revealed Resident #127 presented to the hospital on [DATE] and weighed 111.2 pounds on 09/12/2024. In a readmission Note, dated 09/22/2024, Physician #2 documented that prior to Resident #127's transfer to the hospital, their weight had declined and the resident's readmission weight was pending. Review of Nutrition Assessments revealed a comprehensive Nutrition Assessment had not been completed by a registered dietician on Resident #127's admission to the facility in August 2024 or on their readmission to the facility in September 2024. A Mini Nutrition Assessment (screening tool used to identify residents who are malnourished or at risk for malnutrition) was conducted on 08/12/2024, which identified Resident #127 at risk for malnutrition. A Comprehensive Nutrition Assessment was subsequently completed on 11/14/2024 (by Registered Dietician #1), which included unknown weight loss or gain in the past one, three, and six months. During an interview on 12/05/2024 at 3:01 PM, Registered Dietician #1 stated nutrition assessments were done on admission, quarterly, and if significant changes and were based on the Minimum Data Set Resident Assessments (schedule). Nutrition assessments included review of the resident's electronic health record, visiting the resident, and observing them at meals. Dietician #1 stated a resident's readmission to the facility from the hospital should trigger a Minimum Data Set Resident Assessment, which would show up on their list (to do a nutrition assessment). Registered Dietician #1 stated weights were done monthly or on a weekly basis if needed for tracking, and residents should be re-weighed if something was awry. Registered Dietician #1 stated significant weight loss is the standard for one (5%), three (7.5%), and six (10%) months. Registered Dietician #1 stated the first time they saw Resident #127 was in November 2024 (only works one day a week), and a Comprehensive Nutrition Assessment was done then. Review of the Comprehensive Nutrition Assessment with Registered Dietician #1 at the time revealed that the 11/14/2024 Nutrition Assessment included that Resident #127's (meal) intake was greater than 75%, was receiving Boost supplements to promote weight gain, and they would monitor the resident's weight trends. Registered Dietician #1 stated a Nutrition Assessment should have been done after Resident #127 was readmitted on [DATE], but they were not in the facility that week. Registered Dietician #1 stated Resident #127's weights from September to November met the criteria for significant weight loss, but because the resident had gone to the hospital and had a feeding tube (not in use for nutrition), they chose to use the resident's status in November 2024 as their baseline to work with going forward. During an interview on 12/06/2024 at approximately 3:15 PM, Food Service Director/Registered Dietician #2 stated if a resident was a full readmission (not just a visit to the emergency room), a Comprehensive Nutrition Assessment was required. Food Service Director/Registered Dietician #2 stated significant weight loss or gain is a five percent difference over 30 days and ten percent difference over 180 days. They did not see a Comprehensive Nutrition Assessment following Resident #127's August 2024 admission, were not sure why one was not done, and that they should also have had one when they were readmitted on [DATE], but did not. Food Service Director/Registered Dietician #2 stated they suspected Resident #127's initial weights (in August obtained by the facility) were inaccurate because the hospital notes listed the resident weighing 113 pounds and the Comprehensive Nutrition Assessment (if completed) would have picked up on the weight discrepancies. Food Service Director/Registered Dietician #2 stated they could not recall notifying the medical provider about Resident #127 potential weight loss. During an interview on 12/09/2024 at 10:57 AM, with the facility Administrator and the [NAME] President of Human Resources, the Administrator stated the facility had a performance improvement project related to timely identification of weight losses. 10 NYCRR 415.12(i)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review conducted during the Recertification Survey and complaint investigation the facility did not ensure a resident who displays or is diagnosed with dementia, received the appropriate services to maintain their highest practicable mental and psychosocial well-being for two (Residents #34 and #89) of five residents reviewed for dementia care. Specifically, Resident #34 had a diagnosis of dementia and did not have individualized interventions in place to guide direct care staff in managing behavioral symptoms. Resident #89 who had a history of dementia and behaviors sexual in nature was not appropriately care planned to include interventions to prevent further occurrences. Findings include: 1. Resident #34 had diagnoses that included dementia, repeated falls, and muscle weakness. The 07/30/2024 Minimum Data Set Resident Assessment documented the resident had severely impaired cognition, wandered daily, ambulated with a walker, and required supervision/ touching assistance with most activities of daily living. Resident #34's Comprehensive Care Plan dated 09/16/2024 and the current Bedside [NAME] (care plan used the Certified Nursing Assistants for daily care) documented the resident was at risk for behavior problems related to impaired cognition and impaired thought process. On 11/11/2024 the care plan documented the resident had the potential to be physically aggressive related to dementia as well as being a victim in an altercation. Current interventions included (but not limited to) to analyze triggers for behaviors and what de-escalates behaviors, assess and address contributing sensory deficits, anticipate needs and monitor/document/report any signs/symptoms of resident posing danger to self and others. If the resident became agitated intervene before agitation escalates, guide away from the source of distress, calmly engage in conversation, and if response is aggressive, approach later. Review of the facility's investigation related to an incident on 08/08/2024 revealed the resident had a resident-to-resident interaction with another resident. The incident summary dated 08/18/2024 and signed by the Director of Nursing included there was no care plan violation and no evidence of mistreatment or neglect. Physical contact was made between the two residents that met the definition of abuse. The residents were assessed for injuries, none were noted for the residents and there was no indication that contact had occurred. Interventions included Resident #34 was placed on 15-minute checks until bedtime. On 08/08/2024 at 3:32 PM, the Director of Social Worker documented Resident #34 denied issues with their mood, remained pleasant and social towards other residents, had no observed changes in mood or behavior and that they would continue to monitor the resident as needed. On 08/09/2024 at 1:41 PM, the Director of Social Work documented another altercation with Resident #34 and the same resident as prior altercation where Resident #34 was both the victim and the aggressor. They would continue to monitor and support the resident. Review of the facility's investigation related to another incident on 8/13/2024 revealed Resident #34 was physically aggressive with another resident (not the same as previous). Immediate interventions included the residents were separated and placed on 15-minute checks. The incident summary completed on 8/15/2024 by the Director of Nursing documented no care plan violation, no evidence of mistreatment or neglect, but that physical contact was made between the residents that met the definition of abuse. Intervention included 15-minute checks until bedtime. On 8/14/2024 at 4:23 PM, the Director of Social Work documented they followed up with Resident #34 regarding the altercation the previous day. The resident denied any concerns, touching, or harming anyone and their mood appeared stable and unchanged, and they would continue to provide support as needed. Review of the facility's investigation related to an incident on 10/09/2024 revealed Resident #34 was observed by a staff member punching another resident in the face. The incident summary completed by the Director Nursing on 10/9/2024 documented the residents were eating prior to the incident and after the meal crossed paths and started to argue. Resident #34 punched the other resident in the face and staff intervened immediately. Interventions included Resident #34 was placed on 15-minute checks until bedtime. The interdisciplinary team reviewed the incident and no changes in care recommended. In a progress note dated 10/14/2024 the Director of Social Worker documented that the interdisciplinary team reviewed the 10/09/2024 incident and determined no safety concerns. Staff would continue to monitor in common areas and offer activities as distraction as the resident tolerated. During an interview on 12/6/2024 at 2:32 PM the Director of Social Work stated the interdisciplinary team reviewed all incidents and usually entered a note with interventions added but there were no new interventions added to the care plan after the first several incidents for Resident #34 except for an activity that was added for distraction following the 10/09/2024 incident. During an interview on 12/06/2024 at 3:39 PM and again on 12/09/2024 at 10:50 AM the Director of Nursing stated the nurse supervisor who responded to an incident should review the care plans and interventions to determine if there has been a care plan violation and add new interventions as needed. The Director of Nursing stated Resident #34 had two resident-resident altercations where they were both the victim and aggressor and that they had written up Registered Nurse Supervisor #3 for using the same interventions (without success). The Director of Nursing stated it was important to try new interventions if the ones already in place were not working because it could lead to potentially more resident to resident incidents. 2) Resident #89 had diagnoses that included dementia, muscle weakness, and depression. The Minimum Data Set Resident assessment dated [DATE] revealed Resident #89 was severely impaired cognitively and wandering behaviors occurred daily. Review of Resident #89's Comprehensive Care Plan revealed behaviors that included (but not limited to) removing their clothes and undergarments, being resistive to re-dressing and remaining in a naked state, had potential to be physically aggressive, and intrusive to other residents' space. Neither the Comprehensive Care Plan or [NAME] (care plan used by the Certified Nursing Assistants for daily care) did not include that the resident had a history of sexual behaviors, any potential triggers for such behaviors, or interventions to be used to prevent further occurrences. During observations on 12/02/2024 at 11:38 AM, 11:39 AM and 11:40 AM, Resident #89 was wandering in and out of several other resident rooms talking loudly to other residents. Review of a facility investigation of an incident on 08/29/2024 revealed Resident #89 had contact with a second resident that was sexual in nature. Both residents were immediately separated, and frequent checks were conducted. Review of another facility investigation of an incident on 10/04/2024 revealed Resident #89 had pulled up their shirt in front of the same resident who was subsequently found to touching Resident #89 in a sexual manner. The residents were separated, frequent checks conducted, and the other resident was moved to another floor. An Interdisciplinary Progress Note dated 10/07/2024 at 12:05 PM Licensed Practical Nurse #6 documented Resident #89 had wandered into other residents' rooms and had been redirected out of male residents' rooms several times during the day. In an Interdisciplinary Progress Note dated 11/27/2024 at 7:31 PM, Licensed Practical Nurse #6 documented Resident #89 had been going into male residents' room attempting to pull up their gown requiring redirection by staff. Review of the monthly Treatment Administration Records from September 2024 through December 2024 revealed orders for nurses to document Resident #89's behaviors twice a shift which included such behaviors as inappropriate touching and/or sexual behaviors towards others. There were no documented sexual behaviors coded during this time frame. During an interview on 12/06/2024 at 9:39 AM and at 10:06 AM, Licensed Practical Nurse #7 said they did not know where Resident #89 was at the time but if they were not in their room, then they were probably in another resident's room in another resident's bed. Licensed Practical Nurse #7 said it was hard to get Resident #89 involved in activities and staff just try and keep an eye on the resident. During an interview on 12/06/2024 at 9:50 AM, Certified Nursing Assistant #6 said the [NAME] should include if a resident had any specific behaviors, and that Resident #89 could be hypersexual, which usually occurred after spending time with their significant other. When Resident #89 returned from spending time with their significant other, staff just try to keep an eye on the resident. During an interview on 12/09/2024 at 9:07 AM, Licensed Practical Nurse Manager #4 said if a resident had specific behaviors, including sexual behaviors, they should have a behavior care plan which would include interventions (related to the behaviors). Licensed Practical Nurse Manager #4 said Resident #89 often wandered the unit and had some sexual behaviors in the past but not recently. Licensed Practical Nurse Manager #4 stated they did not see a history of sexual behaviors or interventions related to sexual behaviors in the resident's care plan. During an interview on 12/09/2024 at 10:50 AM, the Director of Nursing said care plans were used to inform staff on how to appropriately care for the residents. The Director of Nursing said Resident #89's history of sexual behaviors and interventions used to be on the resident's care plan but were no longer as they had been considered resolved. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for one (Resident #22) of five residents reviewed for nutrition, the facility did not ensure food was prepared in a consistency to meet the residents needs per speech-language pathologist recommendations and physician orders. Specifically, Resident #22 had a history of dysphagia (difficulty swallowing), was on a mechanical soft diet (a diet that consists of easy to chew and swallow foods), and received a food item that was not appropriate on a mechanical soft diet. Additionally, Resident #22 was not care planned for a risk of aspiration (chance of food or liquids accidently inhaled into the lungs requiring close supervision with eating). This is evidenced by the following: The facility policy Modified Textured Diets, last revised 01/15/2024, included modified texture diets are offered based on facility and speech-language pathologist preference. Consult with the speech-language pathologist for determination of swallowing abilities and the safest diet texture for swallowing. The undated facility policy Aspiration Precautions included the policy was to reduce the risk of aspiration in residents who are at risk of choking or aspiration due to swallowing difficulties, medical conditions, or cognitive impairment. Follow individualized dietary recommendations provided by a speech-language pathologist or dietitian, including prescribed food textures (e.g., pureed, mechanical soft), and liquid consistencies (e.g., thin, nectar-thick, honey-thick) per provider order. Resident #22 had diagnoses that included dysphagia, malnutrition, and schizophrenia. The Minimum Data Resident Assessment, dated 11/19/2024, documented Resident #22 had severely impaired cognition, required supervision or touching assistance with meals, and had a mechanically altered diet (foods that required a change in texture). Review of the active physician's orders revealed a mechanical soft texture diet, initiated 03/11/2022. The orders did not include Resident #22 was at risk for aspiration. The Comprehensive Care Plan, dated 11/26/2024, and the [NAME] (care plan used by the Certified Nursing Assistant to provide daily care), dated 12/06/2024, did not include that Resident #22 was on aspiration precautions. Review of Resident #22's meal tickets (a specific menu that includes what each resident should receive for meals, texture of the meal, and any other resident specific interventions during mealtime) for 12/02/2024 through 12/06/2024 revealed Resident #22 was on a mechanical soft texture diet and was on aspiration precautions. The facility document Therapist Progress and Updated Plan of Care, dated 05/05/2021, documented Resident #22 was receiving a mechanical soft texture diet due to being at high risk for aspiration and did not recommend changing the diet type. During an observation on 12/04/2024 at 12:34 PM, Resident #22 was eating a lettuce and tomato salad, had difficulty swallowing, started coughing, and spit the food out into a napkin. Resident #22's meal ticket did not include a lettuce and tomato salad. During an interview on 12/05/2024 at 3:29 PM, Registered Dietician #1 stated lettuce salads are not on a mechanical soft diet, residents should only get what is on their ticket, and Resident #22 should not have gotten a salad because it was not on their meal ticket. During an interview on 12/06/2024 at 10:17 AM, Certified Nursing Assistant #4 stated they are responsible for delivering trays to residents during mealtime, reading the meal tickets, and checking to make sure everything on the tray matches the ticket. Certified Nursing Assistant #4 stated they should not give a resident something that is not on their ticket. During an interview on 12/06/2024 at 1:38 PM, Speech Language Pathologist #1 stated they coordinate with the dietician to make sure residents have recommendations for a safe diet. A mechanical soft diet would not include a lettuce and tomato salad as it is considered a solid. Diet consistencies are ordered to keep residents safe from choking or aspiration. Speech Language Pathologist #1 stated Resident #22 should not have received the salad as it puts them at a higher risk for aspiration. Speech Language Pathologist #1 stated being on aspiration precautions should be included in the resident's care plan. 10 NYCRR 415.14 (d)(3)

Based on interviews and record review conducted during the Recertification Survey conducted from 12/02/2024 to 12/09/2024, the facility did not refer the resident who had an intellectual disability to the appropriate state-designated authority for a Level II Pre-admission Screening and Resident Review (PASARR) for recommendations for one (Resident #115) of two residents reviewed. Specifically, the resident had a letter from the admitting hospital documentation that the resident required a full Level II assessment (referral process for individuals who were known or suspected of having serious mental illness for care planning recommendations) prior to admission or when a significant change occurred. Consequently, Resident #115 received no Level II referrals or services if needed. Findings include: The facility's revised SCREEN/ PASRR policy, dated 12/13/2018, documented for prospective residents a Level II assessment, based on screen indicators completed by the referring hospital or agency, admissions would request results of the assessment, and once obtained from the hospital or referring agency, the applicant's eligibility for admission would be determined. Level II reports and recommendations would be kept in the resident's chart and Level II recommendations would be incorporated into the resident's care plan. The policy included that a new SCREEN and Level II was required if a previously identified resident with a diagnosis of a serious mental illness or intellectual/developmental disability experienced a significant change in physical and/or mental condition. Resident #115 was admitted with diagnoses including Down Syndrome and acute respiratory failure with hypoxia (low oxygen level). The 09/13/2024 Minimum Data Set Resident Assessment documented the resident had severely impaired cognition, had no behaviors, required substantial/maximum assistance with most activities of daily living, and was receiving hospice care (effective 06/24/2024). The 07/17/2023 (prior to admission) New York State Department of Health Pre-admission Screening and Resident Review form documented that Resident #115 had a diagnosis or documented history of developmental disability before the age of 22 and is likely to continue indefinitely, has received or is eligible for services for the developmental disability, and does have evidence of cognitive deficits and/or adaptive skills which indicate the presence of a developmental disability. The Screening form documented that Level II services were not warranted at the time. Review of an undated New York State Department of Health Office of Persons with Developmental Disabilities response letter from the admitting hospital on admission to the facility documented that Resident #115 required a full Level II Assessment, parts 1-4 and eligibility needs were to be determined. The form documented the Level II process would stop and proceed once eligibility was established. There was no documented evidence a Level II Assessment had ever been completed. The Comprehensive Care Plan, dated revised 11/18/2024, documented the resident had impaired cognitive function or impaired thought process related to developmentally delayed Down Syndrome. Interventions included to ask yes/no questions to determine their needs, communicate with the resident/family/caregivers regarding resident's capabilities, and cue, reorient, and supervise as needed. The plan included the resident had a terminal prognosis (initiated 06/24/2024) related to end stage dementia and received hospice care. Interventions included to encourage support system of family and friends and observe closely for signs/symptoms of pain. During an interview on 12/09/2024 at 8:52 AM, the Administrator stated they were a Qualified SCREENER for New York State and Resident #115 had been admitted prior to them starting at the facility. The Administrator stated due to the resident's diagnosis, they should have had a Level II Pre-admission Screening and Resident Review Assessment completed to ensure the resident was appropriate to be placed at the facility and that they received the necessary services needed related to their diagnosis. During an interview on 12/9/2024 at 11:16 AM, the Director of Social Work stated the admission office reviews all documentation prior to admission. The Pre-admission Screening and Resident Review information would then be passed along to the Director of Social Work for review. The Director of Social Work also stated the previous Director of Social Work should have reviewed Resident #115's paperwork and it was important to ensure residents who were determined to require Level II services had a Level II Assessment completed to ensure they were appropriate to be admitted to the facility and ensure they received the services they needed. The Director of Social Work stated the social work department is responsible for updating the resident's care plan of any Level II services required. 10 NYCRR 415.11(e)

Based on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for one (Resident #4) of two residents reviewed, the facility did not provide specialized care needs for the provision of respiratory care in accordance with professional standard of practice, and the resident's care plan, goals, and preferences. Specifically, Resident #4 was observed intermittently wearing oxygen via a tracheostomy (a surgically created opening in the neck and into the windpipe to breathe through) collar (a soft plastic mask used to deliver oxygen to a person with a tracheostomy tube). There was no physician's order in place for supplemental oxygen use or documentation in the resident's medical record that reflected the use and care of the oxygen. Additionally, the facility was unable to provide evidence that nursing staff had been educated or trained to care for Resident #4's Airvo machine (machine that provides humidified high flow oxygen). This is evidenced by the following: The facility Airvo 2 policy, dated June 2024, included (but not limited to) instructions for use, the step-by-step process for cleaning, and noted that the circuit and water chamber should be changed every 60 days by respiratory therapy. Resident #4 had diagnoses that included chronic respiratory failure, a tracheostomy, and anxiety. The Minimum Data Set Resident Assessment, dated 09/23/2024, documented Resident #4 was cognitively intact, required suctioning and tracheostomy care, and was not receiving continuous or intermittent oxygen therapy. During an observation on 12/02/2024 at 10:34 AM, Resident #4 was observed coming out of their room via motorized wheelchair with an oxygen tank on the back of their wheelchair. An Oxygen in Use sign was on Resident #4's door frame. Review of Resident #4's current physician's orders revealed the resident should use the Airvo machine at all times when in their room with the designated settings (initiated 09/30/2024) and to fill the Airvo water bag with distilled water every four hours (initiated 06/17/2024). The orders did not include the additional use of oxygen via the tracheostomy. Resident #4's current Comprehensive Care Plan reviewed on 12/04/2024, included that Resident #4 had impaired breathing and removed their oxygen at times. The care plan did not include instructions for use of Resident #4's Airvo machine, that the resident was independent with use of the machine, or wore supplemental oxygen via a tracheostomy collar when out of their room. Review of the Medication Administration and Treatment Administration Records from 11/01/2024 to 12/06/2024 did not include any documentation of Resident #4's continuous use of oxygen. Review of a Speech Therapy Evaluation and Plan of Treatment note, dated 06/19/2024, revealed Resident #4 was on three liters of oxygen via their tracheostomy. In an Interdisciplinary Progress Note, dated 11/07/2024, Respiratory Therapist #1 documented they checked Resident #4's Airvo machine and the resident was on three liters per minute of oxygen via a tracheostomy collar. In an Acute Visit Progress Note, dated 11/21/2024, Physician Assistant #1 documented Resident #4 used a tracheostomy collar with oxygen and the treatment plan noted to continue with oxygen via tracheostomy collar. Review of completed Tracheostomy Set-up and Skills Competency Checklists (to be checked as skills were either met or unmet) for Licensed Practical Nurses #11 and #12 (night shift nurses assigned to Resident #4 during the survey), revealed skills related to the Airvo machine were documented as N/A (not applicable). During interviews on 12/02/2024 at 1:12 PM and on 12/03/2024 at 11:40 AM, Resident #4 stated they do not spend a lot of time in their room. The resident stated they wear three liters of oxygen via their tracheostomy collar at all the times (except when smoking). Resident #4 stated the facility's Respiratory Therapist quit three weeks prior and they were nervous that no one else could help them because no one else was trained to care for their tracheostomy. During an observation on 12/04/2024 at 9:58 AM, Resident #4 was wearing three liters of oxygen via their tracheostomy collar. During an interview on 12/04/2024 at 1:05 PM, Licensed Practical Nurse #5 stated Resident #4 wore three liters of oxygen via their tracheostomy collar and Resident #4 was responsible for changing their own inner cannula (tube inserted through main tracheostomy tube, which can be removed for cleaning or replacement) and self-suctioning with staff present. During an interview on 12/05/2024 at 11:19 AM, the Director of Nursing stated Respiratory Therapist #1 last worked on 11/09/2024, and while they were looking to replace the respiratory therapist, no one was currently covering (the position). During an observation in Resident #4's room on 12/05/2024 at 12:40 PM, the Airvo machine's water bag was empty. During an observation on 12/05/2024 at 1:11 PM, Resident #4's oxygen mask was hanging from their wheelchair armrest and the oxygen tank gauge was at empty. During an interview on 12/06/2024 at 4:04 PM, Licensed Practical Nurse #5 stated if a resident required oxygen, it should be on the Medication/Treatment Administration Records so nurses know how much the resident should be on and to monitor it. Licensed Practical Nurse #5 stated Resident #4 did not have a current order for oxygen and should have. Licensed Practical Nurse #5 stated Resident #4 used their Airvo machine overnight when they were in bed and connected it themselves. Licensed Practical Nurse #5 stated they could not explain exactly what the Airvo machine did. During an interview on 12/06/2024 at 4:30 PM, Registered Nurse Manager #1 stated oxygen use should be listed on a resident's care plan and there should be an order. Registered Nurse Manager #1 stated Resident #4 wore oxygen continuously, and believed it was three liters, but would have to check the order. During an observation and interview on 12/06/2024 at 4:45 PM, Resident #4 stated they (staff) would not change their oxygen tank (which was empty at the time) because the resident did not have a current order for the oxygen (via their tracheostomy collar). During an interview on 12/09/2024 at 10:50 AM, the Director of Nursing stated supplemental oxygen required an order. The Director of Nursing stated Respiratory Therapy was responsible for the resident's Airvo machine, and if the resident was independent with use of the machine, they should be care planned for this. 10 NYCRR 415.12(k)(6)

Based on observations, record review, and interviews during the Recertification Survey from 12/02/2024 to 12/09/2024, for one of one main kitchen, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were multiple undated food items not in their original containers and a food item was stored uncovered. The findings are: The undated facility policy titled Prepared Foods and Leftovers documented the maximum storage time for refrigerated prepared food items and leftovers was 72 hours and any foods stored beyond that date were to be discarded. Observations in the main kitchen on 12/02/2024 at 8:50 AM, and in the presence of the Food Service Director/Registered Dietitian #2, included the following: - The breakfast preparation cooler contained one undated two-quart container of cooked pureed eggs, one undated pan of cooked bacon, and one undated pan of cooked pancakes. - The cold production cooler contained 8 undated dishes of pumpkin souffle and one uncovered metal bowl of undated vanilla pudding. During an interview on 12/2/2024 at 9:03 AM, the Food Service Director/Registered Dietitian #2 stated it was important for food to be dated to know when it should be discarded to prevent potential food borne illness, and if food items are taken out of the original container or were leftover from a previous meal, those food items should be discarded after three days. The Food Service Director/Registered Dietitian #2 also stated the coolers and freezers were checked daily by all staff for undated food items, and it was important for food items to be covered to prevent contamination. During the follow up visit to the main kitchen on 12/03/2024 at 4:38 PM, and in the presence of Food Service Director/Registered Dietitian #2, there was an undated two-quart plastic container of chicken salad in the cold production cooler. During an interview on 12/03/2024 at 4:57 PM, the Food Service Director/Registered Dietitian #2, stated food service staff should be labeling and dating all food items once they are opened or taken out of their original container to ensure food safety. 10 NYCRR 415.14(h), 10 NYCRR: Subpart 14-1, 14-1.42, 14-1.43(e)

Based on observations, interviews, and record review conducted during a Recertification Survey from 12/02/2024 to 12/09/2024, for three (Residents #36, #41, #42) of eight residents reviewed, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, Resident #41 had their blood sugar checked by a nurse not wearing gloves. Resident #42 was on enhanced barrier precautions (a strategy used by nursing homes to decrease transmission of infectious disease) and received high-contact care from staff not wearing the required personal protective equipment, and infection control practices were not followed during the care of a cholecystostomy (a procedure that creates a surgical opening of the gallbladder to drain it) site. Resident #36 was on enhanced barrier precautions, had an indwelling urinary catheter, and received high-contact care from staff who were not wearing the required personal protective equipment. Additionally, the facility was unable to provide documented evidence that the infection surveillance plan included ongoing analysis of surveillance data and follow-up activity since August 2024. Additionally, the facility did not ensure the Infection Prevention and Control Program policies and procedure were reviewed at least annually as required. This is evidenced by the following: 1. Resident #41 had diagnoses that included diabetes, dementia, and depression. The Minimum Data Set Resident Assessment, dated 11/14/2024, documented Resident #41 was moderately impaired cognitively. Review of the active physician's orders revealed an order for blood sugar checks before meals and at bedtime. During an observation on 12/05/2024 at 12:34 PM, Licensed Practical Nurse #3 performed a blood sugar check with a glucometer (a machine used to check blood sugar levels via a drop of blood) without wearing gloves. During an interview at this time, Licensed Practical Nurse #3 stated it was important to wear gloves during a blood sugar check to prevent cross contamination and any blood contamination, and they should have worn gloves while checking the blood sugar, but forgot. 2. Resident #42 had diagnoses that included cholecystitis (inflammation of the gallbladder), a cholecystostomy tube (tube inserted into the gallbladder to drain fluid), and diabetes. The Minimum Data Set Resident Assessment, dated 10/01/2024, documented Resident #42 was cognitively intact and had a skin ulcer. Review of the active physician's orders revealed a dressing change and tube flush to the cholecystostomy site daily, a dressing change to the right ankle ulcer, and that Resident #42 was on enhanced barrier precautions. During an observation on 12/02/2024 at 11:00 AM, Licensed Practical Nurse #4 provided wound care to the ankle ulcer and the cholecystostomy site wearing gloves but no gown. An enhanced barrier precaution sign was posted in the room and a blue star (per staff interviews indicated enhanced barrier precautions required) was posted next to Resident #42's name outside their room. The enhanced barrier precautions sign included to wear a gown with high-contact resident care. During an observation on 12/03/2024 at 9:50 AM, Certified Nursing Assistant #5 washed and dressed Resident #42 and changed their incontinence brief. Certified Nursing Assistant #5 wore gloves but no gown. During an observation on 12/05/2024 at 11:18 AM, Licensed Practical Nurse #3 flushed Resident #42's cholecystostomy tube. During the flush process, License Practical Nurse #3 removed the port cap from the cholecystostomy tube and attached a syringe to the tubing without cleaning the flush port and did not clean the cap prior to reattaching it to the flush port. During an interview at this time, Licensed Practical Nurse #3 stated they should have cleansed the flush port prior to flushing and the port cap prior to reattaching it to the tube. 3. Resident #36 had diagnoses that included neuromuscular dysfunction of the bladder (improper drainage of the bladder often resulting in incontinence or difficulty urinating completely), schizophrenia, and chronic pain syndrome. The Minimum Data Set Resident Assessment, dated 10/22/2024, documented Resident #36 had moderate impairment of cognitive function and an indwelling urinary catheter. Review of the active physician's orders revealed Resident #36 had an indwelling urinary catheter and was on enhanced barrier precautions. During an observation on 12/04/2024 at 9:59 AM, Certified Nursing Assistant #5 provided direct hands-on care to Resident #36 (changed their brief and assisted with dressing) and emptied their urinary catheter drainage bag. Resident #36 had a blue star next to their name outside their door and no enhanced barrier precaution sign in their room. Certified Nursing Assistant #5 was wearing gloves and no gown. During an interview at this time, Certified Nursing Assistant #5 stated they did not know what a blue star meant and would look for a sign to see if a resident was on precautions. Certified Nursing Assistant #5 stated they did not know they needed to wear a gown when providing hands on care for Resident #36. During an interview on 12/06/2024 at 5:06 PM, the Director of Nursing stated residents with wounds and indwelling urinary catheters should be on enhanced barrier precautions and all staff should wear a gown and gloves when providing high-contact care. The Director of Nursing also stated the Licensed Practical Nurse should have cleansed Resident #42's cholecystostomy tube's flush port before and after flushing and the port cap should have been cleansed prior to being reattached to the flush port. The Director of Nursing stated all nurses should wear gloves when checking blood sugars. 4. Review of multiple Infection Prevention and Control facility policies that included the Antibiotic Stewardship policy, Bloodborne Pathogen policy, Resident Influenza and Pneumococcal Vaccine policy, Personal Protective Equipment policy, and the Employee Influenza and Pneumococcal Vaccine policy revealed none were dated as to when they were last reviewed or revised. Review of facility form titled Infection and Antibiotic Tracking Tool on 12/06/2024 at 10:19 AM with the Director of Nursing and the Infection Preventionist revealed that the previous Infection Preventionist completed the form for July 2024 and August 2024, but the documentation for September 2024, October 2024, and November 2024 did not include ongoing surveillance, analysis, and documentation of facility follow-up activity of infections and antibiotic use. During an interview at this time, the Director of Nursing stated the facility had no designated Infection Preventionist from mid-August 2024 until 10/31/2024, and the Director of Nursing and Administrator had maintained the tracking and surveillance for resident infections. The Director of Nursing stated facility policies were reviewed and updated on an as-needed basis. The facility policy titled Infection Prevention Plan, last reviewed and updated in March 2024, documented that facility policies are reviewed and approved every three years or as needed based on regulatory guidelines, and the bloodborne pathogen policy should be reviewed annually. 10 NYCRR 415.19(a) (1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during the Recertification Survey completed on 3/16/23, it was determined that for one (Resident #303) of one reviewed for choices the facility did not ensure the resident's right to make choices about aspects of life that were significant to them. Specifically, the resident was not given the choice of bathing opportunities. This is evidenced by the following: Resident #303 was admitted to the facility on [DATE] with diagnoses including right femur fracture, diabetes mellitus, depression, and a pressure ulcer. The Minimum Data Set Assessment, dated 2/27/23, documented that the resident was cognitively intact, required extensive assistance with bathing and that type of bathing was very important to them. Review of Resident #303's current medical orders revealed skin observations with weekly shower every Monday. Review of Resident #303's current Comprehensive Care Plan and Certified Nursing Assistant (CNA) [NAME] (care plan used by the CNA for daily care) revealed the resident was incontinent of bladder and bowel and required extensive assist with bathing and showering. The care plans did not include a scheduled shower day. During an interview on 3/10/23 at 8:50 a.m., and on 3/13/23 at 1:02 p.m., Resident #303 said that they have begged staff for a shower but when they asked the resident was told no showers as there was only one attendant available or that it was not their scheduled shower day (Monday). Resident #303 said that their hair had been washed, but they had not received a shower since prior to their hospitalization (2/3/23). Review of an interdisciplinary progress note dated 2/21/23 and entered by the activities department revealed that Resident #303 said that it was important for them to have a customary bathing routine and to choose their method of bathing, which was showering. During an observation on 3/10/23 at 1:55 p.m., the bath list posted on Resident #303's unit did not include Resident #303 name anywhere on the list. Review of the bathing task in Resident #303's Electronic Health Record (EHR) revealed no documentation that Resident #303 had received any showers since admission. During an interview on 3/15/23 at 10:56 a.m., CNA #1 stated that scheduled shower days should be on the resident's [NAME] and on the bulletin board. CNA #1 stated that they were not aware of when Resident #303 shower day was and could not remember the resident ever asking them for a shower. CNA #1 stated that when a shower is given, they document it in the resident's EHR and if it was a shower or a bath or if the resident refused. CNA #1 stated that it is hard to give showers when they are short staffed. During an interview on 3/15/23 at 12:44 p.m., Resident #303 said that a staff person came into their room with a wet washcloth which had no soap on it and offered them a wipe down. Resident #303 said they could recall asking for a shower at least ten times but denied ever receiving one. During an interview on 3/16/23 at 10:34 a.m., the Director of Nursing (DON) said they would expect residents to receive a shower or bath weekly per their preference and if staff were unable to provide the resident with a shower, the CNAs should notify the nurse. The DON said that if the resident had declined a shower, it should be documented. The facility was unable to provide any documentation that Resident #303 had received a shower since admission or had refused one. 10NYCRR: 415.5(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review conducted during the Recertification survey and complaint investigation (NY00301678) completed on 3/16/23, it was determined that for one of six residents reviewed for abuse the facility failed to protect the residents right to be free from abuse. Specifically, Resident #353 was held down by multiple staff members and an injection was given against the resident's wishes. The resident was observed with bruising on both legs the following day which was believed to be caused by the incident. Resident #353 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, status post cerebral vascular accident (CVA) with aphasia and right sided monoplegia arm and hand contracture. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was cognitively intact, had no hallucinations or delusions, no physical behaviors symptoms directed towards others, and had verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed toward others. The facility policy and procedure titled Abuse and Abuse Reporting, dated March 1, 2023, included that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse, irrespective of a resident's mental or physical condition, cause physical harm, pain, or mental anguish. Abuse includes verbal, sexual, physical, and mental abuse, and includes actions facilitated by or enabled using technology. A review of physician orders for Resident #353 revealed doxycycline (antibiotic) 100 milligrams (mg) had been ordered on 9/19/22 to be given twice per day for 7 days for treatment of left lung infiltrates (pneumonia). In a nursing note dated 9/25/22, the Agency Registered Nurse #1 (RN#1) documented that they had called tele-health due to the resident hallucinating and refusing their medication and that the resident presently had a urinary tract infection. Agency RN#1 documented that the resident's vital signs were at baseline. Agency RN#1 documented that the physician had ordered a one-time dose of Rocephin (antibiotic) 1 gram (gm) to be given intramuscularly (IM). The telemedicine physician progress note signed dated 9/26/22, documented that the Agency RN #1 had called due to Resident #353 refusing to take doxycycline (antibiotic) that was prescribed for UTI that day. Resident #353 was hallucinating per Agency RN #1. The telemedicine physician documented that they had tried to see patient via video counsel, but it did not work. Assessment and Plan: Hallucination, UTI without hematuria, site unspecified. Recommend giving one time IM Rocephin tonight (9/26/23). In an undated written statement, the Agency RN#1 stated that on Sunday, September 25, 22, on the evening shift, they were acting as a supervisor and was notified that Resident #353 was refusing their Doxycycline for their pneumonia, and actively hallucinating, swearing, and swinging their fists at staff. The resident refused the medication from the med nurse and from Agency RN#1. Agency RN#1 documented that their concern was that the resident's infection was spreading, and the resident needed to get the antibiotic to fight the infection. The resident stated that they did not need any medicine because they were not sick, and that staff were trying to drug them. Agency RN#1 documented that they contacted telehealth. Agency RN#1 documented that they had not looked to see what the infection was and thought it was a UTI. The physician ordered a one-time dose of Rocephin 1gm to be given, thinking that the infection was spreading. Agency RN#1 documented that because of the resident's mental status at the time, they felt, in their nursing judgement, that they needed to give the resident the Rocephin as ordered, and due to the resident's constant refusals, they asked other individuals to assist, and they administered the shot. In a progress note dated 9/26/22, the Nurse Practitioner (NP) documented that they were seeing the resident due to reports of the resident hallucinating over the weekend. The NP documented that the resident stated that five employees entered the resident's room overnight and held them down, giving them a shot in their arm. The resident stated to the NP that they had several bruises on their legs and arms from this encounter. The resident stated to the NP that they were feeling sore on their legs and back. The NP documented that the resident had scattered areas of ecchymosis (bruising) on both legs. The resident had an area of redness on their right hand/wrist area, consistent with resident's story of a self-inflicted bite wound. The Resident Incident/Accident Report dated 9/26/22 documented that Resident #353 stated, They held me down to give me a shot. Under the heading: Brief Description of the Incident, it was documented that the resident stated that five staff members held them down to give them a shot. Under the Recommendations heading, it was documented that the Agency RN #1 was notified that their contract was being terminated effective immediately. A statement provided to the Social Worker by Resident #353 on 9/27/22 stated; On Sunday evening, they were ready to go to sleep, maybe around 8pm, when people started coming into their room again. Resident stated that a nurse came in to give them medicine and they did not want it as they were going to sleep. They had to tell the nurse four times and the nurse wouldn't leave. The nurse tried to force pills into their mouth, and they tried to stop them from going into their mouth, and after they pushed the pills away, the nurse threw the cup of water in their face on purpose. The nurse left the room and came back with another staff person and a needle and tried to give them a shot. The resident said they did not want it and the nurse said that they would put it in the resident's leg. After the nurse left, the resident got into their wheelchair and that was when a man came in with four other staff members. Staff were fighting the resident to give the resident the needle, and the resident was pretty sure that staff gave them the shot in their leg while the other staff members held them down. The resident stated that they were not afraid of the staff and that it still hurts. In an email sent to the DON on 9/27/22, the Licensed Practical Nurse (LPN) #3 stated that they had assisted in giving Resident #353 a shot and had been directed to assist by the DON (Agency RN was acting as DON) to help due to safety concerns. The LPN#3 stated that they had questioned this several times and was told that it was okay because it was for the resident's safety. The LPN#3 stated that they thought that the resident should be sent out and let the hospital take care of it. The DON (Agency RN was acting as DON) told the LPN #3 that they had spoken to the doctor, and this was their order. The DON (Agency RN was acting as DON) was told that it was not right, but they continued. In an email sent to the DON on 9/27/22, CNA#3 stated, on September 25th at about 10:30pm, they were asked by a nurse and supervisor to assist in administering an injection to a resident whom they both said was combative. Based on their instructions, the Household Care Assistant assisted the rest of the staff in holding down the resident. In a progress note dated 9/27/22, the former Director of Nursing (DON) (Agency RN was acting as DON) documented that they had visited with the resident that morning after the resident self-reported alleged incident on 9/25/22. Resident was assisted to their room for skin observation/assessment by the DON (Agency RN was acting as DON) and Care Coordinator (CC). Resident was noted with multiple bruises to bilateral lower extremities (BLE). Bruises were scattered and affecting thigh and shin areas on BLE. Resident with discoloration behind left knee area, with scratches present (scabbed and swelling present). Resident also with a scratch like area to right wrist, which the resident voiced was self-inflicted when the resident was attempting to bite staff during incident. Left hand and elbow area present with areas of discoloration. Resident denied pain/discomfort related to incident during the visit. Resident voiced feeling safe at the facility. During a telephone interview on 3/15/23 at 12:48 p.m., the NP stated that they had seen Resident #353 on 9/26/22 and the resident had told them that four to five staff members came into their room and tried to give them the shot and that they did not know what the shot was, and the staff did not tell them. The resident stated that they had tried to kick the staff and hit them and that the staff had held them down and gave them the injection. When asked what the NP would have expected the staff to do when the resident refused, NP stated that they would expect the staff to leave the resident alone as they had the right to refuse. NP stated that Resident #353 was alert and oriented and even if they were confused at the time, it was not a reason to forcibly give the resident an IM injection. NP stated that the facility medical providers were scheduled to be in the facility the following morning to assess the resident and if Resident #353 had needed immediate care, they should have been sent out to the hospital for assessment. When asked what the bruising on the resident looked like when NP assessed the resident on 9/26/22. NP stated that the bruises looked like evolving bruising on both legs, more on the right side. The resident also had a self-inflicted bite on their right arm that Resident #353 had told them happened when they were trying to bite staff. NP stated that the bruising appeared to be from the incident the evening before. When interviewed via telephone on 3/15/23 at 2:58 p.m., the Medical Director stated that there is never a time when it is appropriate to give a resident an injection against their will. 10NYCRR: 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review conducted during the Recertification survey and complaint investigation (#NY00301678) completed on 3/16/23, it was determined that for one of six residents reviewed for abuse the facility did not ensure that an incident of physical abuse was thoroughly investigated to rule out abuse, neglect, or mistreatment. Specifically, Resident #353 was held down by multiple staff and an antibiotic injection administered. The facility did not interview all staff involved and did not put measures in place to prevent further occurrence. Resident #353 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, status post cerebral vascular accident (CVA) with aphasia and right sided monoplegia arm and hand contracture. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was cognitively intact, had no hallucinations or delusions, no physical behaviors symptoms directed towards others, had verbal behavioral symptoms directed towards others and other behavioral symptoms not directed toward others. The facility policy and procedure titled Abuse and Abuse Reporting, dated March 1, 2023, includes that if an employee is involved, they must be sent off duty until an investigation is complete. If the alleged violation is verified, appropriate corrective action must be taken. The Resident Incident/Accident Report dated 9/26/22 documented that Resident #353 stated, They held me down to give me a shot. Under the heading Brief Description of the Incident it was documented that the resident stated that five staff members held them down to give them a shot. Under the Recommendations heading it was documented that the Agency RN #1 was notified that their contract was being terminated effective immediately. In an undated written statement, the Agency RN#1 stated that on the evening shift, on Sunday September 25, 2022, they were acting as a supervisor and were notified that Resident #353 was refusing their Doxycycline to treat their pneumonia, and that the resident was actively hallucinating, swearing, and swinging their fists at staff. The resident refused the medication from the med nurse and from Agency RN#1. Agency RN#1 documented that their concern was that the resident's infection was spreading and that they needed to get and antibiotic to fight the infection. The resident stated that they did not need any medicine because they were not sick, and that staff were trying to drug them. Agency RN#1 documented that they contacted telehealth. Agency RN#1 documented that they had not looked to see what the infection was and thought it was a UTI. The physician ordered a one-time dose of Rocephin 1gm to be given, thinking that the infection was spreading. Agency RN#1 documented that because of the resident's mental status at the time, they felt in their nursing judgement, that they needed to give the resident the medicine and due to the resident's constant refusals of other antibiotics, they asked other individuals to assist, and they administered the shot. In a progress note dated 9/26/22, the Nurse Practitioner (NP) documented that they were seeing the resident due to reports of the resident hallucinating over the weekend. The NP documented that the resident stated that five employees entered their room overnight and held them down, giving them a shot in their arm. The resident stated to the NP that they had several bruises on their legs and arms from this encounter. The resident stated to the NP that they were feeling sore on their legs and back. The NP documented that the resident had scattered areas of ecchymosis (bruising) on both legs and an area of redness on right hand/wrist area, consistent with resident's story of a self-inflicted bite wound. In a statement provided to the Social Worker on 9/27/22 Resident #353 stated; On Sunday evening, they were ready to go to sleep, maybe around 8pm, when people started coming into their room again. Resident stated that a nurse came in to give them medicine and they did not want it as they were going to sleep. They had to tell the nurse four times, and the nurse wouldn't leave. The nurse tried to force pills into their mouth, and they tried to stop them from going into their mouth. After they pushed the pills away, the nurse threw the cup of water in their face on purpose. The nurse left the room and came back with another staff person and a needle and tried to give them a shot. The resident said they did not want it and the nurse said that they would put in the resident's leg. After the nurse left, the resident got into their wheelchair and that was when a man came in with four other staff members. They were fighting the resident to give them the needle and the resident was pretty sure that they gave them the shot in their leg while the other staff members held them down. The resident stated that they were not afraid of the staff and that it still hurts. In an email sent to the DON on 9/27/22, the Licensed Practical Nurse (LPN) #3 stated that they had assisted in giving Resident #353 a shot and had been directed to assist by the DON (Agency RN was acting as DON) to help due to safety concerns. The LPN#3 stated that they had questioned this several times and was told that it was okay because it was due to the resident's safety. The LPN#3 stated that they thought that the resident should be sent out and let the hospital take care of it. The DON (Agency RN was acting as DON) told the LPN #3 that they had spoken to the doctor, and this was their order. The DON (Agency RN was acting as DON) was told that it was not right, but they continued. In an email sent to the DON on 9/27/22, CNA#3 stated, on September 25th at about 10:30pm, they were asked by a nurse and supervisor to assist in administering an injection to a resident whom they both said was combative. Based on their instructions, the CNA#3 assisted the rest of the staff in holding down the resident. When interviewed on 3/16/23 at 9:59 AM, the Administrator stated that they would have expected that all staff would have been interviewed, and that all staff involved be re-educated and possibly disciplined, and that all facility staff would need to be re-educated. The Administrator stated that the investigation was complete. 10NYCRR: 415.4(b)(1)(i)

Based on interviews and record review conducted during the Recertification Survey completed on 3/16/23, it was determined that for one (Resident #49) of 5 residents reviewed for dialysis, the facility did not ensure that each resident was free from significant medication errors. Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the physician orders or acceptable professional standards of practice (principles which apply to professionals providing services. Accepted professional standards and principles include various practice regulations in each state, and current commonly accepted health standards, established by national organizations, boards, and councils). Specifically, antihypertensive medications were not administered prior to dialysis per the physician orders, and medical providers were not notified the medications were omitted for Resident #49. The finding is: The facility policy, Medication Administration/Documentation, revision dated 12/30/22 documented medications are administered by a registered/licensed nurse upon written or verbal physician order. The purpose of the policy is to safely administer medications to the resident, as prescribed by the physician. The medication label and the electronic medication administration record (EMAR) are to be checked by using the 5 r's of medication safety: right resident, right medication, right dose, right time, and right route. 1. Resident #49 had diagnoses including end-stage renal disease (ESRD) requiring dialysis, hypertension (HTN), and diabetes mellitus (DM). The Minimum Data Set (MDS - a resident assessment tool) dated 1/20/23 documented the resident had moderate cognitive impairment. The MDS did not document the resident received dialysis. The active physician orders as of 2/24/23 included the following: * Elder to be brought down to the employee entrance door by 5:00 AM every Monday, Wednesday, and Friday for transportation pickup for dialysis * Please give hypertension medications prior to going to dialysis, on dialysis days * Clonidine HCL (hypertension medication) 0.2 MG (milligram) two times a day for HTN * Coreg (hypertension medication) 12.5 MG two times a day for HTN * Hydralazine HCL (hypertension medication) 50 MG three times a day for HTN * Isosorbide Mononitrate ER (extended release) (hypertension medication) 60 MG one time a day for HTN * Norvasc (hypertension medication) 10 MG one time a day for HTN The EMAR dated 2/1/23 - 2/28/23 included the following: * Clonidine HCL 0.2 MG two times a day for HTN with scheduled administration times at 8AM - 11AM, and 8PM - 11PM. * Coreg 12.5 MG two times a day for HTN with scheduled administration times at 9AM and 5PM. * Hydralazine HCL 50 MG three times a day for HTN with scheduled administration times at 9AM, 1PM, and 5PM. * Isosorbide Mononitrate ER 60 MG one time a day for HTN with scheduled administration time at 8AM - 11AM. * Norvasc 10 MG one time a day for HTN with scheduled administration time at 9AM. The EMAR dated 2/1/23 - 2/28/23 documented the hypertension medications were signed as administered at the scheduled administration times on the following dialysis days: 2/3/23, 2/8/23, and 2/22/23. Additionally, the MAR documented the hypertension medications were not administered on following dialysis days: 2/1/23, 2/6/23, 2/10/23, 2/20/23, and 2/24/23, secondary to Resident #49 out of the facility at dialysis. Review of Interdisciplinary Progress Notes dated 2/1/23 - 2/24/23, revealed no documented evidence a medical provider was notified the hypertension medications were not administered prior to dialysis or not administered on the above dates at all. During an interview on 3/14/23 at 12:24 PM, Resident #49's primary physician stated the residents' blood pressure was normally on the high side, and they expected the hypertension medications to have been administered prior to dialysis per the physician orders, to control the residents blood pressure during and after dialysis. Additionally, the primary physician stated they were not notified Resident #49 had not been receiving the hypertension medications prior to dialysis. During an interview on 3/14/23 at 1:40 PM the Physician Assistant (PA) stated Resident #49's hypertension medication order to be administered prior to dialysis was to assist in controlling the residents blood pressure during dialysis. Additionally, the PA expected a physician order to be followed, and to be notified if a medication is omitted. During an interview on 3/15/23 at 9:51 AM the Director of Nursing (DON) stated they expected Resident #49's hypertension medications to have been scheduled and administered prior to dialysis per the physician order. Additionally, if a medication is omitted, a medical provider should have been notified for updated orders. The DON stated that the order to administer the HTN medications prior to dialysis was entered into the computer as Other and did not link to any specific medications nor did it cross over to the EMAR or pharmacy. The order should have been entered into the system as a Pharmacy order with specific medication, dose, route, and time to be administered. 10NYCRR: 415.12(m)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, completed on 3/16/23, it was determined for four (Resident #49, #75, #303, and #307) of five residents reviewed for dialysis, the facility did not ensure that dialysis services provided were consistent with professional standards of practice, the comprehensive person-centered care plan, physician orders and resident's goals and preferences. Specifically, the issues included: a. That the facility did not have evidence of total fluid intake monitoring for Resident #75 who was on a medically ordered fluid restriction, b. Did not ensure medications were administered as ordered by the physician on dialysis days for Residents #49, #75, #303, and #307. c. Did not have evidence of ongoing communication with the dialysis facility to include the resident's status prior to and post dialysis for Residents #49, #75, #303 and #307. d. Did not monitor or document Residents #75 and #303 dialysis catheter sites (vascular access used to perform dialysis treatments). e. Did not monitor Resident #75 blood pressure as ordered by the physician. This is evidenced by but not limited to the following: Review of the provided facility policies all titled Dialysis revealed that all residents that require dialysis will have established care standards. Residents with a dialysis catheter will receive routine care that includes checking the dialysis catheter site and dressing every shift, remove, replace, or reinforce the catheter dressing per dialysis instructions and add to the Treatment Administration Record (TAR). The policy documented that any specialized dialysis interventions will be addressed on the care plan. The policies did not include ongoing communication with the dialysis facility including any pre and post dialysis information as needed. The facility policy Fluid and Solid Consumption Record, dated 3/14/13, documented that nursing will record the daily fluid and solid intake of the resident on the Fluid and Solid Consumption Record. The 24-hour fluid intake will be totaled and reviewed by the night nurse to determine if the resident's fluid goals for the 24-hour day were met and be reported to the primary nurse or clinical care manager for review and follow-up. Review of facility policy Medication Administration, dated 12/30/22, documented that if a resident does not take a medication, document in the Electronic Medication Administration Record (EMAR) as other and note why the medication was not given. Notify the Registered Nurse (RN) Supervisor of the medication omission and the RN Supervisor will determine the next step such as notify the doctor or obtain a missing medication. Review of the facility policy Vital Signs, dated January 2023, documented that blood pressures will be taken and recorded in the medical record at least monthly for all residents. Vital signs may be ordered by the physician to be done more frequently. 1.Resident #75 had diagnoses including end-stage renal disease (ESRD) dependent on hemodialysis and heart failure. The Minimum Data Set (MDS) Assessment, dated 1/5/23, included that the resident was cognitively intact and received dialysis. The current Comprehensive Care Plan (CCP) included that Resident #75 was at risk for fluid imbalance due to dialysis, was on 1500 mls fluid restriction, required intake and output monitored and documented per facility policy and to coordinate care with the dialysis facility as needed. The CCP also included vital signs taken before and after dialysis, and to check the dialysis dressing every shift. Current Physician orders included the following: a) Hemodialysis every Monday, Wednesday, and Friday 6:00 a.m.-10:00 a.m. b) Fluid restriction 1500 milliliters (mls) daily. c) Check blood pressure (BP) three times a day (off BP meds). For systolic BP >140 or diastolic BP >90 notify medical provider (ordered 2/21/23). Additionally, the orders included 16 different medications ordered to be administered between 8:00 a.m. and 11:00 a.m. and included but not limited to: a) Eliquis 2.5 milligrams (mg) twice daily for atrial fibrillation b) Isosorbide Mononitrate Extended Release 90 mg daily for hypertension c) Levothyroxine 150 micrograms (mcg) one tablet daily for hypothyroid d) Nephplex one tablet daily for chronic kidney disease e) Gabapentin 100mg, one capsules twice daily for spinal stenosis Review of the Medication Administration Record (MAR) from 3/1/23 to 3/13/23, revealed that on five of 13 days, Resident #75 did not receive any of the 16 morning medications due to being at dialysis and no documentation that the medical team or the dialysis center was made aware of the omissions. Review of interdisciplinary progress notes revealed that on 2/6/23 at 1:41 p.m., the nurse documented that Resident #75 had a blood pressure of 79/46 and reported not feeling well. Medical was notified and nursing started forcing fluids. On 3/6/23 at 6:38 p.m., the nurse documented that Resident #75's blood pressure was 80/36 and was given 240 mls of water to drink. Review of Weights and Vitals Summary record in Resident #75's electronic health record EHR 3/1/23-3/15/23 revealed no documented blood pressures values for 10 of 15 days. During observations and interviews on 3/9/23 at 2:17 p.m., and on 3/10/23 at 1:35 p.m., Resident #75 had a gauze dressing covering a dialysis catheter on their left chest. Multiple bottles of soda were in the resident's room. Resident #75 stated that they were not on a fluid restriction that they were aware of but that their dialysis center told them not drink too much and the facility tells them to drink more because their blood pressure is low. Resident #75 stated that no one checks their vital signs after arriving back from dialysis or looks at their catheter site. Resident #75 stated that they drink a couple cans of soda and a cup of water a day and that facility staff do not ask how much they drank. On 3/13/23 at 10:56 a.m., there were 12 bottles of soda and one bottle of water observed in Resident #75's room, some half empty. On 3/13/23 at 12:36 p.m., Resident #75 was observed in the dining area eating lunch. Review of the resident's lunch tray ticket included two 8 ounces of fluid beverages and did not include the resident was on a 1500 mls fluid restriction. The facility was unable to provide documented evidence that Resident #75's total 24 fluid intake was being monitored to ensure adequate fluids and as ordered. Review of Treatment Administration Record (TAR) for February 2023 and March 2023 did not include any documentation related to monitoring Resident #75's dialysis catheter site. The facility was unable to provide documented evidence of consistent communication with Resident #75's dialysis facility including the concerns regarding their blood pressures. During an interview on 03/10/23 at 1:50 p.m., and on 3/13/23 at 10:36 a.m., Licensed Practical Nurse (LPN) #1 stated that they were not sure if they had any residents on fluid restriction. LPN #1 later stated that if a resident was on a fluid restriction nurses document the fluids with meals and medication administration in progress notes. LPN #1 stated that they did not think Resident #75 was on a fluid restriction and that they see the resident with water all the time and family brings in (food and drinks) often. LPN #1 said they were not sure who was responsible for monitoring the resident's 24-hour fluid intake. LPN #1 stated if the resident had a dialysis catheter, they should check the dressing and document in a progress note. LPN #1 stated that communication with the dialysis center consisted of reports from the resident and that they do not see any paperwork from the dialysis center. LPN #1 explained that Resident #75 leaves early for their dialysis and does not take any medications before dialysis because they refuse so they document that the medications were not given due to not being in the facility. LPN #1 stated that the medications scheduled during that time are not administered when the resident returns to the facility. During a telephone interview on 3/13/23 at 9:10 a.m., the Dialysis Register Nurse Manager (RNM) #1 at the dialysis center stated that Resident #75 should be on a fluid restriction and has been having issues with their blood pressure during dialysis. The Dialysis RNM #1 stated that the facility does not communicate with the dialysis center, and dialysis center staff have had problems trying to get in touch with facility staff to discuss the issues. The Dialysis RNM #1 stated communication with the facility is by telephone, but no one picks up the phone at the facility and they have not been able to get an updated medication list. The Dialysis RNM #1 stated that Resident #75 used to keep a communication folder in a bag, but the information was not looked at by the facility and no information was ever sent back to them. During an interview on 3/13/23 at 1:07 p.m., Registered Nurse Manager (RNM) #1 stated that the CNAs and the nurses should be documenting fluid intake if the resident is on a fluid restriction and that the nurses and nurse manager are responsible for monitoring the 24-hour fluid intake. RNM #1 stated that they did not believe they had any residents on a fluid restriction. RNM#1 said that medications should be given as ordered and if not given for any reason (including refusal) medical should be notified. During an interview on 3/14/23 at 11:07 a.m., the Chef Director (CD) stated that if a resident was on a fluid restriction it should be on their meal ticket. 2. Resident #303 was admitted to the facility on [DATE], with diagnoses including ESRD requiring dialysis and diabetes. The MDS assessment dated [DATE] documented that Resident #303 was cognitively intact and received dialysis. The current CCP included to monitor and document any signs or symptoms of infection to the dialysis catheter site. Current Physician orders included 10 different medications ordered between 8:00 a.m. and 11:00 a.m. and included but not limited to: a) Citalopram 40 mg daily for depression b) Lidocaine 5% patch, apply to right hip in morning for pain c) Lotrel 10-40 mg daily for hypertension d) Torsemide 20 mg daily for ESRD e) Tylenol 1000 mg, three times a day for hip pain and to give AM dose prior to leaving for dialysis on Tuesday, Thursday and Saturday. f) Hydralazine 25 mg every eight hours for hypertension Additionally, the orders included dialysis on Tuesday, Thursday, and Saturday and to monitor the catheter (dialysis) site for any redness, bleeding, and pain every shift (ordered 2/23/23) Review of Resident #303 E[DATE]/1/23 to 3/13/23, revealed that on four of 13 days, Resident #303 did not receive the scheduled doses for 10 medications due to being absent from the facility at dialysis including the Tylenol specifically ordered to be given before going to dialysis. Review of TAR for February 2023 and March 2023 and nursing progress notes from admission to 3/13/23 revealed no documented evidence that the resident's dialysis catheter access site was monitored as ordered. During an interview on 3/13/23 at 1:07 p.m. RNM #1 stated that they have told the nurses to send the vital signs with the resident to dialysis on a sheet of paper. RNM #1 stated that there have been some problems with documenting vital signs. RNM #1 stated that they do not use a specific communication form and dialysis centers do not consistently communicate with the facility. RNM #1 stated that the dialysis catheter should be checked for bleeding and that if medications are not administered as ordered, the provider should be notified. During an interview on 3/14/23 at 9:25 a.m., LPN #2 stated that they were assigned to Resident #303 and that they did notice that the resident was due for medications during their dialysis appointment and thought that maybe the resident should have been given the medications prior to leaving for dialysis. LPN #1 said that if the resident returned by 12:00 p.m., they could give them then but if they returned after 12:00 p.m., they would not give the scheduled medications as they would be late. 3. Resident #49 was admitted to the facility on [DATE], with diagnoses including ESRD requiring dialysis, hypertension (HTN), and diabetes. The MDS assessment dated [DATE], documented the resident had moderate cognitive impairment. The MDS Assessment did not document the resident received dialysis. Current Physician orders included that on dialysis days give hypertension medications prior to going to dialysis and included: * Clonidine HCL (hypertension medication) 0.2 mg two times a day for HTN * Coreg (hypertension medication) 12.5 mg two times a day for HTN * Hydralazine HCL (hypertension medication) 50 mg three times a day for HTN * Isosorbide Mononitrate ER (extended release) (hypertension medication) 60 mg one time a day for HTN * Norvasc (hypertension medication) 10 mg one time a day for HTN Review of Resident #49 EMAR dated 2/1/23 through 2/28/23 revealed none of the HTN medications were administered for the morning dose on five days secondary to Resident #49 was out of the facility at dialysis. Review of the resident's interdisciplinary progress noted revealed no documented evidence the dialysis center was notified that antihypertensive medications were not consistently administered prior to dialysis per physician orders, and the dialysis center' request. The facility was unable to provide any dialysis communication or treatment sheets (a communication tool often used by both the facility and dialysis center to document information on each dialysis session) 2/1/23 through 2/28/23. During an interview on 3/14/23 at 12:24 p.m., the Physician stated they do not have contact with the dialysis center and were unaware if there was consistent communication between the dialysis center and facility. During an interview on 3/15/23 at 7:47 a.m., the Dialysis RN #1 stated dialysis treatment sheets are provided to the facility after each dialysis session and included pre and post dialysis vital signs, fluid volume removed, medications administered, laboratory values obtained, and recommendations from the dialysis center. The Dialysis RN #1 stated they questioned whether or not the resident was receiving their antihypertensive medications prior to dialysis secondary to Resident #49's blood pressure was always high. The Dialysis RN #1 stated multiple attempts of telephone contact with the facility were attempted without success. During an interview on 3/14/23 at 1:42 p.m., and on 3/16/23 at 10:09 a.m., the Director of Nursing (DON) stated they were aware the communication between Resident #49's dialysis center and the facility was inconsistent. The DON stated they should be monitoring intake and output, weights, and vital signs before and after dialysis, and assessing a catheter for signs of infection as ordered. The DON stated that there is not a specific communication form, but folders should be sent with residents to dialysis that may include progress notes related to what is current with the resident. The DON stated that vital signs should be taken as ordered and documented. The DON stated that medications scheduled while the resident is at dialysis may need to be given prior to going but that there is no policy on this, and it needs to be addressed and education done. The DON stated that nurses are responsible for monitoring the 24-hour fluid intake and making sure residents did not go over their fluid restrictions. The DON stated there was no facility policy related to fluid restrictions. During an interview on 3/14/23 at 10:40 a.m., the Medical Director stated that some medications should be given before dialysis and some after and some only on non-dialysis days and should be ordered as such for each resident. The Medical Director stated that vital signs should be done as ordered or for specific parameters it should be discussed with the dialysis team. The Medical Director stated their expectation is that communication occurs ongoing with the dialysis team. 10NYCRR: 415.12

Based on observations, interview, and record review conducted during the Standard Recertification Survey completed on 3/16/23, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute, or serve food in accordance with professional standards (U.S. Food and Drug Administration's Model Food Code) for food service safety. Specifically, a low-temperature, mechanical dish washing machine did not maintain an acceptable sanitizer concentration on dishes after the final rinse and had a leak. The findings are: 1. During the initial tour of the main kitchen on 3/9/23 from 8:50 a.m. to 9:35 a.m., it was observed that water was leaking from the vacuum breaker located at the top of the mechanical dish washing machine while the unit was running. Further observations included that when tested with the facility's chlorine test strips, the water on the top of a dish after the final rinse cycle showed a chlorine concentration of zero parts per million (ppm) after each of four full runs of the dish machine. The manufacturer nameplate located on the dish machine identified: the unit was an Ecolab-brand Model ES-2000 dish machine, the minimum rinse temperature was 120 degrees Fahrenheit (°F), and the minimum sanitizer concentration was 50 ppm. During an interview at this time, the Chef Director stated that they would call their vendor to service the machine. 2. During the follow-up tour of the main kitchen on 3/14/23 from 11:47 a.m. to 12:13 p.m., it was observed that when tested with the facility's chlorine test strips, the water on the top of a dish after the final rinse cycle of the mechanical dish machine showed a chlorine concentration of greater than, or equal to, 200 ppm chlorine. In an interview at this time, the Chef Director stated that they would call their vendor to look at the machine again. 3. On 3/14/23 at 2:22 p.m., a policy titled Dishmachine Temps dated 9/7/22 was provided by the Chef Director. Review of the policy included that the range for the final rinse sanitizer solution concentration for a low temperature machine of 50-100 ppm sodium hypochlorite (chlorine) on dish surface in the final rinse. Review of facility log titled Dish Machine Sanitizer Log included sanitizer range = 50 - 150 ppm. 10NYCRR: 415.14(h); Subpart 14-1.112(a), 14-1.112(c), 14-1.113(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during the Recertification Survey, it was determined for one of two residents reviewed the facility did not provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice, and the resident's care plan, goals and preferences. Specifically, Resident #77 did not have medical orders or a care plan for the administration and care of oxygen therapy. This is evidence by the following: Review of a facility policy, Oxygen Therapy, dated April 2020, directs oxygen may be administered to a resident in apparent respiratory distress or chest pain at a rate of one to two liters (L) per minute. All other oxygen treatment will require a physician order for amount in liters and frequency. Oxygen tubing and nasal cannula for residents on long-term oxygen use will be changed every seven days. Documentation of the change is recorded in the Treatment Administration Record (TAR). Resident #77 had diagnoses including chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute respiratory failure with hypoxia (low oxygen level), chest pain and dependence on supplemental oxygen. The Minimum Data Set Assessment, dated 3/24/21, revealed that the resident was cognitively intact and received oxygen therapy while a resident. Review of the Comprehensive Care Plan and the Certified Nurse Aide (CNA) [NAME] Report did not reveal information regarding the administration of, care of, goals or interventions of oxygen therapy until after surveyor intervention. Review of medication orders, dated 3/31/21, did not include any orders for the administration of oxygen or the care of oxygen equipment. Review of the March 2021 Medication Administration Record and TAR did not reveal documentation for the use of oxygen, or care of equipment. Review of a history of the medical orders revealed that the resident's oxygen had been discontinued on 2/21/21, with a history of receiving 2 liters (L) to 5L via nasal cannula. In an observation and interview on 3/29/21 at 2:46 p.m., Resident #77 was wearing oxygen via nasal cannula. The oxygen tubing was not dated as when applied. Resident #77 stated at this time that they use the oxygen continuously and it is set at 2L. In an observation and interview on 3/31/21 at 12:42 p.m., Resident #77 was wearing the nasal cannula, but the oxygen concentrator was off. Resident #77 said at the time that the oxygen should be on & staff was notified. In an observation and interview on 3/31/21 at 1:00 p.m., Licensed Practical Nurse (LPN) #1 said the resident is not on continuous oxygen but that it is ordered for as needed (PRN). LPN #1 said she had turned the oxygen concentrator on and set it at 2L, which was observed at this time. In an interview on 4/1/21 at 1:33 p.m., and again at 3:11 p.m., the Registered Nurse Manager (RNM) said Resident #77 does not have a current order for oxygen use. She said it they did she would review oxygen saturation levels and follow up with a medical provider. The RNM later said a medical provider had written an order to apply oxygen at 2L PRN when O2 saturation was less than 90. The RNM later said the original order had fallen off in February 2021 and the nurses should not have given the oxygen without an order. In an interview on 4/2/21 at 11:56 a.m., LPN #2 said O2 tubing should be dated when applied and then changed weekly. In an observation on 4/2/21 at 12:01 p.m., Resident #77 was receiving oxygen via a nasal cannula at 2L and the tubing remained undated as to when it was applied. 415.12 (k) (6)

Based on observations, interviews and record review conducted during the Recertification Survey, it was determined for one of one resident reviewed, the facility did not ensure that, for a resident receiving dialysis, the services provided were consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for Resident #12, medical orders to monitor the dialysis catheter access site for complications and to notify the medical team if present were not documented as being done. This is evidenced by the following: Review of a facility policy, Dialysis, dated 3/9/20, directs that all residents who require hemodialysis will have established care standards including: to check the site every shift for bleeding and add to the Treatment Administration Record (TAR). Remove the dressing per dialysis instructions and add to the TAR. Any individualized interventions required for dialysis care will be included in the Comprehensive Care Plan (CCP). Resident #12 had diagnoses including end stage kidney disease requiring dialysis three times per week, diabetes mellitus, and major depressive disorder. The Minimum Data Set Assessment, dated 1/28/21, revealed Resident #12 had moderate cognitive impairment and received dialysis. The current CCP for dialysis treatment directs the nurse to monitor blood work as ordered, monitor the dialysis catheter on right upper chest area every shift for bleeding and to notify medical if bleeding, and to monitor vital signs before and after dialysis. The current medical orders included to check vital signs every Tuesdays, Thursdays, and Saturdays, before and after dialysis and keep the dialysis catheter covered with a clean dressing. In an observation and interview on 4/2/21 at 8:31 a.m., Resident #12 was in bed wearing a hospital gown. The gown had slipped down below the right shoulder, exposing the dialysis catheter. There was no bandage in place. When interviewed at this time, the Registered Nurse Manager (RNM) said that she would need to check the orders to verify what was in place regarding catheter site monitoring and the dressing. In an interview on 4/2/21 at 11:53 a.m., and again at 12:14 p.m., the RNM said she reviewed the TAR and that there should have been an order on it to monitor the site and apply a clean dressing if needed but that the dressing order was not listed on the TAR. She said the nurses should have placed a clean dressing if it had fallen off (as observed by the surveyor). In an interview on 4/2/21 at 12:21 p.m., and again at 2:09 p.m., the Director of Nursing (DON) said we would want a clean dressing and no bleeding. The DON said that when the resident first arrived, the CCP directed to monitor the catheter site every shift for bleeding and if present notify the medical team. The DON said what happened was the order was entered in the electronic medical record but was not assigned a time therefore not implemented and not added to the TAR for the nurses to perform site monitoring and document that it was done. The DON said if the site bleeds or there are signs of infection, the nurse is to notify the RNM who will notify the dialysis unit as nursing can only reinforce the dressing. 415.12