Based on interviews and record review conducted during the Abbreviated Survey (Complaint ID: NY00357848/520132) from 08/18/2025 to 08/20/2025, for one (1) (Resident #1) of five (5) residents reviewed, the facility did not immediately notify the resident representative when there was a need to alter treatment significantly. Specifically, Resident #1 was prescribed Lovenox (a medication used to treat and prevent blood clots) injections. Following several refusals of the medication, it was discontinued by a provider, and the resident representative was not notified. This is evidenced by:Review of an untitled facility policy, last revised June 2013, included the facility shall notify the resident if alert and oriented, his or her Attending Physician, and representative (in case of a confused resident) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Alert and oriented residents may elect for their representatives to be made aware of the above conditions.Resident #1 had diagnosis including acute embolism (condition where a blood clot travels through the bloodstream and blocks a blood vessel) and thrombosis (blood clot) of right femoral vein, vascular dementia (cognitive decline caused by damage to the blood vessels in the brain), and a history of cerebral infarction (a type of stroke caused by a blockage in a blood vessel to the brain). The Minimum Data Set (a resident assessment tool), dated 09/23/2024, documented the resident had severely impaired cognition and used an anticoagulant (a blood thinner medication used to treat and prevent blood clots).Review of the comprehensive care plan, dated 09/23/2024, included Resident #1 had a deep vein thrombosis. Interventions included, but were not limited to, give medications as ordered and to monitor, document, and report any signs or symptoms of complications.Review of medical orders, dated 09/20/2024, included Lovenox (enoxaparin sodium) Injection Solution prefilled syringes 60 milligrams/0.6 milliliters, inject 1 syringe subcutaneously every 12 hours for deep vein thrombosis for 29 days.Review of the September 2024 Medication Administration Record revealed Resident #1 had refused the Lovenox on 4 of 14 opportunities. In a medical progress note dated 09/27/2024, Nurse Practitioner #1 documented Resident #1 was seen for refusals of the Lovenox injections and nursing staff had advised the resident on the indication (the specific medical condition or purpose for which a drug is prescribed) for the medication. Nurse Practitioner #1 documented the Lovenox was discontinued.In a progress note dated 10/04/2024, a Licensed Practical Nurse documented Resident #1 was diaphoretic, fluids were pushed, and vital signs were obtained. This information was documented in facility provider book (used by nursing staff to communicate resident concerns to the medical provider) for follow up and the 24-hour report (used by nursing staff to communicate resident concerns from shift to shift) for continued monitoring. Review of progress notes from 09/24/2025 to 10/04/2025 did not include documented evidence Resident #1's representative had been notified of the Lovenox refusals or the medication later being discontinued.Review of an Emergency Department Provider Note, dated 10/04/2024, revealed Resident #1 was transported to the hospital for evaluation and admitted with a diagnosis of acute ischemic stroke (a condition that occurs when a sudden blood flow blockage to the brain causes brain cells to die). The provider documented Resident #1's representative reported they were unsure if the resident was getting Lovenox injections at the skilled nursing facility.During a phone interview on 08/18/2025 at 1:00 PM, the Medical Director stated they were not involved with Resident #1's care at that time. They stated the provider should have notified the resident's representative about the discontinuation of the Lovenox.10 NYCRR 415.3(f)(2)(ii)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews conducted during the Recertification Survey and Complaint Investigation (NY00318393) completed on [DATE], for four of five residents reviewed for advanced directives, the facility did not ensure that there was an organized system to ensure that resident wishes regarding Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR - do not initiate Cardiopulmonary Resuscitation in the event of acute cardiac or respiatory event) were followed. Specifically, Residents #22, #29, and #59 had discrepancies in their code status as identified on facility forms. Additionally, Resident #115 gave verbal consent on their Medical Orders for Life Sustaining Treatment (known as a MOLST) for Full Code (initiate Cardiopulmonary Resuscitation for acute cardiac and/or respiratory event) that was not signed by two witnesses. This is evidenced by, but not limited to the following: The facility policy Advanced Directives, revised [DATE], documented the resident's wishes are communicated to direct care staff and the physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care planning meetings. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. The interdisciplinary team will review annually with the resident, his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the medical record. 1. Resident #59 had diagnosis including heart failure, wound infection, and diabetes. The Minimum Data Set Resident assessment dated [DATE] noted Resident #59 was cognitively intact. Current Physician orders for Resident #59 did not include any orders for the resident's wishes for advanced directives. Review of Resident #59's Medical Orders for Life Sustaining Treatment form dated [DATE] and signed by Nurse Practitioner #2 revealed the resident's wishes as Do Not Resuscitate (allow natural death). Review of Nurse Practitioner #2's notes on [DATE], [DATE], and [DATE] revealed Resident #59's code status was documented as Full Code. During an interview on [DATE] at 10:45 AM Nurse Practitioner #2 stated they were now aware that Resident #59 wishes were for Do Not Resuscitate and that their notes indicated the resident's wishes for Full Code. Nurse Practitioner #2 stated that because there were no medical orders for advanced directives it was presumed the resident was a Full Code. Nurse Practitioner #2 stated they had notified the previous Social Worker of the discrepancy and Resident #59 would be medically documented as a Full Code until the Medical Orders for Life Sustaining Treatment form was completed. Nurse Practitioner #2 stated they were not aware of the Medical Orders for Life Sustaining Treatment form from [DATE]. 2. Resident #22 had diagnoses that included heart failure, hypertension, and chronic obstructive pulmonary disease. The Minimum Data Set Resident assessment dated [DATE], documented the resident was cognitively intact. Review of Resident #22's Comprehensive Care Plan dated [DATE], documented the resident's wishes were Do Not Resuscitate. Resident #22's Medical Orders for Life-Sustaining Treatment dated [DATE] and signed by the resident and witnessed by a Registered Nurse and a family member documented Resident #22's wishes were for Cardiopulmonary Resuscitation. Review of interdisciplinary progress notes since admission revealed in multiple medical and nursing notes that Resident #22 was alert and oriented and able to make their needs known. During an interview on [DATE] at 1:33 PM, Licensed Practical Nurse Manager #1 stated they were made aware that day that Resident #22's care plan did not match their Medical Orders for Life-Sustaining Treatment form. Licensed Practical Nurse Manager #1 stated they were unaware that advanced directives were also in the Comprehensive Care Plan. In an interview on [DATE] at 2:31 PM, the Director of Nursing stated the Social Worker and nursing were responsible for advanced directives. The Director of Nursing stated that nursing should get the physician's orders and input it in the electronic health record and that the Social Worker should take care of the paperwork portion. The Director of Nursing stated that if a Medical Orders for Life-Sustaining Treatment form was changed then the order should be updated the same day. 3. Resident #29 had diagnoses that included depression, schizophrenia, and hypertension. The Minimum Data Set Resident assessment dated [DATE], included that Resident #29 was severely impaired cognitively and advanced directive wishes included Do Not Resuscitate. Review of Resident #29's Medical Orders for Life-Sustaining Treatment form dated [DATE] and signed by the resident revealed their wishes as Do Not Resuscitate. Additionally, Section F, which noted that a physician must review the form from time to time, did not include documentation that Resident #29's Medical Orders for Life-Sustaining Treatment had been reviewed by a medical provider since [DATE]. Current Physician orders included Do Not Resuscitate. In medical progress notes dated [DATE], [DATE] and [DATE] Nurse Practitioner #2 documented that Resident #29's code status as Full Code. Review of medical progress notes for approximately the previous three months revealed no documentation that the medical team had reviewed the resident's code status with the resident or their representative. During an interview on [DATE] at 10:23 AM, Nurse Practitioner #2 said when a resident is admitted to the facility, the Social Worker reviews the resident's code status with them (or their representative) and completes a Medical Orders for Life-Sustaining Treatment form. The form is then placed in a book for the medical provider to review. Nurse Practitioner #2 said a resident's code status is reviewed during care planning meeting or if it is requested and if there is a concern such as the resident's health is declining. Nurse Practitioner #2 stated they (medical team) are not involved in care plan meetings unless specifically asked. Nurse Practitioner #2 said residents' code status (Medical Orders for Life-Sustaining Treatment forms) are not reviewed by a medical provider with the resident or representative at regular intervals. Nurse Practitioner #2 said they would document a resident's code status in their visit note and did not know if Section F of the Medical Orders for Life-Sustaining Treatment forms are signed when reviewed or who was responsible for documenting that a resident's code status was reviewed. Nurse Practitioner #2 said Resident #29 was their patient and that the resident's code status was Do Not Resuscitate. When reviewed at this time and the code status discrepancies, Nurse Practitioner #2 said they use a program to dictate their visit notes and unless they specifically say a resident's code status, it automatically defaults to Full Code. 10 NYCRR 415.3(f)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey and Complaint Investigation (NY00326620), the facility did not ensure each resident was free from misappropriation of resident property and exploitation for two (Residents #28, #57) of four residents reviewed for missing property and for three (Residents #59, #99, and #108) residents interviewed during Resident Council. Specifically, the residents reported missing money, clothing, and personal items and the facility was unable to provide documentation that the missing property complaints had been investigated and/or any resolutions offered for the missing property. This is evidenced by the following: The facility policy Personal Property with a revised date of August 2022, documented the facility promptly investigates any complaints of misappropriation or mistreatment of resident property. The facility policy Lost and Found, dated of January 2008, documented the facility shall assist all personnel and residents in safeguarding their personal property. Resident or family complaints of missing items must be reported to the Director of Nursing, lost and found records will be maintained for one year, then destroyed and reports of misappropriation or mistreatment of resident property are immediately investigated. During Resident Council meeting on 5/30/24 at 10:30 AM several residents reported that they were missing personal items and that the facility had not provided any resolutions. Resident #59 stated they were missing an electric razor, and their cell phone was stolen approximately 6 months ago. Resident #99 stated they have had several items missing and have been asking staff about them for a long time. Resident #108 stated they were missing a cell phone charger and has had no follow-up. When requested the facility was unable to provide documentation regarding any resident's missing property and/or any resolutions for the past year. 1. Resident #28 had diagnosis including dementia, diabetes, and heart failure. The Minimum Data Set Resident assessment dated [DATE] included that Resident #28 was cognitively intact. During an interview on 5/31/24 at 12:34 PM Resident #28's Representative stated they label the resident's clothes, but they still get lost, and that the resident was missing three new tops, four pairs of shorts, and twenty bras within the last year. The Representative stated that they have told staff at the facility, filled out missing item reports, and gone to the laundry room themselves to look. 2. Resident #57 had diagnoses including, chronic kidney disease dependence on dialysis and diabetes. The Minimum Data Set Resident assessment dated [DATE] included that the resident was moderately cognitively impaired. In an interview on 6/4/24 at 10:54 AM Resident #57 stated that they were missing two sweaters, three dress shirts, the padding for their wheelchair, and a blanket. Resident #57 stated that they were also missing $60 a few months ago and the facility did not do anything about it. Resident #57 stated that they reported the missing items to several staff, but no paperwork had been filled out. During an interview on 5/31/24 at 9:44 AM Laundry Aide #1 stated unlabeled clothing should be put in a cart and sent downstairs. If a resident reported missing something they would go to the basement to look for the specific item and if unable to locate it, they would notify the supervisor. During an interview on 6/5/24 at 1:33 PM Licensed Practical Nurse Manager #1 stated that they were informed that day that Resident #57 was missing their wheelchair pillow but were not aware of the other items. Licensed Practical Nurse Manager #1 stated that they email everyone when there is a missing item reported and let staff and other nurse managers know to keep an eye out and to follow up on it. Licensed Practical Nurse Manager #1 stated that the Social Worker should get notified by email and start the paperwork and take care of the issue from there. In an interview on 6/5/24 at 2:31 PM the Director of Nursing stated they would expect staff to look for and report off any missing item and report it to the Social Worker and themselves. If the item was not found, then the item would be replaced. The Director of Nursing stated that they are usually involved with grievance forms and was not aware of Resident #57 missing any items. The facility Social Worker was not available for interview. 10 NYCRR 415.4(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification Survey and Complaint Investigation (NY00327022), for three (Residents #90, #116, #371) of four residents reviewed the facility did not ensure that notification of a discharge/transfer was provided to the resident and/or the resident's representative in writing, and in a language and manner they understood, as soon as possible when an immediate discharge/transfer was required by the resident's urgent medical needs. Additionally, the facility did not ensure a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman. This is evidenced by the following: Review of the facility policy, Transfer or Discharge Notice, dated March 2021 revealed that residents and/or representatives would be notified in writing, and in a language and format they understood as soon as possible but before the transfer or discharge, when an immediate transfer or discharge was required by the resident's urgent medical needs. The policy included that a copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge was provided to the resident and representative. 1. Resident #371 had diagnoses including adult failure to thrive, spinal stenosis, and chronic kidney disease. The Minimum Data Set Resident assessment dated [DATE] revealed the resident was cognitively intact. In a medical team note, dated 3/21/24 Nurse Practitioner #2 documented that Resident #371 had a change in symptoms, difficulty swallowing, and required transfer to the emergency department. Review of Resident #371's electronic health record did not include any documentation that a written notice of the transfer had been provided to the resident and/or their representative. 2. Resident #90 had diagnoses including seizure disorder, dysphagia (difficulty swallowing), and dementia. The Minimum Data Set Resident assessment dated [DATE] revealed the resident had severe cognitive impairment. In a nursing progress note, dated 8/27/24 Licensed Practical Nurse #4 stated that Resident #90 was transferred to the hospital at approximately 4:40 PM to get their Percutaneous Endoscopic Gastrostomy (PEG) (a tube inserted directly into the stomach to provide nutrition for residents with swallowing difficulties) fixed. Review of Resident #90 electronic health record did not include any documentation that a written notice of transfer had been provided to the resident and/or their representative. 3. Resident #116 had diagnoses including chronic obstructive pulmonary disease (lung disease that makes it difficult to breathe), congestive heart failure, diabetes. A mental status interview, dated 3/18/24, revealed the resident was cognitively intact. In a nursing progress note, dated 3/19/24 Licensed Practical Nurse #8 documented that Resident #116 was transferred to the hospital by Emergency Medical Services and the family was to be notified. Review of Resident #116 electronic health record did not include any evidence that a written notice of transfer had been provided to the resident and/or their representative. The facility was unable to provide any documented evidence that a written notice of the transfers, to include the specific reason for the transfer, the date of the transfer, and the location of the transfer had been provided to any of the residents or their representatives. Additionally, the facility was unable to provide any documentation that the Office of the State Long Term Care Ombudsman office had been notified of the transfers per the regulations. During an interview on 6/5/24 at 11:39 AM, Registered Nurse Manager #3 stated when residents are transferred to the hospital nursing staff should complete an electronic alert that notifies all departments that a resident was being transferred and contact the family. Registered Nurse Manager #3 stated transfer notices were completed by the Receptionist or the Nursing Supervisor. During an interview on 6/5/24 at 11:58 AM, the Business Office Representative stated they did not have a role in the resident transfer or discharge process and did not provide any written notices to the resident, the resident representative, or the Ombudsman. During an interview on 6/5/24 at 12:12 PM, the Reception Supervisor stated nursing staff notified the Receptionist why a resident was being sent out and to where. Then the Receptionist would print the relevant medical documentation, complete an electronic alert that notified all departments that a resident was being transferred, and send an email to the Admission/Discharge team. When a resident was transferred during an off shift (i.e., night shift) the Nursing Supervisor was responsible for completing the process. The Reception Supervisor stated they were not involved in notifying the Ombudsman of any resident transfers or discharges and was not sure who was responsible. During an interview on 6/5/24 at 1:42 PM and again at 1:57 PM, the Director of Nursing stated the Business Office was responsible for completing notifications and providing the written notice to the resident and their representative when a resident was transferred to the hospital. The Director of Nursing later stated the Ombudsman's Office was notified of resident transfers and discharges once monthly via fax. Documentation for the notification of the Ombudsman was requested at this time. During an interview on 6/6/24 at 11:37 AM, Registered Nurse Manager #2 stated, on behalf of the Director of Nursing, the facility was unable to provide any documentation that notifications of transfers and discharges had been provided to the Ombudsman due to the inability to access the previous Social Worker's files. 10 NYCRR 415.3(i)(1)(iv)(a-e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during a Recertification Survey and Complaint Investigations (NY318393, NY00323935, NY00328756, and NY00343607) for three (Residents #52, #76, #87) of nine residents reviewed the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #52 was not provided with the assistance to obtain a haircut, Resident #76 was observed with uncut nails and unshaven facial hair and Resident #87 had oily and unwashed hair. This is evidenced by the following: The facility policy Supporting Activities of Daily Living dated March 2018, documented that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out Activities of Daily Living and the date and time of fingernail care, shaving and hair shampooing should be documented in the resident's medical record. 1. Resident #87 had diagnoses including Lewy body dementia (a type of dementia characterized by changes in sleep, behavior, and movement), chronic obstructive pulmonary disease (a chronic inflammatory lung disease), and major depressive disorder (a mood disorder characterized by a persistent feeling of sadness). The Minimum Data Set Resident assessment dated [DATE] documented that Resident #87 was severely impaired cognitively and required assistance with personal hygiene. Review of the current Comprehensive Care Plan and [NAME] (care plan used for Certified Nursing Assistants for daily care) revealed Resident #87 required extensive assistance of staff with showering and personal hygiene. During an interview on 5/28/24 at 1:30 PM Resident #87 and a visitor stated that the resident had only had a few showers since they had been admitted (approximately six months) and wished they could have their hair washed in the shower (versus a no water cap that staff had been using). Resident #87 stated staff wipe them down (with a cloth) for washing but that they would really like a shower. During an interview on 6/5/24 at 11:56 AM Certified Nursing Assistant #5 stated that residents received hair washing on their shower day (weekly) which they documented (in the computer) and if a resident refused care, they documented the refusal and informed the nurse. During an observation on 6/6/24 at 9:30 AM, Resident #87 was observed in the dining room and their hair appeared stringy, oily, and unwashed (despite the previous day being the resident's assigned shower day). Review of Resident #87's electronic health record revealed no documented evidence that the resident had received any showers for the previous thirty days and no documented evidence of refusals. During an interview on 6/6/24 at 8:33 AM, Licensed Practical Nurse #3 stated that washing hair was usually done with residents' showers but sometimes there were not enough staff, and that the water (hot) temperature has been an issue. During an interview on 6/6/24 at 9:05 AM, Certified Nursing Assistant #6 stated Resident #87 did not like their hair greasy. 2. Resident #76 had diagnoses of Alzheimer's disease, legal blindness, and hypertension. The Minimum Data Set Resident assessment dated [DATE], revealed Resident #76 was severely impaired of cognitive function. Review of the current Comprehensive Care Plan and [NAME] revealed Resident #76 required the assistance of staff to complete personal hygiene and nail trimming and required verbal cues and encouragement to complete the tasks. In an observation on 5/28/24 at 9:17 AM, Resident #76 had long nails and several days growth of facial hair. Resident #76 stated at the time that they needed to be shaved. During an observation and interview on 5/30/24 at 11:13 AM, Resident #76 was in the dining room and remained unshaven and with long nails. Resident #76 stated they were not growing out their beard and needed to shave but needed somebody to do it. During observations on 5/31/24 at 4:37 PM, 6/2/24 at 5:19 PM, 6/3/24 at 12:11 PM, and 6/4/24 at 2:21 PM, Resident #76 continued to be unshaven and had long nails. Review of the May 2024 Treatment Administration Record revealed that showers were scheduled for Resident #76 weekly on Monday evenings. There was one shower documented for the month of May on 5/27/24. During an interview on 6/5/24 at 11:56 AM, Certified Nursing Assistant #5 stated that on shower days resident's nails should be cut and facial hair shaved, and this should be documented in the computer when provided or if a resident refused. Certified Nursing Assistant #5 they were a float from another unit and the surveyor would have to ask a unit Certified Nursing Assistant why it had not been completed for Resident #76. During an observation and interview on 6/6/24 at 10:55 AM, Registered Nurse Manager #1 stated the nurses have a section in the electronic health record to document showers and should document if refused. Registered Nurse Manager #1 said that shaving should be offered on shower days and that Resident #76 should have been assisted with shaving. When observed Resident #76 remained with facial hair and several jagged nails. Registered Nurse Manager #1 asked Resident #76 if they wanted a shave and Resident #76 stated yes. 3. Resident #52 had diagnoses that included ankylosing spondylitis (a rare type of autoimmune disease that causes arthritis in your spine), hypertension, and schizoaffective disorder (a mental health condition). The Minimum Data Set Resident assessment dated [DATE], revealed that Resident #52 was cognitively intact and was dependent upon staff for grooming and personal hygiene. Review of the current Comprehensive Care Plan and [NAME] revealed Resident #52 required set-up help for personal hygiene. During an observation and interview on 5/28/24 at 12:20 PM, Resident #52 was in bed. Their hair touched their shoulder. Resident #52 stated they have wanted a haircut for awhile but there was no stylist in the facility and added that their family was trying to get them a haircut for their birthday. During an interview on 6/6/24 at 8:59 AM, the Activities Director stated that the last barber had left the facility over a month ago and the facility has not hired anyone yet. The Activities Director stated that they do not keep a list of requests for haircuts and had not been aware that Resident #52 wanted a haircut. 10 NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Recertification Survey the facility did not ensure that proper treatment to maintain hearing abilities was provided for one (Resident #51) of one resident reviewed for hearing. Specifically, Resident #51 did not have their ears flushed per Physician orders. This is evidenced by: The facility policy, Activities of Daily Living, dated May 2018, documented residents will be provided with care, treatment, and services to ensure that their activities of daily living do not diminish unless the circumstances of their clinical conditions demonstrate that diminishing activities of daily living are unavoidable. Resident #51 had diagnoses including chronic obstructive pulmonary disease, diabetes, and hypertension. The Minimum Data Set Resident assessment dated [DATE] documented the resident was cognitively intact and did not require the use of a hearing device and that the resident's hearing was adequate. Review of the Comprehensive Care Plan initiated 1/1/23 documented that Resident #51 was able to communicate her needs effectively and to refer to Audiology for hearing consult as ordered. In a nursing progress notes dated 3/11/24 the Registered Nurse documented that Resident #51 was seen at their family's request to evaluate their ears for cerumen (ear wax). Using video otoscope, the Registered Nurse found the left ear contained a large amount cerumen and the right ear was impacted with cerumen. A large amount of cerumen was removed but canal remains occluded. Review of a medical progress note, and Physician orders dated 4/17/24 revealed that Resident #51 complained of having wax in their ears not relieved with ear drops and the Physician ordered both ears flushed. Review of Resident #51's April 2024 and May 2024 Medication Administration Records revealed an order to please flush ears bilaterally - cerumen impaction. There was no documentation that the ear flushed were ever completed (all boxes were 'x' out). Review of Resident #51's nursing and medical progress notes from 4/17/24 to 6/4/24 revealed no mention of whether Resident #51's ears had been flushed or any refusals. In an interview on 5/28/24 at 12:38 PM and again on 6/5/24 at 9:33 AM Resident #51 stated that they could not hear and asked the surveyor to yell. Resident #51 stated that they could not hear out of either of their ears and that not being able to hear bothered them and having to say what did you say? to everyone was annoying. During an interview on 6/5/24 at 1:33 PM Licensed Practical Nurse Manager #1 stated they did not know that there was an order to flush Resident #51's ears and an x in the Medication Administration Record would mean that it was not scheduled for that date and time. Licensed Practical Nurse Manager #1 did not know who could flush a resident's ears at this facility and would have to ask where the equipment was kept. In an interview on 6/5/24 at 2:31 PM the Director of Nursing stated that a Licensed Practical Nurse or a Registered Nurse could flush a resident's ears. The Director of Nursing did not know why Resident #51's ears had not been flushed and does not know how the order got missed. During an interview on 6/6/24 at 9:35 AM Nurse Practitioner #1 stated when orders are put in (the system) the nurses are supposed to carry them out and that any nurse could flush a resident's ears. Nurse Practitioner #1 stated that if the nurses wanted medical to flush Resident #51's ears then they should have let them know and that they would have needed notice to bring their own otoscope and curettes as to their knowledge the facility does not have either available. 10 NYCRR 415.12 (a)(3)(b)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observations, interviews and record review conducted during a Recertification Survey, the facility did not ensure that residents with limited range of motion received appropriate treatment, equipment, and services to increase range of motion and/or to prevent further decrease in range of motion for two (Resident #37 and #90) of two residents reviewed. Specifically, the residents were observed on multiple occasions not wearing their therapy recommended hand splints. This is evidenced by the following: 1. Resident #37 has diagnoses including dementia, malnutrition, and contractures (permanent tightening of the muscles and tendons causing joint stiffness and pain and loss of function). The Minimum Data Set Resident assessment dated [DATE] documented that the resident was moderately impaired of cognitive function and had no impairment in range of motion to their upper extremities (shoulder, elbow, wrist and hands). Review of Resident #37's current Comprehensive Care Plan and [NAME] (care plan used by Certified Nursing Assistants for daily care) revealed the resident has contractures and required assist to don (put on) resting hand splints in the morning and doff (remove) at night. Review of an Occupational Therapy Discharge summary dated [DATE] revealed a goal that the resident will tolerate having resting hand splints (one at a given time) to decrease pain and minimize contractures in both hands 100% of the time. The goal was identified as met on 4/29/24. During observations on 5/28/24 at 9:34 AM, 5/30/24 at 11:59 AM, on 6/4/24 at 11:57 AM and again at 3:38 PM Resident #37 was not wearing either hand splint which was observed on their bedside table and one on the floor. On 5/30/24 at 11:59 AM a sign was observed above the resident's bed that included directions to staff to don a splint in the morning and doff at night. In a medical progress note dated 5/6/24 Nurse Practitioner #1 documented that Resident #37 had pain in their hands and wrists due to joint stiffness. In an Occupational Therapy Progress notes dated January 2024 through April 2024 therapists documented that the residents hand splints are applied intermittently. During an interview on 6/4/24 at 12:30 PM Licensed Practical Nurse #2 stated that Resident #37 gets hand splints for straightening due to contractures and that therapy comes up and puts them on and if staff see them off, they will apply them. During an interview on 6/5/24 at approximately 9:30 AM the Certified Occupational Therapist Assistant #1 stated they trained the Certified Nursing Assistants, nurses, and the Nurse Managers on the floor to apply the splints once the residents are discharged from therapy. Certified Occupational Therapist Assistant #1 stated Resident #37 was discharged from therapy 4/29/24 with two hand splints and should have them applied in the morning and removed at night to prevent contractures and increased pain. In an interview on 6/5/24 at 10:12 AM Occupational Therapist #1 stated Resident #37 should have a right- and left-hand splint and a schedule to have one splint on at a time so the resident can have one hand free and to provide stretching. When applied at this time to the resident's left hand, Resident #37 stated the pain was less. In an interview on 6/6/24 at 8:59 AM Certified Nursing Assistant #4 stated Resident #37 has a left-hand splint that is supposed to go on in the morning and off at night and that they put it on when the resident asks and takes it off when the resident asks. 2. Resident #90 had diagnoses including a dementia, seizures, and a stroke. The Minimum Data Set Resident assessment dated [DATE] documented that the resident was severely impaired cognitively and had functional limitation in range of motion to the upper extremity on one side. Review of Resident #90's current [NAME] revealed that the resident had a left resting hand splint with finger separators, to don in the morning and doff at night during care. Review of an Occupational Therapy Discharge summary dated [DATE] revealed a goal that the resident would follow a splint schedule 100% of the time with a comment that therapy will don the splint during therapy but that staff on the floor are non-compliant with donning the splint despite visual reminders in the resident care plan and in their room. The summary included that prognosis to maintain level of function was good with consistent staff follow-through. In a therapy progress note Certified Occupational Therapist Assistant #1 documented that the Nurse Manger was educated on how to don and doff the resident's hand splint. In observations on 5/28/24 at 12:29 PM, Resident #90 was up and dressed and in the hallway. There was no splint on either hand. During observations on 5/31/24 at 12:17 PM (splint observed on nightstand), on 6/3/24 at 4:07 PM and on 6/4/24 at 10:29 AM and again at 12:12 PM Resident #90 was not wearing their hand splint. A sign in the resident's room included a splint schedule and directions for placement of the splint with photo. During an interview on 6/4/24 at 12:15 PM CNA #2 stated that they forgot to put Resident #90's hand splint on. CNA #2 stated they did not have Resident #90 the previous days so did not know why the resident had not been wearing their hand splint. During an interview on 6/4/24 at 10:40 AM Occupational Therapist #1 stated Resident #90 has had contractures for a while and that in using the splints, they are trying to maintain the resident's level (of function). After they are discharged from therapy, the Certified Nursing Assistants are responsible for applying the splint. Occupational Therapist #1 stated that staff were educated (on applying the splint) in May and that Resident #90 does not refuse to wear the splint that they knew of. Occupational Therapist #1 said that the resident's current pain could be from lack of stretching due to not wearing the splint. During an interview on 6/7/24 at 1:38 PM the Director of Nursing stated that the residents care plan should be followed and if a resident refuses, this should be documented. 10 NYCRR 415.12(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey and Complaint Investigations (NY00315983, NY00318393), for one (Resident #42) of two residents reviewed for respiratory care, the facility did not ensure residents who needed respiratory care were provided such care consistent with professional standards of practice. Specifically, Resident #42 did not have a physician order in place for oxygen use, did not have a person-centered comprehensive care plan for oxygen, and was not provided a clean well-functioning oxygen concentrator. This is evidenced by the following: The facility policy, Oxygen Administration, dated October 2010 included to verify there was a physician's order, review the residen's care plan to assess for any special needs, check equipment to be sure it was in good working order, and document in the resident's medical record how the resident tolerated the oxygen. Resident #42 had diagnoses that included respiratory failure, congestive heart failure, and hypertension. The Minimum Data Set Resident assessment dated [DATE] revealed the resident was cognitively intact and received oxygen therapy while a resident in the facility. The current Comprehensive Care Plan reviewed on 5/28/24 did not include that Resident #42 was receiving oxygen therapy. Review of physician orders for oxygen therapy revealed an order to discontinue oxygen on 8/22/23. There were no further orders for oxygen therapy until 5/29/24 (after surveyor intervention) which included oxygen at 6 liters per minute continuously. During an observation and interview on 5/28/24 at 9:47 AM, Resident #42 was lying in bed and had complaints of difficulty breathing. They were wearing a nasal cannula (a device that delivers additional oxygen through a person's nose) connected to a concentrator (a device that filters air from a person's surroundings and delivers oxygen to breathe) set at 8 liters of oxygen per minute. Resident #42's oxygen saturation level as taken by Licensed Practical Nurse #5 at this time was 86 percent (considered a low level that may require medical attention). Licensed Practical Nurse #5 moved the nasal cannula tubing to an oxygen tank in the room and Resident #42's oxygen saturation increased to 96 percent. Licensed Practical Nurse #5 stated a lot of the equipment (oxygen concentrators) in the facility did not work. During an interview on 5/28/24 at 10:34 AM, Licensed Practical Nurse Manager #1 stated that Resident #42 had been using oxygen for a while but after review the the resident's orders, they stated the resident did not have a physician order in place for the oxygen. During an observation and interview on 5/28/24 at 11:10 AM, the oxygen concentrator in Resident #42's room had a filter that was covered with dust. Resident #42 stated the facility staff had just brought in that particular concentrator. During an interview on 5/31/24 at 2:52 PM, the Corporate Infection Preventionist stated there were no preventive maintenance inspections for patient care related equipment (including oxygen concentrators). During an interview on 6/4/24 at 1:15 PM, Registered Nurse Manager #3 stated Resident #42 had no care plan for oxygen and that they had been working with the Director of Nursing to make care plans better. During an interview on 6/6/24 at 10:13 AM with the Administrator and Director of Nursing, the Director of Nursing stated they were not aware of any concerns related to oxygen administration and that there was a quality assurance initiative in place that included ensuring the oxygen supply company was coming as scheduled and checking all concentrators to ensure they were serviced as needed. 10 NYCRR 415.12(k)(6)

**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 (NY00318393) it was determined that for one (Resident #52) of one resident reviewed, the facility did ensure the resident's pain was managed to the extent possible in accordance with the comprehensive assessment and plan of care, current professional standards of practice and the resident's goals and preferences. Specifically, Resident #52's pain medication was not administered as ordered on multiple occasions without Physician notification and the resident did not have a comprehensive care plan for chronic pain that included measurable goals and person centered interventions. This is evidenced by the following: The facility policy Pain - Clinical Protocol dated March 2018, included that with input from the resident to the extent possible, the physician and staff will establish goals of pain treatment. The physician will order appropriate non-pharmacological and medication interventions to address the individual's pain. Resident #52 had diagnoses including ankylosing spondylitis (an inflammatory disease that can cause some of the bones in the spine to fuse), complex regional pain of left lower limb, cervicalgia (neck pain), arthropathic psoriasis (a form of arthritis), temporomandibular joint dysfunction (pain and compromised movement of the jaw joint and surrounding muscles), and schizoaffective disorder (a mental health condition) with hallucinations. The Minimum Data Set Resident assessment dated [DATE], revealed the resident was cognitively intact and had pain that was rated as 9 out of 10 almost constantly making it hard for them to sleep at night, limited their participation in rehabilitation therapy sessions, and limited their day-to-day activities. Resident #52's Comprehensive Care Plan last revised on 4/17/24 included the resident takes pain medication due to history of chronic pain with interventions to monitor for effectiveness of pain medication and document adverse reactions. The care plan did not include person centered goals or any non-pharmacolgical person centered interventions. During an interview on 5/28/24 at 12:11 PM Resident #52 stated they were in alot of pain both in their back and their legs. The resident was observed in bed on multiple occasions throughout the day shift. Current Physician orders included Tylenol twice daily and as needed at night for jaw pain, Lyrica (pain medication) twice daily for neuropathy (nerve damage outside the brain and spinal cord that causes pain or numbness), and oxycodone (narcotic pain reliever) three times daily for pain. Review of the Medication Administration Records for April 2024 and May 2024 revealed that on 4/21/24 there was no documented evidence that Resident #52 had received their morning prescribed doses of Tylenol or oxycodone and on 5/29/24 there was no documented evidence that the resident received their evening prescribed doses of Lyrica and oxycodone. Review of the June 2024 Medication Administration Records along with the Control Substance Count (narcotic) sheets for Resident #52's oxycodone revealed the following: - On 6/2/24 the records documented that Resident #52 received less than the prescribed dose in the [NAME] and more than the prescribed dose for the afternoon and evening doses. There was no documentation that any of the oxycodone had been wasted. - On 6/3/24 at 6:00 AM the records documented that Resident #52 received more than the prescribed dose. There was no documentation that any of the oxycodone had been wasted. There is no documentation of any oxycodone being removed at the 12:00 PM or 5:00 PM scheduled times. When interviewed on 6/4/24 at 1:02 PM and again on 6/6/24 at 10:31 AM Resident #52 stated that recently they were unable to receive their Lyrica medication (unavailable) and only received a partial dose of their oxycodone which caused them to have an increase in pain which caused an increase in their hallucinations. Resident #52 stated that they had pain in their back described as throbbing and sometimes stabbing, had bursitis (painful swelling in the joints) in both hips, neuropathy (nerve pain) of their left leg and foot, neck pain and recently they developed jaw pain. Resident #52 stated that the prescribed medications do help reduce the pain from a 9 to a 5 or 6 out of 10. The resident said staff do not offer them anything such as ice or heat therapy or any topical medications and that they used to get patches for their hips that helped but thought they were too expensive. During a telephone interview on 6/6/24 at 9:45 AM, Nurse Practitioner #1 stated if Resident #52 does not receive the correct dose or missed a dose of their pain medication, it could cause increased pain and anxiety for the resident. When interviewed on 6/6/24 at 11:11AM, Registered Nurse Manager #3 stated that the resident's care plan for pain was not individualized and knew from experience that Resident #52 had said nothing helps their pain and they were just looking for more pain medication. 10 NYCRR 415.12

Based on observations, interviews and record reviews conducted during the Recertification Survey the facility did not ensure the resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #52) of one resident reviewed. Specifically, Resident #52 did not receive medication changes as recommended, did not have a comprehensive care plan that included an individualized person-centered approach to address their behavioral health needs, and did not receive consistent psychiatric services. This is evidenced by the following: The facility policy Behavioral Health Services, dated March 2019, included the facility will provide and the residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident and develop a plan of care accordingly. Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent, or relive the resident's distress or loss of abilities. The facility policy Psychiatric Consultation dated 2/2/24, included the facility will have an established process to ensure residents receive appropriate psychiatric evaluation, treatment, and follow-up services when clinically indicated. Residents receiving psychiatric treatment will have their care plans updated to reflect the associated interventions, monitoring parameters and responsible disciplines. Resident #52 has diagnoses including schizoaffective disorder (a mental health condition), major depressive disorder with psychotic features, visual hallucinations, anxiety disorder, and insomnia. The Minimum Data Set Resident Assessment, dated 4/19/24, revealed the resident was cognitively intact, had moderate depression and was dependent on a wheelchair for mobility. During an interview on 5/28/24 at 11:59 AM Resident #52 stated that their motorized wheelchair was damaged in a flood from the floor above months before and was still not fixed. Resident #52 stated they would prefer to use their own wheelchair (versus a non-motorized one) due to increased pain. Physician orders dated 6/4/24 included Ambien (medication used to treat insomnia) at hour of sleep, lorazepam (antianxiety) three times daily, mirtazapine (antidepressant) at night, Seroquel (antipsychotic) at noon and at hour of sleep. Resident #52's Comprehensive Care Plan last revised on 4/17/24, included the resident had schizoaffective disorder, personality disorder, anxiety, visual and auditory hallucinations, and at times digs at their legs and arms. The interventions including to administer medications per order and to continue to see telepsychiatry for medication management. The Comprehensive Care Plan did not include person-centered interventions to address the identified issues. A Department of Telepsychiatry progress note dated 9/14/23, included recommendation to increase the Seroquel by adding 25 milligrams at noon and to continue 50 milligrams in the morning and 400 milligrams at hour of sleep and to follow-up in two months. Review of Physician orders history revealed that the noon dose of Seroquel 50 milligrams had not been added until 11/2/23 and the morning dose of Seroquel 50 milligrams had been discontinued on 11/8/23 with no explanations as to why the orders differed from the psychiatry recommendations. Review of a purchase order dated 1/25/24 for an evaluation of the resident's power wheelchair revealed a quote from a surgical supply company dated 2/5/24 for the repairs needed for Resident #52's power wheelchair. There was no mention when the power wheelchair would be repaired or if the quote had been accepted. The facility was unable to provide any evidence when the resident could expect their power wheelchair to be repaired and returned to them. In a Department of Telepsychiatry progress note dated 2/7/24 Psychiatric Nurse Practitioner #1 documented that this was the first routine follow-up since 9/14/23 (despite the recommendation for a two month follow up). Psychiatric Nurse Practitioner#1 documented that the recommended medication changes from 9/14/23 had not been made, that Seroquel 50 milligrams in the morning and olanzapine (an antipsychotic medication that the resident was on at the time) had been discontinued with reason unknown. Psychiatric Nurse Practitioner #1 documented they would not recommend any dose reductions of the resident's other psychotropic medications (medications used to treat mental illness) given significant potential for decompensation due to the resident's chronic mental illness. Psychiatric Nurse Practitioner #1 documented that Resident #52 continued to be reclusive in their room as their power wheelchair remained broken and that they reported fluctuation in their tactile, auditory, and visual hallucinations which triggered their anxiety. Recommendations included to increase the Seroquel to 50 milligrams in the morning, 50 milligrams at noon, and 400 milligrams at bedtime and within 10 to 14 days after increasing the Seroquel increase the mirtazapine to 22.5 milligrams at hour of sleep and to follow-up in 4-6 weeks. In a Department of Telepsychiatry progress dated 3/6/24 Psychiatric Nurse Practitioner #1 documented that the recommendations for medication changes made on 2/7/24 had not been implemented. Psychiatric Nurse Practitioner #1 documented Resident #52 continued to report ongoing anxiety, depression, and frustration with the disorganization of their care and the new onset of temporomandibular joint dysfunction (pain and compromised movement of the jaw joint and surrounding muscles). Psychiatrist Nurse Practitioner #1 documented that they had contacted Nurse Practitioner #1 (facility medical team) who had indicated that they had not received the psychiatrist's notes with the recommendations, that they were agreeable to instituting the medication changes as noted and a plan to follow up in four to six weeks. Review of a wound care note dated 3/26/24 revealed that Resident #52 had several wounds of varying sizes and depths in an area measuring 15 centimeters by 10 centimeters on their left lower leg and was reported by the resident that they dig and scratch due to their psychiatric condition. During an interview with Resident #52 on 5/28/24 at 12:19 PM, they stated that they had not seen telepsychiatry since 3/6/24 because the last two appointments on 4/2/24 and 5/17/24 had been missed due to not having the computer access required to meet with Telepsychiatry. Resident #52 stated that since their last appointment they have had two episodes of scratching themselves and that receiving psychotherapy services helped them a lot as they were able to create new coping skills for managing the hallucinations and the pain. When interviewed on 6/4/24 at 9:57 AM, the Corporate Director of Resident Services (acting Social Worker) stated that there had been a discrepancy with telepsychiatry visits as last week the telepsychiatry providers called and cancelled due to the facility not having clinical staff to sit with the residents during their appointments. The Corporate Director of Resident Services stated that the telepsychiatry providers are refusing to see residents without a clinical staff present due to the recommendations not being followed and the facility medical providers reporting that were not made aware of the recommendations. When asked about the repair of Resident #52's power wheelchair, the Corporate Director of Resident Services stated that the facility should have the power wheelchair fixed as it was due to a facility incident that it is inoperable. During an interview on 6/4/24 at 12:40 PM Registered Nurse Manager #3 stated the Social Worker sets up all telepsychiatry appointments and if there are recommendations they should be sent to their mailbox and then they review them, initial them, and make Nurse Practitioner #1 aware. Registered Nurse Manager #3 stated Nurse Practitioner #1 would make any medication changes themselves as they input their own orders into the electronic medical record. During an interview on 6/4/24 at 1:02 PM and on 6/6/24 at 10:25 AM Resident #52 stated they recalled speaking with telepsychiatry about increasing their Seroquel to help with the hallucinations but was not aware that the Seroquel dose had not been increased but that they had not noticed any improvements in the hallucinations either. Resident #52 stated they used to get out of bed more often when they had their power wheelchair and would use it a lot more if they had it. Resident #52 said that they also used to receive psychotherapy (group therapy or talk therapy) but have not received any since last year and has not been offered any since then. Resident #53 said that the facility staff do not keep them informed of medication changes and that what they are taking for depression is not working and does not feel that the facility is meeting their psychiatric needs. When interviewed via telephone on 6/6/24 at 9:35 AM, Nurse Practitioner #1 stated that they do not change psychiatric medications without being told to and that they do not review the telepsychiatry notes and knew nothing about the recommendations for Resident #52 until this week. During an interview on 6/6/24 at 11:11 AM, Nurse Manager #3 stated that Resident #52's care plan is not individualized to meet the residents needs. When interviewed on 6/6/24 at 10:15 AM, the Administrator (with Director of Nursing present) stated that the previous Social Worker had left employment without providing any notice and the regional Social Worker was providing services until a replacement is found. 10 NYCRR 415.12

Based on observations, record review, and interview conducted during the Recertification Survey, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are: On 5/30/24 at 10:00AM, records for inspection and testing of facility carbon monoxide detectors were provided to the surveyor for review. The logs included a monthly signoff and listing of the locations of carbon monoxide detectors in the following areas: boiler room, kitchen, generator, and laundry. Observations on 5/31/24 from 11:10 AM to 11:24 AM included carbon monoxide detectors were not present in the first-floor laundry room and kitchen. Further observations at this time included three natural gas-powered dryers were in the laundry room and a natural gas range was present in the kitchen. During an interview at this time, a laundry employee stated that they did not know if they had carbon monoxide detectors in the laundry room. In another interview at this time in the main kitchen, the Assistant Food Service Director pointed at the wall and stated that there was one (a carbon monoxide detector) but it is not where it should be. The 2015 edition of the International Fire Code (IFC), requires carbon monoxide detection to be provided in an approved location between the fuel burning appliance and the dwelling unit, sleeping unit, or classroom; or on the ceiling of the room containing the fuel-burning appliance. 10NYCRR: 415.29(a)(2), 711.2(a)(1); 42 CFR: 483.70(b), 2015 IFC: Section 915, 915.1, 915.1.4, 915.3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey and Complaint Investigations (NY00327022, NY00323935, NY00343607) it was determined that for five (1st, 2nd, 3rd, 4th, and 5th floors) of five occupied resident-use floors and one of one basement, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, hot water was not maintained above 90 degrees Fahrenheit (°F), floors, walls, and ceilings were dirty and/or in disrepair, bathrooms and shower rooms were dirty and in disrepair, ventilation exhaust units in bathrooms, showers, and soiled utility rooms were not functioning resulting in foul odors, ice machines were dirty, ready stand lifts were dirty, plumbing fixtures were not maintained and/or working properly, there were ceiling plumbing leaks, overhead lights were not functional or functioning properly, light lenses and covers were missing, there were damaged electrical fixtures with exposed wiring, there was a dirty fan, and there was standing water on floors. The findings are: Observations on 5/28/24 at 9:24 AM included a faucet leak in the kitchen two bay sink where the handles were attached and up through the back flow preventer. Observations on 5/28/24 from 9:52 AM to 2:30 PM included the following: 1. There was a black, slimy residue underneath the handwash sink next to the ice machine on the 5th floor near the nurse station. The residue appeared to be coming from a leaking drainpipe under the sink. 2. The lights over the beds in resident rooms [ROOM NUMBERS] were inoperable and the cover was missing from the light fixture in room [ROOM NUMBER]. Additionally, there was a hole in the wall from the doorknob in room [ROOM NUMBER]. 3. There was a strong urine and fecal odor in the 3rd, 4th and 5th floor soiled utility rooms across from the nurse stations. The exhaust ventilation grates in the ceilings of these rooms were observed not drawing air out of the room. Additionally, there was urine, body odor, and a sewage odor throughout the fifth floor and on the elevator. 4. The floor in the shower room near room [ROOM NUMBER] was dirty with hair and dark debris. 5. The bathroom in room [ROOM NUMBER] had a significant fecal odor, the toilet was clogged, and the exhaust ventilation was not functional. 6. There was a Packaged Terminal Air Conditioner (PTAC) unit disassembled on the floor of room [ROOM NUMBER] with the plug missing and exposed wire ends coming from a partially open electrical outlet box. 7. There was a strong urine and fecal odor in room [ROOM NUMBER] (unoccupied) and the bathroom toilet was clogged with yellow and brown material. The exhaust ventilation grate in the bathroom ceiling was observed not drawing air out of the room. 8. The garbage storage room on the 4th floor contained a sink with brown debris in the base and no handles to turn it on. There was also a section of drywall missing in this room that was approximately three feet long by 1.5 feet wide. 9. The sinks in the 3rd and 5th floor garbage storage rooms, near rooms [ROOM NUMBERS], lacked handles and were not functional. 10. The staff bathroom door by the 4th floor dining room was locked with a sign that read: Out of order temporarily. 11. The ice machine dispenser on the counter next to the 4th floor nurse station had a slimy brown, pink, and black residue in the area where the ice ejects. 12. There was a toilet seat in the 4th floor dining room bathroom on the floor next to the toilet. 13. The footrests on ready stand lifts located in the hallway near room [ROOM NUMBER], the 2nd floor therapy room, and in the 2nd floor shower room were dirty with an accumulation of crumbs and other debris. 14. The light lens above the bed in room [ROOM NUMBER] was cracked and damaged, and the exhaust ventilation grate in the ceiling of the bathroom room was observed to not be drawing air out of the room. 15. There was a flower vase in room [ROOM NUMBER] that was filled with a cloudy yellow liquid with dead moldy flowers floating. 16. A Wind Machine brand portable fan located in the hall on an overbed table near the 3rd floor nurse station had a build-up of dust on the cover and fan blades. 17. There was a strong urine and fecal odor in rooms 309, 318, and throughout the corridor from rooms 301 to 308 (3rd floor). 18. The temperature of the water from the shower fixture in the 2nd floor shower room (across from room [ROOM NUMBER]) did not get higher than 74°F, after being run for several minutes. 19. The main fire alarm annunciator panel behind the reception desk in the 1st floor lobby displayed several supervisory trouble signals related to the penthouse exhaust fans for toilets and lounges. 20. The urinal in the 1st floor men's bathroom across from the reception desk would not completely flush. When activated the device would briefly flush and did not push the urine down the drain. 21. One of the three toilets in the basement women's locker room was not functional and one of the two sinks in the room was inoperable. Additionally, one of the two sinks was not functional in the 1st floor women's bathroom near the lobby and the other sink would only dispense cool water. 22. There was approximately four inches of standing water on the floor in the basement boiler room. A sump pump was observed in a pit outside the basement boiler room with an accumulation of water, leaves, and garbage, and the drains in this pit appeared to be clogged. 23. The ceiling lighting in the basement fire pump room, generator room, and boiler room were continuously blinking and flashing brightly. 24. There was standing water on the floor in the basement air handler room with water dripping down from the unit. During an interview on 5/28/24 at 10:22 AM Resident #97 stated that they have not had a shower since early December 2023 and that they receive bed baths with cold water, and were told that the facility does not have hot water. During another interview at 12:41 PM Resident #512 stated that they had not had a shower in a month as staff told them that they were having trouble with the water and that it is cold. Observations on 5/30/24 at 12:08 PM included a floor tile in the 4th floor dining room that was loose, partially broken, and not adhered to the floor. During an interview on 5/31/24 at 4:35 PM Certified Nursing Assistant #1 stated we can usually give resident showers when the water is warm but usually the water is freezing, and that the water has been cold consistently since June of last year. Certified Nursing Assistant #1 also stated that the high side hall on every unit does not have hot water or a full strong stream, and sometimes the water looks green or yellow. Observations on 5/31/24 at 5:11 PM included the hot water temperature in the shower on the 5th floor next to room [ROOM NUMBER] was 73.8°F after running for several minutes, and the water came out at a very low pressure like drips. Observations on 5/31/24 at 10:04 AM included an approximately one foot by four-foot ceiling tile in the 2nd floor corridor outside room [ROOM NUMBER]was brown, stained, and wet from a leak above. During an interview on 5/31/24 at 10:45 AM, the regional maintenance director stated that for maintenance it is just themself, because one of the maintenance staff is out on medical leave and the other one left about two weeks ago. Further record review at 2:52 PM revealed another maintenance technician was hired 5/2/24 and was terminated from employment 5/21/24. Observations on 5/31/24 at 11:12 AM included an electrical connection behind and above the dryers in the first-floor laundry room had green and red wires exposed including the copper wiring ends and wire nuts. During an interview on 5/31/24 at 12:34 PM a resident family member stated that the floors in the room are sticky, dirty, and the facility smells of urine and feces, and that it is not right or humane. During an interview on 5/31/24 at 1:31 PM Resident #97 stated that they denied a bed bath last night because the water was too cold, and they would have taken a shower if the water was warm and if they were offered. Record review of a facility grievance for resident #73 and dated 1/15/24 documented that this resident does not have hot water for when they wash up and that staff wash them with cold water. Observations on 6/2/24 at 5:47 PM included the hot water temperature in the 5th floor shower room near room [ROOM NUMBER] was 75.3°F after running for several minutes, and the water pressure was observed to be just a trickle. Further observations included the toilet in this shower room was filled with paper and stool and the shower room smelled of stool. Review of a nursing progress note dated 6/4/24 at 6:31 AM revealed that Resident #75 had a bed bath and that there had been no hot water on the unit (4th floor). During an interview on 6/4/24 at 10:26 AM Licensed Practical Nurse #1 stated that they knew a couple of times the water went out and that they do not think the water is hot. During an interview on 6/4/24 at 11:23 AM the Regional Director of Maintenance stated that maintenance takes daily water temperatures and records them in a log. Record review of hot water temperature logs revealed multiple temperatures of hot water at points of use in resident rooms were less than 90°F beginning on 5/14/24. During an interview on 6/4/24 at 12:22 PM Certified Nursing Assistant #2 stated that they do not use the showers on the 5th floor because the water is cold and it is very difficult to give residents showers. Certified Nursing Assistant #2 also stated that only the shower on unit two (second floor) had hot water, and they have to get people up and get them downstairs. Certified Nursing Assistant #2 stated that there was a shower list, but they had to go down and check to see if the shower was occupied. On 6/4/24 at 12:41 PM the surveyor thermometer was calibrated using the ice-point method and read 32.1°F. In an interview on 6/5/24 at 2:31 PM The Director of Nursing stated many residents refuse showers as they do not want to go to another floor. The Director of Nursing stated the water pumps are in house and that they are working on someone to get them installed so that the 5th floor can have better water pressure. During an interview on 6/6/24 at 8:51 AM Certified Nursing Assistant #3 stated the water temperatures have been inconsistent for 6 months and the water pressure in the shower room at the end of the hall has been bad for about a month or two. 10NYCRR: 415.29, 415.29(c), 415.29(d), 415.29(g), 415.29(h)(1), 415.29(i)(1,2), 415.29(j)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during a Recertification Survey and Complaint Investigations (NY00337587, NY00324938, NY00321613, NY00323935, NY00317625, NY00328756) for six of six residents reviewed, the facility could not provide evidence that allegations of resident abuse and injuries of unknown origin were thoroughly investigated. Specifically for Resident #22 there was no evidence that an allegation of staff abuse had been investigated. For Residents #44, #68 and #100 there was no evidence that allegations of resident-to-resident abuse had been investigated. For Residents #87 and #371 there was no evidence that the facility investigated injuries of unknown origin. This is evidenced by but not limited to the following: 1. Resident #371 had diagnoses that included a history of falls, adult failure to thrive, and visual hallucinations. The Minimum Data Set Resident assessment dated [DATE] documented the resident was cognitively intact. Review of the Comprehensive Care Plan dated [DATE], revealed Resident #371 had a self-care performance deficit with activities of daily living and was totally dependent on staff for bed mobility, transfers, and toileting. Review of Resident #371's electronic medical record revealed the following: a. On [DATE] Nurse Practitioner #2 documented that the resident had a swallow evaluation due to bilateral neck swelling and demonstrated pharyngeal dysphagia (difficulty swallowing) likely caused by swelling. b. On [DATE] a Nurse Manager documented that the resident was seen by the Physician who said the neck swelling had gotten bigger and that the resident was still complaining of difficulty swallowing with fluids getting stuck. The resident was sent to the emergency department. c. On [DATE], in a hospital progress note, the hospital Physician documented that they evaluated Resident #371 and determined that resident had a laryngeal (voice box) fracture. The Physician documented that laryngeal fractures were most often caused by trauma, but that the patient (Resident #371) had no clear history to account for this. However, fracture during a fall or from non-accidental trauma could not be excluded. d. On [DATE] a Medical Examiner request included that a subpoena had been sent to the facility informing them that Resident #371 had died on [DATE]. The Medical Examiner requested an incident report from the facility that would explain why the resident was transported to the hospital on [DATE]. During an interview on [DATE] at 11:51 AM, the Director of Nursing stated that if a resident had an injury with unknown origin, a Registered Nurse should assess the resident, determine if the resident could state what happened, notify the medical team, the resident's family, and then they would initiate an investigation. The Director of Nursing said they had spoken with the hospital Social Worker who felt Resident #371's injuries were consistent with someone who had been assaulted. The Director of Nursing said they did not attribute the resident's neck swelling to anything that needed to be investigated but that looking back, the Registered Nurse who discovered the swelling to the resident's neck should have initiated an investigation, but they did not think of it at the time. During an interview on [DATE] at 9:53 AM, Nurse Practitioner #2 stated they evaluated Resident #371 and felt it was urgent to send the resident to the hospital because the resident's neck was large, and they were having trouble swallowing. Nurse Practitioner #2 said when an injury of unknown origin occurs, the facility should complete an Incident/Accident report, investigate, and determine a root cause. Nurse Practitioner #2 said that given the hospital provider's notes that trauma could not be excluded, the facility should have started an investigation. During a phone interview on [DATE] at 2:26 PM, a family member said they saw Resident #371 a few days before they were sent to the hospital and that they had had a red mark on the left side of their throat and the following week their neck was swollen. The family member stated that no one from the facility had called them regarding the resident's neck being red and swollen. 2. Resident #22 had diagnoses that included heart failure, hypertension, and chronic obstructive pulmonary disease. The Minimum Data Set Resident assessment dated [DATE] documented the resident was cognitively, able to make themselves understood and able to understand with clear comprehension. An Incident/Accident Report provided by the facility included that a progress note dated [DATE] and written by a nurse documented that physical aggression took place in Resident #22's room. Resident #22 had reported that two Certified Nursing Assistants were rough when providing care, held their arm down and pushed their fingernails into their back. Resident #22 reported that one of the Certified Nursing Assistants pinched their skin and stuck their middle finger out at the resident on their way out of their room. The Incident/Accident Report included that both Certified Nursing Assistants were told to not go back into Resident #22's room for any reason, that the resident was alert and oriented, did not have any injuries and that the investigation was ongoing. The facility was unable to provide any further documentation that the alleged incident had been investigated. During an interview on [DATE] at 2:31 PM, the Director of Nursing stated that they did recall the alleged incident with Resident #22 on [DATE]. The Director of Nursing stated that Resident #22 can be a storyteller but that a lot of the things they say can have some merit. The Director of Nursing stated one of the Certified Nursing Assistants was terminated due to the alleged incident and that they believe a full investigation was completed but the facility could not locate it. 3. Resident # 68 had diagnoses that included weakness, repeated falls, and dementia. The Minimum Data Set Resident assessment dated [DATE], included the resident was severely impaired cognitively. Resident #100 had diagnoses that included dementia, diabetes, and heart disease. The Minimum Data Set Resident assessment dated [DATE], documented the resident was severely impaired cognitively. Review of Resident #68's current Comprehensive Care Plan revealed the resident could display aggression and had impaired cognitive thought process due to their dementia. Review of Resident #100's Comprehensive Care Plan dated [DATE], revealed the resident was aggressive towards others and had impaired cognitive thought processes related to their dementia. Review of an Incident/Accident Report dated [DATE] revealed that Resident #100 sustained a lump on top of their head with a small cut, after being hit in the head with a reaching device by another resident. The Incident and Accident report did not include witness statements, or any additional notes related to the event. Review of the compliant form reported to the Department of Health by the previous Administrator revealed that a resident-to-resident incident involving Resident #100 and Resident #68 had occurred on [DATE]. Upon request, the facility could not provide any evidence that a thorough investigation of the incident had been completed. Additionally, several subsequent incidences were reported to the Department of Health by the facility, and the facility could not provide evidence that any of these incidences had been investigated. During an interview on [DATE] at 10:05 AM, the Corporate Infection Preventionist stated the incident was identified in either February or [DATE] and that the investigations were missing, likely due to changes in facility leadership. In an emailed correspondence dated [DATE] at 11:04 AM, the Corporate Infection Preventionist stated that they could not locate any facility investigations related to these events. 10 NYCRR 415.4(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review conducted during the Recertification Survey and Complaint Investigation (NY00318393), it was determined that for 4 of 10 residents reviewed for medication administration, the facility did not ensure that the residents were free from significant medication errors. Specifically, there was no documented evidence that Resident #37 had received multiple prescribed medications on multiple days, that Resident #42 received the correct dose of narcotic pain medication on several days, that Resident #52 received the correct doses of narcotic pain medication on several days, and that Resident #100 had received the full ordered course of an antibiotic as ordered. This is evidenced by the following: The facility policy Administering Medications, dated April 2019, included that medications are to be administered in accordance with prescribed orders, including any required time frame. The policy noted that the individual administering the medication checks the label three times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication. The facility policy, Adverse Consequences and Medication Errors, dated revised April 2014, defined a medication error as the preparation or administration of drugs or biological which is not in accordance with physician's order, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of a medication error would include but not limited to, an omission (a drug is ordered but not administered) and the wrong dose. 1. Resident #42 had diagnoses that included heart failure, diabetes, and a pressure ulcer. The Minimum Data Set Resident assessment dated [DATE], included that Resident #42 was cognitively intact. The current Physician orders included oxycodone 5 milligrams daily and give 30 minutes before the pressure ulcer dressing change for pain. Review of the Medication Administration Record for 5/14-5/29/24, revealed that oxycodone 5 milligrams had been signed off as administered daily. Review of the Control Substance Record (the list of narcotic medications the nurses remove from the narcotic cabinet per resident) revealed that on 5/16, 5/18, 5/21, 5/22, 5/24, 5/25, 5/26, 5/27, and 5/28 multiple (2 or 3) 5 milligrams oxycodone tablets had been removed for Resident #42 (versus one tablet). In a nursing progress noted dated 5/29/24, Nurse Practitioner #3 documented that more oxycodone may have been administered to Resident #42 than ordered. Review of a Nursing Medication Incident Report dated 5/29/24 signed by the Director of Nursing and a summary dated 5/29/24 signed by the Corporate Infection Preventionist revealed that the Director of Nursing notified the Medical Director and the consulting pharmacist of the error for Resident #42 and Licensed Practical Nurse #5 received immediate reeducation. The Incident Report included a statement from Licensed Practical Nurse #5 that they administered the increased narcotics to Resident #42 as per a previous order (versus the current order). In an interview on 6/6/24 at 9:14 AM, Resident #42 stated they believed they get their pain medication every eight hours but they did not feel it was working and could be stronger. In an interview on 6/6/24 at 11:26 AM Registered Nurse Manager #3 stated nurses should follow the Physician orders when giving medications. 2. Resident #52 had diagnoses that included Ankylosing spondylitis (chronic inflammatory disease of the spine), complex regional pain syndrome of left lower limb, and depression. The Minimum Data Set Resident assessment dated [DATE], included that Resident #52 was cognitively intact. Review of current Physician orders, dated 5/9/24 revealed oxycodone 5 milligrams tablet, give 1.5 tablets (7.5 milligrams) three times daily (scheduled for 6:00 AM, 12:00 PM, and 5:00 PM). The June 2024 Medication Administration Record documented that nursing staff signed off that 7.5 milligrams of oxycodone was administered three times a day to Resident #52 as ordered. Review of the Control Substance Records (narcotic sheets for each resident) revealed the following documentation for Resident #52: a. On 6/2/24 at 6:00 AM and 5:00PM, one 5 milligrams tablet of oxycodone was removed (and no 2.5 milligram tablet) and at 12:00 PM two 5 milligrams oxycodone tablets were removed. There was no documentation of wasting any of the narcotic medication indicating that Resident #52 was undermedicated for two doses and over medicated for one dose per the documentation. b. On 6/3/24 at 6:00 AM, two 5 milligrams tablets of oxycodone were removed. There was no documentation of wasting any of the medication. c. On 6/3/24 at 12:00 PM and 5:00 PM there was no documentation that any oxycodone tablets had been removed from the narcotic cabinet for Resident #52. In an interview on 6/3/24 10:15 AM, Resident #52 stated the facility ran out of 2.5 milligram tablets of their oxycodone, so they only get 5 milligrams sometimes and they told the nurse to do what some of the other nurses do and cut one tablet in half. In an interview on 6/3/24 at 1:45 PM, Registered Nurse Manager #3 stated they were out of 2.5 milligram tablets and that what Licensed Practical Nurse #5 signed off on the narcotic sheet did not match what they signed off as administered on 6/2/24 and 6/3/24, as it appeared that 10 milligrams of oxycodone were removed at 6:00 AM and administered (versus the ordered 7.5 milligrams). In an interview on 6/4/24 at 1:04 PM Licensed Practical Nurse #5 stated Resident #52 ran out of 2.5 milligrams tablets of oxycodone, so they gave two 5 milligram tablets and did not document any waste. In an interview on 6/6/24 at 9:45 AM Nurse Practitioner #1 stated that not receiving the ordered dose or a partial dose of pain medication could cause increase anxiety and increased pain. There was no documented evidence that the Licensed Practical Nurse #5 was suspended pending a thorough investigation related to multiple narcotic medication errors for Residents #42 and #52. 3. Resident #100 had diagnoses that included dementia, hypertension, and diabetes. The Minimum Data Set Resident assessment dated [DATE] revealed Resident #100 was severely impaired cognitively. Review of Physician orders dated 5/18/24 revealed Resident #100 was prescribed ceftriaxone (antibiotic) intramuscularly for three days for pneumonia, with a start date of 5/18/24. Review of the May 2024 Medication Administration Record revealed the first dose of ceftriaxone that was scheduled to be given on 5/18/24 was not documented as administered and was coded at 17 (hold per MD order) and that Resident #100 only received a total of two doses of antibiotic versus the three doses ordered. In a nursing progress note dated 5/18/24 at 9:22 PM Licensed Practical Nurse #4 documented that the ceftriaxone was awaiting pharmacy delivery. There was no documentation that the medical team was notified of the missing dose of antibiotic or that the medical team had ordered to hold the first dose of Resident #100's antibiotic. During an interview on 5/31/24 at 11:04 AM, the Corporate Infection Prevention Nurse said when an antibiotic is ordered, nurses can get a dose out of the Cubex (machine that securely stores and dispenses medications) which usually contains ceftriaxone (in order to give it immediately) or they can call the Pharmacy to get an antibiotic delivered immediately. If unable to get a medication, staff should notify the medical provider. The Corporate Infection Prevention Nurse stated there was no order for the antibiotic to be held and that it appeared as though Resident #100 had not received the full course of antibiotics as ordered and that they would consider that a significant medication error. During a telephone interview on 6/6/24 at 9:41 AM, Nurse Practitioner #1 stated they ordered ceftriaxone for Resident #100 for three days on 5/18/24 and that ceftriaxone should be available from the facility's emergency supply (for that first dose). They said that they had never been notified about the antibiotic being unavailable and should have been. 4. Resident #37 had diagnoses that included dementia, hypertension, and depression. The Minimum Data Set Resident assessment dated [DATE] revealed Resident #37 was moderately impaired cognitively and received antipsychotic and antidepressant medications. Review of the May 2024 Medication Administration Record revealed no documented evidence that Resident #37 had received the following prescribed medications on 5/3/24 and/or 5/12/24: a. atorvastatin (medication for high cholesterol) - 5/3/24 and 5/12/24. b. melatonin (medication for sleep) - 5/3/24 and 5/12/24. c. mirtazapine (medication for depression) - 5/3/24 and 5/12/24. d. trazodone (medication for depression) - 5/3/24 and 5/12/24. e. quetiapine (antipsychotic medication used to treat schizophrenia, bipolar and depression) - 5/3/24 and 5/12/24. f. metoprolol (medication used to treat high blood pressure) - 5/12/24. g. sennosides-docusate (medication used to treat constipation) - 5/12/24. h. acetaminophen (Tylenol) - 5/12/24. Review of nursing progress notes dated 5/3/24 and 5/12/24 did not reveal any documentation that the medications had been administered, that the medications had been unavailable, or that the medical provider had been notified. During an interview on 6/6/24 at 10:55 AM, Registered Nurse Manager #1 said when administering residents' medication, the nurse should make sure that the medications were available, that some medications are in-house stocked medications, and some ordered through a pharmacy and the nurses should order them when they are down to the last column of pills in the blister pack. If unavailable an order would be needed from the medical provider (to hold). Registered Nurse Manager #1 said a blank box on the Medication Administration Record may indicate missing documentation. The nurses scheduled for 5/3/24 and 5/12/24 were not available for interview. In an interview on 6/6/24 at 1:38 PM, Director of Nursing stated there would be no reason for a resident to receive an extra dose of a narcotic beyond what is ordered. The Director of Nursing stated if a medication was not available, nurses should see if it is stocked and available, call the pharmacy or notify the nurse manager or themselves (Director of Nursing) and let the provider know. The Director of Nursing said a blank box on the Medication Administration Record would indicate nothing was done (administered). 10 NYCRR 415.12(m)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the Recertification Survey, the facility did not provide for safe and secure storage of medications and ensure that medications were labeled in accordance with currently accepted professional standards for two (3rd and 4th floor resident units) of two medication rooms and two (3rd and 4th floor) of four medication carts and one clean utility room (3rd floor) reviewed Specifically, medications were observed stored in an unlocked clean utility room, resident specific medications were not labeled, and medication carts contained several unidentified loose pills, and were unclean. This is evidenced by but not limited to the following: The facility policy, Storage of Medications, dated [DATE] documented that drugs and biologicals used in the facility were stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. The nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. During an observation on [DATE] at 1:07 PM, the 3rd floor resident unit clean utility room was unlocked and unsupervised (no staff in view). It contained cleaning supplies and an open cabinet with multiple bottles of over-the-counter medications and topical creams. During an observation and interview on [DATE] at 1:26 PM, the 3rd Floor resident unit medication room contained several bottles of insulin that were open and undated as to when opened or when expired. When interviewed at the time, Licensed Practical Nurse #5 stated any insulin bottle that was not dated should be thrown away. During an observation on [DATE] at 3:49 PM, with the 4th Floor Registered Nurse Manager #1, several opened and expired insulin pens were stored in the medication refrigerator. During an observation on [DATE] at 11:56 AM a 3rd Floor medication cart contained two unlabeled inhalers, multiple loose unidentified pills (medications), spilled red liquid on the bottom of the drawer, and a significant amount of dust and debris. During an observation on [DATE] at approximately 12:00 PM a 4th floor medication cart drawer contained approximately 40 loose unidentified pill medications. When interviewed at the time, Licensed Practical Nurse #6 said the night shift nurse was responsible for organizing the medication room and cleaning the medication carts. During an interview on [DATE] at 3:21 PM and again on [DATE] at 10:13 AM the Director of Nursing said medication cart audits and room audits should be completed weekly and all nurses should manage the cleanliness of these areas on a daily basis. The Director of Nursing said all medications should be kept behind locked doors and/or cabinets. 10 NYCRR 415.18(d)(e) (1-4)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, the facility did not ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; did not ensure all allegations of resident abuse and injuries with unknown origin were thoroughly investigated; did not ensure that residents who required assistance with activities of daily living received the necessary services to maintain good grooming and personal hygiene; did not ensure that each resident received necessary behavioral health care and services; did not ensure all residents were free of significant medication errors; and the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. This is evidenced by the following: Refer to the following citations: F584: Safe/Clean/Comfortable/Homelike Environment F610: Investigate/Prevent/Correct Alleged Violations F677: Activities of Daily Living (ADL) Care Provided for Dependent Residents F740: Behavioral Health Services F760: Residents are Free of Significant Medication Errors F908: Essential Equipment, Safe Operating Condition Review of the Facility Assessment, dated 5/15/24, revealed the facility's average daily census was 120 residents. Information regarding the residents based on facility characteristics included Minimum Data Set Resident Assessment results from 1/20/23. Services and care offered by the facility included, but was not limited to, assistance with activities of daily living, management of medical conditions and medication-related issues causing psychiatric symptoms and behavior, the administration of medications that residents needed, and the prevention of abuse and neglect. The Assessment included the facility resources needed to provide competent support and care daily to its residents included, but were not limited to; Administration (e.g., Administrator, Environmental Services, and Social Services), behavioral, psychiatric, and mental health providers, and support staff (e.g., maintenance and housekeeping staff). The staffing plan to meet the needs for care and support of the residents did not include positions such as social work, maintenance staff, and housekeeping staff. Additionally, the Assessment did not include a process to ensure the adequate supply, appropriate maintenance, or the replacement of physical equipment and other physical plant needs. For five (1st, 2nd, 3rd, 4th, and 5th floors) of five occupied resident-use floors and one of one basement, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, hot water was not maintained above 90 degrees Fahrenheit (°F), floors, walls, and ceilings were dirty and/or in disrepair, bathrooms and shower rooms were dirty and in disrepair, ventilation exhaust in bathrooms, showers, and soiled utility rooms were not functioning resulting in foul odors, ice machines were dirty, ready stand lifts were dirty, plumbing fixtures were not maintained and/or working properly, there were ceiling plumbing leaks, overhead lights were not functional or functioning properly, light lenses and covers were missing, there were damaged electrical fixtures with exposed wiring, there was standing water on floors, and furniture and window blinds were in disrepair and dirty. During an interview on 5/31/24 at 10:45 AM, the Corporate Maintenance Director stated that for maintenance it was just themself, because one of the maintenance staff was out on medical leave and the other one left about two weeks ago. For six residents reviewed for allegations of resident abuse and injuries with unknown origin, the facility could not provide evidence that the allegations were thoroughly investigated. During an interview on 6/3/24 at 10:05 AM, the Corporate Infection Preventionist stated it was identified in either February or March 2024 that investigations were missing, likely due to changes in facility leadership. For three residents reviewed the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene as related to nail care, shaving, bathing, hair washing and hair trimming. Resident #52 did not receive consistent psychiatric services, did not receive medication changes as recommended, and did not have a comprehensive care plan that included an individualized person-centered approach to address their behavioral health needs. During an interview on 6/4/24 at 9:57 AM, the Corporate Director of Resident Services stated that there had been a discrepancy with telepsychiatry visits as the telepsychiatry providers called and cancelled due to the facility not having clinical staff to sit with the residents during their appointments and issues with the providers not being made aware of the telepsychiatry recommendations. For four residents reviewed for medication administration, the facility did not ensure that the residents were free from significant medication errors as they related to omissions of significant medications being administered and incorrect doses of narcotic pain medication being administered. For five of five occupied resident-use floors and one of one basement the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, laundry equipment, hot water boilers, a mechanical dish washing machine, patient care lifts, and ventilation systems were not maintained in working order. Observations on 5/31/24 at 11:12 AM included one of the three commercial dryers and a smaller residential style washing machine in the first-floor laundry room were not functional. During an interview at that time, a laundry staff member stated the middle dryer had not worked in about a year and the smaller residential style washing machine (used for resident personal clothing) had not worked in about three to four weeks. During an interview on 6/4/24 at 11:05 AM, the Corporate Director of Maintenance stated that they were not aware of any issues with the exhaust ventilation in the building. Observations in the presence of the corporate maintenance director at 11:16 AM included two exhaust motors on the roof were not functional. During an interview on 6/6/24 at 10:13 AM, with the Administrator and Director of Nursing, the Administrator stated they were aware of environmental concerns due to turnover and had been working to address the areas of concern and continued to recruit maintenance staff. The Administrator stated they were not aware of concerns related to investigations of alleged abuse and that the facility had a process in place that once an incident was reported the facility completed and documented a thorough investigation. The Director of Nursing stated there had previously been a backlog of investigations, however, the facility was now current in their investigations. The Director of Nursing stated there was an ongoing Quality Assurance and Performance Improvement initiative to ensure that activities of daily living (including nail care, hair care, and showers) were being maintained and documented. The Director of Nursing stated they were aware the facility had concerns related to medication errors. When an error was discovered, each case was investigated and staff were given the opportunity to improve their performance, and if no improvement was achieved, the staff member would be terminated. 10 NYCRR 415.26

**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 that for five (1st, 2nd, 3rd, 4th, and 5th floors) of five resident use floors and one of one basement the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, laundry equipment, hot water boilers, a mechanical dish washing machine, patient care lifts, an oxygen concentrator, and ventilation systems were not maintained in working order. The findings are: Observations during the initial tour of the facility on 5/28/24 from 9:52 AM to 2:30 PM included multiple exhaust vents in the ceilings were not drawing air out of the following rooms, which included, but were not limited to: the 3rd, 4th and 5th floor soiled utility rooms across from the nurse stations, bathroom in room [ROOM NUMBER], and the 2nd floor shower room near 218. There were significant urine and fecal odors noted throughout the facility on all five resident-use floors. Additionally, the main fire alarm annunciator panel behind the reception desk in the 1st floor lobby displayed several supervisory trouble signals related to the penthouse exhaust fans for toilets and lounges. In an interview on 5/28/24 at 9:47 AM resident #42 stated that it was difficult to breathe. It was observed at this time that an oxygen concentrator was running and set at 8-liters and was connected to resident #42 via tubing. The licensed practical nurse read the pulse oximetry of resident #42 at a concentration of 86% and stated that a lot of equipment does not work. The licensed practical nurse then and attached a mask to an oxygen cylinder for the resident and the pulse oximetry of resident #42 was observed to immediately increase to a concentration of 96%. Observations on 5/28/24 at 11:30 AM included two hoyer lifts in the 5th floor shower room (between the dining room and the nurse station) were marked with tags listing broken. There was no documentation to show that the lifts were taken out of service or were being repaired. During an interview on 5/31/24 at 10:45 AM, the regional maintenance director stated that currently two of the three hot water boilers are working and they are waiting on a circulating pump that has been ordered to fix the other one. Further observations included that the basement hot water boilers serve the entire facility. The regional maintenance director also stated that for maintenance it is just themself, because one of the maintenance staff is out on medical leave and the other one left about two weeks ago. Further record review at 2:52 PM revealed another maintenance technician was hired 5/2/24 and was terminated from employment 5/21/24. Observations on 5/31/24 at 11:12 AM included one of the three commercial dryers and a smaller residential style washing machine in the 1st floor laundry room were not functional. During an interview at this time, a laundry staff member stated that the middle dryer has not worked in about a year and the smaller residential style washing machine (used for resident personal clothing) has not worked in about three to four weeks. During an interview on 6/3/24 at 11:40 AM the Director of Dining Services stated that on Sunday 5/26/24 they reported no hot water to the New York State Department of Health. The Director of Dining Services also stated that they (the kitchen) had their own boiler, but something happened on Sunday, and they went to serving meals on paper because their boiler was being shared with the rest of the building and had to be turned down. The Director of Dining Services also stated that their dish machine was not getting hot enough to sanitize the dishes. During an interview on 6/4/24 at 11:05 AM the regional director of maintenance stated that they were not aware of any issues with the exhaust ventilation in the building. Observations in the presence of the regional maintenance director at 11:16 AM included two exhaust motors on the roof were not functional. 10NYCRR: 415.29, 415.29(b), 415.29(f)(3), 415.29(h), 415.29(j)(1), 415.29(k)(9)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the Recertification Survey completed on 2/8/23, it was determined that for one (Resident #109) of one resident reviewed for notification of changes, the facility did not notify the resident's medical team of a change in the resident's physical, mental or psychosocial status. Specifically, Resident #109 was noted to have a skin condition which was not reported to the medical team in a timely manner. This is evidenced by the following. Resident #109 had diagnoses that included Non-Hodgkin's Lymphoma ( a type of blood cancer), anxiety disorder and depression. The Minimum Data Set assessment dated [DATE], documented that Resident #109 was severely impaired cognitively and required extensive assist and total dependance on staff for personal hygiene and bathing respecfully. Review of current physician orders included to check Resident #109's skin for any changes during their shower/bath and to report any changes to the supervisor. During an observation on 2/2/23 at 8:40 a.m., Resident #109 was sitting in bed scratching and rubbing a deep bright red rash on the front of their neck and around their mouth. A white residue was observed in the resident's neck fold. In a family interview at this time, the family member stated that they first noticed this rash when they were there on 1/31/23 and at that time, they reported it to the nurse. The family member reported that on the following day, Resident #109 and a staff member reported to them that they had put some cream and some powder on the rash. During an observation on 2/2/23 at 3:28 p.m., A tube of Barrier Skin Protectant Ointment and Johnson's Baby Powder was on Resident #109's bedside table. During an interview on 2/3/23 at 10:37 a.m., Resident #109 stated that cream and powder had been applied to their neck daily by staff. When asked to describe the cream and powder, the resident pointed to a bottle of Johnson's Baby Powder sitting on their bedside table. In a review at this time of the provider's log (a binder for nurses to communicate issues or concerns to the medical team) which was located at nurse's desk revealed no entry related to the resident's skin rash. During an interview on 2/03/23 at 11:37 a.m., Certified Nurse Assistant CNA#1 stated that they perform skin checks on the resident's shower day and anytime they administer care. CNA #1 stated they document identified skin concerns in the resident's Electronic Medical Record and are expected to report findings to the nurse, which CNA #1 stated they did report the skin rash. During an interview on 2/03/23 at 11:41 a.m., CNA #2 stated that they had been using the barrier protective cream on Resident #109's rash that they use for most of the residents to protect their skin. During an interview on 2/03/23 at 11:47 a.m., LPN #2 stated the CNAs are responsible for reporting skin concerns to the nurse if they find something concerning and from there, the nurse will notify the medical team. LPN #2 stated that Resident #109 likes to lay in bed without the head of bed being elevated and they often spill their drink causing it to drip along their neck. LPN #2 stated that they often have to place a towel around the resident's neck to soak up the moisture. LPN #2 stated that they saw that Resident #109's neck was red but had not realized it had gotten so bad. LPN #2 stated that they had not yet notified the medical team. Review of physician orders revealed that Miconazole Powder (anti-fungal medication) was ordered on 2/3/23 at 3:00 p.m. (after surveyor intervention) to apply to affected areas twice daily for a fungal rash. 10 NY415.3 (f)(2)(ii)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during a Recertification Survey completed on 2/8/23, it was determined that for one (Resident #377) of two residents reviewed for pressure ulcers, the facility did not revise the resident's care plan to reflect the resident's current needs. Specifically, Resident #377's Comprehensive Care Plan (CCP) was not revised to include the presence of multiple wounds, goals and related interventions. This is evidenced by the following: Resident #377 was admitted to the facility on [DATE] with diagnoses of end-stage renal disease (dependent on hemodialysis), diabetes, and heart failure. The Minimum Data Set assessment dated [DATE], documented that Resident #377 was cognitively intact, and did not have any pressure ulcers. Review of the current CCP revealed that Resident #377 had the potential for skin impairment due to decreased mobility and moisture, with related interventions. The CCP did not include that the resident had any current wounds or pressure ulcers with related goals and interventions. Review of Vohra Wound Physicians Progress Notes revealed that Resident #377 was evaluated by wound physician consultant intermittently beginning on 9/28/22 through 12/20/22 with the January and February visits were listed as 'not seen' due to Resident #377 being at dialysis. Resident #377's initial wound evaluation on 9/28/22 noted folliculitis (infection of pocket from which a hair grows) of the left buttock, and a one centimeter (cm) by one cm wound to the left medial buttock. Subsequent evaluations identified a cyst that on the left side of the buttock that was abscessed, and a non-pressure wound 0n the right buttock that required surgical debridement (removal of dead tissue). During an observation on 2/2/23 at 2:14 p.m., Resident #377 was lying in bed on a low air loss mattress. The resident stated at this time that their bottom hurt. During a wound care observation on 2/6/23 at 10:02 a.m., Resident #377 had an open wound to their sacrum (buttocks area) with blanchable redness to the surrounding skin, and a foul-smelling odor (often signs of potential infection). The wound measured approximately three cm deep and tunneled approximately four cm. Wound care was provided by the facility nurse that included cleansing, packing it, and covering the wound with an adhesive dressing. During an interview on 2/8/23 at 12:09 p.m., Licensed Practical Nurse (LPN) #2 stated that they expected that a resident having a pressure ulcer would have it addressed in their CCP. LPN #2 stated that the nurse managers previously were responsible for resident's CCPs but was unsure of who was currently responsible for keeping the CCP updated. During an interview on 2/8/23 at 12:23 p.m., LPN #1/ Unit Manager stated that the Registered Nurses (RNs) were responsible for doing resident CCPs and that they would expect skin wounds to be addressed that would include information about the wound, goals and treatments. LPN #1/Unit Manager stated that a weekly report and a care plan meeting was usually generated for resident CCPs that are due to be reviewed to ensure the information is correct. LPN #1/Unit Manager said they recalled that Resident #377's pressure ulcer (wound) was discussed at a meeting and that it should have been included in their CCP. During an interview on 2/8/23 at 12:51 p.m., the interim Director of Nursing (DON) stated that they had been writing residents' care plans until March 2022, when the task then went to the unit nurse managers but that the responsibility of resident's CCPs had changed frequently due to leadership turnover. The DON stated that based on the Nursing Skin Evaluation dated 12/30/22, Resident #377's wound was a pressure ulcer and should have been care planned for to include goals and interventions such as turning and positioning, a low air loss mattress, a pressure relief cushion, and monitoring the resident's nutrition, pain, and signs or symptoms of infection. 10 NYCRR 415.11(c)(2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during a Recertification Survey and complaint investigation (#NY00299632) completed on 2/8/23, it was determined the facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene. Specifically, one (Resident #116) of four residents reviewed for ADLs did not receive bathing/grooming for their hair and scalp over multiple days. The findings are: The facility policy Activities of Daily Living Support dated March 2018 documented that appropriate care and services will be provided to residents who are unable to carry out ADLs independently, with the consent of the resident and in the accordance of the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). 1. Resident #116 had diagnoses including a stroke and left sided hemiplegia (paralysis on one side of the body). The Minimum Data Set (MDS - a resident assessment tool) dated 6/24/22 documented that the resident was cognitively intact and required assist of one staff member to assist in bathing and that it was very important for them to choose the type of bathing they preferred. During an observation on 2/3/23 at 9:13 AM Resident #116's hair was unwashed and contained white debris in the hair and scalp. During an observation and interview on 2/6/23 at 3:26 PM Resident #116's hair remained unwashed with white debris in the hair and scalp. The resident stated at this time that they have not received a shower for several weeks. The resident stated that their shower day was supposed to be on Sunday (day before) but that they did not receive one. Resident #116 stated that they wanted a shower and it bothered them they have not received one. The resident's comprehensive care plan (CCP) dated 12/15/22 documented that the resident has a self-care performance deficit related to ADLs due to their paralysis, limited range of mobility, musculoskeletal impairment (an impairment to the muscles and skeleton), and a stroke. The CCP documented that the resident was able to communicate effectively with staff. A review of the resident's bedside [NAME] (care plan used by Certified Nurse Aides (CNA) for daily care) dated 2/7/23, revealed in the section titled Bathing that the resident required extensive assist of one staff for bathing or showering. A review of Resident #116's ADL Point of Care report (documentation in the Electronic Medical Record (EMR) of the daily care received) dated 1/8/23 to 2/7/23, revealed no documented evidence that Resident #116 had received a shower or bath during this time frame. A review of the resident's multidisciplinary progress notes dated 1/11/23 to 2/7/23 revealed no documentation that the resident refused bathing or showers. During an interview on 2/6/23 at 3:38 PM CNA #1 stated that they document in the resident's point of care (EMR). CNA #1 stated that if a resident refused a shower, they would attempt to re-approach the resident and inform their nurse. During an interview on 2/6/23 at 3:42 PM Licensed Practical Nurse (LPN) #1 stated that they document any refusals for showers or bathing in the resident's progress notes. They stated that Resident #116 does not refuse showers. During an interview on 2/7/23 at 10:27AM CNA #2 stated that the resident's hair looked greasy and that the resident needed their hair washed. During an interview on 2/7/23 at 10:34 AM the interim Director of Nursing (DON) stated that the resident's hair was soiled and that they needed a shower. The interim DON stated that the resident's shower day is on Sunday, and it should be changed to a day during the week. The DON stated that staffing was better during the week so the resident would be more likely to get their shower. 415.12(a)(3)

Based on interviews and record reviews conducted during the Recertification Survey completed on 2/8/23, it was determined that for three (Resident #29, #71, and #80) of five residents reviewed for unnecessary medications, the facility did not ensure that the Drug Regimen Review (DRR) that was completed by the pharmacist was reviewed by the physician for irregularities/recommendations and action taken if any and/or a rationale if no action taken. Specifically, the pharmacist made recommendations for each of the identified residents during the period of August 2022 through December 2022 and the facility was unable to provide evidence that the recommendations had been addressed by the physician in a timely manner. This is evidenced by the following: The facility policy, Drug Regimen Review (DRR) Monthly Report updated December 2022, revealed that facility supports pharmacy services that includes drug regimen review, defined as the systematic evaluation of drug therapy when a consultant pharmacist reviews the medication regimen of each resident at least monthly. Resident specific drug review recommendations and findings will be documented and acted upon by the facility physician within 14 days of receipt by facility. All recommendations will be provided to the Director of nursing who will ensure timely review and completion by Physician. 1.Resident #71 had diagnoses including Alzheimer's Disease, heart disease, and dysphagia (difficulty swallowing). The current physician orders included that Resident #71 was receiving Seroquel (an antipsychotic medication) at bedtime for depression and Zoloft (an antidepressant medication) every morning for depression. Review of Resident #71's DRRs completed by the pharmacist revealed the following: a. DRR dated 8/18/22, included Gradual Dose Reduction (GDR) Review- recommended that Resident #71 had 2 psychotropic (drugs that affect a person's mental state) medications for at least 3-12 months that are potentially due for a GDR based on Centers for Medicare and Medicaid Services (CMS) guidelines. b. DRR dated 12/21/22, revealed that the pharmacist recommended a Risk -Benefit Assessment since the resident remained on the Seroquel. There was no documented evidence that either recommendation had been addressed by the physician until after surveyor intervention. 2.Resident #14 had diagnoses including paranoid schizophrenia, diabetes, and post traumatic stress disorder (PTSD). Review of Resident #14's DRRs revealed the following: a. DRR dated 8/11/22, included a recommendation had been made to discontinue the Ativan (anti-anxiety) medication ordered to give PRN (as needed) or to write a standing order if still clinically indicated. b. DRR dated 10/5/22, included a recommendation to discontinue a duplicate order for the PRN Ativan of which there were two orders. c. DRR dated 11/2/22, indicated the resident had four psychotropic medication orders (Lexapro (antidepressant), Ativan, Seroquel, and Trazadone (antidepressant) for at least 3-12 months that were potentially due for a GDR based on CMS guidelines. d. Two DRRs dated 12/7/22 included a recommendation that Resident #14 had two psychotropic medication orders that lacked an FDA (Food and Drug Administration) labeled indication. The recommendation also indicated to continue the diagnosis of depression for Trazadone. A second DRR included to consider ordering lab work consisting of a lipid panel, Vitamin D level and Hemoglobin A1c (blood sugar level). There was no documented evidence that either recommendation had been addressed by medical until after surveyor intervention. 3.Resident #80 had diagnoses including vascular dementia, depression, and heart disease. The current physician orders included that the resident was taking Celexa (anti-depression medication) twice daily for depression and Seroquel every morning for depression. Review of Resident #80s DRR completed by the pharmacis revealed the following: a. The DRR dated 10/10/22, included a recommendation that due to Resident #80 being on Seroquel, the resident was in need of a vision consult related to potential risk for cataract formation due to the use of this medication. The vision consult was not completed until 1/14/23 and it was documented that the resident did have the formation of moderate cataracts. b. The DRR dated 12/13/22 revealed that the resident had two psychotic medications ordered, Seroquel and Celexa for at least 3-12 months that are now potentially due for a Gradual Dose Reduction (GDR) based on CMS guidelines. There was no documented evidence that either recommendation had been addressed by medical until after surveyor intervention. When interviewed on 2/08/23 at 11:53 a.m., the Corporate Registered Nurse (RN) stated that the former Director of Nursing had quit and the facility staff were unable to locate the pharmacy reviews documentation. The Corporate RN stated that they had contacted the Consultant Pharmacist and the consultant had not received documentation that the provider had responded to the recommendations. 10 NYCRR 415.18(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Recertification Survey and complaint investigation (# NY00272244) it was determined for 1 (# 302) of 2 residents reviewed for hospitalization, the facility did not notify the legal representative of a change in condition or transfer to the hospital. This is evidenced by the following: The facility policy Transfer and Discharge from the Facility, dated June 2019 included the resident and representative will receive timely notification of any discharge from the facility and in an emergency as soon as practicable. Resident #302 was admitted [DATE] with diagnoses of bacteremia (infection of the bloodstream), methicillin resistant staphylococcus aureus infection, and alcoholic cirrhosis of the liver. The resident was discharged to the hospital on 2/26/21. Review of the interdisciplinary progress notes dated 2/26/21 are as follows: a. At 3:00 a.m. Resident #302 had a large amount of epistaxis (nosebleed) and the supervisor was made aware. b. At 11:07 a.m. the resident was again attended at bedside for the nosebleed and blood work was ordered. c. At 12:01 p.m. the medical interim progress note included that the resident was placed on 15 liters of oxygen via nasal canula and had an oxygen saturation level of 82 % (normal being 95-100%). The note included that the facility was unable to administer intravenous fluids and orders given to transfer the resident by emergency medical services to acute care for further clinical management. d. At 12:06 p.m., the resident had a large amount of coffee ground emesis (vomit), a low blood pressure and further decreased oxygen saturation level and was sent to hospital for evaluation of a possible gastrointestinal bleed. When interviewed on 4/23/21 at 10:00 a.m. the Social Worker said he could not find any documentation that the family was notified of the transfer to the hospital. When interviewed on 4/23/21 at 12:51 p.m., the Director of Nursing said it does not appear the family was notified of changes or transfer. [10 NYCRR 415.3(c)(2)(ii)(a)]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during a Recertification Survey it was determined that for one (Resident #37) of two residents reviewed the facility did not investigate injuries of unknown origin in order to rule out abuse, mistreatment, or neglect. The issue involved the lack of an investigation for multiple bruises. This was evidenced by the following: Review of the facility policy titled Abuse (alleged) Reporting, dated 6/27/04, included an injury is classified as unknown when the source of the injury was not observed by any person or the source of the injury cannot be explained and the injury is suspicious because of the extent of the injury. Resident # 37 was admitted to the facility on [DATE] with diagnoses that included bipolar disease, intellectual disability, and drug induced dyskinesia (involuntary erratic movements). The Minimum Data Set Assessment, dated 1/24/21, revealed the resident was sometimes understood by others and had severely impaired cognition. Current physician orders included skin observations weekly on Saturday day shift. The current Comprehensive Care Plan (CCP) identified that Resident #37 required the assistance of two staff for transfers, one staff for bed mobility and was at risk for falls. The CCP identified that the resident had a history of a skin rash and interventions included to monitor the skin. Review of Incident/Accident (I/A) reports for January 2021 through April 2021 revealed that on 3/31/21 the resident was found on the floor with no injuries noted and no other incidents regarding injuries of unknown origin. Review of Nursing Progress Notes from 3/1/21 through 4/21/21 revealed no documentation that Resident #37 had any bruises. During an observation on 4/19/21 at 9:23 a.m., Resident #37 was noted to have a dark purple bruise on the top of the right hand, multiple purple fading bruises on the underside of left forearm and left bicep, and multiple purple bruising of the right forearm. During an observation and interview on 4/21/21 at 2:30 p.m. the Licensed Practical Nurse (LPN), when reviewing the resident's bruises with the surveyor, stated she was unaware of them or how they were obtained. The LPN then reviewed the resident's medical record and stated there was no documentation of the bruises and no I/A report initiated. The LPN stated she would initiate the I/A report and have an RN assess the resident. During an interview on 4/23/21 at 2:04 p.m. The Registered Nurse Manager (RNM) stated weekly skin checks are completed on the resident's shower day and if the Certified Nursing Assistant (CNA) found a bruise it should be reported to the nurse, a Registered Nurse would complete an assessment of the skin injuries, and an I/A report initiated for any injury of unknown origin unless it was known how it happened. The RNM stated a CNA had reported the bruises to her on 4/21/21 (after surveyor intervention) and apparently more were since discovered, however, she had not documented the bruises or completed the I/A report. [10 NYCRR 415.4(b)(3)]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for 2 (Residents # 41 and #74) of 25 residents reviewed , the facility did not develop and implement a Comprehensive Care Plan (CCP) that included measurable objectives to meet the resident's medical, nursing and psychosocial needs that include the resident's goals, desired outcomes and preferences to attain or maintain the resident's highest practicable well-being. Specifically, there was a lack of care planning to address the use of an anti-depressive medication and an anti-coagulant medication for Resident #41 and lack of care planning to address the use of an anti-psychotic medication for Resident #74. This is evidenced by the following: 1.Resident #41 had diagnoses that included atrial fibrillation (irregular heart rate), anxiety, and repeated falls. The Minimum Data Set (MDS) Assessment, dated 2/18/21, revealed the resident had moderately impaired cognition and received antidepressants and anticoagulants. Review of the current physician orders included sertraline (anti-depressant) 25 milligrams (mg) daily for anxiety, buspirone (anti-anxiety) 10 mg every 12 hours and warfarin 0.5 mg (anti-coagulant medication with potential for serious side effects) every other day for prevention of blood clots. Review of the current CCP and the bedside [NAME] (care plan used by the Certified Nursing Assistants: CNAs) included that the resident had a mood problem, a need for staff to monitor behaviors, and that the resident had no symptoms of anxiety or sadness. Neither care plan included any interventions related to the behaviors, the use of anti-depressive medications or the use of anti-coagulant medications. During an observation and interview on 4/19/21 at 2:37 p.m. the resident was observed in the hall with a worried look on their face speaking nonsensically about someone wanting to kill them, about being buried today and that they were worried they would be overheard. During an observation on 4/20/21 at 2:21 p.m. the resident was sitting in the hall in a wheelchair, crying and repeating that they were scared and needed help. Staff were passing by and occasionally reassuring the resident that they were okay. When interviewed on 4/21/21 at 11:10 a.m. the Registered Nurse Manager stated she was responsible for developing the CCP and that behaviors should be addressed as well as the use of psychotropic (such as anti-depressive) medications and anti-coagulants but that she had not addressed Resident #41's use of psychotropic medications or anti-coagulant medications on the CCP. 2. Resident # 74 had diagnoses that included dementia, diabetes, and recent falls (2/25/21 and 4/7/21). The MDS Assessment, dated 3/15/21, revealed the resident had severely impaired cognition and received an antipsychotic medication. Review of the current physician orders include Risperidone (antipsychotic) 0.5 mg at bedtime for dementia related behaviors. The bedside [NAME] included to monitor behaviors and provide assistance transferring when unsteady. The current CCP did not include any goals, outcomes or monitoring of the antipsychotic medication or regarding the recent falls. During an observation of care on 4/21/21 at 10:05 a.m., two CNA's ambulated Resident #74 (wearing no clothes) to the bathroom for care. Resident #74 refused to sit down, refused dental care, and required much encouragement to complete care. In an interview on 4/23/21 at 11:22 a.m., the Director of Nursing (DON) stated Social Work (SW) monitors psychotropic medications. In an interview on 4/23/21 at 1:32 p.m., the Licensed Practical Nurse (LPN) stated that the clinical coordinators or Nurse Managers add the psychotropic medication piece to the care plans. In an interview on 4/23/21 at 1:38 p.m. a Registered Nurse (RN) Manager from another unit stated that the psychotropic medications should be added to the CCP by an RN. The Nurse Manger for Resident #74's unit is an LPN and I do not know what the LPN Managers do. Neither the LPN Manager or the SW were available for interview. [10NYCRR 483.21(b)]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the Recertification Survey and complaint investigations (#NY00272865, #NY00260255, #NY00260976, #NY00264416, #NY00271424, #NY00268463, #NY00268822, #NY00272312) it was determined that for two of nine residents reviewed the facility did not provide the residents who were unable to carry out activities of daily living (ADLs) the necessary services to maintain grooming, personal care and oral hygiene. Specifically, Resident #26 lacked shaving and mouth and nail care and Resident #58 lacked hair care. This is evidenced by the following: The facility policy ADL Care Guidelines, dated March 2020, included that caregivers will review resident nursing care instructions at the beginning of each shift to assure that care is given according to the individual's plan of care. The resident will be encouraged to make choices during their care. Resident refusals will be followed-up with a second attempt or offer to provide services and continued refusals will be reported to the licensed nurse and documented in the electronic medical record. The resident's hair will be combed neatly. 1.Resident #26 had diagnoses including Parkinson disease, dementia without behavioral disturbance, and adult failure to thrive. The Minimum Data Set (MDS) Assessment, dated 1/21/21, revealed the resident had moderately impaired cognition and required the assistance of one staff member for personal hygiene and transfers. The current Bedside [NAME] (directs daily cares) and the Comprehensive Care Plan (CCP) included that the resident was dependent on staff for personal care. Review of interdisciplinary progress notes, from 2/1/21 to 4/22/21, did not include any documentation that the resident refused care. Observations made on 4/20/21 at 2:54 p.m., 4/21/21 at 9:42 a.m., and again at 1:06 p.m., revealed the resident was lying in bed, had long facial hair that was stained with a yellow substance and long fingernails with dark debris under all the nails. During an observation of morning care on 4/21/21 at 10:03 a.m., the resident's bed was saturated with a strong smell of urine, a foul odor coming from their mouth and continued with long dirty fingernails. When interviewed on 4/21/21 at 10:27 a.m., the Certified Nursing Assistant (CNA) stated that they should be offering Resident #26 mouth care, nail care and assist with shaving but cannot always do so because of inadequate staffing. When interviewed on 2/22/21 at 2:36 p.m., the Licensed Practical Nurse (LPN) Manager stated that the expectation is that when staff preform morning care for the resident, they should shave the resident and offer mouth care. 2.Resident #58 had diagnoses including dementia without behavioral disturbance, osteoarthritis, and polyneuropathy. The MDS Assessment, dated 2/27/21, revealed the resident was cognitively intact, had no behavioral symptoms, and required the extensive assistance of one person for personal hygiene. Review of the CCP revealed the resident is alert and oriented, able to make their own decisions and should be involved in all aspects of their care. The CCP and the Bedside [NAME] included that the Resident #58 needs assistance with ADLs but does not specify the level of assistance the resident requires. Neither the CCP or the [NAME] included a history of Resident #58 refusing care. During observation and interview on 4/19/21 at 12:53 p.m., Resident #58's hair was disheveled and uncombed. The resident stated that most of the time staff will not comb their hair except for a few aides. During an observation and interview on 4/22/21 at 2:09 p.m., Resident #58's hair was again uncombed and flattened in the back. The resident stated that they are left-handed, had bad arthritis, and cannot comb their hair by themself. They have not had their hair combed in about two weeks and was concerned that after a while their hair would get tangled and matted. The resident stated that while they did receive morning care, they felt that the facility very seldom had enough staff to care for the residents completely. They stated the aides that do provide care are in such a hurry, they come in to clean you up and do not have time to do anything else. When interviewed on 4/22/21 at 2:54 p.m., LPN #1 stated that the resident's willingness to accept care is dependent on their mood. She stated that she offered to comb the resident's hair this past weekend, but they refused at that time. She said often staff will offer care, but the resident may not want to do it at that moment and sometimes staffing will not allow them to go back and offer again. When interviewed on 4/23/21 at 1:24 p.m., the Director of Nursing stated that she would expect staff to go back and assist a resident with care later if the resident did not want it done at that time. She stated her expectation is that the resident's care is done. [10 NYCRR 415.12(a)(3)]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review conducted during a Recertification Survey it was determined that for three (Residents #32, #37 and #41) of four residents reviewed, the facility did not provide an ongoing activity program based on the comprehensive assessment and resident care plans to meet the interest of and support the physical, mental and psychosocial well-being of each resident. Specifically, residents were not consistently provided with activities of their choice. This is evidenced by the following: The facility policy titled Responsibilities of Recreation Staff, dated December 2016, included the recreation staff will provide a variety of programs based on the resident's functioning levels that will meet their individual needs and will participate with the interdisciplinary team to establish goals and approaches for group activities or individual activities suited to the resident's functioning level. The facility policy titled Activity Calendar included calendars should be completed by the months end for the upcoming month and posted in the resident's rooms and any common area. During observations on resident care units from 4/19/21 through 4/23/21 revealed there were no activity calendars posted in Residents #32, #37 or #41's rooms or the common areas on the fifth floor where the residents resided. 1.Resident #37 had diagnoses that included bipolar disease, intellectual disability, and drug induced dyskinesia (involuntary erratic movements). The Minimum Data Set (MDS) Assessment, dated 11/5/20, revealed the resident was severely cognitively impaired and it was very important for the resident to do the resident's favorite things. The activity assessment, dated 10/30/20, documented that the resident enjoyed coloring, drawing, crafts, stuffed animals, religious services, and that the resident wished to participate in activities. The current [NAME] (care plan used by the Certified Nursing Assistants or CNAs) included that the resident's activity preferences were religious activities and to provide activity programs that interest and accommodated their needs. The current comprehensive care plan (CCP) included that Resident #37 was at risk for alteration in psychosocial well- being including loneliness, anxiety, and sadness. In an observation on 4/20/21 at 8:21 a.m. Resident #37 was sitting up in a wheelchair in the common area talking on a toy phone. There were no other observations of Residents #37 involved in any activity from 4/19 through 4/22/21. 2.Resident #32 had diagnoses that included multiple sclerosis, bipolar disease and spastic diplegia (form of paralysis). The MDS Assessment, dated 11/2/20, reveled the resident was cognitively intact and that it was very important to the resident to have books, magazines, or newspapers and to listen to music. The CCP included the that Resident #32 will occupy time with activities of choosing such as watching television, computer games, and1:1 visit. During an observation and interview on 4/20/21 at 9:02 a.m., Resident #32 was in their room which was dark, and the curtains closed. The resident stated at this time that no one at the facility ever mentioned any activities. The resident stated they do not have access to a computer and generally played games on a cell phone or just watched TV all day. At 2:30 p.m. the resident was again observed in bed, the room was dark, and the television was on. In an observation on 4/21/21 at 8:36 a.m. Resident #32 was in bed playing a game on their phone. 3.Resident #41 had diagnoses including diabetes, respiratory failure and is legally blind. The MDS Assessment, dated 2/18/21, revealed that the resident had moderately impaired cognition and had activity preferences that included it was very important to them to have books, newspapers, or magazines, listen to music, be around people and attend religious services. During observations on 4/20/21 at 2:20 p.m. Resident #41 was sitting in the common area with two other residents asking if there was anything to do, started crying and repeatedly stating they were scared and asking for help. Staff walking by told the resident they were ok but otherwise did not intervene. Resident #41 was not observed in any activities from 4/19/21 through 4/22/21. During an interview on 4/21/21 at 1:07 p.m., the interim Activity Manager stated the activity assessments and development of the care plans were completed by the Activity Manager. When asked about Resident #37, the Activity Manager stated that they were taken outside once last month and remembered going to a religious service once but could not remember when or provide any dates. The Activity Manager said that one activity a month does not meet their needs. When asked about Resident #32 the Activity Manager stated that the resident does not come to activities, likes to play on the computer but does not know what games they like. She said she was not aware that Resident #32 did not have access to a computer or what computer games they preferred. When questioned about Resident #41 the Activity Manager said that a television was brought to the unit common area the prior week to watch soap operas but did not know if Resident #41 liked soap operas and was unaware what kind of movies Resident #41 preferred. The Activity Manager stated documentation of a resident's refusal for activities should be documented but that this has not been done. She said activities staff try to meet with as many residents as possible but was unable to provide any activity history for Residents #32, #37 or #41 for the past month. [10 NYCRR 415.5 (f)(1)]

**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 2 of 2 residents reviewed, the facility did not ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, Resident #10 was not receiving oxygen according to the physician order and the oxygen tubing was dirty and unlabeled. Resident #43 was not receiving oxygen according to the physician order, there was missing documentation for oxygen administration, and oxygen tubing had not been changed. This is evidenced by the following: The facility policy, Oxygen Concentrators, dated March 2020, included that upon determination that a resident requires oxygen therapy, the medical provider will enter an order for the administration of oxygen in the resident's medical record. Nursing is to enter an order in the resident electronic Treatment Administration Record (TAR) for the maintenance of equipment and supplies. Oxygen tubing, masks, cannulas, and humidifiers are to be changed weekly and tubing dated and initialed. Nursing staff will monitor the administration of oxygen and document proper administration per medical and nursing orders on the resident's TAR every shift. 1.Resident #43 had diagnoses including respiratory failure, chronic obstructive pulmonary disease, and asthma. The Minimum Data Set Assessment, dated 2/20/21, revealed the resident was cognitively intact and was receiving oxygen. Physician orders, dated 6/3/2020, included to administer oxygen at 3 liters (L) per minute continuous every shift and to change oxygen tubing, cannula, or mask weekly on every Wednesday night shift. Review of the current Comprehensive Care Plan (CCP) and Bedside [NAME] (directs daily care) revealed the resident was to receive oxygen via nasal cannula at 3L continually with humidification. When observed on 4/20/21 at 11:38 a.m., Resident #43 was wearing oxygen via nasal cannula at 2L and the oxygen tubing was dated 4/1/21. When observed on 4/21/21 at 11:42 a.m. and again on 4/22/21 at 10:57 a.m., the resident was wearing oxygen at 1.5 L and the oxygen tubing continued with a label dated 4/1/21. Review of the April 2021 TAR revealed the order to change oxygen tubing, cannula, and mask weekly on every Wednesday night shift was signed as being completed on 4/7/21 and 4/21/21 and was not documented as completed on 4/14/21. The order to administer oxygen at 3L per minute continuous every shift was missing documentation on 19 of 63 opportunities. During an interview on 4/21/21 at 11:42 a.m., and again on 4/22/21 at 11:03 a.m., Resident #43 stated that they should be on 2L of oxygen and while they were not feeling short of breath now, they do have trouble breathing at times. The resident stated the tubing had not been changed in a while. Resident #43 later stated they were feeling short of breath and did not feel they were getting good air flow through the nasal cannula. The resident stated they had previously been on 3L of oxygen, but it was decreased to 2L about 3 months ago. The resident did not know why the oxygen was currently set at 1.5L and said that was probably why they were huffing. During an interview on 4/22/21 at 11:15 a.m., the LPN stated the resident was supposed to be on 2L, but that the resident had manipulated the oxygen themselves in the past. When observed at that time, LPN #1 stated the oxygen was set at 1.5L and the tubing was labeled 4/1/21. She said the facility policy was for the tubing to be changed weekly. When interviewed on 4/22/21 at 11:27 a.m., the LPN Manager stated that oxygen tubing should have been changed weekly. After reviewing Resident #43's orders, the LPN Manager stated the resident was supposed to be on 3L of oxygen continuous. She would expect that nurses are checking the liter flow every shift and the TAR should be signed when this is completed. She stated that if the TAR was not signed, then the oxygen administration was not checked by the nurse at that time. 2.Resident #10 had diagnoses including asthma with oxygen use and pulmonary embolism (blood clot). The MDS Assessment, dated 2/8/21, revealed the resident was cognitively intact. Review of the current CCP and Bedside [NAME] included to provide oxygen per physician orders. Review of physician orders, dated 8/27/20, included to administer oxygen at 2L per minute via nasal cannula continuous every shift. Review of the April 2021 TAR did not include orders to change the oxygen tubing. During an observation on 4/19/21 at 1:16 p.m., Resident #10 was in bed wearing oxygen set at 2.5L per via nasal cannula. The oxygen tubing was not labeled and was noted to have brown-colored debris inside the tubing and dry white substance on the concentrator below the humidifier bottle. During an interview and observation on 4/21/21 at 8:39 a.m., Resident #10 stated that the oxygen tubing had not been changed in four months, and that they were independently adding tap water to the humidifier bottle. The oxygen tubing and concentrator remained dirty and the tubing unlabeled. During an interview on 4/21/21 at 8:39 a.m., the LPN stated when a resident is on oxygen, the order is verified, and the tubing is labeled. She said it is the responsibility of the night nurse to change the oxygen tubing. During an interview on 4/21/21 at 9:08 a.m., the LPN Manager said the expectation is that staff will change and label the oxygen tubing weekly. During an interview on 4/21/21 at 12:00 p.m., and again on 4/23/21, the Director of Nursing (DON) said the expectation is that staff will change and label the oxygen tubing weekly should sign it off on the TAR when it is completed. The DON said that the facility was not aware there was a problem with oxygen management. [10 NYCRR 415.12(k)(6)]

Based on interviews and record review conducted during the Recertification Survey, it was determined that for one (Resident # 10) of five residents reviewed, the facility did not ensure that pharmacy recommendations were addressed or acted upon in a timely manner. Specifically, Resident #10 pharmacy recommendations related to a gradual dose reduction (GDR) of a psychotropic medication and irregularities noted by the pharmacist were not addressed. This is evidenced by the following: The facility policy, Psychotropic Medication Monitoring, dated March 2020, revealed that the Medication Regimen Review (MRR) findings will reflect information to assist the medical provider in ordering the most effective medication regimen for the resident. The Nurse Manager or designee will complete the review in the resident's electronic medical record. Upon completion of the evaluation, the nurse manager or designee will forward any findings indicating that a dose reduction is in order to the resident's medical provider. A gradual dose reduction of the reviewed medication will be attempted at regular intervals under the direction of the medical provider (s) unless determined by the provider to be contraindicated. All psychotropic medications will be reviewed monthly at the Psychotropic Drug meeting, with pharmacy present. 1.Resident #10 had diagnoses including major depressive disorder and behavior and emotional disorders. The Minimum Data Set Assessment, dated 2/2/21, included that the resident was cognitively intact, had no signs or symptoms of depression at the time and no behaviors. Physician orders, dated 8/28/20, included Abilify (antipsychotic medication) 2 milligrams (mg) daily for mental health issues. Review of the MRRs, dated 10/28/20 and 11/28/20, revealed that the resident was on Abilify daily, was due for consideration of a GDR and to please evaluate if this resident is a candidate to consider a reduction in the dose or frequency of the Abilify. A third MRR, dated 4/6/21, included that the resident remained on Abilify 2 mg daily, and no GDR had been attempted for the medication. A medical progress note, dated 4/9/21, revealed that the resident was taking Xanax for anxiety frequently and that the increased anxiety might be contributory to side effects of Abilify. Review of Resident # 10's medical record did not reveal any documented response to the recommendations or change in dosage. When interviewed on 4/22/21 at 11:30 a.m., the Nurse Practitioner stated that she did not receive the pharmacy recommendations from the facility, therefore was unable to address the recommendations. When interviewed on 4/23/21 at 9:24a.m., the Director of Nursing stated that the expectation is that the MMRs are to be reviewed monthly by the provider but that has not been done. When interviewed on 4/23/21 at 10:33 a.m., the consultant Pharmacist stated he knows there is an issue with the recommendations not being addressed and that the facility is implementing a new process to address the issue. [10 NYCRR 415.18(c)(2)]

Based on observation and interview conducted during the Recertification Survey, it was determined that for one of one main lobby, the facility did not provide a safe environment for residents, staff, and the public. Specifically, a heating surface exceeded 125 degrees (°) Fahrenheit (F) and was not protected from accidental contact. The findings are: The 2010 edition of the Facility Guidelines Institute (Guidelines for Design and Construction of Healthcare Facilities) requires heating units to have a maximum surface temperature of 125° F or (52°Celsius) or shall be protected from occupant contact. Observations and interview on 4/20/2021 at 12:55 p.m. revealed an electric decorative fireplace located in the main lobby. Further observations revealed the fireplace was equipped with two recessed functional buttons labeled heater and flame, and both were on. When the surface of the upper metal edge was measured using a digital thermometer, the surface temperature was 160° F. There was no barrier in place to prevent accidental contact of the hot surface. When interviewed at this time, a staff member stated that the receptionist usually turns the fireplace on, and that they were not aware that it got that hot. The Director of Building Services then turned the fireplace off. 10NYCRR: 415.29(a), 2010 FGI: 4.1-8.2.6.3(2)

Based on observations, interviews and record reviews conducted during the Recertification Survey, completed on 4/23/21, the facility failed to maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of COVID-19 for 1 (5th floor resident care unit) of 4 units reviewed. Specifically, staff were not wearing required Personal Protective Equipment (PPE) while providing care to residents on transmission-based precautions (TBP). This is evidenced by but not limited to the following: The NYSDOH Health Advisory titled COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities dated 3/13/20 with a revised date of 7/10/20, included that if there are confirmed cases of COVID-19 in a NH, all residents on affected units should be placed on TBP or Droplet (respiratory protection with masks and face shields) and Contact Precautions (gown and gloves for hands on care), regardless of presence of symptoms and regardless of COVID-19 status. The Centers for Disease Control and Prevention (CDC) guidance titled Transmission-Based Precautions (undated), provides: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal Protective Equipment (PPE) upon room entry and properly discarding before exiting the patient room is done to contain pathogens. The Facility Policy Facility Covid-19 Testing-Residents, dated April 2020, included that if any resident may have had an exposure with a positive resident or staff member, the resident will be placed on contact and droplet precautions and be monitored for 14-days. Observations during a unit tour of the 5th floor on 4/22/21 at 9:10 a.m. included resident rooms with new admissions (rooms #501-#509) were on 14-day quarantine with droplet and contact precaution signage on their doors. The remainder of the residents were not on precautions as evidenced by no signage on their doors. 1.Resident #504 admitted to the facility from the hospital on 4/16/21 with acute kidney failure. Admitting orders included droplet and contact precautions every shift for 14 days per policy. During an observation and interview on 4/19/21 at 12:51p.m., a sign indicating contact and droplet precautions required for Resident #504 was posted at the entry to the resident's room. The sign included that full PPE (includes face mask, face shield, gown and gloves to be donned (put on) before entering the room and doffed (remove) upon exiting. A staff member was observed entering the resident's room with a meal tray wearing only a facemask. The staff member set up the resident's tray and proceeded to transfer the resident from the bed to the wheelchair without wearing a gown or gloves and without performing hand hygiene. During an immediate interview the staff member, who identified themselves as the Director of Rehabilitation, stated she only entered the room to serve the resident their meal tray. She said a resident who is on precautions is identified by the sign outside of the room and pointed to it and verified that it included full PPE was required to enter the room and for contact with the resident which she should have done. 2.Resident #503 was admitted to the facility from the hospital on 4/15/21. Admitting orders included contact and droplet precautions every shift for 14 days per protocol. During an observation and interview on 4/19/21 at 2:19 p.m., there was no signage at the entry to Resident #503's room to indicate PPE was required for entry. The Physical Therapist (PT) was observed in the resident's room wearing only a mask. The PT stated at this time that usually there is a sign on the door to indicate precautions but there was not one there. 3. Resident #85 had diagnoses including end stage renal disease, Alzheimer's disease, and depression. In an observation on 4/22/21 at 10:49 a.m., Resident #85's room (#526) had no TBP signage prior to entering the resident's room and there was no PPE supply bin outside of room. The PT was walking (with hands on assist) Resident #85 into the bathroom and was wearing a face mask, face shield and gloves but no gown. Both Resident #85 and the PT went into the resident's bathroom for care and closed the door. In an interview on 4/21/21 at 8:49 a.m. and at 9:11 a.m., the facility's Infection Preventionist (IP) stated that only the new admissions/readmissions (rooms #501-#509) on the 5th floor were placed on 14-day quarantine which included droplet and contact precautions and the rest of the residents on the 5th floor were not on quarantine. She stated that all the 5th floor residents had been exposed to a positive COVID-19 staff member (test results on 4/19/21) but because all the residents tested negative on 4/20/21 they were not placed on TBP. She stated the staff member worked in the facility on the 5th floor from 4/17/21 to 4/19/21. The IP said that her expectations for new admissions is that prior to admission the TBP signs should be posted on the doors and PPE supply bins should be placed outside of each room prior to admission. [10 NYCRR 415.19 (b)(1)]