**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure that a resident was cared for in a manner that maintained or enhanced dignity. This was evident for 1 (Resident #427) of 4 residents reviewed for Catheter out of 36 total sampled residents. Specifically, Resident #427's suprapubic catheter drainage bag and tubing were not covered with a privacy bag.The findings include:The facility policy titled Residents Right to Privacy and Dignity that was last reviewed on 01/2025 documented that residents are treated in a dignified manner and their privacy rights are upheld as outlined in the resident bill of rights.The facility's policy titled Close Urinary system that was last reviewed on 02/2025 documented that drainage bag cover should be utilized for privacy.Resident #427 was admitted to the facility with diagnoses which included Neurogenic Bladder, Cystostomy, Quadriplegia and Seizure Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #427 had severe cognitive impairment, required extensive assistance of 2 staff members for bed mobility, transfer, dressing, toilet use and personal hygiene, and had an indwelling catheter.During observations on 07/01/2025 at 10:02 AM and at 1:16 PM Resident #427 was observed lying in bed. Resident #427's suprapubic catheter drainage bag and catheter tubing were observed with amber urine draining into the bag that was visible from the hallway as it was not contained in a privacy bag.The physician's order dated 06/17/2025 documented suprapubic catheter care every shift, monitor urine output and document amount in every shift for neuromuscular dysfunction of bladder.On 07/09/2025 at 11:03 AM, Certified Nurse Assistant # 1 was interviewed and stated they do not know why Resident #427's urine drainage bag had no cover.On 07/02/2025 at 12:13 PM, Registered Nurse #4 was interviewed and stated that the urinary drainage bag is supposed to be in a privacy bag. On 07/09/2025 at 1:54 PM, the Director of Nursing was interviewed and stated that urinary drainage bag must be in a privacy bag for resident's privacy. The Director of Nursing further stated that in-service education regarding catheter and use of privacy bag was implemented a few months ago and were distributed in the units by charge nurses and supervisors. 10 NYCRR 415.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. This was evident for 1 (Resident #139) of 5 residents reviewed for Activities of Daily Living out of 36 total sampled residents. Specifically, Resident #139 was not showered once a week as scheduled.The findings included:The facility's policy and procedure titled Shower with a reviewed date of 02/2025 documented residents will be given showers in accordance with residents' wishes.Resident #139 was admitted to the facility with diagnoses that included Cerebrovascular Accident, Aphasia, and Hypertension.The annual Minimum Data Set assessment dated [DATE] documented Resident #139 was cognitively intact and was dependent on staff for oral/personal hygiene and showering. The assessment documented it was very important for the resident to choose between a tub bath, shower, bed bath or sponge bath. During observation on 07/01/2025 at 10:44 AM and on 07/02/2025 at 10:26 AM, Resident # 139 was unkempt with facial hair and was observed in hospital gown on both days. During the interview conducted on 07/08/2025 at 10:49 AM, Resident #139 was asked about their bathing preference. Resident #139 stated they prefer showering but had never received a shower since being in the facility. Resident #139 does not recall staff ever offering assistance for showering and was not aware about the weekly shower schedule.The Nursing admission assessment dated [DATE] documented Resident #139's bathing preference was shower.The Care Plan for Activities of Daily Living initiated was initiated on 06/13/2025 and was revised on 06/16/2025 to reflect that Resident #139 requires substantial assistance for bathing/showering and weekly shower schedule was on evening shift every Thursday and bed bath daily.The Certified Nursing Assistant Documentation for Showering from 06/13/2025 to 07/07/2025 documented Resident #139 had not received shower out of 3 opportunities to receive shower from 06/13/2025 to 07/07/2025. It documented Resident #139 refused shower on 06/19/2025 and no documentation recorded that showers or bed baths had occurred on 06/26/2025 and 07/03/2025. A further review of progress notes and care plans revealed no documented evidence that Resident #139 had refused showers. On 07/09/2025 at 9:56 AM, Certified Nursing Assistant #5 stated Resident #139 requires staff assistance for all daily care including washing face and body with washcloth, oral care, toileting, and has shower scheduled once a week. Certified Nursing Assistant #5 stated Resident #139 once refused getting a shower when it was offered on their scheduled shower day. Certified Nursing Assistant #139 stated any shower refusal is documented in their task record and the nurse is notified. Certified Nursing Assistant #5 stated they do not recall if the nurse was notified of Resident #139 refusing shower or if it is documented in resident's task record.On 07/09/2025 at 8:49 AM, Registered Nurse #7 stated that Certified Nursing Assistants are responsible for providing shower according to resident's shower schedule and document them in the task record. If a resident refuses shower, the nurse must be notified, and it will be documented in the medical record. Registered Nurse #7 stated they were not aware that Resident #139 had not received showers and they were never informed that Resident #139 was refusing showers. On 07/09/2025 at 11:42 AM, the Director of Nursing was interviewed and stated that Certified Nursing Assistants are responsible for providing showers for residents and they must notify the nurse if a shower was not given for any reason. The Director of Nursing stated if Resident #139 refused showers, the nurse should have been notified and it should have been care planned to address the resident's behavior of refusing showers. 10 NYCRR 415.12 (a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Recertification Survey from 07/01/2025 to 07/09/2025, the facility failed to ensure residents with indwelling urinary catheters received appropriate care and services to manage the urinary catheter. This was evident for 1 (Resident # 427) of 4 residents out of 36 total sampled residents. Specifically, Resident #427, who had a suprapubic urinary catheter, was observed with the urinary drainage bag and the spigot lying on the floor without a barrier.The findings include:The facility's policy on Suprapubic Catheter that was last reviewed on 01/2025 documented that the drainage bag must not touch the floor and privacy cover must be in place. Resident #427 was admitted to the facility with diagnoses that included Neurogenic Bladder, Cystostomy, Quadriplegia and Seizure Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #427 had severe cognitive impairment, required extensive assistance of 2 staff members for bed mobility, transfer, dressing, toilet use and personal hygiene, and had an indwelling catheter.During multiple observations on 07/02/2025 at 10:08 AM and on 07/02/2025 at 12:11 PM, Resident #427 was observed lying in bed with the suprapubic catheter drainage bag and spigot touching the floor without a barrier.A comprehensive care plan for indwelling catheter was initiated on 06/17/2025. The facility interventions included to assess for complications and observe for signs of infection. A physician's order dated 06/17/2025 documented suprapubic catheter care every shift, monitor urine output and document amount in every shift for neuromuscular dysfunction of bladder.On 07/09/2025 at 11:03 AM, Certified Nurse Assistant #1 was interviewed and stated they change the residents' suprapubic drainage bag once a week every Saturday. They stated they do not know why Resident #427's urinary drainage bag was touching the floor.On 07/02/2025 at 12:13 PM, Registered Nurse #4 was interviewed and stated they just changed the suprapubic drainage bag today and did not realize the drainage bag is touching the floor, and that the spigot is out of place.On 07/09/2025 at 1:54 PM, the Administrator was interviewed and stated the urinary drainage bag must not touch the floor. 10 NYCRR 415.12(d)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure that each resident received care and services for the provision of parenteral fluids consistent with professional standards of practice. This was evident for 1 (Resident #270) of 36 total sampled residents. Specifically, Resident #70's midline intravenous catheter insertion site dressing was undated, and the dressing appeared brownish and was peeling off. The findings include:The facility's policy titled Intravenous Therapy dated 02/2022 that was last reviewed on 03/2025 documented that standard precautions and aseptic technique will be used in the initiation and maintenance of intravenous therapy. The procedure documented, after insertion of intravenous catheter, to secure the catheter with a sterile transparent dressing and to place the label on the dressing indicating nurse's initials and date.Resident #270 was admitted to the facility with diagnoses that included Benign Prostatic Hyperplasia, Multi Drug-Resistant Organism, and Septicemia.The admission Minimum Data Set assessment dated [DATE] documented Resident #270 had intact cognition and required supervision or touching assistance of staff for most activities of daily living. The assessment documented that the resident had a central line on admission.A Comprehensive Care Plan for infection was initiated on 06/03/2025 and documented that Resident #270 had osteomyelitis and was on Vancomycin for toe infection. The facility interventions included to change the dressing as ordered, to administer medication as ordered; and to maintain universal precautions at all times to prevent spread of infection. A physician's order dated 06/06/2025 included midline dressing change once a week on Mondays. A physician's order dated 06/12/2025 documented Vancomycin 0.9% Sodium Chloride 1 gram, infuse 1 gram intravenously every 12 hours for acute hematogenous osteomyelitis of unspecified ankle and foot.On 07/01/2025 at 12:42 PM, Resident #270 was observed in their room. The resident stated their right toe has an infection and they are on intravenous antibiotic. Resident #270's left arm antecubital was observed with a midline inserted. The transparent dressing on the midline insertion site was brownish and was peeling off. There was redness noted on the surrounding skin under the transparent dressing. The dressing was not dated and signed. Resident #270 stated that the midline was inserted in June at the hospital prior to their admission to the facility. They stated they cannot remember when the dressing was last changed.On 07/08/2025 at 9:10 AM, Resident #270 was observed in their room with Vancomycin 0.9% Sodium Chloride infusing via the intravenous midline on the resident's left arm. The dressing observed on the midline site was still undated, brownish, and peeled off at the surrounding edges. Resident #270 stated that the nurses are only giving the medication via the line, but they have not been changing the dressing.During an interview on 07/08/2025 at 9:10 AM, Registered Nurse #2, who administered Resident #270's medication stated they do not work every day on the unit and could not state when the dressing on the midline was last changed. Registered Nurse #2 stated it appeared the dressing has not been changed this week and they are not sure when the dressing is due for a change. Registered Nurse #2 stated they will check the order and change the intravenous site dressing today.On 07/08/2025 at 9:22 AM, Registered Nurse #1, who was the Unit Manager, was interviewed and stated there is an order to change the dressing on Resident #270's midline every week on Mondays. Registered Nurse #1 stated the dressing could have been changed by the wound care nurse or the medication nurse. Registered Nurse #1 stated the dressing appeared it was not being changed and was not able to explain why the nurses are documenting in the Treatment Administration Record that the dressing is being changed as ordered. On 07/08/2025 at 10:08 AM, Registered Nurse #3, who was the Wound Care Nurse was interviewed and stated that they are responsible for changing the dressings on Resident #270's intravenous site whenever they are assigned to the unit. Registered Nurse #3 stated that the intravenous site dressing on Resident #270's midline was not due for a change the last time they worked on the unit. Registered Nurse #3 further stated that when they assessed Resident #270's midline site, they noted there was no date on the dressing, and it appeared as if the dressing has not been changed for a while.On 07/08/2025 at 11:42 AM, the Director of Nursing was interviewed and stated that the nurses administering the medication are supposed to check the intravenous insertion site to monitor skin integrity and change the dressing weekly. They stated the Unit Manager must monitor the staff nurses to ensure this is being done. 10 NYCRR 415.12(k)(2)

Based on observation, record review, and interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure that food was distributed and served in accordance with professional standards for food service safety. This was evident for 1 (Resident #123) of 2 residents reviewed during the dining task observations out of 36 total sampled residents. Specifically, Certified Nursing Assistant #2 who was assisting Resident #123 at lunch time, held a sandwich with bare hands before giving it to the resident.The findings include:The facility policy titled Resident Dining Procedure with Staff with a revision date of 01/2025 documented staff must avoid touching food with bare hands. Food shall be received by the resident in a manner that complies with safe food handling practices. During dining observation on 07/01/2025 at 12:51 PM, Certified Nursing Assistant #2 removed the plastic wrap on a chicken sandwich and held the sandwich with bare hands and gave it to Resident #123. On 07/01/2025 at 1:09 PM, Certified Nursing Assistant #2 was interviewed and stated they should have not touched the sandwich with bare hands after removing the plastic wrap. On 07/01/2025 at 1:14 PM, Registered Nurse #4 was interviewed stated the staff should not touch residents' food with their bare hands. On 07/09/2025 at 1:30 PM, the Infection Preventionist was interviewed and stated staff were given in-service education on how to appropriately assist and serve residents their food that is in compliance with infection control practices. On 07/09/2025 at 2:02 PM, the Administrator was interviewed and stated the Infection Control Preventionist, and the Nurse Educator gives nursing staff in-service education on how to assist residents during dining. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews, the facility failed to ensure garbage and refuse were disposed of properly. This was evident during the Kitchen Observation task. Specifically, the facility's waste compactor was not kept closed when not in use, exposing garbage and refuse and had the potential to attract pests.The findings include:The facility's policy and procedure titled Solid Waste Disposal with a revised date of 01/2025 documented food waste and rubbish will be disposed of in an approved manner to prevent contamination of food, clean dishes, or clean working areas. Lids must be kept closed on all outside trash receptacles. During observation on 07/08/2025 from 10:09 AM to 10:22 AM, Dietary Worker #1 and Food Service Director were observed removing garbage from the kitchen to the compactor located outside of the building. The compactor lid was observed to be open and uncovered.Dietary Worker #1 was immediately interviewed and stated they do not know why the compactor was left opened, but it should have been closed after whomever disposed garbage in the compactor.On 07/08/2025 at 10:23 AM, the Food Service Director stated the compactor is utilized by both food service and housekeeping staff. The staff who last used the compactor did not close it properly. On 07/08/2025 at 10:27 AM, the Director of Housekeeping was interviewed and stated the compactor is used by both food service and housekeeping staff to dispose food waste and regular garbage. They recently repaired the compactor and gave in-service education to their staff on how to properly dispose garbage and proper closing of the compactor after use.On 07/09/2025 at 12:04 PM, the Administrator was interviewed and stated they are going to address this concern. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00369908/728066), the facility failed to protect a resident's right to be free from the misappropriation of resident property and/or exploitation. This was evident for one out of nine residents (Resident #9) reviewed for personal property. Specifically, on 01/23/2025 at 7:10 AM, when counting narcotics (pain relieving) medications, Registered Nurse #1 reported a blister pack containing thirty Oxycodone 2.5 mg tablets that belonged to Resident #9 was missing from the medication cart drawer. During the facility-wide search, the empty medication blister pack had been torn into pieces in the shredder, and 30 Oxycodone tablets were missing. Additionally, Registered Nurse Supervisor #1 was seen on the facility surveillance counted the narcotics medications alone and then removed the medications from the medication cart drawer. The findings are: The facility policy and procedure entitled Abuse Prohibition Protocol, dated 01/2025, documented that residents must not be subject to abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property by anyone including, but not limited to facility's staff, other residents, consultants or volunteers, or staff of another agency serving the individual.The facility policy and procedure entitled Medication Ordering/Administration and Electronic Recordation, with an approved date of 01/2025, documented that all controlled drugs will be counted jointly at the end of each tour of duty by licensed nurses. Controlled medications needed for each med pass are to be placed in a separate locked drawer of the med cart and returned to the locked drug cabinet in the medication room after the med pass is completed. Resident #9 was admitted to the facility with a diagnosis including Humerus Fracture, Anxiety, and Depression. The Minimum Data Set (a resident assessment tool) dated 12/27/2024, documented that Resident #9 had intact cognition. A Physician Order dated 01/02/2025 documented an order for Oxycodone 5 milligrams, give 2.5 mg (1/2 tablet) by mouth every six hours as needed for pain. An image with the torn top part of the blister pack labeled one of two of Resident #9's Oxycodone 5 mg 1/2 tablets=2.5 milligrams revealed holes in all 30 blisters A review of the facility's investigation dated 01/29/2025 documented that during count narcotics medication on 01/23/2025 at 7:10 AM, the day Registered Nurse #1 reported a blister pack of thirty Oxycodone 2.5 mg tablets and a blue narcotic count sheet was missing from the third-floor medication cart drawer. Registered Nurse #1 had worked the day prior and identified that two blister packs were present on 01/22/2025 at 03:00 PM. Registered Nurse #1 immediately contacted the Assistant Director of Nursing. Registered Nurse #2, who worked on 01/22/2025 3-11shift, recalled last seeing both blister packs at 10:30 PM, prior to being counted by Registered Nurse Supervisor #1. The Assistant Director of Nursing attempted to call Registered Nurse Supervisor #1 for any information, but Registered Nurse Supervisor #1 told them they would call back. The search was done on the third-floor medication carts, the medication room, and the garbage. Searches were expanded to all other nursing units immediately, with verification of all controlled substance counts. The blister pack was not found at that time. The nursing office was checked for the missing blister pack. The Director of Nursing reviewed video surveillance of the third unit nursing of the prior night, and it was noted that Registered Nurse Supervisor #1 counted narcotic medications on the third floor alone. Registered Nurse Supervisor #1 was seen entering the elevator to leave the third floor with what appeared to be a blue sheet of paper wrapped around a blister pack. Registered Nurse Supervisor #1 was also noted to be walking in the Nursing Wing hallway and entering the Nursing office. At approximately 1:30 pm, the Assistant Director of Nursing checked shredder boxes in the Nursing wing and located above a missing blister pack with all thirty pills punched out. The blister pack label had been cut from the pack, and the blue sheet was found shredded into pieces. Three additional torn blue count sheets for oxycodone were found with no corresponding blister packs. Upon further interviews with nursing staff, it was relayed that Registered Nurse Supervisor #1 would offer to count on the third floor 3-11 shift, so that the nurses could leave if an 11-7 nurse were going to arrive late. Also, it was stated Registered Nurse Supervisor #1 would ask to collect controlled substances from the third floor for discharged residents. This was not a job responsibility of Registered Nurse Supervisor #1, 3-11 shift supervisor, nor did they follow the proper protocol for removing controlled substances per policy. Interviews with nurses revealed that they had given Registered Nurse Supervisor #1 the keys to count as requested because Registered Nurse Supervisor #1 was their supervisor. A Registered Nurse #4's Written Statement #1, dated 01/23/2025, documented that on 01/22/2025, they saw the evening supervisor holding a blister pack with paper in their hands at the nursing station. A Registered Nurse #4 ‘s Written Statement #2 dated 01/23/2025, documented that last week, Registered Nurse Supervisor #1 came to the unit to collect discharged narcotics. On two other separate occasions, Registered Nurse Supervisor #1 had come to them and collected discontinued narcotics on the 3rd floor. A Surveillance Video was reviewed with the Director of Nursing on 06/13/2025 at 1:50 PM. According to the Director of Nursing, the Surveillance Video was recorded in real-time. The Surveillance Video Camera showed that on 01/22/2025 at 11:00 PM, Registered Nurse Supervisor #1 opened the medication cart, took out the Controlled Substance Sheet and blister pack, wrapped the blister pack in the Controlled Substance Sheet, and walked away holding it in their hand. There was an unsuccessful attempt to contact Registered Nurse Supervisor #1 via phone on 06/23/2025 at 1:50 PM. During a telephone interview on 06/26/2025 at 1:27 PM, Registered Nurse # 2 stated they worked on 01/22/2025, 3-11 shift and at approximately 10:55 PM, Registered Nurse Supervisor #1 came to the floor and told them and another Registered Nurse that they could count out their narcotics if they wanted to leave because the incoming nurse was late. Registered Nurse # 2 stated they gave the key from the narcotic box to Registered Nurse Supervisor #1, who counted their narcotic medications alone at the medication cart. Registered Nurse # 2 stated they did not see Registered Nurse Supervisor #1 counting narcotic medications. Registered Nurse #2 stated that it was not permissible, and they should have counted the narcotic medication with Registered Nurse Supervisor #1 in the medication room as per facility policy. Registered Nurse #2 stated it happened for the first time with them. Registered Nurse #2 also stated that when Registered Nurse Supervisor #1 finished counting their narcotics, they came over to the nursing station, took the key from another Registered Nurse, and went to count on another medication cart. Registered Nurse #2 stated they did not notice anything in the Registered Nurse Supervisor #1's hands at that time because they did not pay attention. Registered Nurse #2 stated that the next day, they were informed that 30 tablets of Oxycodone were missing from their medication cart. Registered Nurse #2 stated they were re-serviced on narcotic counting. During a telephone interview on 06/16/2025 at 12:15 PM, Registered Nurse #3, who worked on 01/22/2025 during the 11 PM to 7 AM shift, Registered Nurse Supervisor #1 informed them that medications were already counted. Registered Nurse #3 stated they still counted narcotics in the medication cart with the leaving nurse, who was still present. Registered Nurse #3 stated they were supposed to count narcotics in the medication room, where there is a double-locked door for narcotic storage. Registered Nurse #3 stated that they did not pay attention to the label on the blister pack, which indicated that 1 out of 2 blister packs contained the medication, because the count was broken down into 30 and 30 tablets, each with a separate blue sheet accompanying the blister pack. At the time of counting, there was only one blister pack and one blue sheet. Registered Nurse #3 stated the missing 30 tablets of Oxycodone were noted when the incoming nurse for7:00 AM to 3 PM shift was counting with them at 7:00 AM and asked where another 30 tablets with blue sheets because the nurse worked prior morning shift and remembered that there was another blister pack with 30 tablets of Oxycodone. Registered Nurse #3 stated that the Assistant Director of Nursing was immediately notified, and a search was conducted, but tablets were not found. During a telephone interview on 07/02/2025 at 12:30 PM, Registered Nurse # 4 stated they were working on 01/22/2025, 3-11 shift, and saw at the end of the shift Registered Nurse Supervisor #1 was coming from the north side, carrying a blister pack with paper in their hand. Registered Nurse # stated they cannot say if it was a blister pack with narcotics that was missing because Registered Nurse Supervisor #1 always delivered narcotics to the floor. Registered Nurse # 4 also stated on three occasions that Registered Nurse Supervisor #1 was collecting discharged narcotics from them. Registered Nurse # 4 stated they knew that only the Assistant Director of Nursing was collecting discharged narcotics. Registered Nurse # 4 stated they asked Registered Nurse Supervisor #1 about it, and Registered Nurse Supervisor #1 told them that the Assistant Director of Nursing is out sick, and they are collecting it. Registered Nurse # stated they did not suspect anything because it was a supervisor, and they gave them a discontinued narcotic, and both signed it. During an interview on 06/25/2025 at 2:42 PM, the Director of Nursing stated that on 01/23/2025, the Assistant Director of Nursing notified them that a 7-3 shift nurse reported missing a blister pack with Oxycodone for Resident #1 that was present at the end of the 7-3 shift on 01/22/2025. The Director of Nursing stated that the total amount of Oxycodone that was delivered was 56 half tablets in two blister packs: 26 half tablets were on one blister pack and 30 half tablets were in another blister pack. The Director of Nursing stated that a 30-half tablet blister pack was missing, along with a blue accountability sheet. The Director of Nursing stated the search was initiated on the 3rd floor and expanded to the entire building, but the blister pack was not found. The Director of Nursing stated they interviewed all nurses on prior shift 3-11 and 11-7 and discovered that Registered Nurse Supervisor #1 was counting narcotics on a few occasions for nurses who were leaving, saying that the incoming nurse was late. The nurses allowed Registered Nurse Supervisor #1 to count the narcotics alone at the medication cart. The Director of Nursing stated that it was against facility policy; two nurses must count the narcotics in the medication room and not at the medication cart. The Director of Nursing stated that, according to the nurses, Registered Nurse Supervisor #1 was also collecting discontinued narcotic medications, which was not the supervisor's responsibility. In addition, Registered Nurse #3, who worked on 01/22/2025 11 PM to 7 AM, did not notice that the blister pack with 30 tablets was missing until the morning shift started to count. The Director of Nursing stated they watched the camera and observed that Registered Nurse Supervisor #1 took a medication cart key from Registered Nurse #2. In another clip, Registered Nurse Supervisor #1 took something that looked like a blister pack wrapped in paper and went to the nursing office downstairs. The Director of Nursing stated that Registered Nurse Supervisor #1 did not respond to multiple attempts to call for information. The Director of Nursing stated that later they found a torn empty blister pack and a blue sheet in the shredder, along with a few other blue sheets. The Director of Nursing stated they notified police and the Bureau of Narcotics, and they came to investigate and took a copy of the camera. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement before and during the time of this survey on 06/13/2025.The facility was cited with past non-compliance, and the following Plan of Correction was implemented All nursing units' cart-controlled substance boxes and wall cabinets were checked to be sure they were operational. All narcotic medications on all units were counted with no additional issues. Police were called and came to the facility. Three Registered Nurses were removed from the schedule as the narcotic policy was not followed for counting narcotic medications. Reeducation started and is ongoing on the requirement to place all narcotics in lock boxes in the medication room when the med pass is completed to ensure the policy on narcotics is being followed. The Pharmacy and Long-term solutions consultants meeting was held on 01/27/2025 to review current processes and policies. Meeting minutes were reviewed. Long-term solutions consultants completed all nursing unit inspections on 01/27/2025. Medication pass audits were conducted by Long Term Solutions once a month. Nursing Leadership meeting was held on 02/14/2025 with addenda included: review of narcotics storage /process Nursing conducted medication pass audits on all three shifts weekly. Results of the audit were reported to the Quality Assurance committee monthly until 100% compliance is achieved in one consecutive quarter. Disciplinary action for those nurses if non-compliant. Ongoing monitoring of controlled substance delivery, storage, administration, and destruction is to be conducted by Nursing leadership. Audit of controlled substance Logbook was initiated and done to ensure reconciliation from delivery to discontinuation, discharge, and RX drug drop box Quality Assurance Performance Improvement dated 03/13/2025 reviewed. 10 NYCRR 415.4(b) \

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, conducted during an abbreviated survey (NY00374579), the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. This was evident for 1 out of 9 residents sampled (Resident #8). Specifically, on 03/09/2025 at approximately 5:22 AM, Certified Nursing Assistant #1 noted a small area of purpura (discoloration) on Resident #8's left knee and informed Registered Nurse #1. Registered Nurse #1 did not do a physical assessment, did not document in the medical record, and failed to inform the Medical Doctor, which resulted in a delay in diagnosis and treatment. On 03/10/2025, Resident #8 was transferred to the hospital due to a swollen left knee with discoloration and was diagnosed with a closed fracture of the Left femur (the thigh bone) and required surgery. Findings are:The facility's Policy and Procedures titled Notification of Resident's Change in Condition, dated 04/2020, documented that the Licensed Nurse /Designee assesses the resident, contacts the physician, and reports pertinent findings. Initiate the action indicated by the physician/physician extender and document in the interdisciplinary notes. The physician, physician extender, or designee notifies the resident's responsible party. Criteria for reporting Change in Condition, including the following, but not limited to injury of unknown origin, including blisters or burns, abrasion, ecchymosis, purpura, skin tears, laceration. Licensed Nurse notifies Nursing Supervisor of resident's change in condition and notes such on 24-hour report, Interdisciplinary Progress Notes, and communicates changes to appropriate staff.Resident #8 was admitted to the facility with diagnoses that include Alzheimer's disease, Anemia, and Inflammatory Spondylopathies. The Minimum Data Set, dated [DATE], identified that Resident #8 had short-term and long-term memory problems. Certified Nursing Assistant #1's Written Statement dated 03/11/2025 documented Certified Nursing Assistant #1 called Registered Nurse #1 to look at Resident #8's legs on 03/09/2025. The Surveillance Video was reviewed with the Director of Nursing on 06/13/2025, at 1:30 PM. According to the Director of Nursing, the video was recorded in real-time. The Surveillance Video Camera #2 revealed that on 03/09/2025 at 05:20 AM, a Certified Nursing Assistant came to the nursing station and gestured for Registered Nurse #1 to come with them. Registered Nurse #1 got up and went in Certified Nursing Assistant #1's direction and disappeared from camera view. Registered Nurse #1 returned to the nursing station at 05:22 AM. The Surveillance Video Camera #3 revealed that on 03/09/2025 at 05:20 AM, Certified Nursing Assistant #1 came out of Resident #8's room and went in the direction of the nursing station. Registered Nurse #1 went to Resident #8's room at 05:21 AM and came out at 05:22 AM. A Review of nursing notes from 03/01/2025 to 03/10/2025, there were no documented nursing notes for 03/08/2025 or 03/09/2025.There was no documented evidence that the Medical Doctor was notified after the Certified Nursing Assistant brought to the Registered Nurse's attention that Resident #8 had discoloration on the left leg. In a Nursing Note dated 03/10/2025 at 07:19 AM, written by Registered Nurse #2, documented during routine care, Certified Nursing Assistant #2 reported to the writer that Resident #8's left knee was swollen, and bruising was observed. Diffuse ecchymosis noted to the left shin, left lateral thigh, left medial thigh, and back of left knee. The area is purple/blue, skin was intact. The left knee is markedly swollen. During Range of Motion, the resident grimaced and groaned. Tylenol 650 milligrams was given immediately. Resident #8 was re-evaluated later and was found to be sleeping. The Medical Doctor was notified and ordered a STAT (immediately) X-ray of the left knee. In a Medical Provider Discharge Summary from the facility dated 03/10/2025 documented that Resident #8 was sent to the hospital for evaluation of left leg discoloration and swelling. Found to have a fracture and was admitted . A review of the facility's investigation, dated 03/17/2025, documented that on 03/10/2025 at 6:00 AM, Resident #8 was noted with left knee swelling with ecchymosis to the posterior knee, left lateral thigh, and left shin. Resident #8 was transferred to the hospital and was admitted with an Acute Distal Fracture of the femur and Diffuse Osteopenia with degenerative changes. Resident #8's care plan was updated on 03/07/2025 to transfer with two-person assistance. Based on staff statements, Certified Nursing Assistant #1 transferred Resident #8 on 03/08/2025, in the evening with one assist, stating that they were unaware of Resident #8's transfer status and had not checked the electronic medical record. On 03/09/2025 at 5:22 AM, Certified Nursing Assistant #1 noted a small discolored area on the Resident #8's knee and reported to Registered Nurse #1. Registered Nurse #1 reported that they looked at Resident #1's leg but became busy and forgot to report the incident. The facility investigated the incident and concluded that there was no evidence of abuse, mistreatment, or neglect. A Patient Discharge Instruction (hospital) dated 03/19/2025 documented a Closed Fracture of the Left Distal Femur (leg). Open treatment of the fracture of the distal femur. During an interview on 06/13/2025 at 3:35 AM, Certified Nursing Assistant #1 stated that they worked a double shift on 03/08/2025-03/09/2025 (3 PM-11 PM and 11:00 PM-7:00 AM shifts). Certified Nursing Assistant #1 stated that they started to provide care (does not remember the time) and saw something wrong with the Resident #8's left leg. Certified Nursing Assistant #1 stated they observed the knee was swollen and there was a red spot (not big) on the skin. Certified Nursing Assistant #1 stated that Resident #8 was crying. Certified Nursing Assistant #1 stated they immediately called the nurse, who came, touched the leg, and left. Certified Nursing Assistant #1 stated that Resident #8 stopped crying, they finished care, and left. During an interview on 6/23/25 at 3:07 PM, Registered Nurse #1 stated they worked 03/08/2025 -03/09/2025 3 PM-11 PM and 11:00 PM-7:00 AM shifts. Registered Nurse #1 stated that Certified Nursing Assistant #1 reported to them between 9-10 PM (insisted that the time was correct) that they should come and see something on Resident #8. Registered Nurse #1 stated that they entered the room and observed Resident #8 lying on the bed, covered with a sheet. Registered Nurse #1 stated Certified Nursing Assistant #1 opened the sheet and pointed to the right leg, under the knee, where there was 0.5 cm purpura, black and blue, with no swelling or skin opening. The resident did not complain of pain and was quiet. Registered Nurse #1 stated they were misled by Certified Nursing Assistant #1, who showed them the right leg, and they did not look at the left leg. Registered Nurse #1 stated that they did not conduct a full body assessment. Registered Nurse #1 stated they were supposed to do a full body assessment and document it in the resident's medical chart. Registered Nurse #1 stated they planned to put a notification in the Medical Doctor's book for follow-up in the morning, but it escaped their mind, and they forgot to put it in the Medical Doctor's book. Registered Nurse #1 stated they also forgot to notify the Supervisor and family as required by the facility policy. During an interview on 06/23/2025 at 4:24 PM, Registered Nurse #2 documented during routine care on 03/10/2025 at approximately 06:00 AM, Certified Nursing Assistant #2 called them to Resident #8's room to see the resident's left knee. Registered Nurse #2 stated that they observed swelling on Resident #8's left knee and bruising on the left shin, left lateral thigh, left medial thigh, and the back of the left knee; the area is purple/blue. Registered Nurse #2 stated that no one reported a fall or trauma. Registered Nurse #2 stated that they palpated gently, and the resident grimaced, indicating that they were in pain. Registered Nurse #2 stated they had notified the Medical Doctor, and Tylenol was given with good effect. Registered Nurse #2 stated that they informed the supervisor immediately. Registered Nurse #2 stated they expect Certified Nursing Assistants to check and change the residents throughout the shift and report any changes. Registered Nurse #2 stated they are responsible for monitoring that staff follow the plan of care through spot checks and rounding. During an interview on 06/24/ 2025, at 11:25 AM, the Medical Director stated that they reviewed Resident #8's x-ray and, in their professional opinion, the fracture was potentially pathological, related to Diffuse Osteopenia, which was also confirmed on the Computed Tomography. The Medical Director also stated that they are unsure if there was a delay in diagnosis and treatment because the staff discovered the bruise on the knee on 03/09/2025. Although it alone would not have necessarily triggered an X-ray order, it would have been evaluated sooner by a Medical Doctor. During an interview on 06/24/25 at 01:30 PM, the Director of Nursing stated that they were notified on 03/10/2025 at approximately 06:00 AM that Resident #8 was observed with a swollen left knee and discolorations. The Director of Nursing stated that during the interview with the staff and review camera, they discovered that Certified Nursing Assistant #1 alerted Registered Nurse #1 on 03/09/2025 at 05:20 AM (both of them worked on 03/08/2025 -03/09/2025 3-11 and 11-7 shifts) to come and see Resident #8's legs. The Director of Nursing stated that Registered Nurse #1 admitted that Certified Nursing Assistant #1 had notified them and showed them Resident #8's right leg that had small purpura, but they became busy and forgot to report to the supervisor and Medical Doctor as required. The Director of Nursing stated that Registered Nurse #1 insisted that it was the right leg. The Director of Nursing stated that Registered Nurse #1 did not perform a full-body assessment and did not document the findings in the resident's medical record as required. The Director of Nursing stated that Registered Nurse #1, the Supervisor, and the nursing administration team are responsible for monitoring Registered Nurses' performance, including reporting, care plan, customer service daily, during rounds, and in the team meetings in the morning.The facility implemented corrective actions and was found to be in substantial compliance on 03/19/2025 before the start of the Abbreviated Survey on 06/13/2025 The facility was cited with past non-compliance, and the following Plan of Correction was implemented:- Resident #8's body assessment was done on 05/10/2025 and was transferred to the hospital.- The facility held an Interdisciplinary meeting on 03/10/2025 and 03/11/2025 to discuss the incident - Registered Nurse #1 was suspended for failure to report the incident timely, was re-educated, and was placed on a Performance Improvement Plan for 6 weeks- Registered Nurse #1's Performance Improvement Plan dated from 04/2025 to 05/16/2025 reviewed. - Certified Nursing Assistant #1 was suspended for failure to follow the care plan and was re-educated on 03/20/2025 - The Physical Therapist was given verbal counseling for the error in transcription- All staff were in-service on Abuse, Neglect, Mistreatment on 03/10/2025 - All staff were in-service on Reporting a Change in Condition/Documentation/ Verbal communication on 03/11/2025 - All staff were in-service on following the plan of care dated 03/12/2025 - Rehab Education Documentation/Activity Daily Living Care Plan, revealed rehab staff received in-service on 03/13/2025 - In-service record with lesson plan dated 03/15/2025-03/18/2025 documents all Certified Nursing Assistants received in-service on Checking Electronic Medical Record, Plan of Care, Transfer Status, Prior Care - A meeting with all Certified Nursing Assistants was held on 03/19/2025 with the topic Residents Safety, Certified Nursing Assistant Accountability, Customer Service, etc. - Audit tool and results from 03/12/2025 to 05/28/2025 reviewed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey from 3/21/23 to 3/28/23, the facility did not ensure a resident's right to voice care and treatment grievances and a prompt effort to resolve resident grievances. This was evident for 1 of 7 residents reviewed for Activities of Daily Living (ADL) of 38 total sampled residents (Resident #11). Specifically, the grievance process was not initiated for Resident #11 when the resident expressed concerns with ADL care received. The findings are: The facility policy titled Grievance Management dated 8/2022 documented each resident has the right to voice grievances to the facility and the facility should ensure prompt resolution to all grievances while keeping the resident and representatives informed. Resident #11 had diagnoses of seizures and ataxia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #11 was cognitively intact, was occasionally incontinent of bladder, always continent of bowel, and required extensive assistance with ADL. On 03/21/23 at 03:18 PM, 03/24/23 at 10:02 AM, and 03/28/23 at 11:01 AM, Resident #11 was interviewed and complained about the ADL care they received, their shower schedule, and waiting a long time to receive care. Resident #11 stated they reported these concerns to staff several times. The Comprehensive Care Plan (CCP) related to ADL care, created 9/19/22 and last revised 1/26/23, documented Resident #11 required extensive assistance of 1 person for dressing, toilet use and personal hygiene. The CCP related to residents' rights created 7/22/22 documented Resident #11 received a copy of Resident Rights and will be informed of their rights as a nursing home resident. The Certified Nursing Assistant (CNA) Documentation Survey Reports (DSR) for February and March 2023 documented Resident #11 was scheduled to receive showers every Wednesday and Saturday. There was no documented evidence Resident #11 received a shower 7 out of 16 opportunities in February and March 2023. The Social Work (SW) Note dated 2/8/23 documented SW #2 met with Resident #11 took resident's concerns regarding care and forwarded such to the Registered Nurse (RN) Supervisor and the Assistant Director of Nursing (ADON). The note documented SW #2 to continue to follow up. There was no documented evidence Resident #11 was provided the opportunity to file a grievance and no documented evidence of a prompt response by the facility regarding Resident #11's care concerns. On 03/28/23 at 11:32 AM, SW #2 was interviewed and stated they report resident care complaints to the charge nurse, the RN Supervisor, or the ADON via email and write a progress note. Resident #11 complained about call bells not being answered quickly enough. SW #2 stated they reported Resident #11's issues to nursing and the nurses take responsibility from there. The SW will be involved if the nursing department wants SW involved. SW #2 stated they sent an email to RN #1 and the ADON on 2/8/23 at 2PM. SW #2 read the contents of the email aloud but stated the email is not part of the resident's medical record and they cannot provide evidence of the documented email. SW #2 stated Resident #11 reported they have not received a shower, cannot recall their last shower, it takes 1 hour for the call bell to be answered, and staff walk into their room without knocking. SW #2 stated they did not think they had to follow up on Resident #11's concerns because they informed the appropriate people. The SW progress note in the resident's medical record was not detailed because SW #2 had been directed to write their notes a certain way. SW #2 stated they need to speak with the Director of Social Work (DSW) before discussing prior to answering any further questions. On 03/28/23 at 11:55 AM, RN #1 was interviewed and stated if a resident complains, staff inform RN #1 and RN #1 would talk to the resident and investigate. RN #1 does not recall receiving a complaint that Resident #11 was not getting showers. RN #1 does not have record of previous email communications and cannot recall receiving an email re: Resident #11's care concerns. On 03/28/23 at 12:07 PM, the ADON was interviewed and stated residents receive showers twice weekly. If a resident refuses showers, the CNA documents on the CNA DSR and the nurse documents in a progress note. If a signature is missing in the medical record, the task was not performed. Residents usually complain to the nurse or SW. The RN or ADON gets involved if further assistance is needed. The resident can also file a grievance. Nursing fills out grievances. The ADON stated they did not receive any emails about Resident #11's care concerns. Staff should document resident complaints in the medical record in detail. On 03/28/23 at 12:50 PM, the DSW was interviewed and stated the SW reports complaint information to the department involved. The communication between SW and the other departments is verbal or via email. The SW also documents the concerns and action taken in a progress note. The SW usually goes back to the resident to see if things have been resolved. For a shower issue, the follow-up should be within the next few days, and a follow-up progress note. The DSW stated they could not recall Resident #11 reporting any concerns related to showers. 415.3(c)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the Recertification/Complaint survey (NY00307807), the facility did not ensure that residents were free from abuse, neglect, misappropriation of property, and exploitation. Specifically, a Certified Nursing Assistant accepted money from a resident in their care to purchase personal items for themselves and their family members. This was evident for 1 of 1 resident investigated for Personal Property out of 38 sampled residents (Resident #56). The facility's Policy and Procedure for Abuse Prohibition Protocol dated 07/2011, last updated 02/2022 documented: Residents must not be subjected to abuse, neglect, exploitation, mistreatment and misappropriation of resident's property by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals. Resident #56 was admitted to the facility with diagnoses that included Paraplegia, Multiple Sclerosis, Anxiety disorder, and Depression. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had intact cognitive status and required extensive assistance of two staff for bed mobility, and total dependence of two staff for both transfer and toilet use. The Comprehensive Care Plan (CCP) for Victimization dated 4/20/2022, last revised 10/11/2022, documented that Resident is at risk for victimization and/or possible emotional or physical injury due to residing in an institutional setting. Goals included that resident would remain free of physical or emotional harm and will remain in a safe and supportive environment The Comprehensive Care Plan (CCP) for Behavior Initiated: 09/14/2022, revised 10/11/2022, and 01/10/2023, documented that resident has behavior problems: - becomes upset when needs are not immediately met; Low frustration tolerance; Resident displays poor personal boundaries with staff at times; expresses that he sees staff as friends/family. This often leads to having expectations of staff that would align with expectations of family, i.e., exchanging personal information, and requesting favors; has difficult if these expectations are not met. Goals included: - Resident will have fewer episodes of noted behavior by review date. The Facility Reported Investigation (FRI) NY00307808 documented that on 12/29/2022 it was reported to Administrator that family of the resident brought documents of purchases made through Amazon on resident's personal credit card for the accused CNA. The Administrator met with the resident, and Resident told the Administrator that he/she gave the credit card number freely to the accused CNA and authorized the staff to use the card for purchases for her/himself and the child. Resident stated that he/she did not think anything was wrong with this as he/she felt as if the accused CNA was like a family member. Further conversation included that staff is not permitted to accept gifts, which the resident understood because in his/her job prior to retirement he/she was also not permitted to accept gifts . 1. Employee was immediately suspended pending investigation. 2. Report made to DOH as per facility policy and police department (122 Pct.) was notified The facility Incident report dated 12/29/2022 documented that interview with Employee #1 revealed that the employee had been taking care of the resident for almost a year and they had been having personal mutual conversations while giving care to the resident, and had been exchanging telephone numbers with the resident. The report also documented that the employee stated that he/she used the resident's credit card information to purchase bicycle. The facility's Employee Disciplinary Notice dated 12/29/2022 documented that Employee #1 had been found to be guilty of misappropriation of resident property up to and including the use of a resident's credit card for personal purchases unrelated to resident care and was being terminated with cause. The facility's investigation dated 1/2/2023 documented that after reviewing the medical record and employee statements, it is evident that Employee #1 did misappropriate resident's property by using Resident #56's credit card to purchase items for self and his/her child. On 03/21/23 at 09:39 AM, an interview was conducted with Resident #56 who stated that they thought they had made a mistake because they wanted the staff to buy something for their child for Christmas because they are a good person to me. Resident #56 also stated that they gave the credit card information to the staff to purchase a gift for the child and to get a gift card for themself. Resident #56 further stated that they have also been giving money to the accused staff to play [NAME] on their behalf for the last 6 months or so. Multiple attempts made to interview the Employee #1 from 03/24/2023 at 2:00 pm to 03/27/2023 at 08:55 were unsuccessful. A voicemail message was left on the employee's mailbox to return the call with no response. On 03/27/23 at 10:01 AM, an interview was conducted with Certified Nursing Assistant (CNA) #2 who stated that they had been taking care of the resident for about 4 years on a regular basis. CNA #2 also stated that Resident #56 had never offered them any gifts. CNA #2 further stated that they were not around when the incident of misappropriation was reported, they were on vacation at that time. On 03/27/23 at 11:00 AM, an interview was conducted with the Licensed Practical Nurse (LPN) #1 who stated that they were not aware of what was happening between the resident and Employee #1 regarding the resident's funds. LPN #1 also stated that the accused employee was a part -time staff and was assigned to the resident only when the regular CNA was not on schedule. LPN #1 further stated that the employee never reported that the resident was offering any gift to them. On 03/28/23 at 11:52 AM, an interview was conducted with the RN Manager (RN #2) who stated that a family member of Resident #56 left a voice mail on the Social Worker's phone on 12/28/2022. The family was called and they reported that the family suspected an inappropriate relationship existed between Resident #56 and Employee #1. Suspicious activity was noted in the resident's financial statement. RN #2 also stated that the case was reported to the facility administration immediately, and Employee #1 was removed from the resident's care immediately. RN #2 further stated that the Employee #1 was a part-time CNA, floating to the unit, and was assigned to the resident if the regular CNA was not scheduled. On 03/28/23 at 12:12 PM, an interview was conducted with the Social Worker (SW) #1 who stated that the resident's family had called at the end of December about concerns with the resident's bank account statements and they noticed that a CNA was taking the resident's money. SW #1 spoke with the resident, and confirmed that resident gave them account access so Employee #1 could buy a gift. It was investigated and confirmed that Employee #1 was receiving money from the resident. SW #1 further stated that they are not sure of how long the relationship had been going on between the Resident #56 and Employee #1. On 03/28/23 at 12:49 PM, the Assistant Director of Nursing (ADON) was interviewed and stated that in-service on abuse and misappropriation of resident's property is given when the staff are newly hired and is also given annually or as needed. The ADON also stated that they were not aware of the relationship between Employee #1 and Resident #56, and as soon as they were made aware, the staff was promptly terminated. The ADON further stated that the nurses on the units make round to supervise the staff when giving care to ensure compliance with the training. ADON stated that they believed that the facility had done everything possible to prevent the occurrence. On 03/28/23 at 04:07 PM, an interview was conducted with the Administrator who stated that based on the investigation conducted, Employee #1 developed a relationship with Resident #56 since last year which was not known to the facility. The Administrator also stated that when the case was being investigated, Resident #56 would not allow the police to get involved. When the police was invited to the facility to interview the resident, the resident refused to press any charges against the staff. The Administrator further stated that the staff was immediately removed from the resident care and terminated, and the facility tried to do everything that needed to be done. 415.4 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification and complaint (NY00310810) survey conducted from 3/21/23 to 3/28/23, the facility did not ensure the prompt report of the results of all investigations within prescribed timeframes to the New York State Department of Health (NYS DOH). This was evident for 1 of 2 residents (Resident #4) reviewed for Notification of Change. Specifically, the facility received a report of resident injury on 3/8/23 which was not reported to the NYS DOH. The findings include: The facility's policy and procedure titled Abuse Prohibition Protocol revised 10/22 documented to report any suspected patient verbal and/or physical abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property occurring within the facility. There will be an investigation and reporting of suspected abuse and neglect occurring prior to admission and/or outside the facility Resident #4 was admitted to the facility with diagnosis of Vascular Dementia, Peripheral Vascular Disease, and Cerebrovascular Accident. The Minimum Data Set (MDS) assessment dated [DATE] documented resident with severely impaired cognition. The nursing note dated 3/8/23 documented resident was noted with lump and bruising under left breast, denies any pain. Family aware and concerned. Notified NP. Will continue to observe. The physician note dated 3/9/23 documented resident seen and examined cc skin change. Left breast intact purple skin with palpable mass, dx breast hematoma vs mass. Rx breast sonogram may need mammogram. The incident report dated 3/8/23 documented daughter reported purple discoloration and lump to resident's left breast. Resident mental/communication status as per MDS: 99. There were no witness. The root cause is resident with decreased mobility, needs assist with ADLs, wheelchair primary mode of locomotion, cognition impaired, on anticoagulant therapy and prednisone. Has fragile skin, discoloration consistent with left arm positioning, leaning breast against arm. Physician's plan of care: breast sonography, may need mammography dated 3/9/23 by the physician. There was no documented evidence that this injury of unknown origin was reported to the NYS DOH. During an interview on 3/28/23 at 12:37 PM, the Assistant Director of Nursing (ADON) stated that this injury was found by the family and unit staff was notified. It was immediately investigated and determined that it came from the way resident was leaning on their side in the wheelchair. The ADON stated they concluded it was not abuse related incident therefore it was not reported to NYS DOH. During an interview on 3/28/23 at 1:05 PM, the Director of Nursing (DON) stated that the resident's injury was not reported because the supervisor was able to assess the ecchymosis and formulate the conclusion that it was from the way resident was leaning to the side while in the wheelchair. The DON also stated it was not suspected as a case of abuse so therefore, it was not reported to the NYS DOH. During an interview on 3/28/23 at 2:25PM, the Administrator stated that the incident was not reportable to the NYS DOH. 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during the Recertification survey conducted from 3/21/23 to 3/28/23, the facility did not ensure that the assessment accurately reflected the resident's status. This was evident for 1 of 5 residents reviewed for Unnecessary Medication (Resident #228). Specifically, the Minimum Data Set 3.0 (MDS) assessment inaccurately documented that a Gradual Dose Reduction (GDR) of psychotropic medication was attempted on 2/9/23. The findings are: The facility's policy and procedure titled MDS 3.0 Completion and Electronic Submission reviewed 1/24/22 documented the MDS shall be completed on every resident according to regulatory guidelines as set forth in RAI Manual, version 3.0. Resident #228 was admitted to the facility with diagnosis of Non-Alzheimer's Dementia, Hyperlipidemia, and Hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #228 had severely impaired cognition, received antipsychotic and antidepressant on 7 of 7 days, and that a Gradual Dose Reduction (GDR) was attempted on 2/9/23. The psychiatry note dated 2/6/23 documented resident's mood is depressed, and sleep is poor. Currently on Melatonin 10 mg once daily, Sertraline 50 mg once daily, Seroquel (Quetiapine) 25 mg once daily. The note also documented to continue the current medications to manage mood, anxiety, insomnia and suggested to increase Sertraline to 100 mg po q HS. The psychiatry note dated 3/21/23 documented resident currently on Seroquel (Quetiapine) 25 mg once daily, Sertraline 100 mg once daily, Melatonin 10 mg once daily. It further documented to consider lowering Seroquel to 12.5 mg q HS. The medical order initiated 1/4/23 documented Resident #228 was prescribed Seroquel (Quetiapine) 1 tablet 25 mg at bedtime for psychosis which was discontinued 2/9/23. The medical order initiated 2/9/23 documented Seroquel 1 tablet 25 mg at bedtime which was discontinued 3/22/23. A review of the Medication Administration Record (MAR) for January, February, and March 2023 revealed Resident #228 received Seroquel 1 tablet (25 mg) at bedtime from 1/4/23 to 3/21/23. There was no documented evidence that a GDR of Seroquel was conducted on 2/9/23. During an interview on 3/28/23 at 11:46 AM, the Consultant Pharmacist (CP) stated Resident #228 is prescribed Seroquel and Sertraline. GDR is usually recommended for antidepressant, antipsychotic medications as per CMS guideline but it was not recommended for this resident. The CP further stated that the Sertraline's dosage was increased recently, and dosage reduction was not yet recommended for Seroquel. During an interview on 3/28/23 at 2:25 PM, Assistant Director of MDS (ADMDS) stated that upon review of Resident #228's electronic medical record, there was no GDR conducted for Sertraline or Seroquel. The ADMDS also stated that it was an oversight and that it should have not been documented on the MDS. The ADMDS further stated that they are currently doing monthly audits for timeliness of the assessment and accuracy During an interview on 3/28/23 at 1:05 PM, the Director of Nursing (DON) stated that they were not aware that the information coded in the MDS assessment was not accurately reflected for Resident #228. 415.11 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #248 was admitted to the facility with diagnosis of Chronic Atrial Fibrillation, Coronary Artery Disease, and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented resident received 7 days of anticoagulant. The medical order initiated 1/10/23, renewed 3/19/23 documented Resident #248 to receive Warfarin Sodium 1 tablet (2.5 mg) at bedtime. A review of the Medication Administration Record for January, February and March 2023 documented that resident received Warfarin Sodium 1 table (2.5 mg) once daily during the months of January, February, and March 2023. Review of the Comprehensive Care Plan (CCP) revised 3/10/23, revealed there was no documented evidence that a care plan for anticoagulant use was not developed. During an interview on 3/28/23 at 10:42 AM, RN Manager (RN #2) stated that Resident #248 has been on the unit since admission and had been on Coumadin and was tested for PT/INR weekly. RN #2 also stated that they were not aware that there was no care plan developed for anticoagulant use for Resident #248. RN #2 acknowledged that it was missed by a mistake and that it will be developed right away. During an interview on 3/28/23 at 1:05 PM, the Director of Nursing stated that they were not aware that there was no care plan developed for anticoagulant for Resident #248. 415.11(c)(1) Based on observation, record review and staff interviews conducted during the Recertification/ Complaint survey, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, 1). a CCP was not developed and implemented for a resident prescribed an antibiotic for chronic Urinary Tract infection (UTI); and 2). a CCP was not developed and implemented for resident's use of Anticoagulant therapy. This was evident for 1 of 1 resident reviewed for Antibiotic Use (Resident #85) and 1 of 1 resident reviewed for Anticoagulant (Resident #248), out of a sample of 38 residents investigated. The findings are: The facility policy and Procedure titled Multidisciplinary Comprehensive Care Plan/Minimum Data Set dated 02/09/2010, approved 01/2022 documented: .That a coordinated CCP for each resident is to be developed, documented, and maintained .consonant with both the attending physician's plan of medical care and Minimum Data Set to assist the individual resident to reach maximum progress toward meeting his/her goals or objectives . That the care plan will be developed and updated on significant change of resident's condition to assist the individual to reach maximum progress towards meeting his/her goals or objectives, for safety and for remedy of symptoms of illness. 1. Resident #85 was admitted to the facility 04/27/2018, with diagnoses that included Cancer, Anemia, Peripheral vascular disease (PVD), Diabetes, Neurogenic bladder, Anxiety disorder, Asthma (COPD) or chronic lung disease. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had intact cognitive status and documented the resident required extensive assistance of staff for most activities of daily living and had an indwelling catheter. The Comprehensive Care Plan (CCP) for Catheter dated 01/23/2022, last revised 10/5/2022 documented that Resident has a Suprapubic Catheter r/t Neuromuscular dysfunction of bladder. Goals included that the resident will be/remain free from catheter-related trauma through review date, and will show no sign/symptoms of Urinary infection through review date. Interventions included position catheter bag and tubing below the level of the bladder, change catheter monthly, monitor/document for pain/discomfort due to catheter, and monitor/record/report to MD for signs and symptoms of UTI. The Order Summary Report which listed medications active as of 3/24/23 documented the following: Methenamine Hippurate Tablet 1 GM 1 tablet by mouth two times a day for UTI with an order start date of 6/16/2022; Acidophilus Tablet (Lactobacillus) 1 caplet by mouth two times a day for PROPHYLAXIS with order start date of 1/6/2022; Furosemide 40mg 1 tablet orally one time a day for HTN (hypertension) with an order start date of 1/6/22. The Medication Administration Record dated 3/1/23 to 3/31/23 documented that resident received Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) 1 tablet by mouth two times a day for UTI for 7 days starting 3/12/23 and Keflex 500mg po QID x 7 days for pustules starting 2/23/23. Progress note Nursing-Health Status Note dated 2/23/2023 documented: Resident noted with pustules on her buttocks bilaterally and some noted in inner thighs. Seen and evaluated by the doctor, ordered Keflex 500mg po QID x 7 days. Progress note Nursing-Order Note dated 2/23/2023 documented: The order you have entered Keflex Oral Capsule 500 MG (Cephalexin) 1 capsule by mouth every 6 hours for pustules for 7 Days .Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction .The system has identified a possible drug interaction with the following orders: Furosemide 40mg 1 tablet orally one time a day for HTN; Severity: Moderate Interaction: Furosemide may enhance the nephrotoxic effect of cephalosporins (eg, Cephalexin Oral Capsule 500 MG and Keflex Oral Capsule 500 MG). Progress note Medical dated 3/12/2023 documented: Patient with recurrent pustular outbreak, now on mid back with some erythema; Also noted to have dark urine, cloudy; Start BACTRIM DS Bid X 7 days; Check Urine. Progress Note Nursing-Order Note dated 3/12/2023 documented: .Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) 1 tablet by mouth two times a day for UTI for 7 days has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. The system has identified a possible drug interaction with the following orders: Methenamine Hippurate Tablet 1 GM 1 tablet by mouth two times a day for UTI Severity: Moderate; Interaction: Co-administration of methenamine and sulfonamides may be contraindicated due to the potential for formation of insoluble precipitates in the urine. There was no documented evidence of interventions in place to address the use of the antibiotic therapy and the potential drug to drug interactions warnings triggered in the resident's plan of care. On 03/27/23 at 11:18 AM, an interview was conducted with Licensed Practical Nurse (LPN) #1 who stated that Resident #85 started Bactrim DS on 3/12/2023 and completed 3/19 2023 for UTI; was on Keflex 500mg Q6H for Pustules, started 2/23/2023, completed 3/2/2023, and currently taking Methenamine started 6/16/2022 prophylactic UTI. LPN #1 also stated that they are not sure if there is a care plan for the medication because they do not normally check the resident's care plan. LPN #1 further stated that RN Manager or RN Supervisor are responsible for the residents' care plans. On 03/27/23 at 11:28 AM, an interview was conducted with the Registered Nurse Supervisor (RN) #1 who stated that Bactrim was ordered for Resident #85 for UTI, and completed, and the resident is currently taking Methenamine for UTI prophylactically. RN #1 also stated that the care plan for the Bactrim and Methenamine should have been initiated by the Unit Manager when the medications were started. RN #1 further stated that they do not know why it was not initiated, because they cover all the units of the facility, and they were not aware that the care plan was not in place for the resident. On 03/28/23 at 12:06 PM, an interview was conducted with the RN Manager, (RN #2) who stated that Resident #85 has chronic UTI and has been on the antibiotic for prophylaxis, which started in June last year and renewed in September 2022 after the Urology consult. RN #2 also stated that the care plan should have been in place for the antibiotic. RN #2 further stated: I don't know how I missed the care plan initiation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification survey conducted 3/21/23 to 3/28/23, the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene. This was evident for 1 of 7 residents (Resident #11) reviewed for ADLs. Specifically, Resident #11 did not consistently receive a shower twice weekly as scheduled. The findings are: The facility policy and procedure titled Provision of ADL care, approved 12/20/11, documented the facility has protocols in place to ensure that residents receive ADL care. The licensed nurse (LPN) develops a plan of care with the resident and communicates it to CNAs, who provide grooming and hygiene and document all care provided to residents during their shifts. ADLs include personal hygiene and toilet management among others. Resident #11 was admitted with diagnoses which included Hemiplegia, Seizures, and Ataxia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented resident had intact cognition and required extensive assistance for dressing, toilet use and bed mobility, and total assistance for bathing. The MDS also documented no rejection of care occurred. Resident #11 was interviewed on 03/21/23 at 03:18 PM, 03/24/23 at 10:02 AM, and 03/28/23 at 11:01 AM. Each time, Resident #11 complained about the care received at the facility specifically, Resident #11 expressed frustration at their shower schedule not being honored and having to wait a long time for care. The Comprehensive Care Plan (CCP) the resident has an ADL self-care performance deficit created on 9/19/22 and revised on 1/26/23, documented Resident #11 required extensive assistance of 1 person for dressing, toilet use and personal hygiene. The Documentation Survey Report for March 2023 documented Resident #11 was scheduled to receive showers every Wednesday and Saturday evening, but received only 4 showers between 3/1/23 and 3/26/23 (on 3/2, 3/8, 3/15 and 3/25.) There was no documentation of Resident #11 refusal of care on the documentation survey report or in the progress notes section of the medical record. On 03/28/23 at 11:17 AM, Registered Nurse (RN) #5 (who is the charge nurse for the morning shift) was interviewed and stated that CNAs are supposed to document the tasks they complete. If a resident refused a shower they should document on their task and notify the nurse in charge, who writes a note in the chart about the refusal. RN #5 also stated the evening nurse may know why showers were not documented. On 03/28/23 at 11:55 AM, RN #1 was interviewed and stated they were not aware that Resident #11 had a concern about not receiving showers. RN #1 also stated that if a resident complains to them, they will talk to the resident first and then conduct an investigation but they did not recall getting a complaint from this resident. RN #1 further stated that the staff knows they are supposed to notify them but sometimes they notify the Assistant Director of Nursing directly. On 03/28/23 at 12:07 PM an interview was conducted with the Assistant Director of Nursing (ADON) who stated residents usually get 2 showers per week. If a resident refuses a shower the CNA should tell the nurse and it should be documented. The CNA documents it on the CNA accountability and the nurse documents it on a progress note. The ADON also stated if it's not signed, it's not done and they would have to talk to the CNAs to see what happened. On 03/28/23 at 03:12 PM, Certified Nursing Assistant (CNA) #7 was interviewed and stated that they were assigned to Resident #11 on the evening shift and they had cared for the resident in the past CNA #7 stated Resident #11 required extensive assistance for toileting and receives showers on Wednesdays and Saturdays, usually before dinner. CNA #7 also stated that Resident #11 had only refused a shower with them once when they were not feeling well. CNA #7 further stated they document giving showers on the resident's chart and if a resident refuses they also document that and inform the nurse. CNA #7 further stated that when there are only 3 CNAs assigned to the floor it is hard to give all residents their shower. In that case, CNA #7 offers the residents a bed bath, and usually they accept and this is documented the same as a shower. On 03/28/23 at 03:22 PM, Licensed Practical Nurse (LPN) #3 was interviewed and stated if residents refuse their shower, the CNAs inform them and they document it in a progress note. LPN #3 also stated that they did not recall any refusals from Resident #11 and maybe the CNA did not document a shower that was given. Sometimes the CNAs offer a bed bath and may not document it. LPN#3 further stated it has been hard, but doable, to complete all the residents' showers when there are only 3 CNAs assigned to the floor, but as far as they know, residents have been getting their showers. 415.12 (a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey conducted from 3/21/23 to 3/28/23, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. This was evident for 1 of 1 resident (Resident #71) reviewed for Respiratory Care out of a total sample of 38 residents. Specifically, Resident #71 had a Physician's order to receive 2 liters of oxygen per minute continuously and was observed receiving 4 liters of oxygen per minute on four consecutive days. The findings are: The facility policy and procedure titled Administration of Oxygen, dated 2/2023, documented that a licensed nurse would administer oxygen (O2) in accordance with the physician's orders. The policy further stated that the licensed nurse should monitor the administration of oxygen and check the equipment daily. The charge nurse/ unit manager ensures that staff members under their supervision follow this policy and procedure. Resident #71 was admitted with diagnoses including respiratory failure, chronic kidney disease and hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition and was receiving oxygen therapy. The Physician's Order dated 9/3/22 documented to administer oxygen at 2 liters per minute (LPM) via a nasal cannula every shift. The Comprehensive Care Plan (CCP) for oxygen therapy dated 09/04/22 documented to provide oxygen as per the Physician's orders. On 03/21/23 at 12:01 PM, Resident #71 was observed in bed in their room. Resident #71 was using a nasal cannula that was attached to an oxygen concentrator at the resident's bedside. The display window on the oxygen concentrator indicated Resident #71 was receiving 4 liters of oxygen per minute (LPM). The resident declined to be interviewed. On 03/22/23 at 10:05 AM, Resident #71 was observed sitting in the wheelchair in their room. Resident #71 was using a nasal cannula that was attached to an oxygen concentrator which showed a flow rate of 4 LPM. On 03/23/23 at 11:15 AM, Resident # 71 was observed again receiving oxygen via nasal cannula at a flow rate of 4 LPM. Resident #71 stated that oxygen helps them breathe better. On 03/24/23 at 09:57 AM, Resident # 71 was observed asleep in bed while using a nasal cannula that was attached to an oxygen concentrator, which showed a flow rate of 4 LPM. During an interview on 03/24/23 at 11:12 AM, Licensed Practical Nurse (LPN) #2 stated the overnight nurse connects the oxygen, and the morning shift nurse checks that oxygen administration is correct. LPN #2 also stated they checked the oxygen rate in the morning, and it was 2 liters per minute. When requested to verify the oxygen rate for resident #71 with surveyor, LPN #2 went into the room ahead of surveyor and adjusted the oxygen concentrator dial while obstructing the view of the concentrator with their body, then stated it was between 2 and 3 LPM. LPN #2 stated that sometimes at night, Resident #71 will complain of shortness of breath, so nurses call the doctor, and the doctor tells them to increase the O2 rate. The charge nurse would document it on the chart. LPN #2 could not explain why Resident #71 had been receiving oxygen at a different flow rate from that prescribed by the physician. There was no documented evidence that Resident #71 complained of shortness of breath or had respiratory symptoms in the previous 2 months, and there was no documentation of communications with the physician regarding respiratory care for the resident. On 03/24/23 at 11:19 AM, Registered Nurse (RN) #5 was interviewed and stated that administration of oxygen would be documented in the Treatment Administration Record (TAR). Nurses administer the oxygen and the CNAs do not touch the equipment. CNA's can fix the cannula, or they would let the nurses know if there are any issues with the oxygen equipment. RN #5 stated they do not regularly supervise the LPNs to see they are administering the right rate of oxygen as the nurses are responsible for checking the oxygen flow rate. On 03/28/23 at 12:16 PM, the Assistant Director of Nursing (ADON) was interviewed and stated that the RNs are responsible for administering oxygen. LPNs can also administer oxygen, following doctors' orders. Nurses sign on the TAR that they check the oxygen on every shift and confirm that the oxygen rate is according to the doctors' orders. The ADON further stated that they provide education, in-services with the staff. 415.12 (k)(6)

Based on observations, record review, and interviews conducted during the recertification survey from 3/21/2023 to 3/28/2023, the facility did not ensure an account of all controlled drugs was maintained and periodically reconciled. This was evident for 1 of 6 units (Unit 3E) observed for Medication Storage. Specifically, a Registered Nurse (RN) on Unit 3E did not reconcile a narcotics supply count. The findings are: The facility policy titled Medication Ordering/Administration and Electronic Recordation date approved 2/2023 documented at the time of administration, in addition to initializing the blister pack and Medication Administration Record, the Controlled Record is completed for each dosage. Resident #247 had diagnoses of Type 2 diabetes mellitus, Peripheral Vascular disease, and Necrotizing Fasciitis. A Physician Order dated 02/27/2023 documented Resident #247 was prescribed Oxycodone HCL 5mg give I tablet by mouth every 4 hours as needed for pain. The Medication Administration Record (MAR) dated 3/24/2023 documented Resident #247 was given 1 tablet of Oxycodone 5 mg at 8:58 AM. The Narcotic Form (NF) was not completed to reflect Resident #247 was given 1 tablet of Oxycodone 5mg on 3/24/2023 at 8:58 AM and 16 tablets were remaining. On 3/24/2023 at 10:00 AM, Registered Nurse (RN) #6 was interviewed and stated Resident #247 was given Oxycodone 5mg at 8:58 AM and RN #6 did not sign the NF form updating the tablet count because he/she was planning to sign this medication out at the end of their shift before the narcotics count at the change of shift. On 3/28/2023 at 10:50 AM, RN Supervisor (RNS) #9 was interviewed and stated RN #6 should have updated and signed the NF form after administering Resident #247's medication. RN #6 was recently hired and has previously completed medication pass and has been instructed on this. On 3/28/2023 at 12:34 PM, the Director of Nursing (DON) stated we instruct the nurses to sign the control sheet at same time that medication is administered and conduct annual and as needed in-services on medication administration. 415.18(b)(1)(2)(3)

Based on record review and staff interviews conducted during the Recertification survey conducted from 3/21/23 to 3/28/23, the facility did not ensure that a medication regimen review (MRR) performed by the consultant pharmacist was reviewed and acted upon by the attending physician or medical director in a timely manner. This was evident for 1 of 5 residents reviewed for Unnecessary Medications Review out of a total sample of 39 residents (Resident #228). Specifically, a pharmacy recommendation to perform a lipid panel for Resident #228 was agreed upon by the Attending Physician (AP), but the test was not completed. The findings are: The facility's policy and procedure titled Drug Regimen Review revised 1/23 documented that the consultant pharmacist performs a comprehensive drug regimen review (DRR) at least monthly on all residents. The DRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Resident #228 was admitted to the facility with diagnoses that included Non-Alzheimer's Dementia, Hyperlipidemia, and Hypertension. The physician order, initiated 10/25/22 and last renewed 3/2/23, documented Resident #228 was prescribed Simvastatin 1 tablet 40 mg at bedtime for hyperlipidemia (HLD). The Medication Regimen Review (MRR) report dated 12/30/22 documented that Resident #288 has been maintained on Simvastatin and recommended to order lipid panel. The Attending Physician (AP) signed the report and responded, will order. There was no documented evidence that a lipid panel was ordered since recommendation on 12/30/22. The Medication Regimen Review (MRR) report dated 2/28/23 documented that lipid panel was not ordered as per last MRR. The Medical Director signed the report and responded ordered The physician orders initiated 3/2/23 documented lab order for a cholesterol one time only related to hyperlipidemia. The order status was documented as Pending Order Signature There was no documented evidence the lab ordered on 3/2/23 was ever completed. A review of the interdisciplinary progress notes and laboratory result reports from 12/30/22 to 3/7/22 revealed there was no documented evidence a lipid panel test was done. Additionally, there was no documented evidence Resident #228 refused to have the lab tests performed. During an interview on 3/28/23 at 11:46 AM, the Consultant Pharmacist (CP) stated that medications are reviewed monthly, and any irregularities/recommendations will be submitted to the Director of Nursing, Medical Director, and Administrator. The CP also stated that on 12/28/22, a lipid panel was recommended for Resident #228 since resident is on Simvastatin. Lipid panel testing was recommended again on 2/28/23 because the initial recommendation of lipid panel testing dated 12/28/22 was agreed on but not ordered by the attending physician. The CP further stated that there was an order for cholesterol lab test initiated on 3/2/23 but they did not know if this had been completed. During an interview on 3/28/23 at 11:40 AM, the Attending Physician (AP) stated they did not agree with the pharmacist's recommendation of ordering lipid panel test because resident had been on this medication for a while and had been stable. The AP was unable to explain why they documented will order in response to pharmacist's recommendation dated 12/30/22. The AP also stated that if they did not agree with the pharmacist's recommendation, that should have been reflected in their response. The AP further stated it was the Medical Director who reviewed pharmacist's recommendation made on 2/28/23 and that lipid testing was ordered in response to the recommendation according to the electronic medical record. During an interview on 3/28/23 at 1:46 PM, the Medical Director (MD) stated that they are responsible for overseeing 9 physicians and 2 nurse practitioners working in the facility. The MD also stated that when they reviewed the February 2023 MRR for Resident #228 the test was ordered immediately, however they did not know that the order did not go through. The MD further stated they have recently started to do weekly audits for MRR. 415.18(c)(2)

Based on observations, record review, and interviews conducted during the recertification survey from 3/21/2023 to 3/28/2023, the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. This was observed on 1 of 6 units during the Medication Storage task (Unit 3). Specifically, one vial of expired influenza vaccine was stored in the medication storage room refrigerator on Unit 3. The findings are: The facility policy titled Expired Medication Protocol reviewed 6/2022 documented outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock and disposed of according to procedures for medication disposal, must then be reordered if a current order does not exist. The policy did not document when opened vials of Influenza vaccines should be discarded. On 3/24/23 at 10:57 AM, an Afluria Influenza Vaccine Quadrivalent multidose vial was observed punctured in the Medication Room refrigerator on Unit 3. The open date on the vial box was documented as 1/14/2023 with a manufacturer's expiration date of 6/30/2023. The Afluria Influenza Vaccine Manufacturer's Package insert documented once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days. An interview was immediately conducted with Registered Nurse (RN) #8 who stated that they were instructed they can store vial for 1 year in the refrigerator and was not aware it should be discarded after 28 days after first puncture. On 3/28/2023 at 10:50 AM, Registered Nurse RNS #9 was interviewed and stated we are supposed to discard the influenza vial 28 days after the first time we puncture it. The nurses have all been inserviced on this in the past. RN #9 further stated all nurses are responsible for checking medication rooms and carts for expired medications. On 3/28/2023 at 12:34 PM, the Director of Nursing (DON) was interviewed and stated we re-educated the nurses that the flu vaccine when punctured is to be discarded in 28 days. The DON also stated that usually the Infection Preventionist (IP) administers the flu vaccine, and it is not kept on the units. 415.18(e) (1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification survey from 3/21/23 through 3/28/23, the facility did not ensure that it promoted and facilitated resident self-determination by supporting resident choice. Specifically, residents' bathing preferences were not honored. This was evident for 2 of the 2 residents reviewed for Choices out of 38 sampled residents. (Resident #5, and #22). The findings are: 1. Resident #5 was admitted to the facility with diagnoses that included Multiple Sclerosis, Quadriplegia, and Trigeminal Neuralgia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 as cognitively intact and dependent on staff for Activities of Daily Living (ADLs). The MDS documented that no rejection of care occurred. The Annual MDS assessment dated [DATE] documented that it is very important for Resident #5 to choose between a tub bath, shower, or sponge bath. On 03/21/23 at 11:12 AM, an interview was conducted with Resident #5. Resident #5 stated that they are supposed to get a shower two times a week, Tuesdays, and Fridays, but they do not get the showers as scheduled. Resident #5 also stated that today is Tuesday and it is 11'o'clock but they had not received a shower and did not think they would get the shower. On 03/22/23 at 10:05 AM, Resident #5 was observed out of bed in a wheelchair in the room, appropriately dressed and groomed and stated they did not get a shower yesterday and said, I hope I will get it on Friday. On 03/24/23 at 9:59 AM, Resident #5 was observed resting in bed. The resident stated that today is Friday, and they are supposed to get a shower but do not think they will get the shower. On 03/24/23 at 11:43 AM, Resident #5 was observed resting in bed, well-groomed, and stated that they were given a bed bath. Resident # 5 also stated that they used to get showers two times a week when they first came to the facility and prefer to take a shower, but now they do not get the shower. Resident #5 stated that they had received a shower once this month. The Documentation Survey Report for Resident #5 dated January 2023, February 2023, and March 2023 documented bathing; prefers to shower every Tuesday and Friday 7-3 shift. The Documentation Survey Report dated 3/1/23 to 3/24/23 documented that bathing occurred on 3/10/23, 3/17/23, and 3/24/23 but did not specify whether a shower or a bed bath was given. The Documentation Survey Report dated 2/1/23 to 2/28/23 contained no documented evidence that showers, or bed baths had occurred. The Documentation Survey Report dated 1/1/23 to 1/31/23 documented that bathing occurred on 1/17/23 but did not specify whether a shower or a bed bath was given. Progress notes dated 1/1/23 to 3/24/23 contained no documented evidence that Resident #5 had been offered and/or refused showers. On 03/24/23 at 12:20 PM, an interview was conducted with Certified Nursing Assistant (CNA) #4 who stated that Resident # 5 is scheduled for showers on Tuesdays and Fridays during the day shift. Resident #5 was given a bed bath, which was documented in the shower column. There is no column for the bed bath. CNA #4 also stated Resident #5 was given a bed bath today because the resident did not shower as the resident said they did not want the shower. On 03/27/23 at 11:53 AM, an interview was conducted with CNA #5 who stated that Resident #5 had a bed bath last Tuesday because it was hectic, so CNA #5 could not give the resident shower. CNA #5 also stated they could not remember when last they gave Resident #5 a shower. CNA #5 further stated that Resident #5 refuses to shower at times and a bed bath is given when the resident refuses to shower although the resident does prefer the shower sometimes. CNA #5 stated that the shower and bed bath are all documented under the same column and the nurse is informed when a bed bath is given instead of a shower. CNA #5 also stated that gets too busy sometimes and they do not document whether showers were done. On 03/24/23 at 12:37 PM, an interview was conducted with the Registered Nurse Manager (RN #3) who stated that the care plan for Resident #5 documents showers two times a week but they are unsure if Resident #5 had a shower on Tuesday because they did not physically see the resident going to the shower room. The CNAs will give a shower and sign it in the kiosk. The CNAs inform the manager if they do not provide the shower and RN #3 depends on the CNAs to let them know when a resident refuses to shower. RN #3 also stated that they would assume that the shower was given if the CNA did not tell them that the resident refused to be showered and they would provide a bed bath if the resident refused to shower. RN #3 further stated that Resident #5 refused to shower this morning but they did not know why CNA #4 signed that the resident had a shower. 2. Resident #22 was admitted to the facility with diagnoses that include Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, and Anxiety disorder. The Quarterly MDS assessment dated [DATE] identified Resident #22 as moderately impaired and required extensive assistance from one person for bed mobility and personal hygiene and that no rejection of care occurred. The Annual MDS assessment dated [DATE] documented that it is very important for Resident #22 to choose between a tub bath, shower, bed bath, and sponge bath. On 3/23/23, during a Resident Council interview at 11:05 AM, Resident #22 said that they are supposed to shower twice a week but do not get the shower twice a week. The last time they had a shower was on 3/5/23. Resident #22 stated they were given a bed bath, but it is not enough. The Documentation Survey Report for Resident #22 dated January 2023, February 2023, and March 2023 documented for bathing that resident preferred to shower every Wednesday and Saturday during the day shift. The Documentation Survey Report for Resident #22 dated 3/1/23 to 3/25/23 documented that bathing occurred on 3/1/23, 3/4/23, 3/22/23, and 3/25/22 but did not specify whether a shower or a bed bath was given. The Documentation Survey Report dated 2/1/23 to 2/27/23 documented that bathing occurred on 2/1/23, 2/22/23, and 2/25/23 but did not specify whether a shower or a bed bath was given. The Documentation Survey Report dated 1/1/23 to 1/30/23 documented that bathing occurred on 1/7/23, 1/11/23, 1/21/23, and 1/25/23 but did not specify whether a shower or a bed bath was given. Progress notes dated 1/1/23 to 3/24/23 contained no documented evidence that Resident #22 had refused showers. On 03/28/23 at 1:02 PM, an interview was conducted with RN Manager (RN #4) who stated that Resident #22 is scheduled for showers on Wednesday and Saturday during the day shift and Resident # 22 refused to shower at times. RN #4 also stated that the CNAs do not document if the shower was given or not given. RN #4 further stated that they are responsible for ensuring that the CNAs provide the shower and document it appropriately and the CNAs should have informed RN # if they could not give a shower. On 03/28/23 at 2:19 PM, an interview was conducted with the Director of Nursing (DON) who stated that showers and the bed bath are documented in the same column. The CNAs reports to the RN Manager (RNM) when a resident refuses to shower. The DON also stated that they did not know why the staff recorded NA at times. The RNM is responsible for ensuring that the showers are given and documented. The DON further stated they did not know why the CNAs did not document showers for Resident # 5 in February. On 03/28/23 at 2:49 PM, an interview was conducted with the Administrator. The Administrator stated they are not aware that the residents have complaints of not getting showers as this concern had not been brought it up in the Resident Council meeting. 415.5(b) (1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews conducted during the Recertification survey from 3/21/23 to 3/28/23, the facility did not ensure that resident or resident's representative were offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, resident and resident's representatives were not consistently invited to participate in their care plan meetings and a care plan was not revised to reflect use of a hand roll. This was evident for 3 of 3 residents reviewed for Care Plan, and 1 of 2 residents reviewed for Position/Mobility out of 38 residents sampled (Residents #9, #155, #250 and #153). The findings are: The facility policy and Procedure titled Multidisciplinary Comprehensive Care Plan/Minimum Data Set dated 02/09/2010, approved 01/2022 documented: That there shall be an Interdisciplinary Team which develops a comprehensive Care Plan (CCP) composed of representatives from the following departments .That the participation of the resident/resident's family/or the resident's representative shall be facilitated 1. Resident #250 had diagnoses which included Fracture of right femur, Dysuria, and Depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #250 was cognitively intact, and Section Q of the MDS documented that the resident and family or significant other had participated in the assessment. On 3/22/2023 at 10:43 AM, Resident #250 was interviewed and stated that they have not been invited to a care plan meeting since admission in October 2022. A Social Service (SS) progress note dated 3/10/2023 documented spoke with Resident #250's child to discuss resident's progress with therapy and Resident will discharge home once services are in place. A SS CCP meeting invitation note undated documented Resident #250 was invited to a Care Planning Conference which will be held via telephone on 11/15/22 at 10:15 AM and to call phone number on invitation if planning to attend meeting. There was no documented evidence in the medical records that Resident #250 participated in the review and revision of comprehensive care plans or attended admission and quarterly care plan meetings. On 3/28/2023 at 12:02 PM, Social Worker (SW) #3 was interviewed and stated residents and their representatives are invited to Admission, Annual, and Significant Change Care Plan Meetings, and are not invited to participate in quarterly meetings. We had Resident #250's Quarterly Care Plan Meeting this month with the Interdisciplinary Team (IDT). There was no formal meeting held with resident or family. After our quarterly meeting, I called the resident's family to provide updates. On 3/28/2023 at 1:11 PM, the SW Director (SWD) was interviewed and stated residents and families are not invited to Quarterly Care Plan Meetings which is our policy. After we receive information from IDT as they do their quarterly, we reach out to the resident and family just for input, discuss changes, and to let them know we are reviewing CCP. We mail out formal invitations to families and residents to attend Admission, Annual, and Significant Change Care Plan Meetings. Since we changed our Electronic Medical Record (EMR) to Point Click Care (PCC), there is no signage record documenting attendance. The SWD further stated that Resident #250 is a short-term rehab resident so there was a lot of back and forth with the family on an ongoing basis.2. Resident #9 was admitted to the facility with diagnoses that included Paraplegia, Multiple Sclerosis, Anxiety disorder, and Depression. On 03/21/23 at 10:51 AM, Resident #9 was observed in their room and during interview stated that they have been in the facility for about 20 years and cannot remember the last time they were invited for a care plan meeting. The Annual Minimum Data Set (MDS) dated [DATE] documented the resident had intact cognition status (BIMS 13). MDS documented that resident, family or significant other participated in assessment. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had moderate impairment in cognition (BIMS 12). MDS documented that resident, family or significant other participated in assessment. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had moderate impairment in cognition; had clear speech, with distinct intelligible words, makes self-understood, and understands others. The MDS documented the resident required extensive assistance of staff for most activities of daily living and that resident, family or significant other participated in assessment. There was no documented evidence that resident or their representative were afforded the opportunity to participate in the review and revision of the care plans. 3. Resident #155 was admitted to the facility with diagnoses that included Peripheral Vascular Disease, Cerebrovascular accident, and Depression. On 03/21/23 at 11:22 AM, Resident #155 was interviewed and stated that they have been in the facility for over 4 years, they have not been invited to a care plan meeting. The Quarterly Minimum Data Set (MDS) assessments dated 10/08/2022, 12/09/2022 and 03/06/2023 documented the resident has intact cognitive status. The MDS also documented that the resident, family or significant other participated in assessment. There was no documented evidence that resident or their representative were afforded the opportunity to participate in the review and revision of the care plans. On 03/24/23 at 11:19 AM, an interview was conducted with the Registered Nurse Manager (RN #2) who stated that the Social Worker (SW) organizes the are planning meeting, sends letters to the resident's family members, and the nurse or the SW will inform the alert residents. RN #2 also stated that each department writes a note in the multidisciplinary section to indicate the resident/family member that participated in the meeting. On 03/24/23 at 11:31 AM, an interview was conducted with Social Worker (SW) #1 who stated that residents are only invited for admission, annuals, and significant change meetings. SW #1 also stated that resident and family members are not being invited for quarterly meetings, and no invitation is sent out to the resident's family/representative to attend the quarterly meeting. Residents are only assessed for BIMS, and the multidisciplinary team meet to discuss and review the resident's care. SW #1 further stated that for the past 27 years they have been working in the facility, residents and resident's family/resident's representatives are not invited to attend the quarterly care plan meetings, but they are called to update them about the resident's care. On 03/28/23 at 10:11 AM, an interview was conducted with Associate Director of MDS (ADMDS) who stated that residents and their representatives are invited to initial, significant change and annual care plan meetings, but not to quarterly meetings. The ADMDS stated that there is no invitation that goes out to the resident/resident's family for quarterly assessments, they only speak with the family members on the phone during the residents' quarterly assessments. The Administrator was interviewed on 03/28/23 at 04:14 PM and stated that residents and their family members are invited to attend the initial, significant change and annual care plan meetings; they are only called on the phone to update them about the resident's care during the quarterly assessments. The facility policy and Procedure titled Multidisciplinary Comprehensive Care Plan/Minimum Data Set dated 02/09/2010, approved 01/2022 documented that the CCP which reflects multidisciplinary assessments is developed upon admission. Each 90 days it is reviewed, discussed, revised, and recorded as appropriate. The policy also documented that episodic events will be reviewed as needed. Resident #153 was admitted to the facility with diagnoses that included Parkinson's disease, Anxiety disorder, and Depression. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had intact cognitive status. The MDS also documented that the resident required extensive assistance of two staff for most activities of daily living and had no impairment on either extremity. The Comprehensive Care Plan for Limited Mobility dated 1/13/2023 documented: Resident has limited physical mobility r/t Weakness and included goal of resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Interventions included OOB (out of bed) to standard wheelchair with pressure reducing cushion, gentle AROM / AAROM to all four extremities BID as tolerated, and Feeding Device: non-spill sip cup and lip plate during meals. On 03/21/23 at 09:54 AM and at 11:54 AM and 12:58 PM, Resident #153 was observed sitting in wheel chair in the room, and noted with contracture on left hand with no device present. Resident was interviewed and stated that the hand roll is sometimes applied by the staff, but not all the time. Resident #153 further stated that they would prefer the special device Carrot shaped brought by the family which holds well. On 03/22/23 at 09:40 AM, Resident was observed in bed, with roll gauze placed on left hand. On 03/23/23 at 08:28 AM, Resident #153 was observed in bed sleeping, with no device noted on resident's hand. On 03/23/23 at 11:34 AM, Resident #153 was observed out of bed and in a wheelchair. No hand roll was applied and Resident stated it had not been given. On 03/23/23 at 01:03 PM, 03/24/23 at 08:54 AM, and 03/27/23 at 09:20 AM, Resident #153 was observed with no hand rolls in place. The Physician's order dated 9/2/2022 documented to cleanse left hand with soap and water, dry well; Apply dry Kling roll into palm of left hand secondary to contracture/prevention. There was no documented evidence that resident's plan of care had been revised to include hand roll placement on the resident's left-hand. On 03/27/23 at 10:19 AM, an interview was conducted with the Certified Nursing Assistant, (CNA) #3 who stated that I think it is the therapist that applies the roll. CNA #3 also stated that they have not been told to place the roll, and it is not in the accountability record to apply it on the resident. CNA #3 further stated that they have not gone to the resident yet today and was not aware that resident was not having the roll in place, the roll is usually taken off during care and put back when resident is taking out of bed. CNA further stated that resident sometimes removes the roll and places it by the bedside. On 03/27/23 at 11:09 AM, an interview was conducted with the Licensed Practical Nurse (LPN) #1 who stated that resident has an order for the treatment of the right hand - to cleanse hand daily and give roll gauze for the resident to hold. LPN #1 stated that the treatment nurse is supposed to do the treatment, and the unit Manager is expected to care plan the treatment for the hand roll, but not sure if it is in the care plan. On 03/28/23 at 08:37 AM, an interview was conducted with Wound Nurse RN, RN #11 who stated that they are responsible to ensure that the resident's care plan related to skin condition is in place when there is a new order. RN #11 also stated that Resident #153 has had increased rigidity due to Parkinson disease, and an order was given for treatment on the affected hand to prevent further skin irritation. RN #11 was unable to explain why hand roll was not documented in the resident's care plan. On 03/28/23 at 12:02 PM, an interview was conducted with the RN Manager (RN #2) who stated that resident's hand had been washed and the Kling roll applied as per doctor's order, but most of the time resident will not want to keep the hand roll. RN #2 further stated that it was a mistake that the roll was not documented in the care plan, and that a care plan was not initiated for the resident's non-compliance. On 03/28/23 at 12:40 PM, the Assistant Director of Nursing (ADON) was interviewed and stated the nurse managers on the unit are expected to initiate the care plan and review care plans quarterly. The ADON also stated that the care plan should be updated when there is a new order or any issues with the resident. The Supervisor is to supervise and check that the necessary care plans are in place. 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification and Complaint (NY00312017) survey from 3/21/23 through 3/28/23, the facility did not ensure sufficient nursing staffing to attain or maintain the well-being of each resident. Specifically, resident units did not have adequate staff to care for a census of up to 300 residents, with multiple residents reporting being given bed baths and not receiving showers as scheduled. The findings include but are not limited to: The Facility Assessment (FA), with the last revised date of February 2023, documented a capacity of 300 residents. The required staff are Certified Nursing Assistants (CNAs); night shift 25, day shift 57, and evening shift 52. The licensed nurse providing direct care- night shift 9, day shift 15, and evening shift 13. The Staffing Sheet dated 3/21/23 documented 7.5 Licensed Practical Nurse (LPN) and 27.5 CNAs for a census of 296 residents for the day shift. The Staffing Sheet dated 3/22/23 documented 9 LPNs and 31.5 CNAs for a census of 295 residents for the day shift. The Staffing Sheet dated 3/23/23 documented 8 LPNs and 24 CNAs for a census of 296 residents for the day shift. The Staffing Sheet dated 3/24/23 documented 8 LPNs and 24 CNAs for a census of 295 residents for the day shift. 1. Resident #5 was admitted to the facility with diagnoses that included Multiple sclerosis, Quadriplegia, and Trigeminal Neuralgia The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5's as cognitively intact and dependent on staff for Activities of Daily Living (ADLs). On 03/21/23 at 11:12 AM, an interview was conducted with Resident #5 who stated that they are supposed to get a shower two times a week, on Tuesdays, and Fridays, but they do not get the showers as scheduled because the facility is short of staff. Resident resided on the 7th Floor. 2. Resident # 22 was admitted to the facility with diagnoses that include Chronic Obstructive Pulmonary Disease, and Peripheral Vascular Disease. The Quarterly MDS assessment dated [DATE] identified Resident #22 as moderately impaired and required extensive assistance of staff with ADLs. On 3/23/23, at 11:05 AM, during a Resident Council interview, Resident # 22 stated that they are supposed to shower twice a week but do not get the shower twice a week. The last time they had a shower was on 3/5/23. The staff give them a bed bath, but it is not enough. There are not enough CNAs, so they do not shower them. Resident resided on the 4th Floor. 3. Resident #56 was admitted to the facility with diagnoses that included Heart Failure, Arthritis, and Depression. The Quarterly MDS dated [DATE] documented that resident had intact cognition and required extensive assistance of staff with most activities of daily living. On 3/23/23 at 11:05 AM, during a Resident Council interview, Resident #56 stated that one CNA would be assigned to take care of 18 residents on the 8th floor during the day shift. They have 3 CNAs on the floor during the day shift, but there used to be 4 CNAs. Resident #56 also stated that the CNAs are nice on each floor and are getting burnt out because they are short of staff. Resident #56 further stated they are supposed to get showers once a week but get them very rarely. 4. Resident #125 was admitted with diagnoses that included Anxiety Disorder, Depression and Dementia. The Quarterly MDS dated [DATE] documented resident with moderately impaired cognition and required extensive assistance with activities of daily living. During an interview on 03/22/23 at 01:42 PM, Resident #125 stated that it takes up to 30 minutes for staff to come assist her due to a staffing shortage on the unit. Resident #125 also stated that it happens during the day on the weekdays, and not just the weekend. Resident resided on the 4th Floor 5. Resident #270 was admitted to the facility with diagnoses that included Cerebrovascular Accident and Other Fracture. The admission MDS dated [DATE] documented that resident had moderately impaired cognition and required extensive assistance with activities of daily living. During an interview conducted on 03/21/23 at 12:36 PM, the representative of Resident #270 stated that the facility is short staffed particularly in the morning. The representative also stated that family visit with the resident 12 hours a day to make sure that the resident is taken to the bathroom and assisted with meals. Resident resided on the 3rd Floor. 6. Resident #202 (Complaint # NY00312017) was admitted to the facility with diagnoses that included Anxiety Disorder and Atrial Fibrillation. The Quarterly MDS dated [DATE] documented resident had moderately impaired cognition and required extensive assistance with activities of daily living. In Complaint #NY00312017 received on 3/6/23, Resident's Representative stated that Resident #202 was left in a soiled incontinence brief overnight and they were told by the nurse on the unit that they were short-staffed. Resident resided on the 3rd Floor. On 03/24/23 at 12:20 PM, an interview was conducted with Certified Nursing Assistant (CNA) #4 on the 7th floor who stated that 10 residents are on their assignment today. The assignment is slightly lighter because they usually have 13 to 17 residents. CNA #4 also stated that they manage to finish their workload but cannot spend time with the residents as they are short of staff. CNA #4 further stated that there used to be six CNAs assigned during the day shift, and it was unusual for them to get 5 CNAs, but now it is usually 3 and 4 CNAs. CNA #4 stated the residents are aware that they are short of staff and they must move fast when they have so many residents. On 03/27/23 at 9:47 AM, an interview was conducted with CNA #11 on the 2nd floor who stated that they are assigned to 12 residents. Depending on the staffing, they will have 12 or up to 16 residents. CNA #11 also stated they can finish their assignment when they have more residents, but they would not take their break. CNA #11 further stated that sometimes they would have between 2-4 residents scheduled for showers and it is tough to do showers when more residents are scheduled for showers. CAN #11 stated that sometimes they cannot give the shower, and they inform the nurse; they are very overwhelmed by the shortage of the staff. On 03/27/23 at 11:53 AM, an interview was conducted with CNA #5 on the 7th floor who stated that staffing has not been stable. They used to have 7-8 CNAs on the schedule before the pandemic, but on average, it is between 3 and 4 CNAs on the shift for 56 residents. Depending on the staffing and the census, they can have 12-18 residents. CNA #5 also stated that they try to finish their assignments but are focused on getting the residents out of bed and doing their documentation later. CNA #5 further stated that they try to give a showers to the residents on their shower days. On 03/27/23 at 11:43 AM, an interview was conducted with RN #12 assigned to the 3rd Floor who stated the call bells go off so we usually have a clerk sitting at desk who will pick up and give a message to the CNAs. RN #12 also stated the staffing is terrible and the most CNA's that are assigned to the unit is 4 to 4 1/2, we never have 5 and sometimes we only have 3. RN #12 also stated that complaints have been received from residents and families about being short staffed. RN #12 further stated that on the day shift we have to get everyone up and ready for therapy. In my district I have 12 patients and 8 have to be up between 9AM and 11AM and sometimes the aides have 15 residents to get ready. On 3/27/23 at 3:35 PM, an interview was conducted with CNA #10 on the 4th floor who stated that their regular shift is the day shift, but they are doing a double shift today. The number of residents assigned depends on staffing and the census. It can be between 10-16 residents during the day. CNA #10 also stated that there are between 3-4 CNAs during the day shift for 50 residents. CNA #10 had 12 residents on the day shift and will have 14-15 residents for the evening shift. CNA #10 further stated that they can complete their assignment, but it is hard and they will have to take a partial break in order for them to complete their assignment. On 03/28/23 at 2:19 PM, an interview was conducted with the Director of Nursing (DON) who stated that they know they are short of staff and are working on recruiting more staff. They have advertised on Indeed and different job sites and use Agency staff. The resident's needs and acuity are used to determine staffing on the unit. The DON also stated that they send a text message to all available staff who are off or who may wish to pick up an extra shift on their off hours. They replace callouts with agency staff, or the staff on duty are asked to do double shift to replace callouts. The DON further stated that residents and families bring workload concerns to them, and they are working on getting more staff. On 03/28/23 at 2:49 PM, an interview was conducted with the Facility Administrator (FA) who stated that they are short of staff and have hired a recruiter to help recruit more staff. They have interviewed 9 CNAs who will start work as soon as they get their fingerprinting done. They have advertised on Indeed to get more staff. The staffing agencies provide them with full-time and part-time nurses. The FA also stated that they hire CNAs directly and give them varied hours such as 9AM-1 PM and 5PM-9 PM shifts to help with the showers. The FA further stated that they were not aware that the residents have complaints of not getting showers. 415.13(a)(1) (i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, (1) BiPap and Nebulizer Masks were observed touching the wall and table without a plastic barrier on several occasions (Resident #126, Resident #136). (2) Two staff members were observed without personal protective equipment (PPE) in the room of the residents on transmission-based precaution (Resident #85, Resident #249, and Resident #51). This was evident for 5 random resident observations on 2 of 8 resident floors observed for Infection Control Practices(Floor 6 and 8). The findings are: Medicated Aerosol/ Inhalant Therapy Policy and Procedure Policy: The facility Medicated Aerosol/ Inhalant Therapy Policy and Procedure documented procedure #15 to replace mouthpiece, tubing and nebulizer weekly. Ensures mouthpiece is stored in plastic bag and secures compressor when not in use. 1) Resident #126 had diagnoses which include Cerebrovascular Accident, Sleep Apnea, and Cerebral Infarction and Occlusion. The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had severely impaired cognition. The resident received oxygen therapy, and a noninvasive mechanical ventilator (BiPAP) was provided for the resident. On 2/12/20 at 11:48 AM, 2/13/20 at 9:54 AM, and 2/14/20 at 09:59 AM and 11:24 AM in the resident's room, an uncovered BiPAP face mask was observed on the bedside table propped against the wall. The Comprehensive Care Plan (CCP) dated 12/4/2019, documented that the resident had sleep apnea. Interventions include providing BiPAP treatment daily at 10:00 PM, and clean BiPAP mask daily with soapy water, allows the mask to air dry and monitor the resident for any respiratory distress. The Physician's Order dated 12/09/2019 documented BiPAP should be provided daily for the resident at 10:00 PM. The Medication, Treatment, and Task Administration Record Report dated February 2020 documented BIPAP Daily at 10: 00 PM. On 02/18/20 at 09:22 AM, an interview with the Infection Control Nurse (ICN) (Other staff #1) stated that all BiPaP or CiPaP should be sanitized daily, air dry, and covered in a plastic bag after use. The ICN stated the staff have been educated, but they will have to reeducate them again. 2.) The facility Medicated Aerosol/ Inhalant Therapy Policy and Procedure documented procedure #15 to replace the mouthpiece, tubing, and nebulizer weekly. Ensures mouthpiece is store in a plastic bag and secures compressor when not in use. Resident #136 had diagnoses of Non-Alzheimer's Dementia, Chronic Obstructive Pulmonary Disease (COPD), and Syncope. The Quarterly MDS assessment dated [DATE] documented that the resident had severely impaired cognition, and the resident received oxygen therapy. On 02/12/20 at 10:30 AM, and 02/14/20 at 09:57 AM, an uncovered nebulizer mask was observed on the bedside table leaning against the wall in the resident's room. On 02/12/20 at 12:01 PM, uncovered oxygen tubing was observed on the bedside table. The nasal cannula touched the top of the table. On 02/14/20 at 11:24 AM an observation was done with unit RN manager the resident's nebulizer mask was touching the resident's side cabinet table the nebulizer mask was not protected nor covered. On 02/14/20 at 11:26 AM, the nebulizer observed resident # 136 nebulizer mask touching the side cabinet table surface. Both nebulizer masks are not protected nor covered with a plastic bag. On 02/14/20 at 11:30 AM, an interview was conducted with the Registered Nurse Manager for the 8th floor (RN #1). The RN stated that all nebulizer masks after use must be cleansed with water and soap, air dry, and covered with a plastic bag. She did not understand why these masks are left uncovered and touching the surfaces. On 02/18/20 at 02:17 PM, an interview was conducted with the 6th and 8th-floor Nurse Supervisor (RN # 4). RN #4 stated that after using the nebulizer mask, it should be cleaned with soap and water, air dried, and covered with a plastic bag. On 02/19/2020 at 10:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that after a nebulizer is used, the mask must be washed with water and soap, air dried, and stored in a plastic bag. The Facility's Policy on Isolation Precaution dated November 2019 documented that gowns are worn during procedures that are likely to generate splashes of blood or body fluids, and when it is likely that these substances will soil clothing. It specified that for droplet isolation/ contact isolation gowns should be worn by all persons entering the room. Contact Isolation is designed to prevent transmission of highly transmissible or epidemiological important infections (or colonization) that do not warrant droplet isolation. All diseases or conditions included in this category are spread primarily by close or direct contact. Examples of disease/ condition include multiple drug-resistant bacteria, including Methicillin-Resistant Staphylococcus Aureus (MRSA), Vancomycin-Resistant Enterococcus (VRE), scabies, clostridium difficile, major draining skin infections that cannot be covered by dressings. The facility policy on Hand Hygiene dated November 2019 documented that hand hygiene is practiced before having contact with residents, putting on gloves, inserting any invasive device, and manipulating an invasive device. 3) Resident #85: The CCP dated 12/15/19 documented that the resident has ESBL infection in urine and has cystitis on 12/6/19. Intervention includes administering antibiotics as per physician orders, vital sign assessment as needed, observing for signs and symptoms of infection, and administering medications as per physician order. The CCP also documented that the resident is bowel and bladder incontinent. A consultation record dated 1/20/20 documented that the resident was seen by the physician due to ESBL isolation. Physician's Active order dated 1/28/2020 documented that the resident continues to be on contact precaution. 4) Resident # 249: The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident has no cognitive impairment. The resident requires extensive assist with two-person physical assist for transfer and toilet use. The resident is bowel and bladder incontinent. The CCP dated 1/25/2020 documented that the resident has ESBL in urine with interventions including administering antibiotics, contact isolation, observing for signs and symptoms of infection. Physician's Active order dated 8/06/19 documented that the resident continues to be on contact precaution as per MD order. The nursing note dated 2/13/2020 documented that the resident has a positive ESBL rectal swab result. On 02/14/20 at 11:59 AM, an observation was done with the RN unit manager (RN #2) and observed Certified nurse assistant (CNA #1) inside room of Resident's #85 and #249, both were inside the room not wearing gown and gloves. A sign was observed on the door of the room that instructed: Visitors and staff, please report to the nurse's station, and on the next page instructed contact precautions in addition to standard precaution. Visitors - report to nurses' station before entering the room, perform hand hygiene, wear a gown and gloves when entering the room, and discard gowns in the room. As per facility protocol for the resident with contact precaution due to ESBL a PPE such as gown and gloves is necessary when entering the room. An Interview with the CNA#1 dated 02/14/20 at 12:01 PM stated that, I was about to provide shower for the resident, I do not know if I should wear the gown or not. I should have worn the gown and gloves until I decided to bring the resident out to the shower room. 5.) Resident # 51: The CCP dated 2/12/2020 documented that the resident is on droplet precaution due to GI discomfort. Intervention includes assessing vital signs temperature as needed, observing for signs and symptoms of infection. On 02/14/20 at 12: 14 PM, an observation was done with the RN unit manager (RN #2) a sign was observed on the door of resident #51's room that documented: visitors and staff, please report to the nurse's station, and on the next page documented droplet precautions in addition to standard precaution. Visitors - report to nurses' station before entering the room, perform hand hygiene, wear a gown and mask to enter the room, discard gowns in the room, do not reuse. Wear gloves when entering the room. Change after contact with infective material. RN #3 was observed preparing medication and entered the resident's room without handwashing, not wearing mask, gown, or gloves. RN #2, acknowledged that RN#3 entered the room without donning gown or gloves. The physician order dated 2/12/2020 documented that the resident is on Droplet Precautions secondary to GI upset. The nursing note dated 2/12/2020 documented that the resident was noted vomiting and was ordered for droplet precaution. The resident's family was informed and educated. On 2/13/2020, the resident was noted with emesis episodes in the morning. The physician continuously orders the resident for Droplet precaution. On 02/14/20 at 12:18 PM an interview with RN# 3 stated that she did not realize there was a sign for contact precautions and that she was not familiar with the resident since she was a float nurse. I see the contact precaution signs now. Earlier I honestly did not notice the signs, and I apologize for not wearing any PPE. On 02/18/20 at 09:22 AM, an interview with the infection control nurse (Other staff #1) stated that any staff entering the room with a contact precaution signage by the door should obtain personal protective equipment (PPE) provided from the station where gown and gloves are provided before entering the room. On 02/18/20 at 02:17 PM, an interview with the 6th and 8th-floor nurse supervisor (RN # 4) stated There is also a physician order for contact precaution, a binder on each floor at the nursing station to see which residents are on contact precautions with contact precaution signage by the resident's rooms. Whenever there are contact precaution signs, the staff should be entering the room with protective devices as per physician's order. On 02/19/2020 at 10:30 AM, an interview with the Director of nursing stated all staff must wear PPE as per ordered before entering the room. For droplet precaution, the staff should be wearing gowns, gloves, and mask when entering the room.