**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification and abbreviated (NY00367212/446001) surveys conducted 8/25/2025-8/29/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for four (4) of fourteen (14) resident units ([NAME] Units 4, 5, 7, and 13) reviewed. Specifically, Resident #63 had dirty linens, and a soiled brief left at their bedside; Resident #187's room had a ceiling tile with a large brown stain and an unclean privacy curtain; Resident #314's room had a ceiling tile with a medium black stain; Resident #21's window shade had several brown spots; and Resident #373's wheelchair was unclean. Findings include:The 12/2018 Housekeeper job description documented job duties specific to housekeeping included cleaning walls and ceilings by washing, wiping, dusting, spot cleaning, disinfecting and deodorizing as instructed; and removing dirt, dust, grease, etc. from all surfaces using proper cleaning/disinfecting solutions.The facility policy “Cleaning and Disinfection/Non-critical care and shared equipment,” dated 7/22/2024 documented cleaning and disinfection of the facility, including resident rooms, was completed in accordance with environmental services policies and procedures. Privacy curtains were removed and laundered on a regular schedule, as needed, when soiled, and when a resident was removed from transmission-based precautions.The undated facility policy, “Safe and Homelike Environment,” documented the resident had the right to a safe, clean, and comfortable environment in which they received treatment and support for daily living. The facility policy “Wheelchair Cleaning,” dated 10/1/2024, documented housekeeping staff did regularly scheduled cleaning of wheelchairs. Certified nurse aides would do daily inspection and cleaning after meals as needed. Additionally, any staff member may place an electronic work order at any time if cleaning was needed outside of the routine wheelchair cleaning schedule. The certified nurse aide placed chairs to be cleaned in the designated area. To clean the chair, remove all equipment from chair (cushions, leg rests, drainage bags, oxygen canisters, and personal devices); and remove the wheelchair seat cushion cover. Both seat cover and cushion needed to be disinfected, cleaned and dried separately. The cushions and covers were placed on a designated rack for proper drying prior to being placed back on the chair. The Wheelchair Cleaning Log sheet was completed and provided to the Housekeeping Manager/Operations/Manager/Designee.Fourth Floor Observations:During an observation on 8/27/2025 at 1:49 PM, Resident #63 was lying in bed and soiled linens and a soiled brief in a mechanical lift pad were on the floor next to the bed.During a telephone interview on 8/29/2025 at 9:51 AM, Resident #63’s family stated the resident’s room frequently has soiled briefs on the floor. They saw soiled linens on the overbed table when visiting. During an interview on 8/29/2025 at 10:43 AM, Certified Nurse Aide #43 stated they provided care for Resident #63 on 8/27/2025. The resident was incontinent and was normally changed after meals. They would take the resident back to their room and change the brief while the resident was in bed. The dirty wash clothes were hung on the side of the cleaning basin and the brief was rolled up at the end of the bed. Once the resident was changed, they put the wash clothes in the dirty linen holder and the brief in the trash. They never left them on the floor as it was not sanitary.During an interview on 8/29/2025 at 11:50 AM, Licensed Practical Nurse #42 stated incontinence products and linens should never be on the floor, it was a contamination and infection control issue. They should be rolled up and put at the end of the bed and discarded before going to the next resident’s room. They had to pick up incontinence products and dirty linens before. During an interview on 8/29/2025 at 12:02 PM, Licensed Practical Nurse Assistant Nurse Manager #41 stated soiled linens and briefs should not be on the floor, they should be disposed of, and the linens should go to the soiled linens bin. During an interview on 8/29/2025 at 1:12 PM, Registered Nurse Unit Manager #48 stated soiled briefs and linens should not be left on the floor, it was unsanitary. Fifth and Seventh Floor Observations:The 6/1/2025 – 8/29/2025 work order log for the 5th floor documented maintenance exchanged ceiling tiles twice on 8/1/2025, on 8/5/2025, on 8/6/2025, and twice on 8/27/2025. Housekeeping provided a privacy curtain on 6/4/2025, and three times on 8/14/2025. During an observation on 8/25/2025 at 10:50 AM, Resident #187’s room had a brown water spot on the ceiling tile in a circular shape about the size of a dinner plate. The privacy curtain had a large brown stain at the bottom corner. During an observation and interview on 8/25/2025 at 1:31 PM, Resident #314’s room had a black stain on the ceiling tile in a circular shape about the size of a wiffle ball. The resident stated the facility changed the tile and the stain came back.During an observation on 8/25/2025 at 1:26 PM, the seventh-floor small resident lounge had a metal bed flipped on its side and parts of the bed were located throughout the room. There were multiple wheelchairs in the room. During an interview on 8/28/2025 at 11:08 AM, Housekeeping Crew Leader #58 stated they went around to the rooms and looked at the resident’s privacy curtains to see if they needed to be replaced. They changed the curtains when they were dirty. The 5th floor and below were done regularly. They kept a record for privacy curtain replacement, but the paperwork was misplaced. They stated they washed about 20 in the last couple of days. During an interview on 8/28/2025 at 3:08 PM, the Senior Director of Operations stated the small lounge was a resident area and the scattered electrical items were bed components on the floor. The repair should not have been made in a resident area. The bed and mattress should be removed from the floor and moved to the maintenance area until repaired.Thirteenth Floor Observations:The 8/2025 housekeeping logs for the 13th floor had a single line through room curtains. There was no documentation if the curtains were cleaned. During an interview on 8/26/2025 at 9:28 AM, Resident #21 stated there were several brown spots on both window shades. The resident stated they were embarrassed by them.During an observation on 8/26/2025 at 9:23 AM and 8/27/2025 at 12:44 PM, Resident #373’s navy blue wheelchair’s armrests were soiled with food particles. During an interview on 8/27/2025 at 12:49 PM, Housekeeper #60 stated they were responsible for cleaning resident wheelchairs in the morning, if they were in the hallway. There was no real schedule, night shift was doing it, but the Housekeeping Director waned them done in the morning. If the wheelchair appeared dirty, they knew to clean them. During an interview on 8/27/2025 at 12:59 PM, Certified Nurse Aide #61 stated if there was a dirty wheelchair they would clean it. Resident #373’s wheelchair armrests were dirty. They thought the night shift would have cleaned it before getting the resident up for the day. If the wheelchair was not on the schedule for cleaning that day, they would clean it when the resident went back to bed. All staff were responsible for cleaning resident chairs.During an interview on 8/28/2025 at 11:49 AM, Licensed Practical Nurse #47 stated staff should wipe down chairs if they notice them soiled. They had a schedule for each floor. Housekeeping typically cleaned chairs per the schedule and the certified nurse aides would put the chairs in the hall on the night shift. During an interview on 8/29/2025 at 12:02 PM, the Director of Maintenance stated they were made aware of the resident room ceiling tile on the 5th floor on a Friday about three weeks ago. They replaced it and by Monday the tile needed to be replaced again. They called the vendor for the leak and changed the tile again. There was a repair done, but it was a heating and cooling pipe, so the repair would require the system on that floor to be unable to heat or cool for approximately three hours at the minimum. The vendor had to come when the temperature was not going to be too hot outside. If housekeeping was unable to clean a window shade, they should order a new one. Once the new item came in, they notified maintenance to install the shade. They were not notified to install any window shades on the thirteenth floorDuring an interview on 8/29/2025 at 12:16 PM, the Director of Housekeeping stated staff had checklists to be completed daily for their room cleaning. Window shades were part of the deep clean, and they should be cleaned if dirty as part of the room cleaning. If the housekeeper was unable to get them clean, they should report it to the crew leader or them and they would attempt to clean it with something different. If they still were not clean, they would contact maintenance to have them replaced. They stated they were not notified of any additional cleaning needed or replacements for the thirteenth floor. The process for cleaning wheelchairs was on the 3rd shift schedule. They had a staff member that worked 4 days a week to clean chairs. Rooms assigned a deep clean got wheelchair cleaning also. If staff saw a dirty chair, they were expected to clean it when they saw it. 10 NYCRR 415.29(j)(1)

Based on observations, record review, and interviews during the recertification and abbreviated (NY002586082/iQIES 446001) surveys conducted 8/25/2025-8/29/2025, the facility did not ensure food was served at palatable and appetizing temperatures in accordance with professional standards for food service for 9 anonymous residents and 2 of 2 test trays (8/27/2025 and 8/28/2025 lunch meals) reviewed. Specifically, the lunch meal test trays on 8/27/2025 and 8/28/2025 were not flavorful or served at palatable and appetizing temperatures; and 9 anonymous residents at the Resident Council Meeting stated the food was often cold, not flavorful, and overcooked. Findings: The facility policy Resident Meals, dated 1/2020, documented each resident received meals that were nourishing and palatable. Food and nutrition staff would monitor and audit food trays, so they were palatable, attractive, and served at a safe and appetizing temperature. A new tray would be issued if it was not. The undated facility policy Tray Service to Residents, documented the Dining Services Department would ensure food carts were docked on each floor at scheduled times. Test Trays were to be performed monthly. Nursing Services was to open the cart doors once the retherm (food reheating) cycle was completed. Trays were then delivered to the residents. During a resident council meeting on 8/26/2025 at 10:00 AM, 9 anonymous residents stated the food was usually cold, overcooked, and not palatable. During a meal observation on 8/27/2025 at 12:26 PM, Resident #528 stated they would not eat the meal as it did not look appetizing and looked overcooked on one side. The tray was tested for temperature and palatability with the following results: -roasted seasoned potato was 148 degrees Fahrenheit and had no flavor.-wax beans were bland.-pot roast was 126 degrees Fahrenheit, looked dry, and was dark brown on one side. -soup was 145.8 degrees Fahrenheit and had no flavor.-juice in a small plastic container was 61.7 degrees Fahrenheit.-gelatin with fruit was 52.5 degrees Fahrenheit. During a meal observation on 8/28/2025 at 12:11 PM, Resident #470's tray was used as a test tray, and a replacement was requested. The tray was tested for temperature and palatability with the following results: -soup was 153.9 degrees Fahrenheit and tasted bland.-hamburger was 143.3 degrees Fahrenheit and tasted warm.-potato salad was 50.9 degrees Fahrenheit.-coffee was 139.1 degrees Fahrenheit.-cranberry juice was 55.2 degrees Fahrenheit and tasted warm. During an interview on 8/27/2025 at 12:46 PM, Licensed Practical Nurse #8 stated residents had stated the food did not taste good. The nurse would then ask for an alternate from the kitchen. One resident told them the meat was just a hamburger in a pool of grease, and the resident was offered some soup. The units usually had the supplies to make a resident a peanut butter and jelly sandwich as a replacement. The kitchen prepared the food portions of the meal tray and unit staff prepared drinks separately. During an interview on 8/27/2025 at 1:37 PM, Certified Nurse Aide #28 stated they used to work in food service in the past. They were aware residents complained about the food being cold and not liking the consistency. The food looked overcooked and dry many times in the past. During an interview on 8/28/2025 at 9:10 AM, Registered Nurse Manager #4 stated they received frequent resident complaints about food. The complaints included the trays taking too long to get to the unit, the food being cold, and items missing from the trays. The residents' meal trays were set up in the kitchen by dietary staff. During an interview on 8/29/2025 at 12:45 PM, Dietary Aide #29 stated they prepared resident foods and brought the meal trays to the units. The cooks tasted the food while cooking. Food temperatures should be cold items below 40 degrees Fahrenheit and hot items above 140 degrees Fahrenheit. The food should be flavorful. During an interview on 8/29/2025 at 12:52 PM, Food Service Supervisor #30 stated tray audits were done on a daily and random basis and were documented. Audits included palatability. Test trays were done to ensure proper food temperature, palatability, and presentation. Cooking was done in the commissary and kitchen staff only plated the food. If the food did not look the way it should, kitchen staff should make the Director of the Commissary aware. They stated the acquired test tray temperatures were out of range. Soups were made on the units and that may be why they tasted bland. During an interview on 8/29/2025 at 1:09 PM, Commissary Director #14 stated they made the food, including the entrees, starches, eggs, and cereal. They also prepared the different consistencies. The food was cooked in the commissary, and the cooks should taste the food. Each meal was cooked 5 days in advance. The pot roast should have some liquid in the pan to keep it moist. The roast was precooked from a vendor and only sliced by the facility. Once the food was sent to the tray line and plated, the trays were placed on a cart, the cart was sent to the assigned unit, and the carts were placed in a machine to warm/heat the food. Each cart was placed in a machine, and the warming timer was set by dietary staff. The temperature differences may have been due to the food positioning on the plate. 10NYCRR 415.14(d)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY00321560, NY00315691, and NY00336003) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure each resident was treated with respect and dignity in a manner that promoted maintenance or enhancement of their quality of life for 2 of 5 residents (Residents #384 and #414) reviewed. Specifically, Resident #384 sat in bed sheets soiled with vomit and was not cleaned in a timely manner and Resident #414 was not shaven, had unkept hair, and had an unclean room. Findings include: The facility policy Resident Rights & Notice of Resident Rights and Responsibilities reviewed 8/8/2022 documented residents would be treated with kindness, respect, and dignity. Resident rights included a dignified existence, to be treated with respect, kindness, and dignity, self-determination, privacy and confidentiality, and equal access to quality care. The facility policy Quality of Life-Dignity dated 1/10/2023 documented each resident shall be cared for in a manner that promoted and enhanced their sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem, and were treated with dignity and respect at all times. 1) Resident #384 was admitted to the facility with diagnoses including hemiplegia (one sided weakness), obesity, and diabetes. The 4/11/2024 Minimum Data Set assessment documented the resident was cognitively intact, required substantial assistance for bathing and toileting, and did not refuse care. The 3/24/2024 comprehensive care plan documented a self-care deficit related to fatigue. Interventions were to encourage the resident to participate in care. The resident was alert and oriented and able to make decisions regarding their care. The resident had an alteration in psychosocial well-being related to depression and anxiety and interventions including administering medications as ordered. The care instructions ([NAME]) documented keep skin clean and dry and provide a homelike environment. During an observations and interview on 4/16/2024 at 8:14 AM, Resident #384 was in bed with their call bell on. They stated they pushed the call bell at 7:30 AM and no one came so they vomited on the floor in to avoid vomiting on themselves. There was yellow liquid with food particles on the floor. At 8:22 AM licensed practical nurse #43 entered the room and stated they were going to get a basin for the resident. Licensed practical nurse #43 returned with a wash basin and gave it to the resident and started cleaning up the floor. The resident had vomit on the front of their tee shirt and on the bed sheets. Licensed practical nurse #43 did not attempt to clean or change the resident or their bed sheets. At 9:58 AM Resident #384 remained in bed. There were two large yellow spots on their bottom sheet. The resident stated that was where they vomited. During an observation and interview on 4/16/2024 at 3:13 PM Resident #384 was in their wheelchair in their room. The bed linen was not stained. The resident stated staff changed the sheet but did not wash them up and they would like a shower. The over bed table had a wash basin with yellow liquid covering the bottom. The resident stated they had vomited in the basin. During an interview on 4/22/2024 at 9:06 AM certified nurse aide #44 stated Resident #384 was cognitively intact. They stated last week the resident was not feeling well and was vomiting. If the resident stated, they put their call bell on at 7:30 AM that was believable because they often noticed call bells not being answered timely. They stated if a resident vomited and was not cleaned but the floor was it was not dignified. They stated they worked with this resident on several occasions and never observed them refusing care. During an interview on 4/22/2024 at 9:36 AM registered nurse Unit Manager #14 stated if they observed emesis on the bed and floor they would tend to the resident first, change the bed sheets, and then clean the floor. They stated if the floor was clean, and sheets were not it is not dignified, and residents should not have to sit in emesis. During an interview on 4/23/2024 at 9:28 AM the Director of Nursing stated they expected call bells to be answered in five minutes and anything over 15 minutes was unacceptable. Anyone could answer the call bell and tell nursing staff what the resident was requesting. If the bell was not answered residents could worry no one would answer their call bell. If a resident vomited, they expected the resident to be assessed, the resident to be cleaned, the nurse notified, the nursing supervisor notified, the bed changed, and the floor cleaned. They stated if the floor was cleaned and the resident was not and the sheets were left with vomit, it was not dignified. 2) Resident #414 was admitted to the facility with diagnoses including heart disease, central retinal vein occlusion (vein in the eye closes off), and malaise (generalized discomfort). The 2/26/2024 Minimum Data Set assessment documented the resident was cognitively intact, required moderate assistance of one staff for bathing and toileting, and did not refuse care. The 2/26/2024 comprehensive care plan documented a potential alteration in skin integrity related to incontinence and the intervention was to identify potential causative factors and eliminate/resolve when possible. The following observations of Resident #414 were made: - on 4/15/2024 at 11:34 AM a large clear trash bag of dirty clothes was in the resident's private bathroom. The entire floor of the room was sticky. - on 4/15/2024 at 1:13 PM the resident had stubble on their face and stated they would like to be shaved. Their hair was greasy, and they wanted a shower and stated, their shower day moved every week for staff convenience. They stated they had all their clothes in the bathroom, and they were dirty because there was no staff to wash them. - on 4/16/2024 at 8:28 AM there was a large overflowing clear bag of dirty clothes in the resident's private bathroom. At 3:31 PM there was a large overflowing clear bag of dirty clothing and a round white basket of dirty clothing in the bathroom. The floor of the entire room was sticky. At 3:36 PM the resident was in the hall wearing an orange t-shirt and a black hooded sweatshirt and had greasy hair and stubble on their face. They stated they did not refuse their shower yesterday. - on 4/17/2024 at 8:30 AM in bed wearing the same orange t-shirt and black hoodie from the prior day. There was a large clear trash bag full of clothes in the resident's private bathroom. The resident had greasy and uncombed hair and had stubble on their face. Their room smelled of urine. The resident stated they were not sure of their shower day, but they wanted a shower. At 12:28 PM there was a brief with a brown smear on the floor in the resident's private bathroom next to an overflowing clear trash bag of laundry. The floor was sticky, and urine was smelled outside the room prior to entering. There was urine and feces in the toilet. - on 4/18/2024 at 8:26 AM the resident had greasy hair and stubble on their face in the dining room and was wearing a green sweatshirt and black pants. They stated they did not get a shower and would like one. At 8:44 AM registered nurse Educator #68 observed urine and feces in the resident's private bathroom. They stated they were not sure why the toilet was not flushed, and the resident might be independent. They stated not flushing the toilet was not dignified. During an interview on 4/18/2024 at 9:16 AM Resident #414's family member stated the family visited the resident several days a week on different days. They had observed a back up of laundry in the resident's bathroom. They brought in additional clothing on several occasions so the resident could wear clean clothes. They stated the resident liked to be clean and well groomed. The resident complained they did not get a haircut and wanted one. The family put extra money in the resident's account so the resident would never have to go without a haircut. During an interview on 4/18/2024 at 10:37 AM certified nurse aide #8 stated they were always assigned to Resident #414 and had never heard them refuse care, The resident's assigned shower was on Monday evening shift. They stated if a resident did not get a shower, they would be dirty and not feel good about themselves. Residents felt better after a shower. They stated laundry came to the unit twice a week on Tuesday and Thursday. Because clothing was backed up for residents, they sometimes had to wash residents' clothes themselves. They were going to wash Resident #414 clothes yesterday because they were overflowing and had run out of pants, however they did not have time to wash the dirty clothing. They saw the resident in the same clothes for two days and that was not dignified. They noticed a smell of urine in Resident #414's room and believed it came from another resident dumping urine in Resident #414 room and they notified the Unit Manager. During an interview on 4/18/2024 at 11:29 AM licensed practical nurse Unit Manager #4 stated laundry was picked up every Tuesday and it was brought back by laundry, but they were unsure of the timeframe. They stated laundry staff had a hard time keeping up and sometimes laundry was off the unit for more than four days. If laundry is piled up in a room, it could lead to odors. During an observation and interview on 4/22/2024 at 9:01 AM the 5th floor had one blue cart of linen that was full, and staff brought up another blue cart as 10 additional bags of linen were on the ground next to the blue cart. Laundry worker # 72 stated each floor had a specific day when laundry was picked up. They stated laundry gets backed up because some residents go through more clothing because they are incontinent of urine, and they are short staffed. During an interview on 4/23/2024 at 9:28 AM the Director of Nursing stated they expected laundry to be picked up on laundry day. If laundry was not picked up timely it could lead to odors and bugs. They stated it was not dignified to have laundry backed up in a resident's room or for a resident to have to smell feces or urine from dirty clothing. They stated it was their expectation that residents' personal care needs were met and failure to do so was a dignity concern. 10NYCRR 415.5(a)

Based on observation, interview, and record review during the recertification survey conducted 4/15/2024-4/23/2023, the facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for 1 of 2 resident (Resident #31) reviewed. Specifically, Resident #31 was not able to use their bathroom sink to effectively perform activities of daily living. Findings include: The facility policy Quality of Life-Dignity dated 1/10/2023 documented each resident shall be cared for in a manner that promoted and enhanced their sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem, and were treated with dignity and respect at all times. Resident #31 was admitted to the facility with diagnoses including hemiplegia (paralysis on one side of the body) affecting the dominant side, kidney disease, and obesity. The 2/12/2024 Minimum Data Set assessment documented the resident was cognitively intact, had functional limitation in the upper and lower extremities on one side, and required substantial/maximum assistance with oral hygiene, toileting, showering, and dressing. The comprehensive care plan initiated 7/24/2023 documented a self-care deficit related to a stroke with right sided hemiparesis. Interventions included encourage participation in activities of daily living, provide assistance with oral care, and moderate assistance with personal hygiene. During an observation on 4/15/2024 at 10:44 AM Resident #31 was attempting to get into their bathroom using a wheelchair. The entrance to the bathroom was narrow and the resident had difficulty entering the bathroom using their wheelchair. Upon entering they were unable to turn on the cold water as the sink was tight against the wall, there was a handicap bar low on the wall by the cold water handle, they were paralyzed on the right and could not reach the cold water handle with their left hand. They stated when bathing the water was often too hot and they had to use hot water to brush their teeth. During an interview on 4/17/2024 at 10:39 AM licensed practical nurse #6 stated Resident #31 was recently moved to a new room. They did not understand why the resident was moved to a room where they could not use the cold water in the bathroom sink because they were paralyzed on the right. They notified the Unit Manager of their concerns. During an interview on 4/18/2024 at 10:37 AM certified nurse aide #8 stated Resident #31 was not able to use the cold water in their bathroom because they were paralyzed on the right side, the bathroom was too small, and the cold water was too tight to the right side of the wall. During an interview on 4/18/2024 at 11:55 AM licensed practical nurse Unit Manager #4 stated Resident #31 was paralyzed on the right side and was not able to turn on the cold water in their bathroom because the cold water was too close to the wall and the resident could not reach it with their left hand. The resident needed a bathroom where they could use both the hot and cold water. During an interview on 4/23/2024 at 9:28 AM the Director of Nursing stated they expected all residents should use the bathroom if they were able and desired to use it. They expected all residents to have access to both hot and cold water for activities of daily living. During an interview on 4/23/2024 at 11:41 AM occupational therapist #84 stated Resident #31 had right sided hemiplegia and was evaluated on 4/15/2024. The resident's strength was 0/5 on the right so they would not be able to use the right side at all. They stated the resident was cognitively intact and might need accommodations if they said they were unable to use the sink on the cold water side for brushing their teeth. All residents should be able to use both the cold and hot water in their bathrooms. 10NYCRR 415.5(e)(1)

Based on observation, interview, and record review during the recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure residents were free from involuntary seclusion for 1 of 1 resident (Resident #429) reviewed. Specifically, Resident #429 reported feelings of social isolation when they were not allowed to leave their room to attend activities, have meals in the dining room, or socialize with peers and family because their portable oxygen tank was empty and was not refilled. Findings include: The facility policy Resident Abuse Reporting dated 8/1/2023 documented the facility to prohibited mistreatment, neglect, or abuse. The facility would not tolerate or permit verbal, mental, sexual, or physical abuse including involuntary seclusion of residents. Involuntary seclusion was defined as separation of a resident from other residents in their room against the residents will or the will of the legal representative. The facility policy Portable Liquid Oxygen System dated 10/10/2029 documented the oxygen cylinders must be filled from the stationary reservoir when empty. The certified nurse aide was responsible for monitoring the delivery of oxygen therapy and filling portable cylinders from the base unit. Resident #429 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (lung disease) and respiratory failure with hypoxia (low oxygen in tissues). The 1/24/2024 Minimum Data Set assessment documented the resident was cognitively intact, did not reject care, felt it was somewhat important to do things with groups of people, required supervision with transfers, required oxygen, was short of breath or had trouble breathing when at rest, with exertion, and when lying flat. The 4/11/2023 physician order documented oxygen 4 to 6 liters via nasal cannula to maintain oxygen saturations of 90% or greater. The comprehensive care plan and the resident care instructions dated 4/23/2024 documented the resident was alert and oriented and required oxygen 4-6 liters via nasal cannula to maintain oxygen levels of 90% or greater. The resident had an alteration in respiratory status related to chronic obstructive pulmonary disease and respiratory failure with hypoxia. Interventions included oxygen at 4-6 liters to maintain oxygen levels over 90%, may use concentrator out of room, and pace and schedule activities providing adequate rest periods. The resident wished to participate in therapeutic activities including group programs, self-directed leisure, 1:1 programming, and special events. The activity attendance record documented Resident #429 attended 21 activities in 2/2024, 37 activities in 3/2024, and 18 activities in 4/2024. Activity categories included group activities, individual engagement, and independent activities all occurring after 11:00 AM. The following observations were made: - on 4/15/2024 at 12:40 PM, the resident was in the dining room at a table with four residents with a portable oxygen tank on the back of their wheelchair set at 5 liters and flowing through a nasal cannula. - on 4/16/2024 at 3:21 PM, the resident was participating in an activity in the common area. - on 4/17/2024 at 8:37 AM the resident was in bed wearing oxygen piped through the wall at 5 liters. The portable oxygen tank on the back of the wheelchair was empty. The resident stated the oxygen tank was empty at 8:00 PM the previous evening and they switched themselves from the portable oxygen tank to the wall oxygen. They stated no one replaced the oxygen tank overnight so they had to stay hooked to the wall oxygen until staff brought a portable tank that had oxygen in it. - on 4/17/2024 at 8:43 AM seven empty oxygen tanks were in a blue cart at the nursing station. There was one full tank. - on 4/17/2024 at 10:00 AM several residents were observed in the activities area listening to music. Resident #429 was not in attendance. - on 4/17/2024 at 10:04 AM the resident was in their room and stated they would like to attend activities in the morning and were not able to because there was never any portable oxygen. They stated certified nurse aides were supposed to fill the portable tanks every shift and they did not. They stated they were told by staff it was on the assignment sheet to complete this task every shift. Staff reported they did not want to fill the portable oxygen tanks because they had to leave the unit and put on a gown to fill the tanks. The resident stated they enjoyed activities and were not able to attend any morning activities because there were no filled portable oxygen tanks most mornings. They would like to attend the morning activities. They stated it started to improve when licensed practical nurse Unit Manager #4 transferred to the unit, but they were back to not filling portable oxygen tanks. - on 4/18/2024 at 9:46 AM the resident was in their room in bed. They stated they did not have breakfast and staff did not get them up for the day. They stated they were very upset because they were going to miss their hair appointment that was scheduled for 9:30 AM. On 4/17/2024 after their visitor left, they went to the activity area to enjoy the activity in the afternoon. They ran out of oxygen and staff checked all the portable tanks in the blue cart and all of them were empty. They stated staff that was assigned on the day shift to fill the portable oxygen tanks started yelling and stated they did not want to fill the tanks. They did not know the name of the staff. One staff was able to locate a ½ full tank that lasted less than one hour. - on 4/22/2024 at 12:32 PM the resident was in the dining room eating at a table with their peers with their portable oxygen at 5 liters via a nasal cannula. They stated they were upset because they did not get up until 11:00 AM today and missed the morning activity. They stated they wanted to get up earlier in the morning so they could participate in activities and leave their room when they wanted. They stated they felt like they were isolated in their room because they did not have portable oxygen so they could go to activities and do other things like getting their hair done. The 4/2024 treatment administration record documented Resident #429 was to receive oxygen at 4 to 6 liters via nasal cannula to maintain oxygen saturations of 90% or greater every shift. Nurses were to check the oxygen tank every 2 hours when the resident was out of the room and not on wall oxygen to prevent the resident from running out of oxygen. The tank check included a key: F=full; R=replaced; and W=wall (oxygen received via wall unit). On 4/17/2024 the treatment administration record documented the W for the entire day; on 4/18/2024 the treatment administration record documented W from 12:00 AM-10:00 AM, F from 12:00 PM-2:00 PM, R at 2:00 PM, and F from 4:00PM-10:00 PM; on 4/22/2024 W from 12:00 AM-8:00 AM, R at 10:00 AM, F from 12:00 PM-2:00 PM, R at 2:00 PM, repla at 4:00 PM, and 6:00 PM. and W from 8:00 PM-12:00 AM. During an interview on 4/17/2024 at 9:40 AM certified nurse aide #5 stated the resident's unit used oxygen on the wall and if residents wanted to be out of their room, they required a portable oxygen tank. They stated the portable oxygen tanks were filled at the end of every shift by certified nurse aides. They had worked when there were no portable tanks available for residents who required oxygen. During an interview on 4/17/2024 at 10:39 AM licensed practical nurse #6 stated many residents on the unit required oxygen but were not sure exactly how many. The unit utilized wall oxygen and when residents wanted to leave their room, they required a portable oxygen tank. They stated they observed portable tanks running out on numerous occasions and when that happened residents were moved to their room to hook up to the wall, so they did not go without oxygen. They stated filling the portable oxygen tanks was assigned on the daily assignment sheet, however, was not always competed because of short staffing. During an interview on 4/17/2024 at 11:18 AM certified nurse aide #7 stated they worked the overnight shift. They were assigned to fill the portable oxygen tanks as it was written on the assignment sheet. They believed they filled the portable oxygen tanks that morning but could not be sure. They stated when they filled portable oxygen tanks, they did not pick up empty tanks from residents' rooms and only filled the tanks in the blue cart. They stated it was important to fill the portable oxygen tanks because residents needed oxygen to breath and could not leave their room if the tanks were empty. During an interview on 4/18/2024 at 10:37 AM certified nurse aide #8 stated portable oxygen tanks were filled every shift by certified nurse aides and were filled in the first floor (basement) oxygen room. Residents on oxygen required oxygen to breathe and Resident #429 was on oxygen. They stated there had been numerous occasions when the portable oxygen tanks were not filled. When there were no portable tanks, the resident was confined to their room and hooked up to wall oxygen until staff was able to go to the oxygen room and fill up empty portable oxygen tanks. If a resident was hooked to wall oxygen they would miss out on activities, appointments, and more. During an interview on 4/18/2024 at 11:04 AM recreation therapist #9 stated they planned and lead two activities on the unit daily, one in the morning and one in the afternoon. They stated Resident #429 attended, participated in, and enjoyed activities. They stated the resident only attended afternoon activities and they did not know why the resident did not attend activities in the morning. They stated Resident #429 left the afternoon activity the prior day because they ran out of oxygen. The resident went to the nursing station to notify staff they needed oxygen. During an interview on 4/18/2024 at 11:55 AM licensed practical nurse Unit Manager #4 stated on this unit oxygen was on the wall and if a resident wanted to leave their room, they required a portable oxygen tank. They stated they noticed portable oxygen tanks were empty when they started on the unit and saw improvement as it is assigned to a certified nurse aide on every shift. When tanks were not filled residents were not able to leave their room which was restrictive. During an interview on 4/23/2024 at 9:28 AM the Director of Nursing stated units 3C and 4C had piped in oxygen and if a resident on oxygen wanted to leave their room, they needed a portable oxygen tank. Certified nurse aides were responsible for filling the tanks and hooking the resident to the oxygen. Nurses checked the amount of the required oxygen to make sure it was accurate for each resident. The certified nurse aide responsible for filling the tanks was listed on the daily assignment sheet. They stated all staff was trained on filling the portable tanks with oxygen. They expected portable oxygen tanks to be filled by staff every shift, every day, and did not expect that residents would be secluded to their room because there was no portable oxygen. If a resident wanted to leave their room and could not that was considered isolation. 10 NYCRR 415.4

Based on interview and record review during the recertification and abbreviated (NY00320334) surveys conducted 4/15/2024-4/23/2023, the facility did not ensure the discharge needs of each resident were identified and resulted in the development of a discharge plan for 1 of 1 resident (Resident #429) reviewed. Specifically, Resident #429 did not have an active discharge plan, expressed interest in a lateral transfer to local nursing facilities, and was not updated on the status of a lateral transfer request. Additionally, Resident #429 was not invited to participate in the development of a person-centered care plan. Findings include: The facility policy Discharge Planning, revised 1/30/2015, documented the interdisciplinary care planning team and social worker would collaborate with the resident/designated representative regularly and reviewed the resident's potential for discharge to establish a projected discharge date . The social worker arranged and facilitated the resident/designated representative discharge planning meeting to discuss rehabilitation progress, clinicals status/needs, discharge goal, and services required upon discharge and documented this in the medical record. The facility policy Comprehensive Care Planning dated 8/8/2022 documented the facility must develop and implement a comprehensive person-centered care plan for each resident and in consultation with the resident and the resident's representative. To the extent practicable, the participation of the resident and the resident's representative. An explanation must be included in a resident's medical record if the participation of the resident and their representative is determined not practicable for the development of the resident's care plan. Resident #429 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (lung disease), respiratory failure with hypoxia (low oxygen), and diabetes. The 1/24/2024 annual Minimum Data Set assessment documented the resident was cognitively intact, the resident and family participated in assessment and goal setting, the resident's overall goal for discharge was blank, and active discharge planning was already occurring for the resident to return to the community. The care area assessment summary did not trigger a return to community referral or a care planning decision. The 4/13/2023 Social Service History and Initial Assessment completed by social worker #29 documented the resident planned to return to the community, had potential barriers to discharge (barriers not specified), and required community services after discharge. The 4/25/2023 progress note by social worker #29 documented upon discharge Resident #429 was going to live with their child. The comprehensive care plan initiated 6/7/2023 documented the resident had a supportive family. Interventions included contact family for Interdisciplinary Care Meetings as needed and invite to care plan meetings as needed. The comprehensive care plan did not include discharge potential or plans. The 6/22/2023 progress note by social worker #29 documented Resident #429's family member requested a lateral transfer to two specific local long term care facilities. The 6/23/2023 progress note by social worker #29 documented one of the two local facilities where Resident #429 had requested a lateral transfer did not have an available bed at this time and the resident was placed on a waiting list. They would follow up at a later date. The 8/7/2023 Social Services Quarterly Note completed by social worker #29 documented the resident did not have any changes regarding their feelings about discharge potential. Comments related to discharge potential documented please see multi-disciplinary notes for updates. A Multidisciplinary Care Conference form documented a quarterly meeting was held on 8/8/2023. Lateral transfer requests were made to three local skilled nursing facilities and there were no openings. The attendees at the meeting did not include the resident or their family. A Multidisciplinary Care Conference form documented a quarterly meeting was held on 11/8/2023. There was no documentation of a discharge plan. The attendees at the meeting did not include the resident or their family. A Multidisciplinary Care Conference form documented a quarterly meeting was held on 2/7/2024. There was no documentation of a discharge plan. The attendees at the meeting did not include the resident or their family. There was no documented evidence of an active discharge plan and follow-up from 8/8/2023 through 2/7/2024. During an interview on 4/16/2024 at 11:26 AM Resident #429 stated they had been in the facility for one year and were never invited to a care plan meeting to discuss their discharge. During an interview on 4/22/2024 at 03:28 PM social worker #60 stated resident #429 was cognitively intact and had a care plan meeting scheduled for the following Friday. Care plan meetings were completed with the interdisciplinary team every quarter and both the resident, and the family were invited to the meetings. Residents' family could choose to attend in person or by phone. Both family and residents had the option to decline attendance except on the annual review. The resident or resident representative had to attend the annual meeting. They stated they were resident's social worker for approximately 7 months. They were not aware of the discharge plan for Resident #429. The resident had a referral sent to a local long term care facility back in June of 2023 and was placed on a waiting list. They stated they had not followed up on the status of the waiting list for this resident and they should have. During an interview on 4/22/2024 at 4:19 PM the Director of Social Work stated care conferences were held with every resident on admission, quarterly, annually, and with any significant change and were completed to provide the best individualized care for the resident. Care conferences were in conjunction with nursing, recreation, and nutrition so all staff knew how to care for the residents. Care conferences included discharge planning and discharge planning was ongoing. They stated Resident #429's medical record documented the resident was interested in a lateral transfer to two local nursing homes. One referral was sent, and the resident was placed on a waiting list in June of 2023. There was no follow up after that referral and they expected follow up should have occurred between June 2023 and April 2024. It was not done because the social worker assigned to the resident was new. During an interview on 4/23/2024 at 8:18 AM Resident #429 stated they were supposed to have a care plan meeting last Friday and no one came to get them, so they did not know if it happened. They wanted to be discharged to two local long term care facilities when they were admitted but were told by the facility that because of insurance reasons they were no longer eligible for a transfer. 10NYCRR 415.11(d)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and abbreviated surveys (NY00318518, NY00318847, NY00320334, NY00331963, and NY00338231) the facility did not ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for 2 of 9 residents (Residents #117 and #323) reviewed. Specifically, Resident #117 was found on the floor between their bed and the wall due to the bed brakes not being locked; and Resident #323 had a history of sexually inappropriate behaviors and propelled their wheelchair independently throughout the facility without an adequate supervision plan. Findings include: The facility policy Resident Abuse Reporting, dated 8/1/2023, documented each resident had the right to be free from all types of abuse, neglect, misappropriation of resident property, and exploitation. The facility policy Off Unit/Leave of Absence, dated 10/2023, documented the resident must notify nursing on the unit and sign out in the resident sign out book when the resident was off the unit, so staff knew their location within or outside the facility. The facility policy Adverse Incident Policy, dated 12/27/2023, documented all adverse incidents would have investigations and care plan interventions to ensure the residents' environments were free from accident hazards and to ensure each resident received adequate supervision. The facility policy Fall Risk Evaluation, Fall Prevention, Management and Standards of Care, dated 1/3/2024, documented registered nurses and licensed practical nurses were responsible for ensuring the care planned interventions were in place and functioning at the time of the assessment and documenting whether they were in place or not at the time of the assessment. The fall care plan would undergo a comprehensive review of the fall prevention interventions quarterly, annually, with a significant change and after the resident experienced a fall. Standard of care included bed in lowest position with brakes on, use floor mats when appropriate, and increase rounding schedule according to the residents' needs. 1) Resident #117 had diagnoses including anoxic brain damage (lack of oxygen to the brain), tracheostomy (opening into the trachea for breathing assistance), and gastrostomy (opening into the stomach for nutrition). The 2/24/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, had upper and lower extremity impairment on both sides, was totally dependent for bed mobility, did not ambulate, and had a fall since admission/entry or re-entry or the prior assessment. The resident's Fall Risk Evaluation dated 5/2/2023, documented upon admission and quarterly, at a minimum thereafter, to evaluate the resident's fall risk. If the total score was 3 or greater the resident should be considered at risk for potential falls. The resident scored a 24. There were no additional Fall Risk Evaluations. The comprehensive care plan initiated on 1/2/2023 and revised on 11/20/2023 documented the resident had a history of falls with no injury related to poor balance and poor communication/comprehension. Interventions included black mat at bedside, continue interventions on the at-risk plan, and for no apparent acute injury determine and address causative factors of the fall. There was no documentation addressing the position of the bed with the left side of the bed against the wall or what side of the bed the fall mat was to be placed. The certified nurse aide care instructions as of 1/20/2024 documented the resident was non-ambulatory, check and change for incontinence every 2 - 3 hours and as needed, and was dependent with the assistance of 2 for rolling left to right in the bed, and assistance of 2 for care at all times. An incident report dated 1/20/2024 at 4:15 AM by registered nurse #35 documented that at 4:15 AM they were notified by the team nurse that the resident was on the floor. On assessment they found the resident lying on the floor near to the wall side, their tube feeding was on, and the gastric tube was intact. No discomfort or apparent injuries were noted. The resident had no distress. The bed was in the low position, but it was not locked. Under Immediate Action Taken the resident was placed back to bed with the assistance of the mechanical lift. Staff was re-educated. The family was notified and wanted the resident sent to the hospital. Nurse practitioner #37 was notified, an ambulance was called and arrived at the facility at 7:47 AM. No injuries were observed post-incident. A 1/20/24 at 5:45 AM progress note by registered nurse #35 documented at 4:15 AM they were notified by the team nurse that the resident was on the floor. On assessment they found the resident lying on the floor near to the wall side, tube feeding on, and the gastrostomy tube was intact. No discomfort or apparent injuries were noted. The resident was placed back to bed with the assistance of the mechanical lift. The resident had no distress. Employee Statement Forms dated 1/20/2024 documented: - licensed practical nurse #39 found the resident lying on the floor at 4:15 AM while doing rounds. The last time they had observed the resident was at 3:00 AM when they were asleep in bed. - certified nurse aide #38 last observed the resident at 2:00 AM during incontinence care. After providing care they put the resident closest to the wall with the bed in low position and forgot to lock the brakes on the bed. There was no injury after the fall. The comprehensive care plan initiated on 1/22/2024 documented the resident was at high risk for falls related to gait/balance problems, incontinence, poor communication/comprehension, unable to make needs known, and poor trunk control related to anoxic brain damage. Interventions included keep bed in lowest position or at wheelchair height, fall mat next to bed while in bed, anticipate and meet the resident's needs, ensure resident was properly positioned while in bed and in chair due to poor trunk control, and in the event of a fall follow facility fall protocol and monitor/document/report as needed for 72 hours to physician. There was no documentation addressing the position of the bed with the left side of the bed against the wall, what side of the bed the fall mat was to be placed, or to ensure the bed was locked when the resident was in it. The certified nurse aide care instructions as of 4/22/2024 documented under the topic of safety: - Fall risk. - Keep bed in lowest position or at wheelchair height. - Fall mat next to bed while in bed. There was no documentation addressing the position of the bed with the left side of the bed against the wall, what side of the bed the fall mat was to be placed, or to ensure the bed was locked when the resident was in it. A 1/30/24 at 12:52 PM progress note by registered nurse Unit Manager #40 documented after further review the care plan was in place but not functioning. The certified nurse aide was re-educated on the importance of ensuring safety interventions were in place prior to leaving the room. The resident was sent to the emergency department per family's request and was evaluated and returned to the facility. Resident was without any injuries and was at baseline at that time. The incident was avoidable. A 1/30/2024 Record of Verbal Counseling given by registered nurse Unit Manager #40 to certified nurse aide #38 documented to be mindful when leaving a room to check if safety precautions were in place such as the bed being locked and in low position and that other safety interventions were completed. On 4/15/2024 at 11:17 AM Resident #117 was observed asleep in their bed. The bed was in the lowest position with the left side of the bed against the wall, a fall mat was on the right side of the bed, a tube feeding pump with the tube feeding disconnected was on the right side of the bed, the bed brakes were locked, and the head of the bed was at 45 degrees. Registered nurse Unit Manager #40 entered the room and stated that sometimes the resident shimmied to the edge of the bed and recalled one time in the last year that the resident had rolled out of the bed without injury. Staff used to do rounds every 2 hours on the resident but checked on them at least once an hour after the resident had rolled out of their bed. They could not recall the specific date when the resident had last rolled out of their bed. During observations on 4/16/2024 at 10:28 AM and on 4/17/2024 at 11:19 AM the resident was in their bed with the left side of the bed against the wall with the fall mat on the right side of the bed. During an interview on 4/17/2024 at 3:23 PM registered nurse Unit Manager #40 stated the staff involved in the 1/20/2024 incident was certified nurse aide #38. They reviewed a copy of the 1/20/2024 incident report and stated the last time certified nurse aide #38 had observed the resident was at 2:00 AM. They stated the incident was a result of a care plan violation. The resident did not receive an injury. They were not sure if certified nurse aide #38 was suspended from work, if the incident needed to be reported to the Department of Health, or if certified nurse aide #38 even worked at the facility anymore. Licensed practical nurse Assistant Unit Manager #33, who was nearby, stated certified nurse aide #38 still worked at the facility on the night shift. During a telephone interview on 4/18/2024 at 12:03 PM licensed practical nurse #39 stated they recalled the 1/20/2024 incident. When they were doing rounds, they found Resident #117 on the floor on the wall side next to the bed. The bed was not locked. The resident slid off the bed pushing against the wall. The resident was on the floor, close to the left side of the bed and the wall. They called the charge nurse. The resident's family was notified, and they wanted the resident sent to the hospital to be evaluated to make sure they were okay. The last time they had observed the resident prior to the incident at 4:15 AM was around 3:00 AM for tracheostomy care. During an interview on 4/19/2024 at 12:45 PM the Director of Staff Education and Development stated starting in February 2024 if staff had a care plan violation they would be directed to their department for re-education. Before February 2024 Unit Managers were responsible for staff education. They were not sure what kind of documentation or where that documentation would be if Unit Managers did any re-education of staff due to a care plan violations. During an interview on 4/19/2024 at 1:16 PM with licensed practical nurse Assistant Unit Manager #33 stated the 1/20/2024 incident involving Resident #117 was an unwitnessed fall. Sometimes verbal counseling of staff was considered the re-education. Not all unwitnessed falls required an investigation, it depended on the circumstances and what was involved in the fall. Any incident report went to Assistant Director of Nursing #42 for review. The bed brakes not being locked was considered a policy violation and not a care plan violation. The resident could have fallen out of the bed from coughing. The momentum from coughing could have caused the resident to shift in bed resulting in the fall. During an interview on 4/22/2024 at 10:53 AM Assistant Director of Nursing #42 stated the 1/20/2024 incident was considered a policy violation and not a care plan violation. Resident #117 had no history of falling out of bed. The bed was not locked which is why they fell out of bed. The resident had no trunk control and when they coughed their body moved. Certified nurse aide #38's statement documented they did not lock the resident's bed before leaving their room. The resident's bed was positioned with the left side of the bed against the wall when the incident occurred. They were not sure if it could have been a potential accident hazard concern because they did not know how far the bed had moved when the resident was found lying on the floor between the left side of the bed and the wall. During a follow-up interview on 4/22/2024 at 1:28 PM licensed practical nurse Assistant Unit Manager #33 stated they were not sure why the resident's left side of the bed was positioned against the wall, it had always been that way, even when the resident was in a different room on the unit. The fall on 1/20/2024 was an isolated incident. They could not state why the bed position was not specified in the care plan or how often fall evaluations were done on residents. The last fall evaluation done for Resident #117 was on 5/2/2023. During an interview on 4/23/2024 at 12:20 PM the Director of Nursing stated residents received fall evaluations quarterly, if they had a fall, or if there was a change in the resident, such as leaning or unsteadiness. The facility had weekly fall meetings. The Unit Manager would read the incident report at the meeting then would have three days to close it out. They expected the plan for the resident's bed to be positioned against the wall be clearly documented in the care plan. If staff stated, they forgot to lock the bed it would be a policy violation and they expected certified nurse aide #38 to be re-educated on the care plan/policy violation by the Unit Manager or the staff education department. The disciplinary form was separate from the re-education documentation. 2) Resident #323 had diagnoses including severe dementia with behavioral disturbances, hemiplegia, and hemiparesis (weakness/paralysis on one side of the body) and wandering. The 2/8/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required supervision for transfers, and was independent with wheelchair use for mobility. The 5/25/23 physician order documented nurses were to document the resident's behaviors every shift and notify the Assistant Director of Nursing immediately for any behaviors of inappropriate touching toward another resident. The 1/24/2024 physician's order documented the resident moved from the 4th floor to the 13th floor. The comprehensive care plan, revised 1/25/2024, documented the resident had a behavior problem of inappropriate physical and sexual contact and sexually inappropriate behavior related to vascular dementia. Interventions included to not seat the resident near female residents during meals or activities, monitor behavior episodes, and intervene as necessary to protect the rights and safety of others. The certified nurse aide care instructions documented to not seat the resident near female residents during activities or at mealtimes. Resident #323 had the following documented incident reports for inappropriate touching of other residents: - on 8/19/2021 the resident was witnessed touching a confused resident's breasts with both hands. - on 10/8/2021 the resident was observed kissing the cheek of a resident who was unable to consent. - on 7/28/2022 at 11:30 PM, the resident was observed in another resident's room. The other resident was in bed and their hand was on Resident #323's groin area. Resident #323 denied anything had occurred. - on 5/24/2023, the resident was observed touching a confused resident under their shirt around the breast area. - on 7/10/2023, the resident was observed brushing their hand down a confused resident's left shoulder down their body to their hand. - on 12/11/2023 at 2:20 AM, the resident was found in another resident's room caressing the confused, unclothed resident. Resident #323's behaviors notes documented: - on the 4/16/2024 evening shift the resident was on and off the unit throughout the shift. - on the 3/13/2024 night shift the resident left the floor several times throughout the night. - on the 3/12/2024 night shift the resident was in another resident's room having a conversation and no inappropriate behavior was noted. The resident was informed they could not be in that resident's room and was directed to leave. - on the 3/9/2024 night shift the resident left the unit at 11:58 PM and returned to the unit at 12:16 AM. - on the 3/8/2024 night shift the resident left the unit at 12:03 AM, returned at 12:16 AM, left again at 1:52 AM and returned at 2:06 AM, and then left again at 3:26 AM and returned at 4:20 AM. - on 3/4/2024 night shift the resident left the unit at 2:32 AM and returned to the unit at 3:55 AM. - on 2/22/2024 night shift the nurse was contacted by the Nursing Supervisor to inquire where the resident was. Security had been informed that the resident had taken food from the basement cafeteria, and they were looking for the resident. The following observations and interviews were made: - on 4/15/2024 at 4:28 PM, the resident was not in their room. Registered nurse Unit Manager #27 stated the resident was not on the unit and was probably outside or in lobby. The resident liked to be out there and spent all day off the unit. - on 4/16/2024 at 9:10 AM, the resident was seated at a table in the dining room across from a female resident. At 11:08 AM, the resident was outside in their wheelchair next to a male resident and a female resident. - on 4/17/2024 at 3:59 PM, the resident was not in their room. Registered nurse Unit Manager #27 stated the resident was all over the building. They stated the resident went down to socialize on the 7th floor and social worker #29 frequently visited them on the 10th floor. Registered nurse Unit Manager #27 stated if the resident's stop sign on their room door was down, they usually were not in their room. The resident usually said hello to the staff and then was gone from the unit. At 4:11 PM, the resident was observed in their wheelchair outside the facility near a picnic table with a female resident. - on 4/18/2024 at 9:21 AM, the resident was in bed with sheet pulled over their head. The resident stated they were off the unit a lot but denied going to other units. They stated they were independent using the elevator. At 9:22 AM, Registered Nurse Unit Manager stated the resident was social and was all over the building, so they were hard to track down. At 4:46 PM, the resident was outside in their wheelchair in an alcove of the building. - on 4/19/24 at 1:15 PM, the resident was in their wheelchair in the front entrance to the building. During an interview on 4/22/2024 at 10:10 AM, certified nurse aide #30 stated they knew what care a resident needed by the written-out list the nurse provided but they also looked at the resident's care instructions. They stated if a resident left the unit, they had to sign out so that nursing staff was able to keep track of them. They were unaware of any behaviors or special instructions for Resident #323. They stated the resident was independent with a lot of their care, so they only had to check on them and make sure the resident did not need anything. During an interview on 4/22/2024 at 10:33 AM, licensed practical nurse #31 stated they knew how to care for a resident based on their care instructions or care plan. They stated if a resident left the unit, the resident let the staff know. If they were leaving the facility property, they had to sign out. They stated Resident #323 did not always let them know they were leaving the unit but usually told staff. They stated they knew the resident went outside but also went to other units. They stated they were not able to monitor the resident's behavior consistently but staff from other units informed them if there were issues. They were not aware of the resident's care plan intervention to not be placed next to female residents during meals or in activities. They were not aware of how the care plan intervention was followed in other parts of the facility as it would have to be communicated to all floors. During an interview on 4/22/2024 at 10:46 AM, registered nurse Unit Manager #27 stated they did not always know when Resident #323 left the unit. They stated the nursing staff knocked on the resident's door to see if they were on the unit. The resident liked to sit outside or in the facility foyer. When the resident was on the floor, they did not have any behaviors, but the nurses should document the resident was off the floor. The resident had a care intervention not to sit with female residents. They stated the intervention was loosely followed because there was a resident who was alert and able to make their needs known who Resident #323 visited in their room and sat next to. Any resident who went outside was alert and orientated so the care plan intervention would not need to be enforced since the residents could make their needs known. During an interview on 4/22/2024 at 12:51 PM, social worker #29 stated the resident was transferred from the 4th floor to the 13th floor a few months ago due to inappropriate behaviors on the 4th floor. They stated the resident was moved from the 4th floor to the 13th floor so intense supervision monitoring could be discontinued. They stated they had expressed concerns as the resident independently utilized the elevator but was told by administration that the resident's monitoring was adequate. They were unsure how the resident was being monitored off the unit and they were unaware if other units were made aware the resident needed to be monitored near females. During an interview on 4/22/2024 at 3:18 PM, the Director of Social Work stated Resident #323 had a history of inappropriate touching. They stated they were unsure why the resident was moved from the 4th floor to the 13th floor. If a care plan intervention stated the resident was not to be placed next to female residents for activities or at mealtimes, it applied to all female residents, including cognitively intact residents. During an interview on 4/22/2024 at 3:45 PM, the Director of Nursing stated Resident #323 had several incidents of inappropriate touching of other residents. They stated the resident was moved from the 4th floor to the 13th floor because the bigger setting of the 4th floor overwhelmed the resident. The resident had independent use of the elevator but the staff on the 4th floor knew the resident and would redirect them off the floor. They were not concerned the resident moved freely from floor to floor in the buildings and if the staff reported any issues, they would address it. During an interview on 4/22/2024 at 4:26 PM, the Administrator stated Resident #323 was moved from the 4th floor to the 13th floor for a better environment. The resident's care plan intervention not to be seated next to female residents was specific to their unit only. They stated the resident independently utilized the elevator, but the resident's care plan could be viewed electronically on any unit they went to. They expected nursing staff to know when the resident left the unit and where the resident planned to go. The Assistant Directors of Nursing should communicate with the Nursing Supervisors and Unit Managers to make sure the resident's behavior was monitored. During an interview on 4/23/2024 at 9:54 AM, Assistant Director of Nursing #18 stated Resident #323 was moved to floor 13 from the 4th floor in the [NAME] building as the environment was quieter and had more alert residents. They stated the resident spent most of their time off the unit and going throughout the building. They stated the resident came back to eat and would visit with other residents on other floors or go outside. During an interview on 4/23/2024 at 10:31 AM, Assistant Director of Nursing #23 stated the resident's care plan to not be seated next to females during an activity or during a mealtime only applied to the resident's current unit and was not enforced throughout the rest of the building. The nursing staff should monitor the resident's behaviors on the unit, and they expected the other units to report to a Nursing Supervisor if there was a concern with the resident's behavior. They stated the managers were aware of the resident's history of behaviors and all the units had access to the electronic medical record to look up the resident's plan of care. They stated the resident had not had an issue since they moved to the 13th floor and the resident's behaviors were always on the resident's home unit, not other floors. 10 NYCRR 483.25(d)

Based on observation, interview, and record review during the recertification and abbreviated (NY00329469, NY00331762, NY00330471) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure pain management was provided to residents who required such services consistent with professional standards of practice for 1 of 2 residents (Resident #168) reviewed. Specifically, Resident #168 did not receive adequate pain management following a fall with a hip fracture. Findings included: The facility policy Pain Assessment, Management, and Evaluation dated 8/24/2022, documented the interdisciplinary team identified residents in need of pain management and completed on-going assessments to control the resident's pain. All residents would have a pain assessment completed upon admission, quarterly, annually, and with a significant change. Resident #168 had diagnoses including Alzheimer's disease, weakness, and osteoarthritis (degeneration of joints). The 10/22/2023 Minimum Data Set assessment documented the resident had severely impaired cognition, was independent with ambulation, and had no indicators of pain. A 12/23/2023 at 10:35 AM incident report completed by registered nurse #45, documented another resident pushed Resident #168. Resident #168 fell backwards to the ground. Resident #168 complained of pain in the left hip and knee. The resident was assisted off the floor by 2 staff into a wheelchair. The provider was called and ordered an X-ray of the left knee and hip. The resident's level of pain was a 3 on the Pain Assessment in Advanced Dementia scale (1-3 indicates mild pain). A 12/23/2023 at 2:59 PM licensed practical nurse #46 progress note documented the resident complained of pain in their left hip and knee. There was no documented evidence the resident's level of pain was evaluated or pain management was provided. A 12/24/2023 at 2:31 PM licensed practical nurse #46 progress note documented the resident still complained of pain in the left hip and knee. The resident was in lots of pain when staff tried to care for them. There was no documented evidence the resident's level of pain was evaluated or pain management was provided. A 12/24/2023 at 10:26 PM licensed practical nurse #47 progress note documented the resident had complaints of pain in their left hip and knee and the resident was non-weight bearing. There was no documented evidence the resident's level of pain was evaluated or pain management was provided. A 12/25/2023 at 11:36 AM licensed practical nurse #48 progress note documented they were called to the floor as the resident's family member asked about the outcome of the resident's fall and pain in their left hip. Licensed practical nurse called the radiology company to obtain the results of the x-ray. The resident was observed lying on their back with a complaint of left hip pain when range of motion was attempted. Internal rotation was noted. The registered nurse Supervisor came to assess the resident. The radiology company was called again for results. The radiology company called back, and a left hip fracture was noted. The resident's family member requested the resident be sent to the hospital. The registered nurse called the provider and awaited a call back. A 12/25/2023 at 12:58 PM licensed practical nurse #48 progress note documented the resident was sent to the hospital for evaluation of a left hip fracture. Physician orders active as of 12/25/2023 did not include strategies for pain management. The 12/2023 Medication Administration Record did not include administration of pain relief measures from 12/23/2023 through 12/25/2023. During an interview on 4/18/2024 at 10:13 AM, Resident #168's family member stated their sibling was notified by a nurse via phone that another resident had pushed the resident over, the resident was fine, and they were doing x-rays as a precaution. They stated their sibling called the facility three times to follow up on the x-rays but only received a voicemail from the nurse that assured them the resident was fine. They went to visit the resident on 12/25/2023 and the resident was lying in bed with one side of their face clenched tight. They stated they got a nurse who informed them the resident had a fall. They asked the nurse about the x-rays and the nurse informed them the x-rays had not been read. An hour or so later the nurse informed them the resident had a hip fracture. The family requested the resident be sent to the hospital. During an interview on 4/22/2024 at 1:31 PM, licensed practical nurse #52 stated they were the covering Unit Manager when the resident #168 was pushed by another resident. They were unaware if the resident was given any pain medication for reported pain on 12/23/2023 and 12/24/2023. They reviewed the resident's orders and medication administration record in the electronic medical record and stated the resident was not provided with pain medication. They stated a nurse should have contacted the provider for pain medication. During an interview on 4/22/2024 at 2:57 PM, physician #53 stated another resident had pushed over Resident #168 and the resident had an x-ray ordered. They stated if the nurses thought the resident needed pain medication or the resident complained of pain, they should have called for orders. They stated there was no note from a provider that pain medication was requested by nursing. During an interview on 4/22/2024 at 3:45 PM, the Director of Nursing stated they expected if a resident had a fall on 12/23/2023 and had pain with care on 12/24/2023, the nurses should have called the medical provider to obtain orders for pain medication. They reviewed the resident's chart and stated they did not see any orders for pain medication or pain management. 10NYCRR 415.12

Based on record review and interview during the recertification and abbreviated (NY00336003) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure licensed nurses had the specific competencies and skills necessary to care for residents' need, as identified through resident assessments, and described in the plan of care for 3 of 5 licensed nurses (licensed practical nurse Unit Manager #4, licensed practical nurse Unit Manager #33, and licensed practical nurse #34) reviewed. Specifically, licensed practical nurse Unit Manager #4 did not have timely online training, annual competencies, or documented orientation competencies completed; licensed practical nurse Unit Manager #33 did not have annual competencies, or documented orientation competencies completed; and licensed practical nurse #34 did not received annual competencies that covered key skill-set areas as outlined in the facility assessment. Findings include: The 4/2024 Facility Assessment Tool documented nurse competencies in the facility included: person-center care, activities of daily living, disaster planning, infection control, medication administration, resident assessments, and specialized care in catheterization, colostomy care, oxygen administration, suctioning, [tracheostomy] care, tube feeding, wound care, and dialysis. The undated facility policy Educational Programs Competency Testing, documented all certified nurse aides and licensed nurses were competency tested according to their scope of practice in areas identified by Nursing Administration on a yearly basis. Competency was completed by a Nurse Educator, Nurse Manager, Clinical Coordinator, charge nurse, or designee. Any staff member that was competency testing another staff member must first be competent in the area being tested and have the competency on file with Nursing Education. Completed competencies were housed in the Department of Nursing Education. 1) Timely online learning modules Licensed practical nurse Unit Manager #4 had the following online trainings that were completed after the due date. - 2022 Code Silver training was due 8/31/22 and completed 4/19/2024. - 2023 corporate reorientation-supervisor was due 12/15/23 and completed 4/19/24. - Active shooter [New Employee Orientation] was due 2/28/24 and completed 4/19/24. - [Health Insurance Portability and Accountability Act for New Employee Orientation] was due 2/28/24 and completed 4/19/24. - Harassment: corporate reorientation for supervisors 2023 only was due 1/31/24 and completed 4/19/24. - [Health Insurance Portability and Accountability Act] do's and don'ts of social media and electronic communication was due 12/31/21 and completed 4/19/24. - [New Employee Orientation] corporate compliance was due 2/28/24 and completed 4/19/24. 2) Nursing skills competencies - Licensed practical nurse Unit Manager #4 did not have documented competencies from orientation and did not attend the competency/skills fair in 2023. - Licensed practical nurse Unit Manager #33 did not have documented competencies from orientation and did not attend the competency/skills fair in 2023. - Licensed practical nurse #34 did not attend the competency/skills fair in 2023. During an interview on 4/15/2024 at 11:07 AM, Resident #185 stated that nurses did not know how to change his ostomy (bodily waste passes through an opening in the abdomen into a pouch) appliances, and frequently had to use 3 or 4 appliances per change. They were concerned that they were only prescribed so many appliances and did not want to waste them. During an interview on 4/19/24 at 10:40 AM, licensed practical nurse #24 stated they had never had education for ostomy care or wound care in the facility. During a follow up interview on 4/23/2024 at 10:55 AM, licensed practical nurse #24 stated they did skill competencies when they were first hired, but only signed a paper monthly with in-service topics from Registered Nurse Unit Manager #28. During an interview on 4/23/2024 at 11:31 AM, certified nurse aide Education Coordinator #25 stated that half of the required trainings were completed on the computer. They were self-paced modules that took about 1 hour to complete but gave the staff 5 credit hours. The annual corporate orientation modules covered resident rights, abuse prevention, Alzheimer's disease/dementia/mental/behavioral health, infection control, safety, safe patient handling, corporate compliance and Health Insurance Portability and Accountability Act, respectful workplace, customer service, cybersecurity, communication, trauma informed care, social media, and workplace harassment. The competency/skills fair was the same for everyone. During an interview on 4/23/2024 at 11:46 AM, licensed practical nurse Nurse Educator #26 stated the only checklist competencies completed annually were at the skills fair once a year. There was an orientation checklist completed when staff was hired, but not again unless they attended the skills fair. They could not confirm a staff member was competent in a skill without the skills fair or checklist for the skill. Licensed practical nurse #26 confirmed the due date and completion dates for licensed practical nurse Unit Manager #4 and stated they were not completed timely. Electronic communication (email) with the Administer on 4/23/2024 at 2:19 PM, documented that licensed practical nurse Unit Managers #4 and #33 did not have completed competencies. During an interview on 4/23/2024 at 2:22 PM, the Director of Nursing stated that nursing staff should have competencies completed annually, as they were mandatory. The education department tracked all nursing staff competencies. If they had not completed their annual competencies, they would be pulled off the schedule until they were completed. It was important to complete the competencies to ensure all licensed staff were updated and could perform the required tasks. The Unit Managers should also have competencies done annually. If there was a Unit Manager without completed competencies, the Director of Nursing would be notified. The Director of Nursing stated they were unaware that licensed practical nurse Unit Managers #4, and #33, and licensed practical nurse #34 did not complete annual competencies. 100% of licensed staff should complete competencies annually. 10 NYCRR 415.26(c)(1)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure certified nurse aide performance reviews were completed once every 12 months for 2 of 5 certified nurse aides (certified nurse aides #20 and #21) reviewed. Specifically, there was no documented evidence certified nurse aides #20 and #21 who had worked for the facility more than 12 months, had performance reviews completed at least once every 12 months. Findings include: The facility policy Appendix A - [NAME] Code of Conduct, dated 5/2023 documented that each supervisor and manager was responsible for monitoring that their personnel were acting ethically and in compliance with applicable federal, state, or local statues, ordinances, executive orders, rules, regulations, judicial, or administrative decisions, ruling or orders, the facility's policies and procedures and the Code. All personnel were responsible for acquiring sufficient knowledge to recognize potential compliance issues applicable to their duties. The annual performance evaluation of each employee will include their compliance with both Health Insurance Portability and Accountability Act regulations and Corporate Compliance Program. Electronic communication on 4/19/2024 at 2:09 PM from the Administrator documented that certified nurse aides #20 and #21 did not have annual evaluations completed. During an interview on 4/22/24 at 1:14 PM, the Administrator stated that annual evaluations were the responsibility of the Unit Managers. If the certified nurse aide was per diem or float staff, the Assistant Director of Nursing was responsible for annual evaluations. During an interview on 4/22/24 at 3:16 PM, registered nurse Unit Manager #28 stated they were responsible for certified nurse aide evaluations, and they were done annually. Certified nurse aide #20 had a review a short while ago but they could not recall the date. There was a computer program that evaluations were completed in. They could not access evaluations once submitted or previous year evaluations for comparison. During an interview on 4/22/2024 3:55 PM, Assistant Director of Nursing #23 stated the Unit Managers were responsible for the certified nurse aide annual reviews. Registered nurse Unit Manager #28 should be able to see certified nurse aide #20's annual evaluation. During an interview on 4/23/2024 at 10:51 AM, certified nurse aide #20 stated they had worked as a certified nurse aide for almost 2 years and had never had an annual evaluation at the facility. During an interview 4/23/2024 at 12:52 PM, the Director of Nursing stated that all staff had annual evaluations. There was no way for them to review evaluations if they were not the direct supervisor. All evaluations went to Human Resources who then reviewed them. They were unable to provide a blank version of the evaluation, but it was made up of 2 questions the first was about following the facility values, the second reflected the previous year. The options for answering were successful or not effective. The Nurse Manager had to generalize the information about the staff member in a narrative. If the Nurse Manager indicated not effective, there would have to be exact reasons, as this meant the staff member would be removed from the job. The Director of Nursing stated that Human Resources read each evaluation and determined what was needed for each staff member. During an interview on 4/23/2024 at 1:33 PM, the Chief People Officer (Director of Human Resources) stated they could not provide a copy of the evaluation form. The evaluation would just be a narrative, and they did not read each one. The evaluator was the person that determined the staff member's abilities. If it was determined by the evaluator they needed re-education, that would be the responsibility of Educational Services. 10 NYCRR 415.26 (d) (7)

Based on observation, record review, and interview during the recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain and or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #158) reviewed. Specifically, Resident #158 had a diagnosis of dementia and was not provided with preferred person-centered activities. Findings include: The facility policy Managing Behavioral Symptoms of Dementia, dated 4/29/2019, documented the facility was committed to ensuring that the needs of residents who experienced behavioral symptoms of dementia were met as much as possible. Behaviors often indicated unmet needs. Behaviors were no longer referred to as aggressive, disruptive, challenging, or difficult. Staff were to obtain history, favorite things, hobbies, personal interests to be included in non-pharmacological strategies and plans of care. A resident-centered plan of care would be developed with interdisciplinary goals and strategies to ensure resident's well-being and high quality of life. The facility policy Participation in Recreational Programs, dated 3/2023, documented residents had the right to attend and participate in recreational programs of their choice. Residents were provided with support, transportation, and assistance to attend programs as needed. Unless otherwise instructed by physician or nursing personnel, all residents would be allowed to attend all programs put on by the recreation department. Consideration for program adaptation included cognitive impairment, behavior, and preference to be in room. Resident #158 had diagnoses that included Alzheimer's disease, dementia with other behavioral disturbances, and muscle weakness. The 2/1/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, had inattention and disorganized thinking, exhibited physical, verbal, and other behavioral symptoms, and required maximum assistance to total dependence for activities of daily living. The 8/3/2023 Minimum Data Set annual assessment documented the resident preferred to have snacks between meals, read books, magazines, or newspapers, listen to music, participate in their favorite activities, and do things with groups of people. The resident's comprehensive care plan, revised 6/9/2023, documented the resident had impaired cognition function due to Alzheimer's dementia. Interventions included to utilize the resident's preferred name, to face the resident when speaking to them, and ask yes or no questions. The comprehensive care plan, revised 2/5/2024, documented the resident was dependent on staff and family to meet their emotional, intellectual, physical, and social needs related to their progressing dementia. Interventions included the resident would be invited to scheduled activities, be provided a program of activities of interest, be provided with materials for individual activities such as a radio, personal harmonica, books, poetry, and opportunities for spiritual care. The resident also needed one-to-one in-room visits and activities if unable to attend out of room events. The resident's care instructions documented to minimize the resident's potential for disruptive behavior by diverting the resident's attention with objects to fiddle with or place the resident near the jukebox with music on. The resident's preferred activities included music, playing the harmonica, singing along to hymns during spiritual programs, listening to a specific radio station, having poetry read to them, and having friends and family visit. The 2/1/2024 unsigned activity assessment documented the resident did best in one-to-one activities as they were disruptive in group activities. The resident spent most of their day in their room listening to music, looking out the window, socialized with residents who wandered in, and visited with family and friends. The resident loved sweets and would accept a snack pass. When the resident was not disruptive, the resident was moved to the activity room for socialization and stimulation. When the resident was too disruptive in activities, they were removed from the activity area. The resident's activity records documented the resident attended three group activities in March 2024, and no group activities in April 2024. The resident had two individual activities or engagements documented in March of 2024, and four individual activities or engagements documented in April of 2024. The resident's certified nurse aide behavior monitor documented the resident had four episodes of screaming (not at others) and one episode of anxious restlessness in April 2024. The unit activity board calendar documented: - on Tuesday, April 16th there was an 11:00 AM Songs You Remember and at 2:30 PM Chair Zumba. - on Wednesday, April 17th there was a 10:00 AM Morning Movement, at 1:30 PM Easy Trivia, and at 3:30 PM Tasty Treats. The following observations were made of the resident: - on 4/15/2024 at 10:27 AM, in their room, leaning forward in a reclining wheelchair chair, facing the wall with the window behind them. Their radio was playing explicit new age rap music from a local radio station. - on 4/16/2024 at 8:25 AM, in their room yelling, leaning forward in their reclining wheelchair. They were next to the closet and not within view of the door. There was no music or TV on. At 10:50 AM, the resident was in their chair around the corner in their room, out of the sight of the door. The radio was set to a station playing quietly. - on 4/17/2024 at 8:51 AM, in their room in their reclining wheelchair, leaning forward, quiet but alert, looking around their room. They were around the corner in their room, out of sight of the door. At 9:57 AM, the resident's radio was playing loud new age rap music. The resident was leaning forward in their wheelchair, staring at the wall. At 11:05 AM, the resident was leaning forward in their wheelchair, staring at the wall, with the radio on. At 3:51 PM, the resident was singing loudly in their room with the radio off. During an interview on 4/16/2024 at 11:16 AM, the resident's family member stated the resident liked sweets and any time they brought the resident sweets they ate the entire package. The resident also liked music especially blues and jazz as the resident used to play guitar. They stated the resident did not like new age rap music. They stated they provided compact discs for the resident to listen to as well. The resident was in their room a lot and it was more for other residents since the resident got loud sometimes. They stated they would like the resident to go to more activities as they believed it would be better for the resident to get out of their room more. During an interview on 4/22/2024 at 1:11 PM, certified nurse aide #70 stated if a resident did not want to get up, they would let them stay in bed and then encourage them to get up for breakfast. They stated Resident #158 got up during the night shift and in the morning, they checked on the resident to see if they needed to be changed and then brought the resident out to a common area. They stated the resident stayed in their room a lot because they yelled. They did not like to leave the resident in their room by themselves. The resident did better in a group setting and if the resident was having a good day, they should be out with everyone. If the resident was yelling, they moved the resident away from everyone. They stated the resident probably would not like new age rap music and they usually put on the compact disc music that was in the resident's room. During an interview on 4/22/2024 at 1:17 PM, licensed practical nurse #46 stated the resident was in their room a lot because they had a lot of outbursts. When the resident was agitated, they started swearing which agitated other residents. If the resident was not having outbursts, they should be out in the common area. If the resident was agitated, they brought the resident to their room and put on music to calm them down. The resident listened to a lot of country and liked to look out the window when in their room. They also liked to participate in activities and did great in activities. The resident would not like to listen to new age rap but sometimes that was what a local radio station would play. The resident also had compact discs to play. During an interview on 4/22/2024 at 1:31 PM, licensed practical nurse Unit Manager #52 stated they were covering for the resident's current unit. They stated that while it depended on a resident's behavior, non-independently mobile residents should be brought to the common area. They stated if Resident #158 was yelling, being in their room with music calmed them down. The family brought in compact discs to put on for the resident. They stated they were unsure what type of music the resident liked. During an interview on 4/22/2024 at 1:46 PM, social worker #71 stated residents who were not independently mobile, especially if they were a fall risk, should be in a common area on the dementia unit. They stated if the resident was not exhibiting yelling behaviors, they should be in a common area. They stated staff were always trying to engage the resident and have them out of their room as much as their behaviors allowed. When the resident was agitated, being in the room with music was a good way to calm them down. The resident enjoyed listening to a specific radio station and looking out the window. A resident with dementia could have negative effects from sitting in their room with no stimulation or interaction. The resident could have a day that did not start well but once the resident was calmed and doing better, they should be engaged in activities. 10NYCRR 415.12

Based on observation, interview, and record review during the recertification and abbreviated (NY00330471 and NY00331762) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure the medical provider was promptly notified of radiology results for 1 of 1 resident (Resident #168) reviewed. Specifically, Resident #168 had x-rays ordered by the medical provider, the radiology provider reported the results to the facility, and the results were not relayed to the medical provider timely. Findings included: The facility policy Radiology Services dated 1/2024, documented radiology services would be provided to all residents in a manner that prevented errors, assured accurate communication, and provided timely ordered service and timely results to the medical provider. The nurse confirmed the order for radiology or diagnostic test in the electronic medical record and notified the technician of an x-ray/diagnostic test by calling the radiology company contracted with the facility. The radiology technician conducted the x-ray/diagnostic test and then notified the charge nurse once completed. The radiology service provided would notify the nursing unit or Nursing Supervisor for acute radiology results. All results were integrated into the electronic medical record and could be viewed in the resident's individual record on the lab/x-ray results dashboard. The nurse would notify the medical providers of the radiology results. Resident #168 had diagnoses including Alzheimer's disease, weakness, and osteoarthritis (degeneration of joints). The 10/22/2023 Minimum Data Set assessment documented the resident had severely impaired cognition and was independent with ambulation. A 12/23/2023 at 10:35 AM incident report completed by registered nurse #45, documented another resident pushed Resident #168. Resident #168 fell backwards to the ground. Resident #168 complained of pain in the left hip and knee. The resident was assisted off the floor by 2 staff into a wheelchair. The provider was called and ordered an X-ray of the left knee and hip. A physician order dated 12/23/2023 documented an x-ray for the resident's left knee and left hip for pain from a fall. The x-ray was completed on 12/23/2023. A 12/23/2023 at 2:59 PM licensed practical nurse #46 progress note documented the resident had complaints of pain to their hip and knee; an x-ray was ordered, and the supervisor was aware of the incident. The radiology results report dated 12/23/2023 documented the resident had fallen and landed on their side. Three radiographs (x-rays) were taken of the resident's pelvis and left hip at 6:03 PM. The finding was a minimally displaced fracture of the left femoral neck (where the thigh bone meets the hip) with a possible extension to the superior aspect of the lesser trochanter (hip fracture). The report was signed by the x-ray company radiologist on 12/23/2023 at 6:37 PM. The report documented the results were provided to the facility. A 12/23/2023 at 10:37 PM licensed practical nurse #47 progress note documented the resident's x-ray was completed and the results were pending. Nursing notes from 12/23/2023 to 12/25/2023 did not include documentation of reported x-ray results. A 12/25/2023 at 11:36 AM licensed practical nurse #48 progress note documented they were called to the floor as the resident's family member asked about the outcome of the resident's fall and pain in their left hip. Licensed practical nurse called the radiology company to obtain the results of the x-ray. The resident was observed lying on their back with a complaint of left hip pain when range of motion was attempted. Internal rotation was noted. The registered nurse Supervisor came to assess the resident. The radiology company was called again for results. The radiology company called back, and a left hip fracture was noted. The resident's family member requested the resident be sent to the hospital. The registered nurse called the provider and awaited a call back. A 12/25/2023 at 12:58 PM progress note by licensed practical nurse #48 documented the resident had been sent to the hospital for evaluation of a left hip fracture. During an interview on 4/18/2024 at 10:13 AM, Resident #168's family member stated their sibling was notified by a nurse via phone that another resident had pushed the resident over, but the resident was fine, and they were doing x-rays as a precaution. They stated their sibling called the facility three times in total to follow up on the x-rays but only received a voicemail from the nurse that assured them the resident was fine. They went to visit the resident on 12/25/2023 and the resident was lying in bed, and they thought the resident had a stroke as one side of their face was clenched tight. They got a nurse who informed them the resident did not have a stroke but had a fall. They asked the nurse about the x-rays and the nurse informed them the x-rays had not been read. They stated an hour or so later the nurse had informed them the resident had a hip fracture. During an interview on 4/22/2024 at 1:31 PM, licensed practical nurse Unit Manager #52 stated they were the covering Nurse Manager for the resident's unit when the resident was pushed over and fell in 12/2023. The resident had x-rays ordered for their left knee and left hip on 12/23/2023. They stated after an x-ray was taken nurses should follow up with the x-ray department and request the results. If an x-ray was done at 6:00 PM on 12/23/2023, they expected the nurse to follow up if the x-ray results were not reported. They stated the nurse should have followed up on the x-ray on 12/24/2023 and before the family requested on 12/25/2023. During an interview on 4/22/2024 at 2:57 PM, physician #53 stated Resident #168 fell, and the resident had an x-ray ordered. The provider group was notified of the x-ray results on 12/25/2023 after the resident was already sent to the hospital. They stated the provider group should have been notified prior to 12/25/2023 of the x-ray results. During an interview on 4/22/2024 at 3:45 PM, the Director of Nursing stated if an x-ray was abnormal, the x-ray provider would call but the report was also sent to the electronic medical record and was red under the alerts. They stated they did not have a policy on when nurses were to follow up on an x-ray, but they expected the nurses to call the x-ray company 30 to 45 minutes after an x-ray was completed if they had not heard back. They stated the x-ray should have been followed up prior to 12/25/2023 if it was taken on 12/23/2023, especially if it had not been loaded into the electronic medical record by the x-ray company. 10NYCRR 415.21

Based on observation, record review, and interview during the recertification survey conducted 4/15/2024-4/23/2024 the facility did not ensure resident rights to personal privacy and confidentiality of their personal and medical records for 8 of 8 residents (Residents #1, #10, #133, #158, #305, #323, #325, and #397) reviewed. Specifically, Residents #1, #10, #133, #158, #305, #323, #325, and #397 identifying and personal information was posted in a public area visible to others. Findings include: The undated facility policy, Identifying Protected Health Information documented the facility was committed to ensuring the privacy and security of individual health information. To support this commitment, the facility would ensure that the appropriate steps were taken to properly identify and secure individuals' protected health information as required. Any health information relating to the past, present, or future physical or mental health or condition of an individual or the provision of health care to an individual would be protected. During observations on 4/18/2024 at 10:33 AM and 4/19/2024 at 11:49 AM personal identifying information for Residents #1, #10, #305 and #325 was posted in a public area on the 4th floor. The identifying information included personal resident information (room number, first name, last name, lab information, primary payor, bed status, diet, diet and liquid texture, and aspiration risk and confirmation). The information was posted in the 4th floor dining area to the left of the microwave and was highlighted yellow. During observations in the 11th floor dining room on 4/15/2024 at 12:12 PM, 4/17/2024 at 8:49 AM, 4/18/2024 at 9:04 AM, 4/19/2024 at 8:58 AM, and 4/22/2024 at 8:50 AM personal identifying information for Residents #158 and #397 was posted in the 11th floor dining room. The information was in a glass case and on a pillar in the middle of the dining room in a public area. The identifying information included personal resident information (the resident room number, the first name, last name, ordered diet including diet and liquid texture with aspiration risks highlighted, and special diet instructions). During observations on 4/16/2024 at 9:20 AM, 4/17/2024 at 8:59 AM, 4/19/2024 at 9:03 AM, and 4/22/2024 at 9:07 AM personal identifying information for Residents #133 and #323 was posted in a public area on the 13th floor next to the fireplace diagonal from the kitchen area. The identifying information included personal resident information (the resident room number, first and last name, and aspiration precautions). During an interview on 4/22/2024 at 10:46 AM, registered nurse Unit Manager #27 stated the posted resident information was a violation of resident's rights and the Health Insurance Portability and Accountability Act (a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) as it divulged private information. They stated it was a facility policy to post the residents on aspiration precautions. They tried to make their unit posting as generic as possible so that there was not a lot of information with highlights. During an interview on 4/22/2024 at 3:18 PM, the Director of Social Work stated staff were educated about the Health Insurance Portability and Accountability Act annually and during orientation. They stated a resident listing that included a full name, diet order, diet texture, liquid consistency, and special instructions posted in a dining room without cover would be considered a Health Insurance Portability and Accountability Act or resident rights violation. During an interview on 4/22/2024 at 3:45 PM, the Director of Nursing stated staff were educated about resident privacy and rights when hired and during monthly meetings. They had a list of the residents, and they highlighted the residents who were on aspiration precautions. They stated they did not have the resident aspiration list covered before and it was posted on the pillar in the dining room for the certified nurse aides to review. The list should only contain resident name, highlighted in yellow with ASP for Aspiration precautions at the top of the list. During an interview on 4/23/2024 at 9:40 AM, the Director of Health Information stated a resident list with personal information, that was not covered and posted on a unit in full view of others was not appropriate. During an interview on 4/23/2024 at 12:07 PM, certified nurse aide/unit secretary #17 stated the Health Insurance Portability and Accountability Act meant staff should not disclose resident information to anyone unless it was to an individual identified in the chart as being allowed to have the information. They stated the aspiration risk sign should be covered because it was a violation of the residents' privacy. During an interview on 4/23/24 at 12:40 PM, registered nurse Unit Manager #16 stated in accordance with the Health Insurance Portability and Accountability Act they should not discuss resident information or leave resident information visible because other people could see the information. During an interview on 4/23/2024 at 12:55 PM, Assistant Director of Nursing #18 stated the Health Insurance Portability and Accountability Act protected residents' personal information. The residents on aspiration precaution list should be visible for staff only and the information should be covered to protect the residents' privacy. 10NYCRR 415.3(d)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY00321560, NY00336003, NY00320334, NY00318518, NY00315691 and NY00330793) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 6 of 14 resident units ([NAME] Units 3, 4, 8, 10, 11, and 13) reviewed. Specifically: - on [NAME] Unit 3, room [ROOM NUMBER]-W had overflowing laundry bags, the bathroom was visibly dirty and had a strong urine odor, and the room floors were sticky. - on [NAME] Unit 4, room [ROOM NUMBER]-W's alternating pressure mattress machine had a missing right hook to secure the machine, and a ceiling tile was missing. - [NAME] Unit 11 had sticky floors; room [ROOM NUMBER]-W had a dirty wall, and liquid and debris on the floor; and room [ROOM NUMBER]-W had a broken stone windowsill. - [NAME] Unit 8's and 13's common area ice and water machine had white dried matter along the grate/catcher plate, the table, the bottom of the shelf it was on, the floor underneath the machine, and the wall to the side of the machine. - [NAME] Units 4 and 10 had fruit flies. Findings include: The undated facility policy, Cleaning and Disinfection/Non-critical care and shared equipment documented the facility would ensure that the appropriate infection prevention and control measures were taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal Regulations. Resident rooms were cleaned and disinfected in accordance with environmental services policies and procedures. The undated facility policy, Safe & Homelike Environment documented the facility provided a homelike environment for those that resided in the facility. The residents had a right to a safe, clean, and comfortable environment. The facility provided residents with furnishings that met individual's desires, the layout of the facility did not pose a safety risk to residents and facilitated resident independence, and the facility ensured residents received necessary care and services. The facility policy, Pest Control Program revised 10/5/2017, documented the facility established an effective pest control program that assured the facility would be pest and rodent free. The facility was professionally inspected weekly and monthly based on observations or findings, and treatments would be scheduled. The undated facility policy, Work Order System documented the facility utilized an electronic workorder system that was accessible to all staff to submit identified items that needed repairs, areas of concern, and pest control. The following observations and interviews were made on [NAME] Unit 3: - On 4/15/2024 at 11:34 AM, room [ROOM NUMBER]-W had a large clear trash bag of dirty clothes in the private bathroom and the floor of the room was sticky. At 1:19 PM, the resident stated they had a bag of clothes in the bathroom but there was no staff to wash them. - On 4/16/2024 at 8:28 AM and 3:31 PM, there was a large overflowing clear bag of dirty clothes in room [ROOM NUMBER]-W's private bathroom. The room's floor was sticky. - On 4/17/2024 at 8:30 AM, there was a large clear trash bag full of clothes in room [ROOM NUMBER]-W's private bathroom. At 12:28 PM, there was a brief with a brown smear on the floor in room [ROOM NUMBER]-W's private bathroom next to an overflowing clear trash bag of laundry. The floor was sticky and there was a urine odor in the room noticeable from the hallway. There was urine and feces observed in the unflushed toilet. - On 4/17/2024 at 8:37 AM, the resident in room [ROOM NUMBER]-W stated the certified nurse aide came into their room last night and left the dirty linen on the floor and it smelled. They stated it had been picked up by the certified nurse aide that did their morning care. At 9:40 AM, certified nurse aide #5 stated dirty linen was left on the floor from the night shift in room [ROOM NUMBER]-W which was not dignified and could be a potential infection or fall risk. During an interview on 4/18/2024 at 10:37 AM certified nurse aide #8 stated laundry came to the unit twice a week on Tuesday and Thursday. They stated because clothing was backed up for residents, they sometimes had to wash resident clothes themselves. They stated they were going to washroom [ROOM NUMBER]-W's clothes yesterday because they were overflowing and had run out of pants, however they did not have time to wash the dirty clothing. They stated they had seen residents in the same clothes for two days and that was not dignified. They have noticed a smell of urine in the room and believed it came from another resident dumping urine in room [ROOM NUMBER]-W. During an interview on 4/18/2024 at 11:29 AM licensed practical nurse Unit Manager #4 stated laundry was picked up every Tuesday and it was brought back by laundry, but they were unsure of the timeframe. They stated laundry staff had a hard time keeping staff, and sometimes laundry was off the unit for more than four days. If laundry is piled up in a room, it could lead to odors. During an observation and interview on 4/22/2024 at 9:01 AM [NAME] Unit 5 had one blue cart of linen that was full and there were 10 additional bags of linen on the ground next to the blue cart. Laundry worker # 72 stated each floor had a specific day when laundry was picked up. They stated laundry backed up because some residents go through more clothing due to incontinence, and they were also short staffed. During an interview on 4/23/2024 at 9:28 AM the Director of Nursing stated they expected laundry to be picked up on laundry day. If laundry was not picked up timely it could lead to odors and bugs. They stated it was not dignified to have laundry backed up in a resident's room or for a resident to smell feces or urine from dirty clothing. The following observations were made on [NAME] Unit 4: - On 4/15/2024, 4/16/2024, and 4/17/2024, room [ROOM NUMBER]-W's alternating air mattress machine was unsecured on the right side due a missing hook. - On 4/16/2024 at 10:10 AM, room [ROOM NUMBER]-W had a ceiling tile that was lifted and turned, and not secured in the ceiling support holder. - On 4/19/2024 at 9:20 AM, room [ROOM NUMBER]-W was missing a ceiling tile, the pieces were resting on the floor leaned against the heater. During an interview on 4/22/2024 at 3:57 PM, registered nurse Unit Manager #16 stated they put in a work request for the ceiling tile in room [ROOM NUMBER]-W a couple weeks ago as critical. When they tried to adjust the tile back into place on 4/19/2024, it broke completely in half and fell to the floor. During an interview on 4/23/2024 at 12:24 PM, housekeeper #62 stated they were responsible for cleaning resident rooms. They swept, dusted, removed trash, and mopped every room as needed. They did not recall any missing or broken ceiling tiles in room [ROOM NUMBER]-W. They would report any broken items to the Unit Manager or unit secretary and a work order would be filed. They would also add it to their own paperwork as the Housekeeping Manager would review it. The following observations were made on [NAME] Unit 11: - On 4/15/24 at 11:12 AM, resident room [ROOM NUMBER] had a whole section of stone windowsill next to the stationary armchair lifted and broken. There was a slightly jagged edge and a large gap underneath the stone windowsill from where it was lifted. - On 4/15/2024 at 10:27 AM, resident room [ROOM NUMBER] had a bed against the wall with brown matter smeared on the wall. - On 4/16/2024 at 10:50 AM, resident room [ROOM NUMBER] had a brown liquid drip mark on the wall behind the headboard of the resident's bed. - On 4/17/2024 at 8:51 AM, 9:59 AM, and 3:35 PM resident room [ROOM NUMBER] had a urine odor. There was a brown dried liquid drip mark on the wall behind the headboard. - On 4/18/2024 at 9:03 AM, the floors were sticky all around the 11th floor dining area. At 9:10 AM, the floors from common TV area down to room [ROOM NUMBER] were sticky. At 11:40 AM, the floor on the side of dining room between the counter and sink combination and round table was sticky. At 11:43 AM, the floor in front of the elevators was sticky. - On 4/19/2024 at 1:21 PM, resident room [ROOM NUMBER] had a large clear liquid puddle in the center of the room on the floor. - On 4/19/2024 at 9:39 AM, the floor to the left of the elevators was sticky. During an interview and observation on 4/16/2024 at 10:53 AM, certified nurse aide #80 stated if they found something broken in a resident room or there was a maintenance issue, they put a work order into their electronic communications system for maintenance. They stated they were unaware of the broken windowsill in resident room [ROOM NUMBER]. During an interview and observation on 4/16/2024 at 10:55 AM, certified nurse aide #70 stated they were assigned to resident room [ROOM NUMBER] that day and was unaware of a broken windowsill. During an interview on 4/23/2024 at 10:13 AM, housekeeper #81 stated if there was a spill or debris on a resident's floor, all staff were responsible for cleaning it. They stated if staff saw something, they were expected to clean it up and not wait on housekeeping. If there was a smear or liquid on a resident's wall whoever saw it was responsible for cleaning it. During an interview on 4/23/2024 at 10:18 AM, licensed practical nurse Unit Manager #82 stated they expected both housekeeping and nursing to clean any messes they saw on the floor. Whoever saw it first should clean it. They stated if there was a smear on a wall, whoever found it should clean it. However, if it is obviously a resident's bowel movement, the certified nurse aides were to clean it and then housekeeping followed through. Pest Control: The following observations were made: - On 4/15/2024 at 12:12 PM, there was a fruit fly in the dining room during the lunch meal [NAME] unit 10. - On 4/23/2024 at 10:06 AM, there were fruit flies in room [ROOM NUMBER]-W on [NAME] Unit 4. Resident use equipment cleanliness: The following observations were made of water/ice machines on resident units: - On 4/15/2024 at 10:10 AM on [NAME] Unit 8, the dining area water/ice machine had a dried white substance around the base of the machine, along the table, on the bottom of the shelf, on the floor underneath the machine, and the wall to the side of the machine. - On 4/15/2024 at 11:39 AM on [NAME] 13, there was an active leak beneath the ice machine with two catch basins full of water. - On 4/16/2024 at 9:03 AM on [NAME] Unit 13, the ice/water machine had white dried matter under and around the leg of the ice machine, and along the grate catcher plate in the bottom of the ice machine. At 9:05 AM, the red wall outlet plate the ice machine was plugged into was splattered with white matter. - On 4/17/2024 at 9:07 AM, on [NAME] Unit 13 there was a sticker on the water/ice machine documenting it was cleaned and sanitized on 1/31/2024. There was white build up on the catch grate and plate and discoloration splatter on the metal back plate under the ice nozzle. The counter under the machine had white build up. The red wall outlet plate the ice machine was plugged into, was splattered with white matter. During an interview on 4/15/2024 at 11:48 AM Maintenance worker #83 stated they cleaned the ice machines last week. 10 NYCRR 415.29(j)(1)

Based on record review, observation, and interviews during the recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure information on filing grievances was available for 11 of 11 anonymous residents present at the Resident Council meeting. Specifically, 11 anonymous residents present at the Resident Council meeting stated they did not know how to file an anonymous grievance. Findings include: The facility policy, Complaint Management Policy dated 2/21/2022 documented all residents would be informed at admission of their right to file a grievance and the information would be posted throughout the facility. Complaints could be filed either in written or in oral format to any staff member. The Director of Nursing served as the grievance official. During a Resident Council Meeting on 4/15/24 at 2:04 PM, eleven anonymous residents stated they were unaware of who the facility grievance officer was. They were told they had to report their concerns to their social worker. They stated they did not always receive follow up on grievances expressed and did not feel they could express concerns. The 11 anonymous residents were unaware they could file a grievance anonymously. During an observation on 4/17/2024 at 9:03 AM, a sign on the 13th floor documented to address any grievances, concerns, or unresolved issues firstly to the Unit Manager or Social Worker, secondly to the grievance officer, who was the Director of Nursing, or thirdly to the Ombudsman. Next to the sign was the number for the New York State Complaint hotline labeled Patient Care Hotline and the New York State Ombudsman poster. The compliance officer contact information was not documented. During an interview on 4/22/24 3:45 PM, the Director of Nursing stated a family member or resident could call them or write an email or letter to report a concern and they would follow up based on the information provided. They stated every grievance they received was written on the grievance log unless it was about a resident who stated they did not receive care, that would be an incident report, not a grievance. They stated grievances included concerns about discharge, the financial department, or missing items. They stated a resident filed an anonymous grievance by contacting them directly or having the social worker contact them. An anonymous grievance could be filed by giving a letter to security to put in their mailbox, sliding it under their office door, or by contacting the Ombudsman. They were aware it was a resident's right to file a grievance anonymously. During an interview on 4/22/24 at 5:01 PM, the Director of Social Work stated the Director of Nursing was the grievance officer. They stated a resident filed a grievance and the staff utilized their grievance form and then turned it into the Director of Nursing. They were unaware of a process in the facility for residents to file an anonymous grievance. They were aware it was a resident right to be able to file an anonymous grievance. During an interview on 4/23/24 at 11:05 AM, the Administrator stated the residents or family could submit anonymous grievances through the compliance officer or through the Ombudsman. They stated they believed the compliance officer number was in the resident handbook. If a resident wanted to remain anonymous, the resident could contact them directly or contact the compliance officer. 10NYCRR 415.3(C)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY00315691, NY00318518, NY00320334, NY00321560, NY00329469, NY00330471, NY00331762, and NY00332641) surveys conducted 4/15/2024 through 4/23/2024, the facility did not develop and implement a comprehensive person-centered care plan to meet the residents medical and nursing needs for 3 of 4 residents (Residents #62, #150 and #201) reviewed. Specifically, Resident #201 did not have a comprehensive care plan developed to include outside privileges or smoking outside on facility grounds; Resident #62 did not have a positioning pillow, palm guard, or pressure reduction boots as planned; and Resident #150 was not wearing their pressure reducing heel boots as planned. Findings include: The 8/8/2022 facility policy Comprehensive Care Planning, documented the facility must develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The services were to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The 4/19/2023 facility policy Smoking Policy, documented the facility was tobacco free. Any form of smoking, including but not limited to e-cigarettes, vaping, and all other uses of tobacco and marijuana products were prohibited on all facility properties. Facility properties included all land, building, structures, parking lots, and means of transportation owned by the facility. No one could smoke along any pathway or walkway leading to or from the parking area, nor at the picnic tables on any of the grassy areas or the parking lots. The 10/2023 facility policy Off Unit/Leave of Absence, documented that the facility would provide residents opportunities to leave the unit that provides safe and appropriate experiences for interacting outside. The attending physician/designee would provide an order for Leave of Absence and would evaluate the order on a minimum of every 30, 60, or 90 days. The order may be completed from the standing order in the medical record. The purpose of the policy was to be aware when a resident was off the unit and their location within or outside the facility. Residents must notify nursing on the unit and sign out and back in on the Resident Sign-Out book. The facility policy Skin and Wound - Pressure Injury Prevention, Identification, Treatment and Documentation of Pressure Injury dated 8/17/2022 documented each resident received treatment and services to promote healing and prevent new pressure injuries from developing. Use heel offloading devices such as pressure reducing boots or heel lifts on heels for protection. The most important function in management of pressure damage was pressure relief. 1) Resident #201 had diagnoses including nicotine dependence, noncompliance with other medical treatment and regimen due to unspecified reason and need for assistance with personal care. The 3/13/2024 Minimum Data Set assessment documented the resident was cognitively intact, had limited range of motion in both upper and lower extremities on both sides, and was independent with wheelchair use, The comprehensive care plan initiated on 8/2/2021 documented the resident had potential for alteration in mood state related to anxiety, depression, and history of nicotine dependence. Interventions included one on one visits as needed, allow time to express feelings as needed, behavior health referrals as needed, provided emotional support to the resident as needed, provider evaluation and/or re-evaluation of psychotropic medications, observe for desired and undesirable effects, reduce environmental stimuli, respect wishes for privacy, and validate feelings. The care plan did not include resident centered interventions for nicotine dependence. The 11/24/2023 incident note by registered nurse Unit Manager #28 documented Resident #201 was observed outside in a wheelchair smoking a cigarette. When questioned about smoking they stated they needed to smoke because the place drove them crazy. The 11/24/2023 social work note by social worker #60 documented a room search was conducted and 4 empty boxes of cigarettes and one lighter were found. The resident turned over the light and boxes were thrown away. There were no documented interventions added to Resident #201's care plan based on the smoking incident in November 2023. During an observation and interview on 4/16/2024 at 8:17 AM, Resident #201 was sitting in their wheelchair in the driving lane of the back parking lot between the visitor and employee lots. The resident stated they enjoyed the sunshine. During an observation on 4/18/2024 at 6:45 PM, Resident #201 attempted to smoke outside, concealed their cigarette, and remained under the awning of the building for several minutes. During an interview on 4/19/2024 at 11:26 AM, certified nurse aide #77 stated Resident #201 usually let the nursing staff know when they were leaving the floor. They left the floor to go downstairs and outside to smoke. The resident was usually in between the 2 front doors or the covered patio next to the employee parking lot. They sat down there and would ask anyone they saw for cigarettes or assistance with lighting a cigarette. The resident had a few other friends that did the same thing. Certified nurse aide #77 stated they had not seen the resident with a lighter but had seen them smoking outside. An electronic communication from the Administrator dated 4/20/2024 at 2:11 PM documented Resident #201 did not have any out of pass assessments or smoking assessments. During an interview on 4/22/2024 at 11:13 AM, registered nurse Unit Manager #28 stated that if the resident was not on the unit, they would go downstairs to find them. The resident was good about telling staff when they were leaving the unit. The resident would not explain where they were going, only that they would return for the next mealtime. The resident did not have an off the unit assessment and therapy listed them as independent with a wheelchair. If there was an emergency in the building, they would call the front desk security to see if they could see the resident. Resident #201 was caught smoking back in November. The current care plan just states a history of smoking. The Minimum Data Set assessment nurse was responsible for quarterly updates and reviews of the care plan, but registered nurse Unit Manager #28 was responsible for updates on episodic issues. An electronic communication from the Administrator dated 4/22/2024 at 11:14 AM, documented Resident #201 did not have any sign-out sheets for leaving the unit from 10/1/2023- 4/22/2024. During an interview on 4/22/2024 at 3:55 PM, Assistant Director of Nursing #23 stated that if a resident was off the unit the floor staff would have to account for them in the event of an emergency. If the resident was outside, they would have to be alert and oriented. There was no specific assessment for whether a resident could be outside. Resident #201 was appropriate to go outside unsupervised. The resident was not a risk to wander or elope. They were aware the resident was a smoker, but the grounds were non-smoking, and the resident was educated. The resident could use their cell phone if they needed assistance when they were off the unit. During an interview on 4/22/2024 4:43 PM, the Administrator stated that if a resident was caught smoking a full investigation should have been completed and interventions added to the resident's care plan and care card based on the findings of the investigation. Residents could leave the facility if they were alert and oriented but should not be in parking lots. If a resident was found in a parking lot staff should intervene. Interventions should be added for safety. There was no assessment to determine ability to go outside. The facility was responsible for keeping the resident safe even when they were outside. Resident #201 was not an elopement risk, if they said they were going outside, they would come back. The resident would communicate via cell phone. During an interview on 4/23/2024 at 1:27 PM, the Director of Nursing stated that creating person-centered care plans was a project. They used to do them on paper and were trying to make them personalized. The Director of Nursing would check to see if an elopement assessment was done for a resident if there was concern, but they checked for completeness, not accuracy. There were no smoking audits as they were a smoke free facility. The expectation was that the resident would have a care plan for the smoking habit. If the resident was caught smoking 3-4 times, they would get a wander alert device. 2) Resident #62 was admitted to the facility with diagnoses including stroke with hemiplegia (one sided weakness), obesity, and chronic obstructive pulmonary disease (chronic lung disease). The 1/25/2024 Minimum Data Set assessment documented the resident was cognitively intact, required extensive of assistance of two for most activities of daily living, was non-ambulatory, and had functional limitation in range of motion in all 4 extremities. The comprehensive care plan initiated 6/3/2021 documented the resident had activities of daily living self-care performance deficits related to limited mobility. Interventions included for left hand contracture, palm guard with roll at all times, resident was allowed to remove the palm guard during the day for a break. The comprehensive care plan initiated 8/12/2022 documented the resident had potential for skin impairment related to fragile skin, complex medical conditions, and the resident preferred to lie on their back while in bed. due to immobility. Interventions included the resident was to wear pressure reduction booties when in bed, a bariatric (referring to obesity) wound surface mattress with positioning pillows to protect skin. The following observations of Resident #62 were made: - on 4/17/2024 at 1:26 PM in bed without pressure reduction booties on their feet. The booties were not observed in the room. Resident #62 stated the pressure reduction booties were removed from their room several months ago and had not been replaced. The resident stated the pressure reduction booties made them more comfortable because they were always in bed. - on 4/18/2024 at 12:24 PM and 3:44 PM in bed. There were no pressure reduction booties on their feet, no positioning pillow, and no left palm guard. - on 4/19/2024 at 8:31 AM in bed without pressure reduction booties on their feet or a positioning pillow. - on 4/19/2024 in bed without pressure reduction booties on their feet or a positioning pillow. During an interview on 4/18/2024 at 3:46 PM certified nurse aide #19 stated they used the care plan to know resident specific care instructions and they were individualized for each resident. They stated Resident #62 was not care planned for pressure reduction booties. If a resident was care planned for p booties and did not have them, they could have skin breakdown on their heels. During an interview on 4/18/2024 at 4:17 PM licensed practical nurse #12 stated residents received individualized care based on their care plan. Failure to follow the care plan could impact resident outcomes. They believed Resident #62 was care planned for positioning pillows as they leaned to the right and looked like they might fall off the bed. During an interview on 4/19/2024 at 9:12 AM certified nurse aide #10 stated Resident #62 should wear a palm guard in their left hand because they had a contracture. They stated failure to wear the palm guard could increase the contracture. They stated the resident always leaned to the right like they are going to fall out of bed because they could not use their left side. They bought the resident a neck pillow to help with positioning, but they had never seen a positioning pillow. They did not believe the neck pillow, or the positioning pillow was on the care plan. During an interview on 4/19/2024 at 10:57 registered nurse Unit Manager #14 stated residents' care plans were individualized and drove the care card which is what the certified nurse aides used to know what care was necessary for each resident. They stated most residents on their unit were transferred from the rehabilitation unit and the care plan was initiated there. They stated they updated the care plan when the physician, therapy, or other discipline had recommendations for the residents. They stated pressure reduction booties were used to offset pressure to prevent skin breakdown on the heels. A positioning pillow was used to change a resident's position to prevent skin breakdown. If a resident was ordered to have pressure reduction booties or a positioning pillow and they did not, they could develop wounds, be uncomfortable, have pain, and increase the potential for infection. If a resident refused the booties or pillow it would be documented in a progress note. There was no documentation stating the resident refused either the booties or the positioning pillow. They stated they expected the items to be in the room if they were recommended. During an interview on 4/19/2024 at 12:15 PM physical therapist #15 stated that positioning devices were assessed for safety by therapy with the individual resident. They stated a risk benefit analysis had to be done prior to implementing that intervention to make sure the positioning device was safe and not being used as a restraint. They stated Resident #62's positioning pillow was not a therapy recommendation but a nursing intervention. 3) Resident #150 had diagnoses including diabetes, failure to thrive, and stroke. The 2/4/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required substantial assistance for hygiene, dressing, bed mobility, and transfers, was at risk for developing pressure ulcers/injuries, did not have pressure ulcers/injuries, and had pressure reducing devices for the chair and bed. The comprehensive care plan initiated on 1/29/2024 documented the resident had an activities of daily living deficit related to decreased mobility. Interventions moderate assistance of 1 when rolling left and right, the resident must wear pressure reducing boots as resident is supine (lying on back) in bed; bed to chair transfer dependent on 2 with mechanical lift, pressure reducing boots on when in wheelchair. The resident had potential for alteration in skin integrity related to decreased mobility and non-ambulatory. Interventions included elevate/float heels with pillows while in bed. A physician order dated 2/3/2024 documented to apply LNard boots (used for pressure reduction and/or foot stabilization) in the AM when out of bed and remove at night. The care instructions active as of 4/22/2024 documented to bilateral lower extremities apply LNard boots in AM when out of bed and remove at night. Pressure reducing boots on when in wheelchair and elevate/float heels with pillows while in bed. The resident was observed out of bed in their wheelchair without pressure relieving boots or LNard boots: - on 4/16/2024 at 8:26 AM in the dining room wearing blue nonskid socks and their feet were resting on the footrest of their wheelchair. - on 4/22/2024 at 12:12 PM in the dining room wearing blue nonskid socks and their feet were resting on the footrest of their wheelchair. - on 4/23/2024 at 10:19 PM in the common activities area wearing blue nonskid socks and their feet were resting on the footrest of their wheelchair. The 4/2024 Treatment Administration Record documented to bilateral lower extremities apply LNard boots in AM when out of bed and remove at night. The treatment administration record documented the LNard boots were in place at 8:00 AM on 4/16/2024 by licensed practical nurse #78 and on 4/22/2024 by licensed practical nurse #79. During an interview on 4/23/2024 at 10:44 AM, certified nurse aide #49 stated they would look in the [NAME] for resident specific care instructions. They were responsible for the resident today and was not aware they required any special pressure prevention devices to their heels. They reviewed the [NAME] care instructions on the computer and stated the resident should have had pressure reduction booties on or at least offered. During an interview on 4/23/2024 at 11:03 AM, certified nurse aide #8 stated the [NAME] provided instructions for the individual resident needs. They stated the [NAME] documented in the section of chair to bed transfer it showed that the resident required pressure reduction booties on when out of bed in their wheelchair. They did not think to look in that area. During an interview on 4/23/2024 at 11:23 AM, licensed practical nurse #50 stated the [NAME] provided the directions for staff to be able to care for the residents. Residents were expected to have the splints or devices worn as ordered and directed. Nurses should sign for them in the treatment administration record. The LNard boots were to prevent skin breakdown. During an interview on 4/23/2024 at 11:34 AM, licensed practical nurse #48 stated the [NAME] information was generated by the care plan, and they should match. The computer documented an order to wear LNard boots in AM and off when in bed every day. They needed them for risk of pressure, and they should have them on their feet. During an interview on 4/23/2024 at 11:45 AM, registered nurse Unit Manager #51 stated staff used the residents care plan to know how to provide care. The computer displayed the resident required LNard boots when out of bed and they expected them to be worn to prevent pressure. During an interview on 4/23/2024 at 12:55 PM, Assistant Director of Nursing #18 stated staff should use the [NAME] or the care plan to care for each resident. The programs worked together, and the information should match. The ordered heel protectors should be applied unless the resident refused and then documented accordingly. 10NYCRR 415.11(c)(1)

Based on observation, record review, and interviews during the recertification and abbreviated surveys (NY00315691, NY00318518, NY00321560, NY00329469, NY00330555, NY00332641, NY00334153, NY00336003, and NY00338231) conducted 4/19/2024-4/23/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 10 of 13 residents (Residents #62, 117, 124, 133, 150, 215, 305, 325, 384, and 414) reviewed. Specifically: - Resident #62 had unkempt hair, excessive facial hair, and unkept fingernails; - Resident #117 had unkept fingernails; - Resident #124 had unkept fingernails, greasy hair, and excessive facial hair; - Resident #150 remained in bed due to mechanical lift battery issues and was poorly positioned for meals; - Resident #133 was poorly positioned in bed for breakfast meals; - Resident #215 was not toileted as planned and had excessive facial hair; - Resident #305 was not toileted for over 5 hours; - Resident #325 had greasy hair and was not toileted as planned; - Resident #384 did not receive a shower as planned; and - Resident #414 did not receive a shower as planned and had excessive facial hair. Findings include: The facility policy Resident Nail Care dated 8/8/2022 documented residents received fingernail and toenail care to prevent potential discomfort or injury. Any nursing staff was able to provide nail care. The facility policy Aspiration Precautions and Standards of Care dated 11/1/2022 documented measures to prevent or lessen the risk of food, fluids, or other ingested material from entering the respiratory tract. Residents were to maintain an upright position throughout the meal and 30 minutes after. The facility policy Meal Service dated 11/1/2022 facility policy documented a staff member must be assigned to monitor the residents during the meal if there were residents that ate in their room and were not on aspiration precautions. The facility policy Quality of Life- Dignity dated 1/10/2023 documented each resident should be cared for in a manner that promoted and enhanced their sense of well-being, level of life satisfaction, feeling of self-worth and self-esteem. Examples were personal grooming such as hair styling, nails, and facial hair. The facility policy Activities of Daily Living (ADLs) dated 3/12/2024 documented the facility would provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless avoidable. Examples included hygiene, mobility, and dining. The resident who was unable to carry out activities of daily living would receive the necessary services to maintain grooming and personal hygiene. 1) Resident #133 had diagnoses including cerebral palsy (a condition affecting movement and posture), stroke affecting the left side with weakness, and gastroesophageal reflux disease. The 2/9/2024 annual Minimum Data Set assessment documented the resident was cognitively intact, had functional limitation impairment of both legs, required set up assistance for eating, maximum assistance for rolling left or right, was totally dependent for bed mobility, and received a therapeutic diet. The 12/22/2022 physician order documented the resident was on a no added salt, unmodified texture diet with thin liquids. The 2/26/2024 revised comprehensive care plan documented the resident had a hiatal hernia (the upper stomach bulges through the diaphragm), gastroesophageal reflux, had a stroke with left sided weakness, had cerebral palsy, and had activities of daily living deficits. Interventions included sit upright after meals, diet as ordered, monitor for difficulty swallowing, monitor for coughing/choking when lying down, speech therapy as needed, anticipate, and meet needs, moderate assistance of 1 from lying to sitting position, and maintain good body alignment. During an interview on 4/15/2024 at 1:47 PM Resident #133 stated staff told them they did not have time in the morning to pull the resident up in bed to eat breakfast properly and this was a frequent occurrence. Resident #133 was observed: - on 4/16/2024 at 9:06 AM, in bed with the head of the bed raised and a pillow behind their head. The resident had an over bed tray table in front of them and the height of the table was raised to the resident's mid face. The resident had to reach up to get the food off the tray. At 9:48 AM, the tray table remained raised to the resident's mid face, the resident was slouched in the bed, and their voice sounded gurgled. The resident cleared their throat and stated it was hard to eat their food that way. The resident reached up to get a banana after turning the tray so they could reach it due to the height of the table. - on 4/17/2024 at 9:22 AM, sliding down in the bed, almost chin to chest, with the head of the bed elevated. The over bed tray table had a meal tray on top and was positioned at chin level to the resident. The resident reached up and pulled a banana and small container of eggs down to their chest to eat. The resident coughed while talking. The resident's voice sounded gurgled. The resident stated staff did not have time that morning to pull them up in bed. - on 4/18/2024 at 9:15 AM, lying in bed with the head of bed raised. The over bed tray table was chin height. The resident had to reach up to retrieve food items from the tray. At 12:27 PM, the resident stated they would prefer to get out of bed for breakfast, but staff had told them multiple times in the past they did not have time. The family was in the room and stated the resident did not like to eat in bed and it was not safe for the resident to eat while lying in bed. The resident agreed they did not like to eat in bed and felt it was not safe. - on 4/19/2024 at 9:21 AM, lying in bed in a slumped posture. The tray table had a meal tray on the top and was at nose height of the resident. The resident reached up and pulled down a small plate of eggs, they placed the plate on their chest, so they did not have to reach up for each bite. - on 4/22/2024 at 9:04 AM slouched in bed eating breakfast. The head of the bed was raised, and the tray table was level with their chin. The resident had to raise their arm to reach food with their fork and move the fork down to their mouth. At 9:29 AM, the resident was attempting to rotate the tray to reach other items at the back of the tray. While drinking from a cup, the resident took breaths and tilted the cup for small sips. During an interview on 4/22/2024 at 10:10 AM, certified nurse aide #30 stated they floated to the unit that day and the licensed practical nurse wrote down resident needs on their assignment sheet. Any resident eating in bed should be properly positioned upright to prevent aspiration (inhaling food/fluids into the lungs) of food or drinks. During an interview on 4/22/2024 at 10:20 AM, certified nurse aide #64 stated they floated to the unit for this shift. Resident specific care was documented in the care plan and care instructions. Residents eating in bed had to be positioned upright. Their tray table should be a comfortable height to eat from and not at chin level or higher. The resident had not expressed to them a desire to be out of bed prior to eating. During an interview on 4/22/2024 at 10:33 AM, licensed practical nurse #31 stated resident specific care was in the care instructions. Awake residents should be out of bed for breakfast unless they did not want to. Any resident needing assistance with eating should be out of bed. If a resident ate in bed, they should be sitting upright with the tray table at chest height to enhance access to meal tray. The aides should round the unit during meals to ensure residents were not having difficulty eating. The nurse had seen the resident slumped in bed having difficulty eating in the past and immediately corrected the situation. During an interview on 4/22/2024 at 10:46 AM, registered nurse Unit Manager #27 stated care plans were updated by the Unit Manager and the appropriate disciplines. Cognitive residents were asked each meal if they wanted to get out of bed for the meal. Resident #133 was able to voice their preference and typically did not want to get out of bed for breakfast. Staff delivering meal trays should ensure the resident was positioned fully upright for the meal and not sliding down in bed during the meal. They stated they rounded the unit during breakfast, the resident was sitting up in bed with pillows under their arm and did not ask to be pulled up in bed. Resident #133 had use of 1 arm to eat and had a difficult time reaching the meal tray with that arm. 2) Resident #124 had diagnoses including epilepsy (seizure disorder), contractures of both hands (tightening of muscle, tendons, ligaments), and morbid obesity. The 3/6/2024 Minimum Data Set assessment documented the resident was cognitively intact, had functional limitations in both arms and legs, used a wheelchair, was dependent for toileting and hygiene, required maximal assistance for upper body dressing/personal hygiene (such as combing hair/shaving), and received physical therapy. The 2/2/2024 updated comprehensive care plan documented the resident was at risk for alteration in skin integrity, was able to make own preferences and choices, had left hemiplegia (one-sided weakness), and had activities of daily living deficits. Interventions included keep skin clean and dry, weekly skin checks by nurse, observe skin with routine care, honor preferences, range of motion with care, physical therapy referrals as needed, provide sponge bath when a full bath could not be tolerated, check fingernail length and trim/clean on bath day and as necessary, dependence on 2 for scheduled shower day every Tuesday on evening shift, maximum assistance of 1 with personal hygiene, and dependence of 1 with upper body dressing. During an observation on 4/15/2024 at 12:32 PM, Resident #124 had a full beard and stated they were supposed to be shaved today. They preferred to be shaved at least every other day, but they were not. The resident stated they were unable to shave themselves and their beard was itchy. They stated they scratched their face when itching due to long, sharp fingernails. The 4/17/2024 care instructions documented the resident was dependent for upper and lower body dressing, 2 staff for all care due to behaviors, bilateral palm grips during sleep, make sure hands were clean, provide regular range of motion on fingers of both hands, maximum assistance of 1 for personal hygiene, dependence of 2 for shower/bath every Tuesday on evening shift, and keep skin clean and dry. The following observations of Resident #124 were made: - on 4/17/24 at 9:12 AM, lying in bed eating breakfast with certified nurse aide #65 sitting in the room supervising. The resident's hair appeared greasy and tangled with white flakes. The resident stated they were given a bed bath the evening before. The resident's fingernails were grown to the tips of the fingers and had pointed edges in various areas on each nail. - on 4/18/24 at 8:30 AM, in their room sitting in a wheelchair. The resident's hair was uncombed, and their fingernails were unkept. - on 4/19/24 at 10:00 AM, resting in bed. Their fingernails were unkept and had brown debris underneath. Their hair appeared greasy and there was facial stubble about 1/8 inch long. The 4/2024 nurse aide task documented the resident was provided personal hygiene every day shift and most evening shifts, received upper body dressing every day shift and most evenings, had a skin observation done every day shift and most evenings and nights. The resident received a shower/bath on evening shifts of 4/15/2024 and 4/16/2024. During an interview on 4/29/24 AM at 2:05 PM, registered nurse Unit Manager #66 stated each resident was scheduled for a bath or shower once a week and as needed. If the bath/shower was refused by the resident, a bed bath was offered. If a bed bath was given, the resident's hair was washed using a shower cap. Resident activities of daily living preferences were obtained from the resident or representative upon admission and then quarterly and entered the care plan and care instructions. Certified nurse aides were expected to review each assigned resident's care instructions daily prior to resident care, unless they were full time on the unit and familiar with the resident, then they should review them weekly. Any changes to the care instructions were discussed during morning report. Unit nurses were responsible to ensure all care was provided. The Unit Manager and Assistant Unit Managers rounded frequently on the unit to ensure care was done. Weekly skin checks were done by a unit nurse on shower/bath days for each resident. Nail care was done on shower days and nails should be trimmed as needed according to resident preferences. Facial hair should be trimmed or shaved per resident preferences on shower days and as needed. Facial hair length was also based on resident's preferences and preferences, such as having a beard or whiskers, should be in the care plan. Nails should be no longer than the tips of the fingers and filed smooth to prevent scratches. Resident #124 only wanted bed baths and often refused shaving. This should be in the care plan and instructions and documented as refusals. Hair washing was included in the shower/bath task and fingernail care and shaving were in the personal hygiene task. Resident #124's hair should not have been greasy unless they refused to have their hair washed. During an interview on 4/29/2024 at 2:15 PM, certified nurse aide #63 stated resident specific care was documented in the resident's care instructions and was reviewed daily. They stated they reviewed each resident's instructions prior to entering the room to provide care. Each resident should receive a shower/bath weekly according to the unit shower list. The unit nurse performed a skin check with each bath/shower. Nail care, hair washing, and shaving were to be done on the bath/shower day. Residents should also be shaved when facial hair was clearly visible or per resident preferences. If a resident refused care, staff were to reapproach and tell the nurse if the refusal continued and documented in the medical record. Any nursing staff could trim nails unless otherwise specified. Resident #124 usually asked when they wanted to be shaved. They stated they noticed Resident #124's hair was greasy in appearance and offered to wash it on 4/29/2024 in the morning. If a resident was given a bed bath, staff were to wash their hair using a shower cap washing device. Nails should be trimmed so the resident did not scratch themselves with long nails. During an interview on 4/29/2024 at 2:25 PM, licensed practical nurse #67 stated skin checks, nail care, and hair care were done on a resident's bath/shower day. If a resident refused care, the aide told the nurse who would reapproach the resident. All refusals were documented in the task section and a progress note made by the nurse. Nurses were responsible for ensuring resident care was completed by the aides as planned. Resident rounding was done by the nurse when performing resident care such as treatments and medications. Any issues were addressed with the aide. They stated they checked Resident #124 that morning and noted they had greasy hair. Aides were allowed to trim nails unless the resident was diabetic, and Resident #124 was not. Nails should be trimmed when at the tip of the finger or longer. If a resident refused a bath/shower after reapproaching, they generally did not get one until the next week. Hair care and nails could be done anytime and by any nursing staff. 3) Resident #384 had diagnoses including hemiplegia (one-sided weakness), obesity, and diabetes. The 4/11/2024 Minimum Data Set assessment documented the resident was cognitively intact, required substantial assistance for bathing and toileting, and did not refuse care. The 3/24/2024 comprehensive care plan documented a deficit with self-care related to fatigue. Interventions included to encourage the resident to participate in care. The resident was alert and oriented and able to make decisions regarding their care. During an interview and observation on 4/15/2024 at 4:18 PM, Resident #384 was unshaven. They stated they only received a shower once a week and did not receive one on 4/12/2024 as scheduled. The usual certified nurse aide was off, and they did not get washed up that day. There was a strong smell of urine in the room. The certified nurse aide task record for Resident #384 was not signed as completed on 4/12/2024. There was no progress note documenting the resident refused their shower 4/12/2024. During an interview and observations on 4/16/2024 at 8:14 AM, Resident #384 stated there was emesis on the floor. They stated the call bell had been on since 7:30 AM that morning and staff had not answered it yet. The call light was on. There was emesis with food particles on the floor. The room smelled of urine and the resident's urine drainage bag was half full. Staff entered the room at 8:22 AM to answer the call light and the nurse cleaned up the emesis at that time. At 9:58 AM, the resident was in bed and there were large yellow spots on the right side of the bed sheets. The resident stated they had vomited on that area of the sheets. At 3:13 PM, the resident was sitting in a chair. The resident stated they had been washed but they had not received a shower and would like one. There was a large wash basin in the room with a yellow liquid. The resident stated they had vomited in the basin. During an interview on 4/17/2024 at 9:40 AM, certified nurse aide #5 stated showers were on the schedule at the nursing station. A resident not receiving activities of daily living would have poor hygiene which could cause an infection and was undignified. During an interview on 4/19/2024 at 10:57 AM, registered nurse Unit Manager #14 stated care refusals were documented in the care plan. A refusal intervention was to reapproach the resident and notify the nurse for documentation purposes. Nail care, shaving and hair washing were done as needed even if not on their scheduled shower day. Repercussions of not providing appropriate care included pneumonia, infection, tooth decay, overall feelings of uncleanliness, negative psychosocial effects, and dignity issues. They expected that all planned care be provided. During an interview on 4/22/2024 at 9:06 AM, licensed practical nurse #44 stated the aides provided residents a shower on their assigned shower day. Residents should be washed each day. Resident #384 should have received a shower on 4/12/2024. They stated there were times when scheduled showers were not done by a certified nurse aide who was covering for a regular aide. Resident #384 was assigned a shower each Friday. The resident never refused a shower since they had been caring for them. During a follow-up interview on 4/22/2024 at 9:36 AM, registered nurse Unit Manager #14 stated if a resident did not get a shower and wanted one, it could impact their overall feelings of wellness, skin breakdown, and infection prevention. They expected that each resident received their shower on their scheduled day. Resident #384 did not refuse care and was cognitively intact. It was not acceptable that the resident put the call light on at 7:30 AM and staff did not answer it until 8:22 AM. 10NYCRR 415.12 (a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification survey conducted 4/23/2023 -4/23/2024, the facility did not ensure drugs and biologicals were labelled and stored in accordance with currently accepted professional principles for 5 of 12 medication carts ([NAME] units 3, 4, 8, 10, and 14) reviewed, and 1 of 6 medication rooms ([NAME] unit 5) reviewed. Specifically, the medication cart on [NAME] unit 3 had nicotine patches without resident labels; [NAME] unit 4 had expired medications; [NAME] unit 8 has insulin without a labeled open date; [NAME] unit 10 had inhalers not in the correct pharmacy box and without labeled open dates and unlabeled eye medications; [NAME] unit 13 had personal food items stored with resident medications; and [NAME] 5 medication room had a refrigerator with a significant amount of ice buildup. Findings include: The facility policy Over the Counter (OTC) Medications- Floor Stock dated 4/5/2019 documented that eye drops, nasal spray, and eardrops should be obtained from the pharmacy to ensure proper resident specific labeling. Each week the Director of Nurses' designee would review supply of house stock. Newly obtained stock items would be placed in the back to ensure proper rotation and that items were used before the expiration date. The existing stock would have expiration dates checked. Any items found expired would be removed immediately. The proper disposal of expired or unused [over the counter] medications was to place them in the same place as the pharmacy medication returns. The facility policy Drug and Biological Storage: Medication Refrigerators dated 10/11/2021 documented that all injectable drugs and biologicals delivered to the facility would have pharmacy labels on the outside container as well as the drug vial, should the container and vial be separated. Once the injectable drug was opened a sticker noting the date the vial was opened and the initials of the nurse should be placed on the vial, or the information written directly on the vial. Medication Carts During an observation and interview on 4/17/2024 at 10:27 AM, [NAME] Unit 3 medication cart 1 had a nicotine 14 mg patch without a resident label. Licensed practical nurse #6 stated the nicotine patch was for a current resident but was not labeled and should have been. They stated if medications were not labeled properly, there could be an error and be given to the wrong resident. During an observation and interview on 4/17/2024 at 11:23 AM, [NAME] Unit 13 medication cart had a glazed donut stored in an opened clear plastic bag in the small second drawer under the narcotic locked box. Registered nurse Unit Manager #27 stated they looked at the cart at 6:00 AM that morning and there was not a donut stored in the medication cart. They stated the donut should not be in the medication cart. During an observation and interview on 4/17/2024 at 3:27 PM, [NAME] Unit 4 medication cart 1 had three bottles of expired medications: 1 stock bottle of oyster shell calcium 500 milligram labeled expired on 2/2024, 1 stock acidophilus with pectin 140 milligram bottle labeled expired 3/2024, and 1 resident specific medication citalopram hydrobromide 40 milligram, expired 11/27/2023. Licensed practical nurse #54 confirmed the 2 stock medications and 1 resident specific medication in the top drawer were expired. They stated the medication nurse was responsible for all the medications within their cart, and they should check the medications before dispensing them. During an observation and interview on 4/17/2024 at 3:30 PM, [NAME] unit 8 medication cart 1 had 2 vials of open insulin without labeled open dates, and there was no labeled pharmacy bag for the insulin vials. There was a blank sticker on the vial for the open date with the resident's name. Licensed practical nurse #73 stated the vial had been opened and belonged in a pharmacy bag with the open date on it. It was important to know the open date of the insulin because the effectiveness of the medication may be reduced after a certain amount of time. During an observation and interview on 4/17/2024 at 3:52 PM, [NAME] unit 10 medication cart 1 had 2 Trelegy Ellipta (inhaler for lung disease) without open dates. The pharmacy label documented to discard 6 weeks after opening. There was a resident specific Systane 0.4-0.3% eye gel medication and Azelastine hydrocholoride 0.1% nasal spray without labeled open dates, or expiration dates on the containers. Licensed practical nurse #74 stated all medications should be labeled with an open date. They were not sure when the 2 inhalers were opened and should be discarded due to lack of dates on the packages. The eye drops and nasal spray should have been labeled with a date open sticker and without the label they should be discarded because the medication could be expired. Medication room During an observation and interview on 4/17/2024 at 1:45 PM, the [NAME] unit 5 medication room refrigerator had significant ice buildup inside and the refrigerator temperature logbook documented the medication refrigerator should be maintained between 36-46 degrees Fahrenheit, when the temperatures were out of range: adjust thermostat, if temperature was not maintained place a high priority work order. Registered nurse Unit Manager #14 stated there was at least 6 inches of ice buildup in the refrigerator and the overnight nurse from 11:00 PM to 7:00 AM was responsible to document in the logbook and confirm appropriate temperatures were maintained. It was important to check the temperatures to ensure the medications were stored properly. During an additional observation and interview on 4/19/2024 at 9:48 AM, licensed practical nurse #13 stated that night shift was responsible for writing the refrigerator temperatures in the logbook. They stated there was about 3 inches of ice in the middle and 5 inches around the edges. They stated if the temperature check was not completed the refrigerator could have been out of range and this would affect medication storage. During an interview on 4/22/2024 at 1:45 PM, Assistant Director of Nursing #23 stated that once insulin was opened it should be labeled with the resident's name label and the open date. There was a little sticker that went on the vial and the pharmacy label should be on the bag where the vial of insulin would be stored. Insulin vials were specific to each resident. If there was no open date listed the insulin vial should be discarded and a new one ordered. There could be a change in effectiveness after opening a medication. The opened nasal spray should have a date on the resident sticker on the bottle, or an expiration date. If it did not have either, the medication should be discarded. The inhalers should have open dates listed, if it was not listed the medication should be discarded and a new one ordered. The inhaler inside the box should match the label on the box. If medications were not labeled and stored properly there was the potential for the resident to get the wrong medication, or an expired medication which may no longer be effective. 10 NYCRR 415.18(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification and abbreviated (NY00330555) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 3 test trays reviewed (4/16/2024 and 4/18/2024 lunch meals). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures. Findings include: The facility policy Food Temperature Control and Correction dated 1/1/2004 documented: - Proper food temperature control and safe food practices were essential to prevent contamination or spoilage that could cause infection or poisoning. - A temperature of 41 degrees or lower was required for all entrees, meats, vegetable, cereals, eggs, starches, soups, desserts, fruits, and milks. - The Dining Service Manager was responsible to record the temperature of all foods at the start of each tray line or meal services. Trayline temperatures should be taken 1 hour from the start of the initial temperature recordings. - Protein based foods/beverages, juices, cold sandwiches, and yogurts were to be always kept in a refrigerated dispenser. During an interview on 4/15/2024 at 9:40 AM, Resident #436 stated the food does not taste good. Breakfast was the best meal, but lunch and dinner were not good. During an interview on 4/16/2024 at 11:24 AM, Director of Food Services #57 stated the meal service took about 2- 2.5 hours to complete. During an observation on 4/16/2024 at 12:55 PM, Unit 3's last tray on the cart, labeled for room [ROOM NUMBER] W, was selected to test. The tray included the following cold food items and measured temperatures: pureed coleslaw was 53 degrees Fahrenheit, pureed pasta salad was 65 degrees Fahrenheit, and the vanilla milkshake was 59 degrees Fahrenheit. The hot food items were within temperature parameters, but the fish sandwich was dried out and the fish flavor was very strong and was not palatable. During an interview on 4/16/2024 at 12:58 PM, Director of Food Services #57 stated the cold food item temperatures should be 41 degrees Fahrenheit or colder. The temperatures for the vanilla milkshake, pasta salad, and coleslaw were not acceptable. They did not do test trays very often. During an observation on 4/18/2024 at 12:22 PM, a random tray was selected on Unit 10 that was labeled for room [ROOM NUMBER]. The tray included the following cold food items and measured temperatures: juice was 54 degrees Fahrenheit, and a salad was 53 degrees Fahrenheit. These food items were not within cold food temperature parameters and did not taste palatable. During an interview on 4/19/2024 at 11:50 AM, diet technician #58 stated they did test trays. The test trays monitored the temperature of the food, taste, and appearance. The cold food items should be less than 41 degrees Fahrenheit. They said it was important for food to be at the correct temperature because people could get sick and the out of temperature parameter food may not be palatable. During an interview on 4/19/2024 at 12:10 PM, the Director of Clinical Nutrition stated cold food items should be less than 41 degrees Fahrenheit and food that had temperatures between 50- 60 degrees Fahrenheit was not acceptable and was not palatable. It was important for food to be served at appropriated temperatures for palatability and food safety. During an interview on 4/19/2024 at 12:16 PM, the Director of Food Services #57 stated for food safety the temperature of the cold food items should be 41 degrees Fahrenheit or below. 10NYCRR 415.14(d)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 4 of 14 food preparation and pantry storage areas ([NAME] Unit 4, and [NAME] Units 4, 5, 6) and in the main kitchen. Specifically, the pantry storage areas on [NAME] Unit 4, and [NAME] Units 4, 5, 6 were soiled with food spills and the refrigerators were not cleaned of food debris and spills. Additionally, the main kitchen tray line had cold food tables with food items temperatures ranging from 40- 55 degrees Fahrenheit. Findings include: The facility policy Food Temperature Control and Correction dated 1/1/2004, documented the dining services management staff were responsible for checking temperatures before food serving starts. Serving of food would not begin until all foods were at the proper cold temperature. A temperature of 45 degrees or lower was required for all entrees, meats, vegetable, cereals, eggs, starches, soups, deserts, fruits, milks, coffee, and tea. Food items that did not meet the minimum required temperatures on the tray line were pulled from the line and blast chilled. The facility Quality Control Temperature Checklist undated included mealtime, menu items to have temperature monitored with a beginning temperature, and one hour re-check of the temperature and should be initialed y the food service manager. Unclean Pantries - During an observation and interview on 4/15/24 at 2:33 PM, the [NAME] Unit 6 resident 2 door cooler in the pantry was soiled with old food spills. The Director of Housekeeping stated the housekeeping staff and Nurse Manager were responsible to keep those areas clean. - On 4/16/24 at 9:49 AM, the [NAME] Unit 5 floor pantry coolers had food spills in and under food stored in the cooler. There were multiple holes measuring half inch to 3 inches in the wall behind the retherm units. - On 4/16/24 at 10:25 AM, the [NAME] Unit 4 floor pantry refrigerator and two door cooler had food spills. The floor around and underneath the refrigerator was sticky and visibly soiled with dried food debris and spills. - On 4/16/24 at 2:25 PM, the [NAME] Unit 4 pantry refrigerator had a bottom freezer that was not in use and visibly soiled with a brown substance. Food out of temperature on the kitchen tray line: During an observation on 4/16/24 at 11:24 AM, the main kitchen tray line for was preparing for supper. The temperatures measured across the three cold tables ranged from 40 - 55 degrees Fahrenheit for diced pears and cooked chicken breast. During an observation and interview on 4/16/2024 at 11:38 AM, the Food Service Supervisor stated they checked the food temperatures with a probe thermometer as the food items were removed from the cooler. They were also supposed check each food item temperature again when they had been sitting in the table. The Food Service Supervisor checked the temperature of the chicken, and the temperature was 47 degrees Fahrenheit. They stated the chicken should be below 45 degrees Fahrenheit and should be thrown out. The temperature of the chicken was not checked earlier, and they were not sure how long the chicken had not been within acceptable temperature. They measured the temperature of the pears, and they were 54 degrees Fahrenheit. They stated the pears sat out for the entire meal service which was about 4 hours. At 12:03 PM, they measured pureed burger (51 degrees Fahrenheit), pureed hot dog (54 degrees Fahrenheit), ground hot dog (54 degrees Fahrenheit.), ground chicken (65 degrees Fahrenheit), American cheese (55 degrees Fahrenheit), and pureed macaroni and cheese (48 degrees Fahrenheit). The Food Service Supervisor stated all those food items were to be used for the meal service and were not within acceptable temperature ranges. They would have come out of the cooler at 7:30 AM and had not been checked throughout the day. They stated food can be left out of temperature for four hours and then should be thrown out. At 12:09 PM, the ground hamburger was 39 degrees Fahrenheit, pureed macaroni and cheese was 47 degrees Fahrenheit, and chicken breast was 49 degrees Fahrenheit. They stated the chicken temperature was last checked around 10:00 AM that morning. 10NYCRR 415.14(h)

Based on record review and interview during the abbreviated survey (NY00308186), the facility did not ensure all alleged violations were thoroughly investigated for 1 of 3 residents reviewed (Resident #2). Specifically, Resident #2 sustained a skin tear of unknown origin and an investigation was not completed to rule out abuse or neglect. When Resident #2 sustained an additional skin tear of unknown origin, the facility's investigation did not address the resident's order for one-to-one supervision and the facility did not determine whether it was provided as ordered. Findings include: The 8/3/2021 Intensive Staff Supervision/Timed Observation For Clinical and Non-clinical Employee Monitoring policy documented: - Intensive supervision, also called intensive staff monitoring (ISM) or timed observation is the act of observing an assigned resident who has been assessed at being at great risk for safety. - ISM is for instances when the resident needs to be under direct supervision at all times. - It is expected that the ISM assigned to the resident does not leave the individual alone at any time unless another staff member is present to relieve them for breaks or at the end of their shift. - The staff member assigned to ISM is to ensure the resident's safety at all times. - They are to provide the resident diversional activities (games, walks, music) and/or provide a calm quiet atmosphere if needed to reduce anxiety or agitation. - At no time is a resident on ISM to be assigned to a staff member that is doing another task. The 10/11/2021 Investigation of Incidents/Injuries of Unknown Origin Policy documented: - The purpose of the investigation is to rule out or confirm abuse, neglect, or mistreatment has occurred with outcome determined by facts, based on evidence and not opinion, which is subjective. - The investigation should include statements from all staff on the unit from the past 3 shifts, review of the medical record if the care plan was followed, and if physician orders followed. - In the conclusion, it must be determined if abuse, mistreatment, or neglect occurred. Resident #2 had diagnoses including Alzheimer's disease, fracture of the left femur (thigh bone), and epilepsy (seizure disorder). The 10/17/2022 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, exhibited behavioral symptoms including physical, verbal, and other behaviors directed toward others, and rejection of care. The resident required extensive assistance of one staff for most activities of daily living (ADL), and sustained falls with injuries including one major injury. The comprehensive care plan (CCP), revised 8/5/2022, documented the resident had an ADL self-care deficit related to dementia. Interventions included extensive assistance of 1 staff for most ADLs. The resident was at high risk for falls and interventions included to anticipate needs, ensure the call light was in reach, a low bed, and wearing appropriate footwear. The resident was at risk for skin impairment and interventions included to identify/document potential causative factors and eliminate/resolve where possible. Incident #1 Nursing progress notes from 8/30/2022 to 9/5/2022 did not contain documentation related to the resident sustaining any new falls or injuries. The 9/6/2022 at 7:16 PM, licensed practical nurse (LPN) #4's progress note documented the resident sustained a skin tear to the left shin, the Supervisor was notified. The 9/6/2022 at 8:48 PM, registered nurse Supervisor (RNS) #5's progress note documented the RNS notified the on-call provider of an approximately 4-inch semi-circular skin tear to the left shin, steri-strips were applied, wound edges nicely approximate,d and covered with an adhesive bordered foam dressing. The 9/6/2022 physician's order documented a treatment to the skin tear to the left shin: cleanse with normal saline (NS), apply an adhesive bordered foam dressing, change every 3 days and as needed, check every shift to be sure intact, and if steri-strips were needed, call the medical provider. There was no documented evidence of an incident report or investigation related to the circumstances in which the resident sustained the skin tear. During an interview with RNS #5 on 6/6/23 at 11:10 AM, they stated they could not recall responding to the resident for a skin tear identified on 9/6/2022. As the RNS responding, they would rule out abuse or neglect by initiating an investigation or incident report. The RNS responding to the incident was responsible for initiating the investigation for injuries of unknown origin and the Nurse Manager would continue it the following day. During an interview with RN Manager #8 on 6/13/2023 at 3:33 PM, they stated they were unable to locate an incident report or investigation for the resident's skin tear noted on 9/6/2022. Incident #2 Nursing progress notes from 9/7/2022 through 10/7/2022 documented the resident had multiple falls and behavioral concerns related to wandering. The CCP, revised 9/21/2022, documented the resident was an elopement risk/wanderer. Interventions included document wandering behavior and attempted diversional interventions, wander alert device on the left ankle, and provide structured activities, toileting, walking, and reorientation strategies. The 10/7/2022 at 8:30 PM RN #17's progress note documented the resident's family was notified of the plan to have the resident on intense supervision with a one-to-one present for all shifts through the weekend. The 10/11/2022 at 10:12 AM, RN Manager #8's progress note documented the resident's ISM (intensive staff monitoring, one-to-one) was discussed in rounds and the resident was to be trialed off ISM for the night shift and would only be on 15-minute checks for the night shift. The 10/11/22 physician's order documented ISM for the day and evening shifts for wandering risk. The 10/2022 Treatment Administration Record (TAR) documented on 10/23/2022, licensed practical nurse (LPN) LPN #3 signed as completing the resident's ISM for the day and evening shifts. The 10/23/22 at 2:51 PM, LPN #3's progress note documented the resident continued on ISM this shift and after lunch began to cry and hit people. The 10/23/22 at 6:07 PM, RNS #6's progress note documented RNS #6 was called to the unit due to a skin tear on the resident's right (later noted as left) front lower leg. The resident was calm with no signs of pain or distress. The area was cleansed with wound cleanser and covered with a non-stick dressing. RNS #6 noted the CCP was followed, policies and procedures were followed, and there was no reasonable cause to suspect abuse or neglect. The 10/23/2022 at 10:17 PM, LPN #3's progress note documented the resident continued on ISM this shift (evening), was physically violent toward staff, and was tearful. The 10/23/2022 schedule for Resident #2's unit documented LPN #3 was assigned to provide ISM on the 3 PM to 11 PM shift. The Incident Accident Investigation completed by RN Manager #8 on 10/28/22 documented: - on 10/23/22 at 6:00 PM, Resident #2 sustained a skin tear of unknown origin on the left shin. - The summary of staff interviews included the skin tear was found by the assigned staff/nurse (LPN #3), the resident had a habit of trying to get out of their wheelchair and could be combative with staff upon redirection. Though it was not directly observed, the nurse assigned one-to-one (LPN #3) believed that the skin tear was a result of contact with the wheelchair. - The CCP and physician orders were followed. - LPN #3's statement included they were assigned to the resident, and they did not provide any care to elder d/t [due to] staffing issues. A note initialed by RN Manger #8 at the bottom of the statement included clarification 10/24, believes resident got skin tear from w/c [wheelchair]. - The conclusion included the evidence of the investigation did not support the skin tear was a result of abuse or neglect in care by staff. The location of the skin tear matched the sharp prominence on the wheelchair when observed sitting in the chair. The investigation did not address the discrepancy noted that the assigned one-to-one staff (LPN #3) did not observe when the resident sustained the skin tear and their statement related to not providing care due to staffing issues. During an interview with RNS #6 on 5/31/2023 at 11:30 AM, they stated they could not recall the incident with Resident #2 on 10/23/2022. When responding to an incident such as an injury of unknown origin, the RNS would look to see if the CCP was followed. If an LPN was assigned as a one-to-one staff person for a resident, that would be their only assignment. If there was a physician's order for one-to-one supervision and it was not provided, this would be a violation of the CCP. If there was an order, it needed to be followed and a staff person would be assigned to provide one-to-one. When interviewed on 6/8/23 at 3:34 PM, LPN #3 stated they only provided one-to-one, also called ISM, to Resident #2 on one occasion. They could not recall when, but they were asked to stay for the assignment from 7 PM to 11 PM and the resident was in their room watching television, and then went to bed. The had never done an ISM assignment aside from that one time and had no information about the 10/23/2022 skin tear. If asked to do ISM for Resident #2, they would refuse as they were a nurse. They could not pass medications and do ISM at the same time and when they signed the TAR for ISM, it was verification it was done, not that they did it themselves. LPN #3 was unaware of the reason they wrote a statement on the 10/23/2022 investigation about not providing care due to staffing and reiterated they never did ISM so they would not provide care to the resident. LPN #3 may have noted they were assigned to the resident due to being the LPN who passed medications to the resident. Following the interview with LPN #3, the following Medication Administration Records (MAR) were reviewed and documented for Residents #4, 5, 6, 7, and 8 on 10/23/2022, LPN #3 administered their medications during the 3 PM to 11 PM shift. During a telephone interview on 6/1/2023 at 10:15 AM, RN Manager #8 stated they investigated the 10/23/2022 incident and interviewed LPN #3. Their responsibility included gathering information and additional statements if needed to resolve the issue. Resident #2 was on one-to-one due to combativeness, wandering, and getting up from their wheelchair. One-to-one (ISM) supervision meant direct supervision in order to keep the resident safe. If an LPN or CNA was assigned as one-to-one, that was to be their sole responsibility that shift. LPN #3 verified no one went near Resident #2 on 10/23/2022, and the RN Manager thought the skin tear could have come from the wheelchair. Regarding LPN #3's statement they could not provide care due to staffing, they probably meant that since the resident was combative, LPN #3 was not able to provide care without additional assistance and there may not have been anyone available at the time to assist. To their knowledge, the CCP was followed. During a follow-up interview with RN Manager #8 on 6/13/2023 at 3:33 PM, they stated regarding the 10/23/2022 incident, it was determined that LPN #3 was providing one-to-one supervision based on the LPN's statement and the unit assignment. If assigned for one-to-one, the LPN would be dedicated to just that resident and would not pass medications on the unit. During a telephone interview on 6/22/2023 at 2:33 PM with the Administrator and Director of Nursing (DON) they stated: - the purpose of an incident report or investigation was to gather information and rule out abuse or neglect. - They were unable to locate an investigation related to the skin tear Resident #2 sustained on 9/6/2022 and an investigation should have been initiated by RNS #5 due to the injury being of unknown origin. - On 10/23/2022, LPN #3 was assigned to provide ISM for Resident #2. ISM meant one-to-one monitoring of the resident. - When reviewing the ISM policy, the DON agreed staff were not to leave the resident alone, to ensure their safety, and have no other tasks assigned to them. - If LPN #3 passed medications on the 3 PM to 11 PM shift when they were assigned for ISM for Resident #2, LPN #3 could have maintained visual contact with the resident. Resident#2 self-propelled in their wheelchair and the LPN probably kept an eye on them in the hall as they passed medications. If the LPN had to go into another room or area for another resident's medication pass, it was reasonable to assume other staff on the unit kept an eye on the resident. It was not typical for the assigned ISM staff to have additional responsibilities such as the medication cart at the same time. LPN #3 had provided ISM in the past to Resident #2 and did not pass medications at the same time. The investigation did not address the level of supervision Resident #2 received prior to the skin tear. 10NYCRR 415.4(b)(3)

Based on record review and interview during the abbreviated survey (NY00308186), the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident #2). Specifically, Resident #2 was placed on one-to-one direct supervision, they were not provided direct supervision, and sustained a skin tear of unknown origin. Findings include: The 8/3/21 Intensive Staff Supervision/Timed Observation For Clinical and Non-clinical Employee Monitoring policy documented: - Intensive supervision, also called intensive staff monitoring (ISM) or timed observation is the act of observing an assigned resident who has been assessed at being at great risk for safety. - ISM is for instances when the resident needs to be under direct supervision at all times. - It is expected that the ISM assigned to the resident does not leave the individual alone at any time unless another staff member is present to relieve them for breaks or at the end of their shift. - The staff member assigned to ISM is to ensure the resident's safety at all times. - They are to provide the resident diversional activities (games, walks, music) and/or provide a calm quiet atmosphere if needed to reduce anxiety or agitation. - At no time is a resident on ISM to be assigned to a staff member that is doing another task. Resident #2 had diagnoses including Alzheimer's disease, fracture of the left femur (thigh bone), and epilepsy (seizure disorder). The 10/17/2022 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, exhibited behavioral symptoms including physical, verbal, and other behaviors directed toward others, and rejection of care. The resident required extensive assistance of one staff for most activities of daily living (ADL). The resident sustained falls with injuries including one major injury. The comprehensive care plan (CCP), revised 8/5/2022, documented the resident had an ADL self-care deficit related to dementia and needed assistance with ADLs. The resident was at high risk for falls related to confusion, incontinence, and poor safety awareness. Interventions included anticipate needs, ensure the call light was within reach with prompt response, low bed, appropriate footwear, and follow facility fall protocol. The resident was at risk for skin impairment and interventions included following the facility protocol for treatment of injury, identify/document potential causative factors, and eliminate/resolve where possible. Nursing progress notes from 7/17/2022 through 9/25/2022 documented the resident had 12 falls, including one with major injury (fracture) and one with a head laceration requiring sutures. Progress notes included the resident had behavioral concerns related to agitation, non-compliance, poor safety awareness, and wandering about the unit. The CCP, revised 9/21/2022, documented the resident was an elopement risk/wanderer and interventions included documenting wandering behavior and attempted diversional interventions, wander alert device on the left ankle, and provide structured activities, toileting, walking, and reorientation strategies. The 10/7/2022 at 11:07 PM, LPN #3's progress note documented the resident eloped off the unit at the beginning of the shift and was found by the Supervisor. The resident was placed on ISM (intensive staff monitoring, also referred to as one-to-one) for the weekend. The 10/11/2022 at 10:12 AM, RN Manager #8's progress note documented the resident's ISM was discussed in rounds, the resident was to be trialed off ISM for the night shift only and would be on 15-minute checks for the night shift. The 10/11/2022 physician order documented: ISM day and evening shifts for wandering risk. The 10/202022 Treatment Administration Record (TAR) documented licensed practical nurse (LPN) #3 signed for completing the resident's day and evening shift ISM on 10/23/2022. The 10/23/2022 at 2:51 PM, nursing progress note entered by LPN #3 documented the resident continued on ISM this shift (day) and after lunch began to cry and hit people. The 10/23/2022 at 6:07 PM RN Supervisor (RNS) #6's progress note documented the RNS was called to the unit due to a skin tear on the right (later noted as left) front lower leg. The resident was calm with no signs of pain or distress. The area was cleansed with wound cleanser and covered with a non-stick dressing. The CCP was followed, policies and procedures were followed, and there was no reasonable cause to suspect abuse or neglect. The 10/23/2022 at 10:17 PM progress note entered by LPN #3 documented the resident continued on ISM this shift (evening), was physically violent toward staff and was also tearful. The 10/23/2022 evening schedule for Resident #2's unit documented LPN #3 was assigned to ISM for the 3 PM to 11 PM shift. The Incident Accident Investigation completed by RN Manager #8 on 10/28/2022 documented: - on 10/23/2022 at 6:00 PM, Resident #2 sustained a skin tear on the left shin of unknown origin. - The summary of employee interviews conducted included the skin tear was found by the assigned staff/nurse (LPN #3), the resident had a habit of trying to get out of their wheelchair and could be combative with staff upon redirection. Though it was not directly observed, the nurse assigned one-to-one believed that the skin tear was a result of contact with the resident's wheelchair. - The CCP and physician orders were followed. - LPN #3's statement included: they were assigned to the resident, and they did not provide any care to elder d/t [due to] staffing issues. A note initialed by RN Manger #8 at the bottom of the statement included: clarification 10/24, believes resident got skin tear from w/c [wheelchair]. The investigation did not address the discrepancy noted that the assigned one-to-one staff (LPN #3) did not observe when the resident sustained the skin tear, their statement related to not providing care due to staffing issues. Medication Administration Records (MAR) for Residents #4, 5, 6, 7, and 8 documented on 10/23/2022, LPN #3 administered their medications during the 3 PM to 11 PM shift. During an interview with RNS #6 on 5/31/2023 at 11:30 AM, they stated they could not recall the incident with Resident #2 on 10/23/2022. If an LPN was assigned as a one-to-one, that would be their only assignment. If there was a physician order for one-to-one supervision and it was not provided, this would be a violation of the treatment plan. If there is an order, it needed to be followed, assigned to a staff and that would be their only assignment. When interviewed on 6/8/2023 at 3:34 PM, LPN #3 stated they only provided one-to-one (ISM) to Resident #2 on one occasion. They could not recall when it was, but they were asked to stay for the assignment from 7 PM to 11 PM and the resident was in their room watching television, and then went to bed. The never did an ISM assignment for Resident #2 aside from that one time and did not know anything about the 10/23/2022 skin tear. They could not pass medications and do ISM at the same time and when they signed the TAR for ISM, it was verification it was done, not that they did it themselves. They were unaware of the reason they wrote a statement on the 10/23/2022 investigation about not providing care due to staffing and reiterated they never did ISM so they would not provide care. The LPN may have noted they were assigned to the resident due to being the LPN who passed medications to the resident. During a telephone interview on 6/1/2023 at 10:15 AM, RN Manager #8 stated Resident #2 was on one-to-one due to behaviors of combativeness, wandering, getting up from their wheelchair, unable to be redirected, and they could not restrain residents. One-to-one (ISM) supervision meant direct supervision in order to keep the resident safe. If an LPN or CNA was assigned to do one-to-one, that was to be their sole responsibility. LPN #3 verified no one went near Resident #2 on 10/23/2022, and the RN Manager thought the skin tear came from the wheelchair. Regarding LPN #3's statement they could not provide care due to staffing, they probably meant that since the resident was combative, the LPN was not able to provide care without additional assistance and there may not have been anyone available at the time to assist. During a follow-up interview with RN Manager #8 on 6/13/2023 at 3:33 PM, they stated it was determined that LPN #3 was providing one-to-one supervision based on the LPN's statement and the unit assignment. If assigned for one-to-one, the LPN would be dedicated to just that resident and would not pass medications on the unit. During a telephone interview on 6/22/2023 at 2:33 PM with the Administrator and Director of Nursing (DON) they stated: - On 10/23/2022, LPN #3 was assigned to provide ISM for Resident #2 and ISM meant one-to-one monitoring of the resident. - When reviewing the ISM policy, the DON stated staff were not to leave the resident alone, to ensure their safety, and have no other tasks assigned to them. - If LPN #3 passed medications on the 3 PM to 11 PM shift when they were assigned for ISM for Resident #2, they thought the LPN may have maintained visual contact on the resident. Resident #2 self-propelled in their wheelchair, and the LPN may have kept an eye on them in the hall as they passed medications. - If the LPN had to go into another room or area for another resident's medication pass, it was reasonable to assume other staff on the unit kept an eye on the resident. - It was not typical for the assigned ISM staff to have additional responsibilities such as the medication cart at the same time. LPN #3 had provided ISM in the past to Resident #2 and did not pass medications at the same time. 10NYCRR 415.12 (h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification survey conducted 9/19/22-9/23/22, the facility failed to ensure residents had the right to a dignified existence for 1 of 4 residents (Residents #127) reviewed. Specifically, Resident #127's urinary catheter drainage bag (collects urine) was not covered and was visible in the dining room and from the hallway while the resident was in their room. Findings include: The undated facility policy, Quality of Life and Dignity documented each resident would be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality by maintaining privacy for medical devices (urinary bags). Resident #127 had a diagnosis of unspecified dementia and neuromuscular dysfunction of the bladder. The 7/20/22 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, was totally dependent with activities of daily living (ADLs) and had a suprapubic catheter (urinary tube placed through the abdominal wall to drain urine). The comprehensive care plan (CCP) initiated 6/20/2021 documented the resident had an indwelling catheter related to a neurogenic bladder (lack of bladder control). On 11/20/2021 interventions were updated to include keeping the catheter bag (urinary drainage bag) below the level of the bladder and away from the entrance door. The CCP did not include instructions for a privacy cover for the urinary drainage bag. The resident was observed: - On 9/20/22 at 9:19 AM, sitting in their high back chair in the dining room with their uncovered urinary drainage bag hanging on the right side of the chair. At 12:37 PM, the resident was sitting in their room near the door being assisted with eating lunch and their drainage bag was hanging on the right side of the chair, uncovered and visible from the hall. - On 9/22/22 at 1:10 PM, lying in bed with their drainage bag hanging on the right side of the bed near the door, uncovered and visible from the hall. - On 9/23/22 at 11:10 AM, lying in bed with their drainage bag visibly hanging on the right side of the bed near the door. The top portion of the drainage bag was covered with a blue bag and the lower portion was uncovered and urine was visible. The resident [NAME] (care instructions) active on 9/23/22 did not include directions for a privacy bag for the urinary drainage bag. During an interview on 9/23/22 at 11:15 AM, licensed practical nurse (LPN) # 2 stated Resident #127 required assistance with catheter care and nursing staff should ensure the urinary drainage bag was covered. They stated Resident #127's urinary drainage bag should always be covered in the dining room for dignity and privacy. During an interview on 9/23/22 at 011:47 AM, certified nurse aide (CNA) #1 stated Resident #127 needed assistance with catheter care. The resident's urinary drainage bag should not be exposed and should be covered for privacy. During an interview on 9/23/22 at 11:56 AM, registered nurse (RN) #3 stated nurses were responsible for documenting when catheter care had been completed, that any staff member could cover the urinary drainage bag, and the bag should be covered for dignity reasons. RN #3 stated instructions for placing a urinary drainage bag into a dignity bag were found on the care plan and the CNA [NAME] (care instructions). Urinary drainage bags should always be covered for dignity and privacy reasons. 10NYCRR 415.5 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 9/19/22-9/23/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 of 12 resident units (Units 5, 7, 9, 11, and 13), for 3 residents (Residents #148, 186, and 416), and for 2 resident rooms (rooms [ROOM NUMBERS]). Specifically, there were multiple unclean, stained, and damaged areas, furniture, and equipment throughout the facility and fruit flies were observed in a dining area. Resident #148 had an unclean wheelchair, linen, furniture, and sticky floors; and Residents #186 and 416 had unclean Broda (positioning) chairs. Additionally, resident rooms [ROOM NUMBERS] had hot water temperatures at the sinks exceeding 120 degrees Fahrenheit (F). Findings include: The facility's undated Daily Housekeeping Task List included the following tasks: - stock toilet paper in resident bathrooms; - clean off resident bed tables; - wipe up any food crumbs or other debris on furniture; - mop resident room floors; and - wipe dining room counter tops. The monthly pest control customer service reports documented a third party vendor had been coming onsite each month to treat the facility. General Environment Unit 5: During an observation on 9/19/22 at 4:25 PM, resident room [ROOM NUMBER] had a damaged lower section of wall behind the bed where metal parts of the bed were inside the wall. The plastic cover base at the bottom of the wall had been pushed into the wall. Unit 7: During an observation on 9/19/22 at 2:33 PM, the resident room [ROOM NUMBER] wall behind the bed had a 3 foot x 3 foot section of rough spackle. During an observation on 9/19/22 at 2:40 PM, resident room [ROOM NUMBER] had a stained ceiling tile with a black substance on it. Unit 9: During an observation on 9/19/22 at 12:50 PM, resident room [ROOM NUMBER] bathroom had a toilet paper holder that was ripped out of the wall and was lying on a working radiator cover along with four toilet paper rolls. The radiator was not on at the time of the observation. There were sharp exposed metal edges, and the light in the bathroom was not working. During an observation on 9/19/22 at 4:30 PM, resident room [ROOM NUMBER] had a four foot section of cove base loose/damaged, and the section of wall by the closet was scraped. Unit 11: The following observations were made: - on 9/19/22 at 11:04 AM and 9/22/22 at 11:37 AM, resident room [ROOM NUMBER] had a ceiling tile out of place over the resident bed. - on 9/19/22 at 11:13 AM, resident room [ROOM NUMBER] had a gap between ceiling tiles with one of the tiles out of place. - on 9/19/22 at 11:30 AM, 9/20/22 at 11:09 AM, and 9/22/22 at 11:43 AM, the nightstand drawer in resident room [ROOM NUMBER] was not lined up properly, a ceiling tile over the heater was warped/buckled, and there was debris on the floor between the nightstand and the wall. - on 9/19/22 at 11:41 AM and 9/22/22 at 11:49 AM, resident room [ROOM NUMBER] had small brown drips on the floor near the closet doors. - on 9/19/22 at 11:49 AM and 9/22/22 at 11:52 AM, resident room [ROOM NUMBER]'s bathroom sink was trickling and would not shut off. - on 9/19/22 at 11:52 AM and 9/22/22 at 11:53 AM, resident room [ROOM NUMBER] had ceiling tiles out of place in the bathroom and in the resident room. The closet door handle was broken with the handle on the floor inside the closet. - on 9/19/22 at 12:35 PM, the 11th floor TV room had a missing section of wall corner guard. - on 9/19/22 at 12:45 PM, resident room [ROOM NUMBER] had a ceiling tile in the middle of the room that was out of place, and with a ceiling suspension piece missing. There was an approximate gap between ceiling tiles of 2 feet x 2 feet. The closet had a ceiling tile that was out of place and had a 1 inch gap. - on 9/19/22 at 1:23 PM and 9/22/22 at 12:04 PM, resident room [ROOM NUMBER] had a cable wire plate cover coming off the wall and wires were exposed (approximately 1/2 inch). - on 9/19/22 at 1:26 PM and 9/22/22 at 12:06 PM, resident room [ROOM NUMBER] had two uneven, rough plaster sections of walls approximately 2 feet x 2 feet in size. - on 9/20/22 at 8:59 AM, resident room [ROOM NUMBER] had a 2 inch x 3 inch brown substance on the wall and a brown smear on top of a dresser near a glove, a washcloth, and tissue paper. - on 9/22/22 at 11:36 AM, resident room [ROOM NUMBER] had a wet stained ceiling tile. - on 9/22/22 at 12:05 PM, resident room [ROOM NUMBER] had 1 stained ceiling tile with a black substance on it. - on 9/22/22 at 11:38 AM, resident room [ROOM NUMBER] had a ceiling tile in middle of room that was out of place. - on 9/22/22 at 12:00 PM, resident room [ROOM NUMBER] had a brown smear on top of a dresser. - on 9/22/22 at 9:00 AM, the 11th floor dining lounge area had over 50 fruit flies present around the sink on the island. Most of the flies were around the shelves above the counter and on the red jars on the shelf, and there was a visible dried spill on the shelf. - on 9/22/22 at 4:38 PM, resident room [ROOM NUMBER] had a granite windowsill that was loose/unsecure. During an interview on 9/22/22 at 11:36 AM, Senior Operations Director stated that the facility had sweating of water from pipes during the summer. During an interview on 9/23/22 at 9:33 AM, housekeeper #32 stated that they usually covered the 11th floor. They stated their daily tasks included mopping/cleaning floors, wiping down dresser/nightstand tops, walls and surfaces, and beds. They followed a task sheet of what should be completed each day. Housekeeper #32 stated that the plaster on the wall in resident room [ROOM NUMBER] had been there for several months, and they had reported this to the Nurse Manager. They stated that if a resident would not let them in their room, they would tell their supervisor. There had been some problems trying to complete all resident rooms on the 11th floor in the past due to resident behaviors. Housekeeper #32 stated that if there was an issue (light out in room, missing/gapped ceiling tiles, etc.) they would tell the Nurse Manager and would expect the issue to be passed on to maintenance staff so a work order could be entered. They stated that they were not aware of the loose/unsecure windowsill in resident room [ROOM NUMBER]. Unit 13: The following observations were made: - on 9/19/22 at 11:10 AM, the dining area had a rotten banana on top of a China cabinet, and there were 5 fruit flies in the area. There were multiple fruit flies in the kitchenette area. - on 9/19/22 at 11:40 AM, the granite windowsill in resident room [ROOM NUMBER] was loose/not attached. During an interview on 9/22/22 at 1:00 PM, housekeeper #29 stated they would clean and sanitize resident bathrooms, sweep resident rooms daily, clean the dining room after each meal, and would follow the housekeeping daily task sheet. Housekeeper #29 stated that they were not aware of the rotten banana or any fruit flies and was not sure of the last time fruit flies had been found on that floor. They stated that they were not aware of the loose windowsill in resident room [ROOM NUMBER]. Housekeeper #29 stated that if an issue was found on the 13th floor they would tell their crew leader, Nurse Manager, or their boss and that person would produce the work order. They stated that they had not been trained on work orders, it was not their responsibility to submit a work order, and they had been employed at the facility for 24 years and knew the facility process for work orders. Housekeeper #29 stated the windowsills would pop out when the resident beds were lifted under the windowsill. During an interview on 9/23/22 at 10:15 AM, the Director of Housekeeping stated that they were not aware of the findings observed throughout the facility. All staff were trained to report any maintenance or housekeeping issue so a work order could be produced, and the issue fixed. They were unaware the wall in resident room [ROOM NUMBER] had been damaged for a few months and stated that the hole in the wall behind the bed in resident room [ROOM NUMBER] did not appear to happen that day. The Director of Housekeeping stated there had been previous windowsill issues in the facility and they were not aware of the loose/unsecured windowsill in resident room [ROOM NUMBER]. They stated that work orders would be entered by the Director of Housekeeping, housekeeping crew leaders, the Director of Maintenance, Housekeeping Supervisor, or Nurse Managers. They stated they were not aware of fruit flies on the 13th and 11th floors and did not know the last time fruit flies had been found on resident floors. A third party pest control vendor came weekly to check the traps inside and outside the building, and any issues identified were documented in a logbook. They were not aware of the toilet paper holder being ripped out of the wall. During an interview on 9/23/22 at 11:18 AM, the Director of Maintenance and the Senior Director of Operations stated that there had been issues getting access to room [ROOM NUMBER] to complete maintenance issues. A work order had been created and work was started. The resident in room [ROOM NUMBER] had a decline lately and had been more violent since being moved to the dementia unit. The Director of Maintenance stated that they were not aware of any of the issues identified during the tour of the facility. Once a work order was received it would be assigned to maintenance staff. They could not recall the last time fruit flies were found on resident units. The Senior Director of Operations stated they had made wooden bed bumper boxes for all resident rooms to prevent resident beds from damaging the walls. Environmental condition room inspections had been completed this past summer when military came to assist the facility due to low staffing. They stated that from February 2022 to July 2022, military staff had helped replace ceiling tiles, fix and/or replace lights, replace closet doorknobs, and housekeeping staff were continuously mopping and deep cleaning resident rooms in 2022. Resident Specific Environment Resident #148 had diagnoses including dementia. The 7/28/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required limited to extensive assistance of 1 with most activities of daily living (ADLs), and used a wheelchair. A grievance form dated 7/22/22 by Resident #148 documented the resident's family complained about the condition of the resident's room. The plan was to clean the room twice a day. The following observations were made of Resident #148's room: - on 9/19/22 at 1:45 PM Resident #148 was sitting in a wheelchair in their room. The wheelchair sides were dirty with dried food drips and build-up on the brakes. The floor was sticky, and the surveyor's shoes stuck to the floor while walking in the room. The resident's overbed tabletop had a sticky feeling to it. - on 9/20/22 at 10:21 AM, Resident #148's room floor remained sticky. The resident had 3 pillows on the bed. Only 1 pillow had a pillowcase on it, and one was uncovered with cracks in the vinyl. The resident's white blanket had various dried tan areas. - on 9/21/22 at 12:27 PM, the resident's white blanket on the bed had multiple tan dried stains on it. - on 9/22/22 at 9:18 AM, the resident was sitting in a wheelchair in their room. The bed was made, and the white blanket continued to have multiple dried tan/brown stains on it. There were 2 uncapped bottles of flavored water on the hand railing next to the toilet and both were about 1/4 full. The resident was eating breakfast and a plastic lid for the plate was lying on the floor next to the overbed table next to the resident. The resident's feet were bare. At 12:00 PM, the same white blanket was still on the bed. - on 9/22/22 at 12:58 PM, certified nurse aide (CNA) #13 reported to registered nurse (RN) Unit Manager #14 that the resident threw their lunch tray on the floor. - on 9/23/22 at 10:08 AM, the resident was sitting in a wheelchair in their room, their meal tray was on an overbed table with the lid on the floor by the nightstand. The same stained white blanket remained on the made bed. Resident #186 had diagnoses including dementia. The 8/4/22 MDS assessment documented the resident had severely impaired cognition, required extensive assistance of 2 with activities of daily living (ADLs), and used a wheelchair. During an interview on 9/19/22 at 12:28 PM, the resident's family stated they had been asking for about 5 weeks to have the resident's Broda (positioning) chair cleaned as it had dried food on the sides and on the armrests. The family stated the footrest and the frame of the Broda chair also had dried tan food spills. The Broda chair was observed during the interview and had dried food on the sides, on the arm, footrests, and on the frame. During observations on 9/20/22 at 9:35 AM, 9/21/22 at 9:58 AM, and 9/22/22 at 9:43 AM, the dried food areas remained on the resident's Broda chair. Resident #416 had diagnoses including dementia. The 9/7/22 MDS assessment documented the resident had severely impaired cognition, required extensive assistance with most ADLs, and used a wheelchair. The resident was observed sitting in the Broda chair: - on 9/19/22 at 12:18 PM and 9/22/22 at 9:43 AM the Broda chair had multiple vertical dried tan streaks on both outer vinyl sides of the chair. - on 9/23/22 at 11:02 AM attending an activity in the unit lounge area with multiple staff members passing by. The Broda chair had multiple vertical tan streaks on the vinyl sides. When interviewed on 9/21/22 at 1:11 PM, certified nurse aide (CNA) #13 stated Resident #148 dressed, toileted and fed themselves. The resident kept their room neat. The CNA stated housekeeper #15 was very good and rounded the unit more than once a day sweeping and mopping the floors. When housekeeper #15 was not on duty, there was an issue with the floors being sticky throughout the unit. When interviewed on 9/21/22 at 1:42 PM, housekeeper #15 stated they cleaned each room at least once a day and Resident #148's room was to be cleaned twice a day per the family's request. The resident spilled their flavored water frequently which made the floors sticky. The resident was accommodating and left the room each time the room was cleaned. The housekeeper stated they were on duty on 9/20/22 but not 9/19/22. Housekeeping procedure was to put the cleaning chemical in the mop bucket, place mopping pads in the bucket to soak, and use a new mop pad with each room. The floors were to be swept prior to mopping. The resident's room was to receive a regular cleaning daily, including mopping the floor, and a deep cleaning weekly. When interviewed on 9/23/22 at 10:26 AM, registered nurse (RN) Unit Manager #14 stated housekeeper #15 had a system to sweep every room and mop the floors. Resident #148's room was done twice a day as the resident spilled things on the floor, including flavored water. The RN Unit Manager stated the resident tried to be as independent as possible, but staff still needed to assist with most ADLs. CNAs were to make each resident's bed and should change the linen when soiled for dignity and infection control purposes. The facility employed support workers who could assist the CNAs with non-direct care tasks such as making beds. The RN Manager stated the unit LPN performed environmental rounds at the beginning and end of each shift, and the Unit Manager performed the same rounds twice a shift also. The RN Unit Manager stated they were in Resident #148's room on 9/22/22 and did not notice the soiled linens. The RN Unit Manager accompanied the surveyor to the resident's room at 10:37 AM and stated the blanket was soiled and should have been changed earlier. When interviewed on 9/23/22 at 10:37 AM, CNA #16 stated the CNAs were responsible for changing bed linens when they saw the linen soiled and on bath day. The CNA stated they brought Resident #148 their meal tray but did not look at the resident's bedding. The CNA stated if staff noted the linen was dirty, they should change it. During a telephone interview on 9/23/22 at 11:07 AM with CNA #13 they stated staff knew resident specific care by following the care plan. Staff were to change resident's linen on shower days and Resident #148 received their shower on the evening shift. Staff should also change the linen when soiled. The CNA stated she cared for the resident most days during the week and the resident's bed was made each time they entered the room, they had not noticed the blanket was soiled. The CNA stated they saw the resident at the linen cart on 9/22/22, the CNA took linen from the cart, entered the resident's room, the bed was already made, and they did not think to check the condition of the linen on the bed. When interviewed on 9/23/22 at 11:33 AM, CNA #17 stated they cared for Resident #416 and AM care was provided by the night shift. The resident was already up in the Broda chair by the beginning of day shift. The CNA did not know who was responsible for the cleaning the residents' chairs, but that any staff member could submit a work order When interviewed on 9/23/22 at 11:41 AM, CNA #18, assigned to Resident #186, stated wheelchairs and Broda chairs were washed on the unit by non-nursing staff. Those staff followed a schedule that was set up for all 3 shifts. When interviewed on 9/23/22 at 11:46 AM, licensed practical nurse (LPN) #19 stated CNAs and housekeeping were responsible for cleaning the wheelchairs. The LPN stated they did not usually round to check for dirty wheelchairs but would inform the CNA to clean one if they noticed during regular duties. All staff should ensure wheelchairs were cleaned when dirty. When interviewed on 9/23/22 at 11:51 AM, RN Unit Manager #20 stated wheelchairs/Broda chairs did not have a specific cleaning schedule, but any staff member could inform their manager. The housekeeping supervisor would be notified, and the chair would be scheduled for night shift cleaning by housekeeping staff. Spot cleaning could be done by unit staff. They stated they looked at Resident #416's Broda chair that morning and the sides needed to be cleaned. They stated they spoke to Resident #186's family about the condition of their Broda chair and sent housekeeping an email about 2-3 weeks ago. Staff should check the cleanliness of Resident #186's chair after meals as the resident tended to spill food while feeding themself. The RN Manager checked their email and the last chair cleaning for Resident #186 was on 7/27/22. No one informed the RN Manager the family mentioned the chair being dirty. Hot Water Temperatures Daily hot water temperature logs from March 2022 to August 2022 documented the facility had been checking the hot water temperatures and all results were within the acceptable limits of 120 Fahrenheit (F). Specifically: - resident room [ROOM NUMBER]'s hot water was last checked on 7/23/22 and the water temperature was measured at 116 F. - resident room [ROOM NUMBER]'s hot water was last checked on 7/4/22 and the water temperature was measured at 118 F. During an observation and interview with the Senior Director of Operations on 9/19/22 at 2:40 PM, the hot water temperature at the sink in the bathroom of resident room [ROOM NUMBER] was measured at 123 F. The Senior Director of Operations stated the hot water temperatures were checked randomly every day. They had no knowledge there were any temperatures that were too high exceeding 120 F. They had not seen any temperatures on the logs with temperatures that hot. During an observation with the Senior Director of Operations on 9/19/22 at 4:15 PM, the hot water temperature at the sink in the bathroom to resident room [ROOM NUMBER] was measured at 123 F. 10 NYCRR 415.29(j)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey conducted 9/19/22-9/23/22, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's nursing needs for 1 of 1 resident (Resident #264) reviewed. Specifically, Resident #264 was care planned to be dependent on 2 with transferring and was transferred by 1. Findings include: The facility's undated policy Resident's Care Assignment Sheet documented: - Nursing staff would follow the plan of care as indicated on the resident's care assignment sheet and notify the charge nurse immediately if the resident's care needs change. - Staff were to check the [NAME] and the dashboard for any changes or updates. - It was the responsibility of the Nursing Care Team to ensure that the plan of care was accurately followed for each resident. Resident #264 had diagnoses including hemiplegia (one-sided paralysis), hemiparesis (one-sided weakness) following a cerebral infarction (stroke) affecting their dominant right side, and dementia. The 8/18/22 Minimum Data (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance of 2 with bed mobility, was totally dependent on 2 for transfers, required extensive of assistance of 1 person with toileting, was not steady and was only able to stabilize with human assistance during surface-to-surface transfers, had impairment to 1 side for both upper and lower extremities, was frequently incontinent of urine, and always incontinent of bowel. The comprehensive care plan (CCP) initiated on 6/15/21 documented the resident had an ADL (activities of daily living) self-care performance deficit related to impaired balance, weakness, spinal fractures, osteoarthritis, history of CVA (stroke) with right hemiplegia, right hand contracture, dementia, and history of TBI (traumatic brain injury). Intervention revisions dated 4/4/22 included total dependence of 2 for toileting hygiene, toilet transfer total dependence of 2 with a Hoyer (mechanical) lift to bed, and on 8/10/22 transfer total dependence of 2 with a Hoyer lift. The undated [NAME] (care instructions) documented: - The resident was totally dependent on 2 for transfers with a mechanical lift. - The resident was totally dependent on 2 for toileting at bed level, needed to be checked/ changed every 2 - 3 hours and as needed. Continuous observations on 09/22/22 were as follows: - at 7:19 AM, the resident was lying in their low level bed with fall mats on both sides of the bed. - at 7:49 AM, certified nurse aide (CNA) #40 entered the resident's room carrying AM care supplies and closed the door. - at 7:59 AM, registered nurse (RN) Clinical Coordinator #43 knocked at the resident's door, spoke to CNA #40, and left. - at 8 AM, CNA #40 exited the resident's room and returned to the resident's room at 8:02 AM with a mechanical lift and closed the door. - at 8:13 AM, CNA #40 exited the resident's room and brought dirty linen to the shower room. - at 8:15 AM, CNA #40 entered the resident's room and brought the mechanical lift back out to the hallway. CNA #40 was the only staff observed entering and exiting the resident's room during the observation. - at 8:20 AM, the resident was seated in their wheelchair in their room. During an interview with CNA #40 on 9/22/22 at 1:18 PM, they stated had been a CNA at the facility for 18 years and worked on all units. They were familiar with the residents on the 5th floor. They received an assignment sheet at the start of their shift that let them know which residents they needed to provide care for. The care instructions documented the level of assistance and number of staff the resident needed to receive care and staff should check the resident's care instructions daily. Total dependence meant staff provided total assistance with care. They stated Resident #264 required assistance of 1 with a mechanical lift with transfers and toileting. The CNA stated they provided toileting assistance and transferred the resident by themselves. They had not reviewed the resident's care instructions prior to providing care. They were unaware the resident was totally dependent on 2 staff for transfers and toileting. They stated it was important to follow the resident's care instructions for safety reasons. During an interview with licensed practical nurse (LPN) #41 on 9/22/22 at 1:58 PM, they stated the level of assistance a resident required was listed on their care instructions. Resident #264 required the use of a mechanical lift with transfers. They stated staff should be following the care instructions and if it documented there were to be 2 people than 2 people should provide that level of care. They were unaware the resident had been transferred and toileted with 1 person. If staff needed help with care, they should let a nurse know. During an interview with the Director of Therapy on 9/22/22 at 4:48 PM, they stated total dependence meant staff completed 100% of the task for the resident. Resident #264 was totally dependent on 2 people for toileting and transfers with a mechanical lift. The care plan recommendations should be followed for resident safety. Nursing staff could not change the level of assistance needed unless they added additional staff and they should let therapy know if there were any changes with the resident's abilities so they could be reassessed. During an interview with RN Clinical Coordinator #43 on 9/23/22 at 10:48 AM, they stated staff received their assignments at the start of the shift and should review the resident's care instructions prior to helping the resident. Total dependence meant staff provided all the care for the resident. They stated Resident #264 had a fall from their bed and sustained a fracture in 12/2021. At that time the resident's care plan was updated to 2 staff with transfers and toileting at bed level. It was important for staff to follow the care plans as they were specific to meet the resident's needs and for safety reasons. They expected staff to let a nurse know if they needed assistance to provide care. They were unaware the resident had been toileted or transferred with 1 staff member. During an interview with RN Unit Manager #9 on 9/23/22 at 11:39 AM, they stated staff received their assignment sheets at the start of their shift and were expected to review the resident's care instructions daily, as they could change. Staff should let a nurse know if they needed help providing resident care. They stated Resident #264 had a fall and sustained a fracture. At the request of the resident's representative the care plan was updated to have 2 staff members provide assistance with transfers and toileting. They stated the CNA should have reviewed the care plan and it was important to follow the care plan for resident safety. During an interview with occupational therapist (OT) #46 on 9/23/22 at 1:38 PM, they stated Resident #264 was totally dependent on 2 people for transfers and toileting. Staff should follow the resident's care plan for safety reasons and staff should not transfer or toilet the resident with 1 person. 10NYCRR 415.11(c)(2)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification and abbreviated surveys (NY00299609, NY00300895, NY00293668, and NY00257181) conducted 9/19/22-9/23/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 15 residents (Residents #8, 238, 264, and 386) reviewed. Specifically: - Resident #8 was not assisted with oral care and their toothbrush was observed on their bathroom sink unopened in a plastic wrapper. - Resident #238 was observed in the same clothing for 5 consecutive days. - Resident #264 was not toileted for more than 5 hours and was not supervised at meals as care planned. - Resident #386 was not assisted with meals and was observed eating independently and spilling food. Findings include: The facility policy Activities of Daily Living (ADLs) dated 1/21/20 documented residents who were unable to carry out activities of daily living would receive all the necessary services to maintain good nutrition grooming, and personal and oral hygiene. Information from the therapy assessments and plan of care would be transcribed by nursing to the certified nursing assistant (CNA) assignment sheet for documentation by the CNA once completed. The comprehensive care plan (CCP) would include specific interventions to maintain or improve the residents ADL status or to prevent, to the extent possible, declines in the resident's ADL status. The facility CNA Protocol dated 9/17/21 documented the 7 AM - 3 PM CNAs would check on the residents at least every 2 hours or more frequently if indicated and complete electronic medical record (EMR) documentation throughout the shift, as care is given. The protocol included time guidelines for the provision of care. 1) Resident #8 had diagnoses including left hand contracture (limited range of motion), generalized muscle weakness, and heart failure. The 9/8/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, did not reject care, and required extensive assistance of 2 with personal hygiene. The comprehensive care plan (CCP) initiated 6/14/21 documented the resident had an ADL self-care performance deficit related to multiple contractures. Interventions included routine oral care in the AM, after meals (PC), and at bedtime (HS). Oral care included brushing teeth, cleaning gums with a toothette, and rinsing with mouth wash. The 9/8/22 Dental Services consult documented an annual exam was performed. the resident had obvious or likely cavities and or broken natural teeth. The resident's teeth were cleaned with a mouth swab and the resident was provided with a new toothbrush. The resident stated they only used their tongue to clean their teeth. Oral hygiene instructions were reviewed Recommendations included staff were to assist with daily oral care. The undated [NAME] (care instructions) documented routine oral care was to be completed in the AM, PC and HS. Oral care included brushing teeth, cleaning gums with toothette, and rinsing with mouth wash. During an interview with Resident #8 on 9/19/22 at 11:04 AM, they stated staff brushed their teeth every once in a while. They were unable to hold the toothbrush on their own due to their contractures and would like their teeth brushed daily. A toothbrush was observed on the bathroom counter, unopened in a plastic protective covering. CNA documentation for personal hygiene was blank for the AM shift on 9/19/22 and the resident received extensive assistance of 1 on the PM shift. The documentation did not include what personal hygiene included. On 9/20/22 at 9:41 AM, the resident was observed seated upright in their bed eating breakfast. A toothbrush was observed on the bathroom counter, unopened in a plastic protective covering. The CNA documentation for personal hygiene documented on 9/20/22 the resident received extensive assistance of 1 in the AM and was not documented for the PM shift. During an observation on 9/22/22 at 10:12 AM the resident was observed in their bed sleeping. A toothbrush was observed on the bathroom counter, unopened in a plastic protective covering. At 1:10 PM, the resident was observed sitting up in their bed watching television. They stated no one had offered to brush their teeth this week. They would like their teeth brushed daily as they were unable to do it themselves. A toothbrush was observed on the bathroom counter, unopened in a plastic protective covering. The 9/22/22 CNA documentation for personal hygiene was blank for the AM shift. During an interview with CNA #40 on at 1:18 PM, they stated each resident had care instructions to let staff know what level off assistance the residents needed for ADLs. Each shift they worked they received an assignment sheet which listed the residents on their assignment for that shift. Staff were to check the resident's care instructions prior to assisting the resident with care. Staff had minicomputer tablets they carried which included each resident's care instructions. They stated AM care included providing oral care. They stated Resident #8 liked their teeth brushed after they had eaten breakfast and staff needed to help the resident had a contracted hand. They stated the resident was able to make their needs known and told them they wanted their teeth brushed later that day when they asked the resident. They had not yet returned to provide oral care to the resident. They were unaware the resident reported they had not had their teeth brushed this week and stated it was unacceptable to go that long without having their teeth brushed. During an interview with licensed practical nurse (LPN) #41 on 9/22/22 at 1:58 PM, they stated oral care was completed when the resident received their AM care, as needed, and at HS. Residents should not have to ask to have oral care completed. During an interview with LPN #43 on 9/22/22 at 2:23 PM, they stated Resident #8 was alert and oriented and did not refuse care. Oral care was supposed to be completed when staff provided the resident with AM care, as needed, and at HS. They were unaware the resident had not had their teeth brushed. During an interview with registered nurse (RN) Unit Manager #9 on 9/23/22 at 11:39 AM, they stated oral care should be provided or at least offered during AM and HS care. They were unaware Resident #8 did not receive daily oral care. 2) Resident #238 had diagnoses of Alzheimer's dementia, adult failure to thrive, and anxiety disorder. The 8/9/22 Minimum Data Set (MDS) assessment documented cognition was not assessed, the resident had delusions, presence of physical behaviors towards others, verbal behaviors towards others, rejected care, and required limited assistance of 1 for dressing, and personal hygiene. The comprehensive care plan (CCP) initiated 3/30/22 documented the resident was alert and oriented and was independent with decision making as it related to daily routine and healthcare. The CCP initiated 7/15/22 documented the resident was resistive to care related to adjustment, anxiety, and dementia. Interventions included allow the resident to make decisions about treatment regime, if the resident resisted with ADLs, reassure the resident, leave, and return 5-10 minutes later and try again. The comprehensive care plan (CCP) initiated on 8/17/22 documented an ADL self-care performance deficit related to confusion, fatigue, and limited mobility. Interventions included extensive assistance of 1 for bathing, toileting, and dressing. The care instructions ([NAME]) documented the resident required extensive assistance of 1 for dressing, bathing, and toileting hygiene. The resident was observed dressed in a short sleeved maroon shirt with buttons at the neck, plaid flannel pants, and tan non-skid socks and had disheveled, uncombed hair: -On 9/19/22 at 12:24 PM in the dining room. -On 9/20/22 at 9:38 AM. -On 9/21/22 at 9:12 AM. -On 9/22/22 at 11:48 AM sitting in a wheelchair with a towel over the chair pad. -On 9/23/22 at 10:39 AM sitting on a towel over their wheelchair cushion. Certified nurse aide (CNA) documentation for 9/19/22, 9/21/22, and 9/22/22 documented the resident performed dressing independently. On 9/20/22 CNA #5 documented the resident received limited assistance with dressing. There was no documentation of resident refusal of care. During an observation on 9/23/22 at 10:56 AM, Resident #238's closet in their room contained 1 shirt and 1 pair of pants hanging up and labeled with the resident's name. There was a box of clothing labeled with the resident's name sitting in a chair in their room, the resident's dresser drawers were empty. During an interview on 9/23/22 at 12:05 PM, licensed practical nurse (LPN) Assistant Unit Manager #6 stated they had not had any reports of the resident refusing care that week. Refusals of care were supposed to be reported to the LPN on the hall where the resident lived, and if the resident continued to refuse, it should have been reported to them. LPN #6 stated after a resident's refusal of care for more than one day, they would expect documentation in the progress notes. During an interview on 9/23/22 at 1:41 PM, CNA #5 stated provided care was documented in the computer. If a task was signed for it meant it was done. If a resident refused care they would reapproach, if the resident refused again, they would tell the nurse. Resident #238 did not want to be touched and refused care most of the time. The evening of 9/20/22, the CNA stated they tried to assist the resident to change their clothes, the resident did not allow care to be done, and they did not remember if they told the nurse about the refusal. During an interview on 9/23/22 at 12:46 PM, CNA #11 stated that care was documented in the computer when it was completed. If a resident refused care, they should be reapproached, and the medication nurse should be notified. They stated Resident #238 was on their assignment on Wednesday 9/21. They checked on the resident, but they did their own care. They did not change the resident's clothing that day. During an interview on 9/23/22 at 2:00 PM, LPN #12 stated they were the medication nurse on the resident's hall on 9/20 and 9/22. The CNAs were supposed to let them know of any residents who refused care. They would then approach the resident, and if they still refused, they would write a behavior note and let the Nurse Manager know. They attempted to get Resident #238 to change this morning, got clothes out for the resident, and they refused. The LPN did not remember any reported care refusals this week. During an interview on 9/23/22 at 2:17 PM, registered nurse (RN) Unit Manager #9 stated if a resident refused care CNAs were supposed to reapproach 3 times, then report the refusal to the medication nurse. The medication nurse was supposed to try and figure out what was going on, and then tell the Unit Manager. If the resident refused care, it should be documented. Resident #238 was difficult to assist with ADLs and refused medications. Nobody had notified the RN of any refusals of care this week and if staff did not report refusals of care, they would not know to try alternate interventions. 3) Resident #264 had diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided weakness) following a cerebral infarction (stroke) affecting their dominant right side, and dementia. The 8/18/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance of 2 with bed mobility, total dependence on 2 with transfers, supervision of 1 for eating, extensive assistance of 1 with toileting, had functional limitation in mobility on 1 side for both upper and lower extremities, was frequently incontinent of urine, and always incontinent of bowel. The comprehensive care plan (CCP) initiated on 6/15/21 documented: - the resident had activity of daily living (ADL) self-care performance deficits related to multiple diagnoses. Interventions included supervision with eating, and total dependence of 2 with toileting hygiene and transfers using a Hoyer (mechanical) lift to bed. Revised interventions on 8/10/22 included extensive assistance of 2 for bed mobility. - bladder and bowel incontinence related to impaired mobility and dementia. Interventions included check and change every 2-3 hours and as needed. The CCP initiated 6/30/21 documented the resident was at nutrition risk related to dementia. Interventions included the resident was to be in the dining room for all meals. The CCP initiated on 9/3/21 documented the resident had potential/actual skin impairment to skin integrity due to impaired mobility. Interventions revised on 8/31/22 included turn and position every 2 hours and as needed. The CCP initiated 7/19/22 documented the resident had not been fully vaccinated for COVID-19 at their request. Interventions included when the resident was out of their room, they needed to maintain 6 ft (feet) away from all residents and a mask was to be worn at all times when out of their room. The 9/2022 physician orders documented the resident received a regular diet, unmodified texture, thin consistency liquid diet, and needed food to be prepped into small pieces. Additionally, on 9/13/22 Furosemide (a diuretic) 20 milligrams tablet once a day at 2 PM for leg edema for 5 days. The undated [NAME] (care instructions) documented: - The resident was to be in dining room for all meals, staff needed to cut food into bite size pieces and required supervision at meals. - The resident was totally dependent on 2 people for transfers with a mechanical lift. The resident was totally dependent on 2 people for toileting at bed level, needed to be checked/ changed every 2 - 3 hours and as needed. The resident was observed seated in their wheelchair in their room on 9/19/22 at 12:11 PM. At 1:06 PM, the resident was observed seated in their wheelchair in their room eating their lunch unsupervised. The resident's meal ticket indicated they were to receive a regular unmodified diet with food items prepped into small pieces. The resident had eaten 50% of their soft salad sandwich, 0% of their corn on the cob, 0% of their salt potatoes, and their oatmeal raisin cookie remained in an unopened package. They had consumed 50% of their 8 fluid oz (oz) chocolate milk shake (an oral nutrition supplement), 100% of their water 4 oz water, 0% of their 4 oz apple juice, 50% of their 8 oz coffee. On 9/20/22 at 9:21 AM, 9:56 AM, and 12:12 PM, the resident was observed seated in their wheelchair in their room. At 12:53 PM, the resident was observed eating lunch in their room unsupervised. The resident's meal ticket indicated they were to receive a regular unmodified diet with food items prepped into small pieces. The resident had eaten 50% of their soft salad sandwich, eaten 50% of their zucchini and tomatoes, 25% of their mashed potatoes, and 50% of their ice cream sandwich was melted on their meal tray and had spilled onto their tray table. They had drunk 100% of their 8 oz of coffee, 25% of their 4 oz of water, 25% of their 4 oz apple juice, and 0% of their chocolate milk shake. There was no staff present in the room. At 1:22 PM, the resident was observed seated in their wheelchair in their room. Their lunch tray remained on the tray table. The following continuous observations of Resident #264 were made on 9/21/22: - at 8:55 AM, the resident was observed sitting in their room, in their wheelchair. - at 9:14 AM, registered dietitian (RD) #44 brought the resident's breakfast tray into their room, left the room, and closed the door. - at 9:18 AM, RD #44 returned to the room to bring the resident sugar, exited the room, and closed the door. The resident was observed seated in their wheelchair in their room. Their meal tray had 1 donut, 1 banana cut into small pieces, an omelet, 2 slices of toast, 1 cup of coffee, and 1 cup of orange juice. There were no staff present in the resident's room. - at 11:03 AM, an unidentified housekeeper entered the resident's room. They brought the plastic meal tray out of the resident's room, down the hallway to an unknown location, and left the resident's door open. - at 11:14 AM, the resident was observed seated in their wheelchair in their room. - at 11:17 AM, the unidentified housekeeper told CNA #45 that they dumped Resident #264's meal tray. CNA #45 walked down the hallway in the opposite direction of Resident #264's room. - at 11:29 AM, the resident was observed seated in their wheelchair in their room. - at 11:38 AM, CNA #45 was observed bringing an unidentified resident into the dining room. - at 12:42 PM, an unidentified CNA provided the resident with their meal tray in their room and exited the room. - between 12:43 PM and 12:45 PM, CNA #45 walked up and down the hallway near Resident #264's room and did not enter the room. - at 12:49 PM, the resident was observed seated in their wheelchair in their room. they had their eyes closed and their chin was down towards their chest. The resident's sandwich was cut into quarters and was untouched. The only staff nearby was an unidentified housekeeper in the hallway. - at 1:21 PM, the resident was observed in their wheelchair in their room and had eaten 50% of their sandwich and 100% of their water. - at 1:36 PM, CNA #45 entered the resident's room and was overheard asking the resident if they wanted to lie down. The CNA exited the room with the resident's plastic meal tray and entered another resident's room. - from 1:46 PM - 2:48 PM, the resident remained seated in their wheelchair in their room and no staff entered the resident's room. On 9/21/22 CNA #45 documented they provided the resident total assistance of 1 for toileting and the resident was incontinent of bladder and bowel. CNA #45 documented the resident was independent after setting up at meals and consumed 51%- 75% of their breakfast and 76% - 100% of their lunch meals. During a telephone interview with CNA #45 on 9/22/22 at 10:51 AM, they stated staff should look at the resident's care instructions prior to providing care and the nurse would also let them know. They stated supervision at meal meant staff did not have to be with the resident the entire meal but needed to check in on them throughout the meal. Total dependence meant staff provided all the care for the resident. They stated they toileted the resident at the start of their shift at 7:00 AM, checked the resident at 10 AM, after the lunch meal, and again at 1:30 PM. They were unsure if the resident was on a toileting schedule. They stated they toileted the resident 3 times on 9/21/22. If they documented, they provided care that meant the care had occurred. CNA #45 then stated maybe I missed the resident, must have mistaken them for a different resident and they made a mistake when they documented under another resident. It was a busy day. They were unsure the if the resident required supervision at meals. They stated they did not let a nurse know they were busy, and it was important to follow the resident's care plan to make sure the resident received the right care. During an interview with licensed practical nurse (LPN) #41 on 9/22/22 at 1:58 PM they stated supervision at meals meant staff provided set up assistance but did not provide any physical assistance at the meals. Staff should be within eyesight of the resident at all times and if the resident ate in their room staff should be in the room for the entire meal. They stated Resident #264 required supervision at meals and was unaware the resident ate in their room unsupervised. The resident needed to be supervised at meals to help with encouragement. They were unaware the resident was not toileted for over 5 hours, and it was a long time to go without being changed. especially since the resident was receiving a diuretic for edema. They were not aware the resident had not been supervised at meals. During an interview with registered nurse (RN) Clinical Coordinator #43 on 9/23/22 at 10:48 AM, they stated staff received their assignments at the start of their shift and should review the resident's care instructions prior to helping the resident. Total dependence meant staff provided all the care for the resident. Residents should be checked every 2 - 3 hours and if a resident had not been toileted for over 5 hours that was too long to not be checked or changed. They were unaware the resident had not been toileted or supervised at meals. They stated Resident #264 was not fully vaccinated and if they were out of their room, they needed to wear a mask and keep 6 feet from other residents. The resident needed supervision at meals for encouragement. They expected staff to let a nurse know if they were unable to provide care or needed assistance to provide care. During an interview with RN unit manager #9 on 9/23/22 at 11:39 AM, they stated staff received their assignment sheets at the start of their shift and were expected to review the resident's care instructions daily, as they could change. Residents were usually checked and changed every 2-4 hours. Staff should let a nurse know if they needed help providing resident care. If a resident had not been checked and changed for over 5 hours that was too long. They were unaware the resident was not checked or changed. Resident #264 was recently started on a diuretic for edema. The resident did require supervision at meals, and they expected staff to attempt to bring the resident out for meals while maintaining 6 feet of distance from other residents. During an interview with occupational therapist (OT) #46 on 9/23/22 at 1:38 PM, they stated OT determined a resident's level of assistance needed at meals. Supervision at meals meant someone was nearby to provide encouragement and verbal cues. Resident #264 required supervision at meals to promote adequate intakes of food and fluids. The resident should be encouraged to go to the dining room for all meals, but if they ate in their room someone needed to be present. 10NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 9/19/22-9/23/22 the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #171) reviewed. Specifically, Resident #171 was on aspiration (inhaling food into lungs) precautions due to impaired swallowing and was observed consuming their meal in their room unsupervised with the door closed. Findings include: The undated facility policy Aspiration Precautions and Standards of Care documented aspiration precautions were the measures implemented to prevent or lessen the risk of food, fluids, or other ingested material from entering the respiratory tract. The standards of care to prevent aspiration did not include resident supervision during eating and/or drinking. Resident #171 had diagnoses including Alzheimer's disease, dysphagia (difficulty swallowing), and gastro-esophageal reflux disease. The 7/29/22 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required limited assistance of 1 for eating, had signs and symptoms of a swallowing disorder including loss of liquids/solids from mouth when eating or drinking, and holding food in mouth/cheeks or residual food in mouth after meals. The comprehensive care plan (CCP) initiated 11/15/21 documented the resident was at nutritional risk due to impaired swallowing related to dementia. The family had signed a waiver to refuse recommended ground consistency foods. Interventions initiated on 6/14/22 documented aspiration precautions with a diet order of regular, unmodified with thin liquids. Physician orders dated 7/14/22 documented a regular diet with unmodified texture, thin consistency, aspiration precautions, liberalize diet for quality of life and weight loss. The CCP initiated 7/15/22 documented the resident had an ADL (activities of daily living) self-care deficit related to dementia. Interventions included extensive assistance of 1 for eating to ensure the resident stayed in the dining room and completed their meals. A speech language pathology (SLP) Discharge summary dated [DATE] documented the resident was referred by nursing for a bedside swallow evaluation to determine need for continued aspiration precautions. The resident was noted to consume large bites and pocketed solids during meals with consistent verbalizations. The resident was not receptive to cues and education due to cognitive impairment. The SLP recommended continuation of aspiration precautions due to poor self-monitoring and safety awareness with inconsistent use of compensatory strategies. During an observation on 9/22/22 at 8:58 AM, Resident #171 was sitting up in their room eating breakfast, the door was closed, the resident was alone, and almost all their breakfast was consumed. Certified nurse aide (CNA) #27 was seated in the next room assisting another resident with breakfast and stated that Resident #171 was in their room with the door closed. The resident's breakfast meal tray ticket dated 9/22/22 documented the resident received a blueberry muffin, scrambled eggs, 2 sausage links, Super Cereal (fortified cereal), a plain donut, orange juice, coffee, whole milk, and fruit cocktail. During an interview with CNA #26 on 9/22/22 at 2:12 PM they stated aspiration precautions meant when giving the resident a meal they should check and make sure they got the right things on their meal tray and try to slow them down while eating and drinking. They would need to be watched at all meals and when they received snacks. They were not sure who was on aspiration precautions on the unit and there was a paper they could look at to tell and it would also be documented on their tray ticket. They stated there was not enough staff on the dementia unit and there was not enough time to take care and keep track of everyone on the unit. During an interview on 9/22/22 at 2:36 PM CNA #27 stated when someone was on aspiration precautions they should be watched for choking and staff should make sure they received the right food consistency. They stated they were assigned to Resident #171 on 9/22/22. They were unsure who was on aspiration precautions on the unit and could tell by looking at the meal ticket or on their iPods. The iPods had information on residents but they did not have access to the unit information yet. They stated they could also ask the Nurse Manager who was on aspiration precautions. They did not realize Resident #171 was on aspiration precautions and the resident should not have been alone in their room when eating. The CNA stated the resident did eat their breakfast alone in their room that morning and they should have brought the resident to the dining room where they could be watched. During an interview with licensed practical nurse (LPN) Nurse Manager #24 on 9/22/22 at 2:48 PM they stated if a resident was on aspiration precautions they were at risk for choking and had issues with swallowing. They would try to keep anyone on aspiration precautions out in the dining room and if they refused to go to the dining room someone should be in their room to monitor them while they ate and drank. Residents who were on aspiration precautions were listed on the wall in the dining room, in the care plans, on the [NAME], and the top of the meal tickets. Resident #171 was on aspiration precautions and should have been monitored while they ate and not alone in their room. There were 4 people on aspiration precautions and one resident who required feeding and it was difficult to monitor and feed with only 3 CNAs scheduled. During an interview with SLP #47 on 9/23/22 at 1:25 PM they stated the resident was last evaluated and seen by SLP at the end of July 2022. Aspiration precautions were determined by the SLP and the medical providers. When someone was on aspiration precautions, they should take small bites and sips at a slow rate. Each resident was different. Resident #171 was on aspiration precautions and should be in staff line of sight and usually would eat in the dining room. If the resident chose to eat in their room a staff member should be present. The resident should not have eaten alone in their room. 10 NYCRR 415.12(h)(1-2)

Based on observation, record review, and interview during the recertification and abbreviated (NY00299609) surveys conducted 9/19/22-9/23/22, the facility failed to ensure residents were free of any significant medication errors for 2 of 15 residents (Residents # 33 and#368) reviewed. Specifically, Residents #33 and #368 did not receive blood sugar (blood glucose) monitoring or insulin administration as ordered. Findings include: The undated facility policy titled Insulin Injection Preparation documented the purpose of insulin injections was to enhance glucose (blood sugar) utilization by all cells in the human body. The medication would only be administered with a physician order including the type of insulin, the dose, and the time frequency. A registered nurse (RN) or licensed practical nurse (LPN) were able to perform the injections. A post-procedure included recording the insulin administration on the medication administration record (MAR). The 8/2021 facility policy Medication Administration documented utilization of registered nurses (RNs) and licensed practical nurses (LPNs) to appropriately and safely administer and provide documentation for medication administered to residents. 1) Resident #368 had diagnoses including diabetes and diabetic chronic kidney disease. The 8/24/22 Minimum Data Set (MDS) assessment documented the resident had mildly impaired cognition, required supervision for most activities of daily living, and received daily insulin injections. The 8/30/22 physician order documented Humalog (fast-acting insulin) Solution 100 unit/milliliter (ml) subcutaneously before meals per sliding scale: if finger stick blood glucose was 151 - 200 = give 2 Units; 201 - 250 = give 4 Units; 251 - 300 = give 6 Units; 301 - 350 = give 8 Units; 351 - 399 = give 10 Units; and if greater than 400 call provider. If Blood sugar (blood glucose) was 400 or higher, give 10 units at the time of result and call a provider using the telephone for further directions. The 9/13/22 physician order documented glargine (long-acting insulin) Solution 100 unit/ml give 22 units subcutaneously in the morning and hold if morning blood sugar is less than 80. Call provider for a lower dose order if blood sugar was less than 80. The 9/19/22 medication administration record (MAR) did not include blood glucose monitoring results before meals, administration of 22 units of insulin glargine solution at 8:00 AM, or administration of Humalog insulin sliding scale insulin before meals as ordered. There was no signature or chart code in the MAR indicating the reason for the omissions. 2) Resident #33 had diagnoses including diabetes with hyperglycemia (elevated blood sugar). The 9/8/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance with activities of daily living, and received insulin injections every day. The 7/1/22 physician orders documented Humalog (fast-acting insulin) Kwik pen 200 unit/ milliliter (ml) subcutaneously before meals per sliding scale: if finger stick blood glucose was 0 - 69 = give 0 units; 70 - 90 = give 4 Units; 91 - 130 = give 6 units; 131 - 150 = give 8 Units; 151 - 200 = give 10 Units; 201 - 250 = give 12 Units; 251 - 300 = give 14 Units; 301 - 350 = give 16 Units; 351 - 400 = give 18 Units. Notify the nurse practitioner (NP)/physician if fingerstick blood sugar was less than 70 or greater than 400. The 8/7/22 physician order documented glargine (long-acting insulin) Solution 100 unit/ml give 40 units subcutaneously once a day and 35 units subcutaneously at bedtime for diabetes. The 9/2022 medication administration record (MAR) did not include blood glucose monitoring results before meals on 9/14/22, administration of insulin glargine at 7:30 AM or 9:00 PM, or administration of Humalog insulin sliding scale before meals as ordered. There were no signatures or chart codes in the MAR indicating the reason for omission. During a medication observation and interview with licensed practical nurse (LPN) #21 on 9/21/22 at 10:26 AM there was an unopened vial of Humalog insulin for Resident # 368 in the top drawer. Licensed practical nurse (LPN) #21 stated they had not administered any insulin to the resident or performed any blood sugar monitoring that morning. They had been passing medications to Resident #368 on 9/19/22 and had not performed blood glucose monitoring or administered insulin that day either. The LPN checked the MAR and stated they did not see an order for finger sticks or sliding scale insulin coverage for Resident #368. LPN #21 stated they passed medication for Resident #33 on 9/14/22 and was unaware they had missed monitoring blood sugars and administering insulin to that resident as well. The LPN stated they were not aware the facility had added a diabetic tab to the electronic MAR for diabetic care. They stated they had not been trained on the addition of the diabetic tab. They stated a possible danger to residents not receiving insulin as ordered could be the resident became hyperglycemic. During an interview on 9/21/22 at 10:45 AM, the assistant unit manager LPN #6 stated that all residents with diabetes had a diabetic tab in the MAR and the medication nurse was to check the diabetic tab for diabetic care orders. The diabetic tab had only been in use by the facility for about 2 weeks. Managers usually provided the floor to floor new practice in-services for nurses. LPN #6 was unable to locate any 4th floor nurses training on the diabetic tab. The danger of a resident not receiving insulin as ordered could be hyperglycemia. During an interview on 9/21/22 at 10:51, registered nurse (RN) Unit Manager #9 stated the diabetic tab was added to the electronic MAR a couple of weeks ago to help float nurses identify diabetics. The plan was to make it easier to identify residents requiring blood sugar monitoring and insulin administration. There was an email from the Director of Nursing (DON) on 9/14/22 which documented nurses were missing the diabetic tab. There was no formal education provided to the nurses. The dashboard feature of the MAR was usually checked by the RN Unit Manager daily and should identify missed medications. RN #9 did not remember identifying the blood sugar monitoring and insulin administration being missed for Residents #33 and 368. During an interview on 9/23/22 at 3:14 PM, nurse practitioner (NP) # 22 stated they received a phone call the afternoon of 9/22/22 notifying them of residents who had not received finger sticks or insulin due to the diabetic tab being missed by staff. This was the first time they had been notified of these medication errors. They expected to be notified of medication errors as soon as they were discovered. The importance of notification was to follow up with the residents and repeat labs or adjust if needed. There was a danger of hyperglycemia if residents did not receive insulin as ordered. During an interview on 9/23/22 at 4:12 PM, the DON stated Nurse Educators and Unit Managers were responsible for communicating to unit staff changes in practice. There would usually be a sign in sheet for the in-service to keep track of those who were in-serviced. The diabetic tab was recently added to the electronic MAR. It separated insulin and finger sticks for quick identification. They were not sure if diabetic orders still showed up in the regular MAR. The rollout of the new practice was sent in email form with a screen shot provided to educate staff. The Nurse Educators and Unit Managers were instructed to review the information with nurses to make sure everyone was aware. If insulin was not administered as ordered the danger to the resident could be hyperglycemia. If a nurse was not trained on the new procedure, they would not know where to look for diabetic instructions. There was a dashboard to identify any missed medications built into the electronic MAR. This was to be used by medication nurses to make sure they had not missed any medications. The Unit Managers were supposed to check for missed medications. Medication nurses should notify supervisors of any missed medications. All nurses were trained in these procedures to protect residents. 10NYCRR 415.12(m)(2)

Based on observation, interview and record review during the recertification survey conducted 9/19/22-9/23/22, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal test tray (Resident #355) reviewed. Specifically, Resident #355's replacement meal was not measured for an appropriate and safe internal food temperature range after being reheated and prior to being served to the resident. Findings include: The facility policy Foods Brought in By Family/Friends for the Intent of Resident's Consumption dated 11/10/21 documented all items that needed to be heated would be heated to the proper temperature before being served to the resident. Food would be heated to an internal temperature of 165 F (Fahrenheit) in the microwave oven, covered, and rotated so it heated evenly. During an observation on 9/21/22, Resident #355's lunch tray was used for testing and a replacement meal was ordered. At 12:45 PM the resident's replacement lunch tray was brought to the 9th floor unit. CNA #10 took the replacement tray to prepare drinks and condiments and delivered the tray to the resident's room. When interviewed on 9/21/22 at 1:10 PM, CNA #10 stated they reheated Resident #355's food earlier using the microwave in the 9th floor kitchenette. They did not have a thermometer, did not know where the thermometer was kept, and did not know the required food temperature when reheating food. The in-service dated 2/4/2020, documented CNA #10 was retrained and educated on appropriate food temperatures and reheating. When interviewed on 9/21/22 at 12:50 PM, the Food Service Director stated meal replacement trays were held in the kitchen's back cooler. The replacement tray was sent up to the unit and nursing staff would be tasked with reheating the food in the kitchenette microwave. The nursing staff should be trained to use probe thermometers and be able to measure the proper internal temperature of food items. The hot food temperature should be 165 F (Fahrenheit) before serving the resident. When interviewed on 9/21/22 at 1:10 PM, the Food Service Director stated they did not find a thermometer for the 9th floor. When interviewed on 9/21/22 at 3:00 PM, the Senior Director of Operations stated there was a clipboard hanging on the wall on each unit kitchenette with a thermometer and the Foods Brought in by Family/Friends for the Intent of Resident Consumption policy attached. Staff had been trained on how to measure the temperature of the food and the policy was available for them to refer to on proper reheating. When interviewed on 9/23/22 at 1:22 PM, the Administrator stated they were not sure why CNA #10 was not trained on reheating food as they were hired in 2002. There was an annual retraining in May for all unit nurses, but CNA #10 was not on the list as having completed the training. At 3:30 PM the Administrator stated CNA #10 last completed food reheating education in 2020 as part of a plan of correction. The procedure and thermometer should be hanging on the wall in all unit kitchenettes. 10NYCRR 415.14(d)(2)

Based on observation, interview, and record review during the recertification survey, the facility did not ensure the right to reside and receive services with reasonable accommodations of resident needs and preferences for 1 of 1 resident (Resident #61) reviewed for call bells. Specifically, Resident #61 did not have her call bell in reach during multiple observations. Findings include: The 3/2019 Call Bell policy did not document the proper position of call bells for a resident. Resident #61 was admitted to the facility with diagnoses including anxiety and depression. The 9/4/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required extensive assistance for most activities of daily living. The 8/2019 comprehensive care plan (CCP) documented the resident was at risk for falls and her call bell should be in reach at all times. The 1/6/2020 Resident Care Assignment Sheet (care instructions) documented the resident required limited assistance of one person for bed mobility and extensive assistance of one for transferring. On 1/2/19 at 12:59 PM, the resident was observed in her wheelchair at her computer in her room. Her computer was to the right side of her bed and the nightstand was on the opposite side of her bed from the computer. The resident's call bell was draped over the nightstand with the button of the call bell on the floor between the nightstand and the wall. The resident's oxygen concentrator was near the end of her bed on the left side of her bed, which prohibited her from wheeling to the call bell. The resident stated she had to go to the bathroom, she could not reach her call bell, and the surveyor had to activate it for her. On 1/6/2020 at 11:47 AM, the resident was sleeping in her bed with the head of bed slightly elevated. The resident's call bell was draped over the nightstand to the left of her bed (the resident's right) with the button near the wall out of reach. On 1/7/2020 at 10:04 AM, the resident was sleeping in bed with the call bell draped over the nightstand with the button near the wall and out of the resident's reach. On 1/7/2020 at 1:30 PM, the resident was sitting at her computer to the right of her bed. The call bell was draped over the nightstand on the opposite side of her bed. She said that the staff do not leave her call bell in reach unless she asked for it. During an interview on 1/7/20 at 1:48 PM, certified nurse aide (CNA) #16 stated a resident's call bell should be in reach when they were in their rooms. She was caring for the resident that day, she was unaware that the call bell had been out of reach, and it should be near the resident. The resident was not able to get out of bed on her own. The call bell should have been in reach for emergencies or if the resident had to use the bathroom. During an interview on 1/8/19 at 10:19 AM, registered nurse (RN) Unit Manager #17 stated call bells should be on the bed with the resident or within arm's reach. There were clips on the call bell cord that should be clipped to the blanket on the bed or to the resident if needed. The resident would not be able to get out of bed on her own, she would not be able to reach the bell if it was draped over the nightstand and would need the call bell clipped to her bed. When in her wheelchair, the resident should have the call bell nearby or on the bed. It should not be on the other side of the room, as the resident would not be able to maneuver her wheelchair to use the call bell. 10NYCRR 415.5(e)(1)

Based on interview, observation and record review during the recertification survey, the facility did not promote and facilitate resident self-determination through support of resident choice for 1 of 4 residents (#28) reviewed for choices. Specifically, Resident #28 did not have food choices honored. Findings include: The 5/6/19 Meal Service Policy documented the resident had the right to choose an alternate meal. If indicated, the licensed practical nurse (LPN) or certified nurse aide (CNA) would ensure the resident's alternate choice was provided in a timely manner. Resident #28 was admitted to the facility with diagnoses including hypertension, peripheral vascular disease and heart failure. The 11/26/19 Minimum Data Set (MDS) assessment documented the resident was moderately cognitively impaired, required extensive assistance with most activities of daily living (ADLs), and was able to eat independently after set up. The 10/4/18 physician order documented the resident was on a no added salt (NAS) diet with an unmodified consistency. The 6/28/19 comprehensive care plan (CCP) documented the resident was at risk of nutritional deficit secondary to leaving 25% or more of each meal uneaten. Interventions included to provide meals with food choices based on the resident's preferences. The 1/7/20 Resident Care Assignment Sheet documented the resident was able to eat independently and was on a NAS, unmodified consistency diet. The undated Alternative Meal Selections posted in the dining room documented soft sandwiches were available at each meal. During a dining observation on 1/3/20 from 12:15 PM to 1:15 PM the following was observed: - At 12:29 PM, the resident did not want the lasagna that was served and requested a peanut butter and jelly sandwich. CNA #9 placed the lasagna in front of the resident and stated the resident would have to talk to a dietitian to get a peanut butter and jelly sandwich because she could only give her what was on the meal ticket. - At 12:49 PM, the resident requested a peanut butter and jelly sandwich. CNA #19 did not respond to the resident and delivered a tray down the hall. - At 12:57 PM, the resident requested a peanut butter and jelly sandwich and CNA#19 did not respond to the resident's request for the sandwich. CNA #19 recorded the resident's meal consumption as 2 drinks and one cookie. - At 1:04 PM, the resident left the dining room without receiving the requested sandwich and did not eat lunch. On 1/8/20 at 11:00 AM, multiple loaves of bread and single serve containers of peanut butter and jelly were observed in the unit kitchenette. During an interview on 1/3/20 at 1:31 PM, CNA #19 stated she did not attempt to get the peanut butter and jelly sandwich the resident requested because she had tried to get people what they wanted before, and it just never came up from the kitchen. An extra tray was delivered with meals which had resident snacks and extra food items. She stated if there was not a sandwich on the extra tray, the resident could not get it. She stated she did not address the resident when she kept requesting the sandwich because she could not do anything about getting it. She stated she knew the resident went without eating lunch. She did not know who to contact in the dietary department to make changes to the resident's meal plan. During an interview on 1/7/20 at 10:29 AM, registered dietitian (RD) #22 stated the resident was on a no added salt, unmodified consistency and she could have a peanut butter and jelly sandwich. She stated the CNAs could make the sandwich on the unit and the kitchens was stocked in case a resident wanted a snack. During an interview on 1/8/20 at 11:05 AM, licensed practical nurse (LPN) Assistant Unit Manager #23 stated the unit kitchenette had ingredients for peanut butter and jelly sandwiches and the CNAs were aware they could make a sandwich for the resident. NYCRR 415.5(b)(1-3)

Based on observation, record review and interview during the recertification survey, the facility did not ensure a thorough and complete investigation was conducted to rule out abuse, neglect or mistreatment for 1 of 7 residents (Resident #479) reviewed for accidents. Specifically, Resident #479 had unwitnessed falls and injuries of unknown origin and there were not thorough investigations to determine the root cause of the falls or injuries. Findings include: The undated Investigation of Incidents/Injury of Unknown Origin facility policy documented investigations should rule out or confirm if abuse, neglect or mistreatment has occurred with the outcome determined by facts, based on evidence and not opinion, which is subjective. Resident #479 was admitted to the facility with diagnoses including dementia, atrial fibrillation (A-fib, abnormal heartbeat), and urinary and bowel incontinence. The 11/12/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognation, required extensive assistance with most activities of daily living (ADLs), and had one fall without injury since admission/previous assessment. The 11/6/19 Fall Risk Assessment documented the resident was at risk for falls. The 11/12/19 comprehensive care plan (CCP) documented the resident had a potential for injury related to decreased balance and strength, generalized weakness/deconditioning, use of psychotropic drugs for dementia and psychosis, impaired judgement, and history of falls. The documented interventions did not include fall mats. The 11/22/19 MDS assessment documented the resident had severely impaired cognition, required extensive assistance for ADLs, used a wheelchair, and had one fall without injury since the previous assessment. The 12/2/19 at 5:15 PM Incident Report documented the resident had an unwitnessed fall in the dining area. He was increasingly restless and asking for his wife around dinner time. The report documented the disoriented, demented resident reported he was trying to walk in the dining room. There were 5 documented witness statements with the incident report which documented that staff were not present, were not aware, and did not witness the fall. There was no documentation in the witness statements regarding the resident's behavior, when he was last seen, or what may have caused the fall. The 12/3/19 at 12:30 AM nursing progress note documented the resident was in the dining room to eat dinner, was asking for his wife, and was redirected to stay in his wheelchair while in the dining room. The 12/16/19 and 12/20/19 Resident Care Assignment Sheet did not document the resident's fall risk or fall risk interventions. There was no documentation that the resident's assignment sheet was updated until 1/3/20, which documented the resident was at risk for falling, fall mats were to be in place, and he was to be toileted every 2 hours. The 12/21/19 at 2:25 PM Incident Report documented the resident was found with abrasions to the tops of both feet. He was unable to recall how they occurred. An investigation into the unknown injury was initiated and the report documented 9 staff provided witness statements, 4 of which documented they were not aware of the skin tear, I am not [the resident's] aide, or they were not present for the incident. It was not documented if witness statements were obtained from shifts prior to the reported incident. The 12/23/19 nursing progress note documented the resident had fall mats per family request due to a previous fall. The 12/25/19 at 12:30 AM Incident Report documented the resident had an unwitnessed fall from his bed and he was incontinent of urine when found during rounds. The report documented the resident's care plan was followed and the care plan was revised for the resident to have fall mats placed while in bed. The 12/30/19 at 7:54 AM nursing progress note documented the resident was day 1 post fall and continued to self transfer. There were no additional progress notes or an incident report regarding a fall on 12/29/19. When interviewed on 1/8/20 at 1:23 PM, certified nurse aide (CNA) #13 stated the resident had fallen a lot since coming to the unit. Interventions included floor mats, going back to bed after lunch, keep call bell in reach at all times, and to check on the resident every hour. The resident had a Broda (positioning) chair and chair or bed alarms were not used in facility. She stated she had never been asked to write on a witness statement when the resident was last seen by staff or the last time care was provided prior to the incident. When interviewed on 1/8/20 at 1:30 PM, registered nurse (RN) Unit Manager #14 stated either the RN Unit Manager or RN Supervisor (RNS) were responsible for filling out the incident report, and that the resident was a high risk for falls. Gathered data was to include statements from staff present at the time of the incident, unit staff on duty for an unwitnessed fall, the resident's statement if they were oriented, and family statements if present. If there was an injury of unknown origin, the RN was to get statements from staff who had worked 24 hours before the incident to determine when care was last provided and when the resident was last seen uninjured. She stated that information was not always written on the statements. She stated there was not an area to remind staff to document it on the forms, as the forms only had ruled lines to document on. She stated that without the time the resident was last seen, or care was provided, the facility would have to hypothesize the root cause based on resident assessment and prior knowledge of that resident. When interviewed on 1/8/20 at 2:13 PM, Assistant Director of Nursing (ADON) #15 stated witness statements were expected to be obtained from staff involved with the incident and for all on duty unit staff at the time of an unwitnessed incident. Witness statements for injuries of unknown origin were needed from those on duty at the time the injury was found and from those working the previous shifts for 24 hours. The witness statements were to include the last time care was provided and the last time the resident was seen. The RN Unit Manager was responsible to ensure the documentation was there. She did not know when staff were last educated about what needed to be included in witness statements. Witness statements were important to determine possible new interventions, prevent reoccurrence and to determine root cause. 10 NYCRR 483.12 (c)

Based on observation, record review and interview during the re certification survey the facility did not provide proper positioning to maximize residents eating abilities for 3 (#49,162, and 394) residents reviewed for dining. Specifically, Residents #49, 162, and 394 were observed not properly positioned during meals. Findings include: The 5/6/19 Meal Service Policy documented adjustable height tables will be used for residents utilizing specialty chairs. 1) Resident #49 was admitted to the facility with diagnoses including Alzheimer's Disease and muscle weakness. The 11/17/19 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required extensive assistance for eating. The comprehensive care plan (CCP) dated 11/16/19 documented the resident was at risk for a nutrition deficit due to significant weight loss and had a self-care deficit. Interventions included to provide the resident necessary assistance at meals and physical assistance for mobility. The resident had a Broda pedal chair (a low chair used to encourage self-mobility) with a gel foam cushion. The 1/7/20 resident care assignment sheet (care instructions) documented the resident used a Broda pedal chair with a gel foam cushion for mobility and required her plate to be set up for meals. During dining observations on 1/2/20 from 12:15 PM to 1:15 PM, on 1/3/20 from 8:30 AM to 9:15 AM and on 1/3/20 from 12:15 PM to 1:15 PM the resident was seated at the dining table in a low Broda chair. The resident's forehead was visible at the height of the top of the table. The resident could not see or reach the food that had been placed on the table. 2) Resident #162 was admitted to facility with diagnoses of cerebral vascular accident (stroke), hemiplegia (weakness of one side of the body) and dementia. The 10/1/19 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired; required extensive assistance for most activities of daily living (ADLs) and supervision for eating. The comprehensive care plan (CCP) dated 12/30/19 documented the resident was at risk for nutritional deficit. Interventions included to provide necessary assistance as needed. The resident required extensive assistance with mobility and utilized a Broda pedal chair with a cushion. The 1/7/20 resident care assignment sheet documented the resident utilized a Broda pedal chair for mobility, required partial assistance when eating and needed meats to be cut into small pieces. The Occupational Therapy (OT) Evaluation dated 12/9/19 documented the resident required a Broda pedal chair with gel cushion for mobility. The resident received OT to improve ability for self-feeding. The OT discharge summary documented the resident had improved in the ability to self-feed but required set up and supervision. During dining observations on 1/2/20 from 12:15 PM to 1:15 PM, on 1/3/20 from 8:30 AM to 9:15 AM and on 1/3/20 from 12:15 PM to 1:15 PM the resident was seated at the dining table in a low Broda chair that was reclined. The resident could not see or reach the meal that was placed on the table. 3) Resident #394 was admitted to the facility with diagnoses including dementia, trigeminal neuralgia (chronic facial nerve pain) and anxiety. The 11/6/19 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, was totally dependent for most activities of daily living and required set up for meals. The CCP dated 11/19/19 documented the resident was at risk for nutritional deficit secondary to history of significant weight loss. Interventions included monitor pattern of consumption at meals and assist as needed. The 1/7/20 resident care assignment sheet documented the resident utilized a Broda pedal chair with cushion and required set up for meals. The Occupational Therapy (OT) evaluation dated 8/19/19 documented the resident should use a Broda chair with a gel cushion for mobility. The Speech Therapy Evaluation dated 10/29/19 documented the resident should be in an upright posture for meals. During dining observations on 1/2/20 12:15 PM to 1:15 PM and on 1/3/20 from 8:30 AM to 9:15 AM, the resident was observed in a Broda pedal chair that was low and reclined. The resident was not able to see or reach the food to eat independently. The resident was removed from the dining room during both observations without the meal being touched. During a dining observation on 1/3/20 from 12:15 PM to 1:15 PM, the resident was seated in a low Broda chair, the resident was not able to see the meal on the table and could not reach the food to eat independently. During a dining observation on 1/6/20 at 1:12 PM the resident was seated in a low Broda chair, the resident was not able to see the meal on the table and could not reach the food to eat independently. A half of a sandwich was lying on the resident's chest and remained there until 1:30 PM, when the resident was removed from the dining room. During a dining observation on 1/6/20 at 4:29 PM, the resident was observed in the dining room seated in a low Broda chair asleep. At 5:29 PM, the resident remained in the dining room asleep, seated in a low Broda chair. During an interview on 1/3/20 at 1:31 PM with CNA #19, she stated many of the residents sat in special chairs and it was difficult to accommodate the chairs at different heights. She did not pay attention to the chair height when setting up residents but focused on setting up the food. She stated many of the residents in Broda chairs required to be fed and were placed at one table. During an interview on 1/3/20 at 1:41 PM with CNA #20, she stated residents had always been left in the Broda chairs and it was not something she had consciously thought about. She stated it was not acceptable if the resident could not see or reach their meal. During an interview on 1/8/20 at 1:10 PM with OT #21, she stated that if a resident was having difficulty with positioning during a meal the nurse should make a referral to OT to observe the resident at meals and make recommendations for positioning to promote improved eating abilities and comfort. During an interview on 1/8/20 at 11:15 AM with registered nurse (RN) Unit Manager #24, she stated resident positioning was difficult because the tables were not all able to be adjusted in height. NYCRR 483.24

Based on observation, record review and interview during the recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming for 2 of 10 residents (Residents #286 and 305) reviewed for ADLs. Specifically, Residents #286 and 305 were not assisted with facial grooming. Findings include: The undated Activities of Daily Living (ADLs) facility policy documented based on the comprehensive assessment and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish. The resident who is unable to carry out activities of daily living will receive all the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1) Resident #305 had diagnoses including chronic obstructive pulmonary disorder (a lung disease). The 10/14/19 Minimum Data Set (MDS) assessment documented the resident required extensive assistance with personal hygiene. The 10/30/19 comprehensive care plan (CCP) documented the resident required supervision for grooming. The CCP did not document the resident's preference or ability to complete personal facial grooming. The resident was observed with heavy facial hair growth on 1/2/20 at 4:40 PM. On 1/6/20 at 3:18 PM, the resident was seated in her room. She began rubbing her hand along her chin. There were whiskers observed along the resident's chin and under her nose. The resident stated she knew the whiskers were there and had asked staff over the weekend if they could shave the whiskers. The resident stated they must have forgotten. She said she was not able to do it herself and staff would have to do it for her. She said no one had brought it up or offered to shave her. She recently had a shower and the staff had not offered to shave her on that day. During an observation on 1/7/20 at 11:35 AM the resident had a one-inch hair at the crease of the left side of her mouth. There was no other facial hair observed. The resident stated she was not shaved until that morning and no one had offered to shave her the night before. She stated she felt better now that she had been shaved. During an interview with CNA #2 on 1/7/20 at 4:35 PM, she stated the resident needed to be shaved once in a while. She stated she was assigned to the resident last week and it had looked like she had been shaved. She stated she did not regularly work on the floor and did not know what the routine was for shaving. She stated there was not always enough staff working on that unit to be able to complete all hygiene tasks, such as shaving. If one shift did not complete shaving it would then be the responsibility of the next shift. She stated the resident would not always speak up and ask for assistance if she wanted to be shaved so staff would have to offer it to her. During an interview with CNA #1 on 1/7/20 at 4:42 PM, he stated the resident required a lot of assistance with personal hygiene. He stated when he went to provide care to the resident she asked to be shaved. The nurses had the razors locked up and when he went to get a razor the nurse was not on the floor and then he forgot about it. He stated the resident would not initiate facial hygiene herself and staff had to be present and assist for grooming to be completed. During an interview with licensed practical nurse (LPN) Unit Manager #31 on 1/8/20 at 9:31 AM, she stated the resident's facial hair should not have gotten to that length and the resident should have been shaved sooner. She stated she had assisted the resident with her care the morning of 1/7/20 and saw the facial hair and shaved the resident herself. If a resident requested to be shaved and a staff member was not able to do it, then another shift should shave the resident. 2) Resident #286 had diagnoses including dementia. The 10/9/19 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired and required extensive assistance with personal hygiene. The 10/9/19 comprehensive care plan (CCP) documented the resident required extensive assistance with grooming. Shaving was not documented on the CCP. The 1/6/20 certified nurse aide (CNA) instructions documented the resident required extensive assistance with personal hygiene. The instructions did not include a plan for shaving. The resident was observed with sporadic long facial hair along the chin line on 1/2/20 at 3:46 PM, 1/6/20 at 10:52 PM, and on 1/8/20 at 10:22 AM. During an interview with CNA #4 on 1/8/20 at 10:48 AM, she stated the resident required total assistance from staff with personal hygiene. The resident was observed sitting in a common area with several long white, course sporadic hairs (approximately 6-10) around her chin and to the side of her mouth. The CNA stated that it was only a couple of hairs. During an interview on 1/8/20 at 10:54 AM, RN Unit Manager #3 stated there were several female residents on the unit that required shaving. She stated Resident #286's facial hair was not as bad as others and the resident was overlooked. She stated regardless of how many stray hairs the resident had on her face, it should be taken care of by staff. 10NYCRR 415.12(a)(3)

Based on observation, record review and interview during the recertification survey the facility did not ensure a resident with limited range of motion receives appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 2 residents (Resident #518) reviewed for positioning and mobility. Specifically, Resident #518 did not have a hand contracture device in place as care planned. Findings include: The undated Range of Motion facility policy documented the facility will provide services, care, and equipment to assure that a resident with limited range of motion (ROM) and mobility maintains or improves function unless reduced ROM/mobility is unavoidable based on the resident's clinical condition. Recommendations for contracture devices i.e. palm guards, hand rolls or splints will be transcribed on the certified nurse aide (CNA) assignment sheet for documentation. Staff must report if the device or equipment is not present. The nurse will obtain a physician order for an alternate device to be utilized until the device can be obtained. Resident #518 had diagnoses including non-Alzheimer's dementia and depression. The 11/18/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance for activities of daily living, and had limited range of motion in upper extremities. The 11/3/18 comprehensive care plan (CCP) documented the resident was to wear a left palm guard during the day, removed for meals and during care, and to be placed back on at HS (bedtime). The 11/18/19 occupational therapist #6 progress note documented the resident should wear a left palm guard during waking hours, off for meals, hygiene and at HS. The 1/6/20 certified nurse aide (CNA) instructions documented the resident was to have a palm guard in place during waking hours and off for meals, hygiene and HS. During an interview with the resident on 1/2/20 at 4:11 PM, she stated that she had a splint that she was supposed to be wearing on her left hand and staff would tell her they did not have to put it on her. The resident was not wearing a palm guard. The resident was observed without a splint/palm guard in place on 1/3/20 at 1:15 PM and 1/7/20 at 9:17 AM with a paper napkin on her palm under her fingers. The resident stated that she had placed the napkin there because the staff had not put her palm guard in place after she finished eating. During an interview with CNA #5 on 1/7/20 at 9:20 AM, she stated the resident used a napkin or wash cloth for her hand contracture and she had never seen a splint in place. She stated it was on the CNA instructions to put a splint in place, she had asked about it, but did not recall who she asked or the answer she had received. During an interview with CNA #4 on 1/7/20 at 9:23 AM, she stated she did not put a splint/palm guard on the resident and the resident did not currently have one in place on her hand. The palm guard was observed hanging on the back of the resident's wheelchair and the CNA stated she did not know why. During an interview with RN Unit Manager #3 on 1/7/20 at 4:14 PM, she stated the care instructions documented a palm guard was to be in place to the resident's contracted hand. The RN stated the resident should have been wearing the palm guard. During an interview with the Director of Rehabilitation on 1/8/20 at 12:33 PM, she stated it was the responsibility of the staff on the unit to ensure the palm guard was applied to the resident. She stated the use of the palm guard would be documented on the CNA instructions. If a palm guard was not put in place as directed it could cause hygiene and skin integrity issues. 10NYCRR 415.12(e)(2)

Based on observation, record review and interview during the recertification survey, the facility did not ensure the medication error rate was less than 5% for 3 of 6 residents (Residents #19, 92 and 317) observed during medication administration. Specifically, Residents #19, 92 and 317 did not receive their medication at the prescribed times resulting in a 57.58% error rate (19 errors out of 33 opportunities for error). Findings Include: The 10/2015 revised Medication Administration policy documented to ensure the right time/frequency when administering a medication. The 6/2/16 revised Medication Administration Schedule policy documented that medication should be administered within one hour of the scheduled time, from one hour before to one hour after. 1) Resident #19 had diagnoses including hypertension (high blood pressure), dementia and edema (tissue swelling). The 11/6/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required extensive assistance with activities of daily living (ADLs). The 1/2020 medication administration record (MAR) documented the following medications were to be administered daily at 8:00 AM: - allopurinol (gout) 100 mg by mouth daily; - Alphagan (glaucoma) 0.1% eye drops administer 1 drop in both eyes twice a day; - Aricept (dementia) 5 milligrams (mg) by mouth daily; - Allegra (antihistamine) 60 mg by mouth daily; - furosemide (diuretic) 20 mg by mouth daily; - Osteo-Bio Flex (supplement) 1 tab by mouth daily; - Protonix (stomach acid reducer) 40 mg by mouth daily every morning; - vitamin B-12 (supplement) 1 tablet by mouth daily; - Duo-Neb (breathing treatment) 1 vial 2 times a day; and - Lyrica (nerve pain) 25 mg by mouth daily. On 1/6/20 at 9:32 AM, medication administration was observed with licensed practical nurse (LPN) #18. She gave the resident allopurinol, Alphagan, Aricept, Allegra, furosemide, Osteo-Bio Flex, Protonix, vitamin B-12, Duo-Neb, and Lyrica. She was aware the 8:00 AM medications were late, and she was unsure if nurse practitioner (NP) #12 was aware. 2) Resident #92 had diagnoses including new onset respiratory infection with flu-like symptoms. The 11/27/19 Minimum Data Set (MDS) assessment documented the resident had intact cognition and required extensive assistance with activities of daily living (ADLs). The 1/2020 medication administration record (MAR) documented the following medication was to be administered at 8:00 AM: -albuterol (breathing treatment) 0.083% nebulizer via inhalation 2 times a day and every 4 hours as needed for 5 days. During a medication administration observation on 1/6/20 at 9:46 AM, licensed practical nurse (LPN) #18 administered albuterol to the resident. 3) Resident #317 had diagnoses including hypertension (high blood pressure), coronary artery disease and hyperlipidemia (high fat in the bloodstream). The 10/21/19 Minimum Data Set (MDS) assessment documented the resident had intact cognition and required extensive assistance with activities of daily living (ADLs). The 1/2020 medication administration record (MAR) documented that the following medications were to administered daily at 8:00 AM: - amlodipine (angina) 5 milligrams (mg) by mouth daily; - artificial Tears (dry eyes) 1 drop in both eyes daily; - aspirin 81 mg by mouth daily; - Lasix (diuretic) 40 mg by mouth daily; - isosorbide ER (high blood pressure) 60 mg by mouth every morning; - metoprolol tartrate (high blood pressure) 50 mg by mouth twice a day at 8:00 AM; - omeprazole (stomach acid reducer) 20 mg by mouth daily; and - ferrous sulfate (iron supplement) 325 mg by mouth in the morning with breakfast. During a medication administration observation on 1/6/20 at 10:14 AM, licensed practical nurse (LPN) #18 administered amlodipine, artificial tears, aspirin, Lasix, isosorbide ER, metoprolol, omeprazole, and ferrous sulfate to the resident. During an interview on 1/6/20 at 2:57 PM, LPN #18 stated the medication administration was late because the floor was short staffed. There was herself and 3 certified nurse aides (CNAs) on the floor that day, and staffing was usually 2 LPN's and 4 CNA's. She stated she had to help residents get ready for breakfast and assist residents with their meals, which caused her to be delayed with medication administration. She stated registered nurse (RN) Unit Manager #3 was aware, the nurse practitioner (NP) was made aware, and there were no medication changes. During an interview on 1/7/20 at 10:25 AM, RN Unit Manager #3 stated that the unit normally had only one LPN and that was the reason that the medications were given late. She stated Administration was aware of the staffing issue. She stated she notified the nurse practitioner (NP) and no changes to the medications were made. She stated that a delay in medications in the morning could be an issue to the resident if they had twice a day medications. During an interview on 1/7/20 at 12:30 PM, NP #12 stated RN Unit Manager #3 notified her of the late medications after they had been given. The expectation was that the NP should be notified prior to medication administration in case other medication administration times had to be adjusted. Medications specifically ordered with a meal were done so for a reason, such as the iron supplement. It was to be given with breakfast to prevent an upset stomach. She stated that late medication administration was an issue at the facility due to staffing and having only one LPN for the floor on 1/6/20. 10NYCRR 415.12(m)(1)

Based on observation and interview during the recertification survey, the facility did not ensure the provision of food and drink was palatable, attractive, and at a safe and appetizing temperature for 2 of 3 meal trays tested. Specifically, food palatability was not maintained for zucchini, hot dog, and rice at lunch and dinner. Findings include: The 5/16/19 Meal Service policy documented if any items are missing or incorrect, dietary is to be notified to obtain the item. The undated Resident Meals policy documented reasonable efforts will be made to accommodate resident choices and preferences. Food and nutrition services staff will monitor and audit food trays to ensure that the correct meal is provided to each resident, and the food appears palatable and attractive. During an interview with Resident #425 on 1/2/20 at 1:29 PM, she stated the facility's food was bland and not visually appealing. During an interview with Resident #215 on 1/2/20 at 3:42 PM, the resident stated the food did not taste good and they did not follow resident meal preferences. During an interview with Resident #908 on 1/2/20 at 3:44 PM, the resident stated she had complaints about the food. During the Resident Council Meeting on 1/3/20 at 11:14 AM, 1 resident stated the facility's food did not taste good. During observation on 1/3/20 at 5:28 PM a dinner food tray was brought to Resident #908. At 5:30 PM, the surveyor tasted the zucchini and it was mushy/not palatable. A replacement tray was ordered for Resident #908. On 1/7/20 at 12:38 PM, the facility staff were completing the meal service pass in the Unit 5 dining room. At 12:56 PM, Resident #215's meal tray was delivered to the resident's room by a certified nurse aide (CNA). There were no drinks on the resident's tray, only empty cups. The CNA stated he did not want to bring them yet as they would spill as he carried the tray. The resident's meal ticket documented she was to receive items including [NAME] Pilaf with mushrooms, coffee, ginger ale, salad, and a hot dog. The resident's meal tray was tested, and a replacement was ordered. The rice dish was plain white rice and tasted bland. There were no condiments on the tray to add to the rice. At 1:29 PM, the surveyor asked staff where the resident's replacement meal tray was. The CNA stated he had been in helping another resident so the tray may have arrived to the unit and was not delivered. At 1:33 PM, the CNA returned to the room and said the tray would be coming up now. The replacement meal tray arrived at 1:41 PM. The resident's hot dog was split, discolored, and overcooked. The resident's salad contained only lettuce with no toppings. The resident had not received any fluids from her original meal tray prior to the replacement meal tray at 1:41 PM. During an interview on 1/7/20 at 4:27 PM, the Food Service Manager stated zucchini was cooked, chilled and then reheated in the kitchens on each floor to bring it back up to temperature. The zucchini was supposed to be solid, not mushy. The zucchini was a frozen product brought into the facility. The [NAME] Pilaf was cooked on site, chilled, then reheated to temperature on the unit She stated she performed a test tray about once a day. During an interview on 1/7/20 at 4:45 PM, the Food Service Commissary Director stated the [NAME] Pilaf was a premix in which the facility added water, cooked it, then chilled it until use. The commissary area did not cook hot dogs; they were heated up to temperature in the retherm unit (used to re-heat food) on the nursing units. The zucchini should be reheated to proper temperature and maintain a solid shape. The mushy consistency was not acceptable. During interview on 1/7/20 at 5:00 PM, the Senior Director of Operations stated the consistency of the zucchini should be solid. He did not know why the resident received the incorrect rice dish for the meal. He stated he was not sure why the hot dog was overcooked as hotdogs could be heated to temperature in the retherm unit on the nursing unit. He stated it was probably overcooked in the microwave by a staff person on the nursing unit and should not have been served. He expected a replacement tray to be delivered in 15 minutes or less. 10NYCRR 415.14(d)(1)(2)

Based on record review and interviews during the recertification survey the facility did not ensure 22 of 46 residents (Residents #17, 19, 21, 24, 25, 26, 28, 29, 30, 32, 33, 34, 36, 39, 40, 41, 42, 44, 45, 92, 318, and 323) assessments were electronically transmitted within 14 days after completion to the Centers for Medicare and Medicaid Services (CMS) System. Specifically, Resident #'s 17, 19, 21, 24,25, 26, 28, 29, 30, 32, 33, 34, 36, 39, 40, 41, 42, 44, 45, 92, 318, and 323 MDS assessments were not submitted within 14 days of the care plan completion and/or MDS completion dates. Findings include: The 2019 Resident Assessment policy documented submission files are transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system using the CMS wide area network. Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan completion date. All other Minimum Data Set (MDS) assessments must be submitted within 14 days of the MDS Completion date. 1) Resident #25 had a scheduled MDS comprehensive assessment with reference date of 11/8/19 and completion date of 11/25/19 per the resident's electronic record. The assessment was to be submitted to CMS by 12/9/19 per the facility's MDS documentation system. The MDS assessment had not yet been submitted to CMS during review of the resident's assessment on 1/7/20. 2) Resident #39 had a scheduled MDS comprehensive assessment with reference date of 11/20/19, completion date of 12/2/19, and the assessment was to be submitted to CMS by 12/16/19 per the electronic record. The MDS assessment had not yet been submitted to CMS during review of the resident's assessment on 1/7/20. 3) Resident #41 had a scheduled MDS comprehensive assessment with reference date of 11/6/19, completion date of 11/19/19, and the assessment was to be submitted to CMS by 12/3/19 to the CMS system per the facility's electronic records. The MDS assessment had not yet been submitted to CMS during review of the resident's assessment on 1/7/20. During an interview with the MDS Manager on 1/7/20 at 10:28 AM, she stated that they were currently short an MDS coordinator so other MDS staff were doing additional assessments they would not normally do. She stated once they completed an MDS they notified the billing department. The billing department would submit and determine if an MDS required revisions and then would return it back to the MDS nurses to complete. Once fully completed the billing department was then responsible for submitting the assessments to CMS. She stated that department would have multiple residents in what they called a batch and they would then submit that batch of residents at one time. The surveyor provided a partial list of residents whose MDS assessments were showing as past due. She stated she would find out if any of the residents listed were part of that batch and find out when their submission dates were and return to surveyor. On 1/7/20 at 3:42 PM, the Assistant Administrator provided a list of MDS assessments from the MDS Manager. Residents #25 and 39 were on that list. Resident #25's 11/25/19 MDS and Resident #39's 12/2/19 MDS were documented as submitted to CMS on 1/7/20. On 1/7/20 at 4:00 PM, a surveyor provided the facility with a second list of residents that were showing as past due MDS submissions to CMS. On 1/8/20 at 9:30 AM, the second list of residents with completion and submission dates were provided to a surveyor. Resident #41 was included on that list. The list documented that Resident #41's most recent MDS was completed on 11/19/19 and was not submitted to CMS until 1/7/20. During a follow up interview with the MDS Manager on 1/8/20 at 9:46 AM, she stated the list the surveyor had received was accurate, and the resident MDS assessments had not been submitted until the noted 1/7/20 date. She stated billing was responsible for submitting MDS assessments to CMS. During an interview with billing representative #8 on 1/8/20 at 11:10 AM, she stated that once the MDS nurse signed the MDS it was considered complete and would then go into what they called a bucket of MDS and she was then able to batch them. She batched the assessments based on the type of MDS. She reviewed the assessments after running them through the system and notified the MDS nurses if anything needed corrections or completion and provided them with a due date. She was able to tell from the electronic system when the assessments were due to be submitted and they tried to follow those dates as best they could. She stated the electronic system they used was finicky as it only allowed her to upload or delete entire batches rather than individual assessment. She stated there had recently been a longer delay submitting the assessments on time as the facility was short an MDS nurse. 10NYCRR 415.11(a)(5)