Based on observation, interview, and record review conducted during a Complaint investigation (#NY00365639) during a Standard survey completed on 3/28/25, the facility did not ensure the resident's right to be free from physical restraints imposed for the purposes of discipline or convenience and is not required to treat the residents' medical symptoms for one (Resident #48) of four residents reviewed. Specifically, Resident #48 was physically restrained by a staff member in bed. The finding is: The policy and procedure titled Abuse, Neglect and Exploitation of Residents with a revised date of 2/2023 documented acts of abuse against residents were absolutely prohibited. Abuse includes control of resident's behavior through corporal punishment. Unlawful restraint is intentionally or knowingly using physical or chemical restraints or medication on a care-dependent person. The policy and procedure titled Resident Rights dated 3/1/17 documented Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse, and physical or chemical restraints that are not required to treat the resident's symptoms. Review of the undated facility's staff education identified as current titled Prevention of Abuse provided by Regional Educator #1 revealed physical abuse includes aggressive act to control behavior including inappropriately restraining a resident. Resident #48 had diagnoses including autistic disorder, dysphagia (difficulty swallowing) with gastrostomy (a surgical opening into the stomach used to deliver nutrition and medications directly, through a feed tube), epilepsy (seizures disorder), impulse disorder (a mental health condition where individuals struggle to control their impulses, leading to repetitive behaviors that can cause distress or harm, despite negative consequences). The Minimum Data Set (a resident assessment tool) dated 11/29/24 documented that Resident #48 was severely cognitively impaired and was dependent on staff for all activities of daily living. The resident had behavioral symptoms not directed toward others that occurred 4 - 6 days, but less than daily. The comprehensive care plan provided and identified as current by the [NAME] President of Clinical Services documented: -2/22/20 Resident #48 had profound mental/medical impairment. Interventions included to approach resident warmly and positively, engage in sensory activities, likes rides in their chair and to go outside. -4/29/20 falls related to poor safety awareness interventions included resident to have 1:1 caretaker during times of increased agitation/anxiety. -6/1/23 Resident #48 has severe intellectual disabilities, self-harm behaviors, anxiety, autism, depression, insomnia and is treated with psychotropics. Non-pharmacological interventions included 1:1 staff, change in environment, take outside (weather permitting), reduce noise, assist in lying down for rest periods. The undated Care Profile (guide used by staff to provide care) provided by the [NAME] President of Clinical Services and identified as current documented that when Resident #48 was agitated staff should redirect and provide reassurance; use distraction and decrease stimuli; use a calm reassuring voice and remove from the loud/busy area; 15-minute checks at all times and 1:1 caretaker during times of increased agitation/anxiety and may need extra assistance due to mood or behaviors. A reported incident dated 12/25/24 completed by the Administrator documented that incident occurred on 12/21/24 at 8:30 PM and there was no reasonable cause to believe that abuse, neglect or mistreatment occurred. The report documented a staff member saw on the monitor what appeared to be the 1:1 aide (Certified Nurse Aide #13) laying on the resident. Facility's immediate response was to remove Certified Nurse Aide #13 from the 1:1 schedule and was interviewed. The Nursing Home Investigative Report Submission #12407 dated 12/25/24 at 3:39 PM and changed on 12/27/24 at 2:51 PM documented It came to light on 12/24/24 that a charge nurse (Licensed Practical Nurse #1) watched the monitor and recorded on their cell phone the incident of the aide laying across the resident during an increased period of aggression. That nurse did not volunteer, nor did they intervene when they saw what they thought was inappropriate behavior. Review of the facility's investigation file revealed the following: Certified Nurse Aide #13's statement dated 12/22/24 documented they watched Resident #48 from 2:00 PM - 10:00 PM on 12/21/24. The resident started to pull out their feeding tube. They stood up in front of the resident then sat on the edge of the bed and leaned back on to them. Licensed Practical Nurse #6 came into the room and told them they should not have done that, and it was the wrong approach to stop a resident from pulling out their feeding tube. Nursing Supervisor Registered Nurse #7's statement dated 12/27/24 documented they were made aware of the accusations of Certified Nurse Aide #13 long after the supposed incident occurred. The certified nurse aide was sitting on Resident's bed trying to prevent the resident from placing themselves on the floor and/or pulling out their feeding tube. Writer did not visualize Certified Nurse Aide #13 sitting on resident. The investigation file did not contain statements from Licensed Practical Nurses #1 and #6. An undated Investigation Summary signed by the Administrator documented that eventually a copy of the video was obtained. After review of the video and the facts, there was no confirmed abuse, mistreatment or neglect. Certified Nurse Aide #13 was attempting to safeguard the resident but used poor judgement in doing so. A Disciplinary Action Form dated 1/7/25 and signed by the Director of Nursing and Certified Nurse Aide #13, documented Certified Nurse Aide #13 physically restrained Resident #48 against their will. During an interview on 3/26/25 at 4:32 PM, the Administrator stated Certified Nurse Aide #4 informed them days later that there was a video sent to them and other employee's phones, related to the accusations regarding Certified Nurse Aide #13 laying on Resident #48. The Administrator stated they copied the video from Certified Nurse Aides #4's phone to their phone and did not know who else had the video, and did not know who originally took the video. The Administrator stated Licensed Practical Nurse #1 denied taking the video during an interview. They stated, they believe the video doesn't clearly conclude Certified Nurse Aide #13 was physically restraining Resident #48 and terminated Certified Nurse Aide #13 for using poor judgement. Observation of video #1 provided by the Administrator on 3/26/25 at 4:45 PM revealed it was undated and without a time stamp but was identified as the recorded video of Certified Nurse Aide #13 laying on Resident #48. Certified Nurse Aide #13 laid back onto Resident #48 while the resident was in bed; they had their back against Resident #48's abdomen and their left arm was outstretched alongside the resident's right leg. Resident #48 was noted frequently moving their legs and attempting to reposition themselves. At the 32 second mark through the 42 second mark Certified Nurse Aide #13 repositioned their left arm over Resident #48's legs and held the resident into a right-side laying position against the bed mattress. Observation of video #2 provided by the Administrator on 3/26/25 at 4:45 PM revealed it was undated and without a time stamp but was identified as the recorded video #2 of Certified Nurse Aide #13 laying on Resident #48. Video #2 revealed Certified Nurse Aide #13 laid back onto Resident #48 with their back against the resident's abdomen and at the 5 second mark, Certified Nurse Aide #13 got up from laying against Resident #48. During an interview on 3/27/25 at 7:40 PM, Licensed Practical Nurse #1 stated they saw Certified Nurse Aide #13 on the video monitor at the nurse's station laying on Resident #48. They stated they told another Certified Nurse Aide to go to Resident #48's room but did recall who they had directed. They stated they informed Registered Nurse Supervisor #7 as to what they saw. Licensed Practical Nurse #1 stated they believed the actions of Certified Nurse Aide #13 were physically abusive because they restrained them. During an interview on 3/28/25 at 10:10 AM, Certified Nurse Aide #4 stated they received the video on their phone of Certified Nurse Aide #13 restraining Resident #48 in bed, and shared the video with the Administrator on 12/26/24. They stated they do not know when they received the video, or who sent the video because of the type of phone app the sender used. During a telephone interview on 3/28/25 at 11:59 AM, Certified Nurse Aide #13 stated they positioned themselves on the bed with their back up against Resident #48's abdomen to prevent the resident from falling out of bed and pulling on their feeding tube. They had tried using their hands to hold Resident #48 but it was ineffective; so they leaned back onto Resident #48. Certified Nurse Aide #13 stated they knew they were physically restraining Resident #48 and believed it was for the resident's safety. They stated Resident #48 had a lot of behaviors and the had facility never taught them how to specifically provide care to Resident #48. They stated they were trained on abuse, mistreatment, neglect and it covered physical restraint. During a telephone interview on 3/28/25 at 12:19 PM, Nursing Supervisor Registered Nurse #7 stated on 12/21/24 staff (unable to identify who), reported to them that Certified Nurse Aide #13 was laying against Resident #48. They were not informed that staff believed Resident #48 was restrained until the following day 12/22/24, when they were questioned by the Administrator. Certified Nurse Aide #13 had reported to them on 12/21/24 they were trying to prevent Resident #48 from falling out of bed and from pulling out their feeding tube by holding onto the Resident's hands and having their body up against the bed. They denied having laid against Resident #48. Therefore they did not have reason to suspect allegations of abuse and did not contact the Director of Nursing or Administrator on 12/21/24. During an interview on 3/28/24 at 1:15 PM, the Assistant Director of Nursing stated Certified Nurse Aide #13 was terminated for physically restraining Resident #48. During a telephone interview on 3/28/25 at 1:54 PM, the Medical Director stated if an employee was laying back onto a resident to prevent them from falling out of bed or trying to prevent them from pulling on their feeding tube then it would be considered a physical restraint. During a telephone interview on 3/28/25 at 2:00 PM, Licensed Practical Nurse #6 stated when they returned to the unit after their break on 12/21/24 there was a lot of commotion. Licensed Practical Nurse #1 had voiced Certified Nurse Aide #13 was getting aggressive with Resident #48. Licensed Practical Nurse #6 stated they immediately went to the resident's room and Certified Nurse Aide #13 was seated on the bed, but not touching the resident. They stated they were not informed by anyone Certified Nurse Aide #13 was laying on Resident #48. During an interview on 3/28/25 at 2:52 PM, Administrator stated there had not been any specific staff training of how to best care for Resident #48, and in hindsight there should have been. Certified Nurse Aide #13 was terminated for physically restraining Resident #48. 10 NYCRR 415.4 (b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Complaint investigation (#NY00335062, NY00338640, and NY00347069) during the Standard survey completed on 3/28/25, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for three (Resident #82, #19 and #79) of six residents reviewed. Specifically, Resident #82 had long fingernails with brown debris underneath them on multiple observations; Resident #19 had facial hair that they wanted removed and during morning care observation staff did not offer shaving; Resident #79 had disheveled, oily hair on multiple observations and during a morning care observation, staff did not wash their face and underarms, oral care was not provided, hair wasn't washed or combed, and they were not dressed in their personal clothing or transferred out of their bed to a chair. The findings are: The policy titled Activities of Daily Living dated 1/8/25, documented the facility will provide care and services for the following activities of daily living: hygiene-bathing, dressing, grooming and oral care. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good grooming, personal and oral hygiene. The policy titled Bathing/Showering dated 3/1/17, documented the certified nurse aide would trim the non-diabetic resident's fingernails on bath/shower days and the licensed nurse would trim the diabetic resident nails on their assigned shower day. Encourage the resident to bathe themselves and assist as needed. The policy documented be sure the resident's skin is free of soap and then dry the resident from head to toe. The policy documented the resident was to be assisted with dressing and grooming. The policy titled Perineal Care dated 2/1/17, documented the purpose of the procedure was to provide cleanliness and comfort to the resident to prevent infections and skin irritation. The policy documented that equipment, and supplies were to be assembled as needed and place on the bed side stand. The wash basin was to be filled ½ with warm water and place at bedside. Wet the washcloth and apply soap the wash the perineal area from front to back and then dry area. Assist the resident onto their side and rinsed the washcloth and apply soap and wash the rectal area. The policy documented to not reuse the same washcloth or water to clean to labia. Rinse and dry the rectum thoroughly. Review of the undated Certified Nursing Assistant job description/competency/evaluation documented Certified Nursing Aides were to assist residents with daily dental, mouth care. They were to provide bath functions as directed, hair care functions, nail care and keep hair on female residents clean shaven (i.e. facial hair, underarms, on legs, etc) as instructed. 1. Resident #82 had diagnoses including dementia, depression and cerebral infarction (a stroke, is a condition where blood flow to the brain is blocked, leading to brain tissue damage). The Minimum Data Set (a resident assessment tool) dated 1/31/25 documented Resident #82 had moderate cognitive impairment and required partial/moderate assistance with shower/bathing including washing, rinsing and drying self and required setup or clean up assistance for personal hygiene. The comprehensive care plan dated 1/24/24 documented Resident #82 had self-care deficit related to dementia and cognitive loss, interventions included establish daily routines, provide consistent caregivers, give one instruction at a time and approach resident warmly and positively. The undated Care Profile (guide used by staff to provide care) provided and identified as current by the [NAME] President of Clinical Services, documented Resident #82 was confused, required moderate assistance to bathe self, including washing, rinsing and drying, and needed setup/clean up assistance to maintain personal hygiene, including combing hair, shaving washing/drying face and hands. Review of Resident #82's Bath & Shower Sheets dated March 2025, documented they preferred bath/showers on Tuesday 6:00AM - 2:00PM and Thursday 2:00PM - 10:00PM. The section regarding if nails were trimmed and cleaned was blank and there was no documented evidence Resident #82's fingernails were trimmed and cleaned 3/1/25 through 3/27/25. During observations on 3/24/25 at 11:36 AM, 3/26/25 at 8:40 AM, 3/27/25 at 9:36 AM and 3/27/25 at 4:00 PM, Resident #82 had long fingernails with brown debris underneath all nails on both hands. During an interview on 3/27/25 at 4:29 PM, Certified Nursing Assistant #12 stated they provided a shower to Resident #82 on 3/25/25 and did not complete the Bath & Shower Sheet because they didn't have time, and they did not provide fingernail care and should have, which included cleaning and trimming their nails. During an observation and interview on 3/27/25 at 4:05 PM, Unit Manager Registered Nurse #5 stated Resident #82's fingernails should be cleaned and trimmed on shower days and as needed. They stated Resident 82's fingernails on both hands were long and dirty with brown debris beneath them. They stated Resident #82 was not a diabetic and expected Certified Nursing Assistant #4 to have provide nail care during AM care that morning, which included cleaning and trimming them. They stated Resident #82's fingernails should have been cleaned and trimmed on their shower days and documented on the Bath & Shower Sheet. Unit Manager Registered Nurse #5 reviewed the Bath & Shower Sheets dated March 2025 and stated the form had a column to check Yes or No if nails were trimmed and clean and there was no documented evidence Resident #82's fingernails were trimmed and cleaned from 3/1/25 through 3/27/25. They stated they would have expected the Bath & Shower Sheets to have been completed by the certified nursing assistants and staff nurses. During an interview on 3/27/25 at 6:06 PM, the Assistant Director of Nursing stated all Certified Nursing Assistants, and Nurses were responsible to ensure resident's fingernails were trimmed and clean. They stated they would have expected the certified nursing assistants assigned to Resident #82 on any shift to have noticed their fingernails to be long with brown debris under them and provided nail care. They stated they would have also expected the medication nurses to have observed the resident's fingernails and ensured they were trimmed and cleaned. They stated they expected the assigned staff for Resident #82 to have completed the Bath & Shower Sheets and stated there was no documented evidence Resident #82 received nail care from 3/1/25 through 3/27/25 and there should be. They stated the Unit Manager was responsible to ensure the staff nurses and certified nursing assistants were providing fingernail care as needed and the Director of Nursing was ultimately responsible to ensure resident care was provided by the nursing staff. During an interview on 3/27/25 at 6:34 PM the Administrator stated they would have expected Resident #82's nail care to have been completed on shower days and as needed for dignity and infection control purposes. 2. Resident #19 had diagnosis dementia, diabetes, and anxiety disorder. The Minimum Data Set, dated [DATE] documented Resident #19 had moderate cognitive impairment, did not exhibit rejection of care, was dependent with shower/bathing self-including washing, rinsing and drying self and required setup or clean up assistance for personal hygiene. The comprehensive care plan dated 1/27/24 documented Resident #19 had decreased activities of daily living, disoriented with short term memory loss with delusions, interventions included establish daily routines, provide consistent caregivers, give one instruction at a time and approach the resident warmly and positively. The undated Care Profile (guide used by staff to provide care) provided and identified by the [NAME] President of Clinical Services as current, documented Resident #19 had agitated mental status with short term memory loss, was dependent for shower/bathing, including washing, rinsing and drying, and setup assistance to maintain personal hygiene, including combing hair, shaving washing/drying face and hands. Review of Resident #19's Bath & Shower Sheets dated March 2025 documented they preferred bath/showers on Monday 6:00AM - 2:00PM and Friday 2:00PM - 10:00PM. The section regarding if the resident was shaved was blank and there was no documented evidence Resident #19 was shaved from 3/1/25 through 3/27/25. During observations on 3/24/25 at 9:51 AM, 3/25/25 at 9:51 AM, 3/26/25 at 8:30 AM and 3/26/25 at 10:00 AM, Resident #19 was observed with facial hair on their upper lip, chin and neck. During an interview on 3/25/25 at 9:51 AM Resident #19 stated the facial hair on their upper lip, chin and neck was not dignified, and they wanted it removed but staff did not shave them. During a morning care observation at 3/26/25 at 9:12 AM, with Certified Nursing Assistant #4 and Licensed Practical Nurse #7 included, washing, dressing, oral care and combing Resident #19's hair. Resident #19 was observed with facial hair on their upper lip and many long whiskers on their chin and neck. Certified Nursing Assistant #4 and Licensed Practical Nurse #7 did not offer to shave and remove Resident #19's facial hair, chin or neck whiskers. During interview on 3/26/25 at 10:00 AM, Resident #19 stated they do not ask staff to shave their facial/chin/neck hair because they believed the staff did not have time and they expected the staff to offer them a shave. They stated the whiskers on their upper lip, chin and neck were undignified and it bothered them. They stated the whiskers were so long they were able to pull the facial chin and neck whiskers with their fingers. During an interview on 3/26/25 at 10:01 AM, Certified Nursing Assistant #4 stated they did not offer to remove Resident #19's facial upper lip, chin and neck whiskers and they should have. During an observation and interview on 3/26/25 at 10:09 AM, Unit Manager Registered Nurse #5 observed Resident #19 and stated they had facial hair on their upper lip and many long whiskers on their chin and neck and would have expected Certified Nursing Assistant #4 to have offered and provided shaving for their dignity. The Unit Manager Registered Nurse #5 reviewed the Bath & Shower Sheets dated March 2025 and stated there was no documented evidence Resident #19 had been shaved from 3/1/25 through 3/26/25 and would have expected the Bath & Shower Sheets to have been completed by the certified nursing assistants and staff nurses. During an interview on 3/28/25 at 10:35 AM, the Assistant Director of Nursing stated they expected Certified Nursing Assistant #4 to have offered Resident #19 shaving during morning care to remove their facial hair for their dignity. 3. Resident #79 had diagnoses that included sacral pressure ulcer stage 4 (full thickness tissue loss with exposed bone, tendon or muscle), dementia and hypertension. The Minimum Data Set, dated [DATE] documented Resident #79 had severe cognitive impairment, sometimes understands and sometimes understood. The assessment tool documented that Resident #79 was dependent for all activities of daily living. The comprehensive care plan revised on 9/17/25, documented Resident #79 had a self-care deficit and had cognitive loss/dementia related to disorientation to time, place, person and inappropriate verbal responses. Interventions included to establish daily routines with the resident and provided consistent caregivers. Review of the Care Profile (used by staff to guide care) dated 3/27/25, documented Resident #79 was dependent on staff for oral hygiene, toileting hygiene, shower/bathing, dressing, and personal hygiene. During a telephone interview on 3/25/25 at 10:57 AM, Resident #79's family member stated staff did not get the resident out of bed nor dressed in their personal clothing. They stated Resident #79 had personal clothing in their drawers. The family member stated Resident #79's hair looked oily at times when they visited, and the staff did not take them into the shower. During observations on 3/24/25 at 9:44 AM, 3/25/25 at 2:44 PM, 3/26/25 at 8:45 AM and 3/26/25 at 5:15 PM, Resident #79 was observed in bed, wearing a hospital gown. Their hair was disheveled and greasy. During a morning care observation and interview on 3/27/25 at 9:33 AM, Certified Nurse Aide #10 and Certified Nurse Aide #11 donned (put on) gowns and gloves and entered Resident #79's room. Resident #79 was in bed, wearing a hospital gown and their hair was greasy and disheveled. Certified Nurse Aide #10 went into the bathroom, filled a wash basin and placed it on the resident's bed side table. Certified Nurse Aide #10, with the assistance of Certified Nurse Aide #11 washed Resident #79's peri area (area between the anus and genitals), buttocks and changed the resident's incontinent pad that was wet with urine. Certified Nurse Aide #11 instructed Certified Nurse Aide #10 that Resident #79's gown needed to be changed. Certified Nurse Aide #10 walked out of the room, retrieved a hospital gown, reentered the room, and put the clean hospital gown on Resident #79. The CNA did not offer the resident to be dressed in their clothing or look in the resident's drawers or closet for their personal clothing. Certified Nurse Aide #10 and Certified Nurse Aide #11, did not wash the resident's face and underarms, provide oral care, hair hygiene, dress the resident in their personal clothing or get them out of bed. During an interview directly after care, Certified Nurse Aide #10 stated they completed AM care and they did not wash Resident #79's upper torso prior to putting on the new hospital gown because they usually worked the 2:00 PM-10:00 PM shift, and they were so nervous. During an interview on 3/27/25 at 10:01 AM, Certified Nurse Aide #11 stated that Resident #79's AM care started off bad from the beginning. They stated that Certified Nurse Aide #10 did not gather all their supplies, did not fill the basin to wash the resident and washed and dried the resident using the same towel. Certified Nurse Aide #11 stated they were unsure if they could direct Certified Nurse Aide #10 during the care. They stated Certified Nurse Aide #10 only washed Resident #79's peri area and buttocks, but AM care consisted of washing the whole body. Certified Nurse Aide #11 stated Resident #79 had uncombed greasy hair. During an interview on 3/27/25 at 10:41 AM, Certified Nurse Aide #10 stated AM care consists of washing the residents upper and lower body, face and teeth. They stated that they did not complete full AM care for Resident #79 because they were so nervous, but the resident deserved to have full AM care completed. During an interview on 3/28/25 at 11:01 AM, Registered Nurse # 2 Unit Manager, stated that Resident #79 could have been out of bed all week, but the certified nurse aides during the week were unfamiliar with the resident's care. Registered Nurse #2 Unit Manager stated that AM care consisted of washing the resident's face, neck, breast, arms and peri area, changing their clothing, oral care, and combing their hair. They stated that only washing Resident #79's peri area and buttocks was incomplete AM care. They stated Resident #79 always had greasy hair, but the staff could utilize shampoo caps to wash their hair if need be. Registered Nurse #2 Unit Manager stated the importance of complete AM care was for the resident's dignity and infection control. During an interview on 3/28/25 at 11:53 AM, the Assistant Director of Nursing stated complete AM care would be washing the resident's face, brushing their teeth, washing the upper and lower body, dressing and grooming. he Assistant Director of Nursing stated that Certified Nurse Aide #10 did not complete full AM care to Resident #79 on 3/27/25. They stated Certified Nurse Aide #10 was very nervous to be observed, usually did not work the day shift and they missed steps in AM care. The Assistant Director of Nursing stated that the importance of proper AM care on the resident was for dignity and healthiness of those residents. During an interview on 3/28/25 at 12:24 PM, the [NAME] President of Clinical Services stated their expectation for completed AM care would be washing of the resident's face, arms, hands, armpits, breasts, peri area, back and buttocks and that should be completed every morning. They stated that just washing the resident's peri area and buttocks was not completed AM care. 10NYCRR 415.12 (a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review conducted during complaint investigations (NY00348183, NY00338640, NY00335062, NY00347069) conducted during a Standard survey completed on 3/28/2025, the facility did not ensure that there were housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for three (3) (Units 1, 2, and 3) of three (3) resident units. Specifically there were issues with dirty floors (Units 1, 2, 3); dirty window curtains in disrepair (Units 2, 3); stained privacy curtains in disrepair (Units 1, 2, 3); window blinds with missing or broken slats (Units 1, 2, 3); walls had chipped paint and spackled areas that were not sanded or painted (Units 1, 2, 3); dirty wall register covers (Units 1, 2, 3); resident's bed had missing molding around the footboard (Unit 3); soiled fall mats (Unit 2): strong urine odors in resident rooms (Units 2, 3); dirty windows (Units 2, 3); spider webs on windows and walls (Unit 3); door threshold was missing (Unit 3); missing or broken tiles in the shower rooms (Units 2, 3); basins and graduated cylinders on the floor in shared bathrooms (Units 2, 3); missing lightbulbs in a wall lamp (Unit 3); broken dresser drawers and an over the bed table soiled with food debris and dried liquid (Unit 3). The findings are: The policy titled Cleaning and Disinfecting Resident's Rooms dated 11/1/2017 documented that resident rooms housekeeping surfaces such as floors and tabletops will be cleaned on a regular basis; environmental surfaces shall be disinfected or cleaned on a regular basis or when visibly soiled; and walls, blinds, and window curtains will be cleaned when these surfaces are visibly contaminated or soiled. The policy titled Cleaning and Disinfecting Environmental Surfaces dated 3/10/2020 documented that environmental surfaces shall be cleaned on a regular basis, when spills occur, and when the surfaces are visibly soiled. The job description of a Maintenance Manager documented the manager was to plan, organize, develop, and direct the general and preventative maintenance of the physical plant and grounds as directed by the Administrator, to assure that the facility was maintained according to policy. The job description of a Maintenance Assistant documented the assistant was to implement required maintenance procedures in an efficient, cost-effective manner meeting all federal, state and local requirements while providing a safe environment for residents. The job description of a Housekeeper documented they were to implement required housekeeping procedures in an efficient, cost-effective manner meeting all federal, state, and local requirements while providing a safe environment for residents. Observations on 3/24/2025 between 8:00 AM to 1:00 PM revealed the following: Unit 1 room [ROOM NUMBER] - a four-foot-long section of wall behind headboard of bed, paint chipped and wall with scrapes and gouges exposing drywall; floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - blinds with approximately four broken slats; the bathroom sink was supported by a round, wooden stick approximately three feet long; floor approximately one to two inches wide from the wall with black and brown debris. Unit 2 room [ROOM NUMBER] -the chair rail on the wall was missing an approximately 10-foot section; a six inch long section of baseboard was missing next to the bathroom door; a three foot by three foot area behind the headboard of the bed had chipped paint and gouged wall; the window curtains were mismatched; a strong urine odor in the room; the floor had a one to two inch area from the wall with black and brown debris. Shower Room - tiles missing from the shower wall approximately eight inches by two inches; baseboard and drywall missing from shower wall approximately six inches by six inches exposing bare wood; tiles missing from the floor in front of missing baseboard approximately seven inches by one inch exposing the subfloor; eight foot by one foot area in front of the small shower stall with chipped paint; entire floor approximately one inch to two inches wide from the wall of shower room with black and brown debris. room [ROOM NUMBER] - a six-foot-long fall mat was stuck to the floor with black and brown debris along the edge of the mat; another fall mat was dirty with black and brown debris; the window blind was broken with missing slats; room floor approximately one to two inches wide from the wall with black and brown debris; the wall register cover was dirty with black, white, and grey debris. room [ROOM NUMBER] - the bathroom tile floor was dirty with black and brown debris; an unlabeled, graduated cylinder was on the floor of a shared bathroom; a three by five foot area behind the bed nearest to the bathroom entrance had chipped paint and was scraped; the window blinds had six broken and missing slats; room floor approximately one to two inches wide from the wall with black and brown debris; a towel with brown debris was on the bathroom sink faucet; the wall register covers under the window and in the bathroom were dirty with grey and white debris; there were brown dried liquid spills on the wall register; the window curtains were dirty with black and brown debris; the window curtain rods were broken; the privacy curtains were dirty with multiple white, brown, and pink spots on them. Unit 3 room [ROOM NUMBER] -the floor had multiple white spots; spider webs were on the inside of the window; white and grey debris on the outside of the window. Shower Room - six inch by one-inch missing tile exposed drywall outside of the large shower stall; six 4 inch by 4 inch tiles with black and brown debris along the walls in the large shower stall; rusty handrails in the large shower stall; approximately four foot section of the baseboard was pushed in and exposing bare floor next to the toilet; black and brown debris along the baseboard outside the smaller shower stall approximately four feet long. room [ROOM NUMBER] - window blinds with three broken slats; window curtains with holes in the fabric, missing curtain hooks, and not attached to the curtain rod; entry door threshold missing molding; baseboard molding missing approximately four feet long that exposed spackled drywall that was not sanded or painted; room floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; the wall had an approximately four foot by four foot area next to the window with peeling paint and was stained brown; there were spider webs in the corner of the room next to the window; the entry door threshold was missing. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; approximately six hooks missing from the privacy curtain and hanging from the track; over the bed table with food debris and dried, liquid spills on it; black non-skid strips on the floor next to the bed were worn with approximately 1.5 feet missing; the bathroom floor tiles were dirty with black and brown debris. room [ROOM NUMBER] -two-foot-long missing baseboard with exposed drywall next to the bathroom door; wall lamp had missing bulbs with electric wires exposed and white debris on top of the sconce; the wall register cover was dirty with black, grey and white debris on it. room [ROOM NUMBER] - outside of window with white and grey debris; room floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - strong urine odor in room; room floor approximately one to two inches wide from the wall with black and brown debris; wall register cover with dried brown liquid spills; windows were missing blinds and curtains; bathroom floor tiles with black and brown debris; grey and white debris on the outside of the window. room [ROOM NUMBER] - strong urine smell in the room. room [ROOM NUMBER] - seven-bathroom floor tiles were missing and coming up from the floor; black debris around the toilet; strong urine smell in the bathroom. Unit 3 utility room - baseboard molding coming off the wall next to the utility room approximately one foot long; drywall spackled, not painted or sanded on the wall above the baseboard molding approximately eight inches. Observations on 3/25/2025 between 7:00 AM to 12:00 PM revealed: Unit 1 room [ROOM NUMBER] - window blinds had approximately five broken slats, brown, dried liquid spills on the wall register cover, the privacy curtain was dirty with multiple brown spots; the floor approximately one to two inches wide from the wall with black and brown debris. Unit 2 room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; four privacy curtains were dirty with brown or white stains, were hanging from the ceiling with missing hook attachments that attach to the ceiling; window blinds with approximately five broken slats; the wall register cover under the large window was dirty with brown liquid spills; approximately six feet along the entry door with missing or cracked drywall; a dresser in disrepair with a drawer face missing from the top drawer and a drawer face falling off another drawer. room [ROOM NUMBER] - bathroom floor with black and brown debris along the base of the wall; room floor approximately one to two inches wide from the wall with black and brown debris; three foot by three foot area next to the bed with paint scraped and chipped exposing drywall underneath; approximately four broken slats on the window blinds. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; fall mat had a one-inch gouge and was dirty with black and brown debris; windows were dirty with white and grey debris on the outside. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; seven foot by three-foot area on the wall next to the bed with paint chipped and gouged exposing drywall underneath; unlabeled basin and graduated cylinder in a shared bathroom; wall register cover with black and white debris on it. Unit 3 room [ROOM NUMBER] - soiled linens on the floor; bathroom tiles with black debris on them; chipped paint on the bathroom door. Observations on 3/27/2025 between 7:00 AM to 11:00 AM revealed: Unit 1 room [ROOM NUMBER] - a four-foot-long section of wall behind headboard of bed, paint chipped and wall with scrapes and gouges exposing drywall; floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - window blind blinds still had approximately five broken slats, brown, dried liquid spills on wall register cover, privacy curtain was dirty with multiple brown spots: floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - blinds with approximately four broken slats; the bathroom sink was supported by a round, wooden stick approximately three feet long; floor approximately one to two inches wide from the wall with black and brown debris. Unit 2 room [ROOM NUMBER] - chair rail on wall missing approximately 10-foot section; baseboard missing next to the bathroom door approximately six inches long; three foot by three-foot area behind the headboard of the bed with paint chipped and wall gouged; mismatched window curtains; a strong urine odor in the room; floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; four privacy curtains with brown or white stains, hanging from ceiling with missing hook attachments that attach to the ceiling; window blinds with approximately five broken slats; wall register cover under the large window with brown liquid spills; approximately six feet along the entry door with missing or cracked drywall; a dresser in disrepair with a drawer face missing from the top drawer and a drawer face falling off another drawer. room [ROOM NUMBER] - bathroom floor with black and brown debris along the base of the wall; room floor approximately one to two inches wide from the wall with black and brown debris; three foot by three-foot area next to bed with paint scraped and chipped exposing drywall underneath; approximately four broken slats on the window blinds. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; fall mat with one inch gouge with black and brown debris; windows with white and grey debris on the outside. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; seven foot by three-foot area on the wall next to the bed with paint chipped and gouged exposing drywall underneath; unlabeled basin and graduated cylinder in a shared bathroom; wall register cover with black and white debris on it. Shower Room - tiles missing from shower wall approximately eight inches by two inches; baseboard and drywall missing from shower wall approximately six inches by six inches exposing bare wood; tiles missing from floor in front of missing baseboard approximately seven inches by one inch exposing subfloor; eight foot by one foot area in front of small shower stall with paint chipped; entire floor approximately one inch to two inches wide from the wall of shower room with black and brown debris. room [ROOM NUMBER] - six-foot-long fall mat stuck to the floor with black and brown debris along the edge of the mat; another fall mat with black and brown debris on it; window blind with broken and missing slats; room floor approximately one to two inches wide from the wall with black and brown debris; wall register cover with black, white, and grey debris on it. room [ROOM NUMBER] - bathroom tile floor with black and brown debris; unlabeled graduated cylinder on the floor of a shared bathroom; three by five foot area behind the bed nearest to the bathroom entrance with paint chipped and scraped; approximately six broken and missing slats on the window blinds; room floor approximately one to two inches wide from the wall with black and brown debris; a towel with brown debris on the bathroom sink faucet; wall register cover with grey and white debris under the window and in the bathroom; brown liquid spills on the wall register; window curtains with black and brown debris; window curtain rods broken; privacy curtains with multiple white, brown, and pink spots on them. Unit 3 room [ROOM NUMBER] - floor with multiple white spots; spider webs on the inside of the window; white and grey debris on the outside of the window. Shower Room - six inch by one-inch missing tile exposed drywall outside of the large shower stall; six 4 inch by 4-inch tiles with black and brown debris along the walls in the large shower stall; rusty handrails in the large shower stall; approximately four feet of baseboard pushed in and exposing bare floor next to the toilet; black and brown debris along baseboard outside smaller shower stall approximately four feet long. room [ROOM NUMBER] - approximately three broken slats in the window blinds; window curtains with holes in the fabric, missing curtain hooks, and not attached to the curtain rod; entry door threshold missing molding; baseboard molding missing approximately four feet long exposing spackled drywall that was not sanded or painted; room floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; approximately a four foot by four-foot area next to the window with peeling paint and stained brown; spider webs in the corner of the room next to the window; entry door threshold missing. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; approximately six hooks missing from privacy curtain and handing from the track; over the bed table with food debris and dried, liquid spills on it; black non-skid strips next to bed worn with approximately 1.5 feet missing; bathroom floor tiles with black and brown debris. room [ROOM NUMBER] - missing baseboard approximately two feet long exposing drywall next to the bathroom door; wall lamp missing bulbs with electric wires exposed and white debris on top of the sconce; wall register cover with black, grey and white debris on it. room [ROOM NUMBER] - outside window with white and grey debris; room floor approximately one to two inches wide from the wall with black and brown debris. Observations on 3/28/2025 between 7:00 AM to 11:00 AM revealed: Unit 3 room [ROOM NUMBER] - strong urine odor in room; room floor approximately one to two inches wide from the wall with black and brown debris; wall register cover with dried brown liquid spills; windows missing blinds and curtains; bathroom floor tiles with black and brown debris; grey and white debris on the outside of the window. room [ROOM NUMBER] - strong urine odor in the room. room [ROOM NUMBER] - seven-bathroom floor tiles missing and coming up from the floor; black debris around the toilet; strong urine odor in the bathroom. Utility room - baseboard molding coming off the wall next to the utility room approximately one foot; drywall spackled, not painted or sanded on the wall above the baseboard molding approximately eight inches. During an interview on 3/24/2025 at 8:11 AM, Resident #5 stated that the room could be cleaner. They stated that the missing tiles wasn't homelike and they minded. During an interview on 3/24/2025 at 8:52 AM, Resident #396 stated that the bathroom needs to be cleaned more and Housekeeping only sweeps but never mops. During an interview on 3/24/2025 at 11:28 AM, Resident #79 stated that the facility was not clean or homelike. They stated that the floors were disgusting and that the walls needed to be repaired. During an interview on 3/24/2025 at 11:29 AM, Resident #25 stated that it bothered them that the floors were filthy and that their window blinds were broken. During an interview on 3/24/2025 at 12:11 PM, Resident #9 stated that with the broken blinds, the sun shines on their television, they can't watch television, and it bothered them. During an interview on 3/24/2025 at 12:33 PM, Resident #1 stated that staff don't clean the room like they should and the spider webs bothered them. During an interview on 3/25/2025 at 8:44 AM, Resident #47 stated that the floors were dirty and needed to be cleaned. They stated that their house would not be like this. During an interview on 3/25/2025 at 9:02 AM, Resident #444 stated that their room was definitely not homelike. They stated that the window blinds were broken, the walls were crusty, and the wall register was all banged up. During an interview on 3/25/2025 at 11:54 AM, Resident #56 stated that housekeeping did not have enough staff to keep the facility clean. They stated that their room smells awful. During an interview on 3/25/2025 at 12:01 PM, Resident #9 stated that the facility wasn't homelike and needed to be cleaned. During an interview on 3/27/2025 at 8:15 AM, Resident #6 stated that it bothered them that they had broken blinds in the window as the sun would get in their eyes. They stated that it was not homelike. They stated they told staff about the bathroom sink having a wooden stick supporting it, but nothing was ever done. During an interview on 3/27/2025 at 8:44 AM, Resident #19 stated that the curtains are filthy, the floors are filthy, the walls are filthy, the windows are filthy and it bothered them. During an interview on 3/28/2025 at 8:33 AM, Housekeeper #1 stated that the floors were dirty because the facility's floor technician has been out and has not stripped and waxed the floor. They stated if the floors were stripped and waxed it would be easier to maintain and keep the floors clean. They stated they used to have a maintenance book that they would put things that needed repair in resident rooms, but they haven't seen it in a while. They stated that privacy curtains should be taken down and cleaned when they became soiled. They stated that any furniture, walls, doors, window blinds that were in disrepair was the responsibility of the maintenance department. They stated that they only cleaned the inside windows, and that maintenance was responsible for the outside of the windows. They stated that Unit 3 wasn't homelike or clean. During an interview on 3/28/2025 at 9:00 AM with Registered Nurse #2 Unit Manager, they stated that basins and graduated cylinders should be labeled with the resident's name and room number as that can lead to cross contamination. They stated that personal use items should be put away in the resident's drawer after being rinsed and clean. They stated that the floors could be cleaner, and they expected staff to report to them or maintenance if there was an issue with the resident's room. They stated that the building wasn't homelike for the residents. During an interview on 3/28/2025 at 9:55 AM, the Director of Housekeeping stated they expected their housekeepers to clean the resident rooms and to report to maintenance or to them any issues in resident rooms. They stated that maintenance was responsible for stripping and waxing floors and that housekeeping was responsible for keeping the floors clean. They stated that they were responsible to wash privacy curtains, and that maintenance was responsible for replacing privacy curtain. They stated that maintenance is responsible for cleaning the outside of the windows and housekeeping was responsible for cleaning the inside of the windows. They stated that they realized this was the residents' home and the rooms could be cleaner. During an interview on 3/28/2025 at 10:00 AM, the Maintenance Director stated that they were aware of issues in the resident rooms and resident areas. They stated that it was a constant battle to repair things in resident rooms due to the age of the building. They stated that they would expect any staff to report things to maintenance if there was an issue in a resident room or a resident use area. They stated they do weekly rounds in the facility to fix things in resident rooms. They stated they needed to hire an outside company to clean the outside of windows and could not remember when they were last cleaned. They stated they expected housekeeping to clean spider webs in the corners of the rooms. They stated that the floors needed to be stripped, waxed, and then maintained to be kept clean. They stated that it was a constant battle to fix the walls and any water issues. They stated that they could do better in maintaining the building. During an interview on 3/28/2025 at 10:10 AM, the Regional Plant Operations Director stated that they were aware of the window blind issues. They stated that they were going to try different types of window shades to see if they will work better in the long-term care environment. During an interview on 3/28/2025 at 11:11 AM, the Administrator stated that the building could be cleaner. They stated that they expected housekeeping to keep the building clean and that maintenance should repair things. During an interview on 3/28/2025 at 11:44 AM, the [NAME] President of Clinical Services stated that they believed the building could be cleaner. They stated they expected the housekeepers to clean the resident rooms, and that maintenance staff should repair things in resident rooms. 10 NYCRR 415.5(h)(1)(2)

Based on interview and record review conducted during a Complaint investigation (#NY00348183, #NY00338640) during a Standard survey completed on 3/28/2025, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, the facility did not have sufficient nurse staffing on a 24-hour basis to adequately care for residents' needs 15 out of 30 days and falling below the State average daily staffing hours per resident per day. The finding is: Refer to F 658 Refer to F 677 Refer to F 561 The policy and procedure titled Nursing Department Staffing dated 2/17/2021 documented the facility provides adequate staffing to meet needed care and services for their resident population. The ACTS Complaint/Incident Investigation Report #NY00338640 dated 4/21/2024 documented the facility was consistently short staffed on the weekends. The ACTS Complaint/Incident Investigation Report #NY00348183 dated 7/15/2024 documented the facility was consistently short staffed with one Licensed Practical Nurse for two units, that administration was aware of the staffing issues, and residents were not getting the care they need pertaining to activities of daily living including personal hygiene. The Payroll Based Journal Staffing Data Report Fiscal Year Quarter 1 (October 1 to December 31) 2025 documented that submitted weekend staffing was excessively low for that quarter. Review of the undated Facility Assessment Tool revealed the facility planned on having at least one Registered Nurse for eight hours a day, seven days a week; two Licensed Practical Nurses in the building for all three shifts; and Certified Nurse Aides were to be staffed with five (5) aides on the 6:00 AM to 2:00 PM and the 2:00 PM to 10:00 PM shifts; and three (3) aides on the 10:00 PM to 6:00 AM shift. Review of the Dear Administrator letter 23-11 dated 6/30/2023 sent to nursing home administrators informing them that starting 4/1/2022 nursing homes were required to have an average daily staffing of 3.5 hours of care per resident per day with 2.2 hours for Certified Nurse Aides and 1.1 hours for Licensed Practical Nurses or Registered Nurses. Review of the Executive Order 4.22 from the New York State Governor's office documented that the emergency staffing waivers expired on 6/22/2023. Review of the facility Report of Nursing Staff Directly Responsible for Resident Care documented the following: 2/24/2025 - Resident census 92; Registered Nurses 0.61 hours per resident per day; Licensed Practical Nurses 0.61 hours per resident per day; Certified Nurse Aides 1.91 hours per resident per day; 3.13 total hours per resident per day. 3/1/2025 - Resident census 90; Registered Nurses 0.36 hours per resident per day; Licensed Practical Nurses 0.98 hours per resident per day; Certified Nurse Aides 1.78 hours per resident per day; 3.12 total hours per resident per day. 3/2/2025 - Resident census 90; Registered Nurses 0.36 hours per resident per day; Licensed Practical Nurses 1.07 hours per resident per day; Certified Nurse Aides 1.78 hours per resident per day; 3.21 total hours per resident per day. 3/14/2025 - Resident census 93; Registered Nurse 0.52 hours per resident per day; Licensed Practical Nurse 0.86 hours per resident per day; Certified Nurse Aides 1.81 hours per resident per day; 3.19 total hours per resident per day. 3/15/2025 - Resident census 93; Registered Nurse 0.34 hours per resident per day; Licensed Practical Nurse 0.77 hours per resident per day; Certified Nurse Aides 1.89 hours per resident per day; 3.0 total hours per resident per day. 3/16/2025 - Resident census 93; Registered Nurse 0.34 hours per resident per day; Licensed Practical Nurse 0.77 hours per resident per day; Certified Nurse Aides 1.81 hours per resident per day; 2.92 total hours per resident per day. 3/17/2025 - Resident census 93; Registered Nurse 0.43 hours per resident per day; Licensed Practical Nurse 0.95 hours per resident per day; Certified Nurse Aides 1.63 hours per day; 3.01 total hours per resident per day. 3/18/2025 - Resident census 96; Registered Nurse 0.50 hours per resident per day; Licensed Practical Nurse 1.0 hours per resident per day; Certified Nurse Aides 1.58 hours per resident per day; 3.08 total hours per resident per day. 3/19/2025 - Resident census 96; Registered Nurse 0.67 hours per resident per day; Licensed Practical Nurse 0.75 hours per resident per day; Certified Nurse Aides 2.0 hours per resident per day; 3.42 total hours per resident per day. 3/20/2025 - Resident census 96; Registered Nurse 0.50 hours per resident per day; Licensed Practical Nurse 1.0 hours per resident per day; Certified Nurse Aides 1.83 hours per resident per day; 3.33 total hours per resident per day. 3/21/2025 - Resident census 96; Registered Nurse 0.58 hours per resident per day; Licensed Practical Nurse 0.92 per resident per day; Certified Nurse Aides 1.67 hours per day; 3.17 total hours per resident per day. 3/22/2025 - Resident census 96; Registered Nurse 0.33 hours per resident per day; Licensed Practical Nurse 0.92 hours per resident per day; Certified Nurse Aides 1.67 hours per resident per day; 2.92 hours per resident per day. 3/23/2025 - Resident census 96; Registered Nurse 0.25 hours per resident per day; Licensed Practical Nurse 0.83 hours per resident per day; Certified Nurse Aides 1.67 hours per resident per day; 2.75 total hours per resident per day. 3/24/2025 - Resident census 97; Registered Nurse 0.41 hours per resident per day; Licensed Practical Nurse 0.91; Certified Nurse Aides 1.90 hours per resident per day; 3.22 hours per resident per day. 3/25/2025 - Resident census 97; Registered Nurse 0.49 hours per resident per day; Licensed Practical Nurse 0.98 hours per resident per day; Certified Nurse Aides 1.98 hours per resident per day; 3.45 total hours per resident per day. The facility fell below both State average of hours of care per resident per day. During an interview on 3/24/2025 at 8:56 AM, Resident #396 they stated that sometimes there were only one to two Certified Nurse Aides on the unit, and they cannot keep up taking care of the residents. During an interview on 3/24/2025 at 11:21 AM, Resident #74, they stated that they have not gotten a shower or gotten out of bed because there has only been two Certified Nurse Aides working. During an interview on 3/24/2025 at 11:31 AM, Resident #25 stated sometimes there was only one Certified Nurse Aides on the unit. They stated on the weekends that it was like a ghost town and you can wait hours before someone answers a call light. During an interview on 3/25/2025 at 8:00 AM, Resident #18's representative stated at times there has been only one Certified Nurse Aide on the entire unit. Additionally, the resident had to wait get their medications and they were not on time. During an interview on 3/25/2025 at 8:43 AM, Resident #47 stated they have to wait between one to two hours for a Certified Nurse Aide to help them. They stated they can wait for up to two hours before their call light was answered. During an interview on 3/25/2025 at 9:46 AM, Resident #19 stated the facility was always short staffed and that they have to wait for incontinent care. They stated it does not matter what shift or day it was as staffing always changes. During an interview on 3/26/2025 at 8:32 AM, Certified Nurse Aide #14 stated that when there were only two aides working on a unit, they cannot do showers or get people changed and dressed. They stated that residents do not get the care they need, especially if the resident was a two assist. They stated that it was hard to pass food trays in a timely manner. During an interview on 3/26/2025 at 2:31 PM, Licensed Practical Nurse #4 stated they feel they cannot get their duties completed. They stated they must help the Certified Nurse Aides when a resident was a two assist. They stated they can get some of their treatments and some of their vitals completed but not everything. During an interview on 3/27/2025 at 3:53 PM, the Staffing Coordinator stated that the minimum staffing was: Unit 1- one Certified Nurse Aide and one Licensed Practical Nurse for all shifts. Unit 2 and Unit 3 - three Certified Nurse Aides on the 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shift with one Licensed Practical Nurse on each unit and one Licensed Practical Nurse that would float between the units. -10:00 PM to 6:00 AM shifts were one Licensed Practical Nurse and two Certified Nurse Aides. They stated if there were call offs after they were done for the day, then whoever was the nursing supervisor must call in people. They stated that they do get people to sign up for extra shifts but that was before they end their day. During an interview on 3/28/2025 at 11:11 AM, the Administrator stated they expected the building to be fully staffed. They stated they expected staff to take care of the residents, to keep the residents safe and dry. During an interview on 3/28/2025 at 12:20 PM, the Assistant Director of Nursing they stated they do the best they can with staffing. 10 NYCRR 415.13(a) (1) (i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Complaint investigation (#NY00347069) during a Standard survey completed on 3/28/25, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for one of one facility reviewed for infection control. Specifically, staff did not utilize enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) during morning care, urinary catheter (foley-a tube inserted into the bladder to drain urine) care, and wound care and staff did not remove their gloves or wash hands after incontinent care was provided and before touching clean items for Resident #19; staff did not use enhanced barrier precautions during administration of intravenous medication through a central line for Residents #396 and #399; staff did not perform hand hygiene in between residents during medication administration and without wearing gloves, instilled eye drops for Resident #108; there was no signage on Resident #444's door that indicated they were on enhanced barrier precautions and staff did not wear a gown during wound care; staff performed urinary incontinent care, did not remove their soiled gloves nor their precaution gown, touched door handles, exited the room, touched the clean linen cart cover and clean linens, then returned to the room and without changing their gloves or performing hand hygiene and completed care for Resident #79. The findings are: The policy titled Infection Prevention and Control Program, last revised 3/21/24, documented the infection prevention and control program was a facility-wide effort involving all disciplines and individuals and was an integral part of the quality assurance and performance improvement program. The elements of the program consisted of coordination/oversight, policies/procedures, enhanced barrier precautions, prevention of infection, and identifying, recording and correcting infection control program incidents. The policy titled Enhanced Barrier Precautions, effective 4/1/24, documented enhanced barrier precautions were used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms to residents. Enhanced barrier precautions employ targeted gown and glove use during high contact resident care activities; gloves and gown were applied prior to performing the high contact resident care activity and changed before caring for another resident, face protection may be used if there was a risk of slash or spray. High contact care activities that required the use of gown and gloves included dressing, bathing, transferring, providing hygiene, changing linen and/or briefs, device care (central line, urinary catheter), and wound care. Enhanced barrier precautions were indicated for residents with wounds and/or indwelling medical devices regardless of multi-drug-resistant organism colonization and remained in place for the duration of their stay or until resolution of the wound or discontinuation of indwelling medical device that placed them at increased risk. Staff were trained prior to caring for residents on enhanced barrier precautions, signs posted on the door or wall outside residents' room and personal protective equipment available outside of residents' room. The policy titled Handwashing/ Hand Hygiene, last revised 4/1/2020, documented all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: when hands are visibly soiled and after contact with a resident with infectious diarrhea. Use an alcohol based hand rub containing at least 62% alcohol, or alternatively soap and water for the following: before and after direct contact with residents, when performing standard and transmission based precautions, before and after touching contaminated personal protective equipment, before and after handling medications, before performing any non-surgical invasive procedures, before and after handling invasive device, before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site during resident care, after contact with a residents intact skin or with blood or body fluids, after handling used dressings, after contact with objects in the immediate vicinity of the resident, after removing gloves, and before and after entering isolation precaution settings. The use of gloves did not replace hand washing/hand hygiene. 1.Resident #19 had diagnosis neuromuscular dysfunction of bladder (condition where nerve damage prevents the bladder from functioning properly, leading to difficulty controlling urination, can result in symptoms of difficulty emptying the bladder) with history of urinary tract infections, and dementia. The Minimum Data Set (a resident assessment tool) dated 2/21/25 documented Resident #19 had moderate cognitive impairment, did not exhibit rejection of care, required partial/moderate assistance to roll from lying on back to left and right side while in bed, and was always incontinent of bowel. The comprehensive care plan dated 7/29/25 documented Resident #19 had potential for infection related to indwelling catheter and history of urinary tract infections, interventions included enhanced barrier precautions, foley catheter care daily and as needed. During an observation on 3/26/25 from 9:12 AM to 9:33 AM, an enhanced barrier precaution sign was on Resident #19's room door that directed staff to wear a gown and gloves during care and there were supplies set up next to the resident's door in the hallway. The following was observed during an observation of AM care, foley care and pressure ulcer treatment care for Resident #19: - Certified Nursing Assistant #4 and Licensed Practical Nurse #7 were observed wearing face masks and they donned (put on) gloves. They did not don a gown to provide care. - Certified Nursing Assistant #4 provided catheter care, bowel incontinence care, and washed the resident's buttocks that had two open areas. They did not remove the soiled gloves, perform hand hygiene and don clean gloves before they placed a clean bed linen pad and a clean brief under the resident. Certified Nursing Assistant #4 removed their soiled gloves, did not wash their hands, and donned a new pair of gloves. Then they provided oral care set up to Resident #19. - While wearing gloves, Certified Nursing Assistant #4 emptied Resident #19's foley catheter bag into a graduate (measuring container), emptied and rinsed the graduate into the toilet, touched the toilet flush handle and the sink faucet handles, removed their gloves and did not wash their hands before donning another pair of gloves. Then they assisted with dressing Resident #19. - During the observed care Licensed Practical Nurse #7 assisted Certified Nurse Aide #4 in positioning the resident and handling soiled linens. Licensed Practical Nurse #7 removed their gloves but did not wash their hands, donned gloves and provided a treatment to Resident #19's left buttocks and coccyx open areas. During an interview on 3/26/25 at 9:34 AM, Certified Nursing Assistant #4 stated Resident #19 was on enhanced barrier precautions because they had an indwelling foley catheter and they should have worn a gown while providing care. They stated they should have removed their gloves and washed their hands after providing incontinent care and before touching any clean items in the room, after draining the foley catheter before touching any handles in the bathroom such as the toilet flush handle and sink faucet handles. They stated they were taught to wash their hands any time they changed their gloves, but they did not because the gloves were too difficult to put on if their hands were damp and stated they did not wash their hands until they have completed all care although they knew they were supposed to. During an interview on 3/28/25 at 8:59 AM, Unit Manager Registered Nurse #5 stated they expected Certified Nursing Assistant #4 and Licensed Practical Nurse #7 to have worn a gown while providing care to Resident #19 because they were on enhanced barrier precautions related to their foley catheter. They stated Certified Nursing Assistant #4 should have changed their gloves and washed their hands at a minimum after peri care/ foley catheter tubing care; after removing feces and providing incontinent care; and they should have removed one glove to facilitate using the toilet flush handle and sink faucets with the ungloved hand for infection control purposes. They stated Licensed Practical Nurse #7 should have changed their gloves and washed their hands before wound care, and between treatment applications to two separate open areas to prevent cross contamination. During an interview on 3/28/25 at 10:35 AM, the Assistant Director of Nursing stated they would have expected Certified Nursing Assistant #4 and Licensed Practical Nurse #7 to have worn a gown while providing care to Resident #19 because they are on enhanced barrier precautions related to their foley catheter. They stated Certified Nursing Assistant #4 should have changed their gloves and washed their hands at a minimum of after peri care/foley catheter tubing care; after removing feces and providing incontinent care; and they should have removed one glove to facilitate using the toilet flush handle and sink faucets with the ungloved hand for infection control purposes. They stated Licensed Practical Nurse #7 should have changed their gloves and washed their hands before wound care, and between treatment applications to two separate open areas to prevent cross contamination. During an interview on 3/28/25 at 4:03 PM Licensed Practical Nurse #7 stated they should have worn a gown while providing care to Resident #19 because they were on enhanced barrier precautions related to having an indwelling foley catheter. They stated they should have changed their gloves and washed hands before wound care, and between treatment applications to two separate open areas to prevent cross contamination. 2. Resident #396 had diagnoses including abscess of the lung with pneumonia, methicillin resistant Staphylococcus aureus (bacteria resistant to multiple antibiotics, making infection harder to treat) infection, and malignant neoplasm (tumor that tends to spread to other parts of the body) of the bronchus or lung. The Minimum Data Set, dated [DATE] documented Resident #396 was cognitively intact, was understood, understands and received intravenous antibiotics. The comprehensive care plan, dated 3/24/25, documented Resident #396 was at risk for infection related to a port, pneumonia/lung abscess, and pressure ulcer with interventions to administer medications as ordered, vascular access device care as ordered, and to maintain precautions as needed. The medication administration record for March 2025 documented Resident #396 had an order to receive Vancomycin (intravenous antibiotic) 1500 milligram/300 milliliter solution via central line every 12 hours for 10 days for infection. The medication had a check mark on 3/24/25, indicating it had been administered. Resident #399 had diagnoses that included acute and subacute endocarditis, (inflammation of the heart), chronic kidney disease, and bacteremia (bacteria in the bloodstream). The Minimum Data Set, dated [DATE] documented Resident #399 had moderate cognitive impairment, was understood, understands, and received intravenous antibiotics. Review of active physicians' orders form dated 3/28/25 documented Resident #399 received Ceftriaxone (antibiotic medication) intravenous solution 2 grams/100 milliliters in normal saline once daily for 25 days starting on 3/13/25. During a continuous observation on 3/24/25 at 12:06 PM, Registered Nurse Unit Manager #2 prepared medications to administer to Resident #396 and #399 at the nurse's station. At 12:09 PM they entered Resident #399's room, performed hand hygiene and donned (put on) gloves but did not wear a gown. The Registered Nurse Unit Manager #2 hung a bag containing a clear liquid medication onto the pole beside the resident, cleansed Resident #399's PICC (peripherally inserted central catheter-a catheter that is inserted through a vein and advanced until the tip enters the central venous system) line with an alcohol pad, flushed the port with normal saline, attached the intravenous catheter tubing to the port, and turned on the pump. They exited the room and grabbed another bag from the nurse's station. Registered Nurse Unit Manager #2 entered Resident #396's room at 12:12 PM, performed hand hygiene, applied gloves, hung the bag containing the antibiotic onto the pole, cleansed Resident #396's left chest mediport (a central venous access device) with an alcohol swab, flushed the port with a syringe of normal saline, attached the intravenous catheter tubing to Resident #396's chest port, turned on the pump and exited the room. Both resident's had signage outside of their rooms that indicated they were on enhanced barrier precautions and staff were to wear a gown and gloves during high contact resident care activities. During an interview on 3/24/25 at 12:14 PM, Registered Nurse Unit Manager #2 stated they had just hung the intravenous medications for Resident's #396 and #399. They stated both residents were on enhanced barrier precautions because they were receiving antibiotic medications for infections through an intravenous medical access device so they should have had on gloves, a gown, and a mask, and they had not. Registered Nurse Unit Manager #2 stated it was important to wear gloves, a gown, and a mask while providing care to a resident on enhanced barrier precautions to lower the risk of infection. They stated they were responsible for ensuring all staff on the unit were wearing proper personal protective equipment when providing hands on care to residents on enhanced barrier precautions, including themselves. During an interview on 3/28/25 at 11:16 AM, Medical Director #1 stated if a resident had methicillin resistant staphylococcus aureus or any other contagious bacteria and were on enhanced barrier precautions they would expect the staff caring for them to wear gloves, a gown, and mask when providing hands on care, especially when administering intravenous antibiotic medication. They stated it was important to wear all appropriate personal protective equipment to prevent the spread of infection. They stated the unit manager was responsible for ensuring all staff adhered to the rules on the unit and the Director of Nursing was responsible for monitoring and any follow through needed. During an interview on 3/28/25 at 12:15 PM, Regional Quality Assurance Nurse/Infection Preventionist stated when a resident was on enhanced barrier precautions, they expected all staff to wear gloves, a gown, and a mask when providing care. A resident receiving intravenous antibiotic medication would be on enhanced barrier precautions so the nurse hanging the antibiotic medication should be wearing gloves, a gown, and a mask when administering the medication. They stated the unit manager was responsible for ensuring all staff wore appropriate personal protective equipment when providing care and the Director of Nursing was responsible for follow through. There was a risk of cross contamination and enhanced barrier precautions were needed to prevent the spread of infection. During an interview on 3/28/25 at 1:33 PM, the Director of Nursing/Infection Preventionist stated they expected staff to wear gloves, a gown, and a mask whenever providing any direct care to residents on enhanced barrier precautions. It was important to decrease the risk of transmission. They stated the unit manager was responsible for ensuring all staff wore appropriate personal protective equipment, and the Assistant Director of Nursing and themselves were responsible for any follow through. During an interview on 3/28/25 at 2:31 PM, the [NAME] President of Clinical Services stated staff should wear gloves, a gown, and a mask when providing care to residents on enhanced barrier precautions, especially when administering intravenous medications. They stated it was important to keep the resident safe and help prevent the spread of infection. 3. During a medication administration observation on 3/27/25 at 9:15AM, Licensed Practical Nurse #3 administered oral medications, then without performing hand or donning gloves went into Resident #108's room and administered the resident's oral medications. Licensed Practical Nurse #3 used their ungloved hand to hold the resident's eyelids open and instilled eye drops into both of their eyes. Licensed Practical Nurse #3 then performed hand hygiene. During an interview on 3/27/25 at 9:18AM, Licensed Practical Nurse #3 stated they cross contaminated by not washing or sanitizing their hands in between residents and not putting gloves on to administer the eye drops and was an infection control risk. Licensed Practical Nurse #3 stated they were not thinking. During an interview on 3/28/25 at 1:04PM, the Assistant Director of Nursing stated the safest way that prevented the spread infection was by performing hand hygiene. Licensed Practical Nurse #3 should have washed their hands in between residents, then donned gloves before giving the eye drops, administered the eye drops, removed their gloves and washed their hands for infection control practices. Licensed Practical Nurse #3 should have washed their hands after giving medications regardless. Hand hygiene and wearing gloves protected the residents from the spread of infection. During an interview on 3/28/25 at 1:30PM, the Regional Quality Assurance Nurse/Infection Preventionist stated the lack of hand hygiene in-between residents' medication pass was unacceptable and against the facilities infection control protocol. 4. Resident #444 had diagnoses that included diabetes mellites with a skin ulcer, acute osteomyelitis (infection of the bone) of the left foot, and orthopedic aftercare. The comprehensive care plan dated 3/11/25, documented Resident #444 was alert and oriented and was at risk for impaired skin integrity related to acute osteomyelitis of the left foot and orthopedic aftercare. The resident had an infection related to bacteremia (bacteria in the blood stream) and a wound. Interventions included to administer meds as order and infectious disease consult as needed. Resident #444's physician orders dated 3/28/25 documented an order dated 3/21/25, to cleanse the left foot wound with normal saline, pack wound with ½ inch of iodoform packing strip (antiseptic gauze dressing), cover with gauze and kling (flexible, absorbent gauze dressing used to wrap wounds) once a day. The physician orders documented that Resident #444 was on Unasyn (antibiotic) 3 grams intravenously every 6 hours for infection. Review of Unit 1 daily unit report from 3/22/25-3/27/25 did not indicate Resident #444 was to be on enhanced barrier precautions. Review of the facility's Enhanced Barrier Precaution signage provided by Registered Nurse #4 documented that staff were to wear gloves and gown for the following high contact resident care activities: wound care; any skin opening requiring a dressing. During observations on 3/24/25 at 10:14 AM, 3/25/25 at 9:00 AM, 3/25/25 at 1:52 PM, 3/26/25 at 11:59 AM, 3/26/25 at 5:21 PM there was no enhanced barrier precaution signage on Resident #444 door/wall near the entrance to their room. Outside of the resident's room there was a red garbage bin and a three-drawer plastic bin that contained masks, gloves and gowns. During an interview on 3/25/25 at 9:08 AM, Resident #444 stated that staff did not wear gowns while they were doing their treatment to their infected left foot or when they administered their intravenous medication. During a wound care treatment observation on 3/27/25 at 4:31 PM, Licensed Practical Nurse #8 performed hand hygiene and donned gloves prior to the start of Resident #444 left foot diabetic wound treatment. The old dressing on the resident's food was observed to have serosanguinous (blood and serum) drainage on it. Resident #444 diabetic ulcer wound bed appeared to be moist with serous (pale yellow or clear) drainage. Licensed Practical Nurse #8 completed Resident #444's treatment without wearing a gown. During an interview on 3/27/25 at 4:45 PM, Licensed Practical Nurse #8 stated they did not wear a gown during Resident #444's treatment because they could not wear paper gowns. They stated Resident #444 was just on universal precautions and not enhanced barrier precautions because the dressings were not sterile. Licensed Practical Nurse #8 stated if a resident was to be enhanced barrier precautions there would be signage on their door, and it would also be written on the 24-hour report sheet. During an observation and interview on 3/28/25 at 10:52 AM, Registered Nurse #4, Unit Manager stated Resident #444 was on enhance barrier precautions because they had an intravenous line and a draining diabetic ulcer to their foot. After Registered Nurse #4 visualized the outside of Resident #444 room they stated that there was not enhance barrier precaution signage but there should have been. Registered Nurse #4 stated that Licensed Practical Nurse #8 should have worn a gown while performing wound care on Resident #444. During an interview on 3/28/25 at 11:53 AM, the [NAME] President of Clinical Services stated that they expected staff members to utilized enhanced barrier precautions during wound care for a diabetic ulcer. They stated that all residents that were on enhanced barrier precautions were to have green or orange signage outside of their door to alert staff that the resident was on enhanced barrier precautions. They stated they expected Licensed Practical Nurse #8 to wear a gown during Resident #444's treatment and a cloth gown could have been utilized. 5. Resident #79 had diagnoses that included sacral pressure ulcer stage 4 (full thickness tissue loss with exposed bone, tendon or muscle), dementia and hypertension. The Minimum Data Set, dated [DATE] documented Resident #79 had severe cognitive impairment, sometimes understands, was sometimes understood, and had one stage IV (4) pressure ulcer that was present upon reentry to the facility. The comprehensive care plan revised on 9/17/25, documented Resident #79 had an infection related to the presence of a sacral pressure ulcer stage 4 and osteomyelitis. Interventions included to administer wound treatments as ordered and maintain enhanced barrier precautions as needed. Review of the Wound Assessment and Plan note dated 3/21/25, revealed the Wound Physician documented that Resident #79 had a stage IV sacral pressure ulcer. The wound status was documented as a healing wound with a large amount of drainage. During an AM care observation on 3/27/25 at 9:33 AM, Certified Nurse Aide #10 and Certified Nurse Aide #11 donned (put on) gowns and gloves prior to entering Resident #79 room. Certified Nurse Aide #10 washed and dried Resident #79's peri area (area between the anus and genitalia) with a towel, rolled the resident onto their side with the help of Certified Nurse Aide #11, and washed and dried the resident's buttocks. Resident #79's sacral wound dressing was observed on the incontinent pad and Certified Nurse Aide #10 picked it up with their gloved hand, exited the room, removed their gloves in the hallway, never doffing (taking off) the gown they were wearing. Certified Nurse Aide #10 reentered the resident's room, donned a new pair of gloves but did not perform hand hygiene. Certified Nurse Aide #10 entered Resident #79's bathroom, filled a basin with water and placed it on the resident's bed side table. Certified Nurse Aide #10 did not doff their gloves or gown, touched the door handle with their gloved hand, exited the resident's room, grabbed additional linens off the linen cart, and reentered Resident #79's room. Certified Nurse Aide #10, with the assistance of Certified Nurse Aide #11 rewashed Resident #79's peri area, buttocks and changed the resident's incontinent pad that was wet with urine. Certified Nurse Aide #10 did not doff their gloves or gown, touched the resident's bathroom door to close it, touched the room door handle, exited the resident's room, touched the cover on the linen cart, and removed a hospital gown from the linen cart. Certified Nurse #10 walked back into Resident #79's room with the clean hospital gown to the resident's bedside, turned around, walked back out of the room with the hospital gown still in their gloved hand, put it back onto the linen cart, removed a second hospital gown from the linen cart, and walked back into the resident's room. Wearing the same gloves that they provided peri care with, they dressed the resident in the gown. During an interview on 3/27/25 at 10:01 AM, Certified Nurse Aide #11 stated that Resident #79's AM started off bad from the beginning. They stated that Certified Nurse Aide #10 did not wash their hands prior to starting care, never took their gown off each time they left the resident room and never washed their hands after reentering the resident's room. Certified Nurse Aide #11 stated Resident #79's incontinent pad was saturated with urine prior to changing it. Certified Nurse Aide #11 stated that staff should perform hand hygiene before and after care was provided, at least four times during care and whenever gloves were changed. They stated the purpose of proper hand hygiene was for infection control reasons and so you don't pass stuff around. During an interview on 3/27/25 at 10:41 AM, Certified Nurse Aide #10 stated they broke infection control barriers by exiting Resident #79's room with their gown and gloves on. They stated they touched everything with their gloved hands, and they were not supposed to do that. Certified Nurse Aide #10 stated they removed a hospital gown from the linen cart, went into the resident's room with the gown and then returned the same gown to the linen cart. They stated that they needed to wash their hands before and after care but not in between glove changes. Certified Nurse Aide #10 stated that they should never wear gloves out in a hallway because they were considered dirty. They stated that they were nervous, and they were not even thinking. During an interview on 3/28/25 at 11:01 AM, Registered Nurse #2 stated that staff should perform hand hygiene before care, after care, anytime they were soiled and anytime a staff member changed their gloves. They stated that gowns and gloves should be doffed at the resident's door and thrown in their garbage can prior to leaving the room. Registered Nurse #2 stated that Resident #79 was on enhanced barrier precautions due to having a pressure ulcer to their sacrum and infection control breaches during care could possibly spread infection to other residents. During an interview on 3/28/25 at 11:53 AM, the Assistant Director of Nursing stated that Certified Nurse Aide #10 had broken infection control practices during AM care for Resident #79 when the staff member left the resident room with their gown and dirty gloves on, touched items and put the hospital gown back onto the linen cart. They stated that staff were to remove their gloves and hand sanitize after providing peri care prior to washing other parts of a resident's body. The Assistant Director of Nursing stated the importance of proper hand hygiene and doffing of gloves and gowns prior to exiting a resident room was to prevent the spread of infection especially with a resident who had a wound. During an interview on 03/28/25 at 12:24 PM, the [NAME] President of Clinical Services stated their expectation for appropriate hand hygiene would be staff washed their hands prior to care being started, after the completion of peri care and anytime the staff member was going from a dirty to clean area. They stated that linens should never be returned to the linen carts after it had already been in a resident's room for infection control reasons. 10 NYCRR 415.19(a)(1-3), 415.19(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the Onsite Post Survey Revisit #1, the facility did not ensure all menus were followed for four (Residents #1, 2, 3 and 4) of 7 residents reviewed. Specifically, residents were not served a ground consistency diet as planned. This is a continuing deficiency from the abbreviated survey completed 11/12/2024. The findings are: The policy and procedure titled, Tray Identification dated 2/17/17, documented the purpose of the policy was to assist in setting up and serving the correct food trays/diets to residents. The Food Services Manager or Supervisor will check trays for correct diets before the food carts are transported to their designated areas. Nursing staff shall check each food tray for the correct diet before serving the residents. If there is an error, the Nurse Supervisor will notify the Dietary Department Immediately by phone so that the appropriate food tray can be served. The policy and procedure titled, Therapeutic Diets dated 1/10/2018 documented, when necessary, the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of a patient/resident to achieve outcomes/goals of care. Available therapeutic diets should coincide with the therapeutic diets on the facility menu extensions. When appropriate, an individual will be educated by the Registered Dietician or designee about his/her therapeutic or consistency modified diet. Review of a facility provided document titled, Dietary Terminology Guide, with an effective date of 4/2022 documented the consistencies offered at the facility included: regular consistency as tolerated, ground included mechanically soft, dental soft, chopped, and pureed included strained or blenderized. 1. Resident #1 had diagnoses which included anemia in chronic kidney disease, dysphagia (difficulty swallowing), and cerebrovascular disease (a decrease of blood flow to the brain causing brain damage). The Minimum Data Set (MDS, a resident assessment tool) dated 9/16/24, documented Resident #1 had moderate cognitive impairment and sometimes understand others and sometimes was understood by others. The Comprehensive Care Plan dated 10/1/24, documented Resident #1 was on a ground diet and required light assistance with eating, was to be out of bed as tolerated, and to monitor for pocketing (holding food in mouth without swallowing increasing the risk of choking if becomes dislodged). The Speech Therapy plan of treatment dated 12/10/24 documented recommendations for Resident #1 that included mechanical soft/ground textures, thin liquids, supervision of oral intake/occasional. Upright posture during meals and greater than 30 minutes after meals. Resident #1's dietary card dated 12/17/24 documented they were to have 2 ounces of ground beef pot roast, 4 ounces of au gratin potatoes, 4 ounces of ground Prince [NAME] blend vegetables, 1 slice of ground cream pie. Supervision: monitor for pocketing out of bed as tolerated for meals. During a lunch observation 12/17/24 at 12:50 PM Resident #1's was eating lunch in the dining room and was supervised by Certified Nurse Aide #1. Their meal consisted of pot roast with gravy, a vegetable blend, au gratin potatoes and pie. The beef pieces were stringy, about 1-2 inches in length and were not of ground consistency; the vegetables and potatoes appeared to be soft in texture but were not of ground consistency. The cream pie was a whipped cream consistency with a graham cracker crust. The resident had eaten 50 percent of the meal at the time of the observation. During an interview on 12/17/24 at 12:54 PM, Resident #1 stated their meat was not ground and should be so that it was easier for them to swallow. They stated their vegetables and potatoes were soft enough for them to swallow and did not have an issue swallowing the cream pie. On 12/18/24 at 1:25 PM Resident #1 stated that sometimes their food was ground and sometimes it was not. During an interview and observation on 12/17/24 at 1:05 PM the Registered Dietician stated the meat on Resident #1's tray was not ground, the vegetables and potatoes were soft enough they did not need to be ground, as well as any cream pie with a graham cracker crust. They stated it was important to ensure the consistency and proper diet of resident's food to decrease any risks of choking or malnutrition. During an interview on 12/18/24 at 1:30 PM, Certified Nurse Aide #1 stated Resident #1 needed supervision and minimal assistance with eating. They stated they felt the beef was soft enough for the resident and made sure the resident did not take too big of mouthfuls. During an interview on 12/18/24 at 1:37 PM, Registered Nurse #1, Unit 3 Supervisor stated were responsible for viewing the resident's tray for accuracy before serving but they had educated the staff and relied on the Certified Nurse Aides to inform them of any discrepancies. Additionally, they stated that no Certified Nursing Aides had informed them of any issues with consistency. 2. Resident #2 had diagnoses of dysphagia following cerebral infarction, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness). The Minimum Data Set, dated [DATE] documented Resident #2 had mild cognitive impairment, could understand others, and could be understood by others. Resident was dependent on staff for eating. Review of a Comprehensive Care Plan dated 10/17/24 documented Resident #2 required a mechanically soft diet, a total assist for all meals and was to be up in chair for all meals. Review of Speech Language Pathologist Evaluation and plan of treatment dated 10/24/24, documented that Resident #2 was to be on a regular mechanically ground diet. The goals documented for Resident #2 to have safe swallowing with the least restrictive diet. Review of a diet card dated 12/17/2024 documented Resident #2 was to have 3 ounces of ground beef pot roast with 2 ounces of gravy, 4 ounces of au gratin potatoes, 4 ounces of ground Prince [NAME] blend vegetables, 1 slice of ground cream pie. During an observation and interview on 12/17/2024 at 1:25 PM, Resident #2 was observed eating lunch in the dining room with assistance from staff. Their meal consisted of pot roast with gravy, a vegetable blend, au gratin potatoes and pie. Certified Nursing Assistant #2 stated the diet card did not match the meal tray and the beef pot roast, vegetables and pie should have been ground. They stated they did not go to the kitchen because the resident did not like the pot roast. They stated they did offer them something different, but they did not want anything else. The resident had eaten a few bites of the pot roast and some of the vegetables. During an interview on 12/17/24 at 3:03 PM, the Speech Therapist stated a resident would be put on a therapeutic diet for ground foods because it would be easier to chew and decrease the risk of them choking. During an interview on 12/18/24 at 1:45 PM, the Registered Dietician stated in the beginning Resident #2 had a hard time adjusting to ground consistency but had adjusted. 3. Resident #3 had diagnoses of dysphagia after a cerebral vascular accident, diabetes, and Barrett's esophagus (lining of the esophagus becomes red and thickened due to acid reflux). The Minimum Data Set, dated [DATE] documented Resident #3 had mild to moderate cognitive impairment, could understand others and could be understood by others. Resident #3 was totally dependent on staff for eating. Review of a Comprehensive Care Plan dated 5/27/24 documented Resident #3 required a ground diet and a total assist from staff for all meals. Review of Speech Language Pathologist progress note dated 9/11/24 documented that Resident #3 was downgraded to a ground diet, nectar, due to mild dysphagia, thin liquids, ground consistency. Review of a diet card dated 12/17/24 documented that Resident #3 was to have 3 ounces of ground beef pot roast with 2 ounces of gravy, 4 ounces of au gratin potatoes, 4 ounces of ground Prince [NAME] blend vegetables, 1 slice of ground cream pie. Extensive Assistance, small sips, and bites, evaluate head of bed at least 30 degrees during meal and for 30 minutes post meals. During a lunch meal observation on 12/17/24 at 12:50 PM Resident #3 was sitting in a Geri chair in the main dining room. Certified Nurse Aide #2 was sitting with the resident and providing total assistance. Resident #3's meal tray consisted of pot roast with gravy, au-gratin potatoes, vegetable blend and a slice of cream pie. The resident had eaten about 50 percent of their meal and the food was not of ground consistency. During an interview on 12/17/24 at 12:58 PM, Certified Nurse Aide #2 stated the diet card documented Resident #3's food should have been ground. They stated they should have notified the kitchen the food was not ground but they never answered the phone. They stated today they improvised and cut the meat up in small pieces for the resident and the gravy helped make it easier for the resident to chew and swallow. They said they did not notify their supervisor because the beef was tender, and they cut it into small pieces for the resident. They stated that sometimes the resident's food was ground, but not always. During an interview on 12/18/24 at 12:38 PM Registered Nurse #2 Unit 2 Supervisor, stated they did not know the policy and procedure documented that they were responsible to view the resident's tray for accuracy before serving. They stated they monitored the staff to ensure they checked all diet cards and trays and educated them on what to do if there was an issue but no issues were brought to their attention. 4. Resident #4 had diagnoses of dysphagia following cerebrovascular disease, acute kidney failure. The Minimum Data Set, dated [DATE], documented Resident #4 was severely cognitively impaired and could not understand others or be understood by others. Resident #4 required setup assistance while eating. The Comprehensive Care Plan dated 10/25/24 documented Resident #4 required a ground diet. Review of a diet card dated 12/17/24 Resident #4 was to have 2 oz of ground beef pot roast, 4 ounces of au gratin potatoes, 4 ounces of ground Prince [NAME] blend vegetables, 1 slice of ground cream pie. During a lunch meal observation on 12/17/24 at 1:20 PM Resident #4 was eating in a supervised dining room. The resident's meal consisted of beef pot roast, vegetables, au-gratin potatoes, and a slice of cream pie. The foods were not of a ground consistency. Resident #4 had consumed all their meal. During an interview on 12/17/24 at 1:22 PM, Certified Nurse Aide #3 stated Resident #4's food was not ground as the diet card specified. Certified Nurse Aide #3 stated they should have ordered a new tray and took the incorrect tray down to the kitchen and had it corrected. During an interview on 12/18/24 at 1:35 PM, the [NAME] Supervisor stated they took full responsibility for the beef pot roast meals that were served to the residents on 12/17/24 with the wrong consistency. They stated they may have not heard the dietary aides call it out. During an interview on 12/18/24 at 1:47 PM, the Director of Food Service stated foods should have been served in the form that met the residents' individual needs. They stated as the Director of Food Services they were responsible to monitor the staff to ensure they verified the diet card with the meal tray. During an interview on 12/18/24 at 1:55 PM, the Director of Nursing stated their expectations would be for staff to ensure the diet card matched the meal tray. If it did not, they need to go to the kitchen and get the accurate items and consistency for the resident. They stated this was important to decrease the risk of harm or even possible death. During an interview on 12/18/24 at 2:05 PM, the Administrator stated their expectations were for the entire staff to review diet cards before trays went out on the floor. Staff who pass the tray on the units should double check and the nurses should monitor and ensure accuracy. NYCRR 415.14 (c) (1-3)

Based on observation, interview, and record review during the Abbreviated survey (complaint # NY00329948) completed on 2/15/24, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one kitchen had issues that included undated and outdated food, a cooked food item stored adjacent to raw meat, flies observed, no single service towels at the handwash sink, multiple soiled surfaces, missing wall tiles, and missing floor tiles. The findings are: The policy and procedure titled Food Receiving and Storage, reviewed 10/4/23, documented foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator will be covered, labeled, and dated. Uncooked and raw animal products will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods. The policy and procedure titled Sanitization, reviewed 10/4/23, documented the food service area shall be maintained in a clean and sanitary manner. All kitchen areas shall be kept clean and protected from flies and other insects. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Additionally, kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The policy and procedure titled Pest Control, revised May 2008, documented this facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 1a. Observation in the kitchen on 2/15/24 at 8:50 AM revealed the following food items were in the reach-in cooler: -A bin that contained five cups of diced pears dated 2/6. -Two large, opened bags of lettuce, each half-full, with manufacturer's stamp best by 2/8, and the bags were not labeled with a date opened. -A bin that contained two cups of jelly that was undated. -Several stacks of sliced cheese covered in plastic wrap that were undated. -An opened bag of shredded cheese that was undated. -Two individual poured cups of applesauce that were undated. -Three hot dogs wrapped in tin foil that were undated. -A bin that contained four cups of applesauce and another bin that contained one cup of applesauce that were undated. -Ten sandwiches, individually covered in plastic wrap, that were undated. -A bin that contained four cups of cut pineapple that was undated. -A bin that contained four cups of diced tomatoes that was undated. -A bin that contained five cups of pudding that was undated. -A cake in a metal pan, with one piece removed, covered with parchment paper that was undated. -A bin that contained two pounds of sliced turkey dated 2/11. -Four individual cups of prepared salad that were undated. During an interview at the time of the observation, Supervisor/Cook #1 stated most foods were only supposed to be kept in the refrigerator for three days, but they were not sure about cut fruit. They stated the bags of lettuce should have been dated when they were opened, and the hot dogs maybe belonged to a staff member, but they were not sure where staff food was supposed to be stored. Supervisor/Cook #1 stated the sandwiches were used the same day they were made, so they knew the sandwiches were made today, the cut tomatoes should be thrown out, they were not sure when the cake was made so it should be thrown out, and the pudding was made yesterday and should have been dated. 1b. Observation in the kitchen on 2/15/24 at 9:06 AM revealed the following food items were in the walk-in cooler: -A bin that contained two cups of cooked ground chicken adjacent to, and on the same tray as, a sealed package of raw meat, which was on the second shelf from the floor, with liquid egg product below it. -A bin that contained two cups of cooked noodles that was undated. -An opened gallon-sized bottle of salad dressing with manufacturer's stamp Manufactured 29Nov23, and hand-written on the lid 11/10. Four unopened gallons of one percent milk with manufacturer's stamp Sell by 2/9 During an interview at the time of the observation, Supervisor/Cook #1 stated the meat in the sealed package was raw pepper steak and it was placed in the walk-in cooler to thaw, and the cooked noodles were undated and should be thrown out. During an interview on 2/15/24 at 2:45 PM, the Food Service Director stated all foods were able to be stored in the refrigerator for up to three days, with a small number of exceptions. Foods such as cut fruit, pudding, applesauce, sandwiches, and leftovers all could be stored in the refrigerator for three days and cake should only be stored in the refrigerator for one day to ensure it was fresh. The Food Service Director stated they expected dates to be written on all items when opened, including sliced and shredded cheese, which should be dated when removed from its original packaging and discarded after three days. They also stated it was the facility's policy to throw out any milk that was past its sell by date, even if it was unopened, and they asked staff to throw out the four gallons dated sell by 2/9, but staff must have forgotten to do it. The Food Service Director also stated the salad dressing's date of 11/10 was the date it was received, not the date that it was opened, and salad dressings can be stored in the refrigerator for one month after opening, but this bottle still needed to be discarded because they were unsure of the date it was opened. They stated Dietary Aides and Supervisors were responsible for writing dates on foods when opened and looking for items that were missing a date, but it was the Supervisors' responsibility to check the refrigerators and oversee this. Additionally, the Food Service Director stated raw meats should always be stored on the bottom shelf, below all other foods, to avoid contamination of other foods. 1c. Multiple observations in the Kitchen on 2/15/24 revealed three live small flies were observed around the dish machine at 8:40 AM, two live small flies were observed around the three-bay sink at 9:18 AM, several live small flies were observed around the dish machine at 9:40 AM, one live small fly was observed around the tray line during lunch meal tray line service at 12:00 PM, and two live small flies were observed around the dish machine at 12:12 PM. At these times, small puddles of standing water were observed on the floor of the dish machine area. Additionally, an insect light trap (light bulbs to attract insects and a glue paper behind to trap them) was observed in the dish machine area and the glue paper appeared to have at least fifty dead small flies attached. During an interview on 2/15/24 at 9:22 AM, Dietary Aide #3 stated they did not usually see flies around the dish machine, but someone left food out last night on the counter in the dish machine area, which may be why flies were here today. During an interview on 2/15/24 at 9:38 AM, the Food Service Director stated they used floor drain chemicals to control flies near the dish machine and a licensed exterminator did treat the area regularly. They also stated small flies had been an issue since they started working at this facility in May 2023, but they had noticed an improvement recently. During an interview on 2/15/24 at 12:00 PM, Supervisor/Cook #1 stated the flies were gnats which mostly stayed near the dish machine, they were not usually seen around the tray line, and the situation had gotten better recently. During an interview on 2/15/24 at 2:20 PM, the Environmental Director stated a licensed exterminator visited the facility monthly for their regular service and every two weeks, the exterminator treated the kitchen drains. Review of the exterminator's most recent Service Inspection Report, dated 2/5/24, revealed it included a drain treatment and inspection and service of the facility's light traps. Further review revealed it noted that none of the insect light traps had activity. 1d. Observation in the kitchen on 2/15/24 at 8:38 AM and 9:28 AM revealed the hand wash sink was not equipped with single service towels. During an interview on 2/15/24 at 9:35 AM, the Food Service Director stated a Housekeeper usually restocked the paper towels, there were none in the kitchen at this time, and paper towels should always be available in the kitchen. 1e. Observation in the kitchen on 2/15/24 from 8:35 AM to 9:50 AM revealed the following environmental conditions: -Exterior of the microwave was soiled with greasy streaks and food debris. -Interior of the microwave was soiled with pooled butter on the bottom and food splatter on all sides and ceiling. -Floor had dried food debris behind the equipment located under the extinguishment hood. -Dried food spills on the bottom of the reach-in cooler -Brown, green, and white greasy debris on the top of the dish machine -Two shelves under the coffee machine where coffee creamer and cup lids were stored were stained dark brown. -Shelf under the food prep table where food trays and mustard packets were stored was rusty. -Bottom of the tray that contained utensils to the left of the stove had dried food debris. During an interview at the time of the observations, Supervisor/Cook #1 stated the microwave needed to be cleaned and the bottom of the reach-in cooler needed to be wiped down. During an interview at the time of the observations, Dietary Aide #2 stated they did not know what the substance on top of the dish machine was, but it was disgusting, and it should be everybody's job to clean the dish machine. They also stated the utensils in the tray to the left of the stove were clean and ready-to-use and no one regularly cleaned the tray. During an interview at the time of the observations, Dietary Aide #1 stated the shelf under the food prep table was rusty and the some of the trays stored on the shelf were used to serve residents' meals and were clean, and the shelves under the coffee machine were stained. During an interview at the time of the observations, the Food Service Director stated the substance on top of the dish machine was lime build-up from the machine's doors. The Supervisor/Cooks were responsible to clean the utensil tray to the left of the stove every other day. 1f. Observation in the kitchen on 2/15/24 at 8:40 AM revealed the wall behind the three-bay sink was missing approximately ten wall tiles. The wall opposite the dish machine was missing approximately six wall tiles. Further observation revealed the floor in the dish machine area was missing approximately ten floor tiles. During an interview on 2/15/24 at 9:40 AM, the Food Service Director stated they had informed the facility's maintenance staff about the missing tiles, and they were working on a plan to fix it. During an interview on 2/15/24 at 9:47 AM, the Environmental Director stated there was a leak in the roof above the three-bay sink, which had caused moisture damage on the wall and the sheetrock had become brittle. They stated the roof repair was being planned and after the roof repair was completed, the wall behind the three-bay sink could be repaired and new wall tiles installed. Additionally, on 2/15/24 at 2:20 PM, the Environmental Director stated maintenance staff had tried to replace the floor and wall tiles around the dish machine, but they didn't stay due to a lot of water on the floor and carts hitting the bottom of the walls. 10 NYCRR 415.14(h) SubPart 14-1 - Food Service Establishments 14-1.43(c), 14-1.110(d)(e), 14-1.143(c), 14-1.160, 14-1.170, 14-1.171

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Standard Survey completed on 9/18/23, the facility did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care for one (Residents #26) of 3 residents reviewed for resident choices. Specifically, residents were not provided a choice to take a tub bath because there was no working bathtub in the facility. The finding is: The policy and procedure (P&P) titled Quality of Life - Self Determination and Participation dated 9/1/17 documented the facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. Each resident shall be allowed to choose activities, schedules and health care that are consistent with his or her interests including personal care needs such as bathing methods. To facilitate resident choices staff shall gather information about the resident's personal preferences on initial assessment and periodically thereafter and document these preferences in the medical record. The P&P titled Care Plans - Comprehensive dated 2/1/17 documented an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The facility will inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process will incorporate the resident's personal and cultural preferences in developing goals of care. The P&P titled Maintenance Service dated 8/16/23 documented the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to maintaining the building in compliance with current federal, state, and local laws regulations, and guidelines. 1. Resident #26 has diagnoses that include anxiety disorder, acquired absence of left leg above knee, and COPD (chronic obstructive pulmonary disease). The Minimum Data Set (MDS - a resident assessment tool) dated 7/28/23 documented Resident #26 was cognitively intact, was understood, and understands. The MDS dated [DATE] documented it was very important to the resident to choose between a tub bath, shower, bed bath or sponge bath. The Therapeutic Recreation Assessment dated June 2023 documented, Resident #26 would prefer to take a tub bath and it was very important to them. The undated Closet Care Plan (guide used by staff to provide care) identified as current by Regional Director of Nursing (DON), documented that Resident #26's preferred to shower two times per week and upon request. The Care Plan Preferences and Choices dated 4/11/22 for Resident #26 documented, Staff will honor Resident's preferences/ choices as able. During an interview on 9/11/12 at 9:09 AM, Resident #26 stated they had taken baths at home daily for the last 20 years and they prefer taking a bath. Resident #26 stated they had told the staff they wanted a bath since their admission over a year ago, but they give them a shower and never offer a tub bath. During an observation on 9/11/23 at 9:13 AM the 2nd floor tub had two packages of briefs stored in it. The bottom of the tub had dark brown debris and the drain was closed and rusty. The faucets to the drain had a dried white/ brown substance with dust build up on the tub edges. During an interview on 9/18/23 at 9:20 AM, Resident #26 stated they had a shower on Friday and preferred a bath over showers because that was what they were used to all their life. During an interview on 9/18/23 at 9:22 AM, Certified Nursing Assistant (CNA) #1 stated they were familiar with Resident #26 and had asked for tub baths. CNA #1 stated the resident prefers a bath over a shower, but they were unable to provide a bath to the resident because the tub doesn't work. CNA #1 stated all the staff know the tub on the floor doesn't work and the residents were only offered showers because a tub was not available. During an interview on 9/18/23 at 9:24 AM. CNA #2 stated they were familiar with Resident #26. CNA #2 stated Resident #26 had asked for baths and prefers baths over showers, but was given showers because the tub doesn't work. During an interview on 9/18/23 at 9:27 AM, Licensed Practical Nurse (LPN) #5 stated they do not know if the tub works or how to turn it on. During an interview on 9/18/23 at 9:29 AM, Registered Nurse (RN) Unit Manager (UM) #1 stated the Activities Department was responsible to ask the residents their preferences and care plan accordingly. RN UM #1 stated they do not ask residents if they would like a bath verses a shower because the facility doesn't have a working bathtub on any of the floors (1, 2, and 3). RN UM #1 stated the bathtubs in the facility have not worked for a couple of years. RN UM #1 stated they were unable to accommodate a resident's preference if they wanted a bath and administration was aware. During an interview and observation of the 2nd floor bathtub on 9/18/23 at 9:36 AM the Assistant Environmental Director stated the tub doesn't work. They also stated the 1st floor and 3rd floor tubs did not work either and that the facility doesn't have any working bathtubs. The Assistant Director of Maintenance stated they had been working at this facility for approximately 1 ½ years and there has not been any working bathtubs in the facility. During an interview and observation of the 2nd floor bathtub on 9/18/23 at 9:36 AM the Environmental Director stated they had been working at this facility for approximately 1 ½ years and all the bathtubs, 1st floor, 2nd floor, and 3rd floor had not worked since they were employed. The Environmental Director stated the Director of Nursing told them this morning that baths were not offered because it is an infection control issue. They stated the facility doesn't offer baths to any of the residents. They stated the 1st floor bathtub was not hooked up at all, the 2nd floor tub was seized up and would not turn on, and the 3rd floor bathtub drain had a leak and was not used. They further stated the facility was unable to provide a tub bath per a resident's preference because they do not have a working bathtub. During an interview on 9/18/23 at 9:43 AM, the Director of Nursing stated the Regional Educator informed them the facility doesn't give tub baths because it was an infection control issue, therefore none of the residents were offered tub baths. The DON stated they had been employed at the facility in the Nursing Department for 2 years and all the bathtubs in the facility had not worked. The DON stated if a resident has a preference of a tub bath over a shower, they would not be able to accommodate their preference. During an interview on 9/18/23 at 9:47 AM, the Regional Educator stated they were not aware the facility didn't have a working bathtub and stated the Environmental Director and DON misunderstood the information provided to them this morning. Regional Educator stated if a resident's preference was to have a tub bath and they were safe and didn't have an infection then a tub bath should be given. The Regional Educator stated the facility should have a working tub. During an interview on 9/18/23 at 9:57 AM, the Activities Department Director stated the activities department had asked and completed the Therapeutic Recreation Assessment with Resident #26 in June 2023 which included their bathing preferences. The Activities Department Director stated the resident voiced their bathing preference was very important to them and they preferred a tub bath. The Activities Department Director stated they were unaware if the facility's bathtubs work but the facility should have a working tub to accommodate a resident's preference. During an interview on 9/18/23 at 11:28 AM, the Administrator stated they were not aware the facility did not have a working tub and would expect to have been informed by anyone who knew they were not working. The Administrator stated that residents have a right to determine their preferences and if a resident wished to use a tub and if they were assessed and safe then the resident should be able to bathe in a tub. The Administrator stated the facility should have a working tub to accommodate residents' preferences. During an interview on 9/18/23 at 11:28 AM, the Regional DON stated residents have a right to preferences and to use a bathtub if they preferred if they were safe. The Regional DON stated they have no evidence Resident #26 would be determined unsafe and the facility should have a working bathtub to accommodate residents' preferences. 10NYCRR 415.5(b)(3)

Based on interview and record review conducted during a Complaint investigation (#NY00294631) during a Standard survey completed on 9/18/23, the facility did not ensure that the resident's representative was notified immediately of a change of condition for one of three residents (Resident #12) reviewed for notification of change. Specifically, Resident #12's representative was not notified of the resident's tooth pain, loose tooth, and the loss of the tooth that required treatment. The finding is: 1. Resident #12 was admitted to the facility with diagnosis of dementia and high blood pressure. The Minimum Data Set (MDS - a resident assessment tool) dated 8/18/23 documented Resident #12 was moderately cognitively impaired, understood by others, and understands others. The MDS documented that the resident did not have any oral or mouth issues. Review of the Resident #12's dental order and progress note dated 4/17/23 documented the resident's tooth (#18 - lower left quadrant second molar tooth) was loose and the resident had refused an extraction. The dental order and progress note documented the resident did not have any other tooth complaints. Review of the nursing progress notes for Resident #12 from 7/21/23 to 7/25/23 documented: 7/21/23 at 1:40 PM, Licensed Practical Nurse (LPN) #1 documented the resident complained of mouth pain and a loose tooth to the lower left side; given pain medication; nurse manager notified. 7/21/23 at 11:24 PM, LPN #8 documented that pain medication was given for complaints of oral pain with positive effect. 7/22/23 at 1:18 PM, LPN #1 documented that pain medication was given for oral pain with positive effect. 7/23/23 at 1:44 AM, LPN #2 documented the resident complained of mouth discomfort and a lower loose tooth, and pain medication was given. 7/23/23 at 12:40 PM, LPN #1 documented that pain medication given for lower left mouth pain with some relief; resident stated, tooth fell out yesterday and I threw out in the garbage; resident was noted with no signs or symptoms of bleeding. 7/23/23 at 5:07 PM, LPN #8 documented resident stated, I pulled my tooth out and threw it away. It was all rotten, no signs or symptoms of infection. 7/24/23 at 1:20 AM, LPN #2 documented resident did not complain of any mouth pain, no bleeding was noted. 7/24/23 at 1:51 PM, LPN #1 documented pain medication given for oral pain with relief. 7/24/23 at 2:48 PM, the Speech Pathologist documented that a referral was requested for Resident #12 for a swallowing evaluation for chewing and tooth removal; stated that resident pulled out tooth as it was loose; no issues with chewing or swallowing. 7/25/23 at 1:56 AM, LPN #2 documented the resident had no complaints of mouth pain. 7/25/23 at 1:56 PM, Registered Nurse (RN) Manager #1 documented that the resident stated they felt their tooth was loose, pulled it out, and threw it in the garbage; dental was in to see resident on 7/24/23. Review of a dental orders and a progress note for Resident #12 dated 7/24/23 documented that tooth #18 was exfoliated (removed) and there were no issues or mouth trauma. During an interview on 9/12/23 at 8:51 AM, the resident's Health Care Proxy (HCP) stated they visited the resident at the end of July 2023. The HCP stated that the resident complained about tooth pain. The HCP stated that they spoke with staff about the tooth pain. Staff reported to the HCP that they were aware of the tooth concern, and it was taken care of. During an interview on 9/14/23 at 9:03 AM, LPN #1 stated that it was the responsibility of the nurse manager to notify family or the resident's representative about any change in the resident's condition. LPN #1 stated they reported the tooth issue to the nurse manager but does not know if the nurse manager reported the tooth issue to the family. LPN #1 stated they would have documented in progress notes and that they would have told the family. During an interview on 9/15/23 at 12:16 PM, RN Nurse Manager #1 stated that themselves or the Nursing Supervisor would notify the family or the resident's responsible party. They stated they would expect their nurses to report any issues concerning the resident to themselves or the Nursing Supervisor immediately so the family could be notified. They stated they do not recall letting the family know about the resident's tooth. During an interview on 9/15/23 at 2:34 PM, the Director of Nursing (DON) stated they expected their nursing staff to notify family or the physician within 24 hours of any change in condition. The DON stated that if the issue occurred during the evening or night shift, they would expect their staff to notify the family or the physician by the next morning. The DON stated that the loose tooth could be an indication of an infection or possibly an accident that would make the tooth loose. The DON stated the floor nurse could have notified the family about the tooth issue and it doesn't have to be the nurse manager or supervisor to make the notification. The DON stated that they expect staff to document in progress notes that the family or responsible party was notified. During an interview on 9/15/23 at 2:44 PM, the Administrator stated that since the family was very involved with this resident that they should have been notified. During an interview on 9/18/23 at 9:43 AM, the Speech Pathologist stated that they saw the resident due to a tooth coming out. They stated that they don't recall speaking with the family or a responsible party. They stated if they did speak to a family member, they would have documented in their note. 10 NYCRR 415.3(f)(2)(ii)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 9/18/23, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (Resident #5) of one resident reviewed for activities. Specifically, Resident #5 was not provided accommodations for activities for an individual who was visually impaired. In addition, the facility did not develop an activities comprehensive person-centered care plan for Resident #5 to accommodate special needs related to visual impairment. The finding is: The policy & procedure (P/P) titled Activity Programs revised 3/30/2020, documented that activity programs are designed to meet the needs of each resident. The activities program is provided to support the well-being of residents and to encourage both independence and community interaction to support resident mental and emotional health. It also documents that adequate equipment will be provided to ensure the needed services identified in the resident's plan of care are met. The P/P titled Programming for Residents with Cognitive Impairments and Other Special Needs revised on 3/22/2020, documented that the Interdisciplinary Team (IDT) identifies each resident's physical challenges and needs (for example visual impairment) during the resident's assessment process. Residents with special needs are discussed with the IDT during care planning. The Activity Department coordinates care planning with nursing and other members of the IDT to develop an effective approach for meeting special activity needs of residents. 1. Resident #5 had diagnoses which included legal blindness, multiple sclerosis (a condition that effects the brain and spinal cord causing symptoms including, but not limited to, blurred vision, numbness, impairment of speech and severe fatigue) and paraplegia (paralysis of lower extremities). The Minimum Data Set (MDS) (a resident assessment tool) dated 6/27/23, documented Resident #5 was always understood, always understands and was cognitively intact. The MDS section labeled Preferences for Customary Routine Activities documented that it was somewhat important for Resident #5 to do things with groups of people and to do their favorite activities. Review of the undated and unsigned document titled Therapeutic Recreation Assessment documented that Resident #5 was blind, and actively participated in the assessment. The assessment documented that it was very important for Resident #5: to have books, newspapers, and magazines to read, and to do things with groups of people. Additionally, it was somewhat important to do their favorite activities. Review of the comprehensive care plan (CCP) dated 3/20/23, documented that the resident was legally blind. However, the section titled Diversional/Recreational, did not address the diagnosis of legal blindness. The CCP documented that Resident #5 required some support during activities/programs and documented a goal to identify and engage in activities of interest/choice. The interventions did not address the need for accommodations for the visually impaired. Review of the undated document titled Closet Care Plan revealed section 11, labeled Activities was blank. During an interview on 9/11/23 at 12:42 PM, Resident #5 stated that the facility did not provide enough activities for the blind. They had not been offered any [NAME] or audio, books, or magazines. Additionally, they stated that they had requested a [NAME] BINGO card about a month ago, and that the activities director was supposed to get them one. During intermittent observations between 9/11/23 and 9/15/23 between 8:30 AM and 1:00 PM Resident #5 was sitting in bed, listening to their TV. There were no activity materials, such as audiobooks or magazines, in the resident's room. The resident did not attend any activities during observation times. During an interview on 9/14/23 at 9:23 AM, Activities Aid #1 stated they thought Resident #5's roommate read them the activities calendar, but that they did let them know when there were activities. They stated that Resident #5 had not been out of their room to activities in a while. They could not recall an exact date. During an interview on 9/14/23 at 9:29 AM, Activities Aid #2 stated Resident #5 used to like to go to BINGO, and that someone would sit with them to play their card. They stated that Resident #5 had not been to activities in a while. They could not recall an exact date. During an interview on 9/14/23 at 9:36 AM, Resident #5 stated that staff did bring an activities calendar into their room, but that no one came in to read it to them or to tell them what activities were offered each day. They stated their roommate could not read the calendar to them because it was posted too far away from their bed. The activities calendar was posted on the wall approximately 10 feet from the roommate's bed. They stated it had been more than a month since they had attended any activities. During an interview on 9/15/23 at 8:23 AM, Resident #5 stated that no one from activities had ever come to read them daily chronicles and that they would be happy if the facility offered them any other activities for the blind such as audio books. They stated that they had a membership with the Library of Congress for the blind and visually impaired, but that there was an issue with their membership, and they needed assistance to set it back up. During an interview on 9/15/23 at 9:50 AM, the Director of Activities stated they were in the process of ordering a [NAME] BINGO card for Resident #5 but had not ordered it yet. They were also looking into other activities for the visually impaired. They stated that they had not requested that the facility provide these items but were planning to purchase them using money raised from fundraisers. The Director of Activities stated that Resident #5's care plan should list interventions to accommodate activities for the visually impaired. During the interview a review of the original attendance records dated May 2023 through September 2023 revealed the records were incomplete and mostly blank. During an interview on 9/15/23 at 9:55 PM, Licensed Practical Nurse (LPN) #7 stated they didn't think Resident #5 participated in any activities recently. During an interview on 9/15/23 at 1:35 PM, the Administrator stated that each resident had individual needs for activities, and that staff should figure out what each of them would like. They felt that the facility should provide accommodations for the visually impaired. 10NYCRR 415.5 (f)(1)(i)(II)

Based on observation, interview and record review conducted on a Standard survey completed 9/18/23, the facility did not ensure each resident be provided at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for three (Unit 1, Unit 2, and Unit 3) of three units. Specifically, resident meal trays were served up to 60 minutes after scheduled mealtimes. Residents' #1, 59, 61 and 75 were involved. The findings are: The undated policy and procedure titled Food and Nutrition Services documented it is the policy of the facility to ensure that facility staff supports the nutritional wellbeing of the residents while respecting an individual's right to make choices about his or her diet. Each resident will receive, and the facility will provide at least three meals daily at regular times comparable to normal mealtimes in the community, or in accordance with resident needs, preferences, requests, and plan of care. Review of the Facility Survey Report dated and signed 9/12/23 revealed the times meals were served in the facility as follows: Breakfast- 1st Floor 7:35 AM, 2nd Floor 7:40 AM, 3rd Floor 7:46 AM; Midday-1st Floor 12:00 PM, 2nd Floor 12:07 PM, 3rd Floor 12:13 PM; Evening Meal-1st Floor 5:35 PM, 2nd Floor 5:40 PM, 3rd Floor 5:45 PM. Review of the posted document titled Dietary Meal Times revealed Breakfast Start Time was 7:30 AM, Lunch Start Time was 11:45 AM, and Dinner Start Time was 5:30 PM. Review of the document titled Meal Times revealed Breakfast: 1st floor- 7:30 AM, 2nd floor- 7:45 AM, 3rd floor- 8:00 AM; Lunch: 1st floor- 11:45 PM, 2nd floor- 12:00 PM, 3rd floor- 12:15 PM. During a lunch meal observation on 9/11/23 the delivery time of food carts to the units were as followed: Unit 1 (first floor): food cart arrived at 12:20 PM Unit 2 (second floor): 1st food cart arrived at 12:33 PM, 2nd food cart arrived at 12:44 PM Unit 3 (third floor): 1st food cart arrived at 1:02 PM, 2nd food cart arrived at 1:15 PM During an interview on 9/11/23 at 3:09 PM, Resident #1 stated their food was always cold and the trays sometimes come up late. During a lunch tray line observation on 9/13/23 between 12:00 PM and 1:17 PM it was noted that the tray line was stopped three times between 12:51 PM and 1:13 PM as they were waiting for plates to be cleaned from previous carts as they had run out of them. The delivery time of food carts to the units were as followed: Unit 1 (first floor): food cart arrived at 12:11 PM Unit 2 (2nd floor): 1st food cart arrived at 12:27 PM, 2nd food cart arrived at 12:45 PM Unit 3 (third floor): 1st food cart arrived at 1:04 PM, 2nd food cart arrived at 1:20 PM During an observation on 9/15/23 at 9:18 AM the 2nd breakfast meal cart arrived on Unit 3 (third floor). During an interview on 9/15/23 at 11:29 AM, Resident #61 stated that their breakfast was really late this morning. They stated last night's dinner was even later and they did not get their meal tray until after 7:00 PM. They stated the meal trays were always late and really bothers them. Roommate Resident #59 agreed. During an observation in the main kitchen on 9/18/23 at 11:53 AM, there were two full breakfast carts still needing to be cleaned. At that time the [NAME] stated the breakfast tray line did not start until after 8:00 AM and that the trays went up late. They stated they could not start the lunch tray line because the food was still cooking, and they were still cleaning up after breakfast. They stated the breakfast tray line was late because when they came in there were no eggs for breakfast and they had to wait for the Director of Food Service (DFS) to buy and bring them some. During an interview on 9/18/23 at 12:19 PM, the DFS stated the breakfast meal was late this morning because many of the staff came in late leaving the cook the only one here. They stated there were no eggs for the breakfast meal and they had to run to the store to get some. They stated the cook over produced eggs this past weekend and did not inform them that they were out of eggs. They stated the lunch line was also late to start because they were still cleaning the breakfast trays. They stated the trays in general have been late because they have to stop the tray line several times each meal because they run out of plates and have to wash the ones from the first couple of carts, so they have enough for the rest of the meal. They stated when they had enough plates the tray line goes by very quick. They stated they were short of plates because the newly hired staff have been dropping them. They stated the Administrator was aware of the issue and has placed an order for more plates. They stated they expect the tray line to run on time because they were aware of the 14-hour regulation and if the trays were late, it could have an impact on the residents' care. They stated going by the start time of the meals listed on the document Dietary Meal Times, each cart should be done within a 15-minute interval. During a lunch tray line observation in the main kitchen on 9/18/23 at 12:43 PM the tray line had just started, and no carts had been delivered to any units. During an interview on 9/18/23 at 12:45 PM, Resident #75 was in their room and stated they were waiting for lunch, and it was very late today. They also stated they did not eat breakfast, as breakfast did not taste good, so they were getting very hungry. During an interview on 9/18/23 at 12:55 PM, Certified Nurse Aide (CNA) #3 stated when trays come late it makes the residents anxious as they have been up waiting for them. They stated it affects the care to the residents by not getting them back to bed to rest. During an interview on 9/18/23 at 12:57 PM, CNA #4 stated the trays sometimes come late. They stated that when they do come late, they are not able to do their jobs properly like being able to change residents after the meal. During an interview on 9/18/23 at 12:58 PM, Registered Nurse (RN) #2 Unit Manager stated the trays do come up late, but not this late. They stated a couple of residents have complained and when the trays come up late it makes them grumpy. During an interview on 9/18/23 at 12:58 PM, the Administrator stated they would expect meals to be served on time. 10 NYCRR 415.14(f)(1)

Based on interview and record review conducted during a Standard survey completed 9/18/23, the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Specifically, one of one facility reviewed for sufficient staffing did not have a full-time (working 35 or more hours a week) qualified Director of Food and Nutrition services. The finding is: Refer to F 804, F 809, and F 812 The undated policy and procedure (P&P) titled Food and Nutrition Services documented it is the policy of the facility to ensure that facility staff supports the nutritional wellbeing of the residents while respecting an individual's right to make choices about his or her diet. If a qualified dietitian or other clinically qualified nutrition professional is not employed full time, the facility must designate a person to serve as the director of food and nutrition services who for designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28 2016, is: (i) A certified dietary manager (CDM); or (ii) A certified food service manager (FSM); or (iii) Has similar national certification for food service management and safety from a national certifying body; or (iv) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning. Review of the undated job title Food Services Director revealed the purpose of the job position is to plan, organize, develop, and direct the overall operation of the Food Services department in accordance with established food services standards, policies, procedures, and practices of this facility and requirements of current federal, state and local standards governing the facility and as may be directed by the Administrator to assure that quality nutritional services are provided in a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner. Education & Qualifications is to be a graduate of an accredited course in dietetic training approved by the American Dietetic Association; must be registered as a Food Service Director in Pennsylvania; must provide documentation of registry/ certificate upon application for position. Review of the Facility Survey Report signed and dated 9/12/23 revealed the Dietitian was not the full-time dietetic service supervisor and the Director of Food Service (DFS) was listed as the full time dietetic service supervisor. Review of the Time Cards from 6/11/23 through 9/9/23 revealed the Registered Dietitian (RD) did not work full time. During an interview on 9/14/23 at 2:48 PM, the RD stated they do not work full time at the facility and that they work between 25 to 31 hours per week. During an interview on 9/14/23 at 2:49 PM, the DFS stated they were hired as the Director of Food Service for the facility this past May. They stated they have never worked in the position as the Director of Food Service, only as a Food Service Supervisor. They stated they do not have a certificate as a CDM or FSM. They stated they have an associate's or higher degree in food service management or in hospitality. They stated they understood the importance of the regulations of the Food Service Director position. During an interview on 9/18/23 at 9:32 AM, the Administrator stated the RD was available in the building a minimum of 20 hours/ week. They stated they thought the DFS was qualified for the position. The qualifications of the regulations were reviewed with the Administrator, and they stated the DFS was not qualified for the position per the regulations. They stated they were waiting for them to complete their 90 days at the facility before they invested in getting them registered. They stated the DFS has recently completed their 90 days and they will now be signing them up for the FSM certification and will be monitored by the RD. 10NYCRR 415.14(a)(1)

Based on observation, interview, and record review conducted during a Standard survey completed 9/18/23, the facility did not provide food and drink that were prepared by methods that conserved flavor, and appearance, were palatable and at a safe and appetizing temperature, for four (1st, 2nd, 3rd, and 4th floors) of four test trays. Specifically, food and beverages during meals were served at suboptimal temperatures and were not palatable. Residents #1, #5, #19, #34, #40, #55, #57, #77, #341, and #388 were involved. The findings are: The undated/unsigned document labeled Food and Nutrition Services documented it was the policy of the facility to ensure that staff support the nutritional wellbeing of the residents while respecting their right to make choices about their diet. In addition, it documented that the facility would provide each resident with a nourishing, palatable, well-balanced diet that met their nutritional and special dietary needs, taking into consideration the preferences of each resident. The policy and procedure (P&P) titled Food Preparation and Service dated 06/26/2018 documented that the danger zone for food temperatures is between 41 degrees (°) Fahrenheit (F) and 135°F. Therefore, foods must be maintained at 40°F or below or at 136°F or above. The policy further documented that the temperatures of foods held in steam tables will be monitored by food service staff. During an interview on 9/11/23 at 9:16 AM, Resident #34 stated the food was terrible. It was always cold and there was never enough. During an interview on 9/11/23 at 10:50 AM, Resident #77 stated the food was sometimes bland and overcooked, the portions were small, and it was not hot. During an interview on 9/11/23 at 10:57 AM, Resident #40 stated the food was bland and the hot foods were frequently cold. During an interview on 9/11/23 at 11:26 PM, Resident #55 stated they did not eat the food at the facility, unless it was a peanut butter and jelly sandwich. They stated that most of the meals were pre-cooked frozen foods, like chicken patties, and that kind of food was not good for them. During an interview on 9/11/23 at 12:53 PM, Resident #5 stated the pureed food was too watery, had no taste and was the consistency of throw-up. During an interview on 9/11/23 at 3:09 PM, Resident #1 stated the food was always cold and had too much rice and potatoes for their controlled carbohydrate diet. During a lunch meal tray line observation on 9/13/23, the unit carts left the kitchen at the following times: -1 [NAME] (1st floor) - 12:09 PM -2 [NAME] (2nd floor) -12:25 PM -2 East (2nd floor) -12:41 PM -3 East (3rd Floor)-12:59 PM -3 [NAME] (3rd floor) - 1:17 PM During a lunch meal observation on 9/13/23, the 1 [NAME] dietary cart arrived on the unit at 12:11 PM. Staff completed the tray pass at 12:18 PM. The tray was set up for a mechanical soft diet. The test tray temperatures were obtained at 12:20 PM with the Director of Activities using the facility's digital thermometer. The Director of Activities stated that hot food temperatures should be at 160 ºF. The results were as follows: -Mashed Potatoes 102.0 ºF, covered half of the plate, were runny and tasted watery, lukewarm, and bland -Mixed Vegetables 113.5 ºF, tasted bland with no salt or spices. -1% Milk 56.7 ºF, tasted warm and not very palatable -Drink of the day 57.9 ºF, tasted warm and grainy During an interview on 9/13/23 from 12:20 PM to 12:26 PM, the Director of Activities stated that the mashed potatoes could be thicker, and the vegetables were on the cooler side. During an interview on 9/13/23 at 12:20 PM, Resident #19 stated the bread in the facility tasted like plastic and the Beverage of the Day was watered-down. They further stated they liked whole milk and recently, the facility began pouring their milk into glasses, and they questioned whether the milk they received was whole milk. During interviews on 9/13/23 at 12:30 PM, Resident #341 and Resident #388 stated the mashed potatoes were too runny. During a lunch meal observation on the 2nd floor on 9/13/23 the first dietary cart arrived at 12:27 PM and the 2nd dietary cart arrived at 12:45 PM. All the meal trays from the dietary carts were passed to the residents by 12:58 PM. The test tray temperatures were then taken in the presence of the Activities Department Director, using the Activities Department Director's digital thermometer at 12:58 PM. The results were as follows: -Tuna fish sandwich, 71.4 °F, tasted bland, too warm, dry, and not enough tuna fish on the sandwich -Mashed potatoes, 104.5 °F, tasted bland, too cool, too thin (liquefied) and appeared unappetizing. -Mixed veggies, 106.7°F, tasted bland and too cool. -Beverage of the day, 58.1°F, tasted too warm and was unappetizing. -Milk, 55.4°F, tasted too warm and was unappetizing. During an interview on 9/13/23 at 12:59 PM, the Activities Department Directed stated they were working in the kitchen today supervising the kitchen. They stated the tuna fish sandwich was too warm and could make a resident sick because it is mayonnaise based. The mixed veggies and mashed potatoes were served too cool, and the food was not served within the appropriate temperatures. They stated they tasted the food while in the kitchen and the mashed potatoes were too runny, did not have any flavor and should not have been served. Additionally, they stated they believed there was not enough tuna fish on the sandwich. They stated they believed the sandwich had approximately half of the required 3 ounces of protein and the tuna fish looked dry, there was not enough mayonnaise on the bread causing it to be dry and bland, and the milk should have been served colder. During an interview on 9/13/23 at 1:34 PM, Resident #17 stated the tuna sandwich was bland and tasted dry, they stated they like mayonnaise on the tuna and the mashed potatoes were bland. During a lunch meal observation on the third-floor East Unit on 9/13/23, the dietary cart arrived at 1:04 PM. All the meal trays from the dietary cart were passed to the residents by 1:15 PM. The tray was set up for a regular diet. The test tray temperatures were then taken by the Surveyor, using the Surveyors digital thermometer at 1:17 PM with the Director of Activities present. The results were as follows: -Meatloaf 107.2°F, was dry hard, bland, and cold. -Mashed potatoes with gravy 103°F, were cold, watery, and tasted bland. -Mixed vegetables 96.3°F, were cold and lacked flavor. -Milk 59°F, tasted warm and unappetizing. -Lemonade 59°F, tasted warm and unappetizing. During an interview on 9/13/23 at 1:34 PM, Resident #57 stated that all the food was cold for lunch, they did not like the meat loaf because it had no taste. During an interview on 9/13/23 1:39 PM Resident #77 stated all the food for lunch was of poor taste and quality, salads were getting smaller and smaller every day and the food was always cold, like out of the refrigerator. During a lunch meal observation on the third-floor [NAME] Unit on 9/13/23, the dietary cart arrived at 1:20 PM. All the meal trays from the dietary cart were passed to the residents by 1:28 PM. The tray was set up for a pureed diet. Test tray temperatures were taken by the Director of Activities using the facility's digital thermometer at 1:29 PM. The results were as follows: -Meatloaf 122.3°F, tasted cool but well-seasoned (not pureed) -Mashed potatoes 122.3°F, runny, tasted cool & bland with noticeable pieces of parsley. -Pureed mixed vegetables 125.6°F were bland. -Pudding 61.7°F tasted warm and was unappetizing -Milk 59.9°F tasted warm and was unappetizing -Applesauce 61.3°F tasted warm and was unappetizing During an interview on 9/13/23 at 1:35 PM, the Director of Activities stated the food temperatures were not acceptable. They stated that hot foods should be served between 140°F - 150°F and cold foods should be served between 35°F - 45°F. During an interview on 9/13/23 at 3:10 PM, Resident #19 stated they received orange juice today as the Beverage of the Day at lunch and it was terrible. The mashed potatoes on their lunch tray were watery and the vegetables on their lunch tray were overcooked. During an observation on 9/15/23 at 9:21 AM, Resident #55 was offered their breakfast tray, they refused, and the aid put it back on the cart. During an interview on 9/15/23 at 9:37 AM, Resident #5 stated the food didn't taste good, so they were just going to drink their supplement shake. 10NYCRR 415.14 (d)(1)(2)

Based on observation, interview, and record review conducted during a Standard survey completed 9/18/23 the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues: floors throughout kitchen, walk in cooler, and dry storage room had debris build-up and/ or dark black substance along the perimeters/ corners, plexiglass in front of the steam table was soiled and cracked, outdated, undated, and/or unlabeled food items, multiple packages of bread products had a green mold like growth on them with outdated sell by date, multiple containers had small dead flies and/or black mold like spots on their lids/ sides, small metal racks and condenser in the walk-in cooler had copious amounts of thick dark black mold like build-up, walk-in cooler had a musty/ mildew smell, outside surface of reach-in cooler had a buildup of grease and food splatters, several crates/ boxes containing sherbet and ice cream were soft/ not frozen, ice build under the freezer condenser, multiple uncovered containers of dry food, one which was sitting directly on the floor. The dish room had a strong smell of sewage, and a large standing fan was used, blowing directly on the clean dishes. Multiple citing's of drain flies noted in dish room and throughout the kitchen. In addition, one (unit 1) of three nourishment stations had issues with expired thickened juices and no thermometer inside the fridge and temperature logs were incomplete. The findings are: The policy and procedure (P&P) titled Food Receiving and Storage dated 6/26/2018 documented that foods shall be received and stored in a manner that complies with safe food handling practices. Non-refrigerated foods will be stored in a designated dry storage unit which will be kept clean. Foods in dry storage areas shall be kept off the floor (at least 18 inches). All foods stored in the refrigerator will be covered, labeled, and dated. Foods in the freezer must be kept frozen solid, and all wrappers of frozen foods must stay intact until thawing. Additionally, food items and snacks kept on the nursing units must be stored below 41ºF (degrees Fahrenheit), refrigerators must have working thermometers and be monitored for temperatures and beverages must be dated when opened and discarded after twenty-four hours. The P&P titled Refrigerators and Freezers dated 2/27/2020 documented that a monthly log for daily fridge temperature checks will be posted to record temperatures for all refrigerators. All foods shall be appropriately dated to ensure proper rotation by expiration dates. That policy also documented that Environmental Service Department will inspect refrigerators and freezers monthly for presence of condensation and any other maintenance needs. Additionally, refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often if necessary. The P&P titled Sanitization dated 6/26/2018 documented kitchen wastes shall be kept in clean, tightly closed containers and shall be disposed of daily. Additionally, kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The P&P titled Pest Control dated May 2008 documented our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 1. During an observation of the main kitchen on 9/11/23 between 8:54 AM and 9:45 AM, the following was observed: Main kitchen area revealed: -Floor was soiled with dark debris along the perimeter and crumbled tiles under the three-compartment sink. -Large open garbage can full of outdated foods. -Shelf under the steam table was soiled with dark debris. -Plexiglass on steam table was soiled and cracked. -Multiple siting's of fruit flies flying around. Walk in Refrigerator contained: -A musty mildew smell. -A serving tray had an open container of thickener dated 8/10, open thickened prune juice dated 8/3 and an open thickened apple juice dated 8/24. Several dead small flies were on the tray and on the lids of the juices. -An 18-pound white plastic container of fruit salad had multiple little dead flies on the lid. - Thermometer hanging inside the fridge was covered in thick, sticky dark substance, and dead flies. Unable to determine the temperature through the substance. There were no temperature logs on outside of the fridge. - Four large metal racks holding the food and the condenser had copious amounts of thick, dark, fuzzy (mold like) debris build-up. -A serving tray on a shelf had approximately half inch of water on it with 2- 5-pound unopened packages of sliced American cheese sitting directly in the water. -Three packages of 6 English muffins dated 9/3/23 had fuzzy green (mold like) growth on them. -An opened half full gallon of chocolate milk was dated 9/10. -Floor of refrigerator was soiled with a dark, wet slippery substance. Reach in cooler contained: -A tray containing several undated cups of milk covered in plastic wrap. -Undated dish containing a 1 pound, half used, block of butter covered in plastic wrap. -Undated open bottle of ranch salad dressing. -The outside surface of the reach in cooler was soiled with splatters of dried food and debris. Handles were coated with dry food. Walk in Freezer contained: -An uncovered, open bag of potato nuggets and an uncovered open bag of sliced carrots, both undated. Both appeared to have frost on them. -Two full milk crates containing individual cups of orange sherbet that were soft to squeeze, not frozen, covered in frost, and a full box of individual cups of vanilla ice cream, also soft, not frozen and covered in frost. -Large chunks of ice buildup beneath condenser sitting directly on top of boxes of food. Dry storage room contained: -An undated, opened, gallon size zipper bag of white rice. -An undated, opened, 25-pound bag of all-purpose flour sitting directly on the floor. -Three packages of 8 rolls dated 9/11 with green fuzzy (mold like) growth on them. -One 6 pack of English muffins with green fuzzy (mold like) growth on them. -On a shelf with a used food service glove and a used Kleenex sitting next to dry food items. -Open, undated sugar free syrup with dead small flies on the lid. -Fruit flies flying around when door was first opened to the dry storage room. -The floor had large amounts of debris under the food racks in the corners and along the perimeter. During an interview on 9/11/23 at 9:52 AM, the Food Service Director (FSD) stated that foods should only be stored in the fridge for 3 days after opening. They stated that they have had an issue with drain flies in the dish room that had gotten into the fridge and storage room. They also stated that foods should never be left directly on the floor or left uncovered and open to the air. During an interview on 9/18/23 at 10:02 AM the Infection Preventionist (IP) stated all perishable foods should be inspected daily and any moldy or outdated foods should be thrown out. They stated that any food containers with dead flies on them should be thrown away immediately and pest control should be called. They also stated that all open food items should be covered, labeled, and dated, and never kept directly on the floor. The IP stated that the fan should not be blowing at the clean dishes because it would be blowing around airborne germs, therefore contaminating the clean dishes. They also stated that dietary staff should be cleaning the kitchen floors at least daily to prevent the spread of germs to other areas of the facility. 2. During an observation on 9/12/23 at 11:12 AM the Assistant Environmental Director was in the dish room with a shop vacuum sucking up the sewer back-up coming from the floor drain in the middle of the dish room. The dish room smelled of sewage. During an observation of the dish room on 9/13/23 at 12:32 PM there was still a strong smell of sewage and multiple sewer flies flying around. There was a large standing, upright fan approximately 5 to 6 feet away from the dish machine blowing directly on the clean dishes. During an observation of the dish room on 9/14/23 at 8:44 AM, the large standing upright fan was still approximately 5 to 6 feet away from the dish machine and was blowing directly on the clean dishes that were coming out of the machine. The dish room had a strong smell of sewage. Sewer flies/drain were flying around on the dirty side of the dish room. During an interview on 9/13/23 at 11:13 AM, the Director of Food Service (DFS) stated the smell of sewage was coming from under the tiles because when the garbage disposal backs up and sewage comes out of the drain it seeps under the tile. They stated the tiles/ floor needs to be replaced and they have put a request in and have been working with the Administrator to get a new floor put in the dish room. In addition, they stated because the floor was always wet in the dish room and with the summer humidity this was why they had so many sewer flies. They stated bleach was dumped down the drains to help prevent growth of the sewer flies. They stated they have had pest services come in for the sewer flies but could not remember the last time. On 9/14/23 at 2:52 PM, the DFS stated when staff was not paying attention with what they were dumping off the tray, things like utensils or creamer containers will go into the disposal which clogs the pipe underneath the disposable. They stated the smell in the dish room had recently gotten worse and they felt it was due to the wet floor and water getting under the broken floor tiles. They stated that the large fan was being used because the smaller, wall fan was not working. They stated that the fan should not be aimed at the clean dishes because it was blowing dirt and dust directly on to the clean wet dishes. They stated the fan should be blowing towards the dirty side underneath towards the disposal. During an interview on 9/15/23 at 8:07 AM, the Assistant Environmental Director stated the garbage disposal became backed up and they were trying to clear it but was unable to. They stated the plumber was then called in and they had to snake the drain. They stated they were using the dry vac to suck up the sewage that was coming up through the floor pipe. They stated they have come down before to try to dislodge whatever was stuck and that the garbage disposal, they have was small. Review of pest control services Service Inspection Reports work dates 8/7/23 and 8/21/23 revealed under general comments: bi-weekly drain service-inspect and treat all drains in the kitchen, basement, and maintenance areas. Replace glue boards in all insect light traps and document activities. Drains in kitchen were serviced drain fly activity noted. Reviewed 7/10/23 condition: standing water in dish room area which can provide a great nesting site for small flies. Dry and clean tile and have a fan plugged in under the sink to ensure floor was always dry. Food debris in disposal-food build up in disposal are providing great food source for fruit flies. Clean disposal and empty frequently. On 7/13/23 accumulated debris around pipes and in floor tiles in kitchen. 3. During an observation on 9/11/23 at 11:46 AM the nourishment kitchen/dining area of Unit 1 revealed: -The fridge for resident use and dining supplies contained one partial 2-quart carton of thickened apple juice concentrate dated as received on 7/16/23 and opened on 8/29/23. The directions on the carton stated to discard after opened for 7 days. Additionally, there was one partial half gallon bottle of prune juice dated as having been opened on 8/29/23 and a partial 2-quart carton of prune juice dated as having been opened on 8/3/23. -There was no thermometer in the fridge and the facility's Cooler/Freezer/Temperature Log affixed to the side of the fridge had not been completed since 8/6/23. During an interview on 9/12/23 at 8:34 AM, Licensed Practical Nurse (LPN #4) stated that it was dining staff's responsibility to clean the nourishment fridge and remove outdated items, but that nursing staff kept an eye on the fridge and its contents, as well. When asked how nursing staff determined what items should be removed from the fridge, LPN #4 stated that they go by an item's expiration date. After reading the instructions on the container that stated to discard 7 days after opening, LPN #4 discarded both prune juice containers and the thickened apple juice. During an interview on 9/12/23 at 8:42 AM, the FSD stated that technically dietary staff was responsible for the nourishment fridge monitoring and stocking. The FSD searched the fridge for a thermometer and did not locate one in the fridge. They stated clearly, there was no thermometer in the fridge. The FSD stated that food can go bad, when not properly monitored and that mold can grow, and it was not healthy to give residents bad food. Residents can get sick. The FSD also stated that the responsible nourishment person from dietary was expected to conduct a three-day-check. Items delivered to the unit fridge were to be removed and discarded on day three after having been placed in the unit nourishment fridge. Dietary staff assigned to the nourishment fridges was expected to make daily rounds to all unit nourishment fridges. During an interview on 9/13/23 at 3:08 PM, The Registered Dietician (RD) stated that if food temperatures in nourishment fridges were not monitored and corrected as needed, a food safety issue could occur. Juice products in nourishment fridges should be discarded three days after opening, if they were poured for residents by staff, and thickened liquid products should be discarded five days after opening. If items past these dates were to be served to residents, food borne illnesses could be caused. During an interview on 9/8/23 at 10:02 AM, The IP stated that nourishment fridges must maintain the required temperatures and temperatures must be monitored on the temperature log daily. If the temperatures were found to not be at the appropriate levels, this could indicate the fridge is not working and food could go bad. The IP stated that they expect dietary staff to maintain the food in nourishment fridges on the facility units and dietary staff should throw out expired foods and should be dating foods when they first open them. 10 NYCRR 415.14(h) 14-1.43(d)(e), 14-1.85, 14-1.110(d), 14-1.130, 14-1.150(b), 14-1.160

Based on interview and record review conducted during a Standard survey completed on 9/18/23, it was determined that the facility did not ensure maintenance of an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for one of one facility water management systems. Specifically, water samples that tested positive for Legionella was not reported to the New York State Department of Health (NYS DOH) and institute short-term control measures when control measures were not met. Additionally, staff that administered the facility's Potable Water Sampling and Management Plan did not notify the facility Infection Preventionist of the positive Legionella water sample results. The findings are: 1. The policy and procedure P&P titled, Legionella Water Management Program dated 12/01/2017, it documented that the purpose of the water management program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. Further review of the P&P, it documented that The Water Management Program will be reviewed at least once a year or sooner if any of the following occur including the control limits are not met. The P&P titled, Identify and/or Prevent Nosocomial Legionnaire's Disease dated 12/01/2017, it documented that when suspected or confirmed cases of Legionella's, the NYSDOH and the local health department are to be notified for follow up surveillance and recommendations including assessment of potable water systems, current water treatment and maintenance. New York State Title 10, Subpart 4-2, Appendix 4-B, documented with the percentage of positive Legionella test sites is equal or greater than 30%, the facility must immediately institute short-term control measures in accordance with the direction of a qualified professional and notify the department. Short term measures may include, but not limited to, heating and flushing the water system; hyperchlorination (temporarily increase the free chlorine residual in the water distribution system); or the temporary installation of copper silver ionization (a process that destroys the biofilms on the Legionella bacteria). Additionally, the water system shall be re-sampled no sooner that seven days and no later than four weeks after disinfection to determine the efficacy of the treatment. Review of a Legionella bacteria laboratory testing results dated 3/9/23 documented that eight of the eight water samples (100% positivity rate) tested positive for the Legionella pneumophila (sero 2-14) bacteria. During an interview on 9/13/23 at 10:12 AM with the Environmental Director (ED), they stated that they the potable water is tested annually in the facility and the last test was done in March of 2023. They stated that they reported to the Administrator the Legionella positivity results and the Administrator is responsible to report the positive results to the NYS DOH. They stated that they gave a copy of the results to the Administrator who signed them. They stated that they were not aware that they had to do preventative measures for Legionella positive water or run another water sample test for Legionella. During an interview on 9/13/23 at 10:25 AM with the Infection Preventionist (IP), they stated that they were not aware of the positive Legionella water sample tests from March 2023. The IP stated expected the Environmental Director to report any positive Legionella water tests to them and the Administrator. The IP also stated that they would also notify the NYS DOH and ask for direction if needed. The IP stated that if there was an uptick in any respiratory symptoms in the residents, they would expect the nurses to report to themselves or the doctor. The IP stated that they had residents who exhibited any respiratory symptoms were tested for Legionella. The IP stated they would also report any infections to the NYS DOH. During an interview on 9/13/23 at 10:40 AM with the Director of Nursing (DON), they stated that they were not aware of the positive Legionella water sample tests from March 2023. The DON stated that they would expect the Environmental Director to report any positive Legionella water tests to themselves, IP, and the Administrator. The DON stated that they would report the results to the NYS DOH and ask for directions. The DON stated they would have residents monitored for any respiratory symptoms, report those symptoms to the physicians, and do any testing for Legionella as needed. The DON stated that they would work with the IP on monitoring residents for symptoms. During an interview on 9/13/23 at 12:50 PM with the Administrator, they stated that they do recall having a conversation with the Environmental Director concerning the positive Legionella test results in March of 2023. They stated they don't recall seeing the actual positive Legionella water sample report. They stated that they believed at the time the Environmental Director is the person responsible for initiating corrective actions. They stated that they should have reported the positive water results to the NYS DOH and ask for directions related to the positive Legionella results. 2. The policy and procedure called, Identify and/ or Prevent Nosocomial Legionnaires Disease, revised by the current Administrator and Medical Director on 3/28/23, documented the facility will adhere to all necessary maintenance and operational requirements of the water system and comply with all applicable regulations. Where Legionella culture sampling results are at least 30% positive for a representative number of sampling points, the facility will immediately notify the Department (NYS DOH) and institute short term control measures. The facility will follow directions of the NYS DOH in control measures and/ or decontamination for any positive environmental samples. New York State Title 10 Subpart 4-2, Appendix 4-B, documented when the percentage of positive Legionella test sites is equal to or greater than 30%, the facility must immediately institute short-term control measures in accordance with the direction of a qualified professional and notify the department. Short-term measures may include, but are not limited to, heating and flushing the water system, hyperchlorination (temporarily increase the free chlorine residual in a water distribution system, or the temporary installation of treatment such as copper silver ionization (a process that destroys biofilms that can harbor Legionella). Additionally, the water system shall be re-sampled no sooner than seven days and no later than four weeks after disinfection to determine the efficacy of the treatment. Review of the facility's Legionella sampling records revealed eight water samples were collected from the facility on 2/27/23 and the outside contracted laboratory report dated 3/9/23 revealed all eight water samples (100%) tested positive for Legionella. During an interview on 9/12/23 at 12:40 PM, the Environmental Director stated they called the outside contracted laboratory for results in March 2023 and the lab representative said the water samples were all a little high, but within specifications. The Environmental Director stated they received the written report from the lab and gave a copy of it to the Administrator at that time. They stated they did not perform any follow-up action on the water system and did not discuss the results with the facility's Infection Preventionist. The Environmental Director also stated they were not aware of the regulation to report positive samples above 30% to the NYS DOH and were not aware of the additional requirement to institute control measures on the water system. During an interview on 9/12/23 at 12:44 PM, the Regional Plant Operations Director stated they were not aware that the water samples tested positive for Legionella in March 2023, as they were not the Regional Director at that time. The Regional Plant Operations Director stated the procedure for greater than 30% positive water samples were to notify the Administrator, who will report the positives to the NYS DOH, consult the facility's water management plan, and then perform follow-up actions as advised by the NYS DOH. During a telephone interview on 9/12/23 at 12:50 PM, a representative from the outside contracted laboratory stated all of the facility's water samples came back with low levels of Legionella in March 2023, which could indicate a systemic issue. 10 NYCRR 415.19(a)(1)

Based on interview, observation, and record review conducted during a complaint investigation (#NY00309036) completed on 1/24/22, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the appropriate officials (including the State Survey Agency) for one (Resident #1) of three residents reviewed. Specifically Resident #1 was involved in an alleged staff-to-resident altercation which was not reported to the New York State (NYS) Department of Health (DOH) as required. The finding is: The policy and procedure (P/P) titled Abuse, Neglect and Exploitation of Residents with a revised date 2/17/22 documented that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation and misappropriation of property. Residents will not be subject to abuse by anyone, including but not limited to, staff, other residents, consultants, volunteers, contractors, and staff from other agencies, family members, legal guardians, resident representative, friends, or other individuals. Federal Regulation (42 CFR 483.13) requires the reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the department of health immediately, but no later than 2 hours after allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. The P/P titled Abuse Reporting with a revised date 2/28/22 Federal Regulation (42 CFR 483.13) requires the reporting of all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the department of health immediately, but no later than 2 hours after allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. 1. Resident #1 had diagnoses including type 2 diabetes mellitus (DM), bipolar disorder, and anxiety disorder. The Minimum Data Set (MDS- a resident assessment tool) dated 10/28/22 documented Resident #1 was understood, understands and cognitively intact. Review of the Careplan Report printed on 1/24/2023 revealed Resident #1 was care planned for disruptive behavior as evidenced by dated 12/24/22 yelling and cursing loudly from room, making false accusations that staff caused scratch under eye- resident was observed scratching area themselves. Review of interventions dated 12/24/22 include educate resident on importance of telling the truth and refer to Psych. Intervention dated 12/29/22, offer room change. During an observation and interview on 1/24/23 at 10:00 AM Resident #1 was lying in their bed playing on an electronic tablet. Resident #1 stated that on Friday, 12/23/22 during the evening/night shift into Saturday 12/24/22, Registered Nurse (RN) #2, 2nd floor Unit Manager (UM) came into their room to answer the call light. Resident #1 stated they asked for the bed pan and was told by RN #2 UM that because of the blizzard they were the only staff member on the unit and that there wasn't anyone that could put the resident on the toilet and then RN #2 UM just left the room. Resident #1 stated they then put the call light back on. RN #2 UM came back into the room and ripped the call light out of the resident's hand and placed it on the floor, took the electronic tablet away from the resident, placed it on the dresser across from their bed and left, closing the door behind them. Resident #1 stated that at that time they begin to cry and was scared because they had no way of communicating with anyone if something where to happen. After about 30-60 minutes later RN #2 UM came back into the room and gave them the call light back. Resident #1 stated they then asked for the electronic tablet back and RN #2 UM picked it up from the dresser and threw it at them, hitting the resident's right eye. Resident #1 stated there was no other staff in the room at the time of the incident. Their roommate was cognitively impaired and would not be able to tell anyone what had happened. Resident stated they reported it to the Administrator and the Social Worker. The resident stated the Social Worker and Administrator came to their room that weekend either Saturday 12/24/22 or Sunday 12/25/22 but could not remember exactly which day. The resident stated the SW said, they had a bed for them on the third floor, unless you want to take back your statement. The resident stated the Administrator was trying to convince the resident that maybe RN #2 UM did not mean to do it. They both were saying that I had scratched my own eye and that I was making up this incident and it never happened. Resident #1 stated they were moved from the 2nd floor to the 3rd floor so that they would not have to see RN #2 UM. Resident # 1 stated if RN #2 UM can do this to me and am capable of reporting it, what is going to stop them from doing this to someone else who cannot speak for themselves. The untitled investigation report dated 12/26/22 re: Resident #1's allegation of abuse completed and signed by the Administrator documented this writer was informed on 12/25/22. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Facility Summary between 12/23/22 and 1/24/23 revealed there was no report from the facility filed regarding the allegation of physical abuse for Resident #1. During an interview on 1/24/23 at 11:36 AM, the Director of Social Work (SW) stated on the morning of 12/25/22 they went into Resident #1's room to talk to them regarding accusations that they were making to some of the aides that a unit manager threw a tablet at them and hit them in the eye. The SW stated Resident #1 had a tendency to make up stories and false accusations and behave like a five-year-old when they do not get what they want. The resident's right eye appeared to have had a scratch under it. I then went and spoke to RN #2 UM and was told they had gone into the resident's room and put them on the bed pan and then took them off and then just put the tablet on the bed. They stated later, with the Administrator, they went back into the resident's room to speak with Resident #1 and at that time told the resident to be truthful. The resident then retracted their story which seems to be common for them. To protect the resident and the staff we thought we would possibly change the resident's room to a different unit which the resident agreed to. I believe the incident was reported to the NYS DOH by the Administrator. During an interview on 1/24/23 at 11:56 AM, the Administrator stated they did not report the allegation of abuse for Resident #1 to the NYS DOH as it was concluded that if it happened, it was by accident with no intent. During an interview on 1/24/23 at 2:13 PM, the Director of Nursing (DON) stated that if there was any indication of resident abuse, neglect, mistreatment it should be reported within two hours of the allegation to the NYS DOH. I would absolutely consider this allegation abuse and it should have been reported. 10 NYCRR 415.4(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review during a complaint investigation (NY00309036) completed on 1/24/23, the facility in response to allegations of abuse, did not have evidence that all alleged violations of abuse were thoroughly investigated and prevent further potential abuse while the investigation was in progress for one (Resident #1) of three residents reviewed. Specifically, there was a lack of a thorough investigation to include nursing assessments/ accident and incident report, interviews with staff and other potential victims into alleged physical abuse by a Registered Nurse (RN) #2 Unit Manager (UM). In addition, the facility allowed the accused RN #2 access to the alleged victim and to continue to work on the same unit as Resident #1 while the investigation was being conducted. The findings are: The policy and procedure (P/P) titled Abuse, Neglect and Exploitation of Residents with revised date of 2/17/22 documented each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation, and misappropriation of property. Residents will not be subject to abuse by anyone. Upon receiving reports of physical or sexual abuse involving an employee the Director of Nursing (DON)/designee will remove the employee from the premises until the investigation is completed. Upon receiving reports of physical and sexual abuse the DON/designee shall immediately examine the resident with findings recorded in the resident's record. The Administrator/DON is responsible to receive and investigate all alleged violations timely, thoroughly, and objectively. The P/P titled Accidents and Incidents-Investigating and Reporting with revised date of 12/10/21 documented all incidents involving a resident shall be documented on the Incident/ Accident Reporting and Investigation Form at the time of the incident. A thorough complete and accurate investigation will be conducted, and safeguard interventions instituted to keep residents safe and prevent reoccurrence. The Nurse Supervisor will complete a Report of Incident/ Accident form and submit original to the DON within twenty-four hours of the incident or accident. An incident/ accident report will be completed per facility policies and procedures for resident abuse, neglect, exploitation, mistreatment, injury, and misappropriation of resident's property. 1. Resident #1 had diagnoses including type 2 diabetes mellitus (DM), bipolar disorder, and anxiety disorder. The Minimum Data Set (MDS- a resident assessment tool) dated 10/28/22 documented Resident #1 was understood, understands and cognitively intact. The Careplan Report printed on 1/24/2023 documented Resident #1 was care planned for disruptive behavior as evidenced by dated 12/24/22 yelling and cursing loudly from room, making false accusations that staff caused scratch under eye- resident was observed scratching area themselves. Interventions dated 12/24/22 included to educate resident on importance of telling the truth and refer to Psych. Intervention dated 12/29/22, offer room change. During an observation and interview on 1/24/23 at 10:00 AM Resident #1 was lying in their bed using an electronic tablet. They appeared relaxed and comfortable. Resident #1 stated that on Friday, 12/23/22 during the evening/night shift into Saturday 12/24/22, Registered Nurse (RN) #2, Unit Manager (UM) 2nd floor came into residents' room to answer the call light. The resident asked for the bed pan and was told by RN #2 UM that because of the blizzard they were the only staff member on the unit and that there wasn't anyone that could put the resident on the toilet and then RN #2 UM just left the room. Resident #1 stated they then put the call light back on. RN #2 UM came back into the room and ripped the call light out of the resident's hand and placed it on the floor and took the electronic tablet away from the resident and placed it on the dresser across from their bed and left, closing the door behind them. Resident #1 stated at that time they begin to cry and was scared because they had no way of communicating with anyone. After about 30-60 minutes later RN #2 UM came back into the room and gave them the call light back. Resident #1 stated they then asked for the electronic tablet back and RN #2 UM picked it up from the dresser and threw it at them, hitting the resident's right eye. Resident #1 stated there was no other staff in the room at the time of the incident. Their roommate was cognitively impaired and would not be able to tell anyone what had happened. Resident #1 stated they reported it to the Administrator and the Director of Social Work. The resident stated the Social Worker and Administrator came to their room that weekend either Saturday 12/24/22 or Sunday 12/25/22 but could not remember exactly which day. The resident stated the SW said, they had a bed for them on the third floor, unless you want to take back your statement. The resident stated the Administrator was trying to convince the resident that maybe RN #2 UM did not mean to do it. They both were saying that I had scratched my own eye and that I was making up this incident and it never happened. Resident stated they were moved from the 2nd floor to the 3rd floor so that they would not have to see RN #2 UM. Resident #1 stated they feel safe on the 3rd floor and that they do not see RN #2, UM. Resident #1 stated, if RN #2 UM can do this to me and am capable of reporting it, what is going to stop them from doing this to someone else who cannot speak for themselves. a.) Review of The Note dated 12/24/22 at 2:21 AM completed by RN #2 UM revealed resident can be heard at nurses' station yelling. Went to room. Resident #1 screaming, they needed the bed pan. Resident placed on bed pan. Explained to resident they do not have the right to disturb their roommate or other residents on the unit. By screaming and yelling unnecessarily. Resident was taken off the bed pan. All requested items within reach. Review of the untitled investigation report dated 12/26/22 re: Resident #1 completed and signed by the Administrator revealed under incident, this writer was informed on 12/25/22 and with the Social Worker, we went to interview Resident #1 after breakfast. Unknown to me was resident posted on a social media website, made multiple calls, each time the story kept changing. This particular incident was Resident #1 never stated they were hit, mistreated or during the blizzard and facility was critically staffed due to no one being able to drive. The RN #2 UM was providing care. When the SW and I interviewed the resident, they were vague at best. Resident motioned to a spot on their cheek by the eye. This writer had noticed this spot several days prior. It looked like a scratch. At no time did resident state they were abused, mistreated, or neglected. I proceeded to inform them of the procedure when submitting a complaint and that an investigation would begin, and they indicated they were not making a complaint to myself and the SW. At this time, I did not know they had placed it on a social media cite. Had I known it, I would have written a formal complaint to protect the RN #2 UM. This resident does not profile as a potential [NAME] adult. They are alert and oriented. This resident keeps the facility I Pad (tablet) in bed with them at all times. If the tablet fell it was purely by accident and when the covers were placed back on the resident, and it accidentally grazed their cheek. This resident is care planned to have two care givers at all times due to false and malicious statements they make regarding staff. This resident is verbally abusive towards staff and other residents. When resident is held accountable, they usually respond by calling the police or deflecting about their parents' death. They are non-compliant with diet and meds. They make appointments and then cancels. Resident is inappropriate unless things go their way. They are care planned for yelling, fabrications as they told this writer and the SW that the tablet was the last thing their mother gave them. It is actually the facility I Pad. Facility had physician look at scratch and noted nothing unusual. Conclusion- due to the apparent mental health of this resident and our necessity to protect the staff in regard to false and malicious statements, this writer determined that this resident needed to be moved to another floor. This has been the intervention in the past for their best interest as well as the staff on the unit. I do not know if due to it being Christmas or knowing the blizzard created staffing challenges. The resident chooses to be bed bound and remain in a nursing home. They could with assistance live in the community. Why the resident chooses to remain at a nursing home at age [AGE] is beyond my understanding. The RN #2 UM treats the resident like an adult they are. They are not treated as a victim. The resident does not like to be held accountable and retaliates when they are held accountable. If this did occur the tablet scratching the resident it was purely accidental. There was no intent or harm indicated by the interview with the RN #2 UM. We will approach resident again about relocating. This writer and the SW spoke with resident on December 25, 2022, about future relocation. After discussion with the clinical team, it was decided that resident would move off Unit 2 to protect the RN #2 UM as well as giving the resident a fresh start on a new unit. There is no abuse, mistreatment, or neglect at the conclusion of this investigation. On the bottom of the statement, it was handwritten moved 12/30/22. Review of the statement dated 12/30/22 signed by RN #2 UM revealed during the evening of Saturday 12/24/22 it was brought to my attention by RN #1 UM/Assistant Director of Nursing (ADON), that Resident #1 had made a social media post claiming that I had thrown a tablet at them in the face. Prior to this I had provided care to the resident multiple times throughout the night of 12/23/22 and the day of 12/24/22 due to staffing shortage because of the weather crisis. At one point on 12/23/22, I had to ask the resident to stop screaming because I was not responding to their call light fast enough as I was providing care to other residents. After toileting the resident, we went on to have a conversation led by the resident about still mourning the loss of their parents and getting into a therapy program. I toileted the resident again around 11:30 PM. Changed their brief and linens. Made sure all requested items, including tablet, call light, bed remote, and fan were within reach. I had no further contact with the resident until the morning of 12/24/22 when I was passing medications, at which time the resident stated, I'm sorry for being such a explicit word to you to which I responded okay. Once I was made aware of the allegations, RN #1 UM/ ADON and myself brought it to the attention of the Administrator and I made sure to have no contact with the resident without a witness in the room with me. Review of an e-mail found in the investigation file/folder dated 12/30/22, addressed to the Administrator from RN #3 UM regarding Resident #1 revealed at approximately 1:00 AM on Friday (12/23/22) into Saturday (12/24/22) I received a call at the 3rd floor nurse's station. The person on the other end was whispering and at first, I couldn't make out what they were saying. I kept telling them to speak up so that I could hear what they were saying to me. They then said they were afraid and when I asked who this was and what they were afraid of they just saying that they were afraid. I asked them again what they were afraid of, and they replied they hit me. At that point I recognized the voice of Resident #1. I then said who hit you and they replied never mind and hung up. Review of the investigation file/folder revealed there were no interviews conducted with other residents RN #2 had contact with or staff that were on the day of the incident. Review of the entire medical record from 12/1/22 through 1/23/23 revealed there was no documented RN Assessment regarding the allegation of physical abuse reported on 12/25/22 for Resident #1. Review of the entire medical record from 12/1/22 through 1/23/23 revealed there was no Accident and Incident (A&I) Report regarding the bruise under Resident #1's right eye. The Note dated 12/27/22 at 12:38 PM completed by the Director of Social Services documented a late entry for 12/24/22, Resident #1 continues with behaviors of falsifying statements and making accusations. Resident has been observed picking at their face near the eye which now has a scab. Resident is argumentative to nursing staff. Resident falsely accused a staff member of causing scratch near the eye. Resident has attention seeking behaviors. Administrator and this writer spoke at length with resident about the importance of working with staff in order for resident to achieve their goal of returning to the community. Resident often uses their past life experiences and medical conditions as a crutch not to participate in activities of daily living (ADLs) and therapies. Resident was also encouraged from making false accusations. Review of the Physician Progress Note dated 12/28/22 revealed reason for appointment smoke exposure, facial scratch, and PTSD (post-traumatic stress disorder)/anxiety. Patient has a small area below the right eye but denies any pain, change in vision, headache, or dizziness. The Note dated 12/29/22 at 3:31 PM completed by the Director of Social Services documented it was reported to this writer that the resident continues telling staff members that a staff member caused a scratch to their face near their eye. Explained to resident that a room change was needed and gave the option of moving to two different rooms. Resident chose and will be moved on 12/30/22. b.) Review of the Time Cards dated 12/18/22 to 12/24/22 and 12/25/22 to 12/31/22 revealed RN #2 UM was clocked in from 12/23/22 at 9:00 AM through 12/25/22 at 5:10 PM and 12/29/22 from 8:50 AM to 10:29 PM and 12/30/22 from 9:13 AM to 4:11 PM. During an interview on 1/24/23 at 10:26 AM, RN #3 UM stated Resident #1 came up from another unit with a slight mark/discoloration under the right eye. The resident stated they called for the bed pan and the person came in the room and tossed the tablet at them and hit them in the face. I did mention it to the Administrator, but by then I believe the resident had reported it to everyone. RN #3 UM then stated, I do know when this happened, but it was during the storm (12/23/22-12/25/22), the resident called up here and stated they were afraid and that someone hit them. When I further asked questions the resident stated, never mind and hung up the phone. I directly reported this to RN #1 UM/ADON and was told that the resident had spoken to them as well. I knew at that time that the resident wasn't in danger as there was only one person down there on the unit, RN #2 UM. During an interview on 1/24/23 at 10:36 AM, Certified Nurse Aide (CNA) #1 stated Resident #1 had a bruised eye when they moved to their unit. CNA #1 stated they reported it immediately to RN #3 UM. During an interview on 1/24/23 at 10:43 AM, RN #1 UM/ADON stated they were never told that the resident made accusations of being hit or that they were scared. They stated they saw on a social media website that Resident #1 had posted a picture of themselves with the bruised eye and implying that RN #2 UM did something to cause the bruise. They then stated they immediately reported it to the Administrator but did not know the specific day this all occurred, it was either 12/25/22 or 12/26/22. RN #1 UM/ ADON stated they did go and speak to the resident after they saw it on social media, but the resident stated they did not want to get RN #2 UM in trouble. RN #1 UM/ADON stated they noticed the resident had a scratch/ redness under their right eye and that Resident #1 and RN #2 UM had a love/ hate relationship. During an interview on 1/24/23 at 11:36 AM, the Director of SW stated on the morning of 12/25/22 they went into Resident #1's room to talk to them regarding accusations that they were making to some of the aides that a certain Unit Manager threw a tablet at them and hit them in the eye. The SW stated they spoke with RN #2. The Director of SW stated, I would normally speak to other residents, but didn't as the resident would often make false accusations and that they have been refusing their medications and to see mental health. During an interview on 1/24/23 at 11:56 AM, the Administrator stated they were told by RN #1/ ADON to come up to the unit to speak with Resident #1 as the resident was implying that something happened when rounds were completed on them. The Administrator and the SW (director) went into Resident #1's room and stated to the resident they were going to initiate a formal investigation and at that time the resident stated to them I am not making a complaint. They stated that Resident #1 never uttered the words that the RN #2 UM intentionally hit them with the tablet in the face. The Administrator stated the resident did have a spot on her right eye but stated I saw that mark on their face earlier in the week and that is why I figured there was no abuse. The Administrator then was approached later by RN #1, ADON showing them that the resident posted a picture of themselves on a social media website implying that something happened to them when rounds were completed. After that with the SW, they both went and spoke to Resident #1 about the incident. The resident was implying that RN #2 UM threw the tablet at them, and the tablet hit them in the eye. The Administrator stated, No, I did not think it was abuse because this resident makes false accusations, and I would think they would have been more articulate and would not have told me they were not filing a complaint earlier. The RN #2 UM was not sent home during the investigation but went home either 12/25/22 or 12/26/22 evening and was not back to work again until we met as a clinical team. The Administrator stated they would normally interview other staff who are on at the time of the incident but did not interview any other staff because RN #2 UM was the only staff member up on that unit and there were not many staff in the building because of the storm. During an interview on 1/24/23 at 12:24 PM, RN #2 UM stated that nothing happened between Resident #1 and them and that they were on that unit by themselves due staffing shortage because of the storm. They stated that Resident #1 was on the call bell a lot the night of 12/23/22. RN #2 UM stated they explained to the resident that they were the only staff on the unit. RN #2 UM stated they provided care to the resident around 10 PM, Friday night 12/23/22. The next day RN #2 UM stated they found out from RN #1 UM/ADON that Resident #1 posted something on social media implying RN #2 UM had caused a bruise to their eye. RN #1 UM/ADON and I went and spoke to Resident #1 about the post on social media. They stated they did continue to work on the unit until the evening of 12/25/22, was then off for a few days and came back on 12/29/22. They stated when they came back the resident was still on the unit and was moved the next day. During an interview on 1/24/23 at 2:13 PM, the Director of Nursing (DON) there was no A&I completed regarding the bruising of the right eye and there should have been. They would have expected would expected an RN assessment to be completed, thorough interviewing with the Resident, resident's roommate, other residents, and other staff members. During a telephone interview on 1/24/23 at 3:35 PM, the Physician (MD) stated Resident #1 had a small area/ bruise under their right eye. When they asked the resident where they got it from, they blamed one of the staff members there at the facility. The MD stated they checked with other staff about this and was told the resident has been telling everyone this. I told them they needed to move the resident as they cannot stay on this floor with that staff member. 10 NYCRR 415.4(b)(3)

Based on interview and record review conducted during the Standard survey completed 11/19/21, the facility did not ensure that grievances were filed on behalf of residents and thoroughly investigated. Specifically, residents voiced complaints of missing personal belongings, the facility did not file grievances on behalf of the residents and did not complete investigations into the missing personal belongings. This involves Residents #5, 18, 40, 47, 66. The findings are: The facility policy and procedure (P&P) titled Resident Council dated 4/12/19 documented the facility would act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility and the facility will be able to demonstrate their response and rationale for such response. The facility P& P titled Investigation of Grievances/Concerns dated 6/2019 documented the facility was committed to fair and equal treatment of all residents and will complete a prompt thorough investigation of all grievances and/ or concerns filed with the facility. In addition, the resident, resident representative, person acting on behalf of the resident will be informed of the findings of the investigation, as well as any corrective actions recommended, within 15 working days of the filing of the grievance. The facility P &P titled Personal Property dated 2012 documented the resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items were replenished. The facility would promptly investigate any complaints of misappropriation or mistreatment of resident property. In addition, Attachment 2 Resident Belongings Protocol documented upon admission, all personal clothing will be brought to the reception desk; the receptionist will inventory the clothing; and the nursing unit staff will bring it to the resident's room. 1. Review of the facility's Resident Council Minutes dated 9/14/21 revealed there were 12 residents in attendance and minutes documented that there were Departmental Concerns - clothing not marked and gets lost. During the Resident Council Meeting dated 11/16/21 at 10:39 AM held by surveyor there were 11 residents in attendance. Residents voiced complaints regarding missing clothing. - Resident #40 stated they had been missing 3 pairs of shorts and many pairs of socks and that the facility was aware. - Resident #47 stated they were missing jeans and underwear, and that the facility was aware. In addition, Resident #47 stated they were wearing Resident #5's pants today because they didn't have any of their own pants in their closet. Resident #47 stated that they would be discharging soon and would like their clothing. - Resident #66 stated they had reported to the Social Worker (SW) a month ago they were missing shorts. Review of the facility's Resident Council Meeting Minutes dated 11/16/21 revealed there were 10 residents in attendance and documented; Departmental Concerns - several residents with lost clothing, date will be set to bring lost clothing cart to activity room for residents to locate unlabeled clothing. During an interview on 11/18/21 at 7:53 AM, The SW Department Director (acting as the Activities Department Leader) stated they held a Resident Council Meeting the afternoon of 11/16/21 and several residents voiced they were missing clothing. The SW stated they do not recall who the residents were that voiced the concerns except Resident #47. The SW Department Director stated they had not filed a grievance on behalf of any of the residents and had not investigated their concerns and should have. The SW Department Director stated Resident #47 had been discharged since the meeting without their missing clothing. The SW stated they should have met with each individual resident to file a Report of Concern and initiated an investigation immediately. The SW Department Director stated the receptionist completes a personal property form when items are brought into the facility for each resident and laundry labels all clothing. SW Department Director reviewed Resident Belongings Inventory sheets for Resident #40 and Resident #66 and stated the form was blank (no inventory documented). During an interview on 11/18/21 at 9:02 AM the Receptionist stated they complete the Resident Belongings Inventory sheet when personal resident items were brought into the facility. The Receptionist identified blank Resident Belonging Inventory forms in the binder at the front desk with resident's names on them. The receptionist stated they had reported to administration in the past the forms were not being completed at times, especially on the off shifts and weekends. During an interview on 11/18/21 at 9:11 AM, the Director of Building Services stated they had received phone calls from residents and staff in the past concerning missing items but has not completed a grievance Report of Concern form when the missing items were reported and does not know the disposition of the concern. The Director of Building Services stated it was the responsibility of the SW Department Director to complete grievances Report of Concern forms for the residents. During an interview on 11/18/21 at 9:20 AM, the SW Department Director stated they held the 9/14/21 Resident Council Meeting and did not file any grievance Report of Concerns for the residents who voiced they were missing clothing and does not recall who the residents were that voiced the concerns and did not investigate their concerns and should have. During an interview on 11/18/21 at 4:17 PM, the Director of Nurses (DON) stated all residents that have personal items should have a Resident Belongings Inventory sheet completed to maintain a log of each resident's personal items. The DON stated the SW Department Director was responsible to hold the Resident Council Meetings and complete a grievance Resident of Concern form for each individual resident when a resident voice's a specific concern of missing items. The DON reviewed the 9/14/21 and 11/16/21 Resident Council Minutes and stated they would have expected the SW Department Director to meet with each resident, completed a grievance form; Report of Concern, with a description of the lost item and forward it to other departments to initiate an investigation. The DON stated they would have expected the SW Department Director to have followed up with each resident with the outcome to the investigation of their missing item. During an interview on 11/19/21 at 12:49 PM, the Assistant Administrator stated they were made aware the Resident Belongings Inventory sheets were not being completed when identified during the survey and they should have been completed for each resident upon their admission and throughout their stay to maintain an accurate inventory of all the resident's items. The Assistant Administrator reviewed the 9/14/21 and 11/16/21 Resident Council Meeting Minutes and stated they would have expected the SW Department Director to meet with each resident who voiced a concern of a missing item and complete a grievance Report of Concerns form with a description of the items. The Assistant administrator stated they would have expected the SW Department Director to inform the individual resident of the outcome of the investigation. 2. Resident #18 was admitted with diagnoses which include diabetes mellitus (DM), anxiety, and hypertension (HTN). The Minimum Data Set (MDS, a resident assessment tool) dated 11/8/21 documented Resident #18 had intact cognition, was understood and understands. During an interview on 11/15/21 at 7:49 PM, Resident #18 stated they were missing a black flip phone. The resident stated the missing flip phone was reported to all the nurses and aides on the unit, but the phone was never found. During an interview on 11/18/21 at 8:49 AM, the Director of Social Work stated they were unaware Resident #18 was missing a black flip phone. Review of Resident #18's Resident Belongings Inventory form provided by the facility revealed the form was blank. Review of the facilities grievance forms (Report of Concern) from the last 6 months revealed there was no investigation completed for the missing black flip phone for Resident #18. During an interview on 11/18/20 at 10:15 AM, the Director of Social Work stated electronics/other valuables would to be labeled and logged in by the receptionist, then delivered to the resident's room. Any staff member could file a Report of Concern to report a missing item. During an interview on 11/18/21 at 11:15 AM, certified nurse aide (CNA) #1 stated Resident 18's black flip phone went missing over a weekend 2 months ago. CNA #1 reported the missing flip phone to the nurse. The Nurse reported the missing flip phone to the Nursing Supervisor. CNA #1 stated they never found the flip phone. During an interview on 11/18/21 at 11:23 AM, Housekeeper #1 stated Resident #18 reported the missing black flip phone over 2 months ago. Housekeeper #1 reported the missing flip phone to the Director of Building Services after searching Resident 18's room and linens. During an interview on 11/18/21 at 3:33 PM, the receptionist was unaware of why Resident# 18's Resident Belongings Inventory form was blank and stated the form should have been completed when Resident #18 was admitted to the facility. During an interview on 11/18/21 at 3:36 PM, the Director of Building Services stated the Director of Social Work was responsible to fill out a Report of Concern form when residents' personal items were reported missing. The Director of Building Services was unaware that Resident #18's flip phone was missing. The Director of Building Services stated there was no Report of Concern form completed for the missing black flip phone. During a telephone interview on 11/19/21 at 12:17 PM, the Administrator stated the receptionist should have logged Resident #18's personal items onto the Resident Belongings Inventory form. Report of Concerns were expected to be completed by the Director of the Social Work or Nursing Supervisor if the item was reported missing on the weekend. Once initiated, the form was given to department heads and a search was conducted. Report of Concerns were closed after the Administrator reviewed and signed the form. The Administrator stated they were not aware of the missing flip phone or would have reimbursed Resident #18, and no Report of Concern was completed and would have expected to see one. 415.3(c)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (NY00282505) during the Standard survey completed on 11/19/2021, the facility did not ensure all alleged violations involving injuries of unknown origin were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency. Specifically, two (Residents #20, 33) of five residents reviewed for abuse bruising of unknown origin was not reported to the New York State Department of Health (NYSDOH) as required. The findings are: The facility policy and procedure (P&P) titled Abuse, Neglect and Exploitation of Residents revised 11/2021 documented once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing as soon as possible and initiate gathering requested information. An investigation must be directed by the Administrator/ designee immediately, report to Department of Health within 2 hours of their knowledge of the alleged incident. The Administrator, Director of Nursing or designee will notify the appropriate state agencies per state regulations. The facility P&P titled Identification and Initiation of Investigation revised 6/18/2021 documented that the Health Commerce System (HCS) site will be used to report allegations of abuse and neglect as required and no later than 2 hours of allegation of abuse, neglect, mistreatment, injury of unknown source, exploitation and misappropriation of resident's property or bodily injury has occurred. 1. Resident #33 was admitted with diagnoses which included hypertension (HTN), dementia with behavioral disturbance, and major depressive disorder. The MDS dated [DATE] documented Resident #33 had severe impaired cognition, was rarely/never understood, and rarely/never understands. Resident #33 had no documented falls. The Comprehensive Care Plan (CCP) dated 2/29/20 documented Resident #33 was at risk for falls and would be free of falls/injury. The CCP further documented Resident #33 had the potential for bleeding secondary to anticoagulant (blood thinning medication) therapy. Planned interventions included to monitor for bleeding and bruising. The undated Closet Care Plan (guide used by staff to provide care) documented Resident #33 ambulated independently without an assistive device. Review of the Nursing Progress Notes dated 7/24/21 at 5:33 PM, Licensed Practical Nurse, LPN #1 documented Resident #33 had large bruise on lower left leg, and the Supervisor was made aware. Further review of the Nursing Progress Notes dated 7/24/21, Registered Nurse (RN #2) documented Resident #33 had a bruise measuring 10 cm (centimeters) x 5 cm. Review of the Facility Daily Unit Report dated 7/24/21, revealed LPN # 1 documented Resident #33 had a large bruise on the lower left leg, and the Nursing Supervisor was aware. Review of the Facility Occurrence Reports provided by the facility revealed there was no investigation completed into the bruising of Resident #33's left lower leg. During a telephone interview on 11/18/21 at 9:39 AM, LPN #1 stated they reported the bruise on Resident # 33's left lower leg immediately to the Nursing Supervisor (RN #2), documented the findings but was unsure how the bruise occurred. During a telephone interview on 11/18/21 at 10:02 AM, Registered Nurse (RN) #2 Nursing Supervisor stated LPN # 1 informed them that Resident #33 had a bruise to their left lower leg over a weekend and RN #2 related the bruise to Resident #33 crossing their legs, therefore did not notify the DON or Administrator. RN #2 stated typically they would report any unusual findings to the Director of Nursing (DON) or the Administrator immediately if abuse was suspected but RN #2 did not suspect abuse. During an interview on 11/18/21 at 11:08 AM, RN #1 Unit Manager stated the Director of Nurses (DON) or the Administrator should have been notified immediately because it was unknown how the bruise occurred and was reportable to the Health Department within 2 hours. During interview on 11/19/21 at 11:49 AM, the current DON stated they were unaware Resident #33 had any bruising on their left lower leg and would have expected the Nursing Supervisor to call them immediately, so they could report the incident to the State Agency within 2 hours. During a telephone interview on 11/19/21 at 12:17 PM the Administrator stated the Nursing Supervisor should have reported the bruise to the DON or me immediately, then the DON or myself could have reported the incident within the 2-hour time frame to the Department of Health as required. 2. Resident #20 was admitted to the facility with diagnoses including Alzheimer's disease, Parkinson's disease, anxiety disorder and age-related physical debility. The MDS dated [DATE] documented Resident #20 had severe cognitive impairment and had a history of physical behavioral symptoms towards others. Review of a facility document titled Investigation Summary/QA (Quality Assurance) Privilege dated 9/1/21 at 1:15 PM documented that on 9/1/21 at 1:15 PM, the DON was notified that a Certified Nursing Assistance (CNA) discovered and reported bruising of unknown origin to Resident #20 face, chin, and left forearm. Investigation was started at 1:15 PM on 9/1/21. Review of the Health Electronic Response Data System (HERDS-system used for online daily reporting to the NYSDOH) report revealed; Date/Time of incident occurrence: 9/1/21 at 1:30 PM. Submitted by facility: 9/1/21 at 4:56 PM. During an interview on 11/19/21 at 3:52 PM, the DON stated (in the presence of the Regional DON) they were aware of regulatory reporting requirements, the bruising was not reported timely and should have been reported within two hours. 415.4(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard Survey (Complaint# NY00272002 & NY00272117) completed on 11/19/21, the facility did not have the evidence that all alleged violations of abuse were thoroughly investigated for three (Resident #9, 33, 68) of five residents reviewed. Specifically, there was a lack of thorough investigations into injuries of unknown origin (#33, 68) and resident self-reported alleged abuse (#9). The findings are: The policy and procedure titled Abuse, Neglect and Exploitation of Residents dated 11/21 documented each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation and misappropriation of property. Residents will not be subjected to abuse by anyone. The policy and procedure titled Identification and Initiation of Investigation dated 6/21 documented all reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The Nursing Supervisor will conduct investigations whenever the Director of Nursing (DON) and Administrator are not on duty. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator and DON will be immediately notified in person or by phone of incident/allegations by the Nurse Supervisor. The Nurse Supervisor will conduct a nursing assessment of the resident and will document the findings in the resident's medical record and on the occurrence form. The policy and procedure titled Accident and Incidents- Investigating and Reporting dated 4/18 documented the facility will ensure that the residents environment remains as free from accident hazards as is possible while providing adequate supervision and assistive devices to prevent accidents. All incidents involving a resident shall be documented on the Accident/Incident Reporting and Investigating Form at the time of the incident. A thorough complete and accurate investigation will be conducted, and safeguards interventions instituted to keep residents safe and prevent reoccurrence. 1. Resident #9 had diagnoses which included paranoid schizophrenia, peripheral vascular disease ((PVD), poor circulation of the lower extremities) and hypertension (HTN). The Minimum Data Set (MDS - a resident assessment tool) dated 8/7/21 documented Resident #9 had moderate cognitive impairment. The MDS documented Resident #9 required extensive assistance of one staff member for dressing. Review of the Progress Notes from 2/1/21 through 2/28/21 revealed Registered Nurse (RN) #12 documented at 4:00 PM they were notified by the Director of Nursing (DON) that Resident #9 had stated they were hit by an aide during the first shift. RN #12 documented Resident #9 stated before breakfast the aide was helping them put on a shirt and the aide hit them on the arm and in the face. RN #12 documented an assessment revealed there was no injury to the Resident #9, a statement was completed for the resident, the MD was notified, and the DON was aware. RN #12 further documented, incident to be investigated. The facility Occurrence Report dated 2/25/21 revealed RN #12 documented, Resident #9 stated as they were receiving assistance getting dressed before breakfast they were hit on the arm and in the face. The Occurrence Report revealed RN #12 signed the RN assessment portion. The signatures lines for the Physician/NP, DON/ADON (Assistant Director of Nursing), and Administrator were blank and without signatures. Review of the facility unsigned Conclusion of Report dated 2/25/21 for Resident #9 revealed there was no evidence the Root Cause Analysis and conclusion was completed to determine if there was reasonable cause or no reasonable cause to believe that alleged abuse, mistreatment, neglect, or quality of care concerns had occurred. Review of Progress Notes 3/1/21 through 3/31/21 revealed there was no documented evidence the alleged abuse reported on 2/25/21 was concluded to rule out abuse and mistreatment. Review of the Physician's Progress Notes dated 1/5/21 through 4/23/21 revealed there was no documented evidence the alleged abuse reported on 2/25/21 was investigated and concluded. During an interview on 11/19/21 at 10:51 AM, the Medical Director (MD) stated they do not recall seeing Resident #9 related to the allegation of abuse and does not recall being informed by RN #5 (former DON) the allegation. The MD stated they should have been notified, should have reviewed the Occurrence Report and should have signed it. The MD stated RN #5 (former DON) would have conducted the investigation and concluded if there was reasonable cause or no reasonable cause to believe that any alleged abuse occurred. During a telephone interview on 11/19/21 at 11:45 AM, the former DON (RN #5) stated they should have signed and ensured the Occurrence Report dated 2/25/21 for Resident #9 was reviewed and signed by the MD and Administrator. RN #5 stated that they believed the conclusion was completed and that the conclusion form should have written on it see typed conclusion, a typed conclusion should be in the file and the form should have been signed. During an interview on 11/19/21 at 11:56 AM, the current DON stated Occurrence Reports were to be reviewed by the Physician/NP, DON, Administrator and signed at the bottom of the page. The SON? Occurrence Report dated 2/25/21 for Resident #9 was missing all required signatures. The current DON stated the conclusion should have been completed by the former DON (RN #5) and if it was a typed word document it should be attached and in the file. The DON stated there was no evidence a conclusion was made to determine if abuse occurred or not. The current DON stated this was an incomplete investigation. During an interview on 11/19/21 at 12:40 PM, the Assistant Administrator reviewed the Occurrence Report and Conclusion Report dated 2/25/21 for Resident #9 and stated there was no evidence the investigation was completed to determine if the allegation of abuse occurred or not. The Assistant Administrator stated the investigation was incomplete 2. Resident #68 had diagnoses which included schizophrenia bi-polar type, anxiety disorder and age-related osteoporosis. The MDS dated [DATE] documented Resident #68 had moderate cognitive impairment. The MDS documented delusions (misconceptions or beliefs that firmly held, contrary to reality) rejection of care not exhibited, and required extensive assistance of two for bed mobility, transfers, and toilet use and extensive assistance of one for dressing. The facility Occurrence Report dated 2/23/21 revealed RN #3 documented, this writer was called to assess right wrist for edema and tenderness. The RN Assessment documented, Resident #68's right wrist swollen and very tender to touch. Resident #68 was not able to perform range of motion (ROM), x-rays were obtained per the MD. Resident #68 was sent to ER for splinting. Resident #68 stated, they did not know how it happened. The Occurrence Report revealed RN #3 signed the RN Assessment portion. The signature lines for the Physician/NP, DON/ADON, and Administrator were blank and without signatures. Review of the facility Conclusion of Report dated 2/23/21 for Resident #6 revealed the form was blank. There was no evidence the Root Cause Analysis and conclusion was completed to determine if there was reasonable cause or no reasonable cause to believe that alleged abuse, mistreatment, neglect, or quality of care concerns had occurred. In addition, the Conclusion Report was not signed. Review of the Physician's Progress Notes dated 2/24/21 through 5/25/21 revealed on 2/24/21 MD documented, the resident was reviewed because of right hands swelling and wrist swelling, x-ray was done on 2/23/21, two views of right hand demonstrated no fracture, dislocation or subluxation. Resident was sent to the hospital for further evaluation of her discomfort. The resident was seen by the orthopedic surgeon, a special splint in place and resident sent back to facility. There was no documented evidence of a conclusion for resident's right wrist pain, swelling. During a telephone interview on 11/18/21 at 5:02 PM, RN #3 stated Resident #68 had pain and swelling of their right wrist and was sent to the ER for evaluation for a possible fracture. RN #3 stated the Occurrence Report was completed and it was the responsibility of RN #5 (former DON) to follow-up, complete an investigation into the injury and to determine a conclusion if abuse occurred. During a telephone interview on 11/18/21 at 5:29 PM, the former DON (RN #5) stated they should have signed and ensured the Occurrence Report dated 2/23/21 for Resident #68 was reviewed and signed by the MD and Administrator. RN #5 stated the Conclusion Report should have been completed and if it was not then it was because they didn't have time to complete their tasks prior to leaving their job on 3/18/21. During an interview on 11/19/21 at 8:53 AM, the current DON stated Occurrence Reports were to be reviewed by the Physician/NP, DON, Administrator, and signed at the bottom of the page. The Occurrence Report dated 2/23/21 for Resident #68 was missing all the required signatures. The DON stated the Conclusion Report including the Root Cause Analysis and conclusion should have been completed by the former DON (RN #5). The DON stated there was no evidence an investigation was completed, or a conclusion was made to determine if abuse occurred or not. The current DON stated this was an incomplete investigation. During an interview on 11/19/21 at 10:43 AM, the MD stated they do not know if the injury to Resident #68's right wrist was related to abuse or not. The MD stated if a resident's wrist becomes swollen and painful, RN #5 (former DON) should have investigated the cause of the injury and determined if abuse occurred or not. During an interview on 11/19/21 at 12:46 PM, the Assistant Administrator reviewed the Occurrence Report for Resident #68 dated 2/23/21 and the Conclusion Report dated 2/23/21 for Resident #68 and stated the form was blank and there was no evidence the investigation had been completed to determine if abuse had occurred or not. The Assistant Administrator stated the investigation was incomplete. 3. Resident #33 was admitted with diagnoses which included hypertension (HTN), dementia with behavioral disturbance, and major depressive disorder. The MDS dated [DATE] documented Resident #33 had severe impaired cognition, was rarely/never understood, and rarely/never understands. Resident #33 had no documented falls. The Comprehensive Care Plan (CCP) dated 2/29/20 documented Resident #33 was at risk for falls and would be free of falls/injury. The CCP further documented Resident #33 had the potential for bleeding secondary to anticoagulant (blood thinning medication) therapy. Planned interventions included to monitor for bleeding and bruising. The undated Closet Care Plan (guide used by staff to provide care) documented Resident #33 ambulated independently without an assistive device. Nursing Progress Notes dated 7/24/21 at 5:33 PM, Licensed Practical Nurse (LPN) #1 documented Resident #33 had large bruise on their lower left leg and the RN Nursing Supervisor #2 was made aware. On 7/24/21 at 6:23 PM RN Nursing Supervisor #2 documented Resident #33 had a bruise that measured 10 cm (centimeters) x 5 cm. Review of the Facility Daily Unit Report dated 7/24/21, revealed LPN #1 documented Resident #33 had a large bruise on their lower left leg and the Supervisor was aware. There was no documented evidence that an investigation was started for the bruising to the left lower leg. Review of the Facility Occurrence Reports provided by the facility revealed there was no investigation into the bruise to Resident #33's left lower leg. During a telephone interview on 11/18/21 at 9:39 AM, LPN # 1 stated they reported the bruise on Resident # 33's left lower leg immediately to the Nursing Supervisor, documented the finding on the Daily Unit Report and the Nursing Progress Notes, but was unsure how the bruise occurred. During a telephone interview on 11/18/21 at 10:02 AM, RN #2 Nursing Supervisor stated LPN # 1 informed them that Resident #33 had a bruise to the left lower leg over a weekend. Resident #33 was combative and kicked and screamed at them at the time of the assessment. RN #2 stated they estimated the measurement of the bruise to be 10 cm x 5 cm. RN #2 stated they should have completed a Facility Occurrence Report, contacted the physician, gathered employee statements but was sidetracked and did not. During an interview on 11/18/21 at 11:08 AM, RN #1 Unit Manager stated the Nursing Supervisor on the weekend should have completed a Facility Occurrence Form for the bruise to the left lower leg, including statements from the staff and notifying the family and physician. The DON or the Administrator should have been notified immediately because it was unknown how the bruise occurred. A full investigation should have been completed to rule out abuse. RN #1 stated the bruise was overlooked on the Facility Daily Unit Report and RN #1 did not ensure an investigation was started. During interview on 11/19/21 at 11:49 AM, the current DON in the presence of the Regional DON, stated the Nursing Supervisor was responsible to start an Occurrence Form, notify the physician, family, and implement any care plan changes if needed. The information should be passed along via the daily unit report and verbal communication to the next shift. The DON stated they were unaware Resident #33 had any bruising on the left lower leg but would have expected a call immediately and informed of the bruise. An investigation should have been done to determine the root cause of the injury and to rule out abuse. During a telephone interview on 11/19/21 at 12:17 PM, the Administrator stated RN Nursing Supervisor #2 should have completed a thorough investigation to rule out abuse, included resident and staff interviews, family and MD notifications. 415.4 (b)(2)

Based on interview and record review conducted during the Standard survey completed 11/19/21, the facility did not ensure that residents who require dialysis received services consistent with professional standards of practice for one (Resident #56) of one resident reviewed. Specifically, the resident's left arm Arteriovenous (AV) fistula (a tube or device surgically implanted to create an artificial connection between an artery and a vein) access site was not monitored for patency by checking for bruit (a rumbling or whooshing sound you can hear) and thrill (a rumbling or buzzing sensation that you can feel) per physician's order. The finding is: The facility policy and procedure titled Dialysis dated 1/19/2019 documented the facility had established standards of care for the dialysis resident. The Registered Nurse (RN) or designated Licensed Nurse will maintain the established standard of care. The access site would be monitored per doctor's order, palpate for thrill and auscultate bruit every shift for the presence of blood flow. Absence of thrill / bruit (for shunt) may indicate a clot and would require immediate intervention. 1. Resident #56 had diagnoses including end stage renal disease, diabetes mellitus, and major depressive disorder. The Minimum Data Set (MDS - a resident assessment tool) dated 10/3/21 documented the resident had moderate cognitive impairment and rejection of care was not exhibited. Review of the Physician's Order Form as of 11/18/21 with a start date of 9/7/21 documented to monitor the AV Fistula for presence of bruit, redness, swelling, pain at site, notify MD (Medical Doctor) if bruit absent, signs of infection, fluid retention, orthopnea (shortness of breath when lying down), neck vein distention, elevated blood pressure, and tachypnea (rapid breathing), every shift. The Treatment Administration Records (TAR) dated 10/1/21 through 10/31/21 and 11/1/21 through 11/18/21 documented to monitor the AV Fistula for presence of bruit, redness, swelling, pain at site, notify MD if bruit absent, signs of infection, fluid retention, orthopnea (shortness of breath when lying down), neck vein distention, elevated blood pressure, tachypnea every shift. There was no documented evidence this was completed per physician's order as follows: From 10/1/21 through 10/31/21 -Day shift (7 AM - 3 PM) there were 17 out of 31 opportunities blank -Evening shift (3 PM - 11 PM) there were 26 out of 31 opportunities blank -Night shift (11 PM - 7 AM) there were 4 out of 31 opportunities blank From 11/1/21 through 11/18/21 -Day shift (7 AM - 3 PM) there were 14 out of 17 opportunities blank -Evening shift (3 PM - 11 PM) there were 13 out of 17 opportunities blank -Night shift (11 PM - 7 AM) there were 4 out of 17 opportunities blank Review of the Progress Notes dated 10/1/21 through 11/18/21 revealed no documented evidence the resident's AV fistula site was assessed or that the resident refused to have the AV fistula assessed for bruit. Review of the facility's Daily Unit Report dated 11/1/21 through 11/17/21 (except 11/2/21 and 11/6/21 as the facility was unable to locate those dates) revealed there was no documented evidence the bruit and thrill were assessed. At the top of each page was the printed statement Dialysis, Thrill, Bruit site assessment (RN only). During an interview on 11/18/21 at 12:00 PM, Licensed Practical Nurse (LPN) #2 stated they were assigned to Resident #56 on 11/15/21, 11/16/21, and 11/17/21 and did not assess the resident's AV fistula for a bruit and thrill because it was a Registered Nurse (RN) task according to the Daily Unit Report sheets. During an interview on 11/18/21 at 12:02 PM, Unit Manager (UM) RN #3 stated they worked full time and were responsible to monitor Resident #56's AV fistula every day they were scheduled to work. Some days they had too many tasks so they did not have time to monitor the bruit and thrill and they were not certain of the last time they had monitored the bruit and thrill. RN #3 stated the bruit and thrill should be monitored every shift to ensure the fistula was patent and if the bruit or thrill were absent, they were to contact the physician. RN #3 stated they believed it was the facility's policy that an RN was responsible to monitor the fistula for bruit and thrill. During an interview on 11/18/21 at 12:19 PM, the Inservice Educator RN #6 stated they educated the RNs to monitor the AV fistula bruit and thrill every shift because it was considered an assessment. RN #6 stated it was important the AV fistula was monitored to ensure patency and if the bruit or thrill was absent, the physician was to be notified. RN #6 observed the October 2021 and November 2021 TARS and stated there were many blanks that probably indicated the AV fistula was not monitored as ordered. During an interview on 11/18/21 at 3:08 PM, Nursing Supervisor RN #8 stated they worked full time as a staff Nurse of Nursing Supervisor on the evening shift. RN #8 stated they were not sure who was responsible to monitor the resident's AV fistula site. RN #8 stated they had not been asked to monitor Resident #56's AV fistula for bruit and thrill and had not monitored the bruit and thrill since hired in mid-October 2021. During an interview on 11/18/21 at 3:16 PM, LPN #4 stated they had not monitored Resident #56's AV fistula for bruit and thrill because it was supposed to be assessed by an RN. LPN #4 stated they had not informed the RN supervisor of the physician's order on the TAR or asked an RN to monitor the AV fistula for bruit and thrill. LPN #4 stated it's always been the facility's policy that the AV fistula bruit and thrill were monitored by an RN. LPN #4 reviewed the TARS from 10/1/21 through 11/18/21 and stated all the blanks could indicate the AV fistula bruit and thrill were not monitored. During an interview on 11/18/21 at 4:35 PM, the Director of Nursing (DON) reviewed Resident #56's October 2021 and November 2021 TAR and stated there were many blanks on the TAR and it didn't appear the bruit and thrill have been monitored as ordered every shift. The DON state the current policy for the facility is the LPNs should be checking the bruit and thrill and documenting on the TAR that it was completed per facility policy. The DON reviewed the Daily Unit Report sheets and stated they were unaware it was documented on the form; Dialysis, Thrill, Bruit site assessment (RN only). The DON stated that was incorrect and might have caused some confusion of who was responsible to monitor the bruit and thrill. During an interview on 11/18/21 at 4:40 PM, the Regional DON stated the information on the Daily Unit Report sheets that indicated Dialysis, Thrill, Bruit site assessment (RN only) was incorrect and needed to be corrected and staff educated. During a phone interview on 11/18/21 at 5:15 PM, Nursing Supervisor RN #9 stated the AV fistula was to be monitored for a bruit and thrill every 8 hours but was not certain if it was an RN or an LPN task. RN #9 stated they often work as a staff nurse as well as a supervisor and didn't have time to check the bruit and thrill on their shift and were not called by the staff nurses to monitor the bruit or thrill. RN #9 stated if a bruit or thrill were absent upon monitoring it would be important to notify a doctor immediately. During an interview on 11/19/21 at 10:54 AM, the Medical Director stated it was important to monitor Resident #56's bruit and thrill every shift by a nurse and if there wasn't a bruit or thrill the nurse was to immediately inform them. The Medical Director stated the facility was responsible to ensure the nurses were monitoring the AV fistula bruit and thrill every shift. 415.12

Based on observation, interview, and record review conducted during a Standard survey completed on 11/19/21, the facility did not provide food prepared in a form designed to meet individual needs for one of 3 residents (Resident #35) reviewed for food. Specifically, the facility did not ensure proper ground consistency was provided. The finding is: The facility policy and procedure (P&P) titled Therapeutic Diets with a revision date of 11/1/21 documented therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his/her goals and preferences. If a mechanically altered diet (requires change in texture of food or liquids) is ordered, the provider will specify the texture modification of ground, chopped or puree. 1. Resident #35 was admitted to the facility with diagnoses including depression, anxiety, and asthma (lung disorder characterized by narrowing of the airways causing shortness of breath, wheezing and cough). The Minimum Data Set (MDS- a resident assessment tool dated 9/13/21 documented Resident #35 was understood, understands and was cognitively intact. The MDS documented Resident #35 required a mechanically altered diet. Physician's order dated 9/6/21 documented Resident #35 was on a mechanically altered diet with ground meats. The comprehensive care plan dated 9/6/21 documented Resident #35 was on a therapeutic diet and required a mechanical soft diet. During an observation on 11/17/21 at 12:35 PM [NAME] #1 during the tray line, prepared the lunch plate for Resident #35. The resident's meal slip dated 11/10/21 documented Resident #35 was to receive the Special consistency ground meat diet. The [NAME] plated one piece of cooked chicken breast and cut the chicken breast with a knife into approximately 8-10 pieces as directed by the Dietary Director. The plated food was then placed on a tray and sent to Resident #35's unit. During an observation and interview on 11/17/21 at 12:51 PM Resident #35's tray was delivered to the resident's room by staff with the cut- up chicken on the plate. Resident #35 stated, the chicken should be ground up; I will choke on that. Resident #35 further stated they often received meat that was not ground, that they don't have any teeth and will choke if the meat was not ground. During an observation and interview on 11/17/21 at 12:56 PM, Certified Nurse's Aide (CNA) #3 observed the meal tray and stated Resident #35 should have ground meat on their tray per the dietary plan. During an observation and interview on 11/17/21 at 1:04 PM, Registered Nurse (RN) #3 Supervisor observed Resident #35's lunch meal tray and stated, the resident should have ground meat on their tray, the resident received cut up meat the other day but was not certain which day it was when the resident was provided the wrong consistency. During an interview on 11/18/21at 1:05 PM, the Speech Pathologist stated they would expect the meat to look like ground cooked meat like hamburger, the rest of the foods would be like soft sandwiches, soft, cooked vegetables, and fruits. During an interview on 11/19/21 at 11:00 AM, the Speech Pathologist stated they were familiar with Resident #35 and the resident should receive ground textured meat, not meat cut with a knife. During an interview on 11/19/21 at 11:02 AM, [NAME] #1 stated the ground meal on (11/17/21) was the red meat sauce, Resident #35 could not have red sauce, so a chicken breast was cut up. The chicken breast should have been a finer texture then cut up and did not have enough time to put the chicken in the food processor. During an interview on 11/19/21at 11:44 AM, the Director of Dietary revealed ground texture should be finally ground chicken, chicken cut with a knife into chunks was chopped not ground. A food processor should be used not a knife. During an interview on 11/19/21 at 11:54 AM, the Registered Dietitian (RD) would expect ground meat to be a fine texture, and a food processer should be used. 415.14 (d)(3)

Based on interview and record review during the Standard survey completed on 11/19/21, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified four (Employees A, B, C, and F) of seven employees that worked in the facility and were subject to the New York State Nurse Aide Registry, had been screened through the New York State Nurse Aide Registry prior to their employment. The findings are: Per Part 415 - Nursing Homes - Minimum Standards: Nursing home shall develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of residents and misappropriation of resident property. The facility shall not employ individuals who have had a finding entered into the New York State Nurse Aide Registry concerning abuse, neglect or mistreatment of residents or misappropriation of their property. The facility's policy titled, Registry of Nurse Aides (NYS Nurse Aide Registry Screen Verification), issued 6/26/18, documented that all each employee (licensed or non-licensed) applying for a position are required to have the New York State Nurse Aide Registry Screen Verification Check completed by the Human Resources Director prior to employment. 1a. Review of the personnel file of Employee-A revealed, Employee-A was hired as a Housekeeping Aide on 8/26/21 and a Nurse Aide Registry Verification check was completed on 11/16/21. Review of the electronic timecards for Employee-A revealed Employee-A worked at the facility for 66 days between 8/26/21 and 11/16/21. 1b. Review of the personnel file of Employee-B revealed, Employee-B was hired as a Dietary Aide on 7/15/21 and a Nurse Aide Registry Verification check was completed on 11/17/21. Review of the electronic timecards for Employee-B revealed Employee-B worked at the facility for 83 days between 7/15/21 and 11/2/21. 1c. Review of the personnel file of Employee-C revealed, Employee-C was hired as a Certified Nurse Aide on 9/2/21 and a Nurse Aide Registry Verification check was completed on 11/17/21. Review of the electronic timecards for Employee-C revealed Employee-C worked at the facility for five days between 9/2/21 and 9/13/21. 1d. Review of the personnel file of Employee-F revealed, Employee-F was hired as a Housekeeping Aide on 8/25/21 and a Nurse Aide Registry Verification check was completed on 11/17/21. Review of the electronic timecards for Employee-F revealed Employee-F worked at the facility for 12 days between 8/25/21 and 11/13/21. During an interview on 11/17/21 at 11:30 AM the Human Resources Generalist stated Employees A and F were Housekeeping Aides and Housekeeping Aides worked on all floors of the building. The Human Resources Generalist further stated Employee-B was a Dietary Aide, Employee-C was a Certified Nurse Aide, and the Human Resources Generalist was not sure which floors of the building Employee-B and Employee-C worked on. The Human Resources Generalist also stated the previous Human Resources Director had not completed the Nurse Aide Registry Verification checks for Employees A, B, C, and F prior to their employment at the facility. 415.4(b)(1)(ii)(a)(b)

Based on observation, interview, and record review during the Standard survey completed on 11/19/21, the facility did not maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. Specifically, a shower plumbing device and hose did not have a vacuum breaker installed to prevent backflow. Also plumbing pipes were open and uncapped. This affected three (Basement, First and Second floors) of four resident use floors. The findings are: 1a. Observation in the Second floor Beauty Shop on 11/15/21 at 8:11 PM revealed the hair washing sink had a shampoo nozzle and hose that did not have vacuum breakers installed. The shampoo nozzle had a hose attached to it that allowed the nozzle to lie flush with the interior of the sink's bowl. The length of the hose allowed the shampoo nozzle to be submerged if the sink's drain did not drain. 1b. Observation in the Second floor Shower room on 11/15/21 at 8:12 PM revealed one of the two shower stalls had a shower and shower wand that did not have vacuum breakers installed. The shower had a shower wand attached to it by a hose that allowed the wand to lie flush with the shower's floor. The length of the hose allowed the shower wand to be submerged if the shower's floor drain did not drain. 1c. Observation in the First Floor Shower room on 11/15/21 at 8:56 PM revealed one of the two shower stalls had shower and the shower wand that did not have vacuum breakers installed. The shower had a shower wand attached to it by a hose that allowed the wand to lie flush with the shower's floor. The length of the hose allowed the shower wand to be submerged if the shower's floor drain did not drain. During the observation, the Building Services Director stated they were not aware the shower and shower wand did not have a vacuum breaker. 2a. Observation in the Basement on 11/15/21 at 9:29 PM revealed a 1.5 inch diameter uncapped plumbing pipe sticking out of the wall of the storage room that was formerly the Men's Locker room. During this observation, the Building Services Director stated the open pipe was the drain for a sink that was removed from the room. The Building Services Director further stated the room was formerly used as the Men's Locker room and was now a storage room. 2b. Observation in the First Floor Kitchen on 11/16/21 at 8:25 AM revealed a 1.5 inch diameter plumbing pipe, part of the drain for the two bay sink located near the dry goods storage room, was uncapped. Further observation revealed the open plumbing was the cleanout for the drain and the threaded cap for the cleanout was resting on the plumbing pipe. During the observation the Building Services Director stated there was no reason for the cap to be off the pipe. 415.29(d)(f)(4)(g)

Based on interview and record review conducted during a Complaint investigation (Complaint #NY00248905) during the Standard survey completed on 2/18/2020, it was determined the facility did not ensure that all alleged violations of abuse, neglect or mistreatment including injuries of unknown injury are thoroughly investigated for one (Resident #240) of one resident reviewed. Specifically, the facility did not complete a thorough investigation to rule out abuse after Resident #240 was diagnosed with an acute displaced fracture of the right (rt.) 7th rib, the facility's investigation lacked documented statements from all staff members involved. The finding is: The facility policy and procedure (P&P) titled, Abuse, Neglect, Mistreatment, Exploitation, Injury of Unknown Sources, For Misappropriation of Resident Property Prevention/Prohibition Program revision dated 11/20/17 included the facility shall conduct a thorough investigation of all alleged violation/sexual abuse involving mistreatment, neglect or abuse, including injuries of an unknown source and prevent further potential abuse while the investigation is in progress. Injury of Unknown Source is described as an injury of unknown incident and facility unable to rule out abuse or care plan violation, source of injury unable to be explained by the resident. The facility P&P titled, Accidents and Incidents - Investigating and Reporting revision dated 4/26/18 included a thorough complete and accurate investigation will be conducted, and safeguards interventions instituted to keep residents safe and prevent reoccurrence. For all injuries of unknown origin and or abuse investigation, the Registered Nurse (RN) Supervisor will obtain all Certified Nursing Assistant (CNA) / Employee statements on shift assigned to ensure a 24 hour look back as occurred. This would include the CNAs and nurses on each shift and all nurses and CNAs from the 2 shifts previous. When the source of the injury is not identified within 24-hours incident will be reported to the Department of Health (DOH) and a 72-hour look back will continue until a reasonable conclusion can be made. 1. Resident #240 had diagnoses which included traumatic brain injury (TBI), generalized epilepsy, and seizures. The Minimum Data Set (MDS, a resident assessment tool) dated 10/22/19 documented the resident was severely cognitively impaired. Review of a radiology report dated 12/2/19 documented an acute (sudden) mildly displaced (is a slight shift in the position) fracture of the right seventh rib. Review of the facility's Incident Accident Investigation Review (Director of Nursing (DON) to complete this section) documented Yes, injuries of unknown source have up to a 72 hour look back of obtaining statements on all shifts for all potential witnesses, employees, resident /roommate and family members on each shift until reasonable cause threshold is met. There were no statements from RN #2, CNA #12, #13, and #14. Review of the Health Emergency Response Data System (HERDS) Incident Report to New York State Department of Health (NYSDOH) dated 12/3/19 revealed; the facility will be completing a 72 hour look back for statements from staff. Review of an undated, facility investigation summary submitted by the DON documented; we did a 72 hour look back and spoke with the staff who worked, and no one saw him fall or bump into anything. Review of the facility's investigation file of staff statements compared to daily staffing sheets revealed four staff members who had worked within the 72 hours assigned to Resident #240 prior to the reported incident did not have statements in the file. During an interview and review of Timecards on 2/18/2020 at 10:49 AM the Staffing Coordinator revealed the following: RN #2 worked 11/30/19 at 11:50 PM through 6:22 AM and 12/1/19 at 11:53 PM through 6:24 AM. CNA #12 worked 11/29/19 at 10:18 PM through 11/30/19 6:04 AM. CNA #13 worked 11/30/19 at 10:11 PM through 12/1/19 6:04 AM and 12/1/19 at 11:03 PM through 12/2/19 at 6:03 AM. CNA #14 worked 11/30/19 at 2:20 PM through 10:03 PM and 12/1/19 at 2:07 PM through 10:13 PM. During an interview on 2/18/20 at 11:35 AM, the Director of Nursing (DON) stated, there were no statements from RN #2, CNA #12, #13, and #14. A thorough investigation was not completed, and he should have ensured all the statements were collected as planned to rule out abuse and neglect related to the rib fracture of unknown origin. During an additional interview on 2/18/20 at 12:33 PM the DON stated, the statements should have been collected prior to closing the investigation. During an interview on 2/18/20 at 12:56 PM, the Administrator stated she was not aware RN #2, CNA #12, #13, and #14 did not submit their statements, and they should have to rule out abuse and neglect. 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 2/18/20, it was determined that the facility did not ensure that a resident who was unable to carry out activities of daily living receives the necessary services to maintain good grooming, and personal hygiene for two (Resident #23, #62) of four residents reviewed for activities of daily living (ADL). Specifically, issues involved long dirty jagged nails (#23) and lack of proper incontinent care (#62). The findings are: 1. Resident #23 had diagnoses which include diabetes (DM), dementia without behavioral disturbances, and anxiety. The Minimum Data Set (MDS, a resident assessment tool) dated 11/11/19 documented the resident was severely cognitively impaired. The resident was not assessed as having behaviors of refusing care. The facility policy and procedure titled Care of Fingernails dated 6/26/18 documented nail care includes daily cleaning and regular trimming on resident assigned bath/shower day. Only Licensed Nurses will cut diabetic nails and document monthly on the MAR. During an observation on 2/10/20 at 12:35 PM the resident had long jagged nails approximately ½ inch above the tip of the fingers with brown dry debris underneath the fingernails. Review of the Care Plan with a print date of 2/13/20 (identified as current) documented the resident was a diabetic, but there was no documented intervention for a nurse to trim nails. Additionally, the Care Plan documented the resident was independent with set up for eating finger foods. During observation of the lunch meal on 2/11/20 at 12:35 PM the resident was feeding themselves finger foods with their right hand. The fingernails were still dirty with brown debris. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked any documented accountability for trimming diabetic fingernails. Review of the Physician orders dated with a print date of 2/18/20 (identified as current) revealed there was no order for a nurse to trim the resident's nails. During an interview on 2/13/20 at 11:30 AM, the Licensed Practical Nurse (LPN) Unit Manager (UM) #1 stated none of the diabetic residents have orders for a nurse to trim nails and they should. Review of the ADL Tracking sheet for January and February 2020 lacked any evidence nails are being cleaned. During interview on 2/13/20 at 9:15 AM, LPN #5 stated she had asked the daughter and resident if they wanted them cut and they both stated no. However, someone still should be cleaning the resident's nails. During an interview on 2/18/20 at 11:30 AM, LPN UM #1 stated we use to have a tracking book for cleaning nails on bath/shower day. If residents are refusing getting nails trimmed or cleaned, they should tell the nurse on their side and then the nurses should notify me. 2. Resident #62 had diagnoses that included DM, cerebral infarction (CVA-stroke), and hypertension (HTN, high blood pressure). The MDS dated [DATE] documented the resident was cognitively intact, required extensive assist of two staff members for toileting, and was frequently incontinent (lack of voluntary control over urination or defecation). Review of the policy and procedure titled Giving a Bed bath (AM/PM Care) dated 3/1/17 revealed in preparation for the care, loosen all bedding from underneath the mattress, leaving the bedding hanging loose on all sides. Change the bathwater as often as necessary during the bath, empty the wash basin in the commode, rinse the basin and refill with clean water. Upon completion, remove gloves, wash and dry hands thoroughly and make the residents bed. Discard soiled bed linens in the soiled laundry container. Review of the policy titled Perineal Care' dated 2/1/17 revealed after washing, rinsing, drying the rectal area, staff are to discard disposable items, remove gloves, and wash and dry hands thoroughly. In addition, the area that was washed is to be rinsed using fresh water and clean washcloth. During an interview on 2/12/20 at 9:32 AM, the resident stated he only gets up once every five weeks to get a haircut. I don't take a shower. I get washed up in bed. During an observation of morning care on 2/13/20 at 10:05 AM, Certified Nurse Aide (CNA) #1 was assisted by CNA #2. CNA#1 washed, rinsed and dried the residents face, hands and underarms. At 10:13 AM, CNA #1 stated, we're out of washcloths. The resident's brief was untabbed and observed to be saturated with urine. Perineal care was completed using a corner of bath towel that had been moistened in the wash basin. The resident was rolled onto right side and was incontinent of a small amount of soft stool. CNA #1 rolled the soiled brief under the resident, washed, rinsed and dried the resident's rectal area with an opposite corner of the towel that had placed over the edge of the basin after perineal care. The bath towel was placed over the edge of the basin with fecal matter coloring the water light brown. At 10:16 AM, without changing gloves or washing hands, CNA #1 rolled a clean brief and barrier pad and placed it under the draw sheet that she rolled up under the resident with the urine soaked brief. The fitted sheet beneath the resident was observed with a wet area approximately 12 inches by 6 inches. The resident was rolled onto the left side. CNA #1 washed the right buttock and hip with a new corner of towel that had been in the fecal contaminated water. At 10:18 AM without changing gloves or washing hands CNA #1 applied barrier cream to the resident's buttocks. CNA #1 removed her gloves, washed hands and put on new gloves. During an interview on 2/13/20 at 10:25 AM, CNA #1 stated she should have changed the water, washed hands, and changed gloves after the fecal incontinent care. She stated that she should have washed her hands and changed her gloves before placing the clean brief and barrier pad. She also stated that she should have washed her hands and changed gloves before washing the resident's right side and applying barrier cream. I didn't even notice the wet spot under the resident on the fitted sheet. She stated, we are out of fitted sheets and washcloths. During an interview on 2/13/20 at 10:45 AM, Licensed Practical Nurse (LPN) #10 stated when the unit is low on linens they call down to laundry for more. She stated the CNA shouldn't have continued using a soiled towel for incontinent care. She stated the basin water should not have been contaminated with a soiled towel/fecal matter or the water should have been changed if it was contaminated. During an interview on 2/18/20 at 11:57 AM, the Director of Nurses (DON) stated he would expect staff to change gloves and wash hands after fecal incontinent care, prior to providing additional care to the resident. I would expect staff to clean the basin and use fresh water after fecal contamination. He would expect staff to call laundry for more linens if they are running low or run out. During an interview on 2/18/20 at 12:55 PM, Registered Nurse (RN) #3 Unit Manager stated she would expect the CNA to change gloves and wash hands after fecal incontinent care. She stated, I would expect the staff to clean the basin and start with fresh water after fecal incontinent care. I will have to do to education with the CNA's. 415.12 (a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review completed during the Standard survey completed on 2/18/20, the facility did not ensure that a resident with limited range of motion (ROM) receives appropriate treatment and equipment to prevent further decrease in ROM for two (Resident #23, & 62) of two residents reviewed for ROM. Specifically, Resident #23 was not provided with bilateral rolled washcloths to both hands, at all times, as recommended by Occupational Therapy (OT) and as planned. Additionally, ROM was not performed during morning care for Resident #62 as planned. The findings are: Review of a facility policy and procedure titled Brace, Splint, Positioning Device Assessment dated 6/29/18 documented if a device is initiated, rehab will notify the Unit Manager who initiates the appropriated contracture care plan. The Unit Manager will update the closet care plan, so the aides are aware and document on ROM as indicated. Rehab staff will in-service the appropriate nursing staff on application, schedule, and care of device indicated for the resident 1. Resident #23 had diagnoses which include diabetes (DM), dementia without behavioral disturbances, and anxiety. The Minimum Data Set (MDS, a resident assessment tool) dated 11/11/19 documented the resident was severely cognitively impaired. The resident did not have documented behaviors of refusing care and had functional impairments of both upper and lower extremities. Review of undated (identified as current) pocket care plan (guide used by staff to provide care) revealed instructions that the resident should have rolled wash clothes in both hands at all times. Review of an Occupational Therapy (OT) Discharge summary dated [DATE] revealed the resident had contractures (loss of joint mobility) and should have bilateral rolled washcloths at all times in hands except hygiene. Review of a a physician's Progress Note dated 11/26/19 revealed the resident had contractures of the upper and lower extremities. During a family interview on 02/10/20 at 12:24 PM, the daughter stated she was told by therapy the resident should have a rolled wash clothes their hands at all times due to bilateral hand contractures. The daughter added she had not seen the rolled washcloths the resident's hands. During observation of range of motion on 2/13/20 at 10:00 AM two Certified Nurse's Aides (CNA #9 & 10) performed range of motion on upper extremities and lower extremities. They did not touch the resident's hands or fingers stating it hurts the resident too much and they can't get the wash clothes in the resident's hands. During an observation on 2/13/20 at 10:55 AM revealed the OT attempting to put a washcloth in the resident's right hand. It appeared difficult but the OT was able to get the washcloth in the right hand. The resident's right hand had a musty odor and the pinky nail was digging into the palm of the hand. The resident was not cooperative with the left hand. At the time of the observation, the OT stated there was a decline in the resident's hand ROM as she was unable to open the resident's left hand and was unable to measure the hand contractures. The last time the OT had worked with the resident, the resident had a 25% (percent) ability to open their hands; the resident now has 0% ability to open their hands. Had staff been putting the wash clothes in the resident's hands all along there would not have been a decline. During an interview on 2/1820 at 11:30 AM, the Licensed Practical Nurse (LPN) Unit Manager #1 stated the CNA's should have been putting the rolled wash clothes in the resident's hands per the care plan and the floor LPN should have followed up to make sure they were placed in resident's hands. 2. Resident #62 had diagnoses which included DM, cerebral infarction (CVA-stroke), and hypertension (HTN, high blood pressure). The MDS dated [DATE] revealed the resident was cognitively intact and required extensive assist of one to two staff members for activities of daily living (adl's). The MDS documented the resident had functional impairment of the upper extremities (UE) on one side and the lower extremities (LE) on both sides. Review of the undated Comprehensive Care Plan (CCP), identified by staff as current, documented limitation of joint/ROM related to CVA with a plan to provide OT consult as needed (PRN) and PROM (Passive Range of Motion- exercises performed on the resident by nursing staff) to right (R) upper (U) and lower extremity (LE) every day (QD). Review of the undated pocket care plan (guide used by staff to provide care) identified as current documented PROM to R UE and LE QD. Review of a Physical Therapy Screen dated 7/16/19 documented the resident was non ambulatory and a mechanical lift with functional limitation in ROM on both sides. Nursing recommendations included PROM QD. Review of a Therapy Referral Form dated 10/1/19 documented the resident was evaluated due to concerns of contractures of both LE. No contracture was found. Response from rehabilitation services was right hip, knee, ankle measure within functional limit for PROM. The OT Evaluation dated 6/19/19 to 7/2/19 and signed by the OT on 7/2/19 documented the resident was seen for decline in wheelchair positioning. Nursing recommendations included PROM RUE QD. The OT Therapy Progress Summary and Goal Tracking Report signed by the OT on 7/11/19 documented nursing recommendations for PROM RUE QD. The OT Therapy Discharge summary dated [DATE] to 1/2/20 signed by the OT on 1/2/20 documented the resident established new baseline with feeding. Continued to recommend PROM RUE QD. During an observation of morning care on 2/13/20 at 10:05 AM, CNA # 1 completed the resident's morning care including incontinent care, bathing, dressing and grooming. The CNA did not complete ROM exercises as planned. During an interview on 2/13/20 at 10:25 AM, CNA #1 stated ROM exercises are done during morning care when dressing. She did not perform PROM to the R upper and lower extremity because the unit was working on a three-man assignment and she still had three more residents to complete AM care that required assistance of two staff members. She stated CNA's do not sign off for completion of ROM. There used to be ROM sheets in the ADL book for the residents who needed ROM, but they are not in the ADL book anymore. During an interview on 2/13/20 at 11:41 AM, the OT stated the resident's right side extremities are flaccid (hanging limply) and PROM was preventative, so the resident does not develop a contracture. The resident should have PROM to RUE and RLE seven days a week. She stated CNA's are responsible to ensure ROM exercises are completed and the Unit Managers are responsible to make sure the CNA's are completing ROM daily. If residents refuse or the CNA can't complete ROM, she would expect nursing to be informed so they could put a referral into therapy for evaluation. During an interview on 2/18/20 at 12:55 PM, Registered Nurse (RN) Unit Manager #3 stated there were no accountability sheets for the CNA's to sign off for ROM. There should be some communication. I have not heard from any CNA that a resident is refusing or having any issues with getting ROM done, I have no answer for how it is monitored by nursing to make sure it is done. During an interview on 2/18/20 at 11:57 AM, the Director of Nurses (DON) stated CNA's are responsible for ensuring ROM is completed on residents' as planned. He stated there are no sign out sheets for accountability, but there use to be sign off sheets. That would be a good QAPI (Quality Assurance and Performance Improvement). We need sign out sheets for ROM accountability. 415.12 (e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the Standard survey, completed on 2/18/20, the facility did not ensure that a resident who is fed by enteral means (by the way of the intestine to deliver part or all of a person's caloric requirements) receives the appropriate treatment and services to prevent possible complications. Specifically, one (Resident #5) of one resident reviewed for feeding tubes, the facility did not provide tube feed formula as ordered by the physician. In addition, the nursing staff inaccurately documented the formula was administered as ordered. The finding is: A facility policy and procedure (P&P) titled Enteral Tube Feeding via Continuous Pump dated 10/13/16 documented the purpose of the procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. Check the enteral nutrition label against the physician order before administration. Check resident name, ID and room number. Check type of formula, route of delivery, method (pump, gravity, syringe) and rate of administration. On the formula label document initials, date and time the formula was hung/administered, and initial the label was checked against the order. 1. Resident #5 was admitted to the facility with diagnoses including diabetes (DM), severe protein-calorie malnutrition and dysphagia (difficulty swallowing). The Minimum Data Set (MDS-resident assessment tool) dated 1/11/20 documented the resident was moderately cognitively impaired and received tube feedings. Review of a hospital Discharge summary dated [DATE] documented gastroenterology (specialist in diagnosis and treatment of conditions involving the digestive tract) placed a PEG (percutaneous endoscopic gastrostomy tube-feeding tube inserted into the stomach) tube on 12/6/19 due to the resident's poor oral intake. It documented continuous tube feed (TF) Isosource 1.5 (TF formula designed for those with increased calorie needs) at 65 milliliter (ml) per hour (hr.) with 125 ml water flush every (q) 4 hours. Review of a hospital Discharge summary dated [DATE], revealed during hospital admission, the residents blood sugars were elevated, and the resident was switched to a diabetic formula. Discharge recommendations included to continue diabetic formula with water flushes of 180 ml q4hr. Review of a facility Progress Note dated 1/30/20 revealed recommendations to change TF, based on last available weight, to Glucerna 1.5 (diabetic formula) to run at 65 ml/hr. for 16 hours, continue 180 ml free water flushes q4hr. This will provide 1560 kilocalories (kcals), 85.8 grams (gm) protein/day and 1870ml total volume. Review of a physician order dated 2/3/20 revealed an order for Glucerna 1.5 via PEG with instructions to infuse at 65 ml/hr. over 16 hours. Start time 6:00 AM and the stop time was 10:00 PM. Review of the Medication Administration Record (MAR) dated February 2020, revealed on 2/10/20 the nurse signed out that Glucerna 1.5 was administered as ordered at 6:00 AM. During an observation on 2/10/20 at 9:15 AM, the resident was in bed sleeping. A TF pump was noted next to the head of bed (HOB). There was no TF formula hanging or infusing at that time. During an observation on 2/10/20 at 12:34 PM the resident was in bed sleeping. A TF formula bag of Isosource 1.5 dated 2/10/20 at 10:30 AM was hanging on the TF pole, with the tubing inserted through the feed pump. The tubing connection to resident could not be visualized because it was under the resident's blankets. The feed pump was not powered on and was not infusing at that time. During an observation 2/10/20 at 1:00 PM revealed the TF Isosource 1.5 bag dated 2/10/20 at 10:30 AM was hanging on the TF pole. The pump was on and infusing at 65 ml/hr. At 2:44 PM the TF formula Isosource 1.5 continued to infuse at 65 ml/hr. Additional review of physician orders in the electronic medical record (EMR) from 1/30/20 to 2/10/20 revealed a lack of documented evidence for a change in formula from Glucerna back to Isosource. During an observation on 2/10/20 at 3:14 PM, in the presence of the Registered Nurse (RN) Unit Manager #1 (UM) revealed the resident still had the Isosource 1.5 formula infusing via pump through the PEG tube. Interview with the RN #1 at the time of the observation stated there may have been an order change. She reviewed the resident's orders in the EMR and stated there were no changes in the orders and the TF formula hanging was incorrect. During an observation and interview on 2/10/20 at 3:28 PM the Unit Secretary #1 took the surveyor to the supply room on the unit to show where the resident's formula was stored. Glucerna 1.5 was observed in the supply room. She stated it was the nurse's responsibility to check the formula to make sure it is correct before they hang it up for the resident. During observation and interview on 2/10/20 at 3:31 PM, the Licensed Practical Nurse (LPN) #7 noted the volume in the formula bag as approximately 1.5 liters (L). She stated it looked like it hasn't been running very long because the initial volume in the bag is 1.5L. During an interview on 2/10/20 at 3:46 PM, the Director of Nursing (DON) stated it would have been the responsibility of the night shift nurse to hang the formula. They leave at 7:00 AM. He stated he was not sure why is wasn't hung and started. Additionally, not hanging the TF will be considered a medication error for the night nurse that didn't hang the formula and for the day nurse that hung the incorrect formula. During an interview on 2/11/20 at 10:53 AM, the Diet tech #1 stated on the most recent hospitalization the resident's blood sugars were not well controlled and running high. The resident was changed to the diabetic TF formula in the hospital and we carried it through when the resident returned. The Isosource could possibly have an effect on the blood sugar but compared to Glucerna it was similar calorically/protein wise. Review of the MAR dated February 2020 revealed blood sugars in range on 2/10/20 and the resident did not require insulin coverage. During interview on 2/12/20 at 3:30 PM, Registered Nurse (RN) #5 Supervisor stated that on 2/10/20 morning she was running around the unit with the formula in my hand to hang. I was very busy, and I guess I forgot to hang it. The resident's TF starts at 6:00 AM. I was busy. During an interview on 2/14/20 at 9:52 AM, LPN #3 stated she got the TF formula from a box in the resident's closet. She stated the previously ordered TF, Isosource, was already hanging when she came on shift the morning of 2/10/20. I just hung the same thing that was already hanging when I hung it up at 10:30 AM. I did not double check the order first, but I should have. LPN #3 stated no when asked if she forgot to turn the TF pump on when she hung the formula. During an interview on 2/18/20 at 7:39 AM, the Registered Dietitian (RD) stated the resident was recently hospitalized , and their blood sugars were not well controlled, so the TF formula was changed to Glucerna 1.5 for more carbohydrate control. She would expect nursing to follow the resident's TF order and schedule as ordered by the physician. If the TF is not administered it could, potentially, affect the resident's blood sugar and cause nutritional decline. During an interview on 2/18/20 at 12:15 PM, the DON stated he would expect the TF to be hung and started at 6:00 AM as ordered by the physician. All nurses should check the five rights. Right resident, medication, dose, route and time. I would expect the nurse coming on shift to make rounds on the residents to make sure things are running like they should be. 415.12 (g)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Standard Survey completed on 2/18/20, the facility did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care. Four (Residents #34, 61, 54, 80) of 27 residents reviewed for resident choice had issues. Specifically, residents were not provided a choice to take a tub bath because there was no workable tub bath in the facility. The findings are: The facility's policy and procedure (P&P) titled Quality of Life - Self Determination and Participation dated 9/1/17 documented the facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. Each resident shall be allowed to choose activities, schedules and health care that are consistent with his or her interests including personal care needs such as bathing methods. In order to facilitate resident choices staff shall gather information about the resident's personal preferences on initial assessment and periodically thereafter and document these preferences in the medical record. The facility's P&P titled Baseline Care Plans (within 48 hours of admission /Readmission) dated 11/28/17 documented the baseline care plan will include the instructions needed to provide effective and person-centered care of the resident that meets Professional Standards of Quality Care. The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to bathing / hygiene grooming needs including but not limited to bathing schedule frequency, tub or shower preference. The facility's P&P titled Comprehensive Care Plan dated 2/1/17 documented an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The facility will inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process will incorporate the resident's personal and cultural preferences in developing goals of care. 1. Resident #34 has diagnoses that include paranoid schizophrenia and history of left ankle fracture. The Minimum Data Set (MDS - a resident assessment tool) dated 11/22/19 documented the resident was cognitively intact, was understood, and understands. Review of the Resident Care Plan Preferences and Choices dated 12/31/18 revealed the resident prefers a shower. 2. Resident #54 has diagnoses that include hypertension (HTN, high blood pressure), chronic pain and osteoarthritis. Review of the MDS dated [DATE] revealed the resident was cognitively intact, was understood, and understands. Review of the Resident Care Plan Preferences and Choices dated 2/11/2020 revealed the resident prefers a shower. 3. Resident #61 has diagnoses that include Diabetes Mellitus, peripheral vascular disease and pain. Review of the MDS dated [DATE] revealed the resident was cognitively intact, was understood, and understands. Review of the Resident Care Plan Preferences and Choices dated 2/1/19 revealed the resident prefers a shower. 4. Resident #80 has diagnoses that include schizophrenia, anxiety disorder and atherosclerotic heart disease (ASHD - a thickening and hardening of the walls of the coronary arteries). Review of the MDS dated [DATE] revealed the resident's cognition is moderately impaired. Review of the Resident Care Plan Preferences and Choices dated 1/3/19 revealed the resident prefers a shower. a.) Observation on 2/14/20 at 8:14 AM, the 2nd floor tub revealed the tub had a can of shaving cream on the tub seat with dried white debris in the base of the tub with dust build up on the tub edges. Resident and staff interviews on 2/14/20 between 8:23 AM and 3:35 PM revealed the following: - 8:23 AM Certified Nursing Assistant (CNA) #7 stated the residents don't get tub baths, because none of the bath tubs work in the facility. - 8:33 AM Registered Nurse (RN) Nurse Manager (NM) # 3 stated, the residents are not offered a tub bath because the tub does not work. - 8:35 AM Licensed Practical Nurse (LPN) #4 stated, none of the tubs work in the facility, the 2nd floor tub hasn't worked for years. - 8:36 AM Unit Clerk (UC) #2 stated, none of the tubs work in the facility. - 3:32 PM Resident #61 stated, I'd like a tub bath but they don't ask me because I don't think they have a tub here, but I'd like to take a tub bath if they had one. - 3:35 PM Resident #54 stated I've never been asked if I want a tub bath, I had one at home, and I'd like a tub bath if they had one. During an additional interview on 2/18/2020 at 8:28 AM at 10:03 AM, the RN NM #1 stated resident #54 and #61 have not been offered a preference of a tub bath verses a shower because the facility doesn't have a working bath tub. b.) Observation on 2/14/20 at 8:44 AM, the 3rd floor tub revealed personal clothing hung over the edge of the tub and had dry white debris around the drain of the tub. Resident and staff interviews on 2/14/20 between 8:34 AM and 2:45 PM revealed the following: - 8:34 AM Resident #34 stated, they never asked me if I wanted a tub bath, and I'd prefer a bath if it was available. - 8:47 AM LPN #5 stated, I don't think the tub works. - 8:54 AM CNA #8 stated I don't think the tub works, I've never seen anyone use it. - 2:45 PM the Resident #80 stated, I would prefer a bath, but they told me I couldn't take a bath because it leaks. During an additional interview on 2/18/2020 at 10:00 AM NM LPN #1 stated she doesn't not offer tub baths to the resident because all the tubs in the building are broken. The tub on the 3rd floor doesn't maintain a proper temperature, so it isn't used. LPN NM #1 stated she does not complete the preference section on the care plans because she is an LPN, therefore the Director of Nursing (DON) has been completing the preference section if a resident would prefer a shower or a tub bath. c.) Observation on 2/14/20 at 8:55 AM the 1st floor tub has a sign hung in the tub above and below the water line stating, Do not put anything in tub. Staff interviews 2/14/20 at 8:56 AM and 8:58 AM revealed the following: - 8:56 AM UC #1 stated, the tubs in the facility have not worked for years. - 8:58 AM NM RN #1 stated she doesn't know if the tub works; and does not ask the residents their preferences if they would want a shower or bath. During an interview on 2/14/20 at 9:28 AM, the Director of Nursing (DON) stated he was aware the bath tubs in the facility have not worked since his employment, February 2019 and that corporate was aware. Staff should be asking the residents on admission and quarterly if they would prefer a tub bath verses a shower and if a resident wanted a tub bath, he would request the tub baths to be repaired. The DON further stated he believed the preferences are documented by the Social Worker. During an interview on 2/14/20 at 9:41 AM, the Administrator stated the residents should be asked if they want a bath verses a shower at least on admission and was not aware there are not any working bath tubs in the facility. During an interview on 2/14/20 at 9:44 AM the Director of Social Worker (SW) stated the nursing department should be asking the residents if they want a tub bath verses a shower and was not aware there were not any working bath tubs in the facility. An additional interview on 2/18/20 at 10:22 AM the SW stated preferences are important and the residents should be asked if they want a tub bath or shower. During an interview on 2/18/20 at 11:28 AM, the DON stated he did not ask Resident #54 or #80 their preferences of a shower verses a tub bath during care planning meetings and was not aware the question was not being asked by the other nurse managers because the facility does not have a working tub. During an additional interview on 2/18/20 at 1:03 PM, the Administrator stated the nursing staff should be asking the residents their preference of a shower or a tub bath on admission and quarterly. The Administrator stated she believed the 3rd floor tub was working and was not aware the tub was broken. During an interview and observation on 2/18/20 at 1:42 PM the Maintenance Department Director stated the last time the tubs in the facility were checked was in July 2019 and believes the 3rd floor tub is working. He stated the 1st and 2nd floor tubs are out dated and too expensive to repair and corporate was aware. During an observation of the 3rd floor tub at the time of the interview revealed the temperature adjustment was not working. He stated the should not be used until it is fixed and was not aware the nursing staff have not been using it. 415.5(b)(3)

Based on observation, interview and record review during the Standard survey completed on 2/18/20, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the Legionella Prevention Program and Water Management Plan was not specific to the facility and the Legionella Management Plan was not updated annually. This affected three (One West, Two East/West and Three East/West) of three resident units. In addition, one (Resident #62) of four residents observed for infection control practices during resident care had issues with the lack of proper disposal of used (soiled) bath water into a shared sink. The findings are: 1a. Review of the facility's binder called Legionella Management Plan on 2/13/20 revealed it contained the following documents: -Facility policy and procedure called Identify and/or Prevent Nosocomial Legionnaires Disease, dated 11/2017 -Centers for Disease Control (CDC) document called Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, dated 6/5/17 -Form DOH (Department of Health)-5222, Environmental Assessment of Water Systems in Healthcare Settings, dated 2/13/18 -Facility layout with water systems identified Further review revealed the facility policy and procedure did not contain information specific to this facility. Under the section called Engineering Controls, it stated the facility would follow directions of the New York State Department of Health for control measures and decontamination, with no further information. Further review revealed page one of the CDC document stated it was to be used as a toolkit for people to use when creating their own water management program. Additionally, page 23 of the CDC document contained the heading Special Considerations for Healthcare Facilities. Under this heading, there was a flowchart of water management program requirements, including to establish a water management team, decide where control measures should be applied and how to monitor them, establish ways to intervene when control limits are not met, and make sure the program is running as designed and is effective. During an interview on 2/18/20 at 3:00 PM, the Maintenance Director stated the requirements on page 23 are not completed for this specific facility and he was unable to locate any other documents that could be part of a facility-specific water management plan. On 2/18/20 at 3:50 PM, a white binder called Infection Control Volume 2 of 3 was submitted for review. Review of the white binder revealed it did not contain any documents that were consistent with a facility-specific water management plan. 1b. Review of the facility's binder called Legionella Management Plan revealed it did not contain an issue date, review date, or revise date. Further review revealed it contained a facility policy and procedure dated 11/2017 and a DOH-5222 dated 2/13/18. During an interview on 2/18/20 at 2:50 PM, the Maintenance Director stated the Corporate Maintenance Director did review the binder at some point during 2019, but he is not certain when or how much of the binder was reviewed. 2. Resident #62 had diagnoses that included diabetes (DM), cerebral infarction (CVA, stroke), and hypertension (HTN, high blood pressure). The Minimum Data Set (MDS, a resident assessment tool) dated 12/28/19 documented the resident was cognitively intact, required extensive assist of two staff members for toileting, and was frequently incontinent. The policy and procedure titled Giving a Bed bath (AM/PM Care) dated 3/1/17 documented to change the bathwater as often as necessary during the bath, empty the wash basin in the commode, rinse the basin and refill with clean water. During an observation of morning care on 2/13/20 at 10:13 AM, CNA #1 rolled the soiled brief under the resident, washed, rinsed and dried the resident's rectal area with an opposite corner of the towel that had placed over the edge of the basin after perineal care. The bath towel was placed over the edge of the basin with fecal matter coloring the water light brown. At 10:19 AM CNA #1 disposed of the dirty water from the basin, used to provide the resident with fecal incontinent care, into the shared sink in the bathroom that adjoined two semi-private rooms. During an interview on 2/13/20 at 10:25 AM, CNA #1 stated, I dumped the dirty water in the sink and should have dumped it in the toilet for sanitary reasons. During an interview on 2/13/20 at 10:45 AM, Licensed Practical Nurse (LPN #10) stated the dirty water shouldn't have been dumped in the sink because a resident that utilizes the same bathroom is independent and uses the same sink on her own. LPN #10 stated It's the same sink they use for four residents and for infection control purposes, it's contaminated. During an interview on 2/18/20 at 11:57 AM, the Director of Nurses (DON) stated, I would expect dirty basin water to be disposed of properly, clean the basin and fresh water after fecal contamination, for infection control purposes. During an interview on 2/18/20 at 12:55 PM, Registered Nurse (RN #3) Unit Manager stated, I would expect the basin to be emptied in the toilet, for infection control, clean it and start with fresh water after fecal incontinent care. I will have to do to education with the CNA's. 415.19(a)(1)(b)(2)(4) 10 NYCRR Subpart 4-2.4